“Good Life is a Process, Not a State of Being”: Overview and Evidence Based Approach

Arunima Datta¹ & Prathama Guha Chaudhuri^2*

¹Department of Clinical Psychology, Netaji Shubhas Chandra Bose Cancer Research Institute, India
²Institute of Psychiatry, Kolkata, India

*Correspondence to: Dr. Prathama Guha Chaudhuri, Institute of Psychiatry, Kolkata, India.

Copyright © 2018 Dr. Prathama Guha Chaudhuri, et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Introduction
The most common psychiatric disorders, and may have their onset upon the diagnosis of cancer or its treatment. It is not uncommon to find individuals suffering from anxiety disorders such as GAD, acute stress disorders, panic disorders or others. The symptoms remain more or less the same for most of the disorders of anxiety: muscle tension, increased heart rate, palpitation, sweating, pain and/or headaches. There was another commonality found in all the patients suffering from anxiety disorders. They reported thoughts and images, reflecting their patterns of thinking, which included injury socially or physically or even both [1]. It is believed that the best treatment for them is cognitive behavioural therapy [2]. The presence of comorbidity has an effect on the quality of life, their approach to their treatments, seeking social support and also their survival. If the direct and indirect effects of the diseases or disorders are dealt with, it results in effective coping strategies.

When faced with the trauma of cancer, the patient has to deal with strong emotions that can interfere with the person’s sleep, diet, exercise, social relationships, and medical care [3]. During the period of before and after treatment and cancer care, the psychiatric symptoms that the patient suffers from have an impact on not only the overall well-being of the patient, but also their families. For many, a diagnosis of cancer brings about the same amount of trauma or distress as do any physical assaults, facing natural disasters or an accident. Therefore, it is essential that they have a positive outlook towards their diagnosis and treatment process. In most of the cases we can see many patients remember the period of diagnosis, for example, the place, date and time of where and when the received the diagnosis, who they received the details it from, the words that were used to tell them of their condition and the feelings that they went through upon the discovery of their condition.

Rokovek et al. had conducted a study on student sample, to test the efficiency of therapies. They concluded that cognitive behavioral therapy had better effects as compared to relaxation plus non-directive therapy. However, contradictory results were found in the study done by Borkovek and Mathews, who showed that treatment effects of two different types of therapies were similar when done at post-test as well as after a follow-up of 12-months. This study was done on clinical participants. Depression symptoms are frequently showed in patients with generalized anxiety disorder. After comparing three studies of different researchers Chambless and Gillis [4] concluded through their study that cognitive behavioral therapy was more effective on depression as compared to the results shown through only behavioural therapy [5]. Although Cognitive behavioural therapy was found to have had greater impact on depression, but it the same was not applicable for applied relaxation [6]. Despite this, in 1987, Borkovec et al [7] had concluded through their investigation that for the patients who completed the entire treatment procedure, there was no significant impact of CBT on their depression levels. To reduce the impact of chemotherapy which causes vomiting, nausea, and anxiety, Arakawa in 1997 [8] found that progressive muscle relaxation therapy was effective. The methods of application of relaxation therapeutic techniques through the efficacy of worry exposure and to treat GAD was investigated upon by Hover et al, using both- the experimental and control groups. The results indicated that indeed such a therapeutic treatment was effective in both cases. It can be said that people who are suffering from chronic illnesses such as cancer, will be able to deal with their situations much better by utilizing proper coping strategies during their treatment periods. These coping strategies may be efforts that have either physical, cognitive or behavioural impact on the person, or even a combination. Payne in 1990 stated that there are four ways of dealing or coping with ones situations: fearfulness, hopelessness, acceptance and thinking positively. And these were studied in patients who were undergoing chemotherapy. Women who had “confrontative” style of coping strategy during their chemotherapy treatment, had less physical as well as psychological symptoms in comparison to those whose coping style comprised of “avoidant” tendency [9]. A further research showed cognitive and behavioural escape avoidance tendencies to coping were the most important strategy. It stated that these tendencies give rise to psychological distress while receiving chemotherapy [10]. Therefore, it was noted that fighting spirit in coping strategies led to the patients dealing better with chemotherapy [11].

Here, we reviewed the pervasiveness of psychological intervention as well as symptoms among breast cancer patients. In the present study, we have discussed well developed screening procedure for attempting to identify and track psychiatric comorbidities. The present review aimed to determine psychological symptoms as well as significant psychological screening procedure for diagnosing psychological symptoms. Along with that, the present study had prominent different types of psychological therapy which had already used among victimized one. Through this review paper we wanted to present the characteristics of each psychotherapy with its experimental evidence.

Methods

Literature Search Strategy
Electronic literature searches were performed using Pubmed databases including publications up to 2017. A list of psychological intervention related keywords was used to identify studies, including relevant interventions, through an rehearsing process of search and refine, and there was no restriction on the year of publication (Table 1).

Study Selection Criteria
The following selection criteria were applied to the articles found in databases:

Type of Studies
Published primary studies were eligible for inclusion and reviews, editorials, and letters, and case reports were excluded. No limitations regarding study design or outcome measures were used. Articles included were in English.

Type of Participants
Eligible studies were those whose title or abstract specifically indicated the inclusion of breast cancer patients. The studies were included even if the sample was not exclusively composed of breast cancer patients. There were no restrictions regarding participants’ age, number of participants, or disease stage.

Psychological Interventions
The efficacy of psychological treatments for depression and anxiety is to minimize complains and improved functioning which interfere their daily life in different field by addressing the different psychological and social factors among in medically ill patients. Different types of psychological intervention, more specifically, educational, interpersonal, psychodynamic and supportive therapies, inclusive of Behavioral Therapy (BT) and Cognitive Behavioral Therapy (CBT), hypnosis and other such methods were deemed successful in various outcome studies (Aziz NM et al., 2003), [12-15].

Review Methods
A list of relevant descriptors was used to obtain the articles (Table 1). The abstracts of the identified publications were screened for relevance to the selection criteria. An article was rejected if it was determined from the abstract that the study failed to meet these criteria. When an abstract could not be rejected with certainty, the full article was appraised. A review template was developed specifying key information about each study. All studies that met inclusion criteria were assessed using this quality tool. Those studies that did not meet quality criteria were rejected from the review.

Results
Of the 1266 articles found through electronic databases, 56 studies were finally included in this review. After applying inclusion method 10 studies were selected for the present study. Apart from this, nine groups of therapies were found: Cognitive behavioural therapy (CBT), Acceptance Commitment Therapy (ACT), Palliative Care, Active Music Making Therapy, Visualization Therapy, Relaxation Therapy, Mindfulness Base Therapy, Group Psychotherapy, Family therapy, Emotional expression.

Study Characteristics

Cancer Patients: Psychological Distress Screening
Previously, most of the research had demonstrated about nature of psychological distress among cancer patients. It can be defined as the presence of psychiatric disorders and/or psychiatric comorbidity, especially anxiety and depressive disorders. Following National Comprehensive Cancer Network which published the Distress Management Guidelines. It is a regularly updated set of rules, used as an instrument by the clinicians of oncology in order to come up with deferential diagnosis of psychiatric disorders, psychosocial issues and other forms of spiritual or physical distresses (nccn.org). A string of short, but valid and reliable measures were published by NIH, not very long ago, and it helps in the measurements of patient-reported results [16,17]. These results are based on commonly used tools for screening: the Symptom Checklist [18] or its short form, the Brief Symptom Inventory [19], the General Health Questionnaire [20] Profile of Mood States [21], the Hospital Anxiety and Depression Scale [22], the State Trait Anxiety Inventory [23], and the Sickness Impact Profile [24].

Psychology Intervention
10 studies with different aspects of study designs were included. Duration of therapy session varied from 4 weeks to 6 weeks, in some cases it tends to be less 2 weeks. Only one study conducted their therapy up to 1 year. In relation to psychosocial issues, all studies reported psychotherapy has positive effects on cancer patients in regard to psychosocial issues. Mean of sample size of all studies 35.12±1.31 years and sample size varied from 51 to 110. In each study number of follow-up patients after giving psychotherapy was almost same.

Study Contents
The efficacy of psychosocial treatments for psychological symptom is to minimize complains and improved functioning which interfere their daily life in different field by addressing the different psychological and social factors among in medically ill patients. Different types of psychological intervention, more specifically, Cognitive behavioural therapy (CBT), Acceptance Commitment Therapy (ACT), Palliative Care, Music Therapy, Visualization Therapy, Relaxation Therapy, Mindfulness Base Therapy, Group Psychotherapy and Positive psychotherapy. Recent studies of each therapy were summarized in table 2.

Discussion
Anna C.G et al. in 2014 had reviewed over positive psychological interventions in breast cancer. There. Authors had summarized the evidence about the clear development of positive aspects which of those breast cancer patients was experienced. David S et al. in 2014 had investigated the screening of psychological symptoms with potentiality and applicability of psychological intervention.

Following their study, to our knowledge, we have attempted at reviewing the fruitfulness of different types of psychotherapy which were already conducted on breast cancer patients. This systematic review had depicted that most of the study deals with a patient’s anxiety, depression, quality of life (reference). Along with some of the studies had focused over additionally wellbeing, hope and optimism (reference).

The efficacy of psychosocial intervention for management of psychological symptoms, particularly Cognitive behavioral therapy (CBT), Acceptance Commitment Therapy (ACT), Palliative Care, Music Therapy, Visualization Therapy, Relaxation Therapy, Mindfulness Base Therapy, Group Psychotherapy and Positive psychotherapy has been establish with numerous outcomes.

Cognitive Behavioural Therapy
“If you correct your mind, the rest of your life will fall into place”- Lao Tzu. CBT improves regimen adherence in challenging clinical problems that require behavioural change, may help similar conditions such as cancer patients who are prescribed an oral agent of treatment. Above mentioned studies focused over the effectiveness of this type of psychological treatment. Following their methodological part we can compare CBT among two groups: with and without depression combined with breast cancer. Psychosocial factors are very important factors for developing depression among cancer patients but sometime patients have to face psychosocial issues but they did not complain depression. In future study we want to observe the fruitfulness of this type of psychotherapy in such case.

Acceptance Commitment Therapy
Stresses begin from the time when a patient comes to know that he or she is a cancer patient. So, during the journey of cancer diagnosis to treatment period they had to face very difficult situation and those situations may because of their depression. This depression may be of cause of their lack of acceptance of present situation. They are generally searching one question that is “why! God has punished me” even they think that their suffering period is just because of their “Bad Karma”. Above mentioned studies had prominent whether their depression and anxiety was improved after giving psychotherapy or not. But, in future study we have to take report about the acceptance ability among cancer patients. In one mentioned study, had focused over the pattern of thought but their number of follow-up patients were too low. For giving a better quality of life we have to just prominent their acceptance ability.

Palliative Care
Palliative care is the symptomatic management of cancer. It is the holistic approach where doctors to social worker play an important role for giving a better quality of life. Obviously, death is not coffee house topic. So, we have to make clear to patients and their family members about the present condition of disease. Every cancer patients know very well about their own physical condition rather than doctors. So, wrong interpretation about the condition may be cause of their severe depression. In mentioned study, only had prominent about the effect of palliative care only just based on the score of quality of life. Another important key, for better quality of life that is sleep. So, in future study we have to include that.

Music Therapy
Music is a therapy of communication for more powerful than words for more immediate fear more efficient. Apart from the immense spiritual, emotional and ethical impact of music in the human mind, to day modern scientific studies are constantly emphasizing on the astonishing benefits that music has in terms of human ailments. Adequate amount of modern scientific researchers in recent time have explicitly show that specific sounds and music resulted in measurable and multiple healing benefits. Even, in case of critical human ailments, “ the ever growing field of health are popularly known as “Music Therapy”. Following mentioned studies’ methodological part in future study we can conduct this type of therapy in the department of palliative medicine. This study had conducted among those cancer patients who were admitted for chemotherapy.

Visualization Therapy
Visualization (guided imagery) is a set of techniques which induce relaxation and help people create positive mental images in order to reduce stress. It is relatively inexpensive and can even be practised by bed bound people. In future study we have to show, visualization to be an effective tool to improve cancer patients’ anxiety, depression and quality of life. The common images used with cancer patients in the developed world are those involving the individual’s body and its strengths. Since breast cancer patients in India are more family oriented and often their main concerns are the stigma of having cancer and subsequent isolation of their families, including their children, we figured that positive images involving acceptance and integration within family and society would be more effective for them.

Relaxation Therapy
Generally, relaxation therapy was applied for the reduction of a patent’s anxiety. In order to reduce or control the amount of stress or increase relaxation, the patients are encouraged to take part in recreational activities, like watching TV, talking over the phone with friends or family, walking, indulging in household chores, reading, and even simple breathing techniques or muscle relaxation techniques. It was also seen that time management was helpful in reducing the stress levels in the patients. This in turn helped in sleep schedule management, which promoted activity, instead of laziness and reduction in fatigue felt by the patients. Muscle relaxation and deep breathing exercises were done. One study which was conducted in Eastern country had reported that most of the patients thought relaxation technique was stupid and less important. One Patient reported that “During the period of relaxation, I laughed again and again” [26].

From the above study, we can understand that a person can always use a wonderful massage it will make us relaxed and open up, every passage we can just lie there and dream and not do anything, let yourself go and enjoy it more, as your masseuse moves his or her fingers up and down.

Mindfulness Based Therapy
A mindfulness therapy helps individual to establish a daily mindfulness practice. This type of therapy has emphasized over what situations and thoughts are problematic with a view to helping a patient become much more aware in these situations. Kabat Zinn J et al in 1992 [29] had pointed out mindfulness-based stress reduction that enhances quality of life for daily living with that also develop tolerance ability of stress. In such cases breathing exercise make an individual more comfortable that relating to one’s body. These techniques have been proved to be effective when done on cancer patients. There are many other studies that have concluded that combining mindfulness and other therapies, such as group, may cause for reduction on symptoms of post-traumatic stress disorder (PTSD) and intrusive thinking [30]. The results also showed increase in energy levels in breast cancer patients. They also showed that the women had reduced levels of depression and fear when referring to recurrence of cancer [27]. Another study showed that the mindfulness based therapy provided to the cancer patients was comparatively better and more effective as compared to emotional expressions in experimental as well as control groups.

Group Therapy
Group psychotherapy is a special form of psychotherapy in which a small number of people meet together and share their experience. Under guidance of this type of psychotherapy therapist try to help themselves and one another. William Breitbart et al. in 2010 [28] had worked over effectiveness of meaning of person centred group therapy for advance cancer patients. They have concluded that this type of psychotherapy can be an effective intervention to reduce spiritual and emotional hardships of the patients. Catherine Classen et al. in 2001 [31] had conducted a research to observe utility of supportive expressive group therapy among metastatic breast cancer patients. In their research they had emphasized on the reduction of psychological distress by providing support to breast cancer patients.

Positive Psychotherapy

Outcome
The present study has documented how psychological therapy impacts breast cancer patients with notable reductions in emotional distress [32,33].

Implications Psychological Support for Overall Survival
The quality of life of a patient suffering from any chronic illness, as well as their time of survival can be affected by the kind of psychotherapeutic intervention he or she receives [34-38]. In a study, which was conducted for a period of one year, showed that through supportive-expressive psychotherapy the patients’ survival time was increased by 4 months in metastatic breast cancer patients [34]. A randomly selected 125 breast cancer patients displayed positive effects on psychological symptoms such as depression, anxiety and stress. The tumour type also played a significant role. Those women in the control group, who had estrogen receptor negative, lived less long than those women randomised to individual conditions who had estrogen receptor-negative tumours. An educational intervention conducted on 72 randomly selected primary stage breast cancer patients showed that relapse rates within 4 months follow-up had markedly reduced upon intervention with emotional support. A multi-centric intervention done on breast cancer patients, showed that though the individual psychological intervention had no impact on survival rates of the patients, but it did reduce levels of anxiety and psychological distress [39]. It was also noted that both the experimental ground and the control group differed in their levels of depression prior to the study was conducted. The control group patients were less depressed than the experimental group. That may indicate risk to shorter survival even before the initiation of the intervention [40]. The accumulation of all these studies account for the suggestion that with the reduction in effectiveness of medical treatments as well as the effects of psychosocial factors are more noticeable [41]. The field of research concerned with finding the benefits of support from psychotherapy on cancer is growing everyday with more support acquired from various studies, but a recent study also suggested that improvement of about 12-33% in rates of survival in breast cancer patients, along with 9 other types of cancer, was seen in married cancer patients [42]. Through their study, they showed that in 173 cancer patients who were married had showed better results in terms of their treatment. It was thus states that this effect was seen independent of other demographic factors. Therefore, there is an actual effect from social support on survival period and progression of the disease.

Survivorship
A comprehensive cancer care provided to the patients of cancer must include survivorship as the survival improves. It is essential that supportive services, care and timely observation for depression and anxiety levels are done even after the cancer treatments have subsided [42]. When observing the overall quality of life of the patients, after their treatments, a range of domains must be checked for assurance; they include: overall maintenance of health; social, behavioural, functional and psychiatric problems; late effects (if any) of treatment, etc. The support for the positive impact of physical activity on breast cancer patients is growing slowly, but steadily.

This area has been neglected until recently. A few studies suggest that improvement in health and quality of life can be led back to their active life, which includes the patients’ moderate to highly active physical exercise DC: National Academies Press, 2005) [43]. Craft LL et al. (2012) [44] show, through their study, that physical exercise is positively correlated to reduction in depression among cancer patients. Survivorship programs are even more important because they help the patients and their families to handle the treatments, provide social and psychiatric support and also through routine survivorship clinics [45-56].

Conclusion
From the above mentioned part, we can be seen that several psychotherapy which had already used for giving a better quality of life among all cancer patients. But, all psychotherapy cannot be able for improving the ability of management of all types of psychological symptoms. Consequently, we observed a requirement of critical discussion of different psychotherapies which had already applied among breast cancer patients with that also discussed the management of psychological symptoms and quality of life. Through our study we want to give the need of direction for future study. By signifying existing literature reviewed by eliciting methodological part and the requirement of each different types of psychotherapy.

Acknowledgements
We give our grateful thanks to all the participants and Dr. David Spiegel et al. for sharing such a great concept which trigger me for piloting the documentation. We would especially like to thank our lay research team member who provide such valuable advice, generously gave their time and shared their experiences for the benefit of the study. We are also most grateful to Mrs. Nabamita Paul for the help and support given by the academic leads.

Conflict of Interest
There is no conflict of interest

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