loading . . . Let's Talk about CBT- Practice Matters: CBT, Cancer and Coping with Dr Stirling Moorey This episode, Rachel talks to Dr. Stirling Moorey about the role of CBT in supporting individuals with cancer. Dr Moorey is a consultant psychiatrist and a leading expert in psycho-oncology as well as the new BABCP President. He has worked extensively in the field of CBT and cancer since the 1980s, contributing to research, clinical practice, and supervision. They discuss how not everyone with cancer will need r want psychological interventions but how CBT and learning coping strategies can be effective for those who do and how therapists can look after themselves when working in this emotionally demanding area. Useful links: Books: Moorey, Stirling, and Steven Greer, Oxford Guide to CBT for People with Cancer, 2 edn, Oxford Guides to Cognitive Behavioural Therapy (Oxford, 2011; online edn, Oxford Academic, 1 June 2015) Papers: Serfaty, M., King, M., Nazareth, I., Moorey, S., Aspden, T., Mannix, K., Davis, S., Wood, J., & Jones, L. (2020). Effectiveness of cognitive-behavioural therapy for depression in advanced cancer: CanTalk randomised controlled trial. British Journal of Psychiatry, 216(4), 213-221. Serfaty, M., King, M., Nazareth, I., Moorey, S., Aspden, T., Tookman, A., Mannix, K., Gola, A., Davis, S., Wood, J., & Jones, L. (2019). Manualised cognitive–behavioural therapy in treating depression in advanced cancer: The CanTalk RCT. Health Technology Assessment, 23(19), 1-106. Serfaty, M., King, M., Nazareth, I., Tookman, A., Wood, J., Gola, A., Aspden, T., Mannix, K., Davis, S., Moorey, S., & Jones, L. (2016). The clinical and cost effectiveness of cognitive behavioural therapy plus treatment as usual for the treatment of depression in advanced cancer (CanTalk): study protocol for a randomised controlled trial. Trials, 17(1), Article 113. Credits: Music is Autmn Coffee by Bosnow from Uppbeat Music from #Uppbeat (free for Creators!): https://uppbeat.io/t/bosnow/autumn-coffee License code: 3F32NRBYH67P5MIF This podcast was edited by Steph Curnow Transcript: Rachel: Today I'm so pleased to welcome Dr Stirling Moorey to the podcast to talk about CBT and cancer. Dr Moorey is BABCP president elect and a recently retired consultant psychiatrist who's been practicing CBT since 1979 when he visited Beck Centre for Cognitive Therapy in Philadelphia for a medical student elective. He's a highly acclaimed clinician, researcher, and teacher, and has specialised in several clinical areas, including psycho-oncology. Stirling is particularly known for his research and work on the application of CBT for individuals with cancer. So thank you so much and welcome Stirling. Thank you for joining us. Stirling: Thank you. Thank you very much for inviting me. It's great to be on the podcast and really lovely to be contributing to what is the growing CPD offer of BABCP to our members. Rachel: And on our agenda today is an understanding of if and how CBT can be helpful to individuals with cancer and how we might apply CBT in this context. To start us off, I wonder if you could tell us a little bit about your journey into this work and what got you interested personally and professionally in working with CBT and specifically CBT with cancer. Stirling: Well, it's interesting. I think that this all began in about 1986 when I passed my membership of the Royal College of Psychiatrists and was looking for what the next job would be as a Senior Registrar. And looking for what might be research opportunities and Dr Stephen Greer, who was a wonderful clinician, but also a pioneer of research in psycho-oncology had received a large grant from what was then the Cancer Research Campaign, is now, Cancer Research UK to look at the effectiveness of psychological treatment in cancer and so he developed, was developing, what he called Adjuvant Psychological Therapy, which was a bit of a mix of some emotional support and CBT type components. So, because I was interested in and had some experience of CBT at that time, he was quite keen for me to come on board and be a member of the team. So that's how it started and really led to us doing some research but also producing our book, which was originally Adjuvant Psychological Therapy. It's gone through I think three or four editions now and has become the Oxford Guide to CBT for People with Cancer. So I got into it through really a research interest and my time at the Royal Marsden meant that we were doing quite a lot of clinical work in the liaison service as well as the research project. Rachel: And just to ask, briefly, Stirling, some people might not be familiar with that term adjuvant. What does that mean? What does that refer to? Stirling: So he called it Adjuvant Psychological Therapy because at that time, adjuvant chemotherapy was a treatment, that is still used, alongside what might be say a surgical removal of a cancer, and alongside that people would have a chemotherapy treatment. So he said, well why don't we sell this in a way to the oncologists by calling it Adjuvant Psychological Therapy, might make it more acceptable. Rachel: And do you think the fact that you had a medical background rather than, a sort of psychological background in terms of a psychology degree, that sort of pathway into psychological therapies, prepared you, drew you in particularly into this kind of work? Stirling: Yes I think I agree. I think that, having a medical background, I think gives you some advantages. It doesn't mean that many psychologists can't be very proficient at working with people with physical illness, but it does give you a different angle. I mean, I think one of the things that perhaps is unfortunate in the CBT world is that I think that biopsychosocial approach that doctors can bring, and nurses can bring is perhaps undervalued a little bit. So yeah, I think that adds a component to the psycho-oncology. Rachel: Perhaps I wonder if you can go places with your patients that perhaps psychological therapists might fear to go for that the fear that maybe their patients might think there's telling them it's all in their mind or, you know, being reductionist about what's going on for them. Stirling: I think that's right. I think that, to some degree, I don't know that being a medic necessarily comes up that often as an issue for patients. I think where the areas where it can be helpful is that you perhaps speak the language of the medical staff, doctors and nurses. So sometimes actually sort of interpreting in both directions, interpreting for the patient what some of these things mean, and vice versa, helping the doctors to understand. And sometimes we would have joint meetings with the oncologist or the nursing staff and again, that, that translation can be helpful, which perhaps is a little bit more difficult from someone who doesn't have a physical, medical background. Rachel: So you had this interest in CBT, this training in CBT, there was this momentum behind this particular area, there was funding for research into cancer. And we know now as then, but increasingly so cancer is undoubtedly a huge global concern. It's one of the most incurable diseases with, I understand, the second highest mortality rate after cardiovascular disease. Macmillan Cancer Support estimated in 2022 that there were approximately 3 million people living with cancer in the UK alone, with that number anticipated to rise exponentially up to sort of 5 million by 2040. And the NHS reports that one in two people will develop some form of cancer during their lifetime. So in that context, the context of the high mortality rates and the high prevalence of cancer, can you tell us a little bit about why we would be thinking about psychological interventions with cancer? Stirling: Yeah, I think that the good news on the psychological front is that we know that about 60 percent of people who go through a cancer diagnosis are going to be coping pretty well. They don't meet criteria for anxiety or depression, and I think that's very encouraging that there's a lot of resilience that we have. But, you know, 20 to 30 percent of people will experience symptoms of anxiety, depression and adjustment problems and that's a significant burden, I think for themselves and for health services in the past was largely unrecognised, but I think it's much more becoming recognized. People experience a whole range of reactions to cancer. The thing about cancer that I think makes it differ from other long term medical conditions is the threat to survival, is, is in our culture, associated very much more with cancer than with other conditions. But someone, say, with heart failure may actually have a much poorer prognosis than someone with cancer but in terms of the psychological impact because of the way in which we stigmatise and see the disease, that threat is often very profound. So fear of recurrence and progression is a big component of the psychological burden of cancer but then alongside that, there's also the impact of physical symptoms. There may be side effects from treatment, such as going through chemotherapy and losing your hair, having nausea, side effects from surgery, which may be major physical changes impacting body image. And also, often in later stage disease, physical symptoms such as fatigue and insomnia really impairing your capacity to cope. And plus the social impact of cancer for people losing, say their, their livelihood, losing their role, and the stigma that is still around. People don't quite know how to talk to someone with cancer. So a whole range of biological, psychological, and social impacts of cancer, that, as I say, fortunately, most people don't need psychological interventions beyond the usual support that might be necessary for any physical illness. But some people really do benefit from having a bit more of a of a look into how they're coping and how we might help them. Rachel: And that figure, you said that 60 percent figure is really striking because it's really not that long ago, as you say, so culturally cancer wasn't even spoken about, you know, it was the C word, wasn't it? People didn't even use it almost from sort of superstitious perspective, if I say it, it might get me, and to realise that, you know, 60 percent of people can adjust and cope, with respect to their psychological wellbeing seems quite extraordinary. I realised hearing that myself, you know, I have maybe some assumptions about how if this were to happen to me, it would be absolutely catastrophic and I might not be able to deal well with it. But also, easy to understand, given that sort of broad range of impacts that not only the problem itself brings, but also the treatment for the problem brings that people would need some support, potentially. So, you know, along those lines of, you know, ideas that are around and myths that we might want to bust or things that may or may not be true, we have a set of true/false statements that we often include in this podcast, which might open up some of those discussions for you. So first up, a majority of people who are diagnosed with cancer will die as a result of the disease? You may have addressed this a little bit. Stirling: Yeah, so that's no. So current figures are that something like 50 percent of people who have a diagnosis of cancer will survive for 10 years or more. And in an illness like, say breast cancer, actually the figures are that people are going to be likely to die from other causes before breast cancer causes them to die. That doesn't mean that actually there are an awful lot of people who will die from the disease, but it isn't inevitably a death sentence as people used to fear and increasingly more and more treatable, but with huge variation in survival rates. So if you're a young man and have a testicular tumour, you have an approaching a 98 percent chance of surviving. If you have pancreatic cancer, unfortunately, figures are really down still around 1 percent of people surviving five years or more. Rachel: That’s a huge variation as you say. but again, cause to pause when we think it's inevitably a death sentence when we hear those words. And how about, the next statement to people with cancer generally do not want psychological support, they just want their physical symptoms to be addressed? Stirling: I think probably on the balance, no, but it is a more nuanced sort of answer because, as you see in that figure of 60 percent of people not meeting criteria for any psychological disorder, those people may not necessarily want to have help. They may benefit from some support because there are still lots of issues that you need to be dealing with, even if that doesn't mean that you have a psychological morbidity that we would say requires sort of professional intervention. But for instance, in the first trial that we did, it was a sort of a screening trial in a way, looking at people who scored high on the health anxiety and depression scale. And they were offered either treatment or treatment as usual or Adjuvant Psychological Therapy and quite a percentage of them would say Oh, well, I’ll help with the trial. But as long as I’m in the control group because I don't really feel I need psychological support. And also looking at the outcomes of studies of CBT and other therapies in cancer, when you offer this to everyone, actually your effect sizes are quite low. If you target it for the people who have significant symptoms, then you get much better effect. So we don't have evidence that it's harmful to offer treatment when people are not hugely distressed, so that's where the nuance is that actually I think everyone would probably appreciate support, understanding, good communication but not necessarily a psychological treatment. Rachel: So psychologically informed approaches may be helpful for everyone, but it makes sense, doesn't it? If you didn't have depression, you wouldn't expect to see a huge impact on your depression if you had a depression treatment would you? So that, that makes perfect sense. So how about this one then Stirling with your passionate commitment to CBT over the years. CBT is too superficial an approach to have anything to offer the kinds of key existential anxieties and questions that people with cancer present with. Stirling: No, I would say to that, that CBT isn't an existential therapy per se, but, I think in terms of the threat to survival and the cognitions that we have around prognosis and the meanings of death are things that can be really can be addressed with a CBT approach. For instance, the sorts of existential concerns that people with incurable cancer have would be say around the process of dying, the pain that might be associated with that and the distress that might be associated with that. And I think that from a traditional CBT perspective can be examined in terms of the evidence and very often people have catastrophic fears, often based upon past experiences, with loved ones at times when perhaps pain control was not so good. So we can examine those beliefs. We can put people in touch with the palliative care team who are excellent at reassuring them about the ways in which pain can be controlled, etc. We can also, I've worked with the imagery that people have around dying and their own deaths, and I might share a little bit later, a very moving experience in using imagery work with one of my patients around that. And then the other area, other areas around projection into the future, what will happen to my family, again, what might I be able to do right now to maybe project into the future memories that I can leave with people. So all of these are very much within the CBT frame. In terms of what happens after death, maybe because we're not primarily an existential sort of therapy, there are other approaches that may address that. But we can work with fears about the consequences of if you believe in an afterlife of what that might mean for you by actually working together with sympathetic and compassionate rabbis, priests, imams to set up a sort of almost like a behavioural experiment that I'm fearing that something that, that I will go to hell. Well, let's actually get you talking to someone rather than just ruminating, being stuck in that guilt. Let's get you talking to someone who might be able to give you a compassionate view of what the future might look like. So all sorts of different things that can be taken from our CBT toolbox, even in this area. Rachel: So working with the patient's own cognitive and spiritual outlook in terms of things that are meaningful and valuable to them. So next statement. If people with cancer simply take a positive attitude to their illness, they'll be more likely to recover. Stirling: The answer to that is no. That first trial that we did, Stephen Greer was very interested in the sort of psychophysiological aspects of psycho-oncology because he'd done a study that had found that women with who'd had a mastectomy, who had a fighting spirit, were lot likely to survive longer than those who didn't. And so this trial was in part aimed at to seeing if we could improve prognosis. In fact, it was quite underpowered in terms of numbers. It did show that we could improve psychological adjustment, but no impact on disease. And subsequent studies have really showed that actually having an optimistic, positive approach doesn't have any impact on your prognosis but does have an impact on your well-being and your coping. Rachel: It's an idea that I think is so prevalent in our culture that somehow there's something that individuals can do just about how they fight cancer or how they, as you say, that, that term fighting spirit, how they man or woman up to it is going to affect the outcome. And that's very interesting to hear what the research says about that. Stirling: Again a sort of just a little also a caveat is there probably is some research that people who are depressed may have poorer prognosis, but whether that is a psycho-immunological effect or whether it's a sort of simply the fact that you perhaps engage less with treatment if you're depressed I don't know, but there's some suggestions that the helpless, hopeless stance may not be,so good. But not that if you think positively, you'll beat this. Rachel: Yeah, you can't think it away. Stirling: Yeah Rachel: So final statement for our true and false section then, treating people with cancer is unrelentingly depressing and difficult as a CBT therapist. Stirling: Very definitely no. There are strains and costs, I think, to working exclusively in this area, but I think one of the things that is most obvious when you're working with people with cancer is that an awful lot of people will have very good coping strategies but have decompensated as a result of the threats of the disease. So actually they can regain those strengths, they can remember those strengths, they have the resilience so they bounce back quite quickly with some brief treatment. There will also be other people who perhaps have longer term problems who already have a history of depression or mental illness who will be more like the patients we usually see in secondary care and so on but actually in many ways the patients that we're seeing are going to be easier to treat in a way and very rewarding to see that rebuilding of their skills quite quickly. Rachel: So, in contrast to what we might think, it's not a depressing prospect treating someone with depression where it's just a kind of downhill process. Actually, you can see this bouncing back, these rewards, these positive outcomes despite the picture of the illness. Stirling: And I’m not sure if this is on your list of myths, but a related myth I can tell you is that if you have incurable cancer then you're inevitably going to be depressed And actually, there's a meta-analysis that showed that the levels of anxiety and depression in people in palliative care who have cancer that can't be cured are around the same as those in people going into an oncology service. So actually, again, it's that resilience but our job is to help the people who perhaps aren't so resilient to cope better with the illness, whether it's either through fear of recurrence or through a knowledge that they are going to die and the negative impact of that on them. Rachel: So I think we've established quite clearly that when we're talking about CBT with folk with cancer, we're not talking about treating the cancer per se. We're not necessarily looking at the outcomes of the cancer diagnosis, but we're thinking about providing treatment for these associated psychological, but also social, and psychosocial functional changes, et cetera. Can you tell us a bit about evidence base and clinical recommendations for the application of CBT with cancer? Stirling: There have been a lot of studies of cognitive behavioural type interventions in cancer. They range from sort of more coping type strategies, often delivered in groups, delivered to people across the board, whether they have distress or not to more focused individual CBT in both second and third wave sort of approaches. And so generally, the finding is that CBT does have an impact on anxiety and depression. We know also that it can be helpful particularly with the insomnia in cancer and with pain and fatigue so lots of studies demonstrating that so overall the evidence is that CBT is an effective treatment and with suggestions that results can be there at least a year after the intervention. When you compare it, head-to-head with other treatments there isn't really evidence that it's more effective for people with cancer with their depression and anxiety. Rachel: So what other therapies has it been compared with? Stirling: So compared with more supportive type therapies, sort of emotional expressive supportive therapy, which is another sort of slightly more humanistic approach. So it's as with I think we could say with a great number of things, particularly depression not possible when you do head to heads to show benefit of CBT as being particularly more effective. Though with the cancer studies the effects, the sample sizes are often quite small, so it's quite difficult to show necessarily a more beneficial effect. We'll talk a little bit more, I think, about the study we did at St. Christopher's Hospice, where we trained nurses to, do CBT, first aid CBT, in patient’s homes when they were visiting them as clinical nurse specialists. And what we found there was an effect for anxiety but less of an effect for depression, but no more than the group who received usual support. And I think there is something about the support that you receive in a clinical setting, or if you have a controlled treatment that is supportive that is really important for people with cancer that actually then means that specific techniques like CBT are added in to that it's not really a placebo effect, but it's a basic effect of having a supportive relationship is a big component of what people benefit from when they're dealing with a serious physical illness. Rachel: So it sounds like there might be slightly different benefits across different treatment targets. So whether that's depression, anxiety and who it's delivered by and in what context. Stirling: I think of the impacts of physical symptoms like insomnia and pain that we would see a benefit of CBT. There have been a lot of studies that have actually compared CBT for insomnia, say, with an active treatment but my, my, my guess would be that for those, sort of more specific problem type areas, we would have some benefit. Yeah. Rachel: And is there a sense of differentiation in effectiveness across different types of cancer or different stages of cancer? Stirling: Again, this is, I think, not clear. There've been a number of studies that people with advanced cancer that have showed an effect. The study that we did, the CanTalk study that we did within IAPT, had some rather disappointing and surprising outcomes. And here, what we did was we helped clinicians who were working in IAPT to have one day a week training in CBT for people with cancer. And then the study took people with advanced cancer who were currently depressed and allocated them to treatment as usual or 10 sessions of CBT within IAPT. And it was a flat line, neither group actually showed any improvement. So we didn't even get a placebo type of CBT. So that was a large study of 200 people. It's not quite clear why there wasn't any effect there, but I think it does, it does tell us that it may be that the skills that you need for working with people with more advanced disease might need a bit more specialist sort of input. So that sort of brings us, I think, to the recommendation. So recommendations are that people with cancer should get a sort of a stepped care approach. That's the professionals in working in oncology services and so on should have some training in communication so that they can give appropriate support. But at the next level, we're talking about perhaps more telephone type support and input of group support and so on. Moving up to the next level, which is psychological treatment services within the cancer setting. I think that there are lots of reasons why treating people with active cancer or with more advanced disease in IAPT is not appropriate. And I think in the, in the guidelines, really cancer is seen as a chronic illness, a long-term condition but Talking Therapist services are going to be focusing more on people who've recovered and the fear of recurrence problem. And we know that, for instance, if you follow up people after a successful treatment for their cancer, over time the incidence of depression is no different from that in the normal population, the healthy population but the incidence of anxiety disorders is four times as high. So I think this is where IAPT can offer something with perhaps some support from psycho-oncology services. but people with active cancer are probably best treated by psychological services embedded within the hospital because of those, you sort of started to talk at the beginning about what being a medic can bring to it. I think that actually working within that setting, can probably be more helpful than going out to a psychological treatment service separate from that. Rachel: So that multidisciplinary approach can really enhance and support the treatment. Stirling: Exactly. Yes. Absolutely. Rachel: So, given these recommendations, we have said that not anyone, not everyone by a long stretch will need psychological intervention. But for those who do or have some of these issues that might benefit from this kind of approach how widely available is psychological therapy for them? You know, would someone your typical individual diagnosed with cancer in the UK, for example, be likely to be offered psychological support at some point in their cancer treatment pathway? Stirling: It's very variable. Pathways sort of are now being developed in most areas, most regions and, and certainly, most hospitals would have, clinical nurse specialists who are working in cancer, who have some of those basic support skills and counselling skills, and some of them have CBT skills too but it's patchy still. It's patchy and many places don't have liaison psychiatry or psychological therapy services. So it's a I think still a little bit of a postcode lottery. Rachel: So it sounds like this is an area where dissemination is really important to enable people to have that equal access to that treatment that, that can, in the right circumstances with the right presentations be really helpful to them. Stirling: That's right. Yes, Rachel: In many areas in CBT currently, there've been really big developments in dissemination around offering self-help or supported self-help or technology assisted CBT to improve that. Is that something that's happening in cancer? Stirling: It is. There are sort of brief interventions, both more general ones and more specific ones for things like insomnia and fatigue and so on. Telephone based, computerised, all sorts of things. It makes sense to provide that, whether just how effective it is, I think, is still, in question and the meta-analyses that I've looked at, I've read, suggest that there's not enough data yet to know how effective those low intensity interventions might be. We would hope that they would be, for instance, if you take people who've recovered and have fear of recurrence, one meta-analysis found that it was more face to face treatment over a period of a month or more had a better outcome than the briefer telephone based treatments And so on. So I think it's early days, but you know, our hope is that we'll find that way of disseminating Another way of doing it is that Kath Mannix, who is a CBT therapist and palliative care consultant has developed is what she calls first aid CBT and this is an approach where we train physical health professionals, so clinical nurse specialists, but also a lot of oncologists have come on the training in basic CBT principles that they can use sort of generically in their work and these include really being able to develop a problem focus, being Socratic in their questioning, using some basic behavioural, maybe mainly behavioural activation, but some behavioural experiments and some simple cognitive restructuring. So the trial that we did at St. Christopher's where we randomly allocated nurses to either getting training or not, and then following up their patients, we found that for anxiety there was a significant reduction when the nurses who'd been trained were working with that. So that's another way as of actually trying to embed some of this in the work that, that the physical health professionals are doing. Rachel: And it does speak to, doesn't it, that importance of training and, evidence-based skills because those nurses are fantastic. I can imagine just having those folk involved in your lives would in itself have a positive effect, but the fact that there's that additive effect of this training really tells the story, doesn’t it? Stirling: I think probably the take home message from the nurses and from the study with that is that they are already trained in listening and supportive counselling skills. But what they found was that actually learning to step back and to do a five areas diagram, either on paper or just in their head, stopped them from doing what they, I think they hadn't realised that they were doing, which was reassuring, and which was problem solving. So simply creating that space and teaching people Socratic questioning, allowed them to maybe hold some of the anxiety that they were feeling in the situation. And we would think these are very experienced professionals who wouldn't be doing that. But we found what they were doing was automatically saying, oh you're feeling a bit anxious Well, I’ll get the social worker to see you or oh you've got some pain and you're really worried about that, let's think about how we might increase your pain control and they learnt to actually sit back And ask a little bit more about what the thoughts and feelings are around the pain, looking then at some of the safety behaviours they might be using or not jumping in straight away to reassure. Rachel: So allowing individuals to build that resilience to internalise those coping strategies to take charge of their own journey, if you like, rather than jumping in and trying to solve everything. Stirling: Exactly. Yes. Rachel: I'm guessing given what we've spoken about the multitude of problems that can present and presenting issues that we might be working with a CBT therapist in cancer there probably isn't such a thing as a generic CBT with cancer formulation. Are there key maintenance factors you might be targeting in this work across presentations? Stirling: Yeah. Yeah so, this is a whole day's workshop really… Rachel: Excellent. I'll give you five minutes. Stirling: in five minutes. So thinking about the sort of the adjustment model that I would use is, to think in terms, if you're formulating someone with cancer, to think in terms of two major threats. So the first one is a threat to survival, which is unique, not unique to cancer in terms of a life threatening illness, but it’s different from, say, something like diabetes or other long term conditions. So, what is the threat to survival? And we can understand that in terms of an adaptation of Lazarus and Falkman's model. So how do I understand the diagnosis? Is it something that I see as a death sentence? Is it something I see as a challenge? Is it something I see as a huge uncertain threat? And then how do I see my capacity to cope with that? So can I rise to the challenge? And if I feel that I can rise to the challenge and I have an optimistic view then that promotes a fighting spirit or what you might call a resourceful spirit to be able to deal with it. But then other people might be focusing very much on this is a loss or a harm, I can't do anything about it and therefore, I'm helpless and hopeless. So, firstly, understanding the threat to survival and then the second threat is really the threat to the self, the self-image. So threat to the image of yourself, maybe as a competent person who can be in control of your life, maybe threats to your perception of your body image which may be important to you. How is that changing? Threats to your social role and so on. So I think understanding generically the cancer in those terms is important and when we talk about maintenance factors, I think we have to remember that we're dealing here often not with a steady state which we would be in traditional anxiety or depression. We're dealing with a process of adjustment that is changing over time. So the threats will be changing as maybe the disease progresses or you experience treatment or you end treatment and so on. And again, in terms of maintenance factors, the difference between a coping strategy and a safety behaviour is less clear cut so, taking an example, any form of avoidance, we would want to get rid of in traditional CBT for anxiety or depression, but sometimes actually making a choice to focus your attention on something else is going to be an adaptive strategy. So in terms of what we know about effective coping. I've been quite impressed by a simple three C's mnemonic that someone has developed for coping with disasters, but it works very well with cancer. So it's about control. So if you're coping, you maybe have can exert control over the disease through complying with treatment, etc. But also control over other aspects of your life that you still can exert some control over by making sure that life goes on. Second C is coherence so it's giving meaning to your experience. We know that people who are able to actually make sense of the cancer in terms of how this fits into their life experience sometimes actually grow from it, sometimes even see benefits that they find in this horrible situation. And then the third C, which we have a lot of evidence for is that social support, connectedness really makes a big difference. And so if we think about the sorts of non-coping behaviours, they're very similar to what we see in anxiety and depressive disorders. So, avoidance is not generally not good, rumination and worry are generally not good. On the more interpersonal front then Actually, people can get stuck in reassurance seeking or over dependency but on the other hand, they can also get stuck in excessive self-reliance. So, actually, the beliefs that they have about it being a weakness to ask for help can prevent them from getting that connectedness and getting that social support. And so, I think, in terms of how we might formulate it, thinking about those threats to survival and to your self-image. And then looking at how those threats are processed and the coping strategies that may be using or you may not be using, that might be adaptive or maladaptive, but there isn't a single sort of statement about what the best way to cope with cancer is cause it's unique for every person. so that's. That's, yeah, we could go on, but that’s a brief overview. Rachel: That's very clear. I know we normally have a challenge to ask people to do that without boxes and arrows being an audio podcast and you did it beautifully, even without being without giving the challenge. And I guess, you know, there's lots that will be familiar to our listeners in there as therapists around thinking about those coping strategies in life that are seem to be ubiquitously unhelpful, like, you know, rumination and worry and avoidance or isolating oneself, et cetera. But again, in common with other problems that we might be intervening with the key factor of formulating the individual. So understanding whether avoidance is actually a positive or a negative coping strategy for that individual depend, I guess, on the function that it's having for them. Stirling: I think that I see that one way of thinking about the function is this something that is moving me towards something that's important or valuable or useful? Or is it something that I'm doing to try and move away from my emotional distress or from something else? So actually, if we're moving towards, sort of think about this in sort of ACT sort of terms, if it's moving towards a valued goal then that is going to often be more effective as a strategy than doing something just to actually reduce your distress if that makes sense?. Rachel: Yes, that makes a lot of sense as I'm thinking about how someone might, for example, be perceived as avoiding certain social situations that they feel a sense of discomfort in. And we might want to say, well, this is not furthering your connectedness. This is, you know, putting you in an environment where you might be more likely to ruminate and worry, but actually they might be exerting some control over how they're choosing to spend their time and how they're spending their time meaningfully and valued activities. Stirling: Exactly. And I think that, when you have relatively sort of reduced energy levels, if you're going through say a chemotherapy or radiotherapy, which we know makes people very fatigued, then actually making decisions about what's a wise thing to do here. And I think, as you say, but it also depends to some extent on whether that avoidance is driven by an anxiety about how you're going to come across to people, what they'll think of you versus is driven by actually it's I don't have the energy to see these people and perhaps use some of my coping strategies to deal with them not knowing what to say to me, not knowing how to ask about my situation, right now, I don't think I have the resources to do that, and that's fine. Rachel: So having asked the impossible question of you to condense a whole day's workshop on maintenance factors and models into a few minutes on this podcast, I wonder if I can ask yet another impossible question, which is there sort of a typical approach to then treating these issues, you know, given these key maintenance factors, what are the main cognitive behavioural strategies one might be using? Stirling: Well there isn't a typical approach and it depends, to some extent on the circumstances and the time you have. So working in palliative care and sometimes also working with people who are undergoing treatment, you have relatively short space of time. And so actually being much more problem focused can be really helpful and again, as I was saying that people have that capacity to cope already. So, if they're not, sort of very decompensated, then focusing on, oh, you've got some avoidance because of those social anxieties like you mentioned. Let's plan, map that out with a five areas model. Let's look at what the maintaining factors are. Let's get you going. With other people, if you have a little bit longer, I do find it really helpful to look at the developmental model to understand what the meaning of cancer is for you, why often it's around people having beliefs about needing to be in control and cancer par excellence is the threat that takes control away from you because you don't have control of your body, you don't have control of your treatment, etc. And so helping people to understand how that their past experiences, their current beliefs, how cancer sort of pulls the rug from under them, I think can be really helpful. And one piece of advice I think I would give to therapists is, if you can find some time to understand the meaning of cancer for the person, that can really help to engage them, I think more and it may be one of the things that perhaps was a bit lacking in the CANTORC trial. I don't know, because I think that talking therapies therapists, may not be so familiar because they go in with a problem descriptor, what's going on, what's the diagnosis, what's the model, let's get on with it. Actually creating that space to understand what does cancer mean to you, and therefore understanding why you're trying to cope with it in the way that you are is going to be helpful. In terms of strategies, I think, behavioural activation for people who are helpless and hopeless or depressed is really an effective treatment strategy because very often people sort of throw out the baby with the bathwater. Because I can't do some of these things I used to do, there's no point in doing anything. Because I can't be the person that I used to be, I've given up. So simple behavioural activation is often very helpful. As I've said, sort of behavioural experiments around the particular focus of something like social anxiety or fatigue leading to reduced activity and then cognitively the challenge really is what do we do when we're working with realistic negative automatic thoughts. How do we help people to evaluate whether thoughts are helpful or not, as well as whether they're realistic, which requires maybe a little bit of thoughtfulness around and sensitivity to how you deal with the cognitive elements of the response to cancer. Rachel: I wonder, we've talked a lot about sort of meaning and values and understanding. This is a dynamic process in which people are not in control of there's a reality of that. I wonder is there any place for an integration of or even indeed intention between sort of second wave and third wave approaches in CBT to these kinds of presentations. Stirling: Very definitely. I think firstly, we’ve always been using some of these third wave techniques. I think I'm going to be writing something for tCBT, for the Cognitive Behaviour Therapist updating the article I wrote on coping with adversity some years back and I’m thinking of calling it where coping with adversity where second and third waves meet because I think there's a danger that we throw out the second wave treatments, and just go for things like sort of mindfulness or ACT or something with people with sort of serious physical illnesses. And the second wave treatments can still help us because we know that, in terms of coping strategies, problem focused coping is one of the most effective coping strategies that people can use. So still being able to look at what are the problem areas that you're bringing, how can we help you do effective problem solving is going to be good for many people with early-stage disease and a good prognosis. We can do a lot of work around their catastrophic misinterpretations of what's going on and the possibility of they're coming to the conclusion that they're inevitably going to die when we have a lot of evidence against that. So all of those second wave can still be very helpful. And bringing in third wave things where you're facing, here's a problem that that can't be solved so how do I then manage this? And, I think there is sort of this rather false dichotomy between the two approaches and a treatment like Dialectical Behaviour Therapy very overtly actually deals with both. So the dialectic is actually we're about change and we're about acceptance. So bringing acceptance methods, I would be using mindfulness with most of the people with cancer. I introduce them to it as a way of accepting thoughts can be really helpful with the ruminations and worry and I'm increasingly using imagery as sort of based methods, which, now are they second wave or are they a third wave in the sense that I see them as more constructivist? They're not really about challenging the evidence, they're not about as sort of the positivist view of is this true or false, they're about can we create new realities here that are helpful to you. So yeah, so I would say yes, I think we can bring the two together. Rachel: And perhaps we've talked about, haven't we, another podcast which talks more in depth about this integration of second and third wave and there are all sorts of false dichotomies made and put out there. The idea that you can do second wave CBT without attending to someone's meaning and values seems to me like very bad CBT full stop but the idea that you wouldn't also formulate what things people can change in the third wave approaches also seems a very simplistic approach to helping anyone. I'm reminded of the serenity prayer as you're talking, this idea that the courage to change things I can, and the serenity to accept the things I can't. There's something about working across that space, isn't there? Stirling: Yeah, absolutely and the wisdom to tell the difference and that I think really sums up this this line of work. Rachel: And many of our listeners will be experienced at working with working with depression, anxiety using CBT, and you've talked about how perhaps the sort of direct treatment of this kind of area in transplanting that into Talking Therapies services might not be effective. There might be lots of reasons for that particularly around kind of understanding and pursuing the meaning of the cancer to individuals. Are there things that therapists should be aware of if they're trying to formulate and work with these presentations in the context of cancer and just trying to sort of wholesale transplant their skills across? Stirling: Yeah, so I think that the good news is that you have all the skills that you need. It's not that different working with someone with cancer and even someone with incurable cancer. So those as we've said those sort of maintenance factors are still there. You have this the skills, you have the Socratic questioning skills and so on. I think the first step is to really try to understand the person. So there's a danger that we get too caught up with the problem and get into problem solving too quickly. So firstly, really properly understanding what cancer means for this person and validating that experience for them that I think is a slight difference from how maybe you might be approaching some of these things in IAPT services sometimes. I think good therapists inevitably always treat the person. But, but remember that, this is a person who's going through a really often traumatic life experience, so that's one tip. The second one is really around empathy, and we'll talk a little bit more about this perhaps when we talk about how we look after ourselves, but you mentioned the existential issues in cancer and this is an area where actually we all have that existential issue of sorry to tell you Rachel, but you're going to die. Rachel: Now that comes as a shock to me, I thought I was the exception to the rule. Stirling: So that's universal and we spend a lot of our time pretending that we're not although intellectually we know we are, but when we're face to face with someone who perhaps is going to die or for whom that threat is very real, that can both activate our own issues about death, but we can also when we respond and relate to the person, we can get rather caught in thinking that we do understand what it's like for them. And so it's actually asking the silly question, what's so bad about dying? Because unless we understand that person what it's like, we can jump to the conclusions that we know. So that's one another area looking at your cognitive empathy. Are you really properly understanding what this person's experience and similarly in terms of a more emotional empathy. Am I getting dragged down by the sadness of this person's life because I can relate to it so well. Another tip is really thinking about how your behavioural activation work might need to be adapted if someone is physically less well. But again, this is something that in working with long term conditions people will be very familiar with. And then final tip on apparently realistic negative thoughts. And, I would suggest, a threefold approach to this. So, we can, first of all ask the question, to what extent is this true? What evidence do you have? So, that's our standard CBT question. That’s a more, that's a sort of a rational perspective on it. But another way that we also use a lot is to ask the question, is this helpful? So even if this thought is realistic, actually, is it helpful to you. So it may be for the person who's had thoughts about dying and is ruminating actually, those may be very accurate thoughts, but not that helpful. So can we help you to explore the pros and cons of this particular thought process or behaviour? And then the third approach is what I call the sort of more constructivist approach is, which regardless of if this is true or not, can we create alternative perspectives that might be more helpful for you? And, and there it's more being aware of perhaps times when the patient says things like, well, you know, it's brought my husband and I closer together and just asking that. Oh, well, how was that? How is that's happened? What have you learned there? And what's that told you about what’s important to you in life? How has that helped you to develop your strengths? which sort of steps outside of that Oh, I’ve got to find a negative thought and challenge it and actually we create new alternatives, it's building on people's strengths and the meaning that they give to life. Rachel: So it sounds like, you know, finding and amplifying the positives, not Pollyanna sort of, you know, invalidating way, but actually allowing people to, to notice in a sense, those things that are positive and meaningful to them, even in this negative place. I'm really struck listening to you about how every therapist might do well to do some of this work Because I'm often think when I'm, when we do these podcasts across different areas, there are lots of lessons to be learned that just make us better therapists. You know, there's things you've talked about, about really focusing in and understanding and validating the experience that the individual, whatever their problem is sitting in front of us, the thinking about, you know, how we empathise and not getting caught in kind of a false sense of cognitive empathy where we think we understand what they're doing, but really, searching for the individual meaning, and not getting caught up in our own thinking. And working on all those levels with negative thoughts, you know, is it realistic? Is it helpful? And are there other perspectives, other ways of looking at this even beyond that? And you did, you intimated that, one of the things, you know, we're concerned about on this podcast is about therapists looking after themselves for their own sake, as well as for that of their patients. And people might worry about their own emotional responses and resilience to this kind of work, particularly working with people who may be terminally ill or really in dark places and how that might interfere with their therapy. So being able to support those more balanced thoughts or helpful thinking or finding those positives or, you know, knowing that this is very real tragedy ahead for the individual getting lost in that. What's your advice for people approaching this work but concerned about their ability to contain the emotional content? Stirling: I think first thing really is to make sure that you're getting good supervision and that you feel safe to bring these issues to supervision. I think that having the third person's view on the relationship in therapy and what you're doing can help you to get that little bit of distance as well as support, noticing when you are getting sort of dragged in a bit too much to identifying. It’s always good, we don't do it very often, do we? But it's always good to actually look at our own negative thoughts sometimes and do a thought record and then I think if we do find ourselves getting very caught up with how terrible this person's experience is there might be some third wave strategies that might be quite helpful. There's a distinction that people sometimes make between empathy and compassion and between the idea of feeling with or feeling for and there's an interesting study that was done in which people were asked to imagine that they were experiencing the same thing as someone who was in a disaster or some traumatic event on the one hand. And then, as an alternative, people were asked to imagine what might it be like for that person. So there's a subtle difference, but even though those two sort of instructions were only subtly different, it made a difference to the extent to which the person, the imaginer, was distressed. So, when the subject was imagining I am this person, they had good empathy but they were also distressed. When they were imagining what might it be like for that person, they had pretty good empathy but were less distressed. And I think when we're using compassion type techniques to help people to do maybe a compassion meditation on the person's experience and helping them to sort of feeling for that person, that's what we're doing. There's also, sort of, an equanimity practice too that you can do in terms of imagining or just simple statements like, you know, I can't experience or change your pain. All I can do is what I can do to help relieve it. No matter how much I want,your pain is your pain. So it's actually helping people to separate out. And the third, that another, sort of third wave type technique, that you might use actually in the session is a brief sort of meditation that Kristin Neff, who's a self-compassion teacher uses which is breathing for yourself and for the other. So we recognise that I'm here with someone who's really in a very sad state. They've just got been given news that there's no more active treatment, for instance. Yeah. And so we simply do, one breath for them and then one breath for me, because actually I'm suffering too in being with you because I'm a human being. I relate to you. I understand to some degree how horrible that must be and so that's horrible for me too. So we say one for me and one for you So it might be breathing in one for me and one feeling for you, one sense of compassion for you helping to both ground you and recognise that it's okay to be upset in this situation rather than trying to force yourself to be always a therapist who is unmoved by the people you're working with. Rachel: And that word you just used moved is quite moving, even hearing about those, there's different approaches actually, and how they might help us both hold that empathic space but hold our own space so that we can be there for the client and not stepping too far into their pain so that we can't actually help them, support them with that pain. In other ways these problems can affect us. We know as we stand up at the top of the podcast, you know, one and two people, suffer or will suffer from cancer at some point in their life. Therapists are very likely to either suffer themselves or have friends, family members, colleagues, acquaintance who are suffering from cancer at any given moment. How would you advise therapists working with patients with cancer whilst also potentially dealing maybe with their own symptoms or in relationship with people in their personal lives with cancer and they're finding that challenging? Stirling: I think we have to look after ourselves. So it may be that if you have someone close to you who has cancer and that is very upsetting for you, it may be it's wise not to take on a cancer patient and obviously if you're working in a cancer setting that's not possible. But if you're working in other settings, I think that you know, we need to set some boundaries sometimes for ourselves. So that's one thing to bear in mind. If you're working in a cancer setting or, you have to take on the patient who has cancer, then I think from a cognitive perspective, it can be helpful to really do some sort of what you might call stimulus discrimination. So discrimination between how their experience is not the same as my experience. So it may be, so again, we jump to those conclusions that this is the same that if they've got a poor prognosis, then my family member has a poor prognosis. Well, it may be the case, but let's actually check that out so that we remain with a rational perspective of just how much is this resonating, that's another way. I think that, it’s about, then also this, I think, for, anyone working with cancer is being able to maybe compartmentalise a little bit and to say actually, when I'm going back to the home situation, that's going to be different from what I'm doing in the therapy situation which and that means sort of looking after ourselves because as a therapist we have responsibility for the other person, as a family member we don't have the same responsibility and we maybe have to be clear about what is my role here. I'm not necessarily I may be in a position of having to look after this person, but I may not be and I shouldn't make the assumption that I have full responsibility for this person's well-being. Rachel: And I’m just aware of a couple of really inspiring colleagues who sadly in the past, recent history have passed away with cancer themselves, you know, notably Hannah Murray, who I know was celebrated at the most recent BABCP conference, who did such amazing work in PTSD through her diagnosis and a colleague of mine in the Ministry of Defence, Jonathan Young, who gave some very inspiring talks and insights into his own experience with cancer as he was going through it was really drew a lot of meaning and value from what he could give the insights that he could provide and the reflections that he had during that time. And a real gift of that to his colleagues. And I know both of those individuals as will many more that we maybe don't know of go unsung, do work through these difficult scenarios and find tremendous value in continuing to do the work that inspires them. And that has so much meaning for them in terms of helping other people. Stirling: Yes and I think a lot of people a lot of people do that. As we've said it depends, everyone has their own way of coping and so I think. For many, therapists and professionals actually continuing to work, that, when we started our, we started our work Beck came and gave us a, a sort of a, an informal seminar. And I always remember one of the phrases he says is you can't control your death, but you can control your life. And so I think that many people continue working because that gives their life meaning, it's valuable but some other people may choose actually not to. They may say actually what I value in life is something different and so I’m going to give up work and do something different. So we again, it's that it's finding the meaning for you that is most helpful and as we've said that people may find that having the diagnosis of cancer makes them re-evaluate what's important to them. I think that often people in the helping professions recognise that actually helping people is what's important to me. So I'm going to continue doing that. But if you were working as a hedge fund manager, you might have a different attitude towards your work if you had cancer. Rachel: Not that we would like to suggest on this podcast that isn't a very valuable role in society. One of the wonderful things about being a therapist that we often reflect on in this podcast is the opportunity we have to see into the very intimate details of individuals lives. And, you know, at this moment where people are taking stock of what is important to them or grappling with these big questions in life, I'm wondering what you might have learned from the people you've worked with over the years or how that might've made a personal difference in your life. Stirling: Yes. I think working with any patients, we can find things that are inspiring but it's I think the courage that people with cancer has that is always, most I know it's quite moving that when the chips are down, people rise to the occasion. They may not have thought that they would, but they do. And seeing that, I think, for me, has always been very inspiring. I'm thinking of the, I don't see many patients individually now. I've mainly doing supervision and teaching, but the last person I worked with who was had incurable cholangiocarcinoma and what I found really very, moving about was that he was able to, actually say, I've lived my life. I've got no regrets about the way I've lived my life. I've achieved the things that I wanted to achieve. Maybe there were other things that I wanted to go on to achieve, but that he said that having cancer, actually made him, grateful for everything he had and jokingly he said that for the first time having been a cis-white male, he was experiencing what it was like to be in a minority, in a minority group. And the fellow feeling he had sitting in the waiting room with other people that we're actually, we're all in this together. And he was so positive that he- I asked him and he made a whole list of ways in which cancer had enriched his life which you know was absolutely incredible and he felt that by using one of the biggest shifts that he felt that he wasn't you know, particularly it was more of a meeting from time to help him with coping strategies rather than a treatment for a psychological disorder, but we did some mindfulness together and the key shift for him, I think, was in thinking that he said that, by being in the present moment, I can appreciate what I have now with a recognition that actually things are going to change in the future. So it brings an even greater appreciation of being pain free right now, without then ruminating about the pain that might come. So, that was very inspiring. And, I think I'm sure, I think he would be okay about me sharing one of the interventions that we used, because he was okay about me sharing these things, but He had a memory of his mother's death and of her being in pain, he wasn't sure whether she was conscious or not, and he wasn't so his interpretation was that she was in great distress. She was also very frail and had lost a lot of weight and this was sort of feeding into his own fear of his own death. And that he would inevitably die in a distressed state, and he had considered, if he could go into Dignitas or something like that because of his family. So first of all, we did some, more straightforward cognitive work around what evidence he had that actually she was in distress. And the fact is that it's much more a mind reading, we don't know if that person is aware or conscious or not, but we make the assumption that actually they're suffering. And so it’s difficult to hold that uncertainty, but we don't, we don't know that. And then we did some imagery work around his mother and the image that he chose was He had a memory of her being lost a lot of weight. He carried her somewhere and he had an image of lifting her and holding her in his arms and loving her and amazingly that image then transformed his own view of his own death. So his fear of death he said just went, I don't know how much that's true, but I think that's sort of illustrates you know just the power of imagery but also his capacity to engage with and use that to really transform, so I think he was a very inspiring man. Rachel: absolutely sounds like an inspiring man and, you know, really, it's really inspiring hearing about that work and understanding even that, you know, the worst things we can imagine, or the things that have the worst meaning for us can be transformed in terms of their emotional content when we get that different perspective on them and get what we need in those moments. I'm almost struggling to move on from that. I'm so, so, so struck by that image, but we have done a whistle stop tour of this today, Stirling, at many points, we've said that these would be whole days of workshops, lots to learn. If people do want to learn more about this work, where can they access training? Stirling: Well there aren't sort of formal training programs. I think that Kath Mannix is doing some training, but it's it tends to be more around professionals working in palliative care. So, looking up her name, you'll find stuff on that. I do periodically workshops for BABCP and if you're in a Talking Therapy service, then quite often I will do a one day top up for people on the long term conditions services. If services want to commission me to do an online or face to face workshop, they could always do that. And although our book is quite old in some ways now, it's about 12 years since we published the last edition. people still find it quite helpful; I think. So that's, I would, direct them to have a look at Cognitive Therapy, Oxford Guide to Cognitive Therapy for People with Cancer, still. Still in print, I think. Rachel: And we'll put that link in the show notes for people to be able to access us. I guess one of the things we've, that has been a theme of today is the fact that there is so much more to learn, so much more research to be done around the specificity of what helps, what those effects are and also in terms of training and disseminating this treatment, you know, and hopefully, you know, where we started was with you saying that you got interested in the area because there was some momentum and impetus behind researching this, but it sounds like that, that needs to keep going, that there are lots of future avenues to explore. So thank you so much, Stirling. And in CBT we like to summarise and think about what we're taking away from each session. So in time honoured fashion, what key message would you like to leave folk with regarding working with CBT with cancer. Stirling: Well, I think the key message is you have all the skills already, they just need to be perhaps tweaked a little bit for working with people facing a life-threatening illness. The important thing is to really understand the person in front of you rather than the problem they're bringing. And if you have that at the forefront of your mind then I think it will make it much easier to engage with and work with them. And two don't make assumptions about what they're feeling, how they're feeling it, how terrible their life might be, find out, and you often find that people have the strengths and resources to cope with this. But you just need to help them unlock them. Rachel: Wow. So, CBT is about working with people, not problems and meaning is key. Thank you so much for your time today it's been really fascinating talking to you and I think, whether people are working in this area or really quite unconnected areas in CBT, I think there's something to learn from what you've told us about the processes, the understanding, the interventions and these wonderful examples from working with your patients as well. So thank you so much. And to our listeners, thank you as always for the work you do. And until next time, look after yourself and look after each other. Thank you. Stirling: Thank you Rachel: Thanks for listening to another episode and being part of the Practice Matters Therapist community. You can find useful links and references relating to each podcast in the show notes. If you have any questions or suggestions of what you would like to hear about on future Practice Matter podcasts, we would love to hear from you. Please email the Let's Talk About CBT team That's You can also follow us on X and Instagram @BABCPpodcasts. 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