Regret and guilt are complex emotions. I always think that in approaching them clients need to adopt a compassionate voice in how to respond to them. Thinking about what they would tell a friend or family member who said that to them. I also think that it is important to normalise that everyone has done things not good for their health at times, and to talk about self-forgiveness. I often pose the question of how long do they feel that they need to punish themselves for that behaviour. Then I try to shift the focus to what they can do now to make the most of whatever time they have left (assuming the condition is terminal, which is where I have seen this most often).

Usually I would develop a series of behavioural experiments around small goals that the client is prepared to attempt. So, for example, if you might start with a 10 minute walk – and you could increase safety by having someone go with him, or walking near a hospital – or even with you. I would get the client to state how likely it would be that he would have a heart attack during the walk, as well as rate anxiety and any symptoms (e.g., chest pain, racing heart). And I would do the task over and over until his belief in having a heart attack in that 10 minutes was close to zero. I would also look at the client’s meta-cognition – do they think that the worry will keep them safe – or will kill them, and then challenge these beliefs using metacognitive approaches.

It will be completely normal for the client to have a period of adjustment and grieving. They have had a loss and need the time and space to grieve for what they have lost – their future self as they saw it. I would provide support, and a place to share negative emotions in the short term and would not rush to any solution focused therapy in the short term. Ultimately, you would want to get the client to clarify their values and find new ways to orient their life towards those goals.

I am personally not big on the importance of diagnosis in this context and don’t think it necessarily makes a difference. You can differentiate based on criteria – as in DSM-5. If it is an adjustment disorder and the “trigger” event was very recent, you might want to allow more time to understand the meaning of the change that they are adjusting to and to grieve any loss that accompanies it. But otherwise, treatment would be based on the content of concerns rather than the diagnosis, in my opinion.

There is a very large literature on this topic and the most comprehensive meta-analysis shows that more contemporary versions of cognitive behaviour therapy produce the largest changes. It is important to acknowledge that the cancer could come back, even if that is unlikely – but if it is very likely to recur, it is important to acknowledge that. Our Conquer Fear program is based on the following strategies: (1) clarifying values and setting goals so that people can focus on what is important to them; (2) metacognitive therapy: people often think the worry will help them catch the cancer in time if it comes back – which is not the case as long as they are on a sensible surveillance schedule. They also worry that the worry will bring the cancer back – there is no evidence for this either. We then work on strategies, including Attention Training, Detached Mindfulness, Worry postponement, which allow the person to develop skills to control worry and break the worry cycle. Finally, if the client checks their body for cancer, we negotiate a contract of what is a reasonable level of checking with them.

I think any treatment that focuses on a person’s view of the illness but doesn’t result in behaviour change will not be successful, and likewise any behavioural approach that does not change beliefs will not be effective long-term. So, I think the key is using behavioural strategies to produce cognitive change (e.g. behavioural experiments) where possible to maximise the efficacy of both behavioural and cognitive approaches.

I often get people to think about what they would want people to say at their “Distinguished career award” which would presumably focus on work-related achievements; and then get them to think what they would want family to say in the eulogy. This can help clarify what their values are – usually people want accolades for their work, which relates to their job and loss of job-related identity – but most people do not focus on what they’ve achieved for what they want people to say at their funeral. Usually, these are more characteristics that are important. This allows you to explore with the client what is important to them. I often talk about who we are is different to what we do, and explore how they judge others (which is usually more compassionately than they judge themselves).