Grieving in response to cancer
by Jimmy Henderson
Research indicates that the news of a life threatening disease such as cancer can set off a grief response similar to that experienced by the loss of a loved one. As a result, various physical and psychological symptoms can manifest and persist even for a number of years. This talk examines these responses, as well as the factors resulting in pathological grief and the kind of support necessary for the affected person.(Barlow & Durand, 2002) To conclude the talk, I will provide you with a few skills that will help you support a person in this unfortunate situation.

Finding out that you have cancer can result in a process of grieving. The reason for this is that one is suddenly faced with the fact that you may not have a long term future. This can produce a sense of loss similar to that experienced by the loss of a loved one.
The grieving process itself has been well researched in psychology and, in fact, under normal circumstances, has a clear and definite role in the re-adjustment of the individual. Problems arise when, for a number of reasons, the process is either delayed or the person does not receive the necessary support.
I shall now briefly describe the three stages in the process of grieving.
It should be of comfort to those of you, or your friends, who are caught in this cycle, that this is a normal process and nothing to be ashamed of.

Stage 1 - Initial response stage
This is the first reaction of severe stress that can last a few days.
Psychological reactions
During this time, you could expect to experience shock, dazed disbelief, a numbness, much confusion and sometimes intense emotions, usually presenting as crying and sobbing.

Physical reactions
One will typically experience fear and other reactions, a tight chest, breathing problems, a hollow or painful stomach, and a raised heart-rate and high blood pressure. You could have problems sleeping and become hypersensitive and exhausted.
You could also become ill (due to a drop in you immune system)
This initial stage will usually pass in a few days when more serious symptoms could emerge.
Support required.
During this time it would be good to have family or a friend to talk to and someone who can assist you with the day to day running of your home until you have stabilised somewhat. Visits and support from support groups or organizations are very important as the person needs to feel supported and cared for. It may not be possible to do deeper counselling at this time as the person is still in shock and may require a few days before he or she is willing to talk about it. If she is willing then it is fine.

Stage two : Emotional and cognitive stage.
This stage can last for up to one year. What is happening is that after a few days , your coping mechanisms begin to kick in. These are meant to protect you, but sometimes can be so severe that you are unable to function normally. Some people may tend to avoid contact with family and friends altogether and want to be left alone. This is avoidance behaviour and not uncommon. However, someone should be on hand to assist when the person decides to talk about it.
Psychological effects
At this stage they should be encouraged to talk about the cancer. The anxiety and tension from the initial news needs to come out in a healthy way. Sometimes the tension does not easily come out an the person could become angry, irritable and unreasonable, This is also not uncommon and is due to the fact that he or she is trying to deny the situation, has regressed into an almost childhood response or is displacing her anger onto family or friends. This is not personal and is merely a bad way of trying to release the anxiety and stress.
At the same time, this person could have many problems sleeping, have bad dreams and become totally preoccupied with negative thoughts. Their relationships and other functions requiring concentration such as work will usually suffer. They may also become quite sad and depressed.
Physical reactions
The kind of physical symptoms typical during this stage is persistent illness (on top of the cancer symptoms), headaches, loss of appetite, sleeping problems, tiredness, apathy ( don’t’ care ).
Support required.
It is quite important for the person to try to keep more or less to the same work and social routine, as sitting alone with such negative thinking is not helpful. Once again the person should be encouraged to speak about their illness, their concerns and the issues bothering them and not keep it bottled up. At this stage it would also be a good idea for the person to seek professional help from a counsellor or a psychologist or otherwise they could end up with other disorders such as major depression and symptoms such as severe withdrawal, chronic negativity and despair, loss of meaning in their lives (directionless), helplessness and thoughts of suicide.

Stage three. Closure or adaptation stage 1-2 years.

After a year or so, the person should be having episodes of relative normality, when things are not going too badly. Rosemary Thompson, in her book Counselling Techniques, (1996) speaks of a number of tasks that a grieving person would need to accomplish if there is to be some sort of psychological recovery.
For instance , the initial deadening of feelings (numbness) should have been replaced by a feeling of once again being in touch with your feelings. In other words, still sometimes feeling sad, but also able to experience some joy and happiness in your life again.
The anger that many have been directed at other people, has been redirected into a fighting spirit, that the cancer will not win or get me down.
The initial denial or avoidance of the issue should have been replaced by some sort of understanding and acceptance of the reality and the need for adjustment.
The coping mechanism of avoiding contact with people, should have been replaced by a willingness to reinvest energy in life and the things that are important, such as family and friends.
Finally , there would have had to be some sort of adjustment to the different circumstances taken place. In other words, that the person has moved on, made some new positive decisions and is coping as best as they can under the circumstances.
Pathological grieving
The grieving process in human beings is naturally designed to enable one to work through these issues and resolve them. If, however, the recovery is blocked or delayed as the result of other factors, these issues can remain unaddressed and the person can expect to develop some or other form of psychological disorder.
There are a number of factors involved.
Delayed/ absent or incomplete grief
Firstly, the grieving may have been delayed or has not yet been fully expressed.
This can due to the fact that the reality of the illness has been avoided, repressed or denied.
The person refuses to deal with it and tries to keep it out of their mind by means of very active defence mechanisms. For instance, denial or avoidance, in which the emotions are avoided altogether. (‘What cancer?, ‘so what? we all die ’)
2. As a result of their personality or fear of breaking down and crying, which they believe is socially unacceptable in terms of their upbringing or values. (“cowboys don’t cry’).
3. Possibly the family situation, in which he or she is worrying about the kids.
(‘Trying to be strong for their sakes’)
4. It may also be due to their culture which may discourage an excessive show of emotions.
(‘I must be strong’)
Or simply their trying to rush through the process of grieving because it is simply too painful.
(‘I got over it in a few days’)
In many cases of absent grief, the stress can actually emerge in a number of physical ailments.
Unresolved or Chronic grief
This is a situation where the person goes through the normal reactions but these responses and the behaviour continues unabated for more than one year. (carries on for many years.)
This can be due to existing problems which are unresolved and are keeping the stress level high, such as financial problems, an unhappy marriage, an immature personality, other pre-exiting psychological disorders such as depression and so on.
Lack of social support
However, the main problem resulting in chronic unresolved grieving, is a lack of social or psychological support.
Human beings are social animals and there is no better way of adjusting to such a difficult issue as cancer, as the loving support of family and friends. A situation where the person has received no support , no counselling and feels isolated and rejected, is a recipe for disorders such as major depression, schizophrenia, paranoia, substance abuse and suicidal behaviour.
However, this support has to be appropriate in terms of timing and quality.
Comments such as ‘get over it’, are not support. Families and friends who are afraid of talking about the subject due to their upbringing, beliefs or cultural taboos, can create a conspiracy of silence which does not help the person concerned.
And bad advice can also create a new set of problems. Caregivers need to be able to see from the view of the ill person and not from their own point of view. This is why a support organisation of volunteers who have first hand experience of the feelings and problems associated with cancer, is of primary importance.
Dr Merle Friedman (2001) described to me the benefits of traumatic growth. This is a situation where the person comes to realise that they have benefited or learnt in some way from the experience (of cancer) . Whether it is a greater inner strength and ability to cope with difficult circumstances, closer family ties or spiritual growth.
Where to from here ?
Existential therapy looks at these important questions of life and death, illness and heath and
stresses that merely finding the courage to continue and to face the future in spite of such a bad situation, brings with it a new meaning to life. (Corey, 2001)

Stages of a basic counselling process
Stage 1. Building a relationship
Skills required:
Focus (non-verbal communication)
Attending (reflection and listening)
Empathy (body language, voice and words)
Unconditional positive regard.
Outcome required ......relationship of trust

Stage 2. Dealing with feelings
Skills required:
Listening /reflection ( Acknowledge feelings)
Questioning (Identify, name and take ownership of feelings )
Silence
Support (physical)
Outcome required .....................Catharsis
( a visible release of pain from the client)

Stage 3. Dealing with thoughts
Skills required:
Listening (acknowledge and clarify thoughts)
Questioning (Identication of underlying thoughts)
Challenging (negative self -talk and other cases)
Analysing (looking for the big picture or underlying issues.
Outcome required................a good understanding of his /her situation (turning point)
Stage 4. Options and planning :
Skills required :
Frame of reference (clients real life options)
Linking
Summarising ( looking at the real issues involved)
Analysing ( present, past and future possibilities)
Empowerment (to overcome self-doubt, negative thinking or apathy)
Outcome required - a realistic , workable plan of action

Stage 5 Termination of the session
Skills required:
Summarisation (review the process, turning point and reinforce decisions taken)
Read body language
Correct referral
Outcome required .... An overall visible improvement in the clients emotional and mental state (improved mood)
The willingness to continue (no doubts or possible unresolved emotions or issues)

References.
Barlow, D.H.& Durand, V.M. (2002). Abnormal psychology: An integrated approach. (3rd ed.). Belmont : Wadsworth/Thompson Learning.
Corey, G.T. (2001). Theory and practice of counselling and psychotherapy (6th ed.) Belmont : Brookes /Cole.
Thompson, R.A. (1996). Counselling techniques. Improving Relationships with Others, Ourselves, Our families, and our Environment. Taylor and Francis: USA.