CBT For Chronic Illness And Palliative Care: A Workbook and Toolkit Nigel Sage, Michelle Sowden, Liz Chorlton and Andrea Edeleanu Slide Set 2 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Does CBT work? With general psychological difficulties? In cancer and palliative care? In the book we also review research on using CBT with other physical health problems: Cardiac problems, chronic pain, MS, diabetes, COPD, Parkinson’s Disease Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

General psychological difficulties DoH and N.I.C.E (2001) Identified Treatment of Choice in psychological therapies Meta-review (Mackay and Barkham,1998) of best available evidence Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Good evidence that CBT is effective with: Social phobia Obsessive compulsive disorder Eating disorders Generalised anxiety disorder PMT Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

CBT is the treatment of choice for: Depression Panic disorder Chronic pain Chronic fatigue Pelvic pain Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Summary CBT has an impressive evidence base for general psychological difficulties No reason to assume this is not also the case for people with physical health care needs Studies have addressed this specifically Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

CBT in cancer and palliative care Moorey, S. and Greer, S. (2002). Cognitive behaviour therapy for people with cancer, Oxford University Press Chapters 3-4 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Is there evidence that: CBT improves quality of life? CBT affects duration of survival? A fighting spirit helps? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Quality of life Is CBT more effective than supportive counselling / no treatment? Is CBT better applied early or late after diagnosis? Is CBT effective in later stages? Is group work effective? Should we select distressed patients for CBT or offer to all? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Is CBT more effective than supportive counselling (SC) or no-treatment control (NTC)? Studies largely support that CBT >SC or NTC Specific CBT techniques e.g., graded task assignment, relaxation training, distraction, challenging negative thoughts, appear to be critical ingredients E.g. Greer et al 1992, Moorey et al 1994, Linn et al, 1982 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Is CBT better applied early or late after diagnosis Edgar, 1992 Compared 5 sessions CBT at 11 weeks and at 28 weeks after diagnosis CBT applied late > CBT applied early Initial emotions may impair ability to use CBT Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Can CBT be effective in the later stages of cancer? Linn et al 1982 Men with L.E. 3-12 months CBT included increasing meaningful activity, hope, self esteem and reducing denial CBT > NTC Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Summary CBT >SC or NTC CBT is more effective applied later than earlier after diagnosis CBT can be effective in later stages of cancer Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Psycho-educational groups 1 Relaxation and stress management Communication and assertiveness Problem solving Helpful thinking Managing emotions Activity planning Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Psycho-educational groups 2 Cunningham 1989 2 hours X 6 weeks PsyEd > SC groups PsyEd groups are effective across various cancers and stages PsyEd groups can be delivered by therapists from different backgrounds Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

CBT groups More flexible in application of techniques than PsyEd groups Results are mixed More studies are required Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Edelman 1999 12 sessions CBT vs SC Breast cancer CBT > SC By f/u CBT = SC Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

CBT Groups cont. In contrast: Fawzy et al 1990 6 sessions CBT vs standard care CBT > NTC At f/u CBT > NTC Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Should we select distressed patients for CBT or offer to all? Moynihan et al (1998) assessed whether CBT could help all patients with testicular cancer Compared 6 sessions of CBT with treatment as usual They concluded that routine CBT is not indicated Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Quality of the research Results confounded by study design Difficult to generalise findings Effectiveness may be influenced by type of cancer stage of disease process patient characteristics Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Summary: Can CBT improve quality of life? CBT > routine care in improving quality of life CBT is effective with selected patients exhibiting psychological distress Structured PsyEd groups = treatment of choice for non-selected groups Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Summary cont. Some evidence that people with advanced disease can benefit Intervening too early may not be beneficial Intervening too early may be detrimental May interfere with existing coping resources Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Can CBT affect duration of survival? Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Ground breaking research did initially show this E.g. Spiegel 1985 claimed survival increased by 18.9 months with group therapy Led to a big debate within the field Subsequently supported by other studies e.g. Richardson et al 1990, Fawzy et al, 1993 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Can CBT affect duration of survival cont.? However, sample sizes small With different cancer types and stages More recent studies contradict earlier findings e.g. Edelman 1999a Overall no consistent evidence to suggest that CBT increases duration of survival Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Is fighting spirit helpful? Initially claimed that fighting spirit led to better adjustment and duration of survival (Moorey and Greer, 2002) This work paved the way for CBT in c&p Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Is fighting spirit helpful cont.? Earlier claims have subsequently been refuted (Petticrew et al, 2002) It is no longer considered helpful to think in terms of adjustment style per se More helpful to think about what strategies help individual patients to cope at different stages of different cancers Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

Conclusions CBT has an excellent evidence base for a broad range of psychological difficulties relevant to people with cancer The benefits are in terms of QoL not duration of survival Different coping styles are effective for different people at different stages of different cancers Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008

CBT For Chronic Illness And Palliative Care: A Workbook and Toolkit Nigel Sage, Michelle Sowden, Liz Chorlton and Andrea Edeleanu Publisher: John Wiley & Sons (2008) ISBN: 978-0470517079 Sage, Sowden, Chorlton and Edeleanu Copyright John Wiley & Sons, 2008