Steven Greer

Adjuvant psychological therapy for patients with cancer: a prospective randomised trial.

OBJECTIVE--To determine the effect of adjuvant psychological therapy on the quality of life of patients with cancer. DESIGN--Prospective randomised controlled trial comparing the quality of life of patients receiving psychological therapy with that of patients receiving no therapy, measured before therapy, at eight weeks, and at four months of follow up. SETTING--CRC Psychological Medicine Group of Royal Marsden Hospital. PATIENTS--174 patients aged 18-74 attending hospital with a confirmed diagnosis of malignant disease, a life expectancy of at least 12 months, or scores on various measures of psychological morbidity above previously defined cut off points. INTERVENTION--Adjuvant psychological therapy, a brief, problem focused, cognitive-behavioural treatment programme specifically designed for the needs of individual cancer patients. MAIN OUTCOME MEASURES--Hospital anxiety and depression scale, mental adjustment to cancer scale, Rotterdam symptom checklist, psychosocial adjustment to illness scale. RESULTS--156 (90%) patients completed the eight week trial; follow up data at four months were obtained for 137 patients (79%). At eight weeks, patients receiving therapy had significantly higher scores than control patients on fighting spirit and significantly lower scores on helplessness, anxious preoccupation, and fatalism; anxiety; psychological symptoms; and on orientation towards health care. These differences indicated improvement in each case. At four months, patients receiving therapy had significantly lower scores than controls on anxiety; psychological symptoms; and psychological distress. Clinically, the proportion of severely anxious patients dropped from 46% at baseline to 20% at eight weeks and 20% at four months in the therapy group and from 48% to 41% and to 43% respectively among controls. The proportion of patients with depression was 40% at baseline, 13% at eight weeks, and 18% at four months in the therapy group and 30%, 29%, and 23% respectively in controls. CONCLUSIONS--Adjuvant psychological therapy produces significant improvement in various measures of psychological distress among cancer patients. The effect of therapy observed at eight weeks persists in some but not all measures at four month follow up.

Promoting psychological well‐being in the face of serious illness: when theory, research and practice inform each other

This article describes the interplay among theory, research and practice regarding the maintenance of psychological well‐being during serious illness. The ideas emerged from two independent lines of work, one that evolved through clinical practice within the medical model, the other that evolved through theory and field research within a behavioral science model. Each of these lines of work independently points to the importance of focusing on psychological well‐being and the coping processes that support it, as a complement to the traditional focus in both the medical and behavioral sciences on psychiatric symptoms. This article describes a theoretical framework for the discussion of psychological well‐being during serious illness. Then, this framework is used to define variables that research indicates contribute specifically to psychological well‐being during serious illness, and finally, based on theory and research, a therapeutic program is described for patients with serious illness. The goal of this paper is to encourage researchers and clinicians to give as much attention to the development and maintenance of psychological well‐being in the face of serious illness as they do to the etiology and treatment of psychiatric symptoms. Copyright

Psychological attributes of women who develop breast cancer: a controlled study.

As part of an interdisciplinary study of breast cancer, psychological investigation of a consecutive series 160 women admitted to hospital for breast tumour biopsy was carried out by means of detailed structured interviews and standard tests. Interviews and testing were conducted on the day before operation, without knowledge of the provisional diagnosis. Information obtained from patients was verified in almost all cases by separate interviews with husbands or close relatives. Present results are based on statistical comparisons between 69 patients found at operation to have breast cancer and a control group comprising the remaining 91 patients with benign breast disease. Our principal finding was a significant association between the diagnosis of breast cancer and a behaviour pattern, persisting throughout adult life, of abnormal release of emotions. This abnormality was, in most cases, extreme suppression of anger and, in patients over 40, extreme suppression of other feelings. Extreme expression of emotions, though much less common, also occurred in a higher proportion of cancer patients than controls. Previous reports of correlations between breast cancer and extraversion, previous stress and depression were not confirmed.

Development of a questionnaire measure of emotional control

A questionnaire measure of emotional control was developed to evaluate the extent to which individuals report controlling anger, anxiety and depressed mood. Scale items were derived from responses to semi-structured clinical interviews with patients who were awaiting breast biopsy. Internal consistency and test-retest reliability data are reported, as well as correlations with the Marlowe-Crowne, the Spielberger State-Trait Personality Inventory, the Eysenck Personality Questionnaire and the Bortner Type A Behavior Scale. Although intended for use with breast cancer patients this scale is envisaged to have wider application to other clinical populations.

Relationships between emotional control, adjustment to cancer and depression and anxiety in breast cancer patients.

The possible relationship between psychological responses among breast cancer patients and disease outcome continues to be an area of controversy and debate. Two parallel findings are reported separately in the literature: first, that emotional control is more common among women with breast cancer than in women with benign breast disease or in healthy controls and second, that a helpless attitude towards the disease is related to a poor prognosis. These previously unrelated psychological responses are examined here in a group of women (N = 359) with early stage breast cancer, who were seen one to three months after diagnosis. The relationships between emotional control, adjustment to cancer and psychological morbidity were examined. Prevalence levels of 16 and 6% were observed for anxiety and depression respectively, which are lower than reported more generally in the literature. The results indicated a highly significant association between scores for the tendency to control emotional reactions and a fatalistic attitude toward cancer. A significant association was observed between anger control and a helpless attitude. Psychological morbidity was also linked to type of adjustment to cancer. The data are interpreted in terms of a process model of psychological responses which suggests that emotional control (an important component of the Type C behaviour pattern) fatalism, helplessness and psychological morbidity are linked.

The Mini-MAC

Development of self-report measures of coping remains important to thc process of monitoring the mental state of patients suffering from cancer. The present study extended and refined the scope of the Mental Adjustment to Cancer (MAC) scale, a self-report measure designed to give a rapid assessment of coping style. A heterogeneous group of 573 cancer patients completed a questionnaire containing the MAC scale and an additional 26-item research scale. A rigorous factor analysis procedure was used to determine the items that would be retained for a new scale: the Mini-MAC. The scope of the original MAC scale was widened to include items relating to avoidance (an important psychological response), and the original response items were clarified and refined. The Mini-MAC should be a useful tool for obtaining a rapid, reliable, and economical assessment of coping style.

Psychological response to cancer and survival

The hypothesis is advanced that the psychological stance which patients adopt in response to cancer can, in some cases, influence the course of their disease. This hypothesis is examined in the light of the authors 15-year follow-up study of women with early breast cancer and of other pertinent studies. The available evidence supports the hypothesis in respect of certain early-stage non-metastatic cancers.

Patterns of expression of anger and their psychological correlates in women with breast cancer

Abstract Previous work from the Faith Courtauld Unit described an association between the diagnosis of breast cancer and an apparent tendency to suppression of anger, particularly in younger patients. A detailed study of this phenomenon has been carried out in 71 patients prior to breast biopsy, using structured interviews, the Eysenck Personality Questionnaire (EPQ) and the Spielberger State—Trait Anxiety Inventory (STAI). Taped transcripts of interviews, independently rated, using a revised anger rating scale, again demonstrated a significant difference between patients with benign breast disease and those with breast cancer in expression of anger. Mean EPQ ‘N’ score was significantly lower for cancer patients. STAI A-State and A-Trait anxiety scores were significantly higher than standard scores for all patients other than young cancer patients. The pattern of correlation between variables differed for the two diagnostic groups suggesting (a) that cancer patients are more stressed by impending biopsy and (b) that young cancer patients are more likely than other patients to use denial in the face of stress.

Locus of Control and Adjustment to Cancer

The English form of the Cancer Locus of Control Scale was administered to an heterogeneous sample of 68 cancer patients. A principal components analysis confirmed the three subscales described in the original Dutch form, however, with five items excluded. Correlations with other measures indicated that high internal control over the course of the illness was associated with a tendency to adopt an attitude toward cancer of ‘fighting spirit’ whereas high internal control over the cause of the illness was associated with an ‘anxious preoccupation’ about cancer. No specific relationship was found between scale scores and either depression and anxiety or the tendency to be emotionally controlled. It was concluded that the scale provides a valid measure of perceptions of control of cancer patients and is a useful method of assessing these important psychological responses.

Towards a psychobiological model of cancer: psychological considerations.

To date, the evidence relating to the role of stress and psychological variables in cancer aetiology and promotion is contradictory. We have attempted to clarify the issues by presenting an hypothetical psychobiological model. Two components of this model are described: (1) a characteristic behaviour pattern (Type C) which may mediate stress reactions and (2) the biological concomitants of this behaviour pattern. The mechanisms of cancer initiation and promotion are described in a companion paper (Pettingale). The main hypothesis advanced by this model is that the psychological factors described may promote cancer development; the model is offered for investigation.