Training in Psychological
Support:
Using Cognitive Behavioural
Approaches in Palliative Care
Ms Clare Gadd
Marie Curie Hospice Solihull
Dr Iñigo Tolosa
Pan Birmingham Cancer Network
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Format
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A day a fortnight for Six Months
Eight Hospice Staff (Ward & Community)
Two or Three Trainers (Psychologists)
Day Schedule:
– Checking in: Progress and Obstacles
– Teaching session
– Joint Clinical Practice
– Clinical Supervision
• Follow up: 10 monthly refresher & SV sessions
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Training on Cognitive-Behavioural
Approaches in Palliative Care
Teaching Session Relevant
chapters
Teaching Topics
Session 1
Ch 1 & 2
Introductions; ‘norming, storming & forming’;
Introduction to Cog Beh Theory; Relevance of CBT
Session 2
Ch 4
Communication skills
Session 3
Ch 5 & 6
CBT communication and Guided Discovery
Session 4
Ch 7
Assessment; questions to ask; tools
Session 5
Ch 8
Formulation
Session 6
Ch 9-11
Intervention
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From “CBT for Chronic Illness and Palliative Care: A Workbook
and Toolkit”. Sage, Sowden, Chorlton & Edeleanu, 2008
Session 7
Ch 9-11
Goal setting; Step by step; Practicalities, problems
Session 8
Ch 12
Bringing about change
Session 9
Ch 13
Behaviour change; graded exposure; resistance,
avoidance
Session 10
Ch 14 & 15
Cognitive change; challenging unhelpful thinking
Session 11
Ch 16
Managing emotions and unpleasant sensations
Session 12
All Book
Consolidation and Practice
Session 13
All Book
Preparing for Goodbye
Session 14
All Book
Endings & Saying Goodbye (Pros, Cons, Costs,
Losses)
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Cognitive Behavioural Approaches
• Problem-oriented
• Look at Emotions, Thoughts, Behaviours
and Physiological Responses
• Interpersonal
• Related to cancer type
• Psychoeducational – client taught cognitive
model and shown how their thoughts
contribute towards distress (homework)
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6
Translating the Stages 1…
• Assessment – what would you like to know?
– How?
– What questions do you need to ask to get the
information?
• Formulation – what is the problem/issue the
patient wants help with
– Why/when/how did it start?
– Why is it a problem?
– How is it maintained?
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Translating the stages 2…
• Tackling the problem:
– Agreeing the goal/s or the desired change?
– Setting the steps (SMART)
• How /where/ what to bring about change – use
the toolkit
Which techniques?
– Emotional focus
– Cognitive focus
– Or a mix?
-- Behavioural focus
-- Sensations focus
• Constantly checking back – is this the right goal?
How is it going?
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• What might other useful questions be?
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Cognitive Techniques for changing
decision making
• Breaking old cognitive habits
• Distinguishing between intention and action
• Commitment:
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Acceptance – of the problem
Belief
Pros and Cons
Considering others’ views and reactions
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Behavioural techniques
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Relaxation training
Activity scheduling
Graded task assignment
Planning for the future
Behavioural experiments
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Examples of clinical application A
• Nature of Psychological Distress:
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Deterioration in Patient’s condition; and
Feelings of loss of control over life.
• HP’s Observations and Opinions of what was happening:
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Patient seemed to be in a vicious cycle of:
thinking they were not in control → increased stress, anxiety, worry and hopelessness →
sleeplessness → tiredness and loss of confidence → avoiding people and situations,
becoming more withdrawn → feeling more out of control.
• HP’s intervention:
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Used Guided Discovery to explore what was causing most concern to the Patient.
Worked together on plan for patient to regain more control with step by step approach.
• HP’s Assessment of how the course helped this situation:
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Gave me the confidence to explore difficult issues with patients which I would not have
done before.
Helped me to think with patients about the thought patterns, behaviours and emotions,
and perhaps to change them.
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Examples of clinical application B
• Nature of Psychological Distress:
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Patient felt she was letting her family down by being ill and imminently dying.
Rift with one daughter, the other had disabilities and was in a residential home.
• HP’s Observations and Opinions of what was happening:
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Patient was tearful and expressed many regrets about her life and her desire to have
changed things. Her anxiety brought on her pain.
• HP’s intervention:
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Did a ‘hot cross bun’ with patient to explore links between thoughts, emotions,
physiological sensations and behaviour.
Patient was able to see the link between her anxiety and pain. Explored what patient
wanted to do to change things with her estranged daughter. She expressed some
thoughts and we made time to meet again. Unfortunately we were unable to revisit the
issues because the patient’s condition deteriorated.
• HP’s Assessment of how the course helped this situation:
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Gave me confidence to explore painful issues. It felt okay that the patient was tearful.
I was able to reflect that her feelings made her cry rather than me.
I was able to use Guided Discovery and the downward spiral of unhelpful thinking.
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Over to Clare...
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