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When the POS psychologists were asked about particular forms of therapy they used for clients with different cancer types, all reflected that they used an “eclectic approach”, making use of specific aspects of different therapies to suit the client’s identified needs. This was similar to the comments made by psychologists surveyed by Weiner et al. (2012) in which they reflected using a range of therapies. The POS psychologists did not make therapy distinctions between the needs of clients with different cancer types, rather they reflected that they treated clients as individuals with unique therapeutic needs.

P2 talked about the challenges that the referrers unintentionally introduced to the Service where they would be unaware of what was possible to accomplish in specific periods of time.

So a couple of things come to mind …. one of those is the, the fact that

sometimes the expectations of the referrers…, or our perceived expectations is a little difficult. So sometimes, . for example somebody with a phobia like a

claustrophobia or a needle phobia will be referred .. like the week before they have their treatment. So with the traditional CBT approaches … they take sort of like months to work and yet we’re expected to deliver. ….that was particularly difficult as a new service, ..they (referrer) hadn’t had psychologists involved at all before, so they didn’t know and we were also trying to show that we were useful…….. which was um, a challenge both, both to the Service, and to us as psychologists and to us as people …. it’s always nice to be able to deliver, so that’s been the reason why um, [psychologist] and I have um explored things like hypnosis ….. looking for, for techniques to take, take on those challenges you know, because there are some other techniques which can speed those processes up….. (P2)

At the time when POS was a new Service P2 expressed feeling additional stress to deliver good outcomes for clients referred and subsequently this resulted in POS psychologists looking at alternative evidence supported approaches to usual therapies. This need for additional training was also reflected in Weiner et al.’s (2012) survey of paediatric psycho-oncologists.

One identified challenge was that some clients took the opportunity to use the Service to deal with unresolved personal issues not directly related to cancer. This was similar to findings by Salander (2010) in which it was identified that one of the most common reasons for seeking counselling for cancer patients was the desire to discuss interpersonal relationships not obviously related to the cancer diagnosis.

P2 explored the challenge of recognising that once a client is seen at the Service there are times when previous issues, unrelated to their cancer, come to the surface and are impacted by or impact on their illness. They accepted that the need to continue sessions beyond the six expected is considered a balancing act.

….so ours is a short to medium term service yeah, I describe it as a wee bit like digging a hole in the sand right and when you dig a hole in the sand um, more sand pours into the hole and um you’ve got to dig a slightly bigger hole to stop, to get a degree of solidity, to stop the sand building in, er pouring in and so that then becomes a difficult judgement. So, our service is there to deal with cancer related distress um. but … people do come along with on-going issues, so they might come along with a marriage issue which has actually been there for quite a while, it’s just flared up now um, or they might come along with some distress now but actually that’s based on um ways of being which have been around for quite a long time and um you can’t just get in there and do the two, three session fix you know, just listening and, and a chance to talk isn’t just what that person needs…. so while our service averages around six to seven sessions you know, each of us have clients which have, sort of gone well beyond that, …you know that’s that balance isn’t it, ..we’re in this to help people um so we want to stay

around and help people um we, we don’t want to finish with somebody and just have them fall over again in a month’s time and come back, so, we need to stay in there but at the same time, every six sessions we spend with that longer person, time person, there’s another person who might not get to access the service, so it’s that constant weigh up, so you’re doing it as a service. (P2) This clinician remarked on the feeling that other issues unrelated to cancer cannot be totally ignored, especially when failing to deal with them may exacerbate on the present illness or prevent them dealing with it. This is important given that research has indicated that when life stressors or negative events, co-occur within a year, there is an increased possibility of exacerbated illness, disability or death Thoits (2010).

P1 also remarked on the challenge of clients who clearly have major historical life issues such as domestic violence and the difficulty of knowing that the issues they bring are not directly related to cancer but that sometimes there can be no other agencies for them to access the help they need. In such a case helping the client becomes the priority rather than applying the Service client criteria.

Basically, though, there are a lot of people who are only just hanging on for whatever reason, and then cancer comes along. And all the other things that were happening beforehand, which were just being managed, or sometimes not being managed very well, becomes much, much bigger, and much, much more difficult to handle. So, um, I guess the way I figure it out, if the current

functioning is cancer related or not, is to look for well what were you like before the cancer came along? What was going on in your life? But it’s a real grey area, it’s not always easy to figure out. um you know, and cancer’s sometimes the straw that breaks the camel’s back, you know in terms of managing

something into not managing at all. I guess the pre-functioning, the pre-cancer issues, make dealing with the cancer very, very difficult. So in order to be able to manage the cancer better it’s very hard not to look at those pre-existing issues, because otherwise you’re just skimming the surface, and you’re kind of doing a superficial patch-up job basically. ….So sometimes with the really well functioning prior to the illness... you can see the effect that it’s had and chosen a

more discrete way. So those are the six therapy session people who are actually are quite ….it’s ah manageable yeah, yes, it more clear cut, .and then you’ve got these really, really messy situations, it’s just all the on-going things for a very long time. If I had said strictly, domestic violence, emotional abuse, is not cancer related, I really wouldn’t have made any difference. (P1)

All clinicians reported using the ORS as a guide to when it was time to end therapy with a client but also felt that it was a mutual decision. P2 reflected that recognising when to end therapy can vary and that they used a variety of outcomes to recognise when no further therapy would benefit the client. This reflects an element of doing POS work in that you do what you have to in the time available to do it.

…sometimes the client just decides it’s time to end therapy, so they say, yep that’s good, got enough, sometimes um, it’s just about um, that they live out of the area and so they, they’re going home. Um, I use the outcome rating scale a lot and so, um myself and the client are looking at progress over time and um you know, the, the scores means and stuff and so when they get into an area which suggests they’re operating um similarly to um, to the rest of the population then it’s, it’s a sign but often they, they’ll be talking about it you know and you can see the change in the way they’re sitting and they’re talking about, you know, no longer feeling anxious or their mood improved or become more active or that their problems with the family have resolved and, and so it becomes quite evident um that, that the problem that they came for isn’t a problem anymore, …… people come with an issue and you work on the issue and then the issue isn’t an issue any more, yeah it’s time to move on, I mean it’s not time to look for another issue. (P2)

P1 expressed finding the ORS useful in helping to identify the appropriate time to end therapy however, they noted that because of the nature of cancer, a client can be seen to be doing well but then there may be a reoccurrence or progression of the cancer creating additional distress. A recurrence of cancer where there had been positive

expectations of cure can create distress that is similar or greater than that at first diagnosis (Stein et al., 2008; Vivar, White & McQueen, 2005).

That is something else that I struggle with. Um, and I think that, I try to go on ORS as much as possible. Um, the number of times that I’ve got to a point that I’ve thought they’re [client] functioning really well, and then there’ll be some set-back, and everything just crashes again. … That’s happened to me a number of times, and it’s been around people who’ve been in remission and their

cancer’s come back, and it’s not looking good at all, and they’re highly

distressed about it. Um, I think that mmm, that’s happened a number of times, with me…. (P1)

The POS clinicians identified a number of challenges they experienced

identified within therapy and the therapeutic process. These were what issues to focus on when non-cancer problems arose and also when to end therapy given that cancer is a long term condition which can have significant changes in its course.