A Virtual Q & A with Dr. Karen Ritchie

Q - Please expand on what you had in mind when you wrote in the introduction to your book Angels & Bolters: Women?s Cancer Scripts, that "...medicine as a whole is blinded by its own script."

A - American medicine sees its role as battling against death and disease. This is true for most physicians, many nurses, and often patients too. These fighters are portrayed in movies and on television as larger-than-life heroes, as in the script for an action-adventure movie. For many, the fight is an obvious good, the highest calling, and to question it would be unthinkable. But warrior medicine, like everything we do, has positive and negative effects, risks and benefits. Medicine tends to ignore the risks of the warrior script, or consider them inevitable. In fact, the risks are significant, and there are other options.

Q - What was the process that led you to identify the five cancer scripts?

A ? I have long been frustrated by the problems with warrior medicine. Instead of getting better, it seems to be getting worse ? we are more warrior-like every year. The war image prevails in cancer more than any other area of medicine. Cancer patients are scolded if they don?t see themselves as fighters and behave the way fighters are supposed to behave. When I worked in a cancer hospital I had the opportunity to see the problems caused by the warrior script, and to see how real patients lived with cancer and cancer treatment.

The biggest problem I encountered was that our language is a warrior language, so there were no words to talk about other choices. I was familiar with Carol Pearson, author of The Hero Within, which identifies the Warrior as only one type of hero, and I found her language helpful. I also drew on Eric Berne, author of Games People Play. He used the term scripts, although I use it a bit differently than he did.

Q - Can you share a definition of what you mean by a "cancer script?"

A ? Scripts are our mythology, the stories that make sense of our lives. A script tells us what to do and what to expect. Our ancestors had epic stories of gods and heroes that were passed down by storytellers. Our own mythology is more like movie scripts. The "official" script for cancer is what I call The Good War. People who are diagnosed with cancer encounter this script immediately. The other scripts I describe in Angels & Bolters are Taking Control, Sadness and Loss, Love Story, and Transformation.

Q - Have you ever thought of the five cancer scripts as a process that survivors experience in parts, stages or in sequence, one after another? Have you found that survivors fit into more than one of the scripts?

A ? These five scripts are very common, and most of the women I have heard from say they can identify with all of them. But they are not universal. I have heard from some very, very angry people who insist that the war is all there is; there is nothing else. For these women, The Good War is the only script. I suspect, however, that they are not able to follow it all the time. I don?t believe it is humanly possible.

These five are not the only scripts. When I explain the concept of scripts, and describe the five I propose, women catch on to the idea and come up with some really creative names for their own scripts. That might be a good topic for a support group discussion: "What is the name of your cancer script?"

Q - Where do cancer scripts come from? To stretch the metaphor a bit, how do we survivors "learn our lines?" Or should we?

A ? The Good War script is the only one that is taught, or perhaps preached. The fighter image of cancer is impossible to avoid, whether in a disease-of-the-week TV movie, or even in routine news stories about medical treatment, where having cancer is synonymous with fighting cancer. Some groups that call themselves support groups are really supportive, but others are places where people preach the necessity of being a positive-thinking fighter. Other scripts reflect the woman?s personal style: if a woman has always dealt with problems by gathering together with friends and family, when she has cancer her script is likely to be Love Story. Or a script may result from necessity: the Transformation script may result from the toxicity of cancer treatment, the struggle a woman goes through, or the shattering of illusions she had before she had cancer. The Sadness and Loss script comes when the losses are so great they can no longer be denied.

Q - While I was reading Angels & Bolters, I looked for a cancer script that either dealt with the notion of blame or the search for the meaning of getting cancer. Does the search for meaning (or the need to blame someone, anyone, anything for a cancer diagnosis) "fit" with your cancer script model?

A ? Those with the Sadness and Loss script sometimes focus on blame, as do those with The Good War script, as it allows them to be angry. As for the meaning of getting cancer, I don?t discuss that directly in Angels & Bolters, but I do talk about the role of cancer in each script. In The Good War, the role of cancer is the enemy, which has invaded the territory and must be fought off and killed. The only thing that matters is to win the fight, which takes precedence over everything else. In the Taking Control script, the cancer is a problem to be solved. It may be the biggest problem in your life, or it may not. You choose how you will deal with it.

In the Sadness and Loss script, cancer is a thief that has robbed you of something valuable. You may not even know what has been taken, but you know it is a great loss and even if you get it back you will never be the same. In the Love Story script, the role of the cancer is a shared burden that brings you closer together with people you love and people you didn?t even know cared about you. And in Transformation, cancer is a wake-up call that spurs you to make changes in your life.

Q - In your clinical experience, do any of the cancer scripts in particular correlate positively with recovery and healing?

A ? Data from a variety of diseases have shown that those who have a social support system generally live a little longer and heal faster, so we can say that Love Story correlates with recovery and healing. But otherwise it?s hard to compare, because the script may vary from day to day. No one lives one script for the whole cancer journey. You will probably have a Sadness and Loss day, then a Transformation day, then a Good War week, etc. What is healing for you depends on what?s going on in your life, or your cancer treatment, at the time, as well as what is comfortable for you. Trying to fit yourself into the image of the Perfect Cancer Patient and fearing that you don?t measure up is not going to going to help much in healing.

Q - What is the healing value of a survivor seeing her own experience reflected in a cancer script?

A ? I hope women who see their stories reflected here will be relieved. Maybe they will understand that they don?t have to be Cancer Barbie in running gear and full makeup, never showing weakness, ready to kick cancer?s butt.

Q ? Angels & Bolters is filled with so many colorful examples of well meaning folks making insensitive comments to cancer patients. Do you have any strategies to recommend for dealing with these types of incidents when they occur?

A ? Most people just ignore them. But I have heard some good comebacks. My favorite all-purpose response, which I believe comes from Miss Manners, is, "Now, why in the world would someone say that?"

For more information on Dr. Ritchie, her book Angels & Bolters or the concept of cancer scripts, please visit www.cancerscripts.org.