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Should all patients with cancer receive mental health counseling?
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Counseling provides benefits for most patients with advanced cancers.
There is a whole skill set around managing a cancer diagnosis that most people are not born with. Counseling can relieve distress, identify better coping mechanisms, provide support and ultimately address the particular issue faced by patients living with advanced cancers. Communicating with family members, spouses and children can produce anxiety in and of itself, and sitting down with a neutral third party can help patients work through some of the stress they feel about addressing issues of their treatment, prognosis and goals with their loved ones.
In cancer care, there are many options for patients who are struggling with distress, depression or anxiety after their diagnosis. Traditional psychotherapy can be used to work through feelings about loss and grieving, and to reduce the fear that often accompanies a dire medical situation. Counseling with a social worker can provide a safe space to address issues that feel a little too frightening for home. A major concern for providers caring for patients with a history of mental illness is reducing the risk for recurrent mental health episodes. High-risk patients and patients with depressive histories can be referred to psychiatry, and particularly to psychiatrists with experience caring for patients with cancer. There are even situations where a primary care provider can intervene.
Emotions are tremendously varied among patients with advanced cancers. Usually, the initial reaction is one of being overwhelmed, which can translate to high levels of emotional distress. This may subside, but it is a pattern that can repeat itself throughout care — and a pattern that can be addressed by mental health providers. New symptom developments or upcoming procedures can increase distress, so it is important that patients’ psychological well-being is considered throughout treatment.
Mental health care for patients with cancer is not a one-size-fits-all proposition. Social workers can help assess the best course of action for a given patient. All patients should be made aware of their options and guided toward the mental health treatment that will best suit them.
Gregory D. Garber, MSW, LCSW, is director of oncology support services at Sidney Kimmel Cancer Center at Thomas Jefferson University. He can be reached at gregory.garber@jefferson.edu. Disclosure: Garber reports no relevant financial disclosures.
Not all patients will benefit from mental health counseling.
Patients who receive a diagnosis of advanced or metastatic cancer commonly experience dismay, devastation and sadness. Depending on the prior physical health of the patient, the diagnosis may or may not come as a surprise. Someone experiencing a lot of symptoms leading up to the diagnosis may have a building suspicion they might have cancer, whereas for others, it really does come as a surprise. This can often lead to increased risks for anxiety, depression and, in some cases, posttraumatic stress.
On the opposite end of the spectrum, you might encounter patients who are at peace with their diagnosis. They might feel that they’ve lived a long life, or that their disease is God’s will, and the perspective they bring is quite different from a patient who struggles to accept his or her prognosis. As such, I caution providers not to assume the reaction a patient will have. Everything should be grounded in the patient’s experience and their reaction. I learned early in my career that each patient should be treated individually, and it is our responsibility to meet them where they are.
There are certainly benefits to offering mental health counseling to patients with advanced cancer. Data have shown that this patient population is more likely to be distressed, depressed or anxious, and they are more likely to carry a greater symptom burden. Dealing with all of these factors may increase the need for counseling. I certainly think that all patients should be offered counseling, but like any medical treatment, some patients are not going to be receptive. Just as a National Comprehensive Cancer Network guideline might indicate radiation therapy for a certain disease, not all patients will elect that therapy; it is the same situation with mental health care. We should provide our patients with all of the information needed to access counseling, but it should not be forced on them if it goes against their wishes.
I am a big proponent of distress screening, but I think that we also need to move away from the belief that all distress is psychological distress. Often patients may feel distress due to physical symptoms, and palliating those symptoms may do the greatest good for them.
There are many reasons why a patient might elect not to receive counseling. Many patients with advanced cancers receive aggressive treatment, and the treatment burden may already weigh heavily on other aspects of their lives. Adding one more appointment for those patients may feel overwhelming. Other patients who have made peace with their diagnosis may feel that they do not need any further counseling, and we should respect that choice.
I believe that all people can benefit from counseling; that doesn’t mean that all people need or want counseling. The same is true of patients with cancer.
Teresa Deshields, PhD, is associate professor of clinical medicine at Washington University School of Medicine and manager of the counseling service at Alvin J. Siteman Cancer Center. She can be reached at tdl2593@bjc.org. Disclosure: Deshields reports speakers bureau positions with Genentech and Lilly.