Lecture
Pestereva E.V., Kondratyeva K.O., Chulkova V.A., Karavaeva T.A.
Oncological disease has its own specific features, which are, first and foremost, associated with severe stress factors linked both to the semantics of a diagnosis of malignant neoplasm for the particular patient and to the high frequency of unfavorable disease progression, rapid disability, and serious complications accompanying tumor treatment (chemotherapy, radiation therapy, extensive surgical interventions, including those with pronounced cosmetic defects).
Professional psychological care for the oncology patient is a particular case of psychotherapy for a person in extreme and crisis situations. It is aimed at helping the person who has fallen ill to cope with the psychological consequences caused by oncological disease and to adapt to the changed life situation.
Two tendencies are observed in patients' experience of the situation of oncological disease. Some patients experience the disease as the collapse of their former life, as a turning point in their life story, which prompts them to gradually recreate their life, but now taking the disease into account. In doing so, they reflect on the illness, on its place and role in a person's life, reappraising their life and restructuring the personality's system of relationships. Another group of patients does not experience the situation of illness as an event in their life, as a pivotal moment of life dividing life
into «before the illness» and «after the illness»; these patients live in a state of chronic tension. A psychologically unprocessed traumatic life situation – in this case the situation of oncological disease – does not allow them to adapt to the changes that have appeared in their life.
There is no doubt that oncology patients need not only timely, adequate, and high-quality medical therapy, but also qualified professional psychological care; however, there are no unified standards for its provision. In some cases psychotherapy is aimed merely at the patient's acceptance of treatment and the effectiveness of its delivery; in other cases a broad arsenal of psychotherapeutic methods is used with the aim of resolving the global psychological problem of the oncology patient – acceptance of the malignant nature of the disease, which largely determines their adaptation to the illness: in the process of accepting the disease, information about the illness becomes information about how, having a diagnosis of oncological disease in the present or in the past, one can continue to live.
In working with oncology patients, the medical psychologist uses a variety of methods of psychological counseling and psychotherapy from various theoretical schools. In the present work we will present only some of them, those most frequently encountered in the psychological counseling and psychotherapy of oncology patients.
Clinical interview
Despite the fact that the method of the clinical interview is classified as a diagnostic method, it also has a psychotherapeutic effect. Thus, the clinical interview, on the one hand, is aimed at studying the patient's attitude toward the illness and the socio-psychological situation in connection with the disease; on the other hand, in the course of the conversation the patient has the
opportunity to speak out, to voice their fears, to structure their experiences, and thereby to already reduce emotional tension.
The clinical interview is aimed at obtaining information from the patient in order to assess their personality as an established system of relationships with various aspects of reality and with themselves. The clinical interview addresses issues including the psychological history of the illness and of life. The psychological history of the illness is gathered by talking with the patient about their reactions to the disease, attitude toward treatment, and the fears associated with it: the psychologist assesses the quality of the information the patient has about the disease, the degree of recognition of its malignancy, and also elicits the patient's own conceptions of the disease, its causes, motives for recovery, and the presence of a personal meaning of the illness. In doing so, it is essential to assess the extent to which the illness has altered the person's pre-illness system of relationships: whether the patient counts on the support of the family, whether they experience difficulties in informing others about their diagnosis, how they assess their relationships with significant others in connection with the disease, their attitude toward life as a whole, and so on. The psychological history of life involves talking with the patient on the following topics: the most difficult events of past life and reactions to them, professional development, the development of family and intimate relationships, and relations with the immediate circle outside the family.
Crisis intervention
Crisis intervention is, first and foremost, work with intense feelings and with the problem caused by the current situation (loss of health, intense fear of a procedure, fear of loss of femininity, and so on), but not with the patient's personal problems (long-standing grievances, internal conflicts). The psychologist's task is not to distract the patient from the peak of their experiences, but to give them the opportunity to express their feelings and thereby reduce the chaos: the mental and emotional disorganization, and to facilitate the restoration of control over what is happening. In this case the psychologist
uses techniques of empathic and active listening, including reflection of feelings, paraphrasing, joining feelings to content, introductory words, clarification, and reflection of one's own feelings. The use of listening skills makes it possible to formulate the patient's psychological problem or to reformulate it in such a way that it becomes possible to work with it.
Crisis intervention is also used in working with patients prone to suicide.
Self-regulation techniques
Self-regulation techniques are a system of training methods aimed at forming internal means of managing one's own emotional state through the patient's action upon themselves with the help of words (affirmation), mental images (visualization), and control of muscle tone and breathing.
Breathing exercises. Breathing is directly linked to a person's emotional state. The basis of breathing gymnastics is a strictly set rhythm. The method of breathing exercises, intended to reduce tension, is based on deep, measured breathing.
Relaxation methods are aimed at eliciting a muscle-relaxation response, which is characterized by reduced activation and a decrease in sympathetic activity. The relaxation response is achieved through the patient's concentration of attention on a word, sound, bodily sensation, or muscle activity and the adoption of a passive attitude toward intruding thoughts. Relaxation methods can be divided into deep and superficial. The following strategies are used: progressive muscle relaxation, autogenic training, and breathing training. When using the relaxation method, it is necessary to take into account the risk of adverse reactions in the form of intrusive thoughts, fear of loss of control,
muscle spasms, anxiety, and panic in patients with a history of generalized anxiety or panic disorders and with a history of experiencing states of hyperventilation.
Biofeedback (BFB) is training in managing one's physiological reactions to stress and pain under conscious control. In this process, sensors register one or several
physiological indicators that correlate with the patient's state. These may be surface electromyography (EMG), registering muscle tension in a given muscle, breathing parameters, heart rate, galvanic skin response (GSR), and peripheral temperature. On the screen the patient sees the change in the indicator in real time and learns to manage their physiological reaction. Thus, EMG biofeedback targets the muscle groups associated with the patient's reaction to pain. Relaxation of these muscles helps to elicit a general relaxation response, which can then alter the perception of pain or reduce anxiety. Biofeedback can be used for any motivated oncology patient with pain or anxiety, provided there is the resource and the ability to participate in the work. It should be borne in mind that patients with chronic or recurrent depression may react negatively to stress-reduction methods, since these tend to further reduce the patient's already low level of activation.
Dynamic psychotherapy
Dynamic psychotherapy presupposes work with the patient's repressed experiences, the affective aspect of which is actualized in connection with the situation of illness. Oncological disease, with its subsequent social and psychological changes, is a kind of «trigger mechanism» for the actualization of psychogenic reactions of fear, anxiety, and hypochondria. In this case, the psychogenic reactions are
«symptoms» of the internal adaptive work of the person's mental apparatus. The goal of psychoanalytic psychotherapy is the retrieval and awareness of the repressed mental material, the direct perception of reality, and the emotional experience of the therapeutic relationship
[4, 5].
The psychodynamic approach presupposes a psychotherapeutic process that is lengthy in time, which, unfortunately, the oncology patient may not have. At the same time, this therapeutic approach is present eclectically in the work of the medical psychologist. Thus, psychoanalysis and depth psychology are the theoretical basis for working with a person's inner imagery experience – their memories, imagination, and dreams.
Work with imagery
In contemporary psychotherapy there is practically no school that does not turn to work by means of imagery. Work with imagery is based on the use of the functions of imaginative thinking and imagination, actively produced by the patient in the process of psychological counseling, and represents a whole arsenal of psychotherapeutic techniques for working with a person's inner space.
Visualization is a collective term for psychotherapeutic techniques aimed at recreating and managing visual images in a person's inner, subjective space. The possibilities for applying the visualization method are determined by the theoretical concept within which the principal psychotherapeutic method – of which they are a component – was developed. In psychoanalytic psychotherapy, visualization images are regarded as one of the forms of obtaining material for analysis.
Symboldrama (guided affective imagery) is one of the schools of analytically oriented psychotherapy. At the basis of the method is free fantasizing. The patient paints a picture in their imagination on a
given theme (motif) and mentally moves into it, telling the psychologist (psychotherapist) about their feelings and sensations. The psychologist (psychotherapist) accompanies them on this «journey». They ask clarifying questions or request that certain actions be performed, which helps to reveal psychological defense mechanisms and to resolve unconscious conflicts. In symboldrama it is possible to create a symbolic image of a significant experience (for example, an image of the oncological disease) and its subsequent working-through on an emotional level in order to reappraise the attitude toward it.
Gestalt therapy
Gestalt therapy offers an experimental path of working with the images that the subject has remembered from their dream, which is relevant in the psychologist's work in oncology. Even if the oncology patient does not accept the illness and perceives it as an external event in relation to their personal history, this does not mean that no meaning-making of the situation is taking place – unconsciously, patients try to master the meaning of the disease. Thus, oncology patients not infrequently bring an account of dreams into the psychotherapeutic conversation. In Gestalt therapy, each element of a dream is regarded as a potential source of content connected with a particular aspect of the patient's real existence: the objects of the dream and its individual fragments are «acted out» and used for the integration of the personality.
Gestalt therapy, along with work with dreams, includes a large number of verbal and nonverbal methods of work, among them – intensification of bodily reactions, the «empty chair», work with metaphors, and others, aimed at expanding the person's awareness of themselves (their feelings, needs, bodily processes, mental activity) and of the external world. Focusing the patient's attention on awareness of what is happening «here and now», their involvement in the nuances of the current moment of life on condition of nonjudgmental perception, brings about the achievement of greater
fullness and meaningfulness of the patient's life, and develops their capacity to accept what exists in their life now as something valuable and transient.
Cognitive behavioral therapy
Cognitive behavioral therapy is aimed at restoring the distorted perception of the appraisal of oneself and the surrounding world, and at ridding oneself of intrusive thoughts. Within this approach, cognitive and behavioral methods are distinguished, applied in oncology patients, in particular in the treatment of post-traumatic stress disorder.
The cognitive processing of traumatic experiences in connection with the disease is based on the assumption that maladaptive symptomatology is caused by the destruction of a stable picture of the world and the conflict between new information and old conceptions. In situations of oncological disease we are dealing with a real threat to life, a sense of danger, a decline in self-esteem, a new social role, and a change in close relationships. These cognitive conflicts may be
the cause of intrusive thoughts, physiological hyperarousal, and avoidant behavior. Consequently, the main task of therapy is the identification and modification of conflicts between old conceptions and new information. In the cognitive behavioral approach, visual images are equivalents of cognitions, jointly constituting the so-called schema of automatic thinking, an element of which may be «self-anticipation» – the involuntary creation of an image of possible, as a rule negative, consequences.
The visualization method in this approach includes the creation of healing images. For example, the patient, accompanied by the psychologist, learns to imagine what is happening in their body and develops a healing symbolism – a set of images that help to cope with the disease.
Widely used in oncology is the visualization technique developed by Simonton C. and Simonton S.: the patient imagines how leukocytes destroy tumor cells, how the dead cells are eliminated from
the body, mentally visualizes the change in the tumor's size: imagines how the treatment received reduces the level of pain; imagines themselves as vigorous, healthy, and full of energy. This technique helps the patient to feel control over their recovery.
Patients' setting of goals and objectives for the future is an important component of psychotherapy, since it not only contributes to satisfying patients' needs, but also becomes the first attempt to consciously formulate the reasons why the patient wants to live. The reasons named turn into the recovery motives of the particular patient, and thereby their connection with their own life is restored. This process serves as emotional and intellectual preparation for actions in which the person's decision to recover is to be strengthened.
The decatastrophizing technique. Even if the patient is in remission and has outlived the life span diagnosed by the physicians, and even if no signs of the disease are detected in them, there is a constant probability of a recurrence of the disease with a fatal outcome. The decatastrophizing technique is aimed at overcoming the fear of recurrence.
Narrative therapy
Narrative therapy is based on the idea that people's lives and relationships are shaped by the knowledge and stories that have been created by a community of people and are drawn upon by these people to make sense of and describe their experience. In the course of the conversation the patient retells the story of their life, the events of which, in the course of therapy, are presented in a somewhat different sequence over a certain span of time. The main form of work in this approach is the re-authoring of the story, the patient's creation of their own authorial position by means of questions posed by the psychologist and aimed at developing the story, but now with an effect that is positive for the patient. The main psychotherapeutic techniques are: externalization, deconstruction, restoration of the patient's participation in the creation of their life story, work with outside witnesses, letter-writing, and the creation of chronicles.
Bibliotherapy
Bibliotherapy is a corrective influence on the patient by means of reading specially selected literature with the aim of normalizing or optimizing their mental state.
Fairy-tale therapy
In fairy-tale therapy, the main instrument is precisely the fairy tale. All fairy-tale characters are archetypal images that address two mental levels simultaneously: the conscious and the unconscious. It is held that the work during a fairy-tale therapy session can be classified by directions: psychodiagnostic – identification of the existing life scripts and behavioral strategies (analysis of basic life scripts and behavioral strategies); prognostic – diagnoses the possible course of events on the basis of an analysis of the diagnostic fairy tale; therapeutic – "replacement" of an ineffective strategy / script with a constructive one.
Fairy-tale therapy makes it possible to freely synthesize and apply techniques of other schools of psychotherapy, including art therapy.
Art therapy
Art therapy is a method of psychotherapy that uses the patient's creative activity in working with painful experiences. In doing so, it is recognized as natural that a person's consciousness wants to «slip away» from painful experiences, and therefore the psychologist suggests that these experiences be drawn, sculpted, depicted, and so on. To help the patient in this process, the psychologist asks, for example, such questions: «What does the pain resemble, what color is it, what size, how is it felt in the body?» and so on. All of this allows the person to concentrate and express their experiences: the more precisely and in more detail the patient can imagine a sensation or feeling, the more deeply they experience it. Work by the art therapy method is based on the projective mechanisms of the person's mental apparatus: through drawing, the patient unconsciously «communicates» to the psychologist about the experiences that they have
encountered and that they cannot express verbally. In this sense, the instruments of art therapy are an effective way of discharging negative emotions that the patient does not know how to express constructively (for example, aggression, guilt, mental pain). Art therapy techniques are used in working with a person who is in a crisis state, who has a psychological trauma, or who is experiencing loss.
In art therapy, drawing, sculpting, music, photography, film, and literary creativity are widely used.
Existential therapy
Oncological disease inevitably confronts the patient, their family, and their immediate circle with existential problems that in ordinary life may be hidden. Existential experiences in most patients manifest in the form of psychic pain, in a feeling of the injustice of fate, in despair, loneliness, and in a subjectively significant need to «give the illness meaning». On the one hand, there is a view that it is important for the psychologist to be empathic and cautious with respect to the patient's need to find meaning in their illness and suffering, and not to intensify the feelings of guilt and shame characteristic of them. On the other hand, discussing with the oncology patient the real and imagined chances they have missed in their life may lead to a genuine working-through of this theme and will allow them to grieve [10]. People in the situation of illness feel the importance for themselves of reflecting on their inner loneliness, on the finitude and meaning of life, and on responsibility for their own life. As a result of such discussions, patients say, in their own words: «The will to live awakens», «When you share grief, something greater than grief grows out of it».
Logotherapy
One of the types of existential psychotherapy is logotherapy (Greek «logos» – meaning, and «therapy» – care, tending, treatment). The oncology patient always develops the questions «Why has this illness come to me?
Why me?», which may gradually be transformed into the following: «What is the meaning of my illness? What is the I? What is my life?», «What is the meaning of life?». From the standpoint of logotherapy, it is precisely the search for answers to these questions that motivates a person to live, since the search for meaning is the main driving force of life and the principal resource for coping with any life
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each person: the unique meaning of life can be found only on one's own, in creativity, in experiences, and in the conscious acceptance of those circumstances that cannot be changed. The central problem in logotherapy is the problem of responsibility: a person is free in their choice of meaning, but, having found it, they bear responsibility for the existence of their unique meaning. The main methods of logotherapy are: the method of dereflection (the person is advised to switch attention from themselves to the meanings and values that they can embody in the surrounding world); the nonspecific method of paradoxical intention (the aim of which is to make the patient able to distinguish real experiences from «contrived» ones and to distance themselves from the latter, with a sense of humor often being used in the process); and personal meaning-making of life (to show a person who has lost the meaning of life that they are needed by another person, that life without them loses its meaning for the other).
Movement therapy
The modern person not infrequently lacks contact with their own body; however, the onset of illness forces them to concentrate on the symptoms of ill-being coming from the body (the sensory component of the attitude toward the illness). The oncology patient sometimes forms an ambivalent attitude toward their body: on the one hand, there is a striving to avoid an encounter with the source of pain, up to and including alienation from their own body and a sense of betrayal on its part. On the other hand, the patient may develop a feeling of guilt for a disdainful attitude toward their body. It is difficult for the oncology patient to express their sensations and to
picture their body. They are often unaware of the part of their body where the tumor is developing. Inclusion in the overall complex of psychological care contributes to the normalization of bodily expression, the harmonization of the perception of one's bodily identity, and also the resolution of deep-seated personal conflicts. The initial theoretical premise of movement therapy is the thesis that the movement of the body is the basis of all manifestations of life, including cognitive and emotional ones.
Eye movement desensitization and reprocessing
Eye movement desensitization and reprocessing (EMDR) is based on a model of information processing, according to which all people have a special psychophysiological mechanism that ensures the processing of information, including emotional information associated with stresses. Under normal conditions these processes take place in a person at the stage of sleep accompanied by rapid movements of the eyeballs. If for some reason the information-processing system is blocked, the processing of traumatic experience does not occur. In this case the neural structures that store the dysfunctional material in unchanged form are isolated from other areas of the cerebral cortex. The goal of therapy is to reprocess these stressful memories: during the reprocessing phase, the patient's concentration on the disturbing memories is combined with therapist-guided eye movement, which triggers processes analogous to those occurring in sleep. At present, in connection with the difficulties patients experience in simultaneously performing two actions (fixating the gaze on a moving pen and reliving the psychotraumatic events), various modifications of EMDR exist. Thus, eye movement is alternated with a specially selected technique, and it is also possible to fully replace eye movement with breathing movements, in which case muscle tension and
involuntary movements are eliminated by applying expressive techniques of Gestalt therapy (simple repetition, exaggeration, development).
Individual psychotherapeutic consultations are aimed at working through individual problems associated with the disease. In some cases, individual consultations contribute to the development of psychological readiness for group work.
Work in a group gives the patient the opportunity to share their experiences with others, to learn to give one another support, to become convinced that they are not alone, and to gain the experience of solving similar problems. The opportunity to express and share one's experiences with other people in the special group atmosphere gives the patient strength and energy.
During psychotherapeutic work it is necessary to remember the individual approach to each patient and to adjust the course of therapy depending on the current situation: one cannot expect equally good results of psychotherapeutic interventions by applying identical psychotherapeutic techniques to all patients who have a particular disease. In the opinion of H. Eysenck, not every psychotherapeutic method can be effective and safe in working with an oncology patient
.
It should also be noted that the psychological care of a medical psychologist is not necessary for every oncology patient, since one must not underestimate the personality of the patient themselves in the process of adaptation to the disease. At the same time, professional psychological care should be available to every oncology patient.
In addition, for full-fledged psychological rehabilitation, psychological consultations for the members of the family and relatives of the patient are desirable and, in a number of cases, necessary.
Thus, psychological care for patients and their loved ones in the situation of oncological disease includes the following:
Chulkova V.A., Pestereva E.V.
In the situation of oncological disease, the patient faces the psychological task of adapting to the illness. Adaptation to oncological disease consists in the ability to live under the conditions of the illness and to accept all those changes that it introduces or may introduce
into life. In the process of adaptation the patient uses, as was already indicated in Chapter 4, various unconscious defense mechanisms and unconscious and conscious psychological strategies of coping behavior (coping strategies).
Turning to professional psychological care is one more opportunity for the patient to cope with excessively powerful stress and to resolve a life crisis. It should be noted that not infrequently patients, experiencing agonizing and excessively powerful feelings and striving to reduce psychic pain, turn to psychological care in the hope that the psychologist will in some «miraculous» way be able to make the situation not so unbearable. However, it must be acknowledged that resolving the existential and other psychological problems that have arisen in connection with the illness requires enormous inner work on the part of the patient themselves.
Psychological care is based on the proposition that, for solving life's problems, a person always has a resource that is located within the person themselves, but to which they do not always have access.
The focus of the medical psychologist's attention in working with the oncology patient is directed at the personality of the person who has fallen ill, and the psychologist bases
their work by appealing not to the painful manifestations, but to the patient's personality, to their capacities to adapt to the situation of the disease. The psychologist's task is to form a relationship with the oncology patient in such a way that, in the process of their interaction, the patient, through their experiencing, is able to come into contact with the traumatizing circumstances of their life and to discover within themselves an inner resource in order to make use of it.
In this connection, the role of the psychologist's responsibility toward the work increases, consisting, first and foremost, in creating a space that is safe for the patient. The psychologist cannot «correct» the patient's feelings, cannot «cure» them, but they can create conditions in which the patient is able to suffer, to openly express feelings, regardless of what they are and at whom they are directed. In the therapeutic space the patient can express fear about the disease, about their past and future, can speak about suicide, and can share the most «delusional» ideas about the causes of their disease and their «long-standing» grievances (some of them go back to the earliest childhood). The patient can express themselves in a manner that does not correspond to socially acceptable norms as they understand them. Finally, the patient can come into contact with existential problems (the main of which is the problem of death) and take the risk of setting off on a «journey» into the depths of their I.
The creation of such a space is not only a professional responsibility but also a requirement of the psychologist's personality: it is necessary to strive to track one's own feelings and check in with them, to be aware of one's own motives and needs (why did I choose to work with oncology patients, what needs do I fulfill in this activity), and one's own existential problems. In our view, honest answers to oneself to these questions and the ability to reflect on these problems allow the psychologist to correspond to their own authenticity. It cannot be said that in the space of interaction the psychologist and the oncology patient are in equal positions: they have different life situations, but at the same time, they are equally open to new experience. In doing so, the psychologist is «enriched» not at the patient's expense, but as a result of their own inner work.
The oncology patient has a global psychological problem – the acceptance of the malignant nature of the disease, which also influences the acceptance of treatment and largely determines the patient's adaptation to the disease. Moreover, the resolution of this problem may be lengthy, and it does not always coincide with informing the patient of the diagnosis of the disease.
Our experience shows that in the process of adapting to the disease the patient passes through three phases in the dynamics of the mental state. The division into phases is conditional, and the amount of time needed by a patient to live through any of them is individual: each patient has their own pace of progress in the process of adaptation. It is necessary to take into account that the phases in the dynamics of the mental state may not correspond to the stages of treatment and of the course of the disease.
In providing psychological care, the psychologist needs to take into account that the situation of oncological disease, as was shown in Chapter 4, can be regarded both as extreme and as crisis. Despite the fact that patients' experiences in both cases are agonizing and of extreme intensity, the psychological care in each is different. It also differs depending on the phase in the dynamics of the patient's mental state and, chiefly, depends on the psychological task that is being solved by the oncology patient at a particular phase in the process of adaptation. In this way, a distinctive model of psychological care for oncology patients arises.
The first phase in the dynamics of the mental state. The patient faces the psychological task of accepting the fact – «I am ill». This applies, first and foremost, to patients who have denial of the illness. Most often they do not turn to professional psychological care, since
they live in a reality where there is no cancer, and their task is to «hold on» in this state. Their rigid psychological defense in the form of denial allows tension to be reduced to a certain extent, and they do not experience strong feelings about the disease. In some cases the psychological defense begins to «fail». Patients may, while denying the illness, turn to the psychologist themselves, or be referred by physicians for some symptoms (for example, pain that is not connected with somatic manifestations of the disease). Others of them turn to the psychologist with problems not directly connected with the disease (for example, relationships with someone close). The psychologist works with whatever the patient has turned to them about. And sometimes, in the safe conditions of the therapeutic space, in the process of working on a symptom or problem, acceptance of the fact of the disease may occur.
Far more often, patients turn who are informed about the disease and who experience strong feelings in this connection, feelings that they are at times unable to cope with. These patients accept the disease on a cognitive level, but on an emotional level they cannot accept it («with my mind I understand, but with my feelings I cannot accept it»). Emotional acceptance of the illness is possible in the process of experiencing. In this case the psychologist creates a safe space for the patient to express feelings. In this safe space the patient begins to speak about what troubles and frightens them. The psychologist, being present in this space, with great caution helps to express feelings, without trying to calm the patient and thereby to reduce the «intensity» of the feelings. The force of the feelings may be so great that the patient develops a fear of «going mad», a fear of destruction. Unexpressed feelings are transformed into inner tension. In this situation it is important for the psychologist to show the patient that all of their feelings are normal and adequate, and that it is the very situation of oncological disease that is «abnormal». By their presence, the psychologist lets the patient feel that the world has not collapsed. «In the psychologist's office I finally cried for real. I cried without holding back my grief, smearing snot across my face, across the sleeves of my black sweater, not ashamed of my unattractiveness, my pitiful helplessness. And I talked, talked, talked» (from the diary of patient S., aged 44). The patient expresses their feelings in the process of telling their story: about the symptoms and causes of the disease, which are at times irrational but necessary in the process of accepting the fact of the illness, about encounters with physicians, about relationships with loved ones, and about their life.
There are always patients who hold themselves back from expressing feelings. These are patients with alexithymia. Others, following cultural traditions, consider a strong expression of feelings unacceptable for themselves, and they need «permission» to express them.
Certain features of patients who are in the terminal stage should be taken into account. These patients constantly think about their disease. They are overcome by thoughts of death; the fear of death overwhelms them. They cannot talk about this with physicians, since, according to our research, it is very difficult for physicians to speak about death with patients. For family and loved ones, conversations about death are a «taboo»; it seems to them that it is hard for the patient to talk about death and that conversations about it may cause them pain. But it is precisely these conversations that patients need. They feel very lonely. At times the psychologist is the only person with whom they have the opportunity to talk about what has built up: «For me it was important to say this out loud» (patient P., aged 36) (the authors' comment: «this» means about death, about the fear of death). The psychologist should not themselves propose the topic («Let's talk about death»), however important it may seem to them. They follow the patient; they cannot change the patient's thoughts and feelings, but allow them to be.
Calming and reduction of tension occur when the patient expresses and speaks through what is troubling them at the present moment.
By no means all patients turn for help right away; they try to cope on their own. Thus, for example, after being informed of the diagnosis one patient went off to the bay and walked and walked along the shore until exhausted, listening to the sound of the waves and observing nature.
It should be emphasized that the psychologist helps the patient not only to express feelings, but also to be aware of what those feelings are. Awareness of feelings and experiences is the first step toward control over one's state in a situation of uncertainty. The use of various art therapy techniques can help patients in the expression and awareness of feelings.
The situation gradually turns from unbearable into more bearable. An understanding appears that it is necessary to act and to undergo treatment, that «tears will not mend grief». The emotional tension of patients at this phase decreases, they become psychologically more at ease, and a certain portion of patients no longer turn for psychological care.
For the psychologist it is important to preserve contact with the patient, which provides the opportunity to turn for help again, but when and under what conditions this will happen is decided by the patient themselves.
The second phase in the dynamics of the mental state. Acceptance of the illness has occurred, a new identity has appeared («I am a patient»). The patient develops a desire to be treated and to control the situation of the disease and life to the extent that this is possible, and in the way that they understand it. They intuitively feel that they have an inner potential that is not being used in treatment. During this period the patient acquires new experience that allows them to live in the changed life situation.
With the help of learning and using relaxation, the patient gains the ability to control their state and mood within certain limits. The application of guided imagery and
visualization allows them to influence the diseased part of the body and the organism as a whole.
The oncology patient, comparing their past with an unbearable present, appraises it as good, but on the sensory level they cannot recall anything good: «there was nothing good». In this connection, the patient needs help to «see» their life achievements and successes; these memories give them strength and energy. Meditation of the «revival of pleasant memories» type allows the patient to see something good in the past, their achievements, to see their life not fragmentarily but as a whole, noticing both the bright and the dark sides. It is also important to help the patient find the good in the present moment; this allows them to learn to live in the present.
The patient is already able not only to express but also to discuss their feelings, and the psychologist can use certain techniques (including Gestalt therapy) that help to turn to hidden feelings (for example, grievances), to learn to accept them, which increases the range of responding.
The better the patient controls their state in the situation of illness, the more they feel their responsibility for their own life and their own health. And the interaction of the patient with the psychologist can largely contribute to this.
For patients who experience the situation of illness as extreme, work with the psychologist usually ends at the second phase. Such patients are the majority.
Despite the fact that the psychologist faces a great temptation to continue the work in the direction of further changes, it is necessary to stop, since the choice rests with the patient.
Patients who perceive the situation of illness as a crisis may continue their work with the psychologist, and this will be the third phase.
The third phase in the dynamics of the mental state. Psychological work aimed at self-change, reconstruction of the patient's personality, and personal growth is the most lengthy and the most varied in content. The patient experiencing the situation of oncological disease as a crisis has passed through the phases described above. Wherever the work in the third phase may begin: work with the body, awareness of the finitude of life, the building of new relationships, and so on (the psychologist follows what the patient offers them), the patient, through turning to authenticity, arrives at a new integration.
In the patient in a crisis situation, questions arise: «Why has such an illness come to me?», «What is the meaning of my illness?», «Who am I as a person?», «Who am I in this world?». «So I must have been living somehow wrongly, if since the age of 28 something has constantly been cut out of my body?» (patient M., aged 45). «After all, this was the first time I began to look inside myself» (patient T., aged 42). These reflections turn the person toward existential questions: «What is my life?», «What is the meaning of my life?», «What is death for a person?».
The psychologist can use a variety of therapeutic techniques – art therapy, keeping a diary, inner dialogue, bibliotherapy – all that allows a person to develop and contributes to their personal growth.
«In Stephen Levine's book «Who Dies?» (which became for me one of the «saving hooks») I found an interesting exposition of the teaching of the Hasidim. The teaching itself is based on the belief that a person is born for one single, most important, examination event of their life. The aim is to notice it, to single it out from the constantly changing sequence of others, and to rise to the occasion at the moment of the trial. No one, including you, knows when this will happen or what the examination will consist of, but it is precisely then that the answer to the questions that torment us about the meaning of being may flare up. Simple attentiveness will not do here; one must be extremely focused and vigilant – always on the alert – one must literally lie in wait for,
track down, catch one's moment, like some cunning quarry, and for this one must not discard, without checking, a single other – even the very smallest – movement of life – one must constantly participate in it. Only it seems to me that we always either miss our moment or die, for as to how to live after that – not having faltered – there exists, perhaps, only a «yearning for the angelic rank», while the rank itself is unattainable. And now – in pursuit of what was missed – I want to replay everything anew in my head and still grasp the lost meaning» (from the diary of patient S., aged 44) (italics added by the authors).
The psychologist does not impose on the patient their opinion about how to live on, but provides them with the opportunity for creativity in relation to their own life. The presence and involvement of the psychologist turn the patient's inner monologue into a dialogue with the psychologist, which is then re-interiorized. The sensitive being of the psychologist alongside the patient allows the latter to come into contact with themselves, with their own authenticity. The situation of an illness connected with a vital threat, when all social roles and masks cease to have meaning, contributes to this contact. The patient develops the opportunity to build new relationships with loved ones: «The past year was the best for me, everything changed: I experienced real closeness with my wife, with my son» (patient K., aged 26), «I developed an incredible feeling of love toward everyone, and it does not make me weak but gives me strength» (patient N., aged 48).
Reflecting on the illness, on its place and role in their life, patients gradually recreate their life taking the disease into account. Turning to oneself and discussing existential questions allows a person to identify what helps them to survive (the «saving hooks»). A person makes a «journey» inside themselves, and «it does not matter how you travel,… you always learn something, you learn to change your thoughts».
«After the illness I became more alive» (patient N., aged 47). Of course, the patient meant not that she had been dying but became alive. It is about something quite different: what does it mean to be truly alive? And how remarkably the patient's words echo what the well-known psychotherapist J. Bugental writes: «I ask the old question: what does it mean to be alive? I listen to my friends, teachers, and patients, who struggle with the death living within them and try to attain a level of more intense life that is located within them… What we can do is to understand, with the help of our inner consciousness, how one can experience one's existence differently… To be truly alive
– means to be sentenced to constant development, to endless change».
Acceptance of personal responsibility for one's own life as one of the criteria of personal maturity and mental health is characteristic of many psychological and psychotherapeutic schools: humanistic psychoanalysis (E. Fromm), Gestalt psychology (F. Perls), humanistic psychology (A. Maslow), and existential psychology (I. Yalom). The role of the personality's responsible position in the psychotherapeutic process is emphasized by such outstanding researchers as G. Allport and R. May. Thus, I. Yalom, who conducted group psychotherapeutic meetings with oncology patients, reports that increasing awareness of one's own personal responsibility for one's life significantly improved their psychological state and their level of social adaptation. «I am convinced that the concept of taking responsibility is therapeutically indicated for any cancer patient, even in far-advanced disease… Some patients give in to despair and die a premature psychological death, and also, judging by the data of some studies, a premature physical death as well. Others… transcend their illness and use the approaching death as
a stimulus to improving the quality of life». Data from clinical observations may indicate that the patient's adoption of a responsible position plays a significant, though not always obvious, role in the process of treating oncological disease.
Studies of people who have lived a long life despite having an oncological disease reveal the following qualities in them: 1) they are able to endure uncertainty, they view changes not so much as a threat as a challenge, they do not cling to the habitual and are open to building new relationships with the world; 2) they are characterized by self-control, exercised through their own independent decisions, and therefore they do not feel helpless in the face of life; 3) they show an interest in life and feel themselves included in meaningful connections; 4) they look after their health and pay attention to their appearance and well-being; 5) they have reliable social connections.
The family of the oncology patient, like the patient themselves, is in an extreme or crisis situation. It seems to us that work with the family of the oncology patient should be structured in the same way as with the oncology patient, while, naturally, it is necessary to take into account the specifics of working within the family.
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Часть 1 Methods of Psychotherapy in Working with Oncology Patients
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