Therapy in cancer patients at the end of life Marcus James Fidel, M.D. PGY 4 University of Oklahoma...

Therapy in cancer patients at Therapy in cancer patients at the end of lifethe end of life

Marcus James Fidel, M.D.Marcus James Fidel, M.D.PGY 4PGY 4

University of Oklahoma TulsaUniversity of Oklahoma Tulsa Family Medicine -PsychiatryFamily Medicine -Psychiatry

ObjectivesObjectives Facilitate an understanding of the basic psychology of Facilitate an understanding of the basic psychology of

death and dying: Kübler-Ross model, Frankel’s Existential death and dying: Kübler-Ross model, Frankel’s Existential Model and Kohut’s Self Psychology Model and Kohut’s Self Psychology

Facilitate an understanding of the supportive and Facilitate an understanding of the supportive and expressive techniques that derive from the above models expressive techniques that derive from the above models and elucidate their appropriate utility in the therapy of and elucidate their appropriate utility in the therapy of cancer patients.cancer patients.

SupportiveSupportive ExpressiveExpressive

Case presentation Case presentation

Video PresentationVideo Presentation

Family Practice-Psychiatry Family Practice-Psychiatry PerspectivePerspective

Death and Dying are the final steps of the normal human lifecycle

Friedman Labor CurveFriedman Labor Curve

Kübler-Ross ModelKübler-Ross Model

Kübler-Ross, Elisabeth. On Death and Dying. New York: Macmillian, 1969.

Grief CurvesGrief Curves

Maciejewski, P.K., Zhang, B., Susan, B.D., Holly, P.G. (2007). An Empirical Examination of the Stage Theory of Grief The Journal of the American Medical

Association, 297(7), 716-723.

Normalized Normalized Grief CurvesGrief Curves

Maciejewski, P.K., Zhang, B., Susan, B.D., Holly, P.G. (2007). An Empirical Examination of the Stage Theory of Grief The Journal of the American Medical

Association, 297(7), 716-723.

DenialDenial The most common defense and noted to be The most common defense and noted to be

adaptive and protective in death and dyingadaptive and protective in death and dying Existential denial: Universal capacity to Existential denial: Universal capacity to

suppress awareness of hazards present in suppress awareness of hazards present in everyday life.everyday life.

Psychological denial: A defense against the Psychological denial: A defense against the anxiety evoked by danger or the threat of it. anxiety evoked by danger or the threat of it. (much anxiety)(much anxiety)

Non-attention denial: denial that is partially Non-attention denial: denial that is partially conscious and not usually accompanied by undue conscious and not usually accompanied by undue anxiety. (persistent hope of miracle cure)anxiety. (persistent hope of miracle cure)

Stedeford, A Psychotherapy of the Dying Patient: British Journal of Psychiatry (1979), 135 7-14 Kübler-Ross, Elisabeth. On Death and Dying. New York: Macmillian, 1969.

Denial and odds of deathDenial and odds of death

PSA from the American Lung Association titled “Odds” SOURCES: National Center for Health Statistics, CDC; American Cancer Society; National Safety Council; International Federation of Red Cross and Red Crescent Societies; World Health Organization; USGS; Clark Chapman, SwRI; David Morrison, NASA; Michael Paine, Planetary Society Australian Volunteers

High Level of Denial Low Level of Denial

DisplacementDisplacement

Patient’s use the defense of Patient’s use the defense of displacement as a means of coping displacement as a means of coping with powerful emotions which would with powerful emotions which would most appropriately felt about most appropriately felt about themselves. By directing their themselves. By directing their feelings on to others they remain feelings on to others they remain calm except when thinking about calm except when thinking about those who have become the focus.those who have become the focus.Stedeford, A Psychotherapy of the Dying Patient: British Journal of Psychiatry (1979), 135 7-14


AngerAnger Anger about the terminal illness is often Anger about the terminal illness is often

displaced onto the physicians or the displaced onto the physicians or the nurses who are blamed for making the nurses who are blamed for making the diagnosis too late or not providing diagnosis too late or not providing enough care.enough care.

Relatives are often blamed for not Relatives are often blamed for not caring enoughcaring enough

Displacement allows him to express the Displacement allows him to express the anger and frustration about death and anger and frustration about death and dying without having to confront it dying without having to confront it directlydirectlyStedeford, A Psychotherapy of the Dying Patient: British Journal of Psychiatry (1979), 135 7-14


Depression /AnxietyDepression /Anxiety

Often due to uncontrolled painOften due to uncontrolled pain Appropriate and inevitable responseAppropriate and inevitable response A sign that distress needs to be A sign that distress needs to be

verbalizedverbalized Issues of pain, loss of control, Issues of pain, loss of control,

abandonment, and dependency are very abandonment, and dependency are very commoncommon

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


Dialogue Dialogue /Bargaining/Hope/Bargaining/Hope

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

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

Hope, even small hope is healthy Hope, even small hope is healthy and should be encouragedand should be encouragedStedeford, A Psychotherapy of the Dying Patient: British Journal of Psychiatry (1979), 135 7-14


AcceptanceAcceptance In the terminal phase, a patient’s heroic In the terminal phase, a patient’s heroic

attempts to maintain independence at attempts to maintain independence at all costs can cause harm to himself and all costs can cause harm to himself and to his relativesto his relatives

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

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


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

process of dyingprocess of dying Anxiety and Anxiety and

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

These two indicators These two indicators can serve as can serve as emotional barometers emotional barometers of “level of of “level of acceptance.”acceptance.”Larry Goldberg, MD Psychologic issues in palliative care: depression, Larry Goldberg, MD Psychologic issues in palliative care: depression,

anxiety, agitation, and delirium Clinics in Family Practice - Volume 6, anxiety, agitation, and delirium Clinics in Family Practice - Volume 6, Issue 2 (June 2004)Issue 2 (June 2004)

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

triad:triad:1. Unavoidable suffering 2. Guilt 3. Death 1. Unavoidable suffering 2. Guilt 3. Death

Logotherapy Victor FrakelLogotherapy Victor FrakelGuernica Pablo PicasoGuernica Pablo Picaso

Normal reactions Normal reactions

Shock Shock Apathy Apathy DepersonalizationDepersonalization Moral deformityMoral deformity BitternessBitterness DisillusionmentDisillusionment

Frankl, V. E. (1984). Man's Search for Meaning. New York: Frankl, V. E. (1984). Man's Search for Meaning. New York: Washington Square Press.Washington Square Press.

Existential ModelExistential Model

The human being is an entity The human being is an entity consisting of: consisting of:

1. Body (soma) 1. Body (soma) 2. Mind (psyche) 2. Mind (psyche) 3. Spirit (noetic core)3. Spirit (noetic core)

MeaningMeaning

Life has meaning under all Life has meaning under all circumstancescircumstances

People have a will to meaningPeople have a will to meaning People have freedom under all

circumstances to activate the will to meaning and to find meaning

Fredrich Nietzsche: Fredrich Nietzsche: ““He who has a why to live can bear with He who has a why to live can bear with

almost any how.”almost any how.”

Logotherapy: Socratic Logotherapy: Socratic questioningquestioning

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

Try to help client find a meaning within Try to help client find a meaning within his soma, psyche and noetic corehis soma, psyche and noetic core

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

Logotherapy: Pardoxical Logotherapy: Pardoxical IntentionIntention

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

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

Logotherapy: Pardoxical Logotherapy: Pardoxical IntentionIntention

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

Bill Davis: To check out. Bill Davis: To check out. Hunter Patch Adams: To shuffle off this mortal coil. Hunter Patch Adams: To shuffle off this mortal coil. Bill Davis: To head for the happy hunting ground. Bill Davis: To head for the happy hunting ground. Hunter Patch Adams: To blink for an exceptionally long period of time. Hunter Patch Adams: To blink for an exceptionally long period of time. Bill Davis: To find oneself without breath. Bill Davis: To find oneself without breath. Hunter Patch Adams: To be the incredible decaying man. Hunter Patch Adams: To be the incredible decaying man. Bill Davis: Worm buffet. Bill Davis: Worm buffet. Hunter Patch Adams: Kick the bucket. Hunter Patch Adams: Kick the bucket. Bill Davis: Buy the farm. Bill Davis: Buy the farm. Hunter Patch Adams: Take the cab. Hunter Patch Adams: Take the cab. Bill Davis: Cash in your chips. Bill Davis: Cash in your chips. Hunter Patch Adams: And if we bury you ass up, I have got a place to Hunter Patch Adams: And if we bury you ass up, I have got a place to

park my bike. park my bike.

Limitations of Limitations of LogotherapyLogotherapy

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

Viktor Frankl's Contribution to Spirituality and Aging By Melvin Viktor Frankl's Contribution to Spirituality and Aging By Melvin KimbleKimble

Limitations of Limitations of LogotherapyLogotherapy

Some critics reject Logotherapy as inadequate Some critics reject Logotherapy as inadequate and charge that Frankl is unable to deal with and charge that Frankl is unable to deal with people who have found life to be meaningless people who have found life to be meaningless (shock and denial phases of illness) “lack of (shock and denial phases of illness) “lack of empathy” “too much expression and not enough empathy” “too much expression and not enough support”support”

Viktor Frankl's Contribution to Spirituality and Aging By Melvin Viktor Frankl's Contribution to Spirituality and Aging By Melvin KimbleKimble

Interventions according Interventions according to phaseto phase

PhasePhase SymptomsSymptoms TreatmentTreatment

Diagnosis Diagnosis

(Newly diagnosed or(Newly diagnosed or

good prognosis)good prognosis)

Shock/DenialShock/Denial (educational)(educational)

(short term)(short term)

(supportive/interpretive)(supportive/interpretive)

RecurrenceRecurrence Anxiety/Fear/DepressionAnxiety/Fear/Depression (Patient issue driven)(Patient issue driven)

(long term)(long term)

(supportive)(supportive)RetreatmentRetreatment

Cure unlikely prognosis Cure unlikely prognosis of 2 or more years)of 2 or more years)

PalliativePalliative

No cure less than 2 No cure less than 2 years prognosisyears prognosis

DependenceDependence

AcceptanceAcceptanceMeeting dependency Meeting dependency

needs needs (supportive/expressive)(supportive/expressive)

Facilitating Facilitating disintegrationdisintegration

FI Fawzy: Psychosocial interventions for patients with cancer: what works FI Fawzy: Psychosocial interventions for patients with cancer: what works and what doesn't. and what doesn't.

Eur J Cancer. 1999 Oct;35(11):1559-64Eur J Cancer. 1999 Oct;35(11):1559-64

Focus not on the model but Focus not on the model but on the patienton the patient

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

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

Focus not on the model but Focus not on the model but on the patienton the patient

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

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

Self PsychologySelf Psychology

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

--Joseph D. Lichtenberg, MD, 18 August --Joseph D. Lichtenberg, MD, 18 August 19971997

Kohut’s Bipolar SelfKohut’s Bipolar Self

NarcisismNarcisism

Libidinal Cathexis

Narcisism refers to the “Libidnal cathexis of the self which holds Narcisism refers to the “Libidnal cathexis of the self which holds the self together, gives it cohesion which it relates to others” the self together, gives it cohesion which it relates to others”

(Kohut 1971)(Kohut 1971)

With a diagnosis of Cancer With a diagnosis of Cancer the self is fracturedthe self is fractured

Martha Brouwer Seattle, WA 98117

Narcisism vs Narcisism vs DeathDeath

Libidinal Cathexis

Decathexis

In the decathexis process of dying the libinial energy is In the decathexis process of dying the libinial energy is directed inward and there is a return to primary narcissism – directed inward and there is a return to primary narcissism –

Koppel 2004Koppel 2004

Implications for the dying Implications for the dying and those around themand those around them

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

This helps them prepare for the afterlife. This helps them prepare for the afterlife. The dying person’s withdrawal of energy The dying person’s withdrawal of energy

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

Koppel, M PhD : Pastorial psychology, Vol 53, No. 2 November Koppel, M PhD : Pastorial psychology, Vol 53, No. 2 November 20042004

Implications for the dying Implications for the dying and those around themand those around them

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

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

Koppel, M PhD : Pastorial psychology, Vol 53, No. 2 November 2004Koppel, M PhD : Pastorial psychology, Vol 53, No. 2 November 2004Kübler-Ross, Elisabeth. On Death and Dying. New York: Macmillian,

1969.Empathy and quality of care Mercer S.W.; Reynolds W.J. Source: British Journal of General Practice, Volume 52, Supplement 1, November

2002 , pp. 9-12(4)

Kohut: EmpathyKohut: Empathy

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

Lifelong ability to experience what Lifelong ability to experience what another person experiencesanother person experiences

Role of the therapistRole of the therapist

Therapists attitude a critical factor Therapists attitude a critical factor toward the healing process toward the healing process

Development and successful Development and successful communication of empathy is criticalcommunication of empathy is critical

2 Critical questions:2 Critical questions: What was it that my client was deprived What was it that my client was deprived

of and of and What could the therapist do about it?What could the therapist do about it?

To consider: Therapist role to provide To consider: Therapist role to provide or reflect the mirror? or reflect the mirror?

Kohut: Specific to death Kohut: Specific to death and dyingand dying

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

Kohut, H: How Does Analysis Cure? Edited by Arnold Goldberg with the collaboration of Paul E. Stapansky 254

pages, © 1984

Complexity and Complexity and interpersonal factors interpersonal factors

including therapist and including therapist and client imago of death and client imago of death and

cultureculture

C

T TD

CD

TC

CC

Imago of death from my Imago of death from my childhood childhood

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

The Penitente Brotherhood: Patriarchy and Hispano-Catholicism in New Mexico by Michael P. Carroll (Hardcover - Oct 9, 2002)

Common American Imago Common American Imago of death of death

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

Psychodrama: A Humanistic Approach to Psychiatric Treatment for the ElderlyBuchanan Hosp Community Psychiatry.1982; 33: 220-223

Imago of death from New Imago of death from New OrleansOrleans

Jazz funeral is a common Jazz funeral is a common name for a funeral tradition name for a funeral tradition with music which developed with music which developed in New Orleans, Louisiana. in New Orleans, Louisiana. The tradition arises from The tradition arises from African spiritual practices, African spiritual practices, French and Spanish martial French and Spanish martial musical traditions, and musical traditions, and uniquely African-American uniquely African-American cultural influences. The cultural influences. The tradition was widespread tradition was widespread across ethnic boundaries at across ethnic boundaries at the start of the 20th century. the start of the 20th century. For much of the mid-20th For much of the mid-20th century, the Catholic Church century, the Catholic Church officially frowned on secular officially frowned on secular music at funerals, so for music at funerals, so for generations the tradition was generations the tradition was largely confined to African largely confined to African American ProtestantsAmerican Protestants.Secundy MG Lit Med. 1989;8:100-5.Links

Coping with words and song: the New Orleans jazz funeral.Secundy.

Summary: Psychotherapy of Summary: Psychotherapy of the dying patientthe dying patient

The psychiatrist who provides The psychiatrist who provides psychotherapy for the terminally ill psychotherapy for the terminally ill needs to be something of a jack-of-all-needs to be something of a jack-of-all-trades, and the prospect might seem trades, and the prospect might seem dauntingdaunting

However, sophisticated psychotherapy is However, sophisticated psychotherapy is note as necessary as sensitivity, a note as necessary as sensitivity, a wiliness to follow the patient rather than wiliness to follow the patient rather than lead him, some knowledge of the lead him, some knowledge of the psychology of dying and the ability to psychology of dying and the ability to accept the inevitability of death.accept the inevitability of death.Stedeford, A Psychotherapy of the Dying Patient: British Journal of

Psychiatry (1979), 135 7-14

Therapy in cancer patients at the end of life Marcus James Fidel, M.D. PGY 4 University of Oklahoma...

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