CBT for Psychological Well-Being in Cancer

A Skills Training Manual Integrating DBT, ACT, Behavioral Activation and Motivational Interviewing

Mark Carlson

• Publisher: Wiley-Blackwell
• Year: 2017
• ISBN:
  9781119161448
• Edition: 1
• Topic: Psychology
• Subtopic: Cognitive Behavioral Therapy (CBT)
• Index: Psychology

CBT for Psychological Well-Being in Cancer is the first clinical manual to target psychological well-being in cancer by combining skill sets from DBT and other well-researched approaches, providing clinical material in a clear session-by-session structure organized by topic.

• The first skills training manual in the field to provide an integrated session-by-session outline that clinicians can customize for their own needs
• Adaptive and contextualist in approach – Carlson integrates skill sets from DBT, ACT, behavioral activation, and motivational Interviewing to promote efficacy and cost-effectiveness
• The text provides a unique range of resources to support for clinicians, including session guides, specific interventions, client handouts, and invaluable measurement and tracking tools for those clinicians required to report outcomes
• The content can be flexibly deployed by clinicians into their existing work to meet the needs of specific patients in individual or group treatment contexts, by selecting the most appropriate sessions, skills, and handouts

Chapter 1
Introduction to CBT for Psychological Well-Being in Cancer: Orientation to the Manual

When the word “cancer” is mentioned, people typically pay attention. When it is in the context of a medical appointment, or when discussing testing results, one of our biggest fears may become reality. Most everyone knows someone with cancer. There are stories of triumphs and stories of pain in every family. Reactions to the diagnosis of cancer, its treatment, and its course vary greatly between individuals. Although individual reactions may be quite different, there are many common themes found in what is experienced and what is needed. The first main theme is that cancer affects an individual's functioning and their quality of life. The other main themes can be organized into biological, psychological, and social perspectives. The focus of this manual is to address the complex needs of individuals diagnosed with cancer. Since there are more than 100 types of cancer, I have chosen not to focus on any one specific type. It seemed more appropriate to address the common reactions and issues that individuals with cancer experience. This is not designed to be an exhaustive and all-inclusive work, but rather another step in the direction toward treating the whole person.

Chapter 2 provides an overview of cancer statistics and treatments, to orient the reader to the enormity of the impact of cancer. Chapter 3 outlines a proposed treatment structure that addresses flexible treatment modalities for the professional. Chapter 4 makes up the bulk of the manual, and is organized into four sections: general, biological, psychological, and social. The general section consists of six headings that orient the clinician to the treatment of this population, ranging from skills training to work with safety issues. The biological section addresses themes such as treatment compliance and self-advocacy. The psychological section addresses issues of anxiety, depression, finding meaning, and more. The social section focuses on the individual's needs, as well as the needs of their support systems and strategies to increase healthy interactions.

Each section of Chapter 4 is presented with an outline of its contents, beginning with an introduction to the topic and points of discussion. The discussion points can be covered in either group or individual therapy as a way to ground the individual and explore their experience. The sections then transition into sets of skills to teach, which are designed to increase the patient's functioning and quality of life. They also provide assessments tools, which can be used to track progress or identify key aspects of the patient's functioning. Participants are encouraged to practice the skill sets in session using handouts, and to generalize what they are learning outside of the therapeutic sessions by completing the homework assignments/tracking tools and reviewing them in the following session. The sections conclude with notes to the clinician, which are designed to highlight key points and provide suggestions.

There is no “right” way to incorporate a manualized approach. The goal is to focus on the needs of the individual seeking services, while striving to increase their functioning and quality of life. Our health care system is moving toward integrated health care. This manual is designed to assist in narrowing the gap between health care professions by integrating different treatment approaches in order to increase overall health and wellness. The World Health Organization (1948) defines health as a state of complete physical, mental, and social well-being, and not merely the absence of disease or infirmity. This definition has not changed since it was adopted in 1948, and I hope this work will help clinicians move in the direction of embracing it.

Chapter 2
Cancer Statistics and the Scope of the Topic

The prevalence and cost of cancer are a growing concern in the United States and beyond our borders. There is an immense need for coordination of medical and psychological management to treat individuals suffering with cancer and residual conditions that often result from the disease. The American Cancer Society reported that in 2013 “about 1,660,290 new cancer cases are expected to be diagnosed in the US”, with “about 580,350 Americans…expected to die of cancer, almost 1,600 people per day.” It further estimated that in 2014 there were 14.5 million Americans alive with a history of cancer and that by 2024 there will be 19 million. Currently in the United States, “men have a 1 in 2 lifetime risk of developing cancer; for women, the risk is a little more than 1 in 3” (American Cancer Society, 2013). “Cancer is the second most common cause of death in the US, exceeded only by heart disease, [accounting] for about 1 of every 4 deaths in 2013” (American Cancer Society, 2013). Nearly one-fourth of people with chronic conditions also reported experiencing limitations to daily activity due to their illness and experienced clinical mental health concerns. “The 5-year relative survival rate for all persons diagnosed with cancer between 2002 and 2008 is 68%, which is up from 49% in 1975–1977” (American Cancer Society, 2013). This indicates that “60% of 1-year cancer survivors experience clinically significant concerns about disease recurrence influencing the individual's functioning and quality of life” (American Cancer Society, 2014).

Survival from chronic health conditions brings new challenges for individuals throughout their lifespan, including lifelong and acute physical, psychological, and social adjustment difficulties. According to the American Childhood Cancer Organization (2013), “Two-thirds of those who survive the disease develop at least one chronic health condition that is classified as severe or life-threatening caused by late-effects of treatment. These effects often include heart damage, lung damage, infertility, cognitive impairment, growth deficits, hearing loss, and second cancers.” Childhood cancer often results in lifelong disabilities, in addition to chronic health conditions. Because of this, cancer survivors are subject to ongoing monitoring across their lifespan. “Persons diagnosed with cancer will likely need physical and psychosocial care throughout their lives” (American Childhood Cancer Organization, 2013). “Patients and providers often are influenced by life circumstances and competing priorities, attitudes and beliefs about specific treatments, health literacy and understanding the health care system. These factors influence treatment compliance and overall cost” (American Cancer Society, 2014).

Health Care Costs

Cancer is linked with a wide range of illness, injuries, diseases, and mental health issues. “Cancer has been found to cause pain and the associated symptoms arising from a discrete cause, such as postoperative pain or pain associated with a malignancy. Millions suffer from acute or chronic pain every year and the effects of pain exact a tremendous cost on our country in health care costs, rehabilitation, and lost worker productivity, as well as the emotional and financial burden it places on Survivors and their families” (American Academy of Pain Medicine, 2015). According to a recent Institute of Medicine (IOM) report titled “Relieving Pain in America: A Blueprint for Transforming Prevention, Care, Education, and Research,” “pain is a significant public health problem that costs society at least $560–$635 billion annually, an amount equal to about $2,000.00 for every person who lives in the United States. This includes the total incremental cost of health care due to pain ranging from $261–$300 billion and losses of productivity and associated issues ranging from $297–$336 billion. The costs of cancer can result in longer hospital stays, increased rates of re-hospitalization, increased emergency room visits, and a decreased ability to function that leads to lost income and insurance coverage. As such, Survivors' conditions often result in an inability to work and maintain health insurance, especially over the duration of their medical treatment.”

“The financial costs of cancer are high for both the person with cancer and for society as a whole” (American Cancer Society, 2013). According to the National Institutes of Health (National Cancer Institute, 2015a), cancer “is a significant public health problem that costs society an estimated overall cost of $201.5 billion annually: $77.4 billion for direct medical costs (total of all health expenditures) and $124.0 billion for indirect mortality costs (cost of lost productivity due to premature death).” According to the American Cancer Society (2013), in 2006, the average cost of a single 30-day cancer drug prescription was $1,600; it is even higher today. Newer cancer treatments can cost as much as $10,000 for a month, and many protocols require more than a month of treatment. The American Cancer Society (2013) reports that “while those with health insurance face less worry regarding payment for treatment, those with no health insurance acquire extra worries when facing such an expensive disease. There is no guarantee that cancer expenses will be covered through insurance plans. Most personal bankruptcies that happen as a result of medical problems are filed by people who have health insurance.”

Cancer and Functioning

A diagnosis of cancer causes distressing emotional experiences that decrease a person's ability to cope with their disease and treatment effectively. It is common for signs of impaired coping abilities to go unnoticed due to the severity and symptoms of the disease and treatment. Medical teams can assist patients in managing various side effects and symptoms, but patients may also benefit from mental health, social work, and counseling services to restore their quality of life and teach them coping skills (American Cancer Society, 2014). The American Cancer Society (2014) has found that 30–40% of patients have diagnosable mood disorders. Additionally, it suggests that psychological interventions can improve treatment adherence and patient–provider communication. Complete treatment adherence and improvements in communication between patients and their care teams were found to be correlated with low levels of depression and anxiety among cancer patients. Subpopulations at particular risk for elevated distress include racial/ethnic minorities, people diagnosed at younger ages, and those of lower socioeconomic status. These subpopulations have also been found to report greater difficulty regaining their quality of life in recovery. Distress is reported to negatively impact education and employment, at great cost to society (American Cancer Society, 2014).

The American Cancer Society (2014) states that “cancer patients experience pain at the time of diagnosis, during the course of active treatment, and after treatment has ended, even if their cancer does not return.” Among cancer patients, pain is often underreported and undertreated. It has been found that 59% patients in active treatment report significant pain and about 33% of survivors report significant long-term pain post-treatment. Surgery, radiation therapy, and chemotherapy drugs can cause nerve damage. What manifests is chronic pain and a heightened risk of suicide among this population (American Cancer Society, 2014).

The comorbidity of mental health and physical problems resulting from pain is well established in research (Gatchel, 2004). Common comorbidity includes anxiety, depression, adjustment disorder, obsessive–compulsive disorder (OCD), histrionic personality disorder, and borderline personality disorder (BPD). The triggers are the pain and the uncertain prognosis of the diagnosed condition – specifically around progression of the disease, recurrence, reduced lifespan, end-of-life issues, treatment and side effects, cognitive, physical and behavioral impairments, and functional limitations (Ownsworth, 2009). Pain often results from chronic illness, injury, degeneration, and many related triggers in a chronic population. “People who experience chronic pain often experience a decrease in quality of life including: overall physical and emotional health, psychological and social well-being, fulfillment of personal expectations and goals, economic burden and financial stability, functional capacity to carry out daily routines, and activities of daily living. Additionally, destruction of family and social life, problems with treatment adherence and support systems, and decreased participation in sports or leisure activities have been found to increase the risk of clinical anxiety and depression, resulting in greater functional impairment and poor quality of life” (Pao & Weiner, 2011). This functional impairment and reduction in quality of life often leads to a variety of mental health concerns, including demoralization and a reduction in effective participation in treatment, as well as in life in general.

Cancer and Suicide

Cancer is often seen as a death sentence by mainstream society. Within the past decade, research has consistently demonstrated a strong correlation between cancer and suicide. In a survey of 2,924 cancer outpatients treated at one regional cancer center, 7.8% thought they would be “better off dead” or had considered hurting themselves in response to their diagnosis. While the general American population has a suicide rate of 10.6 out of every 100,000 persons per year, about 24 cancer patients out of every 100,000 complete suicide. Gender, prognosis, type of cancer, stage of disease, ethnicity, and family situation all contribute to suicide risk. Male cancer patients are nearly five times more likely to commit suicide than female patients, which remains consistent with suicide rates in the general population. Given the correlations, cancer patients may benefit from psychosocial support (Kendal & Kendal, 2012).

Medical Interventions

“Cancer is a group of diseases characterized by uncontrolled growth and spread of abnormal cells. Cancer can result in death, if the spread of abnormal cells is not controlled” (American Cancer Society, 2013). The American Cancer Society (2014) reports that cancer can be caused by both external factors (including tobacco, infectious organisms, chemicals, and radiation) and internal factors (including inherited mutations, hormones, immune conditions, and mutation...

Table of contents

• Cover
• Title Page
• Copyright
• Dedication
• Acknowledgments
• Chapter 1: Introduction to CBT for Psychological Well-Being in Cancer: Orientation to the Manual
• Chapter 2: Cancer Statistics and the Scope of the Topic
• Chapter 3: Introduction to the TAG Concept for Group and/or Individual Therapy
• Chapter 4: Clinical Manual
• Handouts and Homework
• References
• Index
• EULA