Abstract
The psychoanalytic tradition offers important insights into the emotional experiences of patients and their providers. Palliative care clinicians routinely consider mental health issues during patient encounters, but rarely focus on understanding serious illness from the psychoanalytic perspective of a unique life crisis. In this compilation of essays, Norman Straker of Memorial Sloan-Kettering Cancer Center and his colleagues offers helpful perspectives into the widespread death anxiety that affects individual health care decisions as well as large-scale policy imperatives. Straker argues that clinician discomfort with issues of death and dying may lead to strained patient communication, inappropriately aggressive treatments, and health care systems that are predicated on extending longevity with less concern for quality of life and meeting individual goals.
The book is composed of twelve essays, four of which are written by Straker. Several are jointly written by small groups of psychiatrists from a variety of academic institutions. The book is structured into three sections attending, respectively, to medical issues, psychoanalytic aspects, and case presentations. The essays are a blend of historical perspectives, literature reviews of psychoanalysts grappling with the therapy of seriously ill patients, and personal narratives of illness and resulting psychological accommodation.
In the first section Straker provides historical perspective on the relation of psychoanalysis and end-of-life care. He references psychiatrist Irvin Yalom, who observes that “it took a supreme effort of inattention for Freud to have omitted death as a precipitating factor [for the patient distress seen in his classic case studies from the early 20th century]” (p. 38). Straker observes that although death anxiety may lie below the surface, a therapist's “calm demeanor can create a holding environment that allows for an exploration of all the issues that confront dying patients” (p. 40). As palliative care clinicians, it is exactly this “holding environment” that we seek to create for our colleagues, patients, and their loved ones.
Several essays describe an oscillation between attending to the proximate psychological stressors of illness with allowing for, but not insisting upon, exploration of one's emotional biography through therapy. Straker promotes an understanding of the seriously ill patient as one who “lives with uncertainty” but is not consigned to the role of a “dying person.” This complicates the role identity of palliative care patients in a potentially helpful way by fostering a flexible prognostic awareness for both provider and patient. Psychiatry has developed what Straker refers to as a “pendulum view,” where patient experiences and identities are “fluid, shifting, and multiple” (p. 66). He quotes psychatrist P. Bromberg who writes that the “challenge of authentic self-awareness in the face of mortality depends on the individual's capacity to tolerate the ongoing dialectic of different self-states” (p. 66). This psychiatric approach mirrors the efforts of palliative care and social work to support patients as they slowly develop prognostic awareness through the transitional phases of diagnosis, treatment, advance care planning, and end of life.
One prominent theme across multiple essays is the optimal use of the psychoanalytic frame for patients with terminal illness. In the literature review by Straker as well as several of the narratives by therapists there is a tension between adherence to a classic analytic model and use of a more flexible approach that meets patients where they are in terms of physical limitations and time constraints due to prognosis. This complexity mirrors a tension in palliative care between defining a patient's story through a biomedical lens versus a more integrated psychosocial perspective. Straker advocates for a “commonsense approach” that is both flexible and active, responding to needs while encouraging the possibility of emotional growth at the close of life. While coping with a life-limiting illness, a patient of psychiatrist Alison Phillips described the personal insights gained in her analysis as “a luxury…like allowing yourself hot chocolate” (p. 119). Phillips describes those psychotherapeutic sessions as intensive occasions of treatment not unlike chemotherapy; carefully titrated to intended effect without overwhelming the patient. She views patient defenses as potentially helpful supports and means of survival as opposed to obstacles to self-awareness. Rather than a clinical relationship “without limits,” the psychiatric frame can introduce helpful boundaries that may be applicable to the “extra layer of support” concept introduced in recent years to characterize palliative medicine. The psychoanalytic approach introduces a time-tested model for structuring clinical relationships, possibly applicable to palliative care, which is both flexible and responsive to patient circumstances.
The personal essays in the book provide robust accounts of clinicians challenged by life-threatening illness. Drs. Birger, Swiller, and Straker describe the psychiatric project as an attempt to “detoxify death” within the setting of their medical crises. The narratives offer emotional ballast to the more technical discussions of analytic and philosophical approaches to the problem of “nonbeing.” Although illness journals written by the public abound in the popular press, the stories in the book are crafted by highly attuned observers of human emotion. The reader is provided with a unique opportunity to peer inside varying states of existential threat, guided by analysts of superior psychological insight. Relying on their own objective reports of subjective experiences, the illness narratives demonstrate the importance of maintaining intact defenses to manage the dread and anxiety incumbent in these situations.
On the whole, the text is succinct, well written, and wide ranging in its sources of knowledge while staying grounded in psychiatric theory. Palliative care clinicians will likely find this book to be interesting and helpful. The issue of deciding the optimal use of the psychoanalytic frame (and which rules to break) has relevance for palliative care consultants who often navigate the difficult waters of end-of-life decision making. The psychiatric perspective featured in the book provides palliative care clinicians with a refreshing approach to understanding complex psychodynamics in various clinical settings. The personal essays as well as case presentations are bracing in their honesty and are invaluable sources of insight for all who care for seriously ill patients.