Monday 10th September 2012
Dr Frances Goodhart, Consultant Clinical Psychologist and author, explains how cognitive behaviour therapy can help people with cancer cope with their emotions after treatment.
'Having cancer is a bit like being in a boat when a massive storm hits,’ says Dr Goodhart, ‘Your boat is terribly damaged, but you have a lifeboat – your cancer team. They patch you up, tow you towards shore, but then they sail away. You can see the harbour, but you can’t quite get there.’
When treatment ends, many cancer survivors expect to feel jubilation. Instead, they feel alone and afraid. ‘This is the hidden story of living beyond cancer,’ says Dr Goodhart, ‘and it can be tough.’
‘There is huge pressure to be positive after cancer and many people worry that the worry itself will make the cancer come back.’ Low mood, anger, relationship and sexual issues, self-esteem and body image concerns, sleep problems and fatigue are also very common post-cancer emotions. And it doesn’t help that loved ones, colleagues, sometimes even cancer teams, may be baffled as to why the person can’t just be happy that the cancer is gone.
Dr Goodhart wrote The Cancer Survivor’s Companion, which contains a range of strategies to help people living after cancer treatment feel better. ‘Thought taming’ is the foundation of these methods. It’s a key component of cognitive behaviour therapy (CBT).
The central hypothesis, explains Dr Goodhart, ‘is that thoughts, feelings and behaviour are interlinked. But many thoughts are our interpretations of events, rather than facts.’
People often struggle after cancer treatment because they are caught up in unhelpful patterns of thinking, where thoughts are skewed or extreme. ‘Imagine how a person living beyond cancer must feel if they are saying to themselves “I must be positive in order to stay well”, but they have a day, week, or more when they feel anxious or low,’ Dr Goodhart explains. ‘A vicious circle of fear and depression can develop.’
Recognising negative thoughts
Thought taming helps people living beyond cancer to recognise their ‘thought traps’ and examine and re-evaluate or ‘tame’ the thoughts that keep them feeling sad, worried or angry. They can then find more realistic and helpful ways of thinking such as, ‘I’m having a bad day, everyone has them; I’m not damaging my health, I’ll get through this.’
Anila, a breast cancer survivor in her 50s, was struggling with depression when Dr Goodhart saw her. ‘She began by saying, “I’m pathetic; I can’t clean the house; visitors will think I am hopeless. I’ve failed”,’ says Dr Goodhart.
‘She was treating these repetitive negative thoughts as facts, but they were her interpretation of the situation. We worked together to identify the thoughts then unpick the “traps” she was falling into.’
These thought traps included labelling herself (‘I’m pathetic’), mind reading (‘visitors will think …’) and selective thinking (‘I’ve failed’). During their sessions, Anila learned to become her own ‘thought detective’, writing down and examining her thoughts. She gradually realised that many weren’t factual or fair. This was her first step towards lifting herself out of depression.
Numerous individual studies show that CBT improves outcomes for people with post-cancer difficulties such as distress and pain, insomnia and fatigue. A large-scale meta analysis in 2006 showed that CBT has a positive impact on post-cancer anxiety, depression and quality of life. Importantly, the effects are maintained at long-term follow-up.
One young lymphoma survivor, Claire, successfully used thought taming to manage her anxiety about recurrence. ‘In the first year after treatment Claire needed reassurance, information and frequent follow-up from her clinical nurse specialist and consultant,’ says Dr Goodhart. ‘But she built up an understanding of her post-cancer body.’
Claire says, ‘When I notice a change in my body I’m not sure I’ll ever be able to stop my first thought from being “it’s the cancer back”, but what I’ve learned through thought taming is that this doesn’t have to be my last thought!.’
Tips for professionals
Flag it up As follow-up begins, acknowledge with your patient that the next phase has its challenges too.
Reassure them Worry is normal and will not make the cancer come back.
‘Hold on…’ If they are labelling themselves (‘I’m pathetic’) encourage them to question the thought trap before it takes hold, eg ‘Hold on … am I pathetic? Didn’t I just cook dinner?’
Suggest an anxiety diary Each day they write down the incidents that made them worry. What were they doing, what did they think when the worry hit? Now try to spot ‘traps.’
Ask ‘what would you say to a friend in your situation?’ This can show us the unrealistic expectations we have for ourselves that we’d never impose on anyone else.
1. Tatrow K and Montgomery G.H. Cognitive behavior therapy techniques for distress and pain in breast cancer patients: a meta-analysis. Journal of Behavioral Medicine. 2006; vol 29.
2. Savard J., Simard S, Ivers H, Morin C.M. Randomized study on the efficacy of cognitive behavior therapy for insomnia secondary to breast cancer. Journal of Clinical Oncology. 2005; vol 23.
3. Gielissen M, Verhagen C, Bleijenberg G. Cognitive behaviour therapy for fatigued cancer survivors: long term follow up. British Journal of Cancer. 2007; vol 97.
4. Osborne R.L, Demoncada A.L and Feuerstein, M. Psychosocial interventions for depression, anxiety and quality of life in cancer survivors: a meta-analysis. International Journal of Psychiatry in Medicine. 2006; vol 36.
Email Dr Frances Goodhart.
We have more information about common emotions that people may experience after cancer treatment.
The Cancer Survivor’s Companion: Practical ways to cope with your feelings after cancer, 2011, by Dr Frances Goodhart and Lucy Atkins, is published by Piatkus.