Psychotherapy with Dying People

The professional literature often does not make enough distinction between psychosocial care and psychotherapy. Most professional caregivers are primarily concerned with psychosocial care rather than exploration of the mind. The primary goals of psychotherapy with dying people are to help people understand the complex psychic activity they are experiencing, to help them see how these unseen forces affect conscious behavior, and to help them achieve the highest possible level of mindful self-awareness and centered presence prior to death.

Therapists often rely upon abstract models of "stages of dying" such as the popular five-stage model popularized by Elisabeth Kubler-Ross. John Bowlby's four-stage model of grief is less well known by the general public but forms a good basis for much general work with issues of loss.

Getting one's affairs in order includes working through deep emotions with friends and loved ones, including dealing with grief and bereavement. Unresolved family issues may become very urgent, with old memories and regrets pushing to the forefront. It is a time to say goodbye, and there is little time to waste. People may need help finding ways to say their goodbyes in an appropriate manner. The importance of saying goodbye cannot be stressed enough from the point of view of preparing for a successful bereavement process in the survivors.

Psychologists who work with transpersonal paradigms may also find themselves talking about issues such as meaning, value, and the ongoing realities of being. These topics occur often in everyday conversation with dying people, and cannot easily be excluded from a professional therapeutic model. Some transpersonal psychologists such as Kathleen Singh are open to defining some of these changes in spiritual rather than purely psychological terms. Regardless of their own personal opinions regarding transpersonal content, professional therapists must recognize these themes when they occur and must be capable of responding to them in an appropriate way.

Another hallmark of work with dying people is that conversations may become more difficult for the therapist because the speech or thematic contents of the dying person's statements are simply hard to understand. The remarkable book Final Gifts by hospice nurses Maggie Callanan and Patricia Kelley discusses the changes which take place in communication patterns at the end of life and point out that dying people often use metaphorical language and seemingly irrational statements in ways that may have great meaning if the observer understands the context within which this communication is taking place. In some cases organic changes in the brain, circulatory system, or other physical states may interfere with clear thinking, as explained in the book How We Die by physician Sherwin Nuland.

Therapists must be open to and be able to converse appropriately about certain predictable content themes driven by practical concerns. For example, it is normal and important for a person to express preferences about health care at the end of life. Failure to talk openly about such matters may be a sign of denial. Therapists can be helpful by encouraging their clients to create written advance directives including naming a trusted party to have durable power of attorney. There is often conflict within families about what to do when conditions become grave, and having a clear expression from the dying person is helpful to everyone.

The professional therapeutic relationship may become a safe space to consider practical decisions such as choosing home or hospice care as an alternative to a hospital setting. During the course of therapy a person may also express preferences for death with dignity, palliative care, and pain management. There are also issues around planning funeral and memorial arrangements. The extent to which such practical matters will enter into the therapy relationship should be considered in advance by the therapist, who must also be ready to help the person work through the issues that will affect their decisions.

The decision to end one's life when death is approaching anyway is sometimes called self-deliverance, rational suicide, or voluntary euthanasia; this is a special case of the more general topic of suicide. The "right to die" is the subject of controversial legal battles on an international scale. A therapist must be prepared to respond to right to die issues if the dying person raises them. The person may consider these difficult topics "taboo" and may hesitate to raise them even if they are actually a source of great concern. Therapists must be careful to create a non-judgemental atmosphere that will allow this difficult content to emerge if it is part of the dying person's mental processes.