Psychological Aspects

Supporting Recovery and Return To Work

Keep your body as healthy, and your mental attitude as positive, as you can. - Leslie Haines, The Alpha Book, p.119.

1. Psychological Reactions - Initial Diagnosis

Powerful emotions are very much a part of living with cancer, this is true from the moment of diagnosis and applies throughout the course of the illness. The person who has just received a diagnosis of cancer can respond with a range of emotions:

• Fear - shock, devastation, horror
• Anger - irritability, upset, blaming
• Grief - sadness at being ill
• Guilt - somehow he or she caused the illness.

It is not unusual for those recently diagnosed with cancer to experience a period of depression, isolation, and loneliness. Denial, a response in which the person exhibits no emotions and does not address the issue of cancer at all, may also occur. The latter response is sometimes puzzling to those close to the person with cancer. As a short term psychological defence denial is useful - it keeps the person functioning and calm. In the long term denial impedes the process of acceptance and "working through" the diagnosis of cancer.

As time passes the person who has been diagnosed with cancer will begin to identify and accept their emotions. It is vitally important that there is opportunity for the person to express his/her emotions in a healthy way to an objective and caring listener. This support may exist in the family or close friends or professional counsellors.

Difficult and unpleasant as the initial reactions to a cancer diagnosis may be, these feelings are the first step towards an acknowledgment of what has happened and the prelude to effective coping.

Key Points  

• Powerful emotions are a part of living with cancer.
• Initial reactions of fear, anger, grief, guilt, depression are common.
• Denial, lack of any emotional response, is not unusual at first.
• Supportive listening is essential at this time.  

2. Three Common Symptoms

Once the shock of initial diagnosis has passed, the person with cancer begins to develop coping mechanisms and skills. The loss of control precipitated by the disease gradually declines as the person assesses his or her own feelings and learns more about the disease. Speaking with others who have faced the same challenges in dealing with cancer can help to dispel a sense of isolation.

The process of treatment has its own stresses and uncertainties for any particular individual. The three most troublesome symptoms are pain, tiredness, and depression.

Pain
The anticipation of pain causes acute concern in people undergoing cancer treatment. It is often a belief that pain, severe pain, must be a feature of the illness and that nothing can be done about it. Happily, this is largely a misconception. Physical pain does not necessarily occur in, every cancer or all stages of cancer. In the great majority of cases pain can be effectively controlled.

Analgesics are drugs which act against pain. In recent years advances have been made in anti pain medication and the optimal combination of drugs to relieve both pain and anxiety. If the person with cancer experiences pain, accurate reporting of this fact will assist caregivers. The exact site, nature, duration and factors which worsen the condition are important factors to report.

Pain control is based on the proper analgesics, consistent administration, and reduction of side effects. Routes of administration include oral medication, injections or the use of intravenous medication pumps.

Tiredness
Fatigue accompanies any serious illness. It is not unusual for those in cancer treatment to feel fatigue after surgery, or during chemotherapy and radiation. The person may find that even light tasks of everyday living, such as getting dressed, doing household chores, or driving a car, place great demands on their energy.

Frustration can result if the person undergoing treatment is not aware that reduced stamina is to be expected. They should be reassured that decreased energy is normal for the circumstances and that these limitations are temporary.
At work, people with cancer are often happy to be active again, but they tire easily and worry that their colleagues will think less of them. Reduced hours may be a solution while the person is recuperating from treatment.

Depression
Nearly everyone has the occasional bad day or "blue mood", but true depression is not to be confused with these temporary periods of low energy. Depression is an illness in which emotional changes are pronounced, enduring, and adversely affect the person's life. Losses can cause depression and there are many losses in the experience of living with cancer; loss of former abilities, work, social contacts, and body image, to name a few. Self esteem can suffer in these circumstances.

No definitive test exists to diagnose depression. Symptoms such as depressed mood, sudden weight loss or gain, fatigue, sleep disturbances, agitation, lack of concentration and suicidal ideation are indicators of depression. If a depressed person with cancer expresses a desire to commit suicide, prompt action should be taken.

Depression is a treatable illness; there are two general therapeutic approaches which may be used in combination.

• Antidepressant Medication often dramatically changes the way a person feels. These medications are not addictive and should be taken as prescribed.
• Therapeutic Dialogue, the person "talks out" the issues related to the depression and illness.

With these techniques depression can be alleviated, resulting in improved coping with the demands of the illness.

Key Points

• In coping with the stresses of cancer the three most difficult symptoms are pain, tiredness, and depression.
• Pain does not exist in every cancer. Effective pain control is available.
• Tiredness is often a result of treatments, it can be a temporary feature of the illness.
• Depression is a response to the losses of cancer. Effective treatment alleviates depressive symptoms.
   

3. Learning To Cope: The Challenge Of Living With Cancer

Whether patients want to believe it or not, they will be exposed to all sorts of new ideas and people, and their lives will change for the better. - Charles Maggart, The Alpha Book, p.368.

Survivors of cancer describe a gradual process of regaining control in their own lives, once they have faced their fears, expressed these feelings and found ways of dealing with the illness. Increasingly people living with cancer are encouraged to be active participants in the management of their illness. Support groups or Cancer Associations are valuable sources of information and assistance. The basics of recovery are good nutrition, moderate exercise, adequate rest and emotional/spiritual support. 

1. Obtain Information
2. A Positive Attitude and Humour Help
3. Maintain Good Communication
4. One Step at a Time
5. Reach Out
6. Problem Solving Approach
7. Resolve Strained Relationships
8. Use the Team Approach (doctors, nurses, friends, cancer support groups, members of your church, counsellors.)
9. Counselling Helps (marriage and family counsellors, social workers, psychologists, psychiatrists, clergy.)
10. Set Small Goals
11. Don't Forget to Reward Yourself!

Learning to Cope; Some Good Ideas From Survivors (adapted from The Alpha Book, p.185.)

Coping Program - Some Activities

• Fresh Air and Sunshine
• Walking and Hiking
• Keep a Pet
• Journal Your Experiences
• Prayer, Meditation
• Visualization
• Massage Therapy
• Deep Breathing
• Music
• Relaxation Techniques

Key Point

Most of the above activities and ideas are well known to people. But under severe stress people often forget what they know.
 

4. Work and Recovery

I had been crying all night. I went to work and found that by the time I hit the classroom until the time the children left, I didn't have a single thought about it. It was the best therapy I could have had. - Esther Joyce, The Alpha Book, p.363.

Work, for most people, is more than economically rewarding - it gives a sense of purpose, connection to other people, and a way of contributing to society. For lawyers, work can be an important part of their identity and self esteem. Once health has been regained, work can help legal practitioners recovering from cancer to build a sense of themselves and renew confidence in their abilities.

The practice of law is a demanding occupation and the decision to return to work calls for a careful consideration of the lawyer's stamina, physical health, and ability to concentrate. Work can be redesigned to facilitate re-entry of the recovering lawyer:

• A modified schedule; and a partial workload, flexible hours
• Accommodation of some work at a home office
• Special arrangement of office work space
• Redirecting the focus of work.

Part of returning to work will be the task of dealing with colleagues, who may be uncomfortable with the fact of a severe illness in their co-worker. A certain work prejudice still exists for people recovering from cancer, there are fears of contagion and it may be thought that the recovering person is not capable of working hard.

The following issues are important to consider before returning to work.

• The returning lawyer may want to decide whether or not to discuss cancer with colleagues at work.
• During treatment it may be an idea to keep in touch, just to let your colleagues know in general terms how the recovery is progressing.
• Honestly discuss the workplace issues with the most trusted partner or colleague. Consider staff education, if appropriate.

Modifications to the workplace or the work schedule may assist the recovering lawyer in returning to work:  

• Restructuring of the workplace for optimal comfort and efficiency
• A reduced work schedule, i.e. partial days
• Different focus of work, less client contact at the beginning
• Home office for certain tasks
• Delegation of non essential tasks

5. Supporting the Person with Cancer

We are not living in a society or era in which serious subjects such as cancer (or serious illness in general) are regarded as legitimate subjects for ordinary everyday conversation. It is not the fault of your friends or family and it is certainly not your fault - it is just the way things are at the moment.  - Dr. Robert Buckman What You Really Need to Know about Cancer, p.290.

One of the difficult realities for a person living with cancer is that some of their family members, friends, or colleagues will begin to avoid them. Some people find it very difficult to deal with an illness in friends; they may feel frightened or embarrassed or guilty. Others want to help but do not know what to say or do and feel awkward around people with cancer.

There are a number of ways, as a friend or colleague, to demonstrate your support to a person recovering from cancer.

• Identify your feelings. What is upsetting about this situation. Is it the fear of illness or death? Anxieties about contagion? Are you feeling guilt because you are well?
• In conversation it is not necessary to initiate discussion about the illness. Some people are quite happy not to talk about their cancer, others will disclose readily. Take your cue from the other person.
• Effective listening is one of the most important forms of support.
• A visit can mean a lot to your ill friend. If you find this an uncomfortable prospect set a short time limit e.g. 10 to 15 minutes. Try not to worry about what to say, your presence is the most important thing.
• If you prefer not to visit, consider a telephone call or a short note.
• Offer to help with concrete tasks and keep your promises.

Summary Points

• There are powerful emotions to be dealt with in all stages of cancer and recovery.
• Most patients will experience the symptoms of pain anxiety, tiredness, and depression. Effective treatment is available.
• Support groups and associations for people with cancer provide information, assistance, and counselling for those in recovery.
• Formulating a personal coping program helps to re-establish a sense of control.
• A return to work can enhance recovery. Work redesign may be considered.
• Friends and colleagues can help support the person in recovery.

Discussion Point: Cancer as a Teacher

The Canadian Cancer Society is a national community based organization of volunteers whose mission is the eradication of cancer and the enhancement of the quality of life for people living with cancer. There are Canadian Cancer Society divisions in each province and territory.

Affiliated Programs:  

• Candlelighters Childhood Cancer Foundation
• CanSurmount - one to one visitation program
• International Association of Laryngectomies
• Reach to Recovery - for breast cancer patients
• United Ostomy Associatio
• Community Nurses
• Homemaking Services
• Local Cancer Clinics
• Palliative Care Associations
• Pastoral Care
• Wellness Centres

References

• Alpha Book on Cancer and Living; for Patients, Family and Friends. The Alpha Institute, Almeda CA, 1993.

• Altman, R. and Sarg, MJ. The Cancer Dictionary. Facts on File, New York: 1992.
• Buckman, R. What You Really Need to Know About Cancer: A Comprehensive Guide for Patients and Their Families. Key Porter, Toronto: 1995.