Four Psychotherapy Approaches to a Terminal Cancer Case

Overview of the Case

The case surrounds Carlos, a man in his late thirties with a growing tumor that will not respond to radiation or chemotherapy. Carlos has been fighting this cancer for about a decade, but it has now reached the point at which medical science can do no more for him. Carlos was referred to therapy by his oncologist and responded somewhat to individual therapy, but became combative and confrontational in group therapy. Carlos is a classic narcissist and misogynist. He has few friends, is estranged from his children, and is, at best, cynical and sarcastic.

However, through individual therapy, Carlos was able to reach some conclusions about the walls he had built around himself and the tremendous insecurity he harbored — typically using sex and sarcasm to cover up his need to belong. He eventually revealed two insights about himself and his relationship to the world: (1) everyone has a heart and should be treated with respect and kindness; and (2) "I am not my shoes" — that is, one's work, clothing, and outward appearance are only partially indicative of one's psychological makeup (Yalom, pp. 73–92). Using four systems of psychotherapy, this paper uses Carlos's case as a basis for understanding different approaches to treatment.

Irvin Yalom is existential in his approach to Carlos. He is initially not fond of Carlos, but finds over time that there are issues that can be addressed — specifically Carlos's countertransference and isolation from emotional intimacy. Yalom uses this approach to convince Carlos that it is his own perceptions of the world, and the resulting actions, that cause people to react negatively toward him. Unless Carlos opens up to the world, the world will never open up to him. Yalom is ultimately successful with Carlos because he employs a particularly clever role-reversal technique that asks Carlos to put himself in another's shoes in order to address many of his insecurities. This is especially powerful when Yalom asks Carlos whether he is ready to die without first making peace with himself, his children, and the universe.

Freud's approach to psychoanalytic theory did not evolve in a vacuum; it was built upon years of observation and prior research. Freud's approach focuses on the overwhelming influence of the subconscious — fears, desires, thoughts, and so on — that become part of the conscious mind and behavior. Many of these issues develop during infancy and childhood for a variety of reasons, and are bound up in the formation of certain psychological conditions that express themselves in adolescence and adulthood. Freud believed there were three components of personality: the id, the ego, and the superego.

Freudian Psychoanalytic Approach

The id focuses on the emotional, and often irrational, segment of the mind. At birth, a baby's mind is essentially "a bundle of id" — it contains all basic needs and feelings, is the source of libido, and operates according to only one rule: the pleasure principle. The ego functions as the rational part of the mind; it recognizes the need for compromise and negotiates between the id and the superego. The ego's role is to satisfy the id's drives while remaining reasonable and bearing long-term consequences in mind, avoiding both instant gratification and excessive denial. The superego functions as the moral part of the mind: it stores and enforces rules, and its power to do so comes from its ability to generate anxiety (Corsini & Wedding, 2011, pp. 57–58).

Applying a Freudian model to Carlos reveals several compelling possibilities. The most obvious is the parallel between his conscious and unconscious personality and inner needs. Carlos is preoccupied with sex because he is relatively incapable of emotional intimacy and fears rejection. To manage this, he erects a confrontational wall between himself and the world, reverting to sexual pleasure to seek validation. The goal of psychotherapy in this framework is to engage Carlos as a "whole person" — including his problems, stresses, fantasies, and feelings — in order to uncover and treat the underlying issues he presents (Corsini & Wedding, 2011, pp. 58–59).

Carl Rogers, the American psychologist and founder of the humanistic, or client-centered, approach to therapy, believed that all individuals are unique and continue to evolve within a constantly changing environment, and that behavior is goal-directed toward satisfying the concept of self. For Rogers, Carlos is continually evolving as the center of a world in which external and internal experiences are in constant flux. Using Rogerian therapy, the goal is to move Carlos toward his full potential — regardless of the time he has remaining — to become a positive force, to exhibit helpful qualities toward others that he rarely demonstrated before, and to form a new self-image that is less rooted in negativity (Corsini & Wedding, 2011, pp. 164–165).

Rogerian Client-Centered Therapy

To move toward this fully functioning state, Rogerian therapy moves away from defensiveness and encourages openness and frank honesty, as well as living each moment fully without excessive worry about the future. The therapist's role is to provide unconditional positive regard and empathy to the client; through that experience, patients like Carlos come to understand alternatives to the fight-or-flight response. By effectively modeling positive and optimistic attitudes, the therapist helps the client gradually recognize that there is little purpose in negativity and hostility. In Carlos's case, the aim is to accept him so that he, in turn, will accept others and learn to empathize just as the therapist empathizes with him. The respect the therapist shows Carlos must be consistent and genuine so that Carlos comes to understand that respect breeds respect. The central issue is not Carlos's sexual needs or his judgmental nature — it is how to lower his defensive walls and open himself up to other people (Corsini & Wedding, 2011, pp. 164–166).

REBT (rational emotive behavior therapy) theory holds that neurotic dysfunction occurs when individuals demand that their wishes be satisfied. If these individuals succeed, then the world will be more favorable to them, and their interactions with others will be more positive. When people like Carlos make excessive demands, they often experience emotional difficulties and are thus unable to actualize their potential. Over time, this becomes a gradual downward spiral into negativity and depression. The goal of the therapist is to focus on resolving these emotional and behavioral difficulties and to help the client understand that needs and wants are different and context-dependent (Corsini & Wedding, 2011, pp. 212–213).

In Carlos's case, applying REBT would focus on his inflexibility and adversarial stance, helping him see that these patterns do not resolve his interpersonal difficulties and do not bring him pleasure or satisfaction in the long run. The therapist would also address Carlos's self-sabotaging and pessimistic behavior: because Carlos does not feel trusted by others, he covers up that anxiety by withholding trust himself, maintaining walls that become self-destructive. However, insight alone is rarely sufficient to produce lasting behavioral change (Corsini & Wedding, 2011, pp. 213–215).