PSYCHOTHERAPY: THEORY, RESEARCH AND PRACTICE

VOLUME 14, #4, WINTER, 1977

PSYCHOTHERAPY WITH TERMINALLY ILL PATIENTS1

TERRY E. ZUEHLKE JOHN T. WATKINS

University of South Dakota Oklahoma University Health Sciences Center
Vermillion, South Dakota 57069 Oklahoma City, Oklahoma 73190

ABSTRACT: This study investigated the effectiveness limit a person s capacity to approach life in a manner
of a psychotherapeutic technique, logotherapy, with which enables him to continue to value his own
terminally ill patients. Twenty male Veterans Ad- existence.
ministration volunteers were randomly assigned to
one of two possible treatment conditions: (a) treat- Until recently, few clinicans have dealt with
ment group or (b) delay ed-treatment, control group. the psychological needs of terminally ill pa-
Patients participating in the original treatment tients (LeShan & LeShan, 1961). Review of the
group received eight forty-five-minute sessions of literature suggests that part of the difficulty and
psychotherapy over a two-week interval. Pre- and
neglect of psychological intervention on behalf
post-treatment measures were taken as indices of
change resulting from the treatment experience. The of the dying person has resulted from resistance
five dependent measures used were: (a) Minnesota by medical personnel, particularly physicians.
Multiphasic Personality Inventory (MMPI) K scale; In reference to this situation, Krant (1972)
(b) MMPI L scale; (c) Death Anxiety Scale; (d) Brief suggested that the "modern medical commun-
Psychiatric Rating Scale; and (e) Purpose in Life ity" is not meeting its responsibility to provide
Test. Pre-treatment measures were used as total health services to the dying patient. In his
covariates for the five post-treatment dependent mea- article he stated:
sures.
The trend in medical care has been to emphasize denial
Those patients assigned to the second group com- of death. . . . Those who can't " d o " or who can't be
pleted the dependent measures before and after the repaired—such as the aged and the terminally ill—
two-week delay and thus served as a no-treatment receive a low claim on active medical and other
control in the primary study. Following the comple- resources.
tion of the waiting period, these subjects received the
treatment. Completion of the treatment experience Eissler (1955) believed that doctors hesitate
and the post-treatment dependent measures by the to tell their patients the exact nature of their
control group provided a quasi replication of the illness for fear of inducing psychopathology.
original study. Barton (1961) added to this position by citing a
A multivariate analysis of covariance indicated an typical quotation from a medical student who
overall significant difference between the treatment
explains why he is reluctant to approach the
group and the control group. Univariate analyses of
covariance indicated significant group differences on subject of terminal illness with a patient. He
three of the five dependent measures. Results of the quoted the student as follows:
quasi replication analyses supported the findings of I don't want to do anything bad . . . It's like a feeling of
the original study. extreme fragility, and if you do the wrong thing some-
The empirical findings of the study, as well as the thing is going to break. . . . You feel you might destroy
clinical impressions of the therapist, confirm the idea some defense mechanism he has built up.
that terminally ill patients can benefit from
psychotherapy involvement. Imminent death need not Clearly, a number of investigators strongly
believe that resistance to dealing with the needs
1
This study was sponsored by the Veterans Administra-
of the dying person is inappropriate and unwar-
tion Hospital, Minneapolis, Minnesota. The authors wish ranted (Feifel, 1959; Glaser & Strauss, 1966).
to thank Arnoldous Goudsmit and the nursing staff of In her book, Kiibler-Ross (1969) reported that
Ward 71 for their assistance in the conduct of this communication with the dying, if only in the
research. format of honesty regarding the person's diag-

403
404 T. E. ZUELKE & J. T. WATKINS

nosis, can be very therapeutic. Unfortunately, the extent to which a systematic psycho-
such references to psychotherapy with the dying therapeutic approach could assist a terminal
consist mainly of clinical reports of an anec- patient in his efforts to cope with his feelings
dotal nature. For example, Hertzberg (1972) about his impending death. Also attempted was a
described the use of a weekly case conference in further clarification of the various psychological
which terminally ill cancer patients were inter- dimensions involved in a person's reaction to
viewed before the ward staff. Cited as a major dying.
goal of such a conference is the increased
sensitivity of ward personnel to the emotional METHOD
concerns of the patients and their families. The
result of the approach was to facilitate better Subjects
understanding by patients and staff of the
others' needs. Parsell and Tagliareni (1974) 5s were 20 male in- or out-patients on the
conducted group therapy with incurably ill Cancer Chemotherapy Ward of the Veterans
cancer patients and reported positive feedback Administration Hospital in Minneapolis, Min-
from patients. Themes of helplessness, life and nesota. Each 5 was completely aware of his
death, and concern for daily problems were condition and had been given his physician's
predominant. permission to participate in the study. All 5s
Pahnke's (1969) study on the use of were informed of the general nature of the study,
psychedelic psychotherapy utilizing LSD is an but did not know the specific hypotheses being
example of a more empirical consideration of a investigated. Each patient was told the follow-
therapeutic treatment approach to the ing:
psychological aspects of facing a terminal ill- We are doing a study to see how seriously ill patients feel
ness. Results of his research suggest that some about their condition and to see if we can help with those
of the cancer patients were enabled to face the feelings in any way. We would appreciate talking with
last days of their lives with a greater sense of you so that we can learn how you feel and to see if we can
meaning. learn from you so that we can help others.
Hineman (1971) discussed with dying patients
their self-concept, acceptance of themselves and The mean age of the patients was 54.6 with a
others, and their ability to live creatively in the range from 20 to 80 years. On the average, the
face of impending death. His results indicated patients had known about their cancer diagnosis
that the patients he worked with were ready and for approximately three months. Each patient
willing to discuss their innermost feelings re- who volunteered to participate was randomly
garding death and that all continued in their assigned to the treatment or delayed-treatment,
attempts to live fulfilling lives. In a similar control group.
regard, Wesch (1970) was able to validate
"existential assumptions" that there is an in- Measuring Instruments
verse relationship between self-actualization and
death anxiety. Purpose in Life Test (PIL). The PIL is a
The studies reviewed which have attempted 20-item, 7-point, Likert-type attitude scale de-
some type of psychotherapy with terminally ill signed to measure the extent to which a person
patients all seem to recognize the importance of reports his perception of the meaning in his life.
the patient's fear of death, his willingness to The PIL is based on existential considerations
discuss such fears, and a sense of meaningful- reported by Frankl (1969).
ness in his life. In a preliminary study, Zuehlke Death Anxiety Scale (DAS). The DAS de-
and Watkins (1974) investigated the effective- veloped by Templer (1970) was utilized to assess
ness of a psychotherapy technique, logotherapy, a patient's reported fear of death. In order to
with terminally ill Veterans Administration pa- disguise the purpose of the instrument, the
tients. Following a series of therapy sessions fifteen items were randomly intermixed along
based on Frankl's (1969) existential approach, with items from the A^ andL validity scales of the
six patients reported improvement in the purpose Minnesota Multiphasic Personality Inventory
and meaning to their lives. (MMPI). Precedent for such an alteration of test
The present study was designed to determine format is cited in Templer's (1970) report on the
 TERMINALLY I I I PATIENTS 405

development of the questionnaire. The final therapy sessions, these patients and their pri-
format of the instrument consisted of 60 state- mary nurse again completed the test instru-
ments which the patient applied to himself and ments. Following these sessions and collection
answered as to whether they were true or false of the final data, each patient was informed that
about him. the information provided on the test instruments
Brief Psychiatric Rating Scale (BPRS). The related to their participation in the study and
BPRS is designed for objective recording of their permission to use the data was obtained.
clinical judgments concerning level of severity Three of the original ten subjects did not com-
of psychiatric symptomatology (Overall & plete this third administration because two died
Gorham, 1962). The measure includes 16 during their treatment and the other was too sick
7-point scales for recording judgments in 16 to complete the post-treatment testing. Collec-
symptom areas. Each S was rated by a ward tion of the data following the control group's
nurse familiar with his behavior. Prior to com- treatment permitted an own-control, quasi-
mencement of the study, five ward nurses were replication of the original experimental versus
trained as BPRS raters on non-participating delay ed-treatment, control group comparison.
patients. A Pearson product-moment correlation
of .64 was obtained by averaging all combina- A Brief Outline of the Psychotherapy
tions of paired correlations among thefiveraters.
Such a correlation demonstrated inter-rater con- Logotherapy is a system of existential psy-
sistency and consensual understanding of the chotherapy based on the view that man's pri-
rating constructs. mary goal in life is to find personal meaning and
identity. The approach maintains that man is
PROCEDURE always free to choose from among his alterna-
tives the way he wishes to respond to any set of
Following their agreement to participate, pa- circumstances. In this sense, each individual is
tients were randomly assigned to a treatment or a charged with the responsibility for changing
delayed-treatment, control group. Patients were his attitudes about his present condition in a
then asked by a member of the nursing staff to manner which will enable him to continue to
complete the test battery. It was expected that value his own existence. The person is thereby
collection of the data by the nursing staff would permitted to react to, examine, evaluate, and do
minimize demand characteristics of the study. something constructive about his inner experi-
When gathering the information, the patients ence and his interpretation of his present condi-
were informed that the test materials were to be tion.
filled out as a routine part of the hospital The therapy sessions of all the patients were
procedures. At the same time the BPRS was conducted by the same therapist (the senior
filled out on each subject by the nurse primarily author). The following discussion is a descrip-
responsible for his treatment. tion of the various phases of the course of
The ten patients who had been assigned to the therapy. Each phase refers to approximately
treatment group then received eight 45-minute two 45-minute sessions.
therapy sessions over a two-week interval. At Phase One. These sessions were utilized to
the conclusion of therapy, the patient's primary provide the patient and therapist with an oppor-
nurse again requested that the test instruments tunity to become better acquainted. In order to
be completed by her patient and filled out the enhance development of trust and rapport, the
BPRS again herself. conversation in these first sessions related
The ten delay ed-treatment, control group pa- primarily to an elaboration of the patient's
tients were separately informed that schedule family background, occupational experiences,
demands would necessitate a delay in their and areas of avocational interest. When appro-
therapy sessions. Two weeks later, the primary priate, the therapist shared with the client his
nurse had each patient complete the dependent own background, experiences, and interests.
measures and she filled out the BPRS for a The purpose of these initial conversations was
second time. These patients then received the threefold: (1) to enhance development of rap-
psychotherapy sessions provided the patients in port, (2) to provide the therapist with informa-
the treatment group. Upon conclusion of the tion about those activities and individuals which
406 T. E. ZUELKE & J. T. WATKINS

would seem to provide meaning in the patient's panding perceptual awareness" (Crumbaugh,
life, and (3) to illustrate for both the patient and 1968).
therapist typical coping techniques utilized by Phase Three. Review of the intersession
the patient when he had previously dealt with exercises at this point in therapy frequently
difficult problems. resulted in patients' reactions of surprise and
Usually, by the conclusion of the second enjoyment when they realized that a second
counseling session with the patient, an interses- observation resulted in perception of elements
sion homework assignment was given each or relationships that had previously been over-
patient. This assignment consisted of a request looked. The consequence of such reactions was
that he obtain a family picture, study the pic- that the picture took on new meanings. As noted
ture, and record the feelings the picture aroused above, such an ability to recognize alternative
for him (Zuehlke, 1974). interpretations enhanced development of the
Phase Two. Completion of the homework patient's ability to view his present condition
assignment was utilized by the therapist as a from different perspectives.
means for focusing the next sessions on the Once this level of awareness and open com-
patient's reactions to his current hospitalization. munication was reached, the logotherapeutic
The usual result of the patient's focus upon the techniques of dereflection and/or paradoxical
family picture was a stimulus for him to contrast intention were incorporated. Determination of
his current condition with past events. For the use of these techniques was made according
example, one patient recorded reactions to the to the nature of the patient's reaction to his
family picture which indicated anger, resent- approaching death.
ment, and fear that he was no longer able In some instances, a patient's fear of not
physically to participate in the family business. dying with dignity produced emotional reac-
Thus, by encouraging attention to the pre- tions and behavior precisely characteristic of
sent, the patient was assisted to begin to realize that which he feared. For example, a patient
and express a wide variety of feelings relating to who is afraid of not being able to control his
his views of himself as a hospitalized patient feelings about wishing to die peacefully may
and the resultant effect such a situation had on actually react in such a manner as to be later
his family relationships. Movement in this di- described by family and hospital staff as a
rection also began to help make the patient difficult and uncooperative patient. In situations
cognizant of the fact that his life continued to be where such hyperintention was observed,
an ongoing process in which he still maintained paradoxical intention was utilized. Such cir-
responsibility for choices that could take him in cumstances involved the patient's being en-
whatever direction he chose. Recognition of couraged to intend, even if only for a few
this fact served to clarify and provide perspec- moments, exactly that which he feared. Ac-
tive for the patient on concerns involving per- cordingly, the patient would be encouraged to
sonal meaning and identity. tell himself that he was going to be the most
In general, it was these discussions involving unmanageable patient possible. By exaggerat-
hospitalization and family relationships which ing such fears to a humorous extreme, the
introduced into the counseling sessions the topic patient is enabled to detach himself from his
of the patient's impending death. Throughout undesirable feelings and behavior and his at-
the study, the therapist did not discuss death as titude is reversed in that his fear is replaced by
an imminent factor for the patient until he, the that which he desired.
patient, mentioned the word "death" in relation Excessive attention, or "hyper-reflection" as
to himself. it is called in logotherapy, also resulted in
Due to the usefulness of the picture-reaction emotional problems for some patients. Such
technique in serving as a catalyst for enhancing situations frequently were noted when patients
an open and honest discussion by the patient reviewed their reactions to their family pictures.
about his limited life expectancy, the patient Frequently, a patient would choose to focus
was asked to repeat the assignment and to almost entirely upon himself and his physical
record again his feelings as he viewed the condition and would give only minimal atten-
picture of his family. Repetition also provided tion to other family members. Through dereflec-
training for the patient in the process of "ex- tion the patient is helped to reevaluate his
 TERMINALLY I I I PATIENTS 407

current circumstances. Drawing upon informa- nificant univariate differences on three of the
tion obtained earlier, the therapist directed the dependent measures. The MMPI K scale score
patient's attention away from himself and his decreased (F = 6.65, p < .02), the Death
medical condition to those areas in his life Anxiety Scale mean increased (F = 4.99, p <
situation which provided him meaning and a .04) and the Purpose in Life Test scores in-
sense of worthiness as a human being. In creased (F = 13.34, p < .003) for the treatment
connection with this shift from a prior focus group versus the control group. No significant
upon himself and his somatic concerns, the differences were found on the MMPI L validity
family picture and the patient's feelings were scale (F = 1.98, p < .18 nor on the Brief
again discussed. Psychiatric Rating Scale (F = 1.0, p < .34).
Phase Four. The final sessions extended the
discussions begun in the earlier phases about the Quasi Replication Analysis
patient's physical condition and his emotional
reactions to it. Efforts were directed to consid- Analysis of the effect of the psychotherapy
eration of alternative ways of relating to sig- sessions on the delayed-treatment, control group
nificant others in the patient's life sphere. Em- after the two-week postponement may be consi-
phasis was given to providing opportunities for dered a quasi replication of the study. A test of
an interpersonal encounter between the patient multiple comparisons using averaged difference
and others. A sense of closure for the patient's contrasts (Buhler, 1971) was performed on the
involvement was also given attention. data, with pre-waiting period, post-waiting
period, and post-treatment measures as the three
RESULTS treatment conditions. Table 2 presents the means
and standard deviations for the five dependent
A multivariate analysis of covariance was measures.
used to compute the change between the treat- The overall differences between the before
ment and delayed-treatment, control group. All and after treatment conditions were significant (F
five of the pre-treatment (or in the case of the = 3.05, p < .01). Univariate F tests of the
control group, the pre-waiting period) measures treatment condition on each dependent variable
comprised the covariates. The post-treatment with the pre-waiting and post-waiting periods as
scores showed an overall significant difference the covariates were performed. The MMPI K
(F = 7.97, p < .004) between the treatment scale and the Death Anxiety Scale scores showed
group and the control group. significant differences (F = 11.80, p < .001, and
The means and standard deviations of the five F = 6.90, p < .007, respectively) following
dependent measures are shown in Table 1. treatment. The Purpose in Life Test did not
Univariate analysis of covariance which used the evidence a significant change (F = 1.15, p <
five pre-measures as covariates indicated sig- .34), nor did the MMPI L scale (F = 2.41, p <

TABLE 1. Treatment Versus Control Group Means and Standard Deviations for
Measures of Psychotherapy Improvement

Treatment Group Control Group

Pre- Post- Pre- Post-

treatment treatment waiting waiting

(N = l0) (N=10)
Dependent Measures Mean S.D. Mean S.D. Mean S.D. Mean S.D.

MMPI K Scale 16.3 2.0 13.8 1.8 16.7 2.6 16.3 1.6
MMPI L Scale 3.2 2.2 4.1 3.1 4.4 2.1 3.8 1.3
Death Anxiety Scale 4.3 1.5 8.9 3.6 4.6 1.4 5.5 2.5
Brief Psychiatric
Rating Scale 31.0 15.7 33.3 10.9 28.1 9.3 30.0 13.7
Purpose in Life Test 89.8 16.6 102.7 9.9 90.0 15.6 87.0 14.1
408 T. E. ZUELKE & J. T. WATKINS

TABLE 2. Pre-waiting Period, Post-waiting Period and Post-treatment Means and Standard Deviation of
Control Group Measures of Improvement Following Psychotherapy

Pre-waiting Post-waiting
Period Period Post-treatment

(N = 7) (N = 7) (N = 7)
Mean S.D. Mean S.D. Mean S.D.

MMPI K Scale 17.3 2.4 16.1 1.9 13.6 4.2

MMPI L Scale 3.9 1.4 3.7 1.2 3.4 .26
Death Anxiety Scale 4.9 1.6 4.9 2.1 7.7 1.2
Brief Psychiatric
Rating Scale 26.8 5.3 26.7 7.3 29.7 5.4
Purpose in Life Test 85.3 14.5 86.7 17.3 95.0 13.1

" Two subjects died during the therapy period and one was too sick to complete the post-treatment testing. The analysis
was therefore performed only on the seven subjects who completed all of the test materials.

.12) or the Brief Psychiatric Rating Scale (F = No significant differences were found on the
0.39, p < .69). TheK scale and the DAS scores Brief Psychiatric Rating Scale. In fact, the mean
were significantly different in both studies, while ratings actually increased slightly under both
the PIL, although not significant in the quasi treatment conditions. Such results may at least
replication study, was in the same direction as partially be attributed to the relative inexperience
the scores in the primary study. of the nursing staff at rating their patients along
psychiatric constructs.
DISCUSSION Inspection of the MMPI K validity scale data
shows a significant decrease under the conditions
Essentially the same results were obtained in which patients participated in psychotherapy.
from the treatment versus delayed-treatment, According to Dahlstrom et al. (1972) categories,
control group analysis and the quasi replication this decrease was from the high average range to
analysis. The two groups of patients differed the middle range. Since high scores on the K
significantly on three of the five dependent scale may be interpreted as indicating "defen-
measures in the primary study, and two of those siveness" upon the respondent's part (Rosen,
three measures noted significant differences be- 1956), a decline in that score suggests that the
tween the no-treatment, control and the post- patients became more open to self-exploration
treatment conditions in the quasi replication as well as motivated to struggle with the stress
study. The Purpose in Life Test scores, although generated by the reality of their physical demise.
not significant in the second study, increased as When viewed as a measure of the tendency to
they did in the first study. The failure to obtain give socially desirable responses in describing
significance with this factor may at least in part themselves (Edwards, 1957), the K scale
be attributed to the loss of data from the three changes indicate that psychotherapy decreased
subjects who did not complete the final admini- the patients' need to present themselves in a
stration of the dependent measures. highly favorable light. A lowers score also in-
The MMPI L validity scale values remained dicates the respondent is more open in his com-
fairly constant throughout the course of the munications with others and is less likely to be
study. Inspection reveals the L scores were all restricted by denial, repression, and disowning
very close to a raw score of 4, the typical score of his problems (Dahlstrom et al., 1972).
for normals on this scale (Dahlstrom et al., The treatment result of lowering the dying
1972). The lack of significant differences be- patients' tendency to deny their feelings about
tween the treatment conditions suggests the par- their death may have been the reason the Death
ticipants in the study did not deliberately attempt Anxiety Scale scores increased significantly.
to distort their responses on the self-report The initial DAS scores were nearly one standard
measures. deviation below the mean (Templer, 1970),
 TERMINALLY I I I PATIENTS 409

suggesting a tendency to deny even an average tients' fear of dying a painful death. Pain seemed
amount of death-related anxiety. The decrease in to be associated very closely with the individu-
defensiveness and denial, as a result of the al's concept of dying with dignity in that the two
therapy sessions, resulted then in patients' facing were seen to be mutually exclusive. Most pa-
the reality of their situation in a realistic manner tients were very concerned that they not be
with a commensurate increase in reported death allowed to die in any condition in which they
concerns. experienced a great deal of pain because to do so
The interesting component in this response increased the chances they would not die in a
pattern to psychotherapy is the fact that the respectable manner. Certainly the alleviation of
patients also reported a significant increase in unnecessary pain is an important goal. Unfortu-
their sense of purpose and meaning in their lives nately, however, some medical personnel seem
as measured by the Purpose in Life Test. The to use medication such as morphine to help the
increase in PIL scores, when considered with the patient obliterate reality, not so much because of
decline in K scale scores and an increase in DAS the patient's needs, but rather in an effort to
scores, suggests that these patients, as a result of avoid dealing with the patient's emotional con-
the psychotherapy sessions, were able to lower cerns. The patients frequently discussed their
their efforts to deny their concerns about dying awareness of such staff methods during the
and to participate more openly in exploring the therapy sessions.
true nature and extent of their feelings. Such The results of this study suggest that
exploration on their part resulted in an increase in psychotherapy with terminally ill patients seems
their death-related anxiety, but an increase to be an important factor in helping them cope
which approached more closely the average with their emotional reactions to death. How-
degree of such feelings. Along with greater ever, the authors wish to point out that such
openness and more acceptable levels of death results were obtained from a narrow and quite
concerns, the patients experienced a significant homogeneous subject population. Caution
increase in their personal meaning and identity. should therefore be exercised in applying the
The clinical impressions of the therapist sup- results and interpretations of these data to other
ported the experimental findings that the emo- clients and clinical settings. Future research
tional adjustment of terminally ill patients is should consider a more heterogeneous subject
improved by enabling patients to approach the population and explore alternative treatment
end of their lives with a sense of meaning and approaches as well.
purpose as well as to be relatively free from
excessive or unrealistic emotional distress.
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