Fear I Palliative care I Psychotherapy

The aim of psychotherapy is not to achieve freedom from fear and anxiety, but to show ways of dealing with them, so that the patient can keep hold of herself when experiencing fear. In addition to effective short-term avoidance and compensation strategies (e.g., distraction, singing/whistling, tapping, breathing and physical exercises), which patients can quickly learn to apply, palliative care patients need stabilizing and benevolent human relationships to be able to deal with their disease, possible dying, suffering and death. “Inner empowerment” through self-development and self-training, e.g., with the help of psychotherapy, is possible even in this phase of the illness. Terminally ill patients often have spiritual questions about the meaning of the disease, about dying and death and the indestructibility of the human spirit. However, such questions are only raised when the conversation creates space for them. Near-death experiences are an essential topic. Again and again they lead in astonishing ways to overcoming the fear of death and to the transformation of hopelessness and gloom into light and new perspectives. Near-death experiences have been reported by numerous people and are often experienced in palliative and hospice patient care especially, although people exercise restraint in talking about this. It can be frightening even just to know about inner and spiritual experiences, so this topic takes on a special significance when providing psychotherapeutic support.

Differential diagnosis must be used to recognize somatization of depression. There are also patients who are traumatized by the diagnosis and the course of the disease, fulfilling the criteria for a post-traumatic stress disorder or acute traumatic reaction.

The therapeutic conversation

The topic of fear is a major one in therapeutic conversations. Even just speaking about it provides relief and counteracts fear-entrenching avoidance behavior (1). Discussing scary taboo topics can lead patients to new orientations even when dying, opening up the scope of possible actions and thus motivating them to actively shape their lives. Questions of meaning and spiritual orientation are essential for maintaining and, if necessary, regaining dignity at the end of life (2). It is absolutely essential to cooperate with providers of spiritual counseling.

The involvement of relatives/partners/friends is indispensable in coping with fear, since they are usually directly involved and can intensify or alleviate existing fears.

Therapeutic approach

The prerequisite for psychotherapy is a trusting, sustainable alliance, so that the “view into the abyss” and venturing along this abyss can succeed. The inner stability of the therapist offers the patient the possibility to hold on to him inwardly, at least temporarily (auxiliary “I” function).

In a first step the patient learns that fears and the associated emotional arousal can be reduced through his power of thinking and judgement. This is done, for example, in

  • guided relaxation and visualization exercises.

In addition, the patient engages his own thinking power to strengthen the effect on his inner life. A wealth of exercises and different forms of meditation are available for this, which can be experienced under therapeutic guidance and patiently practiced by the patient. Important instruments include:

  • the anthroposophic training program by Harald Haas and Theodor Hundhammer (3),
  • the six steps to self-education by Rudolf Steiner (4), and
  • retrospection/review of the day

Here the patient practices working with his own thoughts, which enables him to experience control over his thoughts and feelings.

Verses and meditations can be added to these exercises. The therapist should have familiarized himself with their content in order to be able to give the patient effective help.

Tried and tested meditations

In cases of agitated fear, many patients experience help through the following meditation. The therapist should have familiarized himself or herself with its content in order to be able to give the patient effective help.

I bear tranquility within me,
I bear within me
The forces that strengthen me.
I will fill myself
With the warmth of these forces,
I will permeate myself
With the might of my will.
And I will feel
How tranquility pours
Through my entire being
When I strengthen myself
To find within me
Tranquility as strength
Through the might of my striving.

Rudolf Steiner (5, p. 169)

In cases of an anxious mood and discouragement the following meditation can be recommended:

Victorious spirit
Blaze through the powerlessness
Of faint-hearted souls.
Burn up the I’s desires
Kindle compassion,
So that selflessness,
The stream of life for humankind,
Will surge as the source
Of spiritual rebirth.

Rudolf Steiner (6, p. 73)

The following meditation is suitable for relatives who want to help the patient inwardly:

Spirit of your soul, ever working Guardian!
May your wings carry
Our soul’s imploring love
To the one in the spheres entrusted to your care!
United with your power,
May our prayer be a shining help
To the soul it lovingly seeks.

Rudolf Steiner (7)

The following short meditation by Rudolf Steiner can create a special source of strength when patients are engaged in existential confrontation with their disease:

You spirit of my life, protective companion,
Be goodness of heart in my willing,
Be human love in my feeling,
Be light of truth in my thinking.

Rudolf Steiner (8, p. 180)

This meditation is headed by “In danger of death”. The date of its creation and the person who asked for it are unknown. This meditation is addressed to the person’s angel, who carries and can lead the person’s “I” and who bestows strength in thinking, feeling and willing. The qualities that we marvel at in many patients in palliative care can then develop and be promoted: a wisdom-filled view of life as a light of truth in thinking that no longer illuminates only the personal but recognizes new perspectives; human love that no longer develops egocentrically, but is attentive to its surroundings; and finally, a kindness of heart that can almost be perceived as a power capable of blessing. In such inner development something akin to an angel appears as the fruit of the patient’s confrontation with the disease, which can carry individuality forward into the future either in this or a later destiny.

1 Quetz M. Gesichtspunkte anthroposophischer Psychosomatik und Psychotherapie in der Onkologie. Der Merkurstab 2009;62(4):398-405.

2 Chochinov HM et al. Dignity therapy: A novel. Psychotherapeutic intervention for patients near the end of life. Journal of Clinical Oncology 2005; 23(24):5520–5525. [Crossref]

3 Haas H, Hundhammer T. Selbsterziehung und der achtgliedrige Pfad—ein Gruppenprogramm. In: Reiner J (ed.). In der Nacht sind wir zwei Menschen—Arbeitseinblicke in die anthroposophische Psychotherapie. Stuttgart: Freies Geistesleben; 2012.

4 Steiner R. Die Nebenübungen. Sechs Schritte zur Selbsterziehung. 5. Aufl. Dornach: Rudolf Steiner Verlag; 2016.

5 Steiner R: Mantric sayings. Meditations 1903–1925. Herndon: Steiner Books; 2015. Translated by Dana L. Fleming and Christopher Bamford.

6 Steiner R. Mantric sayings. Meditations 1903–1925. Herndon: Steiner Books; 2015. Translated by Dana L. Fleming and Christopher Bamford.

7 Steiner R. Der Tod—die andere Seite des Lebens. Wie helfen wir den Verstorbenen? Worte und Sprüche. Dornach: Rudolf Steiner Verlag; 2000.

8 Steiner R. Steiner R. Mantric sayings. Meditations 1903–1925. Herndon: Steiner Books; 2015, p. 180. Translated by Dana L Fleming and Christopher Bamford.