The Official Publication of the International Society of Schema Therapy
In This October Issue
This Issue - Schema Therapy in Healthcare Settings
Using the Schema Therapy Model to Help Patients Cope with a Cancer Diagnosis
by Lissa Parsonnet PhD., LCSW , USA
While nothing prepares a person for a diagnosis of cancer, one’s entire life experience prepares a person to cope with cancer or other serious illness. A cancer diagnosis can ignite feelings of fear, anxiety, confusion, anger, sadness and overwhelm. It also threatens a person’s identity as “healthy”, and catapults them into the new and unwanted identity of “cancer patient”. Webster’s on-line dictionary cites the origins of the word “patient” as the Latin word patiens, or the Greek word pema, meaning “to suffer” or “suffering”. How people adjust to this new identity of “sufferer”, will impact the medical care they seek and receive, the treatment decisions they make, and their emotional experience throughout the illness process. It will also impact their family and friends, as well their relationships with family, friends, colleagues and their health care team.
The role of a cancer patient is extremely demanding physically, cognitively and emotionally/socially, and the “suffering” can occur in all these realms. Physical demands include coping with the impact of both the disease and of its treatments, as well as any self-care required. Cognitively it demands the rapid acquisition, processing and integration of information and language necessary to make informed decisions and comply with treatment protocols. Emotionally/socially one must be able manage anxiety and fear, trust in their treatment team, rely on their support system for help, accept assistance from others, clearly express their symptoms, needs and questions, take responsibility for getting needs met, ask for help when needed, cope with their new limitations, maintain realistic expectations of themselves and others, adjust to decreased contact with people in their “normal” lives (family, friends, colleagues, classmates, etc), integrate new body image and adjust to changing treatment plans, schedules and medical personnel. Each of these challenges presents an opportunity for schema activation. When schemas are active it becomes more difficult to meet these challenges, especially under the pressure to make decisions, adjustments and accommodations quickly.
Early maladaptive schemas are an outcome of unmet childhood needs. Whatever adaptation an adult has made to his/her schemas can be undermined by the crisis of a cancer diagnosis, or the ensuing crises of making treatment decisions, initiating and undergoing treatment, completing treatment, and either adjusting to life after cancer treatment, or adjusting to a re-occurrence and the possibility of dying from the disease. The patient labeled as “crazy”, “difficult”, “in denial” or “demanding” may simply be a patient whose schemas are activated, and who is responding in a dysfunctional way. Understanding this can redirect treatment in ways that enable the patient to cope with the crisis of cancer in an adaptive and effective manner, as illustrated by the following patients:
A 42 year college educated, married woman with a complicated medical history was diagnosed with breast cancer. As she had with past illnesses, she complied stoically with the many demands of her treatment, no matter how unpleasant or painful. She was unable though to endure the fear, sadness, anger, frustration and disappointment that often accompanies the cancer illness process, and instead abused prescription medication, creating a group of additional, debilitating medical conditions, as way to subdue these (normal) feelings. This woman had no prior history of substance abuse. She was raised in a family in which the matriarch and patriarch (her grandparents, now deceased) never complained, about anything, not even when they were seriously ill. This stoicism was highly valued in the family, and it was understood that nothing upset her grandparents; this lack of emotional response to pain, struggle and suffering was a defining feature to be admired and emulated. This woman’s substance abuse was understood as a strategy to avoid feeling shame that she had (unacceptable) feelings of sadness, fear, anger, etc., at her situation. Her substance abuse began to abate when she was able to discuss how inadequate she felt for not coping as her grandparents had, and about the demand she felt from the expectations of their legacy. She was able to recall in imagery the unconditional love and acceptance she experienced in her grandparents home, and then imagine her grandmother comforting her, telling her that it was ok to feel sad, scared and even angry that she was suffering, and that she loved her and was proud of her.
The role of a cancer patient is extremely demanding physically, cognitively and emotionally/socially
A 52-year-old married corporate executive with two college-aged children, diagnosed with early stage breast cancer suffered from extreme and unremitting anxiety that seemed even to her, disproportionate to her diagnosis. She responded to this anxiety by placing countless calls to her physicians and their staffs, seeking reassurance about every sensation she experienced, comment a well-intended friend or relative made, and news item about cancer. Her worries eclipsed everything else, dominating conversation with her husband to the point that he felt unable to engage productively in conversation with her, and preventing her from being able to work. Her medical team, though very supportive at first, was finding it difficult to meet her needs for reassurance and had become less responsive to her calls, increasing her fear. Though she tried to protect her children from her obsessive worrying, her ability to control herself was waning and her behavior was beginning to make her feel badly about herself as a mother. Exploration of her history, and examination of her schemas revealed that her father had died suddenly when she was 15 years old. She has vivid memories of him falling down, and of hiding in her room in fear, looking out the window as the ambulance took him away. When the call came that he had died, her mother sent her to the hospital to identify his body, and then to inform her aunts and uncles of his death. Needless to say this teenager felt overwhelmed by, and unprepared for these tasks.. Her mother, who was described as “fragile”, was immobilized by the loss of her husband, and unable to parent her overwhelmed daughter, who therefore felt alone with her distress, and confused by the sudden changes in her life. She remembers feeling scared and alone, unable to talk with anyone about what she’d endured, and the feelings of helplessness, overwhelm and inadequacy she experienced. She developed a vulnerability to harm or illness schema, as well as a negativity/pessimism and unrelenting standards schemas that are triggered only by health and medical related situations.
Because these schemas are only activated by health/medical events, she had not developed a means to effectively cope with them; nor had her family or friends who found her uncharacteristic behaviors puzzling and frustrating, as nothing they said or did seemed to help assuage her distress. She experienced some relief when we identified these schemas and their origins, and she was able in imagery to re-parent her 15 year old self. In subsequent exacerbations she was able to engage her Healthy Adult mode to reassure her overwhelmed, over-burdened and unprepared 15 year old self (Vulnerable child) that she (now) has the skills, maturity and resources to cope with whatever occurs. While attempts at reassurance by family and friends made her feel misunderstood and more alone, re-parenting and reassuring the vulnerable, over-burdened child reduced her anxiety, enabling her to respond to the demands of her cancer diagnosis and it’s treatment in constructive, adaptive ways. The schema therapy model is a useful tool in both understanding and addressing patient’s adjustment to cancer.
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