Member Contributor — Anne Front, LMFT, APHSW-C

Palliative Care Psychotherapy

Being diagnosed with, and living with a serious, life-limiting health condition is not only physically challenging, but an emotional journey. As a palliative care psychotherapist, my patients report psychological distress related to the shock and processing the illness. From the moment of diagnosis, patients realize their life is forever changed. They will go through painful or laborious medical treatments. They will need procedures or take medications that often have cumbersome side effects. There will be changes in daily life whether it be missing out on family activities, taking time off from work or needing help for their care. They are, smack-down, faced with the realization that someday, they will die.

Okay, we all know that we are going to die. We’ve been to funerals. We have lost loved ones. We read books and watched nature teach us about the cycle of life. Yet most of the time, we live in a delusion of immortality. We live in a death-denying culture. Consider what we watch on television and film. Fast-action heroics during medical dramas or Marvel films show us that when a person gets close to death, they will live. In real life, sophisticated medical interventions are now available. Many diseases that our grandparents were plagued with are now either no longer in existence or have curative treatments. Serious illnesses such as cancer, kidney failure, AIDS, cardiac disease, and others now have interventions that often change a terminal prognosis into a chronic illness.

In addition to the death-denying culture that we live in, many Americans have not planned for illness. People have limited support systems or are not accustomed to asking for help. According to CNBC, 56% of Americans could not cover an emergency $1,000 bill with savings. The threat of not being to financially support their family due to serious illness can be highly distressing. People may not be prepared for high deductibles or their medical insurance not covering private caregiving which they may need as their illness progresses.

I have had the privilege to work in private practice and on palliative care teams. Palliative care is a support services for patients and families who are dealing with serious illness. It focuses on symptom management for total pain – physical, psychological, social, spiritual, and existential. It is available at any stage of illness from new diagnosis throughout curative treatment, and as patients transition to end of life. Palliative Care is often confused with hospice. Hospice is a model of care which is provided in the last six months of a person’s life. Palliative care is upstream and available throughout the entire illness, not just the end.

Palliative care teams treat the patient in the context of the family unit. As Marriage and Family Therapists, we know that people do not respond in isolation of others. Someone once said that “the family is the second patient, and sometimes the first.” There are often strong emotions of anxiety, fear, anticipatory grief and questioning about mortality and purpose. Palliative care teams work with the patient as well as the loved ones and caregivers to provide strong support as they cope with the illness and plan for the future.

The holistic support provided under the palliative care model is an important part of quality care for patients. Because palliative care emerged as a medical model, the key team members follow the structure of a typical medical team. Physicians and nurse practitioners often form the leadership of the team, followed by nursing, social work, and chaplaincy. An important team member is missing in the medical model – the psychotherapist. While social workers provide psycho-social care that is essential, due to time and caseloads, there may not be significant time available to attend to the intense emotional needs of the patient and loved ones. Many patients who are going through serious illness benefit from a psychotherapist on the team.

Palliative care psychotherapy focuses on the complexity of emotions while going through serious illness. It provides a safe space to talk about difficult subjects including experience of trauma during medical treatments, grief, loss of self-identity, planning and preparing for death. It supports loved ones as they cope with caregiver burden and anticipatory grief. My outpatient care team often partners with psychotherapists to round out the care. With the patient authorization, care needs can be addressed quickly and appropriately between palliative care team members and the outpatient psychotherapist. As a private practice palliative care psychotherapist, I use my systems lens to advocate with the medical care team to support my patients.

Palliative care psychotherapists lean into the distress patients experience. Assessing for medical trauma, opening dialogue about finances and advance care planning are excellent ways to dig into distress points. I often ask patients “what keeps you up at night?” This question cuts straight to intense fears and anxieties that can be processed through. Asking direct questions about advance care planning is essential. Does the patient have an advance care directive and a durable power of attorney for medical decisions? Do they have preferences about emergency medical treatments such as use of CPR or going to the hospital? Have they discussed their health care wishes with their medical providers? How do they define quality of life? When would they choose quality of life over quantity of days?

Leaning into heavy discussions such as illness and mortality requires palliative psychotherapists to face their own mortality. How do you feel about illness and dying? Are you prepared for the possibility that you might get sick, not be able to work, need help or go through traumatic medical treatments? Have you completed advance care planning documents or financially saved for emergencies? What end-of-life decisions you would make if you were dying? It’s hard to ask our patients these questions if we haven’t gone there ourselves.

Palliative care psychotherapy work is sacred. We walk with people who are experiencing painful experiences, we listen to suffering and we provide comfort at the deepest level. Reminding people that they are more than just their illness, they are people first and patients second, allows them to get back to center. Creating a safe space for patients with serious illness and their loved ones is a gift, a flashlight along a darkened path. It offers opportunity to make sense of what they are going through, process loss and prepare for the future. Knowing that they do not have to journey alone can move a seriously ill person from suffering to finding peace .

Anne is a Licensed Marriage and Family Therapists and Advanced Palliative and Hospice Social Worker. She is in private practice in Studio City. She works on the outpatient palliative care team at Motion Picture Television Fund and an affiliate faculty member at California State University Palliative Care Institute and teaches social workers and mental health professionals at the post-graduate level. Anne is a published author and national educator on advanced health care planning and palliative care.. Website: www.annefront.com, Email: anne@annefront.com