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  1. Health Psychology (11) Christine L. Whitley Dying is nothing to fear.  It can be the most wonderful experience of your life.  It all depends on how you have lived. Elizabeth Kubler Ross (1926-2004)

  2. Review Chapter 11: serious illness: the patient’s perspective • Acute phase: patient’s survival is of paramount importance • Rehabilitation phase: goal is for the patient to achieve the highest levels of health and functioning that are possible. • Chronicity phase: all possible rehabilitation has been accomplished and the remaining limitations must be accepted and coped with • Terminal phase: illness or injury cannot be cured or helped, and the patient is dying

  3. Psychosocial issues • Material support • Emotional support • Long-term support • Maintenance support

  4. Threats • Self-image • Alteration one’s body

  5. Chronic Conditions Impairment or deviation from normal physical structure and functioning that remains permanent; usually accompanied by residual disability • Age-related difficulties • Age-related stereotypes

  6. Erik Erikson “old age” “Middle age” Early adulthood Adolescence 6th year through puberty 3rd to 5th year 2nd year 1st year

  7. Complex Health-Behaviors Factors: • One important factor is the complexity of the treatment regimen itself • Another is the side effects that sometimes occur • Another is the financial burden associated with the treatment • Another is the social isolation or “differentness” that is brought about the necessary of adhering to a strict routine • Another is the degree to which the routine limits other daily activities

  8. Social Isolation • In order to avoid social isolation, those with chronic illness may try to “normalize” their conditions • Normalizing can help counteract identity spread • Avoiding social contact at certain times (ex. Great pain, highly visible symptom)

  9. Social Isolation • Counteract social isolation: • Sometimes distressed patients may, by their own behavior, drive away those who are trying to offer them support and social comfort • The stresses of illness and the experience of crises together may lead families to a stronger and deeper relationship

  10. Being future oriented and setting goals • Individuals who develop contingency plans are better off than those who have only a single plan of action • Individuals with more flexible coping styles are better off than those whose coping styles are more rigid • Assimilative coping describes a coping style in which the person persistently pursues goals that may not be realistic • Accommodative coping refers to a coping style that is flexible, and that allows the individual to modify goals so that she or he is working toward something that is attainable.

  11. Erik Erikson “old age” “Middle age” Early adulthood Adolescence 6th year through puberty 3rd to 5th year 2nd year 1st year

  12. Loss • One’s occupation • Independence • Cognitive functioning • Once-envisioned future • Relationship with others

  13. Older adults • Stereotypes • Deal not only with their own loss, but also with those of their spouse, and those of their friends • Need emotional support (physical care, meals, driving, etc…) • Still need some control and autonomy!

  14. Terminal Illness and Bereavement • When the plans for the future becomes uncertain • Where there may be internal struggle about whether to continue life as usual, or to prepare for death…

  15. Defense Mechanisms • Repression • the basic defense mechanism that banishes anxiety-arousing thoughts, feelings, and memories from consciousness • Regression • defense mechanism in which an individual faced with anxiety retreats to a more infantile psychosexual stage, where some psychic energy remains fixated

  16. Defense Mechanisms • Reaction Formation • defense mechanism by which the ego unconsciously switches unacceptable impulses into their opposites • people may express feelings that are the opposite of their anxiety-arousing unconscious feelings

  17. Defense Mechanisms • Projection • defense mechanism by which people disguise their own threatening impulses by attributing them to others • Rationalization • defense mechanism that offers self-justifying explanations in place of the real, more threatening, unconscious reasons for one’s actions

  18. Defense Mechanisms • Displacement • defense mechanism that shifts sexual or aggressive impulses toward a more acceptable or less threatening object or person • as when redirecting anger toward a safer outlet

  19. Depressive Disorders • Major Depressive Disorder: Person feels sad and hopeless for weeks or months. • Often loses interest in all activities and takes pleasure in nothing. • Often accompanied by changes in eating and sleeping habits. • In extreme cases, may have delusions. • Dysthymic Disorder: Sad mood, lack of interest, and loss of pleasure is not as intense and lasts for a longer period.

  20. Integrity vs. despair Generativity vs. stagnation Intimacy vs. isolation Identity vs. role confusion Industry vs. Inferiority Initiative vs. Guilt Autonomy vs. Shame and doubt Trust vs. Mistrust Integrity vs. despair Generativity vs. stagnation Intimacy vs. isolation Identity vs. role confusion Industry vs. Inferiority Initiative vs. Guilt Autonomy vs. Shame and doubt Trust vs. Mistrust

  21. What has a begining has an end… Life is a deadly disease… Life saves… © ChLW, 2005

  22. Elizabeth Kubler-Ross • Eulogy • Dr. Elisabeth Kübler-Ross, psychiatrist and prolific author of the ground- breaking book, On Death and Dying, died Tuesday evening, August 24, 2004, in Scottsdale, Arizona of natural causes. She was surrounded by her family and close friends. She was 78. • " Every moment of her life was devoted to dying patients and what they were going through," noted long-time friend Mwalimu Imara, who has been close to her since the beginning of her research. "Her prolonged illness following several strokes only made her even more determined to speak up for the rights of the terminally ill." http://www.elisabethkublerross.com/pages/eulogy.html

  23. Kübler-Ross: Awareness Denial « No, it cannot be true! » Anger « Why me? » Bargaining « I will change, I swear… » Depression « Preparatory sorrow » Acceptance « It is time. I am ready and at peace » Submission Control Resignation

  24. The process (Ref: Hanus M. (1994) and Poletti R. & Dobbs B. (1993)) Shock can last several minutes or several weeks deny Emotional phase (physiological reaction to the loss) protestation: anger, responsible sadness: regrets, guilt… anxiety: not again, not me… fear to live tears: let the pain be expressed Integration of the loss intellectual acceptation: rationalization global acceptation: after one or two years new attachments: the energy is again available forgiveness: let go growth © ChLW, 2005

  25. Grieving: « it is a process… » INEVITABLE P O S S I B L E Death End Rupture Loss PAINFUL Passage Accept Life Memory THREATENING Trust Reciprocal process « Defense » Beliefs Self and the meaning of life Self-consistency Self-growth Self-awareness MEANINGFUL © ChLW, 2005

  26. http://www.elisabethkublerross.com/pages/AboutGrief.html About Grief & Bereavement • Grief is a natural process to death and dying.  It is not pathological in nature, but rather, is a necessary response to helping heal from the overwhelming sense of loss when a loved one dies.  It is important to understand grief as part of the human experience.  If you are grieving, some things you can do to help yourself include: • Attending support groups in your area • Therapy with a psychologist or other qualified mental health professionalJournaling • Eating well • Exercise • Get enough rest • Reading and learning about death-related grief responses • For some, seeking solace in the faith community • Seek comforting rituals • Allow emotions • Avoid major changes in residence, jobs, or marital status

  27. Culture norms • A good death depends on culture and changes over time • There are different notions of the good death, especially in a multicultural society • Religion and secularism influence ideas about the good death • Individualistic societies promote the personal autonomy of the dying, including palliative care and voluntary euthanasia • A challenge today is how to die well from the slow degenerative diseases of old age http://www.caringinfo.org/i4a/pages/index.cfm?pageid=1 http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=1126582