62 COGNITIVE THERAPY IN CLINICAL PRACTICE

Pain

For some patients the control of pain is a major problem. There is a fairly extensive literature available on the application of CBT techniques to control pain (e.g. Pearce and Richardson 1987). As well as ensuring that adequate physical treatment is being employed, additional strategies include the following.

1.The use of a pain diary to monitor fluctuations in intensity and duration and allow any factors that reduce the pain to be identified.

2.Examination of pain-related cognitions.

3.Distraction techniques.

4.As with physical disability the pain may limit the patient’s ability to engage in particular activities. The intensity of the pain may be ‘coded’ by the patient, e.g. using a ‘colour coding’: pain of medium severity equals orange, more severe pain equals green, etc. Activities are similarly coded depending on difficulty in accomplishing them with a particular level of pain. The patient then chooses activities from the list according to the colour coding. This often avoids disappointment and anger at not being able to achieve or enjoy a specific activity at any time and engenders some feelings of control, e.g. a male cancer patient enjoyed golf, but had a metastatic lesion in his spine. He coded severe pain as green and moderate pain as orange. Nine holes of golf were coded as orange and eighteen holes as green. He overcame some of his frustration by avoiding attempting too much and got positive reinforcement from successful outings.

Treatment issues

The patient may wish to discuss their radiotherapy or chemotherapy treatment, as the side-effects of these can be very distressing. Some may wish to stop treatment entirely. In addition, issues of long-term hospitalisation or moving into a hospice may need to be tackled. The following strategies may be helpful:

1.Examining the pros and cons of continuing treatment; this includes issues such as the quality of life, prognosis without treatment, and effects on significant others. Collaboration with treating physicians and family is vital.

2.Generating alternative solutions with regard to whether to accept hospice or other care and discussing the timing of any moves that may be desired or become necessary.

Longstanding deficits in coping strategies

Many patients who fail to cope with cancer show longstanding deficits in coping strategies (Worden 1987). It was found by Weisman and Worden (1977) that ‘poor copers’ showed two main deficits in their coping repertoire. First, they tended to over-use strategies that were least effective in resolving problems e.g. drinking as a means of avoidance of issues. Second, they were unable to generate alternative coping strategies. These deficiencies were accompanied by high levels of emotional distress.

‘Good copers’ not only generated more alternatives, but were more effective at evaluating and rank ordering the potential solutions to a variety of problem situations. Hopefully, it is obvious from this description that standard CBT interventions could be used to deal with ‘poor copers’.

Specific problems in applying cognitive behaviour therapy in cancer patients

There are many potential pitfalls in trying to apply CBT to cancer patients. Perhaps one of the most important is simply that for many patients their negative view of reality is not a distortion but an accurate reflection of the problems they are facing. This does not preclude the use of CBT, but it must be acknowledged. The therapist must not attempt to make the patient into an unrealistic optimist, nor should they identify with the patient’s hopelessness to the extent that they cannot function effectively. Other problems that may need addressing are the following:

1.The prevalence of organic brain syndromes in cancer patients is estimated to be about 40 per cent (Levine et al. 1978). It should be borne in mind that the patient may have or may develop subtle cognitive deficits that impair their ability to engage in CBT. In some instances these problems can be overcome by modelling task assignments within the sessions and ‘overlearning’, as described by Hibbard et al. (1987) in their work with brain-damaged patients.

2.Co-operation with other health care professionals. A vital feature of CBT in physically ill patients is its role in giving information about the disorder and discussing the patient’s views about the treatment options available. Close collaboration is required with other members of staff to ensure consistency in these communications.