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11 May 2014

Published 2013 Watson M, White C, Lynch A.

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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.

Author contact details:


Maggie Watson B.Sc.,Ph.D, Dip.Clin. Psych., Chartered Clinical Psychologist, AFBPs
Email: maggie.watson@live.co.uk

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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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Personal Meaning of Illness


The beliefs that patients hold are likely to play an important role in adjustment.Therefore
understanding how beliefs contribute to emotions is an important part of the assessment
and therapy formulation. This is illustrated in the following case example:
Miranda was in her late forties and had a right-sided early breast cancer treated
by mastectomy and radiotherapy. She described her beliefs about cancer as
follows:
I had an aunt who was treated with a mastectomy and radiotherapy but
sadly she died. I remember watching her become more ill and having a lot of
pain before she died. This memory has stuck with me... Im very frighten that
this will happen to me
She strongly linked cancer to suffering and death and assumed that this would
also be her fate. Her personal meaning of illness was embedded in beliefs
based on her aunts experience. She had no other experience of cancer in close
family members or friends. The focus of the sessions was on examining
differences between her and her aunt and whether she could challenge her
automatic negative thoughts and expectations, which have arisen from her
previous experience and the associated beliefs.
It was important during sessions that Miranda was able to view the evidence
about her aunts cancer in a rational way. Working collaboratively she thought
of some alternative ways to view her cancer, such as

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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ISSUES RELATING TO TELEPHONE-DELIVERED CBT


Basic Principles
As the patient cannot see facial expressions there needs to be more verbal
reassurance so that the patient knows you are listening; [for example uh-huh, yes,
ok, right].
At the beginning of the session check that the patient is speaking to you from
somewhere quiet and comfortable where they will not be disturbed.
The same confidentiality issues apply in telephone therapy as regular face-to face
methods. Check that the patient is able to talk about private matters without being
overheard.
More checking of understanding is needed as you need to ensure you are picking up
on the underlying emotion and to reassure the patient that you have been listening.
You need to concentrate on the nuances of their voice to recognise signs of emotion.

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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There are sometimes unexpected interruptions that are unavoidable, such as a


delivery being made to the patients home or a friend could drop round for an
uninvited visit to the patients home. This can cause the session to become
disjointed and stilted and may mean a session ends early. Always ensure that a new
appointment time is made for the next session and that your clinical notes for session
flag up any unresolved issues caused by the interruption.

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

I didnt quite catch what you said there...

Im having a bit of difficulty following what you are saying...are


you OK to continue with the session?

Cant catch everything youre saying clearly...so forgive me if I


sometimes interrupt you and ask you to repeat things. If it gets
to be a nuisance please let me know so we can decide what we
might do.

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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

We seem to be coming towards the end of our session...

As were coming towards the end of the session is there


anything you want to say that I havent asked you about yet...

Were nearly at the end of our session...Im wondering what


you would like us to spend some time talking about when we have
our next session... just in case we dont get through everything
today.

Where should the therapist be based?


An issue that sometimes arises relates to where the therapist is based if they are offering
telephone-delivered therapy; at home, in a clinic, in a hospital?
Most psychotherapists or counsellors will work within a particular organisational structure
and from a designated office or clinic. Telephone therapy allows freedom to be located
elsewhere e.g. at home.
The principle guiding about where the therapist should be located is that it needs to be
anywhere that confidentiality can be maintained and professional principles and a code of
practice can applied.
Privacy, confidentiality and professional principles guide decisions about where a telephone
therapist will be located. The same principles of clinical practice apply across contexts.
All therapists must work according to standards set out by their registration authority.

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OVERALL AIMS OF THERAPY


I.

Initial stage

a) Make an assessment and formulation


b) Normalise patients emotions
c) Describe and teach problem-solving
d) Introduce ideas linked to symptom relief
e) Emphasise the importance of living an ordinary life
f) Teach the cognitive model
g) Encourage open expression of emotion as being appropriate

II.

Middle stage of therapy

a) Set priorities for change


b) Plan goal-setting
c) Use Activity Scheduling
d) Teach distraction, thought stopping methods
e) Teach use of monitoring and re-scripting/challenging irrational beliefs and negative
automatic thoughts
f) Review progress

III.

Ending therapy

a) Cover plans for the future


b) Consolidation of patients learning
c) Summarise therapy outcomes with the patient
d) Make an assessment of progress for your clinical notes
e) Agree on procedures for future access to therapy
f) Agree with the patient what reports or correspondence may be exchanged about
their progress between you and other cancer professionals

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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.

a. Assessment and Formulation


Assessment: the process of gathering information to help with formulation
and to evaluate the impact of therapy on functioning. Usually done using a
clinical interview and/or standardised questionnaires or tests. History-taking is a
standard part of psychotherapies.
Formulation: is the process of analysing the characteristics of the patient and
their problems based on the assessment information collected i.e. a diagnostic
procedure. This involves building up a picture of the person, the things that
concern them most, and their priorities.

See Appendix 1: for a useful history-taking schedule that can be kept with
therapy notes.

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The following is a guideline for areas to be covered in a preliminary


history-taking and assessment.
How the patient feels
What the patient understands about their cancer (are they aware?)
What support the patient has
What changes they have experienced
What transitions they have had to make
Previous history of psychological/psychiatric problems
Current and past medications/treatments
How is the patient thinking about their problems?
Are there irrational thoughts?
Is the patient being overly negative?
Do they have low self-esteem?
Do they have a helpless attitude?
Other problems not related to cancer
Family structure
Financial factors
Any other personal or medical details

Re-evaluate formulation as information and understanding of the patient accumulates


across the sessions

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.

Teaching Coping Strategies

IV.

Collaborative Relationship

V.

Homework

VI.

Challenging Negative Automatic Thoughts

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.

Teaching Coping Strategies


Although the patient is seen as the expert on their own feelings and behaviours, the
therapist is an expert in different coping strategies that may help the patient to
identify and change unhelpful behavioural or thought patterns.
This is complemented by a Patient Workbook that is handed out to patients, which
describes and leads patients through different coping strategies. The Patient
Workbook includes; defining goals and practical problem-solving, activity scheduling,
thought challenging and thought diaries, relaxation strategies and some help with
specific problems such as sleep and fatigue management.

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IV.

Collaborative Relationship: Therapist and patient work in partnership

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 order in which issues are to be tackled is agreed: Agenda setting

Progress is checked regularly and mutually throughout the sessions.

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.

Goals should be incremental and according to what patients can manage.

Example
Did you get time to complete the homework?
Was it helpful? What worked for you?

VI.

Challenging Automatic Negative Thoughts


For many patients with clinically significant symptoms of anxiety or depression there is a
relationship between ways they think about problems and the how they feel.
Patients who have very negative thoughts are more likely to experience uncomfortable and
life-limiting levels of anxiety or depression.
Self-monitoring of thoughts using a diary (see Patient Workbook) of feelings and behaviour
helps patients see the relationships between thoughts and emotions.

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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.

TIP: Stick to what works

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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.

Basic elements of patient safety are:


Make clear to the patient you are concerned about them
Use a well accepted method of ascertaining risk including asking about suicidal
plans (for further guidance we recommend you become familiar with the SCID
assessment of psychiatric risk [3]).
Does the patient have a suicide plan and how and in what circumstances will they
enact it?
Always check whether the patient is alone or has someone close at hand to help
Where appropriate refer on urgently to specialist mental health services or call
emergency services.
Always immediately inform the patients cancer doctor and community doctor
(General Practitioner) that the patient may be at risk.
Inform the patient of your Duty of Care and this involves contacting their
community physician (General Practitioner) or cancer doctor and alerting them to
your concerns about the patients safety.
Always write a management plan in your patient notes.

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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THERAPY SUPERVISION AND DUTY OF CARE RESPONSIBILITIES


All therapists should have access to supervision.
If there is no on-site mental health staff member to provide supervision, consider finding an
external clinical supervisor.
Multidisciplinary Psycho-oncology professional teams should meet regularly to discuss
clinical cases as part of peer supervision.
Therapists should work within their professional capabilities and according to the code of
conduct for their profession within their countrys code of practice.
Qualified therapists need to accept responsibility for any unqualified therapist acting under
their supervision.
All therapists should keep clinical case notes.
Clinical case notes are subject to confidentiality rules.
Therapy sessions are confidential and details should be shared with other professionals only
with the patients permission or where it is an issue of patient safety.
In case discussions patients rights to confidentiality should be respected. This may include
the withholding of any information which allows the patient to be identified (unless the
patient gives permission).

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1. Seligman, M.E.P. Helplessness: On Depression, Development, and Death. San Francisco:


W.H. Freeman, 1975.
2. Bandura, A. Self-efficacy: Toward a Unifying Theory of Behavioral Change. Psychological
Review 1977; 84, No. 2, 191-215.
3. First MB, Spitzer RL, Gibbon M, Williams JBW. The Structured Clinical Interview for DSMIII-R Personality Disorders (SCID-II) Part I: description. Journal of Personality Disorders
1995; 9:83-91.
4. Horne D, Watson M. Cognitive-Behavioural Therapies in Cancer Care. In Handbook of
Psychotherapy in Cancer Care. Eds Watson M, KIssane D. John Wiley & Sons 2011.
5. Watson M, White C, Davolls S, Mohammed A, Lynch A, Mohammed K.
Problem-Focussed Interactive Telephone Therapy [ProFITT] for Cancer Patients: A Phase
II Feasibility Trial. Psycho-oncology 2013 in press

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PATIENT NAME:

CONTACT DETAILS:

Referred By:

Service Brochure:

Given

Explained

Reason for Referral:


Psychosocial screen completed

SEEN BY:
Name:____________________________________________

Signature: _______________________________________

(print name)

Designation: _______________________________________

Date: ________________

Presentation:

Summary of Cancer Diagnosis and Treatment


Cancer Diagnosis: _______________________ Consultant: ____________________

Current Concerns

1.

2.

3.

4.

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Psychosocial Background
Additional Notes:

Occupation/finances

Living Arrangements

Social Support(who and how many)

Coping Strategies

Relevant and Additional Family/Psychiatric/Medical History Notes

_________________________________________________________________________________________________

Questionnaire Scores:
Pre-therapy ( insert date of assessment)

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Post-Therapy (insert date of assessment)

Number of therapy sessions provided:

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A workbook is available which includes records, diaries and related


materials for patients to use.
The workbook is a very helpful adjunct to therapy and copies can
be obtained by contacting:
maggie.watson@rmh.nhs.uk
maggie.watson@live.co.uk