AbstractThe effectiveness of a preoperative psychotherapeutic intervention with breast cancer patients was assessed in a randomized controlled trial: (1) preoperative interview plus a 30‐minute preoperative psychotherapeutic intervention; (2) preoperative interview plus a 30‐minute chat to control for the effects of attention; (3) preoperative interview only; and (4) routine hospital care control. A clinical psychologist interviewed the patient in hospital the afternoon before surgery. A consultant surgeon trained in listening and counselling skills conducted a 30‐minute psychotherapeutic intervention or chat. Psychological measures included anxiety and depression, body image distress, stressful life events, social support, and coping. Patients receiving a preoperative interview had lower body image distress at 3 months and 1 year than controls. Controls also showed significantly less Fighting Spirit in 1‐year interviews, and more control patients were cases for both anxiety and depression on Present State Examination criteria at 1 year than patients in the experimental groups. The psychotherapeutic intervention was superior to the chat among patients with severe stressful life events. Patients in the chat condition used their 30 minutes with the surgeon to explore symbolically themes of loss and restitution. In a multivariate model for predicting psychological outcome at 3 months and 1 year, experimental group remained a significant predictor when surgical procedure and age were included in the regression equation. Patients undergoing sector mastectomy had lower body image distress scores than mastectomy patients both at 3 months and 1 year. Psychological morbidity in the sample was high preoperatively (59%) and at 1 year (39%), but detection of morbidity by health professionals was poor. Predictors of caseness at follow‐up included caseness preoperatively, severe stressful life events, age, marital status, and social support. Implications of the findings for the care of cancer patients in hospital are