Individual Psychotherapy

Psychotherapy is the treatment modality unique to mental health clinicians. Within its framework, the child seeks to integrate the facets of his or her life. Through words, art, and play, the child conveys the experience of living with the threat of loss and transforms the essence of his or her reality into expression. Self-help techniques, such as relaxation, guided imagery, and hypnosis, may be integrated into the psychotherapy to reduce symptoms of nausea, fatigue, insomnia, and pain (Kazak 2005; Kazak et al. 1996; Kersun and Shemesh 2007; Steif and Heiligenstein 1989). These techniques are not restricted to psychotherapeutic intervention and may be employed by other disciplines trained in their methodology.

Play therapy enables the seriously ill child to "reenter" childhood. Through play, children can approach and retreat from the intensity of their illness at will, thereby allowing some containment and mastery over their emotional experience. Play is the fundamental means of communication. Any trauma, including illness, can extinguish a child's capacity for play or erode its range of expression into rigid patterns (Sourkes 2000; Terr 1990). Within the context of play therapy, emotional restoration is evident when the child's play reflects earlier patterns of activity and liveliness.

For older children and adolescents, psychotherapy can facilitate psychological adjustment by enabling discussions about their illness and prognosis (Brown and Sourkes 2006). Abstract reasoning enables adolescents to anticipate the future in a way that many younger children cannot (Aldrich 1974; Brown and Sourkes 2006). Responding to adolescents' questions about their illness and prognosis or about the possibility of their death requires careful exploration of what is already known by the child, what is really being asked (the question behind the question), and why these questions are being asked at this particular time (Brown and Sourkes 2006; Sourkes 1992). Parents, in their own struggle with grief, sometimes discourage such questioning or provide optimistic responses in an attempt to avoid the pain associated with threatened loss. As a result, children often express frustration or resignation over their parents' unwillingness or inability to acknowledge the severity of their illness and the possibility of death.

Psychotherapy can provide children with a space of their own in which their thoughts and feelings are protected and confidential and their emotions can be expressed openly without fear of others' reactions. Adolescents can talk about their feelings that they feel are too painful for the family to bear. Through psychotherapy, children can experience a sense of stability and continuity during a time that may otherwise feel chaotic and unanchored. The therapeutic relationship in and of itself may be a profound intervention, even when issues of death and loss are not explicitly addressed. Often, mental health providers working with adolescents who are facing a life-threatening illness feel pressured to elicit the teens' emotions around their prognosis and to assist them in finding some meaning in their illness or impending death. However, such therapist-driven goals are typically not therapeutically indicated; rather, the mental health clinician should follow and respect adolescents' cues to ensure that issues important to them are addressed.

Individual psychotherapy can play a critical role by helping children formulate a hierarchy of their chosen goals (e.g., graduation from high school, travel, admission to college). For this reason, children have the right to know their diagnosis and prognosis. The information can provide a time context within which to organize and reorganize priorities, thereby instilling an increased sense of control over the time remaining. At present, no empirical evaluation has been reported of group psychotherapy for children with life-limiting conditions. However, research in adults with life-threatening conditions has demonstrated that group psychotherapy is effective in reducing psychological distress (e.g., depression, anxiety) and improving quality of life and coping symptoms (Breitbart 2002; Miller et al. 2005). Thus, group psychotherapy may be a potentially useful modality for enhancing the end-of life experience for children as well.

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