I recently retired after more than 30 years as a psychotherapist. I have worked in a variety of settings during my career, but spent several years at Breast Cancer Haven, both in Wessex and London. Breast Cancer Haven offers limited-term, psychological therapy (usually not more than six sessions) to people who have been diagnosed with breast cancer, their partners and wider family.

As well as counselling, each client is offered up to 10, free sessions of complementary therapies, which can include dietary advice, acupuncture, massage and reflexology. There are also group activities, such as yoga, mindfulness and sound bath therapy.

The therapies offered are known to be useful and effective to people seeking support with breast cancer. After 10 sessions, the client can pay a fee if they wish to continue – and if the therapy is assessed as still helpful.

People can come for counselling at the point of diagnosis, during or after treatment. For those who come later, it is not unusual to find that an event in their life has activated feelings about the breast cancer that they were either not aware of or thought they had laid to rest. Some common trigger events include birthdays, family occasions, such as weddings or Christmas, the anniversary of diagnosis or end of treatment.

People who come before or during treatment are usually trying to cope with a multitude of feelings about the diagnosis, such as fear, anxiety, loss, anger, self-blame, stress, depression and low mood.

Often, they are frightened of telling friends and family that they have breast cancer. Telling other people about the diagnosis can make it ‘real’, in a way that can tap into a profound fear of the future, especially if others respond in an unhelpful way, such as offering false hope, or expecting the person to ‘be over’ the cancer once treatment ends.

Some people with cancer choose not to tell friends or family, because they fear the distress it might cause or because they wish to avoid their own difficulties in managing the illness.

Maria, 50, was diagnosed with breast cancer after finding a lump on her breast. Her diagnosis came as a shock. Maria had believed that breast cancer had a genetic component – and there was no breast cancer in the family.

Maria worked in a local firm, dealing with the accounts. She realised she would have to take time off for the proposed operation and radiotherapy to follow, but she was anxious about telling her employer she had cancer. She was even more distressed at the thought of telling her elderly parents.

When Maria came for counselling, she had already had a lumpectomy (removal of the cancerous tumour, often including an area around the tumour, but retaining most of the breast material) and was scheduled for radiotherapy. She had told her employer, who was understanding about her time off and complied with guidelines on supporting employees with cancer.

Maria had decided not to tell her parents, who lived at some distance from her. But she was conflicted about this decision. She wished to spare her parents worry, but felt unhappy about the lies she was telling them in daily phone calls. Maria had also relied on her mother for emotional support before the cancer, and now missed her warmth and advice.

During therapy, Maria disclosed that her parents had previously had a daughter who had died at the age of five. We explored her desire to protect her parents in the context of her sister’s death and her own experience of cancer. Ultimately, Maria elected not to tell her parents about her illness, but was able to use counselling to obtain some of the emotional support she might otherwise have received from her mother.

Breast cancer often provokes feelings of anxiety, which can be centred on the treatment of the illness. Many people describe the experience of focusing only on the word ‘cancer’ at the point of diagnosis; they are unable to take in any more information.

Anxiety can be long lasting, often persisting after treatment has ceased, even if the person is assured by medics that treatment has been successful, with no evidence of metastases (spread of cancer to other organs). Many clients report anxiety about the future, because of a fear that the illness will return.

Anxiety can sometimes be related to perceptions of what is expected of cancer patients. Common terms, such as ‘battling cancer’, can increase anxiety. Most clients have told me that dealing with cancer is not a battle, but an act of endurance, during which they undertake various recommended treatments, in the hope that the cancer will go into recession.

People with a cancer diagnosis can experience a loss of trust in the future, a loss of certainty about what the future will look like. Feelings of loss are also often focused on the potential changes to their body.

We might assume that possible scarring or breast removal would be the chief source of grief, but other changes are more likely to cause distress.

Many people, particularly women, struggle with hair loss through chemotherapy. The loss of healthy functioning after chemotherapy and radiotherapy can also evoke feelings of helplessness.

Some women are treated with hormone drugs following breast cancer (often for the next five or 10 years). They might, therefore, have to deal with the symptoms of the menopause, including hot flushes, night sweats, joint and muscle aches and cognitive lapses. There are also implications for fertility.

The symptoms that continue after treatment can be a constant reminder of the cancer, even when the tumour has been treated. They can cause a loss of confidence in functioning and it can take some time to come to terms with the permanent changes brought about by the cancer.

People are often angry about a diagnosis, especially if there is no family history of cancer. The anger can sometimes be directed at others, which can be confusing for everybody. If a treatment fails, or there is a limited healing response to the treatment, anger can be aimed at medics, or those who tested or offered the treatment regime. The expression of anger can be linked to understandable feelings of despair or depression. 

It is common for people to look for reasons for their cancer – and to blame themselves, often for an unhealthy diet or lifestyle. But the causes of breast cancer are not fully understood. Self-blame can therefore be a defence against the feeling of helplessness and lack of control.

Managing medical appointments and juggling family life can be stressful. It can be difficult to find someone to pick up the children from school, or to ask for time off work to attend appointments. Some people also find it hard to ask for, or receive, help, perhaps because it arouses feelings of vulnerability or a sense of failure.

Many diagnosed people go through a period of sadness and low mood. It is perhaps to be expected during the often-intrusive treatments for cancer, but it can persist for a long time after treatment. Clients report they find it hard to get up, carry on and face another day. Often, they describe trying to hide their feelings by ‘pasting on a smile’.

Dean, aged 45, was diagnosed with male breast cancer after a GP found a lump on his chest, close to the nipple. Dean was shocked, as he had visited the GP with what he thought was a pulled muscle. The area of the chest was excised, removing the tumour. Dean was then referred for chemotherapy and radiotherapy. Dean had not realised that men could get breast cancer and found it extremely hard to tell his family and friends. He also struggled with the loss of his nipple and stopped getting undressed in front of his partner, Gareth.

Dean worked in a high-pressured environment and felt he had to ‘put on a face’, even though his low mood was negatively affecting his work. Dean also felt that his workmates avoided any mention of the cancer, so he found it difficult to discuss his situation.

In counselling, Dean explored his feelings about the changes to his body, which included hair loss. He also talked about his relationship with Gareth. Dean felt he had to protect Gareth from the depth of his unhappiness and made efforts each day to seem his usual self. However, the ‘pretence’ was taking a toll on his mental wellbeing, because he was unable to share his feelings of loss and depression.

Counselling offered Dean an outlet freely to express his feelings. In time, Dean was also able to talk to Gareth. He did not feel able to open up at work. But we discussed keeping a journal, where he could write about his experiences in the office, allowing an outlet for anything he found hard to share at work.

When someone is told they are in remission, they sometimes feel they have been given a second chance and start making changes. They might return to education, change jobs, end an unhappy marriage or simply look to enjoy life more. 

Eva, 33, came for counselling after noticing changes to the shape of her nipple. An investigation confirmed breast cancer and Eva had a full mastectomy (removal of the whole affected breast), chemotherapy and radiotherapy.

During this time, Eva felt her partner was not supportive, either practically or emotionally. He had not accompanied her to hospital for diagnosis, scans or treatment. He had also expected her to continue to manage the house and care for their young son.

Eva discussed in therapy her sadness and anger at her partner’s behaviour – deficits that had been highlighted by her illness. Eva came from a traditional Asian family, where women were expected to carry out most of the domestic responsibilities. Although her family had been supportive, she was preoccupied with the lack of care she received from her partner, challenging her lifelong acceptance of her cultural and family background.

During counselling, Eva felt able to talk to her partner about his lack of support. She used one session to ‘practise’ how and what to say. When she managed to tell him what she was feeling, Eva was surprised to discover he had felt somewhat ‘shut out’ by her family, who had accompanied her to hospital appointments and taken over the majority of childcare.

Eva found that counselling gave her the courage and tools to discuss important matters with her partner, enabling her to better manage her cancer and her relationship with her husband.

Sadly, some clients develop secondary cancer, which can sometimes result in serious illness or even death. Working with these clients is challenging. There can be an intensity not experienced in other therapeutic relationships, particularly if they have been given only a short time to live.

Some clients want to reflect on past life; others express the desire to grasp the moment, or to talk about something they had previously withheld. People who are supporting someone through an incurable illness might want to talk about their fear of loss. Or, after a death, they might want to reflect on the process of the illness and treatments, as well as their response to these in the light of their bereavement.

Jane, 32, is a deputy head teacher who had been treated for breast cancer two years previously. She came for counselling after a diagnosis of secondary breast cancer in her liver (meaning the cancer cells were derivative of the original breast cancer and not a primary liver cancer). Jane explained she had been through an operation, chemotherapy and radiotherapy after her original diagnosis. She now faced further medical treatments for the secondary tumours, which were inoperable. Jane had been told by her hospital consultant that the cancer was treatable but not curable.

She was devastated by this news, especially as she and her partner, Wesley, had hoped they would be able to start a family after her initial treatment. Jane had frozen eggs before chemotherapy, in the hope that IVF would allow her to have a child.

Jane used counselling to discuss her fears, which kept her awake at night, that she would die soon. She did not tell Wesley, because she wanted him to treat her as if ‘she did not have cancer’. Jane found it hard to believe she could have a shortened life span, but also wanted to discuss the likelihood of not living into old age.

Counselling allowed these contradictions to be aired and recognised, giving Jane some respite from the anxiety and sadness she felt most days. Jane also discussed her grief at losing the prospect of parenthood, using the counselling room as a space where both her negative and positive feelings could be accepted as of equal importance and expressed without judgment.

My experience of working with clients who have received a breast cancer diagnosis has been one of continual adaptation, as I learnt more about what works – and what doesn’t – when supporting cancer sufferers.

I have met a wide range of responses to diagnosis, from resistance and denial to a toleration of treatments with little or no emotional disturbance. As in all therapeutic relationships, it’s crucial to accept where the client is and what they bring to the session, however daunting.

When I began counselling clients with cancer 20 years ago, there were only a few treatments available. Since then, ongoing research has produced many different treatments that have cured or extended life, where previously this would have been impossible. In counselling, this often raises issues about the purpose and quality of life ahead, if treatments are ongoing and have severe side effects.

A diagnosis of breast cancer can be sudden and unexpected. A person can walk into a diagnostic centre, believing themselves to be healthy, and come out knowing they are sick. It’s a reversal of the usual, anticipated, medical experience. Consequently, the client can be referred to, or seek, therapy suddenly and unexpectedly. Over the course of the sessions, they can begin to use therapy to meet their needs. Accepting and understanding the role of therapy can, however, be painful and challenging in the context of their disease.  

I often share with my clients an image of someone with a cancer diagnosis as washed up on a beach after a storm. They have survived, but they are unsure of where, and who, they are now. The storm can be the shock of diagnosis, the fear of treatment, or the anxiety of a future life undermined by cancer – or a combination of all three. I see my role as waiting on the beach, willing to walk with the client in the liminal space between the sea and the land, as they explore a new way of living and being, during and beyond cancer.