1. The programme at a glance
Indication. The distress of an adult with cancer, at any point in the illness — diagnosis, treatment, the period after treatment, recurrence, advanced disease — when it becomes excessive, becomes fixed or prevents them from living: an adjustment disorder, depressive or anxiety symptoms that do not reach the threshold of an established disorder, an invasive fear of recurrence, existential distress. An established major depressive episode, anxiety disorder or post-traumatic stress disorder belongs to its own manual, with which this one works in tandem (section 3).
Reference model. A cognitive behavioural therapy (CBT) adapted to serious illness, which brings together the components evaluated in psycho-oncology: problem solving (Nezu et al., 2003); behavioural activation, that is, the resumption of scheduled activities, here paced to energy; work on worry and fear of recurrence, in the spirit of the CBTs that target thought processes — worry, rumination, attention fixed on threat — rather than their content, which Tauber et al. (2019) call "contemporary" CBT; and, when the disease progresses or the question of meaning dominates, the principles of the CALM approach (Rodin et al., 2018) and of meaning-centred psychotherapy (Breitbart et al., 2015). The general framework is the transactional model of stress (Lazarus and Folkman, 1984; section 7).
Format. Ten individual sessions of 45 to 50 minutes, the first lasting 60, fitted around the treatment schedule, shortened to 30 minutes when fatigue requires it, in the consulting room, in hospital, at the bedside, by telephone or by video call (section 14). Session 9 has two versions depending on the phase of the illness, and is split in two when both are useful: the programme then has eleven sessions at most. When the disease progresses and energy is lacking, it is condensed into five sessions (1, 2, 8, 9 and 10). Three booster sessions follow, at one, three and six months; when the disease progresses, follow-up becomes less frequent without stopping (section 25). This length is consistent with the evaluated interventions — three to six sessions for the CALM approach (Rodin et al., 2018), seven or eight for meaning-centred psychotherapy (Breitbart et al., 2012, 2015), five for fear of recurrence (Butow et al., 2017) — and with the meta-analysis by Faller et al. (2013), in which longer interventions had more lasting effects. The programme itself has not been evaluated: its structure, the two versions of session 9, the condensed format, which borrows the brevity of the CALM approach without being that approach, and the spaced follow-up are choices (section 12).
Mechanism targeted. The programme does not try to make the threats of cancer less serious than they are. It aims at four changes: that concrete problems stop piling up; that daily life resumes in proportion to energy; that worry and fear of recurrence stop taking up the day; and that the person can live according to what matters to them, including when time is short.
| Session |
Focus |
Session output |
| 1 |
Welcome, assess, sort |
Sorting done, risk assessed, baseline measures |
| 2 |
Understand what weighs, and choose |
Circle drawn, three-column sort, aims written |
| 3 |
One problem at a time |
One dated action, three questions for the team |
| 4 |
Days in proportion to energy |
Days scheduled, physical activity discussed |
| 5 |
Worry and waiting |
Worry time, plan for waiting, mid-point measures |
| 6 |
The body and self-image |
One avoided situation resumed, belief re-rated |
| 7 |
Loved ones and children |
One conversation prepared, one request for help made |
| 8 |
What matters |
Sources of meaning named, two dated actions |
| 9 |
The uncertain future |
Monitoring rule written, or wishes for what lies ahead expressed |
| 10 |
Review and plan for what comes next |
Measures repeated, plan written, boosters scheduled |
What the person takes away. Nine printable worksheets, including a daily record, a safety plan, a worksheet for loved ones and a plan for what comes next (section 34).
What distinguishes this programme from the other manuals on this site. It treats not a disorder but a situation, and it begins by deciding whether there is anything to treat (section 3). It follows the course of the illness, instead of assuming that the stressor is behind the person. And it works with the team treating the cancer, because part of the distress comes from a poorly controlled symptom, and part of what weighs on the person is settled by a well-put question to the oncologist.
2. Before you begin
The five preliminary decisions
Is there anything to treat? Sadness, fear or disturbed sleep are expected after a cancer diagnosis, and many ease as the person gets organised. The National Comprehensive Cancer Network (NCCN), which publishes the American guidelines on distress in oncology, explicitly asks teams to recognise that distress is normal and expected (Riba et al., 2019). This programme begins when distress becomes excessive, becomes fixed or prevents the person from living (section 3).
Does what looks like distress belong first to the doctor? Poorly relieved pain, fluctuating confusion, insomnia that appeared with a treatment, a change of mood at the start of corticosteroid treatment: you look for a medical cause before concluding that the cause is psychological (section 9).
What is the suicide risk? It is higher than in the general population, particularly in the first weeks after diagnosis (section 10). It is asked about at session 1, then at every session.
Where is the illness at? Each phase of the illness calls for different work (section 5), and the answer decides which version of session 9 and which format are used.
Who is the team? The oncologist, the general practitioner, the coordinating nurse: the programme is conducted with them (section 14).
What this programme does not treat
An established disorder, which follows its own manual (section 3). This programme can accompany it: its sessions on concrete problems, energy and loved ones are then added to the manual for the disorder.
An acute suicidal crisis. It is managed first, with emergency services and according to Suicidal behaviour in adults: a therapist's manual (section 10).
Cancer in children and adolescents, and support for the parents of a sick child, which require a different framework. The children of an ill parent, on the other hand, are part of this programme (session 7 and section 30).
Medical decisions. You do not give information on the prognosis, you do not advise on a treatment, and you do not comment on a therapeutic choice. You help the person to ask their questions and to decide according to what matters to them (session 3).
How to use it
Read the whole manual before the first session, in particular sections 3, 5, 10 and 28: sorting, the phases of the illness, safety and the end of life. Each session follows the same framework: the aim, the steps, what you say, common errors, and the criterion for moving on.
The first trap is to put everything down to the situation. "With what she is going through, it is normal to be depressed": this is how major depression goes untreated in someone who is ill. A real ordeal does not rule out a disorder (section 3).
The opposite trap is to make every fear a distortion. The fear of recurrence, of suffering or of death rests on a real threat. You do not dispute it; you work on what it costs, and on what maintains it.
3. Five presentations not to be confused
Five situations arise in a person with cancer, and they do not call for the same approach.
1. Expected distress
What you observe. Sadness, fear, anger, recurring thoughts, disturbed sleep, especially at turning points: diagnosis, the start of a treatment, waiting for a result, the end of treatment. The person is suffering, and they go on doing the essentials.
What points the way. Proportion and trajectory: distress in proportion to what is happening, which fluctuates with the stages of the illness, and which eases when the person knows what to expect.
What this implies. Information, support, access to supportive care (section 32) and reassessment at the next turning point. No programme, but an open door.
2. Adjustment disorder
What you observe. A preoccupation that invades the days, centred on the illness and its consequences, and a life that no longer keeps up: the person no longer sleeps, no longer does anything, leaves paperwork untouched, withdraws.
What points the way. An identifiable stressor — here, the illness or one of its stages — a clear impact on functioning, and the absence of another disorder that would better account for the picture. It is one of the most frequent diagnoses in interview-based studies in oncology (section 8).
What this implies. It is the main indication for this programme. Adjustment disorder: a therapist's manual describes the same disorder after other stressors; here, the stressor continues, and the work takes this continuity into account.
3. The major depressive episode
What you observe. Low mood or loss of interest nearly every day for at least two weeks, and a picture that goes beyond the illness: no pleasure at all any more, even at visits from the grandchildren, feelings of worthlessness, guilt, hopelessness.
What points the way. Psychological symptoms more than physical ones. Fatigue, loss of appetite and sleep disturbance may come from the illness or the treatments: rely first on mood, loss of interest, worthlessness, guilt, hopelessness and thoughts of death, and do not rule out an episode on the grounds that its physical symptoms have a possible cause.
What this implies. Treating depression in adults: a therapist's manual, with a medical opinion, and this programme's adjustments for energy and treatment. Major depression in someone who is ill is treated, and it responds to treatment: in a Scottish trial of 500 people, a programme of care coordinated between cancer nurses, psychiatrists and general practitioners achieved a response in 62% of people, against 17% with usual care (Sharpe et al., 2014).
4. Anxiety disorder and invasive fear of recurrence
What you observe. Anxiety that goes beyond the turning points: worries all day long, panic attacks, avoidance of examinations or incessant checking of the body, and, after treatment, a fear of recurrence that prevents the person from making plans.
What points the way. Fear of recurrence is not a diagnosis, but it has a consensus definition: fear, worry or concern relating to the possibility that the cancer will come back or progress. It becomes a clinical problem when it is accompanied by high levels of preoccupation, ways of coping that maintain it, functional impairment, excessive distress and difficulty making plans (Lebel et al., 2016). People who experience it at a clinical level more often meet the criteria for a psychiatric disorder, especially an anxiety disorder (Simard and Savard, 2015).
What this implies. Fear of recurrence is treated in this programme (session 9 and section 26). An established anxiety disorder follows its own manual, for example Treating generalised anxiety disorder in adults: a therapist's manual; health anxiety that predates the cancer, or that extends to other illnesses, follows Health anxiety and somatic symptoms: a therapist's manual.
5. Existential distress and demoralisation
What you observe. The feeling that life has lost its meaning, a sense of being helpless and trapped, shame at depending on others, the feeling of being a burden. The person is not necessarily sad all day, and can still enjoy a visit or a meal.
What points the way. Kissane et al. (2001) proposed calling this picture a demoralisation syndrome, made up of hopelessness, loss of meaning and existential distress, distinct from depression and identifiable in palliative care. It is a conceptual proposal, not a category in the classifications; its authors consider that it can lead to a desire to die, or even to suicide, which is enough to justify an explicit assessment of risk.
What this implies. Sessions 8 and 9, and the explicit assessment of the wish to die (section 28).
The three sorting questions
"What is weighing on you most at the moment?" It opens the inventory of what weighs on the person, often more concrete than one imagines.
"Are there still things that give you pleasure, even small ones?" It separates sadness linked to the illness from the generalised loss of pleasure of depression.
"How much time a day do you spend worrying, and what does it stop you from doing?" It measures the room taken up by worry, and its impact.
4. What the person is going through
The distress of a person with cancer has several sources, and they are not treated in the same way. The NCCN defines it as an unpleasant experience of a psychological, social, spiritual or physical nature that may interfere with the ability to cope with cancer, its symptoms and its treatment; the term was chosen because it is less stigmatising than "psychological" or "psychiatric" (Riba et al., 2019).
Concrete problems. Transport to treatment, loss of income, childcare or paperwork sometimes weigh more than the person says, because they feel it would be out of place to complain about them to a psychologist. They are dealt with one at a time (session 3), often with the hospital's social worker.
The body and its symptoms. In a German study of 3,724 people, fatigue was the most frequent problem (56%), ahead of sleep problems (51%) and difficulty getting around (47%); 81% of the people who reported sadness, fatigue and sleep problems together had high distress (Mehnert et al., 2018). Energy becomes the resource that organises the days (session 4), and sleep has its own treatment (section 27).
Uncertainty. It accompanies waiting for results, then the fear that the cancer will come back, and it never lifts completely: the work focuses on the room it takes up (sessions 5 and 9).
The changed body and identity. A scar, a stoma, an induced menopause or an altered sex life raise the question of who one still is (session 6).
Relationships. The partner keeps quiet so as not to cause worry, the person wants to protect the children, friends drift away or do too much (session 7 and section 30).
Meaning and death. "Why me?", "what's the point?": these questions, together with the fear of dying, of suffering and of leaving one's loved ones, often arise from the moment of diagnosis (sessions 8 and 9, section 28).
5. The phases of the illness
The illness is not an event but a succession of stages, each with its tasks and its dangers. Situate the person from session 1: that is what decides how much room to give each session.
Diagnosis
What happens. Being told the diagnosis is a shock: the person is often stunned during the consultation, then retains almost nothing for days. Fear and incomprehension dominate, and suicide risk is at its highest in the first weeks (section 10). In France, breaking the news takes place within a structured disclosure process, the dispositif d'annonce (a provision of French law; elsewhere, the local equivalent), which includes a dedicated medical consultation and a time of support from the care team, during which a nurse restates the information and refers the person on, in particular to the psychologist.
What the programme does at this point. It does little, and quickly: listening, helping the person to ask their questions, settling urgent problems, looking for suicide risk. Sessions 1 to 3 may be enough at this point; the rest will wait until the person knows their treatment.
Treatment
What happens. For weeks or months, life is organised around surgery, chemotherapy, radiotherapy or other treatments, their fatigue and their side effects, and it shrinks to treatment.
What the programme does at this point. Sessions 3, 4, 6 and 7 dominate, fitted around treatment cycles: you do not schedule a demanding session the day after chemotherapy.
After treatment
What happens. The end of treatment, awaited as a release, is sometimes experienced as a void: appointments become less frequent, the team that provided reassurance recedes, and those around consider that "it's over", whereas fatigue, after-effects and fear of recurrence remain. This fear affects all cancer sites and all periods after diagnosis (Luigjes-Huizer et al., 2022).
What the programme does at this point. Version A of session 9 and sessions 4 and 8 take up the most room; the return to work is prepared as a problem broken down into steps (session 3), with the occupational health doctor. In France, a comprehensive care pathway after cancer treatment (a provision of French law; elsewhere, the local equivalent) may include, in the year following the end of treatment, a physical activity assessment, a dietary assessment and a psychological assessment. And the "right to be forgotten" (a provision of French law; elsewhere, the local equivalent) has, since the law of 28 February 2022, prohibited loan insurers from collecting medical information about a cancer more than five years after the end of the treatment protocol.
Recurrence
What happens. It is a new diagnosis, with one difference: the person knows what the treatments demand, and the hope of a cure has sometimes changed in nature. Discouragement dominates, and sometimes guilt at "not having done enough".
What the programme does at this point. You go back to session 1, you look for this guilt, which sometimes rests on the false idea that mood or willpower could have prevented the recurrence (section 12), and you decide again which version of session 9 to use.
Advanced disease and the end of life
What happens. The illness will not be cured; treatments aim to control it and to relieve symptoms. The person lives with two realities at once, the life that goes on and the death that is approaching, and with loss of independence, the fear of suffering and of being a burden, and sometimes a wish to die (section 28).
What the programme does at this point. It switches to the condensed format when energy is lacking, to version B of session 9 and to section 28, in close liaison with the palliative care team. Palliative care offered early is in no way a giving up: in people with metastatic lung cancer, introducing it from diagnosis improved quality of life and reduced the proportion of people with depressive symptoms, from 38% to 16%, without shortening life (Temel et al., 2010).