Cancer grief, trauma, and crisis: theories and client-counsellor issues

Cancer grief is associated with death of the victim is experienced by the relatives, trauma is the pain from the time the disease is diagnosed, and crisis is mainly due to the disruption of normal life for all lifestyle change from the event of diagnosis. This essay discusses grief, trauma, and crisis in cancer cases through review of existing literature, discussion of theories of grief, trauma, and crisis for cancer, and identification of the issues for clients and counsellors working with grief, trauma and crisis associate with cancer. The reviewed literature is from a professional health practitioner perspective and how they can provide the adequate care to clients undergoing trauma, grief, and crisis. Hence, there is an information gap for literature targeting non-professional care givers in supporting cancer patients e.g. relatives. The theories of grief can be categorized into two; the early grief theories and the second generation theories. The early generation theories date pre-1990s and were pioneered by Freud while the second generation theories range from the 1990s to date and were pioneered by Parkers. These can be summarized into four to explain how grief comes about in case of loss of a loved one to cancer; repression theory, attachment theory, continuing bonds, and assumptive world change. In the counselling event, there are issues that arise for cancer clients and counsellors. These issues are adherence to professional ethics by counselors, client dependence, values and the helping relationship, multicultural perspectives and diversity, client rights and counselor responsibilities, legal issues, and professional competency and training.

• Introduction

Many diseases cause trauma, may result to grief, and cause crisis in life. The level of grief, trauma, or crisis is dependent on the threat posed by the disease and especially those that have no cure, or require expensive treatment or care programs. Some of the diseases that cause grief, trauma, and crisis include high blood pressure, diabetes, HIV, and cancer. Grief, which is mainly associated with death of the victim is experienced by the relatives, trauma on the other hand can be during the diseases from prognosis to cure or palliative care and it is experienced by both the sick individual, relatives, and the care giver, and crisis is mainly due to the disruption of normal lifestyle for all the involved in the event of diagnosis (Pazdur et al., 2009). This essay will discuss grief, trauma, and crisis in cancer cases. The discussion will be done through review of existing literature, discussion of theories of grief, trauma, and crisis for cancer, and identification of the issues for clients and counsellors working with grief, trauma and crisis associate with cancer.

• Literature review

James & Gilliland (2012) present what is considered to be the latest skills and techniques for handling of real crisis situations. In their book “Crisis Intervention Strategies”, the authors have provided a six-step model that clearly illustrates how to deal with people in crisis. Even though the book is not specific to cancer, it is highly applicable for cancer-crisis situations. The six steps are defining the problem, ensuring client safety, providing support, examining alternatives, making the necessary plans, and obtaining commitment. The book is written from the perspective of a health professional to a client – in this case a cancer patient. The book presents relevant crisis situations through cases and scenarios and how the health practitioners should engage with the patient.

In her work “Working with Loss and Grief: A New Model for Practitioners”, Linda Machin (2009) illustrates how health practitioners need to relate and associate with persons in grief. The book is replete with illustrative case studies and the author writes from both a psychological and sociological point of view and brings together theory and research in order to develop a way of thinking about grief and loss understandable to the ordinary person. According to Machin (2009), grief and the process underlying, is highly specific to an individual, but can be understood through general concepts. The book suggest a framework for practitioners to understand personal grief; listening to stories of grief, identifying common grief patterns, recognizing individual difference in grief response, prompt therapeutic dialogue, guide therapeutic focus, appraise clients, and evaluation of outcome (Machin, 2009).

In dying, death and Grief, Brenda Mallon writes for anyone who provides support to persons after bereavement. According to Mallon (2008), professional care after bereavement can be under professional engagement or simply volunteer, regardless of this, care after bereavement should deliver the much needed empathy, in the right way for the right situation. For example, care after long battle with cancer is different from immediate death after diagnosis. The author explains the theoretical background to attachment and loss of a loved one in an effort to ensure the right and relevant support is available to people after bereavement. In addition, the author provides case studies and takes a sexual, cultural, and spiritual perspective.

In the above reviewed literature, the primary target is professional health practitioners and how they can provide the adequate care to clients undergoing trauma, grief, and crisis. Even though as stated by Larson & Hoyt, (2007) professional practitioners stand a better chance of providing the required support to overcome grief, it is also worth understanding that there are other caregivers who need guidelines on how to support and care for the patients. Among the native communities in Australia, a health issue for example cancer is a family concern and it requires the family to make crucial decisions. In trauma and crisis cases when one has been diagnosed with cancer, family caregivers need to know how to support the patient (Field & Filanosky, 2010). Hence, there is an information gap for literature targeting non-professional care givers in supporting cancer patients.

• Theories of grief, trauma and crisis informing cancer

The theories of grief can be categorized into two; the early grief theories and the second generation theories. The early generation theories date pre-1990s and were pioneered by Freud (Paul & Ruth, 2006) while the second generation theories range from the 1990s to date and were pioneered by Parkers (Worden, 2009).the early theories were psychoanalytic theory, attachment theory, psychosocial transitions, stage model, tasks of mourning, and integrative theory. The second generation theories developed as a result of health practitioners realizing that the aspects ascribed towards grief hence forming the foundation of early theories were not entirely correct and didn’t represent what grievers were feeling at the time of bereavement, especially the individual response to grief (Worden, 2009). Due to research, second generation theories were developed and they are stress and coping  theory, dual process theory, continuing bonds theory, meaning making, loss of assumptions, and range of response to loss (Mallon, 2008).

According to Larson and Hoyt (2007), the above theories can be summarized into four to explain how grief comes about in case of loss of a loved one to cancer; repression theory, attachment theory, continuing bonds, and assumptive world change.

3.1.       Repression theory

Repression is a psychological attempt to repel one’s own impulses and feeling by excluding the desires from ones consciousness by holding and subduing the thought in the unconscious (Larson & Hoyt, 2007). According to Pazdur et al (2009), repression is a psychoanalysis concept and a defence mechanism. Repression theory was developed by Freud’s by asking his patients to remember the past in a conscious state, and because it proved a difficult process, Freud concluded that there are forces that prevent consciousness and compel one to remain in the unconscious.

In cancer, patients as well as the bereaved will adopt repression to push the thoughts of the condition or the loss respectively to the unconsciousness. This is possible through primal repression or abnormal repression. According to Freud, primal repression is the first phase of repression where the thought is denied entry into the consciousness through psychical representations. On the other hand, abnormal repression causes anxiety and can lead to illogical behaviour, self-destruction, or anti-social. A health practitioner is required to act as a mediator by bringing the repressed aspects to the conscious of the patient.

3.2.       Attachment theory

All animals are social and so is man (Machin, 2008). Due to this social aspect, people develop attachment to one another. In the case of cancer patients or death of someone suffering from cancer, the bond between the two is threatened and lost hence the reaction by grieving. While grieving is common for loss of a loved one through death, trauma is the common when a loved one or one has been diagnosis with cancer.

Attachment develops as a result of searching for security (Worden, 2009). Security is provided in numerous forms; against adversaries, security through guaranteed wants, and the physical presence which provides emotional companionship which is ensuring and provides the strength needed to continue with life. When this attachment bond is threatened, the affected will react by crying which presents the grief period and searching for alternatives (Rothschild, 2009). In advanced conditions when a loved one is lost and depending on the level of attachment, one might react by suicide attempts. The response to grief, trauma and crisis in cancer cases is dependent on the age of the bereaved, the process to loss of the loved one; the prevailing conditions e.g. availability of alternatives, among others.

3.3.       Continuing bonds

Closely related to the attachment theory is the continuing bonds theory. Continuing bonds theory determines and affects grief, trauma, and crisis for cancer depending on their availability of absence. In case of the positive, the grief period is considerably short, easy to manage, and resilience capabilities highly enabled (Worden, 2009). However, in case of the negative, the reactions to bereavement or cancer diagnosis are severe and might be life threatening. The presence of alternatives creates a reassurance of continuing bonds with minimum or no change to the loss or to the life-threatening cancer disease.

Given the positive effect of continuing bonds in dealing with grief, individuals as well as professional care givers will try to create enabling conditions for bouncing back through creation of continuing-bonds situations (James & Gilliland, 2012). One of the common is the creation healthy resolutions of grief to enable one to maintain a continuing bond with the deceased. The other is whereby the deceased provided resources for enriched functioning for example, through insurance policies, wise investments, and a creation of a will. According to Worden (2009), continuing bonds are not denial.

3.4.       Assumptive world change

According to Machin (2009), every individual has an internalised model of the world and how it operates. This model is created out of experiences in life and the type of model created by an individual is the true and ideal world to them. This assumptive world enables an individual to recognise and cope with the various situations he/she meets. In case one loses a loved one to cancer, this becomes a major vicissitude that disrupts the entire assumptive world through insecurity or fear.

Once the assumptive world is created, through childhood experiences to any stage in life, it is hard to change it, but not impossible (Worden, 2009). When one loses their loved one through cancer, the immediate response is resistance to the change hence grief, trauma, and crisis. In unchecked, the crisis can cause ripple effects which disrupt the individuals life and those close to him or her. Continued feeling of insecurity or fear will advance the effects of grief, but anything that provides confidence and security will boost resilience. Professional practitioners help the individual to change their assumptive world in when successful, the result is personal growth.

• Grief, trauma and crisis issues for cancer clients and counsellors

Cancer is a life-threatening condition, and in 2011, there were 43,221 deaths in Australia due to cancer (Pazdur et al., 2009). Given the nature and the level of deaths per year, cancer can cause trauma, crisis, and obviously grief. This requires the intervention of professional care givers to manage the situations effectively. To achieve this, there are various issues to be observed by the practitioners and the clients.

4.1.       Adherence to professional ethics by counselors

Counselors are also human beings and can be easily carried by the emotional changes that occur during grief. According to Corey et al (2014), the counselling professional, just like every other profession is guided by a code of ethics. In Australia, counselling code of ethics is set by the Australian Counselling association. Some of the issues in the code of ethics include interest in client’s welfare, practise within one’s competence, protection of client’s confidentiality and privacy, avoiding harm and exploitation, etc. However, some issues in managing grief cannot be handled within the code of ethics (Corey et al, 2014), hence the need for intelligent personal judgement.

4.2.       Client dependence

Client dependence is an issue that cuts across both clients and the counselor (Rothschild, 2009). Client dependence will happen temporarily especially soon after the start of the counseling sessions. For some clients, consulting with a counselor is a sign of weakness, but when they start to, they might end up being overly dependent. Either way, excessive client dependence on the counselor is a vice. After bereavement and during the grieving period, the client will seek for support from another party, and because the counselor is the immediate option, temporary attachment will occur. However, it is the responsibility of the counselor to gradually and seamlessly transfer this dependence to another party.

Overly client dependence might happen when the counselor prolongs the sessions for financial gains, which is an ethical issue, while overly counselor dependence will occur due to the vulnerability of the client and search for continued bond (Worden, 2009).

Other issues in cancer client and counselors include values and the helping relationship, multicultural perspectives and diversity, client rights and counselor responsibilities, legal issues, and professional competency and training (Corey et al, 2014).

• Conclusions

Grief, trauma, and crisis related to cancer involve the patient, those around him or her and the professional health practitioner. For effective management of grief, trauma and crisis, the health practitioner has a greater stake to play. From the literature review done in the essay, it is evident that the counselor has to manage the situation as all the literature indicates client and counselor relationship. There are two categories of theories associated with grief, trauma, and crisis for cancer; the early and the new second generation theories. These can be summarized into four; repression theory, attachment theory, continuing bonds, and assumptive world change. During the counsellor and client relationship, the issues that matters include adherence to professional ethics by counselors and client dependence among others.

• References

Field, N.P. & Filanosky, C. (2010). Continuing bonds, risk factors for complicated grief and adjustment to bereavement. Death Studies, 34, 1-29.

Larson, D.G., & Hoyt, W.T. (2007). What has become of grief counselling? En evaluation of the empirical foundations of the new pessimism. Professional Psychology: Research and Practice, 38(4), 347–355.

Paul, A.F. & Ruth, A.L. (2006). Toward a Psychobiology of Posttraumatic Self-Dysregulation. Reexperiencing, Hyperarousal, Dissociation, and Emotional Numbing, Annals of the New York Academy of Sciences 1071 (1), 110–124.

James, R. & Gilliland, B. (2012). Crisis Intervention Strategies, 7^th edition. Cengage.

Rothschild, B. (2009). Eight keys to safe trauma recovery: Take-charge strategies to empower your life. New York, NY: Wiley.

Machin, L. (2008). Working with loss and grief: A new model for practitioners. New York, NY: Sage

Mallon, B. (2008) Dying, Death and Grief: Working with Adult Bereavement. Sage publications.

Worden, J.W. (2009) Grief Counselling and Grief Therapy, Fourth Edition: A Handbook for the mental health practitioner, 4^th edition. Springer publishing company.

Corey, G, Corey, M., Corey, C., Callanan, P. (2014) Issues and Ethics in the Helping Professions, 9^th edition. Cengage.

Pazdur, R., Camphausen, K.A., Wagman, L.D., & Hoskins, W.J.  (2009). Cancer Management: A Multidisciplinary Approach. Cmp United Business Media.