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Psychotherapy Casebook

Two For the Road

Two For the Road

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EDITOR’ S NOTE

Through this column, we hope that practitioners in general medical settings will gain a more complete knowledge of the many patients who are likely to benefit from brief psychotherapeutic interventions. A close working relationship between primary care and psychiatry can serve to enhance patient outcome.

Dr Scott is an internist and a member of the palliative care team at the Ralph H. Johnson Veterans Affairs Medical Center in Charleston, South Carolina.

Prim Care Companion CNS Disord 2016;18(2):doi:10.4088/PCC.16f01948

Published online: April 28, 2016.

Corresponding author: B. J. Scott, MD, Geriatrics/Extended Care, Ralph H. Johnson Veterans Administration Medical Center, Charleston, SC 29401 (BJ.Scott@va.gov).

Funding/support: None.

Potential conflicts of interest: None.

So, the diagnosis has been made. You have cancer. Whether it is large, small, or metastatic, it is not something alien. It is not just "a" cancer, it is "your" cancer. It is a part of you and you own it. Maybe you were born with the potential that has finally expressed itself through no fault of your own. Did you eat, breath, or touch something that released it from a dormant state? Did you know at the time that what you were eating, breathing, or touching was going to cause your cancer? Probably not. Hindsight is 20/20, but "shoulda, coulda, woulda" is just a waste of energy that you are going to need moving forward.

You and your cancer are going on a journey together. It will be like no other journey you have experienced—one where your surroundings will be unfamiliar and you may not have any road maps to guide you. It will be a journey where you either come back alone and healed or diverge down a path that ends abruptly at a precipice. I believe that this type of imagery is a far healthier mindset than the traditional one where you engage in war with the cancer, with only one possible victor staggering off the field of battle.

Medicine is supposed to be a healing art. However, that is not reflected by the current mindset in US medical culture in which the first reaction is to immediately begin to "fight" and "attack" the cancer. I believe that the use of these and similar terms, and the ideology that goes along with it, to be counter-productive. To wage war against your cancer is in essence to wage war against yourself.

Your cancer is part of you. You didn’ t want it or ask for it, but here it is. What is your plan? What is your strategy for removing all traces of it from your body, while at the same time preserving as much of the rest of yourself as possible?

Should you rage? That probably won’ t accomplish much other than to raise your cortisol levels, which isn’ t very good for you. Will you grieve uncontrollably? That may leave you with little impetus or energy to move forward.

Any prolonged state of a strong, negative emotion will be detrimental to your health. Positive psychological support is vital, and friends will try their best. They will always be in your corner. A neutral third party doesn’ t sound particularly warm and fuzzy, but his or her role will be to advise you when you are being your own worst enemy. Your friends and family will unlikely be able to do that for you.

Expect that your emotions are going to be in a state of flux until they are not. In 1969, Kubler-Ross1 described 5 stages that occur when an individual faces death. However, those same 5 stages are no longer thought to be confined to terminal illness and can be applied to any unwelcome life-changing event: (1) denial, (2) anger, (3) bargaining, (4) depression, and (5) acceptance. They may not occur in order. You don’ t have to go through all of them. You can bounce back and forth and even revisit stages, but it is important to try and not get stuck in any one of them for a prolonged period of time.

During the anger and depression stages, you are likely to agree to anything and everything aimed at "getting rid of this thing growing in me." Surgery? You could end up going from bad to worse. Chemotherapy? What if the drugs or radiation predispose you to another cancer down the road? What if the agents destroy your immune system and leave you vulnerable to infection? During these stages, you might think that you’ re fighting, but it may be more akin to "tilting at windmills." Your goal should be to reach acceptance so that you can start your plan, your strategy, your journey, through what will be a myriad of decisions between you and your physician in an attempt to return your body to its precancerous state.

Warfare is not pretty and, as has always been its nature, leaves destruction in its wake. Instead of a battle where victor takes all, your thought processes should be more in keeping with planning a stealthy company takeover where you end up in charge of an intact, functioning company. The strategy of treating this journey as a marathon race might also be a good analogy. You wouldn’ t just go out and run as fast and hard as you can to reach the finish line. You need to respect your abilities: when you can sprint, when you may need to slow down and walk, when you should stop and rest, and when to take in fluids and nutrition. It goes without saying that you will also need some really good shoes and a comfortable, yet stylish, outfit. Success often takes good planning, not just reacting.

Your family may have the best of intentions, but they will most likely use fighting words when they talk with you about your cancer. You may hear phrases such as "You need to fight, if you would just fight harder, don’ t give up, you’ ll win this battle, you’ ll defeat this cancer." Well, what if that is not a possibility? What if your cancer is going to take over your body no matter what you do? What if you find yourself at the precipice despite everything you’ ve tried? Does that mean that you are a failure for not fighting hard enough? Do not let these doubts creep in. The last thing you need is a layer of guilt on top of the fear of dying.

The normal person is terrified of dying, both for him or herself and for those who will be left behind. You may be in overdrive in a way that someone without a cancer diagnosis can’ t possibly understand. Take pride in your daily accomplishments, no matter how big or how small. There should never be the slightest suggestion that you are slacking in any way.

Your family or friends may push you for just "one more step." It is a natural response for them to feel that you need to "try anything, even if it’s unlikely to work." They may say this because they are scared for themselves and scared for you. However, this is not the time to smile and be polite and accommodating for the sake of others. You need to remain calm and in charge. If you feel that you have done as much as you can for that day, it is enough.

Our culture of fighting and not giving up can be exhausting, demoralizing, and downright depressing. Focus instead on living. Wave the white flag. Sometimes, a truce can be just the ticket to recharge your batteries. Indulge yourself. Eat Cherry Garcia and binge-watch "I Love Lucy" for 2 days if that’s what you need. Treat yourself kindly.

The hope is that your cancer will be abandoned by the wayside, and that by the end of this journey, what was initially seen as a curse might instead be viewed as a blessing. If you are able to see your new life with different eyes and an open heart, then in the words of Dr Seuss, "Oh, the places you’ ll go."

However, if you do find yourself at that precipice, it may be very difficult to prepare for that final step if you are mired in a never-ending war zone. Instead, strive to surround yourself with beauty and peace, which can be found in even the smallest and simplest of things. Surrendering to the inevitable is not giving up or losing the battle. Do not rage against the dying of the light! Instead, go gently into that good night.

REFERENCE

1. Kubler-Ross E. On Death and Dying. New York, NY: MacMillan Publishing Company; 1969.

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