PRACTICE MATTERS

Section Editors: Heather M. Hylton and Wendy H. Vogel

Cognitive Behavior Therapy

for Patients With Cancer
SHEENA DANIELS, DNP, ARNP, FNP-BC

C
From Florida Agricultural &
Mechanical University, Tallahassee, Florida
ancer is the second most WHAT IS CBT?
common cause of death Cognitive behavior therapy is
Author's disclosures of potential conflicts of
interest are found at the end of this article. in the United States. It a psychotherapeutic approach that
Correspondence to: Sheena Daniels, DNP, ARNP,
is estimated that there emphasizes the significance of how
FNP-BC, Florida Agricultural & Mechanical were 1,665,540 new cases diagnosed our thinking affects the way we feel.
University, 1601 S. Martin L. King Jr. Boulevard, in 2014 (American Cancer Society It has historically been used for psy-
Tallahassee, FL 32307. E-mail: sheena.daniels@
famu.edu
[ACS], 2014). The mainstay treatment chological disorders yet is now being
The author was a participant in the 2014 NLN
options for various cancers include explored for a number of different
Scholarly Writing Retreat, sponsored by the surgery, radiation, chemotherapy, and problems, including pain associated
NLN Foundation for Nursing Education and hormonal therapies or some combi- with various oncologic and hemato-
Pocket Nurse.
nation. In addition to the effects can- logic disorders (Anie & Green, 2012;
© 2015 Harborside Press® cer itself may have on the patient, its Tatrow & Montgomery, 2006).
treatment often brings about adverse Cognitive behavior therapy is built
effects such as fatigue, insomnia, pain, on the foundation that it is difficult
and depression (ACS, 2014). These to change our emotions directly. The
side effects can have an impact on the aim of CBT is to change emotions by
patient’s physical condition as well as first changing thoughts and behaviors
on his or her quality of life. (Cully & Teten, 2008). Offered in 30- to
Because of the multiple effects 60-minute increments, CBT is target-
cancer can have on a patient’s life, it ed to change the perceptions of how
is important for oncology advanced and what patients think based on the
practitioners (APs) to include both basic principle that says how a person
pharmacologic and nonpharmaco- thinks has a tremendous effect on his
logic management methods in the or her emotions and behavior (Mus-
plan of care. One intervention that taffa, Musa, Abu, & Yusof, 2012). The
has been recognized as beneficial is patient works with a CBT practitioner
cognitive behavior therapy, or CBT to develop skills to recognize, counter-
(Brothers, Yang, Strunk, & Andersen, act, and manage problematic thoughts
2011; Greer, 2008; Lee, Lim, Yoo, & and beliefs (Aschim et al., 2011).
Kim, 2011; Tatrow & Montgomery, If resources are available, APs
2006). This article will describe the can refer patients to licensed cogni-
use of CBT as an intervention for pa- tive behavior therapists; many coun-
tients with cancer and the positive selors have extensive training in this
J Adv Pract Oncol 2015;6:54–56 impact it may have on quality of life. technique, which would be a benefit

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 COGNITIVE BEHAVIOR THERAPY PRACTICE MATTERS

to both the AP and the patient. However, if these can be utilized for various cancer patients and for
resources are not accessible, APs are in a perfect a range of symptoms (Brothers et al., 2011; Greer,
position to offer CBT to their patients with mini- 2008; Lee et al., 2011; Tatrow & Montgomery, 2006).
mal training. Cognitive behavior therapies may include cognitive
Cognitive behavior therapy sessions can be di- restructuring, relaxation, skills training, and visual
vided into stages that start with gathering impor- imagery, among other modalities. Lee et al. (2011)
tant information about the patient (and what con- conducted an exploratory study in patients with
cerns the patient has) and end with a final stage breast cancer who were undergoing radiotherapy
that helps the patient integrate what was learned and were experiencing side effects, including fa-
in the sessions to help them cope with the concerns tigue and decreased quality of life. After a 6-week
associated with living with cancer (Mustaffa, Musa, nurse-led CBT intervention, Lee et al. found that
Abu, & Yusof, 2012). the participants were able to better control their fa-
The first stage generally focuses on identifying tigue levels and had significantly higher quality of
the problem. For example, the AP would ask the pa- life than the participants in the control group.
tient questions: “What made you come here today? Brothers et al. (2011) conducted a study with 36
What is the biggest challenge you are facing?” Gath- cancer survivors who were diagnosed with major
ering this information helps the AP identify which depressive disorder to determine the effectiveness
approach and technique would benefit the patient of biobehavioral and cognitive behavior interven-
most. For instance, Susan has stated that she has tions. They found that patients receiving CBT re-
been feeling nauseated from the side effects of che- ported improvements in their mental health, de-
motherapy. The AP would then discuss the poten- pression, and fatigue posttreatment.
tial techniques that could be used, such as cognitive Distress and pain are other common side effects
restructuring. Using this particular technique, cog- associated with cancer and its treatment. Cognitive
nitive restructuring, would include asking Susan behavior therapy has been linked to alleviating both
to identify her negative thoughts and the impact of these concerns (Greer, 2008; Tatrow & Montgom-
those negative thoughts would likely have during ery, 2006). A meta-analysis conducted by Tatrow and
her chemotherapy treatments. The AP would then Montgomery (2006) studied the use of CBT for dis-
ask her, “What can be changed about the situation? tress and pain in breast cancer patients. That study
Is there anything you can change about how you revealed that 69% of the patients who participated in
think that could possibly make you feel better?” the treatment group reported less pain and less dis-
This open-ended question will lead Susan into ex- tress. Greer (2008) observed that fostering positive
ploring different perspectives and possibly chang- environments and building rapport with patients are
ing her feelings or thought processes. The AP then essential and can aid in the effectiveness of CBT in
might ask Susan to start thinking and journaling reducing helplessness and hopelessness.
positive thoughts and to practice this positivity in
her daily life and during chemotherapy treatments BARRIERS TO IMPLEMENTATION
(Mustaffa et al., 2012). Barriers to APs offering CBT to their pa-
tients who have been identified as potential can-
TRIALS IN CBT didates include distractions within the practice,
A number of studies have been conducted indi- lack of time, and various interruptions. Barriers
cating that CBT is a beneficial therapy option that to patients accepting or actually using CBT in-
clude having a preference for pharmacotherapy
and lack of interest and/or motivation (Wiebe &
Griever, 2005). Advanced practitioners can try to
Use your smartphone to access the
Beck Institute for Cognitive Behavior
overcome some of these barriers by starting small:
Therapy website to find out more incorporate a condensed version of CBT that fits
about training and consultations. your schedule, give the patient “homework,” and
SCAN HERE provide feedback on the return visit (Wiebe &
Griever, 2005). Completing homework and re-

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 PRACTICE MATTERS DANIELS

ceiving feedback can make the patient feel like a Disclosure

full participant in his or her health care. The author has no conflicts of interest to dis-
close.
HOW CAN APs IMPLEMENT CBT?
Oncology APs can implement CBT into their References
practice in a number of ways. Studies have shown American Cancer Society. (2014). Cancer facts & figures 2014.
Retrieved from http://www.cancer.org/research/can-
that incorporating CBT into regularly scheduled cerfactsstatistics/cancerfactsfigures2014/index
medical visits can be a practical way to integrate it Anie, K., & Green, J. (2012). Psychological therapies for sickle
into patient care (Keefe, Abernathy, & Campbell, cell disease and pain. Cochrane Database of Systematic Re-
views, 2, CD001916. http://dx.doi.org/10.1002/14651858.
2005). The use of guided self-help CBT through CD001916.pub2
books, manuals, and handouts has been studied. It Aschim, B., Lundevall, S., Martinsen, E. W., & Frich, J. C.
(2011). General practitioners’ experiences using cogni-
has been found to be more effective in improving tive behavioural therapy in general practice: A qualitative
mood for the treatment of depression than usual study. Scandinavian Journal of Primary Health Care, 29,
treatment alone (Williams et al., 2005). A review 176–180. http://dx.doi.org/10.3109/02813432.2011.595582
Brothers, B., Yang, H., Strunk, D. R., & Andersen, B. L. (2011).
on the effectiveness of CBT in primary health care Cancer patients with major depressive disorder: Testing
suggested that primary care practitioners are in a a biobehavioral/cognitive behavior intervention. Journal
good position to offer this type of therapy to pa- of Consulting and Clinical Psychology, 79(2), 253–260.
Cully, J. A., & Teten, A. L. (2008). A therapist’s guide to brief
tients without extensive specialized training; they cognitive behavioral therapy. Houston, TX: Department
found that it is an effective therapy for anxiety and of Veterans Affairs South Central MIRECC.
depression and can be delivered in primary care Greer, S. (2008). CBT for emotional distress of people with
cancer: Some personal observations. Psycho-Oncology,
(Høifødt, Strøm, Kolstrop, Eisemann, & Waterloo, 17, 170–173.
2011). Additionally, the review described other Høifødt, R. S., Strøm, C., Kolstrup, N., Eisemann, M., & Wa-
methods of delivery, including Internet/computer, terloo, K. (2011). Effectiveness of cognitive behavioural
therapy in primary health care: A review. Family Practice,
face-to-face, and self-help materials. This is consis- 28(5), 489–504. http://dx.doi.org/10.1093/fampra/cmr017
tent with another study that found educated part- Keefe, F., Abernathy, A. P., & Campbell, L. (2005). Psychologi-
ner–guided CBT was beneficial in helping increase cal approaches to understanding and treating disease-
related pain. Annual Review of Psychology, 56, 601–630.
self-efficacy and reduce pain (Keefe et al., 2005). Keefe, F., Ahels, T., Sutton, L., Dalton, J., Baucom, D., Pope, M.
There are informal and formal ways for APs to S.,…Scipio, C. (2005). Partner-guided cancer pain man-
learn how to implement CBT. There are a number of agement at the end of life: A preliminary study. Journal of
Pain and Symptom Management, 29(3), 263–272. http://
CBT manuals available for the AP who has no formal dx.doi.org/10.1016/j.jpainsymman.2004.06.014
CBT training. These manuals are designed to give a Lee, H., Lim, Y., Yoo, M. S., & Kim, Y. (2011). Effects of a nurse-
led cognitive behavior therapy on fatigue and quality of
brief therapy model to assist in rapid training (Cully life patients with breast cancer undergoing radiotherapy:
& Teten, 2008; Rosselló & Bernal, 2007). Formal An exploratory study. Cancer Nursing, 34(6), E22–E30.
training is available through the Beck Institute for Mustaffa, S., Musa, A. M., Abu, S., & Yusof, R. M. (2012). Effects
of cognitive behavior approaches in anxiety for cancer pa-
CBT, which offers both individual and group train- tient undergone chemotherapy. International Journal of
ing on-site as well as consultations for your facility. Fundamental Psychology & Social Sciences, 2, 70–73.
Roselló, J., & Bernal, G. (2007). Treatment manual for CBT for
depression. Center for Psychological Services & Resarch.
CONCLUSION University of Puerto Rico. Retrieved from http://ipsi.uprrp.
The therapies we use for cancer treatment of- edu/pdf/manuales_tara/individual_manual_eng.pdf
ten affect the patient mentally as well as physically, Tatrow, K., & Montgomery, G. H. (2006). Cognitive behavior
therapy techniques for distress and pain in breast cancer
causing distress and symptoms that affect quality patients: A meta-analysis. Journal of Behavioral Medicine,
of life. Oncology APs can integrate CBT in a variety 29(1), 17–27. http://dx.doi.org/10.1007/s10865-005-9036-1
of ways and allow nonpharmacologic treatments to Wiebe, E., & Griever, M. (2005). Using cognitive behavioural
therapy in practice: Qualitative study of family physicians’
aid in the symptom management that comes with experiences. Canadian Family Practice, 51, 992–993.
a cancer diagnosis. Implementing CBT into prac- Williams, C., Wilson, P., Morrison, J., McMahon, A., Walker,
tice may appear challenging at first, but efforts to A., Allan, L.,…Tansey, L. (2013). Guided self-help cogni-
tive behavioral therapy for depression in primary care:
help this unique population in achieving better all- A randomised controlled trial. PLoS One, 8(1), e52735.
around health are efforts well spent. l http://dx.doi.org/10.1371/journal.pone.0052735

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