Nasopharyngeal Carcinoma (Stage II): a patient case study
This patient case study focuses on nasopharyngeal carcinoma (NPC). Specifically, it analyses the progress of becoming and being ill as well as the process of recovery. It identifies and explains how the illness affects the psychosocial functioning of the patient. It similarly analyses how the patient’s own psychosocial characteristics (e.g. belief, personality, social relationship etc.) influence the process of illness and recovery.
Nasopharyngeal Cancer: a brief description
The National Cancer Institute (NCI) of the U.S. National Institutes of Health defines nasopharyngeal carcinoma (NPC) as a “cancer that forms in tissues of the nasopharynx (upper part of the throat behind the nose).” It is believed that nearly all nasopharyngeal cancers are considered squamous cell carcinomas due to its identified origin in flat cells lining the upper part of the throat behind the nose or the nasopharynx. Wang and colleagues (2008) agree that the usual case of nasopharyngeal carcinoma (NPC) include the upper part of the throat behind the nose with a well-developed group of lymphatics and cervical lymphadenopathy. They also describe it as a common cancer among Asians, especially in southern China. There have been abundant collections and a number of documented examples presented in epidemiological studies supporting the hypothesis of a relationship between childhood diet and later cancer. For example, Huang (1991) reported that it is the most prevalent cancer in Hong Kong because of genetically determined susceptibility, early infection, and superinfection by the ubiquitous Epstein-Barr virus and early consumption of elements in traditional Cantonese diets, particularly salted fish. The more consistent evidence relates to the relationship between salted fish consumption in various Chinese populations and the risk of nasopharyngeal cancer. This relationship, which is supported by animal experimental work, shows that early dietary effects on cancer can be highly specific and of appreciable magnitude. There are, unfortunately, no other similar examples. This type of cancer when detected early and treated has a high rate of survival (Ma 2008).
Stage II nasopharyngeal cancer
From the same reference as above, “Stage II is divided into stage IIA and stage IIB. In stage IIA, cancer has spread from the nasopharynx (the upper part of the throat behind the nose) to the oropharynx (the middle part of the throat that includes the soft palate, the base of the tongue, and the tonsils), and/or to the nasal cavity. In stage IIB, cancer is found in the nasopharynx and has spread to lymph nodes on one side of the neck, or has spread to the area surrounding the nasopharynx and may have spread to lymph nodes on one side of the neck.”
The Case
Mr. Lam was a 43 year-old young man. When we first met, he had just been told he had a nasopharyngeal carcinoma stage 2 by his case MO Dr. Chan. Then he became very depressed about his diagnosis because he was the breadwinner of the family. He was very reluctant to start radiotherapy, being fearful of the side-effect – both during and after treatment. He also claimed that his appetite was deteriorating and he could not sleep at night after hearing this bad news. And Mr. Lam also expressed increasing feeling of hopelessness and helplessness about the direction of his life. He was experiences a loss of dreams and ambitions. The future is no longer assures, there is often a realization that long-term plans may be inappropriate
Background
Mr. Lam is a secondary school teacher. Working for many years in a secondary school environment, Mr. Lam was confident, motivated and dedicated to his work. He has a three year old son and also has been studying part time for his Master degree in education for three years. His wife is also a teacher and together they work in same school. Mr. Lam’s son will be looking after by his mother when they are going to school. Mr. Lam states he enjoys his job but it can be demanding and physically tiring at timed. He has previously enjoyed his studies but is now finding it difficult to finish the part-time degree time.
How the illness affects the psychosocial functioning of the patient
I first talked with Mr. Lam the morning after he had been told his diagnosis. He was in his bed. He was very depressed and reluctant to talk to me. He expressed that he felt guilty to his family and unable to take care to his son and wife any more. He also told me that the doctor had side that even though they would not be able to remove the tumor, radiation could perhaps allow him several years of normal life.
On this case, I felt that the patient needs someone who can reinforce his negative emotions and turn them into positive ones. I first thought of applying any person-centered approach. I chose the person centered therapy or PCT. The Person Centered Therapy (PCT), also known as Client-centered Therapy, non-directive, or Rogerian therapy, is characterized by the idea of empowering the client in the therapeutic relationship as the expert, rather than the therapist, and set out against the standard of traditional therapy (Schapira 2000). Accordingly, the most outstanding attributes of this approach is the involvement of human relationship of the therapist and the client (Bower 2000). This more personal relationship offered by the therapist assists the patient to reach a state of realization particularly on the thought that they can help themselves. PCT is mainly used in order for people to achieve personal growth and solve problems or overcome situations that they are having (Schapira 2000). The core concepts or values of PCT are empathetic understanding (empathy), congruence or genuineness, unconditional positive regard, and self-actualization (Levant and Shlien 1984; Lietaer et al. 1990). Schapira (2000) identified the most fundamental concepts of PCT namely: trust; empathy; congruence; genuine respect for the other; and unconditional regard for the client that includes a non-judgmental view of them.
When I already established a rapport with the patient, he began to open up and comfortable in communicating with me. In application, the person-centered counselor’s role is to stay with whatever the client feels, and this is to let the client lead. The counselor reflects back the client’s feelings to him/her, so that s/he can hear them from another point of view. This clarifies his/her feelings for him/her or makes them more apparent. His/Her empathy encourages him/her to express the feelings that s/he has. Furthermore, it is the therapist’s role to help individuals to discover their own potential for themselves, and resist the temptation to solve clients’ problems for them. This may be one of the difficult aspects of the training in the person-centered approach (Schapira 2000). It is highly emphasize in person-centered counseling that clients define their own goals, and counselors strive to deeply understand the world as their clients see and experience it (Merry 1995).
How the patient’s own psychosocial characteristics (e.g. belief, personality, social relationships, etc.) influence the process of illness and recovery
Mr. Lam is a person of principle. Like any other man, he has the strength to endure whatever circumstances he faces. Upon knowing his condition, he was severely affected and turned depressed. This is due to his worries that he will no longer support his family who expects a lot from him. He is the breadwinner. He does not want his family to suffer or worry about his condition. He wanted to recover and get healed. His family was always there to support him. His own disposition is considerably shaken by his illness. His own psychosocial characteristics are affected. Thus, there is a need to reinforce this negative behavior and turn it in positive ones.
The progress of patient becoming
The support of his family helps the patient to feel better emotionally. Although the physical pain is endured and facilitated with the aid of medications, there is a need for psychotherapeutic intervention. The primary reason of using PCT approach is bounded on the idea that the victim is concerned with his self-concept associated with human emotions/relationships and personality development (self-actualization). Such are needed to be effectively facilitated. By looking on the purposes of PCT, these are, increasing self-esteem and greater openness to experience; increasing client’s independence and integration; fostering client including closer agreement between their idealized and actual selves as well as better self-understanding; lowering levels of defensiveness, guilt, and insecurity; creating more positive and comfortable relationship with others; and increasing capacity to experience and express feelings at the moment they occur, the reason of utilizing this approach is to provide a clear understanding of the patient’s situation and eventually to achieve self-acceptance and actualization. It is presumed that by possessing truthful knowledge on the patient’s condition, he is able to continue to live a normal life leaving no traces of the negative impacts of his health condition.
The process of recovery
The process of recovery entails a lot of therapeutic communication. Conversations using formal and informal methods but mostly interpersonal in nature are useful. Communication is among the most influential technique of intervention and it also aids in predicting necessary steps that work for the eventual positive progression of the case. Through communication, trust is cultivated which result to development of connection with the two interacting bodies. The process of communication is ultra dynamic and surpassed the expectations of some of its deliberate functions. The interpretation of the message or information being relayed through communication poses a challenge on the therapist, particularly on the establishment of human relations or patient’s relationship. In general, communication becomes effective when both parties involved are honest, sincere, and open to share information and have the ability to decipher the meaning of their messages. Effective communication must always be practiced as it is significant to individual health as well as for the creation of positive relationships. Specifically, the ability to communicate directly affects an individual’s stress levels, self-esteem and relationship quality (Donatelle and Davis 1998; Fetro 1992). The client dynamic includes individual factors that personally influence the idea of self-identity and societal role, community factors, and freedom. In the PCT approach, the client is free to choose any directions but inherently chooses positive and beneficial pathways.
Synthesis
Both ends and means used in the attempt to bring out change in client’s behavior are open to inspection, which is certainly not true of many other psychotherapeutic approaches and management. It must be understand that because approaches and styles of counselors vary as well as the coping-mechanisms of clients, the idea of flexibility on practice is cultivated. In particular, the therapist or counselors in general need to pay attention to issues relating to the client’s boundaries and sense of self and be wary of taking on individuals who have such poor ego boundaries that a fragile sense of self-actualization may disintegrate to a point where boundaries between self and other are no longer discernible and capable of being respected. Additionally, therapy for some may only be safely proffered in an environment that provides security and protection for both client and therapist, for instance within the confines of a secure psychiatric unit where the risk of the client acting out destructive fantasies against the therapist is reduced by institutional safeguards that serve to protect and preserve the physical welfare and anonymity of the therapist. The use of self is also, and crucially, about therapists knowing and respecting their own limits as well as those of their clients. Further, the best quality of a therapist or counselor, in my own opinion, is the ability to remain authentic and realistic with what is really practical and functional to daily human development and overall existence.
Therapeutic relationships can be achieved through different means. Primarily, the therapist can use the process of collaboration, which involves establishing an equal partnership with the client through bringing skills, knowledge, emotion, and techniques that would help the client in the process. Another way is through formulation, which is a unique map of presenting problems or situations to the client that would integrate information from assessments of the therapist. Third, the therapist can use a Socratic dialogue or guided discovery, which involves gently probing or questioning for people’s meanings to stimulate alternative ideas. It explores and reflects on styles of reasoning and thinking differently. Lastly, the therapist can assign homework to the client, to allow him or her to try things out in between therapy sessions, thus, putting into practice what the client has learned in the therapy sessions (Grazebrook and Garland 2005). With such methods, the therapeutic relationship between the client and the therapist can be established and determined. However, the problem that can be encountered in this sense is the fact that the client may have apprehensions towards the therapist, thus, limiting his or her disclosure of information. In this regard, the statement of Beck, emphasizing that such therapeutic relationship may not be enough to obtain desired outcomes come into picture.
The therapeutic relationship established through such means may not be effective due to a number of reasons. Primarily, the therapeutic relationship would not be effective in achieving healthy outcomes without the trust of the client to the therapist. It has been reported that the cognitive behavior therapist works with schemas, which are the collections of people’s beliefs, experiences and rules of behavior about themselves, others and the world (Niolon 1999). If the client has schematic beliefs of mistrusting other people, then the therapist would have a hard time encouraging the client to disclose information. In this regard, the genuineness of the therapist must be observed, which has to do with confidence, appearing relaxed and at with one’s self, thus, presenting the therapy in a way that it would not sound artificial to put up a barrier between the therapist and the client (Sheldon 1995). Another hindrance to the practice is the lack of sensitivity on the part of the therapist. If the therapist is not sensitive enough for the needs of the client, then the client would not be able to obtain the best treatment that would help him or her to improve and develop as an individual. In this regard, non-possessive warmth must be expressed by the therapist, which consists of getting across to clients feelings of respect, liking, caring, acceptance, and concern, and managing these in a non-threatening way (Sheldon 1995). It is not enough that probing and collaboration with the client must be done, but the client must be able to feel the care and concern of the therapist.
Therapeutic relationship is also not enough if there is incompatibility between the client and the therapist. Incompatibility can be observed through the incompatibility of the approaches of the therapist, and incompatibility on the response of the client that hinders adequate and effective assessment. In this regard, it can be perceived that the relationship of the client and the therapist must be based on compatible approaches and strategies that would not only benefit the client, but provide learning and experience on the part of the therapist as well. Having a client-therapist relationship is not a mechanical and predictable relationship that provides help to the client because of sympathy. In this regard, empathy must be extended by the therapist, which involves letting the client know that the therapist has a grasp on his or her problems, showing the client that the therapist sees things on the client’s perspective, and letting the client feel and see that the mood and feelings of the therapist are in tune with him or her (Sheldon 1995). As such, the trust and confidence of the client can be obtained. In addition, the time allotted by the therapist also counts in cognitive behavior therapy. Therapeutic relationships must not only focused in providing cognitive activities and workshops to the client, but making the client feel that his or her problems matter to the therapist through providing ample time for listening to the client. However, psychotherapies, such as cognitive behavior therapy takes a lot of time and effort on both the client and the therapist, is a time-consuming process, and its full analysis may take several years (Rycroft 1988). In this regard, each therapy session between the client and the therapist must be grasped and taken advantage in order to yield the best possible result. However, the problem that can be encountered due to the slow and time-consuming process is that the client or the therapist may get tired, given the slow development of the client. In this case, psychotherapeutic activities must be done simultaneously to ensure the speedy improvement and treatment of the client. From this, it can be perceived that the therapeutic relationship between the client and the therapist that was established through probing, collaborating, and assigning homework must not be based only on by-the-book approaches. Such activities must be done with the empathy, genuineness, and sensitivity of the therapist to the needs of the client.
References
Donatelle, RJ and Davis, LG (1998) Access to Health, Allyn and Bacon, New York
Fetro, JV (1992) Personal and Social Skills: Understanding and Integrating Competencies across Health Content, ETR Associates, Santa Cruz, CA
Grazebrook, K and Garland, A (2005) International Institute for Cognitive Therapy, [online] (cited 13 November 2008) Available from http://www.cbtonline.biz/cognitive_therapy.htm
Huang, DP (1991) ‘Epidemology and aetiology’, In C. A. van Hasselt & A. G. Gibb (Eds.), Nasopharyngeal carcinoma (pp. 23-36), Chinese University Press, Hong Kong
Levant, RF and Shlien, JM (Eds) (1984) Client-Centered Therapy and the Person-Centered Approach: New Directions in Theory, Research, and Practice, Praeger Publishers, Westport, CT
Lietaer, G, Rombauts, J, and Van Balen, R (Eds.) (1990) Client-Centered and Experiential Psychotherapy in the Nineties, Leuven University Press, Belgium
Ma, JLC (1998) ‘Effect of Perceived Social Support on Adjustment of Patients Suffering from Nasopharyngeal Carcinoma’, Health and Social Work, 23: 3, 167+
Merry, T (1995) Invitation to Person Centred Psychology, Whurr Publishers, London
Niolon, R (1999) The Therapeutic Relationship – Part II, [online] (cited 13 November 2008) Available from http://www.psychpage.com/learning/library/counseling/thxrel2.htm
Rycroft, C (1988) Anxiety and Neurosis, Maresfield, London
Schapira, SK (2000) Choosing a Counselling or Psychotherapy Training: A Practical Guide, Routledge, London
Sheldon, B (1995) Cognitive-Behavioral Therapy: Research, Practice, and Philosophy, Routledge, New York
The National Cancer Institute (NCI) of the U.S. National Institutes of Health (2008) ‘Nasopharyngeal Cancer and Stage II Nasopharyngeal Cancer’, The National Cancer Institute (NCI) of the U.S. National Institutes of Health, [online] (cited 13 November 2008) Available from http://www.cancer.gov/Templates/db_alpha.aspx?CdrID=46179
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