The Psychology of Cancer: Fear, Anger and Hope After a Diagnosis

What is the psychology of cancer like? Read about the fear, anger and guilt that follow a diagnosis, the role of family and where psychological support fits in.

The half hour you spent waiting in the hospital corridor for the pathology result was perhaps the longest half hour of your life. As the doctor explained the result, you heard some words and missed others. "Mass", "stage", "treatment plan"... When you left the room, everything outside was the same: the car park, the simit seller, people talking on their phones. But for you, the world had changed in that moment. The psychology of cancer is a broad area covering the emotional process that a person diagnosed with cancer, and those close to them, go through from that moment on: the shock, the fear, the anger, the uncertainty and the hope that can, over time, begin to grow again. In this article I will try to explain the feelings commonly experienced after diagnosis, the point at which extra support is needed, the particular difficulties that patients and families face in Turkey, and how psychological support can play a part along the way.

What Is the Psychology of Cancer? What Happens at the Moment of Diagnosis?

A cancer diagnosis is a life event that affects not only the body but also all of a person's plans for the future, how they see themselves and their relationships. That is why a separate field has developed in medicine that deals with the psychological and social dimensions of the illness: psycho-oncology. The psychology of cancer is concerned with the question at the heart of this field: How does a person cope with news like this, and how can they be accompanied through the process?

In the first days after diagnosis, many people live in a kind of fog. The following reactions are common:

• Shock and freezing: Struggling to take in what is being said, a sense of unreality, a feeling that "This isn't happening to me".
• Denial: Thoughts such as "There must be some mistake" or "Let's get another doctor's opinion". Short-lived denial is a protective reaction that helps the mind digest the news piece by piece.
• The question "Why me?": A deep sense of protest at having been faced with something undeserved.
• Hunger for information or avoidance of it: Some people research the illness online all night long; others do not want to hear anything at all.

None of these reactions is wrong. Everyone digests this news at their own pace and in their own way.

Common Feelings After Diagnosis: Fear, Anger, Guilt and Hope

Fear and uncertainty

Will the treatment work? Will I be in pain? What will happen to my children? Will I lose my job? Perhaps the most exhausting part of the cancer experience is uncertainty. Test results, CT scan appointments and the waiting periods between check-ups are when anxiety is felt most intensely. You can find more on the tension experienced during this waiting in the article on anxiety while waiting for test results.

Anger

Anger is one of the feelings experienced most often during cancer, yet it is one of the least talked about. You may be angry with your body, your luck, the doctors, the long hospital queues, even with the healthy people you love. This anger is often a natural reaction to losing control. Being able to express anger safely rather than suppressing it also helps protect relationships.

Guilt

Thoughts such as "If only I had gone to the doctor sooner", "If only I had given up smoking" or "I was so stressed, that's what caused it" occupy many patients' minds. The causes of cancer are complex and often cannot be pinned on a single behaviour. The thought "it came from stress" in particular can lead a person to see the illness as the result of their own feelings and to blame themselves even more. Looking back with blame steals energy from what can be done today.

Changes in body and identity

Hair loss, weight changes, surgical scars or the loss of an organ can change how a person looks at themselves in the mirror. No longer feeling "like before" can lead to withdrawal from social settings and to shame. For people who have had to stop working or whose roles at home have changed, the question "Who am I now?" also comes up.

Hope

Hope on the cancer journey is not a fixed feeling; it can change from day to day, even from hour to hour. On some days there is trust in the treatment; on others everything looks dark. Hope does not always mean "I will recover completely" either. Sometimes it turns into closer, more concrete goals, such as having a good day today, seeing a grandchild graduate or spending a weekend without pain.

The Psychology of Cancer and Depression: When Is It Something More?

Feeling sad, crying and having pessimistic thoughts about the future after a cancer diagnosis are expected reactions, and they do not on their own mean depression. And because treatment itself can cause tiredness, loss of appetite and sleep problems, telling depression apart can become harder.

Even so, the following signs may suggest that further assessment is needed:

• Low mood that lasts for weeks and hardly eases at all,
• Being unable to take pleasure in anything that used to bring enjoyment, even on good days,
• Intense feelings of worthlessness and thoughts of "being a burden",
• A marked drop in the wish to take part in treatment, missing appointments,
• Constant, uncontrollable anxiety or panic attacks,
• Withdrawing completely from loved ones.

When these signs are noticed, they should also be shared with the oncology team. For a wider picture of the psychological load of living with a long-term illness, you can take a look at the article on the psychology of chronic illness.

Living With Cancer in Turkey: "Let's Not Tell the Patient" and "Keep Your Spirits Up"

In our country a cancer diagnosis is often a matter not only for the patient but for the whole family. This solidarity is very valuable; but it also brings certain difficulties with it.

The tendency to hide the diagnosis: Particularly with older patients, families still sometimes try to keep the diagnosis hidden, saying, "Don't let them hear, it'll bring their spirits down." Yet most patients sense that something is wrong, and the hidden information leaves them alone. As far as possible, the patients themselves should be asked what and how much they want to know.

The pressure to be positive: The sentence "Keep your spirits up, morale is everything" is said with good intentions; but it can shut off the patient's chance to express their fear, anger and sadness. There is no strong evidence that negative feelings alone determine the course of the illness. Feeling obliged to appear strong all the time, on the other hand, creates an extra burden.

Everyone has advice: The herbal mixture a neighbour recommends, the "really good doctor" a relative suggests, the incredible recovery stories circulating on social media... This advice can confuse a person and shake their trust in the treatment team. It is important that every decision during treatment is made after talking it through with your doctor.

Travel, queues and costs: Many patients have to travel to another city for treatment, rent a place near the hospital or stay with a relative. Long waiting times, the fatigue of travel and non-treatment expenses multiply the stress when combined with financial difficulties.

Let's say a retired teacher moves to the big city to live with her daughter after being diagnosed with breast cancer. Her daughter takes her to every check-up, takes over the housework and answers the relatives' phone calls. The mother is grateful, but at the same time she feels like a burden and, so as not to upset her daughter, tells no one about her fears. Her daughter, meanwhile, tries to look strong beside her mother all the time and cries at night. Both stay silent to protect each other, and both become lonelier. In a situation like this, making conversation possible lets both the patient and the relative breathe.

How Can You Support Yourself After a Diagnosis?

• Take in information at your own dose: Rather than reading statistics online at three in the morning, write your questions in a notebook and ask your doctor. Deciding which information you want, and when, is your right.
• Go to appointments with someone close to you: Forgetting what is said in a moment of intense anxiety is very common. Having the person with you take notes makes things easier.
• Plan your energy like a budget: If your energy is low on treatment days and afterwards, organise the day around the one or two most important tasks. Try leaving the rest to others.
• Make room for your feelings: Crying, getting angry or being afraid does not mean your "morale is low"; these feelings are a natural part of the process. Express them with a person you trust or in a journal.
• Protect a space outside the illness: Find small spaces that do not let cancer cover the whole of your life: a series, a game with the grandchildren, the pots on the balcony, a piece of music you love.
• Decide on a way of talking about it at work and in your circle: If you are working, deciding in advance whom you will tell at work, and how much, protects you from being caught off guard. You are not obliged to give everyone the details; saying "I have a health problem and I'm having treatment" is often enough.
• Set boundaries: If answering the same questions every day is tiring, you can appoint one person in your family as a "spokesperson". Arranging visits according to your energy is also your right.

Brief notes for family and friends

Relatives often wrestle with the question "What should I say?" Often there is no right sentence; listening, being there and offering concrete help are far more valuable. Saying "I'll take you to Thursday's check-up" instead of "Tell me if you need anything" genuinely reduces the patient's load. Take care of yourself too; carer burnout is very common during a long period of caring. The article on carer burnout may offer guidance on this.

When Should You Seek Professional Support?

Not everyone diagnosed with cancer needs psychotherapy; but for many people, talking to a professional during this process can be an important source of support. It is especially worth seeking help in the following situations:

• If anxiety or low mood is making daily life and adherence to treatment difficult,
• If sleep, appetite and energy have broken down beyond the effects of treatment,
• If communication within the family has become blocked, or everyone is staying silent to protect each other,
• If, after treatment has ended, fear of recurrence is getting in the way of life,
• If, as a relative, you feel burnt out.

If you are having thoughts of not wanting to live, of harming yourself or of ending your life, share this immediately with someone close to you and with your treatment team. In an emergency, call 112 (emergency services) or go to the nearest emergency department. Depending on the severity of the symptoms, an assessment by a psychiatrist may also be needed; this assessment should be carried out in cooperation with the oncology team.

How Is the Psychology of Cancer Addressed in Therapy?

Psychological support during cancer is not about teaching "positive thinking to beat the illness". The aim is to make the feelings a person is experiencing understandable, to learn to live with uncertainty and, despite the illness, to keep a connection with what is meaningful to them. In this process the following approaches are commonly used:

• Cognitive behavioural therapy: Noticing catastrophising thoughts ("If there's pain, it must have spread"), developing skills for coping with anxiety and maintaining daily functioning.
• The acceptance and commitment approach: Making room for what cannot be changed rather than fighting it, and taking small steps in line with one's values.
• Working with fear of recurrence: Making the anxiety that rises before every check-up after treatment more manageable.
• Family and couple sessions: Talking about the effect of the illness on communication, roles and closeness within the family.
• Meaning and grief: Grieving lost health, body, work or plans for the future, and building a new pattern of life.

Psychological needs do not end when treatment ends. Many people say that during active treatment everyone was around them, but when treatment ended they were suddenly alone and felt the pressure of "I should be fine now". This transition period may also need support. For people diagnosed at a young age, issues such as career, plans to have children and relationships come up as well; in therapy each of these questions is addressed according to the person's own priorities and without rushing.

Hope is not the absence of fear; it is being able to live today in spite of fear.

You can read about how this is worked on individually on the individual therapy page. During periods when travelling to and from the hospital for treatment is difficult, sessions can also continue online.

Frequently Asked Questions

Does stress cause cancer?

The causes of cancer are complex and cannot be pinned on a single factor. There is no strong evidence that stress alone causes cancer. So the thought "I was so upset, that's why it happened" can lead a person to blame themselves unfairly.

My treatment has finished, so why am I still so frightened?

Fear of recurrence after treatment is very common. During active treatment the mind focuses on survival; when treatment ends, everything that happened begins to be processed again. This fear can ease over time, but if it is noticeably restricting your life, getting support is helpful.

How should I tell my children about my illness?

Telling children in simple, honest language suited to their age generally causes less anxiety than hiding it. Explanations such as "I have an illness, the doctors are treating it, and in the meantime I'll sometimes be tired" open the door to the child's questions. It is also important to say that the illness is nobody's fault and that it is not contagious.

If my morale is low, will it harm my treatment?

Feeling bad does not mean that the treatment will fail. That said, prolonged depression can make areas such as sleep, nutrition and sticking to treatment harder. So the aim is not to appear cheerful all the time, but to be able to get support when needed to cope with your feelings.

• #cancer
• #psycho-oncology
• #chronic illness
• #family carers
• #fear of recurrence

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Eda Erkan Alapala

Klinik Psikolog. İstanbul Kent Üniversitesi Klinik Psikoloji Tezli Yüksek Lisans mezunu; bilişsel davranışçı terapi, çocuk merkezli oyun terapisi ve çocuk-ergen psikoterapisi alanlarında eğitimlerini tamamlamıştır.

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