Utilizing a Manualized Therapy to Provide Parallel Treatment to Older Adults With Cancer and Their Caregivers: A Case Study

Abstract

The experience of anxiety is a common and understandable reaction to a diagnosis of and treatment for cancer. Patients of any age may experience negative psychological and physical symptoms during cancer treatment; older adults with cancer simultaneously face the impact of cancer and the effects of aging. Caregivers of older adults with cancer are also vulnerable to experiencing anxiety as their loved one navigates the physical and emotional sequelae of their illness and treatment. This article describes the use of Managing Anxiety from Cancer (MAC), a seven-session telephone-delivered manualized cognitive behavioral intervention that includes strategies from acceptance and commitment therapy and problem-solving therapy, with an older woman with cancer and her adult daughter. MAC includes a variety of techniques for patients and caregivers, who are encouraged to use these strategies individually or in different combinations to manage their anxiety. This brief treatment provided a parallel experience for the participants, as the older adult patient and her caregiver were taught the same anxiety-management techniques by their individual therapists. We will discuss the advantages and drawbacks of using a manualized psychotherapy intervention in this case, as well as MAC’s impact on each member of this pair and on the dyad as a unit. Both individuals reported experiencing benefits from MAC and identified MAC-acquired skills they planned to use in the future to manage their anxiety and improve communication. While assessment data did not reflect a decrease in anxiety, it is possible that the stress of the COVID-19 pandemic confounded these data.

Keywords

cancer anxiety older adult cognitive behavioral manual-based psychotherapy

1 Theoretical and Research Basis for Treatment

Psychosocial interventions have been found to be efficacious in reducing anxiety in adults with cancer, as well as having positive long-term effects on quality of life (Greer et al., 2012; Jacobsen & Jim, 2008; Osborn et al., 2006). Cognitive behavioral therapy (CBT) is a recommended treatment approach for cancer patients with anxiety (Andersen et al., 2014) and has been shown to be effective in older adults (Ayers et al., 2007). In addition to traditional CBT principles, problem-solving, psychoeducation, and relaxation training have been associated with reductions in anxiety in cancer patients (Jacobsen & Jim, 2008). Cognitive behavioral therapy with cancer patients was found to be equally beneficial when delivered by phone or in person (Watson et al., 2017). However, CBT interventions for cancer patients do not consider the unique needs of older adults and their caregivers.

Noting the need for psychosocial interventions tailored for use with older adults with cancer, Trevino et al. (2020) developed Managing Anxiety from Cancer (MAC). MAC is a seven-session, phone-delivered therapy administered to an older adult with cancer (OAC) and their caregiver concurrently by two different therapists. MAC is novel in that it addresses the compounding impact the range of physical and cognitive changes associated with cancer and aging may have on an individual with cancer and their caregivers. Both participants receive their own workbook with parallel content specifically tailored to either the OAC or caregiver experience. Assigning separate therapists for the OAC and caregiver allows each dyad member to express concerns independent of their partner, and the two therapists do not confer during the course of the intervention to maintain this confidentiality. Patient and caregiver workbooks provide easy-to-read information and case examples that illustrate session content. The therapist manuals incorporate therapist instructions embedded directly into the patient and caregiver workbooks, allowing therapists to view both simultaneously (Trevino et al., 2020).

The goal of MAC is to teach OACs and their caregivers various techniques from cognitive behavioral therapy, acceptance and commitment therapy, and problem-solving therapy to manage the anxiety associated with cancer and aging. Caregivers are informed about the importance of self-care and work with the therapist to identify life areas in which self-care improvements can occur. Session content includes information on relaxation and mindfulness exercises, cognitive restructuring, assertive communication, problem-solving, and aspects of acceptance and commitment therapy. Audio files with guided muscle relaxation, guided imagery, and mindfulness exercises are included with the participant workbook. Each session concludes with the development of a practice plan to encourage completion of worksheets and utilization of learned strategies between sessions (Trevino et al., 2021).

The following case presentation describes the course of the MAC intervention with an OAC and her daughter during their participation in a randomized controlled trial of MAC (for additional information on this RCT, see Trevino et al., 2021).

2 Case Introduction

Treatment Dyad

Shirley was a 78-year-old Caucasian woman diagnosed with lymphoma and lung cancer 2 years prior to her participation in the MAC treatment, and Melissa was her 50-year-old adult Caucasian daughter. A.S. was the therapist assigned to work with Shirley. R.H was the therapist who worked with Melissa.

3 Presenting Complaints

Shirley endorsed increased anxiety over several months, which was noted by her oncologist. Melissa reported anxiety related to her mother’s illness and the caregiving responsibilities she faced.

Shirley and Melissa began their participation in the MAC study in June 2020, as New York was emerging from the first wave of the coronavirus pandemic that had resulted in a record number of deaths, the shutdown of most of the economy, and strict stay-at-home orders. Consequently, both women expressed heightened anxiety related to this global health crisis and the potential dangers associated with contracting this virus.

4 History

Shirley was divorced and lived alone in her home in the suburbs outside of New York City. She was a retired Director of a not-for-profit agency, a job that she greatly enjoyed. Two years prior to her participation in MAC, Shirley was diagnosed with both lymphoma and lung cancer; she underwent a lobectomy to remove the cancer on her lung at that time. She was initially responsive to the chemotherapy and immunotherapy treatments she received but experienced medical setbacks during her treatment, including a drop in her red blood count and the need for blood transfusions. After resolution of these issues, she resumed treatment for her lymphoma early in 2020, receiving weekly infusions that successfully put the lymphoma in remission. Shirley’s social supports included her two adult children, Melissa and David, and her two siblings. Melissa lived approximately 30 minutes from Shirley, while her son David and his family lived an hour and half away.

As a young adult, Shirley had participated in both individual and group psychotherapy related to her divorce but had no other experiences with psychotherapy. Shirley was prescribed the antidepressant Wellbutrin 150 mg daily by her internist 3 months before beginning MAC and found it helpful; she described having had “spontaneous crying spurts” that subsided once she began the antidepressant. Shirley had a prescription for the anti-anxiety medication Xanax .25 mg that she took as needed but infrequently for episodes of increased anxiety.

Melissa was a single woman who lived alone in New York City. She worked full-time in the fashion industry as a manager. During the COVID-19 pandemic, she continued to go in person to her place of work. She was never married and did not have any children. Her supports included friends and co-workers. She had been in therapy before for a specific problem in the past and was on a stable psychotropic medication regimen of Wellbutrin and Xanax for depression and anxiety (dosages of medication unknown).

5 Assessment

The OAC and caregiver were each interviewed separately by phone by a research assistant before the start and following the completion of MAC sessions. The Hospital Anxiety and Depression Scale (HADS) was administered to both MAC participants. Quality of life measurements were obtained with the Functional Assessment of Cancer Therapy-General (FACT-G) for Shirley and the Caregiver Quality of Life-Cancer scale for Melissa.

Additionally, at the conclusion of the therapy, Shirley and Melissa were asked to rate the perceived helpfulness of the overall intervention and specific intervention components of MAC. Each item was rated on a five-point scale from “not at all helpful” (0) to “very helpful” (4).

Assessment Measures

The HADS

The HADS (Zigmond & Snaith, 1983) consists of 14 items measuring symptoms of anxiety (7 items) and depression (7 items). Each item is rated on a 4-point (0–3) scale with higher scores indicating more severe symptoms. Items are summed into a total and subscale scores. Anxiety and depression subscale scores are categorized as normal (0–7), mild (8–10), moderate (11–14), or severe (15–21). The HADS has been used extensively in cancer patients (Moorey et al., 1991; Smith et al., 2002) and caregivers (Gough & Hudson, 2009; Lambert et al., 2011) and is valid for use with an older adult population (Djukanovic et al., 2017).

The FACT-G

The FACT-G is a reliable and valid 27-item self-report scale that assesses health-related quality of life (Cella et al., 1993; Victorson et al., 2008). Each item is rated on a Likert scale from 0 to 4 with higher scores indicating better quality of life.

Caregiver quality of life-cancer

The Caregiver Quality of Life-Cancer scale is a reliable and valid 35-item measure of quality of life in cancer caregivers (Edwards & Ung, 2002; Weitzner et al., 1999). Each item is rated on a Likert scale from 0 to 4 with higher scores indicating better quality of life.

6 Case Conceptualization

Shirley reported experiencing lifelong anxiety and perceived it as part of her way of being. She was able to tolerate or accommodate her anxiety in most circumstances and coped well with prior stressors. However, she did not have previous experience purposefully employing specific strategies in order to manage or reduce her level of anxiety. By conceptualizing this case through a cognitive behavioral lens, Shirley was provided with a selection of anxiety-management techniques and empowered to use them as needed. The process of gaining insight into what triggered her worry allowed her to more clearly identify when anxiety management would be beneficial. For example, Shirley quickly identified PET scans as a trigger of anxiety and noted that she experienced heightened anxiety prior to a scheduled scan (thinking about it beforehand), during (undergoing the test), and following (waiting for the results). In subsequent MAC sessions, Shirley learned and practiced a variety of strategies to aid in her anxiety management related to medical procedures. The strategies were conceived of as “tools in a toolbox” that could be used in different combinations for varying situations. Cognitive restructuring was found to be useful prior to a medical test, deep breathing most effective during the test, and both communication strategies and cognitive restructuring proved helpful following the test.

Shirley identified her daughter Melissa as her caregiver. The impact of caregiver stress is well documented; it not only impacts the emotional and physical well-being of the caregiver herself but may impact the caregiver’s ability to help the care recipient and can influence the interpersonal relationship between the caregiver and the care recipient (Sun et al., 2019). Melissa experienced significant anxiety related to both concerns for her mother’s health as well as worries related to her abilities as a caregiver. Therefore, it stands to reason that addressing Shirley’s and Melissa’s anxiety simultaneously would prove beneficial to both. Providing them with the same arsenal of anxiety-management tools, as indicated by the treatment manual, not only gave them the means to manage their own anxiety but also provided a common cognitive behavioral language.

7 Course of Treatment and Assessment of Progress

Shirley

Session 1: Introduction

During the first session, Shirley described her experience of her cancer diagnosis and treatment.

Shirley and her therapist, A.S., reviewed the content of Session 1, beginning with a discussion of the symptoms of anxiety and Shirley’s specific anxiety triggers. A.S. provided psychoeducation on the importance of identifying anxiety-triggering situations in order to anticipate what future circumstances might produce anxiety and to develop strategies to help manage the anxiety. Shirley spoke of the anxiety she felt surrounding medical appointments and procedures, beginning when scheduling a visit, occurring during the exam itself, and again triggered when awaiting test results.

Shirley discussed the challenges she experienced related to cancer and aging, such as forgetfulness, activity restrictions, and being viewed as “old” by others. Additional social and recreational limitations due to recent COVID-19 stay-at-home requirements were also addressed; Shirley acknowledged that her age and cancer diagnosis put her at greater risk for poor outcomes of COVID-19, and therefore, she had been engaging in few activities outside of her home. Shirley identified values and areas of expertise that she had gained as she and the therapist reviewed the assets of aging. She valued her familial relationships and friendships, saw herself as someone with special skills and knowledge related to her professional life, and described possessing qualities such as patience, wisdom, and independence. Shirley also stated that she identified with and valued her Judaism but described herself as an atheist; the cultural and spiritual aspects of Judaism guided Shirley’s decisions and informed the ways she lived her life.

Shirley’s practice plan was to record past and current situations, people or thoughts associated with increased anxiety, and the symptoms of anxiety she experienced during those times.

Session 2: New actions

A.S. began the session by briefly recapping the topics discussed during the first session and then reviewing Shirley’s homework. Shirley detailed her anxiety-provoking visits to doctors’ offices and reported experiencing nervousness, muscle tension, and stomach pain associated with these visits.

Managing Anxiety from Cancer’s second session focused on behavioral practices for managing anxiety, such as deep breathing, muscle relaxation, and mindfulness. Shirley reported that she had tried breathing exercises in the past with varying success but was open to revisiting this strategy. She also selected muscle relaxation as a new strategy to learn. A.S. spoke to the benefit of engaging in behavioral practices during times of minimal stress in order to gain comfort and familiarity with them, thereby making them easier to access during times of heightened anxiety. Shirley and A.S. practiced these new actions during the session and agreed on a plan for Shirley to practice deep breathing once a day and muscle relaxation twice during the upcoming week.

Session 3: New thoughts

While reviewing the content of the previous session, Shirley stated that she engaged in deep breathing daily during the previous week as planned and listened to the muscle relaxation, guided imagery, and mindfulness audio recordings as well. Shirley found the deep breathing helpful and noticed immediate benefits. She reported enjoying the other strategies but admitted difficulty maintaining focus during the muscle relaxation exercise. A.S. reinforced how continued practice of these strategies may allow her to use them with greater ease over time.

The third MAC session focused on cognitive restructuring, including examining the relationship between current thoughts and anxiety, identifying cognitive distortions, and creating new thoughts that do not contain errors and are less anxiety-provoking. Shirley identified the situation of waiting for test results as triggering anxiety and reported having thoughts such as “it’s going to be a bad report.” She was able to expand on the thought including statements such as, “I am going to have bad test results. I will need a transfusion, and I will be sick all over again.” As Shirley explored the content of her thoughts, the reason for her anxiety became clearer. She developed the coping statement of “I have faith in my oncologist, he knows what he is doing, and he’ll look out for me” as an alternative thought that was less anxiety-provoking. In reviewing common cognitive distortions, she also noticed her original thought reflected some “All or Nothing” thinking, as well as the assumption that her scan would definitely show disease progression. Her new, modified thought consisted of this reappraisal: “I do not know for sure what my test results will be. I can wait and see what the doctor says and can make a plan for care at that time.” Shirley agreed to the practice plan to work on noticing and examining thoughts associated with anxiety and to record coping statements and modified thoughts.

Session 4: Communicating well

Shirley shared her use of the new coping statements and modified thoughts throughout the week. She reported that this strategy was very useful in helping her manage and reduce anxiety.

The fourth MAC session consisted of a discussion of assertive communication and use of I-statements to promote effective communication (“I feel _____ when _____ because _____.”). Shirley spoke about how she often had difficulty communicating with doctors and loved ones about her illness because she began crying and felt uncomfortable. She and A.S. discussed an upcoming doctor’s appointment and developed a plan that she could say “I feel embarrassed when I cry while talking about my illness, and I don’t know why. However, I have some questions I want to ask you, and want to know if you can talk with me even if I start crying.” Shirley decided this statement would help her feel more comfortable speaking with her doctor, and she intended to use it during her appointment the following week.

The practice plan was to write out two additional I-statements on her worksheet during the course of the upcoming week.

Session 5: Problem-solving

During the review of communication strategies, Shirley reported that she did not in fact use her pre-conceived I-statement during her doctor’s appointment; nonetheless, she felt that having this statement in mind helped her feel more confident during the appointment. Shirley stated that she found the information on cognitive restructuring so useful that she had continued identifying anxiety-provoking thoughts and trying to develop coping statements and modified thoughts.

Session 5 of MAC is a brief review of the steps of problem-solving therapy. Shirley selected the problem of “when people ask me how I’m doing, I experience a fear of recurrence.” During the session, she brainstormed possible solutions, with the understanding that generating multiple possible solutions does not commit her to using all of them but does allow her to think creatively about how to deal with the problem. Shirley conceived of many possible solutions, including dismissing her friends’ questions, providing a standard superficial answer, ceasing all contact with certain people, and giving herself a pep-talk before social encounters. Shirley selected the solution of utilizing mindful self-talk to manage the fear, saying to herself “I’m in a situation I want to be in right now and, in this moment, I’m feeling good. That’s all that matters.” She developed a step-by-step plan for managing future social situations so as to navigate this problem of being asked about her condition. Shirley did not have a particular social engagement coming up at which she can try out the problem-solving plan but would use the problem-solving strategy when one arose.

Session 6: Willingness (acceptance)

After reviewing the content of the previous session, the sixth MAC session addressed the strategy of Willingness, an adaptation of acceptance and commitment therapy techniques designed to help patients manage anxiety associated with problems outside their control. The technique consists of three steps: (1) noticing the anxiety without judgment, (2) imagining it is an object, and (3) allowing it to be present without trying to reduce it. Shirley reported that during the course of her cancer treatment, she had found ways to move forward with activities despite her anxiety. When asked to imagine her anxiety as an object, she visualized a fire in her stomach. Shirley felt ambivalent about the notion of Willingness and felt she might not be able to “allow the anxiety to be” but made a practice plan to try over the upcoming week.

Session 7: Planning for the future

At the start of the session, Shirley reported that she found herself engaging in Willingness naturally simply by doing activities despite having anxiety, but she remarked on the difficulty of imagining her anxiety as an object and letting it be.

During this final MAC session, Shirley and A.S. reviewed the topics covered in MAC. Shirley reported that identifying triggers of anxiety, deep breathing, and information about developing new thoughts were all particularly useful to her.

The conclusion of the session involved planning for future anxiety. Shirley and A.S. developed a plan to utilize deep breathing, problem-solving, and assertive communication to manage anxiety for an upcoming doctor’s appointment.

Assessment of progress

At the baseline assessment, Shirley reported minimal symptoms on the HADS with a score of 10 (HADS-Anxiety = 7, HADS-Depression = 3). On the FACT-G, she had a summed score of 87, indicating a high perceived quality of life (the highest possible rating on the scale is 108) and was generally positive on many of quality of life items except for a response of 0 “not at all” on the final question inquiring if she was “content with the quality of my life right now.” Despite these assessment scores, Shirley reported experiencing frequent and persistent anxiety related to her cancer diagnosis and possible recurrence.

After the completion of the MAC intervention, Shirley was assessed and scored a 13 on the HADS (HADS-Anxiety = 9, HADS-Depression = 4). FACT-G items were rated similarly to those at baseline, with a summed score of 89.83.

Shirley’s response to the treatment satisfaction question “Overall, how helpful was MAC to you?” was “very helpful.” This is consistent with her comments to the therapist throughout the intervention.

The HADS uses a subscale cutoff score of ≥8 to indicate clinically significant anxiety and depression. From the baseline to follow-up assessment, Shirley’s HADS-Anxiety score increased from below to above this cutoff (Zigmond & Snaith, 1983). During MAC sessions, Shirley spoke of her heightened feelings of vulnerability and fear of contracting COVID, as well as frustration at the inability to engage in social and recreational activities that had given her pleasure in the past. The persistent stress of navigating day-to-day life during COVID may have contributed to the increase in her HADS-Anxiety scores from pre- to post-intervention. Alternatively, participating in MAC may have increased Shirley’s anxiety by increasing her focus on her distress. However, this explanation contradicts Shirley’s report that MAC was “very helpful.” In addition, Shirley’s depression score fell below the HADS cutoff at both time points and the change in her quality of life score did not meet the three-point threshold for a minimally important difference (Webster et al., 2003). These findings indicate that Shirley did not experience an overall decline in her mental health, but may have had a specific reaction to the COVID pandemic. However, this explanation cannot be confirmed as the effects of COVID, cancer, and MAC on Shirley’s anxiety cannot be disentangled in the current study.

Melissa

Session 1: Introduction

During the first session, Melissa discussed her mother’s cancer diagnosis and treatment. She focused on her role as a caregiver, the challenges she felt meeting her mother’s expectations, and the significant stress she felt from her job. Melissa and her therapist, R.H., reviewed the content of Session 1, beginning with a discussion of symptoms of anxiety and Melissa’s specific anxiety triggers. She endorsed numerous physical symptoms of anxiety such as neck pain and tension, difficulty staying asleep, and racing thoughts. The primary trigger of Melissa’s anxiety was the belief that she could never do enough for her mother. Further, as the COVID pandemic escalated, Melissa experienced increasing concern over her mother’s health and safety, as well as worry about the impact of social isolation on her mother’s mood.

Melissa also experienced anxiety related to her work. As she described it, she felt compelled to complete all her daily work, a self-imposed and unrealistic expectation. The thoughts driving her work-related anxiety were consistent with those that emerged in her caregiving role. Melissa continuously struggled with the belief that she was not doing enough at work, similar to her thoughts about her role as a caregiver. These thoughts triggered feelings of worthlessness. Further, during COVID, Melissa was required to return in person to her workplace. This produced significant anxiety regarding potential exposure to COVID that directly and negatively impacted her quality of life.

R.H. discussed the significance of identifying anxiety triggers as a means of anticipating future situations that might produce anxiety and developing strategies to prevent or manage anxiety in these situations. The most anxiety-producing trigger for Melissa was weekend visits with her mother which included the (anticipated and real) travel time and tense interpersonal exchanges with her mother. During these visits, Melissa often felt she had upset and disappointed her mother. She would avoid direct communication about problems that emerged during the visit and often left feeling guilty for being angry and concerned she upset her mother. Tangible requests for assistance by Shirley, such as when Shirley asked her to attend a doctor’s appointment, were also triggers for Melissa’s anxiety. She had difficulty prioritizing her mother’s needs and wants which made her feel pressured to respond to all of her mother’s requests. Finally, Melissa had specific thoughts about how well she was meeting her mother’s needs such as “Did I call enough during the day?” and “Did my mother want me to visit next weekend?” These thoughts further exacerbated her anxiety.

Self-care was presented as an important component of caregiver physical and mental health. Melissa endorsed guilt for considering self-care because she felt she should use free time to call or visit her mother. She felt her mother relied on her for emotional support, yet their calls were often draining for Melissa. She was better able to accept self-care to manage work-related anxiety than anxiety related to her caregiver responsibilities. She developed an awareness that she was better able to engage in self-care if someone encouraged and gave her permission to do so and identified a colleague as a possible support for self-care.

Melissa and R.H. also discussed the importance of engaging in enjoyable activities to reduce anxiety, including the importance of modifying an activity to make it feasible to complete. Using MAC worksheets, Melissa identified weekly self-care activities in four areas: physical, emotional, social, and spiritual health. For the practice plan, Melissa chose to focus on physical health, specifically to move more by walking to work and to stand more during the workday. Her initial goals were to set an alarm to stand every 20 minutes during the workday and to walk to work at least 1 day during the week.

Session 2: New actions

R.H. began the session by briefly reviewing the topics discussed during the first session and then discussing Melissa’s practice plan. Melissa had asked a co-worker to stand every 20 minutes with her, which helped her to be accountable. She was not able to walk to work as she had discussed in the first session but was able to recognize that this could be added as a future goal.

Managing Anxiety from Cancer’s second session focused on behavioral practices for managing anxiety. This concept fit with Melissa’s practice plan goals to improve her physical, emotional, and social health. Melissa selected deep breathing and guided imagery to learn during the session. She expressed feeling immediate physical relief from her anxiety during the deep breathing exercise. She noted during the session that hearing the therapist prompts throughout the breathing exercises helped her stay focused. Melissa also noted that she experienced nearly constant anxiety at work associated with thoughts such as I have so much to do.” In hopes of reducing this anxiety, she developed a plan to listen to the MAC deep breathing exercise audio recording for 5 minutes each morning at her desk.

Session 3: New thoughts

During the review of the prior session, Melissa reported difficulty implementing her plan to move more during the day, specifically to walk to work. She stated that she was standing more often during the day but that finding time to walk in the morning was challenging. She was using the MAC audio recordings at work and found they reduced her anxiety at the beginning of the workday and she noticed being more patient with others as a result. However, Melissa still experienced feelings of guilt associated with doing something to care for herself. Psychoeducation around caregiving was provided in response to her guilt to normalize the experience and address it as a barrier to self-care activities.

The third MAC session focused on cognitions that trigger anxiety, starting with education on cognitive distortions and identification of distortions in thoughts. Melissa identified the distressing thought, “if I am not doing something for my mother, I am a piece of shit.” This thought was extremely powerful for Melissa and reflected the core belief of “never being good enough” that she had expressed in earlier sessions. Melissa linked this belief about her inadequacy to her relationship with her father and was surprised by this connection, as she believed she had worked though this issue previously in counseling. The idea that her father still had influence over her thoughts and feelings angered and frustrated Melissa. This presented a challenge; with only one session dedicated to cognitive restructuring, there was limited time to explore these deeper interpersonal issues.

Together Melissa and R.H. reviewed information on thought distortions and identified the thought error of “Mind Reading” as something she experienced. For example, Melissa often believed her mother felt Melissa should be visiting or calling more, which was associated with the identified self-deprecating thought. However, Melissa realized there was no evidence to support this belief about her mother’s expectations and her feelings of worthlessness were in fact related to wanting her father’s approval rather than fulfilling her mother’s requests. Melissa created a less extreme thought than the original, resulting in the modified statement “I have done and continue to do a lot for my mother. I am a good person.” She developed a coping statement, “I am doing the best I can, and that is good enough.” By the end of the session, Melissa felt she had a clearer understanding of the thought, distortion, and meaning. For the practice plan, Melissa decided to work on noticing and examining thoughts associated with anxiety and to record coping statements and modified thoughts. She planned to read the modified thoughts and coping statements as needed.

Session 4: Communicating well

At the next session, Melissa reported using the modified thoughts and coping statements. She reported thinking about that session often during the week and was comforted by knowing that thought errors are normal. She had engaged in deep breathing at her desk as planned three times that week and continued to stand throughout her workday.

The fourth MAC session addressed assertive communication and use of I-statements. Melissa shared her belief that her mother expected her to be available for all medical appointments, despite the fact her mother never made this request. Yet, Melissa’s perception was that she needed to be available at the expense of work and other activities. Melissa also focused on the weekend visits with her mother and her belief that her mother expected her to visit often. Melissa developed I-statements to communicate her needs and wants in these situations. For example, Melissa developed the statement “I feel stressed when I can’t visit because I know how much it means to you. I am often tired on the weekends because work is so busy, and I am not always able to come over as much as I would like.” Melissa planned to use this I-statement with her mother to clearly express her views of visiting her mother.

Session 5: Problem-solving

Session 5 began with a review of the communication practice plan. Melissa reported being proud of her ability to use this strategy. She described using the I-statement format to speak with her mother throughout their recent visit and felt it reduced anxiety for both of them. The use of I-statements also increased her confidence in and comfort with communication with her mother. Melissa stated that she also continued the self-care activity of deep breathing at her desk at the beginning of the workday, which further improved her mood.

Session 5 of MAC focused on problem-solving techniques. Melissa selected the problem of her mother being depressed and isolated. When considering why this was a problem for her, Melissa stated that she felt the need to compensate for her mother’s loss of interaction due to COVID-19 which increased her anxiety about her caregiving role. Building on the previous session, she identified multiple potential solutions including use of an I-statement to convey concern to her mother. Melissa had attempted to discuss this with her mother in the past, but it had resulted in an argument and hurt feelings. The developed statement was “I am concerned about your mental health and want you to feel better because I love you. When I see you staying inside, I worry because I know how important it is to see friends and family.”

The second solution she identified was to ask two other family members to call her mother at a scheduled, consistent time each week. She developed I-statements to guide this discussion and ensure her thoughts and feelings were clearly expressed. These strategies reduced her feelings of anger and resentment and decreased her belief she was solely responsible for her mother’s emotional well-being.

Session 6: Willingness (acceptance)

Melissa began the sixth session by remarking that she experienced improved communication with her mother and that the relationship felt “easier.” The sixth MAC session addressed the strategy of Willingness. Melissa viewed Willingness as a tool to try and gain control over her emotions, which she viewed as a central issue for her. Melissa related this to her relationship with her father and noted this issue prompted her to pursue therapy in the past. She embraced the concept of Willingness as a strategy to disengage from the struggle with her emotions. She imagined her anxiety as an external jagged object that was heavy, and she carried it around in her handbag. She resonated with the image of dropping the rope, symbolic of releasing control, and not putting energy toward feeling anxious. She used this insight to formulate the practice plan. She would notice when she was feeling anxious and then imagine her anxiety as an object she put down the ground and allowed to remain there.

Session 7: Planning for the future

The purpose of the final session was to review MAC strategies and develop a plan for managing future anxiety. Melissa identified an increased ability to notice anxiety in herself and the associated triggers. She identified communication as the most significant and useful strategy from MAC. Melissa felt she had less anxiety related to attending her mother’s medical appointments and that both she and her mother had changed how they communicated with each other. Melissa stated that she valued her increased understanding of the impact of caregiving on her well-being and her relationship with her mother. She expressed a strong desire to continue to build upon and improve those aspects of her life. Melissa also noted that cognitive restructuring was helpful for her. The coping statement she developed in Session 3 was so meaningful that she had typed it, framed it, and placed on her work desk where she would see it every day.

Melissa also reported a shift in perspective regarding the value and importance of self-care over the course of MAC. The inclusion of a self-care check-in at the beginning of each MAC session prompted Melissa to engage in one daily self-care activity. She often cited work responsibilities as a major obstacle to self-care and was able to identify these barriers and strategies for overcoming them. Melissa’s new view of self-care was particularly notable when she began to integrate self-care into her daily work routine by standing every 20 minutes and practicing guided imagery at her desk for 5 minutes. Overall, Melissa stated that while previous therapy had been helpful, the practice assignments and interactive therapeutic style of the MAC intervention was enjoyable and productive.

Assessment of progress

Melissa’s baseline HADS score was a 3 (HADS-Anxiety = 3, HADS-Depression = 0), reporting only minimal symptoms. On the QOL scale, Melissa scored an 89 (in the moderate range, with the highest possible rating a 140). Melissa responded “Very much” on statements such as “I fear my loved one will die” and “I fear the adverse effects of treatment on my loved one.” Melissa additionally rated a “Quite a bit” for the comment “the need to manage my loved one’s pain is overwhelming.”

At the conclusion of the intervention, Melissa scored a six on the HADS (HADS-Anxiety = 5, HADS-Depression = 1) and her QOL score decreased to 85. Melissa responded “very helpful” to the question “Overall how helpful was MAC to you?”

At both time points, Melissa’s anxiety and depression scores fell below the cutoff for clinically significant distress, indicating low and stable distress levels over time. The maintenance of this low distress is notable given the stress Melissa reported due to impact of COVID on her work-life and concerns about her mother’s risk of COVID infection. While we cannot confirm, MAC may have prevented increases in anxiety related to these stressors. Clinical cutoff scores and estimates of clinically meaningful change are not available for the Caregiver Quality of Life-Cancer scale. However, Melissa’s scores were consistent with scores reported in the literature and the four-point change she reported is well below published SDs for the scale that range from 16.3 to 24.7 (Weitzner et al., 1999). These findings suggest that despite the negative impact of her caregiving responsibilities and the COVID pandemic on her daily life, Melissa’s distress and quality of life remained stable. Multiple factors may have contributed to this stability, including that MAC prevented exacerbations of distress and worsening quality of life. However, it is also possible that the low baseline levels of anxiety reported by Melissa did not allow for notable improvement over time.

8 Complicating Factors

COVID-19 Pandemic

While the effect of the pandemic on anxiety was not measured directly in MAC, the impact should be considered. The duration of the pandemic, the effort required to sustain coping mechanisms and manage anxiety over time, limitations on socializing, increased work demands and frustrations as well as increased concerns over one’s health likely contributed to and further increased patient and caregiver anxiety. Further, caregivers were unable to be physically present during procedures, treatments, and doctor visits as they were in the past, thereby increasing their feelings of helplessness and reducing patients’ access to important social supports.

An unanticipated benefit of this telephone-delivered therapy was the ability to work with Shirley and Melissa during the COVID-19 pandemic. For older adult cancer patients with compromised immune systems and medical comorbidities, the restrictions on social and recreational activity due to COVID-19 further limited their ability to receive functional and emotional support from family and friends. Shirley expressed heightened anxiety about leaving her home simply to take a walk for fear of exposure to COVID-19. The very real risks involved in engagement in activities with others or in public spaces made it all the more challenging to identify activities that could aid in management of anxiety and improve quality of life. Although the MAC intervention could not remove COVID restrictions on activity, telephone delivery maintained Shirley’s access to psychotherapy which allowed for identification of anxiety-management techniques feasible within COVID restrictions.

In addition, Melissa expressed her increased anxiety about her mother’s safety and the impact social isolation was having on her mother’s mood. Melissa’s problem-solving session focused specifically on this concern and identified a new solution that helped her feel empowered to potentially increase her mother’s social connections while adhering to the COVID restrictions and reducing her caregiving burden.

9 Access and Barriers to Care

There were no significant barriers to care during this treatment intervention. As a telephone-based intervention, MAC was easily accessible to Shirley and Melissa. The hard copy version of the MAC manual was mailed to each participant prior to the start of therapy, and audio files connected to the relaxation, guided imagery, and willingness exercises were sent on a computer-compatible CD and by email.

Although not an issue for Shirley and Melissa, time is often a barrier to care, particularly for caregivers who are juggling work and family responsibilities in addition to caregiving tasks. For patients, treatment schedules often include numerous appointments and the symptoms of cancer and treatment effects (e.g., fatigue and nausea) can make engaging in psychotherapy difficult. Remote delivery (i.e., telephone and video conference) of psychotherapy can overcome some of these barriers by eliminating travel to the clinic.

Stigma toward mental health services can also be a barrier to care, particularly for older adults. MAC explicitly normalizes anxiety in order to address possible stigma and increase OAC and caregiver comfort with engaging in mental health services. However, stigma may reduce OAC and caregiver willingness to seek and initiate mental health services. Strategies for reducing stigma earlier in the process of initiating mental health services may increase engagement in effective mental health services, particularly for populations like older adults for whom stigma interferes with mental health treatment (Sirey et al., 2001).

10 Follow-Up

Both Shirley and Melissa concluded their participation with therapists A.S. and R.H. after the completion of the seventh MAC session. As an intervention provided in the context of a randomized controlled trial, there was a pre-determined end to therapy and no post-treatment follow-up. However, it is important to note that the research team offers research participants a referral to psychotherapy after completion of the research protocol. Shirley did not express interest in continuing psychotherapy after completing the study, but Melissa requested a list of providers in her community.

11 Treatment Implications of the Case

This case study highlights the benefits of several aspects of the Managing Cancer in Anxiety intervention, including (1) utilizing a manualized therapy, (2) providing parallel treatment to two members of familial dyad, and (3) introducing a variety of cognitive behavioral strategies for patients and caregivers to use alone or in combination to manage anxiety.

First, treatment manuals offer a systematic approach to psychotherapy interventions. MAC provides a consistent structure and content to cover during each session which seemed beneficial to both Shirley and Melissa. The completion of a practice plan and the anticipation of its review the following week created a sense of expectation and accountability and likely encouraged engagement with the MAC skills in-between sessions.

The acknowledgment of caregiver stress embedded into each MAC session was particularly important for Melissa. Research shows that cancer caregivers report clinically significant anxiety and general psychological distress (Dumont et al., 2006; Rossi Ferrario et al., 2003; Selamat Din et al., 2017). The manual’s focus on self-care during each session validated Melissa’s experience and demonstrated concern for her well-being. The consistent discussion of self-care elevated its importance and encouraged integration into her daily routine.

Despite the structured nature of the MAC manual, the implementation is intended to be flexible to allow the psychotherapist to integrate their own practice style and personality into the administration of the therapy, thereby supporting the development of a strong therapeutic alliance. This flexibility allowed A.S. and R.H. to develop relationships with Shirley and Melissa in a way that promoted effective provision of MAC content.

However, there are therapeutic constraints associated with the use of a manualized treatment that mean certain topics that emerge are not fully explored. For example, during Session 3, Melissa revealed a conflictual relationship with her father, exploring that relationship or its impact on present coping would have been out of the scope of the manual. However, not addressing it at all could have negatively impacted rapport and potentially reinforced a thought error. Therefore, a clinical decision was made to acknowledge Melissa’s insight and then return focus back to the session content, which allowed for preservation of the therapeutic rapport and fidelity to the intervention. However, the interpersonal challenges Melissa experienced with her father were appropriately not explored as there was not flexibility to modify the intervention as one might if this was occurring in a traditional clinical setting.

Second, the provision of parallel treatment to an OAC and caregiver is another unique aspect of the MAC intervention. As previously mentioned, the OAC sessions and caregiver sessions mirror one another week to week and cover the same material with minor customization to address either the OAC or caregiver experience. Therefore, as Shirley was discussing assertive communication strategies with her therapist, Melissa was doing the same with hers. Melissa commented to her therapist that she noticed a change in the way both she and her mother communicated with each other, stating it was “easier” and they were using the same “language” that was acceptable to both of them.

Of note, the OAC’s therapist and the caregiver’s therapist did not communicate with one another as was indicated in the MAC protocol. This aspect of the MAC structure has both benefits and drawbacks. This protocol ensures maintenance of confidentiality between the two participants and protects against the possibility of one therapist’s perspective influencing the nature of the intervention of the other. In addition, patients and caregivers could withhold information from their therapist if there was concern that discussions would be revealed to the other dyad member. However, by prohibiting communication between the two therapists, the therapists are unable to collaborate in ways that might benefit both members of the dyad as well as the dyadic relationship. For example, not until the development of this case study did Shirley and Melissa’s therapists discuss this dyad and in doing so discovered how very differently each participant perceived their role and circumstances. Throughout the course of the intervention, Shirley only minimally spoke about Melissa, Melissa’s caregiving role, and her expectations of Melissa. Rather, Shirley discussed problems associated with medical visits, communicating with her oncologist, and fears of recurrence. It was therefore of great interest when Melissa’s therapist revealed that Melissa talked often about her relationship with her mother, her expectations of herself as a caregiver, and her imagined expectations of her mother.

Finally, each MAC session introduces a new therapeutic technique; this approach allows the clinician to teach a range of anxiety-management tools in a short period of time. Patients and caregivers are encouraged to practice each technique to gain familiarity and integrate the concept into their daily lives. For example, Shirley reported that deep breathing exercises learned in Session 2 were helpful and she used them weekly while learning other new strategies. She also expressed an affinity for cognitive restructuring in Session 3 and independently constructed coping statements and modified thoughts for anxiety-producing situations in subsequent sessions. When discussing problem-solving steps in Session 5, both deep breathing and the use of alternative thoughts were pieces of her problem-solving plan. Having multiple tools at her disposal allowed her to apply techniques in different combinations to optimize their impact.

While the model of teaching new strategies each week provides a range of anxiety-management strategies, it also potentially increases the risk of material being siloed from session to session. An experienced clinician and/or an insightful participant can integrate themes and skills discussed in previous sessions into each week’s new material. Further, while the intent of MAC is to introduce OACs and caregivers to an array of anxiety-management strategies, the scope of topics covered prohibits an in-depth exploration of each technique. For example, it can be therapeutically challenging to cover a topic as broad as cognitive restructuring during a single session. For Melissa, Session 3 opened up deep feelings and negative core beliefs. Melissa stated at the time that it was a difficult session. MAC does allow time to review and revisit previous material in depth; for Melissa, it may have been beneficial to have had more than one session dedicated to cognitive reappraisal techniques and the core beliefs that emerged. However, for Melissa and other MAC participants, this initial exposure to cognitive behavioral strategies may prompt engagement in longer-term psychotherapy following completion of the MAC sessions.

12 Recommendations to Clinicians and Students

The authors encourage clinicians and students to consider manualized treatments when conceptualizing treatment strategies for your patients. MAC was developed and implemented as part of controlled trial, but the application of this intervention demonstrates how treatment manuals can be of value in clinical practice. A well-designed manual may provide a structure to treatment that keeps both the participant and therapist focused on treatment goals.

However, manualized therapies are sometimes viewed as a one-size-fits all model that does not allow for individualization for the patient and caregiver or the style of the treating therapist. Yet, clinicians who have exposure to and experience with treatment manuals appear to have more positive views about their use than those without prior experience (Forbat et al., 2015), suggesting that experience may reduce these concerns. Further, training in the intervention also influences the use of and comfort with a manualized therapy. Both therapists from this case study are experienced clinicians who underwent thorough training and supervision with the psychologist who developed the MAC intervention; comfort with the material gave the therapists the freedom to adhere to the structure of the manual without being stifled in their approach. Concerns that use of a therapy manual may undermine a clinician’s artistry have been deemed unfounded (Forbat et al., 2015; Wilson, 1996). The experience of the therapists in this case study is consistent with these findings in that the therapists were able to adhere to the manual while using their unique style to develop rapport and individualize MAC for each patient and caregiver.

Footnotes

Acknowledgments

We thank Simon Cohen and Chrystal Marte for their assistance with recruitment and project management.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This research was funded by the National Institute on Aging and American Federation for Aging Research (K23 AG048632, Trevino).

ORCID iD

Amy Stern

Author Biographies

Amy Stern, LCSW-R is a senior clinician at Weill Cornell Medicine’s Institute of Geriatric Psychiatry and an interventionist at Memorial Sloan Kettering Center’s Department of Psychiatry and Behavioral Sciences. She is involved with research on the use of psychosocial interventions for the treatment of depression and anxiety in older adults.

Robin Hershkowitz, LCSW-R is an Assistant Professor of Psychiatry at New York Medical College and an interventionist at Memorial Sloan Kettering Center’s Department of Psychiatry and Behavioral Sciences. She is involved with research using psychosocial interventions for older adults with cancer focused on reducing physical and psychological symptoms of distress.

Kelly M. Trevino, Ph.D. is an Associate Attending Psychologist and co-Director of the Psycho-oncology of Aging and Cancer laboratory in the Department of Psychiatry and Behavioral Sciences at Memorial Sloan Kettering Cancer Center. Her research examines the efficacy of interventions to improve distress and advance care planning in patients and caregivers.

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