Middle Phase

Juana came to Session 4 feeling really upset, physically and emotionally. She had had a bad reaction to chemotherapy. She had started a new medication regimen and was having all sorts of physical symptoms, including fatigue, stomach ache, and painful mouth sores. We explored the different options she might have with her chemotherapy regimen. Juana decided she would discuss this with her oncologist. We talked about her asking about the possibility of switching back to the previous regimen, on which she had had only minor reactions, or at least telling her oncologist that she wasn’t feeling well and asking whether there might be a better and more tolerable treatment.

We discussed how new it was for her to be able to ask for what she needed: to ask for a different option that could make her feel better. Juana felt good about that. She realized that she usually didn’t act that way—even when not depressed, but especially now—and reported feeling somewhat empowered by the thought of being able to bring up the issue with her doctor.

Questions we worked on were: How entitled did Juana feel to ask questions? How comfortable did she feel addressing these issues? Did she feel understood by her doctor? Could she really ask for what she wanted? Juana realized that sometimes she had difficulties in asking certain questions. We worked on her feelings of intimidation. She talked about being a Mexican in an English-dominant culture. Juana rehearsed through role-play a dialog with her doctor and nurse. In this, she was able to express her concerns about the side effects she was having and to ask for an alternative treatment. Some anger arose during the role-play, particularly about her side effects.

I used this moment to bring up the issue of her cancer, her experience and emotional reaction to it. It seemed to be easier for Juana to experience and react to somatic challenges than emotional ones. Juana was more comfortable becoming angry and frustrated with side effects than in having an emotional reaction towards her illness. She was feeling very discouraged and disappointed, particularly that she couldn’t perform her normal activities. I normalized her feelings, especially her anger at feeling badly physically and about being ill. Juana again had trouble accepting this. She rationalized that “those medications are for my well-being” and that “I shouldn’t be angry about it because the medicine is going to protect me.” I told Juana that it was okay to feel angry, even when doctors are trying to provide the best medical treatment: side effects can still be annoying, and so can the fact of having breast cancer. I normalized her anger. We discussed that people often get upset and angry when they are undergoing chemotherapy. Juana briefly discussed being angry but switched to a different topic, focusing more on her accomplishments. I asked her if talking about anger was upsetting to her, but she said she really wanted to talk about something else.

By the end of the session, Juana started describing her strengths, which were associated with activity. I was torn between pushing Juana to confront and tolerate her feelings more, and allowing this depressed woman to bolster her sense of her strengths.

Juana came to Session 5 feeling better. She reported having more energy and being in a much better mood. She was able to visit friends and be more social. Juana had had a chance to discuss her treatment options with her doctor, after which they decided to stop her regimen for a week. We agreed that her sense of well-being was probably two-fold. First, she felt better physically, without side effects. Second, she felt empowered by having been able to confront the doctor and make a positive change in her life. We discussed her self-efficacy in making this happen. I also pointed out her greater use of social supports in seeing her friends.

The idea of her being the agent of change led her to review her experience of losing her breast. She discussed how difficult it was for her to go through the surgery. Juana recalled a discussion in which her oncologist offered her the possibility of having only a partial mastectomy. She refused, explaining that she wanted to live, to survive, and wanted to “take everything that is ill out.” She felt that a full mastectomy was the only way for her to feel safe. I addressed her powerful will to live. I asked her how it felt to go through this experience of losing her breast. Juana started to cry. We talked about how natural and human it is to feel sad about such a loss. She talked about fighting that feeling and criticizing herself for having such feelings. We also discussed the meaning of mourning and some of its common symptoms. In her case, she had lost a breast, a part of her body, a part of her feminine body. Juana talked about how scared she was to be confronted with such a great loss. She described her experience of losing a breast as “feeling less like a woman, less attractive.” She shared fears of “not ever being loved again” by a man due to the loss of a breast. She talked about her anticipation of rejection and her consequent isolation from social situations and avoidance of potential relationships. She spoke about how it was easier to be alone and avoid any painful situation that would remind her of the loss of her breast. She also discussed how “inferior” she felt in comparison to other women. She felt “less of a woman,” as if she couldn’t be loved, or compete with women who were “intact” We discussed how it was possible that her “man” could love her despite her deformity and not be concerned with her physical loss.

Juana started to talk about her sense of empowerment within the chaos of illness and loss. She described that she was starting to feel the pain of what she had been through, recognizing the tremendous loss and the deep fear she had experienced. Nonetheless, she focused more on her strengths. She talked about her desire to live and have a good life for herself. She described the empowering life events that had happened within the context of her cancer. She started really putting into perspective her past relationship when she realized that Paul had left her during an extremely difficult moment. She freely expressed her anger and disappointment toward him for leaving her in one of the most difficult and painful moments of her life, while she had still believed he loved her. She realized that he was not the type of man she wanted to have in her life. She talked about how the cancer had opened her eyes to exactly the type of relationship she wished to have. She talked about a new ability to consider options, not to stay stuck and “depressed in the bed” That she was living in a shelter led her to be “on the go”; every morning she would wake up and start looking for a place to stay.

I phoned Juana the next week because she had missed her appointment. She sounded very depressed and hopeless. She told me that she had been trying so hard to get disability benefits and “nobody is helping me” She had been contacting agencies and found no help at all. I spent time on the phone feeling completely stuck and hopeless myself. What would be my arguments in a situation that seemed to have no way out? I contemplated my own limits as I was listening to her. She then told me that she was so disappointed that she didn’t feel like seeing doctors or psychologists because she had lost trust in them as well. She told me she didn’t see the purpose in it “if everything fails at the end."

I empathized and validated the way she was feeling. I told her how angry I would feel in so frustrating, so surreal a situation. She agreed with me and owned her anger against the world, the agencies, and the huge obstacles she was now facing. I also repeated that she—one more time—was still fighting, was still voicing her feelings and her disagreements with a system that was obviously ill equipped. During this conversation, I felt her becoming emotionally alive. She asked what I thought she could do next. I pointed out to her that she was again contemplating options, brainstorming about ideas to achieve her goal. She told me she was considering contacting a Hispanic channel news program to get them to publicize her situation and put some pressure on her issue. She also thought about recontacting a legal aid lawyer, although she had previously done so with discouraging results.

This session raised a dilemma. Juana’s despair elicited my urge to help her in a more concrete manner, to try to assist her in obtaining disability benefits. I quickly recognized, however, that my job was not to help her materially but to support her emotional issues, to empathize with her, encourage her, to find options so that she would persevere in sorting out her own role transition. Offering direct instrumental help might have helped to cement our treatment alliance but would have set up a potentially uncomfortable precedent for her expectations of my role.

Juana arrived for Session 6 looking and sounding much better. She said that she was feeling good. When I asked her to tell me more about that positive feeling, she replied that she was feeling “pretty strong," physically and emotionally. I asked her whether she had any thoughts, feelings, or reactions from the previous session. She said she had a hard time thinking about what we discussed. I empathized and reminded her that we had started discussing what it meant for her to connect to the pain of her illness, her loss of her breast. She said that actually it wasn’t so bad to talk about those issues. She felt better mentally, calmer, and more hopeful. She discussed at length her many activities with friends and family in the past week: going out to eat at a restaurant, going to see a movie, and going to the park. I reinforced that having social supports was as an antidote to her depression. She realized that having a supportive social network was allowing her to survive financially, as everyone was helping her out with money. Adding to the social network, she had resumed going to church. She said something like: “My strength is mediated by God" I told her it was a great partnership she had with God, because she was also actively working towards getting better, both emotional and physically. When I said that, she made a connection to her decision to leave Paul. She again experienced deep anger towards him. She told me that she didn’t understand how he could leave her at a time when she was so weak that she literally needed him to walk and hold her arm so she wouldn’t fall.

Juana arrived for Session 7 feeling frustrated. She had been trying to get disability, without success. She had been doing what she could be expected to do and more. As she described it, the agency was being neither helpful nor effective. Once more, I was confronted with my own sense of hopelessness as Juana kept bumping into walls and obstacles. She told me that she was confident in her workers from the agency but at the same time was starting to doubt their efficacy and integrity and felt she was being lied to and that they were not doing their job. Juana repeated that she felt cheated and added that she hadn’t chosen to have cancer, be unable to work, and have no money to pay her rent. She was becoming more upset, and I empathized with her. I felt that my words weren’t enough, reflecting this sense of social unfairness she had been dealing with. Having allowed her to express her distress at some length, I validated her feelings. Once again I cited her unbeatable strength, her ability not to crack under pressure and to keep going, despite these circumstances. She agreed and said that in a funny way, her difficulties gave her strength to try to find what she really needed for herself. I asked her whether she had ever experienced such a sense of power and will to make something happen. She couldn’t remember a similar situation.

I asked her to think for a moment that her life was mine and I was sharing it with her. Then I asked her what her reactions would be. Although not a typical IPT intervention, I felt it was a direct way for her to experience what I had been saying about her strength. She started to laugh. She told me she was laughing because she thought: “I wouldn’t be able to survive what this person is going through.” My idea was for her to connect with her amazing spirit and her unwillingness to give up, particularly because she was facing so many real obstacles that I was afraid she would, at some point, decide to give up. This session, however, she left with a sense of hope.

Juana came to Session 8 and reported feeling not so well. She described a series of events the prior week that led her to be down, disappointed, and hopeless. We connected her mood change to these setbacks. However, I had been thinking a lot about how all her material losses had distracted her from really connecting to her deepest fears and feelings. I decided to share that idea with her. She reacted with surprise. I emphasized that I wasn’t denying the severity of her financial situation. I told her that her feeling down and hopeless could be associated with her having cancer, that she lost her breast and hair, and also that she might have faced the idea of dying.

She paused for a second, looked me in the eye, and told me that she didn’t want to talk about that. When I asked why, she became tearful. I encouraged her to tell me what made her tearful. She said that she didn’t want to die; that she was terrified of dying; that if she laid down her arms, she could also let herself die. I encouraged her to keep talking about it. She cried and talked about the fear she went through before the surgery. She told me that she had always been used to being strong, sort of a fighter, her entire life; that people would come to her for help and advice; that she wasn’t allowed to be weak. I told her how difficult it must have been for her to hold herself together without being able to be vulnerable, what an effort she had to make. I told her that connecting to our feelings doesn’t kill us, and allowing ourselves to feel the most vulnerable feelings can help us to understand situations and make us stronger. She agreed, and her facial expression softened. I told her that at the moment that she allowed herself to let her tears come, she was being extremely strong; she was in the process of becoming whole, and possibly by connecting to and tolerating her feelings, she would feel less hopeless and less depressed.

We talked at length about the normalcy of painful feelings when we go through extreme situations like having cancer. I asked her how it felt to let those tears come. She said it was okay. I asked how new this experience was for her. She said that she usually tried to choke her tears. I kept silent at points to let her feel her feelings, but also periodically encouraged her to realize that she had allowed herself to feel strong emotions and hadn’t died (her original fear). She agreed. She told me that she never associated tears or pain with strength. I asked how that experience was for her, and she told me that it was new (she was a bit shy about it) but felt more released. She also expressed how when she allowed herself to have her feelings, she started to connect to the fear of getting ill again. She realized that being disconnected prevented her from having fears but—at the same time—made her feel “numb and dead inside." Juana scored 16 on the Ham-D, indicating mild to moderate depression, an improvement in her symptoms since the beginning of treatment.

In Session 9 Juana seemed a bit distressed. I asked how she had been during the previous week. She said that she was feeling slightly better, particularly more hopeful. I asked whether she had any feelings about our last session. She said that she was thinking about our conversation on feelings. She added that she wanted to talk about another loss: herself. Surprised and curious, I asked what she meant. She explained how painful it had been for her to realize that she hadn’t taken care of or paid attention to herself during these years. She realized that by being “strong” for everybody else, she had forgotten her own needs. She realized that she had maintained a relationship with a younger man and had been taking care of him, supporting him emotionally; she was the giver, the caretaker. I encouraged her to explore how that made her feel. She said it made her angry, frustrated with herself for allowing that to happen. She also realized now why she had had so much difficulty reaching out and asking for help. She talked at length about the association between her lack of awareness of her needs and reaching out. Why should she if she didn’t “need” anything? I noticed that at that point, she looked more alive, full of life and feelings. I asked how she was feeling and remarked on what I had noticed. She agreed. She told me that she felt as if she were waking up from a deep dream.

 
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