Maggie Watson is Consultant Clinical Psychologist at the Royal Marsden NHS Trust and Honorary Senior Lecturer and team leader at the Institute of Cancer Research. She holds degrees from the University of Bath and University of Sheffield. Her post-doctoral research was at the University of Oxford and University of London (Kings College Medical School). She has worked with cancer patients for more than 20 years. She is an editor of the journal Psycho-oncology and author, with Dr Mary Burton of a standard textbook called "Counselling People with Cancer".

She has approximately 150 publications relating to psychological aspects of cancer. She was awarded an Honorary Life Membership of the British Psychosocial Oncology Society in 1990. She has developed and run support groups for breast cancer patients over the last decade. She has a special interest in coping and breast cancer and breast cancer genetics.

Question (Q): What is the current state of art of psycho-oncology in cancer centres?

Answer (A): State of the art may well not be quite the right label, I prefer to call it the state of science. Perhaps one of the struggles that we have in psycho-oncology is to be able to demonstrate that it is a science. So I think that part of looking at, if you like, the state of art is about the way in which we draw together evidence based practise and use it to support the development of the area. I think that it is important we view ourselves as practitioner scientists in order that credibility for our area continues to improve. Certainly there has been a substantial accumulation of evidence over the last decade to support many aspects of psycho-oncology. Further work is still needed to integrate this evidence into changes in clinical practice.

Q.: Different forms of psychotherapy, such as individual or group interventions, can be applied in people with cancer. What is your opinion about these two main forms?

A.: There’s a place for both and in fact there is evidence to show that both can be useful with different groups of patients. The most important thing is that patients need to be offered options. There will always be some patients who don’t want to go into support groups, some patients who prefer to be in groups but prefer not to be singled out to go into individual therapy. So I think its more interesting to develop both forms of therapy. There is still no strong research evidence to say that group work is more effective than individual therapy and the choice of therapy is best tailored to the patients perceived needs.

Q.: Among the types of psychotherapy, cognitive-behavioural intervention (CBT) has been shown to be efficacious in oncology. What is your experience and opinion about this?

A.: I have to say that I support the use of CBT, because my background and training is in CBT. I find that it applies very broadly to the problems that our patients present. It is brief and problem-focussed and has proven efficacy based on randomised controlled trials. There is some limited evidence to suggest that CBT is perhaps, more efficacious than supportive counselling for patients with more serious psychological problems. Problem-solving therapy has also demonstrated efficacy within psycho-oncology. In my own practise I actually work with a very eclectic approach depending on presentation of problems, and I like to be able to make decisions with the patient about what’s appropriate for them. We are presented with a broad range of psychological and psychiatric problems in psycho-oncology and need to be able make choices with patients about the appropriate treatment modality rather than trying to apply one method to all cases.

Q.: What are the possible applications of counselling in cancer centres ?

A.: There is a place for counselling because the approach we use is rather like thinking of the patients needs like a pyramid that the bottom layer are all of the everyday emotional needs that the doctors and nurses need to be able to deal with. So every doctor and nurse should feel able to ask the question "how are you feeling?" and not be afraid to ask that question. The next level up I think are patients who have more difficult problems, but at the top of the pyramid are patients with more complex problems that are referred perhaps to the psychologists and psychiatrists. I think that counselling has a place in that middle section, and it would probably be less effective with patients who have l more severe problems in coping. Part of the difficulty in looking at the evidence is that rarely do we select patients according to their needs for the studies we do The tendency has been to conduct randomised trials with an unselected series of patients. Our research needs to become more sophisticated .The question perhaps is not "does counselling work better than other treatments but rather does it work best with this level of problem and the same with the CBT "does it work best with patients who have more complex problems". So I would like to keep an open mind about the use of counselling. It is likely that a substantial number of patients with mild to moderate psychological problems and adjustment difficulties will benefit from a simple counselling approach. Psycho-oncology teams therefore need to include a good skills mix .

Q.: Do you have any information or experience about what the general practitioners or family doctors do in terms of counselling with cancer patients?

A.: In the UK there are still very limited support and treatment resources available within the community. General Practitioners sometimes have counsellors attached to their services. The amount of psychological supported provided by GP’s themselves is limited due to both the heavy workload they bear and also a lack of skills in dealing with more complex psychological problems. Within the UK, psycho-oncology services where these are provided, tend to be either hospital based or provision is made by the voluntary sector. The expansion in support provided by volunteers and charities has been very significant over the last decade. Limited financial resources within health services for countries such as the UK which has a national health service are likely to continue to limit the provision of psychological care by GP’s and their clinic staff for the foreseeable future. There is also very little research evidence on which to base any conclusions about the efficacy of support provided by GP’s or community physicians. The GP has an important role to play in supporting patients with cancer but limited resources with which to achieve the desired level of service provision.

Q.: Palliative care, or palliative medicine, is developing as an important area for patients in an advanced stage of illness and psycho-oncology is closely linked with palliative care. What are the possible applications of psychological interventions in palliative care?

A.: The palliative care area has advanced hugely within the last ten years. There’s been real recognition by palliative care doctors and nurses that psycho-oncology has an important part to play, In the hospital where I work, the palliative care doctors are the first doctors to come and say "we want a psycho-oncologist in our multidisciplinary team" and they encounter a wide range of problems in their patients, right through from the more serious organic mental health syndromes to patients who have more existential problems facing their own death. So I think there is a huge development, which could take place where psycho-oncology and palliative care collaborate clinically and scientifically.

Q.: One of the most important problems in psycho-oncology is training. How is it possible to collect funds for that, how can we convince administrators of the importance of having a core curriculum in psycho-oncology in cancer centres or hospitals caring for people with cancer?

A.: There are two things to mention very briefly about training. I think there is the role that psycho-oncologists have to play in training other staff

A persuasive argument would focus on convincing service managers that we are there to train other staff and help improve their competencies in dealing with the everyday psychological problems they encounter in their patients. We need to draw upon the available evidence which shows that good psychological care by all oncology staff can be cost effective. That’s one part of the issue on training and the other is that it’s absolutely essential that we develop post graduate training programmes in psycho-oncology and we have accreditation systems in place. I know that in Europe there are some countries where this is going on at present but the professionalisation of psycho-oncology is so important and accredited training courses are the next step. They still need to be developed further throughout Europe and certainly in the UK, so it would be very useful to have some system of communication available where people are creating specific curricula in psycho-oncology. Many groups now throughout the world are developing psycho-oncology curricula and it should be possible to learn from their experiences. Historically it has usually been the case that professional acceptability comes from setting out requirements for the skills needed to practice optimally. The establishment of post-graduate training courses is the next step. The profession of psycho-oncology will be better accepted by the colleagues we work alongside in oncology if we are qualified and the patients benefit because systematic training improves the skills we have to offer. Accredited training schemes provide the recognition needed.