An integrative model of the psychological approach in palliative care

Scientific Article

Nowadays, when there are about 400 models of psychotherapy, it is difficult to find the right one to apply to the field of emotional care in palliative care.  In fact, during the years of development of palliative care in Spain and with the inclusion of psychologists in the care team, there has often been a lack of reflection on the most appropriate psychological work model to apply in this field (Gómez Batiste, Buisan, Gonzalez, Velasco, Pascual y Espinosa et al, 2011). In view of this complex and dispersed reality, there is a growing tendency to apply an eclectic or integrative treatment to the work of psychotherapy in general, (Demichelis Machorro, 2011) and to the field of palliative care specifically.  In fact, in the United States, for many years now, it has been common for the training of psychotherapists to be quite eclectic, teaching a broad theoretical and practical base, chosen from various schools, and developing the practical skills of the therapist through extensive hours of practice closely supervised by experienced therapists.

In the same way that psychotherapy itself is in a constantly evolving process, the most valuable therapist, too, is continually adjusting through accumulated experience and newly developed knowledge.

If the whole of psychotherapy were a tree, we would say that psychoanalysis would be the common trunk and that each branch, one of the 400 subsequent schools that are currently in the process of growth and evolution.  With all the diversity of existing theories and techniques, it would be logical to assume that not all of them would be equally adapted to the specific characteristics of palliative care intervention.

This article represents a reflection and proposal of a common model for the work of the psychologist in palliative care.

Humanistic psychology as a basis

Before entering into theoretical considerations of psychotherapy branches, it is convenient to set a basic global premise that is independent of the framework or school from which we start.  This is related to the therapist himself.  We should bear in mind that in the health professions in general, but in psychotherapy in particular, the "person" of the professional is involved and has a strong influence on the therapeutic process for better or worse.  Their personality, their neuroses with fears, internal conflicts, etc. function as a filter that limits the success of the work they intend to do, which is why psychodynamic schools require their future therapists to undergo psychoanalysis, hence the emphasis Carl Rogers placed on the "person" of the therapist interacting with the person of his client.  In fact, some studies that have attempted to compare the effectiveness of one or another psychotherapy technique have concluded that the therapist as a variable weighs more than the applied technique itself in predicting the success of the work performed (Rogers, 1996).

This reflection leads us to consider the responsibility of the psychotherapist to carry out an internal, personal process of preparation of himself/herself in addition to the objective preparation of professional training to minimize the interference of the therapist's personal emotional conflicts in the treatment and to allow a relatively more objective view of the "other".  Specifically in the field of palliative care, for example, it will require appropriate management of one's own anxiety in the face of death, among other things.

As a general theoretical framework for therapeutic work in palliative care, it is the model of humanistic or existential psychology that is best suited.  With regard to the techniques to be applied, those of counselling are perfectly adapted to this field of intervention.  Therefore, it is recommended to apply them as a universal basis (used in each case) (Arranz, Barbero, Barreto and Bayés, 2003).  However, this basis will later be complemented and enriched by the application of a variety of other useful techniques (e.g. cognitive, systemic, logotherapeutic, behavioural, etc.) according to the needs of each individual case and the training of each therapist.

Some premises of the humanist model that make it appropriate for palliative work are the following:

It moves away from the medical model of relationship with the patient, with its verticality (an aspect that characterises psychoanalysis, for example, and which poses a dynamic in which there is a pathology to be cured and the doctor is the one who has the knowledge and resources necessary to carry out this work, being the one who directs a passive patient towards his cure or improvement). In contrast, we find ourselves in the humanist model with a more horizontal vision of relationship.  The humanist vision of the therapist with respect to the patient (or client) is not centred on diagnosing pathologies, but on encouraging the person to exercise their autonomy, develop their own potential and the internal resources they need to change painful situations and grow or evolve as a person.  The approach is individual, understanding each person as unique (Rogers, 1951).  It is a "heightened psychology" as Victor Frankl called his own existential model (in fact, many writers bring together existential and humanistic models into one because of their common theoretical points). (Frankl, 1987; Thompson, 1997).  Far from pessimistic psychodynamic determinism, here we believe in the capacity of the human being to choose, to overcome and to transcend (although when it comes to therapy with terminally ill patients, we must also be careful with the optimistic model, since, as Freud pointed out, we are not interested in changing one delusion for another in the sense of obviating the patient's inevitable level of suffering by creating a fantasy that everything is fine).

The person has an active part to play in the development of therapy that occurs within a semi-directive context in which the therapist explores certain areas while shaping the intervention according to what the patient "brings" or needs to treat. (Rogers went further to develop a non-directive model in which the therapist minimises his level of directivity of the process; but this non-directivity is considered to be too limited and, over time, Rogers himself evolved to allow a somewhat more interventionist part of the therapist in his model).

Due to the situation of great psychological fragility in which patients with advanced illnesses find themselves, due in turn to the vital crisis or important emotional impact that the physical illness produces in people, the emphasis on respect for the patient, not forcing the encounter, the context of a highly empathic, warm and close but non-intrusive relationship offered by the humanist model is particularly appropriate in this field.

 

Translating this theoretical basis into daily practice, it is recommended to respect the decision of the patient or family member in palliative care whether or not to receive specialised emotional support.  The service's doctor and reference nurse should introduce the figure of the psychologist to all patients on admission, thus standardising this care and offering it.  (An example of this presentation is attached in Annex I.) This simple presentation model can be provided to medical teams to help them present the figure of the psychologist in a natural way and to reduce the level of perceived threat to a minimum.

In the palliative care service, doctors and nurses should be well aware of the criteria for referral (see Annex II to recommend more strongly psychological care in cases where the need is greatest).  And this does not just mean being well informed, it requires that they have acquired a view of the patient that encompasses and attaches importance to the emotional as well as the physical.

When a patient or family member that the team considers to be in need of an intervention rejects it, the option remains for the psychologist to introduce himself or herself to the person without intending to make an intervention.  Experience tells us that this presentation, if handled well, that is to say, by normalising psychological care and from a position of accompaniment, often allows resistance to be changed, the perception of threat is reduced and the person accepts the intervention.

 The relationship model

Within the humanist model, the therapeutic relationship becomes fundamental as the basis of the process. Specifically, importance is given to what is called "a helping relationship" (Bermejo, 1996).  In fact, Carl Rogers stated that when the "necessary and sufficient" components of a good helping relationship are given, this in itself produces positive changes in people, independently of the use of other therapeutic techniques (Rogers, 1951).  We could say that what heals is the look of appreciation from someone you care about.  Therefore, the psychologist has to be very adept at creating and sustaining the therapeutic bond with the patient, adapting his or her verbal and non-verbal communication style and approach to the individual person in front of him or her.  Thus, the premise of the NLP school is shared in which the flexibility of the therapist is considered an extremely valuable quality for the success of the therapy (Carrion López, 2001).

Rogers' definition of the helping relationship is as follows: "It is that relationship in which one of the participants tries to bring about, from one or both parties, a better appreciation and expression of the individual's latent resources and a more functional use of them". (Rogers, 1996, p. 46) The necessary and sufficient conditions that Rogers established as the basis of a helping relationship were: empathy, authenticity and unconditional acceptance of the person.  In contrast to the distance of the psychodynamic relationship, this relationship assumes that the person of the therapist is much more involved in the encounter, creating a warm, close, and quite horizontal relationship.  It requires a dual consciousness during therapy in which the therapist is aware of both the feelings and experiences of the other and his or her own inner experience during the encounter.  It allows self-revelation as a therapeutic technique and also physical contact when appropriate.

Based on this global humanist foundation, other schools of psychotherapy offer us theories and techniques that are very useful for the development of psychological work.  Cognitive restructuring, for example, will be very useful in reframing the perception of overwhelming situations; speech therapy will alleviate existential or spiritual suffering; a systemic view can be fundamental in attending to the family; and behaviour modification techniques will improve specific problems that arise.  These are just a few examples among the 400 schools of how psychotherapy can be enriched from an integrative application model.  There is so much more that every therapist can discover, learn and apply.

Conclusion

At this time in the development of palliative care, we should reflect on the model of psychological intervention that best suits the needs of this field.  The proposal in this article is to take the theoretical and practical framework of the humanist school of psychology as the basic global foundation and then expand the possibilities of intervention with techniques from other lines of psychology from a preparation and integrative vision that will vary according to each therapist and each case to be treated, always starting from a personal work of the psychologist that will improve their ability to care for the other.

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