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Understanding the Psychology of Skin Care Clients With Cancer

Contact Author Morag Currin March 2015 issue of Skin Inc. magazine
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Understanding the Psychology of Skin Care Clients With Cancer

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Cancer is more openly discussed today than ever before and it is classified among other chronic diseases. Yet, treatment for cancer can be debilitating for many people. It is wise for skin care facilities to have experienced team members trained to work with individuals living with cancer. This assures clients who frequent spas that their esthetician can personalize treatments according to their medical history and provide a mindful, safe service that ultimately enhances the client’s quality of life. A well-trained esthetician should be knowledgeable not only about the physical effects of cancer and cancer treatments, but also that individual’s psychological coping skills.

Every person experiences this disease differently, so it is impossible to predict what meaning they will attribute to such a traumatic event. It will vary depending on the type and seriousness of cancer, the patient’s personality and age, and the changes they are going through, as well as sociocultural conditions. Despite these variances, clinical experience over the years provides an understanding for the general experiences and reactions characterizing patients in different stages of the disease.1

In most cases, cancer is an asymptomatic disease, so it often is discovered by chance. Once the need for tests has been identified, the first stage of procedure begins—the pre-diagnostic stage. During this period, and until the time of diagnosis, the client is usually in a state of shock and emotional paralysis, followed by reactions of alarm and concern. Some may minimize or deny the possibility of a malignant outcome, while others take the opposite pessimistic attitude and are full of anxiety.

Coping styles

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The human mind has a way of defending itself from disease, and there are different styles of coping. A cancer diagnosis is certainly one of the most difficult and stressful events a person may encounter in her life; not only for the implications directly connected with the disease and its treatments, but also for the psychological consequences that inevitably affect the client and her family members.

Although everyone copes with a cancer diagnosis in different ways, and with different degrees of awareness, it is possible to identify certain common strategies for dealing with this, as well as other stressful life events. These approaches are referred to as individual styles of coping. The main types include physical, social, spiritual and psychological, and their preference will depend on the individual’s resources.

Physical. The traditional medical view of cancer focuses on the physical affliction itself, treatments and their side effects. However, all of these aspects can compromise the psycho-physical well-being of the client affected by cancer. Since those who manage to maintain good body function can count on many resources to cope with the difficulties of the illness, today many medical professionals are paying more attention to the quality of life of their patients by managing symptoms and adverse effects from cancer treatments.

Social. Equally important are the social factors, which comprise of all the relationships an individual has, both intimate and nonintimate. Many researchers have underlined how the impact of stressful or traumatic events can be modulated by the presence of significant and supportive interpersonal relationships.2-4

Spiritual. Spiritual groups are another important resource for coping with cancer. Everyone places different meaning on life and experience, derived from culture and the context of belonging. Therefore, resources include not only religious groups, but also meditation and awareness practices, which allows access to a deeper knowledge of oneself, enhancing health, well-being and, potentially, psychic balance.5

Psychological. An equally important coping style is that of a psychological nature. In particular, this comprises the personal history of an individual and the organization of her personality, temperament and defense mechanisms. These latter mechanisms are aimed at preserving one’s psychic balance and adapting to reality with regard to the anguish caused by an illness. Defense processes can be adaptive when they enable a person to better face their condition, or maladaptive when used in a rigid and dysfunctional way. The main defensive processes can vary, and change in the course of time and stages of the disease, and according to the awareness of the patient of her situation.6

Defense mechanisms. The five main defense mechanisms for living with cancer include: denial, projection, regression, intellectualization and a fatalistic attitude. An individual in denial attempts to dull one or more aspects of their experience generating anguish. Projection is just that—projecting one’s own thoughts and negative feelings to others. Regression takes the individual back to an earlier stage in life, when they were more dependent on others; almost to a childish level, in search of reassurance. Intellectualization involves the individual distancing herself from emotional discomfort to focus on a logical and rational level, for example, by searching the Internet for information about the disease and talking about it as if the situation does not apply to them. And a fatalistic attitude refers to the person accepting her illness without any resistance, considering it their destiny.

Psychological vulnerabilities

Studies in the psycho-oncologic field have shown that nearly 40% of patients have, at least once during their illness, had a clinically serious psychiatric disorder.1 The most vulnerable individuals are those who have had issues in the past; particularly disorders involving anxiety and depression, which appear to be the most frequent in oncology patients. With regard to coping factors, patients with a smaller number of personal and interpersonal resources are usually more vulnerable to psychological stress. The following are the most frequent psychological disorders observed in an oncology setting.

Anxiety and depression. In oncology patients, anxiety can be one of the main symptoms of potentially a series of disorders that have different clinical, prognostic and therapeutic features.7 Depression is also common among oncology patients. Much like anxiety, the accompanying dismal mood may assume variable intensity, duration and quality, and can be associated with other symptoms that can produce further types of disorders. Trauma- and stress-induced disorders can also accompany a cancer diagnosis and its related treatments, which are considered extremely stressful and even traumatic life events.

Sleep disorders are common with anxiety and depression. Waking up during the night can be due to psychological as well as physical reasons, such as discomfort from the disease. Examples may include pain from surgical wounds, the site of disease or from metastases; the presence of any catheters or surgical drains; the need to urinate frequently; or breathing difficulties. In any event, insomnia compromises the person’s quality of life in a significant way, setting off a vicious circle of fatigue, irritability and depression.

Body image disorders resulting from anti-cancer treatments may lead to intense emotional discomfort, compromising the individual’s self-esteem and everyday social life. The specific psychological aspects of body image are covered in more detail as follows.

Cancer and body image

The life of an individual who experiences cancer firsthand is affected on all dimensions. However, among the many aspects involved, the body plays the leading role. From the diagnosis and through treatments, the body and its fragility are at the forefront of the illness, visibly impacted by feebleness, alopecia, changes in weight, mutilations, edema, paleness, nausea, vomiting, taste changes and loss of energy. These physical changes highlight a changed and suffering body, and one the individual feels is no longer recognizable as their own.8

It is common for patients reacting to their illness to experience body dysmorphic disorder, which specifically affects their perception of their personal appearance, causing an extreme concern for any defects or impairments in their appearance. This causes significant discomfort and can negatively affect other areas of their life, such as interpersonal relationships.

While the topic of body image has been studied extensively in other sectors, as noted, it has achieved greater importance in the oncology world, with more attention now being paid to the patient’s quality of life and her adaptation to the disease and to cancer treatments. Currently, researchers agree that body image is defined as the mental representation related to what one thinks and feels about one’s own body.9-11 What is most important is the way an individual experiences and perceives herself, and the feelings that accompany such experiences. It is easy to understand how through the course of cancer and cancer treatments, body image is affected, especially considering the changes the body is forced to undergo.

Physical scars

For many types of cancer, surgery still represents the treatment of choice. Yet, despite improvements to limit the invasiveness of surgical procedures and the damage they cause, scarring or mutilations often remain visible. For the patient, this represents the most substantial evidence of her disease, as well as an element of social stigma.

With breast cancer, for example, a series of studies has shown that women treated by radical mastectomies present with a more negative experience of their body image, especially in the short term, compared with women treated using conservative surgeries.8, 12 These women describe themselves as unhappy with their body and appearance,13 and obtain lower scores on the scales measuring physical and functional well-being.14 Similar results were observed in relation to oral cancer.15 The more invasive or mutilating the surgery is—where visible changes are noticeable—the worse it is for the patient to adapt to the new condition. And this ultimately leads to an impairment in their quality of life, including poor self-esteem, and higher levels of depression and irritability.

Alopecia

Alopecia, or the total or partial loss of hair, often is associated with the loss of eyelashes and eyebrows as well, and is one of the most frequent negative effects of chemotherapy. It also can occur if radiation therapy has been administered to the head area. There are many drugs that can cause hair thinning or loss; however, it depends on the dose and protocols. It is one of the most feared elements at the beginning of cancer treatment, particularly for younger patients and the female population. In fact, alopecia is often considered among the top three most traumatic side effects to cancer treatment,16 sometimes more so than breast removal.17

For women, the loss of hair often means the loss of one’s identity, femininity and beauty and self-identity, and can lead to diminished social activities and relationships due to this visible evidence of their disease. It is also a constant reminder, to oneself and others, of their stigmatized and easily recognizable condition of a “person with cancer.”11

A series of studies has shown that alopecia is associated with a significant impairment in the perceived quality of one’s life and well-being; a reduction in levels of self-esteem and self-confidence; an increase in psychological distress; and higher levels of anxiety and depression.18 In relation, many patients describe their experience as feeling, “unprotected, naked, exposed to the outer world and deprived of their intimacy.” They also report experiencing social situations of discomfort and embarrassment, and the sense they were being observed and judged. In these cases, the patient ends up avoiding social situations, worsening their affection and sexuality despite reassurance from their partners.19

Other adverse events

Additional visible changes due to cancer that affect an individual’s perception of herself include skin paleness and an increase or loss of weight. Some cancer treatments, including new biological (targeted) drug therapies, also produce more intense side effects on the skin, such as acne-like or papular/pustular rash, which is especially found on the head and upper body. Skin is not only the largest organ, it also provides a psychical and psychological sense that enables a person to feel good about themselves. It also acts as a barrier against external aggressions, and represents a means for communicating with the outer world and for establishing relationships.

Skin ensures ourself as individuals, and at the same time is an instrument for exchanges with the external world. In the light of all this, it becomes easier to understand how damage, even temporary, to the skin container may manifest itself with feelings of deep discomfort, affecting deep emotional dimensions of the individual and deteriorating their life—further risking treatment compliance.21

Oncology esthetics

All the factors described have resulted in a more recent focus on the need for a variety of treatments to complement traditional medical treatment in oncology. The aim is to give patients a time and place to focus and cope with all those problems on a daily basis, even if they are not strictly medical, and of a more psychological, social or practical nature. This primary role to provide coping strategies is played well by estheticians certified in Oncology Esthetics (oti-oncologytraining.com) and those participating in the Salute allo Specchio project (www.hsr.it/salute-allo-specchio) under way at the prestigious San Raffaele Hospital in Milan, Italy, in which women with cancer are provided with resources to rediscover their smile in the mirror.

REFERENCES

  1. L Grassi, M Biondi, A Costantini, Manuale pratico di Psico-oncologiam Roma: Il Pensiero Scientifico Editore (2003)
  2. S Cobb, Social support as a moderator of life stress, Psychosom Med 38 300–314 (1976)
  3. G Caplan, Support Systems and Community Mental Health, Behavioral Publications, New York (1974)
  4. www.ncbi.nlm.nih.gov/pubmed/18759983
  5. J Kabat-Zinn, Vivere Momento Per Momento, TEA (2010)
  6. V Lingiardi, F Madeddu, I Meccanismi di difesa, Raffaello Cortina Editore, Milano (2002)
  7. www.siponazionale.it/pdf_2008/LINEE%20GUIDA%20SIPO.pdf
  8. www.ncbi.nlm.nih.gov/pubmed/23132765
  9. www.ncbi.nlm.nih.gov/pubmed/10871714
  10. www.sciencedirect.com/science/article/pii/S1740144503000111
  11. www.ncbi.nlm.nih.gov/pubmed/22179546
  12. www.ncbi.nlm.nih.gov/pubmed/19701698
  13. annonc.oxfordjournals.org/content/14/7/1064.full.pdf
  14. www.ncbi.nlm.nih.gov/pubmed/11571745
  15. www.ncbi.nlm.nih.gov/pubmed/14724907
  16. www.ncbi.nlm.nih.gov/pubmed/12115329
  17. www.ncbi.nlm.nih.gov/pubmed/7525048
  18. www.ncbi.nlm.nih.gov/pubmed/14998604
  19. www.tandfonline.com/doi/abs/10.1080/13648470601106335#.VLbjFCvF98E
  20. www.ncbi.nlm.nih.gov/pubmed/18089143
  21. www.ncbi.nlm.nih.gov/pubmed/23955138

(All websites accessed Jan 1 2014)

Morag Currin is an esthetic instructor with more than 25 years of spa industry experience, and more than 10 years of training and training management experience. She pioneered the Oncology Esthetics advanced training for spa professionals, and is the author of Oncology Esthetics: A Practitioner’s Guide Revised & Expanded (Alluredbooks, 2014; www.alluredbooks.com) and Health-challenged Skin: The Estheticians’ Desk Reference (Alluredbooks, 2012; www.alluredbooks.com).

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