Table 3.

Detailed descriptions of study components by session.

Session 1. Participants introduce themselves and describe their experience with cancer and related symptoms, including pain, fatigue and distress. The rationale for cognitive behavioral coping skills training is presented. Examples of CRC-specific and stage-of-life challenges are reviewed, and challenges specific to the patient are identified to inform tailoring of skill applications (Fig. 2). A simplified theoretical rationale for the program grounded in the Neuromatrix Theory of Pain is presented [[44], [45], [46], [47]]. This introduces the concept that how one thinks about symptoms, what one does, and how one feels can impact the symptom experience, and how these elements are interrelated. A menu of skills to be taught is presented and the first skill, Progressive Muscle Relaxation (PMR), is introduced. Participants are provided with a rationale for the skill, then taught the skill through therapist instruction and video demonstration. The participant and therapist practice the skill together using a guided audio-recording, then discuss the participants' experience. Participants are asked to practice PMR 1–2 times daily until the next session. Problem solving is used to identify time(s) and place(s) where the patient can practice and to identify barriers and solutions.

Mobile Application. Participants use the app in session to view a video demonstration of PMR and to access a guided audio-recording. The app is used to facilitate PMR review and home practice.

Session 2. Participants learn activity/rest cycling as a strategy for activity pacing. Often in the context of cancer and its treatment, patients find their activity levels fluctuate as a function of their symptoms. Some patients overdo activities when feeling good, which can exacerbate symptoms and require extended rest. Conversely, some patients limit or avoid activity due to fear of exacerbating symptoms, leading to a cycle of avoidance. Activity/rest cycling teaches patients to schedule both activity and rest to improve functioning, productivity and mood. In addition, participants are taught pleasant activity planning. Participants are encouraged to generate a list of activities that may be enjoyable and/or meaningful. Increasing engagement in pleasant activities can help to distract patients from symptoms, increase patients' sense of meaning and purpose, and reduce distress. Participants are encouraged to think creatively about how to adapt activities to be accessible in the context of cancer and stage-of-life challenges.

Mobile Application. Participants complete a journal entry in the app, noting what pleasant activities they will engage in during the week. Video demonstration of the activity/rest cycle and pleasant activity planning skills are available for review.

Session 3. Participants learn cognitive restructuring to recognize how thoughts can impact feelings and behavior and the ability to cope with symptoms. Participants are introduced to the cognitive behavioral triad to demonstrate how thoughts, feelings and behavior are interrelated and how negative thoughts about symptoms can negatively impact feelings and behavior. Common examples of unhelpful thoughts are described (e.g., “shoulds”, all-or-nothing thinking), and unhelpful thoughts that resonate with the participant are identified. The diagram of stage-of-life challenges (Fig. 2) is used to help identify areas where patients may be prone to unhelpful thinking. Strategies to challenge and shift unhelpful thinking and to generate more balanced thinking are introduced. Participants watch a video demonstration of how to challenge and shift unhelpful cancer-related thoughts, then apply cognitive restructuring to a personal cancer-related thought. Calming self-statements are introduced (e.g., “This too shall pass”; “Let it go”).

Mobile Application. Participants complete a journal entry listing a calming self-statement that resonates with them. This unique statement is then sent as a text message the following week. Brief videos reviewing cognitive restructuring are available.

Session 4. Participants learn and practice mini-relaxation, a brief, portable relaxation technique that combines muscle relaxation and deep breathing. Participants identify internal (e.g., pain) and external (e.g., work) cues as reminders to engage in mini-relaxation practices. Next, participants learn pleasant imagery, using the mind to create a pleasant scene. Participants identify personally pleasant scenes and are taught to utilize their five senses to vividly imagine the scenes. Pleasant imagery is practiced in session.

Mobile Application. Participants practice mini-relaxation and pleasant imagery using app-based audio-recordings. Brief videos describing these skills are available for review.

Session 5. All coping skills are reviewed and benefits and challenges associated with practicing skills are discussed. Participants create a coping skills practice schedule and problem solve barriers that might interfere with continued practice. Goal setting is introduced as a final tool to plan for continued coping skills use, and continued use is emphasized as a strategy to help patients manage symptoms and stressors and to engage in meaningful activities.

Mobile Application. Participants have access to the app for one year following session completion and continued utilization is encouraged.