Abstract
Patients facing serious illness may respond to distressing medical information with avoidance or denial, limiting their ability to engage in values-based decision-making. Exposure therapy—an evidence-based psychological treatment for anxiety disorders—offers conceptual tools that can inform communication and therapeutic approaches with patients who struggle with avoidance in the context of serious illness. This article describes the care of a patient with advanced cancer who declined prognostic and hospice conversations due to death-related anxiety. Drawing on core exposure therapy principles—including safety, individualization, titration, and enhancement of coping—we illustrate how serious illness communication strategies can be intentionally adapted to support patient engagement, reduce distress, and strengthen psychological resilience. Through techniques such as progressive disclosure, calibration of language potency, and the “container” metaphor, clinicians can match communication to patients’ emotional readiness, enhancing tolerance over time. Integrating exposures-informed approaches into palliative care practice helps bridge the gap between emotional avoidance and values-concordant care.
Keywords
Introduction
A substantial body of psychological and behavioral literature supports the efficacy of exposure therapy in helping patients to confront fears in a manageable way.1,2 Exposure therapy reduces patient distress or avoidance by exposing them gradually to a feared stimulus in a controlled manner. Over time, as individuals develop new learning about the source of their fear and increase their capacity to cope and regulate their emotional responses, situations that previously felt intolerable become more manageable. 2
While some patients with serious illness are equipped to process the information being shared with them, many patients experience this task as highly distressing. To prevent emotional overwhelm or dysregulation, they may exhibit behaviors of avoidance (e.g., refusing to have certain discussions or meet with certain clinicians) or even denial (e.g., clinicians may wonder why patients aren’t “understanding” what has been told to them). 3 In these situations, by conceptualizing overwhelming medical information as the “feared stimulus,” clinicians can apply exposure therapy principles to serious illness communication (SIC). 4 Integrating psychotherapeutic concepts into palliative care has been highlighted in prior scholarship as a means to enhance communication, coping, and clinician effectiveness. 5 This article is the first in a nine-paper series on psychotherapeutically informed SIC.
Case Description
Ali is a 55-year-old cis woman with metastatic ovarian cancer. Ali’s team is worried that her prognosis is shorter than she realizes. While they are willing to offer another round of cancer-directed treatment, they wonder whether the harms may outweigh the benefits. They want to ensure that Ali has all of the information that she needs in order to make care decisions most aligned with her values. However, the team has noted a pattern of missed appointments, particularly those involving discussions about goals of care. 6 When the team asks permission to give Ali more information about what hospice services entail, Ali declines, stating, “that’s not something I need right now.” When the team offers to share prognostic thoughts, Ali again declines, stating, “Nobody has a crystal ball. Your guesses wouldn’t be useful to me because new discoveries happen every day and odds are defied every day. I prefer to focus on the positive and keep my spirits up in this fight.” 7
Discussion
The possibility of dying does not feel tolerable for Ali to consider at this point, leading her to avoid any discussions or topics that even trigger awareness of her mortality or intensify death anxiety. 8 While not every patient needs to directly process their mortality, Ali’s level of avoidance is jeopardizing her ability to make values-based choices about her medical care, and ultimately about how she wants to spend her remaining time.
To support Ali in processing her medical realities in a more tolerable way, clinicians can draw upon exposure therapy principles to inform SIC techniques tailored to her psychological needs.3,6,9
Exposure therapy principles
Exposure therapy example: A patient who fears flying may co-create a hierarchical list of exposures with their therapist, where the patient determines the assigned intensity rating of each step (e.g., the patient may rate looking at pictures of planes 3/10 intensitybut boarding an actual plane 9/10 intensity). Together they will select a moderate intensity exposure (3–4/10) that the patient chooses to take on with support.
Exposure therapy example: With two patients who have a fear of flying, one may have notable anxiety just looking at a picture of a plane, while the other may only start to feel anxiety rise when stepping onto a plane. Different starting points would be indicated.
Exposure therapy example: A patient who fears flying might first look at pictures of planes, then watch videos of planes taking off, then watch real planes take off, then take a shorter flight with a loved one, until reaching the step of successfully tolerating a longer flight alone. Pacing may depend on both internal factors (e.g. motivation level) and external constraints (e.g. a scheduled flight date).
Exposure therapy example: If a patient with a severe fear of flying were forced onto a plane, they may become flooded with distress and deem the possibility of ever flying as impossible. The act of working through their hierarchy of exposures, learning to tolerate things that are uncomfortable but not completely overwhelming, allows them to incrementally strengthen their coping mechanisms and emotional resilience over time, such that when the exposure of actually getting on a plane comes, they are far more prepared to tolerate it.
Mapping exposure principles to SIC strategies
When certain medical information triggers thoughts or feelings that are experienced as overwhelming or even intolerable by patients, that information can be conceptualized as the “feared stimulus.” Clinicians can support patients in discussing their medical situation in a psychologically tolerable way, helping patients developing new learning that they can indeed tolerate engaging with this information. While operationalized exposure therapy would be outside of the scope of general palliative care practice, Table 1 illustrates how core exposure principles can helpfully guide our nuanced use of SIC strategies.
Applying Exposure Principles to Serious Illness Communication
SIC techniques aligned with exposure principles
In a case like Ali’s, communication strategies can support coping and deepen cognitive integration of her distressing circumstances. When considering the large arsenal of SIC communication skills available in HPM, Ali’s team can mindfully select and employ techniques, skills, and strategies that align with evidence-based exposure therapy principles,4,13,15 such as the following:
It makes sense that these decisions feel overwhelming. Right now, we’re in information-gathering mode. Our only job is to get a sense of what different care choices might look like. We’re not needing to make a decision or commitment today. If you find yourself getting overwhelmed thinking many steps ahead, remind yourself that our primary goal now is just simply to gather information that may help guide your care. We’re also here to understand what matters most to you—what you most hope for, and what you most hope to avoid.
It must be so hard to tolerate the uncertainty of this situation–uncertainty about what the future holds, as you hope for the best and try to focus on the positive, while also wrestling with worrisome possibilities.
“Uncertainty” and “worrisome possibilities” are lower potency words than “terminal” and “die.” Once a patient strengthens their ability to tolerate these lower potency words, a clinician can then up-titrate to medium potency words (e.g., “time may be shorter than we hope,” “stops responding,” “continues to worsen”), knowing that over time the patient will be more psychologically prepared for titration to higher potency words (e.g., “terminal,” “die”). 17 While the use of less direct terminology would not be appropriate as a way to deceive patients or to manage our own discomfort with a topic, in a case like Ali’s, it can be mindfully implemented as a way to introduce difficult topics at a manageable potency.
I cared for a patient a few months ago who was such a focused, capable problem-solver at baseline; it was hard for them to imagine their identity if they weren’t trying the most aggressive treatment options possible. I wonder if that is a feeling you relate to?
Rather than directly suggesting that Ali consider different types of treatment options, the clinician presents the situation through someone “other” and with a “wonder,” which decreases its intensity and increases its tolerability.6,17,18
It sounds like you’re not yet at the point of wanting to hear about hospice. I’m curious how we will know when the right time to talk about some of their services will be? Do you have any thoughts on what might signal to us that it may be time for that conversation– maybe it will be a point when your body starts to feel certain symptoms or a point when you are surrounded by the people you would want present?
This technique plants seeds upstream that increase a patient’s future readiness for exposure to information. When faced with an overwhelmed patient such as Ali, clinicians may sometimes feel the urge to delay sharing difficult information until absolutely necessary in order to “spare” distress. However, planting these seeds early often reduces patient distress over time by gradual desensitization.17,19
Framing a conversation: I know that these discussions can sometimes feel too difficult to think about. One strategy we might use is imaging that we have a box. We can take pieces of this difficult topic out of the box to look at it together briefly, then put it back in the box when we feel like we have discussed it enough for the day. We don’t have to keep the box open for very long and you can control when we open it and for how long.
Checking in mid-conversation: We talked about some really important elements of your medical situation today, as well as clarifying some of the priorities that are most important to you. Would it be helpful for us to keep exploring what different care paths could look like, or would you rather put it back in the box for now?
Responding if signs of emotional overwhelm arise: This has been a lot to think about, and you bravely shared some really important feelings. We don’t have to do it all at once. We can put this back in the box for now and revisit it when you feel ready.
Conclusion
Exposure therapy principles can be readily applied to SIC to help patients incrementally integrate and cope with distressing topics and information. Since patients have unique coping profiles, clinicians are tasked with adjusting to different psychological needs.3,9 If distress from medical information becomes a significant barrier to quality-of-life or engagement with values-based decisions, exposure-aligned communication may be particularly beneficial. Clinicians can remain mindful of patient goals when utilizing these techniques. Not all patients need to integrate all pieces of information about their illness, but a clinician may thoughtfully increase exposure to support patient coping, decision-making and preparation for future events.6,7,17
Consent to Publish
All cases presented in this series are hypothetical composites developed for illustrative and educational purposes. They do not represent real patients, and therefore, consent to publish was not required.
Footnotes
Author Disclosure Statement
No competing financial interests exist.
Funding Information
No funding was received for this article.