How Therapy Can Help People Affected by Breast Cancer

This podcast is made possible through the support of AstraZeneca.

Jamie DePolo: Hello! As always, thanks for listening. Being diagnosed with breast cancer can be scary, upsetting, and traumatic for the person diagnosed as well as their family members. Many people could benefit from counseling and therapy but don’t know what services are available or how to find them. Our guest today is Dr. Stephanie Ross, a clinical health psychologist and the founder and director of Illness Navigation Resources, a multidisciplinary practice that offers specialized resources and support to patients and their families who are facing serious medical issues.

Dr. Ross is also an assistant clinical professor of psychiatry at the Feinberg School of Medicine at Northwestern University. She is especially interested in helping patients and families with a genetic mutation linked to cancer, particularly breast, ovarian, and colon cancer, as well as Lynch syndrome.

Dr. Ross is going to talk to us about how therapy can help people diagnosed with breast cancer as well as how one goes about finding a therapist. She’s also going to dispel some of the myths and stigmas that still cling to therapy. Dr. Ross, welcome to the podcast.

Dr. Stephanie Ross: Thank you for inviting me to join you today.

Jamie DePolo: So, let’s start with the benefits that either therapy or counseling — and I have to ask, is there a difference between therapy and counseling, or is one term preferred over another? You know, how can therapy help somebody who has been diagnosed with breast cancer as well as their family?

Dr. Stephanie Ross: Well, Jamie, to start, therapy and counseling seem to be used interchangeably, and there are lots of practitioners who are able to provide these services. So, one thing coming into the process of finding a clinician to help you is to know that there are psychiatrists, there are counselors, there are marriage and family therapists, there are psychologists, all of whom can be helpful in helping somebody to cope with breast cancer. So, I would say is there a preferred term? No. I think it’s just important that you see someone who is qualified, not necessarily who has a specific degree or another.

You asked me how therapy can be helpful to someone who is diagnosed with breast cancer. I should start by saying that therapy can also be helpful for anyone who isn’t diagnosed with breast cancer.

Jamie DePolo: Excellent point.

Dr. Stephanie Ross: Quite simply enough, but especially in the context of a serious medical illness, patients and their families are often just leading their lives. In our practice, we often say nobody calls us because they’re having a great day. A cancer diagnosis often comes out of the blue. So, when people have a sudden and life-altering, in many cases, diagnosis, of course, having a place to go to talk about it is essential and can be extraordinarily helpful along the journey.

I think in our culture we speak a lot about when somebody is diagnosed with cancer that they need to… we use euphemisms like warrior or survivor. And while this can be quite empowering, oftentimes patients and their families have a need to have a public image of being strong or being strong for their family or strong for their friend. And the truth is, this can be a very scary diagnosis. So, having a place where not only they can speak about their fears, but also where they can learn practical tools for coping, for managing perhaps the anxiety or some of the side effects that treatment presents, learning how to have some difficult conversations or perhaps empowering conversations with their family and friends, all of this can be achieved with an experienced therapist or counselor.

Jamie DePolo: Okay, thank you. It’s interesting that you brought up that idea of being a warrior and being strong and cancer being a battle, because I have talked to a number of people who have been diagnosed and for some people it’s fine, they like that metaphor, but other people hate it. And I don’t know if it’s because then they feel, as you kind of hinted at, that they have to keep up that front the entire time and they never get to be vulnerable. But that’s very interesting to me that you brought that up.

Dr. Stephanie Ross: Jamie, that comes up a lot in our practice. So, oftentimes patients will come into our office and speak about feeling lucky. Lucky that they didn’t have it worse or lucky that they didn’t need expensive surgery or chemotherapy. And I’ve often told patients, “Lucky is the person who goes for their annual mammogram and gets a letter in the mail two weeks later saying you’re fine. Come back in a year.” I think we’re socialized in our culture to always be positive and to look on the bright side. And oftentimes, people feel that they are a failure if they are having anxiety or they’re crying or they’re having trepidation or worries that this need to not only be strong, but to minimize anything that you’re feeling is somehow going to not only turn people off around you, but also really affect the outcome of your treatment.

A counselor or a therapist can often help meet patients where they’re at, which is in a place where any of us would be facing a potentially life-limiting diagnosis: frightened, depressed, anxious. And besides those clinical terms, this is a huge, life-altering diagnosis for many people, and it affects all aspects of our lives. Our work life, our income, our finances, our relationships. There’s so much there that comes with this diagnosis.

Jamie DePolo: Yes. Yes, those are excellent points. And I think I know your answer to this next question, but I’m going to ask it anyway. Do you think that every person who has been diagnosed with breast cancer can benefit from therapy, as well as their family members?

Dr. Stephanie Ross: I think that every person diagnosed with any kind of cancer can benefit from some kind of what we call psychosocial intervention. Whether that’s therapy, whether it’s a support group, whether it is a peer-to-peer type of support intervention, whether it’s just a meeting with a social worker or somebody within the cancer center to normalize that there is an emotional component to this. So, can everyone going through cancer treatment and their family members benefit from therapy? I’d say absolutely. But the caveat is we can’t force anyone into therapy.

Jamie DePolo: Sure.

Dr. Stephanie Ross: So, we really have to make sure, before somebody comes to get treatment, that they’re interested. And one of the ways we can do that is by dispelling the myths about what it is that happens in the therapist’s office.

Jamie DePolo: Okay. So, this is kind of a complicated question. How does somebody go about finding a therapist that’s right for them? In the beginning you talked about, you know, there are a number of different people that can offer these types of services. And I know there are also a number of different types of therapy: talk therapy, cognitive behavioral therapy, I don’t even know all the names. So, I’ve talked to friends, too, where they had to sort of visit a couple of different therapists before they figured out somebody who was right for them. How does somebody start with this? Because you know they’ve been diagnosed with breast cancer and now this is kind of like one more thing that they have to do, so what’s the best way to start?

Dr. Stephanie Ross: So, there is no best way to start. And I wish and my hope is that we can streamline this process a bit to really have a go-to resource where everybody who has experience in treating cancer patients would be able to tap into and find somebody. I think this is exponentially harder now with insurance issues and waitlists and the global mental health crisis, so this is a tall order. So, finding someone, I think it’s really important that the professional that a breast cancer patient or their family member sees knows a bit about breast cancer.

Oftentimes, patients already have a therapist. That can be wonderful, and they have a relationship with somebody who they trust, and it’s completely adequate in supporting someone through breast cancer treatment. But if you can find somebody, if you are looking for somebody with a bit of knowledge or the willingness to learn about the disease and the treatment, is really important.

So, there’s many ways to identify a therapist who might be able to help you. You can always call your primary care provider. They generally have relationships with counselors and therapists in the community.

If you’re being treated at one of the major cancer centers, oftentimes they actually have psycho-oncology professionals available within the cancer center. You can ask the social worker who’s affiliated with the place where you’re getting your treatment. You can contact the American Psychological Association or your state psychology association. For instance, we’re in Illinois, so you could contact the Illinois Psychological Association. And you can also call training programs. So, some of the major centers actually train psycho-oncologists, so you can call those places and ask if they have a list of their alumni. Oftentimes, these are great people who practice in communities across the country.

One of the other things I should mention is that there is now an organization called PSYPACT. PSYPACT was created to increase accessibility, especially in rural areas, where there aren’t many mental health providers. So, there are psychologists who have what we call an interstate license. And there’s now 33 states that have enacted legislation that allow these special group of providers who have a PSYPACT credential to practice across state lines. So, telehealth has been wonderful in enabling that to happen.

Jamie DePolo: Oh, that’s great. What about — I know some people have talked about some apps. Now, do you think that if somebody… is that an adequate stand-in, I guess, I’m wondering? Do those work?

Dr. Stephanie Ross: You know, the data is still being collected. I’m, by training, a clinical researcher, so I always follow the data. We have a lot of evidence-based research to support certain types of therapy and certain kinds of interventions, and we don’t know yet. You know, is it better to use an app and have some treatment versus no treatment? I think people who are in major crisis — and cancer patients are not exempt from this — oftentimes when we’re evaluating a patient we uncover long standing psychological issues that predated the cancer, long standing family issues.

So, I think having a thorough evaluation, whether it’s face-to-face in person or over telehealth, you want to make sure that the person doing the evaluation is experienced enough and also is in touch with what are the local resources around them if, for instance, we identify a patient who is suicidal. So, it’s hard to do over an app.

Jamie DePolo: Sure. Okay. Okay. I’m also curious, too. This comes up, I would say often, on our website where people aren’t sure — and I’ll use the oncologist as an example — that maybe they want to get a second opinion, but they feel like they’re going to offend their oncologist. So, I’m thinking in therapy, if, say, a person gets referred to one doctor and maybe they just don’t click. And because it’s so personal, I think people may wonder, “Oh, I don’t want to offend that doctor by going to see somebody else.” So, could you talk a little bit about that? Like, if somebody meets with a therapist and it just doesn’t seem right, I mean, the doctor’s not going to be offended if they go and see somebody else, are they?

Dr. Stephanie Ross: A good therapist should never be offended.

Jamie DePolo: Okay.

Dr. Stephanie Ross: The fit between patient and treatment provider is the most essential element of all therapy, so this is really important. It’s a personal relationship, so patients respond sometimes to a different style, perhaps. I’ve had patients say, “You know, I like working with you because you answer practical questions, and you respond a lot and you give a lot of examples.” Other patients prefer someone who is quiet. There are other patients who really click with someone who is specifically trained in certain interventions. And if you meet with someone and you’re interested in, perhaps, cognitive behavior therapy or acceptance and commitment therapy, which have both been proven to be very effective in treating cancer patients’ distress, perhaps the person you saw isn’t familiar with that.

So, I think we need to empower patients, whether it’s with their own medical team and their oncologist, to ask, “Hey, is there someone else I should be seeing?” The same goes with mental health clinicians, oftentimes people don’t click. Oftentimes, clinicians will offer a brief phone consultation, and you can get sort of a feel for the person’s personality beyond their website and their experience. And oftentimes, it’s a ‘meet in person for a session’ where you can get to know the person. Sometimes you need to meet with the person a couple of times or three times before you can really feel if it’s a good connection. Because a good connection is essential, so is the trust.

Jamie DePolo: Okay, thank you for that. You did mention a couple of specific types of therapy that have been shown to be beneficial for people who have been diagnosed with cancer, and I know your practice focuses on people with serious medical issues. So, in your experience, have you found that certain types of therapy are really beneficial for people with cancer?

Dr. Stephanie Ross: I think it’s really based on what the patient comes in with. But there is evidence to support that both cognitive behavioral therapy and acceptance and commitment therapy, which is a newer intervention, both can be very beneficial. I should also mention that psychotropic medication — so antidepressants and anti-anxiety drugs — can also be very effective in managing patient symptoms and their family’s symptoms.

So, oftentimes these medications are associated with somebody who’s “mentally ill,” but there is a place sometimes for these medications when a patient is evaluated by a psychiatrist or even if a counselor or therapist can work with the patient’s oncology team to make people more comfortable. There’s a lot of suffering that goes on physically with cancer, and we don’t need to add psychological distress to the mix. We can treat that.

Jamie DePolo: Okay. Okay. Now, that’s going to be a great lead into my next question, which is about some of the stigma. Even though we’ve been in the midst of COVID for the last few years and it’s made people talk a little bit more openly about therapy and how they’re feeling depressed, sad, stressed by all this, it still seems like there’s a lot of stigma and embarrassment attached to it where people don’t want to admit they need help. As you said in the beginning, they want to put on a shiny, happy face and say, “I can get through this by myself.” So, could you, I guess, talk a little bit about why this is and then how people can kind of overcome that within themselves if they’re feeling like, “I don’t know if I’m doing so well, but I absolutely cannot ask for help”?

Dr. Stephanie Ross: I think that there still is a tremendous amount of stigma about getting psychological or psychiatric help, and that’s unfortunate. I think that if we apply the term self-care, self-care is very popular and it’s widely accepted. We see cancer patients and people in our communities getting trainers and using massage therapists and hypnotists and acupuncturists. Therapy is the ultimate in self-care, yet we have medicalized it in a way in our culture so it’s associated with a problem instead of seeing it as what I like to call the ‘hour of power.’ How often do you get to sit where it’s socially appropriate to talk about yourself and your problems for a full hour? It’s actually a wonderfully empowering situation. So, I like to turn it around and look at it as you’re giving yourself self-care.

Also, I’d like to destigmatize this — and I think some of the major cancer centers have helped to do this — by automatically building this into the process. Where I trained at Memorial Sloan Kettering Cancer Center it was — when I trained there many years ago, we always called, for patients who were struggling in some way or even around initial diagnosis, it was just part of the process to call what we called the three Ps, which was psychology/psychiatry, pastoral care, and pain management. So, the more that we can normalize this as part of the process, that is going to be inordinately helpful.

I like to tell patients that if they had a physical problem, perhaps they were limping and they were limping and limping and had extreme pain in one of their limbs, they wouldn’t not get it treated. Everyone around them would say you need to see someone. You’re limping. But somehow mental health is seen differently. That it’s only people who are “crazy” who need a therapist, instead of seeing this as an incredibly helpful coping tool to get through a traumatic situation.

Jamie DePolo: That’s an excellent point. And it’s also making me rethink what we should call this podcast. Instead of saying therapy, now I’m thinking maybe we should call it self-care. And the fact that cancer centers are now just making this part of treatment makes so much sense. Hopefully it will help to normalize it and get a lot more people help if they need it.

I’m wondering, too — so, if there’s somebody out there who is listening to this podcast right now and thinking, “Yes, I think that would be really helpful for me. I think therapy would be helpful.” So, how would you suggest that they start? Talk to their cancer center or talk to their GP?

Dr. Stephanie Ross: I think reaching out to their PCP, reaching out to the cancer center and their oncologist usually should have some relations either within the medical center or within the community. I think in certain areas — and I’m fortunate to be in the Chicago area where we have places that are cancer support centers, nonprofits — I know the cancer wellness center here offers limited numbers of free therapy. And if a patient needs more than what they can offer, in limited sessions, they maintain an excellent referral list. So, there are organizations in many communities who do lots of — the Gilda’s Club and organizations like that do have lists of providers and do provide some of those services.

Jamie DePolo: Excellent. Excellent. So, there are options.

Dr. Stephanie Ross: And I guess the other thing I should mention is Facebook groups and people who have connected. I can’t tell you how many referrals we get in our practice from patients who have connected through Facebook groups and support groups and they share resources. And this is just one of the many resources that should be offered to cancer patients. I mean, it’s really easy to share where did you get your wig? And who’s your lymphedema therapist? I’d like to see it as: Who’s helping you and your family to cope? That should be part and parcel of this, not do you need it, but who is helping you? It really is important.

And I would just like to speak for a moment as well about caregivers and family members. The psychosocial research has really found that what families do, and especially couples, is a concept we call ‘protective buffering.’ And protective buffering is where you put on a really strong face around your partner and your family, and so does the caregiver. Both the patient and the spouse or partner or caregiver or adult children will do this around each other, so everyone is trying to be strong for each other.

But when we get them into our office and we’re able to say, “How do you really feel?” We can not only help them by providing the caregiver, the family, the partners, the kids, the adult children a place to really talk about their fears, their anxieties, and how to best support the patient, but we can also help to facilitate conversations between people in a family. So, really recognizing that, as I say, caregivers are people, too. It’s so interesting that in our society you will often hear from men who will say, “We’re pregnant,” but you won’t often hear, “We have cancer.” The cancer patient is often really alone in this. You can have as much support as you want, but the caregiver is also alone. It’s not a “we.” There are defined roles here, and both and all can benefit from some support.

Jamie DePolo: Dr. Ross, thank you so much. This has been really helpful. I appreciate your insights.

Dr. Stephanie Ross: Absolutely. Happy to be here.