As you note, CBT for anxiety disorders commonly involves searching for overestimations of threat. At the same time, anxious cancer patients may not be inaccurately appraising their survival prospects or the likelihood of treatment succeeding. So, what to do?

There is a useful heuristic that I draw upon in these common situations. It’s called “The Anxiety Equation”, and it was first developed by Paul Salkovskis, and has been used by a number of British CBTers. It goes like this:

Anxiety = Perceived likelihood of threat X Perceived cost/Awfulness __________________________________________________________ Perceived ability to cope + Perceived rescue factors

To unpack this briefly: The numerator involves the combined perception of threat and the high cost, or awfulness if the threat comes to pass. A diagnosis of metastatic pancreatic cancer, or a glioblastoma, is rightly viewed as a grave existential threat. That’s no distortion, and fear is natural.

But take a look at the denominator in the equation, involving the person’s perceived ability to cope, as well as the presence of perceived rescue factors. Starting with rescue factors, we might take a look at the relationship between the client and her medical team, ranging from the presence or absence of trust to the ability to work collaboratively with one’s team. We might also look at the interpersonal supports that are available to help manage the situation and its attendant fears. Spiritual or religious supports can be rescue factors, as well. Interventions might involve helping the patient access, and utilize those supports.

Last, we can focus on helping the client build a more accepting and engaged problem-solving orientation. Here, many cognitive, problem-solving, and experiential interventions can be used to help strengthen that sense of one’s ability to deal with life’s challenges, even the biggest ones.

Of necessity, many cancer patients require rapid relief or management of distress. They often have neither the time nor the interest in longer-term treatment. I would say that quite often we are limited to one to four sessions. Working with cancer patients often involves a high number of patients and a limited number of available sessions. That said, if appropriate, a client may become a long-term therapy case, or may use therapy episodically over the long course of diagnosis, treatment, end-of-life concerns, and/or survivorship.

For me, rather than thinking about the number of sessions I’m going to offer, I think about the efficient use of time in every session with a new cancer patient. My aim is to make something happen, if possible, that will make a rapid difference in a person’s life. I organize sessions in a manner that allows me to establish quick rapport, to pinpoint core psychological processes where the client may be ‘stuck’, and to work collaboratively with the client to create a suitable strategy for alleviating or managing distress. Having a clear framework for creating a rapid case conceptualization, a clear sense of a problem list, and the capacity to be inventive in-the-moment, help achieve these objectives. With disciplined practice, the therapist creates a broad repertoire of techniques and tools from which to draw flexibly to achieve therapeutic ends.

Besides my own book on this (https://www.amazon.com/gp/product/1138942634/ref=dbs_a_def_rwt_hsch_vapi_taft_p1_i0), I strongly recommend three other books. Although none of these other books deal specifically with cancer, they do address how to think in a strategic and focused manner about change. Two are cognitive-behavioral; one is in the Acceptance & Commitment Therapy camp. Strosahl et al, in particular, gets at how to think ‘brief’.

And speaking of brief, the answer to your second question is: Yes.

Kennerley, H. (2021). The ABC of CBT. London: Sage (https://www.amazon.co.uk/ABC-CBT-Helen-Kennerley-ebook/dp/B0895YXTM9) Sokol, L. & Fox, M. (2019). The Comprehensive Clinician’s Guide to Cognitive Behavioral Therapy. Eau Claire, WI: PESI (https://www.amazon.com/Comprehensive-Clinicians-Cognitive-Behavioral-Therapy/dp/1683732553) Strosahl, K., Robinson, P., & Gustavvson, T. (2012). Brief Interventions for Radical Change:
Principles and Practices of Focused Acceptance & Commitment Therapy. Oakland, CA: Context Press/New Harbinger (https://www.amazon.com/Brief-Interventions-Radical-Change-Principles/dp/1608823458)

There isn’t a formulaic answer to this question, though it is a thoughtful one. Surely, for some clients, the offer of tissues might signify that the therapist is uncomfortable and wishes to close down emotional displays in session. Yet for other clients, the offer of tissues is a compassionate and validating experience.

Behaviorism teaches that the function of a behavior is often more useful to focus on than is the form of the behavior. That means that as therapists, we want to tune in to our intended function and the received function, ie how the client experiences our interventions. In other words, the question isn’t whether to give or to refrain from giving tissues, as an overall policy. The question is what is our intended function in giving tissues, and what function does the tissue actually serve for the client: avoidance, closing down, opening up? In truth, we often don’t know in advance how any intervention of ours might land with our clients, regardless of our intent.

I advise engaging in an intensive study of those evidence-based therapies that improve our abilities to listen and to be present. That may include studying Motivational Interviewing, Beckian Guided Discovery/Socratic Questioning Techniques, DBT Validation principles, or ACT’s emphasis on present moment awareness and psychological flexibility. By grounding ourselves in a disciplined practice of listening and intervening, we learn to trust the client and ourselves to know what action might bear fruit. We also learn to be brave. And finally, we learn to rectify therapeutic errors when they cause a breach in the therapy relationship.

For example, if the therapist notices that the client sits up, closes down emotionally, and is silent following our offer of tissues, we would consider immediately exploring with the client what just occurred. The therapist may have intended the tissues as a compassionate offer to keep experiencing and expressing emotionally charged material; the client, on the other hand, might have thought: “She wants me to quit acting like a baby and crying.” Exploring and rectifying moments like these can be pivotal in improving the therapy relationship and our therapy outcomes.

To borrow from a long ago pediatrician-turned-analyst, Donald W. Winnicott, we just need to be ‘good enough’ therapists. Not perfect. If we err, or our interventions fail to achieve their intended function, we rectify, and try again. Fortunately, most of our clients respect a good faith gesture.

Finally, and frankly, I keep a box of tissues available for clients when they want them. I also keep a box by me. There are sessions in which it may not be just the patient who is moved to tears.

Yes, it has at times been my experience, also. As therapists, we want to ease suffering and help people make sense of painful and unfair experiences. A cancer diagnosis, especially metastatic cancer, can upend long-held core beliefs and implicit operating assumptions about life. Despair and rage ensue when those implicit operating assumptions are shattered. Here are a few ideas about how to navigate these challenges:

1. A sense of therapeutic helplessness likely stems from a couple of sources. One is a possible belief that we ‘must’ ease our clients’ suffering rapidly. The other may be our own difficulties facing illness and death. First, remember that it's not always what we 'do' that helps; it's often our silent, compassionate presence that can be of benefit, along with appropriate validation of client pain. There is no quick or easy fix, and we cannot be expected to manufacture one. Marsha Linehan's validation strategies can be immensely helpful (https://psychwire.com/ask/topics/uagy2j/ask-marsha-linehan-about-dialectical-behavior-therapy-dbt-skills-).

2. Commit to learning evidence-based therapy, including obtaining case supervision. This will provide a theoretical, technical, and personal 'anchor' in those challenging clinical moments. Therapies that emphasize a balance of acceptance and change strategies may be especially useful, such as ACT and DBT.

3. Learning to face our own fears about illness and death is also important. You might consider developing a contemplative or meditative practice. I mentioned ACT and DBT in part because they create ample opportunities for therapists' psychological and even spiritual growth. They are therapies that are also 'life ways.'

4. Consider participating in an ongoing case consultation group, for emotional support and for support adhering to a high standard of clinical practice.

5. Finally, personal therapy may also be useful. Irvin Yalom, a prominent existential therapist and writer, has talked openly about how his cancer work propelled him into personal therapy.

Judson Brewer, MD, describes anxiety as “fear + uncertainty.” (https://drjud.com/book/) Intolerance of uncertainty is a common feature of many anxiety disorders. And this intolerance of uncertainty frequently involves events that have never happened, and likely never will. Indeed, that is one of the hallmarks, for example, of Generalized Anxiety Disorder.

Fear of cancer recurrence is different. Something really painful and frightening in all likelihood already happened. Going through a cancer diagnosis and treatment can be harrowing. It may require tolerating disfiguring and painful surgeries; chemotherapies that cause hair loss, nausea, and fatigue; radiation therapies that burn and damage tissue in and around the affected areas. Adaptive functioning may decline during treatment, affecting work and family life. Long-term effects of treatment can at times be debilitating.

So when cancer patients worry about a recurrence, they often know exactly what could happen to them. In addition, recurrence may mean death. This is where two theoretical ideas and a host of tools and techniques can be useful. First, the ultimate ‘cure’ for worry is to be fully, wholeheartedly, in the present moment. By practicing the skill of throwing oneself into the moment, we live in the only place we really are: here, now. Fortunately, this is not just an abstract idea; it is a skill to be learned and practiced. CBT, ACT, and DBT all contain skills and techniques to help cultivate engagement in the present moment. And that links to another idea: Helping connect the client to their deepest values in life. This can both dignify and energize the willingness to face whatever life demands of us. If we can help the client make contact with WHY they would endure treatment again, if need be, we can help free them to some extent of the incessant worry about recurrence. Last, helping the client process their cancer experiences, work through strategies for managing recurrence, deal with trauma memories and phobias that resulted from treatment, we can further help clients face life, and the future, with greater resolve and calm.