For the past 12 years, I have worked as a counsellor with women who have been diagnosed with breast cancer. In this article, I would like to share a key area of that experience, namely the positive personal growth that I have witnessed in women as they seek to come to terms with what has happened to them. The nature of this growth has some specific characteristics, which I explore through a case study, fictionalised to protect confidentiality, but highlighting actual issues brought to me.
The concept of post-traumatic growth (PTG) was first introduced by Richard Tedeschi and Lawrence Calhoun in 19951 and refers to the positive changes that individuals often report following adversity. Ongoing research in this area has included exploration of the experiences of post-traumatic growth in those who have suffered a life-threatening illness,2 and the development of several psychometric tools, such as the Post-Traumatic Growth Inventory (PTGI)3 and the Psychological Well-Being Posttraumatic Changes Questionnaire (PWB-PTCQ),4 which assess individual differences in positive changes following adversity. The facilitation of post-traumatic growth is being increasingly recognised as a valid focus in therapy.5
As a person-centred counsellor who believes in the growth potential, or actualising tendency, of human beings, the concept of PTG chimes with my own philosophy. Other key principles guiding my work are a belief in each individual’s unique instinct as to the direction in which they need to go to achieve personal growth, and that the therapist’s main task is to harness this ‘exquisite inner compass’.6 So my own approach is facilitative and non-prescriptive, closely attuning myself to my client’s own process and tailoring what I do to this process. In closely following them and responding to them, I work in a pluralistic way,7 drawing upon all of what I may have to offer by way of knowledge, experience and skills and providing these as part of a collaborative, facilitative dialogue. I am committed to ongoing learning about what is helpful and unhelpful to my clients, learning from them and from others, with the aim of constantly growing as a practitioner.
The environment and context within which I work supports my counselling in several ways. I work for the UK-registered charity, Breast Cancer Haven, which offers holistic care to people diagnosed with breast cancer at six centres around the country – in London, Leeds, Hereford, Wessex, West Midlands (Solihull) and at the Royal Worcestershire Hospital’s breast care unit. Founded in 2000, the charity offers individuals up to 10 free sessions of complementary therapies, which can include acupuncture, reflexology, hypnotherapy, nutritional therapy and counselling. It also offers two hours of healthcare professionals’ time at the beginning and end of their programme. All therapies are tailored to the individual, with close dialogue with NHS teams in order to ensure that the therapies dovetail with the person’s medical care. In addition, up to four free hours of counselling can be accessed by family or close friends of people diagnosed with breast cancer.
Breast Cancer Haven’s aim of responding to the needs of the whole person, through a programme tailored to the individual and supported by group sessions and workshops, gives me an important sense of being part of a team, who are working together to promote the individual’s wellbeing and quality of life. I gain personal support and understanding from my colleagues, as well as the opportunity to learn from them about the ways in which their therapies help those who access our services. This learning from others has increased my capacity and confidence to have helpful conversations with those from other disciplines, including those from a medical background. Although we speak differing languages, we share a mutual aim to support those living with breast cancer.
Since its inception, Breast Cancer Haven has fostered close collaborative relationships with the NHS, with the aim of supplementing its aftercare services for breast cancer patients. Information about the charity’s work is distributed in hospitals, to GPs and district nurses. Haven staff also join multidisciplinary meetings when invited, as well as local cancer networks and study days. NHS staff are regularly invited to the charity’s Health Professionals Days, where they can come to a centre and learn first-hand about our services. The following case study gives a flavour of my work as a counsellor within this setting, with the aim of sharing some of my professional experience and in the hope that it may interest and inspire others who work in this field.
Maggie, aged 49, came to see me 14 months after her initial diagnosis. She had undergone a mastectomy, chemotherapy and radiotherapy, all of which had gone well, and she was shortly to go back to her job, teaching children with special needs. However, she was overwhelmed with feelings of anxiety around the cancer coming back and about coping with the stresses of returning to work. A single mother of two teenage boys, she also worried about them and how they might cope if she became ill again. At the same time, she felt bitter and angry towards her sons, who never mentioned her breast cancer or helped out much at home and she admitted to shouting at them a lot. She felt she was only valued if she was looking after others and she resented her own needs being ‘constantly relegated to the margins’. Maggie’s mother had died 18 months previously and Maggie, who had looked after her a lot since she had been injured in a car accident when Maggie was eight years old, also acknowledged continuing complex feelings of loss and grief.
My foremost aim in working with Maggie was to foster a collaborative relationship with her, one which would create safety and build trust. I wanted to enable her to focus on her current concerns and to find her own way forward. In listening to her, conveying empathy, unconditional positive regard and genuineness, I was seeking to understand all the dimensions of her experience, including the context in which she had experienced her breast cancer.
Our first two sessions focused on her intense, complicated feelings of grief over her mother and how she had felt somehow detached from her own breast cancer. She knew that she needed to focus on the medical aspect of her treatment, but could not and did not really want to access any feelings over this at the time. ‘It was almost like it wasn’t happening to me’, she said; ‘I just got on with it.’
In my reflections on these sessions, I noted how Maggie seemed to have sidelined her grief over her breast cancer at the time, even dissociating herself from it, in order to cope. This trauma response is one that I often see in the women I work with. I noted, too, Maggie’s strong internal belief that she must care for others in order to feel valued and how her identity, both personally and professionally, was bound up with this. I wanted her to feel unconditionally valued and accepted by me, as I believe these consistent therapist attitudes create a climate of stability and foster self-acceptance and self-valuing in the client.
In line with this, my early interventions involved helping her to acknowledge, articulate and begin to accept her own feelings, as they were, without judgment. My reflective responses and affirming acknowledgements helped her pace her narrative, and she was able to talk with increasing openness about her feelings, and to focus on how she might help herself to be with them in ways that helped her cope. Maggie talked about the interest she had had in meditative practice when she was younger. We discussed this and she commented on some of the literature on mindfulness and meditation that she had seen at the centre. I noticed an energy and enthusiasm in her when she began to get in touch with her own growth-promoting resources.
In session three, Maggie said that she was sleeping better and feeling a lot less anguished. She had begun to think more about what she would like to do to nurture herself. She said that she now felt ready to access the acupuncture sessions, which had been selected as part of her programme of therapies at the centre, when she had seen our breast care nurse for her first consultation. She felt more confident to try this now to help with her hot flushes. I acknowledged her progress and invited her to say more about her thinking around self-nurture. We explored her interests in more depth. As she spoke, I was very affirming of the attempts she was making to help herself, saying things like, ‘You’re really finding ways of supporting yourself at this time.’ She said she had enjoyed art at school and that she had recently picked up a colouring book for adults that someone had given her; she had enjoyed selecting a picture to work on and choosing the colours she would use. ‘How did it feel, doing this?’ I asked her, and she spoke about feeling silly at first, but then getting very absorbed in it, losing track of time and feeling very relaxed. ‘I must have spent an hour or more doing it,’ she said. When I asked her how she might develop this creative side of her to support her healing, she talked about how she had particularly enjoyed sketching at school and thought she still had some art materials in a cupboard somewhere.
In my reflection afterwards, I noted the difference in Maggie’s tone of voice and body language. There was an energy and lightness in her, especially when she remembered her enjoyment of sketching. She made much more frequent eye contact with me and there was a sense of fun. We also shared some laughter when she talked about her colouring attempts and how she had given herself ‘permission’ to colour outside the lines! I felt a sense of freeing-up in her. She continued to talk about her mother at times in the session, too, though I noted how she now seemed able to oscillate between feelings of grief and loss, and feelings of enjoyment and motivation; the accessing of her own trauma and her own enthusiasm for life seemed to go hand-in-hand. She was now very open in expressing and exploring her feelings with me and seemed much more accepting of them.
In sessions four and five, Maggie continued to nurture her creative side. She also focused on returning to work and she began to talk about her vocation for working with children with special needs and the values underpinning this that mattered to her. She felt that she would like to update her training, develop some new skills and think about how she might move forward in her career. She also highlighted some of her present difficulties in communicating with her sons and was able to express her disappointment, anger and resentment towards them for not being more helpful at home or ever mentioning her breast cancer to her. Although she knew that her sons were growing up, she wanted to explore ways of remaining close to them.
I felt that Maggie was getting back in touch with her own strengths and abilities. She sounded confident when talking about her work with children; I reflected this back to her, fully acknowledging, too, the values of compassion and altruism that shone through. I felt that her own drive for self-fulfilment was very much in evidence and I could see her looking to the future more readily. Harnessing Maggie’s professional confidence and teaching skills, we worked together to devise appropriate communication strategies to use with her sons, where she would seek to understand how this period of time had been for them, share how it had also been for her and invite them to work with her on a way forward.
Session six revolved around return-to-work strategies, which included rehearsal of responses to use when facing questions from staff and pupils about her illness. Maggie also talked about a ‘shift’ in herself around creating greater balance between her own and others’ needs and a desire to ensure that she took sufficient time to care for the deeper, more spiritual needs she felt were developing in her. Maggie had one more session in her programme and wanted to take this a few months’ later, after she had returned to work.
In this final session, Maggie was overwhelmed by the response she’d had from school. She had felt listened to, supported and cared for, which had meant so much to her. She now felt glad to be back at work. She looked really well and was taking time to be with her sons and enjoy their company. They had started cooking together and going for walks with the new dog they had recently acquired from a rescue centre. Maggie had been to visit her Mum’s grave to take some flowers, and she felt she was beginning to ‘gain more perspective’ about her relationship with her, and what she had gained, as well as lost, from her caring responsibilities. Maggie felt she was really moving on. Although she could still get anxious at times about her health, she felt she was enjoying the present so much more and deeply appreciating life.
A key area of growth in the women I have counselled after breast cancer is in their relationships with others. In reflecting on what matters to them now, their core relationships take centre stage. There is a reassessing of relationship strengths and diffi ulties, together with a strong motivation to work to improve things, with practical problem-solving featuring strongly, especially in the area of communication skills. I have noticed how, in developing their own abilities to communicate effectively around breast cancer, women also often gain greater confidence in tackling other communication diffi ulties. They often experience a general deepening of empathy in their relationships.
Similar to most of the women I work with, I noticed a significant shift in Maggie’s relationship with herself. She seemed less self-critical, more accepting of her strengths and weaknesses, and more compassionate and forgiving towards herself, with a resulting growth in confidence that had a tender quality about it. In particular, there was a noticeable shift in her need to find self-worth by looking after others, while denying her own needs. She had been able to accept both practical and emotional support from her family and friends, and this freed her up to spend more quality time with them.
In talking about the deepening of her own vocation as a teacher, Maggie reflected on how her own suffering, vulnerability and confrontation with mortality were prompting her to learn more and be more open towards others who were struggling, especially other women with breast cancer. This increase in altruism and personal vocation is another key feature of the growth I regularly witness in women following breast cancer.
My sessions with Maggie also highlighted something else I often observe in women at this time – a deepening of their sense of what matters to them and a reaffirming or development of their personal faith or personal philosophy. Having confronted their own mortality, there is often a deepening of their daily enjoyment of life. Many women re-engage with or deepen their personal spiritual practices, or develop an interest in doing so, for the first time. This growth is transpersonal, accessing those aspects of us that search for higher meaning in life. The development of women’s wisdom, creativity, unconditional love and compassion is notable, linking them to the growing fulfilment of their highest potential as human beings.
My work with women following breast cancer has influenced my own practice in one particular way. I have become ever more in touch with and accepting of my own vulnerability, especially my own conflicting emotions around my own mortality. Moreover, I have become much more open in sharing this vulnerability with my clients, who often ask me how I feel about these things. I feel very much in tune with the fundamental life issues they grapple with, and by being so in tune, I have noticed that my clients are increasingly able to recognise both their own fragility and mine, with this leading them to access a deeper empathy for themselves and others. There is a growing sense of synergy in my therapeutic relationships – a sense that our mutual searching, our mutual openness and our mutual collaboration creates a combined power for growth that often feels greater than both of us.
Carol Morgan is a person-centred/integrative counsellor, currently working at Breast Cancer Haven, Hereford. She completed an MSc in Counselling at the University of Strathclyde in 2012 and has a private counselling and supervision practice in Hereford.
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