Stuck in Despair: Cognitive Behavioral Therapy Informed Communication for Serious Illness Care

Abstract

Patients with serious medical illnesses may respond to the challenges of their illness in unique ways, shaped by personal, relational, and contextual factors. For many patients, depression and anxiety are common and may feature avoidance or withdrawal, negative expectations for outcomes, repetitive negative thinking (rumination and/or worry), sad mood, and/or irritability. These symptoms often arise from a complex and bidirectional interplay between a patient’s emotions, thoughts, and behaviors. This dynamic system provides clinicians with multiple, clinically actionable entry points to foster patient engagement in treatment and coping with serious illness. This article illustrates how core principles from cognitive behavioral therapy (CBT) can inform serious illness communication, adapted for use by general palliative care clinicians in appropriate clinical contexts. Using a composite clinical case, we demonstrate the use of CBT principles as a way of organizing our clinical understanding of a patient who is feeling “stuck,” from which CBT-informed techniques, such as guided discovery, cognitive restructuring, and behavioral experiments, can be implemented to reduce distress and promote adaptive coping.