All participants were females with diagnoses of primary breast cancer with metastases. Four participants out of five were White British and one was Black British. Two out of five participants had higher educational degrees, while the other three had no qualifications above secondary level.
Four main themes emerged from the data analysis. Participants used the sessions to release emotions, yet also avoided other difficult feelings and thoughts at times. The sessions were also used to focus on the positive aspects of individuals’ lives. Lastly, participants engaged in self-reflection on ways to overcome their difficulties.
TC sessions served as an opportunity for cathartic release. Participants discussed a variety of difficulties which included cancer-related issues as well as other personal or day-to-day struggles.
Unleashing the weight of daily difficulties
The sessions served as a space in which participants were able to release frustration, anxiety or other emotions relating to their day-to-day struggles. For example, 4 out of 5 participants expressed feelings of being overwhelmed due to the accumulation of daily stresses and practical difficulties:
“But yeah it’s just so many different people in and out and it’s just like oh god, when people phone me like that woman the other day…and I missed my acupuncture and I was quite angry” Participant A, Session 4
Many participants also released feelings relating to their physical symptoms, issues with doctor appointments and other practical difficulties relating to their cancer.
Allowing for the release of more difficult emotions
Aside from discussing day-to-day difficulties, participants (4 out of 5) often appeared to view the sessions as a safe space in which they could unleash more difficult feelings or emotions that had been burdening them for a while.
Many participants discussed how they felt with regards to the uncertainty of their illness. For instance, some participants revealed their distress regarding the worsening of their condition.
Participants also released feelings relating to how their illness was affecting other people around them, revealing, at times, possible feelings of guilt:
“it is, very hard and to see that you can look at him (brother) and that he's very tired but he's just making sure that everything is, and not making you feel I tell him are you tired” Participant B, Session 4
More difficult non-illness related emotions were also discussed. These often revolved around unresolved relationship or family difficulties, that had been burdening participants for a while. One participant repeatedly discussed her difficult relationship with her granddaughter:
“I notice my relationship with my granddaughter is quite strained actually, we’re going away next weekend to…yeah I feel sad about it …” Participant C, Session 4
A common difficulty that was expressed was the struggle of letting go of the past. For example, one participant discussed not being able to work anymore:
“I’ve found it incredibly hard that adjustment of not working, I mean […] that adjustment ... I mean support work was a big part of my life… um so in that 6 months it was very difficult to sort of let go of my job” Participant D, Session 1
The TC session even served as a space in which one participant was able to open up about suicidal feelings and engage in a more in-depth exploration of those thoughts. The degree to which emotions were discussed varied widely amongst participants. One participant was particularly open to discussing her feelings from the start, while three other participants opened up gradually about their difficult emotions as the sessions progressed. The participants brought up these concerns themselves rather than being prompted or asked by a therapist as they may do in therapy sessions. Many participants acknowledged the usefulness of being able to release their feelings. The TC was often viewed as a non-judgmental space which made it easier to discuss emotions, even for participants who didn’t often do so:
“It’s nice to have done it (the therapy)…sometimes I've released my feelings which is the hardest thing for me to do…but you did get me at probably my worst time actually…but maybe that was good…” Participant A, Session 8
One participant stood out in that she was not able to deal with many difficult emotions as she had done a substantial amount of therapeutical work in the past:
“You know I feel a bit like I wish I had an issue I could think of at the moment, so I could really try it out but at the moment its’ not like I haven’t had them in my life, but I think this whole process of having the cancer has taken through that, you know it’s been a process of dealing with that very very deeply” Participant E, Session 5
Even though the sessions were used as a means of cathartic release at times, participants also attempted to avoid certain thoughts, feelings, emotions and sensations, a behaviour known as experiential avoidance . Domains that were avoided varied among participants, but emotions pertaining to their illness and prognosis were most often subject to experiential avoidance.
Difficult emotions or thoughts which related to the participants’ cancer were often minimised by participants and only discussed lightly A few participants engaged in laughter when discussing certain difficulties.
“Because you always pain, if it’s not your neck then it’s your (laughs) you have always pain so that’s what they are trying to help s out to deal with the pain, sometimes you take the tablets but you know it can be effective for 45 minutes, 1 hour , 2 hour but you have to wait for 3 or more hours to take another one but uh…” Participant B, Session 1
Others tried to maintain a positive mindset despite having to deal with a difficult situation, suggesting a possible attempt to deny negative feelings. A participant discussed plans with her friends:
“I'm not eating—and I keep thinking I'm gonna be sick all the time, but yeah…I'm sure once I'm in that limo, I’ll be fine, got to get me in their first though—it’s quite high up apparently…mmm…but I will be in there somehow” Participant A, Session 4
Participants also engaged in emotional avoidance by distancing themselves from their situation. In particular, some participants described their illnesses in a matter-of-fact way, possibly indicating a wish to disengage from the emotional charge associated with their situation:
"Yes…like you never know, you never know, today the medicine is working tomorrow it’s not working anymore, and you are trying another drug and be helpful that every time you change your body will be able to support, to be in good condition to receive it because if you’re not well…” Participant B, Session 4
Certain topics were completely avoided by some participants during the sessions, particularly in the beginning sessions. One participant briefly mentioned some difficulties such as a deterioration of symptoms but then did not seek to expand on the issue and shifted the conversation to other topics. One participant admitted to having engaged in cognitive avoidance:
“Um…as you say, I haven’t been well for quite a while and I kept just…pretending I suppose that I was” Participant A, Session 8
Participants also appeared to purposefully engage in a battle against their feelings as an attempt to keep difficult emotions at bay:
“Because…I can be sort of…detached from emotion around it, although I wouldn’t want emotion around it all the time…I feel, I've got quite the lump in my throat now…thinking about it…oh god, go away lump” Participant C, Session 4
Focusing on the positive
The TC sessions also served to engage with the more positive aspects of participants’ lives, cultivate gratitude and appreciate future sources of happiness.
Discussing and recognising sources of joy and fulfilment
Sessions were used by some individuals as a way to take a step back and appreciate the sources of joy in their lives. Many participants discussed enjoyable moments they had experienced in previous days. For example, the following person described an enjoyable ice-skating outing she had enjoyed with her daughter a few days prior.
Participants discussed hobbies, and family and friends as important sources of positive emotions:
“So, I'm starting to paint here, and that’s been a lot of fun and enjoyable” Participant C, Session 4
Many of the participants also recognised the usefulness of their support system. In particular, the hospice services or cancer support groups were often discussed in a positive light. Positive talk also sometimes extended directly to their illness, where some participants reflected on the positive elements it had brought to their lives. One participant explained that having cancer had turned her life around and helped her get out of a depressive episode. Two other individuals mentioned the cancer as an opportunity to engage with new interests or activities:
“I’m incredibly pleased that I’m having to do all these creative things that I absolutely love but I’ve always squeezed because there’s never been enough time, or I’ve never allowed enough time)” Participant A, Session 1
Engaging in future-oriented positive talk
The TC session also served to focus on the future, especially positive activities participants were looking forward to. Participants talked about looking forward to future activities such as family or friends’ gatherings or birthday celebrations. One participant talked about an upcoming spiritual event:
“T: What was it um what was it how did you describe it last week?
T: The shaman um… event
P: Yeah I’m really looking forward to that, that’s got me quite excited and uh - so its feels like some nice stuff it’s starting to happen, feels like coming out of the winter but with movement a bit more looking forward to - that is just a massive thing to look forward to…” Participant E, Session 5
Being grateful and appreciative
The TC were also used as an opportunity to foster feelings of gratitude. Many participants expressed being thankful to the help they received from their family members as well as medical staff. One participant acknowledged the efforts made by doctors whilst also recognising the challenges associated with treating cancer. Additionally, many participants were able to take a step back and recognise when they felt better physically, which often led to subsequent feelings of gratitude.
“I’m getting better... it’s a pleasure that nobody knows if you were never in the situation yeah …small things now even to be able to go to the shower, and be there, wash yourself the way you like—you know it’s wonderful because you know how it is when you’re not able to do things… can’t begin to tell you and to feel now that you can wash yourself properly” Participant B, Session 4
Reflecting on ways to handle adversity
Although to varying degrees, participants used the sessions to reflect on ways to handle difficulties.
Reflecting on the importance of being psychologically flexible
It was acknowledged by some that to be able to manage adversity they would have to accept their thoughts and feelings. Some reflected on the idea that one can choose how to respond to difficulties and that uncertainty should be embraced rather than feared:
“You know some days I feel, I am adjusting, I am getting on with this and then there’s bound to be moments when you just think, you just think argh, you know, and its completely natural and I know, no I’m not going to get of that completely and it’s about how you minimise that pushing against…. So, it is about …. That continual adapting to having sort of things to look froward to, having an aim within that uncertainty of, and within that acceptance of uncertainty…” Participant D, Session 4
Mindfulness and meditation were mentioned as being helpful tools for three participants. One participant discussed the importance of acknowledging the fleeting nature of sensations and emotions:
“And you see the thing with the pain was, because of the Vipassana I taught myself to experience things just as a vibration” Participant E, Session 5
Taking action to resolve difficulties
Participants also used the sessions as an opportunity to reflect on ways they could take action to resolve some of their difficulties. The importance of regular self-care was noted by some. One participant even mentioned that the TC sessions had served as a way of encouraging her to commit to self-care activities:
“I thought it was quite interesting, everything I've said to you that I’ll do, I've done—which I can drag things out a bit, so there’s something positive” Participant C Session 5
Two participants noted the importance of connection with people and finding the courage to reach out for help to the people around them. Two participants reflected on ways in which they could take action to solve family difficulties. For example, one participant reflected on her struggles with her granddaughter and decided she would talk to her honestly to try and solve their issues. Another common topic of reflection centered around the need for participants to alter their lifestyle habits in the aim of better managing their physical symptoms. Three participants mentioned the importance in engaging in regular pacing.
Differences between participants
The participants presented with varying levels of self-reflection. Three participants engaged in occasional reflection, while another participant mainly used the sessions as a means of psychosocial reflection. She also planned the topics she wanted to discuss before the session to prioritise the areas she wanted to focus on. She also recognised that the TC provided her with a space to talk freely:
“It’s (TC) incredibly helpful because it’s that space to think out loud and … if you have that space… it’s still sort of guidance of re-emerging to do those strategies and remember to focus on highlighting things that you want do differently” Participant D, Session 8
One participant mainly discussed the reflection she had carried out in the past and how this had helped her get to a place of happiness and acceptance. She did not see the TC as being useful for her as she did not have many issues she was struggling with. She also noted that her friends already provided her with a space in which she could reflect on potential difficulties and perceived the therapist’s approach as not being ‘fully’ genuine (i.e., paid to be there).