Integrative medicine and integrative oncology

1. Introduction

Version followed: the Society for Integrative Oncology (SIO) consensus definition (Witt et al., 2017), the SIO–ASCO guideline on integrative medicine for pain management in oncology (Mao et al., 2022) and the SIO–ASCO guideline on integrative approaches to anxiety and depression in adults with cancer (Carlson, Rowland et al., 2023), read together with the companion ASCO guideline on psychosocial management of anxiety and depression in adult survivors (Andersen et al., 2023); the general field is described with the Academic Consortium for Integrative Medicine & Health definition. This guide describes the field as its own organisations publish it (sections 1–3); section 4 is the psychotherapist's own work alongside it.

What it is. Integrative medicine and integrative oncology are a field and a model of care, not a single therapy. The Academic Consortium defines integrative medicine and health as an approach that reaffirms the practitioner–patient relationship, "focuses on the whole person, is informed by evidence", and uses all appropriate therapeutic and lifestyle approaches and disciplines [source: Academic Consortium, Mission and Vision]. SIO defines integrative oncology as "a patient-centered, evidence-informed field of cancer care" that uses mind and body practices, natural products and/or lifestyle modifications from different traditions "alongside conventional cancer treatments", aiming to optimise health, quality of life and clinical outcomes across the cancer care continuum and to help people become active participants before, during and beyond treatment [source: Witt et al., 2017].

Complementary, never instead. Integrative oncology is complementary to standard cancer care only. Its authors explicitly separate it from "alternative" medicine, which is used instead of conventional treatment, and state that dangerous or unproven methods do not belong in the field even when marketed as integrative [source: Witt et al., 2017]. NCI and NCCIH use the same distinction: complementary = used together with conventional care; alternative = used in place of it; integrative = the coordinated combination [source: NCI, Complementary and Alternative Medicine; NCCIH, What's in a Name?]. No integrative modality is presented by these organisations as a treatment for cancer itself; the published recommendations concern symptoms and side effects such as anxiety, depression and pain [source: SIO–ASCO 2022, 2023].

Core idea of how change happens (as published). Benefit is expected from adding selected, evidence-graded mind–body, physical, natural-product and lifestyle approaches to conventional care, coordinated by the treating team and chosen with the patient, so that symptoms and side effects are better managed and the person takes an active part in their own care [source: Witt et al., 2017; MSK Integrative Medicine]. For the psychotherapist, change comes from open, informed conversation that keeps the client connected to their oncology team, supports choices consistent with their values, and treats the anxiety, depression, grief and conflict that cancer and treatment decisions bring [synthesis; source for psychological care: Andersen et al., 2023].

2. Framework

2.1 The field as its organisations publish it

Theory and categories. Three intervention categories: mind and body practices (the NCCIH term, covering e.g. acupuncture, massage, meditation, hypnosis), natural products, and lifestyle modifications [source: Witt et al., 2017]. NCCIH groups complementary approaches by primary input: nutritional, psychological, physical, and combinations (e.g. yoga, tai chi) [source: NCCIH, What's in a Name?].
What a client experiences (example of a comprehensive cancer centre service). The patient books an integrative medicine consultation, where they and their family discuss the side effects that concern them most; the team then builds a personalised plan of classes and individual therapies (acupuncture, massage, mind–body medicine, exercise, yoga, tai chi, mindfulness, music therapy) and gives guidance on safe use of herbs and supplements. The service states these therapies are designed to be used alongside surgery, chemotherapy and radiation [source: MSK, Integrative Medicine – Developing Your Personal Care Plan].
Who practises it. Integrative medicine physicians, nurse practitioners and physician assistants within cancer centres, alongside acupuncturists, massage therapists, music therapists, mind–body and movement instructors [source: MSK Integrative Medicine]. Physicians who have completed an integrative medicine fellowship (e.g. the University of Arizona Andrew Weil Center) are listed in a directory [source: SIO–ASCO 2022 patient summary]. Psychologists and other psychotherapists deliver the psychological components (mindfulness-based interventions, CBT, behavioural activation, ACT, hypnosis, relaxation) [source: Andersen et al., 2023; SIO–ASCO 2023].
Published recommendations (symptom management only).
- Anxiety, during active treatment [source: SIO–ASCO 2023 slide deck]: mindfulness-based interventions (strong; high-quality evidence); yoga in breast cancer (moderate); hypnosis around diagnostic or treatment procedures (moderate); relaxation therapies (moderate); music therapy or music-based interventions (moderate; low-quality evidence); reflexology (weak); lavender essential-oil inhalation around procedures (weak).
- Anxiety, after treatment: mindfulness-based interventions (strong); yoga in breast cancer (moderate); acupuncture, tai chi and/or qigong in women with breast cancer (weak); reflexology (weak).
- Depression, during treatment: mindfulness-based interventions (strong); yoga in breast cancer (moderate); music therapy (moderate); relaxation and reflexology (weak). After treatment: mindfulness-based interventions (strong); yoga in breast cancer (moderate); tai chi/qigong in breast cancer (weak). Expressive writing is not recommended for depression after treatment (no net benefit).
- Inconclusive for anxiety or depression: nutritional interventions, light therapy, psilocybin, massage, biofeedback, autogenic training, energy healing, healing touch, melatonin and other natural products or supplements, among others.
- Pain [source: Mao et al., 2022, patient summary]: acupuncture for aromatase-inhibitor joint pain; acupuncture, guided imagery, hatha yoga, massage, reflexology or acupressure for general or musculoskeletal pain; acupuncture and reflexology/acupressure for chemotherapy-induced neuropathy; acupuncture/acupressure, hypnosis and music therapy for procedural and surgical pain; massage in palliative care. Evidence was insufficient for or against other integrative treatments, including natural products, and no recommendations were made for children.
Regulation and licensing (main jurisdictions).
- USA: "integrative medicine" is not itself a licensed profession; each practitioner works under their own professional licence or credential. There is no national credentialing system for complementary health practitioners: each state sets its own requirements, which differ by state and by profession (mandatory licensure, title licensure or registration); licences are granted by state agencies, certification by professional organisations, and neither guarantees competence [source: NCCIH, Credentialing, Licensing, and Education]. Dietary-supplement adverse events are reported to FDA via the Safety Reporting Portal; drug, device and cosmetic problems via MedWatch [source: FDA 101]. FDA has primary responsibility for claims in product labelling, the Federal Trade Commission for claims in advertising [source: FTC, Health Products Compliance Guidance].
- UK: section 4 of the Cancer Act 1939 still prohibits advertising (written or spoken) that offers to treat cancer, prescribe a remedy for it or advise on its treatment, in England, Wales and Scotland; it is enforced by Trading Standards. Complementary therapists may offer support for symptoms and side effects, must not imply treatment of cancer, and should advise clients to speak to their clinician [source: CNHC Guidance on the Cancer Act 1939]. The Advertising Standards Authority applies the CAP Code to complementary-therapy advertising: objective treatment claims need clinical-trial evidence (rule 12.1), claims can be implied (including through testimonials), and claims about serious conditions may be judged to discourage essential medical treatment (rule 12.2) [source: ASA, Advice for National Complementary Therapy Week 2025]. Suspected side effects of medicines, including herbal and homeopathic remedies, are reported to the MHRA Yellow Card scheme, which patients and the public can use [source: MHRA, Yellow Card scheme guidance].
- Other jurisdictions: check the national regulators for each profession and product [uncertain].
Regulatory status (one line). A model of care delivered by separately regulated professions inside conventional cancer services; individual products, advertising and practitioners are regulated under their own regimes [source: CNHC; FDA 101; FTC; ASA; MHRA; NCCIH; uncertain beyond the US and UK].
Evidence status (one line). Graded by SIO–ASCO per modality and per symptom: mindfulness-based interventions carry strong recommendations for anxiety and depression; most others are moderate or weak; many, including natural products, are inconclusive; none is recommended as a treatment for cancer itself [source: SIO–ASCO 2022, 2023].

2.2 The psychotherapist's framework alongside it [synthesis, structured on Andersen et al., 2023 and SIO–ASCO 2023]

There is no published phase model for a psychotherapist's work alongside integrative oncology. The following phases organise the section 4 inventory; they run inside ordinary psycho-oncology or general psychotherapy, not as a separate course.

Ask and record (first contact and at each cancer-care juncture). Goal: a complete, non-judgemental picture of what the client uses or is considering. Move on when use, intent (alongside vs instead) and whether the oncology team knows are recorded.
Understand meaning (folded into ongoing work). Goal: the client's hopes, fears, explanatory model and what draws them. Move on when the client feels understood and the therapist can state the client's own reasons back accurately.
Support informed, values-based decisions (as decisions arise). Goal: the client decides with their oncology team, with accurate information and without pressure from anyone, including the therapist. Move on when a decision is made and the client knows who to ask about safety.
Coordinate (with consent, whenever product safety, treatment delay or mental-health care overlaps). Goal: the oncologist or pharmacist knows what matters for safety.
Monitor and treat distress (ongoing). ASCO advises screening for depression and anxiety at diagnosis, start of treatment, changes in disease or treatment status, transition to palliative or end-of-life care, and when clinically indicated, with stepped care using the least intensive effective intervention [source: Andersen et al., 2023].
Respond to risk, loss and conflict (whenever it appears): delayed or refused conventional treatment, children, financial exploitation, palliative transitions, family conflict, grief and regret.

Format: individual or couple/family sessions within a psycho-oncology service, primary care psychology or private practice; session count follows the client's wider therapy plan [synthesis].

3. Guiding principles

Complementary, never instead. Integrative oncology is used alongside conventional cancer treatment, not in place of it [source: Witt et al., 2017; NCI]. Practical meaning: whenever a client describes any approach, establish whether it is alongside or instead of their oncology plan.
Patient-centred. Care centres the person's values, preferences and quality of life [source: Witt et al., 2017]. Practical meaning: start from what matters to the client, not from the therapist's view of the method.
Evidence-informed, not evidence-free. The definition covers a range of evidence and excludes dangerous or unproven methods [source: Witt et al., 2017]. Practical meaning: be honest that recommendations are graded per symptom, and that most products are inconclusive.
Whole person and relationship. Integrative medicine emphasises the practitioner–patient relationship and the whole person [source: Academic Consortium]. Practical meaning: the therapeutic alliance is the main tool; keep it intact even when you disagree with a choice.
Coordinated care. Integrative health means coordinated care among providers [source: NCCIH]; ACS and NCI advise discussing any integrative therapy with the cancer care team before starting [source: ACS, Talking to Your Doctor; NCI]. Practical meaning: with consent, keep the oncologist and pharmacist informed; never become a parallel, secret channel.
Active participation. The field aims to help people become active participants in their care [source: Witt et al., 2017]. Practical meaning: treat interest in complementary approaches as a wish for agency, and support it.
Stay in scope. The psychotherapist does not perform, sell, prescribe or recommend any remedy, product, diet or procedure, and never advises starting, stopping or changing a medicine or supplement [synthesis]. Practical meaning: route every product and medicine question to the prescriber or pharmacist.
Psychological care follows ASCO. For anxiety and depression in cancer, ASCO recommends CBT and behavioural activation, mindfulness-based stress reduction, ACT, structured physical activity and psychosocial interventions in a stepped-care model, with medication not first-line [source: Andersen et al., 2023]. Practical meaning: offer evidence-based psychological care yourself or refer to it.
Screen at junctures. Screen at diagnosis, start of treatment, changes in status, palliative transitions [source: Andersen et al., 2023]. Practical meaning: diary these points.
Autonomy without coercion. [synthesis] Practical meaning: give information and reflect, never pressure, threaten to discharge, or bargain the relationship.
No cancer-treatment claims. UK law prohibits advertising offers to treat cancer [source: CNHC]. Practical meaning: never describe any complementary approach, in session or in publicity, as treating cancer.
Attribute, do not adjudicate, beliefs. Energy and spiritual concepts in some modalities are described as each method holds them [synthesis]. Practical meaning: explore the meaning for the client without endorsing or ridiculing it.
No conflicts of interest. [synthesis] Practical meaning: no commissions, product sales, referral fees or dual roles with integrative providers.

4. Intervention inventory

These are the psychotherapist's own interventions alongside integrative oncology. The psychotherapist never performs, sells, prescribes or recommends any remedy, supplement, device, diet or procedure. Where the psychotherapist is trained in a psychological method that also appears in the SIO–ASCO recommendations (mindfulness-based interventions, relaxation, hypnosis), delivery follows that method's own guide elsewhere in this guide set; this guide covers only how to place it within cancer care [synthesis]. Unless a source is tagged, steps are [synthesis] built on the principles in section 3.

4.1 Routine, non-judgemental asking and recording

Purpose / when: at intake, at each cancer-care juncture (diagnosis, start of treatment, change in disease or treatment status, palliative transition) and whenever the client mentions a new practitioner, product, diet or programme. NCI, ACS and NCCIH all advise that complementary use be discussed with the health care team [source: NCI; ACS; NCCIH]; the therapist's routine question makes that easier.
Steps:
1. Normalise first: say many people with cancer use or consider complementary approaches.
2. Ask openly about all categories: mind–body practices, bodywork or acupuncture, supplements, herbs and other natural products, special diets, devices, spiritual or energy healing, and online programmes.
3. For each, ask: started when, from whom (oncology integrative service, independent practitioner, online seller, friend or group), cost, and whether the oncology team and pharmacist know.
4. Ask the key question: is this alongside your cancer treatment, or instead of any part of it?
5. Record in neutral language (what, source, alongside/instead, team informed yes/no, client's stated reason). Avoid evaluative words in the record.
6. Revisit at the next juncture; use changes as a cue for phase 2–4 work.
Example language (illustrative): "Lots of people add things to their cancer care: classes, acupuncture, supplements, diets, prayer or healing. I ask everyone, not to judge, but so I understand your whole picture. What are you using or thinking about?" / "Is that something you're doing as well as your hospital treatment, or in place of any part of it?"
Watch for / signs it is working: disclosure that grows over sessions; clients who stop mentioning a practice after a sceptical reaction (a sign you showed judgement); "instead" answers (go to 4.9); products from online sellers or multi-level-marketing networks (4.11). Working: the client volunteers new practices unprompted and reports they have told their oncology team.

4.2 Exploring meaning, hopes, expectations and the explanatory model

Purpose / when: after any disclosure, especially when a client invests strongly in an approach, feels let down by conventional care, or the approach conflicts with family or medical advice.
Steps:
1. Ask what drew them: symptom relief, control, hope, distrust of medicine, identity, faith, family tradition, community, a friend's story.
2. Elicit their explanatory model: what they believe caused the cancer and what they believe will help. Reflect it in their words.
3. Ask what they hope the approach will do, and separate hopes about comfort and wellbeing from hopes about the cancer itself.
4. Ask what it would mean if it did not help as hoped.
5. Where energy, spiritual or traditional concepts are part of the method, explore what they mean to the client without endorsing or disputing them.
6. Link to emotions: fear, anger at the illness or at clinicians, guilt, loss of control. These are often the real therapeutic target.
Example language (illustrative): "What is it about this that feels right to you?" / "If it does what you hope, what would be different?" / "Some people say these practices give them back some control when so much is being done to them. Does that fit for you?"
Watch for / signs it is working: hope narrowed onto a single product or practitioner; a sense that conventional clinicians dismissed them (repairable through coordination); guilt or self-blame in the explanatory model ("I caused this by stress"); magical thinking under extreme fear. Working: the client can name their own reasons and emotional needs and distinguish wellbeing goals from cancer-control goals.

4.3 Clarifying alongside versus instead

Purpose / when: whenever it is unclear whether an approach is complementary or is replacing, delaying or reducing conventional treatment.
Steps:
1. Share, neutrally, the published distinction: complementary is used together with standard care; alternative is used in place of it; integrative oncology is defined by its professional society as alongside conventional treatment [source: Witt et al., 2017; NCI; NCCIH].
2. Ask whether any planned surgery, chemotherapy, radiotherapy, hormone therapy, appointment or test has been postponed, declined or reduced.
3. If yes, move to 4.9 (respectful conversation about alternative treatment) and 4.7 (coordination).
4. If no, record and continue to 4.4–4.6.
Example language (illustrative): "The cancer societies that study these approaches describe them as something to add to treatment, never to replace it. Where does what you're doing sit for you?"
Watch for: vague answers ("I'm taking a break from chemo"), missed appointments, a practitioner advising against conventional treatment, or a client seeking the therapist's agreement to stop. The therapist does not advise on medical treatment; the decision belongs with the client and oncologist.

4.4 Information-sharing about integrative oncology as published

Purpose / when: the client asks what is "proven", or is choosing between offerings.
Steps:
1. Explain that cancer professional societies have published guidelines on which complementary approaches help specific symptoms (anxiety, depression, pain), and that these are designed to be used with the oncology team [source: SIO–ASCO 2022, 2023].
2. Describe accurately rather than recommend: e.g. that mindfulness-based programmes have the strongest recommendation for anxiety and depression, and that evidence for supplements and natural products was inconclusive [source: SIO–ASCO 2023].
3. Point them to their oncology team or the hospital's integrative medicine service to decide what fits, and to the oncology pharmacist for anything taken by mouth or applied to the body.
4. Point to reputable patient information (NCI, ACS, the Memorial Sloan Kettering "About Herbs" database) for products [source: NCI; MSK].
Example language (illustrative): "There are guidelines from the cancer societies on which approaches help with things like anxiety and pain. I'm not the right person to say which one suits you, but your oncology team can talk it through, and they know your treatment."
Watch for: sliding into endorsing a product or practitioner; a client hearing "recommended for anxiety" as "treats cancer" (correct gently); information overload in acute distress (keep it to one point and a next step).

4.5 Placing psychological mind–body interventions within cancer care

Purpose / when: the client wants a mind–body approach for anxiety, low mood, procedural fear or pain, and the therapist is trained in one that SIO–ASCO or ASCO list (mindfulness-based interventions, relaxation therapies, hypnosis around procedures; and, from ASCO, CBT, behavioural activation, MBSR, ACT) [source: SIO–ASCO 2023; Andersen et al., 2023].
Steps:
1. Assess the target (anxiety, depression, procedural fear, pain coping) and severity; screen as in 4.8.
2. Agree that the work is for coping and symptom relief, not for treating the cancer; record this in the consent conversation.
3. Deliver the method as its own manual and guide describe (see the relevant mindfulness, relaxation, hypnosis, CBT, BA and ACT guides elsewhere in this set).
4. Adapt to medical realities: fatigue, nausea, pain, neuropathy, lines and ports, hospital rooms, procedure schedules; inform the oncology team with consent, e.g. before using hypnosis around procedures.
5. For movement-based or bodywork approaches (yoga, tai chi/qigong, acupuncture, reflexology, massage, music therapy), refer the client to discuss them with their oncology or integrative team; do not deliver them unless separately qualified and in that role.
Example language (illustrative): "What we'd do here is a mindfulness-based approach, which the cancer guidelines suggest for anxiety during and after treatment. It's to help you cope; it isn't a treatment for the cancer."
Watch for: exercises that increase intrusive imagery about the body or the tumour; breath-focused practices with breathlessness; body scans with pain or treatment-related body-image distress (offer external-focus alternatives); the client using practice to "fight" the cancer and then feeling guilt when the disease progresses. Working: reduced distress scores and better coping with procedures.

4.6 Supporting informed, values-based decisions without coercion

Purpose / when: the client faces a decision involving complementary or alternative approaches, or feels pressured by family, groups or practitioners.
Steps:
1. Name the decision precisely and who has the authority and expertise (client and oncologist for medical choices).
2. Elicit values: survival, time, comfort, control, faith, family, avoiding side effects, staying true to identity.
3. Help the client list what they need to know and who can answer (oncologist, pharmacist, integrative service, the practitioner's own credentials and regulator); help them prepare questions for appointments, including cost and number of sessions [source for cost questions: ACS].
4. Map pressures: who wants what, and what the client wants when those voices are set aside.
5. Reflect the decision against the values the client named; accept the client's choice; record the process.
6. No published decision aid is endorsed here; if a service uses one, use it as published.
Example language (illustrative): "This is your decision, with your oncologist. My part is helping you get clear on what matters most to you and what you still need to find out." / "If no one else's opinion counted, what would you choose?"
Watch for: the therapist's own anxiety pushing persuasion; collusion against the oncology team; decisions made in acute panic (slow down, arrange a medical conversation); decisions made under group or seller pressure (4.11).

4.7 Coordinating with the client's doctor or pharmacist

Purpose / when: the client is taking or considering supplements, herbs or other products during cancer treatment (NCI and ACS warn some may interfere with treatment or be harmful) [source: NCI; ACS]; the client is delaying treatment; psychological care needs to be co-ordinated with the oncology plan.
Steps:
1. Explain why: products can interact with cancer treatment, and the team can only keep the client safe if they know.
2. Ask for consent to share specific information, with whom and for what purpose; record it.
3. Prefer empowering the client to tell the team themselves; offer to rehearse, write a list, or join a call.
4. If the client consents to direct contact, send a brief, factual note (what is used, alongside or instead, your role, your concerns about distress or risk) without giving any opinion on the product.
5. Never advise starting, stopping or changing any medicine or supplement; route every such question to the prescriber or pharmacist.
6. Respect refusal except where safeguarding or immediate risk to life overrides confidentiality under your professional code and law.
Example language (illustrative): "I can't tell you whether that's safe with your treatment, but your oncology pharmacist can. Would you like to bring a list next time, or shall we write it now?"
Watch for: fear of being judged by the oncologist (rehearse; reassure that ACS and NCI ask patients to share this); the therapist being drawn into product advice; contact made without documented consent.

4.8 Screening, monitoring and stepped psychological care

Purpose / when: at the junctures ASCO names (diagnosis, start of treatment, changes in disease or treatment status, transition to palliative or end-of-life care, and when clinically indicated) [source: Andersen et al., 2023].
Steps:
1. Screen for depression with the PHQ-9 and anxiety with the GAD-7, as ASCO specifies (licensed or public instruments, used as published; items not reproduced here) [source: Andersen et al., 2023].
2. If screening shows risk of harm to self or others, arrange emergency evaluation and start risk-reduction steps, per ASCO and your local risk protocol [source: Andersen et al., 2023].
3. Offer information and resources on depression and anxiety to the client and any identified caregiver or confidant [source: Andersen et al., 2023].
4. Choose the most effective, least resource-intensive intervention for the severity (stepped care) [source: Andersen et al., 2023].
5. First-line psychological options per ASCO: CBT, behavioural activation, mindfulness-based stress reduction, ACT, structured physical activity and psychosocial interventions; medication is not first-line but may be considered in specified circumstances by the prescriber [source: Andersen et al., 2023]. The therapist never advises on medicines.
6. Where the client uses complementary approaches for mood, monitor scores alongside; do not attribute change to any product.
Example language (illustrative): "This is a point where a lot of people's stress goes up, so I'd like to do a quick check on mood and worry, like we did at the start."
Watch for: distress masked by positive-thinking norms in some groups ("I must stay positive"); physical symptoms confounding scores (interpret with the medical team); rising scores after a treatment decision. Working: scores fall or stabilise and function improves.

4.9 Respectful conversations about alternative treatment (when "instead")

Purpose / when: the client is declining, delaying or reducing conventional cancer treatment in favour of an alternative approach, or is seriously considering it.
Context for the therapist: in a US National Cancer Database study of non-metastatic breast, prostate, lung and colorectal cancer, people who chose alternative medicine alone had about 2.5 times the risk of death of matched patients receiving conventional treatment (adjusted HR 2.50), with the largest differences in breast and colorectal cancer [source: Johnson et al., 2018]. ACS states that choosing alternative methods instead of standard treatment for the most common curable cancers raises the risk of dying from cancer [source: ACS]. These are facts for the therapist's awareness and, where the client wants information, for accurate sharing; the oncologist is the right person to discuss the client's own prognosis.
Steps:
1. Keep the relationship first: thank the client for telling you; say you want to understand, not to argue.
2. Explore reasons fully (4.2): fear of side effects, previous bad experiences, distrust, financial barriers, faith, a persuasive practitioner or community, depression or hopelessness, avoidance.
3. Screen for treatable psychological drivers: panic or phobia about procedures, depression, trauma from previous treatment, needle or claustrophobia fears. Offer psychological help with these (4.5, 4.8).
4. Ask permission before sharing your concern; then state it once, briefly, with the published facts, and without threat.
5. Encourage a dedicated conversation with the oncologist (and second opinion if wanted) about what declining or delaying means for them; offer to help prepare questions.
6. Respect a capable adult's decision; keep the door open for return to conventional care; agree what would prompt a re-think.
7. Coordinate with consent (4.7); record the conversation, your concern and the client's decision.
8. If capacity is in doubt or the person is a child, follow capacity and safeguarding procedures (4.12).
Example language (illustrative): "Thank you for trusting me with this. Can I ask what's led you here?" / "May I share one worry I have? The research on people who choose other approaches instead of treatment for cancers like yours is concerning, and I'd want you to hear it from your oncologist before you decide. Whatever you choose, I'll still be here."
Watch for: the client withdrawing from therapy after feeling lectured; a practitioner or seller instructing the client to avoid medical contact; rapid symptom progression; hopelessness or passive suicidal thinking behind "I don't want treatment" (assess). Working: the client keeps talking to you and to the oncology team.

4.10 Supporting palliative-care referral

Purpose / when: disease is advanced, symptoms are burdensome, or the client is relying on alternative approaches to manage symptoms that palliative care could address.
Steps:
1. Explore what "palliative care" means to the client; many equate it with dying or "giving up" [synthesis].
2. Explain, in plain terms, that palliative care is specialist symptom and support care that can run alongside other treatment [synthesis].
3. Note, where relevant, that SIO–ASCO include massage for pain in palliative care, i.e. integrative approaches can be part of palliative services [source: Mao et al., 2022].
4. Encourage the client to ask their oncologist or GP for referral; with consent, raise it yourself.
5. Address fears and family disagreements about referral (4.13).
Example language (illustrative): "Palliative care teams are specialists in comfort and quality of life. Some of what you value, like massage or relaxation, is often part of what they offer."
Watch for: referral heard as abandonment; family members blocking referral; the client's spiritual framework (explore with respect; offer chaplaincy or faith-leader involvement if wanted).

4.11 Recognising commercial, group and financial pressure

Purpose / when: the client pays large or rising sums, buys from multi-level-marketing networks, is recruited to sell, is in an online or in-person group that discourages medical care, or is pressured by a practitioner.
Steps:
1. Ask about costs, payment plans, crowdfunding, debt and who profits [synthesis].
2. Ask how the group or practitioner responds to doubt, to medical treatment, or to leaving; note isolation from family or clinicians, secrecy, or testimonials of "cure".
3. Name, non-judgementally, any red flags you notice: claims to treat or cure cancer (unlawful to advertise in England, Wales and Scotland under the Cancer Act 1939 [source: CNHC]); advice to avoid or stop conventional treatment; pressure to buy more; recruitment to sell.
4. Help the client prepare questions about cost, number of sessions and products needed [source: ACS].
5. Consider reporting (4.16); consider safeguarding for adults at risk of financial abuse under local law [synthesis].
Example language (illustrative): "How much has this cost so far, and how do you feel about that?" / "What happens in the group when someone decides to have chemotherapy?"
Watch for: shame about money spent; the client recruiting family; high-control group dynamics (cutting contact, punishing doubt). Working: the client can weigh costs openly and keeps outside relationships.

4.12 Children, pregnancy and eating-related risk

Purpose / when: a child or young person with cancer is being given products or kept from medical care; a pregnant client uses products; a client adopts restrictive "anti-cancer" diets.
Steps:
1. Children: involve parents respectfully (4.2, 4.6); seek the young person's own view and assent at a developmentally appropriate level; inform the child's medical team with consent where safe. If a child is being deprived of medical care or given harmful products, follow local safeguarding and child-protection procedures, which override confidentiality [synthesis]. Note SIO–ASCO made no pain recommendations for children [source: Mao et al., 2022].
2. Pregnancy: route every product question to the obstetric and oncology teams and pharmacist; offer no opinion on safety [synthesis].
3. Restrictive diets: screen for restrictive or orthorexic eating, rapid weight loss, fear of particular foods, and preoccupation with dietary "purity"; refer to the oncology team and an oncology dietitian; screen for eating-disorder history and use established eating-disorder care if present [synthesis; medical risks of restriction during cancer treatment: uncertain].
Example language (illustrative): "What do you make of what your parents are trying?" (to a young person) / "Has the diet changed how much you're able to eat, or how you feel about food?"
Watch for: weight loss, fatigue, fainting, food fear, conflict at meals, a child's distress or silence. Escalate medical concerns to the treating team promptly.

4.13 Working with family conflict about treatment choices

Purpose / when: family members disagree about alternative or complementary use, or one person is driving the choice.
Steps:
1. With consent, meet with relevant family members; set the frame: the patient's informed decision with the oncology team is central [synthesis].
2. Let each person say what they fear and hope; reflect shared love and fear underneath positions.
3. Separate roles: the oncology team informs; the patient decides; the family supports.
4. Check privately for coercion of the patient in either direction.
5. Agree how the family will support whatever choice is made, and how they will talk about it.
Example language (illustrative): "It sounds like everyone here is frightened of losing her, and that fear is pulling you in different directions."
Watch for: the patient silenced; scapegoating; coalitions with a practitioner against the medical team; children caught in the middle.

4.14 Grief and regret after choosing alternatives

Purpose / when: a client, or a bereaved relative, regrets delaying or declining conventional treatment, or blames themselves or others.
Steps:
1. Offer a non-blaming space; acknowledge the decision was made with the information, fears and hopes of that time [synthesis].
2. Assess complicated grief, depression, guilt, anger at practitioners or at self, and suicidal thinking; use established grief and trauma-informed approaches [synthesis].
3. Distinguish appropriate responsibility from hindsight bias; use compassion-focused and ACT-style work where trained [synthesis].
4. Support reconnection with oncology or palliative care where still relevant.
5. Where the client was misled, discuss reporting options (4.16) without pressure.
Example language (illustrative): "You made the best choice you could see at the time, with the fear you were carrying. It makes sense to grieve that, too."
Watch for: self-punishment, withdrawal, anger displaced on clinicians, family blame; suicidal risk.

4.15 Health anxiety, somatic presentations and fear of recurrence

Purpose / when: the client seeks complementary approaches to manage intense fear of recurrence, body checking, reassurance seeking, unexplained symptoms, or chemical/environmental sensitivities.
Steps:
1. Assess health anxiety, somatic symptom presentation and fear of recurrence using established approaches; cross-refer to the Domain II guides on health anxiety and somatic symptom disorder [synthesis].
2. Ensure any new symptom is assessed medically first; coordinate with the oncology or primary-care team.
3. Work on checking, reassurance seeking and avoidance with CBT, ACT or mindfulness-based methods as those guides describe.
4. Explore how complementary practices function: soothing and engagement versus another form of safety-seeking.
Example language (illustrative): "It makes complete sense to be watchful after cancer. Let's look at whether all the checking is giving you peace, or keeping the fear going."
Watch for: missing genuine medical symptoms (always route to the medical team); products bought to neutralise fear in escalating amounts.

4.16 Reporting routes

Purpose / when: a product causes an adverse event, a practitioner claims to treat cancer, a client is financially exploited, or a professional breaches their code.
Steps:
1. USA: adverse events with dietary supplements go to FDA's Safety Reporting Portal; problems with drugs, devices, cosmetics and other products via MedWatch (online, phone or fax); consumers can also complain through FDA consumer complaint routes [source: FDA 101]. False or unsupported advertising claims, including claims that a product treats cancer or another serious condition: the Federal Trade Commission, which has primary responsibility for health claims in all forms of advertising [source: FTC, Health Products Compliance Guidance].
2. UK: advertisements offering to treat cancer, in England, Wales and Scotland, are enforced by Trading Standards [source: CNHC]. Suspected side effects of medicines, including herbal and homeopathic remedies, and fake or counterfeit medicines or devices: MHRA Yellow Card (online or by phone) [source: MHRA, Yellow Card scheme guidance]. Misleading health claims in advertising, including complementary-therapy advertising: Advertising Standards Authority [source: ASA].
3. Other jurisdictions: the national medicines/devices regulator and consumer-protection agency [uncertain].
4. Professional misconduct: the practitioner's licensing board or register.
5. Children or adults at risk: local safeguarding procedures [synthesis].
6. Encourage the client to report; report yourself where your code requires it or the client consents; record decisions.
Example language (illustrative): "You can report what happened. Would you like help working out where?"
Watch for: confidentiality limits; client fear of the practitioner or group; timeliness for active harm.

4.17 Managing your own scope and conflicts of interest

Purpose / when: always; especially if you also practise a complementary method, are affiliated with an integrative clinic, or are asked for a referral to a specific practitioner.
Steps:
1. Do not sell, recommend, prescribe or perform remedies, supplements, diets, devices or procedures; refer product and medical questions to the prescriber or pharmacist [synthesis].
2. Accept no commissions, referral fees or affiliate income; disclose any affiliation [synthesis; profession's ethics code applies].
3. Keep your own beliefs about complementary medicine out of the client's decision; seek supervision when you feel strongly.
4. Never advertise or describe any service as treating cancer [source: CNHC].
Example language (illustrative): "I don't recommend particular products or practitioners; that's for your medical team. What I can do is help you think it through."
Watch for: personal enthusiasm or scepticism steering the client; dual relationships.

5. Handling problems

The published sources address the field and psychological care for anxiety and depression; they do not address the psychotherapist's process problems directly. All responses below are [synthesis] unless tagged.

Client will not disclose complementary use. Likely fear of judgement. Response: normalise again, ask about categories rather than "alternative medicine", and show neutrality when something is disclosed. Remind the client that ACS and NCI ask all patients to share this with their team [source: ACS; NCI].
Client asks you to endorse a product or practitioner. Response: decline warmly, explain your role, offer to help prepare questions for the oncologist or pharmacist (4.4, 4.7).
Client asks whether to stop chemotherapy or a medicine. Response: never advise; explore what is driving the question (side effects, fear, despair), and help arrange an urgent conversation with the prescriber.
Client is "stuck" between family and a practitioner or group. Response: values clarification (4.6), family session (4.13), and exploration of group dynamics (4.11).
Resistance after you voiced concern. Response: repair explicitly; acknowledge you may have sounded like others who dismissed them; reaffirm that the decision is theirs and that you will stay.
Rupture with the oncology team spills into therapy. Response: validate the experience; help the client voice it to the team or seek a second opinion; avoid joining a split against conventional care.
Overwhelm (information overload, competing online claims). Response: narrow to one decision and one next step; use grounding and the client's trained coping skills; point to one reputable source (NCI, ACS, MSK About Herbs).
Non-adherence to psychological work (e.g. mindfulness practice) because of fatigue, nausea or pain. Response: shorten, simplify, adapt posture and timing; coordinate symptom control with the team; drop practices that increase distress (4.5).
Client invests hope in "fighting" cancer with mind–body practice, then disease progresses. Response: address guilt and self-blame directly; separate coping from cure; grief work (4.14).
Client chooses alternative instead of conventional treatment and you feel alarmed. Response: take supervision; use 4.9; check capacity concerns properly rather than through your own anxiety; document.
Client's condition worsens while relying on alternatives. Response: name concern for physical safety; urge prompt medical assessment; with consent contact the team; if life is at immediate risk, follow emergency procedures.
Financial exploitation discovered. Response: support without shame; help with practical steps (stopping payments, advice services); consider reporting and adult safeguarding (4.11, 4.16).
A child is being kept from medical care. Response: follow safeguarding procedures without delay; this overrides confidentiality (4.12).
Spiritual or energy explanations conflict with medical advice. Response: explore meaning respectfully; consider involving a trusted faith leader or chaplain with consent; keep the focus on the person's values and safety rather than debating the belief.
Your own beliefs (enthusiasm or scepticism). Response: supervision; check whether you are steering; return the decision to the client and their oncology team (4.17).
Practitioner advertising cancer treatment. Response: in England, Wales and Scotland, such advertising falls under the Cancer Act 1939 and Trading Standards [source: CNHC]; elsewhere use the national consumer and health regulators (4.16).

Sources

Web sources:

Cited by title, details as given in the pages above: Carlson LE, Ismaila N, Addington EL, et al., Rowland JH, Integrative oncology care of symptoms of anxiety and depression in adults with cancer: Society for Integrative Oncology–ASCO guideline, J Clin Oncol 2023, doi:10.1200/JCO.23.00857 (volume and pages not given in the record used). Andersen BL, Lacchetti C, Ashing K, et al., Management of anxiety and depression in adult survivors of cancer: ASCO guideline update, J Clin Oncol 2023, PMID 37075262.

Not covered by the sources above [uncertain]: regulation outside the US and UK; details of individual US state licensing laws.

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