Professional Documents
Culture Documents
11 May 2014
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All rights reserved. No part of the publication may be reproduced, stored in a retrieval system, or
transmitted, in any form or by any means, electronic, mechanical, photocopying, recording or
otherwise, except as permitted by the UK Copyright, Designs and Patents Act 1988, without
permission of the authors.
The authors claim their intellectual rights over the content of the manual.
The contents of this therapy manual are not intended and should not be relied upon as
recommending or promoting a specific diagnosis or treatment. Readers should consult with a
specialist where appropriate. The authors are not liable for any damages arising herefrom.
All patient or other names used within the manual are pseudonyms.
Cases are compilations used to protect patient confidentiality.
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INDEX
Section A:
Theory and cognitive model of adjustment...... 4
Section B:
Issues relating to telephone-delivered CBT ...... 6
Section C:
Overall aims of therapy...... 9
Section D:
Organisation of sessions ..... 10
Section E:
Therapy techniques...... 12
Section F:
Case example...... 16
Section G:
Emergency policies...... 19
Section H:
Therapy supervision and Duty of Care Responsibilities.....20
References...... 21
Appendices......22
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Section A
THEORY AND COGNITIVE MODEL OF ADJUSTMENT
The Manual describes a one-to-one psychological therapy suitable for delivery provided by
trained mental health professionals (psychiatrists, clinical psychologists psychotherapists
and certified counsellors) either face-to-face or via telephone. It is based on principles and
techniques of Cognitive Behavioural Therapies (CBT) with specific modification to cancerrelated problems and can be adapted to telephone delivery.
The theoretical elements of the therapy integrate aspects of Learned Helplessness [1] and
Self-efficacy [2] theory. The approaches described in the manual aim to help patients
develop a sense of control over the stresses arising from cancer and its treatments. This
approach aims to minimise any patient-related dependency on therapists and maximise the
development of their own coping strategies.
The aim is to change unhelpful thought patterns and replace them with more realistic and
helpful ways of thinking, and changing behaviours that may compound these negative
thought patterns. Adjustment is improved incrementally as patients learn that they can find
ways to manage issues that have been challenging and taxing of their personal emotional
resources.
Further reading
Horne D, Watson M. (2011) Cognitive Behavioural Therapies in Cancer Care. In Handbook of
Psychotherapy in Cancer Care. Eds Watson M, Kissane D. Pp 15-26 Wiley-Blackwell.
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The fact that her aunt had a more advanced form of cancer than she
did.
Her doctors, who she trusted, seemed happy that she was clear of
cancer.
And finally, if the cancer did come back, pain is much better managed
now than it was when her aunt was ill.
Being able to identify the assumptions she had about being ill meant that she could
start to think in a more balanced way and have more control over her fears.
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Example
It sounds like you are feeling very anxious...Have I picked up on
this correctly?
Can you tell me a bit about how youre feeling at the moment?
Dealing with silences is more difficult over the telephone. It can be difficult to
interpret what is happening with the patient, for example,are they thinking about an
answer, are they becoming emotional, are they crying or are they waiting for the
therapist to say something? There is no problem in having a period of silence but the
therapist must reassure the patient that they are still listening.
Example
Im still listening...
Youre very quiet can you tell me what youre thinking (or feeling)
right now?
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Example
I can hear your doorbell... do you want me to wait so we can continue
our session?
Would you like us to make another time or may I ring you back in a few
moments?
There are some people for whom telephone therapy is not suitable including: those
with hearing or communication problems; people whose first language is not English
(or is not the same as the therapists); those who feel uncomfortable speaking over
the telephone. If you struggle to understand what the patient is saying it is better to
clarify this and decide on a strategy
Example
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Ensure that it is the patient who ends the call first. Never hang up on the patient. If
you need to end the session you should give the patient a warning shot.
Example
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Initial stage
II.
III.
Ending therapy
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ORGANISATION OF SESSIONS
CBT for cancer patients is a brief (average 4-8 sessions) therapy which is problem-focused.
Initially the patient is offered four sessions. However, patients differ in the speed at which
they learn to develop coping strategies and in the severity of problems experienced, and so
clinician judgement and flexibility is built into decisions about the number of therapy
sessions to be offered.
At the end of four sessions a review can be undertaken with the patient to see what has
been helpful, what has not been as helpful and whether or not a further four sessions will
be agreed.
The therapy is time-limited to eight sessions but can be extended depending on individual
therapists and service provider policies and patient needs.
Occasionally this type of therapy can extend beyond 10 sessions and a re-formulation and
consideration of therapeutic needs is advised if the number of sessions goes beyond 10
sessions.
Consideration of other therapeutic approaches is useful. In addition the therapist needs to
consider when therapy is providing patients with no further gains and discuss this within
the session and in professional supervision.
See Appendix 1: for a useful history-taking schedule that can be kept with
therapy notes.
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Establish therapist-patient rapport at this point by giving verbal feedback that you have
listened. Provide cues indicating that you are trying to understand what it is like to be in
their shoes even if you are not.
Ensure the patient has enough time to tell their story of what has happened to them.
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THERAPY TECHNIQUES
These can include:
I.
Agenda Setting
II.
Guided Discovery
III.
IV.
Collaborative Relationship
V.
Homework
VI.
I.
Agenda Setting
At the beginning of each session the patient can be invited to recap on events since the last
session. The session agenda would be set. This ensures the session stays focussed on the
patients goals for therapy, which are set out in the first or previous sessions.
Example
What would you like to focus on during todays
session?
Are there particular things you would like to talk
about during todays session?
Identify the goals. This keeps the session problem targeted/and problems focused.
Example
The patient was checking their body for signs of
cancer 20 times a day (anxious pre-occupation).
Goal: As a goal of therapy they wanted to reduce
the amount of time they were checking.
Discuss Goals: The problem has been clearly
explained and defined and it can be measured, for
example if the patient is now checking once per day
you can see that they are making progress in the
right direction.
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II.
Guided Discovery
It is not the therapists role to generate solutions but to guide the
patient towards finding them.
The therapists task is to assist patients to discover what they are doing that is
helpful or unhelpful.
This guided discovery may be achieved through asking open and curious questions
about what does and doesnt work for the patient.
This is not intended to be interrogative. The aim is to have a conversation with the
patient asking them to explain how things are, how they feel, and what they think
happened.
For example Mrs A felt that everyone thought that she was strong and coping with
everything. She felt she could not confide in anyone about the fact that she was not
coping because she would be letting them down.
The therapeutic technique of guided discovery is illustrated in the example below.
Therapist to Mrs A:
How do you know that people are thinking that way about you?
What do you think might happen if you did speak to someone else
about your distress?
What would be the best thing and the worst thing that could happen?
If the situations were reversed would you want your family member to
talk to you about these problems?
III.
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IV.
A vital element of CBT is the collaborative relationship between patient and therapist.
During therapy the goals and issues to be resolved are agreed between the therapist and
patient.
The therapist always follows the patients agenda as a key element of the collaborative
relationship.
The patient is the expert on their experiences and deciding which coping strategies will work
best for them.
V.
Homework
Therapeutic change occurs in the patients everyday life rather than in the session.
Therapist and patient agree on homework assignments for the patient to do between
sessions.
Use activity scheduling, identifying with the patient what goals they will have for each day of
the week, usually starting with small things, such as going for a short walk, calling a friend,
getting washed and dressed in the morning.
Example
Did you get time to complete the homework?
Was it helpful? What worked for you?
VI.
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The therapist should provide some patient education which includes talking about how
thought affects mood. Examples from the patients own experience are helpful e.g. When
you feel tearful what are you thinking?
A table describing thinking errors is included in the Patient Workbook (Page 32).
Describe the use of thought diaries for monitoring negative automatic thoughts (see Patient
Workbook)
Encourage patients to find less negative ways of thinking about the situation.
Many patients are not naturally self-reflective and if they are uncomfortable with
cognitive techniques or cannot make progress, then it is worthwhile to ask them to take
you through the things they are doing that seem to help and then shift the focus in
therapy to increased use of what helps.
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CASE EXAMPLE
A patient presented with symptoms of clinical depression including, withdrawing from
friends, low self confidence, difficulty making decisions, difficulty getting to sleep,
waking in the night and tearfulness. She had just completed treatment for locally
advanced breast cancer and had ongoing problems with fatigue, lymphoedema and pain
at the operation site.
Sessions 1-2
In the initial session the patient was assessed, which included some
questions that are usually asked in the initial session to get some
background on the patient, this information is slightly different depending
on the therapist, but may include the following questions:
What are the presenting problems?
What is the patients family situation? Are they supportive? Does she live
alone? Does she have any good friends with whom she can talk?
What does she currently do on a daily basis.
Has she ever been depressed in the past and if so how did she cope? Has
she had counselling or medication in the past or ay the moment. If so was
it helpful.
What resources and coping strategies are already possessed and being used
are they working in this situation?
Open expression about feelings and thoughts was encouraged. The cognitive
model was described and the patient felt that fitted well with her world
view and felt that being armed with appropriate coping strategies would be
helpful.
Problem-focussed Goals
Currently patient was spending large proportions of time ruminating about
her current situation, with fears about the future and she was convinced
she would get cancer again. The goals of the therapy were for her to
prevent this pattern of rumination, which was making her unhappy, through
changing her behaviours and cognitions.
The patient had recently completed her breast cancer treatment and many
of her experiences were normalised, which made the patient feel more
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normal and helped to build the relationship and rapport between therapist
and patient.
Sessions 3-6
Behavioural strategies
She used activity scheduling, ensuring that rest and relaxation was included
as she was still suffering from extreme fatigue. This was helpful as a
distraction technique when she started to ruminate and meant she had
something to look forward to. Distraction was also a helpful means of
preventing this rumination and sometimes when she felt herself thinking
negative thoughts and becoming lower she would go out for a walk or do
some knitting, which are both activities she enjoyed.
Cognitive strategies
Patients utilised expressive writing techniques, which she found beneficial in
identifying and venting her emotions.
A thought diary was used to identify when anxious thoughts were triggered
and what they were eg. I have a pain in my breast, the cancer must be
back. It allowed her to step back from this thought and look at alternative
thoughts. She looked for other explanations eg. Where the pain is is the
same place that I had the operation and I was told by the Doctor that it
may be painful for a while. Have I been doing something strenuous that
could have caused me to pull a muscle?
When I had breast cancer
previously the lump did not hurt.
This patient was prone to spend hours at a time sitting and thinking about
how she would cope with her next cancer, what would happen to her children
and husband and how she could not cope. By identifying the triggering
thoughts and looking at alternative viewpoints she could prevent herself
from slipping into rumination.
Sessions 7 and 8
This patient throughout the therapy sessions had built up some helpful
coping strategies and the final two sessions were focused on how she could
maintain these gains and what she could do if she started to feel down.
Together we drew up a list of all the coping strategies that she had found
useful so that she could put them on her fridge to remind her that there
were things she could do to help herself.
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We also talked about how she would recognise when she was beginning to
get lower in mood. For this patient when she started to spend longer
amounts of time doing nothing, but ruminating she realised that her mood
was lowering and she needed to do something to change this pattern. When
she recognised this she could refer back to the strategies she had found
helpful.
We also identified that there comes a time when if these strategies do not
work and her mood continues to lower then there is a point where she would
contact the service again or her GP for further professional support.
The main point of this case example is to emphasize the structured and focussed nature of therapy.
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Emergency Policies
All therapists need to work to an agreed policy on how to deal with psychiatric emergencies,
including occasions when patients put themselves or others at risk.
If your client or patient is at home and deemed to be at risk you need a procedure to follow as you
have a clinical responsibility to manage that risk.
The procedures will vary depending on the context and country in which you are based as a
therapist.
For medical emergencies call the designated country code emergency service and explain patients
problems as reported on the telephone. Provide patient contact details.
Disclaimer:
The contents of this therapy manual are not intended and should not be relied upon as
recommending or promoting a specific diagnosis or treatment. Readers should consult with a
specialist where appropriate. The authors are not liable for any damages arising herefrom.
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PATIENT NAME:
CONTACT DETAILS:
Referred By:
Service Brochure:
Given
Explained
SEEN BY:
Name:____________________________________________
Signature: _______________________________________
(print name)
Designation: _______________________________________
Date: ________________
Presentation:
Current Concerns
1.
2.
3.
4.
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Psychosocial Background
Additional Notes:
Occupation/finances
Living Arrangements
Coping Strategies
_________________________________________________________________________________________________
Questionnaire Scores:
Pre-therapy ( insert date of assessment)
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