It is apparent that patients undergoing treatment and surveillance for thyroid cancer may be experiencing much greater levels of psycholog ical distress than healthcare staff have generally anticipated, based on a relatively good prognosis. A significant minority of people with any type of cancer experience clinical levels of distress at some point in their cancer journey and it may well be that those with thyroid cancer experience higher levels of distress than some other subgroups.
Therefore a key role of the clinical psychologist is to educate other staff about psychological responses to diagnosis, treatment, and surveillance. This may start with advice to managers in order to influence the provision of resources and facilities; for example, understanding of patients' need for careful preparation for treatment may support the case for having specialist nurses allocated to thyroid cancer. Considering the impact of the immediate environment on psychological wellbeing may strengthen the case for modifying treatment rooms.
A clinical psychologist should be involved in the design and implementation of a program of education for healthcare staff involved with thyroid cancer patients. The education program should include psychological needs of patients, communication skills, and evidence-based information on risks of radiation exposure and relevant precautions. Nuclear medicine technicians as well as doctors and nurses should be included in the educational program. The clinical psychologist could also offer consultation and advice on preparation of patients for treatment and the provision of both oral and written information.
Provision of supervision and support for specialist nurses who would themselves be offering frontline psychological support to patients is an important role of the clinical psychologist. This may involve training nurses in specific clinical skills, for example counseling skills or cognitive behavioral techniques.
A clinical psychologist may offer advice and consultation to specialist nurses and/or former patients who wish to establish a patient support group. The clinical psychologist could usefully provide a regular presentation on psychological aspects of thyroid cancer and coping skills to the support group. If the support group operates a "buddy system" for new patients undergoing treatment, the clinical psychologist may offer support and supervision to the buddies.
Psychological assessment and direct clinical interventions should be provided by the clinical psychologist for more complex psychological problems, for example clinical depression or anxiety, post-traumatic stress disorder, phobic avoidance of treatment. Enabling other clinical staff to recognize and detect such distress and make appropriate referrals is part of this role.
Following referral, the clinical psychologist would offer the patient a comprehensive assessment. On the basis of assessment the patient may be offered a course of therapy (e.g. cognitive therapy, interpersonal therapy, brief psychotherapy). If therapy is not deemed appropriate, advice on management may be offered to the referrer. Psychological therapy would be based on the patient's idiosyncratic needs, but may focus on: preparing for and coping with treatment; re-establishing roles following treatment; overcoming depression; addressing marital and sexual difficulties; living with ongoing surveillance and threat of recurrence.
For patients complaining of memory problems, a neuropsychological assessment, using formal psychometric tools, such as the Wechsler Memory Scale III , may be useful. This would be followed by careful feedback to both the patient and the referrer, and appropriate advice on management of memory problems.
As cancer is understood to have psychological and social ramifications for partners and families, as well as for patients themselves, it is sometimes advantageous to involve significant others in assessment and therapy. (This would only occur with the patient's consent.) Other family members often offer valuable perspectives on problems and potential solutions. Addressing marital and sexual difficulties is usually more successful when both partners are engaged in therapy. Occasionally a whole family group may be involved in a systemic intervention, aimed at improving communication and renegotiating roles and boundaries. Systemic psychological interventions may be particularly appropriate for families affected by medullary thyroid carcinoma associated with the inherited disease multiple endocrine neo-plasia type 2a.
For some patients and their families, particularly in cases of medullary or anaplastic carcinomas, psychological support through terminal care and bereavement may be indicated. Psychological support for terminally ill patients and their families focuses on enabling people to maximize their quality of life and address unresolved psychosocial issues. Following a patient's death, the clinical psychologist could be asked to intervene where other family members experience complicated or prolonged grief.
It is clear from the existing literature that there is much scope for further research into psychosocial aspects of thyroid cancer. Given the relatively rare nature of this disease and the need for larger population studies, cross center studies would be more useful than single center studies. Clinical psychologists should collaborate with colleagues in medicine, nursing and academia to implement carefully designed studies. Clinical psychologists can also usefully contribute to audit of services. For example, monitoring the prevalence of depression and anxiety in patients being treated for thyroid cancer or comparing different methods that non-psychology staff may use to detect psychological distress are examples of useful audit projects to be undertaken at a local service level.
The expectation is that the clinical psychologist would be a valuable resource to colleagues in other professions treating the patient with thyroid cancer. The aim is to promote psychological wellbeing, detect and alleviate psychological distress, enhance staff morale, and promote holistic patient care.
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