Helping the partner of a terminally ill patient

In my experience, it is vitally important to understand how to help the partner who presents with psychiatric symptoms both during the illness and after the loss of a patient. His or her psychic pain is often far greater than that of the patient, who is taken care of by the full medical team. The mental health of the partner is, of course, vital to the whole enterprise of cancer treatment and to the survival of the family. Some general observations based on my experience are:

• Men tend to have much greater difficulty in accepting a bad prognosis and use denial more frequently.
• Men are more likely than women to look for more alternative methods of treatment.
• Men have much less support from friends but have less difficulty in finding a new mate after the loss of their partner.

Complicated grief—a serious complication of loss—is more likely to occur in those who have highly dependent or idealized relationships; those who are not prepared for loss either because of denial or a lack of preparation; and those with poor support systems. Specific interventions are indicated to address these factors. For example, in the case of a terminally ill cancer patient whose partner is in denial, it is important to ask the partner what the issues are that make him or her not see the obvious. This gentle approach allows the denial to be challenged and the partner to be prepared. In the case of the partner with a highly dependent or idealized relationship, longer-term therapy may be needed.

The distinct challenges facing partners of terminally ill patients include loss of hope, overwhelming anxiety, anger, loss of faith, functioning as the sole parent, preparing for the loss, preparing children for the loss, grieving, and beginning a new life. The Table provides some interventions that may be helpful to the surviving partner.

It is important to accept that each person grieves in his own unique manner. Do not expect grieving to unfold in a pattern of stages. Factors that affect grieving include age, the relationship to the deceased, the nature of the relationship, the personality of the bereaved, support systems that the bereaved has access to, and the preparation for loss and the relationship to the dying patient in the terminal phase.

Summary

Each of the phases of the cancer experience presents emotional challenges that can destabilize a patient’s defenses. A dynamically oriented approach with interventions that shore up defenses is recommended. The challenges of treating the dying patient deserve separate attention because they are the most demanding and because they probably cause the greatest anxiety in the therapist. The therapist will be better prepared if he recognizes that this experience will stir up anxiety about one’s death, feelings of helplessness, fear of the patient’s anger, and survivor guilt. However, if done well, this work is very rewarding. Doing it well requires that the therapist focus on:

• Preserving the patient’s identity and dignity.
• Affirming and validating the person’s life.
• Helping the patient transcend pain.
• Helping the patient find some meaning in his experience.

Allow the patient to review his life, affirm his accomplishments, help him feel good about himself, and remind him of the person he still is, ie, preserve his identity in spite of weakness and infirmity. Some patients are inclined to explore unfinished goals, define a legacy, and resolve problematic relationships. When the end is near, the therapist should promote regression and provide a good self-object as the patient drifts into coma.

Following the loss of a loved one, I recommend an approach that facilitates grieving, monitors the health of the bereaved, and finally, helps the survivor return to the world. This may, at the appropriate time, include encouraging a return to work and an attempt at a romantic relationship.

Previous psychotherapy, which focused on resolving conflict with the deceased, can play a constructive role in the grieving process. In my experience, recognizing survivor guilt in both the families and the therapists of dying patients is extremely important. The conscious or unconscious wish for the ordeal and suffering to be over often gets confused with the wish for the death of the spouse and leads to guilty self-recriminations and questions about one’s caregiving behavior.

I recommend updating Freud’s theories of mourning to incorporate more contemporary views.8,9 This includes the development of a new internalized relationship with the deceased rather than a “decathesis” of the lost object. Rather than moving on and giving up the old relationship, an acceptance of the loss and a new internal relationship of memories of the deceased is stressed. Attention is also directed to guiding parents in helping their children grieve. It is now accepted that children are capable of grieving, especially if they are not distracted by adults and are helped to face their omnipotent fears and wishes toward the deceased.10

Finally, when people ask me whether I find this kind of work depressing, I always reply, “No, in fact I find that this work is very rewarding and uplifting.” Working with seriously ill and vulnerable people is challenging, meaningful, and creative, especially when the pressure of time motivates both patient and therapist to make the best of it.

 

Table Interventions that may be useful in treating the surviving partner
  • Help the partner become the best caregiver he or she can be, minimizing survivor guilt
  • Help the partner preserve his physical and emotional health because he may become the only caregiver and parent
  • Help interpret medical information
  • Prepare the partner for the impending death of his loved one to prevent complicated grief
  • Help the partner prepare the children
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