NORMAN POSTONE, M.D.*
Cancer is associated with significant psychosocial morbidity. Although psychodynamic psychotherapy is a valuable intervention for some cancer patients, this modality has been underutilized because psychotherapy with medically ill patients has been linked historically to work with patients who have psychosomatic illnesses. Psychotherapy with patients who have cancer has unique features, such as the prominence of illness-related issues during the initial phase of treatment, the mixture of supportive and interpretive therapy, focused goals, and special issues pertaining to the transference/countertransference field. Understanding of those special issues will improve psychiatrists' ability to use long-term psychotherapy as an effective psychosocial intervention for patients with cancer.
Psychodynamic psychotherapy can be a very useful adjuvant treatment for some patients diagnosed with cancer, including those whose illness and treatment have precipitated a major psychiatric disorder and those with symptoms arising from an intensification of intrapsychic conflict. This valuable application of psychotherapy is underutilized, however, and as little is written about the topic in the psychiatric literature, there are serious gaps in our understanding of how best to treat patients who have cancer or other chronic or life-threatening illnesses.
In this paper, I will review the important role psychosocial intervention can play in the treatment of cancer, and discuss some of the historical reasons for the underutilization of long-term psychotherapy with the medically ill. Then I will describe some special features of doing psychotherapy with cancer patients, and illustrate with a case vignette.
Research in psychooncology has put our understanding of the psychosocial sequelae of cancer on a scientific footing and has provided methods for assessing psychosocial interventions.
In some of the earliest studies on psychiatric morbidity in cancer patients, Craig and Abeloff1 found that, of all patients admitted to an oncology research unit, more than 50% had symptoms of depression and 30% had elevated levels of anxiety. In a more comprehensive review of 215 cancer patients, Derogatis2 reported a prevalence of psychiatric disorders of 47%. Diagnoses included adjustment disorder (68%), major affective disorder (11%), and organic mental disorder (8%). In a series of studies, others3 have shown that 1.5 % to 50% (mean 24%) of patients with cancer, depending on tumor type and severity, suffered from depression.
These studies show that close to 50% of patients with cancer experienced significant psychological distress that manifested primarily as anxiety and depression. It is important to note that most of these patients had no prior history of psychiatric difficulties.
Surviving cancer, which occurs more commonly today than in the past, is also associated with psychosocial morbidity. Generally, patients with cancer must confront a variety of ongoing stressors, such as fear of recurrence, secondary malignancy, delayed medical sequelae of chemotherapy, maintenance of health insurance, and employment difficulties.4 Although most survivors of childhood cancer have been found to cope well with their illness, some difficulty with school, work, physical symptoms, and relationships is universal among them.5
A subgroup of cancer patients, however, particularly those with prior psychological difficulties, experience more severe residual psychological strain. For example, although most couples who went through the crisis triggered by testicular cancer felt that their relationship was strengthened, 10% thought that their relationship had suffered. Furthermore, men who are divorced or living in a relationship that has involved conflicts are more likely than other patients to experience impairment following recovery from testicular cancer.6
Therefore, considering the substantial psychological morbidity that patients with cancer and cancer survivors experience, it is important that psychosocial interventions become an integral part of their treatment. …