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The background and role of the clinical
psychologist in cancer care

By Phyllis Alden

 ‘The background and role of the clinical psychologist in cancer care’ is written by Phyllis Alden who is a Consultant Psychologist in Oncology and Palliative Care at Southern Derbyshire Acute Hospitals NHS Trust. She provides clinical and other psychological services to people with cancer.  Her interest in working with cancer patients developed gradually from her first real involvement in the 1980s when, whilst working primarily in mental health, she began to see patients with cancer and assisted in the setting up of a Home Hospice Support Team.

Clinical Psychology – the background 

Clinical Psychology, as a profession, probably began in the 1950s.  Psychology itself is the scientific study of behaviour, by which we mean everything that makes us ‘tick’ – learning, memory, intelligence, personality, thinking, development from infancy to death, effects of society on the individual, the brain and nervous system etc.  Clinical psychology is the application of psychology to the assessment, understanding and treatment of the problems people get as they go through life, for example emotional reactions to traumatic events, anxiety, depression, and phobias.

 In the past psychologists’ work was quite generic, i.e. their work would encompass a whole range of clients from children to the elderly and all kinds of problems from those who were seriously mentally ill to individuals with specific fears.  Nowadays we specialise.  So, instead of working across the board, a psychologist will have a particular area, e.g. medicine, adult mental health, the elderly, child health, and those who are long term mentally ill.  Even within medicine we specialise, for example, I only work in cancer care. 

 Also, psychology differs from psychiatry.  Psychiatrists are medical doctors who have specialised in mental illness, whereas a clinical psychologist will have a good honours BSc or MA degree in psychology.

For many years from the 1950s psychologists operated firmly within psychiatry in psychiatric hospitals.  In the 1970s this started to change and members of the profession started to work alongside GPs and within general hospitals.  Psychologists began to work with those who were physically ill rather than just with those with mental health problems.

Since the 1960’s there has been increasing recognition of the psychological needs of cancer patients.  Not only that, but over the last 40 years there has been increasing acknowledgement of the fact that all life threatening and chronic illnesses generate psychological issues which may result from these diagnoses or play a part in the illness itself.

Increasing the service

However, it was really in the 1990s that clinical psychology in cancer care really took off.  It was all thanks to a government report produced by Sir Kenneth Calman and Dr Deidre Heine.  This report was a blueprint for how cancer services should be organised; it laid down guidelines for everything from diagnostic procedures to psychological care. As a result of the Calman report, health regions devised sets of standards; hospitals then had to sign up to meet these standards if they were to continue to treat cancer patients.

This report facilitated an increased recognition and legitimisation of the psychological needs of patients and their carers.  It led to the development and funding of many more clinical nurse specialist and clinical psychology posts to help address the real need for psychological support for patients with cancer.

Since then, we have seen the NHS Plan, the Cancer Plan, and most recently, a draft of a Supportive and Palliative Care Strategy.  All of these documents have increasingly acknowledged psychological issues and the importance of providing services to address them.

It is highly unlikely that those diagnosed with a cancer 50 years ago would have been invited to discuss how they felt emotionally.  Indeed, it is likely that they would not have been told that they had cancer at all and feelings would have been ‘swept under the carpet’. At that time many treatments were in the early stages of development and such a diagnosis would probably have been terminal, but no one (perhaps apart from the patient’s priest) would have discussed this. Nowadays many forms of cancer can be cured and the lymphomas are amongst the most treatable.

Slowly but surely the recognition of psychological aspects of illness have resulted in increasing provision of psychological support in healthcare. We have seen the growth of the Macmillan movement, for which nurses are specially trained to have expertise in symptom control and psychological support.  We have also seen an increase in the numbers of Clinical Nurse Specialists whose role includes psychological support.

What sort of things can the clinical psychologist help with?

Feelings

“Imagine you are sailing along on a yacht on a beautiful day knowing exactly where you are going and looking forward to your trip.  Your journey is planned and you know how to get to your destination.  Then along comes a terrifying storm which threatens to capsize you.  You lose your bearings, you are terrified you’ll drown and you no longer know where you’re going or how you are going to get anywhere.”

“It is like being on a train which goes faster and faster.  You want to get off but it won’t stop at your station.  You feel out of control and you don’t know where you are going”.

These two metaphors were used by different clients describing the experience of a cancer diagnosis and indicate their anxiety.

Some degree of anxiety and depression are very normal in cancer patients.  Symptoms of anxiety include feelings of worry and/or fear, feeling tense and uptight, often accompanied by physical symptoms such as churning stomach, shaking, sweating and racing heart.  It also manifests itself in poor concentration, sleep difficulty and not being able to stop thinking about the thing that is causing concern. Symptoms of depression include very low mood, inability to enjoy things, lack of interest, difficulties sleeping and concentrating and feelings of pessimism about the future or life in general

Some patients and their relatives might feel angry that this has happened to them, in turn affecting their relationships. This feeling of anger is also a normal reaction.

If our body image changes it can affect the way we cope and feel about things.  The side effects of treatment such as weight change and hair loss cannot be disregarded; surgery can leave scars.  Interestingly, most people think that hair loss will bother women and not men.  This is not true.  I recall talking to a man who was seriously considering not having chemotherapy for his very treatable Hodgkin’s disease because he couldn’t face the prospect of losing his hair. If it is needed, the opportunity to talk through issues of concern and getting psychological support can help people to come through their distress; indeed many people say that through the cancer experience they have found a new way of looking at life and their illness.

Coping with treatments

The clinical psychologist can also help individuals cope with their treatments. Some people having chemotherapy become sick at the thought of treatment.  Perhaps they felt nauseous or were sick the first time they had chemotherapy or have heard stories about sickness and chemotherapy. This can develop into such a problem that they vomit when arriving at the hospital.  I treat this difficulty with hypnosis.

Sometimes someone will be very frightened of injections or needles to such an extent that they faint when they see one, even before having the injection or blood test.  Again psychological therapy can help.  One of my first cancer patients was a lady who had postponed going with her breast lump because she was so frightened of needles.  She needed chemotherapy but stated categorically that she wouldn’t be able to go through it without help.

Some people are claustrophobic and can’t face the prospect of entering a scanner or find it too difficult to have something covering their face (for example during the preparation of a mould) in radiotherapy. These patients often need psychological therapy immediately so that they can continue with their diagnosis or treatment.

For some people their fears interfere with their quality of life. There are a variety of psychological therapies that can help in this situation.  One such is cognitive-behavioural therapy, which involves looking at the way we think about things, then challenging and modifying our thoughts and this can influence our beliefs.  I recently saw a lady two and a half years after she had been successfully treated for Hodgkin’s disease.  She was depressed because she believed that her “time was running out”. Her misunderstanding was that the closer she got to the “5 year survival” the more likely it would be that she would die, she hadn’t realised that it meant that her illness would be much less likely to come back.

Symptom control is also amenable to psychological interventions, for example, pain can sometimes be relieved through relaxation techniques.

Other work

As well as working directly with patients, I spend time working with other staff to help them with their work with patients.  This can take the form of advising them.  It can also mean teaching and training in the understanding of psychological problems, communication skills and psychological interventions.

Other areas of work include audit and research.  From our undergraduate days we are taught to carry out good scientific research and that continues to be emphasised in clinical training.  In order to justify our clinical input we need evidence and that includes research on the psychological issues that cancer can generate as well as trials of psychological interventions.

The National Institute of Clinical Excellence (otherwise known as NICE) which provides guidance for both  the NHS and patients on practice and medicines, sets great store by research findings and an important part of our work is to produce the necessary data to justify funding for psychological care.

Although there are an increasing number of clinical psychologists working in this field there are still not nearly enough of us, so, unfortunately, many hospitals still do not have this service readily available. However, all in all, the emphasis placed on good psychological care has grown over the years.

Whilst psychologists such as myself can treat patients and spread the word about the importance of such care, it is also down to you, the patients, to help us make your case.  Please don’t be silent.