Abstract
Dear Editor:
Life-limiting illness adversely affects the psychological well-being of patients and families. Dignity therapy (DT)1,2 has effectively addressed psychological and existential suffering among patients with life-limiting illness. DT focuses on illness-related concerns, psychological and spiritual issues concerns, and social aspects of care and support impacting dignity. Family therapy (FT) has also demonstrated efficacy in treating psychological distress among families coping with chronic illness. 3 Conjoint treatment of these two interventions may offer greater opportunity for nuanced discussions that promote ego integrity, psychological growth, family coping, and illness acceptance. We present a case example of the feasibility and utility of concurrently delivering DT with FT to match the psychological needs and physical functioning of a patient with life-limiting illness and depression. A solid case conceptualization that accounted for the patients' specific needs guided treatment adaption and implementation.
Cameron, a 53-year-old, Caucasian married man with adult children, was diagnosed with multiple sclerosis in his early 30s. With total care needs and use of only his right hand, he entered a skilled nursing facility in his 40s. At 50, Cameron was diagnosed with an aggressive soft tissue cancer, underwent radiation, and was referred to psychology for adjustment to life-limiting illness. Psychological intake revealed that Cameron was an intelligent, resilient man who coped by using humor and social engagement. Losses related to independence and protector role affected his feelings of dignity and purpose. Although he was self-sacrificing for his family, he had concerns about being a burden on his wife. Thus, DT was chosen to promote dignity and meaning, and FT was used to address perceived sense of burden and mutuality.
Twelve DT sessions and nine FT sessions were completed at bedside. Adaptations included a voice amplifier (because of Cameron's dysphonia) and audio-recorded (instead of written) generativity product. His life history, roles, accomplishments, advice, and legacy were discussed. He reconnected to “mental toughness,” which lessened emotional avoidance of fear and sadness. Given his wife's interests in the arts and tendency to emotionally avoid unwanted emotions, a life book was used to emotionally connect and process loss related to Cameron's illness and included pages with photographs representing life themes (e.g., independent identities, courtship, and parenthood). Post-treatment, Cameron and his wife evidenced improvements on measures of meaning, mutuality, and care recipient and caregiver burden, respectively. He reported reduced depression symptoms; she reported higher life satisfaction. Both reported high satisfaction with treatment, greater willingness to discuss distress, greater acceptance of health change, and improved adaptability to change.
This is the first case study reporting on the feasibility and utility of (1) concurrently delivering DT and FT and (2) adapting DT to match the patient's level of physical functioning and psychological needs. Disability and comorbid mental health concerns need not preclude patients from engaging in DT. Clinical judgment should be used when adapting treatments to meet patient needs and care, while also conserving treatment fidelity as best possible. Furthermore, clinicians should consider the time commitment involved in effectively and appropriately adapting DT before beginning treatment.