CANCER PATIENTS 61

within the classic CBT framework. Sobel and Worden (1980) focused on problem-solving skills, whilst Gordon et al. (1980) utilised a programme of supportive therapy with education and information giving and environmental manipulation. This aimed to give patients a more realistic outlook, increase their daily activities, and improve their adjustment to the disorder.

Specific issues in applying cognitive behaviour therapy to cancer patients

The following section refers to specifie issues that may need to be tackled in a course of CBT with a cancer patient who is suffering from psychological problems. It is obvious that some of these difficulties may also be experienced by patients with other physical illnesses.

Grieving for the ‘lost self’

One of the major problems confronting the patient will be the effect of the illness on their self-esteem and self-image. The role of the individual in the family and work situation may change significantly. Self-esteem will be affected by loss or changes in role. Cancer sufferers often feel stigmatised by colleagues and friends. Those close to them often feel uncomfortable in the patient’s company, not knowing if they are or are not allowed to discuss the illness.

The disfigurement brought about by surgery can have a tremendous effect on the individual’s self-image. Many women report sexual difficulties following mastectomy related to their anxieties about their body image (Morris 1979). These difficulties are often compounded by a sense of personal failure and self-blame that the individual has developed cancer in the first instance.

In many ways the patient’s view of themselves is tackled in the same way as it would be in CBT in general (e.g. see Beck et al. 1979; Williams 1984). In addition the following points should be remembered:

1.With the physically ill, subjective perceptions of personal worth and degree of handicap may be distorted, but in tackling these issues there is also a need for a realistic appraisal of the patient’s role and help is needed in adjusting to actual changes that may be required.

2.It is often important to involve the spouse in discussions about self-image in patients who have undergone disfiguring surgery.

3.Role-plays can be used to enable the patient to take the lead in interactions with friends and colleagues. This allows the patient to take control of discussions about the illness and its treatment.

Locus of control

Patients frequently feel hopeless because of the overwhelming sense of lack of personal control over their illness and prognosis. This sense of powerlessness is very demoralising. At some point a sensitive exploration of the patient’s fears about coping with death is necessary. The patient can be helped in several ways:

1.An acknowledgement that the future is uncertain, accompanied by the provision of clear information about what is and is not known about their particular illness.

2.According to Gomez (1987), most patients’ fantasies about their death include images of ‘disastrous dyscontrol’ and an agonising, often painful and lonely end. It is important to take on these anxieties and to talk in detail about all aspects of concern. Additional meetings can be organised with the clinicians to discuss pain control, etc.

3.Avoiding overgeneralisation of feelings of lack of control by getting the patient to define those aspects of life that they are in control of and those which no one can control.

4.Helping the patient overcome any guilt or anger they feel about their lack of control.

Physical status

There may be realistic limitations placed on the patient because of physical disability or side-effects of treatment. This needs to be taken into account when planning activity schedules by:

1.planning activities that require less exertion or mobility;

2.using activities that enhance residual abilities rather than expose deficits;

3.putting limitations on what the patient is allowed to tackle at a given time, e.g. in the initial time after radiotherapy (which can be particularly tiring) only allowing the individual to choose from a specific number of activities that have been preselected as feasible for someone in that physical state.