Kanser, Tanı Aşamasından Başlayarak Ciddi Uyum (adjustment) Sorunlarına Yol
12 Temmuz 2007
Kanser, tanı aşamasından başlayarak ciddi uyum (adjustment) sorunlarına yol açmaktadır.Tanı ile başlayan süreçte fizyolojik, psikolojik ve sosyal bir çok değişim meyadana gelir. Kişilerin yaşam stillerinin çok boyutlu modifikasyonu medikal tedavinin başarısı açısından büyük önem taşımaktadır. Bu süreç, değişik uzmanların işbirliğini gerektiren çok boyutlu ve uzun bir süreçtir ve hastalığın her aşamasını kapsamaktadır.( tanı, tedavi öncesi, yoğun medikal tedaviler, palyatif)
Kanser tanısı ile başlayan süreç hastalar için bir çok psikolojik sorun yaratmaktadır. Bunlar: uyum bozukluğu,depresyon, delirium/demans, anksiyete bozuklukları, travma sonrası stress bozukluğu, cinsel uyum ve fonksiyon bozuklukları, uyku bozuklukları, psikosomatik bozukluklar gibi kişinin hayatını ve medikal tedavi sürecini ciddi olarak etkileyebilen sorunlardır. Bu sebeple hastaların kanser ve kanser tedavisi ile ilgili acı veren, yıkım yaratan, fiziksel,duygusal ve yaşam tarzı değişimleri ile nasıl başaçıkabileceğinin öğrenillmesini hedefleyen psikolojik destek ve tedavi yaklaşımları büyük önem taşımaktadır. Kanser tedavisi sonucu ortaya çıkabilen, ağrı, yorgunluk, saç dökülmesi gibi semptomlarda psikolojik tedavilerin kapsami içine girmektedir.
Psikolojik yaklaşımlara geçmeden önce , klinisyenin ayrıntılı anamnezini çok büyük önrm taşıdığını vurgulamak gerekir. Bu sebeple herhangi bir yaklaşıma karar vermeden önce biopsikososyal formülasyon tamamlanmalıdır. Hastanın tarif etmekte olduğu sorunların altında yatan sebepler araştırılmalıdır. Yaşanılan sorunlar medikal tedavilerden kaynaklanabilir ve bu tedavilerin modifikasyonu ile azaltılabilir.Bu aşamada terapist hastadan sorumlu hekim ile birlikte çalışır. Yaşanan sorunun temeli psikolojik ise öncelikler farmakolojik destek gerekip gerekmediği belirlenir ve daha sonra psikoedukatif yaklaşımlar ve psikoterapi uygulanır.
Kanserin hasta , hasta yakınları ve kanserle çalışan sağlık personeli üzerindeki etkileri hedef alan psikoterapi ve eğitim çalışmaları aşağıda özetlenmiştir.
A.
Cognitive Techniques:
Guided self dialogue:
Guided self-dialogue is a method of dealing with negative automatic thoughts. The patients are taught to focus on their internal dialogues - that is on the statements that they are saying to themselves. The therapist assists the patients to identify self-talk that is irrational, faulty or negative and helps exchanging them with more adaptive alternatives.
Guided self dialogue aims to help the patient to,
determine what she is really afraid will happen
asses the actual probability that something terrible will happen during a stressful situation
manage overwhelming avoidance behaviours
control self criticism and self devaluation
engage in anxiety provoking behaviours
use coping self statements
use self reinforcement for attempting the feared behaviour.
Role-Play:
Role- play consists of acting out behaviours, rehearsing lines and actions. Role-playing is a way to learn new behaviours and words for old ways of doing things. During the role -laying training the therapist and the client act out scenes in which the patient confronts a disturbing situation. In each role- play exercise, first the therapist plays the patients part and demonstrate with the appropriate social and assertion skills. After the role play the patient is encouraged to make a self critique and than the therapist gives feedback to the patient (always starting with positive feedback).
Covert Modeling:
Covert modeling is the imaginal analogue of role-playing. It aims to help the patients cope with anxiety provoking situations through the rehearsal of coping strategies in their imaginations. In the first step the patient imagines someone else in a stressful situation (other than the initial trauma) later on imagines herself in the same scene and lastly imagines herself in the initial trauma
Cognitive restructuring (CR):
As a result of a traumatic experience, patterns of disturbed thinking is frequently seen in PTSD patients. Two different levels of disturbed thinking can be distinguished; negative automatic thoughts which are thoughts or images that go through a persons mind during a situation that provokes an emotional response and dysfunctional beliefs, which are general assumptions people hold about the world and about themselves that result in extreme negative and dysfunctional interpretations.
The role of cognitive restructuring is to reduce anxiety or other emotional distress by teaching clients to identify, evaluate and modify their negative automatic thoughts and dysfunctional beliefs. CR aims to teach the patient to have more realistic thoughts about their abilities to cope .
Examples of questions that challenge negative automatic thoughts:
1.What evidence do you have for this thought?
2. How would someone else think in that situation?
3.What would be the worst thing that could happen?
4.How will things look, seem, work in———- months ?
5.What are the advantagesdisadvantages holding on to this belief?
Anxiety Management Training:
Anxiety management techniques were developed from the understanding of pathological anxiety as a result of skills deficit. Various strategies such as; self-instruction, biofeedback, breathing retraining and relaxation training aim to teach patients specific skills toward anxiety.
Stress Inoculation Training (SIT) was developed by Meichenbaum (1974) as an anxiety treatment. In SIT it is accepted that anxiety is conditioned during the traumatic event and generalized to many situations. Patients learn to manage anxiety by learning new skills. SIT incorporates a number of educational and skills components such as relaxation, thought stopping and guided self-dialog (Foa, Meadows, 1997). A modified version of SIT for the treatment of rape victims. Included, education, breathing retraining, role-playing and covert modeling. (Foa, Keane, Friedman, 2000). SIT composes of 9 sessions and homework assignments. The first two sessions are devoted to information gatherings, breathing retraining, presentation of rationale and treatment planning. The remaining seven sessions focuses on teaching coping skills to manage anxiety and post-traumatic problems. These skills are, deep muscle relaxation, cue controlled and differential relaxation, thought stopping, cognitive restructuring, guided self-dialogue, covert modeling and role-play. Homework assignments include practicing those skills. (Foa et.al, 1999).
Breathing Retraining:
There are two main components of breathing retraining
a. Patients are thought to focus on the exhalation rather than the inhalation
Focus is on taking slower breaths and pausing between breaths to get the patient feel a physical calmness.
Patients learn to inhale during counting to four than exhale slowly while saying calm to themselves. A four-second pause is placed between breaths, further slowing the breathing process. In the beginning, the therapist does the counting until the patient learns the method. Once the method is learned, patients are instructed to practice breathing for homework, at least twice daily for 10-20 minutes each time.
Affect Management in Group Therapy
For women with PTSD
Traumatized individuals may benefit from group treatment because it reduces feelings of stigma, isolation and shame and allows opportunities for observation, learning modeling and sharing of new coping skills.
The affect management group is a structured, time-limited first stage treatment for adult survivors of childhood sexual abuse with PTSD The group goes parallel with ongoing individual therapy. Based on the cognitive behavioural approach the affect management group focuses on current difficulties and symptoms It does not address core beliefs or aims to restructure traumatic memories or meanings. A wide variety of affect-management skills such as mindfulness distraction, self-soothing ,crisis planning, relaxation, time out and challenging distorted thinking are presented to the patients.
The focuses of the group are:
1. restructuring distorted thinking about current difficulties and trauma related affect ( for example; polarized thinking, emotional reasoning and overgeneralization)
2. Increasing patients ability to manage and tolerate distress without the use of maladaptive coping strategies
3. helping patients control destructive behaviours such as self-mutilation and dissociation
4. restoring for patients a sense of control and mastery over their trauma related symptoms.
The group contains fifteen 90 minute sessions with the same structure. The structure of a session is as follows: reviewing of homework, psycho-education about how to use a skill, rehersal of a skill assignment of new homework. Topics of the sessions are: PTSD, sleep problems, dissociation, identification of feelings, model for describing emotions, distraction skills, self-soothing skills, improving the moment (3 sessions), a crisis plan, twisted beliefs, stinking thinking, anger management skills, review and termination.
Anger Management Skills: Objectives are teaching patients to recognize their anger triggers, to learn discriminating problematic anger from adaptive anger ,to use appropriate coping skills to deal with anger .In the education part general information about anger and description of adaptive management skills for anger is given.
A Crisis Plan: Patients are guided through the development of a personalized , detailed crisis plan by identifying 10 specific activities ( taken from affect management skills, like using of relaxation skills) they may engage when faced with overwhelming distress. After the group leaders feedback patients are asked to practice the plan in non-crisis situations before implementing in it crisis.
Interactive Psycho-educational Group Therapy
Interactive psycho-educational group therapy attempts to apply elements of effective PTSD treatment in a group therapy format The therapy was originally designed for multiply traumatized and chronically ill women. The main aim of this approach is to get significant discount in the core PTSD symptoms in addition to providing benefits of increased hopefulness, self-esteem, and interpersonal skills. This trauma-focused group therapy embeds components from other established treatment approaches, including direct therapeutic exposure and cognitive-behavioural approaches, in which group support, instillation of hope, interpersonal learning, and universality are emphasized . Psycho-educational and cognitive behavioural interventions are used to maintain the focus on the women’s adaptational strategies in response to the experience of being traumatized rather than on the relationships among group members.
Therapy Procedure:
The treatment is implemented for 16 consecutive weeks with groups meeting 90-minute sessions once a week over. Session structure is as follows, a brief psycho-educational lecture (about 15 minutes), followed by an interactive discussion directed by the therapists (about 1 hour) and then a wrap-up with an educational emphasis (about 15 minutes).
Patients are provided booklets summarizing the series of lectures; at the end of each session, homework is given to the patients. The therapists uses a blackboard to highlight essential points in the lectures.
The therapy model has three treatment phases, each with a distinct focus. The aim of the first phase is to explore the effects of the trauma on the individual’s sense of self, particularly the issues of shame, trust, and disturbances in feminine identity. During this phase, each subject reviewed her traumatic events with the group and received feedback from group members and the therapists. The aim of the second phase is to discover the effects of the trauma on the individual’s interpersonal relationships, such as difficulties with intimacy, dependency, and sexual dysfunction. The lectures during this phase were centered on identifying maladaptive coping strategies and defense mechanisms that interfered with these relationships. The third phase aims to explore the ways of finding meaning in one’s life despite the trauma. Lectures highlighted existential challenges that hinder ways of finding meaning, focused on ways to transform the traumatic experiences, and reviewed the importance of social support.
Lubin et.al examined the effectiveness of a 16-week trauma-focused, cognitive-behavioural group therapy, named Interactive Psycho-educational Group Therapy, in reducing primary symptoms of PTSD in five groups (N=29) of multiply traumatized women diagnosed with chronic PTSD. The authors made assessments at base line, at 1-month intervals during treatment, at termination, and at 6-month follow-up by using self-report and structured interview measures of PTSD and psychiatric symptoms. After the therapy, patients showed significant reductions in all three clusters of PTSD symptoms (i.e., re-experiencing, avoidance, and hyperarousal) and in depressive symptoms; they showed near-significant reductions in general psychiatric and dissociative symptoms. These improvements were sustained at 6month follow-up
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