Marta is 46 and has four cycles of chemotherapy left. She arrives at her first session with a notebook full of questions she hasn't dared to ask her oncologist, and with one sentence she repeats several times: "Everyone tells me I have to stay positive". She sleeps badly, has been on sick leave for two months and doesn't know what to tell her eleven-year-old son. She doesn't have a mental disorder. She has cancer, and cancer has turned almost everything else upside down. This is the ground psycho-oncology covers.

This guide is for psychologists who work with, or want to work with, people with cancer and their families. It covers what psycho-oncology is, how distress shows up at each stage of the illness, how to assess it with short tools such as the Distress Thermometer, which interventions have support, how to work with the family and the medical team, and how to run a practice where the diary is set by treatment cycles rather than by the client.

What psycho-oncology is

Psycho-oncology is the branch of psychology that deals with the emotional, social and behavioural side of cancer: how the illness affects the person who has it and the people around them, and how those factors shape quality of life, adjustment to treatment and the relationship with the healthcare team. It works with patients, with relatives and with the professionals who work in oncology.

The field took shape in the late 1970s. In 1977 the psychiatrist Jimmie Holland set up the first psychiatry service in a cancer hospital, at Memorial Sloan Kettering in New York, and in 1984 she co-founded the International Psycho-Oncology Society (IPOS). The IPOS standard of quality cancer care asks for psychosocial care to be part of routine cancer care and for distress to be measured as the sixth vital sign, after temperature, blood pressure, pulse, respiratory rate and pain.

Today a psycho-oncologist works in hospitals, palliative care units, patient associations and, more and more often, in private practice. In Spain the Spanish Association Against Cancer (AECC) offers free psychological care to patients and relatives, and many hospitals have their own unit. Even so, provision doesn't reach everyone with the same intensity or the frequency some people need, and a good share of psychological support for people with cancer ends up going through practices like yours.

Emotional distress in cancer

Most people with cancer don't meet the criteria for any mental disorder. That doesn't mean they're coping well. Distress is an unpleasant emotional, psychological, social or spiritual experience that gets in the way of dealing with the illness and its treatment. It is seen as a continuum: at one end sit the sadness, fear and worry you would expect after a diagnosis like this; at the other, conditions that do need treatment, such as an adjustment disorder, depression or an anxiety disorder.

The US National Cancer Institute's summary for health professionals on adjustment to cancer, anxiety and distress reports rates of significant distress between 22% and 58% depending on the study, and around 40% when the results are pooled. Put another way: nearly half of patients struggle enough for it to be worth asking, and the other half adjust with their own resources. Telling the two apart is the first job.

Some factors raise the risk: a history of anxiety or depression, little social support, money problems, young children at home, poorly controlled pain or an uncertain prognosis. There is also an idea from the people around the patient that is worth taking apart early: that a good mood heals, or that thinking positively is a duty. There is no solid evidence that a positive attitude changes the course of cancer, and the pressure to be fine usually adds guilt for someone who is already having a hard time.

What changes at each stage of the illness

What worries a person with cancer on the day of diagnosis is not what worries them two years after treatment ends. Psycho-oncology adjusts its goals to each moment.

Diagnosis

The first weeks tend to be a shock: disbelief, fear, a sense of unreality and a flood of medical information that is hard to take in. It is common for the person not to remember half of what they were told in the oncology clinic. What helps here is listening, psychoeducation about normal reactions, sorting out the questions for the medical team and, sometimes, something as concrete as working out together how, and whom, to tell.

During treatment

Surgery, chemotherapy, radiotherapy or immunotherapy bring tiredness, changes to the body, time off work and a life organised around the hospital. Anxiety rises before every scan and every result, which in English already has its own name: scanxiety. The aim is to support adjustment, manage specific symptoms and stop the illness from taking over the person's whole identity.

Survivorship

Finishing treatment doesn't always bring relief. Many patients describe it as stepping off a moving train: the medical team is no longer there every week, the people around them expect everything to go back to normal, and the physical after-effects, the difficulty of going back to work and the fear of cancer recurrence appear. This is a stage where private practice has a lot to offer, because the hospital is no longer so close.

Advanced illness and the end of life

When cancer can't be cured, the work focuses on symptom control, dignity, meaning, communication with the family and the decisions still to be made. The psycho-oncologist also supports relatives through anticipatory grief and, later, through bereavement, which has its own stages and needs and which we cover in the guide to grief therapy.

Assessment in psycho-oncology: screening for distress

The most studied tool is the Distress Thermometer, from the National Comprehensive Cancer Network: a visual scale shaped like a thermometer that runs from 0 (no distress) to 10 (extreme distress), with a problem list covering practical, family, emotional, spiritual and physical issues. It takes a couple of minutes. In the research, a score of 4 or more is the one that best separates people with clinically significant symptoms of anxiety and depression, and it is the point from which a fuller assessment is recommended.

Other common tools are the HADS (Hospital Anxiety and Depression Scale), designed for people with a physical illness because it doesn't rely on somatic symptoms that the treatment itself can cause, and the PHQ-9 or GAD-7 to track depression and anxiety over time. None of them replaces the interview. Screening tells you who to look at more closely, not what is wrong.

In the interview it is worth exploring what the client knows and wants to know about their illness, their support network, their work and financial situation, worries about children or partner, pain and sleep, alcohol and other substance use, psychological history and, always, suicidal thoughts, which in people with cancer deserve a direct question.

Psycho-oncology interventions with evidence behind them

There is no single technique. The usual approach is to combine several, depending on the stage, the symptom and what the client wants to work on.

Psychoeducation and support

Explaining expected reactions, normalising fear, giving useful information about the process and helping to prepare for medical appointments. It seems like little, and it is often what brings anxiety down most in the first weeks.

Cognitive behavioural therapy

CBT has the strongest support for anxiety, depression and insomnia in cancer patients. It works on worry and rumination, behavioural activation when the person has stopped doing things that mattered to them, problem-solving and relaxation. It adapts well to brief formats and to shorter sessions when fatigue is heavy.

Mindfulness and acceptance and commitment therapy

Mindfulness programmes adapted for cancer and ACT help people live with what can't be controlled, such as uncertainty, symptoms or results that take their time, without it bringing life to a halt. They fit particularly well in survivorship and in fear of recurrence.

Therapies focused on meaning and dignity

In advanced illness there is support for William Breitbart's meaning-centred psychotherapy, Harvey Chochinov's Dignity Therapy and the CALM model (Managing Cancer and Living Meaningfully), which works on symptoms, changes in identity and relationships, meaning and preparing for the end. They don't try to remove sadness. They aim to let the person live the time they have in line with what matters to them.

Couples and groups

Cancer is lived by the whole couple. Joint sessions help with communication, sexuality and sharing out the caring. Well-run patient groups reduce isolation and let people learn from others who are a step ahead.

Symptoms you work on in sessions

  • Cancer-related fatigue. Rest doesn't make it go away. The work covers pacing activity, adapted exercise when the medical team allows it, and the expectations of the client and those around them.
  • Insomnia. Very common and very treatable. CBT for insomnia also works in cancer patients and avoids long-term sleeping pills.
  • Anticipatory nausea. Some people start feeling sick at the smell of the hospital or the sight of the nurse, sometimes days before a cycle. It is classical conditioning and responds well to relaxation and systematic desensitisation.
  • Body image and sexuality. A mastectomy, a stoma, hair loss or weight changes affect self-esteem and sex life, and they rarely come up in the medical appointment. It is worth raising them yourself.
  • Cognitive difficulties. Memory lapses and poor concentration during and after treatment, what many patients call "chemo brain" or brain fog. Validate that they exist, agree compensatory strategies and, if they persist, refer for a neuropsychological assessment.
  • Pain. Pain control is medical, but the emotional side, catastrophising and fear of movement are worked on in session.

Fear of cancer recurrence

Fear of cancer recurrence, the fear that the cancer will come back or progress, is one of the most frequent worries among people who have finished treatment, and for some of them it doesn't ease over time. It shows in constant checking of any symptom, in the weeks before each check-up, in avoiding the subject or, the other way round, in searching for information non-stop.

A little fear is logical and even protective. It becomes a problem when it takes up a good part of the day, stops the person making plans or leads them to book a doctor's appointment for every twinge. There are specific, brief interventions. ConquerFear, developed in Australia and tested in a trial published in the Journal of Clinical Oncology, works over five sessions on attention training, beliefs about worry, acceptance, checking behaviour and values-based goals. Scheduling booster sessions around medical check-ups is good practice: that is exactly when they are needed most.

Family, children and carers

A cancer patient almost never comes alone. The family suffers, cares, wears itself out and sometimes protects so much that it isolates. The so-called conspiracy of silence, the more or less explicit agreement to keep information about the diagnosis or prognosis from the patient, almost always comes from love and fear, but it leaves the patient alone with questions they can't ask. Working on it with the family, respecting the patient's pace and what they want to know, is one of the most delicate tasks in psycho-oncology.

With children, the most common question is what to tell them. The general answer is the truth, adapted to their age: name the illness, explain what changes they will notice at home, make clear it isn't their fault and that it isn't catching, and keep routines going. Children pick up far more than they are told, and silence leaves them imagining worse things.

Main carers are at high risk of overload, anxiety and depression. It is worth asking how they are doing, not just how the patient is, and offering them a space of their own if they need it.

When the patient is a child: paediatric psycho-oncology

With children the work is done with the child and the parents at the same time: preparation for medical procedures, managing pain and anxiety, going back to school, siblings who feel pushed aside and parents holding everything together for months. It usually involves coordinating with the hospital and the school, and consent forms signed by the parents where required.

Coordinating with the oncology team

Doing psycho-oncology from a private practice means talking to the oncologist, the GP or the palliative care unit. A few guidelines that prevent problems:

  • Ask the client for written permission to coordinate with their medical team, and record what information is shared and with whom.
  • Ask about the treatment calendar: the weeks of greatest fatigue or lowest immunity decide whether a session is in person or online.
  • Refer without delay if there are suicidal thoughts, confusion, possible delirium or severe depressive symptoms, which may need a psychiatric assessment or a change in medication.
  • Bear in mind that some drugs and treatments cause symptoms that look psychological: corticosteroids affect mood and sleep, and anaemia or thyroid problems bring tiredness and apathy. When there is a sudden change, ask about medication before interpreting it.

Running psycho-oncology in a private practice

The clinical side matters most, but logistics decide whether treatment holds together. A cancer patient can't fit into a rigid diary, and some decisions are best made from the start:

  • Flexible scheduling. Treatment cycles bring good weeks and bad weeks. Being able to move an appointment without any fuss shows in attendance.
  • Online and home sessions. In weeks of heavy fatigue or infection risk, video sessions keep continuity going. In advanced stages, some sessions can take place at the client's home or in hospital.
  • Variable length. Some days half an hour is all the client can manage, and on others a session with the family needs an hour and a half.
  • A common-sense cancellation policy. Cancelling because of a fever or a hospital admission can't be treated like forgetting. Put it in writing in your therapeutic frame so nobody has to justify themselves.
  • Fees. Cancer often brings sick leave and new expenses. Some psychologists offer reduced fees or session packs to these clients; if you do, set clear criteria. It also helps to tell them about free resources from associations and hospitals.
  • Tighter confidentiality. Health data is a special category under the GDPR, and in psycho-oncology the clinical record holds very sensitive medical information. Keep it in a system with protected access and share only what is essential, with permission.

Looking after the psycho-oncologist

Accompanying people with cancer, and sometimes their death, takes an emotional toll. Compassion fatigue and burnout are common in oncology. Supervision, peer consultation, limiting how many advanced-illness cases you carry at once and protecting your own time are part of the job, not an extra. The guide to psychologist burnout and self-care has warning signs and practical measures.

What to record in each session

In psycho-oncology the clinical record is there to follow emotional change and also to keep track of a medical process that shifts every few weeks. This is usually enough:

  • The stage of the illness and where the client is in treatment: cycle, pending tests, recent results.
  • The Distress Thermometer score or another short scale, if you use one, and the problems the client ticks.
  • The symptoms worked on (sleep, fatigue, anticipatory nausea, fear of recurrence) and how they are changing.
  • What has been discussed with the family or the medical team, with the relevant permission.
  • Risk: suicidal thoughts, isolation, alcohol or other substance use.
  • What was agreed for the next session and whether it will be in person or online.

Organising psycho-oncology with My Psico Agenda

My Psico Agenda doesn't do the intervention or replace your clinical judgement. It handles the practical side, which in psycho-oncology weighs more than usual: appointments that move with treatment cycles, families who are involved, sensitive information and clients who some weeks can't come.

  • Each appointment can last 30, 45 or 60 minutes, 1 h 30 min or 2 hours, so there is room both for the short session in a chemotherapy week and for the long family session. When you pick the client, the appointment shows in small print which session number it is, "(Appointment no. 8)".
  • Each client has their own space where they can request or cancel an appointment, always within your working hours. If they cancel a session because of a fever or a hospital admission, you see it in your diary and that hour shows up as a free slot for someone else.
  • WhatsApp reminders go out 24 hours before with buttons to confirm or cancel, and they can be switched off for a specific client from their file, for example at an advanced stage when the family would rather arrange appointments by phone.
  • In the clinical record you write the note for each session, and in the client's files you keep medical reports or scales (the space available depends on the plan). Informed consent is signed in the app or remotely through a link, and a minor's file lists both mother and father.
  • Each client's statistics show how many sessions they have had, how often they come and how many days have passed since the last one, which helps you keep sight of anyone who has stopped coming during a hard patch.

The app doesn't do video calls: if a session is online, you note the link to whatever tool you use in the appointment. If several psycho-oncologists work together in a centre or association, the centre diary shows each therapist's week at a glance. There's a summary of everything on the software for psychologists page. Individual plans start at €4.99/month + VAT (Semilla plan, with up to 25 clients) and centre plans at €124.99/month + VAT. No lock-in: cancel whenever you like.

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Frequently asked questions

The questions that come up most in sessions and supervision about psycho-oncology.

What does a psycho-oncologist do?

They assess and treat the emotional distress of people with cancer and their families at any stage of the illness, from the impact of diagnosis to survivorship, advanced illness and bereavement. They work on specific symptoms such as insomnia, anticipatory nausea, fatigue or fear of recurrence, help with communication with the medical team and the family, and can also support oncology professionals themselves.

Does everyone with cancer need a psychologist?

No. Many people adjust with their own resources and support network. Around 40% experience significant distress at some point, and that is where psychological care makes a real difference. That is why a short screening, such as the Distress Thermometer, is recommended at the start and whenever treatment changes.

When is the best time to start: at diagnosis or after treatment?

Whenever distress starts to interfere with the person's life, whatever the stage. Many patients ask for help at diagnosis; others when treatment ends, when everyone expects life to be back to normal and fear of recurrence appears. There's no need to wait for a particular moment.

Can psycho-oncology be done online?

Yes, and at some stages it is the best option: in weeks of heavy fatigue or infection risk, or when the client lives far away. It is worth agreeing what to do if the connection drops or a crisis comes up, and alternating with in-person sessions when the client's condition allows.

What training do you need to work in psycho-oncology?

In Spain, psychological care in a practice is a healthcare activity and requires being a general health psychologist or a clinical psychology specialist. Beyond that, specific training in psycho-oncology and palliative care, supervised practice and a good knowledge of cancer treatments and their effects are advisable, because they shape all the work.

How do you explain to a child that their mother or father has cancer?

With the truth, adapted to their age: name the illness, explain what changes they will notice at home, make clear that it isn't their fault and that it isn't catching, and answer what they ask without going further than they want to know. Keeping routines and letting the school know helps. Silence tends to frighten children more than a simple explanation.

What is fear of cancer recurrence and when should it be treated?

It is the fear that the cancer will come back or progress. Some fear is normal, especially before check-ups. It should be treated when it takes up a good part of the day, stops the person making plans or leads to constant body checking or a doctor's appointment for every symptom. There are specific, brief interventions, such as ConquerFear, with good results in clinical trials.