Therapy in Cancer Patients at the End of Life Marcus James Fidel, M. D

Therapy in Cancer Patients at the End of Life

• Marcus James Fidel, M.D.

• PGY 4

• University of Oklahoma Tulsa

• Family Medicine -Psychiatry

Objectives

• To outline the basic psychology of death and dying: Kübler-Ross model, Frankl’s Existential Model and Kohut’s Self Psychology

• To outline supportive and expressive techniques that derive from the above models and show their uses in the therapy of cancer patients.

• Supportive Expressive

Case Presentation

Video Presentation

Family Practice-Psychiatry Perspective

Friedman Labor Curve

Kübler-Ross Model

Grief Curves

Normalized Grief Curves

Denial

• The most common defense and noted to be adaptive and protective in death and dying

• Existential denial: Universal capacity to suppress awareness of hazards present in everyday life (low anxiety)
• Psychological denial: A defense against the anxiety evoked by danger or the threat of it (much anxiety)
• Non-attention denial: Denial that is partially conscious and not usually accompanied by undue anxiety (persistent hope of miracle cure)

Denial and Odds of Death

Displacement

• Patients use the defense of displacement as a means of coping with powerful emotions which would most appropriately be felt themselves. By directing their feelings onto others, they remain calm except when thinking about those who have become the focus of their displaced feelings.

Anger

• Anger about the terminal illness is often displaced onto the physicians or the nurses who are blamed for making the diagnosis too late or not providing enough care.

• Relatives are often blamed for not caring enough.

• Displacement allows the patient to express the anger and frustration about death and dying without having to confront it directly

Depression/Anxiety

• Often due to uncontrolled pain

• Appropriate and inevitable response

• A sign that distress needs to be verbalized

• Issues of pain, loss of control, abandonment, and dependency are very common

• Patients want to talk about depression and anxiety, but not all the time

Dialogue/Bargaining/Hope

• Truth does not destroy hope. The withholding of information to “protect the patient” is destructive.

• Dying patients have a great facility for holding two incompatible ideas at the same time. They make preparations for imminent death, but also plan for a holiday a year hence.

• Hope, even small hope, is healthy and should be encouraged.

Acceptance

• In the terminal phase, a patient’s heroic attempts to maintain independence at all costs can cause harm to himself and to his relatives.

• Acceptance is not a loss of hope or even a resolution of denial, it is a recognition that it is not shameful to ask for help.

• Anxiety is usually lowered and energy that was previously used for anxiety is often transferred to joy.

Therapy should not get in the way of the natural process of dying

• Anxiety and depression in the face of terminal illness are normal responses and not necessarily pathological.

• Anxiety and depression can serve as emotional barometers of “level of acceptance.”

Since life is dynamic, we are faced all the time with the elements of the tragic triad:

• 1. Unavoidable suffering 2. Guilt 3. Death

Normal Reactions

• Shock

• Apathy

• Depersonalization

• Moral deformity

• Bitterness

• Disillusionment

Existential Model

• The human being is an entity consisting of:

• 1. Body (soma)

• 2. Mind (psyche)

• 3. Spirit (noetic core)

Meaning

• Life has meaning under all circumstances

• People have a will to meaning

• People have freedom under all circumstances to activate the will to meaning and to find meaning

Logotherapy: Socratic Questioning

• The first thing is to make the patient realize that he is NOT A VICTIM of circumstance! He might have symptoms, but he IS NOT his symptoms.

• Try to help the patient find a meaning within his soma, psyche, and noetic core.

• Make the patient independent of the therapist by helping him find his guidance within.

Logotherapy: Paradoxical Intention

• Take a horrible reality and laugh in the face of it.

• Patch Adams “What's wrong with death sir? What are we so mortally afraid of? Why can't we treat death with a certain amount of humanity and dignity, and decency, and God forbid, maybe even humor. Death is not the enemy gentlemen. If we're going to fight a disease, let's fight one of the most terrible diseases of all, indifference.”

Logotherapy: Paradoxical Intention

• Hunter Patch Adams: Death. To die. To expire. To pass on. To perish. To peg out. To push up daisies. To push up posies. To become extinct. Curtains, deceased, Demised, departed And defunct. Dead as a doornail. Dead as a herring. Dead as a mutton. Dead as nits. The last breath. Paying a debt to nature. The big sleep. God's way of saying, "Slow down."

• Bill Davis: To check out.

• Hunter Patch Adams: To shuffle off this mortal coil.

• Bill Davis: To head for the happy hunting ground.

• Hunter Patch Adams: To blink for an exceptionally long period of time.

• Bill Davis: To find oneself without breath.

• Hunter Patch Adams: To be the incredible decaying man.

• Bill Davis: Worm buffet.

• Hunter Patch Adams: Kick the bucket.

• Bill Davis: Buy the farm.

• Hunter Patch Adams: Take the cab.

• Bill Davis: Cash in your chips.

• Hunter Patch Adams: And if we bury you ass up, I have got a place to park my bike.

Limitations of Logotherapy

• Although most critics praise the existential characteristics and spiritual aspects of Frankl's Logo therapeutic theory, others criticize as essentialist and reductive his insistence on the "will to meaning"—like Freud's "will to pleasure" and Adler's "will to power"—as the underlying motivational force governing all human behavior.

Limitations of Logotherapy

• Some critics reject Logotherapy as inadequate and charge that Frankl is unable to deal with people who have found life to be meaningless (shock and denial phases of illness) They note it shows a lack of empathy and not enough support for vulnerable suffering patients.

Interventions According to Phase

Focus not on the model but on the patient

• Kohut maintains that caring for others requires that one “resist the temptation” of “tool and method pride” so that one’s theories may become one’s “help-mates...not masters” or one’s “guides, not Gods.”

• Kohut includes his own theory among those that may serve as “rigid mold's” into which the analyst may be tempted to fit the patient.

Focus not on the model but on the patient

• For Kohut, the truth of theory resides not in its correspondence to some body of psychological facts, but to the degree to which it helps one to attend to the needs of one’s patient.

• Kohut frequently warns practitioners, rich in any particular theory, against attending to the illusory truths of their theory at the expense of attending to their patient’s needs.

Self Psychology

• “Self psychology is a mode of psychoanalytic treatment originating from a theory of Heinz Kohut that states that each individual’s self cohesion, self esteem, and vitality derive from and are maintained by the empathic responsiveness of others to his or her needs.”

• --Joseph D. Lichtenberg, MD, 18 August 1997

Kohut’s Bipolar Self

Narcissism

With a diagnosis of cancer the self is fractured

Narcissism vs Death

Implications for the dying and those around them

• A healthy function of narcissism for the dying person, nonetheless allows the self to disengage from the affairs and concerns of the world.

• This helps them prepare for the afterlife.

• The dying person’s withdrawal of energy inward triggers response in their caretaker—family, friends, doctors, therapists—who have a need to be seen and recognized (grandiose self needs). The sense that something is wrong, is more a reflection of the idealized patient imago of the caretaker and not any pathology in the patient.

Implications for the dying and those around them

• Kübler-Ross noted that there is an aversion countertransference of physicians and nurses in the care of the dying. The failure of the “idealized patient imago” likely accounts for this non-empathetic response that according to Kübler-Ross was pervasive in 1969, and still exists today.

• On the other hand, empathy has been shown to be a significant factor in quality of care.

Kohut: Empathy

• The capacity to think and feel oneself into the inner life of another person

• Lifelong ability to experience what another person experiences

Role of the Therapist

• Therapist’s attitude is a critical factor toward the healing process

• Development and successful communication of empathy is critical

• 2 essential questions:

• What was it that my patient was deprived of?
• What can the therapist do about it?

• Is the therapist’s role to provide or reflect the mirror?

Kohut: Specific to Death and Dying

• Caregiving with those who are dying involves listening to the silence and quietly observing the ways in which the self undergoes transformation -- “A human death can be …and should be an experience that however deeply melancholy is comparable to a fulfilled parting—it should have no significant admixture of disintegration anxiety”

Complexity and interpersonal factors including therapist and client imago of death and culture

Imago of Death from my Childhood

• Members of the Penitente Brotherhood or Hermandad de Nuestro Padres Jesus Nazareno would do penance during holy week by placing an image of death, Doña Sebastiana, in a cart filled with stones and pulling it in a reenactment of Christ's suffering on the procession to Calvary.

Common American Imago of Death

• In America, death is often given the name the "Grim Reaper" and shown as a skeletal figure carrying a large scythe and wearing a midnight black gown, robe, or cloak with a hood, or sometimes a white burial shroud.

Imago of Death from New Orleans

• Jazz funeral is a common name for a funeral tradition with music which developed in New Orleans, Louisiana. The tradition arises from African spiritual practices, French and Spanish martial musical traditions, and uniquely African-American cultural influences.

Summary: Psychotherapy of the Cancer Patient

• The psychiatrist who provides psychotherapy for the terminally ill needs to be something of a jack-of-all-trades which is a prospect that may seem daunting.

• However, sophisticated psychotherapy is noted as less necessary than sensitivity, a willingness to follow the patient rather than lead him, some knowledge of the psychology of dying, and the ability to accept the inevitability of death.

Questions? Thanks!

• [e-mail]

• Marcus James Fidel, MD OU Psychiatry

• Thanks to Dr. Koduri for his time in helping me understand some of the issues and theory involved in death and dying.