Thursday, June 24, 2010

Coping with melanoma

A clinical psychologist at UC San Francisco published an essay a few years ago titled, “Coping with Melanoma,” that’s useful reading for anyone with advanced disease. Most of what I’ve found in the psychological literature is simplistic and not especially credible. What Andrew Kneier has written is a refreshing exception.

I suspect that cancer patients of all types would find Kneier’s coping strategies familiar. He notes in his introduction, however, that the issue of coping, and thus of emotional well-being, is especially relevant to those with melanoma because the immune system is so clearly affected by one’s emotional state. Melanoma patients may be able to promote a more effective immune response by virtue of how we cope with the stressful aspects of our illness. The mind-body connection is seriously in play for us.

I’ve never much cared for the term “coping,” as it seems to imply an approach to problems that’s superficially therapeutic. Kneier defines coping as attitudes and behaviors that have an “adaptive intent” that safeguard one’s emotional state and that don’t aim to resolve anything. Taken in this broader context, I agree that how we respond to a threatening situation is worth examining. Coping strategies that embrace all of whom I am, and not just the immediate threat of melanoma, helps to give me command of a situation that, at times, seems out of control.

Among the various strategies that Kneier cites is one on maintaining hope and optimism, which I excerpt here:

If the first step in coping is to face reality, the second step is to maintain hope and optimism in relation to that reality. Not surprisingly, patients who are hopeful and optimistic show a better adjustment to their illness than patients who are pessimistic. In some studies, optimism has also been associated with improved medical outcomes. For example, patients with stage 4 melanoma who were optimistic about the treatment regimen were found to live longer than those who were considered to be more “realistic.”

Most patients tell themselves to be positive, but for many, this is easier said than done. This is certainly true for patients with melanoma. Feeling optimistic that the disease will not recur implies that the person feels lucky. But many patients feel they were unlucky to get melanoma in the first place, and thus feel like an "unlucky person." Therefore, they cannot expect that they would now enjoy the good fortune of a long remission or cure. For some, optimism can also seem presumptuous: after all, other patients with the same diagnosis have not done well, and a person might think, "What right do I have to expect that I will do better?" Optimism could also make a person feel that he or she were not worrying enough about the risk posed by melanoma—that is, that the person was not giving melanoma the fear it deserved, that the person was acting too bold or confident in the face of it, and thus asking for if the melanoma might recur to teach a lesson.

Finally, if a person’s prognosis is more favorable than other melanoma patients, he or she may feel that it is not right to enjoy this good fortune or to take advantage of it (that is, by being optimistic and going forward with one’s life in a positive and constructive manner). The bottom line is that patients often feel that it is wrong and dangerous to be too optimistic. Sometimes patients are not fully aware that their optimism is being inhibited for these reasons.
No shrink could say it better. In my case, I zig and zag between optimism that I’m in long-term remission and pessimism that my melanoma could return any day. I feel guilt over feeling good, when I personally know people with cancer who are really suffering, and when I’m anxious and worried, I compound my misery by believing things will only get worse.

It’s been hard lately not to engage in magical thinking that because of some personal virtue, I may have been purged of cancer. I keep finding myself thinking, “What have I done right?” On the other hand, let me assure you that I do not underestimate the dark power of melanoma. It can come and go just as easily as come and stay. It says something about my emotional state that I can hold both these thoughts—magical optimism and defensive pessimism—in my mind at the same time.

My medical situation provides a basis for hope and a basis for worry, as with most melanoma patients. Kneier writes that this mixed emotional response reflects good psychological health. It might also just mean that I’m seriously mixed up. Psychology is a soft science and while it may partially explain what’s going on in my head, I must ultimately decide for myself the best way to live in the shadow of an ambiguous, persistent threat.

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