Psychological Support for the Breast Cancer Patient

Common sense, as well as research data, indicate that recovery from breast cancer is better if the patient receives emotional support during and after the initial stages of diagnosis and treatment. But is in-depth psychotherapy ever needed? If it is, who needs it and when does it become apparent that the problems being experienced are different from those of other breast cancer patients?

A small percentage of breast cancer patients do need in-depth psychotherapy to help them cope with the problems that are stirred up by diagnosis and treatment. However, the decision to go beyond seeking emotional support and enter in-depth psychotherapy is difficult.

For Stage I and Stage II disease, the general rule is that one can expect the return of both normal physical functioning and emotional equilibrium roughly two years after diagnosis and treatment. When emotional equilibrium does not return within that time frame, it would be wise to ask for a psychological evaluation to determine if the woman is experiencing psychological problems.

We have encountered four problems which may occur separately or in some combination, and which we believe interfere with the return to emotional balance. The problems are difficulties in interpersonal relations, the revival of conflicts existing before diagnosis and treatment, repeated loss of functionality, and the continued intensification of emotional reactivity.

Interpersonal Relations
Difficulties in interpersonal relations typically involve the patient and her husband. Treating the patient and husband in conjoint therapy has been used for problems involving withdrawal, anger, failure to communicate, overprotectiveness, problems with autonomy, and lack of closeness. In some cases, problems existed prior to the illness which simply brought the difficulties to the forefront. In others, the stress of the illness has drained the husband of all resources and he, as well as his wife, need revitalization. In a few instances, the husband decides to abandon his wife and seeks divorce. The decision may reflect a basic problem with narcissism or indicate that the husband is overwhelmed with the fear of his wife's death.

Revival of Pre-Existing Conflict
While almost any prior conflict may be reactivated by breast cancer, patients with this problem have a history of interpersonal involvements in which they felt dependent and were punished for "failing to meet expectations" and the blamed as if they were personally defective. The relation may have been with almost any significant other; parent, husband, employer or whomever. In this instance, the patient reactivates the definition of self as victim and begins to enact that role, thus confounding the psychological effects of her illness.

Loss of Functioning
Confronting breast cancer is the equivalent of confronting death and will, by definition, arouse intense anxiety which often seems out of control. Coping with that anxiety is necessary to recovery, and many patients use isolation or blocking of feeling to live through the experience. The problem is that the feeling that has been blocked later needs to be integrated into personality. Otherwise, it will function outside the level of awareness and later reactivate. As the patient does integrate, the experience may resemble a post-traumatic disorder with disruption of functioning in all areas of living. Short periods of relief from the demands of job and family are helpful. With some women, the disruption of functioning requires that they be seen in treatment where the focus is on strengthening personality resources rather than on deconditioning or the use of medication alone.

Continued Intensification of Emotionality
The fourth problem resembles the third in that both share an intensification of feeling. They are different, however, in that women who experience the fourth problem do not have difficulty in functioning. The problem is an overwhelming expression of feeling which is misplaced in time and displaced onto people and things that are not actually threatening.

In treating this type of patient, we have frequently used medication to reduce emotionality to a level where the patient can process verbal therapeutic input and deal with family-of-origin issues which may have predisposed her to massive regression.

Husbands
We would be remiss if we did not also mention the need of the husband for therapy. There are two conditions which interfere with his adjustment and thus indirectly affect his patient-wife. The first is withdrawal, and the second is overprotectiveness. Both are anxiety based and represent different ways of dealing with the fear of his wife dying. Typically, a few individual therapy sessions with a male therapist suffice to allow for ventilation and reality checking. We emphasize a male therapist since therapy with the wife-patient is accommodated if the therapist is female.

Charlene A. Carter, PhD
Ross E. Carter, PhD
Associate Professor, Psychiatry

Psychiatry and Behavioral Medicine

Each year, Medical College of Wisconsin physicians care for more than 180,000 patients, representing nearly 500,000 patient visits. Medical College physicians practice at Children's Hospital of Wisconsin, Froedtert Memorial Lutheran Hospital, the Milwaukee VA Medical Center, and many other hospitals and clinics in Milwaukee and southeastern Wisconsin.