In a series of brief clinical accounts, this article elaborates the thesis that cancer patients' intolerance of the side effects of chemotherapy is not merely the effect of the drugs' toxicity but also a way of displacing onto the treatment the fears and anxieties related to the disease. In relational terms, the rejection to the side effects may be a 'pretext' for psychological support and in some cases the occasion for initiating psychotherapy.

The hypothesis is that side effects (asthenia, nausea, vomiting, muscular pain, etc.) are not merely dependent on drug toxicity but are also a way of displacing onto the treatment the fears and anxieties related to the disease and, in my clinical cxperience, such reactions can often be relieved in a few psychological sessions.

In this brief account I would like to underline the importance lor physicians to be aware that the inner world of the patient is not something to sweep aside or a dangerous ground in which one risks losing the objective diagnosis and the scientific view of the disease, but a reality that can influence treatment compliance.

For this reason, when my work in the Haematology Department began (after a period of participatory observation of institutiona1 dynamics of the ward), the physicians and myself decided to act on two planes. On one hand we formed Balint groups for psychological training to help doctors accept the patient in his or her psychosomatic reality and, on the other hand, I offered individual psychoanalytical sessions with patients, in order to give them an opportunity to work through their difficulties.

CLINICAL ILLUSTRATION

Three clinical accounts are presented below to illustrate the complex relationship between psychological reactions to illness and the treatment tolerance level.

The most common psychological hypothesis on the variability of rejection reaction to chemotherapy is that the more massive the side effects, the less chance the patient has had to live with and suffer from the illness. Thus when cancer is diagnosed early (now an increasingly common situation), the therapy replaces the disease in the patient's perception as the cause of the pain, damage and mutilation, and for this reason it provokes stronger rejection reactions. On the contrary, when a disease has already taken its course and caused suffering, it is more likely that a patient will consider the treatment as a help and it is therefore better tolerated

Case A

A. was a truck driver from the south of Italy. He was a hard-working man, married, with children. At the age of about 50 years, after several months of high temperatures, asthenia and weight loss, he was diagnosed as having lung cancer. Given the extent of the disease, his local doctors informed him that he did not have long to live and that there was no point in attempting treatment. Overcoming the initial trauma, A. apparently resigned himself to his fate. However. a close friend advised him to get a second opinion, from a hospital in Rome.

Thus A. came to the Haematology Department, where tests and analyses were run immediately and, within hours, a much 1ess desperate diagnosis, Hodgkin's disease, was given. Chemotherapy began at once and the same evening A. felt better. In three days his tempetature had gone, his malaise was attenuated and he had recovered strength. His regular chemotherapy caused no disruption. He would merely take a day off frorn work (having in the meantime resumed his job) in order to come to Rome for the treatment.

The account of this case appears to confirm the working hypothesis, highlighting the relation between the tolerance of treatment and the basic condition of the patient. For A., who had been convinced that he was under imminent sentence of death and had been suffering from the disease for some time already, the treatment was greeted as the source of relief and hope, and perhaps precisely for this reason was well tolerated.

Case B

The case of B. allows further scrutiny of this hypothesis. B. is now cured, but when I met her, 3 years ago, she was an 18-year-old girl with Hodgkin's disease. Despite the trauma connected wilh learning of the diagnosis, B. faced treatment with apparent courage and proceeded wilh the treatment, tolerating the side effects quite well. When she suffered a relapse, however, a rejection crisis appeared. What had seemed bearable, had suddenly become intolerable, not so much at the psychic level (B. did not show signs of depression or loss of confidence in the cure) but because of the emergence of very strong side effects. B. fantasized about discharging herself and breaking off the treatment.

At that point, I saw B. for a consultation and she related an episode that is worth reporting at some length, because it illustrates the close relationship betwecn fantasies and tolerance of treatment. B. was then in the third year of high school and was eager to take part in a class play at the end of the school year. She really wanted to share this moment, the fruit of a year's work, with her clssmates. Unfortunately, her treatment was scheduled for two days before the class presentation, and B., who for some time had been suffering severe disorders after the chemotherapy, was afraid that she would not be able to participate.

On this occasion, however, the treatment failed to produce the heavy side effects to which B. had become accustomed. She went through the dress rehearsal and, the next day, the performance itself, without the slightest disturbance. The effects in B. appear to be opposite to those in A. The anxieties connected with the relapse of the disease were clearly displaced onto the treatment and, just as clearly, the patient's enthusiasm for her class play temporarily overcame the habitual side effects of the therapy.

Investigating further, I asked B. what her class play was about and she recounted the plot, which she, together with her classmates, had developed during the course of the school year. It was about a group of students in hospital, in coma after an accident during a school outing. Death comes to claim them, but they outwit him, changing places with their teachers and doctors. Fooled, Death takes the adults away and the studcnts are saved.

This uncommon script immediately suggested the interpretation of the play as a real psychodrama in which B. could at last express her fear of dying and her hostility to the world of grown-ups. The school presentation, then, did not just take B.'s mind off her troubles, but allowed her to express her inner world. This raises the question as to whether the side effects of treatment, when they are as dramatic as in this case, are not the expression of unspeakable fears of death displaced onto the treatment.

In this case, the school play enabled the patient to express and share, on a metaphorical plane, fantasies and emotions that were always otherwise suppressed. A good girl, 'strong and brave', B. had never been able to permit herself to do this. Several interviews With her parents, both utterly incapable of empathizing with their daughter, further clarified B.'s need for self-expression, albeit indirect, through her somatic reaction to treatmcnt.

In this context, I would argue, B.'s classmates, more empathetically open that her parents, unconsciously made a space that could contain her death anxieties and thus make it possible for her to think them through, offering appreciable .symptomatic relief and temporarily obviating the need for somatization. The thesis in this instance, then, is that violent rejection reactions to treatment are an unconscious effort, in extremis, to communicate and share the death anxieties connected with cancer.

Case C

A third instructive case is that of C., a young woman who had bcen treated for a lymphoma five years before I met her. She consulted me about disturbances that bcgan shortly after the doctors informed her that she was cured and that no more check-ups were needed. Her symptoms were nausea, fainting spells and alopecia. I was struck by these symptoms both because they were all at the somatic level (C. said she was happy and satisfied with her life) and because they so closely resembled the side effects of chemotherapy.

This case seems to confirm our hypothesis, namely that these severe treatment-related disturbances are some patients' only way of expressing their anxiety about death. As soon as the real threat of death had been lifted, C. began elaborating her anxieties on the symbolic level, and to do so, through displacement, she 'selected' the symptoms conneclcd with her therapy instead of those connected with the lymphoma.

CONCLUSION

these cases are not exceptional. It is well known that our fantasies and emotions can widely influence our psychological and physical existence. These thrce cases were chosen to illustrate: (1) the deep relationship between psychological attitude and treatment tolerance; (2) the importance of offering a psychological space to patients that have no psychiatric symptoms and (3) to stress the critical phases of the illness experience: the beginning of the disease (case A.), the possible relapse (case B.) and the return to health (case C.).

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