Since Spiegel's first report, two other groups have made similar findings. Jean Richardson, of the University of Southern California, offered counseling and home visits to lymphoma (lymph cancer) patients, and found that they outlived the control group (see "The Effect of Compliance..." in the bibliography)
And Fawzy I. Fawzy, of the University of California at Los Angeles, randomly assigned malignant melanoma (skin cancer) patients to support groups, and found significantly lower death rates (see "Malignant Melanoma: ..." in the bibliography).
However, a 10-year follow-up of a cancer support group that focused on positive emotions showed no survival advantage (see "Survival of Breast Cancer Patients..." in the bibliography).
It's safe to say Spiegel's findings rocked the medical community. Doctors had begun accepting the notion that psychotherapy could reduce pain, anxiety, and fatigue, but many were skeptical that it could help people live longer.
Perhaps most controversial was Spiegel's focus on emotional expression, which he calls a "crucial" factor that "differentiates us from almost all other approaches." Obviously, the emotions of cancer patients tend to be negative, which are scary to patients and their physicians. "We're trained to treat crying as bleeding," Spiegel says of his colleagues, "to apply direct pressure to stop it. But if a strong emotional response is appropriate, you should allow it." To do otherwise "tells the patient that a normal reaction to a life-threatening event is not normal, not acceptable."
Spiegel says he's not advocating that doctors become counselors. "My years of experience convince me that a little bit of empathy can go a long way. I'm not asking for 60 minutes with a box of Kleenex. Take a couple of minutes, look the patient in the eye, and say, 'I'm really sorry this is happening to you.' That admits a lot of the sadness, and will be very helpful."
When training support group leaders, Spiegel puts it this way: "If you see somebody crying, don't just do something -- stand there." These are other guidelines for the support groups:
Personalization: Bring the issue into the room. Don't talk about how someone else is responding to your cancer, talk about your own feelings.
Emotional expression: Follow the affect [expression of emotion], not the content.
Supportive interactions: Give everyone a chance to talk.
Facilitate active coping: Aid the members' real-world efforts to obtain better medical information or otherwise change their lives with, for example, meditation or self-hypnosis.
Helping patients face the fears directly creates an intimacy that builds what Spiegel calls "social glue." Members, he adds, "will give time, energy and attention, all kinds of thing to one another, even though they are very sick." Furthermore, expressing negative emotions allows patients to feel more joy. "You develop a battlefield humor. When you have a good cry, you have a good laugh afterwards."
I got a right to sing the blues...
Spiegel's program begins with the recognition that cancer patients are "extraordinarily isolated, have fears and anxiety, yet emotional expression is actually discouraged. Many cancer patients think their bodies are betraying them. It's unsurprising that people have a normal sadness when they have a cancer diagnosis, yet it's often not handled well, or not recognized."
What he calls "the grief that is not spoken" seems to initiate a downward mental-physical feedback spiral. Many studies show that emotional problems go hand in hand with physical illness. For example, major depression (defined) is seen in 11 percent of hospital in-patients, compared to 3 percent of the general population. And some form of depression or other emotional illness appears in anywhere from 4.5 percent to 50 percent of cancer patients, depending on whose research you believe.
This is not to say that depressed patients get cancer, but rather that cancer patients get depressed, which in turn increases the likelihood of pain and disability. It's a feedback mechanism that degrades both mental and physical health, Spiegel says. "Although depression and other psychiatric disorders may amplify pain, it is likely that persistent pain contributes to depression."
