Monday 21st December 2015
Mac Voice, the magazine for Macmillan professionals: Winter 2015
In part one of Sharing Good Practice, Dr Anne Johnson, Macmillan Consultant Clinical Psychologist at the Velindre Cancer Centre, discusses psychological support.
Acute psychological distress is an understandable reaction when someone is given a diagnosis of cancer, which will change their future forever. Most people react with numbed shock and disbelief, followed by anxiety, anger, and sadness.
The NHS Cancer Plan  highlighted the fact that the diagnosis and treatment of cancer can have a devastating impact on the quality of patients’ lives and those of their families and carers.
The impact of cancer is related to four main factors:
- The existential threat of the disease.
- Its psychosocial consequences: such as the potential effects on employment, family role and social life
- The consequences of the morbid disease process, such as pain, fatigue and shortness of breath.
- The treatment and its effects, such as nausea, hair loss, body changes resulting from surgery, or loss of fertility.
Coping with this impact means an intense period of adjustment to the challenges faced. It also means coming to terms with a perceived loss of control and living with uncertainty about the future.
In most cases and with the right support, a person’s acute psychological reaction to diagnosis reduces within a few weeks. This happens as they learn, sometimes painfully and slowly, to come to terms with their disease and its impact on their life. They can be helped to make this adjustment through using their own coping strategies, and through the emotional and practical support of their family, friends and the medical team.
That adjustment can change over time as they cope with different treatment demands. They may begin to understand the extent of permanent disabilities and ultimately, changes in the future of certain relationships and the long-term uncertainty of their future. Added to this, they may also be coping with financial challenges, employment impacts, childcare demands and changes to their role within the family.
Some people continue to struggle to adjust, and experience significant emotional and psychological effects of cancer and its treatment. These effects can include depression, anxiety, memory problems, difficulty concentrating,sexual problems and reduced confidence in social situations.
This distress is associated with a range of harmful outcomes, including amplification of physical symptoms, poorer levels of functioning, adverse impact on carers, an enhanced desire for death, reduced adherence to cancer treatment, and probable reduction in life expectancy. It also vastly increases utilisation of constrained healthcare resources.
Patients and their loved ones are likely to benefit from some form of professional psychological support, whether they experience mild and transient emotional turmoil or severe depression. Around one in four patients will require expert psychological assessment and intervention as a result of their diagnosis.
One in ten will require specialist support from a clinical psychologist or psychiatrist. The costs of such support are often far lower than the costs that would result from their absence.
Psychological care services
Psychological services should be given equal priority alongside diagnosis and treatment. They should help the patient to maximise the benefits of treatment and to live as well as possible with the effects of the disease. Best practice standards recommend promoting psychological well-being and preventing the onset of more serious mental ill health.
A good psychological care pathway should empower patients to take greater control of what happens to them and support them to self-manage their needs.
Simultaneously, it should provide access to additional coping strategies and resources, thereby increasing psychological and physical resilience throughout treatment and beyond. It should provide focused preventative interventions to people who are more vulnerable to distress, as well as a reactive service that supports those who are coping with significant psychological distress, including depression and anxiety.
Psychological support services need to address the full range and severity of psychological problems associated with cancer, including:
- adjustment difficulties
- problems with personal relationships, including communication with health professionals
- psychosexual and body image difficulties
- alcohol and drug-related problems
- personality disorder
- deliberate self-harm
- psychotic illness and organic brain syndromes.
The four level model
The National Institute for Health and Care Excellence (NICE) issued guidance in 2004 on the provision of supportive and palliative care for adults with cancer. It recommends a four level model for psychological support services for all patients with cancer and their families. This is underpinned by recognition that patients and carers can often assess their own emotional status and meet their own needs for support.
Psychological support can be separated into two distinct categories, provided by:
- professionals with some training in assessment and frontline interventions of psychological problems, but who are not mental health or psychological support professionals (levels one and two)
- trained mental health or psychological support professionals (levels three and four).
All professionals supporting people affected by cancer should offer high-quality information to empower them. This information can enhance people's understanding, and their ability to participate in key decisions about how their cancer is managed. Information also facilitates adjustment, prevents unnecessary anxiety, and contributes to informed consent, all at a relatively low cost.
Clinicians should also provide general emotional support, based on skilled communication and compassionate listening, as a routine part of their practice. They also need to be able to skilfully elicit health beliefs, support decision-making, mobilise coping and promote adherence to treatment plans.
Professionals guided by the holistic needs assessment (HNA) need to be able to formally detect and assess psychological distress. Level two clinicians should also be able to: offer focused interventions designed to enhance self-care skills and perception of control; improve ability to adjust to life situations; problem solve; and provide enhanced psychological information.
In many cases, the psychological distress and concerns identified can be addressed and resolved, increasing the patient’s ability to cope on a day-to-day basis. However, they may need to be offered a referral to specialised psychological care services appropriate to their needs and preferences.
Psychological care professionals (counsellors or therapists) should offer targeted interventions to enhance a person’s psychological well-being, by enabling them to adjust to their situation. Or they should work with the person using psychological therapy – such as solution-focused or cognitive therapy – to manage more mild to moderate levels of depression and anxiety.
Professionals, such as clinical psychologists, are trained to manage complex psychological health needs and provide specialist care for people with a diagnosis of pre-existing severe mental health illness that has been exacerbated by cancer.
The integrated pathway to success
A successful psychological care pathway should influence, and be embedded within, a person-centred care pathway. This is a pathway where patients receive the right services, at the right time and from the right people. It is a pathway that empowers people to support their own holistic needs, including psychological needs, from diagnosis to living with and beyond cancer.
The preferred model is to embed psychological services within the setting of active treatment or palliation (at hospitals and hospices), but integrated with the work of community professionals providing psychological care.
Pyramid of psychological support
Studies have shown that 65% of people diagnosed with cancer will need the ‘universal’ services shown in the diagram below (levels one and two). 25% will require more targeted interventions (level three) and 10% will struggle with significant psychological distress and require level four services such as clinical psychology. This model ensures cost-effective use of these more constrained resources.
Clinical psychologists have the skills to enhance psychological well-being. They are able to understand and minimise the psychological impact of acute and chronic health conditions and can provide interventions to ‘treat’ mental health issues.
A skilled clinical psychologist can offer skills that impact on each level of the four level model. This can range from developing psychological resources for patients and families, to training clinicians in compassionate communication, detecting psychological distress and offering psychological interventions. They can then support the application of training for colleagues within clinical practice, through ongoing consultation with multidisciplinary teams (MDTs) and by offering clinical supervision to level two practitioners.
There is general recognition that those providing psychological care need to be properly supervised, either in one-to-one situations or in groups, peer groups and work teams. Research suggests that without ongoing supervision, level two trained individuals will not maintain their skills, as this is not their core profession. Evidence also suggests when professionals are not trained in communication and psychological skills needed to carry out a comprehensive HNA, only 3% of co-morbid psychological distress detected results in an evidence-based psychological intervention.
Clinical psychologists can also develop, deliver and supervise focused psychological interventions such as therapy and groups at level three, as well as complex interventions at level four. They are trained to apply psychological interventions systemically within MDT and in-patient environments that support an individual’s well-being.
They are also skilled at understanding the impact of cancer on a family, including children’s and young people’s psychological well-being. Clinical psychology can also support clinicians' psychological well-being when working in such an emotive and demanding clinical area. It does this by offering supervision and support to enhance their own skills in self-care, manage occupational stress and to recognise and prevent ‘burn out’.
When the psychological needs of staff are adequately met, it enhances their ability to provide good-quality care. In summary, clinical psychologists can positively influence the design of care pathways and the approach of clinicians across all cancer services. They can ensure there is a coherent psychological care pathway throughout the person-centred care pathway, which supports patients, their families and professional psychological well-being.
A positive outcome at a reduced cost
When the psychological needs of people living with cancer and those close to them are met during treatment, they feel empowered to take control of their lives and cope with the uncertainty of their future. The psychological impact of cancer is not just in terms of distress, but relates to engagement with and utilisation of healthcare.
Better psychological outcomes offer a significant economic saving by increasing adherence to treatment, reducing take-up of additional services, reducing bed days and improving decision-making about treatment choice. This creates a much higher rate of return than the investment in the services set up.
Estimates indicate that having professional psychological services embedded within adult cancer services can save up to 20% of healthcare utilisation costs.
In their 2004 review, Carson and Bultz wrote: ’The literature review clearly supports the notion that psychosocial interventions are not only effective, but also economical‘. They refer to the ’usually overlooked long-term cost savings that may be accrued to overburdened health-care systems’.
1 NHS. The NHS Cancer Plan. September 2000. Department of Health. London.
2 London Cancer Alliance. Developing a pathway for mental health and psychological support services for adults. 2014. London.
3 National Institute for Health and Care Excellence. Improving supportive and palliative care for adults with cancer. NICE guidelines. 2004.
4 Mannix KA et al. Effectiveness of brief training in cognitive behaviour therapy techniques for palliative care practitioners. Palliative Medicine. 20(6):579-84.
Email Anne Johnson.
Continue reading Sharing Good Practice
Part 1: Psychological support - Dr Anne Johnson, Macmillan Consultant Clinical Psychologist, Velindre Cancer Centre.
Part 2: Evidence base - Janice Rees, Macmillan Consultant Clinical Psychologist, Cardiff and Vale University Health Board.
Part 3: Acceptance and Commitment Therapy - Dr Claire Delduca, Macmillan Clinical Psychologist, Velindre NHS Trust.
Part 4: Helping parents with cancer support their children - Dr Claire Delduca, Macmillan Clinical Psychologist, Velindre NHS Trust.
Part 5: How a clinical psychologist can support shared decision-making - Dr Rachel Criddle, Macmillan Clinical Psychologist, Cwm Taf University Health Board.
Part 6: Psychological supervision for staff - Dr Rachel Criddle, Macmillan Clinical Psychologist, Cwm Taf University Health Board.
Part 7: Extend your psychological support skills - Resources and training for professionals.