Cancer can completely upend your life and the lives of those who love you. It not only affects you physically, but also has profound emotional and psychological consequences for everyone involved. From the moment you receive the diagnosis to the often challenging or even excruciating medical treatments, cancer brings a whirlwind of difficulties that can lead to symptoms of posttraumatic stress. People living with cancer may have symptoms of post-traumatic stress at any point from diagnosis through treatment, after treatment is complete, or during recurrence. This can range from experiencing irritability, hypervigilance, and sleep disturbances, to loss of interest in life and feeling detached from oneself or reality.  

In simple terms, the trauma of cancer can greatly reduce your ability to handle and cope with stress and emotions, narrowing your “window of tolerance.” Within this window of tolerance, we usually feel safe, calm, and capable of effectively managing stress and emotions. However, cancer pushes us to our limits, often causing this window to shrink. It becomes much more challenging to find that sense of safety and calmness in the face of overwhelming stress. 

However, survivors of cancer also often report experiencing posttraumatic growth (PTG) after their journey. PTG refers to the positive psychological changes that can occur in people following the experience of a traumatic event or significant life crisis. PTG can include improved relationships, new possibilities for life, a greater appreciation for life, increased personal strength, and spiritual development. 

PTG coexists with personal distress and does not diminish the emotional impact of traumatic events or the amount of work that it takes to achieve it. It is not a universal or inevitable outcome for all people who experience trauma, but by working with a mental health practitioner, you can work towards achieving PTG. Embracing the potential for posttraumatic growth means embracing the opportunity to discover new paths and possibilities that may have never been considered before. It means finding a deeper appreciation for what life has to offer and a renewed sense of purpose. 

Cancer-related post-traumatic stress. National Cancer Institute. (n.d.). https://www.cancer.gov/about-cancer/coping/survivorship/new-normal/ptsd-pdq  

Jim, H. S., & Jacobsen, P. B. (2008). Posttraumatic stress and posttraumatic growth in cancer survivorship: A Review. The Cancer Journal, 14(6), 414–419. https://doi.org/10.1097/ppo.0b013e31818d8963  

Tedeschi, R.G. & Calhoun, L. (2004). Posttraumatic Growth: A New Perspective on Psychotraumatology. 21(4). https://www.bu.edu/wheelock/files/2018/05/Article-Tedeschi-and-Lawrence-Calhoun-Posttraumatic-Growth-2014.pdf 

Laura McKinney, B.A., is a therapy and assessment practicum student working under the supervision of Dr. Lila Hakim, C. Psych., currently completing her master’s in psychology. Alongside her placement at CFIR, Laura is training as a therapist at Princess Margaret Cancer Centre, where she is working with individuals living with cancer. As a practicum student, Laura offers therapy at a discounted rate. Please check out her profile on the Toronto team page on the CFIR website for more information.

REGULATING NERVOUS SYSTEM RESPONSES TO TRAUMA

Please see blog post: PART I: TRAUMA AND THE NERVOUS SYSTEM prior to reading this post

There are many different ways to regulate our nervous system. Body-based or somatic approaches are accessible and can create lasting changes to our feelings, thoughts, and behaviours. 

HYPERAROUSAL:

1. Hand on heart: 
   • place your hand on your heart and start to notice the gentle contact between your hand and your chest. Notice the weight of your hand on your chest.
   • Notice the temperature (e.g., warm or cold)
   • Notice any sensations (e.g., tingly, spacious, energized, airy)
   • Notice if the sensation starts to spread
   • Notice your breathing 
   • Deep breathing
2. Deep breathing:
   • Inhale for 4 counts; hold for 4 counts; exhale 8 counts
   • *try: inhaling through your noise and exhaling through your mouth (making an “O” shape with your mouth)
3. Belly breathing:
   • Place your hand on your belly
   • Inhale for 4 and actively expand your stomach
   • Hold for 4 
   • Exhale for 8 and collapse your stomach 

HYPORAROUSAL:

1. Posture change: 
   • Elongate your spine (*imaging your spine being pulled up to the top of your head)
   • Pull your shoulder back 
   • Gently push your chest out 
   • Take a few breaths here
2. Breathing:
   • Inhale for 8 counts; hold for 4 counts; exhale for 4 counts
3. Grounding through contact:
   • Stand up and notice your feet on the floor; elongate your spine and start to peddle your feet to apply more weight to one foot at a time; notice activation of muscles in your legs and glutes; bring attention to sensations (e.g., pressure, energized) and temperatures in your feet.  

Whitney Reinhart, M.A., R.P., is a psychotherapist who provides psychological services to adults and couples experiencing a wide range of issues, with a special interest and expertise in trauma and relationships. She uses a variety of trauma-informed approaches, including sensorimotor psychotherapy, somatic experiencing, and parts-based therapies.  

When we experience threat, our nervous system reacts in the best possible way for that situation, either by fight, flight, freeze, submit, or cry for help. When we experience threatening situations or traumas where we aren’t able to mobilize and run to safety or fight back, we will freeze or submit. In freeze, we feel stuck; there is an internal sense of danger and threat, but we are unable to move or act. In submit, we collapse; everything goes offline, our muscles become flaccid, and breathing decreases. 

When we have unresolved trauma (chronic or acute; attachment-based or threat to body), we can go throughout our lives reliving the trauma through our nervous system – often leaving us in a chronic state of hyperarousal (fight, flight, freeze, attach) or hypoarousal (submit). In chronic hyperarousal, our nervous system is geared up and activated. For example, we might find ourselves feeling irritable and on edge (fight), using substances for relief, distancing from relationships (flight), relying heavily on others, clinging to avoid abandonment (attach/cry for help), feeling frozen and/or experiencing panic attacks and flashbacks (freeze). In chronic hypoarousal, our nervous system is shut down and numbed out, and can result in us feeling depressed, ashamed, disconnected, unable to think, and passive.  

If you identify with some of these internal experiences, therapy is a great step for understanding your nervous system responses, what you had to do to stay safe, and how to regulate your nervous system. 

Stay tuned for Part II on regulating your nervous system.

Whitney Reinhart, M.A., R.P., is a psychotherapist who provides psychological services to adults and couples experiencing a wide range of issues, with a special interest and expertise in trauma and relationships. She uses a variety of trauma-informed approaches, including sensorimotor psychotherapy, somatic experiencing, and parts-based approaches. 

How we understand, feel, and behave interpersonally in adulthood stems from our experiences in our earliest relationships. As children, caregivers help us make sense of our experiences. They translate a physical reaction, such as crying, into a conscious feeling, thought, or desire. They do so by mirroring the child’s emotion, marking it with exaggerated facial, vocal, or gestural displays, and responding to it sensitively. They also put into words their own reactions, modeling ways to make sense of a child’s behaviours, and allowing the child to understand that people experience situations differently. These interactions foster what is called “mentalization”, which is the capacity to understand oneself and others in terms of possible thoughts, feelings, wishes, and desires. 

And what about children who did not benefit from such interactions with caregivers? In cases of child abuse and neglect, the child’s physical experiences are often ignored or met with anger, resentment, and irritation. These responses leave a child with the impossible task of processing his experience alone, therefore compromising the development of mentalization. It is not surprising that many adults having suffered maltreatment in childhood often encounter difficulties in their adult relationships. They may often feel hurt or angry in relationships as their understanding of others’ intentions or feelings is either lacking or inaccurate, leading to conclusions drawn by their own painful experiences in childhood. Therefore, behaviours such as withdrawing from a situation may be perceived as an intentional rejection, when, in fact, it may result from other intentions or needs. 

At CFIR, we can help you develop your mentalization skills by taking a step back from situations that trigger strong reactions. By learning how to think about how you feel and feel about how you think, we can support you to create stronger bonds in your relationship with others. 

Lorenzi, N., Campbell, C. & Fonagy, P. (2018). Mentalization and its role in processing trauma. In B. Huppertz (Ed) Approaches to psychic trauma: Theory and practice (p. 403-422). Rowman & Littlefield. 

Camille Bandola, B.Sc., is a counsellor at Centre for Interpersonal Relationships working under the supervision of Dr. Dino Zuccarini, C.Psych. She is currently in the fourth year of my doctoral program in Clinical Psychology at Université du Québec en Outaouais.

“Playing is itself a therapy,”

Donald Winnicott (1971)

One of the reasons I love Winnicott is that he realizes just how much a child misses out on if they do not have a chance to play or truly ‘be a kid’. This is especially the case for children who have experienced abuse, parental neglect, all resulting in them having to grow up too soon. 

To play means to allow creativity and imagination to flourish. To laugh. 

Be silly. 

Get messy.

As adults, we sadly also sometimes lose this ability to play. In my practice in Toronto (www.cfir.ca), I really start to see the impact of therapy on clients when we get to play together in session through laughter, art and using our imagination. As we share in these moments of creativity, it is incredible to see the bounds of trauma start to loosen its grip. 

As much as the psychodynamic field may have once admonished its therapists to be a ‘blank screen,’ people like Winnicott showed just how essential it is to let go and be silly. It is incredible to see how clients open up and come alive as we share in a private joke or get creative together. This sense of wonder is especially the case as a trauma therapist; while much of our session may delve into darker aspects of a client’s past, being creative and playful enables a start to freedom from these bonds. 

For me, playing comes on the wheel.

In the video below, I am doing what potters call ‘throwing off the hump,’ which means I throw smaller bowls on a large mound of clay so I can cut off the bowl and then immediately make another. This process is incredibly fun because while it produces many pieces (often tinier bowls), it is a rather messy process and requires a level of creativity that makes me feel alive. 

As someone who has also faced past trauma, I find that playing on the wheel, and being messy means that I can let go of some of my guardedness and simply play. I love the way it makes me feel like a kid again.

(This post is shared content from centredself.ca)

Jess A.L. Erb, D.Psychotherapy, R.P. (Qualifying) is a Registered Psychotherapist (Qualifying) who believes that the best therapy happens when a deep trust can form between counsellor and client. She works with adults and adolescents in an array of issues such as depression/suicidal ideation, anxiety/panic disorders, grief and loneliness, as well as all forms of abuse – emotional, physical, sexual, self-harm, and eating disorders. Before working as an associate at CFIR, she trained as a doctor in psychotherapy at the University of Edinburgh, UK.

by: Andrea Kapeleris Ph.D.

More common than you think! About 20-50% of children and teens who have experienced trauma meet the criteria for Post-Traumatic Stress Disorder (PTSD) and nearly 75% also experience depression and substance use (Elwood, Hahn, Olatunji, & Williams, 2009). Statistics also show that about 14% of people exposed to a major stressor go on to develop PTSD (Terhakopian, Sinaii, Engel, Schnurr, & Hoge, 2008), and women are about twice as likely as men to develop PTSD after a trauma (Kessler, Berglund, & Demler, 2005). Stressors can be one-time events that cause actual or threatened death or harm to yourself or a loved one (such as, a car accident, sexual assault, mugging, natural disaster), or they can include on-going negative and damaging experiences – such as, chronic stress resulting from military service, or childhood experiences in which there was repeated damage to the attachment relationship between you and your caregiver. These chronic experiences can shatter a child’s sense that the world is benign, the world is meaningful, and the self is worthy, and often results in avoidance coping and an increase in overall level of arousal and anxiety (Roth et al., 1997).

Symptoms of PTSD are Normal Reactions to a Non-Normal Experience

• Re-experiencing the event in a number of ways including, flashbacks, nightmares, or vivid memories that come to you unexpectedly 
• Avoiding any reminders of the event (people, places, or things associated with the event), and a feeling of numbness
• Increased feelings of anxiety or emotional arousal

Treating Trauma

Overstuffed Cupboard Metaphor

The mind is like a pantry cupboard. When a traumatic event occurs, it is as if very large and oddly shaped boxes were hurriedly stuffed into the pantry. Since there was no time to properly place the boxes in the pantry in an organized fashion, each time you open the pantry to get something you need, a box suddenly and unexpectedly falls on you – startling you and possibly hurting you! The same thing happens when our mind experiences trauma. Due to the sudden and overwhelming nature of the traumatic event, the mind doesn’t have the opportunity to process all of the emotions associated with it, and as a result, unpleasant memories or emotions may come to us when we least expect them too. For example, you may become startled by an unsettling memory or emotion when you are relaxing at home, watching TV, or spending time with friends. As a result, you may begin to avoid things you previously enjoyed. 

The purpose of therapy is to help you organize this pantry. We need to take each box out of the pantry slowly and carefully, examine its contents, and then place it in its proper place. Once all of the boxes are organized accordingly, you will be able to enter the pantry without fear, and will no longer need to avoid that part of your home. Similarly, the goal is to slowly process the trauma and place events and their accompanying emotions into sequential order. In this way, your mind will be able to integrate the trauma and make sense of it. You will be able to think more freely and move forward with your life. 

Fight or Flight mode

When we encounter a traumatic event (something that threatens our physical or psychological integrity) our bodies enter a process called the “Fight or Flight” mode. This mode is evolutionarily necessary and served an important purpose – in the times of cavemen and women when our ancestors were being chased by predators (e.g., a tiger) all of the resources in their bodies left the frontal cortex (the part of our brain used to reflect on our thoughts and feelings, and make decisions) and automatically went to their muscles (to prepare them to flee or fight the predator), and also went to pump up their heart rate, breathing, and overall adrenaline (again, to make it easier for them to flee or fight predators). In modern times, when we are faced with a trauma, our bodies go into ‘Fight or Flight’ mode in order to protect us. Later, any experiences, people, places, or things that remind us of the trauma stimulate our body to again go into this fight/flight mode in case we need to be protected again. Part of our work in therapy is to help your body and mind recognize that this threat occurred in the past and that you are no longer in danger. We foster this safety on many different levels:
1) Physiologically: We must help the physical body itself feel safe and come down from overarousal. This may partly be achieved through learning relaxation strategies or overcoming avoidance-coping strategies that maintain and intensify anxiety. 

2) Emotionally: We must help the mind itself feel safe and come down from overarousal. This is achieved through:
a) processing the trauma as described above in ‘the cupboard metaphor’; 
b) learning Emotion Regulation strategies

Emotion Regulation

Emotion regulation is a process of 1) identifying and increasing awareness of your feelings (e.g., what are the names/labels for the vague and sometimes uncomfortable sensations that happen inside?), and 2) ‘sitting with’ the sensations that go on inside and experiencing the waxing and waning of your feelings – all feelings do wax/wane, come and go – the only thing we can be certain of is change from moment to moment. Physiologically, our bodies experience of any emotion follows a bell-shaped curve (i.e., it must come down from its peak) – our bodies cannot maintain the high emotional arousal indefinitely – but sometimes, our feelings about our feelings (feeling angry that we are sad, for example) may intensify our original emotion. In therapy, we help to disentangle this, and in effect, help you to regulate your emotions. Importantly, we also begin to look at your feelings as an important signal that there is something inside that needs our attention

Read more about our Trauma Psychology & PTSD Treatment Service.