Lauren Behrman, PhD., Elizabeth Giamatti, M.F.A., M.A.  Josephine Johnson, PhD., and Jana N. Martin, PhD

Continuing Education Information

Editor’s note: In keeping with the theme of this issue of The Register Report, the following article addresses the challenges of working with an often-difficult patient group—patients with terminal illness, including those who are actively dying. It is written in a highly narrative, personal style, with each author drawing from personal experience as they confronted, in their own ways, diagnoses of serious illness in colleagues, patients, and themselves.

This brings an immediacy to their observations that a traditionally written professional publication could not hope to convey. The article was inspired by a panel given at the APA annual convention in August 2016. I am grateful to the authors for their insights, but more so for their selfless disclosure of personal information and experience that helps us—more than any text could do—in understanding how to integrate our own responses into effective treatment for the terminally ill.

Author’s note: Ms. Giamatti’s work was based in her experience in co-directing and producing an experimental documentary titled A Woman Like Me. She introduces and summarizes the film and the issues that arose for her when collaborating with someone carrying a terminal diagnosis. Dr. Johnson then discusses working with patients dealing with life-threatening illnesses, and Dr. Martin examines the issue of psychologists living and practicing with cancer themselves. Finally, Dr. Behrman discusses commonalities among their experiences in coping with life-threatening diagnoses, the synergy or antagonism that can arise from the intersection of self-care for the therapist and patient needs, and the opportunities that can arise out of facing these challenges with consciousness and courage. This collaboration was created with the thought of how to use the lessons and insights of the movie to inform therapeutic, educational and training models for their colleagues and patients facing serious illness and terminal diagnoses, and the authors see this article as an ongoing exploration in that regard.

I. Elizabeth Giamatti: Through A Glass Darkly; A Cinematic Romp Through Terminal Illness

In the summer of 2011, my friend and colleague, filmmaker Alex Sichel, was diagnosed with metastatic breast cancer. As she and her family tried to get their bearings in a new and difficult terrain, Alex, somewhat incredibly, also began to think about making a fictional movie based on her experience. She asked if I would be interested in working with her on the film, albeit in this very extenuating circumstance.

As we talked about the project, Alex wrestled with whether fiction was the best mode to use during a time of crisis. On the plus side, she said:

I’ve always used fiction to help access my experience, to feel my feelings. I need someone who isn’t me to reflect my emotions. It has to filter through my imagination. I don’t always know what’s happening until later. I need playback.

On the other hand, she observed that in her life as a filmmaker she had often used fiction as an escape, and in this difficult moment she wanted to face her prospects and prognosis head on. In light of this, we felt it was critical to consider non-fiction forms of storytelling: documentary, memoir, a video diary, a blog. That said, we continued to be inexorably drawn to the powerful art and craft of fictional filmmaking.

In early 2012, when the results of a scan indicated progression of Alex’s disease, we realized that these discussions of form were a luxury. We felt a pressing need to pick up the camera and start shooting—we didn’t want to miss the opportunity to record key moments in Alex’s life and treatment. By dint of circumstance, our approach (and ultimately our treatment of the subject matter) became unconventional: we continued to discuss the form and style of our movie at the same time that we dove straight into making it.

We filmed Alex taking her regimen of cancer medication one day, and we filmed her a few weeks later after she learned that the cancer had again progressed. We followed her as she refused the next round of chemotherapy and went in search of alternatives, from homeopaths and acupuncturists and energy healers who believed she could heal with no help from western medicine. We interviewed Alex’s parents about their hope that Alex would decide to follow her doctor’s advice and drop the alternatives, and her sister, with whom she had made films in the past. Alex took her camera with her on a meditation retreat at a Buddhist temple as she searched for a way to face the death sentence she had received. She filmed nurses, she filmed her husband, and she also filmed her own shifting emotions and thoughts in an ongoing video diary.

As Alex faced the possibility, on camera and off, that she might not be able to will her incurable cancer into spontaneous remission, she began to wonder if she could at least change the way she related to the disease. Was it possible to feel something other than terror, anger and regret? For the sake of her young daughter as much as for herself, she wanted to create a more positive legacy. She was determined to leave behind a joyful story and find a way to thrive emotionally during whatever amount of time was left. As a long-time student of Tibetan Buddhism, this didn’t seem completely impossible.

Meantime, the fictional movie kept playing in Alex’s mind: she saw a woman a lot like herself, in a similar situation, who was “dealing with it much better than I am.” At times, Alex saw her character, whom she named Anna, practically having fun with her terminal diagnosis. Aspirational? Yes. But Anna offered something powerful: a way to transform Alex’s reality through the use of imagination. Writing about this alternate self gave Alex an opportunity to disconnect from the tightness of her fear and take a step back. Maybe her fictional foil could slow things down and live more fully, and maybe she would find the courage to face questions Alex hadn’t been able to on her own. Somewhat miraculously (and perhaps somewhat unrealistically), Anna was able to skip lightly through the world of cancer, and her emergence as a character encouraged Alex to keep looking for one small measure of peace amidst the chaos. Eventually, she was able to use Anna to envision forward movement and the possibility of a change in attitude. Anna helped her get unstuck. As Alex conceived of and constructed her, this fictional avatar would be able to do things Alex couldn’t yet do: talk frankly to her daughter about death, for example, or understand why her husband drank too much. Maybe even, in a whimsical alternate reality, Alex could watch as Anna’s doctor told her she would live forever.

The film’s form finally emerged for us midway through the process of filming, as it became clear that we were making a movie about making a movie; more to the point, we were making a movie about making a movie in a time of terrible crisis. What are the power and limits of our craft, we wanted to know, and how could we push them? Our project eventually became a hybrid documentary, a mix of fact and fiction, or fact and fantasy. The finished movie is as much about the power of the creative process as it is about anything else, and the experience of making it was a rich and joyful one with enormous benefits, chief among them for Alex the deep pleasure of doing something she loved—both in spite and because of the knowledge that her time was finite. As she points out in the movie, it’s one thing to say, “Life is short, you could get hit by a bus tomorrow,” and quite another to know that the bus is hurtling toward you with terrible speed.

I also believe that for Alex the value of having a fictional mirror was immeasurable, but as I have gained some distance there is another aspect of the filmmaking process that I think bears scrutiny, and that is my own relationship to Alex’s diagnosis and prognosis. With time, it has become clear to me that in order to make this movie I had to be willing to step directly into someone else's magical thinking, much as Mary Poppins and the Banks children step into Bert’s sidewalk drawing. I entered into an implicit conspiracy with Alex, engaging with her in a certain kind of mutual denial. Obviously, denial is often adaptive and can be productive, and it was certainly so in this case, but I think it’s important to be clear-eyed about its dangers as well.

Even during our early days of conceptualization, the question we often posed to help articulate our film was, in retrospect, strangely abstract and euphemistic: How do you create a work of art in the face of a life-threatening illness? Life-threatening, yes, but why didn’t we ever use the word terminal? Certainly, from a narrative storytelling point of view, life-threatening is a much more useful and open-ended term than terminal. A note here, too, that for most of the two-and-a-half years that Alex carried this diagnosis she was virtually asymptomatic, so denial came easily with respect to physical appearance, which is so often a visceral cue to illness. And yet....

Also, consider for a minute that the movie started as a fantasy (i.e., Alex seeing the story of Anna in her head), and it was a fantasy Alex invited and even encouraged me to join. Indeed, that is generically how filmmaking works: it’s a collaborative art form, and on a given film we conspire to make sure we are all telling the same story. Each department’s narrative strategy must cohere in order to understand, support and articulate the writer and/or director’s vision, i.e., fantasy. Indeed, it serves everyone not to disrupt the fantasy, because in the end that’s what makes good movies. The result, if we do it right, is the audience’s willing suspension of disbelief.

Arguably, in this instance, joining an artist in creating her fantasy was a dangerous position to take—quite literally. So why was it so easy for me to leap right on board with the movie’s implicit mission, to help Alex find a cure for an incurable disease? As we filmed a variety of fascinating interview subjects with deeply alternative (and sometimes questionable) practices, I was confident of the weight and value the footage would have in the edit room and ultimately on the screen. On another level, however, with each interview we conducted, Alex would fervently hope to be healed, sometimes in the face of hard scientific evidence that that wasn’t the direction things were going. And I was right there with her, hoping for the same thing. Of course, who wouldn’t? But it does sometimes beg the question of responsible adult behavior.

On some days, we even thought that the very act of making the movie could halt the course of Alex’s disease and save her life. Absolutely magical thinking, to be clear, but in retrospect I think it speaks to the vast and transformative power of the imagination, which we were experiencing on a daily basis during this process. What is more, our joint denial had demonstrable value to us in the sense that we were making something tangible, and doing so with great love for our craft.

Conventional wisdom has it that we should take our cues from the patient, just as in film we take our cues from the director. Who are we to disabuse her of the notion that she is going to cure an incurable disease, especially if that notion serves her? Indeed, in this case the fantasy was an integral piece of the filmmaker’s very strong vision. But sometimes I think supporting that vision as a producer was at the cost of supporting my friend in the frank assessment of her reality that she also explicitly craved.

In truth, I think people with cancer likely need support in both realism and optimism (read: in some instances, denial). That said, it’s not always easy to accurately assess which is called for at any given moment. Hopeful thinking, wishful thinking, denial and magical thinking intersect in a complex matrix where we find the question we all struggle with endlessly: how to keep one foot in the optimistic place and one foot in the realistic place? Clearly, there is value in both; the trick is in finding the balance.

In structuring the narrative of the fictional script, even as Alex struggled to find Anna’s story, we always knew where it ended. We weren’t looking for an unrealistically “happy” ending in which someone—a fictional someone, of course—magically finds a cure (especially when one doesn’t exist in the medical literature). Ultimately, we wanted for Anna what Alex hoped for herself: acceptance. That is, to be able to live joyfully with a time bomb ticking loudly in her ear.

II. Josephine Johnson: The Health Challenged Patient

Whether the therapist begins treatment knowingly addressing patients’ health challenges and life-threatening illnesses, such issues almost inevitably arise. While one cannot be expected to prepare for all conditions and circumstances, some basic preparation is important. Heeding two caveats is a helpful start.

Caveat 1: Stay in Your Own Lane

Developing the appropriate therapeutic skills to work with patients with life-threatening illnesses does not mean that one must or can practice as a qualified health psychologist. Psychologists' Ethics Code (American Psychological Association, 2002; Standard 2.10) cautions about providing services only within the boundaries of one’s competence.

Caveat 2: Know Yourself

Before you work with patients’ issues around illness and death, deal with your own fears and anxieties. The challenges of countertransference can become more pronounced around life and death issues. If your own existential crises are triggered you may need to consider personal therapy and/or transfer.

Caveat 3: This is NOT Treatment as Usual

Treatment with patients who are ill and may be facing death can be quite different from what we typically provide. We need to consider time constraints, specific assessments and screenings, type and severity of illness, and stage of life among other factors.

Working with terminally ill patients typically demands adjustments in length of treatment, even for brief therapy. Brief approaches have the underlying assumption that additional treatment is possible, if desired. This may not be possible with the dying patient. Goals themselves may have to be modified to be realizable within the available time. For example, we may not have the luxury of working on changing long-term relationship patterns.

The American Society of Clinical Oncology (2014) recommends that all patients with cancer be screened for depression and anxiety at diagnosis and at regular intervals thereafter. They report that psychiatric disorders are more common in patients with cancer than in those with any other chronic illness. It is estimated that among cancer patients 20.7% have mood disorder, 10.3% have anxiety disorder, and 19.4% have some type of adjustment disorder. The recommended assessment instruments are the nine-item Personal Health Questionnaire (PHQ-9;Kroenke, 2001) for depression and the seven-item Generalized Anxiety Disorder (GAD-7;Spitzer 2006) scale for anxiety.

For patients dealing with chronic illnesses, therapy may have to be adjusted to accommodate medical conditions. Some illnesses are more incapacitating, distressing, and painful than others. Some deference must be given to the effects of pain. Appointments sometimes must be flexible and consideration may have to be given to doing therapy where the patient is if she or he is unable to come to the office.

Know your biases. Many of us view illness and death through a stage-sensitive lens. A terminally ill child evokes a different set of responses than a terminally ill octogenarian. Perhaps we view the elderly patient’s illness or impending death as acceptable or even appropriate. What is the patient’s reaction to the inevitable? Erickson (1994) addresses this in his final Psychosocial Stage, “ego integrity vs. despair.” The latter likely contributes to the elevated suicide rate among seniors. Among Americans of all ages, 12.4 per 100,000 take their own lives each year, according to 2010 statistics from the CDC Interim Health Care 2013). But among those over 65, the official number is 14.9.

Caveat 4: What We Must Take from Treatment as Usual

Whether we are behaviorists focusing on controlling feelings through stress management techniques, humanists helping patients make meaningful use of the time they have, or dynamic therapists addressing self-defeating defenses, the overall goal is to address the patient’s needs. As therapists we must be prepared to deal with common emotions that become intensified when associated with chronic and life-threatening illnesses; e.g., anxiety, anger, depression, and family stress.

Anxiety and fear are frequent presenting problems in psychotherapy and all the more with serious illness and end-of-life issues. There are fears about extent of suffering, unfulfilled family responsibilities, negative self-percepts, and unrealizable goals. Alex describes the imagined and real impact of a terminal disease on her life. She says, “…I’ve just been living in the terror of cancer.” Extreme anxiety is toxic. Managing anxiety and stress facilitates any possible physical healing and allows the patient to more fully engage in “rest of life” decisions.

Anger and resentment over the “unfairness” of suffering and death do not come as a surprise. What may be unanticipated is the outward focus. Patients may feel justified in lashing out at others who seem to be enjoying a long and healthy life.  They may also resent the therapist because he or she is not dying. How can they understand? Depression has been classically viewed as anger turned inward. How should we view depression in the seriously or terminally ill? Treatment goals for the depressed patient often call for increasing understanding of depressive feelings, addressing issues of helpless and hopelessness, addressing underlying causes. What are our goals when chronic suffering and/or impending death is the reality? The bottom line is, understand that depression may be normative under these circumstances.

There’s a colloquialism that says, “You mess with me, you mess with the whole family.” Chronic or terminal illness messes with the whole family. Alex explains it this way, “I feel like my whole family is living in shock. I want us to wake up while we still have time to wake up.” Be prepared to function as “family therapist.” Dr. Susan Silk developed a useful tool to help families and friends keep the patient’s needs as the central focus. When Dr. Silk was being treated for breast cancer, a colleague wanted to visit, but Dr. Silk declined. Her colleague responded, "This isn't just about you." "It's not?" Dr. Silk wondered. "My breast cancer is not about me?” She developed the “Draw a circle” technique. In the innermost ring put the name of the person at the center of the current trauma. Draw a larger circle around the first one; put in the name of the person next closest to the trauma.  Repeat the process as many times as needed—parents and children before more distant relatives; intimate friends in smaller rings, less intimate friends in larger ones.

The rules: The person in the center ring can say anything he or she wants to anyone, anywhere. He or she can kvetch and complain and whine and moan and curse the heavens and say, "Life is unfair" and "Why me?" That's the one payoff for being in the center ring. Everyone else can say those things too, but only to people in larger rings. The first rule is comfort in, dump out.

Caveat 5: But Again, This is NOT Treatment as Usual

“Not usual” in this case refers to treatment factors that may fall outside of one’s typical worldview. This is especially relevant with regard to cultural differences and religious preferences.

APA’s Multicultural Guidelines (American Psychological Association, 2003; Guideline 2) encourages psychologists to recognize the importance of multicultural responsiveness, knowledge, and understanding about ethnically and racially different individuals. Cultures differ in attitudes towards disclosure of information, collectivism vs. individualism, and perceptions of illness, among other factors. Sometimes the good of the family outweighs the good of the individual. The therapist should explore what a specific illness means in a patient’s life and culture, and the availability and importance of social and familial support networks. Ask if there is anyone else that patient would like to be involved in treatment.

Honor the personal sacred. Alex says, “You get strength when you believe in something.” Faith systems are perhaps more important in treating the seriously ill patient than in other treatment situations. They can be very helpful in solving problems of uncertainty, powerlessness, and finality that death creates. Through religion patients may find meaning for otherwise inexplicable suffering—meaning that psychological theories cannot provide. This is particularly germane in working with African American patients. Religion has always facilitated coping in an oppressive society. According to the Pew Research Center, African-Americans stand out as the most religiously committed racial or ethnic group in the nation. 79% say religion is very important in their lives, compared with 56% among the U.S. adult population overall.

Caveat 6: Treatment Will End

“By having a fictional version of me I get to change the story. I get to rewind it when I want to. I get to re-write the facts,” per Alex. Perhaps this is what end-of-life therapy should aspire to, offering patients a more hopeful, not necessarily truthful, vision of their life and death. How far should we go in supporting a patient’s desire to create a fiction in order to change or face the reality? It doesn’t fit neatly into the traditional theoretical schema, but it may offer a creative alternative.

There is the concept of a “good death”: acceptance of the reality of approaching death, which allows clear communication with family and friends of their value and importance. Ira Byock (1997), a palliative care physician, condenses the necessary communications at the end of life to these four messages: I love you. Thank you. I forgive you. Please forgive me. Therapy is well positioned to help the patient articulate and communicate these needs.

III. Jana N. Martin: When Psychologists Have Cancer or Serious Illnesses—Clinical, Ethical and Personal Challenges

It is important for us all to accept that psychologists struggling with life-altering medical problems may be especially vulnerable to a lack of awareness of changes in our competence or a failure to exercise good self-care. We are as capable of denial, anxiety reactions, and withdrawal as are any other human beings. We have a responsibility to discontinue providing services when we’re too distressed to do so effectively, and yet we may not be aware of how distressed we are or be able readily to have someone else support and care for our patients.

Ethics Standard 2.06, Personal Problems and Conflicts, (American Psychological Association, 2002) addresses our obligation:

  • “Psychologists refrain from initiating an activity when they know or should know that there is a substantial likelihood that their personal problems will prevent them from performing their work-related activities in a competent manner.
  • When psychologists become aware of personal problems that may interfere with their performing work-related duties adequately, they take appropriate measures, such as obtaining professional consultation or assistance, and determine whether they should limit, suspend, or terminate their work-related duties.”

Standards 3.04, Avoiding Harm, 3.12, Interruption of Psychological Services, and 10.10 Terminating Therapy (American Psychological Association, 2002) also have relevance to serious medical issues.

Good risk management requires us to be prepared to take several actions if we are diagnosed with cancer or other serious illnesses. I’ll share with you some of my own experiences after I was diagnosed with follicular lymphoma along with some risk management recommendations.

Seek Support and Supervision

Being resilient doesn’t mean you’re immune to feelings; it does mean you have the skills to move forward. One of the best first steps to follow in building resilience is to reach out to colleagues for support and supervision. In all likelihood you’ll already know someone who has been through cancer or other illnesses. Try to find someone who has the same kind of cancer/illness and recommended treatment. The connections with other professionals, though, is comforting and empowering regardless of differences in diagnoses and treatment regimens. When I was diagnosed, I discovered that so many colleagues had gone through cancer. That was empowering, especially in the early phase: here were healthy, strong survivors who were living models of bouncing back no matter how difficult their journey had been. That allowed me to envision myself as I am today—doing what I love, enjoying my life, having a life. That is worth more than I can tell you, and my resilience grew stronger.

In addition to emotional support, having someone to ensure you are competent and focused on your patients’ needs is very important. This is best done through supervision with someone whom you can trust to be sensitive but brutally honest with you.

Being resilient doesn't mean you're immune to feelings; it does mean you have the skills to move forward.

Develop a Practice Management Plan

There are many things to consider when being diagnosed with cancer or a serious illness. First, you need to make treatment decisions (e.g., chemotherapy, radiation, surgery). Then, consider how that treatment and other obligations such as family needs impact your decision about how much you can/will work during treatment. Some psychologists continue to see patients because they love the work and benefit from remaining mentally engaged and, perhaps, distracted from physical concerns. Research shows that continued work engagement can promote well-being and reduce anxiety and depression (Johnson & Barnett, 2011). Others are too ill, tired, or uncomfortable to work during treatment. Only you can make this decision since other factors such as changes in your appearance, self-imposed pressure and disappointment that you may not able to be yourself through treatment, will impact your decision (Coons & Martin, 2011).

Johnson and Barnett (2011) suggest psychologists ask themselves, “How can I manifest integrity, caring and some measure of grace throughout this process?”  Remember, too, that your plan needs to be flexible, especially as your treatment proceeds—what works the first three months of treatment may not work the last three months of treatment. Whether, what and when to tell patients about your diagnosis is influenced by your theoretical orientation, the age of your patients and what you do. The length of time you’ve been seeing a patient, his or her diagnosis, and the impact of the side effects of treatment all affect how you handle specific issues. Again, it must be tailor-made for you. For minors, it’s important to share with the parents how you’re going to talk to their children about your illness to ensure your comments are not insensitive to personal and cultural issues and do not stimulate issues of which you’re unaware. Many psychologists find that in telling their patients, they are able to model adaptive behaviors which can be therapeutically very beneficial for their patients. It’s helpful to be prepared for various reactions of patients—e.g., flight into health; letting go of dependency; insight into concerns about their own mortality, etc.

Be aware of how your diagnosis may change your emotional and personal priorities—all of which need to be considered when making your plan. Consider several transference and countertransference issues when deciding whether or not you will treat patients who have chronic or terminal illnesses, have recently lost a loved one, have significant attachment issues, or require a high degree of treatment consistency. Importantly, remember that your own treatment experience is very different from having the expertise in psychosocial oncology necessary to provide evidence-based assessment and treatment to those with early and advanced cancers (Coons & Martin, 2011). Supervision can be invaluable when considering all of these issues.

Pace Yourself During/After Treatment

Being resilient also doesn’t mean you have to be super psychologist! In fact, it means facing your reality and making reasonable decisions and, in our case as psychologists, it means practicing what we preach—identifying obstacles, making a plan for dealing with them, using resources efficiently, and avoiding self-defeating behaviors.

It also means keeping in mind our ethical responsibilities: It is important to recognize when treatment or our physical and/or emotional reactions may be impairing functioning. Fatigue, pain, nausea, and medications may compromise your ability to meet the demands of clinical practice, and chemotherapy and other medications can diminish cognitive functioning. This may mean you’ll have to change the way you usually do a lot of things. Sometimes the emotional impact of your treatment may not be as apparent to you, so an independent assessment of your functioning and supervision is good risk management to protect you and your patients.

Designate a Clinical Power of Attorney

You have an ethical obligation to ensure the well-being of patients, students, supervisees, and others (American Psychological Association, 2002). Designate a colleague and establish a clinical power of attorney in the event you are unable to take care of your patients. Your colleague should be able to access your office, files, relevant patient records, and appointment schedule and should be willing to re-schedule, provide care to patients, or refer them to other colleagues with the appropriate clinical experience (Coons and Martin, 2011). Be sure to obtain proper consent from your patients.

I talked with my patients about the possibility of needing to cancel sessions without much warning and created a release form for them to sign authorizing either of two named colleagues to know their names, their contact information, and their appointment times and to call them if a cancellation was needed. I made a list of active patients and contact numbers and gave it along with the signed authorization to my designated colleagues and gave them my schedule weekly. One of them was my office mate, so she had a key to the office, and I gave a key to one other colleague just in case. I also reviewed what to say; e.g., “Dr. Martin regrets not being able to make your appointment and wants you to know she is taking more time to rest. There is no emergency.” This was followed by information about re-scheduling or getting in touch with them later. This was a gift to myself to make one call and a gift to my patients not to worry too much based on how I sounded on the phone or if I missed a session. It also helped me to keep some boundaries.

Our work as psychologists is often powerful, poignant, demanding, and at times taxing. Regardless of how resilient we are, meeting our professional obligations in the context of cancer or other serious illnesses and their treatment can be both satisfying and overwhelming. Carefully consider your ethical responsibilities and what is important to you during this challenging time and engage in good risk management. Remember that you do not have to face the complex decisions related to your health or your work alone. Reaching out to colleagues who have survived these treatment protocols can help you face the necessary decisions that are before you.

IV. Lauren Behrman: Discussion and Next Steps

The film A Woman Like Me, and Alex Sichel’s open, transparent and authentic approach to her challenge of living fully with a life-threatening diagnosis inspired us to create our workshop and write this article. Our goal is to find a way to use this film as a tool for raising awareness, training and educating our colleagues, and perhaps using clips from the film to stimulate discussion in therapeutic groups of individuals facing these diagnoses.

The common element in these discussions is our underlying humanity and the commonality of our human experience whether we are the individual, patient, or clinician facing a terminal illness. In these moments, we all need to find a way to integrate the realization that we are facing our mortality and subsequently create an authentic and meaningful way to live, whether our days are few or many. For those of us who are clinicians in independent practice, we also need strategies to deal with our patients and the logistics of our practices during medical treatments that may impact our stamina, availability and physical appearance while maintaining high ethical professional standards.

What is common to all of us when faced with life-threatening illnesses is how sharply one’s lens is focused on life—looking at our lives and the choices we’ve made, the circumstances we are in, and the relationships we have with the people in our lives. Some of us will find upon reflection that there are areas in our current lives that are not reflective of our values. For those individuals who have time, there is the opportunity to make life changes, as priorities become clearer and more defined, and attention becomes more focused. For many of our patients and colleagues going through treatment, illness is a catalyst for growth and change, ushering in moments of clarity about ways in which certain circumstances and/or relationships were toxic to their health, and were sustained at too high a cost to their integrity, dignity, and self-esteem. We hear many stories about profound realizations that lead individuals with chronic or terminal illnesses to divorces, changes in career, or confronting or ending toxic or unsustainable relationships with family members and friends.

Gilda Radner said, "Cancer changes your life, often for the better. You learn what's important, you learn to prioritize, and you learn not to waste your time. You tell people you love them…If it wasn't for the downside, having cancer would be the best thing and everyone would want it. That's true. If it wasn't for the downside."

As psychologists, it’s important for us to equip ourselves with the tools we need to be able to assist our patients and ourselves in the changes that may be ahead when faced with diagnoses of life-threatening or terminal illnesses. We’ve given you multiple perspectives and, hopefully, stimulated you to think about some issues that must be addressed when you are treating patients with life-threatening diagnoses, or find yourself in that circumstance. What is the role of denial, life review, forgiveness of self and others? What preparation is needed to heal critical relationships? How does one go about cleaning one’s psychological house in the time given? How can we empower our patients and/or ourselves to face a new unwanted reality? How can we help our patients re-discover self? We benefit from learning how we can help our patients face these challenges, and how we can face them ourselves in a way that does not impair or impede our work if we choose to work through a period of treatment. We believe the knowledge we’ve presented and issues we’ve raised is valuable food for thought and planning when we are in the position of ailing clinician and/or treating clinician. We hope you will ponder them and find ways to use them in your personal lives and clinical work.


lauren-behrmanDr. Lauren Behrman is a psychologist in solo Independent Practice for over 30 years in Manhattan and Westchester, NY. She specializes in working with children and adults and helping families transition successfully through divorce. Dr. Behrman is also a founding partner of The Practice Institute which helps mental health professionals build thriving practices.

elizabeth-giamattiElizabeth Giamatti is a partner at Touchy Feely Films, where she has produced four independent feature films, including A Woman Like Me, which she also co-directed. The film premiered at SXSW in 2015 where it won a Special Jury Prize for Directing and is currently on Netflix and iTunes. Other films include Pretty Bird, Cold Souls and All Is Bright. She holds an M.F.A. in Dramaturgy from the Yale School of Drama, an M.A. in Cinema Studies from NYU, and a B.A. in Semiotics from Brown University.

josephine-johnsonDr. Josephine Johnson’s private practice in Livonia, Michigan provides services to children, adults, and families. As a consultant to Community Mental Health agencies and residential treatment facilities, Dr. Johnson administers psychological evaluations, provides clinical supervision to Doctoral/Master’s level psychologists, provides group case consultation, and conducts training workshops.

jana-martinAfter years of independent practice, Dr. Jana Martin became CEO of The American Insurance Trust (The Trust) in 2010. She has worked to provide more support services for Trust policyholders such as expanding clinical and risk management consulting and educational resources and products and presenting workshops on strategic planning for successful practices for psychologists at every level of their careers. Dr. Martin focuses on promoting the profession of psychology by empowering psychologists with information and support.


American Psychological Association (2002).  Ethical principles of psychologists and code of conduct. Washington, DC:  Retrieved from

American Psychological Association (2003). Guidelines on multicultural education, training, research, practice, and organizational change for psychologists. American Psychologist, 58, 377–402.

Byock, Ira (1997) Dying well: the prospect for growth at the end of life / by Ira Byock.  Byock MD, Ira (1998-03-01). Dying Well. Penguin Publishing Group. Kindle Edition.

“CDC: Suicide rate spikes among seniors”, Interim HealthCare, Sunrise, Florida (August 8, 2013).

Clinical Oncology Guideline Adaptation; Journal of Clinical Oncology, Vol. 12, Number 15, May 20, 2014, pp. 1605-1620

Coons, H.L. & Martin, J.N. (2011).  Clinical, ethical and practical concerns among psychologists with cancer.  The California Psychologist, 44(6), 17-19.

Erikson, E. H. (1994). Identity and the life cycle. WW Norton & Company.

Johnson, W.B. & Barnett, J.E.  (2011).  Preventing problems of professional competence in the face of life-threatening illness.  Professional Psychology: Research and Practice, Vol. 42(4), 285-293.

Kroenke K, Spitzer RL, Williams JB; The PHQ-9: validity of a brief depression severity measure. J Gen Intern Med. 2001 Sep; 16 (9): 606-13.

“New analysis finds African-Americans are markedly more religious than overall U.S. population” Pew Research Center, Washington, D.C. (January 30, 2009).

Silk, S. & Goldman, B. (2013, April 7). How not to say the wrong thing. Los Angeles Times

Spitzer RL, Kroenke K, Williams JB, et al; A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22; 166 (10): 1092-7.