6 Psychotherapy Questions for Medically Ill Patients

Assertive coping is the ability to confront adversities in a goal-directed and problem-solving manner, rather than avoiding, withdrawing from, or submitting to them. A failure to cope assertively with a medical illness and its treatment prompts a psychiatric assessment to gauge where and how to focus a medical intervention. Relational coping is a common coping response to adversity. Many individuals turn first to important relationships, rather than to individual problem solving.[1,2]

Patients coping with severe illness can become so apathetic that they lose their capacity to be motivated by either pleasure or pain. Impaired relational coping can result from markedly dissimilar processes: apathy, depression, negative symptoms of psychosis, or avoidance cluster symptoms of PTSD; logistical obstacles to family or friend visits; relational cutoffs due to alienated friends or family members; patient’s efforts to hide distress to protect loved ones from witnessing his suffering; emotion dysregulation that alienates family members and friends.

Helping a patient who uses relational coping begins by assessing which types of relationships matter most and how, then reestablishing access to that relationship or reproducing its function by using members of the treatment team as proxies. These 6 questions can be used to assess relational coping and mobilize assertive coping.[3-6] The also act as a springboard to further action.

1. This is difficult to face alone-who do you want to be there to support you during your illness? This is difficult to face alone. Responses to this question indicate which kinds of relationships are most important. From the moment of entry into the room, meeting the patient as another person takes precedence over any other agenda. This entails learning about the priority of concerns.

2. On your most difficult days, who do you want to turn to for support on your most difficult days? Hospitalizations too often strip patients from their vital connections. Yet the missing relationships or their functions often can be restored. Existential neuroscience offers a new perspective for conducting bedside psychotherapy that can contribute to its greater effectiveness, efficiency, and portability across clinical settings.

3. Does anyone know what you are really going through? Who do you talk with about your illness? A creative consultation-liaison psychiatry service can replicate the roles of confiding relationships and social network relationships when patients are physically cut off from contact with familiar people.

4. In whose presence do you most feel at peace? For patients with active religious lives, prayer and spiritual practices provide confiding and/or attachment relationships with the Divine or with important people and even pets.

5. To whom does it matter that you recover from this illness? Relational interventions can be made by facilitating hospital visits by important attachment or confiding figures (parents, children, siblings, partners, or companions, either in person or electronically). Clinicians can also help a patient to reassert a family or work group role (eg, suppporting an elderly patient's position of family leadership during a family meeting of illness-related issues).

6. To whose life do you most want to have made a contribution? In whose life will you make a difference? This question facilitates a patient's efforts to contribute to the lives of others, whether by kindnesses shown to patients or by phone calls or e-mails to individuals outside the hospital. For someone with a chronic medical illness, this means imagining a life worth living despite the illness.