Psycho-Social and Sexual Health: Balancing Acceptance and Change
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Andrea Bradford, Ph.D., from the Department of Gynecologic Oncology and Reproductive Medicine at MD Anderson Cancer Center, offers tips to ovarian cancer survivors.
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Psycho-Social and Sexual Health: Balancing Acceptance and Change
- 1. Psycho-social and Sexual Health Balancing Acceptance and Change Andrea Bradford, Ph.D. Department of Gynecologic Oncology and Reproductive Medicine
- 2. 0% 20% 40% 60% 80% 100% Fear of recurrence Sadness/depression Grief and identity Family member risk Personal appearance Cancer stigma Personal relationships Faith/spirituality A lot A little Not at all Percentage of Cancer Survivors Who Experienced Emotional Concerns (n = 3129) Source: Livestrong Foundation, 2010
- 3. 0% 10% 20% 30% 40% 50% Fatigue Sexual dysfunction Sleep disturbance Neurologic symptoms Urinary dysfunction Bowel problems Memory problems Depression Anxiety Leg swelling/lymphedema Percentage of Gynecologic Cancer Survivors with Symptoms During or After Treatment (n = 1029) Westin S, et al. Journal of Cancer Survivorship (2015)
- 4. Managing Symptoms: Balancing Acceptance and Change Acceptance Change Fatalism Unnecessary lifestyle adjustment Hopelessness Pessimism/cynicism
- 5. Managing Symptoms: Balancing Acceptance and Change Acceptance Change Anxiety Frustration/disappointment Losing contact with the present
- 6. Managing Symptoms: Balancing Acceptance and Change Acceptance Change Open, non-judgmental awareness Living according to values, goals Careful choice of interventions based on evidence
- 8. • Avoidance is only a temporary solution • Thoughts and feelings come and go; what we do in response determines our outcome The Struggle Is Part of the Problem
- 9. The Struggle Is Part of the Problem
- 10. The Struggle Is Part of the Problem Can you notice your thoughts and feelings of discomfort, and make room for them, without letting them distract you from the task? Can you stay in the task by distracting yourself from thoughts and feelings of discomfort while thinking about something positive instead? Gutierrez et al., Behavior Therapy 2004;35:767-783
- 11. • Avoidance is only a temporary solution • Thoughts and feelings come and go; what we do in response determines our outcome • Interpretations and judgments shape our realities The Struggle Is Part of the Problem
- 12. Be Here Now: An Exercise
- 13. • Mindfulness meditation/practice • “Time outs” for noticing, feeling, grounding in the present • Forge a different relationship with your thoughts Developing the Here-and-Now Mindset
- 14. • Brief mindfulness-based sex therapy improves sexual function for women, including cancer survivors • Mindfulness associated with greater arousability and higher rates of orgasm in women Mindfulness and Sexual Function
- 15. Living according to values
- 16. A Purposeful Life • Values are guideposts for actions and decisions • Values can be attributes we aspire to – not achievements • Values aren’t things we can “do” but they are qualities of ongoing action
- 17. A Purposeful Life • Honesty • Compassion • Family • Intellectual challenge • Faith in God • Fun • Meaningful work • Adventure • Appreciation of nature • Helping others
- 18. A Purposeful Life • Example: Attending an anniversary party
- 19. A Purposeful Life • Example: Lovemaking
- 20. Putting It All Together • Acceptance and commitment therapy (ACT) shows promise as an intervention to improve emotional adjustment and quality of life • ACT has been tested in at least one group of women with advanced ovarian cancer
- 21. 50 55 60 65 70 75 80 85 90 95 100 Baseline Session 4 Session 8 Session 12 FACT-GAverageScore Acceptance and Commitment Therapy Versus Conventional Cognitive-Behavioral Therapy in Women with Advanced Ovarian Cancer ACT Conventional Rost et al., Cognitive and Behavioral Practice 2012;19:508-517
- 22. 0 2 4 6 8 10 12 14 16 18 20 Baseline Session 4 Session 8 Session 12 BAIAnxietyAverageScore Acceptance and Commitment Therapy Versus Conventional Cognitive-Behavioral Therapy in Women with Advanced Ovarian Cancer ACT Conventional Rost et al., Cognitive and Behavioral Practice 2012;19:508-517
- 23. 0 5 10 15 20 25 Baseline Session 4 Session 8 Session 12 BDI-IIDepressionAverageScore Acceptance and Commitment Therapy Versus Conventional Cognitive-Behavioral Therapy in Women with Advanced Ovarian Cancer ACT Conventional Rost et al., Cognitive and Behavioral Practice 2012;19:508-517
- 24. Choosing treatments based on evidence
- 25. • Does this treatment work better than a placebo for most people? • What are the possible side effects? • How can this treatment help me to do the things that are important to me? Critical Questions
- 26. • Physical activity (esp. aerobic exercise) Fatigue, sexual dysfunction • Cognitive behavioral therapy (including ACT) Insomnia, pain, sexual dysfunction, depression, anxiety • Self-help/self-management Beyond Medications: Lesser Used Interventions that Work!
- 27. • Common in ovarian cancer survivors, esp. if taking aromatase inhibitors • It’s not “all in your head” • Major cause of loss of interest in sex • Many providers are not aware of optimal treatment A Word About Painful Sex
- 29. • Fully commit • Use reminder systems, diaries, and other tools as recommended • Judge the effectiveness of a treatment based on the outcomes that are important to you Trying New Treatments for Symptoms and Side Effects
- 30. • Breakthrough symptoms/flare ups • Tolerance or reduced efficacy of treatment • When nothing seems to work • When nothing seems to matter Have a Plan for…
- 31. • Expertise in psychosocial and sexual adjustment after cancer may be hard to find • “You’ll just have to live with it” is not acceptable Asking for Help
- 32. • Expertise in psychosocial and sexual adjustment after cancer may be hard to find • “You’ll just have to live with it” is not acceptable Asking for Support
- 33. “Between stimulus and response, there is a space. In that space is our power to choose our response. In our response lies our growth and our freedom.” Viktor Frankl, M.D., Ph.D.
- 34. For more information: Andrea Bradford, Ph.D. (713) 756-4466 abradford@mdanderson.org
Editor's Notes
- With that being said, I should back up and address the question of why do we care about psychological services in cancer care settings? For a substantial number of people, cancer is distressing and it can be distressing for a very long time. This does not always mean that psychological services are needed, but there are many opportunities to help.
- There are a lot of symptoms, many of which overlap or coexist with one another. As I thought about what to say about managing these symptoms and side effects during my 30 minutes, I came to the conclusion that I can’t address all of these. However, I can share a general framework or approach to living with symptoms, one that I hope is helpful to you or to those you care about. This approach is based on psychological principles and treatments that address our relationship to our distress and suffering. I’ll share a few examples from that research but I mostly want to introduce the concepts to you today. I’ve prepared a handout with some additional resources if this approach seems valuable to you and you’d like to learn more.
- In therapy we usually start with acceptance
- Unfortunately, some symptoms and side effects are long lasting. They can disable us, make us uncomfortable, or make us feel despair. The first, natural human instinct is to get away from those feelings at all costs. We do a really wonderful job in medicine of trying to do just that. We willingly join with patients in that fight. We want your pain, your impairment, your distress to disappear. Sometimes we can make that happen. But often, there is some residual change that we just can’t take away. We have to choose what to do with that. Often that choice comes down to some sort of avoidance. The same thing can happen when we’re avoiding other feelings too. What if we turn down an opportunity to feel joyful because it might also put us in touch with our sadness? Ever felt that urge? What if we tune out our sexual desire because it doesn’t fit with the way we see ourselves as damaged or unattractive? We’ll go out of our way to avoid not only negative feelings, but also experiences that might put us in conflict with how we see ourselves. We like consistency, we like order, and we definitely like the feeling of being in control. But what if we decided to sit a little while with the feelings or symptoms that we try to avoid or get rid of?
- Many of you I suspect are familiar with the old white bear thought experiment. I can command that you not think of a white bear, and maybe some of you can do that for a while. But eventually, inevitably, that white bear is going to pop up. What if, instead of trying very hard to keep that white bear away, we decided to let it have some space in our heads. Not trying to fight it, not trying to make it front-and-center, just letting it be there and neither acting on it nor suppressing it.
- What if the white bear wasn’t an image but a feeling? What if the white bear was physical pain? In fact, there has been an experiment to test this very idea of what would happen if you didn’t try to suppress or ignore a feeling. This particular experiment involved electrical shocks delivered to the forearm while they were doing some task. The volunteers for this experiment each got a shock and rated how well they tolerated the pain. Then they were randomly picked to get one of two sets of instructions for coping with the next round of shocks. About half were asked to think of a vivid mental image – something positive and relaxing, like a sandy beach or a flower garden – and try to crowd out any thoughts about their discomfort. The other half were asked to go ahead and think about the pain, let it come to mind, but treat those thoughts as just what they are – momentary thoughts – and continue with the task at hand. What the researchers found was that, on the second round of shocks, the volunteers who had been asked to tolerate those thoughts actually rated their pain tolerance as better, even improved over the first round of shocks. What this shows us is that it doesn’t necessarily pay to distract ourselves from what’s bothering us. Rather, we might benefit from noticing our thought process without necessary acting on our first impulse to do something about it.
- When we say to ourselves “I can’t stand this!” or “I can’t live like this!” we are shaping what it is like to be us. This has no bearing on reality. How many times have you said “I can’t take this” and you found a way? There’s nothing inherently wrong with having the thought “I just can’t deal with this!” – but where we go wrong is when we become so attached to that thought that it dictates our actions. That is practically the definition of suffering. We can choose to get hooked into those terrible thoughts and interpretations or observe them, detach from them a little, get a little distance from the first thought that pops into our heads.
- There are some ways to develop this skill. Many of you have probably heard of mindfulness practice. It’s a big buzzword right now. Mindfulness was once confined to contemplative or spiritual traditions but began to be incorporated into counseling, psychotherapy, and self-help in the 1980s and 1990s, and today it’s become completely mainstream. But the essence of mindfulness is actually paying attention to what’s going on here and now. Noticing thoughts, feelings, memories, images as they come up but not getting caught up in them. Just letting the 24/7 mental chatter go on without getting hooked into it. It’s a way to have a different kind of relationship with your thoughts, focus, and make more deliberate decisions.
- SO if we’re not necessarily acting on all the mental chatter, what are we supposed to act on instead? I would argue that through our discomfort and distress we need to stay connected to our values, perhaps more so than at most other times.
- Values are our ideas about what’s important in life. They’re ours to choose. It’s not about right or wrong or adhering to a specific code or dogma. We’re not talking about virtues here. We’re talking about what actually matters to you, what you want your actions and your life to stand for. Values are different than goals. They’re not actions or achievements, rather they’re qualities of those things. People who cope well with cancer often share that the experience put them in closer contact with their values. When I talk about values I’m really talking about the big picture. Imagine it’s your birthday, five years from now, the person that is closest to you in this world is standing in front of you and all of your loved ones, beaming with pride and emotion, and giving a speech about you. He or she is talking about your process of moving through this challenge. He or she speaks about what personal qualities moved you through it. What personal characteristics do they say helped you overcome this? In the face of this challenge, what kind of person were you? How do they describe you? When we make decisions in line with our values, the pieces start to fall into place. That isn’t to say that it’s easy. Sometimes our values are in direct conflict with what’s easy or the default. But if we make a habit of being aware of our
- When we make decisions in line with our values, whatever those might be, the pieces start to fall into place. That isn’t to say that it’s easy. Sometimes our values are in direct conflict with what’s easy or the default. But if we make a habit of being aware of our values and whether our actions are in line with our values, we can come to some peace and sense of meaning in our lives.
- What does this have to do with managing symptoms and side effects? Well, some of the suffering caused by our symptoms is a consequence of getting off track from our values. Imagine you are tired and in pain and maybe not looking your finest, but you have an invitation to a friend’s anniversary party. And you value your friendships and your social life, deeply. In another time and place there would be no question about your attending. But you know that going is going to wear you out, you’re likely to get some awkward looks or intrusive questions about your cancer. Perhaps celebrating your friend’s anniversary will raise your own fears about your marriage, or about living to celebrate the same anniversary year yourself. So you get hooked on those thoughts of what bad things might happen and you start to think of a way out. Let me be clear: this is not about wrong or right, being a good friend or not. It is an example to demonstrate how easy it is to act on that desire to avoid the bad, rather than engage with the good. Sometimes life does not give us a choice about these situations. But when it does, it is worthwhile to be deliberate about acting in accordance with our values, to the extent that we can.
- There is now a fairly well developed psychotherapy that focuses on the concepts I’ve been talking about. It’s called acceptance and commitment therapy, or ACT, and it seems to be a promising therapy for many people with cancer. In fact, there has been one recent clinical trial in women with advanced cancer. This was a head-to-head trial of two different therapy approaches, one focused on changing one’s thoughts, developing relaxation techniques and problem-solving strategies. In other words, the conventional therapy was really focused on doing something about the bad stuff. This was tested against ACT, which focused more on nonjudgmental awareness, observing one’s thoughts without getting caught up in them, and clarifying and acting on one’s values.
- Quality of life scores
- Anxiety scores
- Depression scores
- I’ve deliberate talked about accepting and living with symptoms and side effects because from a therapeutic standpoint, I find it helpful to start with acceptance. But certainly we don’t have to be stoic about this. Symptoms that get in the way of living the life you want to live should be treated if at all possible. However, finding that ability to sit with those symptoms, rather than struggle against them constantly, can make it easier to seek treatment and make good choices.
- Commit – if you have made a conscious, deliberate choice that is in line with what’s important to you, you owe it to yourself to give it a fair trial. Even placebos work better if you take them consistently. Remember to tie your treatment decision to what’s important to you. For instance, you can tell yourself, “I’m going to try to reduce my fatigue,” and leave it at that, or you could say, “I’m going to do what I can to reduce my fatigue so that I can spend more time playing with my grandchildren.” Doesn’t that sound more compelling?