Lung Cancer Adjustment

They’re the guilt cancers: lung cancer in smokers, oral cancers originating at the very spot where a wad of tobacco nested for years, advanced-stage colorectal cancer in patients who long neglected ominous but obvious signs such as hematochezia.

The festering emotional consequences of self-blame play out in the clinic in many forms: denial, displaced anger at staff, and passive self-harm through noncompliance.

But the question lingers: How can we help these guilt-ridden patients refocus their gaze from the rearview mirror to the path ahead?

Although it may be necessary and cathartic for a patient to acknowledge and process the role that behavior may have played in the development of his or her cancer, the ultimate goal, it seems to me, must be to help such patients muster the energy to cope with challenges here and now.

A recent study may help the oncology community toward that end (Ann. Behav. Med. 2012;44:331-40).

Dr. Kathrin Milbury of the University of Texas MD Anderson Cancer Center, Houston, and her associates studied 158 couples, illuminating not only the potent negative impact of guilt on adjustment to lung cancer but offering a fresh and revealing perspective on inward self-blame’s evil twin – reproach from a spouse.

Among the participants, 85.4% acknowledged a smoking history, with 46.7% blaming themselves "very much" or "completely" for engaging in behaviors that may have contributed to their cancer. Spouses were less likely to blame patients at that early stage of treatment, but when it was present, blame was far more powerfully correlated with distress (P less than .0001), versus P less than .05 for patients who blamed themselves for their disease.

Nonsmoking spouses were more likely to blame patients for their cancer; current or recent smokers were more likely to be blamed than former smokers.

Among patients, the researchers found that a good marriage was protective, mediating the link between blame and distress. (Ratings of marital adjustment were based on measures of consensus, satisfaction, cohesion, and affectionate expression.)

Not so for spouses. Regardless of dyadic adjustment, high levels of blame were associated with sharply increased distress. Only having a good support network helped to reduce distress, but only marginally.

"Prospectively, there was no buffering effect for patients or spouses," the researchers said. "In fact, initial blame predicted later distress above and beyond initial distress emphasizing the lingering harmful effects of blame in couples."

The authors offered a number of important insights into their findings.

"Blaming one’s loved one for developing a life-threatening disease may be particularly psychologically taxing because spouses may experience conflicting cognition and emotions (e.g. anger, guilt, fear, worry, compassion, and affection)," they noted.

Moreover, previous research (Oncol. Nurs. Forum 2008;35:681-9) demonstrates that "caregivers who blamed the patient for developing cancer were more likely to experience negative affect, which in turn was associated with fewer helping behaviors," Dr. Milbury and her associates wrote.

The importance of early, couple-based interventions, especially among current or recent smokers, was emphasized by the authors to hopefully prevent "a snowballing effect of distress."

Cognitive restructuring, helping patients and spouses to connect with supportive networks, and bolstering marital communication all were seen as important and viable interventions to help couples acknowledge and work through the toxic issue of blame.

"It is possible that in well-functioning marriages, couples have discussions about the cancer cause in a factual, non-accusatory manner, as opposed to displaying derogatory or punitive behaviors," the investigators said.

Helping to foster such communication might be seen as a key goal of interventions with couples.

"Rather than holding back distressing thoughts and emotions, teaching couples how to mutually engage and openly exchange thoughts, concerns, and feelings with the goal of providing and receiving support may be particularly effective components of such programs," they suggested.

Certainly, this new study points to potential benefits for the patient with such an approach. For spouses, whose blame-linked distress persisted despite the health of their marriages, better links to supportive networks may offer relief.

As with so many aspects of emotional adjustment in cancer patients and their families, more research is needed.

But it is valuable for all in the oncology community to know that blame – whether self-directed or coming from a spouse – may seriously complicate emotional perspective and care in the "guilt cancers" well beyond their physical toll.

Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist. This column "Vitality Signs," appears regularly in The Oncology Report. Visit www.oncologyreport.com to see what is new in Vitality Signs.

They’re the guilt cancers: lung cancer in smokers, oral cancers originating at the very spot where a wad of tobacco nested for years, advanced-stage colorectal cancer in patients who long neglected ominous but obvious signs such as hematochezia.

The festering emotional consequences of self-blame play out in the clinic in many forms: denial, displaced anger at staff, and passive self-harm through noncompliance.

But the question lingers: How can we help these guilt-ridden patients refocus their gaze from the rearview mirror to the path ahead?

Although it may be necessary and cathartic for a patient to acknowledge and process the role that behavior may have played in the development of his or her cancer, the ultimate goal, it seems to me, must be to help such patients muster the energy to cope with challenges here and now.

A recent study may help the oncology community toward that end (Ann. Behav. Med. 2012;44:331-40).

Dr. Kathrin Milbury of the University of Texas MD Anderson Cancer Center, Houston, and her associates studied 158 couples, illuminating not only the potent negative impact of guilt on adjustment to lung cancer but offering a fresh and revealing perspective on inward self-blame’s evil twin – reproach from a spouse.

Among the participants, 85.4% acknowledged a smoking history, with 46.7% blaming themselves "very much" or "completely" for engaging in behaviors that may have contributed to their cancer. Spouses were less likely to blame patients at that early stage of treatment, but when it was present, blame was far more powerfully correlated with distress (P less than .0001), versus P less than .05 for patients who blamed themselves for their disease.

Nonsmoking spouses were more likely to blame patients for their cancer; current or recent smokers were more likely to be blamed than former smokers.

Among patients, the researchers found that a good marriage was protective, mediating the link between blame and distress. (Ratings of marital adjustment were based on measures of consensus, satisfaction, cohesion, and affectionate expression.)

Not so for spouses. Regardless of dyadic adjustment, high levels of blame were associated with sharply increased distress. Only having a good support network helped to reduce distress, but only marginally.

"Prospectively, there was no buffering effect for patients or spouses," the researchers said. "In fact, initial blame predicted later distress above and beyond initial distress emphasizing the lingering harmful effects of blame in couples."

The authors offered a number of important insights into their findings.

"Blaming one’s loved one for developing a life-threatening disease may be particularly psychologically taxing because spouses may experience conflicting cognition and emotions (e.g. anger, guilt, fear, worry, compassion, and affection)," they noted.

Moreover, previous research (Oncol. Nurs. Forum 2008;35:681-9) demonstrates that "caregivers who blamed the patient for developing cancer were more likely to experience negative affect, which in turn was associated with fewer helping behaviors," Dr. Milbury and her associates wrote.

The importance of early, couple-based interventions, especially among current or recent smokers, was emphasized by the authors to hopefully prevent "a snowballing effect of distress."

Cognitive restructuring, helping patients and spouses to connect with supportive networks, and bolstering marital communication all were seen as important and viable interventions to help couples acknowledge and work through the toxic issue of blame.

"It is possible that in well-functioning marriages, couples have discussions about the cancer cause in a factual, non-accusatory manner, as opposed to displaying derogatory or punitive behaviors," the investigators said.

Helping to foster such communication might be seen as a key goal of interventions with couples.

"Rather than holding back distressing thoughts and emotions, teaching couples how to mutually engage and openly exchange thoughts, concerns, and feelings with the goal of providing and receiving support may be particularly effective components of such programs," they suggested.

Certainly, this new study points to potential benefits for the patient with such an approach. For spouses, whose blame-linked distress persisted despite the health of their marriages, better links to supportive networks may offer relief.

As with so many aspects of emotional adjustment in cancer patients and their families, more research is needed.

But it is valuable for all in the oncology community to know that blame – whether self-directed or coming from a spouse – may seriously complicate emotional perspective and care in the "guilt cancers" well beyond their physical toll.

Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist. This column "Vitality Signs," appears regularly in The Oncology Report. Visit www.oncologyreport.com to see what is new in Vitality Signs.

They’re the guilt cancers: lung cancer in smokers, oral cancers originating at the very spot where a wad of tobacco nested for years, advanced-stage colorectal cancer in patients who long neglected ominous but obvious signs such as hematochezia.

The festering emotional consequences of self-blame play out in the clinic in many forms: denial, displaced anger at staff, and passive self-harm through noncompliance.

But the question lingers: How can we help these guilt-ridden patients refocus their gaze from the rearview mirror to the path ahead?

Although it may be necessary and cathartic for a patient to acknowledge and process the role that behavior may have played in the development of his or her cancer, the ultimate goal, it seems to me, must be to help such patients muster the energy to cope with challenges here and now.

A recent study may help the oncology community toward that end (Ann. Behav. Med. 2012;44:331-40).

Dr. Kathrin Milbury of the University of Texas MD Anderson Cancer Center, Houston, and her associates studied 158 couples, illuminating not only the potent negative impact of guilt on adjustment to lung cancer but offering a fresh and revealing perspective on inward self-blame’s evil twin – reproach from a spouse.

Among the participants, 85.4% acknowledged a smoking history, with 46.7% blaming themselves "very much" or "completely" for engaging in behaviors that may have contributed to their cancer. Spouses were less likely to blame patients at that early stage of treatment, but when it was present, blame was far more powerfully correlated with distress (P less than .0001), versus P less than .05 for patients who blamed themselves for their disease.

Nonsmoking spouses were more likely to blame patients for their cancer; current or recent smokers were more likely to be blamed than former smokers.

Among patients, the researchers found that a good marriage was protective, mediating the link between blame and distress. (Ratings of marital adjustment were based on measures of consensus, satisfaction, cohesion, and affectionate expression.)

Not so for spouses. Regardless of dyadic adjustment, high levels of blame were associated with sharply increased distress. Only having a good support network helped to reduce distress, but only marginally.

"Prospectively, there was no buffering effect for patients or spouses," the researchers said. "In fact, initial blame predicted later distress above and beyond initial distress emphasizing the lingering harmful effects of blame in couples."

The authors offered a number of important insights into their findings.

"Blaming one’s loved one for developing a life-threatening disease may be particularly psychologically taxing because spouses may experience conflicting cognition and emotions (e.g. anger, guilt, fear, worry, compassion, and affection)," they noted.

Moreover, previous research (Oncol. Nurs. Forum 2008;35:681-9) demonstrates that "caregivers who blamed the patient for developing cancer were more likely to experience negative affect, which in turn was associated with fewer helping behaviors," Dr. Milbury and her associates wrote.

The importance of early, couple-based interventions, especially among current or recent smokers, was emphasized by the authors to hopefully prevent "a snowballing effect of distress."

Cognitive restructuring, helping patients and spouses to connect with supportive networks, and bolstering marital communication all were seen as important and viable interventions to help couples acknowledge and work through the toxic issue of blame.

"It is possible that in well-functioning marriages, couples have discussions about the cancer cause in a factual, non-accusatory manner, as opposed to displaying derogatory or punitive behaviors," the investigators said.

Helping to foster such communication might be seen as a key goal of interventions with couples.

"Rather than holding back distressing thoughts and emotions, teaching couples how to mutually engage and openly exchange thoughts, concerns, and feelings with the goal of providing and receiving support may be particularly effective components of such programs," they suggested.

Certainly, this new study points to potential benefits for the patient with such an approach. For spouses, whose blame-linked distress persisted despite the health of their marriages, better links to supportive networks may offer relief.

As with so many aspects of emotional adjustment in cancer patients and their families, more research is needed.

But it is valuable for all in the oncology community to know that blame – whether self-directed or coming from a spouse – may seriously complicate emotional perspective and care in the "guilt cancers" well beyond their physical toll.

Dr. Freed is a clinical psychologist in Santa Barbara, Calif., and a medical journalist. This column "Vitality Signs," appears regularly in The Oncology Report. Visit www.oncologyreport.com to see what is new in Vitality Signs.