Introduction: psychotherapy with terminally ill patients.

"Illness is not simply a personal experience; it is transactional, communicative, profoundly social." (1, pp. 185-186) Continued progress in treating pain and depression with medication has enabled us to keep seriously and terminally ill patients comfortable. The papers in this section illustrate the value of another procedure, psychotherapy, based upon the view of terminal illness as a biopsychosocial event. Kubler-Ross (2) demonstrated as much when she found that dying patients respond to an interviewer who listens and is interested in them. Kleinman's (1) similar belief was based upon his own experiences as a physician who became a patient. The following contributions to psychotherapy with the terminally ill include a variety of treatment modalities; individual, group, and a combination of individual and family therapy. Mindy Greenstein Ph.D., and William Breitbart M.D., (pp. 486-500) describe a program for group psychotherapy with oncology patients, based upon Viktor Frankl's teachings on the universal need for meaning. Their contributions have broad implications. Everyone with a terminal illness is dealing with the last stage of life, but all people are confronted at one time or another with the meaning and purpose of life. The need for meaning applies to all the psychotherapies, and to all populations. Dr. Greenstein (pp. 501-511) describes eight sessions with a group of patients with advanced cancer, in which the experience and process of meaning-focused therapy came alive. When a terminally ill patient is offered psychotherapy, there is a nonverbal message that they are still alive and worthy. In the group psychotherapy interaction described in Greenstein's paper, there was a mutual reinforcement by the patients of such life-oriented experiences. The need for meaning not only applies to the terminally ill. Patrick A. McGuire (3) reported an impressive success rate in the treatment and even cure of chronic schizophrenics, provided with psychiatric rehabilitation. The definition of recovery, according to William A. Anthony, director of Boston University's Center for Psychiatric Rehabilitation, was "the development of new meaning and purpose as one grows beyond the catastrophe of mental illness" (p. 25). The emphasis upon meaning brings the two dreaded conditions of terminal illness and schizophrenia, into the realm of hope and integrity. The therapeutic experiences at the end of life are consistent with the description by Erikson (4) of the major life task and crisis at the last stage of life, as disgust and despair or else ego integrity and wholeness. Within that framework, Thomas A. Caffrey, Ph.D., (pp. 519-530) describes the development of a therapeutic relationship with Bruce, a Viet Nam veteran, with a posttraumatic stress disorder precipitated many years before by the death of a fellow soldier in combat. The patient was also HIV positive and suffered from heart disease. With the help of Caffrey, Bruce moved from a state of disgust and despair, to ego integrity, and a resolution of major crises at the end of his life, including a dramatic resolution of his posttraumatic stress disorder. The therapist's emphasis was on being a presence, with the assurance that the patient would never be abandoned. Caffrey's approach resembled the experiences described by Hagglund (5) a physician who also helped terminally ill patients move from a state of disgust and despair to ego integrity and acceptance. She conducted individual psychotherapy in Finland with five terminally ill and emotionally distressed patients, all in the last days or weeks of their lives. Michael St. Clair, Ph.D., (pp. 512-518) describes an unusual situation involving combined individual and family therapy for a dysfunctional and enmeshed family, where a series of deaths necessitated changes in the treatment process. Enmeshed families stubbornly maintain their dysfunctional pattern. St. Claire convincingly argues for the importance of understanding attachment bonds throughout the life span, even to the end, not only for the ill or dying patients, but for the heritage they might hand down. …