Beyond the Cancer Diagnosis: Interview with Cristian Ochoa, Hosted by Adrian Pogacian

In the recent episode of ‘Beyond the Cancer Diagnosis’, Adrian Pogacian tries to find the answer to a demanding question: How positive should a cancer patient be? together with Prof. Cristian Ochoa, Clinical Psychologist in Psycho-oncology Service and Chief of Digital Health Program in Catalan Institute of Oncology.

Prof. Cristian Ochoa is a specialist in clinical psychology and expert in Psycho-oncology at University of Barcelona and Catalan Institute of Oncology, where he lead ICOnnecta’t, the digital health psychosocial program and the Psychooncology and digital health research group in IDIBELL research foundation. He started 20 years ago a fruitful clinical research line in stress-growth processes in cancer. The main outcome of this research was the development and creation of Positive Psychotherapy in Cancer (PPC), an innovator psychological treatment for distressed cancer survivors. Randomized controlled trials showed execellent and better results for PPC than stress management intevention after oncological treatment in online and in-person format.

In recent years he has aligned its lines of research in psycho-oncology and e-health to facilitate the construction of healthy experiences in cancer. Some of the topics used by his group has been the use of Internet in cancer, communication-digital alliance user-health professional, early stepped psychosocial and cognitive treatments and behavioral change to reduce cancer incidence. His mission is to reduce the impact of cancer by improving access and digital integration of health education, psychosocial interventions and evidence based psycho-oncological treatments. Nowadays, he is the principal investigator and coordinator of several national and international competitive projects

Adrian Pogacian, MS Psychology, clinical psychologist with executive education in Psycho-oncology, holding a degree in Global Health Diplomacy from Geneva Graduate Institute. Currently, researcher and associate lecturer with focus on Impact of Cancer Diagnosis on Couples and Families, Communication in Cancer Care and Posttraumatic Growth. His expertise is on Coping with Cancer and managing Fear of Recurrence.

Additionally, Founder of INCKA Psycho-oncology Center, Host of Beyond the Cancer Diagnosis Interview Series as well as Writer and Host Content in Psycho-oncology at OncoDaily.com, co-author of the first Romanian Multimodal Care Guideline in Pediatric Onco-hematology, active contributor to the International Psycho-oncology Society, presently IPOS Fear of Cancer Recurrence SIG member and IPOS Early Career Professionals in Psycho-Oncology Committee founder member.

Adrian Pogacian: Hello everyone, nice to meet you again to a new episode from Beyond the Cancer Diagnosis interview series. Today it’s my pleasure to present you Dr. Cristian Ochoa. He’s a psych oncologist at the Catalan Institute of Oncology, also professor of psychology at the University of Barcelona.
Dr. Ochoa, Cristian, thank you very much for accepting my invitation.

Cristian Ochoa: Thank you, good morning and it’s a pleasure to be here with you, Adrian.

Adrian Pogacian: And together with Dr. Ochoa, we’ll approach a concept very interesting in psych oncology, positive psychotherapy in cancer, and with the main question, how positive should the cancer patient be at the end of these discussions? We’ll try to figure out, but for the first questions to begin our discussion, I would like very much Dr. Ochoa to develop this concept and the main aim of this positive psychotherapy in cancer.

Cristian Ochoa: Okay, thanks Adrian. First of all, cancer patients don’t need to be positive. Positive is not a mandatory enemy that people have to maintain in such an adverse situation.

Positive is sometimes the way that we explain in a popular way how to find our best version, how we can live, fully live in this situation, but it’s not a mandatory, it’s not a kind of tyranny of the patients. It’s a kind of natural response. As you say, post-traumatic growth is a natural response of a lot of people who are living with this kind of street cancer.
And that’s the thing. We begin to study cancer in this kind of two main processes that are really involved in this situation, stress and growth. And stress and growth are very connected concepts and connected response in cancer.

But we are, in the past, we are very focused in the part of this duality in stress, but we know more a lot of this other part, post-traumatic growth, which in a simple way is positive vital changes that people could explain after cancer. And now we know a lot of this positive growth response and positive psychotherapy is that we are trying to put in clinical settings, all this knowledge related with positive vital change that has a lot of potential in the attention of patients in cancer. And this was our research previously to find positive psychotherapy in cancer.

Adrian Pogacian: And when you start this project?

Cristian Ochoa: Well, positive psychotherapy is a kind of live project. And it begins in 2020. Sorry.
And 2020, I’m sorry, it’s 2010, where we organized when we published the first draft of the positive psychotherapy program in Spanish. And three or four years after we published the same program with little changes in English in a comprehensive guide. Then we are working in this field around 15, 20 years.

Adrian Pogacian: I was asking this because you mentioned post-traumatic growth and also this theory, this concept, it’s also new in kind of new as a concept in the field of psychoncology. Of course, post-traumatic growth, it is a concept in other areas with history, but related to psychoncology, it is also a new concept. And I saw that you apply the principles of post-traumatic growth.

And I want to ask you that when you are talking about post-traumatic growth as a scientist professor, from a theoretical point of view, everyone is thinking to Dr. Tedeschi, Dr. Calhoun theory of post-traumatic growth. Of course, you use that also, but I know that you use also other, not theory, but other interpretation to put it this way of more European way of Dr. Joseph and Dr. Linley. Can you explain a little bit, there are differences in approach or where is that line that makes the difference?

Cristian Ochoa: I think it’s a kind of more, the difference are more related with a theoretical and application of these principles, but Calhoun and Tedeschi were the pioneers in this field in the United States. And also a lot of people are involved in this area because they began to do a very good job related with these positive life changes that people do in other situation, not only in cancer. But there are a lot of people also in Europe doing this work.

And this other theoretical models has some peculiarities that I feel more comfortable with this. For example, Joseph and Linley explained in a more humanistic and existential way, how we could approach this adverse situation. For example, I think Calhoun and Tedeschi also could think similar things, but the way that they explain it’s different.
For example, in Joseph and Linley model, stress is more a normal response to a normal situation. And a lot of our approach is trying to help people to understand what’s happening. What are these reactions meaning in their lives?

And these things, it’s for me, it could be the main thing that could be different. For Joseph and Linley, stress and growth are interpreted in the same human experience framework. And for me, it’s interesting because, for example, they have developed instruments to assess stress and growth involving both processes.

Processes. And they have, in their model, it combines very well stress and growth as mechanisms that could be, that explain this other equilibrium that people have after this adverse situation. And perhaps this is, for me, the most important difference in these models.

But, of course, both of them are explaining similar things and the approach normally are similar. But for me, it’s important because if we think that post-traumatic growth is in a kind of individual fight or war or a kind of we need to be better in each moment, it’s different that if we involve, for example, the other people around us, a more relational and community approach, then I always see it both in the United States and Europe. But I think it’s more typical to see it in Europe.

If we think that post-traumatic growth is not an individual approach, it’s a kind of relational work with our caregivers, with the people that are surrounding us and supporting us during cancer.

Adrian Pogacian: I guess it’s also a problem of cultural background at the end, because as we know, Professor Tedeschi and Carhun developed post-traumatic growth for the veterans from the US Army to help them pass the traumatic events. In Europe, as you mentioned, it’s a more humanistic approach related to what the cancer patients feel and to take it from point A to point B. It’s a cultural background.

Cristian Ochoa: Yeah, of course, that’s it. I agree with you that it’s a kind of a cultural and it’s different the way that they began to study post-traumatic growth in different adverse situations. When I have to talk about positive psychotherapy in cancer, one of the things that I explained at the beginning is that cancer is a different stressor.

It’s not this kind of acute stressor, and this changes a lot of the psychological response related with cancer. For example, one example is, where is the threat or the reference of the threat in cancer is the future. It’s death, it’s the loss of autonomy, it’s suffering, and it’s be a problem for my family in the future.

But in other post-traumatic situations, the reference of my traumatic memories is the past. For example, in soldiers in Vietnam is what they live, not what is going to happen in the future. This changes a lot how we can approach these situations because we have to approach more the possibility to be in the future for patients with cancer, because cancer is an ongoing threat.

It’s a threat that is not restricted to a period of time, like acute stressor. It’s involving your life perspective and how you can project yourself in the future. Your identity in the future could be changed related with this threat.
That changes a lot how to approach both things, stress and growth.

Adrian Pogacian: Cancer is like a sinusoidal issue, because today you are feeling good, but tomorrow you are not feeling good and you are asking why. So it is very important, as you mentioned, how you see yourself in the future, what are the further plans to deal with, and also, as you mentioned, cancer is a stressor.

Cristian Ochoa: Yeah, and another thing that is related to what you have mentioned, perhaps we need people a lot in cancer, because perhaps cancer could be invalidating some moments and you need more people and how we work with this kind of needs, because if some people around me respond good, I feel this kind of incremented connection with them, but if not, we need to work with this kind of potential damage in our relations and forgiveness and something like that. That’s one of the things that normally in acute situations also could appear, but normally it’s different when the needs and the threat is maintained entirely.

Adrian Pogacian: You mentioned the patients and the very important relations with the patients, because if they don’t give us, as specialists, the feedback that we need, we have to start wondering what has happened. In order to facilitate these life changes, I know that you’ve developed a positive psychotherapy in cancer program. Could you tell us what is about the program, the structures, the issues, and especially the stages of this program?

Cristian Ochoa: Of course, but this program has the same idea I mentioned, is we need to combine the negative changes in my life around cancer with these potential new areas that could be positive if we can do well our experience in cancer. Then the program, in a formal way, has 12 weekly sessions, around 90 to 120 minutes, with two follow-ups, three months and 12 months after the end of the active psychological treatment. It’s obviously focusing on humanistic, existential approach, but with a philosophy of cognitive and behavioral focus in each session.

But the main idea is we are going to work with two processes, assimilation and accommodation. Assimilation is the way that, because it’s important to mention that our program is validated with randomized clinical trials in people at the end of their primary oncological treatments, because we saw that these people are in a kind of, what is happening now in my life? They are trying to return to their lives.

Everyone thinks that now they could be cured, but they feel that a lot of changes have passed, and they need to assimilate all these changes and try to change them to incorporate the things that cancer has questioned in their life. Then the most important thing is this positive psychotherapy program is the definition, and the best way that we can conduct this treatment is for people at the end of their oncological primary treatments.

Then, at this point, we dedicate four or five sessions for assimilation process.
Then we are going to talk at the beginning about what are the most difficult things around cancer. We are not denying what is passing in cancer. We are not trying to see only the positive part of cancer.

That is the right of the patient to see or not to see what are all the changes in their lives. The first sessions are related with emotional expression, processing. We try to promote the bitter awareness, curiosity, work with positive and negative emotions in the same way in sessions, trying to symbolize and significate these post-traumatic stress symptoms that normally appears in the first session in our positive psychotherapy, because we begin the program with what was your experience after cancer.

They actualize and update all the problems that they have at the beginning of cancer, and we work with this negative or these not pressureable symptoms. After this assimilation process, we talk about emotional expression processing first. After that, we talk about emotional regulation and coping.

We try in the cases that symptoms are really high. We try to train with some relaxation, guided imagery, management of anger, irritability, sleeping, and roles. Normally, it is not the most important area for us because our idea is post-traumatic stress symptoms that has been updated in these first sessions of the program are normal reactions for an abnormal reaction.

Our focus is trying to find the function in their lives of these reactions. Then this first part is a part to reactivate all the negative impact of cancer. Then we move to the most important part of the program, which is the accommodation part.
The accommodation part is sometimes summarized with this word, post-traumatic growth. Post-traumatic growth is what we need to change in our lives to incorporate all the important information that appears in cancer in our life, mortality, the roles that I could or not maintain in my life, how people are around me, how I can express or share my experience, people could understand me or not.

Then in this part, there are also in this part of accommodation, which are the main part of the program.
Eight sessions are focusing this part. The first part is related with facilitation of post-traumatic growth. Here, there are some techniques that we could discuss if you want for not be too much longer.
This is the most important part of this model. After that, the last two, three sessions are focusing existential and spiritual aspects.

More or less, it’s also with this field of recurrence.
But for recurrence, it works in all the other parts. But for example, we could anticipate a potential relapse and how we can deal with this. We can also discuss about positive models in these adverse situations.
These are a kind of framework of psychotherapy. It’s solved with eight to 12 group members.

Adrian Pogacian: And since we don’t have too much time left for our interview, I have to admit that it’s a tremendous work behind this project because it seems very complex. As far as I know, it’s unique in Europe in this way that you approach things, trying to take the patient in the past, in the future, to put it in the present. You took it to all the stages, which is very important for a cancer patient to realize, to deal with, to confront itself, the others.

So, it is something really great that this program. As for the last question, a question if you can ask briefly, it is a statement within psychoncologists that said that too much hope, it’s a false hope. Do you agree?
You don’t agree?

Cristian Ochoa: Yeah, it’s difficult to say yes or not, but I can understand that sometimes there is a hope that is a denial of hope. If the hope is only focusing in the disease, in survival, I think this hope sometimes could be, and it’s too much hope. That could be a dysfunctional hope, not a false hope, but it’s a dysfunctional hope.

And sometimes when situations that the hope of survival are compromised, for example, people who have advanced cancer or terminally cancers, we can brought hope if the hope is not only focused in survival and in the disease. Brought hope is related with how we can be engaged in our lives in these situations that perhaps life is not, it has a short time. And this kind of brought hope is trying to be engaged with my people, trying to find relevant issues to do in each day, in each moment.

And in realistic hope, normally we can find that the hope is really adaptive. In false hope, people normally are trying to avoid or deny what’s happening around him. Because people who has a hope that is sustained with the people around them, these people who normally are more adaptive, people who wants to be very high hope, but not talking about what’s happening, trying to see only the desired future.

Normally are people that the communication are too much rigid. And the way that share of experience in cancer is too much stereotypical. It’s not a kind of flexible or like a routine, for example, kind of a rigid mantra that I have to say, I’m going to be I’m fighting every moment.
I try, I’m going to be cured. The people who doesn’t contemplate other options, normally people who that needs to be very monolithic in their ways of cope with cancer.

Adrian Pogacian: Dr. Rocha, thank you very much for your ideas. Thank you very much for your thoughts. Was a wonderful discussions.
And for sure, our audience, the patients, especially will find very interesting and hopefully they will try to adapt or to apply some of your ideas. Thank you very much. And good luck further in your activity.

Cristian Ochoa: Thank you very much for your interest. To give us the opportunity to explain something related to psychology and this kind of positive psychotherapy treatments. Thank you.