Psychosocial Oncology for Individuals Coping with Cancer

The American Psychosocial Oncology Society defines psychosocial oncology as: "a cancer specialty that addresses the variety of psychological, behavioral, emotional and social issues that arise for cancer patients and their loved ones. In the broadest terms, there are two psychological dimensions of cancer. The first is the emotional response patients and families have to cancer. The second are the emotional, behavioral, and psychosocial difficulties that influence living with cancer. Psychosocial oncology is the specialty that addresses all of these dimensions, more information can be found on the website: American Psychosocial Oncology Association.

Great question! My opinion is that it's typically the patient's call. I will typically follow the patient's lead on this. However, if I believe that an interaction with the oncologist will be helpful or that a patient particularly needs advocacy, I will strongly encourage the patient's consent for this. In general, I don't think it's a good thing to be positioned BETWEEN the patient and oncologist.

From the aspect of supportive care, there are a number of possibilities. This is certainly not an exhaustive list, but there is good evidence for the use of cognitive-behavioral therapy or acceptance and commitment therapy for pain. There is also evidence for the use of acupuncture to address pain. For nausea, there is evidence for a number of interventions (again not exhaustive) such as relaxation techniques, mindfulness, hypnosis, imagery, and acupuncture.

There is the most extensive evidence base for the use of exercise in addressing fatigue. And this involves a broad view of exercise, including gentler versions such as yoga. Mindfulness has also been studied as an intervention for fatigue. Psychological support can be helpful in strategizing around how to engage with exercise as an individual.

Excellent question. Whether you are the one with cancer or the family member, it's not unusual to see this sentiment - worrying more about your loved ones than yourself. There can also be significant variability in how well one or the other can cope with the challenges of cancer diagnosis and treatment. I think the most helpful thing is to talk things out, trying to understand each other's perspective and finding ways to support each other. It can also be helpful to get counseling support (for either person) or peer support (through a support group or online resources) if the distress is not resolving.

ACT is a great fit for work with those diagnosed with cancer. There are several helpful resources, and I will mention a few. There is a chapter on ACT by Hulbert-Williams and Owen in the classic reference guide "Psycho-Oncology" by Jimmie Holland and colleagues (published in 2015). There is also a review (The Use of Acceptance and Commitment Therapy in Oncology Settings: A Narrative Review) published in 2018 in Psychological Reports by Fashler, Weinrib, Abid Azam, & Katz. Another review is Acceptance and Commitment Therapy in Cancer: Review of Applications and Findings by González-Fernández & Fernández-Rodríguez, published in Behavioral Medicine in 2019. Thank you for taking on a volunteer role in helping those living with cancer!

In my experience, CBT and ACT can be utilized to address many of the same psychological and physical symptoms. I tend to go back and forth between the two approaches. Sometimes I will have a sense that one or the other might be a better fit for a patient, although I’m not sure I can articulate how that “sense” is derived. Or sometimes I’ll explain to the patient how one might approach the problem from both perspectives and ask if one of the strategies feels more comfortable to them.

That does seem like a paradox, doesn't it? I'd explain it like this, with mindfulness, you are observing a sensation (or sound, feeling, etc.) without judgment (e.g. "this is awful"). Sometimes when we strip away the emotional responses to an unpleasant sensation, like nausea, it's not as bad as we thought it was. (This is like the concept of primary and secondary distress.) For some people, regarding the nausea objectively and clinically reduces the distress around it. Of course, it could also be that the relaxing qualities of mindfulness help to soothe the body and thus reduce the nausea.

I'm sorry, while I have heard of this, I am not well-versed in these approaches. Something I should look into!

I believe in meeting the patient where they are. If they aren’t receptive to psychological interventions, I try to make sure they know about the options (education), and I leave the door open for them to explore any of these later when/if they are ready to do so. Sometimes the cancer experience is overwhelming enough that people don’t have the bandwidth to take on anything else.

From an ACT perspective, the goal would not be to move away from anxiety (including fear of recurrence), but instead to either make room for it or to use defusion techniques. I think an ACT approach would say that a big part of the problem is trying not to have the anxiety. This is also an area where mindfulness (or present-centeredness) can be helpful, since a lot of the fear and anxiety is related to future possibilities.

There are so many possibilities to choose from, depending on the particular difficulties that your patient is having. For example, CBT can be helpful with fears or anxiety about recurrence or progression of disease, or about death, or about medical treatment (needle phobia, claustrophobia). For these, you can do reframing work, challenging/disputing, stimulus control, or desensitization. Is anxiety interfering with sleep? In which case, CBT for insomnia is a great approach with a strong evidence-base. Does the person need to focus on decreasing maladaptive behaviors (physical checking behaviors or unhealthy habits like smoking) or increasing healthy behaviors (exercise, social engagement)? CBT could be helpful in this regard, perhaps incorporating goal setting or pacing.

My suggestion is always to meet the client where they are. I'm assuming that the client acknowledges that they have cancer, so the work can focus there. Given that present-centeredness/mindfulness is an important component of ACT, and the client is not dying today, this gives you space in which to work. Certainly the concept of values-based living could be relevant, no matter how much time the person has left. If the client wishes to go there, their values could also be brought to bear in making treatment decisions. I have found that some people cannot directly address the prospect of their death, and I've rarely found a worthwhile reason for pushing them to do so.

This approach (requiring psychological assessment/intervention) is common with some medical procedures, such as bariatric surgery, organ transplantation, and implantation of spinal cord stimulators. It is also common to require psychological assessment before a stem cell transplant, but I haven’t heard of this type of requirement for reconstructive surgery. In general, I’m not a big fan of requiring psychological intervention. I think it works better when the patient requests it.

This is a tough question for me. I guess I don't really look for certain characteristics or personality traits in terms of deciding which approach to use with a patient. I tend to use both approaches and to move back and forth between them easily. I will often lay out the options to address a particular problem and seek the patient's input in deciding how to begin. I like to assure the patient that there are options, and that if our first approach doesn't work, there are other approaches we can try.