Brief Psychotherapy for Demoralization in Terminal Cancer: A Case Report

Abstract

Coping with terminal illness and dying are fundamental challenges for patients and providers. The term ‘demoralization’ has been coined to describe a failure to cope with existential threats such as cancer. Thirty years ago, authors such as de Figueiredo and Frank began to define demoralization and formulate clinically applicable interventions. Kissane et al formulated diagnostic criteria for demoralization that included (1) existential distress, including hopelessness and loss of purpose in life; (2) pessimism, (3) absence of drive or motivation to cope differently; (4) features of social isolation or alienation; (5) persistence of symptoms of longer than 2 weeks; and 6) absence of a primary depression or psychotic condition. Whereas major depression is a more omnipresent, anhedonic, and vegetative state, demoralization remits when the stressor abates or when the patient’s coping skills for the stressor improve. Demoralization, then, is an excellent target for psychotherapy. Psychotherapy interventions for demoralization in oncology patients have included a range of targets and modalities, including self-transcendence and spirituality-and-meaning-centered group interventions. Recently, Griffith and Gaby articulated seven pairings of “existential postures of vulnerability and resilience to illness” as psychotherapy targets in demoralization. These pairings include confusion and coherence, isolation and communion, despair and hope, helplessness and agency, meaninglessness and purpose, cowardice and courage, and resentment and gratitude. The couplets allow a framework with which to pursue psychotherapy for demoralization. While Griffith and Gaby directed their publication towards brief, at-the-bedside interventions, their formulations lend towards the construction of an organized psychotherapy sequence for palliative care outpatients.