Top Ten Tips Palliative Care Clinicians Should Know About Applying Key Psychotherapy Concepts in Practice

Abstract

Psychological symptoms are notably prevalent in palliative care (PC) settings, significantly impacting quality of life for patients and their families. Given the inherent multidimensionality of suffering in PC, addressing these psychological aspects is essential. This article aims to introduce and integrate discrete concepts from various schools of psychotherapy, which are directly applicable to PC practices, thereby providing clinicians with a rich toolkit to manage psychological distress. The article focuses on 10 key concepts from different psychotherapeutic traditions. They are a small sample from the vast and deep pool of wisdom contained in psychotherapeutic theory, and they were selected due to their direct applicability to PC practice. Adopting psychotherapeutic principles, along with leveraging the interdisciplinary wisdom inherent in PC practice, enhances our therapeutic relationships in PC and empowers patients to navigate their illness with greater resilience and adaptive coping.

Introduction

Psychological symptoms are prevalent in palliative care (PC) settings and range from normative responses to serious illness to psychiatric comorbidities. The fields of psychology and psychotherapy offer rich insights into how to conceptualize and provide therapeutic care to patients.¹ Various “schools” of therapy each contribute their own unique wisdom. We provide a curated selection of tips derived from common schools of therapy with a focus on simple, yet high-yield, insights and techniques that can be adapted for PC clinicians to more effectively respond to psychological distress (Table 1).

Table 1.

Top Ten Tips Palliative Care Clinicians Should Know About Applying Key Psychotherapy Concepts in Practice

Tip 1	Moving from dualistic thinking (“either/or”) to dialectical thinking may help patients integrate their illness experience.
Tip 2	Exploring behaviors and thoughts rather than emotions may be most effective in supporting some patients’ emotional states.
Tip 3	Helping patients make value-based decisions can foster a sense of agency and security when situations feel out of their control.
Tip 4	Clinicians can engage with patients as curious explorers rather than all-knowing experts.
Tip 5	Focusing on the relationship dynamics within a group, rather than individuals, is sometimes more therapeutically effective.
Tip 6	Ambivalence is at the center of many patient struggles; palliative care clinicians can create the space for patients to explore their inner conflicts.
Tip 7	Using meaning and narrative can deeply change patients’ experiences of serious illness.
Tip 8	Palliative care clinicians can help patients acknowledge and cope with death anxiety as fundamental to the human condition.
Tip 9	Helping patients be nonjudgmentally mindful of the present moment can enhance their coping capacity.
Tip 10	All patients benefit from safety, security, and predictability in their treatment relationship, especially those with a history of trauma.

While many of these insights and techniques are shared across multiple therapeutic traditions, we italicize some of the psychotherapeutic traditions most deeply connected to each concept. Although these tips can be applied by interdisciplinary PC specialists and teams, some patients require a referral to specialized psychological or psychiatric services. A secondary aim of this article is to increase awareness of the various psychotherapy options available for referral to PC patients (Table 2).

Table 2.

Common School of Therapy Pertinent to Palliative Care

School	Brief description
Cognitive Behavioral Therapy	Focuses on changing unhelpful behaviors and distorted patterns of thinking through practical, action-oriented strategies. Emphasizes problem-solving and behavioral change to improve emotional well-being, often within a time-limited framework.
Acceptance and Commitment Therapy	Purpose- and action-oriented technique stemming from many similar concepts as CBT. Emphasizes acceptance of inner emotions and commitment to behavior change aligned with one’s values.
Dialectical Behavioral Therapy	Aims at improving relational dynamics and managing one’s strong emotions in more helpful ways. Honors the coexistence of seemingly contradictory truths. Traditionally includes components of group instruction and individual sessions.
Psychodynamic Psychotherapy	Delves into unconscious thoughts and emotions, bringing them to conscious awareness for evaluation. Uses therapist–patient interactions as a microcosm to understand patterns in outside relationships.
Mindfulness-Based Therapies (including MBSR or MBCT)	Incorporates mindfulness practices to help patients become more aware of their present thoughts, feelings, and sensations. Used to reduce stress, manage symptoms, and improve overall well-being.
Internal Family Systems	Focuses on the mind’s multiple subpersonalities or “parts,” each with distinct perspectives and roles. Aims to achieve internal harmony and self-leadership.
Couples and Family Therapy	Improves communication and relationships within couples and families. Addresses dynamics and interactions that contribute to the emotional and psychological health of the family unit.
Existential Psychotherapy	Explores the human condition, including themes such as mortality, freedom, isolation, and meaning. Helps patients find purpose and meaning in their experiences, especially in the face of serious illness.
Meaning-Centered Psychotherapy	Helps patients find and maintain a sense of meaning and purpose in life, despite their illness. Explores life stories, values, and legacy.
Dignity Therapy	Enhances the end-of-life experience through questions that prompt patients to reflect on their lives, share important memories, and pass on messages to loved ones, enhancing their sense of dignity and legacy.
Managing Cancer and Living Meaningfully (CALM) Therapy	Designed for patients with advanced cancer, focusing on supporting them through emotional, social, and existential challenges. Includes structured, supportive conversations to improve quality of life and adaptation to illness.
Narrative Therapy	Empowers patients to author their life stories to create personal narratives that identify meaningful values and skills.
Grief Therapies	Provides support for individuals experiencing grief and loss. Helps patients and families process emotions, adapt to their loss, and find ways to live meaningful lives.
Supportive–Expressive Therapy	Combines support and expression, encouraging patients to openly discuss their emotions and experiences. Creates a supportive holding environment for patients to express their feelings and receive validation and understanding.

Moving from Dualistic Thinking (“Either/or”) to Dialectical Thinking May Help Patients Integrate Their Illness Experience

A crucial element of therapeutic alliance in PC is creating a sense of safety for patients to express thoughts and worries that may have been too challenging to share with their closest supporters. The PC team’s ability to hold space for these thoughts and feelings fosters present-moment awareness and encourages patients to engage in dialectical thinking.

Patients commonly experience dualistic, “all or nothing” thinking as they face serious illness. Patients may feel compelled, for example, to exhibit unwavering positivity, never showing fear of the “what-ifs,” or to focus solely on living well without considering the possibility of getting sicker. They may also exhibit dualistic views about clinicians, idealizing or undervaluing their oncologist or PC clinician.

Dialectical thinking invites patients to hold the tension between two seemingly conflicting ideas, creating room for both to be simultaneously valid. Dialectical Behavioral Therapy (DBT), which emphasizes that a person can simultaneously accept who they are while also striving to grow, highlights the importance of this type of thinking.² In PC, common dialectics include “hoping for the best, while preparing for the worst,” or “living fully, while facing dying.”³

As clinicians, we can use the word “and” to make space for both sides of the dialectic. “Hoping for the best and preparing for anything that may happen” can allow both parts of the dialectic to be recognized. Over time, these reflective experiences can help patients establish new patterns of thinking, strengthening their ability to process and cope.

Exploring Behaviors and Thoughts Rather Than Emotions May Be Most Effective in Supporting Some Patients’ Emotional State

Cognitive Behavioral Therapy (CBT) posits that thoughts, behaviors, and emotions are all interconnected and influence one another. It can be challenging to “will” one’s emotions to change by focusing directly on those emotions. By exploring and helping patients either restructure their unhelpful thoughts or change their unhelpful behaviors, they may garner the capacity to shift their emotional state.

While many patients’ thoughts are valid (e.g., “This is never going to get better”), it is important to explore the thoughts that may not be helpful (e.g., “There is no hope”). We may explore with the patient what they mean by hope and if there are ways to restructure how they conceptualize hope (e.g., maybe it is not hope to live, but hope to have a death consistent with their values).

Patients may also engage in cognitive distortions, such as personalization, where they think, “This is all my fault because I did something wrong,” even when their actions had no impact on the illness. In addition, patients may exhibit negative self-talk (e.g., “I am no longer fun to be around, so people won’t enjoy seeing me”) or catastrophizing (e.g., interpreting every physical symptom as a lethal threat or disease recurrence). Recognizing and restructuring these thoughts can lead to an emotional shift.

Behaviors are often more easily accessible targets for many people than thoughts. For example, many patients may isolate themselves because they are embarrassed or do not want to ask for help. These behaviors only serve to depress their mood more, disallowing opportunities to experience more joy. We may encourage (or even “prescribe”) small concrete behaviors that help patients engage with sources of meaning, joy, or connection (i.e., trying out a new activity), which in turn could promote improved emotional states.

Helping Patients Make Values-Based Decisions Can Foster a Sense of Agency and Security When Situations Feel Out of Their Control

Acceptance and Commitment Therapy (ACT) suggests that rather than attempting to alter the content of one’s thoughts, clients should focus on mindfulness, acceptance, and values-driven behaviors. By fostering these aspects, patients can feel a sense of agency and security, particularly when a situation feels out of their control.

Per ACT, values are the guiding principles of how one wants to act. Values can change over one’s life, but differ from goals, as they are not “achievable” (i.e., can’t be marked as complete). In ACT, living a meaningful life involves identifying what truly matters to one’s self (e.g., connection, compassion, creativity) and aligning one’s actions with those values.

One of the most helpful discussions to inform goals of care is a conversation with the patient about their guiding values. If a patient values independence, we can consider how that value fits into their care decisions. Beyond medical decisions, exploring values can help patients clarify how they want to live day-to-day in the context of their illness. Do they want to continue working? Do they want to connect with different people? What areas of their life do they want to prioritize? Helping patients focus on their values—what brings meaning and joy—can provide clarity when making necessary life adjustments.

According to ACT, when patients make decisions and live their lives aligned with their values, they are better able to endure life’s inevitable suffering. Committed action, a tenet of ACT, involves taking steps toward one’s values even when faced with difficulties. As clinicians, we can accompany patients as they create meaningful goals and commit to actions that cultivate a fulfilling life, even amid loss.⁴

Clinicians Can Engage with Patients as Curious Explorers Rather Than All-Knowing Experts

The therapeutic stance in mainstream medicine is characterized by a power differential between the patient and clinician.⁵ In contrast, the psychotherapeutic stance posits that patients hold the expertise. A psychotherapist is not the authority in a patient’s personhood. Rather, the psychotherapist serves as a source of supportive guidance for the patient to safely explore their inner world. This requires curiously and compassionately encouraging patients to investigate their own selves rather than imparting information, addressing specific diagnostic questions, or making value judgments.⁶ Psychodynamic psychotherapy emphasizes the importance of understanding the underlying psychological processes and the therapeutic relationship itself as a vehicle for change.

These two stances—the powerful expert and the supportive guide—are not dichotomous. In PC, clinicians must make dynamic use of both expertise and humility. Clinician expertise is crucial during opioid prescribing. However, humility is key to ensure a patient’s personhood is reflected in their care.

Exploring patients’ psychosocial well-being or goals and values requires a more expansive, open curiosity than many clinicians may be used to, especially as we attend to patients’ ever-changing experiences and illness uncertainty and embrace our ignorance over expertise. Not only is it okay to not have all the answers, but at times we glean many benefits by assuming the stance of coexplorer rather than authority, supporting to actualize concrete decisions that align with their personal values and wishes.⁷

Focusing on the Relationship Dynamics Within a Group, Rather Than on Individuals, is Sometimes More Therapeutically Effective

When working with a couple or multiple members of a family, being attuned to the common family system patterns allows us to manage interactions effectively (e.g., recognizing patterns that trigger family members). In some situations, focusing on the relationship dynamics within a group, rather than on individuals, can help us be more therapeutically supportive. At the core of Systemic Family Therapy is an attempt to identify patterns among family members’ interactions and how these affect the larger unit.⁸ Simply put, we are products of our surroundings. Often, patients do not have the ability to change the systems they inhabit, but clinicians can work to help patients understand their role within a system and find ways to adapt, cope, and create achievable goals.

When patients better understand their interpersonal systems, they can more easily recognize supportive stakeholders, easing their decisional process to become more aligned with their needs and values. Systems-based processing may be helpful when facing challenging intrafamilial dynamics or in moments when a patient prefers collaborative decision making.⁹

When assessing a patient’s familial supports, consider asking the following questions:

• •How does your family typically make decisions?
• •Is that also your preferred method of decision making?
• •Is there a person or group you generally rely on for major decisions?
• •Who or what supports you during difficult times?
• •Is there anyone you would like to be present during our serious discussions?
• •Is there anyone in your life who triggers you or whom you would prefer to not be present during our visits?

Ambivalence Is at the Center of Many Patient Struggles; Palliative Care Clinicians Can Create the Space for Patients to Explore Their Inner Conflicts

Conceptually related to Systemic Family Therapy, which focuses on the different parts of a larger family system (see Tip 5 in Table 1), Internal Family Systems (IFS) theory offers insight into a person’s psyche by defining specific parts that exist within one mind. The mind comprises a system of subpersonalities, each with its own thoughts, feelings, perspectives, and, most importantly, roles designed to protect the true Self.^10,11

When faced with a medical decision or crossroads, patients often display ambivalence, expressing feelings of being stuck or uncertain about the “right answer.” IFS provides a helpful framework that supports clinicians to explore how different parts of the patient feel. For example, a clinician might offer the following reflection: “On one hand, I hear you saying that a part of you wants to continue all these intensive interventions because it’s important to your family, and you desire to please them. On the other hand, it seems like another part of you desires to transition to a focus on comfort with a more peaceful death.”

Clinicians may use Motivational Interviewing tools (Table 3) to guide patients through their internal struggles. Clinicians can start by openly and intently listening to a patient’s hopes and worries, understanding the barriers they confront, and acknowledging the different parts that exist within their mind. Throughout this process of change, a patient’s right to self-efficacy—their ability to adapt their values, strengths, and skills—is centered. The change process is nonlinear and dynamic, requiring continual revisitation of a patient’s readiness and ability to change, and offering empathy when change is difficult.^12,13

Table 3.

Using the OARS of Motivational Interviewing in Practice^12,13

OARS	Examples
Open-ended Questions	- Tell me more about what you would like help with. - What have you tried in the past to address this issue? - Who or what has helped you make changes in the past?
Affirmations	- I appreciate how resourceful you are. - I can see how difficult change can be. - Thank you for your openness and willingness to share.
Reflective Listening	- It seems like you are struggling with … - I wonder if you’re questioning whether …
Summarize	- This is what I am hearing. Please let me know what I miss.

Using Meaning and Narrative Can Deeply Change Patients’ Experiences of Serious Illness

Therapies such as Dignity Therapy,^14,15 Meaning-Centered Psychotherapy,^16,17 Narrative Therapy,^18,19 Existential Therapy,^20,21 and some forms of Grief Therapy are constructed to support patients in their search for meaning as they experience illness in the larger context of their lives. Patients often closely align with and internalize their medical outcomes, ingraining their experiences into their personhood, and at times verbalizing self-defeating rhetoric. Through meaning-making exercises, clinicians can help patients redefine their narrative and separate their medical outcomes from their identities. Meaning-making exercises can include reconnecting a patient to their important relationships, hobbies, work, spirituality, and personal legacy. Clinicians can begin this work by asking a patient to tell their story in an open, respectful and nonjudgmental manner. From there, we can wonder with them together as they refine the narratives they hold of their experiences.

Questions to consider include the following:

• –What is your personal story?
• –What are your most important memories?
• –What are your significant accomplishments?
• –What relationships have helped define you as a person?
• −What are the characteristics that uniquely define you as a person?

Palliative Care Clinicians Can Help Patients Acknowledge and Cope with Death Anxiety as Fundamental to the Human Condition

Reflecting on one’s mortality is a universal experience that can not only bring great meaning but also lead to anxiety and distress. Psychiatrist Irvin Yalom, pioneer of Existential Therapy, described death anxiety as a type of “awakening experience” where people can find clarity around the people, memories, and beliefs that imbue each life with value.²⁰

When patients meet with PC clinicians, the very appointment can stimulate a variety of contradictory feelings about mortality, death, and fear of dying. This anxiety can manifest in different ways, including missing appointments or avoiding certain topics during the encounter. Death anxiety and death terror may also prompt patients and families to cling to toxic positivity. PC researchers and psycho-oncologists have suggested that short-term, meaning-oriented, and often spiritually focused therapies can yield the greatest benefit for patients, particularly for those with briefer life expectancies.²¹

PC clinicians can support patients through a period of adaptation where they begin to grapple with their newly realized mortality and find ways to manage this angst amid everyday life. An essential skill that PC clinicians offer is a comfort exploring people’s feelings toward death. By creating a space in which we remain present with a patient’s greatest existential fears, we model for patients the capacity to tolerate, explore, and process these fears for themselves.²²

Helping Patients Be Nonjudgmentally Mindful of the Present Moment Can Enhance Their Coping Capacity

Mindfulness-Based Cognitive Therapy and Mindfulness-Based Stress Reduction maintain mindfulness practices at their core. Mindfulness modalities are prevalent in PC due to promising effects, such as improved analgesia, mood symptoms, and even quality of life among certain populations.^23–26 When attempting to engage patients in mindfulness practices, there can be a pressure to know exactly what to do—a striving to “get it right.” However, this striving is the antithesis of mindfulness practice. Mindfulness is the act of paying attention on purpose, in the present moment, in a nonjudgmental way.²⁷ This type of conscious attention and awareness requires a moment-to-moment openness, a nonjudgmental curiosity.

One way to achieve this presence during a clinician–patient encounter is by intentionally engaging in the moment with the patient and allowing all other thoughts to pass. As we engage in our own present moment awareness, sitting with the patient in this exact moment, we implicitly encourage them to do the same. With this practice, we model a powerful coping tool.

Some patients benefit from concrete exercises such as square breathing to help center themselves in a moment of stress. Other patients engage well with metaphors like imagining their thoughts to be leaves on a river, intentionally setting them down and watching them float away. Many patients appreciate the reminder that uncomfortable feelings can be likened to riding a wave in the ocean: the more we try to resist the waves, the stronger they seem. There are innumerable ways to invite mindfulness into the room with our patients. It begins with us as clinicians being grounded, attuned, and nonjudgmentally present in the patient encounter.

All Patients Benefit from Safety, Security, and Predictability in Their Treatment Relationship, Especially Those with a History of Trauma

Managing Cancer and Living Meaningfully (CALM) Therapy conceptualizes the therapeutic relationship as the “secure base” from which patients can explore themes such as distress, uncertainty, and mortality.²⁸ PC clinicians seek to foster trust and safety, helping patients feel accompanied as they process their experiences. Ideally, patients can hold onto that sense of security even outside of their appointments. Interventions such as framing and boundaries, which clearly define the nature of our treatment relationship, can help patients experience predictability.¹ “Frame” can be used to create borders for the therapeutic interaction by clarifying parameters such as time, location, duration, and scope.^29,30

Trauma-informed care suggests that these concepts are particularly important for those with a history of trauma. “Trauma results from an event, series of events, or set of circumstances that is experienced by an individual as physically or emotionally harmful or threatening and that has lasting adverse effects on the individual’s functioning and physical, social, emotional, or spiritual well-being.”³¹ The surrender of control intrinsic to the serious illness experience can serve to exacerbate other traumatic memories when patients were stripped of control or autonomy.

Our first role as trauma-informed clinicians is to employ “universal precautions”—approaching every patient interaction with the consideration that they may have experienced significant trauma in their past. This framework can help contextualize the anxiety often seen around medical tests and procedures. When there is concern for possible prior trauma, clinicians can be even more explicit with patients about the frame while trying to create a holding environment. This includes being very clear about parameters such as how often they will see us, who are our team members, what roles our service can (or cannot) provide, and when upcoming clinician transitions are anticipated. This type of information can be experienced as quite containing, giving patients a sense of control, predictability, and agency over how they make use of their time with us.

Conclusion

The schools of therapy discussed in this study offer rich and dynamic wisdom to improve PC delivery. As we look to the future, we must explore how these psychotherapeutic techniques can be systematically integrated into standard PC practice. Advancing the application of psychotherapeutic principles within PC will allow for more effective patient-centered care models that comprehensively address the diverse needs of patients and their families.

Author Disclosure Statement

No competing financial interests exist.

Funding Information

No funding was received for this article.