Psycho-oncology

1. Introduction

Version followed: NCCN Distress Thermometer and Problem List (NCCN form, Version 1.2025, and NCCN Guidelines for Patients: Distress During Cancer Care) with an Ontario clinical-practice summary; the NICE (2004) four-level model of psychological support as set out in a 2017 NHS West of Scotland referral guidance draft; CALM as described in Rodin et al. (2018, J Clin Oncol) and Malfitano, Hales and Rodin (2022); Individual Meaning-Centered Psychotherapy (IMCP) as specified in the MSKCC trial protocol (IRB 11-021, approved 2017); ConquerFear as reported for the Butow et al. (2017, J Clin Oncol) trial, with session content taken from the City of Hope adaptation "Conquer Fear SUPPORT" (protocol dated 10/12/2020); paediatric care following the Psychosocial Standards of Care for Children With Cancer and Their Families (Pediatric Blood & Cancer supplement, December 2015).

Psycho-oncology is a field and a service framework, not a single therapy. It is the psychological, social and spiritual care of people affected by cancer (patients, partners, families, children, bereaved relatives), delivered alongside oncology care. In practice it combines (1) routine distress screening, (2) stepped psychological care matched to need, and (3) specific manualised psychotherapies for defined problems, such as CALM for people with advanced cancer, Meaning-Centered Psychotherapy for loss of meaning and hope, and ConquerFear for fear of cancer recurrence. [source: Use of the Distress Thermometer in Clinical Practice; WoSCAN Psychological Therapies Referral Guidance; Rodin et al. 2018]

What it does not do. No psychological method in this guide treats cancer. It does not shrink tumours, prevent recurrence, prolong survival or replace surgery, radiotherapy, systemic therapy or any other medical treatment. Its aims are to reduce distress, depression, anxiety and fear; to support coping, decision-making, communication with the oncology team, relationships and meaning; and to help people prepare for the end of life. Say this explicitly to clients, families and referrers, especially where a client hopes that mood, attitude or "fighting spirit" will control the disease. [synthesis]

How change is understood. NCCN defines distress as a multifactorial unpleasant experience with psychological, social, spiritual and/or physical dimensions, ranging from normal feelings of vulnerability to disabling problems such as depression or existential crisis [source: Use of the Distress Thermometer in Clinical Practice]. Change happens through early detection and matched care; through a relationship that provides a reflective space in which a person can acknowledge the realities of illness while still living (CALM) [source: Rodin et al. 2018; UHN "Keep CALM to Find Peace"]; through reconnecting with sources of meaning despite limitation (IMCP) [source: MSKCC IMCP protocol]; and through changing the person's relationship with worry and uncertainty rather than trying to eliminate the risk (ConquerFear) [source: City of Hope CFS protocol].

2. Framework

2.1 The care pathway

Screen every patient for distress at the first visit soon after diagnosis and at later visits, with extra attention at remission, recurrence, progression and referral to palliative care. Patients rate distress over the past week on a 0–10 thermometer and tick a Problem List covering practical, family, emotional, physical and spiritual or religious concerns. [source: Use of the Distress Thermometer in Clinical Practice]
Triage by score and Problem List. A score of 4 or higher prompts further assessment; the summary reports that different cut-offs have been used in some populations and at some time points (for example, a lower one in the first month after diagnosis). Use the cut-off your service has adopted. [source: Use of the Distress Thermometer in Clinical Practice] A peer-reviewed nursing study reports that recent NCCN guidelines treat a score of 4 or higher as moderate to severe distress (the original cut-off was 5), and that lower cut-offs such as 3 have been proposed, especially in the first weeks after diagnosis [source: Cutillo et al. 2017]. NCCN's current form and patient guide do not print a cut-off; the patient guide says the cancer care team often manages mild distress itself, by explaining that distress is normal, giving cancer education and teaching new ways to cope, and refers on to chaplains, social workers or mental health providers as needed [source: NCCN Guidelines for Patients, Distress During Cancer Care].
Match to a level of care (NICE four-level model) and to the right profession: psychologist or psychotherapist, social worker, chaplain, psychiatrist, palliative care, or community resources, taking account of what the patient prefers. [source: WoSCAN Referral Guidance; Use of the Distress Thermometer in Clinical Practice]
Deliver the intervention that fits the problem (sections 2.3 and 4).
Document, feed back to the team and rescreen at later visits. [source: Use of the Distress Thermometer in Clinical Practice]

2.2 The four levels (NICE 2004, as applied in NHS guidance)

Level 1. All cancer staff. For mild or recent worry and for information needs about decisions. Assessment is informal recognition. Interventions are information, compassionate communication, emotional support, listening, peer and group support, complementary therapies, and signposting.
Level 2. Staff with additional psychological expertise. For moderate or persisting worry, symptoms such as pain or fatigue that are affecting quality of life, and mild adjustment difficulties. Assessment is distress screening (for example, a needs assessment or GAD-7). Interventions are active listening, facilitated groups, stress management, problem solving, relaxation, and structured programmes such as mindfulness-based stress reduction.
Level 3. Trained and accredited psychological therapists. For significant mood problems (depression, anxiety or panic, anger, hopelessness, suicidal ideation), treatment-related problems (procedural distress, feeling overwhelmed, distress that blocks engagement with treatment) and difficulties adjusting after treatment. Assessment is a semi-structured interview. Interventions are counselling and specific psychological therapies.
Level 4. Counselling or clinical psychologists, or psychiatrists. For more complex needs: living with uncertainty such as intrusive fear of recurrence, adjustment to changes in the body or sexual functioning, facing mortality, and decisions to end active treatment. Assessment is a clinical interview and formulation, including attention to severe distress or psychopathology. Interventions are formulation-driven specialist psychological or psychiatric care, including systemic work.

[source: WoSCAN Psychological Therapies Referral Guidance]

Moving up a level. Staff at every level signpost upwards when needed. The guidance suggests considering Level 4 if any one of these applies: previous mental health history; other recent stressful events; significant hopelessness, suicidality or self-harm; complexity that needs substantial multidisciplinary liaison; trauma-like intrusive thoughts or images about cancer; and the person is motivated to work with a psychological therapist. [source: WoSCAN Psychological Therapies Referral Guidance] Moving down or ending: distress has fallen below the service cut-off on rescreening, the agreed goals have been met, and the person knows how to come back at later transitions. [synthesis]

2.3 Specific programmes: format and session count

Programme	Who it is for (as studied)	Format	Sessions
CALM	Advanced cancer, expected prognosis of roughly 12–18 months in the trial	Individual, semi-structured; primary caregiver may join one or more sessions; outpatient, telephone or inpatient palliative unit	3–6 sessions over 3–6 months, at least monthly in the first 3 months, 45–60 min
IMCP	Advanced solid tumours, ambulatory	Individual; didactic content, discussion, experiential exercises, readings, homework	7 weekly sessions of about 1 hour, flexible within about 14 weeks
ConquerFear (original)	Survivors of curable breast or colorectal cancer or melanoma with clinically significant fear of recurrence	Individual, face to face	5 sessions of 60–90 min
Conquer Fear SUPPORT (adaptation)	Advanced lung or gynaecological cancer, fear of progression	First session in person, then video	7 sessions over 8 weeks, about 45–60 min, with home practice

[source: Rodin et al. 2018; MSKCC IMCP protocol; ASCO Post report on Butow et al. 2017; City of Hope CFS protocol]

Who delivers. CALM trial therapists were master's-level social workers and psychiatrists; the authors state psychologists and clinical nurse specialists can deliver it after training (a 2-day workshop, at least two supervised cases, and ongoing supervision with audio review). IMCP trial therapists had at least a master's degree in mental health counselling, social work or psychology, with workshop training, boosters and supervision. Conquer Fear SUPPORT was delivered by trained advanced practice nurses under psychologist oversight. [source: Rodin et al. 2018; MSKCC IMCP protocol; City of Hope CFS protocol] Formal certification in these programmes runs through their developers; check current training routes with them. [uncertain: current training availability not verified]

Choosing among programmes [synthesis]: high distress with advanced disease → CALM. Demoralisation, loss of meaning, or desire for hastened death with intact cognition → IMCP. Disproportionate fear of recurrence or progression, with checking, reassurance-seeking or avoidance of follow-up → ConquerFear. A major depressive episode, panic disorder, PTSD or substance problems → evidence-based treatment for that disorder, adapted to the medical context, plus a psychiatric review if indicated. Delirium, cognitive impairment or uncontrolled symptoms → medical or palliative review first.

3. Guiding principles

Psychological care runs alongside cancer care and never replaces it. You never imply that a mental state causes, cures or controls cancer. [synthesis]
Distress is expected, not pathological, and is screened routinely. Normalise it, measure it, and act on it. [source: Use of the Distress Thermometer in Clinical Practice]
Match care to need (stepped care). Offer the least intensive level that fits, and move up promptly when the criteria are met. [source: WoSCAN Referral Guidance]
Patient preference guides referral. Ask which kind of help the person wants (psychological, social work, spiritual or community) before referring. [source: Use of the Distress Thermometer in Clinical Practice]
Acknowledge the realities of illness. Talk directly about disease, prognosis and dying when the person is ready, rather than reassuring them falsely. [source: Rodin et al. 2018]
Double awareness. Help the person live as fully as possible while also preparing for the end of life; neither denial nor giving up is the goal. [source: UHN "Keep CALM to Find Peace"]
Flexible, tailored, relational stance. Shift between supportive, exploratory and problem-solving work as health and energy allow; respond genuinely; keep professional boundaries; make interpretations collaboratively. [source: Rodin et al. 2018]
Regulate affect. Pace emotional intensity so that sessions open feelings without overwhelming a physically ill person. [source: Rodin et al. 2018; Malfitano, Hales and Rodin 2022]
Meaning remains available despite limitation. Meaning can be found in legacy, attitude, creativity and responsibility, and in experiences of love, beauty and humour (IMCP's framework, which draws on Frankl). [source: MSKCC IMCP protocol]
Change the relationship with worry, not the risk. In fear of recurrence, the target is worry processes, beliefs about worry, checking, and values-based living, not certainty about the future. [source: City of Hope CFS protocol]
Include the family system. Partners, caregivers, children and siblings are affected and may be invited into sessions with the patient's agreement. [source: Rodin et al. 2018; Psychosocial Standards (ecancer report)]
Collaborate with the oncology team. Communicate findings, flag medical red flags, and keep psychosocial and medical providers in open communication with patients and families. [source: Psychosocial Standards (ecancer report); Rodin et al. 2018]
Respect autonomy in treatment decisions, including decisions to decline treatment, while making sure decisions are informed. Your role is to explore and support informed choice, never to steer for or against a medical treatment. [synthesis]
Flex the frame for illness. Allow telephone or video sessions, bedside sessions, shorter sessions and breaks in the schedule during treatment or deterioration. [source: Rodin et al. 2018; MSKCC IMCP protocol]
Developmentally appropriate care for children. Involve children at their level of understanding, seek their assent alongside parental consent, and attend to safeguarding. [synthesis]

4. Intervention inventory

The inventory runs in pathway order: A. screening, assessment and collaboration; B. CALM; C. Meaning-Centered Psychotherapy; D. fear of recurrence (ConquerFear); E. couples, family, survivorship, end of life and bereavement; F. children with cancer and their families; G. unproven alternative cancer treatments. Example language is illustrative unless quoted.

A1. Distress screening with the Distress Thermometer and Problem List

Purpose / when: routine detection of distress at diagnosis, at every later visit, and at key transitions (remission, recurrence, progression, palliative referral). [source: Use of the Distress Thermometer in Clinical Practice]
Steps: (1) Use the licensed NCCN form your service holds; do not recreate it. (2) Ask the patient to rate distress over the past week, including today, from 0 (no distress) to 10 (extreme distress) [source: NCCN Distress Thermometer form, Version 1.2025]. (3) Ask them to mark the Problem List items that apply; the current form groups them as practical, social, emotional, physical, and spiritual or religious concerns, plus "other" (older versions had a family section) [source: NCCN Distress Thermometer form, Version 1.2025]. (4) Apply the service cut-off (commonly 4 or above [source: Cutillo et al. 2017]) to decide on further assessment. (5) Go through the ticked items with the patient. (6) Agree referrals that match both the problems and the patient's preference. (7) Document the result and rescreen at later visits. [source: Use of the Distress Thermometer in Clinical Practice]
Example language (illustrative): "We ask everyone this at each visit, because cancer affects much more than the body. On a scale from 0 to 10, how much distress have you felt this past week? Which of these areas has been hardest?"
Watch for: the word "distress" may not translate well across languages, literacy levels or cultures, so explain it in plain words or use an interpreter [source: Use of the Distress Thermometer in Clinical Practice]. A low score with a ticked item such as worry, sadness or hopelessness still needs a conversation, as does a score that keeps rising [synthesis]. Working if: every distressed patient leaves with a named next step, and repeat scores fall.

A2. Level allocation and referral (stepped care)

Purpose / when: after screening, or whenever needs change.
Steps: (1) Compare the presentation with the level criteria (section 2.2). (2) Screen for Level 4 indicators: prior mental health history, recent other stressors, hopelessness, suicidality or self-harm, complexity that needs multidisciplinary liaison, trauma-like intrusive images, and the person's motivation. (3) Discuss the referral with the care team. (4) Refer and tell the patient what will happen and when. (5) Signpost practical help (finances, transport) to social work. [source: WoSCAN Referral Guidance; Use of the Distress Thermometer in Clinical Practice]
Example language (illustrative): "From what you've said, the worry has gone on for months and is keeping you from sleeping. I'd like to offer you sessions with someone who specialises in this. Would that suit you, or would you prefer something else first?"
Watch for: over-referral of normal sadness, under-referral of quiet hopelessness, and referrals with nowhere to go. Map your local services in advance. [synthesis]

A3. Level 1–2 supportive care: information, listening, problem solving, relaxation

Purpose / when: mild to moderate distress, information needs, and early adjustment. [source: WoSCAN Referral Guidance]
Steps: (1) Ask what the person already understands and what they want to know. (2) Listen actively and reflect feelings. (3) For practical stressors, use a structured problem-solving sequence: define the problem, generate options, choose one, plan it and review it [synthesis]. (4) Teach a simple relaxation or breathing practice, or refer to a facilitated group or mindfulness-based programme. (5) Signpost peer support. [source: WoSCAN Referral Guidance]
Example language (illustrative): "Let's pick just one of these worries, the one that's loudest this week, and see what's in your control."
Watch for: relaxation can increase awareness of pain or breathlessness in some patients; offer alternatives such as an eyes-open practice [synthesis]. If distress persists, step up a level.

A4. Specialist assessment and formulation (Levels 3–4)

Purpose / when: before any specific therapy, and whenever the picture changes.
Steps: (1) Get the medical context with the patient's consent: diagnosis, stage, treatment intent (curative or palliative), current treatments, symptoms and prognosis as the team has communicated it [synthesis]. (2) Take a semi-structured psychological history, including previous mental health problems and recent stressors. (3) Screen for depression, anxiety and panic, trauma-like symptoms, demoralisation, substance use and cognitive change. (4) Assess risk (A5). (5) Assess the family and social system, and spiritual concerns. (6) Write a formulation linking illness factors, personal history and maintaining processes. (7) Agree goals and choose the intervention. [source: WoSCAN Referral Guidance (interview and formulation at Levels 3–4); other steps synthesis]
Example language (illustrative): "Before we plan anything, I'd like to understand what the doctors have told you and what that means to you, as well as what life was like before all this."
Watch for: symptoms that may be medical rather than psychological (fatigue, poor appetite, poor concentration, agitation, sudden confusion that may be delirium, effects of steroids or other treatments). Refer for medical review and do not attribute them to mood without that check. [synthesis]

A5. Suicide risk, hopelessness and desire for hastened death

Purpose / when: hopelessness, suicidal ideation and self-harm are Level 3–4 indicators [source: WoSCAN Referral Guidance]. Ask whenever mood is low or the person expresses wanting it to be over.
Steps [synthesis, standard practice]: (1) Ask directly about suicidal thoughts, intent, plans, preparations and past attempts. (2) Distinguish passive wishes for death, a wish for hastened death driven by uncontrolled symptoms or fear of the dying process, and active suicidal intent. (3) Explore drivers: pain, breathlessness, fear of dependency, feeling a burden, depression, demoralisation. (4) Urgently communicate uncontrolled symptoms to the medical or palliative team. (5) Make a collaborative safety plan: warning signs, coping steps, people to contact, and crisis contacts. (6) Counsel on lethal means: with the team and family, arrange safe storage of medicines kept at home and removal of other means. (7) Follow local procedures for urgent psychiatric assessment when risk is high. (8) Where assisted dying is legal and the person raises it, explore the request, respond within your local law and professional guidance, and liaise with the team. [uncertain: jurisdiction-specific rules not verified]
Example language (illustrative): "Many people in your situation have moments of wishing it were all over. Have you had thoughts like that? Have you thought about ending your life?"
Watch for: sudden calm after deciding, stockpiling medicines, giving away belongings, and new isolation. Desire for hastened death often falls when symptoms are controlled and meaning work begins (C1–C8). [synthesis]

A6. Psychoeducation: what psychological care can and cannot do

Purpose / when: at the start of any psychological work, and whenever a client links mood or attitude to survival.
Steps [synthesis]: (1) Name the aims of the work (less distress, better coping, relationships, meaning, decision support). (2) State plainly that psychological work does not treat the cancer or change its course. (3) Remove blame: neither stress nor "negative thinking" earns or causes cancer, and nobody needs to be positive all the time to get the best from treatment [uncertain: causal evidence not reviewed here]. (4) Explain how distress screening and support fit with the oncology team.
Example language (illustrative): "I want to be clear: what we do here won't treat the cancer itself. Your medical team does that. What we can work on is how you're coping, sleeping, talking with your family and making decisions."
Watch for: relief, which suggests the client was carrying a burden of "thinking positively", or disappointment, which suggests they hoped therapy would heal the disease; explore either. [synthesis]

A7. Supporting communication with the oncology team and shared decision-making

Purpose / when: confusion about the disease, difficulty asking questions, weighing treatment options (CALM domain 1 covers these). [source: Rodin et al. 2018]
Steps: (1) Ask what the person understands about their disease and treatment. (2) Clarify what they still want to know, and how much. (3) Help them write down questions and priorities for the next appointment [synthesis]. (4) Rehearse how to raise a concern, ask about the aim of treatment, or ask for a second opinion [synthesis]. (5) Explore values and fears behind a decision without recommending an option. (6) With consent, pass relevant concerns on to the team (A8).
Example language (illustrative): "What would you most like to ask your oncologist next week? Let's write it down in your words."
Watch for: your own views influencing a medical choice. Your task is to make sure the decision is informed and the person's own; the medical facts come from the team. [synthesis]

A8. Collaboration and liaison with the oncology team

Purpose / when: throughout. The paediatric standards include establishing communication and collaboration among medical and psychosocial providers, patients and families [source: Psychosocial Standards (ecancer report)]; CALM therapists can trigger social work, psychiatric and palliative care input [source: Rodin et al. 2018].
Steps [synthesis]: (1) Agree at the outset what will be shared with the team and get the client's consent. (2) Attend MDT or psychosocial meetings where your role allows. (3) Write brief, jargon-free notes: problem, risk, plan, and what you need from the team. (4) Flag medical red flags promptly: new or uncontrolled pain, breathlessness, confusion or delirium, suspected treatment side effects, and signs of recurrence the client reports. (5) Request a psychiatric review when severe depression, psychosis, delirium or a medication question arises; do not advise the client on medicines.
Example language (illustrative): "You've mentioned the pain is keeping you up every night. I'd like to let your nurse specialist know today. Is that alright?"
Watch for: splitting (the client tells you things they will not tell the team) and role drift into medical advice.

B. CALM (Managing Cancer And Living Meaningfully)

CALM is a brief, semi-structured, manualised individual (or couple-based) psychotherapy for people with advanced cancer. It draws on supportive-expressive, relational, attachment and existential theory, and aims to support affect regulation, attachment security and reflective functioning. The four domains below are not a fixed sequence: the therapist follows what matters most to the patient, and most courses touch all four. [source: Rodin et al. 2018; Malfitano, Hales and Rodin 2022] The manual itself has not been consulted for this guide, so the steps under each domain are illustrative ways of working within the published domain content and processes [synthesis].

B1. Establishing the CALM frame

Purpose / when: first session, for a patient with advanced disease and distress.
Steps: (1) Explain that there will be roughly 3–6 sessions over 3–6 months, tailored to the person's health, and that sessions can move to telephone or the ward if needed [source: Rodin et al. 2018]. (2) Ask which concerns are most pressing [synthesis]. (3) Offer to invite the primary caregiver to one or more sessions if the patient wants this [source: Rodin et al. 2018]. (4) Agree what will be shared with the oncology and palliative teams [synthesis].
Example language (illustrative): "These sessions are a space to think about what you're going through, both the practical side and the bigger questions. We'll go at your pace and fit around your treatment and how you're feeling."
Watch for: fatigue and symptom burden; shorten sessions rather than cancel. Working if the person uses the space to reflect rather than only to report. [synthesis]

B2. Domain 1. Symptom management and communication with health care providers

Purpose / when: confusion about the illness, passivity or conflict in care, difficult treatment decisions. Content includes understanding the disease, active involvement in care, weighing treatment options and communicating with clinicians. [source: Rodin et al. 2018]
Steps [synthesis]: (1) Explore the person's understanding of the illness and how they learned it. (2) Identify gaps and unasked questions. (3) Explore feelings about the care team. (4) Problem-solve communication (A7). (5) Link to symptom control through the team rather than managing symptoms psychologically alone.
Example language (illustrative): "How did you find out the cancer had spread? What did you make of what they told you?"
Watch for: protective non-asking ("I don't want to know"); respect it, while checking whether this is a choice or fear.

B3. Domain 2. Changes in self and relationships with close others

Purpose / when: loss of roles, self-worth, regrets, strain in relationships, fear of dependency and loss of autonomy, difficulty giving or receiving support. [source: Rodin et al. 2018]
Steps [synthesis]: (1) Invite a life history: who the person has been and what they have valued. (2) Explore how illness has changed identity and roles. (3) Explore attachment patterns in giving and accepting care, for example the self-reliant person who cannot accept help. (4) Work on renegotiating roles and support with partner and family, possibly in a joint session (B6). (5) Address regrets and disappointments, and what might still be repaired.
Example language (illustrative): "You've always been the one who looks after everyone. What is it like to need looking after now?"
Watch for: shame about dependency, which often shows up as refusing help; and grief for the former self. Working if the person can name what they need from others.

B4. Domain 3. Spirituality, sense of meaning and purpose

Purpose / when: questions of why, loss of purpose, spiritual distress. Content includes spiritual beliefs, the personal meaning of suffering and dying, reviewing priorities and goals, and building new meaning. [source: Rodin et al. 2018]
Steps [synthesis]: (1) Ask about beliefs and practices, religious or not, and whether they help now. (2) Explore what illness has meant to the person. (3) Review priorities for the time ahead. (4) Identify sources of meaning still available. (5) Offer chaplaincy or a faith leader if the person wants it.
Example language (illustrative): "What has given your life meaning? Is that still there for you, or has it changed?"
Watch for: imposing your own frame of meaning, and spiritual struggle (feeling punished or abandoned) that may need chaplaincy input.

B5. Domain 4. Mortality and future-oriented concerns (double awareness)

Purpose / when: fears about dying, need for advance care planning, tension between hope and realism. Content includes hopes and fears about living and dying, expressing sadness and anxiety, feelings about death, advance care planning, and sustaining realistic hope while acknowledging mortality. [source: Rodin et al. 2018] The aim of double awareness is to live as well as possible while also planning for end of life. [source: UHN "Keep CALM to Find Peace"]
Steps [synthesis]: (1) Ask permission to talk about the future and dying. (2) Explore specific fears, for example pain, breathlessness, being a burden, the moment of death, or what happens to loved ones. (3) Separate fears that can be addressed (symptom control, place of care) from those that need to be borne. (4) Support advance care planning conversations with the team and family. (5) Explore what the person still hopes for, near and far. (6) Hold both: "and" rather than "but".
Example language (illustrative): "It sounds like part of you is planning for next summer and part of you is wondering whether you'll be here. Both of those can be true."
Watch for: pushing a person to accept death on your timetable; and collusion with total avoidance when decisions are urgent. Working if the person can move between hope and preparation without collapsing into either.

B6. CALM caregiver session(s)

Purpose / when: when the patient agrees, the primary caregiver joins one or more sessions to offer another perspective and to address strengths and strains in the couple relationship, the illness's effect on the family, and future planning. [source: Rodin et al. 2018; Malfitano, Hales and Rodin 2022]
Steps [synthesis]: (1) Agree with the patient beforehand what they want from the joint session. (2) Invite each person's view of how they are coping as a pair. (3) Name strengths. (4) Gently surface unspoken worries, often the same fears held separately to protect each other. (5) Discuss practical and future planning together. (6) Signpost caregiver support.
Example language (illustrative): "I wonder if you've each been trying to protect the other by not saying how scared you are."
Watch for: a caregiver who dominates or a patient who stops speaking; balance airtime and meet separately if needed.

B7. Ending CALM

Purpose / when: after the course or as the person's health declines.
Steps [synthesis]: (1) Review what has changed across the domains. (2) Plan ongoing support (palliative care, social work, caregiver support). (3) Leave the door open for booster contact. (4) If death is near, say goodbye explicitly if the person wishes.
Example language (illustrative): "What would you like to take with you from our conversations?"
Watch for: your own avoidance of endings with dying clients; take this to supervision.

C. Individual Meaning-Centered Psychotherapy (IMCP)

IMCP is a flexible 7-session individual intervention combining didactic content, discussion and experiential exercises on meaning in advanced cancer, with assigned readings (including Frankl's Man's Search for Meaning) and homework tied to each session's theme. [source: MSKCC IMCP protocol] The session titles below are from the trial protocol; the treatment manual (Oxford University Press) has not been consulted here [uncertain: not verified], so the steps under each session are illustrative ways of working with that theme [synthesis]. Follow the published manual where you have it.

C1. Session 1. Concepts and sources of meaning

Purpose: introduce the idea that meaning remains possible despite illness, and get to know the person.
Steps [synthesis]: (1) Hear the cancer story briefly. (2) Introduce the framework of sources of meaning (historical, attitudinal, creative, experiential). (3) Invite one or two moments when life felt most meaningful. (4) Set reading and reflection homework.
Example language (illustrative): "Tell me about a time when life felt especially meaningful to you, when you felt most alive."
Watch for: a wish to talk only about symptoms; acknowledge this, then return to the theme gently.

C2. Session 2. Cancer and meaning: identity before and after diagnosis

Purpose: explore how cancer has affected identity and what remains of the self. [source: MSKCC IMCP protocol (title)]
Steps [synthesis]: (1) Invite the person to describe who they were before the diagnosis, through roles, values and qualities. (2) Explore how cancer has changed those. (3) Separate what has been lost from what endures.
Example language (illustrative): "If you list who you are – roles, qualities, things you care about – which of those has cancer touched, and which are still entirely yours?"
Watch for: grief surfacing strongly; slow down and allow it.

C3. Session 3. Historical sources of meaning: legacy (past, present, future)

Purpose: connect with the life already lived as a source of meaning, and with what will continue. [source: MSKCC IMCP protocol (title)]
Steps [synthesis]: (1) Explore formative relationships and memories. (2) Identify achievements and what the person is proud of. (3) Explore what they want to pass on. (4) Introduce the Legacy Project (C8).
Example language (illustrative): "What has your life given to the people around you that will stay with them?"
Watch for: regrets and unfinished business; note these for C5.

C4. Session 4. Attitudinal sources of meaning: encountering life's limitations

Purpose: explore the freedom to choose one's stance toward suffering and limitation that cannot be changed. [source: MSKCC IMCP protocol (title)]
Steps [synthesis]: (1) Name the limitations the person faces. (2) Explore how they have met adversity before. (3) Explore what attitude they want to bring to this, and to dying. (4) Discuss what a good or meaningful death might mean to them, if they are willing.
Example language (illustrative): "You can't choose what the cancer does. Is there anything about how you face it that still feels like your choice?"
Watch for: turning this into a demand to be brave; any stance, including anger, can be chosen.

C5. Session 5. Creative sources of meaning: creativity and responsibility

Purpose: explore meaning through what the person creates, does and takes responsibility for. [source: MSKCC IMCP protocol (title)]
Steps [synthesis]: (1) Identify creative acts in the broad sense, such as work, raising children or making things. (2) Explore responsibilities still held and any tasks still to complete. (3) Plan one achievable action, which may include repair of relationships.
Example language (illustrative): "Is there something you still want to do, say or finish while you have the energy?"
Watch for: plans that exceed physical capacity; scale them to energy.

C6. Session 6. Experiential sources of meaning: beauty, love and humour

Purpose: reconnect with meaning found through experiencing: love, connection, nature, art and humour. [source: MSKCC IMCP protocol (title)]
Steps [synthesis]: (1) Invite recent moments of beauty, love or humour, however small. (2) Plan to notice and seek such moments each day. (3) Explore connection with loved ones.
Example language (illustrative): "What made you laugh, or moved you, this week, even for a moment?"
Watch for: feeling guilty about enjoyment; normalise it.

C7. Session 7. Transitions: reflection and hopes for the future

Purpose: consolidate, review the Legacy Project, and look ahead. [source: MSKCC IMCP protocol (title)]
Steps [synthesis]: (1) Review learning across sources of meaning. (2) Share progress on the Legacy Project. (3) Name hopes for the time ahead, including hopes for others. (4) Plan ongoing support.
Example language (illustrative): "Looking back over these weeks, what has mattered most?"
Watch for: abrupt endings due to deterioration; offer a final session by phone or at the bedside. The protocol allows occasional biweekly spacing and, rarely, telephone or teleconference sessions. [source: MSKCC IMCP protocol]

C8. The Legacy Project

Purpose: an optional project, done outside sessions, that expresses and preserves meaning, for example an autobiography, artwork, photo album or family history. [source: MSKCC IMCP protocol]
Steps [synthesis]: (1) Introduce it around session 3. (2) Let the person choose the form and scale. (3) Involve family if wished. (4) Review it in session 7.
Example language (illustrative): "Some people like to make something to leave behind, such as letters, a photo book or recordings. Would anything like that appeal to you?"
Watch for: pressure to finish it before death; it can stay unfinished, and family can complete it.

Comparison format: supportive psychotherapy. In the same trial, a manualised 7-session Rogerian supportive psychotherapy, emphasising empathy, encouragement and emotional expression focused on cancer and the here and now, was the active comparator. This is a legitimate option where structured meaning work does not suit the person. [source: MSKCC IMCP protocol]

D. Fear of cancer recurrence or progression: ConquerFear

ConquerFear was developed in Australia and tested in survivors of curable (stage I–III) breast or colorectal cancer or melanoma who scored above the clinical cut-off on the Fear of Cancer Recurrence Inventory (FCRI) severity subscale. It has five components: attention training, metacognitions, acceptance and mindfulness, screening behaviour, and values-based goal setting. The comparator was a relaxation-based attention control ("Taking-it-Easy"). [source: ASCO Post report on Butow et al. 2017] The City of Hope adaptation describes the theoretical basis as metacognitive therapy and the Self-Regulatory Executive Function (S-REF) model, plus acceptance and commitment therapy (ACT) components, and lists its goals as teaching worry control, changing unhelpful beliefs about worry, encouraging acceptance of uncertainty, and values-based goal setting. [source: City of Hope CFS protocol] The original session-by-session map has not been verified [uncertain: not verified]; the order below is a workable sequence [synthesis].

D1. Assessing fear of recurrence or progression

Purpose / when: before treatment, to distinguish proportionate concern from clinically significant fear.
Steps: (1) Use a validated measure such as the FCRI (licensed; do not reproduce items) [source: ASCO Post report on Butow et al. 2017]. (2) Map triggers (scans, anniversaries, bodily sensations, media), time spent worrying, checking and reassurance-seeking, avoidance of follow-up or of reminders, and impact on life [synthesis]. (3) Assess vulnerability factors such as previous losses, traumatic events and other stressors [source: City of Hope CFS protocol]. (4) In advanced disease, frame this as fear of progression, which has a realistic basis [source: City of Hope CFS protocol].
Example language (illustrative): "When the fear comes, what sets it off, how long does it stay, and what do you do to try to get rid of it?"
Watch for: new physical symptoms reported as worry. Any new, persistent or unexplained symptom goes to the medical team first, and is never reassured away by the therapist. [synthesis]

D2. Values-based goal setting

Purpose / when: early, to give the work a direction beyond less fear. [source: City of Hope CFS protocol; ASCO Post report]
Steps [synthesis]: (1) Ask what matters most in key life areas (relationships, work, health, leisure, contribution). (2) Note where fear has narrowed life. (3) Set one or two small, concrete goals in line with those values. (4) Review them each session.
Example language (illustrative): "If the fear took up less room, what would you be spending that time and energy on?"
Watch for: goals that are about controlling recurrence, such as perfect diets or constant vigilance; redirect them toward living.

D3. Attention Training Technique (ATT)

Purpose / when: to strengthen flexible control of attention so the person can disengage from worry and body-scanning; practised in session and at home, with logs. [source: City of Hope CFS protocol]
Steps [synthesis, general description of ATT in metacognitive therapy]: (1) Explain that the aim is not distraction or relaxation, but training attention as a skill. (2) Guide the person to focus on several different environmental sounds in turn, then switch rapidly between them, then widen attention to take in many at once. (3) Rate self-focus before and after. (4) Set daily home practice with a recording, and log it.
Example language (illustrative): "This is like exercise for your attention. Your mind will wander, and that's fine. Just bring it back to the sound I name."
Watch for: use of ATT to push thoughts away (thought suppression); reframe it. Working if the person reports more choice over where attention goes.

D4. Detached mindfulness

Purpose / when: to let worry thoughts come and go without engaging with or suppressing them. [source: City of Hope CFS protocol]
Steps [synthesis]: (1) Explain the difference between having a thought about recurrence and engaging with it (analysing, checking, seeking reassurance). (2) Practise noticing a trigger thought and leaving it alone, using metaphors such as clouds passing or a voice on a radio in another room. (3) Practise around a real trigger, such as an upcoming scan date. (4) Set home practice.
Example language (illustrative): "When the thought 'what if it's back?' comes, see whether you can notice it, leave it where it is, and carry on with what you're doing."
Watch for: confusion with relaxation or with positive thinking.

D5. Working with metacognitions and worry management

Purpose / when: to change positive beliefs about worry ("worrying keeps me safe", "worry will help me catch it early") and negative beliefs ("worry is uncontrollable", "the worry itself is harmful"). [source: City of Hope CFS protocol (modifying beliefs about worry; S-REF model)]
Steps [synthesis]: (1) Elicit beliefs about worry. (2) Examine their evidence and costs. (3) Run a worry-postponement experiment: set a short, fixed worry time later in the day and postpone worry until then. (4) Review what happened to control and to safety.
Example language (illustrative): "Has worrying ever actually changed what the scans showed?"
Watch for: fear that worry itself could cause recurrence; correct this clearly, since no evidence links worrying to cancer coming back [uncertain: evidence not reviewed here].

D6. Checking, self-examination and follow-up behaviour

Purpose / when: when self-examination, symptom monitoring or requests for tests are excessive, or when follow-up is avoided. The adaptation used a behavioural contract for appropriate checking. [source: City of Hope CFS protocol; ASCO Post report (screening behaviour component)]
Steps [synthesis]: (1) Find out from the team what follow-up and self-checking they actually recommend. (2) Map the person's current checking and its short-term relief and long-term cost. (3) Agree a written plan matching the medical recommendation, covering frequency and what symptoms to report and to whom. (4) Plan a response to urges outside the plan. (5) For avoiders, build steps toward attending follow-up.
Example language (illustrative): "Let's write down exactly what your team wants you to check and when, so you can trust the plan rather than having to check all the time."
Watch for: the therapist setting medical rules. The checking schedule always comes from the oncology team.

D7. Acceptance of uncertainty

Purpose / when: throughout, with ACT components. [source: City of Hope CFS protocol]
Steps [synthesis]: (1) Acknowledge that the risk is real and cannot be made zero. (2) Explore the costs of trying to achieve certainty. (3) Practise willingness to carry uncertainty while pursuing valued goals (D2). (4) Link to scan-time plans.
Example language (illustrative): "Neither of us can promise it won't come back. The question is how you want to live with not knowing."
Watch for: being heard as "just accept it"; validate the fear first. Working if FCR measures fall and valued activities rise.

D8. Relaxation (comparison condition and Level 2 option)

Purpose / when: lower-intensity anxiety, sleep difficulty, and as a Level 2 intervention. Relaxation was the attention-control condition in the ConquerFear trial and is listed under Level 2 in the NICE model. [source: ASCO Post report; WoSCAN Referral Guidance]
Steps [synthesis]: teach a breathing or progressive muscle relaxation practice, then set daily practice.
Example language (illustrative): "Let's practise a way of settling your body that you can use in the waiting room."
Watch for: relaxation used as a safety behaviour before every scan; if fear persists, move to D3–D7.

E. Couples, family, survivorship, end of life and bereavement

Most of this subsection is [synthesis]: it rests on the level criteria in the NICE model (adjustment to body and sexual changes, decisions to end active treatment, facing mortality, adjustment after treatment, bereavement support) and CALM's caregiver component, but no single manualised protocol for it was consulted. [source: WoSCAN Referral Guidance; Rodin et al. 2018]

E1. Couples work

Purpose / when: relationship strain, mutual protection through silence, caregiver burnout, sexual and intimacy changes.
Steps [synthesis]: (1) Get each partner's account. (2) Identify protective buffering, where each hides fears to spare the other. (3) Coach turn-taking: one speaks about a fear while the other listens and reflects without fixing. (4) Address changes in roles and intimacy, and refer for sexual or physical problems that need medical input. (5) Plan practical support and respite for the caregiver.
Example language (illustrative): "Could you tell your husband one thing you've been worrying about but not saying? And could you just listen and tell her what you heard?"
Watch for: intimate partner violence or coercion; see each partner alone at least once and follow safeguarding procedures.

E2. Family meetings and talking with children about a parent's cancer

Purpose / when: parents unsure what to tell children; family conflict.
Steps [synthesis]: (1) Help parents decide what to say, using honest, age-appropriate language and the word "cancer". (2) Prepare them for common questions (Is it my fault? Will you die? Can I catch it? Who will look after me?). (3) Keep routines going. (4) Inform school with consent. (5) Plan updates as things change, including if treatment stops working.
Example language (illustrative, for parents): "Children usually sense that something is wrong. Telling them simply and truthfully helps them feel less alone with it."
Watch for: children taking on carer roles, or regression and school problems; refer to child services if these persist.

E3. Survivorship and the end of active treatment

Purpose / when: loss of the treatment safety net, fatigue, return to work, changed identity, adjustment difficulties after treatment (a Level 3 criterion). [source: WoSCAN Referral Guidance]
Steps [synthesis]: (1) Normalise the post-treatment dip. (2) Address fear of recurrence (D). (3) Plan a graded return to roles and work. (4) Address body-image and sexual changes, with referral for medical aspects. (5) Agree when to come back (at scans, anniversaries).
Example language (illustrative): "Everyone expects you to feel relieved now, and many people instead feel lost. That's very common."
Watch for: depression masked as fatigue; ask for medical review of fatigue.

E4. End of life and decisions to end active treatment

Purpose / when: facing mortality and decisions to end active treatment are Level 4 criteria. [source: WoSCAN Referral Guidance]
Steps [synthesis]: (1) Use CALM domain 4 work (B5) or meaning work (C). (2) Support the person to clarify values about further treatment, without steering. (3) Support advance care planning with the palliative team. (4) Help with saying important things to loved ones, such as thanks, forgiveness, love and goodbye. (5) Coordinate with palliative care on place of care and symptom control. (6) Offer sessions at the bedside, by phone, or with family as energy fades.
Example language (illustrative): "What matters most to you about the time you have, however long that is?"
Watch for: delirium, which needs medical attention and is not a psychological problem; and family disagreement about stopping treatment.

E5. Bereavement support

Purpose / when: after a death; bereavement is a point at which carer and family support is offered. [source: WoSCAN Referral Guidance]
Steps [synthesis]: (1) Offer follow-up contact. (2) Normalise grief. (3) Screen for prolonged or complicated grief and for risk. (4) Refer to specialist bereavement services when needed.
Example language (illustrative): "I wanted to check how you've been since your wife died. There's no right way to be doing."
Watch for: guilt about the care given or decisions made; and isolated bereaved children.

F. Children with cancer and their families

The Psychosocial Standards of Care for Children With Cancer and Their Families comprise 15 standards. They were developed over three years by more than 60 clinicians and researchers from the US, Canada and the Netherlands, and published in a December 2015 Pediatric Blood & Cancer supplement (lead introduction by Lori Wiener). APOS endorsed them, and the aim is a minimum level of psychosocial care from diagnosis through survivorship, end of life and bereavement. Standards named in reports include monitoring psychosocial health, assessing financial burden, meeting siblings' needs, school re-entry support, and communication and collaboration among medical and psychosocial providers, patients and families. [source: ecancer report; ASCO Post report on APOS endorsement] The full list of 15 has not been verified here [uncertain: not verified]; consult the supplement.

F1. Routine psychosocial monitoring of the child and family

Purpose / when: from diagnosis onward, at transitions. [source: ecancer report (monitoring psychosocial health)]
Steps [synthesis]: (1) Assess the child's emotional, behavioural and developmental status with age-appropriate tools. (2) Assess parental distress and mental health, family resources and practical burden. (3) Repeat at key points: treatment changes, relapse, end of treatment, transition to adult services. (4) Feed findings back to the paediatric oncology team.
Example language (illustrative, to a parent): "We check in with every family about how everyone is coping, not just your child, because this affects the whole household."
Watch for: procedural distress, treatment-adherence problems (especially in adolescents), and parents neglecting their own health.

F2. Consent, assent and developmentally appropriate involvement

Purpose / when: before psychological work with any child or adolescent.
Steps [synthesis; follow your jurisdiction's law and professional code]: (1) Obtain consent from the person with parental responsibility, and from older adolescents in their own right where the law allows. (2) Seek the child's assent: explain in age-appropriate terms who you are, what you will do and what will be shared, and ask whether they agree. (3) Explain limits of confidentiality, including safeguarding. (4) Respect a child's dissent to non-essential psychological work where possible, and revisit it later. (5) Use play, drawing and story with younger children. (6) Involve children in conversations about their illness at a level they can manage, working with parents and the medical team on how much to tell them.
Example language (illustrative, to a 9-year-old): "My job is to help kids who are in hospital with their worries and feelings. We can draw or play or talk. Most of what you tell me stays between us, unless I'm worried you're not safe. Would you like to try?"
Watch for: families asking you to keep a diagnosis or prognosis secret from a child who is clearly aware; explore the parents' fears and work toward honest, paced communication with the team.

F3. Safeguarding

Purpose / when: whenever there are concerns about a child's safety, including neglect of medical care.
Steps [synthesis; follow local child protection procedures]: (1) Know your service's safeguarding lead and procedure. (2) Record concerns factually. (3) Discuss with the lead and the medical team. (4) Make referrals as procedures require. (5) Where parents refuse effective treatment for a child, the medical team and legal processes handle this; your role is to support the family, share relevant concerns, and avoid taking sides in a way that harms the alliance.
Example language (illustrative): "Because I'm worried about [child]'s safety, I have to talk with the team about this. I'd like to do that with you, not behind your back."
Watch for: parental mental illness, substance use, domestic abuse, or exhaustion that affects care.

F4. Siblings

Purpose / when: meeting siblings' needs is a named standard. [source: ecancer report]
Steps [synthesis]: (1) Ask parents about each sibling. (2) Offer age-appropriate information to siblings. (3) Look out for jealousy, guilt, fear and school problems. (4) Signpost sibling groups. (5) Keep siblings in mind at end of life and in bereavement.
Example language (illustrative, to a sibling): "Lots of brothers and sisters feel left out or cross, and then feel bad about that. Has that happened to you?"
Watch for: the "good" sibling who hides distress.

F5. School re-entry

Purpose / when: before and during the return to school. [source: ecancer report]
Steps [synthesis]: (1) With consent, liaise with the school about attendance, infection precautions, fatigue and appearance changes. (2) Prepare classmates if the child wishes. (3) Request neuropsychological assessment if there are learning concerns after treatment. (4) Plan for bullying.
Example language (illustrative): "What would you like your class to know, and what would you rather keep private?"
Watch for: school avoidance, or academic decline after treatment.

F6. Financial and practical burden

Purpose / when: assessing financial burden is a named standard. [source: ecancer report]
Steps [synthesis]: ask about work loss, travel and costs; refer to social work and charities.
Example language (illustrative): "How are things practically, with money, work and getting to the hospital?"
Watch for: shame preventing disclosure.

F7. End of life and bereavement in paediatrics

Purpose / when: the standards cover care through end of life and bereavement. [source: ASCO Post report on APOS endorsement]
Steps [synthesis]: (1) Support parents in decisions and in talking with the dying child at a level the child can understand. (2) Support legacy-making if wanted (C8). (3) Include siblings. (4) Offer bereavement follow-up to parents and siblings.
Example language (illustrative): "Children often know more than we think. Would it help to think together about what [child] might be wondering?"
Watch for: marital strain after a child's death, and parental suicide risk.

G. When a client is considering unproven alternative cancer treatments

A study of the US National Cancer Database (breast, prostate, lung and colorectal cancer; diagnoses 2004–2013) found that patients who chose alternative medicine instead of chemotherapy, surgery and/or radiation had a greater risk of death, persisting for breast, lung and colorectal cancer. The authors distinguished this from the common practice of using complementary approaches alongside conventional treatment. [source: Yale Cancer Center news on Johnson et al.] The NICE model lists complementary therapies at Level 1 as supportive care, not as cancer treatment. [source: WoSCAN Referral Guidance]

G1. Exploring and responding

Purpose / when: a client says they are thinking about stopping, delaying or replacing recommended cancer treatment with an unproven remedy, diet, clinic or practitioner, or is spending heavily on one.
Steps [synthesis]: (1) Respond with curiosity, not alarm, so the person keeps talking to you. (2) Explore what draws them: fear of side effects, distrust after a bad experience, a wish for control, hope, family pressure, cultural or spiritual beliefs, or online communities. (3) Explore what they understand about their recommended treatment and its aim, and about the alternative. (4) Distinguish complementary use alongside treatment from replacing treatment, and say clearly that the evidence shows replacing treatment with alternatives is linked to higher risk of death. (5) Say plainly that psychological therapy also does not treat cancer, and that you are not in a position to recommend any cancer treatment. (6) Encourage, and help them prepare for, an open conversation with their oncologist, including about fears of side effects, a second opinion, or the option to decline treatment. Suggest they tell the team about any supplements or remedies in case of interactions. (7) With consent, inform the team. (8) Respect the final decision of a person with capacity, while staying in contact. (9) Warn gently about red flags: claims of cure, secret or suppressed cures, requests to stop medical treatment, large upfront payments, testimonials instead of trials, and attacks on doctors. (10) Where a parent proposes this for a child, involve the paediatric team and follow safeguarding procedures (F3).
Example language (illustrative): "It makes complete sense to want something that feels gentler and more in your control. Can we look together at what you're hoping it will do? I should be honest that the evidence we have shows people who replace standard treatment with alternatives do worse, and I'd really like you to talk this through with your oncologist before deciding."
Watch for: feeling judged, which leads to withdrawal from both you and the team; magical thinking driven by terror; financial exploitation; and your own urge to argue. Working if the person brings the question to their oncology team and makes a decision with full information.

G2. Requests to use psychological methods to fight the cancer

Purpose / when: a client asks for visualisation, positive thinking or emotional work to make the tumour shrink, or believes they caused the cancer through stress or emotions.
Steps [synthesis]: (1) Validate the wish to do something. (2) State that these methods do not treat cancer. (3) Offer what they can help with: anxiety, sleep, coping with treatment, and a sense of agency. (4) Remove self-blame.
Example language (illustrative): "Imagery can help you feel calmer during treatment, but it won't change the cancer. I don't want you to feel that whether the cancer grows depends on how well you do the exercises."
Watch for: the person blaming themselves at recurrence for not having been positive enough.

5. Handling problems

The sources consulted address only some of these points: flexible scheduling and modes of delivery, caregiver involvement, step-up criteria, and supervision. Everything else here is [synthesis] unless a source is given.

Physical deterioration, cancelled or missed sessions. Expect this rather than treating it as non-adherence. Shorten sessions; switch to telephone, video or the bedside; space sessions out. CALM and IMCP both build in this flexibility (CALM: 3–6 sessions over 3–6 months, by phone or on the inpatient unit; IMCP: about a 14-week window for 7 sessions, with occasional biweekly spacing and, rarely, remote sessions). [source: Rodin et al. 2018; MSKCC IMCP protocol] Prioritise the domain that matters most now, such as goodbyes or decisions, over completing the protocol.
Overwhelm and affect flooding. Modulate affect, which CALM names as a core therapist process [source: Rodin et al. 2018]: slow down, ground the person in the present, move from exploratory to supportive work, and return to the topic later. Check whether panic or breathlessness has a medical cause, and inform the team.
Avoidance and "I don't want to talk about dying." Respect the person's pace. Avoidance can be adaptive. Work in the "living" side of double awareness first, and offer the topic again later. Revisit it if urgent decisions are pending (advance care planning, children's care), naming the tension gently (illustrative): "I'll follow your lead, and I also want to make sure you have a say in things that may come up."
Stuck in hopelessness or demoralisation. Check for treatable depression and refer for psychiatric review. Check pain and other symptoms. Shift to meaning-centred work (C), with small experiential goals (C6). Reassess risk (A5).
Homework not done (IMCP readings, ConquerFear practice logs). Fatigue, "chemo brain" and low concentration are common. Shrink tasks (one page, two minutes, an audio recording), do the practice in session, and involve a caregiver as a reminder if the person wants. Explore whether the task feels pointless or too painful.
Persistent reassurance-seeking in fear of recurrence. Avoid giving medical reassurance yourself. Name the reassurance cycle, refer back to the agreed checking plan (D6), and route genuinely new symptoms to the team.
Ruptures: anger at the team displaced onto you, or you seen as part of "the system". Validate the anger. Distinguish legitimate complaints, which you can help the person raise through A7 or the service's complaints route, from displaced fear. Repair openly (illustrative): "I may have pushed toward talking about the future too soon. Did it feel like that?" In the CALM trial, interpretations were the competency with the most room for improvement [source: Rodin et al. 2018]. Offer interpretations tentatively and collaboratively.
Family wants information withheld from the patient, or cultural norms differ about disclosure. Explore the family's fears and the cultural meanings involved. Ask the patient directly how much they want to know and who should be told. Work with the oncology team, who are responsible for medical disclosure.
Client asks you about prognosis or treatment choices. Do not answer medical questions. Explore what the question means to them, and help them prepare to ask the team (A7).
Cognitive impairment or delirium. Insight-oriented work may not be possible. Request medical review; shift to supportive, family-centred work; assess capacity for decisions with the team.
Pre-existing serious mental illness or substance use. Coordinate with the psychiatric team. The Level 4 criteria include previous mental health history. [source: WoSCAN Referral Guidance]
Couple or family conflict in joint sessions. Return to individual sessions with each person, agree ground rules, and refer for specialist couple or family therapy if the conflict predates the cancer.
Unproven treatments, "positive thinking" and self-blame. See G1–G2. Do not argue. Keep the person connected to their oncology team and state the limits of psychological care.
A child dissents or parents disagree about the child's psychological care. Pause non-urgent work, explore the reasons, and seek a joint plan. For safety concerns follow safeguarding procedures (F3).
Telehealth problems. Agree a back-up phone number and a plan if the person becomes unwell during a call. The City of Hope adaptation provided tablets and a coordinator for technical help. [source: City of Hope CFS protocol]
Confidentiality versus team communication. Agree at the outset what will be shared (A8). Share risk and medical red flags; keep personal content private unless it is relevant to care and the client consents.
Death of a client during therapy. Consider (within your service's policy) a condolence contact or attending the funeral, offer bereavement support to the family if appropriate (E5), and take time in supervision.
Therapist distress, over-identification and burnout. Repeated exposure to death, young patients, or clients resembling one's own family is demanding. Use regular supervision: the CALM and IMCP trials used weekly or regular supervision with audio review. [source: Rodin et al. 2018; MSKCC IMCP protocol] Keep a manageable caseload mix, and watch for avoidance of dying patients or for rescuing.

Sources

Online sources:

Books and papers cited:

Rodin G, Lo C, Rydall A, Shnall J, Malfitano C, Chiu A, Panday T, Watt S, An E, Nissim R, Li M, Zimmermann C, Hales S (2018). Managing Cancer and Living Meaningfully (CALM): A randomized controlled trial of a psychological intervention for patients with advanced cancer. Journal of Clinical Oncology, 36(23), 2422–2432.
Malfitano C, Hales S, Rodin G (2022). Managing Cancer and Living Meaningfully (CALM) Therapy. In Handbook of Psychiatry in Palliative Medicine (3rd ed.). Oxford University Press.
Butow PN et al. (2017). Randomized trial of ConquerFear: a novel, theoretically based psychosocial intervention for fear of cancer recurrence. Journal of Clinical Oncology. doi:10.1200/JCO.2017.73.1257 [uncertain: full author list not verified]
Individual Meaning-Centered Psychotherapy for Patients with Advanced Cancer: A Treatment Manual. Oxford University Press. [uncertain: authors and year not verified]
Frankl VE. Man's Search for Meaning (assigned reading in IMCP). [uncertain: edition not verified]
National Institute for Clinical Excellence (2004). Improving Supportive and Palliative Care for Adults with Cancer. [uncertain: cited as described in the WoSCAN guidance; original not verified]
National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Distress Management. Distress Thermometer and Problem List form, Version 1.2025 (11/18/2024); the form does not state a cut-off. Full guideline text [uncertain].
Wiener L et al. (2015). Psychosocial Standards of Care for Children With Cancer and Their Families. Pediatric Blood & Cancer, December 2015 supplement. [uncertain: exact title, pages and full list of standards not verified]
Johnson SB, Park HS, Gross CP, Yu JB. Alternative medicine and survival in cancer, Journal of the National Cancer Institute. [uncertain: title and year not verified]
International Psycho-Oncology Society (IPOS) standards and guidance on quality cancer care. [uncertain: not verified]

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