Facing Cancer and the Fear of Death: A Psychoanalytic Perspective on Treatment Edited by Norman Straker (Jason Aronson Publishers, 2013.)

Of Recent Interest… is the new collection of essays Facing Cancer and the Fear of Death: A Psychoanalytic Perspective On Treatment, edited by Norman Straker (Jason Aronson Publishers, 2013). This book emerges out of concerns psychiatrist Norman Straker has noticed in current medical education, treatment and policy. In medical education, students are pushed in a direction that most rewards those who are able to set feelings aside, suppress a sense of vulnerability and helplessness, and make treatment decisions in an impersonal manner. This continues in medical education despite the fact that the AMA has explicitly advised that students should be selected giving more weight to interpersonal skills and signals of empathy. Why is it so difficult for medical education to shift in that direction?

In the area of treatment, despite new areas of medicine such as palliative and hospice care that explicitly recognize the limitations of life, the overriding momentum in treatment is to ignore such limitations. The very concept of “futile treatment” hardly makes sense in much of medical practice, except perhaps in hindsight, after the “battle has been lost.” Likewise, in medical policy, the momentum is strongly in the direction of treatment as if each and every patient were on the road to full recovery, and only need to be kept on that road. All of the rewards are in the direction of more treatment, especially for those who have money or good insurance, and even while the costs of medical care are sky-rocketing, it is all but impossible to move National healthcare policy in a more rational direction.

Each of these problems of inertia in the system, Dr. Straker concluded, have a related core, namely, the fear of death and the inability to understand human life within a framework in which death is not the extreme enemy. Straker has gathered essays organized around the theme of death anxiety and its impact on medical students, practitioners, policy makers and the general public in order to demonstrate this common thread. Because he is a psychiatrist, publishing on a psychotherapy-oriented press, his writers also tend to be psychiatrists and psychiatric themes run throughout the chapters of the book. However, the points being made are not confined at all to the psychiatric specialty; one can think of examples and studies drawn from psychiatry as cases in point of the wider world of medical care and policy.

Of special interest to readers of this newsletter will be the chapter contributed by Molly Maxfield, Tom Pyszczynski and Sheldon Solomon, which proposes the Terror Management framework as a way to understand the psychological defenses and coping behaviors people develop in facing a terminal diagnosis. Much of the research points toward the conclusion that younger and older adults react very differently to the experience of a terminal diagnosis. This is in line with the concept being picked up by observers in gerontology of a general developmental shift that often (though by no means universally) occurs in late middle age and older adulthood, in which the prospect of death becomes less anxiety provoking. This concept is bolstered by TMT research that suggests the younger people tend to become more punitive toward others when acting under the influence of reminders of death, whereas in older adults the tendency is to become more tolerant and forgiving. Other studies indicate that older adults tend to focus more on creating a pro-social legacy when reminded of their mortality, in contrast to younger subjects in whom there are no noticeable changes in this area. The chapter concludes by placing TMT research with groups suffering post-traumatic stress experiences, and with older adults, into the stream of research coming from different perspectives with terminally ill patients. Like most of this research (much of it reported on in other chapters of this book) TMT also points toward to fruitfulness of therapy aimed at reorganizing and strengthening people’s sense of meaning, value and building personal relationships.

In my view, Straker succeeds adequately with this book in his goal of showing the common threat of death fear running through medical education, treatment and healthcare policy, although I was convinced of that before and thus may not be the best judge of his efforts here. In terms of solutions, I was not satisfied with how little attention was given throughout the book to hospice care and all that we have been learning from the last 20 years related to it. Perhaps because physicians in general and psychiatrists in particular play such a small role in hospice care, it was easily overlooked by the writers contributing to this collection. Nonetheless, the literature and research relating to hospice care represents a rich pool of accumulating knowledge relating directly to the topics at hand, all but ignored here.

Daniel Liechty is Professor of Social Work and a member of the Graduate Faculty at Illinois State University,and also serves as Vice-President of the EBF.

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Our Guiding Principles

"The root of humanly caused evil is not man's animal nature, not territorial aggression, or innate selfishness, but our need to gain self-esteem, deny our mortality, and acheive a heroic self-image. Our desire for the best is the cause of the worst."

-Sam Keen foreword to The Denial of Death