Living a Value-based Life with Cancer

Transcript

00:00 --> 00:03Funding for Yale Cancer Answers is
00:03 --> 00:06provided by Smilow Cancer Hospital.
00:06 --> 00:08Welcome to Yale Cancer Answers
00:08 --> 00:10with Doctor Anees Chagpar.
00:10 --> 00:11Yale Cancer Answers features
00:11 --> 00:13the latest information on cancer
00:13 --> 00:15care by welcoming oncologists and
00:15 --> 00:17specialists who are on the forefront
00:17 --> 00:18of the battle to fight cancer.
00:18 --> 00:20This week it's a conversation about
00:20 --> 00:23living a value based life with cancer
00:23 --> 00:25with doctor Gabriel Cartagena.
00:25 --> 00:26Dr. Cartagena is an assistant professor
00:26 --> 00:29of Psychiatry at the Yale School of
00:29 --> 00:31Medicine where Doctor Chagpar is
00:31 --> 00:32a professor of surgical oncology.
00:34 --> 00:36Gabriel, maybe we can start off
00:36 --> 00:38by you telling us a little bit more
00:38 --> 00:39about yourself and what it is you do.
00:41 --> 00:43I'm a licensed clinical
00:43 --> 00:45psychologist with an emphasis in
00:45 --> 00:47training in health psychology and
00:47 --> 00:49further expertise in psycho oncology,
00:49 --> 00:51which is the psychosocial support
00:51 --> 00:53of cancer related distress.
00:53 --> 00:55I grew up in a military
00:55 --> 00:57family from Puerto Rico,
00:57 --> 00:59and after moving around a lot,
00:59 --> 01:01one of the things I was observing
01:01 --> 01:03between the diaspora and my homeland
01:03 --> 01:05in Puerto Rico was the significant
01:05 --> 01:08disparities with regard to cancer
01:08 --> 01:11mortality, cancer occurrence,
01:11 --> 01:12the juxtaposition between that
01:12 --> 01:13for individuals who lived on
01:13 --> 01:15the island as opposed to those
01:15 --> 01:17diaspora who lived on the mainland.
01:17 --> 01:19And that completely impacted my family
01:19 --> 01:22and continues to impact my family and
01:22 --> 01:24was very formative for the way that I
01:24 --> 01:26was viewing health at a very young age.
01:26 --> 01:29From there, I developed a really,
01:29 --> 01:31I would say,
01:31 --> 01:34passionate interest in public health
01:34 --> 01:37at the Nexus of psychology and medicine.
01:37 --> 01:39So in my undergraduate training,
01:39 --> 01:41I studied survivorship and chronic illness,
01:41 --> 01:44particularly HIV and cancer in
01:44 --> 01:47Alaska as well as in South Africa.
01:47 --> 01:48And then I completed my graduate
01:48 --> 01:50training at the University of Florida,
01:50 --> 01:51specifically in Psycho Oncology.
01:51 --> 01:53And the rest is history.
01:53 --> 01:54I never looked back.
01:54 --> 01:55I fell in love with this field.
01:55 --> 01:58You certainly have been around a lot and
01:58 --> 02:01have had a lot of life experiences.
02:01 --> 02:04Talk to us a little bit more
02:04 --> 02:05about those formative experiences
02:05 --> 02:07that kind of shaped your career.
02:07 --> 02:10You had talked a little bit about
02:10 --> 02:12the disparities that you
02:12 --> 02:15saw growing up in Puerto Rico.
02:15 --> 02:18Tell us a bit more about what
02:18 --> 02:21exactly those disparities were and
02:21 --> 02:23how it is that that really shaped
02:23 --> 02:26what you do now and how do you
02:26 --> 02:28try to address those disparities?
02:28 --> 02:30These are great questions,
02:30 --> 02:32some of the most formative
02:32 --> 02:33experiences that influence not
02:33 --> 02:35only my career in Psycho Oncology,
02:35 --> 02:36but also my career in cancer
02:36 --> 02:38health disparities research and advocacy
02:38 --> 02:41work has been in noticing the fundamental
02:41 --> 02:44lack of infrastructure when it comes to
02:44 --> 02:46healthcare access in Puerto Rico itself.
02:46 --> 02:49So the ability for family members
02:49 --> 02:51to just get regular screenings,
02:51 --> 02:53the accessibility that's there,
02:53 --> 02:54the access to and supply,
02:54 --> 02:56for lack of a better word,
02:56 --> 02:57of healthcare professionals
02:57 --> 02:58working on the island.
02:58 --> 03:00Each of those was detrimental to the
03:00 --> 03:01outcomes of particular family members,
03:01 --> 03:04but also to the Puerto Rican
03:04 --> 03:05community at large.
03:05 --> 03:07And so those experiences,
03:07 --> 03:09as I saw the lack of access
03:09 --> 03:11really impacting long term,
03:11 --> 03:12the occurrence of cancer,
03:12 --> 03:14the outcomes of cancer and unfortunately,
03:14 --> 03:17the mortality that struck my family
03:17 --> 03:19started to make me think about why
03:19 --> 03:21these inequities exist structurally,
03:21 --> 03:23what is the relationship between
03:23 --> 03:25historically Puerto Rico and the United
03:25 --> 03:27States that facilitated these disparities?
03:27 --> 03:29And then as someone who's growing up,
03:29 --> 03:30then in the diaspora,
03:30 --> 03:33who has the privilege of more
03:33 --> 03:34accessibility to healthcare,
03:34 --> 03:36different access to education and
03:36 --> 03:38different opportunities in that realm,
03:38 --> 03:41what could I do with my privilege to address
03:41 --> 03:43these disparities in a comprehensive way?
03:43 --> 03:44And so,
03:44 --> 03:45going through my undergraduate
03:45 --> 03:46training and then my graduate training,
03:46 --> 03:49I started to realize that as a psychologist,
03:49 --> 03:51there is not only a level of education,
03:51 --> 03:52but also a level of power,
03:52 --> 03:55particularly within the healthcare system,
03:55 --> 03:57to not only support the psychosocial
03:57 --> 03:59needs of someone who's undergoing cancer
03:59 --> 04:01treatment or even in survivorship,
04:01 --> 04:03but to also be the loudest voice in
04:03 --> 04:05the room when it comes to advocating
04:05 --> 04:07for the needs of this individual in a
04:07 --> 04:09medical setting or a healthcare team.
04:09 --> 04:10And that proved to be really
04:10 --> 04:11invaluable to me,
04:11 --> 04:13not only in the clinical context
04:13 --> 04:15where individuals who are going
04:15 --> 04:16through treatment don't necessarily
04:16 --> 04:18know what should be next or what
04:18 --> 04:20could be next and are relying on
04:20 --> 04:22the voice of their provider in
04:22 --> 04:24order to guide their next steps.
04:24 --> 04:25But that should always align
04:25 --> 04:26with what their values are and
04:26 --> 04:28sometimes that gets lost in the mix.
04:28 --> 04:29So from the clinical standpoint
04:29 --> 04:31all of my previous experiences have
04:31 --> 04:33informed the way that I advocate for
04:33 --> 04:35the patient on top of providing
04:35 --> 04:37therapeutic intervention as well as
04:37 --> 04:39my research work when it comes to
04:39 --> 04:41provider level and community level
04:41 --> 04:43interventions to improve cancer
04:43 --> 04:44outcomes for minoritized groups.
04:45 --> 04:47You know one of the
04:47 --> 04:50statements that you made just now
04:50 --> 04:53was really aligning what you are
04:53 --> 04:57advocating for thinking about living
04:57 --> 04:59a value based life with cancer.
04:59 --> 05:01Can you talk a little bit more
05:01 --> 05:02about what exactly that means?
05:03 --> 05:04Absolutely. This conversation
05:04 --> 05:06that I have with my patients,
05:06 --> 05:09when I get the feedback that
05:09 --> 05:11it often feels sort of a trite
05:11 --> 05:15phrase, living based on your values.
05:15 --> 05:16It's definitely one that we use a
05:16 --> 05:17lot within the psychological realm,
05:17 --> 05:19but it holds a lot of weight
05:19 --> 05:20and a lot of importance,
05:20 --> 05:22particularly in the context of a
05:22 --> 05:24cancer diagnosis and treatment
05:24 --> 05:26where a lot of my patients call it a
05:26 --> 05:28right hook to the jaw in their life.
05:28 --> 05:30They didn't see it coming.
05:30 --> 05:32They had no guidebook as to what to
05:32 --> 05:34do next and no understanding of what
05:34 --> 05:36to do next other than the skills
05:36 --> 05:37that have that they've acquired
05:37 --> 05:38throughout their entire life in
05:38 --> 05:40order to get to where they are now.
05:40 --> 05:41And there's a sense of helplessness
05:41 --> 05:44and hopelessness and in the pursuit
05:44 --> 05:46of figuring out what the next step
05:46 --> 05:49is to grapple with this uncertainty,
05:49 --> 05:52what gets lost in the mix more often
05:52 --> 05:54than not is what's valuable to you.
05:54 --> 05:55You're undergoing treatment.
05:56 --> 05:58You are shifting your entire life,
05:58 --> 05:59your family's life,
05:59 --> 06:01the life of your chosen family or your
06:01 --> 06:03loved ones to survive essentially.
06:03 --> 06:04And in that process,
06:04 --> 06:06there's very little time for
06:06 --> 06:07individuals to sit and reflect
06:07 --> 06:09on what's important to them in
06:09 --> 06:10the moment other than survival.
06:10 --> 06:12And one of the key aspects that
06:12 --> 06:14I do in my work is to work with
06:14 --> 06:15the individual on a one-on-one
06:15 --> 06:17basis as well as with their team
06:17 --> 06:20to truly tap into and understand
06:20 --> 06:22what is the richness of their life,
06:22 --> 06:24what is valuable to them and what's
06:24 --> 06:26important to them throughout this process.
06:26 --> 06:27Because without those as anchors,
06:27 --> 06:28it's incredibly,
06:28 --> 06:29incredibly distressing to go
06:29 --> 06:31through this process.
06:31 --> 06:34I can imagine how those conversations play
06:34 --> 06:37in particular for patients who may be,
06:37 --> 06:41you know, at the end of life thinking
06:41 --> 06:45about decisions like do I pursue more
06:45 --> 06:48aggressive treatment that may make me sicker,
06:48 --> 06:52may make me be in the hospital longer versus
06:52 --> 06:56being with my family and being comfortable.
06:56 --> 06:59Can you talk a little bit more about
06:59 --> 07:01those kinds of discussions that you
07:01 --> 07:03have with patients? Because I can
07:03 --> 07:05imagine that that's very difficult
07:05 --> 07:08because one would imagine that the base
07:08 --> 07:11instinct is, I want to survive at any cost.
07:11 --> 07:14I'll do whatever it takes.
07:14 --> 07:16But sometimes that may not be exactly
07:16 --> 07:18aligned with your true values.
07:19 --> 07:21Absolutely.
07:21 --> 07:23In having these conversations,
07:23 --> 07:25they often come up, as you mentioned,
07:25 --> 07:27that this really critical and difficult Nexus
07:27 --> 07:29where the individual's trying to balance,
07:29 --> 07:32well, I want to live the most life that
07:32 --> 07:36I possibly can and balance it with well,
07:36 --> 07:37what is the quality of the life that
07:37 --> 07:38I'm going to be living as well.
07:38 --> 07:40And it's a hard conversation that's
07:40 --> 07:42often preempted by the medical team
07:42 --> 07:44and then brought to bear within the
07:44 --> 07:46therapeutic context where we talk about,
07:46 --> 07:47well, what would quality of life
07:47 --> 07:49actually look like if you took
07:49 --> 07:50option A with regard to treatment?
07:51 --> 07:53If you pursued more aggressive treatment,
07:53 --> 07:55understanding some of the risks,
07:55 --> 07:57processing some of the risks that your
07:57 --> 08:00medical provider had just discussed with you,
08:00 --> 08:01what would your life look like?
08:01 --> 08:05Is that something that you would be OK with?
08:05 --> 08:07Would you feel comfortable living months,
08:07 --> 08:10if not a year more if it meant that
08:10 --> 08:13your quality of life was lesser?
08:13 --> 08:15If you're perhaps less mobile,
08:15 --> 08:17less able to connect with your family members
08:17 --> 08:19or your loved ones or your chosen family,
08:19 --> 08:21in what way would you feel
08:21 --> 08:22comfortable with that process?
08:22 --> 08:24And what decisions are going to align
08:24 --> 08:26you the most with how you would like
08:26 --> 08:28your quality of life to be and how you
08:28 --> 08:30would like your life to continue to be?
08:31 --> 08:32Yeah, for sure.
08:32 --> 08:34And I can imagine that not all
08:34 --> 08:36of these conversations necessarily
08:36 --> 08:39have to be at the end of life.
08:39 --> 08:42I can imagine that some of these
08:42 --> 08:45conversations maybe even while you're
08:45 --> 08:48undergoing treatment and thinking about,
08:48 --> 08:52you know what is valuable to you and
08:52 --> 08:55where do you want to expend your energy.
08:55 --> 08:59So I know that many patients
08:59 --> 09:01before they get a cancer diagnosis,
09:01 --> 09:03which as you mentioned is very
09:03 --> 09:06often like the unseen
09:06 --> 09:09right hook, are doing everything.
09:09 --> 09:11They are looking after the kids
09:11 --> 09:14in the home and going to work
09:14 --> 09:15and doing 17,000 things.
09:15 --> 09:19And now all of a sudden, you know,
09:19 --> 09:20you're faced with this diagnosis,
09:20 --> 09:23you're undergoing treatment and
09:23 --> 09:26you have to prioritize where you
09:26 --> 09:28are going to expend your energy.
09:28 --> 09:30Are those the kinds of conversations
09:30 --> 09:32that you have with patients as well?
09:32 --> 09:34And what kinds of advice do
09:34 --> 09:35you give them when they have
09:35 --> 09:37what one of my patients called
09:37 --> 09:39the superwoman complex?
09:39 --> 09:41I'm very familiar with
09:41 --> 09:42the superwoman complex.
09:42 --> 09:43It comes up a lot with the people
09:43 --> 09:45that I work with and it's a
09:45 --> 09:46difficult conversation to have
09:46 --> 09:48because for many individuals
09:48 --> 09:49while they recognize that it's
09:49 --> 09:50important to take care of themselves.
09:50 --> 09:52I mean, that's why they're coming
09:52 --> 09:53to their oncologist to begin with.
09:53 --> 09:55They have a profound love for their family,
09:55 --> 09:56for the roles that they have,
09:56 --> 09:58for the many hats that they wear.
09:58 --> 10:03And there's external feedback that
10:03 --> 10:05individuals were given that any difficult
10:05 --> 10:07emotions that they are experiencing at the
10:07 --> 10:10time is too much for anyone else to handle.
10:10 --> 10:11And it needs to be put in a way,
10:11 --> 10:12in the box.
10:12 --> 10:13And then we have internal feedback
10:13 --> 10:14that tells us, well,
10:14 --> 10:15I'm have to put on a strong
10:15 --> 10:17face for the people that I love.
10:17 --> 10:20I can't let anyone know that I'm
10:20 --> 10:22struggling because there are
10:22 --> 10:23implications or implications for
10:23 --> 10:25my character or my sense of self
10:25 --> 10:27if people were to know that I was
10:27 --> 10:29struggling with this diagnosis.
10:29 --> 10:32And so the conversation more often
10:32 --> 10:35than not begins with talking about the
10:35 --> 10:37different roles that are important to you.
10:37 --> 10:39What hats do you wear?
10:39 --> 10:41What things make you who you are and what
10:41 --> 10:43things do you have a profound relationship with?
10:43 --> 10:45And then we start to challenge
10:45 --> 10:46and talk about, well,
10:46 --> 10:49if you're struggling with this and
10:49 --> 10:50you were to let your family see,
10:50 --> 10:51for instance,
10:51 --> 10:52or the people that you care
10:52 --> 10:53about see this for instance,
10:54 --> 10:54how would that change their
10:54 --> 10:55perception of you?
10:55 --> 10:56Would it actually change
10:56 --> 10:57their perception of you?
10:57 --> 10:59Or would they perhaps view you
10:59 --> 11:00as even stronger for seeking
11:00 --> 11:02out support for modeling what
11:02 --> 11:04healthy coping looks like?
11:04 --> 11:07Yeah, for sure. I can imagine that
11:07 --> 11:10for many patients that's
11:10 --> 11:12difficult to ask for help.
11:12 --> 11:13But as you say, it
11:13 --> 11:18often is not only modeling what
11:18 --> 11:20good coping behavior looks like,
11:20 --> 11:22but giving your family the opportunity
11:22 --> 11:25to be part of this journey with you.
11:25 --> 11:28Because very often people want to
11:28 --> 11:30help and they want to be close to you
11:30 --> 11:32and they want to show you that they
11:32 --> 11:34they love you and they care for you.
11:34 --> 11:38And by voicing how they can do that,
11:38 --> 11:40you often can allow them to be
11:40 --> 11:41part of that journey with you.
11:42 --> 11:43Absolutely. And I want to
11:43 --> 11:45recognize some of the the prior
11:45 --> 11:47question that you had mentioned,
11:47 --> 11:49which is what advice would I give with
11:49 --> 11:52regard to having these conversations?
11:52 --> 11:54Starting these conversations and then
11:54 --> 11:55developing the coping strategies
11:55 --> 11:57that are necessary to get through this.
11:57 --> 11:58For someone who's newly diagnosed
11:58 --> 11:59or starting in treatment,
11:59 --> 12:01there are a few things that
12:01 --> 12:02I would really recommend.
12:02 --> 12:04The first one almost feels a little
12:04 --> 12:06bit trite too, but it's breathe.
12:06 --> 12:07It'll be the first thing
12:07 --> 12:09that any therapist tells you,
12:09 --> 12:11and the only thing that will
12:11 --> 12:13allow you to ground yourself to
12:13 --> 12:15your body and to the present moment.
12:15 --> 12:17And the next one is to be
12:17 --> 12:18compassionate with yourself.
12:18 --> 12:19No one has developed a guidebook
12:19 --> 12:21and given it to you regarding
12:21 --> 12:23how do you navigate any of this.
12:23 --> 12:24This is all uncharted territory
12:24 --> 12:26and you're using the skills that
12:26 --> 12:27you've developed throughout your
12:27 --> 12:29entire life in order to survive this
12:29 --> 12:31moment and you're doing the absolute
12:31 --> 12:34best that you can. And the next one
12:34 --> 12:36really aligned with our topic of
12:36 --> 12:38conversation is to be true to yourself.
12:38 --> 12:39Thinking about and reflecting
12:39 --> 12:41on what's important to you,
12:41 --> 12:42whether that's your family,
12:42 --> 12:43your different roles,
12:43 --> 12:44the values that you have,
12:44 --> 12:46those are the anchors that
12:46 --> 12:48are important to develop.
12:48 --> 12:49Think about,
12:49 --> 12:52harness and touch base on,
12:52 --> 12:54and then from there giving yourself
12:54 --> 12:57permission to feel what it is you're feeling.
12:57 --> 12:59Our society more often than not has a
12:59 --> 13:01really complicated relationship with
13:01 --> 13:03complicated feelings such as grief,
13:03 --> 13:05anger, frustration, and fear.
13:05 --> 13:08Allowing yourself to feel those
13:08 --> 13:10allows you to essentially name
13:10 --> 13:11what the struggle is,
13:11 --> 13:13and it gives you more power and it
13:13 --> 13:15gives you more ability to develop
13:15 --> 13:16the coping strategies that are
13:16 --> 13:18necessary to battle the uncertainty,
13:18 --> 13:19battle the depression,
13:19 --> 13:22battle the anxiety that are often
13:22 --> 13:24inherent to a cancer diagnosis,
13:24 --> 13:26and then finally kind of dovetailing
13:26 --> 13:27reminding yourself that it's OK
13:27 --> 13:29to get support from others.
13:29 --> 13:31Support systems are crucial,
13:31 --> 13:32particularly here.
13:34 --> 13:36Yeah, all good, good tips.
13:36 --> 13:38We do need to take a short
13:38 --> 13:40break for a medical minute,
13:40 --> 13:42but please stay tuned to learn
13:42 --> 13:44more about living a value based
13:44 --> 13:46life with cancer with my guest,
13:46 --> 13:48Doctor Gabriel Cartagena.
13:48 --> 13:50Funding for Yale Cancer Answers
13:50 --> 13:52comes from Smilow Cancer Hospital,
13:52 --> 13:55where the lung cancer screening program
13:55 --> 13:57provides screening to those at risk
13:57 --> 13:59for lung cancer and individualized,
13:59 --> 14:02state-of-the-art evaluation of lung nodules.
14:02 --> 14:07To learn more visit smilowcancerhospital.org.
14:07 --> 14:09The American Cancer Society estimates that
14:09 --> 14:12more than 65,000 Americans will be diagnosed
14:12 --> 14:15with head and neck cancer this year,
14:15 --> 14:18making up about 4% of all cancers
14:18 --> 14:20diagnosed when detected early.
14:20 --> 14:22However, head and neck cancers are
14:22 --> 14:24easily treated and highly curable.
14:24 --> 14:26Clinical trials are currently
14:26 --> 14:28underway at federally designated
14:28 --> 14:30Comprehensive Cancer Centers such
14:30 --> 14:33as Yale Cancer Center and Smilow
14:33 --> 14:35Cancer Hospital to test innovative new
14:35 --> 14:37treatments for head and neck cancers.
14:37 --> 14:39Yale Cancer Center was recently
14:39 --> 14:41awarded grants from the National
14:41 --> 14:44Institutes of Health to fund the Yale
14:44 --> 14:46Head and Neck Cancer Specialized
14:46 --> 14:48Program of Research Excellence,
14:48 --> 14:49or SPORE,
14:49 --> 14:51to address critical barriers to
14:51 --> 14:54treatment of head and neck squamous cell
14:54 --> 14:56carcinoma due to resistance to immune
14:56 --> 14:59DNA damaging and targeted therapy.
14:59 --> 15:01More information is available
15:01 --> 15:02at yalecancercenter.org.
15:02 --> 15:06You're listening to Connecticut Public Radio.
15:06 --> 15:06Welcome
15:06 --> 15:08back to Yale Cancer Answers.
15:08 --> 15:10This is Doctor Anees Chagpar and
15:10 --> 15:11I'm joined tonight by my guest,
15:11 --> 15:13Doctor Gabriel Cartagena.
15:13 --> 15:15We're discussing the field of
15:15 --> 15:17psycho oncology and living a
15:17 --> 15:19value based life with cancer.
15:19 --> 15:21Now, before the break,
15:21 --> 15:23we were talking about the many kind
15:23 --> 15:26of psychological afflictions on top
15:26 --> 15:29of the physical afflictions that a
15:29 --> 15:31cancer diagnosis brings everything
15:31 --> 15:35from fear to existential crisis.
15:35 --> 15:35So Gabriel,
15:35 --> 15:38maybe you can talk a little bit
15:38 --> 15:40more specifically about some of
15:40 --> 15:42the tricks and tools that you
15:42 --> 15:45give your patients in terms of
15:45 --> 15:47managing through these crises.
15:48 --> 15:49That's a great question.
15:49 --> 15:51So there are different evidence based
15:51 --> 15:53modalities that I use in my
15:53 --> 15:55work in Psycho Oncology and there's
15:55 --> 15:57no one size fit all treatment
15:57 --> 15:58for the people that they work with.
15:58 --> 16:01In fact, it's a combination of different
16:01 --> 16:03skills and different tactics that
16:03 --> 16:05are the most important to helping anyone
16:05 --> 16:08develop their toolbox to manage their
16:08 --> 16:10cancer diagnosis and get through treatment.
16:10 --> 16:12And so one of the primary ones
16:12 --> 16:13is cognitive behavioral therapy,
16:13 --> 16:14also known as CBT.
16:14 --> 16:16And that's a psychotherapy that
16:16 --> 16:19really focuses on how we feel,
16:19 --> 16:20how we think and how we behave
16:20 --> 16:23intertwines and where in that triangle
16:23 --> 16:25exists the most distress for you.
16:25 --> 16:26And so for instance,
16:26 --> 16:28I like to pull an example that's
16:28 --> 16:31cancer related for an individual who
16:31 --> 16:34has really no history of being truly
16:34 --> 16:36angry or frustrated or having outbursts.
16:36 --> 16:38They're noticing that since
16:38 --> 16:40their diagnosis,
16:40 --> 16:42they're more angry and frustrated at
16:42 --> 16:45what they regard as the smallest things.
16:45 --> 16:46They can't really anticipate that.
16:46 --> 16:47They don't know where it's coming from,
16:47 --> 16:48but suddenly they're having an outburst
16:48 --> 16:50in the kitchen at family members that
16:50 --> 16:52they would have never done that with.
16:52 --> 16:54And so one of the the places that
16:54 --> 16:55we start when it comes to cognitive
16:55 --> 16:56behavioral therapy, for instance,
16:56 --> 16:58is really honing in on, well,
16:58 --> 16:59what was your experience before?
16:59 --> 17:02What are the events that led up to
17:02 --> 17:04or the antecedents to that moment?
17:04 --> 17:06Can you remember what you were thinking
17:06 --> 17:07and feeling during that moment?
17:07 --> 17:09How did your body feel?
17:09 --> 17:10And then afterward,
17:10 --> 17:12how did you feel and think?
17:12 --> 17:13And more often than not,
17:13 --> 17:14the people that I work with at
17:14 --> 17:15the very outset,
17:15 --> 17:16when we start to ask these
17:16 --> 17:17fundamental questions,
17:17 --> 17:20have a hard time remembering any
17:20 --> 17:22of the nuance of the moment or the
17:22 --> 17:23distress that they were going through.
17:24 --> 17:25And so the key part of CBT at the
17:25 --> 17:27very beginning is to build awareness.
17:27 --> 17:30How am I thinking, feeling, responding,
17:30 --> 17:33behaving throughout these instances,
17:33 --> 17:34both in distress and outside of distress?
17:35 --> 17:36And that greater awareness allows
17:36 --> 17:38us to dig deeper into, well,
17:38 --> 17:39why did that occur?
17:39 --> 17:41And so in this particular instance that
17:41 --> 17:43I'm bringing up for the cancer patient,
17:45 --> 17:47they find that they're being
17:47 --> 17:49triggered when there's even a
17:49 --> 17:51semblance of a mention of the future.
17:51 --> 17:53So a family member talks about
17:53 --> 17:54a concert that they want to
17:54 --> 17:56go to in five to six months.
17:56 --> 17:58Well, that five to six months
17:58 --> 17:59to this patient is uncertain.
17:59 --> 18:02But to be reminded
18:02 --> 18:04of that uncertainty brings a
18:04 --> 18:05significant level of distress.
18:05 --> 18:06And at this point,
18:06 --> 18:08they don't really have the language to
18:08 --> 18:09be able to express to the person that
18:09 --> 18:11they love that this is distressing,
18:11 --> 18:13but they do know within their
18:13 --> 18:14body that it exists.
18:14 --> 18:15And so the next level of work
18:15 --> 18:17that we do in CBT,
18:17 --> 18:20now that we've kind of identified
18:20 --> 18:21the how and the why, is, well,
18:21 --> 18:23what do I do with this knowledge?
18:23 --> 18:24What do I do with this awareness?
18:24 --> 18:26And what skills do I pull in?
18:26 --> 18:27And in a moment where you're feeling
18:27 --> 18:29particularly angry and irritable.
18:29 --> 18:30And it feels as though,
18:30 --> 18:32let's say for instance,
18:32 --> 18:33uncontrollable skills like
18:33 --> 18:34diaphragmatic breathing,
18:34 --> 18:36progressive muscle relaxation are
18:36 --> 18:38things that you can do individually,
18:38 --> 18:40even outside of the sight of family members.
18:40 --> 18:42You can do them privately.
18:42 --> 18:43That allow you to touch base
18:43 --> 18:45with your body and how you're
18:45 --> 18:47feeling and bring you back to
18:47 --> 18:49awareness of the current moment,
18:49 --> 18:52awareness of your emotions and an
18:52 --> 18:55understanding of what was the antecedent,
18:55 --> 18:56what did you experience?
18:56 --> 18:58And now that you have the skills to
18:58 --> 19:00kind of temper the previous frustration,
19:00 --> 19:02then we develop the language
19:02 --> 19:03to respond differently,
19:03 --> 19:05to start to develop the communication
19:05 --> 19:07styles that would be necessary to
19:07 --> 19:09talk through the distress with
19:09 --> 19:11a partner or with a loved one.
19:11 --> 19:12And then eventually be able to
19:12 --> 19:15look at the mention of the future,
19:15 --> 19:16of the mention of uncertainty with
19:16 --> 19:18a few more skills in your toolbox
19:18 --> 19:20than you had before and a supportive
19:20 --> 19:22partner who's on the same page
19:22 --> 19:24with you in understanding of what
19:24 --> 19:26you're experiencing in the moment.
19:26 --> 19:28Another one of them is acceptance and
19:28 --> 19:30commitment therapy, also known as ACT.
19:30 --> 19:32And that one is sort of similar to CBT,
19:32 --> 19:35but it's more focused on being present,
19:35 --> 19:37mindful and non judgmental of the
19:37 --> 19:39thoughts and feelings that you're having.
19:39 --> 19:41It often characterizes the anxiety
19:41 --> 19:43that you experience as fleeting and
19:43 --> 19:45something that you should welcome.
19:45 --> 19:46And I know that can sound
19:46 --> 19:48kind of strange, but I
19:48 --> 19:52often talk to my patients about
19:52 --> 19:54welcoming uncertainty into the room.
19:54 --> 19:56You pull up a chair for it.
19:56 --> 19:59You sit down. You get acquainted with it.
19:59 --> 20:01You get a better understanding of it.
20:01 --> 20:02And through welcoming uncertainty
20:02 --> 20:05and allowing it to exist in the
20:05 --> 20:06space so you can both live your life
20:06 --> 20:08in a fruitful and meaningful way.
20:08 --> 20:10In a value based way as well as
20:10 --> 20:12allow the thought and the feeling,
20:12 --> 20:14however scary or however dangerous
20:14 --> 20:16it may feel to come in,
20:16 --> 20:17sit with you and come out.
20:19 --> 20:21Yeah, a lot of that sounds
20:21 --> 20:24very similar to techniques of
20:24 --> 20:26mindfulness that we've talked
20:26 --> 20:29about previously on this show.
20:29 --> 20:30Are the two related?
20:31 --> 20:32They are often related,
20:32 --> 20:33and that's a great question because
20:34 --> 20:35there are many different mindfulness
20:35 --> 20:37principles, particularly in the
20:37 --> 20:38evolution of psycho oncology,
20:38 --> 20:40that are being folded into evidence
20:40 --> 20:42based practices and treatment.
20:42 --> 20:43And so mindfulness,
20:43 --> 20:47in and of itself, as an Eastern practice,
20:47 --> 20:50focuses on the present moment and allows
20:50 --> 20:54different aspects of the present moment
20:54 --> 20:58to continue to pass in an acceptable way.
20:58 --> 20:59So without any judgement,
20:59 --> 21:00the reality of the situation
21:00 --> 21:01as it occurs now,
21:01 --> 21:03the reality of your thought as it occurs
21:03 --> 21:05now is a thought that is occurring now.
21:05 --> 21:08But it has no predication on the future
21:08 --> 21:10and therefore can be experienced now,
21:10 --> 21:12can be welcomed now and then can
21:12 --> 21:14pass through so that you can move
21:14 --> 21:16on to the next aspect of your life.
21:16 --> 21:18And so those core tenets of being able
21:18 --> 21:21to accept the current moment and be
21:21 --> 21:22present with the current moment as
21:22 --> 21:24much as possible in a non judgmental
21:24 --> 21:26way are folded into some of the
21:26 --> 21:27Acceptance and commitment therapy
21:27 --> 21:30principles that we do in treatment,
21:30 --> 21:31as well as something like
21:31 --> 21:32cognitive behavioral therapy too.
21:32 --> 21:34Now the cognition piece of CBT,
21:34 --> 21:35for instance,
21:35 --> 21:39we start to break down and chew on the
21:39 --> 21:41really distressing thoughts that might
21:41 --> 21:44occur to someone who's going through cancer.
21:44 --> 21:46And a lot of that approach
21:46 --> 21:47necessitates a non judgmental
21:47 --> 21:49stance and a mindful stance.
21:50 --> 21:54I can imagine that some
21:54 --> 21:56people who may be listening to this,
21:56 --> 21:58this might really resonate with them
21:58 --> 22:02and the the concept of being present
22:02 --> 22:05and non judgmental and
22:05 --> 22:08having a thought, accepting the
22:08 --> 22:11thought and then letting it go,
22:11 --> 22:13very much similar to meditation
22:13 --> 22:15practices and so on.
22:15 --> 22:17Others I can imagine, however,
22:17 --> 22:19may be thinking, you know,
22:19 --> 22:22this is all a little too Zen for me.
22:22 --> 22:25If I've been just diagnosed with cancer,
22:25 --> 22:27my thoughts are going to be racing.
22:27 --> 22:29In terms of #1,
22:29 --> 22:32I don't really like the diagnosis,
22:32 --> 22:34#2 I'm grappling with my own mortality,
22:34 --> 22:36and #3 I'm worried about
22:36 --> 22:38all of the practicalities.
22:38 --> 22:39What's going to happen to my kids?
22:39 --> 22:41What's going to happen to the finances,
22:41 --> 22:42What's going to happen,
22:42 --> 22:44am I going to be able
22:44 --> 22:46to keep my next meal down?
22:46 --> 22:50And so it may be really difficult for
22:50 --> 22:53some people to kind of accept this idea
22:53 --> 22:57of being present and non judgmental.
22:57 --> 22:59How do you deal with that?
23:00 --> 23:01That's a wonderful question
23:01 --> 23:03because most of the people that
23:03 --> 23:04I work with out out of the gate,
23:04 --> 23:07that is their response to not only some
23:07 --> 23:09of the principles I start to introduce.
23:09 --> 23:11So if I'm starting to give a little bit of
23:11 --> 23:13psychoeducation as to what ACT or CBT is,
23:14 --> 23:16but also feedback that they have from what
23:16 --> 23:19they've heard about psychotherapy so far.
23:19 --> 23:20And the first thing I always want
23:20 --> 23:22to do is completely validate the
23:22 --> 23:24reactions and the responses that they
23:24 --> 23:26have to this primordial uncertainty.
23:26 --> 23:28Like I said before, it is a right
23:28 --> 23:30hook that you did not see coming.
23:30 --> 23:31And so your responses and
23:31 --> 23:32your questions with regard to,
23:32 --> 23:33well, what happens tomorrow?
23:33 --> 23:36What will happen to my family members?
23:36 --> 23:37What will that relationship look like?
23:37 --> 23:39Whether the practicality is both financial,
23:39 --> 23:40we could talk about financial toxicity
23:40 --> 23:42in the way that that plays in there too,
23:42 --> 23:44but also more practical with regard
23:44 --> 23:45to schedule, with regard to work,
23:45 --> 23:47with regard to what my body will
23:47 --> 23:48look like afterward.
23:48 --> 23:51Each of these questions is so
23:51 --> 23:54incredibly valid and important.
23:54 --> 23:58To even begin psychotherapy and begin
23:58 --> 24:00a treatment that's going to be helpful
24:00 --> 24:02does not necessitate the idea of
24:03 --> 24:06that's a thought and it can pass
24:06 --> 24:08through and then you will be OK.
24:08 --> 24:10It's about sitting with the uncertainty
24:10 --> 24:11of validating it completely,
24:11 --> 24:13knowing that it will exist and that
24:13 --> 24:15it is inherent to the process and
24:15 --> 24:18being able to contend with it in a way
24:18 --> 24:20that allows you to make something of
24:20 --> 24:22it and allow you to live your life.
24:22 --> 24:23So what does that look like?
24:23 --> 24:26So you come in with incredible anxiety
24:26 --> 24:28and distress regarding this diagnosis.
24:28 --> 24:30You're asking the questions about the
24:30 --> 24:32future and the uncertainty that that holds.
24:32 --> 24:32However,
24:32 --> 24:34when you sit in the therapy room or
24:34 --> 24:37you try to navigate things with a
24:37 --> 24:39spouse or a partner, for instance,
24:39 --> 24:41complete shutting down with regard
24:41 --> 24:43to the conversation and avoidance
24:43 --> 24:45is what we would call it in the
24:45 --> 24:46therapeutic terms.
24:46 --> 24:48But that avoidance fosters
24:48 --> 24:49much more distress,
24:49 --> 24:52more levels of depression, more anxiety.
24:52 --> 24:53And so there needs to be a balance,
24:53 --> 24:56particularly when it comes to psychotherapy.
24:56 --> 24:58And that's what the core
24:58 --> 24:59tenet of being mindful is,
24:59 --> 25:01the balance between the distress that
25:01 --> 25:03you experience and allowing yourself
25:03 --> 25:05to experience it and sitting with
25:05 --> 25:07it in such a way and developing the
25:07 --> 25:09skills to manage your emotions when it
25:09 --> 25:11comes to how you're feeling about it,
25:11 --> 25:13such that you can observe it differently
25:13 --> 25:15when you're in the heat of distress.
25:15 --> 25:15Without those skills,
25:15 --> 25:17it's really hard to think of,
25:17 --> 25:18well, what do I do next?
25:18 --> 25:20Even when it comes to something like
25:20 --> 25:21scheduling the next appointment,
25:21 --> 25:23if you have the skills developed
25:23 --> 25:25in therapy to be able to look at
25:25 --> 25:26the situation differently,
25:26 --> 25:28still feel the same amount of
25:28 --> 25:29anxiety because nothing about
25:29 --> 25:30that anxiety has changed,
25:30 --> 25:31but to merely look at
25:31 --> 25:32the thought differently,
25:32 --> 25:35to look at the experience differently,
25:35 --> 25:36you might be able to contend
25:36 --> 25:37with it differently as well.
25:37 --> 25:38You might be able to say, well,
25:38 --> 25:39I'm going to schedule it in this way
25:39 --> 25:40that aligns with my values.
25:40 --> 25:43Now I can talk a little
25:43 --> 25:44bit more to my partner,
25:44 --> 25:47the people that I value about this now,
25:47 --> 25:49and start to build my support network.
25:49 --> 25:50I can start to engage with things
25:50 --> 25:51that are really important to me,
25:51 --> 25:53despite feeling fatigue,
25:53 --> 25:54despite feeling pain.
25:54 --> 25:56And I get to choose what that looks
25:56 --> 25:58like rather than the anxiety or
25:58 --> 25:59depression feeling so overwhelming
25:59 --> 26:01that you wouldn't be able to do
26:01 --> 26:03either of those things.
26:05 --> 26:08Yeah, it makes me think that you
26:08 --> 26:11know this idea of being present.
26:11 --> 26:13It really may not solve all
26:13 --> 26:16of the problems of the world,
26:16 --> 26:19but it may not put out the fire,
26:19 --> 26:22but it might clear some of the
26:22 --> 26:24smoke so that at least there's clear
26:24 --> 26:29air for you now to think about
26:29 --> 26:31how you will put out the fire,
26:31 --> 26:34how you will deal with the issues
26:34 --> 26:38without having the the fog of all
26:38 --> 26:40of the emotions that you might
26:40 --> 26:42be feeling running rampant that
26:42 --> 26:45that sometimes can get in the way.
26:45 --> 26:48And I think that that might
26:48 --> 26:51really be a way to help people who
26:51 --> 26:52may come at this with,
26:52 --> 26:55but I just need solutions to my problems.
26:55 --> 26:58It sounds more like that what you're
26:58 --> 27:02doing with Psycho Oncology might not
27:02 --> 27:04be solving the problem of you know,
27:04 --> 27:06this is how you're going to make
27:06 --> 27:08your schedule and this is
27:08 --> 27:10how the finances will play out.
27:10 --> 27:14But more so let me help you to clear
27:14 --> 27:17your mind such that you are able
27:17 --> 27:20to now more productively focus on
27:20 --> 27:21those solutions. Is that right?
27:22 --> 27:26Absolutely. The ability to gain clarity
27:26 --> 27:28and also master what it is that you're
27:28 --> 27:30feeling in a way that's productive,
27:30 --> 27:32in a way that's value based.
27:32 --> 27:34So when you are in situations in which
27:34 --> 27:36you're feeling incredible distress,
27:36 --> 27:39those even getting closer to a solution
27:39 --> 27:41oriented or problem focused sort
27:41 --> 27:43of path when it comes to what's my
27:43 --> 27:46schedule going to look like or finances
27:46 --> 27:47or even how I'm going to navigate.
27:47 --> 27:50The fact that I have these things at home
27:50 --> 27:52that I want to do but I'm experiencing
27:52 --> 27:54pain or fatigue from treatment.
27:54 --> 27:56It's more difficult to do those things
27:56 --> 27:58when you're in the depths of distress,
27:58 --> 27:59if you're avoiding the distress or
27:59 --> 28:01if you have no support system there.
28:01 --> 28:03So psychotherapy, as you'd mentioned,
28:03 --> 28:06really does a lot of the the validation
28:06 --> 28:08work as well as skill work in order
28:08 --> 28:10to be able to clear some sort of
28:10 --> 28:12path for you to get to the next
28:12 --> 28:14step that you want to get to.
28:14 --> 28:15And so the brush,
28:15 --> 28:18we would say is the emotional distress
28:18 --> 28:20that is inherent to and completely
28:20 --> 28:23valid for the experience and the
28:23 --> 28:26skills are your machete pretty
28:26 --> 28:28much to clear through the brush
28:28 --> 28:31and give yourself the the vision of
28:31 --> 28:32what that new path could look like.
28:33 --> 28:35Doctor Gabriel Cartagena is an
28:35 --> 28:36assistant professor of psychiatry
28:36 --> 28:38at the Yale School of Medicine.
28:38 --> 28:40If you have questions,
28:40 --> 28:42the address is canceranswers@yale.edu,
28:42 --> 28:44and past editions of the program
28:44 --> 28:47are available in audio and written
28:47 --> 28:48form at yalecancercenter.org.
28:48 --> 28:51We hope you'll join us next week to
28:51 --> 28:53learn more about the fight against
28:53 --> 28:54cancer here on Connecticut Public Radio.
28:54 --> 28:57Funding for Yale Cancer Answers is
28:57 --> 29:00provided by Smilow Cancer Hospital.

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Exercise as a Standard of Care for Breast Cancer with guest Dr. Gabriel Cartagena January 7, 2024