Mental Health in Terminal Illness, Expected Loss, and Grief

The majority of life is experienced as unencumbered, free of multiple hospital visits, and without a death sentence in the near future.   With the advancement of modern medicine, more individuals are being diagnosed with illnesses that require treatment, resulting in quality of life questions, loved ones becoming caregivers, and the urgency to take care of one’s estate.   These stresses add up very quickly following the discovery of cancer, auto-immune diseases, organ failure, stroke, and many other issues that affect general health.  Understanding the interconnectedness of physical and mental well-being, therapy offers services at multiple stages of the terminal illness process.  Mental health treatment can be geared toward those who are terminally ill and everyone involved in their care.  Therapy may aid in each of the following periods: the initial shock of diagnosis, coping with treatment, accepting limits in the face of exhaustive measures, and grieving post-departure. 

Exposing misconceptions may be a key to offering more psychological services to those suffering from terminal illness and their loved ones.  There seem to be a few common misconceptions that confine treatment attitudes to physical health and disallow the integration of mental health.  Do the following misconceptions sound familiar?

1. I am already going to the hospital too much so therapy is not how I want to spend my free time.

Negative attitudes towards treatment, whether in a psychotherapy office or hospital, are defensive scripts that get handed down through family, media, and culture.  The truth is, mental acuity can be kept in tact regardless of most physical conditions.  The despair that often accompanies terminal illness may best be treated by preparing quality of life goals in therapy.  Caretakers can prepare for a provision of care without future regret.  Most caretakers are not well versed in weighing work, self-care, family, and caretaking responsibilities.  Therapy allows caretakers to identify how they can best spend the remaining time they have with their loved ones while being able to work on their individual functioning in the here-and-now.  Terminally ill individuals can maximize the potential of whatever time in life remains.  Existential questions come up for those who are diagnosed as terminally ill, yet they often feel isolated with no one to talk to.  Therapy normalizes their experience, providing the space to process end-of-life issues.

2. Grief is only experienced after a death. 

Though loss is most significantly related to death, there are multiple types of loss that can be effectively treated with grief work.  Multiple identities and parts of the self can be experienced as lost, including work, sexuality, physical fitness, social life, aspirations and goals, spirituality, emotional regulation, family roles, and mental states.  Therapy often provides services beyond the identified patient, treating caretakers (e.g. nurses, spouses, children, parents) and their anticipated loss.  Loss is not purely a linear experience.  Losses may be complex with the delay of individuality caretakers experience from putting their own lives on hold in order to care for their loved ones, combined with the anticipation of then handling post-departure duties and uncertainties.  In addition to therapy being able to treat caretakers’ anticipated loss, there is most likely a thoughtful dialogue that terminally ill individuals want to undergo but may feel guilty about putting others through.  Proper timing, forgoing last minute confessionals in favor of forgiving the self, and attributing meaning to life’s events are all enhanced through therapy. 

3. If I don’t dwell on the disease then it won’t have as much power. 

Magical thinking is a powerfully denying experience.  Some terminal illnesses are not fully understood and may not have treatment plans with a defined period of time and/or modality (e.g. number of months receiving chemotherapy, dialysis).  Someone who has just been diagnosed may be confused about the technicalities of their illness and question whether their loved ones should become caretakers or not.  In lacking information related to prognosis, denial may rear its head in the form of an imagined, pre-terminal illness state that can be cured.  Therapy plays a very important role in that denial can be normalized while irrational beliefs are not colluded with or encouraged.  Therapy can help terminally ill individuals and their loved ones process uncertainty, minimize assumptions, and find proactive ways to approach medical consults to glean useful information. 

4. Estate planning is depressing and I can do it later. 

Taking care of important legal documents such as advanced health care directives (living wills) can be intimidating.  Most imaginations make legal tasks like these seem a lot scarier than they actually are and more prone to be avoided.  Therapy can expose how putting things off actually gives more power to the incomplete task.  Death, grief, and loss are conditions that can be managed when professional care is sought.  Therapy involves case management, including, but not limited to, making referrals to estate planners who are sensitive to end-of-life issues.  By making these difficult decisions, life can be experienced with a reduced anxiety as loved ones will be able to make the right choices for care and terminally ill individuals will have “faced their fears.”

Greg Stanford, Psy.D. is a licensed clinical psychologist with private practices in Arcadia and Beverly Hills, California.  He specializes in treating anxiety, depression, grief & loss, sexual & gender diversity, relationship difficulties, and life transitions.  He can be reached by phone at (626) 415-4452 and by email at drgstanford@gmail.com.