Children and adolescents diagnosed with cancer must be perceived as being involved in a continous battle with this chronic and potentially life-threatening condition. Each must endure a succession of traumatizing events, beginning with the diagnosis and prognosis of the disease, and which continues until death occurs. Albeit the prognosis for certain cancers continues to improve and survival time increases, the turmoil associated with the experience of having cancer remains, forever closely affiliated with the uncertainity and unpredictability of each individual's situation and life span. This knowledge, as well as the disease itself and associated treatments, can precipitate an emotional equilibrium that is untenable and precarious, putting the individual at risk for cognitive, psychosocial, and affective dysfunction. However, such knowledge and experiences can also have consequential and profound effects on others involved, such as parents and siblings (constituting the family unit) as well as peers and teachers.

For children and/or adolescents experiencing cancer, the pattern of life may now become one involving frequent hospital visits and/or admissions for a therapeutic regimen, which may or may not result in more frequent and lengthly remissions. This paradigm can be seen as epitomizing the psychological impact of cancer. How then does life for these children and/or adolescents continue on a day to day basis? The ability of these children and/or adolescents to comprehend and affectively contend with the protracted course of their illness (and well beyond) must be an issue of some consequence for all participants of the multidisciplinary team who treat, care, and interact with them. This assertion is also relevant to those professionals who work with these students within the parameters of the educational system.

Research indicates that school counsellors can provide assistance to these students when they experience difficulties. Here the counsellor, as a member of a professional team, can fulfil a role that will promote enhanced emotional and psychological well-being for this student. In the midst of this turmoil, the counsellor functions by implementing interventions that will benfit not only the student-patient, but also the family and the community of the school as a whole. Yet, all can be jeopardized if the school counsellor fails to maintain a balance between personal fears and anxieties and that which is of benefit for the individual(s) involved. Books can sometimes assist, facilitating the counsellor in these endeavours.

The Process

In the profession of counselling, the onus is on each counsellor to develop and implement a personal counselling theory which serves as the basis for counselling goals and decisions, and for the selection of various counselling techniques.In this regard, theories of counselling present systematic ways of comprehending psychological problems, and describe methods for assisting individuals in resolving them. However, when the client is a student living with cancer, the counsellor should not accord any one single process (i.e.,emotional, cognitive, psychological, or behavioural) primacy.

Although a well-integrated theory can in effect steer a counsellor through the therapeutic process, here an eclectic model must be perceived as being apropos. Instead of the counsellor relying on one exclusive approach to counselling, the consolidation of numerous destinct techniqes and concepts into an inclusive, but practical approach to therapy may prove to be more advantageous for this client-student.

When interacting with students experiencing cancer, each counsellor can function in a myriad of roles including that of confident, information giver, advocate, and therapist. This parallels the assertion that the responsibility of a counsellor is to purposefully choose interventions, and to harmonize theoretical concepts and techniques into a coherent framework that will benefit the client. In order to facilitate this process, each counsellor must be knowledgeable of both the student's condition and its implications for not only the client, but for the family unit, peer groups, and even the school as a whole. Any anguish will only be increased if the counsellor fails to understand related problems, issues, and concerns. However, counsellors must also be aware that the issues of primary concern for these students may not be related to their experiences with cancer. This is especially germane when the client is an adolescent.

What these students know about their illness, medical regimen, and the severity of side effects can profoundly effect their ability to adapt. It has been asserted that the adaptive capabilities of such clients are significantly constrained when issues such as control, decision-making, and the comprehension of treatments are taken from them. The outcomes for the client involved can only be feelings of hopelessness, depression, and immobilization. It is apparent that in order for the counselling process to be effective, the counsellor must be cognizant of what this student has been told and/or comprehends. Only then can interventions be selected which will enhance not impede the student's subsequent adjustment.

In the initial stages of the counselling process, the counsellor has to establish a rapport with this client, in what has been delineated as a 'working alliance'. During this time, the counsellor encourages these clients to express their perceptions of the problems that are paramount in their lives, Basically the counsellor needs to engage the student/client in a process of self-exploration, one where the student/client can clarify his/her concerns. Interventions which are tailored to these problems are then selected and implemeted utilizing a collaborative, constructive manner. One which can be effective, especially with adolescents experiencing cancer, is the therapeutic use of literature.

Is This Bibliotherapy?

The use of literature (for example, bibliotherapy, and transitional literature) is one of the most readily accessible of counselling interventions. There are also manifest indicators that its use (e.g., bibliotherapy) with the chronically ill, such as the adolescent living with cancer, can have significant results. As a treatment modality, this intervention has demonstrated that it can empower clients who are chronically ill, to verbalize their feelings; modify their environment; establish realistic goals and expectations; and, to augment their knowledge base. Furthermore,the use of literature has been shown to increase the sensitivity and understanding in significant others, such as peers, teachers, and even the counsellor. In addition, the creative and selective use of literature has been shown to be therapeutic in terms of facilitating the individuals's ability to cope with health alterations, to maintain hope and feel comforted, and to endure health related and/or life demands.

When literature is utilized as therapy with the chronically ill, it can be extremely effective in healing both mind and spirit. Its implementation speaks not only to spiritual needs but also ecourages the chronically-ill in their search for meaning in or through their illness. This is also relevant for those adolescents living with the experience of cancer and enduring to survive - cognitively, psychosocially, and affectively.

There are a number of books available whose focus is the psychological impact that this disease has on children and/or adolescents. Two of our favorites are David Bearison's "They never want to tell you" Children talk about cancer and Elena Dorfman's The c-word: Teenagers and families living with cancer. Although both of these books have similar frameworks, they differ in the author's rationale for accruing such narratives.

Bearison's book is written from the perspective of a researcher, utilizing the clinical method to investigate and "illustrate the variety of ways in which children who have cancer feel comfortable talking about their experiences" (p. 15). Dorfman's purpose can be deemed as one of initiating her own personal catharsis, since she states that this book was a quest to "make sense of (her) illness by compiling a documentary containing pictures and personal narratives from young adults confronting cancer . . . ." (p. 12). Her intent is to address the emotional and psychological turmoil encountered by all adolescents who confront cancer.

As one reads these books, it becomes apparent that for these individuas, akin to others living this experience, any expectations in regards to maintaining a normal lifestyle are exceedingly untenable. However, each individual interviewed was willing to share their personal struggle with the reader, and each endeavours to speak candidly about the subsequent emotional turmoil and crucial adjustments. For the school counsellor, who is interacting with these students, as well as others who are affected by the parameters of this disease, such books can be utilized to generate a life experience that is meaningful, productive, and less emotionally traumatic.

Dorfman's book when utilized as therapeutic literature by the school counsellor can function to (1). assist such students in focusing and in verbalizing their inmost thoughts by making the words available; (2). empower these students (as well as their families and peers), so they can 'name' the distress, the turmoil they are experiencing. (Here naming becomes an essential component of psychological-spiritual care); (3). help them to become aware of how other adolescents have undergone and survived similar experiences; and; (4). help them ascertain what 'remains of health within (their) illness" (Hobus, 1992). Each one of the four can function to lessen the emotional isolation that is experienced by these adolescents, from their peers, the school and even the community in which they reside.

Research demonstrates that the care of individuals categorized as 'dying' precipitates significant levels of stress in caregivers who interact with them. This assertion is as applicable to school counsellors (as wells as other teachers) who interact with these students. Due to their illness, these individuals are oftern perceived as belonging to a minority , who, inadvertently, frighten healthly individuals, making them feel uncomfortable, anxious and helpless, for the most part because they remind us of our own vulnerability and mortality. Such a reaction by a counsellor will only serve to bias the interventions selected for implementation and as well precipitate reactions which can be deleterious for the students involved. Ultimately, the oucome can only be emotional isolation for all concerned.

The Ultimate Purpose

The foremost aim of counselling is to assist clients in maintaining as well as augmenting the quality of their lives. The fulfillment of this goal is especially crucial when the client is a child and/or adolescent living with cancer. As these individuals progress through the disease state and the treatment process, they become vulnerable for psychological and emotional disequilibrium. One professional who can assist these students to move toward an enhanced well-being is the school counsellor.

In order to accomplish this endeavour, the school counsellor needs to be cognizant of the issues and concerns that are of paramount importance in the lives of these clients. An awareness of what these students know about their disease, its prognosis and/or the aftermaths of the medical treatments required is essential. But each counsellor must also be aware of their own beliefs, values, anxieties, and fears, since these can jeopardize the counselling relationship. It is only then that the counsellor is cognitively capable of selecting and implementing interventions that can help these students elucidate their concerns and/or resolve their problems. One such intervention which can be utilized with the adolescent who is living with cancer is the use of literature as therapy. Bibliotherapy as a therapeutic modality can help these students by emphasizing that others have had the similar experiences and have found ways of living with what they (and/or others) could not change.

This article did not present a synopsis of the two aforementioned books. Our objective was to underscore how both are appropriate in fostering the counselling process, and how each can be utilized by the school counsellor when working with students diagnosed with cancer. While Dorfman's is a book which is appropriate for use when the client is a student, an adolescent living with cancer, Bearison's can be utilized by any counsellor to initiate the process of personal discovery and the development of self-awareness. Such reading can only add to the counsellor's general awareness of this subject and its repercussions for all involved. After all. in the long term, it is this knowledge that will assist these students to survive this maelstrom - cognitively, affectively, and psychosocially.

Bearison, D (1991). "They never want to tell you"; Children talk about cancer. Cambridge, MA: Harvard University Press.

Dorfman, E. (1994). The c-word: Teenagers and their families living with cancer. Portland, OR: NewSage.

Hobus, R. (1992). Literature: A dimension of nursing therapeutics. In J. Miller (Ed.). (2nd. ed.) Coping with chronic illness: Overcoming powerlessness. (pp. 323-352). Philadelphia. PA: F.A. Davis.

(Further references available upon request)

Authors: F.T. Wells; L. Gilbert, MEd.