Loss of Self-Cohesion in Terminal Illness

The study of the emotional problems that arise in a patient with terminal illness has occupied a growing area of interest in psychiatry and other mental health disciplines. The work of Elizabeth Kubler-Ross (1969) and others (Rothenberg, 1961; ; Hertzberg, 1972) has delineated the expectable responses in the dying patient. Kubler-Ross has outlined what she considers to be a prototypic progression in stages of denial, anger, bargaining, depression, and acceptance. The major focus of writings about therapy with the dying patient has been on problems of anger and depression which arise as part of the anticipatory grief or mourning process. Many suggestions have been made regarding therapeutic strategies to unblock the mourning process and encourage its natural progression. This paper will suggest a framework for psychotherapy with the dying patient based on Kohut's (1971) self-psychology.

In Kohut's view, the cohesive functional self encompasses the sense of self-awareness, self-esteem, and the range of coping skills that make up an individual's personality and self-experience. The fears and affects aroused by terminal illness can be seen as a time of stress to self-cohesion. Pattison (1967) outlines these fears: of the unknown, of loneliness, of loss of body and body function, of loss of self-control, of loss of identity, and of regression to primitive levels of functioning. Regulation of and coping with these fears and their impact are functions of a cohesive self. Although vulnerability of the cohesive self varies individually, these stresses are present in all dying patients. The group of patients with pre-existing difficulties in some of these areas may be especially susceptible to a degree of self-fragmentation during terminal illness. Although patients may present with symptoms of depression, they may require intervention specifically focused around reestablishment of self-equilibrium.

Work with terminally ill patients has convinced me that some of the difficultie