**7. How can one help**

Medical professionals and health team may be able to reduce caregiver distress related to cancer if it is identified early and adequate steps are taken to relieve the causes of distress. Also, they can work with caregivers to help them attain something of emotional significance from the experience of loss or suffering [13]. Cancer patient caregivers will benefit from improving their *coping skills* and learning more adaptive coping skills (**Table 3**). They need to preserve their emotional balance, sense of know-how, sustain social relationships and above all, be prepared for the uncertain future. Expression of emotions to social support system is shown to improve optimism and reduce distress in cancer patients [14–16]. Similar strategies


#### **Table 3.**

*Proposed interventions to relieve caregiver distress.*

aimed at increasing the social support for caregiver may be desirable. *Adaptive coping*, in terms of emotion focused and problem focused, may help the caregiver to match their response to a difficult medical situation. Avoidant strategies may not be that adaptive and useful in the long run [17, 18]. The components of adaptive coping are- facing not fleeing, altering the perception, coping actively, social support and expressing emotion. The caregiver of a terminally ill cancer patient needs to be able to cope with uncertainty of eminent death. Usually they are anxious to know the 'time left with the patient'. It is good to ask the caregiver that why they wanted to know in the first place. They may express a particular concern, like, the wedding of a loved one or travel plans. This opens a forum for discussion and scope for addressing the real concerns. Acknowledging that living with this kind of uncertainty is in fact difficult for most people will help the caregiver to get some perspective. Lastly, discuss certain coping strategies like living only one day at a time, living and planning till the next event like a birthday, learning to hope for the best but be prepared for the worst.

*Group psychotherapy* has already been shown to be efficient in providing psychological support to cancer patients [19, 20]. The same concepts could be applied to support cancer caregivers. The components of group therapy include- social support, emotional expression, demystifying dying, living in the present and reorganizing life priorities, family support enhancement and effective communication with medical team.

*Good communication skills* on the part of the medical team are a starting point for identification of distress in the cancer caregivers. A good approach would be to identify not just the telltale signs and symptoms of distress (like depression), but identify all psychological issues relevant to the caregiver at that moment. The person may be in a phase of denial or anger or disbelief or sadness. Identifying these and working on the core issue may serve better to take care of psychological distress. For example, if a cancer caregiver has received news of cancer recurrence in the patient, he may be in 'denial' for some time. This is a usual response when one is unable to deal with the weight of the reality and looks for alternate explanations. The 'denial' may result in anxiety. Rather than treating the anxiety with drugs, addressing the core issue, which was 'denial' in this case, acknowledging its effect on the person and an open honest discussion may be a better path to take. In addition to verbal communication, an effective way of conveying the message is 'nonverbal cues'. These include things like eye contact, facial expression, act of sitting with the person, posture, placement of hands, pace of voice, voice pitch and touch. For effective communication 'privacy' is equally important. The person should feel safe and confident to share their emotions and thoughts. Another important aspect is not to hurry up the conversation, we have to create the illusion of 'time' and should not interrupt as far as possible. Lastly, 'avoiding medical jargon' will allow for a smoother conversation and better understanding on the part of the caregiver. Nodding from time to time, reflective questioning, picking up cues from caregiver's statements, asking and validating their feelings, picking up non-verbal cues and finally summarizing the contents of the whole conversation are part of *active* 

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*Caregiver Distress in Cancer*

*What worries you so?*

of distancing behaviors.

stay of management.

**7.2 Management of depression**

may be used in a few instances.

**7.3 Management of adjustment disorders**

**7.1 Management of anxiety**

*DOI: http://dx.doi.org/10.5772/intechopen.96386*

Closed question- *Do you feel anxious today?* Open question- *How is your anxiety today?*

*listening*. Active listening will help finding out about caregiver's emotions, feelings and concerns. Asking 'open questions' is better than asking leading or closed

*How do you think you feel today as compared to our previous consultation?* Next important thing to remember as a medical professional is to not use 'distancing behaviors'. Non-verbal cues like facial expression, looking very busy and tone of voice; labeling a patient, e.g., 'she is cancer colon patient; lecturing, criticizing, making threats, issuing orders, addressing only the physical problems, using closed questions, inappropriate humor and normalilsing prematurely are examples

The first step is impeccable assessment keeping the following components in mind. Firstly, look for the common features of anxiety like- vigilance, scanning, autonomic hyperactivity, increased motor tension and excessive worrying. Secondly, we need to assess the character of anxiety, whether it is acute or chronic in nature, whether it is part of a psychiatric syndrome. Thirdly, there may be some features leading to anxiety, which may be reversible. For example, the patient's symptom control could be better or the medical team could address anxiety resulting from fear of unknown prognosis by counseling the caregiver in depth regarding patient's cancer related prognosis. It is important to note here that, one needs to give ample time to listen to the caregiver, so the real reasons behind the anxiety could be explored. The main concerns and worries mentioned by the caregiver will be helpful in understanding the reasons behind anxiety. Just the act of sharing these concerns may result in decreased anxiety. Treatment approach could be pharmacological or non-pharmacological. The non-pharmacological options are- psychological counseling, progressive muscular relaxation and distraction. The main pharmacological management is use of benzodiazepines like- Lorazepam, Diazepam, Midazolam and Clonazepam. Medications should be used only for short period to break the cycle of anxiety; non-pharmacological approaches are the main

As with management of anxiety, we assess for the reversible causative factors and try to eliminate these. Enough emphasis cannot be given to the fact, that spending time with the caregiver, active and patient listening is important to uncover the main concerns and fears. Addressing these fears and concerns, emotional and social support and counseling are the main stay of management. Tricyclic antidepressants

Psychotherapy is the main stay of treatment. The focus will be on spending enough time with the caregiver and listening to his/her concerns and fears. Thereafter, focus will shift to addressing these concerns, help them find solutions to problems that are reversible. There will be need to resolve conflicts. For example, there may be ongoing conflict due to collusion, the patient may not be aware of

questions if you want to understand their feelings and concerns. Leading question- *Are not you feeling less anxious today?*

#### *Caregiver Distress in Cancer DOI: http://dx.doi.org/10.5772/intechopen.96386*

*Suggestions for Addressing Clinical and Non-Clinical Issues in Palliative Care*

aimed at increasing the social support for caregiver may be desirable. *Adaptive coping*, in terms of emotion focused and problem focused, may help the caregiver to match their response to a difficult medical situation. Avoidant strategies may not be that adaptive and useful in the long run [17, 18]. The components of adaptive coping are- facing not fleeing, altering the perception, coping actively, social support and expressing emotion. The caregiver of a terminally ill cancer patient needs to be able to cope with uncertainty of eminent death. Usually they are anxious to know the 'time left with the patient'. It is good to ask the caregiver that why they wanted to know in the first place. They may express a particular concern, like, the wedding of a loved one or travel plans. This opens a forum for discussion and scope for addressing the real concerns. Acknowledging that living with this kind of uncertainty is in fact difficult for most people will help the caregiver to get some perspective. Lastly, discuss certain coping strategies like living only one day at a time, living and planning till the next event like a birthday, learning to hope for the best but be prepared

*Group psychotherapy* has already been shown to be efficient in providing psychological support to cancer patients [19, 20]. The same concepts could be applied to support cancer caregivers. The components of group therapy include- social support, emotional expression, demystifying dying, living in the present and reorganizing life priorities, family support enhancement and effective communica-

*Good communication skills* on the part of the medical team are a starting point for identification of distress in the cancer caregivers. A good approach would be to identify not just the telltale signs and symptoms of distress (like depression), but identify all psychological issues relevant to the caregiver at that moment. The person may be in a phase of denial or anger or disbelief or sadness. Identifying these and working on the core issue may serve better to take care of psychological distress. For example, if a cancer caregiver has received news of cancer recurrence in the patient, he may be in 'denial' for some time. This is a usual response when one is unable to deal with the weight of the reality and looks for alternate explanations. The 'denial' may result in anxiety. Rather than treating the anxiety with drugs, addressing the core issue, which was 'denial' in this case, acknowledging its effect on the person and an open honest discussion may be a better path to take. In addition to verbal communication, an effective way of conveying the message is 'nonverbal cues'. These include things like eye contact, facial expression, act of sitting with the person, posture, placement of hands, pace of voice, voice pitch and touch. For effective communication 'privacy' is equally important. The person should feel safe and confident to share their emotions and thoughts. Another important aspect is not to hurry up the conversation, we have to create the illusion of 'time' and should not interrupt as far as possible. Lastly, 'avoiding medical jargon' will allow for a smoother conversation and better understanding on the part of the caregiver. Nodding from time to time, reflective questioning, picking up cues from caregiver's statements, asking and validating their feelings, picking up non-verbal cues and finally summarizing the contents of the whole conversation are part of *active* 

**92**

for the worst.

tion with medical team.

Improving coping skills Learning adaptive skills Group psychotherapy Good communication

*Proposed interventions to relieve caregiver distress.*

**Table 3.**

*listening*. Active listening will help finding out about caregiver's emotions, feelings and concerns. Asking 'open questions' is better than asking leading or closed questions if you want to understand their feelings and concerns.

Leading question- *Are not you feeling less anxious today?* Closed question- *Do you feel anxious today?* Open question- *How is your anxiety today? What worries you so?*

*How do you think you feel today as compared to our previous consultation?* Next important thing to remember as a medical professional is to not use 'distancing behaviors'. Non-verbal cues like facial expression, looking very busy and tone of voice; labeling a patient, e.g., 'she is cancer colon patient; lecturing, criticizing, making threats, issuing orders, addressing only the physical problems, using closed questions, inappropriate humor and normalilsing prematurely are examples of distancing behaviors.
