This transcript is about psychosocial distress and cancer survivors and includes sample conversations between Dr. Flores and his patient, Ellen.
Distress screening tools are an important part of care for cancer survivors. Medicine has come a long way in treating cancer and increasing survival rates. While health care providers routinely address the physical health needs of cancer survivors, their psychosocial concerns associated with cancer are often overlooked. We find that some patients don’t volunteer this information to their providers, as they may have reservations about discussing mental health. You might have heard patients say something like, “my problems aren’t that bad, I don’t need help.” or, “I don’t have time to see another doctor. Furthermore, many health care providers are not assessing their patient’s psychosocial concerns. In fact, a third or fewer cancer survivors have had a discussion initiated by their doctors about psychosocial needs and concerns, and fewer are receiving treatment for distress.
Caring for both the mental and physical health needs of patients is critical for better medical outcomes. Patients’ mental health concerns can impact their ability to adhere to medical care and surveillance recommendations, not to mention their overall quality of life. Patients have better outcomes when their psychosocial concerns are addressed; such as fewer physical symptoms, improved functioning, and better treatment results.
This is why distress screening is so important—screening helps to identify your patients’ distress symptoms and distress level, and guide them to appropriate care. Today, you’ll learn about how you can use distress screening to help support your patients.
First, let’s define what distress looks like in relation to cancer survivors:
The National Comprehensive Cancer Network defines distress as a “multifactorial unpleasant emotional experience of a psychological (cognitive, behavioral, emotional), social and/or spiritual nature that may interfere with the ability to cope effectively with cancer, its physical symptoms, and its treatment.”
Distress is on a continuum, ranging from mild to severe, and can include symptoms such as fear, sadness, anxiety, depression, panic, and stress reactions related to posttraumatic stress disorder. When combined with post-treatment neurocognitive challenges, financial issues, lack of support system, and challenges at work, any of these distress symptoms can negatively impact a patient’s overall being and health outcomes. Keep in mind that psychosocial concerns will differ depending on a number of factors, like a patient’s age, and medical and psychological history.
Distress screening is a useful way to start the conversation about your patient’s experience and concerns. When you’re choosing screening tools, it’s critical that they’re standardized and validated, have appropriate cut-off scores, and are appropriate for your patients and your setting. And while screening results are NOT diagnoses, they DO provide useful information, help you decide when to monitor and when to intervene, and give you an “in” to discuss the patient’s experience.
The insight you gain from a distress screening can also help you suggest appropriate referral needs. Your patients may have different referral needs depending on their level of experienced distress. Patients with minimal distress may only need psychoeducation or patient-patient support. Patients with severe distress may benefit from: crisis intervention, professionally lead support groups, or psychotherapy/pharmacologic treatment.
Remember to work with your patients to find what works best for them. You and your team also should be prepared to address insurance concerns and have resources available to explain different referral options.
It is important to implement routine distress screening for cancer survivors using established standards and practice guidelines. The United States Preventive Services Task Force recommends depression screening for all adults. The National Academy for Science recognizes routine distress management as the new standard in quality cancer care. The National Comprehensive Cancer Network has guidelines for distress management, and the American College of Surgeons Commission on Cancer has new standards for cancer centers that include recommendations for distress screening.
National Comprehensive Cancer Network’s Standards of Care for Distress Management:
This is a transcript of one conversation between Dr. Max Flores and his patient, Ellen Grunberg, about her psychosocial concerns. Ellen finished colorectal-cancer treatment a year ago and is seeing Dr. Flores for a follow-up cancer screening. While in the waiting room, Ellen completed a distress screening tool that indicates moderate to severe levels of distress over this past week. Dr. Flores’ goals today are to discuss the results of the distress screening tool with Ellen, and work with her on a plan to address her indicated psychosocial concerns.
There are a few communication techniques Dr. Flores can use to help Ellen feel more comfortable discussing her distress. Generally, these can also help providers make effective referrals and keep the discussion concise to make a good use of time.
Ask Ellen about her screening with Open Ended Questions to elicit more details and better understand her experience.
To share information respectfully, use Ask-Tell-Ask. First, ask for permission or ask what Ellen already knows. Then correct any misconceptions, share anything new, and follow up with a question to hear her reaction.
Summarize what Ellen says and Reflect it back to her without judgment. This helps her process her thoughts and feel heard.
Finally, Normalize Ellen’s emotional experience as well as, the need for a the need for a referral, and Share Actionable Information to help Ellen feel capable of change.
Dr. Flores: Thank you for waiting while we got those test results.
Ellen: No, thank you for being flexible about rescheduling the appointment. Work’s been crazy. We pushed an update for a client’s app the night before and I… I messed something up so… there was a lot of scrambling around that day.
Dr. Flores: (warmly) Sounds stressful. I hope everything worked out.
Ellen: It did. Eventually. (pause) So… What’s the news.
Dr. Flores: The results of your colonoscopy are normal. One year out, and you are still cancer-free.
Ellen: Oh thank God… (sigh of relief) Feels like my palms have been sweaty all week.
Dr. Flores: You can relax now. No more sweaty palms.
Ellen: Yeah I guess.
Dr. Flores: You don’t seem happy about it.
Ellen: No, I am. These visits just - there’s a lot of build up. It’s… draining, getting mentally prepared.
Feedback: Reassuring patients is important, but encouraging Ellen to relax assumes that her test results were the only reason she was nervous. Dr. Flores should try to be more specific so as not to come off as dismissive of Ellen’s feelings.
Dr. Flores: Regarding those nerves, we need to talk about your mental health screening.
Ellen: Okay, that’s - I didn’t think that’s why I was coming in today.
Dr. Flores: It’s worth taking a couple of minutes to talk about the distress screening even if we didn’t plan on it.
Ellen: Um… sure.
Feedback: Mental health can be a sensitive topic. Instead of setting the agenda of the conversation, Dr. Flores should ask for permission to discuss the screening. This allows the patient to guide the conversation based on their comfort.
Dr. Flores: Your scores indicate that you’re very anxious.
Ellen: I - I don’t think so. I mean, I was just… I didn’t think that thing was important, or… that we’d be talking about it, but… Is this like a formal diagnosis?
Dr. Flores: I’m not making a diagnosis yet. That’s why I want to talk with you about it.
Ellen: It’s just doctor-visit-anxiety, worrying about health. There’s nothing to talk about.
Ellen Thought: He wouldn’t understand even if I got into it all.
Feedback: Calling Ellen “very anxious” made her defensive. Patients may react poorly to anything that could be perceived as labelling. A better tactic is to focus on specific, objective observations.
Dr. Flores: The assessment you completed today shows more signs of distress than the last time you came to see me.
Ellen: Really? I mean… What does that mean, “more?” How much more?
Dr. Flores: Well, you reported increased difficulty sleeping, trouble staying focused, and you circled work and family as contributing factors.
Ellen: I don’t know, I mean… (almost more to herself, trying to think it through) It’s weird… I honestly don’t even remember filling that form out.
Dr. Flores: You sound surprised. Anything different in your life?
Ellen: Maybe… I don’t know… I have more time to think. When I was going through treatment, everything was “Go! Go! Go!” I was on autopilot. I don’t know if this makes sense, but… I was too tired to have the luxury of worrying all through the night.
Dr. Flores: Instead of thinking of the free time as stressful, think of it as an opportunity. For example, you could pick up old hobbies that maybe went by the wayside when you started treatment.
Ellen: I started bowling again. That’s fun.
Dr. Flores: That’s great.
Ellen: (shrugs, looks down - not hopeful) I guess.
Ellen Thought: Not like it shuts my mind up or helps me sleep though…
Feedback: Telling patients to “look on the bright side” can be dismissive. Ellen felt like Dr. Flores was diminishing her struggles. Validating a patient’s emotions, even if it isn’t how you would view things, increases their comfort.
Dr. Flores: How does worrying affect your engagement in day to day life?
Ellen: I don’t like worrying if that’s what you mean.
Dr. Flores: Does it ever get in the way?
Ellen: I don’t know if this is what you’re getting at, but my husband and I were watching our favorite show, “Vortex,” and I realized half-way through that I had no idea what was going on in the episode. I mean, I was there, on the couch, with my husband, but my mind was somewhere else. He tried explaining what I had missed, but that wasn’t the point? It’s funny. It’s like the plot of the show - I’m in the same house as my family, but in another dimension.
Dr. Flores: Since you’re not getting support at home, you could consider seeing a counselor.
Ellen: I didn’t say I’m not getting support at home. My family is very supportive. I don’t need a therapist.
Feedback: While you might already know the best referral option for your patient, you should wait until they confirm they want the support. Otherwise, your suggestion could come off as pushy.
Dr. Flores: On the screening form, you mentioned having difficulty sleeping. Would it be alright if we discussed your sleeping habits in more detail?
Ellen: I guess.
Dr. Flores: How many hours are you sleeping each night?
Ellen: I don’t know…maybe about four, five hours at most? I try to get in bed by 11 ’cause I have to be up at by six for work. But most nights I feel so restless and spend hours either lying in bed and staring at the ceiling or… getting up, walking around…
Dr. Flores: Are your sleep patterns the same or different than before your cancer diagnosis and treatment?
Ellen: Hmmm… Before my cancer diagnosis, I used to sleep like a rock. (quickly, almost more to herself) My head would hit the pillow, next thing I know my alarm is going off in the morning. But now? I feel so restless I spend hours either lying in bed and staring at the ceiling or… getting up, walking around…
Dr. Flores: What are you thinking about when you’re staring at the ceiling or walking around?
Ellen: These screenings, and… I go down these rabbit holes of what would happen if the cancer comes back. Or I think about work and what would happen if I lost my job and I start to actually feel sick. My palms get sweaty my heart gets going, my breathing is… (talking it out, she’s not sure how to describe it) Tight? Short? Both?… My husband tries to help - he’ll tell me to calm down, but that gets me more worked up… I don’t know, it’s hard to talk to him about this stuff, he doesn’t get it. As long as I keep busy, though, it’s fine. That’s why I went back to work so quickly.
Dr. Flores: Being more open to your husband’s attempts to help could lower your stress levels. If he’s not great at talking about your stress, one thing that could help would be letting him pick up tasks around the house that overwhelm you.
Ellen: Cooking and cleaning aren’t what’s keeping me up at night.
Dr. Flores: It’s all the things you listed on the form - stress at work and family relationships.
Ellen: And I don’t think my family can do anything about that. I just have to deal with it on my own.
Feedback: Telling Ellen to be more open to her husband is not an helpful approach. Although Dr. Flores may feel like he’s giving good advice, he is accidentally assuming things Ellen hasn’t expressed yet. Instead, he should reflect on what Ellen is feeling.
Dr. Flores: You’ve mentioned work a few times now. You started back working full time pretty soon after treatment. That was really brave of you to dive in so quickly. Tell me how that’s going.
Ellen: I love it, and it’s important for the family, but I will say this - coding is harder than it used to be. They said I might have difficulties with doing things due to the treatment I had, but I didn’t think… Sometimes, I stare at my computer screen, and I just… don’t have the clarity I used to. I sometimes have difficulty remembering how to write code that came to me so easily before. But I need to be there.
Dr. Flores: I find with most of my patients it’s probably not as bad as it feels to them. I’m sure no one else has even noticed the difference.
Ellen: Well, it feels pretty different than the old me.
Dr. Flores: I didn’t know you before treatment, but I’m sure that’s not the case.
Ellen: (semi-sarcastically) Thanks.
Feedback: Saying “it’s probably not as bad as it feels” implies Ellen’s feelings are incorrect. Dr. Flores should try normalizing Ellen’s experience to make her feel more comfortable.
Dr. Flores: Your family would understand if you couldn’t work anymore.
Ellen: (semi-sarcastically) You’re right that I shouldn’t worry about that. I should just stop worrying.
Dr. Flores: I only mean that they would support you the way you said they did before.
Ellen: I know they would. I don’t want them to. I want things to go back to… I don’t know. Normal…like here’s a thing that happened - I was making lunch for my daughter Kat the other day and we got into this whole thing about how I cut the bread wrong which somehow led to a fight about the kind of tuna I bought, which… it’s dumb, but that never would have happened before. See, she started making her own lunches when I was going through treatment, and… I don’t know. It’s just bread, it’s just tuna, but… It left me feeling like… I don’t know.
Ellen Thought: She grew up while I was in treatment. I can’t take care of her like I used to.
Feedback: Although reassuring a patient is important, it can be unintentionally dismissive. Dr. Flores should focus on reflecting Ellen’s feelings back to her rather than disagreeing with what she’s saying.
Dr. Flores: Based on all these stressors, you’re saying you could use mental health treatment.
Ellen: Okay… that’s a pretty big conclusion to jump to…
Dr. Flores: Anybody with as much going on as you’ve told me about could benefit from mental health treatment. I’d like to talk to you about it.
Ellen: (annoyed, but not wanting to argue it) Okay. Yeah. Fine.
Feedback: Dr. Flores came across like he was making assumptions about what Ellen wanted. It’s important to remember that she should control the flow of conversation. Dr. Flores has taken the time to review Ellen’s distress, and she seems open to hearing options for further treatment. With his new understanding of Ellen’s mental health, it’s time to pivot toward discussing potential options and forming a more concrete plan.
Dr. Flores: Medication could help with some of your anxiety. It’s worked for my other patients.
Ellen: I can’t do meds.
Dr. Flores: Are you worried about the side effects?
Ellen: That and… I had a colleague who went through a whole… thing. Trying to find the right medication, the right dosage, constant mood swings… He’d go from being okay to being really out of it, missed deadlines… I just can’t do that.
Dr. Flores: Okay… you could try therapy.
Ellen: Therapy… I don’t know… Feels weird. And the last thing I need is my boss thinking I’m not fit to work because I’m leaving an hour early to lie on a couch and talk about my “issues.”
Dr. Flores: Going to therapy can be uncomfortable, but no one would know.
Ellen: But if they did find out… (shifting gears) Actually, now that I think about it, I’d have to tell my family, and then that’s just another thing proving I still don’t have my stuff together. I’m not above getting help, but…I have plenty of people I can talk to if I want. I re-joined my old bowling league. I go out with my friends. It’s nice.
Dr. Flores: Your friends are a good source of support right now.
Ellen: I don’t feel like I have to talk and explain myself all the time, I can just listen if I want to. When I’m in a moment at home and my husband sees it and he’s trying to help me calm down, it feels like there’s this… spotlight on me. Like it’s “snap your fingers and make everything better.” Hearing my friends talk about their own issues and insecurities and everything else, it… kinda helps me think about myself.
Dr. Flores: Based on what you say you’re looking for, I’m going to recommend group therapy.
Ellen: (not wild about the idea) Um… really?
Dr. Flores: What’s your hesitation?
Ellen: I don’t know, I just… don’t really know how that works.
Feedback: By jumping straight to recommending group therapy without clearly laying out the benefits for Ellen first, she doesn’t see how it may benefit her. Getting her buy-in by reflecting her own reasons for wanting treatment can help her feel more comfortable.
Ellen: Listen, I get you’re trying to help, but… I don’t really have time for this, and I need to get back to work. Anything else I need to know as far as… the cancer screening?
Dr. Flores: Nope.
Ellen: Great, so… see you next time.
That was a sample of the conversation. Here is some feedback on what could have gone better.
Dr. Flores struggled to make Ellen comfortable discussing the results of the distress screening and the referral. As a result, Ellen was not interested in seeking psychosocial support.
While Ellen was comfortable discussing the distress screening, Dr. Flores could have used more open ended questions and asked for permission to further increase her comfort. When patients feel like you have an agenda, they may be less likely to share information.
Dr. Flores made Ellen comfortable discussing her stressors by normalizing and reflecting her experience. However, he also made some assumptions and invalidated Ellen’s experience. This made her less willing to share.
Ellen was less willing to discuss referrals because Dr. Flores insisted she need support rather than reflecting and summarizing Ellen’s experience to her. Additionally, Dr. Flores used leading language and accidentally stigmatized the need for mental health support. Next time, Dr. Flores should not push a certain referral option without asking for permission and reflecting Ellen’s experience.
When Ellen is ready to pursue the referral, Dr. Flores should provide actionable information to increase the chances of Ellen following up.
To hear a more successful conversation with Ellen, listen to the next example.
Dr. Flores: Thank you for waiting while we got those test results.
Ellen: No, thank you for being flexible about rescheduling the appointment. Work’s been crazy. We pushed an update for a client’s app the night before and I… I messed something up so… there was a lot of scrambling around that day.
Dr. Flores: (warmly) Sounds stressful. I hope everything worked out.
Ellen: It did. Eventually. (pause) So… What’s the news.
Dr. Flores: The results of your colonoscopy are normal. One year out, and you are still cancer-free.
Ellen: Oh thank God… (sigh of relief) Feels like my palms have been sweaty all week.
Dr. Flores: I’d like to talk a little more about that. Can I explain the distress screening you filled out in the waiting room?
Ellen: Um… I guess.
Dr. Flores: We have everyone fill out the distress screening form as a routine part of patient in-take, to help us identify how our patients are feeling and functioning. Socially, at work, at home… How things are going, essentially. Which then allows us to make recommendations to help our patients live happier, healthier lives. We spend a lot of time caring for our patient’s physical health, but caring for their mental health is equally important. How do you feel about that?
Ellen: Oh, that’s - okay. Is something wrong?
Ellen Thought: Great, something else to worry about… How can I get out of this?
Dr. Flores: Some problems you reported experiencing on the form indicate you may be experiencing increased distress. What do you think of that?
Ellen: Well… (taking it in) Okay, but… “Increased Distress,” that sounds so… something. It’s not like I’m… (she makes a gesture, searching for the words, then gives up) I don’t know. I feel weird talking about this. I’m just concerned about my health - the usual stuff when I have a doctor visit.
Feedback: Though Ellen is hesitant to discuss distress at this point, this was the right approach. Sometimes mental health can be an off putting topic for patients. Focusing on the objective facts of the screening without using labels like “anxiety” can make the topic more approachable for patients.
Dr. Flores: The assessment you completed today shows more signs of distress than the last time you came to see me.
Ellen: Really? I mean… What does that mean, “more?” How much more?
Dr. Flores: Well, you reported increased difficulty sleeping, trouble staying focused, and you circled work and family as contributing factors.
Ellen: I don’t know, I mean… (almost more to herself, trying to think it through) It’s weird… I honestly don’t even remember filling that form out.
Dr. Flores: You sound surprised. Anything different in your life?
Ellen: Maybe… I don’t know… I have more time to think. When I was going through treatment, everything was “Go! Go! Go!” I was on autopilot. I don’t know if this makes sense, but… I was too tired to have the luxury of worrying all through the night.
Dr. Flores: It’s common for patients to have difficulty adjusting to life after treatment.
Ellen: Really?
Dr. Flores: Absolutely. I hear that all the time. Patients who’ve been diagnosed with and treated for cancer will report having trouble sleeping, trouble staying focused, and… experiencing changes with their families and other relationships.
Ellen: It just feels like… I don’t feel like I should be allowed to complain anymore. Whenever you read those inspirational articles online, they talk about their “second chance at life.” It’s a lot more complicated than that. I’m not even sure how to describe it.
Dr. Flores: Every survivor’s journey is different.
Ellen: Well, my journey involves trying to stay very busy. That’s why I went back to work so quickly.
Feedback: Talking about mental health can be a sensitive topic for many people. Normalizing it is a useful way to put a patient at ease. It lets them know they can open up because they aren’t being judged for being different.
Dr. Flores: On the screening form, you mentioned having difficulty sleeping. Would it be alright if we discussed your sleeping habits in more detail?
Ellen: I guess.
Dr. Flores: How many hours are you sleeping each night?
Ellen: I don’t know… maybe about four, five hours at most? I try to get in bed by 11 ’cause I have to be up at by six for work. But most nights I feel so restless and spend hours either lying in bed and staring at the ceiling or… getting up, walking around…
Dr. Flores: Are your sleep patterns the same or different than before your cancer diagnosis and treatment?
Ellen: Hmmm… Before my cancer diagnosis, I used to sleep like a rock. (quickly, almost more to herself) My head would hit the pillow, next thing I know my alarm is going off in the morning. But now? I feel so restless I spend hours either lying in bed and staring at the ceiling or… getting up, walking around…
Dr. Flores: What are you thinking about when you’re staring at the ceiling or walking around?
Ellen: These screenings, and… I go down these rabbit holes of what would happen if the cancer comes back. Or I think about work and what would happen if I lost my job and I start to actually feel sick. My palms get sweaty my heart gets going, my breathing is… (talking it out, she’s not sure how to describe it) Tight? Short? Both?… My husband tries to help - he’ll tell me to calm down, but that gets me more worked up… I don’t know, it’s hard to talk to him about this stuff, he doesn’t get it. As long as I keep busy, though, it’s fine.
Dr. Flores: Things are different now, and that’s creating new family dynamics.
Ellen: I hadn’t thought of it like that before, “family dynamics”. Like one thing that’s different is just… what I choose to share with my husband. I try not to overwhelm him with every little thing that comes to mind. Which is weird because we used to talk about everything, but… I don’t know, I just… Don’t want to bother him with every little emotion I’m feeling and “what if” that’s going through my head. And I guess I… sometimes avoid, like… anything that may lead to… (awkward pause) Intimacy?
Dr. Flores: What’s making you avoid intimacy?
Ellen: I get really stressed out about my colostomy bag! Like how am I supposed to feel attractive or want to cuddle with this thing always… It’s embarrassing. I hate it. Even at work, I’m always thinking about it, worried it’s going to leak, the sounds it makes, or if people can see it through my clothes…
Dr. Flores: I understand it’s uncomfortable. How often would you say it bothers you?
Ellen: I mean… All the time? At home, at work, in the car… I really don’t want to talk about it if that’s alright.
Dr. Flores: Sure. You’ve mentioned work a few times now. You started back working full time pretty soon after treatment. That was really brave of you to dive in so quickly. Tell me how that’s going.
Ellen: I love it, and it’s important for the family, but I will say this - coding is harder than it used to be. They said I might have difficulties with doing things due to the treatment I had, but I didn’t think… Sometimes, I stare at my computer screen, and I just… don’t have the clarity I used to. I sometimes have difficulty remembering how to write code that came to me so easily before. But I need to be there.
Dr. Flores: That sounds stressful. Sometimes other cancer survivors experience the difficulties you mentioned as a side effect of treatments like chemotherapy. The good news is - there are treatment and supportive services that help them address these concerns.
Ellen: I can handle it as long as I don’t actually lose my job. My boss is already frustrated with the amount of time I had to take off for treatment.
Dr. Flores: Do you have reason to believe you may actually lose your job?
Ellen: No actually, but I think about what that would mean. Like, if I can’t keep up at work, then I might lose my job. If I lost my job, we would have money problems. I already cost us enough money during treatment. I don’t want to cause more issues for us at home.
Feedback: Dr. Flores did a good job normalizing Ellen’s experience. By sharing that others have overcome similar challenges, Ellen feels validated and more open to discussing her concerns.
Dr. Flores: It sounds like it’s really important to you to keep working.
Ellen: Yes! I just want things to be… normal again. It’s hard, keeping everything like it used to be. …like here’s a thing that happened - I was making lunch for my daughter Kat the other day and we got into this whole thing about how I cut the bread wrong which somehow led to a fight about the kind of tuna I bought, which… it’s dumb, but that never would have happened before. See, she started making her own lunches when I was going through treatment, and… I don’t know. It’s just bread, it’s just tuna, but… It left me feeling like… I don’t know.
Ellen Thought: She grew up while I was in treatment. I can’t take care of her like I used to.
Dr. Flores: You have a lot to think about, between difficulties with memory and attention at work, new family dynamics, the stress about recurrence affecting your sleep, and still adjusting to life with a colostomy bag.
Ellen: Huh… I guess I… I’ve never really laid it out there that way before.
Dr. Flores: Sometimes we aren’t always able to process everything we’re going through as it’s happening.
Ellen: Yeah… I just… I don’t know. I kept saying, “Oh this is just how it is now.” or “this will go away, don’t bother anyone with this,” but… I don’t know, maybe it’s not as simple as… you know… “this too shall pass.” (pause) Something my mom always said. (pause) So…
Feedback: By summarizing Ellen’s concerns without judgement, Dr. Flores has shown that he’s listening and that you understand her needs. It’s a great tactic for pivoting the conversation towards discussion of further treatment. You’ve taken the time to review Ellen’s distress, and she seems open to hearing options for further treatment. With your new understanding of Ellen’s mental health, it’s time to pivot toward discussing potential options and forming a more concrete plan.
Dr. Flores: What do you know about how mental health treatment works?
Ellen: My brother did it for a bit, but he didn’t really talk about it. I just remember he complained about getting the time off from work. I guess most of what I do know comes from TV.
Dr. Flores: It’s a little different in real life. The frequency and timing of sessions is something that patients determine together with a therapist. How does that compare to what you thought?
Ellen: That sounds nice, but… I have plenty of people I can talk to if I want. I re-joined my old bowling league. I go out with my friends. It’s nice.
Dr. Flores: Your friends are a good source of support right now.
Ellen: I don’t feel like I have to talk and explain myself all the time, I can just listen if I want to. When I’m in a moment at home and my husband sees it and he’s trying to help me calm down, it feels like there’s this… spotlight on me. Like it’s “snap your fingers and make everything better.” Hearing my friends talk about their own issues and insecurities and everything else, it… kinda helps me think about myself.
Dr. Flores: You have a lot of people you can talk to and you like the social dynamic of a group in particular.
Ellen: Yeah… Of course none of my friends have been through what I’ve been through so there’s that… they can sympathize, but don’t really get it. Sometimes they’ll say things like, “oh, you should just do this,” and “you should do that.” Or, God forbid they start complaining about something like traffic or the latest CA regulation. My eyes just glaze over.
Dr. Flores: You’d prefer having someone who could relate to your experience with cancer.
Ellen: Yeah.
Dr. Flores: I don’t know if you’ve heard of these, but there are cancer-specific support groups which bring counselors and survivors together to work through their collective experiences.
Ellen: Oh. Huh. That actually sounds pretty nice. Still, I don’t have time to research and call twenty different therapists and then the first one isn’t right so I gotta go through the whole thing again and so on and so forth… My insurance might not even cover it…
Dr. Flores: Could I give you a referral for further consultation with our mental health specialist? Dr. Murphy could help you with relaxation techniques and behavioral strategies that could help you with everything we discussed. She could also help you think through changes that you can make to your environment, diet, and physical activity…
Ellen: Sure, okay. It’s either that or I’m heading down the internet rabbit hole.They’re confidential too. Right? Like one-on-one therapy.
Dr. Flores: Yes. You have the option to schedule that consultation with Dr. Murphy now while you’re already here. That way you don’t have to take time away from your week.
Ellen: I would like that. It makes my life easier. The only thing is that my schedule changes pretty unpredictably. We have crunch time at work, and I don’t usually know when those are going to come up until they hit me in the face.
Dr. Flores: Well, if your schedule changes, just call Dr. Murphy’s office and let ’em know. Let’s chat in a few weeks and check-in to see if you’ve made contact with Dr. Murphy. We could do a phone call or email using the patient portal. How does that sound?
Ellen: A phone call never hurt anybody.
Dr. Flores: I think it’s really great that you’re reaching out. It’s not easy asking for help, especially after you’ve finished treatment.
Ellen: Thanks.
Dr. Flores: I look forward to hearing how it goes.
Let’s see why that conversation was much more successful.
Dr. Flores made Ellen comfortable discussing the results of the distress screening and referral options. As a result, Ellen followed up on her referral for group therapy to receive additional support for her psychosocial distress.
Overall, Dr. Flores did well by asking lots of open ended questions, asking for permission, using reflections, as well as summarizing and normalizing Ellen’s experience. Additionally, Dr. Flores avoided making assumptions as well as using leading and stigmatizing language.
These techniques made Ellen comfortable discussing the results of the distress screening, her stressors, and different referral options.
Dr. Flores provided Ellen with actionable information which made her more confident in pursuing the referral for group therapy.
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