Abstract
The Journal of Palliative Medicine is pleased to be the home for a special series of articles exploring psychologically rich, or psychologically informed, palliative care. The article by Brenner and Rosenberg et al. in this issue sets the stage for the series by outlining what they see as the psychological aspects of palliative care. This excavation of the psychodynamic workings of palliative care is based on their collective years of clinical experience, program development, and high-quality research at the intersection of palliative care and psychology. Indeed, several of the authors of this article, which summarizes and analyzes a two-day interdisciplinary seminar at Radcliffe Institute for Advanced Study in May 2019: “Healing Beyond the Cure: Exploring the Psychodynamic Aspects of Palliative Care,” have been at this intersection for some time, leading and elucidating palliative care's relationship with psychology. It is thus with great delight that I have this opportunity to reflect on what my colleagues, teachers, and friends have taught me and continue to share with the wider palliative care community.
In short, the authors have recognized that palliative care practice—specifically, integrated outpatient palliative care practice—contains critical elements that can best be described using the discourse of clinical psychology. Moreover, the psychological aspects of palliative care may explain the profound benefits patients and families received in the landmark Temel et al. NEJM study. 1 A secondary analysis of the results of that study suggested that differences in adaptive coping may be the “mechanism” responsible for the positive outcomes. 2 If this is the case, then strategies to understand and better utilize psychological approaches to improve patient and family coping would further improve outcomes with palliative care involvement.
The psychological anchor for understanding human coping in the face of a terminal illness can be found in the writings of Avery Weisman (1913–2017), an eminent Harvard psychiatrist and researcher. Dr. Weisman described the cognitive state of “middle knowledge” as one in which a terminally ill individual cannot yet completely comprehend their mortality. His study elucidates the complexity of the denial of death and how we cope with our mortality. As Bill Breitbart, writes in On the Inevitability of Death, in 2017 after Weisman's death: “This concept of middle knowledge was important for several reasons: it suggested the benefits of denial in preventing us from being overwhelmed by death terror, thus allowing us to assimilate and even accommodate the reality of our deaths at a manageable pace, and it suggested that human nature and biology utilize denial in complex ways that are not uniformly detrimental to the process of dying.” 3 Palliative care providers enter this hidden place with our patients, so we should become familiar with its contours and psychological elements.
Rosenberg and Cramer et al.'s article gives us a tour through this terrain highlighting the key psychological aspects of how palliative care can support our patients' coping and the future implications of this study. They emphasize that relationships matter and are at the heart of our therapeutic practice. They point out that it is the empathic connection palliative care clinicians bring to the encounter that facilitates a “healing alliance between the patient and clinician, where the patient experiences feeling known and understood.” They describe how palliative care clinicians support patients in their anticipatory grief work as they face the end of their lives. They describe how palliative care providers help patients work through the dialectic of living well while acknowledge dying, incorporating constructs of prognostic awareness and hope. They point out how our patients' coping strategies and attachment styles before their illness affect their illness experience and how we can learn skills to support our patients' current coping and potentially offer them other strategies that may become necessary. They emphasize the nature of resiliency of palliative care providers, that we keep coming back, even if initial attempts had not gone well, and how this has important emotional effects on the patient. Lastly, they highlight the impact that early integrated palliative care can have on the referring clinician—helping them work through an emotionally difficult case, experiencing vulnerability and loss together, and even allowing the relationship between the patient and referring clinician to be supported and more connected. In short, we learn about the many ways that the practice of palliative care involves itself in the collective emotional work that needs to take place when a patient is facing their mortality in the context of a serious illness.
This psychological terrain will be further explored in subsequent articles in the Journal. However, I suspect that we will need additional expeditions to fully map out what is concealed from our current view. The authors point out that their analysis is limited by its lack of geographic as well as racial and socioeconomic diversity. Indeed, understanding the impact of trauma, systemic racism, and poverty on coping with a serious illness, especially in historically oppressed and marginalized communities, is missing from this overview. Some have argued that palliative care should align itself with elements of trauma-informed care, especially as we grapple with the increasing recognition of collective trauma in many communities made more salient during the COVID-19 pandemic. 4 Resource constraints, cultural factors, and other social and political forces all affect the conditions in which we practice palliative care and should be considered in the research, education, and clinical integration of psychologically informed palliative care, so it can best be adapted, refined, and integrated for more diverse communities and environments.
Furthermore, might we consider including the integration of psychedelic-assisted therapy (PAT), which has been suggested in these pages,5,6 as another tool in the psychological armamentarium of palliative care. PAT offers a potentially alternative mechanism for what may explain the healing that occurs in the face of dying. Studies investigating PAT in patients with cancer have found an interesting correlation between the intensity of the subject's mystical experience and dissolution of the ego, with the psychological benefits of the therapy, including reduction in depression and death anxiety.7,8 This ineffable experience seems to enable subjects to acknowledge death without the inherent terror and anxiety that may be too overwhelming, like staring too long at the sun, as Yalom 9 puts it, depriving us of happiness and fulfillment. The current state of the science suggests a psychospiritual mechanism of healing closer to what Carl Jung described. That it is the numinous—the arousal of “spiritual awe” and dissolving of our ego—that is the cure for our psychoexistential distress.
Lastly, if we wish to fully unlock the healing potential of our multidisciplinary palliative care practice, allowing patients (and ourselves) to be at peace with things as they are, then we may wish to go beyond the psychological terrain and explore the rich landscapes of religious and spiritual care, including that of indigenous peoples and diverse cultural traditions, contemplative practice, and the integration of body-centered or interoceptive awareness.
Perhaps a psychospiritually informed palliative care is next.