David: This is Smarter Than Cancer, and I'm David Hoffman.
Hajar: And I'm Hajar Eldaas
David: Today, I wanna share a conversation that I had that I
thought was really important and really moving, honestly.
Hajar: Okay, tell me about it.
David: I spoke to Dr. Meghan Pahler. She's a clinical psychologist who's the head of the Department of Psychology here
at Roswell Park.
Hajar: Interesting. Does a psychologist at a cancer center do different things than a psychologist anywhere else?
David: Well, it is interesting. Like anywhere, she really just talks to people and gets them to talk to her. But the way that she does it and the way that she spoke with me is not exactly about trying to make people feel happier, at least not in the short term. It's more about giving people permission to feel how they feel, and then using that as a jumping-off point for centering themselves and, you know, acknowledging the challenges they're going through, but also finding balance and acceptance and happiness.
Hajar: Wow. Yeah, that sounds amazing.
David: It really was. Let's listen.
(Theme Music)
Pailer: The bulk of my work here at Roswell is providing psychotherapy to cancer patients and also to their families. And so for the most part, that involves helping somebody with cancer cope with the really significant emotional toll that the disease takes, and also the tremendous disruption to somebody's life. That can be disruption to their work, to the roles that they
play in their family, to their appearance, um, to their ability to feel like they are a productive member of the workforce of society, and that can take a really significant emotional toll.
David: Yeah. I mean, I imagine people are coming into you inevery possible state of distress and, like, you must see an incredible range of emotional expression over the course of a day or a week or a month.
Pailer: Oh, absolutely. Absolutely. There's a huge range. There are people who, uh, just experience overwhelming sadness and struggle then to get out of bed, to function in their lives, to
try to have hope and there are people who are so scared that it's hard to, again, it's hard to function. It's hard to, uh, think around the beast that is fear. And there are also many, many people who are able over time to figure out how to sort of cohabitate with cancer. That's, uh, a lot of times people come to me and say, "I wanna not be scared," or, um, "I wanna be happy again." And my response to that is, that fear is not something you're gonna be able to kick out of the vehicle, you know?
David: Right.
Pailer: But the goal is to not have it sit on your lap as you're trying to drive about in your life. So maybe we'll have it sit next to you. Maybe we'll have it in the backseat, or, uh, if we're really successful, it can sit in the trunk for a while. Um, but fear and overwhelm are, um, they're sort of like the roommates that you never wanted, but they're there. So it's not necessarily about getting rid of them, but about trying to live with them and live well.
David: I saw a meme, I don't know, a couple months ago that said, uh, "Sometimes I wrestle with my demons, and sometimes we just cuddle."
Pailer: Exactly. And sometimes they can, uh, they can sit quietly. And actually, we like to use the word “distress” specifically because it doesn't pathologize it, specifically.
David: Right.
Pailer: Because feelings of sadness and anxiety are sort of part of the territory. Whatever the distress is that they're experiencing, what it looks like, you know, is it anxiety? Is it depression? Is it normative adjustment? And people are usually very relieved to hear that they're not the only one who experiences these types of emotions.
David: I'm interested in that phrase normative adjustment. What's the difference? What, where's the line between depression and norm- normative adjustment? I mean, how sad is too sad?
Pailer: It's, uh, it's such a spectrum, right? So the cardinal symptoms of depression are pervasive sadness, where you feel sad most of the day, nearly every day, um, and also anhedonia, which is a loss of the ability to experience pleasure at an event that would normally bring you pleasure. So, you know, if I used to really enjoy when everybody came over to visit, and now I just, I can't wait for them to leave. That's an example of an anhedonic symptom.
David: Could be anywhere, like I used to like listening to music and now I just don’t care about it.
Pailer: Exactly. So those are the kinds of things that I look for. The lines between, you know, sort of normative adjustment versus, a clinical depressive episode are really based on how pervasive those mood symptoms are and how much they interfere with somebody's ability to live their lives.
David: Where can you get someone to through this process? You know what I mean? How is this just not gonna suck? Like, how do you... What can, what can you do?
Pailer: That's a very, very good point, because the goal is not to not be sad, right? Right? To not feel upset about a cancer diagnosis. Uh, we actually had a joke among the psychologists
for a while because we saw somebody put in a consult that said, "Sad." And the thing that was so ridiculous about that is that there was, that, that there would be something wrong with
feeling sad.
David: I’ve analyzed Lake Erie and determined that it's wet
Pailer: Correct.
Pailer: And, it's interesting because there are s-there's so much overlap between side effects of chemotherapy and depressive symptoms.
David: Oh, that's interesting.
Pailer: So, if you look at the, um, DSM diagnostic criteria for depressive symptoms, there's sadness, there's anhedonia, there's fatigue, there's sleep disturbance, there's appetite disruption, a sense of worthlessness, worry. And if you look at a lot of those chemotherapy side effects, you have fatigue, you have appetite disturbance, you have, uh, medications that impact
sleep, either, you know, insomnia or hypersomnia. There's a lot of overlap. And I used to work a lot on the bone marrow transplant service, and I used to say to people all the time that if I wanted to create a depressive episode in a lab, I would give people bone marrow transplants.
David: Right.
Pailer: Because you take them out of all things that bring them joy, you make them feel very, very sick and disrupt sleep, appetite, and you tell them that they have to be away from their loved ones, and it's gonna last four months. So, you know, there are, uh, there are a lot of factors at play here that can impact people's moods. So, you know, uh, a lot of what we do really is normalizing the whole gamut of emotional reactions to a cancer diagnosis because people are allowed to feel sad, they're allowed to feel angry, they're allowed to be scared, and that doesn't mean you're not doing it right.
Pailer: We have such a message for cancer patients of positivity, and I think positivity is a wonderful thing, but the expectation that a cancer patient should feel positive all of the time, and that there's something wrong if they show a negative emotion or don't feel positive, there's a wonderful psychiatrist who is considered the founding mother of this field
of psychosocial oncology, and she used the term, the tyranny of the positive thinking.
David: Yeah. Wow.
Pailer: Because cancer patients are expected to adjust, um, to go through all of these very difficult treatments, and they're supposed to do it with a positive attitude. And the challenge of
that is that, then people put all sorts of expectations on themselves.
David: And to give back and to inspire others and to all of this.
Pailer: And your positive attitude is gonna make your cancer more easy to treat.
David: And so if you're not positive enough, you're, you know, if, if you get sick, or it's because you weren't positive enough
Pailer: That's right. That's right. If attitude is everything and then your cancer doesn't get better, then you're not doing it right, or that's the, that's the fear, which then puts a whole lot of pressure on people to try to cope a certain way. and then if they're not or if they're feeling these negative feelings, it can be difficult to talk about it
David: How do you feel... We've, we've talked about this, the, the little team that makes this show about the, the terminology of “fighting” cancer. How do you feel about that? You winced
when I said it.
Pailer: Yes. I think that, um, that the fighting cancer terminology is tricky because in fights, there's often a winner and then a loser. And so to fight and then to have your cancer progress, there's an implication there of failure.
David: You're a loser. You've lost.
Pailer: That's right. You've lost your battle. Um, and then similarly, if people are deciding, I don't want to do active treatment anymore, or my disease has progressed to a certain point, there's an implicit message there of giving up, you know, surrendering, which is part of that battle, imagery, and I think it can be damaging to people.
David: Is part of it sounds like what we're talking about is learning to live with cancer and that continuing to live while you're going through whatever journey cancer's gonna take you
on. Is part of that learning to be okay with the idea of mortality generally?
Pailer: Being okay with mortality is a very, very challenging task.
David: For sure.
Pailer: And some people can interact with their mortality in such a way that they can talk about it, think about it, have perspective. Um, and for other people, that's just too overwhelming, and I don't think that there's a real right or wrong with that. I think the conceptualization of meaning is really important if, if we're thinking about, how do you live with cancer. It starts with a question of what's meaningful to you, because then you're not trying to fix some negative emotion or, or a thing like that. And there's a lovely type of psychotherapy called meaning-centered psychotherapy that was developed with advanced cancer patients. And meaning-centered psychotherapy focuses on these sources of meaning that people have. So you have, meaning as far as how you see yourself, uh, where you come from, what are your stories if I asked you to tell me some stories about your childhood that make you you. You know, people have stories like that. They have family stories. Meaning can also be things like appreciating beauty or humor or nature. It can be what sort of legacy you're gonna leave, and where you derive love and connection. Yeah.
David: Yeah.
Pailer: if you think about all those different sources of meaning and how disruptive cancer can be there-
David: Yeah.
Pailer: It throws a wrench in all of that. But also, how do you then reconnect with some of those sources of meaning and make sure that a life, your life that you're leading, continues to,
that you continue to have access to those things? One of the things that I do with people is explore their worlds, their identity, their sense of self, and try to figure out ways of increasing the proportion of time that they spend in their life identity relative to their cancer patient identity.
David: That's interesting. That's an interesting distinction.
Pailer: I usually have, I draw a pie chart, and then make terrible jokes about my artistic ability. Um, but I draw the pie chart, and then have people estimate for me the proportion of their sort of life roles that are presently occupied by being a cancer patient. So then from there, we look at, say, for example, seventy-five percent of their world is being taken up by their cancer-related stuff. I look at what's in the twenty-five percent, and one of the goals is to try to scooch the twenty-five percent, a little bit more to have it encompass maybe thirty percent or, or thirty-five.
David: and maybe even just to be more aware that that 25% exists and to-
Pailer: That's right
David: take more deli- as much delight in it as you can or something?
Pailer: And to work on the fact that it doesn't have to be all or nothing. So if you're not feeling up for socializing with your friends like you used to, but you could go for half an hour, it's probably worth it because you'd be able to feel a little bit more like yourself than you do now. And if you're feeling badly about all the changes that are happening in your appearance, maybe you spend a little bit of time, um, getting dressed in something other than sweatpants when you go out and putting on a, a cool hat or a pair of earrings, uh, because it
makes you feel like you're attending to your, your, uh, physical self a little bit. Ways of inhabiting your identity to the extent that you can. I keep coming back to that. so that's a-- that's an important thing. Also, I do a lot of work with people on coping with anxiety, and that can, that can look a number of different ways. It can be, um, connecting them with some, um, mindfulness resources, uh, meditation, things like that, diaphragmatic breathing, relaxation skills training. I do a lot of that. And then also this idea of how do you conceptualize anxiety in such a way that you can see around the edges of it a little bit? The fancy term for that is cognitive defusion. So rather than being stuck up against your anxiety you
pull back from it a little bit.
David: Mm-hmm.
Pailer: so that you can recognize it's there. In a way, you make room for it so that you're not constantly fighting with it or struggling.
David: Yeah.
Pailer: So those are some ways of managing anxiety that don't involve, looking for the off switch of the anxiety, which I still haven't found. And when it comes to people who are very,
very much struggling with depression, again, it comes back to are there things that you do that bring you joy? And how can you find those things? One of my favorite exercises is to have people keep a notebook where they're looking for, um, any event that happened over the course of their day where they were able to be in that moment and they experienced some joy with it. I took a mindfulness class at one point when my kids were little, and I was doing this assignment where I was looking for those moments of joy. And there was one day I got home from work and the kids were running through the sprinkler, but the sprinkler was hitting the neighbor's house. So I went to try to move the sprinkler, and I'm dressed for work, and the sprinkler hit me all in the face. So I just decided to go for it, and I ran through that sprinkler over and over again in my work clothes with my kids. And because I was doing that exercise, I wrote about it in the journal. And so this is ten years later, and I remember it vividly. So the recording of the joy episodes in the journal, it does a couple of things. One, it causes you to be on the lookout
for them. And the other is that you can reflect on them, and then you have a lovely anthology of, of fun, interesting, little, tiny moments of joy. And that can be a way of, um, beginning the process of trying to have some level of mindful presence and also a little bit of joy.
David: You know, of all the places you could practice psychology, of all the tracks you could've gone down, why here? Why did you choose to work here?
Pailer: I came here out of total serendipity because I was, um, moving to this area and, and there were... this position was available, and then there was another position available which
much more closely met my thoughts about what I wanted to do with my life.
David: What were those thoughts? What were you doing before? What were you doing previously?
Pailer: I was doing research at a children's hospital.
David: Hmm.
Pailer: Uh, we were designing interventions for kids seeking care in the emergency department.
David: Oh.
Pailer: Oh, wow. so I thought that I wanted to work primarily with children, and I was, to be absolutely honest with you, scared of illness.
David: Wow.
Pailer: So I didn't know how I was going to be able to work at a cancer hospital. But working here with the struggles that people go through is such a very, very specific and intense experence, and the opportunities for, um, for just seeing people who end up doing so well, and emerging from this very difficult time. That's really, really where it's at. I work with a young man who was so, so sick for years really, and, and it didn't look like things were gonna end well.and I saw him last week, and he's enrolling in college, and I asked him if he had anything else
that he wanted to share at the end of the session, and he was gonna ask somebody out to the movies.
David: Fantastic.
Pailer: And I thought, "This is why I do this.”
David: That's an act of hope.
Pailer: She said “yes.”
David: I'm so glad.
Pailer: But it's this idea of being able to really bear witness to these extremely difficult things and to help people have, uh, have some level of hope. It's such powerful work.
David: Are you still afraid of illness?
Pailer: I have been, um, engaging in a 20-year exposure therapy exercise with myself.
David: How's it going?
Pailer: I'm in a different place now than I was, for sure. For sure
David: Do you think that that helps you in what you do maybe? 'Cause you're, it will put you in a place of relating to someone else
Pailer: Oh, absolutely. Absolutely. And I think that's important, right? It's being able to really understand where people are coming from and how difficult this whole process is, and then being able to draw from all the stories I've heard and the strategies that people have used to get through it.
David: An overarching theme I feel like to almost every conversation we've had for this show has been this idea of treating the whole person, and it's, it's heartening to see
people at every discipline sort of thinking this way now or talking about it. That, you know, I feel like maybe in the, the dark ages of the 1960s or something, you know, the idea was, you know, cut the tumor out, blast them with chemo, kick them to the curb, good luck kind of thing, you know? Like... And this is-- You're doing something very different here. Um, I wonder if you could speak to that, you know, this idea of treating a whole body and, you know, the mind and the spirit being part of that.
Pailer: Oh, absolutely. And that is by no means unique to the work that we do in the psychotherapy room. I think that's one thing that, that I see over and over again, is, um, medical teams who have awareness of the fact that people are whole people, and doing things like learning a little bit about their lives and knowing what's important to them, and making sure that if you have a trip planned to Paris, you're gonna coordinate your, uh, chemotherapy regimen to accommodate that whenever possible. Um, I think that there has been a tremendous amount of advances in that whole person approach to treating cancer. and that also extends to the family members of cancer patients. That's one thing that we're actually working on now, is making sure that we offer supportive resources to the loved ones that are providing the care for the cancer patients as well because the person exists within a family context, and that support, social support is one of the most important variables as far as somebody's psychological adjustment to cancer. So making sure that people's support networks are given some attention and TLC as well. it's part of the whole kind of comprehensive aspect of it.
David: I mean, is a big part of this of, of what your, your work and your, your goals just helping people figure out what they want now that they've reached this new... That they're, they're
in this new phase of their life, like what they want to accomplish, where they wanna go, how they wanna get there?
Pailer: Oh, absolutely. A lot of times people emerge out the other side of a cancer diagnosis with a different sort of sense of what's important.
David: Sure.
Pailer: And how to build a life moving forward that is more congruent with the life they want to be living. There's maybe a mindset that, uh, being a psychologist in a cancer center is a depressing thing to do or, you know, that we're with sadness all the time. And I spend so much time with people laughing, finding joy in the ridiculous, um, and, talking to people about hope. and I think that's a really important part of what I do, and it's not necessarily what people would think of, but, uh, but it's a really, really rewarding and valuable piece of it for me.
(Closing Credits)
