The Cancer Counselling Center of Ohio

The Cancer Counselling Center of Ohio has worked mainly with persons who have a life-threatening or chronic illness. Loss (of job, of money, of physical mobility, etc.) and possible death are constants in the treatment process. Zimpfer's (1992) holistic model includes perspectives that focus on the body, mind, spirit, and emotions. A spirit of harmony among these dimensions is sought, whether one strives to maintain a life amid losses, or whether one anticipates death. The model is based on the concept of wellness:

... wellness refers to positioning all the resources of the self so that they are neither competitive among themselves nor interfering ... In short the patient allows his or her body the full use of its capacities for healing by removing impediments and by optimizing its innate tendencies towards health. Healing in this instance implies not merely bodily recovery but also inner harmony and fullest use of personal potential. (1992: 205)

In the situation of life-threatening illness, anticipatory grief is compounded by uncertainty. At the Center, many clients have a disease which is potentially lethal. They face, as if this threat were not bad enough, the incursions and perhaps the worsening of bodily illness, the difficult treatments and their often debilitating side-effects, and the loss of many aspects of their customary daily life. The possibility of dying is just one facet of a much greater complex of issues. Treatment in these cases often calls for unique methods. We routinely use tools which can access the internal states - the subliminal message systems - that lie beneath the surface of conscious awareness. It is our belief that where denial, doubt, and ambivalence prevail, clearer messages can often be obtained from the 'inner self'. We begin with relaxation, brainwave biofeedback, or other calming techniques to create a disposition of openness. Then, mental imagery, searching for internal direction (i.e., intuition, what my 'heart' or my 'gut' tells me), and hypnosis are often used to facilitate clarity on the issue of living or dying. Many concerns must be dealt with: the fundamental orientation to live or die; the will to persist or to give up; the desire to fight the illness using the standard medical treatments or to use alternative treatments or to let the body do its own work; and the reliance on God, on cosmic energy, or on some other higher power. Issues such as these are addressed as part of the fullness of the person, and to prevent such concerns from becoming impediments. Clients are involved in both the recovering and the dying process. Doubt about whether one is going to live or die, or even whether one wants to live or die, is tremendously complicating to the grief resolution process. Counselling involves evaluation of current lifestyle for modifications that are more consistent with physical abilities; attention to psychodynamics that allow for the release of past resentments, guilts, and emotional pain; and resolving old interpersonal conflicts that may be interfering with inner peace.

Our experience with persons who have cancer is that they are often isolated. Their associates at work, their neighbors, relatives, even fellow churchgoers, will 'write them off' as already dead and interact with them no longer. A spouse may abandon the ill one on the premise that he/she didn't get married to take care of an invalid. Sometimes spouses or friends exert pressure to 'get well', or accuse the ill one of not trying hard enough. This only compounds the desolation, the seriousness of their awareness of vulnerability, and the physical toll of the disease itself.

In dealing with life-threatening illness, the practitioner treads a narrow line between counselling for living or counselling for dying. In our own experience we 'go with the flow' of the client, picking up on his or her basic direction. It is after all not our choice but that of the client. This may be at odds with those medical practitioners whose viewpoint is that once their patient has invoked their help, their duty is to preserve life no matter what. The counselling process may alienate such a physician and in the process even compound the client's dilemma. If a client has resigned him/herself to the inevitability of dying, the counselling task is to help with reconciliation with the others in one's life, with living as physically and spiritually at ease as possible, and finishing any life tasks that may be still incomplete. For some there may even be a renascence of energy to pursue unfulfilled dreams.

Occasionally a client will present what appears to be continual denial of the possibility of death, even in the face of worsening symptoms and physical decline and the ineffectiveness of medical treatments. This person's focus may be entirely on restoring a former way of life, returning to their job, and maintaining friendships. Saying the unsayable may be appropriate in this event (namely, introducing the possibility of death to the client); it many unleash a cascade of fears and other emotions heretofore bound up in stoic silence. The counsellor must be cautious, however, that his or her own expectations or conclusions (namely, about the inevitability of death) do not become prophecies to be imposed on the ill one. And the reverse is true also, i.e., that the counsellor not impose a desire to live at all costs. It is, after all, the client's life to live. As helpers we can nudge and challenge a client's expectations, but we cannot prod or push toward what we consider is 'best' for the client.

Counselling for the dying involves a reinstatement of harmony of body, mind, spirit, and emotion. In the final stages of dying, the mind cognitively accepts the likelihood or inevitability of death; the emotions have resolved quarrels and guilts with other people living or dead, and have moved beyond the anger of perhaps being cheated of a more productive life; the spirit has accepted whatever sense of immortality or nothingness, welcome or anonymity that may come after death; and the body prepares itself for dying, perhaps even by ceasing to fight with its own resources any longer.

Anticipating death, as it is seen in this chapter, is a property of both the dying person and the significant others (particularly the family) around him or her. We have worked with families who were all present during the dying hours or days, who by turns held or caressed or breathed in unison with the ill person, who reminisced together, who cried and laughed together, and who in general turned what is often a solitary event into a loving community experience.

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