Day 2: Practising Dignity Therapy
In dignity therapy, three types of stories are often shared by terminally-ill patients: (a) happy stories (contain elements of gratitude, experience of love and joy), (b) sad stories (contain elements of personal tragedies, perceived failure, and regrets), and (c) ugly stories (contain elements that may potentially harm the identified recipients). “Not all stories are pretty, and they don’t have to be,” said Dr. Lori Montross Thomas, an assistant professor in the Department of Psychiatry as well as Family and Preventive Medicine at the University of California, San Diego (UCSD). Generativity documents should contain information uniquely present in a person’s life; the stories being shared could be a mixture of happy, sad, and ugly stories. Dignity therapy provides an opportunity for individuals to reflect upon their less-pleasant stories positively and find meaning in those stories. Ultimately, what we have experienced and how we interpret our experiences shape who we are today; validating those experiences allows us to see who we are in whole, instead of parts of who we are.
That being said, it is crucial to have a safety plan ready at the back of our minds to manage ugly stories. This ensures patients receive adequate care and support in the midst of creating their generativity documents. Dignity therapists are expected to exercise their clinical judgment throughout the therapy process in order to ensure that they do no harm to the patients and also the recipients of generativity documents. For example, when we assess some stories to be potentially harmful to the recipient, it is essential to reflect this to our patients and process with them the suitability and beneficence of adding such content into their document. This offers opportunity for patients to re-examine their documents and promotes patients’ sense of control by giving them the options of what stories can be included or excluded from their documents. In view of the principle to do no harm, dignity therapists are NOT obliged to deliver harmful messages to recipients.
Given that the nature of dignity therapy revolves around reviewing one’s past experiences, it does not come off as a surprise that patients feel overwhelmed in the midst of recalling unpleasant memories, particularly the sad or ugly stories. In such situations, dignity therapists may put the session on hold and proceed with providing support via counselling or psychotherapy. Dignity therapy does not have to be completed within a session. If patients are feeling overwhelmed due to the stories being shared or feeling fatigue due to their medical conditions, dignity therapists are recommended to take a break or schedule a different session before resuming the process when patients are feeling better.
Like many other therapeutic relationships in counselling and healthcare settings, dignity therapists are seen as experts and may often be perceived as a figure of authority holding greater power in compared to patients themselves. Therefore, it is important to be mindful of our power in the relationships when conducting dignity therapy so that the process can be therapeutic for patients and even family caregivers. We can address our power in the relationships by being upfront about it from the beginning of the session, highlighting that patients and family caregivers are the experts of their respective life, not us; doing so empowers patients and family caregivers to share their stories and perspectives without the concerns of being judged or being in the wrong. Since the focus of dignity therapy is ultimately on constructing the content of generativity document which will be passed on to identified recipients, it is therefore crucial to be mindful of our personal agenda versus the patients’. For dignity therapists who come from counselling, psychology, or social work backgrounds in particular, it can be a delicate balance between completing the generativity documents as per patients’ identified goals versus engaging patients to address their emotional experiences in the midst of reviewing their lives. Time is limited. When dealing with patients who are receiving palliative end-of-life care, we ought to prioritize short-term dignity therapy goals in which they could benefit from instead of long-term psychotherapy goals.
In order to facilitate our understanding of the dignity therapy process, we were asked to pair up to engage in role play, where we took turns to play the role as a therapist and subsequently as a patient. I chose to pair up with Geraldine as we have a strong rapport and I was comfortable enough to share some of my stories with her (to make the role play more genuine), including the sad stories. That experience truly opened my eyes. As Geraldine gently took me on a journey in reviewing glimpses of my life thus far, I have surprisingly uncovered the significant events I held close to my heart. It was a mixture of happy and sad stories, weaving into the themes of resiliency, social support, and a pursuit of dreams. The journey was relatively short, approximately 20 minutes; nevertheless, it was indeed thought provoking, and it strengthened my sense of purpose in life. When I took on the role as a therapist, I struggled to find that balance between focusing on the content of generativity document versus processing Geraldine’s disclosure from a psychotherapy perspective. Despite that struggle, I was able to connect with Geraldine as she was sharing her stories. That connection was beyond words, and I look forward to experiencing more therapeutic alliance as such during our upcoming FDI intervention phase.
When it comes to editing and producing the generativity document, it is important to retain the voice of dignity therapist (also known as interviewer in the document) in order to provide a context on the content. Clinical judgment needs to be made to what extent a dignity therapist would include their exchange with patients in the document. Dignity therapists need to keep the patients’ voices in their heads as they are doing the editing, and constantly reflect on how the recipients would receive the messages; doing so ensures the genuineness of said generativity documents. We were also given the opportunity to edit a generativity document as part of the experiential activities. In my perspective, it is easy to edit a normal document but it is challenging to edit a generativity document while making sure that it still “sounds” like the patient at the end. Nevertheless, the end results would be satisfying, existentially speaking.