CASE REPORT Jane is a 60 year old single woman who was diagnosed with breast cancer 1 year ago

via a screening programme. Since the diagnosis, she has been feeling tearful, fragile and irritable. She has a tremendous sense of being alone and having no one to share her sorrow with. These feelings last for a few moments and then she stifles them and gets the emotion "back in". She has also had a sense of being out of control. She is still able to get pleasure out of life and can laugh if she gets drawn out of herself. Her appetite is normal, but she has had some early morning wakening. She is currently being treated with Trimipramine 2 tablets nocte which helps her sleep. Her cognitions centre around being a failure and not having made the most of her life. This applies to her work, but more significantly to relationships. Although she has not wanted to marry, she feels that she has never had any close friends and that this is a failure. She says "it would be nice to have one person for whom I came first". Recent histology has shown that she had some positive axillary lymph nodes and she is awaiting further tests to see if there is metastatic spread. She feels that because she had a reconstruction after the mastectomy she was able to cope with the disfiguring effects of the cancer much better and she was not too worried by this. She has, however, been worried on and off about the recurrence and has become anxious about any little lumps or bumps she finds. She is understandably concerned about whether the cancer will spread. Personal History The cancer activated memories of traumas from her past. Her parents' marriage was never a very happy one. In her early teens there were a lot of disruptions. Her brother was evacuated and her father evacuated because he worked for the Bank of England. Jane stayed in Ilford with her mother. Then she was evacuated for 3 years. This was an unhappy time, partly because of her eczema and she was eventually sent back home because it became too severe for them to cope with. She went to live with her mother in North Wales, but then her brother had TB and somehow Jane ended up being left there on her own for a while. When she was 17 her mother developed a brain tumour and died fairly rapidly. She doesn't remember grieving her death, and she thought that her mother was out of her suffering, out of the war and out of her marital problems. Her father had been having an affair and after her mother's death married the woman. Jane seems then to have lived an odd life where she lived with her unmarried aunt during the week and then at weekends came home to look after her brother and father. She spent many years working in a bank and then the rest of her working life was involved with either church or charity work. She finished work at 60, but has been closely involved with the church on a voluntary basis ever since. She has never had a serious sexual relationship because she had seen her parents and others marriages go wrong. However, she regrets that she has no one that she is close to. She feels she gives the impression of being independent, self-reliant and caring for others, but it is difficult to show her own needs. She also feels that when she has reached out to friends they have always let her down and she does not want to take the risk of being rejected. At interview she was a very pleasant, friendly, well groomed, rather demure lady. She was tearful through much of the interview when she talked about her cancer and the sadnesses from the past.

Coping with Adversity

Dr Stirling Moorey

Enhancing a sense of personal control

Technique
Identify and test specific NATs about control (challenge attributions of permanent and pervasive causes). Set up behavioural experiments to overcome avoidance and safety behaviours.

Comments

Focus on what you can control, not what you cant (positive data log).

Work within individuals value and belief system to find empowering behavioural tasks.

Use imagery techniques.

Identify past strengths coping experiences.

and

Coping with Adversity

Dr Stirling Moorey

Video
1. How rational is this patients sense of guilt? 0% 100%

2. How confident do you feel that you could reduce the guilt? 0% 3. What strategies would you use? 100%

Coping with Adversity

Dr Stirling Moorey

Imagery Exercise Images/memories

Thoughts

Emotions

Physical sensations

Coping with Adversity

Dr Stirling Moorey

Thinking Errors Our thinking can be distorted and unhelpful, even when we are facing illness, someones death or a serious trauma. Some common thinking errors are: All or nothing thinking You see things in black and white, missing all the shades of grey in between. If you are ill you may think If I cant do everything I used to do, then theres no point in doing anything. If you do less well than usual you may think, If I dont succeed, I must be a total failure. Overgeneralisation From the real negative event, you predict a never ending pattern of loss or defeat which may be exaggerated and not based on fact. Magnification and selective attention You focus on the negative aspects of the problem and selectively attend to them. You tend to filter out or disqualify more positive information. If you face an operation you remember all the possible side effects, but fail to hear that they are extremely rare. Self-blame You incorrectly hold yourself accountable for something bad that has happened, instead of assessing all the factors which might have contributed. For instance, a woman whose best friend was murdered when she was a teenager could not stop blaming herself 40 years later. She ignored the fact that schoolteachers and the killers themselves had responsibility for what happened. She thought that if she had only been more supportive of her friend in her loneliness she would never have left their boarding school and been killed. Negative prediction Instead of looking at the evidence available you jump to conclusions about the future. For instance, a cancer patient with a good prognosis is convinced she will die, a bereaved man cannot see that there will ever be any happiness in his life again. Labelling Here the distortion leads to a global, overgeneralised negative view of yourself. You label yourself as hopeless, incompetent, an invalid or a victim. Shoulds When bad things happen we sometimes try to force ourselves to function as if nothing was wrong. Instead of making allowances for illness, bereavement or trauma, should statements are used to bully us into activity. Instead of accepting that there are limitations you say I should be able to do it as well as I used to!

Coping with Adversity

Dr Stirling Moorey

COGNITIVE THERAPY IN ADVERSE LIFE CIRCUMSTANCES Antonovsky A (1987) Unraveling the Mystery of Health: How People Manage Stress and Stay Well. Jossey Bass Social and Behavioral Science Series. Emmelkamp PMG & van Oppen P (1993) Cognitive interventions in behavioral medicine. Psychotherapy & Psychosomatics, 59, 116-130. Fawzy FI, Fawzy NW, Arndt LA & Pasnau RO (1995) Cricital review of psychosocial interventions in cancer care. Archives of General Psychiatry, 52, 100-113. Greer S & Moorey S (1997) Adjuvant Psychological Therapy for Cancer Patients. Palliative Medicine, 11, 240-244. Greer S, Moorey S, Baruch JDR et al (1992) Adjuvant psychological therapy for cancer patients: a prospective randomised trial. British Medical Journal, 304, 675-680. Liese BS & Larson MW (1995) Coping with life-threatening illness: a cognitive therapy perspective. Jounal of Cognitive Psychotherapy: an International Quarterly, 9, 19-34. Meyer TJ & Mark MM (1995) Effects of psychosocial interventions with adult cancer patients: a metaanalysis of randomized experiments. Health Psychology, 14, 101-118. Moorey, S. & Greer, S. (2002).Cognitive Behaviour Therapy for People aith Cancer. Oxford University Press. Moorey S, Greer S, Watson M, Baruch JDR, Robertson BM, Mason A, Rowden L, Tunmore R, Law M & Bliss JM (1994). Adjuvant Psychological Therapy for Patients with Cancer: Outcome at One Year. Psycho-oncology, 3, 39-46. Moorey S, Greer S, Bliss J & Law M (1998) A comparison of Adjuvant Psychological Therapy and supportive counselling in patients with cancer.Psycho-oncology, 7, 218-228. Moorey S (1996) When bad things happen to rational people: cognitive therapy in adverse life situations. In Salkovskis P(ed.) Frontiers of Cognitive Therapy. New York:Guilford Press. Peterson C & Seligman MEP (2004) Character Strengths and Virtues: A Handbook and Classification. Oxford University Press. Seligman MEP (1992) Learned Optimism: How to Change Your Mind and Your Life. Pocket. Snyder CR (ed) (2001) Coping with Stress: Effective People and Processes. Oxford University Press. Snyder CR (ed) (2004)Coping: The Psychology of What Works. Oxford University Press. Taylor S & Armor D (1996) Positive illusions and coping with adversity. Journal of Personality, 64, 873898. White C (2001) Cognitive Behaviour Therapy for Chronic Medical Problems. London: Wiley. Williams C (1997) A cognitive model of dysfunctional illness behaviour. British Journal of Health Psychology. 2(2), 1997, 153-165.

Coping with Adversity

Dr Stirling Moorey