Abstract
Emerging evidence supports the efficacy of transdiagnostic approaches in the treatment of comorbid conditions. Given that both depression and anxiety disorders have been consistently noted as the most common psychological presentation across site and stage of illness in patients with cancer, psycho-oncology as a specialty may benefit from approaches that implement transdiagnostic approaches to treatment. This paper presents an adaptation of emotion-focused therapy for comorbid anxiety and depression in women with breast cancer. The described approach outlines how the chronic problematic emotion schemes are triggered by the experience of cancer and its medical treatment as well as transformation of those schemes through a sequence of steps. A process of change occurs through overcoming emotional avoidance and demoralization, increasing distress tolerance, differentiation of core painful feelings, articulation of unmet needs; and generation of adaptive emotions such as boundary setting anger and self-compassion. Implications for practice in a cancer context are discussed in terms of case conceptualisation and therapeutic strategy. Further investment in the clinical development and research of emotion-focused therapy in psycho-oncology may prove informative and supportive in efforts to widen the evidence base and the choice of clinical treatment available to patients with cancer and comorbid anxiety and depressive disorders.
Similar content being viewed by others
References
Barlow, D. H., Farchione, T. J., & Bullis, J. R. (2017). The unified protocol for transdiagnostic treatment of emotional disorders compared with diagnosis-specific protocols for anxiety disorders: A randomized clinical trial. JAMA Psychiatry,74(9), 875–884. https://doi.org/10.1001/jamapsychiatry.2017.2164.
Begovic-Juhant, A., Chmielewski, A., Iwuagwu, S., & Chapman, L. (2012). Impact of body image on depression and quality of life among women with breast cancer. Journal of Psychosocial Oncology,30(4), 446–460. https://doi.org/10.1080/07347332.2012.684856.
Boquiren, V. M., Esplen, M. J., Wong, J., Toner, B., & Warner, E. (2013). Exploring the influence of gender-role socialization and objectified body consciousness on body image disturbance in breast cancer survivors. Psycho-Oncology,22(10), 2177–2185. https://doi.org/10.1002/pon.3271.
Boss, P. (2009). The trauma and complicated grief of ambiguous loss. Pastoral Psychology,59(2), 137–145. https://doi.org/10.1007/s11089-009-0264-0.
Brandão, T., Tavares, R., Schulz, M. S., & Matos, P. M. (2016). Measuring emotion regulation and emotional expression in breast cancer patients: A systematic review. Clinical Psychology Review,43, 114–127. https://doi.org/10.1016/j.cpr.2015.10.002.
Bray, F., Ferlay, J., Soerjomataram, I., Siegel, R. L., Torre, L. A., & Jemal, A. (2018). Global cancer statistics 2018: GLOBOCAN estimates of incidence and mortality worldwide for 36 cancers in 185 countries. CA: A Cancer Journal for Clinicians, 68(6), 394–424. https://doi.org/10.3322/caac.21492.
Campbell-Enns, E. H. J., & Woodgate, R. L. (2017). The psychosocial experiences of women with breast cancer across the lifespan: A systematic review. Psycho-Oncology,26(11), 1711–1721. https://doi.org/10.1002/pon.4281.
Canadian Cancer Society’s Advisory Committee on Cancer Statistics. (2018). Canadian Cancer Statistics 2018. Canadian Cancer Society, Toronto. Retrieved from http://www.cancer.ca/~/media/cancer.ca/CW/cancer%20information/cancer%20101/Canadian%20cancer%20statistics/Canadian-Cancer-Statistics-2018-EN.pdf?la=en.
Connolly, A. J. (2016). Developing emotion-focused therapy for CAD in women with breast cancer: An analysis of six case studies. (Unpublished doctoral dissertation). Trinity College, Dublin, Ireland.
Curran, L., Sharpe, L., & Butow, P. (2017). Anxiety in the context of cancer: A systematic review and development of an integrated model. Clinical Psychology Review,56, 40–54. https://doi.org/10.1016/j.cpr.2017.06.003.
Doka, K. J. (1989). Disenfranchised grief. In K. J. Doka (Ed.), Disenfranchised grief: Recognizing hidden sorrow (pp. 13–23). Lexington, MA: Lexington Books.
de Figueiredo, J. M., & Frank, J. D. (1982). Subjective incompetence, the clinical hallmark of demoralization. Comprehensive Psychiatry, 23(4), 353–363. https://doi.org/10.1016/0010-440X(82)90085-2.
Dumalaon-Canaria, J., Hutchinson, A., Prichard, I., & Wilson, C. (2014). What causes breast cancer? A systematic review of causal attributions among breast cancer survivors and how these compare to expert-endorsed risk factors. Cancer Causes and Control,25(7), 771–875. https://doi.org/10.1007/s10552-014-0377-3.
Elliott, R., Watson, J. C., Goldman, R. N., & Greenberg, L. S. (2004). Learning emotion-focused therapy: The process-experiential approach to change. Washington, DC: American Psychological Association. https://doi.org/10.1037/10725-000.
Engelmann, D., Scheffold, K., Friedrich, M., Hartung, T. J., Schulz-Kindermann, F., Lordick, F., et al. (2016). Death-related anxiety in patients with advanced cancer: Validation of the German version of the death and dying distress scale. Journal of Pain and Symptom Management,52(4), 582–587. https://doi.org/10.1016/j.jpainsymman.2016.07.002.
Gold, M., Dunn, L. B., Pheonix, B., Paul, S. M., Hamolsky, D., Levine, J. D., et al. (2016). Co-occurrence of anxiety and depression symptoms following breast cancer surgery and its impact on quality of life. European Journal of Oncology Nursing.,20, 97–105. https://doi.org/10.1016/j.ejon.2015.06.003.
Goldman, R. N., & Greenberg, L. S. (2015). Case formulation in emotion-focused therapy: Co-creating clinical maps for change. Washington, DC: APA.
Gonen, G., Kaymak, S. U., Cankurtaran, E. S., Karslioglu, E. H., Ozalp, E., & Soygur, H. (2012). The factors contributing to death anxiety in cancer patients. Journal of Psychosocial Oncology,30(3), 347–358. https://doi.org/10.1080/07347332.2012.664260.
Greenberg, L. S. (2004). Emotion–focused therapy. Clinical Psychology & Psychotherapy, 11(1), 3–16. https://doi.org/10.1002/cpp.388.
Greenberg, L. S. (2017). Emotion-focused therapy (2nd ed.). Washington, DC: American Psychological Association.
Greenberg, L. S., Rice, L., & Elliott, R. (1993). The moment by moment process: Facilitating emotional change. New York: Guilford Press.
Greenberg, L. S., & Watson, J. C. (2006). Emotion-focused therapy for depression. Washington, DC: American Psychological Association.
Gurevich, M., Devins, G. M., & Rodin, G. M. (2002). Stress response syndromes and cancer: Conceptual and assessment issues. Psychosomatics,43(4), 259–281. https://doi.org/10.1176/appi.psy.43.4.259.
Holland, J. C., Jacobsen, P. B., Andersen B., et al. (2016). NCCN clinical practice guidelines in oncology: distress management, v2.2016. National Comprehensive Cancer Network, Inc. Retrieved from https://www.nccn.org/professionals/physician_gls/pdf/distress.pdf.
Kannan, D., & Levitt, H. M. (2013). A review of client self-criticism in psychotherapy. Journal of Psychotherapy Integration,23, 166–178. https://doi.org/10.1037/a0032355.
Lichtenthal, W. G., Nilsson, M., Baohui, Z., Trice, E. D., Kissane, D. W., Breitbart, W., et al. (2009). Do rates of mental disorders and existential distress among advanced stage cancer patients increase as death approaches? Psycho-Oncology,18(1), 50–61. https://doi.org/10.1002/pon.1371.
Maass, S. W. M. C., Roorda, C., Berendsen, A. J., Verhaak, P. F. M., & de Bock, G. H. (2015). The prevalence of long-term symptoms of depression and anxiety after breast cancer treatment: A systematic review. Maturitas,82(1), 100–108. https://doi.org/10.1016/j.maturitas.2015.04.010.
McCreaddie, M., Payne, S., & Froggatt, K. (2010). Ensnared by positivity: A constructivist perspective on “being positive” in cancer care. European Journal Of Oncology Nursing,14(4), 283–290. https://doi.org/10.1016/j.ejon.2010.03.002.
McNally, S., Timulak, L., & Greenberg, L. S. (2014). Transforming emotion schemes in emotion focused therapy: A case study investigation. Person-Centered & Experiential Psychotherapies,13, 128–149. https://doi.org/10.1080/14779757.2013.871573.
Mehnert, A., Brähler, E., Faller, H., Härter, M., Keller, M., Schulz, H., et al. (2014). Four-week prevalence of mental disorders in patients with cancer across major tumor entities. Journal of Clinical Oncology,32, 3540–3546. https://doi.org/10.1200/JCO.2014.56.0086.
Mitchell, A. J., Chan, M., Bhatti, H., Halton, M., Grassi, L., Johansen, C., et al. (2011). Prevalence of depression, anxiety, and adjustment disorder in oncological, haematological, and palliative-care settings: A meta-analysis of 94 interview-based studies. The Lancet. Oncology, 12(2), 160–174. https://doi.org/10.1016/S1470-2045(11)70002-X.
Neel, C., Lo, C., Rydall, A., Hales, S., & Rodin, G. (2015). Determinants of death anxiety in patients with advanced cancer. BMJ Supportive & Palliative Care,5(4), 373–380. https://doi.org/10.1136/bmjspcare-2012-000420.
Norton, P. J., & Paulus, D. J. (2016). Toward a unified treatment for emotional disorders: Update on the science and practice. Behaviour Therapy,47(6), 854–868. https://doi.org/10.1016/j.beth.2015.07.002.
O’Brien, K., O’Keeffe, N., Cullen, H., Durcan, A., Timulak, L., & McElvaney, J. (2017). Emotion-focused perspective on generalized anxiety disorder: A qualitative analysis of clients’ in-session presentations. Psychotherapy Research, 29(4), 524–540. https://doi.org/10.1080/10503307.2017.1373206.
Paivio, S. C., & Pascual-Leone, A. (2010). Emotion-focused therapy for complex trauma: An integrative approach. Washington, DC: American Psychological Association. https://doi.org/10.1037/12077-000.
Pascual-Leone, A. (2009). Dynamic emotional processing in experiential therapy: Two steps forward, one step back. Journal of Consulting and Clinical Psychology,77(1), 113–126. https://doi.org/10.1037/a0014488.
Pascual-Leone, A. (2018). How clients “change emotion with emotion”: A programme of research on emotional processing. Psychotherapy Research, 28(2), 165–182. https://doi.org/10.1080/10503307.2017.1349350.
Pascual-Leone, A., & Greenberg, L. S. (2007). Emotional processing in experiential therapy: Why “the only way out is through”. Journal of Consulting and Clinical Psychology,75, 875–887. https://doi.org/10.1037/0022-006X.75.6.875.
Robinson, S., Kissane, D. W., Brooker, J., & Burney, S. (2015). A systematic review of the demoralization syndrome on individuals with progressive disease and cancer: A decade of research. Journal of Pain and Symptom Management,49(3), 595–610. https://doi.org/10.1016/jpainsymman.2014.07.008.
Schlatter, M. C., & Cameron, L. D. (2010). Emotional suppression tendencies as predictors of symptoms, mood, and coping appraisals during AC chemotherapy for breast cancer treatment. Annals of Behavioural Medicine,40(1), 15–29. https://doi.org/10.1007/s12160-010-9204-6.
Shahar, B., Kalifa-Bar, E., & Alon, E. (2017). Emotion-focused therapy for social anxiety disoders: Results from a multiple-baseline study. Journal of Consulting and Clinical Psychology,85(3), 238–249. https://doi.org/10.1037/ccp0000166.
Sharpe, L., Curran, L., Butow, P., & Thewes, B. (2018). Fear of cancer recurrence and death anxiety. Psycho-Oncology,27(11), 2559–2565. https://doi.org/10.1002/pon.4783.
Simard, S., Thewes, B., Humphris, G., Dixon, M., Hayden, C., Mireskandari, S., et al. (2013). Fear of cancer recurrence in adult cancer survivors: A systematic review of quantitative studies. Journal of Cancer Survivorship,7(3), 300–322. https://doi.org/10.1007/s11764-013-0272-z.
Smith, K. W., & Greenberg, L. S. (2007). Internal multiplicity in emotion-focused psychotherapy. Journal of Clinical Psychology,63(2), 175–186. https://doi.org/10.1002/jclp.20340.
Spitzer, R. L., Williams, J. B. W., Gibbon, M., & First, M. B. (1992). The Structured Clinical Interview for DSM-III-R (SCID): I: History, Rationale, and Description. Archives of General Psychiatry, 49(8), 624–629. https://doi.org/10.1001/archpsyc.1992.01820080032005.
Sun, L., Ang, E., Ang, W. H. D., & Lopez, V. (2018). Losing the breast: A meta-synthesis of the impact in women breast cancer survivors. Psycho-Oncology,27(2), 376–385. https://doi.org/10.1002/pon.4460.
Timulak, L. (2015). Transforming emotional pain in psychotherapy: An emotion-focused approach. Hove, UK: Routledge.
Timulak, L., & McElvaney, J. (2015). Emotion-focused therapy for generalized anxiety disorder: An overview of the model. Journal of Contemporary Psychotherapy,46(1), 41–52. https://doi.org/10.1007/s10879-015-9310-7.
Timulak, L., & McElvaney, J. (2017). Transforming generalized anxiety: An emotion-focused approach. Hove, UK: Routledge.
Timulak, L., McElvaney, J., Keogh, D., Martin, E., Clare, P., Chepukova, E., et al. (2017). Emotion-focused therapy for generalized anxiety disorder: An exploratory study. Psychotherapy,54, 361–366. https://doi.org/10.1037/pst0000128.
Timulak, L., & Pascual-Leone, A. (2015). New developments for case conceptualization in emotion-focused therapy. Clinical Psychology & Psychotherapy,22(6), 619–636. https://doi.org/10.1002/cpp.1922.
Vehling, S., Oechsle, K., Koch, U., & Mehnert, A. (2013). Receiving palliative treatment moderates the effect of age and gender on demoralization in patients with cancer. PLoS ONE,8(3), 59417. https://doi.org/10.1372/journal.pone.0059417.
Watson, J. C., & Greenberg, L. S. (2017). Emotion-focused therapy for generalized anxiety. Washington, DC: American Psychological Association.
Zigmond, A. S., & Snaith, R. P. (1983). The hospital anxiety and depression scale. Acta Psychiatrica Scandinavica, 67(6), 361–370. https://doi.org/10.1111/j.1600-0447.1983.tb09716.x.
Acknowledgements
This paper is based on a research project funded by the St. Luke’s Cancer Research Fund (Ireland).
Funding
This research was funded by the St. Luke’s Cancer Research Fund (Ireland).
Author information
Authors and Affiliations
Corresponding author
Additional information
Publisher's Note
Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.
Rights and permissions
About this article
Cite this article
Connolly-Zubot, A., Timulak, L., Hession, N. et al. Emotion-Focused Therapy for Anxiety and Depression in Women with Breast Cancer. J Contemp Psychother 50, 113–122 (2020). https://doi.org/10.1007/s10879-019-09439-2
Published:
Issue Date:
DOI: https://doi.org/10.1007/s10879-019-09439-2