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Psycho-oncology notes

Clinical Psychology (Amity University)

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Psycho-Oncology Notes

Module 1: Introduction to Psycho-oncology

Introduction to the meaning and concept

INTRODUCTION: Psycho-oncology is a collaborative, cross- disciplinary subspecialty of

oncology with domains in the psychological, social, behavioral, and ethical aspects in clinical
care. It is more concerned with relationships between cancer and the mind.
‘Psychosocial oncology’ is a similar term with the broader implication that cancer concerns not
just individual patients but their families, friends and colleagues, and the society in which they
live.

This area deals with the psychological; the emotional reaction to this illness at all stages of
disease for the patient’s family and staff who have their own burden in taking care of the
patients.

HISTORY AND DEVELOPMENT OF PSYCHO-ONCOLOGY

• The formal beginning of psycho-oncology dates to the mid- 1970s, when the stigma
making the word “cancer ” unspeakable was diminished to the point that the diagnosis
could be revealed and the feelings of patients about their illness could be explored for the
first time.
• However , the second stigma has contributed to the late development of interest in the
psychological dimension of cancer: negative attitudes attached to the mental illness and
psychological problems, even in the context of medical illness.
• In the new millennium, a significant base of literature, training programs, and a broad
research agenda have evolved with application at all points on the cancer continuum:
behavioral research in changing life-style and habits to reduce cancer risk; behavior and
attitudes to ensure early detection; psychological issues related to genetic risk and testing;
symptoms control (anxiety, depression, delirium, pain and fatigue) during survivor; and
management of the psychological aspects of palliative and end –of –life care.
• At the start of the third millennium, psycho-oncology came of age as one of the youngest
subspecialties of consultation- liaison psychiatry and psychosomatic medicine.

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HISTORICAL BARRIER RELATED TO CANCER

• In the 1800s, like the preceding centuries, a cancer diagnosis was viewed as the equivalent
of death. There was no known cause or cure.
• Fear of cancer was so great that the family would not reveal the diagnosis to others because
of the stigma that became attached to the family. Shame and guilt were dominant emotions,
combined with the fear that it was contagious.
• Early in the twentieth century, as surgery improved and anesthesia was developed, it
became possible (though uncommon) to cure a cancer if the tumor was found early and
could be removed before it had spread.
• The American Cancer Society, formed in 1913, was the first attempt in the United States to
alter the public’s fatalistic attitudes towards cancer..
• The Society’s mandate was to “ disseminate knowledge concerning the symptoms,
treatment and prevention of cancer.”
• Radiation joined surgery as a treatment for cancer early in the first quarter of the twentieth
century, thanks to the pioneering work of Marie Curie in Paris. However, it was offered
mainly as palliation, often after surgical failure, and people feared it as they did surgery.
• In 1937, the National Cancer Institute was created in the United States as the first of the
National Institute of health.
• In 1948, the first temporary remissions of childhood acute leukemia occurred with
aminopterin, followed by the early responses of Hodgkin’s disease to nitrogen mustard.
• Thus chemotherapy was added as the third treatment modality for cancer, combined with
increasingly more effective surgery and radiation.
• The first chemotherapy cure of a cancer, choriocarcinoma, a tumor common in Asian
women, by the single agent methotrexate, was achieved in the early 1950s.

HISTORICAL BARRIERS RELATED TO PSYCHOLOGICAL ISSUES

• The centuries old stigma attached to mental illness and its treatment had a profound impact
on developing psychological care for medically ill patients.
• In the nineteenth and early twentieth centuries, mental patients and their physicians were
seen as alienists, isolated and located at a distance from general hospitals.
• In 1902, the first psychiatric ward was opened in a general hospital in Albany, New York.
• The 1930s saw the arrival of many psychoanalysts from Europe to the United States.
Flanders Dunbar and Franz Alexander were well – known figures whose research focused
on a possible psychoanalytic base for several medical diseases.

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Scope of Psycho-oncology

● Psychosocial distress is commonly noted in persons suffering from cancer. A variety of

psychiatric and psychosocial disorders are also observed in cancer patients, at different
stages of their disease.
● The commonest psychiatric disorders observed in cancer patients are adjustment
disorders, depression, anxiety, delirium and specific cancer related psychosocial
disorders.
● A patient with cancer is expected to have a certain level of psychological distress but
when this distress becomes a clinical problem, it needs to be addressed.
● Psychiatric oncology as a sub-specialty, focuses on several issues, which include –
➔ The role of life events, stress, and other psychological factors in the causation,
maintenance, and prognosis of cancer;
➔ Psychological and emotional reactions to diagnosis of cancer, its recurrence, metastasis; -
➔ Psychiatric disorders in relation to cancer and its treatment; -
➔ Psychological methods of treatment, and counseling, -
➔ Communicating with cancer patients and their relatives; -
➔ Terminal care and palliative care; -
➔ Study and management of grief and bereavement associated with cancer; and –
➔ Staff stress and burnout among professionals treating cancer patients.

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Module II Introduction to Cancer

● Cancer as a disease
● Cancer Biology

What is cancer?
Cancer is a disease in which some of the body’s cells grow uncontrollably and spread to other
parts of the body.

Cancer can start almost anywhere in the human body, which is made up of trillions of cells.
Normally, human cells grow and multiply (through a process called cell division) to form new
cells as the body needs them. When cells grow old or become damaged, they die, and new cells
take their place.

Sometimes this orderly process breaks down, and abnormal or damaged cells grow and multiply
when they shouldn’t. These cells may form tumors, which are lumps of tissue. Tumors can be
cancerous or not cancerous (benign).

Cancerous tumors spread into, or invade, nearby tissues and can travel to distant places in the
body to form new tumors (a process called metastasis). Cancerous tumors may also be called
malignant tumors. Many cancers form solid tumors, but cancers of the blood, such as leukemias,
generally do not.

Benign tumors do not spread into, or invade, nearby tissues. When removed, benign tumors
usually don’t grow back, whereas cancerous tumors sometimes do. Benign tumors can
sometimes be quite large, however. Some can cause serious symptoms or be life threatening,
such as benign tumors in the brain.

A Collection of Related Diseases

• Cancer is the name given to a collection of related diseases. In all types of cancer, some of
the body’s cells begin to divide without stopping and spread into surrounding tissues.
• Cancer can start almost anywhere in the human body, which is made up of trillions of cells.
Normally, human cells grow and divide to form new cells as the body needs them. When
cells grow old or become damaged, they die, and new cells take their place.
• When cancer develops, however, this orderly process breaks down. As cells become more
and more abnormal, old or damaged cells survive when they should die, and new cells form

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when they are not needed. These extra cells can divide without stopping and may form
growths called tumors.
• Many cancers form solid tumors, which are masses of tissue. Cancers of the blood, such as
leukemias, generally do not form solid tumors.
• Cancerous tumors are malignant, which means they can spread into, or invade, nearby
tissues. In addition, as these tumors grow, some cancer cells can break off and travel to
distant places in the body through the blood or the lymph system and form new tumors far
from the original tumor.
• Unlike malignant tumors, benign tumors do not spread into, or invade, nearby tissues.
Benign tumors can sometimes be quite large, however. When removed, they usually don’t
grow back, whereas malignant tumors sometimes do. Unlike most benign tumors elsewhere
in the body, benign brain tumors can be life threatening.

Loss of normal growth control

The body is made up of many types of cells. These cells grow and divide in a controlled way to
produce more cells as they are needed to keep the body healthy. When cells become old or
damaged, they die and are replaced with new cells.

However, sometimes this orderly process goes wrong. The genetic material (DNA) of a cell can
become damaged or changed, producing mutations that affect normal cell growth and division.
When this happens, cells do not die when they should and new cells form when the body does
not need them. The extra cells may form a mass of tissue called a tumor.

Difference between normal cell (benign) and cancer cell (malignant).

1. Growth

Normal cells stop growing (reproducing) when enough cells are present. For example, if cells
are being produced to repair a cut in the skin, new cells are no longer produced when there are
enough cells present to fill the hole (when the repair work is done).

In contrast, cancer cells don’t stop growing when there are enough cells present. Cancer cells
reproduce rapidly before they have had a chance to mature. This continued replication often
results in a tumor (a cluster of cancer cells) being formed.

2. Communication

Cancer cells don’t interact with other cells and do not respond to any signals as normal cells do.
Normal cells respond to signals sent from other nearby cells that say, “you’ve reached your
boundary.” When normal cells “hear” these signals they stop growing.

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3. Stickiness

Normal cells secrete substances that make them stick together in a group. Cancer cells fail to
make these substances, and can “float away” to locations nearby, or through the bloodstream or
system of lymph channels to distant regions in the body.

4. Spread

Normal cells stay in the area of the body where they belong. For example, lung cells remain in
the lungs. Some cancer cells may lack the adhesion molecules that cause stickiness, and are able
to detach and travel via the bloodstream and lymphatic system to other regions of the
body—they have the ability to spread.

5. Appearance

Under a microscope, normal cells and cancer cells may look quite different. In contrast to normal
cells, cancer cells often exhibit much more variability in cell size—some are larger than normal
and some are smaller than normal.

In addition, cancer cells often have an abnormal shape—both the cell and the nucleus (the
“brain” of the cell.) The nucleus appears both larger and darker than normal cells.

6. Function

Normal cells perform the function they are meant to perform, whereas cancer cells may not be
functional.

or example, normal white blood cells help fight off infections. In leukemia, the number of white
blood cells may be very high, but since the cancerous white blood cells are not functioning as
they should, people can be more at risk for infection even with an elevated white blood cell
count.

7. Evasion of the Immune System

When normal cells become damaged, the immune system (via cells called lymphocytes)
identifies and removes them.

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Cancer cells are able to evade (trick) the immune system long enough to grow into a tumor by
either escaping detection or by secreting chemicals that inactivate immune cells that come to the
scene.

8. Maturation

Normal cells mature. Cancer cells, because they grow rapidly and divide before cells are fully
mature, remain immature. Doctors use the term undifferentiated to describe immature cells (in
contrast to differentiated to describe more mature cells.)

Types of Cancer

There are more than 100 types of cancer. Types of cancer are usually named for the
organs or tissues where the cancers form. For example, lung cancer starts in the lung,
and brain cancer starts in the brain

Here are some categories of cancers that begin in specific types of cells:

1. Carcinoma

Carcinomas are the most common type of cancer. They are formed by epithelial cells, which are
the cells that cover the inside and outside surfaces of the body. There are many types of epithelial
cells, which often have a column-like shape when viewed under a microscope.

Carcinomas that begin in different epithelial cell types have specific names:

● Adenocarcinoma is a cancer that forms in epithelial cells that produce fluids or mucus.
● Basal cell carcinoma is a cancer that begins in the lower or basal (base) layer of the
epidermis, which is a person’s outer layer of skin.
● Squamous cell carcinoma is a cancer that forms in squamous cells, which are epithelial
cells that lie just beneath the outer surface of the skin.
● Transitional cell carcinoma is a cancer that forms in a type of epithelial tissue called
transitional epithelium, or urothelium.

2. Sarcoma

Sarcomas are cancers that form in bone and soft tissues, including muscle, fat, blood vessels,
lymph vessels, and fibrous tissue (such as tendons and ligaments).

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Osteosarcoma is the most common cancer of bone. The most common types of soft tissue
sarcoma are leiomyosarcoma, Kaposi sarcoma, malignant fibrous histiocytoma, liposarcoma, and
dermatofibrosarcoma protuberans.

3. Leukemia

Cancers that begin in the blood-forming tissue of the bone marrow are called leukemias. These
cancers do not form solid tumors. Instead, large numbers of abnormal white blood cells
(leukemia cells and leukemic blast cells) build up in the blood and bone marrow, crowding out
normal blood cells. The low level of normal blood cells can make it harder for the body to get
oxygen to its tissues, control bleeding, or fight infections.

There are four common types of leukemia, which are grouped based on how quickly the disease
gets worse (acute or chronic) and on the type of blood cell the cancer starts in (lymphoblastic or
myeloid). Acute forms of leukemia grow quickly and chronic forms grow more slowly.

4. Lymphoma

Lymphoma is cancer that begins in lymphocytes (T cells or B cells). These are disease-fighting
white blood cells that are part of the immune system. In lymphoma, abnormal lymphocytes build
up in lymph nodes and lymph vessels, as well as in other organs of the body.

There are two main types of lymphoma:

● Hodgkin lymphoma – People with this disease have abnormal lymphocytes that are called
Reed-Sternberg cells. These cells usually form from B cells.
● Non-Hodgkin lymphoma – This is a large group of cancers that start in lymphocytes. The
cancers can grow quickly or slowly and can form from B cells or T cells.

5. Multiple Myeloma
Multiple myeloma is cancer that begins in plasma cells, another type of immune cell. The
abnormal plasma cells, called myeloma cells, build up in the bone marrow and form tumors in
bones all through the body. Multiple myeloma is also called plasma cell myeloma and Kahler
disease.

6. Brain and Spinal Cord Tumors

There are different types of brain and spinal cord tumors. These tumors are named based on the
type of cell in which they formed and where the tumor first formed in the central nervous system

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How Does Cancer Develop?

Cancer is a genetic disease—that is, it is caused by changes to genes that control the way our
cells function, especially how they grow and divide.

Genetic changes that cause cancer can happen because:

● of errors that occur as cells divide.

● of damage to DNA caused by harmful substances in the environment, such as the
chemicals in tobacco smoke and ultraviolet rays from the sun. (Our Cancer Causes and
Prevention section has more information.) they were inherited from our parents.

The body normally eliminates cells with damaged DNA before they turn cancerous. But the
body’s ability to do so goes down as we age. This is part of the reason why there is a higher risk
of cancer later in life.

Each person’s cancer has a unique combination of genetic changes. As the cancer continues to
grow, additional changes will occur. Even within the same tumor, different cells may have
different genetic changes.

Cancer is caused by certain changes to genes, the basic physical units of inheritance. Genes are
arranged in long strands of tightly packed DNA called chromosomes.

When Cancer Spreads

A cancer that has spread from the place where it first formed to another place in the body is
called metastatic cancer. The process by which cancer cells spread to other parts of the body is
called metastasis.

In metastasis, cancer cells break away from where they first formed and form new tumors in
other parts of the body.

Metastatic cancer has the same name and the same type of cancer cells as the original, or
primary, cancer. For example, breast cancer that forms a metastatic tumor in the lung is
metastatic breast cancer, not lung cancer.

Under a microscope, metastatic cancer cells generally look the same as cells of the original
cancer. Moreover, metastatic cancer cells and cells of the original cancer usually have some
molecular features in common, such as the presence of specific chromosome changes.

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In some cases, treatment may help prolong the lives of people with metastatic cancer. In other
cases, the primary goal of treatment for metastatic cancer is to control the growth of the cancer or
to relieve symptoms it is causing. Metastatic tumors can cause severe damage to how the body
functions, and most people who die of cancer die of metastatic disease.

Symptoms of cancer

• Cancer can cause many symptoms, but these symptoms are most often caused by illness,
injury, benign tumors, or other problems. If onehave symptoms that do not get better after a
few weeks, see The doctor so that problems can be diagnosed and treated as early as
possible. Often, cancer does not cause pain, so do not wait to feel pain before seeing a
doctor.
• Cancer can cause many different symptoms.
➔ Most often these symptoms are not caused by cancer, but by benign tumors or other
problems.
➔ If someone have symptoms that last for a couple of weeks, doctor will do a physical
exam and order tests or other procedures to find out what is causing your symptoms.
➔ If someone find out that he/she have cancer, doctor will order another set of tests or
procedures to figure out its stage. Stage refers to the extent of cancer and is based on
factors such as how large the tumor is and if it has spread.
➔ Once doctor knows the stage of cancer, he will be able to suggest treatment and discuss
prognosis. Understanding cancer and knowing what to expect can help patie and the
loved ones feel more in control and cope with diagnosis.
• Some of the symptoms that cancer may cause include:

Breast changes Eating problems

• Lump or firm feeling in your • Pain after eating (heartburn

breast or under your arm or indigestion that doesn’t go
• Nipple changes or discharge away)
• Trouble swallowing
• Skin that is itchy, red, scaly,
• Belly pain
dimpled, or puckered • Nausea and vomiting
• Appetite changes

Bladder changes Bowel changes

• Trouble urinating • Blood in the stools

• Pain when urinating • Changes in bowel habits
• Blood in the urine

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Mouth changes Swelling or lumps

• A white or red patch on the • anywhere such as in the

tongue or in your mouth neck, underarm, stomach,
• Bleeding, pain, or numbness and groin
in the lip or mouth

Skin changes Neurological problems

• A flesh-colored lump that • Headaches

bleeds or turns scaly • Seizures
• A new mole or a change in • Vision changes
an existing mole • Hearing changes
• A sore that does not heal • Drooping of the face
• Jaundice (yellowing of the
skin and whites of the eyes)

Fever or night sweats for no Cough or hoarseness that does

known reason not go away
Fatigue that is severe and lasts

Swelling or lumps anywhere Weight gain or weight loss for

such as in the neck, underarm, no known reason
stomach, and groin

Treatment
Clinical examination -A patient with cancer has to be evaluated with a thorough history of
symptoms and clinical examination. If required, endoscopy may be required to assess the lesion.
Presence of any other disease which may affect the treatment of cancer is also looked for.
Presence of any distant metastases is also evaluated.

Radiologic assessment - Clinical examination is supplemented with radiologic imaging. This

may include X-ray, Ultrasonography, CT scan, MRI scan or PET scan as clinically applicable.
They help in better evaluation of the lesion, its extent and presence of loco-regional or distant
metastasis.

Pathologic assessment–Along-with clinical evaluation, a small part of the lesion is biopsied and
sent for histopathological examination. If required aspiration from the lesion is sent for
cytological examination. In both these tests, a microscope and some special stains are used to
assess the presence of and type of cancer cells.

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Surgery–Surgical excision with reference to cancer refers to excision of the lesion with wide
margins. Along with the primary lesion, regional lymph nodes are also addressed. The defect
created may be closed primarily or may have to be reconstructed with local, regional or free flaps

Radiotherapy – It involves the use of ionizing radiation for treatment of cancer. It may be used
as a primary modality or as an additional therapy following or preceding surgery.

Chemotherapy – a wide range of drugs are used to treat [Link] drugs have a variety of
actions and act on different stages of the cell cycle to cause cell death. The detail of their
mechanism of action and activity is beyond the scope of this chapter. These may be used in
different settings for cancer treatment. It may be the primary modality used along with radiation
or may be used in adjuvant settings or also as a palliative therapy.

Palliative care – Many a time, cancer may progress beyond a stage where a curative treatment is
possible. Patients may have a very advanced stage of or may have developed distant metastasis.
In cases, where cure is not expected the patient is treated with a palliative intent. Palliative care
involves relieving the symptoms of cancer rather than curing it. Chemotherapy or radiotherapy
may be used in a selective group of patients.

Prevention of cancer
prevention of cancer. What can you do to prevent cancer? First and foremost comes –

cessation of tobacco consumption. Tobacco is the single most important cause of deaths related
to cancer in upto 20% of people. One should stay away from both chewable as well as
non-chewable forms of tobacco.

Alcohol cessation – alcohol itself is carcinogenic and also has increased carcinogenic effect
when consumed along with tobacco.

Healthy lifestyle – regular physical activity along with diet rich in fruits and vegetables help in
reducing the chances of developing cancer.

Good genital hygiene – maintenance of good genital hygiene along with safe sexual practices
reduce the risk of infection with Human Papilloma Virus (HPV) and decrease the risk of
developing cervical and oropharyngeal cancer.

Vaccination against HPV infection is also available for adolescent girls.

Curbing pollution - reduction of both household and outdoor pollution helps in reduction of risk
of cancer.

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Household pollution with fossil fuels like coal can result in lung cancer. Outdoor pollution
includes contamination of both air and water with various carcinogens.

Workplace precautions – those involved in occupations associated with exposure to

carcinogenic compounds or radiation should be provided adequate protection and should be
examined at regular intervals.

Hepatitis B Virus infection can result in liver cancer. Proper precautions should be taken to
prevent the spread of infection through infected blood products. Vaccination against Hepatitis B
virus is also available and its full dose should be taken.

Family history – those with a family history of breast, thyroid, colo-rectal cancer should be
aware of risk associated with their developing cancer. They should have themselves examined by
a doctor and should be aware of the early signs of cancer.

Types of Genes that Cause Cancer (Drivers of cancer)

● The genetic changes that contribute to cancer tend to affect three main types of
genes—proto-oncogenes, tumor suppressor genes, and DNA repair genes. These changes
are sometimes called “drivers” of cancer.
● Proto-oncogenes are involved in normal cell growth and division. However, when these
genes are altered in certain ways or are more active than normal, they may become
cancer-causing genes (or oncogenes), allowing cells to grow and survive when they
should not.
● Tumor suppressor genes are also involved in controlling cell growth and division. Cells
with certain alterations in tumor suppressor genes may divide in an uncontrolled manner.
● DNA repair genes are involved in fixing damaged DNA. Cells with mutations in these
genes tend to develop additional mutations in other genes and changes in their
chromosomes, such as duplications and deletions of chromosome parts. Together, these
mutations may cause the cells to become cancerous.
● As scientists have learned more about the molecular changes that lead to cancer, they
have found that certain mutations commonly occur in many types of cancer. Now there
are many cancer treatments available that target gene mutations found in cancer. A few of
these treatments can be used by anyone with a cancer that has the targeted mutation, no
matter where the cancer started growing.

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Cancer staging (EXAMS ME AANE K CHANCES)

Stage refers to the extent of your cancer, such as how large the tumor is and if it has spread.
Knowing the stage of your cancer helps your doctor

● understand how serious your cancer is and your chances of survival

● plan the best treatment for you
● identify clinical trials that may be treatment options for you

A cancer is always referred to by the stage it was given at diagnosis, even if it gets worse or
spreads. New information about how cancer has changed over time is added to the original stage.
So the stage doesn't change, even though the cancer might.

There are many staging systems. Some, such as the TNM staging system, are used for many
types of cancer. Others are specific to a particular type of cancer. Most staging systems include
information about

● where the tumor is located in the body

● the size of the tumor
● whether the cancer has spread to nearby lymph nodes
● whether the cancer has spread to a different part of the body

The TNM Staging System

The TNM system is the most widely used cancer staging system. Most hospitals and medical
centers use the TNM system as their main method for cancer reporting. You are likely to see your
cancer described by this staging system in your pathology report unless there is a different
staging system for your type of cancer. Examples of cancers with different staging systems
include brain and spinal cord tumors and blood cancers.

In the TNM system

● The T refers to the size and extent of the main tumor. The main tumor is usually called
the primary tumor.
● The N refers to the number of nearby lymph nodes that have cancer.
● The M refers to whether the cancer has metastasized. This means that the cancer has
spread from the primary tumor to other parts of the body.

When your cancer is described by the TNM system, there will be numbers after each letter that
give more details about the cancer—for example, T1N0MX or T3N1M0.

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(extra info ¸)
The following explains what the letters and numbers mean.

Primary tumor (T)

● TX: Main tumor cannot be measured.

● T0: Main tumor cannot be found.
● T1, T2, T3, T4: Refers to the size and/or extent of the main tumor. The higher the number
after the T, the larger the tumor or the more it has grown into nearby tissues. T's may be
further divided to provide more detail, such as T3a and T3b.

Regional lymph nodes (N)

● NX: Cancer in nearby lymph nodes cannot be measured.

● N0: There is no cancer in nearby lymph nodes.
● N1, N2, N3: Refers to the number and location of lymph nodes that contain cancer. The
higher the number after the N, the more lymph nodes that contain cancer.

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Distant metastasis (M)

● MX: Metastasis cannot be measured.

● M0: Cancer has not spread to other parts of the body.
● M1: Cancer has spread to other parts of the body.

Other Ways to Describe Stage

The TNM system helps describe cancer in great detail. But for many cancers, the TNM
combinations are grouped into five less-detailed stages. The following chart shows how your
doctor or nurse may describe your cancer.

The higher the number, the more advanced the cancer is. Letters and numbers are often used after
the first number to describe the cancer in more detail. For instance, Stage 2 prostate cancer may
be further divided into 2A, 2B, or 2C.

Another staging system that is used for all types of cancer groups cancer into one of five main
categories. This staging system is more often used by cancer registries than by doctors. But you
may still hear your doctor or nurse describe your cancer in one of the following ways.

● In situ—Abnormal cells are present but have not spread to nearby tissue.

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● Localized—Cancer is limited to the place where it started, with no sign that it has spread.
● Regional—Cancer has spread to nearby lymph nodes, tissues, or organs.
● Distant—Cancer has spread to distant parts of the body.
● Unknown—There is not enough information to figure out the stage.

Many Factors Can Affect Your Prognosis

Some of the factors that affect prognosis include:

● The type of cancer and where it is in your body

● The stage of the cancer, which refers to the size of the cancer and if it has spread to other
parts of your body
● The cancer’s grade, which refers to how abnormal the cancer cells look under a
microscope. Grade provides clues about how quickly the cancer is likely to grow and
spread.
● Certain traits of the cancer cells
● Your age and how healthy you were before cancer
● How you respond to treatment

Understanding the Difference Between Cure and Remission

Cure means that there are no traces of your cancer after treatment and the cancer will never come
back.

Remission means that the signs and symptoms of your cancer are reduced. Remission can be
partial or complete. In a complete remission, all signs and symptoms of cancer have disappeared.

If you remain in complete remission for 5 years or more, some doctors may say that you are
cured. Still, some cancer cells can remain in your body for many years after treatment. These
cells may cause the cancer to come back one day. For cancers that return, most do so within the
first 5 years after treatment. But, there is a chance that cancer will come back later. For this
reason, doctors cannot say for sure that you are cured. The most they can say is that there are no
signs of cancer at this time.

Because of the chance that cancer can come back, your doctor will monitor you for many years
and do tests to look for signs of cancer’s return. They will also look for signs of late side effects
from the cancer treatments you received.

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Tissue Changes that Are Not Cancer

Not every change in the body’s tissues is cancer. Some tissue changes may develop into cancer if
they are not treated, however. Here are some examples of tissue changes that are not cancer but,
in some cases, are monitored because they could become cancer:

Hyperplasia occurs when cells within a tissue multiply faster than normal and extra cells build
up. However, the cells and the way the tissue is organized still look normal under a microscope.
Hyperplasia can be caused by several factors or conditions, including chronic irritation.

Dysplasia is a more advanced condition than hyperplasia. In dysplasia, there is also a buildup of
extra cells. But the cells look abnormal and there are changes in how the tissue is organized. In
general, the more abnormal the cells and tissue look, the greater the chance that cancer will form.
Some types of dysplasia may need to be monitored or treated, but others do not. An example of
dysplasia is an abnormal mole (called a dysplastic nevus) that forms on the skin. A dysplastic
nevus can turn into melanoma, although most do not.

Carcinoma in situ is an even more advanced condition. Although it is sometimes called stage 0
cancer, it is not cancer because the abnormal cells do not invade nearby tissue the way that
cancer cells do. But because some carcinomas in situ may become cancer, they are usually
treated.

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Multistep carcinogenesis

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Module III:Psychological impact on

cancer patient and caregiver

● Impact and assessment on

individuals and families.

• The diagnosis of cancer is a family experience that changes the lives of all its members,
bringing an immense amount of stress and many challenging situations. The daily routine,
common activities and distribution of duties all have to change.
• Family members follow the phases of the disease, very often suffering comparable or
greater distress than the patient. They use various coping methods which aim at helping
both the sick relative and themselves. These methods, together with emotional responses,
change over time according to the phase of the disease
• Family caregivers often feel overloaded with the additional obligations and roles they have
to pick up. They find it increasingly burdening to care full-time for the household and
provide emotional support for the patient. The family's problems and the way family
members regard the disease may be also a result of the family system they are in.

Emotional Reaction

• The emotional reactions may include anger, resentment, guilt and adjustment pain, and may
or may not lead to the acceptance of the disease
• The cancer's diagnosis, as well as the subsequent phases of the disease and its treatment,
may be a source of intense stress both for the patient and for the family.
• Christ identified main transition points for the patient and the family, being:
➔ diagnosis,
➔ treatment initiation,
➔ treatment completion,
➔ cure,
➔ treatment recurrence,
➔ decision to discontinue treatment,
➔ terminal illness and death.

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• Cassileth defined several areas, which affect family functioning.

➔ cancer may be a threat to the previous model of family interaction. It brings the
alternation of roles, which can be perceived by one as a loss and by the others as an
excessive overload.
➔ The disease forces the alteration of future plans due to the fact that the presence of cancer
introduces a sense of uncertainty. Some families need to refrain from planning for the
future and this can destabilise family functioning, bringing a sense of lack of goals or
suspension.
• Thirdly, it affects the functioning of family members in external groups like, for instance,
job or school environments. Also new groups of functioning appear – doctors, nurses, and
other patients and their families. All of these people create a new environment and are of
tremendous importance for the patient and his/her family.
• Cancer is a disease that can concern anybody, of any age.
• Thus, families may experience different concerns and issues according to their
developmental stage and age.
• Childless couples who are just establishing an atmosphere of mutuality will have different
needs and problems than those couples who have been together for many years and have
adolescent children, or others who are at the end of their life span.

A family in the course of cancer

The role of a family in the course of cancer changes according to the needs of the patient and the
cancer's phase

1. In the diagnosis phase, depending on the type of family, a big mobilisation, with readiness to
give support to the patient, is observed.

2. The treatment phase : Associated with the alternation of roles within the family. Very often
all of the members need to cope with the treatment symptoms, they need to substitute for the sick
person with his/her household obligations, and take him/her to the hospital for chemotherapy or
radiotherapy. This can be very burdening, both physically and psychologically. In particular, the
family may feel in suspension between fear and hope for the treatment result

3. The chronic phase : Disease may last for months or even years including periods of treatment
and remission. It is also the time when the family slowly returns to its routine life. In some
families the end of chemotherapy or radiotherapy is recognised as the end of the disease itself.
They may thereby impose a pressure on the patient to pick up his/her old responsibilities, behave
healthily, and stop pondering on the disease, which should remain in the past.

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4. Come back to life as it was before : Can create an uncomfortable situation for the patient
who may not yet feel strong enough to resume full activity or who needs his/her family to still
support him/her. Other families, fearing or not yet knowing whether the patient is or is not
healthy, may fall into overprotection, thereby hindering the patient's social rehabilitation or
putting him/her in a position in which he/she feels unneeded or isolated from family life.

5. The recovery phase is also fraught with psychological problems. First of all, there is always
the threat that the cancer can come back. The family have to constantly face the fear that there
could be a recurrence, and every check-up brings a tension that the tests could detect new
carcinogenic cells.

Secondly, some treatment processes bring long-term effects on the health of the patient, i.e. organ
dysfunctions or persistent conditioned reflexes, which can be a source of stress or negative
psychological conditions both in the patient and his/her family.

Thirdly, having a close relative with cancer always puts a burden on the offspring in terms of
genetics. In these ways cancer always stays in the family, forcing it to live in its shadow.

6. The end of the life phase is the most stressful for the family members . The strong stress
reaction may be caused both by the fear of separation and of staying alone, as well as by the
anticipated pain the patient will have to face, the lack of control over the situation, and the
moment of death. The way family members are able to deal with the dying of their relatives
depends on their own psychological and physical condition and also on their support network

Negative emotional and cognitive reactions of a family towards cancer

• Anger is the first intense reaction which is usually directed towards the medical staff. It can
be shown as a reaction to the diagnosis or if the family considers that the care provided by
the doctors or nurses is unprofessional or not sufficiently caring.
• Although directed towards the external environment, their anger can have its roots in a
sense of guilt, injustice or a lack of comprehension.
• Family members may accuse themselves of not being attentive enough and for not forcing
the patient to have regular medical examinations and a healthier lifestyle
• The genetic basis of increasingly more tumours is becoming known. Although genetic
testing is going forward with appropriate attention to counselling (though there are far too
few trained genetic counsel-ors), there is still much need to study its psychological and
social consequences on patients and their fami-lies.

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• Cancer therapies create a range of psychiatric and neuropsychiatric disorders, and new ones
will likely continue to present similar issues.
• Interferon, standard treatment for chronic myelogenous leukemia and metastatic melanoma,
creates severe mood and cognitive problems.
• In some cases they might perceive the disease as a punishment for their or the patient's sins.

Psychological Reaction to the Cancer Diagnosis

Elisabeth Kübler-Ross after she had interviewed numerous dying patients the phases of coping
conceptualised stages/ phases of emotional reaction after the diagnosis of cancer:

1. Denial is the first of the five stages of grief. It helps us to survive the loss. In this stage, the
world becomes meaningless and overwhelming. Life makes no sense. We are in a state of shock
and denial. We go numb. We wonder how we can go on, if we can go on, why we should go on.
We try to find a way to simply get through each day. Denial and shock help us to cope and make
survival possible. Denial helps us to pace our feelings of grief.

As you accept the reality of the loss and start to ask yourself questions, you are unknowingly
beginning the healing process. You are becoming stronger, and the denial is beginning to fade.
But as you proceed, all the feelings you were denying begin to surface.

expression : “It cannot be true”

2. Anger :The second stage in grieving is anger. We are trying to adjust to a new reality and are
likely experiencing extreme emotional discomfort. There is so much to process that anger may
feel like it allows us an emotional outlet.

Keep in mind that anger does not require us to be very vulnerable. However, it may feel more
socially acceptable than admitting we are scared. Anger allows us to express emotion with less
fear of judgement or rejection.

Expression: “why me?”

3. Bargaining : When coping with loss, it isn't unusual to feel so desperate that you are willing
to do anything to alleviate or minimise the pain. During this stage in grieving, you may try to
bargain to change the situation, agreeing to do something in return for being relieved of the pain
you feel.

Expression: “yes me, but..”

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4. Depression: During our experience of processing grief, there comes a time when our
imaginations calm down and we slowly start to look at the reality of our present situation.
Bargaining no longer feels like an option and we are faced with what is happening.

In this stage of grieving, we start to feel the loss. Our panic begins to subside, the emotional fog
begins to clear, and the loss feels more present and unavoidable.

Expression: “why bother?”

5. Acceptance : The last of the 5 Stages of Grief is acceptance. When we come to a place of
acceptance, it is not that we no longer feel the pain of loss. Instead, we are no longer resisting the
reality of our situation, and we are not struggling to make it something different.

Sadness and regret can still be present in this phase. But the emotional survival tactics of denial,
bargaining, and anger are less likely to be present during this phase of the grieving process.

Expression: “i can't fight it, i may as well prepare for it”

Cancer impact on Spouses

● The effects of cancer vary from couple to couple. For some couples, facing the challenges
of cancer together strengthens their relationship. For others, the stress of cancer may
create new problems and worsen existing problems.
● Changing relationship roles. Cancer often forces changes onto the usual roles in a
relationship. Someone who has always been in charge or served as the caregiver may
have trouble accepting a more dependent role.
● Changing responsibilities. In most relationships, each partner handles specific chores
during daily life. One partner may do yard work and cook, while the other cleans and
pays bills.
● Changing physical needs. Cancer and its treatment can impact physical needs, such as
your energy level or appetite. Your partner may not realize you need help or know how to
help. So it is important to talk openly and to clearly express your needs.
● Changing emotional needs. Each partner may have different emotional needs that
change frequently. After a cancer diagnosis, both people may experience sadness, anxiety,
anger, or even hopelessness. Both partners may need extra reassurance that they are still
loved.

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Impact of Cancer on Children

● Talking to children about cancer. one may want to protect children from fear and other
difficult feelings. But it is important to talk openly with them about your diagnosis and
treatment.
Changes in children’s behavior. Expect shifts in children's behavior as they adjust to the
changes resulting from cancer diagnosis and treatment.
● Role reversal. Adult children may act as caregivers for a parent with cancer. This is a
change that is often difficult for both parents and children
● children’s needs. Being a parent while living with cancer is often physically and
emotionally exhausting. one may wonder how you can continue to care for your family
while caring for yourself and coping with a cancer diagnosis.

Cancer Impact on Friends & Family-Ways to Deal

● Put one person in charge of giving medical updates. Repeating medical information
and answering the same questions over and over again can be tiring and time-consuming.
Ask a trusted family member to share medical information with other family and friends.
● Expect relationships to change. Many people have little experience with
life-threatening illnesses. They may not know what to say to you or how to act. For these
reasons, some of your friends or family members may not be able to offer you the support
that you expect.
● Let people help you. Your friends and family members will likely want to help you. But
they might not know what you need or how to ask you.
● Stay involved in social activities. As much as possible, try to maintain social contact
with friends and family.

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Co-morbid Mental Health Conditions:

At times, psychological distress can be severe for cancer patients, resulting in clinically relevant
mental health conditions. Numerous studies have investigated the frequency of these conditions
in cancer patients over the past years

about 30% of the patients suffer from a mental health Psychosocial Impact of Cancer 3 condition
(Singer et al. 2010; Mitchell et al. 2011; Vehling et al. 2012; Mehnert et al. 2014; Kuhnt et al.
2016).

Known risk factors for mental disorders in cancer patients are pain, high symptom burden,
fatigue, mental health problems in the past and disability.

• Potential Positive Impact:

• traumatic experiences can lead to emotional growth in patients and relatives
(Hungerbuehler et al. 2011; Kahana et al. 2011; Kim et al. 2011; Love and Sabiston 2011;
Demirtepe-Saygili and Bozo 2011; Fromm et al. 1996).
• Such posttraumatic growth has been defined as positive psychological change experienced
as a result of the struggle with highly challenging life circumstances (Calhoun et al. 2000;
Calhoun and Tedeschi 2001).
• It describes the experience of individuals whose development has surpassed what was
present before the struggle
• According to Tedeschi and Calhoun (2004), positive changes can be found in five
dimensions, representing different types of posttraumatic growth:
➔ greater appreciation of life and changed sense of priorities;
➔ warmer, more intimate relationships with others;
➔ a greater sense of personal strength;
➔ recognition of new possibilities of paths for one’s life;
➔ and spiritual development (Tedeschi and Calhoun 2004)
• Individuals’ experience of posttraumatic growth depends on several predictors. Many
facilitating factors have been reported:
➔ younger age,
➔ female gender,
➔ low consumption of alcohol,
➔ low levels of pessimism and depression,
➔ high life satisfaction,
➔ high levels of extraversion,
➔ having an active sexual life and
➔ receiving counselling

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• only a few studies have investigated whether or not psychosocial interventions can help to
increase posttraumatic growth after traumatic events or serious illness.
• Especially in cancer patients, evidence is scare.
• Own research has shown that art therapy once weekly over a period of 22 weeks in the
outpatient setting did not increase posttraumatic growth (Singer et al. 2013b).
• This finding is in accordance with scepticism towards the concept of growth in the context
of adversity, including serious illness, and towards positive psychology in general (Coyne
and Tennen 2010).

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MODULE 4 : Theory & Application of Psycho-oncology

Cancer is a disease that requires important resources and needs optimization in efficacy and
efficiency of the interventions.
In this sense, consideration of the psychological and social aspects in integral and
multidisciplinary management of the oncology phenomenon is gathering increasing Importance
in patient care and research.
Psycho-oncology, as this body of knowledge has been called, focuses on the knowledge of
psychological, social and behavioural dimensions of cancer from two perspectives.

Psycho-oncology focuses on two main perspectives -

● Psychobiological - Psychological social and behavioral aspects that influence morbidity

and mortality.
● Psychosocial - Responses of the patients and their families to each one of the disease
stages.

Cancer prevention programs are most likely to be effective and sustainable when they are based
on theoretical models which underpin a clear understanding of the factors that influence the
target population’s behavior, including their personal beliefs and attitudes, and social and
physical environments.

In that regard, application of theory informs the interpretation of research findings and
understanding of the dynamic interactions between behavior and the environmental and social
context, hence increasing the likelihood of effective translation of cancer prevention strategies
into public health policy or clinical practice.

Theories and their applications at the individual (intrapersonal),interpersonal, and community

levels are relevant.

Strategies intended to change people’s behavior can often be derived from individual-level
theories such as the health belief model, stages of change model, theory of planned behavior, and
precaution adoption process model.

These theories are important for cancer prevention campaigns, as they are related to individuals’
knowledge, perceptions, attitudes, beliefs, intentions, and decision-making processes about
cancer prevention behaviors, barriers, and benefits. However, on their own, individual-level
theories are usually insufficient to change cancer-related behaviors; to be effective they need to
be considered within the social and environmental context.

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1. Health Belief Model

The Health Belief Model is a theoretical model that can be used to guide health promotion and
disease prevention programs. It is used to explain and predict individual changes in health
behaviors. It is one of the most widely used models for understanding health behaviors.

The HBM derives from psychological and behavioral theory with the foundation that the two
components of health-related behavior are 1) the desire to avoid illness, or conversely get well if
already ill; and, 2) the belief that a specific health action will prevent, or cure, illness. Ultimately,
an individual's course of action often depends on the person's perceptions of the benefits and
barriers related to health behavior. There are six constructs of the HBM. The first four constructs
were developed as the original tenets of the HBM. The last two were added as research about the
HBM evolved.

1. Perceived susceptibility - This refers to a person's subjective perception of the risk of

acquiring an illness or disease. There is wide variation in a person's feelings of personal
vulnerability to an illness or disease.
2. Perceived severity - This refers to a person's feelings on the seriousness of contracting an
illness or disease (or leaving the illness or disease untreated). There is wide variation in a
person's feelings of severity, and often a person considers the medical consequences (e.g.,
death, disability) and social consequences (e.g., family life, social relationships) when
evaluating the severity.
3. Perceived benefits - This refers to a person's perception of the effectiveness of various
actions available to reduce the threat of illness or disease (or to cure illness or disease).
The course of action a person takes in preventing (or curing) illness or disease relies on
consideration and evaluation of both perceived susceptibility and perceived benefit, such
that the person would accept the recommended health action if it was perceived as
beneficial.
4. Perceived barriers - This refers to a person's feelings on the obstacles to performing a
recommended health action. There is wide variation in a person's feelings of barriers, or
impediments, which lead to a cost/benefit analysis. The person weighs the effectiveness
of the actions against the perceptions that it may be expensive, dangerous (e.g., side
effects), unpleasant (e.g., painful), time-consuming, or inconvenient.
5. Cue to action - This is the stimulus needed to trigger the decision-making process to
accept a recommended health action. These cues can be internal (e.g., chest pains,
wheezing, etc.) or external (e.g., advice from others, illness of family member, newspaper
article, etc.).
6. Self-efficacy - This refers to the level of a person's confidence in his or her ability to
successfully perform a behavior. This construct was added to the model most recently in
mid-1980. Self-efficacy is a construct in many behavioral theories as it directly relates to
whether a person performs the desired behavior.

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Limitations

There are several limitations of the HBM which limit its utility in public health. Limitations of
the model include the following:

● It does not account for a person's attitudes, beliefs, or other individual determinants that
dictate a person's acceptance of a health behavior.
● It does not take into account behaviors that are habitual and thus may inform the
decision-making process to accept a recommended action (e.g., smoking).
● It does not take into account behaviors that are performed for non-health related reasons
such as social acceptability.
● It does not account for environmental or economic factors that may prohibit or promote
the recommended action.
● It assumes that everyone has access to equal amounts of information on the illness or
disease.
● It assumes that cues to action are widely prevalent in encouraging people to act and that
"health" actions are the main goal in the decision-making process.

The HBM is more descriptive than explanatory, and does not suggest a strategy for changing
health-related actions. In preventive health behaviors, early studies showed that perceived
susceptibility, benefits, and barriers were consistently associated with the desired health
behavior; perceived severity was less often associated with the desired health behavior. The
individual constructs are useful, depending on the health outcome of interest, but for the most
effective use of the model it should be integrated with other models that account for the
environmental context and suggest strategies for change.

2. Theory Of Planned Behaviour

The theory of planned behavior (TPB) a cognitive theory by Azjen (1985) that proposes that an
individual’s decision to engage in a specific behavior such as gambling or stopping gambling can
be predicated by their intention to engage in that behavior (Fig. 1).

'Intentions are assumed to capture the motivational factors that influence a behavior; they are
indications of how hard people are willing to try, of how much of an effort they are planning to
exert, in order to perform the behavior. As a general rule, the stronger the intention to engage in a
behavior, the more likely should be its performance' (Ajzen, 1991 p. 181).

three variables:

1. Personal attitudes - This is our personal attitude towards a particular behavior. It is the
sum of all our knowledge, attitudes, prejudices …. positive and negative that we think of
when we consider the behavior. For example, our individual attitude to smoking might

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include tobacco is relaxing and makes me feel good but it makes me cough in the
morning, costs a lot of money and smells bad.
2. Subjective norms - This considers how we view the ideas of other people about the
specific behavior e.g. smoking. This could be the attitude of family and friends and
colleagues to smoking. It is not what other people think but our perception of others’
attitudes.
3. Perceived behavioral control - This is the extent to which we believe we can control our
behavior. This depends on our perception of internal factors such as our own ability and
determination and external factors such as the resources and support available to us. The
theory argues that our perception of behavioral control has two effects: It affects our
intentions to behave in a certain way i.e. the more control we think we have over our
behavior, the stronger our intention to perform the behavior. It also affects our behavior
directly, if we perceive that we have a high level of control we will try harder and longer
to succeed. The present view of perceived behavioral control, however, is most
compatible with Bandura*s (1977, 1982) concept of perceived self efficacy which ìs
concerned with judgments of how well one can execute courses of action required to deal
with prospective situationsî (Bandura, 1982, p. 122).

3. Social Cognitive Theory

4. Transtheoretical Model

The Transtheoretical Model (also called the Stages of Change Model), developed by Prochaska
and DiClemente in the late 1970s, evolved through studies examining the experiences of smokers
who quit on their own with those requiring further treatment to understand why some people
were capable of quitting on their own. It was determined that people quit smoking if they were
ready to do so. Thus, the Transtheoretical Model (TTM) focuses on the decision-making of the
individual and is a model of intentional change. The TTM operates on the assumption that people
do not change behaviors quickly and decisively. Rather, change in behavior, especially habitual
behavior, occurs continuously through a cyclical process. The TTM is not a theory but a model;
different behavioral theories and constructs can be applied to various stages of the model where
they may be most effective.

The TTM posits that individuals move through six stages of change: precontemplation,
contemplation, preparation, action, maintenance, and termination. Termination was not part of
the original model and is less often used in application of stages of change for health-related
behaviors. For each stage of change, different intervention strategies are most effective at
moving the person to the next stage of change and subsequently through the model to
maintenance, the ideal stage of behavior.

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1. Precontemplation - In this stage, people do not intend to take action in the foreseeable
future (defined as within the next 6 months). People are often unaware that their behavior
is problematic or produces negative consequences. People in this stage often
underestimate the pros of changing behavior and place too much emphasis on the cons of
changing behavior.
2. Contemplation - In this stage, people are intending to start the healthy behavior in the
foreseeable future (defined as within the next 6 months). People recognize that their
behavior may be problematic, and a more thoughtful and practical consideration of the
pros and cons of changing the behavior takes place, with equal emphasis placed on both.
Even with this recognition, people may still feel ambivalent toward changing their
behavior.
3. Preparation (Determination) - In this stage, people are ready to take action within the next
30 days. People start to take small steps toward the behavior change, and they believe
changing their behavior can lead to a healthier life.
4. Action - In this stage, people have recently changed their behavior (defined as within the
last 6 months) and intend to keep moving forward with that behavior change. People may
exhibit this by modifying their problem behavior or acquiring new healthy behaviors.
5. Maintenance - In this stage, people have sustained their behavior change for a while
(defined as more than 6 months) and intend to maintain the behavior change going
forward. People in this stage work to prevent relapse to earlier stages.
6. Termination - In this stage, people have no desire to return to their unhealthy behaviors
and are sure they will not relapse. Since this is rarely reached, and people tend to stay in
the maintenance stage, this stage is often not considered in health promotion programs.

Psychosomatics and Cancer

Psychosomatic research in the study of cancer has existed for a long time. Many authors have
tried to establish links between psychological problems and the onset of cancer.

They have primarily engaged in retrospective studies, starting with isolated cases where there
was a striking correlation between emotional traumas and the appearance of tumors after a
certain delay

A central observation seems to run unanimously through all these publications: the experience, in
the course of patients’ lives, of separation, emotional upheavals (for example, divorce), or very
painful bereavements, often cumulative, and without the possibility of working through them in a
favourable environment (LeShan1963).

Galen, in the second century AD, thought that melancholic women were predisposed to breast
cancer.

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In the eighteenth century by Gendron(1701), who found that his patients who suffered from
depression and anxiety were more subject tocancer.

Guy (1759) added a little more detail by observing that nervous and hysterical women developed
cancer after existential traumas and bereavements.

Psychodynamic Approach

The ‘cancer personality’ has been graphically described by several authors, including Bahnson
(1980).

Bad memories of their childhood, with the impression of having lacked affection, and above all
of never having been able to express needs and feelings in the face of cold and distant parents.

resentments exposes one (in reality, or at least in one’s imagination) to the threat of desertion and
break-up.

Such a child can only maintain a harmonious relationship with his parents at the cost of great
effort, in prematurely taking on too-heavy tasks, which goes together with a considerable feeling
of inadequacy. This is one of the basic mechanisms of dependency.

In adolescence, liberation is perceived as a too-painful deprivation, which one later tries to

overcome by establishing bonds with an idealized object or by engaging with all one’s energy in
an intense activity (producing conflict between the ideal of the ego and reality). A new affective
trauma in adulthood, if it is superimposed on such a history, can only be devastating.

Bereavement or divorce may precede the onset of cancer by several years.

This psychodynamic model establishes a link between repeated emotional stress and cancer.

One could say that we are dealing with people who have developed a double life, or a double
self, or else a fundamental ambivalence,

with on the one hand a definition of self well adapted to reality and to others, and on the other,
deeply buried, a ‘phantom ego’, which feels isolated, unloved, hurt, and often empty

The at-risk personality (after Bammer 1981)

•Courtesy and Cordiality
•Submission to authority
•Submission to social norms
•Ready neglect of one’s own feeling and behaviour according to the general expectation, of
others
•Sense of responscibility, conscietiousness and zeal

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•Religiosity
•Sense of sacrifice
•Inhibition of aggressive feeling
•Guilt, readiness to be self-critical , feeling of inferiorty, depressive tendency

THE SYSTEMIC APPROACH

Family, where mutual isolation and distancing are the rule, a certain precocious individuation is
necessary, for the child can neither say who he is nor share his experiences with his relatives. It is
in such conditions that, often, the repression of these negative feelings (sadness, anger, or
jealousy) and the inhibition of desires appear in order to ‘protect the family equilibrium’: one has
the impression that in such systems the emphasis is not on social opening-out, adaptation, and
blossoming, but rather on self-mastery and control. Thus the future patient has made a habit of
relying only on his own strength, and he expects no extra help from his family circle. It is
precisely when he finally realizes that he is alone that he will fall ill. Certain studies (Greene
1966, Schmaleand Iker 1966) seem to indicate that the passage of the family through an
important stage of the life cycle—the emancipation of the children for example—may also
engender illness: breast cancer in the mother, or else leukaemia, or testicular cancer in the young

BIOPSYCHOSOCIAL PERSPECTIVE
Certain studies (Greene 1966, Schmaleand Iker 1966) seem to indicate that the passage of the
family through an important stage of the life cycle—the emancipation of the children for
example—may also engender illness: breast cancer in the mother, or else leukaemia, or testicular
cancer in the young

The biopsychosocial model (Engel 1977) and general systems theory (von Bertalanffy 1964)
offer a way of integrating psycho-oncological data. In fact, if we limit ourselves to the
biomedical model we can hardly achieve an integrated understanding of cancer, which has a
multidimensional aetiology (Baltrusch and Waltz 1985).

Stressful life events require increased efforts of adaptation on the part of the individual, and
generally lead to painful states of tension; depending on the gravity of the situation, this may
bring about the exhaustion of the capacity to fight, and to ‘giving up’. For a physical illness to
ensue, a synergy seems to be necessary between stress, the patient’s personality structure and an
unfavourable socio familial situation.

Epidemiological studies have demonstrated, for example, that compared with the average for the
population of the same age, widows or divorcées suffer more from depressive illness,
cardio-vascular diseases and cancers (Weisman and Worden 1975, 1976–7).

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Some people have exhibited anomalies in the immune function after bereavement, with a
significant diminution in the number of lymphocytes (Ader 1975; Dutz et al. 1976).

The richness of social relations plays a considerable part in the maintenance of the mental and
physical health of the adult. It is clear that good-quality affective bonds are an essential factor in
helping one to cope with difficult existential situations. Conversely, poor relationships, notably
an undermined marital or family background, constitute a very un favourable milieu.

THE PSYCHOBIOLOGICAL MODEL OF CANCER

•The only certainty is that somatic mutation is an important factor, but is not a sufficient
explanation for cancers (Greer and Watson 1985).

•More simply, one could say that there are mechanisms which control tumor growth and cellular
dissemination, where the psyche certainly plays a protective role.

•Conversely, with certain individuals, psychological conflicts contribute to the emergence of

cancers in synergy with biological disturbances.

•The role of stress has been mentioned (Greerand Morris 1975) but also contested (Schonfield
1975). One explanation of this contradiction is that often, in replying to questionnaires, patients
are reluctant to admit that they have been through painful existential episodes.

•Point of agreement is that there is some correlation between the diagnosis of cancer and a
certain kind of behaviour characterized by abnormal control of aggression and affects (Bahnson
and Bahnson1966).

•The work of Greer demonstrates, for example, that women of under age 50 affected by cancer
express less anger than members of a healthy control group of the same age (Greer and Morris
1975).

•Personality of the coronary patient, there have been attempts to define a type ‘C’ behaviour
typical of the cancer patient (Morris 1980). This is characterized principally, as seen above, by
the inhibition of emotions and of aggressive reactions, as well as by conformism, exemplary
submission, relationships without conflict, and patience. The importance of this profile is useful
for indicating a prognosis. For melanoma, for example, this corresponds to the more invasive
tumours (Temoshok 1985).

•The growth of the whole organism is under hormonal control. Psychological responses,
particularly emotional reactions, produce alterations of tissues by limbic, hypothalamic,
hypo-physical, and endocrinological routes.

•Cancer is a disorder of the growth of cells which introduces a dysregulation of normal tissue
balance.

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•One could well imagine that psycho-endocrinological mechanisms play a part in the
development of cancer.
•A significant number of studies have shown that individuals who repress their emotions can
only deal with stress by exercising increased physiological control. The question for cancer
patients is to know whether type ‘C’ biological reactions have a pathogenic effect (Watson and
Greer 1983).
•Although suppression of emotion seems to play a part as much in psychosomatic ailments as in
cancer, the precise mechanism of the action is not clear.

In oncology, it could be true that the disease does not appear in response to the repetition of
stressful events but depends on the specific biological and behavioural response that one brings
to them
•The growth of the whole organism is under hormonal control.
•Psychological responses, particularly emotional reactions, produce alterations of tissues by
limbic, hypothalamic, hypophysial,andendocrinological routes.
•Cancer is a disorder of the growth of cells which introduces a dysregulation of normal tissue
balance.

•One could well imagine that psycho-endocrinological mechanisms play a part in the
development of cancer. Up till now, there has been mostly talk of the immunological regulation
of tumors, with the concept of immuno-surveillance and notably of the control of isolated cells of
the NK (Natural Killer) type by psychological factors (Herberman 1982;

•Irwin et al. 1988; Bovbjerg 1989; Contrada et al. 1990).

•Their disposal to attain them.
•The general framework of an intervention might be defined in the following way:
•– Provision of opportunity for the persons involved to ‘tell the story’
•– Recognition and acceptance of the varied emotions that people express in relation to a
significant loss
•– Provision of support for the expression of difficult feelings, such as anger and sadness, with a
recognition that people have to do this in their own way and in their own time frame
•Inclusion of children in the grieving process
•– Encouragement in the maintenance of established relationships
•– Acknowledgement of the usefulness of mutual help groups

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•– Encouragement of self-care by family members, with particular attention to the person who is
the primary caregiver
•– Acknowledgement of the usefulness of counseling for problems that seem especially difficult.

THE NEED FOR AN INTEGRATIVE MODEL

•The fact that so many disciplines contribute to psycho-oncology speaks to the breadth of issues
involved in understanding and treating the psychosocial problems of cancer patients and their
families.

•An integrative model would be useful to adequately explain the struggle patients face as they
deal with the physical symptoms of disease and the psychological, social, spiritual, and
existential crises it produces.

•The fact that so many disciplines contribute to psycho-oncology speaks to the breadth of issues
involved in understanding and treating the psychosocial problems of cancer patients and their
families.

•An integrative model would be useful to adequately explain the struggle patients face as they
deal with the physical symptoms of disease and the psychological, social, spiritual, and
existential crises it produces.
•Shakespeare, in King Lear, eloquently expressed the totality of the issues raised by
life-threatening illness:
•“. . .We are not ourselves when nature, being op-pressed, commands the mind to suffer with
the body.”
•The core of psycho-oncology addresses this “suffering of the mind” that occurs with cancer. It
incorporates the psychological, social, spiritual, and existential dimensions and seeks to help the
patient find a tolerable meaning to the presence of the unwelcome intruder of serious illness and
threat to the future and to life itself.

•Finding a theoretical model that incorporates all aspects of “suffering of the mind” would serve
as an integrative force in our work in psycho-oncology while recognizing that each discipline
continues to bring unique knowledge, skills, and experience that address a particular domain of
the patient’s concerns and “suffering.”
REFER TO PDF “THEORIES OF PSYCHO-ONCOLOGY” given in brief down below
•Folkman has proposed a revision of the original Lazarus and Folkman stress and coping
paradigm to include “making meaning.” Developed from studies of patients with AIDS and their
caregivers, the revised model provides a frame-work for

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1. Understanding coping with life-threatening illness and the “suffering of the mind” that
accompanies serious illness and loss It is a conceptual base from which to understand the range
of interventions used to facilitate coping. As such it may, with further research, provide an
integrative principle to guide the researchers from the diverse disciplines that contribute to
psycho-oncology

2. Coming to grips with the existential dimension of the illness;

3. Feeling concern for the family, who is affected by cancer;

4. Seeking a comforting philosophical, spiritual, or religious belief structure or values that give
meaning to life and death.

•Hackett said it well: “As our colleagues in medicine explore new kingdoms of life-saving
technology, we often find psychological wrecks in their wake. We can help to reconstitute these
people. Our interventions can be life-saving.”

•Because of this, the close interaction with cancer clinicians and investigators has been critically
important.
•Strength of Psychology and the reason for its fascinating and challenging nature, is that it
simultaneously addresses
[Link] new psychological challenges patients with cancer face
[Link] seeking to apply and test new approaches in psychotherapies, behavioral interventions,
and psychopharmacologic agents coming from general psychiatry, consultation-liaison
psychiatry, health psychology, and behavioral medicine.
[Link] ensures that psycho-oncologists have a keen interest—and one foot—in both oncology and
psycho-oncology

GENERAL

•In 1998, cancer mortality in the United States fell for the first time.

• Cancer survivors, long out of the closet and strong advocates for better psychological care, now
number 8 million.
•These changes have challenged the initial narrow role of consultation-liaison psychi-atry, which
was dealing primarily with hospitalized patients. Most oncology care today is given in clinics,
not in hospitals, leading us to focus on ambulatory psychosocial services. Figure 3 shows the
active role of psycho-oncology throughout the continuum of cancer—from prevention (primary

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and secondary) and preclinical cancer (known genetic risk or positive can-cer markers for a
specific cancer in the absence of clinical disease); through diagnosis, curative treatment,
survivorship, and cure; to palliative and end-of-life care. Recurrence after a treatment attempt at
cure will lead today to non curative but life-extending.

Contemporary role of psycho-oncologists

Continuum of cancer care

Prevention - detection - diagnosis - active treatment - survivorship - palliative care - end

of life

Prevention of Cancer

•Primary prevention of cancer depends on changing behaviors and lifestyle.

• Smoking prevention and cessation research in psycho-oncology has resulted in models for
planning rational interventions for smoking cessation .

•The relationship between depression and smoking has emerged.

•Prevention and treatment of obesity and attention to exercise and diet are the cornerstone of
prevention for both cancer and heart disease

•The viral cause of more cancers is emerging, particularly the human papilloma virus in cervical
cancer, suggesting the need to educate women about exposure and possibly earlier recognition of
disease by viral markers and treatment by vaccines

Scope of Psycho- Oncology

All represent new challenges and areas for behavioral and psycho-logical research.
In addition, as new therapies are tested, it will be important that patient-reported quality of life
be included as an out-come measure in more clinical trials in which an arduous treatment seems
efficacious but carries with it a high price in quality of life. More and more, patients have an
opportunity to make decisions about therapies offered, and quality-of-life information is
important in helping them choose.

Survivors are now numerous, and they have psychological baggage, first described extensively in
1981 by Koocher and O’Malley (59). Side effects of therapies lead many to experience
symptoms of posttraumatic stress disorder (PTSD) and conditioned responses

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Module 5 : Treatment & Rehabilitation

○ Onco-genetic Counselling -Skills & Issues
○ Palliative Counselling – Skills & Issues
○ Paediatric Counselling - NOT DONE!
○ Support & Rehabilitation Counseling
○ Primary, Secondary & Tertiary

PALLIATIVE CARE

Palliative care is an approach that improves the quality of life of patients (adults and children)
and their families who are facing problems associated with life-threatening illness. It prevents
and relieves suffering through the early identification, correct assessment and treatment of pain
and other problems, whether physical, psychosocial or spiritual.

Addressing suffering involves taking care of issues beyond physical symptoms. Palliative care
uses a team approach to support patients and their caregivers. This includes addressing practical
needs and providing bereavement counselling. It offers a support system to help patients live as
actively as possible until [Link] approach was based on a new set of values that humanised
care of dying individuals, who were invited to actively participate in their care and all families
who were supported before and after the patient's death. According to this approach individuals
have the right to have a say in their experiences and care they receive in the face of death.

Palliative care uses the capabilities of many different professionals. This includes nurses,
doctors, counsellors, therapists, psychologists and volunteers along with social workers. Quality
palliative care includes explaining, informing and making the process comprehensible even if
one cannot correct all problems for the patient and their family. This can help patients in finding
meaning even in their last days. It should provide care for patients' physical, social and
existential problems. It should also provide support to the family.

Role of a psychologist

Counsellors are “highly skilled professionals who have completed a lengthy training course,
including the theory of psychological and social functioning, and a period of supervised practice.
They may be skilled in group work as well as working one to one. In Palliative care they may
work directly with patients or families focusing on those people who have complex relationship
problems or psychological needs. The social worker can listen in a unique way, for they are not

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involved with physical therapy and are experienced as the recipients of unacceptable feelings and
projected angers. Negative feelings in this situation may be frighteningly strong and these are
better expressed than buried only to appear in a different guise, often affecting both family and
staff”. the information in terminal illness is often of grave significance, communication at the
end of life needs to be conducted with sensitivity to and a deep understanding of the
psychological processes entailed in taking in, adapting to, and making use of difficult, usually
highly undesirable, information. In every human interaction there is a ‘right distance’. Move in
too close and the other person will feel intruded upon; back away too far and they will feel
alienated or rejected. ‘The right distance’ varies with the nature of the relationship and the
circumstances, and it is constantly changing so that a distance that feels right at one time may be
uncomfortable at another.

Support must be given to help staff to deal with the griefs that are a normal part of their work. It
needs to be multidimensional and no one strategy will suit all members.

People with serious illness are often in unknown territory. Not only have they not experienced
these current illness circumstances before, nor faced their imminent mortality but, in present day
western culture, many people have not witnessed another person’s death. Most patients lose
consciousness well before the moment of death. For them the last experience of life is a quiet
slipping away,

Viktor E. Frankl was an Austrian neurologist and psychiatrist as well as a Holocaust survivor.
His experiences as a concentration camp inmate led him to study the reasons why some people
were better enabled to cope even in the most difficult of environments. His work led him to
establish logotherapy, which is a form of existential analysis. he question of the meaning of life
arises naturally during adolescence but can also become very prominent when fate intervenes in
one’s life through some unexpected trauma such as an accident, death of loved ones, or being
faced with a debilitating disease etc. Our relationships take on a new meaning and through them
we find the strength to face the situation. he first step towards helping a patient is to understand
the context of his or her life. All information is vital, demographics (age, occupation, education,
religion ethnic background, geographical location of the family etc.), functional (medical,
emotional, behavioural) and critical family events

ETHICAL ASPECTS

Challenges of providing palliative care or end of life care in the country

Legal Challenges - There exists no legal framework for end of life care in the country, thus the
physician has to provide support in the best interest of the patient following the ethical guidelines
of medical [Link] the patient or family consistently desires that life support be withdrawn, in

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situations in which the physician considers aggressive treatment non beneficial, the treating team
is ethically bound to consider withdrawal within the limits of existing law.

Cultural challenges - Contemporary Western bioethics tends to emphasise the values of access to
information, autonomous decision- making and planning for end-of-life [Link] the Indian
setting,there is vast diversity in the culture, religion, family relationships and family obligations
which majorly influence the decision making in the end of life [Link], the approach to care is
generally a paternalistic approach as the concept of autonomy is weak. Patients have great
respect for the doctors and dependence on family which influences their decision regarding the
end of [Link] families often wish to protect their patients from the knowledge of the seriousness
of the disease as they perceive this to be harmful for their patient's physical and mental well
being.

Ethical principles in End of life care practice

The foundation of medical ethics is supported by the four pillars, namely;

Autonomy- Patient has the right to choose or refuse a particular treatment. In the event the
patient has diminished decision making capacity, surrogates acting on the patient's behalf can
communicate the patient's previously expressed wishes.

Beneficence- The doctor should act in the best interest of the patient. In the context of an
advanced progressive illness with no scope for reversal, the best interests of the patient are
controlling the patient's pain and symptoms, and reducing the sufferings of the patient and his
family, providing emotional support and protecting the family from financial ruin.

Non-Maleficence- Do no harm to the patient. Thus, withholding and withdrawing of the life
support, in this context, is a humane approach of 'allowing natural death,' that is, allowing the
patient to die of the underlying illness, with symptoms well–controlled, in a dignified manner, in
the presence of his family and loved ones and this in no way amounts to euthanasia.

Justice- Equitable distribution of service and equal right to care for all patients.

Added to the above four, are two more aspects which form the cornerstones of medical practice:
Dignity - the patient and the persons treating the patient have the right to dignity

Truthfulness and honesty - the concept of informed consent and truth telling should be engrained
in the practice of end of life care.

Thus, it is crucial to integrate the ethical principles in practice of palliative care and end of life
care in the background of cultural and social influence.

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Process Involved In End Of Life Care

A. Recognize the dying process

It is often a challenge to predict impending death, certain markers which include vital parameters
like blood pressure, heart rate and respiratory rate, immobilisation, decreased food and fluid
intake, decreased spontaneous verbalisation will help recognise the limited life expectancy.
However, it is always important to treat the reversible cause whilst accepting the impending
death.

B. Recognise the medically inappropriate treatment

the physicians may have to rely on their professional judgement and consider patient autonomy
to make an informed decision.(Jiang et al, 2014) It is ethical for physicians to decline a particular
treatment, which is judged to be medically inappropriate, either where such treatment is not in
the interest of the patient, or where there are insufficient resources to provide treatment of this
level of benefit.

C. End of life decision making process and initiation of the end of life care pathway

Once the primary treating team recognises the medical inappropriateness of a particular
treatment; they could call upon the other teams involved in caring for the patient and the
palliative care team and discuss all the possible options for correcting the reversible cause. If the
team members have reached a consensus of saturating all the options, they could then call upon a
meeting with the patient and the family members

SPIKES model of reflective communication will be used for communicating with the patient.
This will include;

1. Set up: The set up should be a quite room free from any disturbance. There should be enough
time given for communication.

2. Perceptions: It is essential to assess the perception of the patients and caregivers about the
disease diagnosis, progression and prognosis. This gives us an understanding of how prepared
the patients and caregivers are likely to be for the end of life decision.

3. Invitation: It is essential to confirm that the patient wishes to get the information about the
diagnosis and prognosis.

4. Knowledge: Patients and caregivers are explained the prognosis and likely course of the
disease in a language that is understandable to them.

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5. Emotional support: Appropriate response to the emotions that the patient/caregivers express.
6. Strategy and Summary: Summarize the discussions, provide options of care and
documentation of the discussion and give an appointment to meet again in case of uncertainties
or further concerns.

Documentation of the process of end of life discussion

It is imperative to document the case notes of the discussion between the physician, patient and
the family. The documentation must include the names of the individuals with the relationship
with the patient, details of the discussions, signature by the patient, next of kin(is not mandatory)
and physician. This will ensure that the patient has been explained the prognosis and the
treatment options. This document will also provide a security for the patient and the physician in
case of a future conflict.

Role Of Oncological Treatments

Radiotherapy - Radiotherapy is an indispensable modality in the palliation of cancer. Around

50-60% of all patients in palliative care require some form of palliative radiotherapy. The main
indications are: pain relief (particularly bone pain), control of hemorrhage, fungation and
ulceration, dyspnoea and the shrinkage of any tumors causing problems by virtue of space
occupancy.

Surgery - Surgeons play an important role in the multidisciplinary care of palliative patients.
Palliative surgeries are quite common and offer good relief from symptoms and improve quality
of life in well selected patients. As surgery is an invasive procedure the goal should be
predefined. The benefits of doing the procedure should be weighed against the predicted side
effects. The expectations of the patient should be given due consideration and a realistic
approach should be encouraged. It is imperative that the patient has a good understanding of the
disease and its outcome. The extent on invasiveness of the procedure should be justified in the
context of an incurable illness.

GENETIC COUNSELLING

Genetic counselling is a communication process, which aims to help individuals, couples and
families understand and adapt to the medical, psychological, familial and reproductive
implications of the genetic contribution to specific health conditions. This process integrates the
following:

● interpretation of family and medical histories to assess the chance of disease occurrence
or recurrence
● education about the natural history of the condition, inheritance pattern, testing,
management, prevention, support resources and research

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● counselling to promote informed choices in view of risk assessment, family goals, ethical
and religious values
● support to encourage the best possible adjustment to the disorder in an affected family
member and/or to the risk of recurrence of that disorder

The goal of genetic counselling is to enhance the clients’ ability to use genetic information in a
personally meaningful way that minimises psychological distress, increases personal control (2)
and facilitates informed decision-making. The diagnosis and information discussed in genetic
counselling frequently has implications for other family members and this may impact upon
relationships and family dynamics. The process of genetic counselling may involve multiple
phases, including pre-clinic contact with clients, clinical consultation, follow-up and review.

Process of Genetic Counseling

Pre-consultation contact - genetic counsellor should contact the client prior to the scheduled
clinic appointment. The genetic counsellor may outline or review the purpose of the consultation
as well as explain the consultation process and aims, including the possibility of a physical
examination so that concerns that the client may have regarding the nature and conduct of the
consultation may be addressed. The counsellor ascertains the needs and expectations of the client
/ family (their agenda), identifying any
special requirements e.g. wheelchair access or interpreter services. Social and/or cultural issues
which may impinge on the consultation may be identified by the counsellor. Signed consent
forms may need to be obtained from the client or other relatives to facilitate release of this
information. clarify unrealistic expectations of the clinical consultation. provide emotional
support to reduce any pre clinic anxiety.

Preparation for consultation - check that all information needed for the consultation has been
obtained. prepare information that will be given to the client, including appropriate support
group information and fact sheets as applicable.

The consultation - The physical setting for the genetic counselling consultation is important. The
consultation room and examination facilities should ensure total privacy for the client. Consent
should be obtained from the client for other health professionals, such as students and trainees, to
be present at the consultation. The agenda for the consultation should be set early, taking into
consideration the needs and expectations of the client or family. Information may be gathered in
several ways. Information about the client / family medical history may be available via the
referring doctor and hospital / medical records.A genetic diagnosis or test result may have direct
risk implications for other family members and genetic counselling should be made available to
them, as appropriate. Support and assistance in conveying genetic information to ‘at risk’
relatives should be offered by the counsellor. It is important for the genetic counsellor to check

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the client’s level of understanding throughout the consultation. To enable the client to make an
autonomous and informed decision.

SUPPORTIVE COUNSELLING

Supportive techniques are general measures that comfort and guide the client. They are directed
at reducing client-distress without specifically addressing the psychological and behavioural
causes. Thus, supportive procedures are non-specific in nature.

Supportive techniques can be used at any time during therapy, but are commonly most employed
during the early phases of therapy. This is because during the later phases of therapy, more
specific techniques may be required.

Ventilation - Ventilation means allowing the client to speak about his problems without
restriction or inhibition. Ventilation is an important technique in therapy, particularly during the
early phases.

● It provides the client with an opportunity to speak. It is very likely that, prior to entering
therapy, the client has listened to a lot of people giving him advice but rarely listening to
him or his problems. Ventilation enables the client to 'get everything off his chest' during
these initial stages of counselling.
● As the client speaks, he obtains a feeling of relief because his problems are no longer his
own. They are now shared with the counsellor who, by virtue of his position, will take up
at least some of the responsibility for finding solutions.
● As the client puts his feelings into words and communicates them to the counsellor, he
begins to see his problems in a more objective light, thereby gaining objectivity over the
problems. He therefore becomes more likely to think of solutions for the problems, and to
accept the guidance given by the counsellor.

Catharsis - Catharsis refers to the tumultuous expression of emotions, a letting off of steam. This
often takes the form of tears, but may include expressions of anger and rage. The release of
pent-up emotions in itself can be therapeutic.

Clarification- Clarification refers to the process whereby confused thoughts in the client's mind
are sorted out so that he understands better the why and how of his feelings and reactions. To
some extent, clarification occurs spontaneously during ventilation.

Prestige Suggestion - Most clients, who enter therapy, suffer from low self-esteem and a loss of
self- confidence. The counsellor constantly needs to remind these clients of their positive
attributes, their achievements, and capabilities. Clients are better equipped to face their problems

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when they understand that there is much that deserves appreciation in their personality and
behaviour.

The Utilisation of Social Support - May persons in distress can benefit from an increase in their
social networks. For instance, an unhappy married woman could be encouraged to build up her
social networking with relatives, friends, and neighbours. The increased socialisation will
provide her with an outlet for her suppressed feelings as well as afford her greater emotional and
material support when she needs it.

As a special extension, alcoholics could join Alcoholics Anonymous while their wives could join
Al-Anon, and their children Al-Teen. Clients with drug-related problems could try out the
Narcotics Anonymous.

Behavioural techniques

Problem Solving - Many clients enter counselling because of difficulties that they have not
attempted to resolve or difficulties that they have failed to resolve. These difficulties can be
resolved into specific problems, which can then be addressed by conventional problem-solving
methods. it is very effective because it encourages clear thinking, leads to practical solutions, and
goes beyond thinking into doing.

Rehearsal and Role Play - Clients can at times improve their assertiveness, self-confidence, and
ability to handle difficult situations by anticipating these situations and rehearsing their responses
early on. A degree of role-play between client and therapist may be called for.

Contracting - Contracting seeks to effect behaviour change by offering incentives that are
contingent on the client's compliance. There are two important kinds of contracts: good faith
contracts, and 'quid pro quo' contracts.

In a good faith contract, the client is given an incentive with the hope and expectation that he
will show the desired behaviour change. For example, a father may consent to buy his son a
bicycle provided that the son promises to study for at least one hour daily.

In a 'quid pro quo' contract, the client receives an incentive for each occasion that he shows the
desired behaviour. For example, when counselling a couple with marital discord, a 'quid pro quo'
contract may link a husband's attention to his wife's emotional needs to his wife's attention to his
sexual needs. For example, if he agrees to take her for a movie at least once a week, she
cooperates with him for sex at least twice a week. Thus, a 'quid pro quo' contract is a
'you-scratch- my-back-and-I-scratch-your-back' arrangement.

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Although contracting may seem to be a very artificial way of effecting behavioural change, it
serves two very useful purposes: the desired behaviour is brought about; and this behaviour
could, in course of time, possibly become spontaneous after sufficient repetition.

PRIMARY SECONDARY TERTIARY CARE

primary professional (medical) care is a care of the “first contact” of the individual with the
health care service, which is provided in ambulatory settings by qualified health professionals
(general practitioner-GP, family doctor, or nurse) when a patient came, usually for the first time,
with certain symptoms or signs of disease. The primary professional level of care includes a
doctor and members of its team: nurse, birth attendant, home visiting nurse, social worker, and
sometimes a physiotherapist, too. The most common role of the physician is “gate keeper”,
which means that the doctor is motivated and empowered to treat and cure broader scope of
illnesses and conditions

Secondary or intermediate level of care is general specialist care, delivered by “general

specialist doctor” for more complex conditions, which couldn’t be resolved by the general
practitioner or primary professional care level. General specialists (surgeons, internal medicine
specialists, gynaecologists, psychiatrists etc.) usually deliver this type of care through specialised
services of district or provincial “general hospitals”.Usually patient is directed by the general
practitioner from primary professional level to the secondary level as the first referral level of
care through referral.

Tertiary or central level of care is sub-specialist care including highly specific services, which
might be delivered in specialised institutions or by highly specialised health professionals -
sub-specialists i.e. neurosurgeons, plastic surgeons, nephrologists, cardiologists etc. The
specialised institutions, which provide this type of care are, also, educational institutions for
health manpower (university hospitals, Administrative unit, university clinics, etc.).

Secondary and tertiary care support primary health care by providing technologically-based
diagnosis, treatment and rehabilitation. WHO recommend that in most Member States, secondary
and tertiary care should more clearly serve and support primary care, concentrating on those
functions that cannot be performed effectively by the latter. Planning secondary and tertiary care
facilities in accordance with the principle of a population-based "regionalized" system allows for
more rational use of expensive technologies and of the expertise of highly trained personnel

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