Psychotherapy for Pain in Palliative Care

Psychotherapeutic treatment is prescribed as part of multimodal pain therapy to address a patient’s mental experience and processing. Chronic pain has a biography that usually goes back a long time. Mental trauma in childhood, for example, can become “embodied” in the course of life and turn into somatic pain. Biographical connections are well known in musculoskeletal pain syndromes and are essential aspects in psychotherapeutic treatment (1).
Palliative patients may experience different levels of pain. There are somatic causes such as bone metastasis, abdominal discomfort in peritoneal carcinomatosis, etc. The patient’s perception and evaluation of pain are also influenced by psychological experiences: anxiety and depressive moods can change the way that pain is experienced. Even a life situation that is no longer perceived to be meaningful can trigger a pain experience. The person’s social situation and previous biographical experiences also play important roles. We therefore distinguish between somatic causes and the dimensions of soul and spirit (2). A person’s perception and experience of pain is largely determined by their soul and spirit, which essentially determine the extent of their suffering (3). Conversely, psychotherapeutic treatment can apply different procedures to positively change the patient’s perception and experience of pain and support his or her steps in development in dealing with disease.

Various methods of behavioral and psychological pain therapy are used to alleviate pain in multimodal, integrative treatment (4, 5, 6):

  • Relaxation and imagination techniques
  • Biography-oriented psychotherapy
  • Cognitive-behavioral therapeutic interventions
  • Dignity-oriented interventions
  • Meaning-based interventions
  • Word and image meditations
  • Family-centered grief therapy

These approaches help to order and strengthen the members of the person’s fourfold nature, lead to a changed experience of the pain and to increased self-efficacy, and they include the patient’s social environment.

Finding meaning and significance in pain

In the palliative phase of an illness, the affected person is often faced with taking stock of his or her biography. Unprocessed conflicts, traumas and somatization of grief may require processing. Pain can be understood as a signal and an appeal (7). Dying, death (and birth) are central threshold experiences of human life on earth. Other threshold transitions and crises in our biographies are also often associated with pain (8). Pain leads to a special intensity of consciousness (awakening experience) and as a consequence often to special gains in knowledge and new perspectives and impulses (9). Pain can thus become a kind of midwife for development of the soul and spirit, which in turn can lead to new meaning, but can also help prepare the person for life after death. Approaches that work with meaning are particularly helpful. The search for meaning can give rise to decisive new powers: “Anyone who knows a ‘why’ can bear almost any ‘how’”, as Viktor Frankl put it in reference to Friedrich Nietzsche, making it the basis of his psychotherapy (10). He does not call for depth psychology, but rather – since it is a matter of finding spiritual meaning in life – height psychology (10, S. 37).

Biography work, conversational therapy and psychotherapy are helpful companions for palliative patients and people who are approaching death. The therapist's personal exploration of topics such as near-death experiences and other borderline experiences of human consciousness provide an indispensable foundation for accompanying this process.

Tried and tested meditations

Some patients ask for spiritual deepening as a source of strength and meaning. Word and image meditations can be used for this. Image meditations can be borrowed, for example, from the world of fairy tales (Grimm’s fairy tales) and their essential motifs for development. Often patients remember their childhood (“Did you have a favorite fairy tale?”), enabling them to gain balance and confidence. Fairy tale pictures can be taken up and actively shaped in painting therapy, thus meaningfully complementing the two therapeutic methods.
In word meditations, the patient can begin by simply reading and speaking the texts. Even just reading them attentively aloud can convey inner strength. Depending on the possibilities and wishes of the patient, they can then be “taken inwards” and worked with meditatively.

The following meditation can be helpful for anxiety and restlessness, which often accompany pain and may intensify it:

I bear calm within myself,
I bear within myself
The forces which strengthen me.
I want to fill myself
With the warmth of these forces,
I want to pervade myself
With the power of my will.
And I want to feel
How calm spreads
Through all my being
When I strengthen myself
To find calm as
The force within me
Through the power of my striving.

Rudolf Steiner (11, p. 179 and Leadership Questions, p. 182)

When patients are undergoing existential battle with their illness, the following short meditation by Rudolf Steiner can engender a special source of strength:

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 (11, p. 190 and Mantric Sayings, p. 180)

This meditation is headed with “In danger of death”. It 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. It can help the person to develop and promote the qualities that we marvel at in many patients in palliative care as the ripe fruit of their confrontation with their illness: a wisdom-filled view of life as a light of truth in thinking that no longer illuminates only the personal but recognizes new perspectives and meaning; human love that no longer develops egocentrically, but is attentive to its surroundings; and a kindness of heart that can almost be perceived as a power capable of blessing.

The following meditation is suitable for relatives who want to support a patient inwardly:

Spirit of your soul, working Guardian,
May your wings carry
Our souls’ entreating love
To the one on earth entrusted to you
So that, united with your power,
Our appeal may helping shine
On the soul whom we seek in love.

Rudolf Steiner (12)

1 Buscemi V, Chang WJ, Liston MB, McAuley JH, Schabrun S. The role of psychosocial stress in the development of chronic musculoskeletal pain disorders: protocol for a systematic review and meta-analysis. Systematic Reviews 2017;6(1):224. [Crossref]

2 Girke M. Schmerzverständnis und Schmerztherapie in der anthroposophischen Therapie. Der Merkurstab 2008;61(5):419-434.

3 Schopper C. Leibliche, seelische und geistige Aspekte des Schmerzes. Der Merkurstab 2008;61(5):412-418. [Crossref]

4 Mehnert A. Psychotherapie in der palliativen Versorgung. Psychotherapie, Psychosomatik, Medizinische Psychologie 2015;65(09/10):387-397. [Crossref]

5 Egger JW. Verhaltensmedizinische Therapie für chronische Schmerzpatienten. In: Egger JW. Integrative Verhaltenstherapie und psychotherapeutische Medizin. Wiesbaden: Springer; 2015.

6 Riedel C. Psychological Care am Lebensende. Psychotherapie in der Sterbe- und Trauerbegleitung. Stuttgart: Kohlhammer; 2017.

7 Treichler M. Die Botschaft des Schmerzes. Anregung und Orientierung für betroffene, Ärzte und Therapeuten. Frankfurt: Info3 Verlag; 2017.

8 Glöckler M. Schmerz verstehen und behandeln. Der Merkurstab 2008;61(5):469-473. [Crossref]

9 Paxino I. Brücken zwischen Leben und Tod. Begegnung mit Verstorbenen. 6th ed. Stuttgart: Verlag Freies Geistesleben; 2019.

10 Frankl VE. Wer ein Warum zu leben hat. Lebenssinn und Resilienz. Weinheim: Beltz Verlag; 2017.

11 Steiner R. Mantrische Sprüche. Seelenübungen II. GA 268. Dornach: Rudolf Steiner Verlag; 1999. English translation: Steiner R. Mantric sayings. Meditations 1903–1925. Great Barrington: Steiner Books; 2015. See also Glöckler M, Heine R (eds.). Leadership questions and forms of working in the anthroposophic medical movement. Dornach: Verlag am Goetheanum; 2016.

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