Intervention Research

Several approaches intended to reduce stress primarily through emotion-focused coping have been investigated. Emotion-focused coping refers to dealing directly with the emotional concomitants of life events, such as distress and existential angst, rather than trying to solve the problem directly—it is useful in circumstances when one has little or no control over the specific situation, such as fears of cancer recurrence or death and dying.68 Our experience is predominantly in the application of mindfulness-based stress reduction (MBSR). However, before reviewing this research in detail, we present an overview of several other approaches that have shown some benefit for cancer survivors. The three approaches we summarize are cognitive-behavioral stress management (CBSM), supportive-expressive group therapy (SEGT), and creative arts interventions.

CBSM was developed by the Miami Behavioral Medicine group in the 1980s to help people diagnosed with AIDS cope with the demands of chronic illness. The 10-week group program is manualized and structured, and covers a variety of areas including stress awareness, aspects of cognitive-behavior therapy such as identification of automatic thoughts and cognitive distortions, physical relaxation and breathing techniques, meditation, social support, anger management, and as-sertiveness communication training. It has since been reformulated for application to cancer populations and a manual on CBSM specifically for the treatment of breast cancer published by the American Psychological Association.69

The CBSM program has been applied to groups of women with breast cancer and men with prostrate cancer by the Miami group. They found that CBSM compared to a 1-day stress management seminar decreased depression, improved emotional processing, and increased optimism and a sense of benefit of having gone through the cancer experience in women with early stage (0-II) breast cancer.44 They also investigated biological outcomes and found that women assigned to CBSM showed decreases in cortisol levels after group completion,70 and increases in immune cell response to a T-cell challenge at the end of adjuvant therapy.71 In addition, the physiological changes were greatest in those women who showed the most psychological improvements. In the longer term, women in CBSM showed a stronger immune response of NK cells up to 6 months after completing the CBSM intervention. In men with prostate cancer, similarly, CBSM improved quality of life, enhanced benefit finding and improved stress management skills.72

SEGT is a form of professionally led group psychosocial intervention that evolved specifically to address the support needs of seriously ill medical patients. Two key interrelated goals of SEGT are to build social bonds and to facilitate the expression of emotion. Within the supportive context of the therapy group, patients are encouraged to express the full range of authentic feelings they are experiencing as they confront the existential reality of living with a life threatening and often debilitating illness. The adaptive function of emotions is validated and a shared group ethic of acknowledging and expressing emotion serves to normalize expectable reactions of fear and sorrow. This frees patients from harmful, emotionally stultifying social proscriptions against expressing what are commonly seen as negative emotions and unconsidered, though well-meaning, exhortations to "keep positive." Other goals of SEGT include detoxifying illness and death, redefining life priorities, improving coping, enhancing the doctor-patient relationship, and fortifying existing networks of friends and family. Thus, the group becomes a vessel for the expression, containment, and processing of current distress. At the same time, ample scope is provided to explore the longer-term meaning and implications of living with a serious or life-threatening medical condition. This enables patients and their families to proactively address foreseeable challenges, to marshal appropriate resources and to make the most of whatever life remains.73

Though an early finding of extended survival for metastatic breast cancer patients enrolled in a supportive-expressive group74 was not replicated in the large breast expressive-supportive therapy pan-Canadian trial (BEST75), success of the approach in alleviating pain and suffering, as well as enriching the lives of patients diagnosed with metastatic cancer, has led to successful utilization of the therapeutic model for patients with early stage breast cancer76 and investigations of its applicability for patients diagnosed with a range of other serious illnesses (see ref. 77).

The third area of interest encompasses a variety of interventions based on principles affirming the healing capacity of creative activity. Creative therapies for cancer patients are generally intended to integrate physical, emotional, and spiritual care by facilitating creative ways for patients to respond to their cancer experience.78 Some have suggested that by offering opportunities to engage in the arts and creative expression, persons with cancer can be enabled to mourn, grieve, celebrate life, be empowered to endure their situation, and find healing and meaning.79 The overall mission of one program was stated as the identification and development of connections between the creative arts and the healing arts that improve the physical, mental, emotional, and spiritual health within the community.80 The basic assumption underlying this program was that creating opportunities to explore artistic expression without judgment or criticism can lead to greater self-awareness and self-esteem and can stimulate innate creative and healing processes. Similarly, the stated goals of another program developed cooperatively by artists and health care professionals were to: (1) provide an environment that develops into a nurturing community; (2) create opportunities for emotional healing; (3) help participants to find meaning in their experiences; and (4) promote creativity as a vehicle for self-knowledge through the creation of a piece of artwork.81

However, although there are many descriptions of various programs in the literature, with content ranging from the visual arts82 to dance,83 music therapy,84 creative writing,82 and mixed-modality programs,78,80 few have included rigorous evaluation components. Benefits that have been reported from creative therapy programs include social support, psychological strength, and new insights about the cancer experience.79 Research on expressive writing paradigms have supported its benefits in groups of medical patients,85 and in another study, cancer patients who wrote about their cancer experience reported significantly less sleep disturbance, better sleep quality and sleep duration, and less daytime dysfunction than those who wrote about a neutral experience.86 Additional well-controlled research in creative arts therapies utilizing visual arts, sculpture, music, and dance are needed.

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