Over the past few decades, the oncology community has incorporated new evidence-based therapies to address the psychosocial needs of patients with cancer, especially those with advanced disease. To bring a global perspective to this evolving discipline, The ASCO Post recently spoke with Monika Renz, PhD, a palliative care psychotherapist at the Cantonal Hospital in St. Gallen, Switzerland.
Early and Later Influences
Please tell the readers about your background, where you grew up, and whether there were any early influences in your decision to enter the palliative care field?
I grew up in Zurich. My father was a business leader; my mother was a psychologist. Since childhood, I have been interested in the human condition, particularly health and spirituality. I was first influenced by my father’s focus on efficiency, and as a psychotherapist, I began looking for efficient therapy methods.
A second early influence was music: My mother told me that I had begun singing before speaking. Since I was 5 years old, my hobby has been piano improvisation. Without reading notes, I played whatever I heard and as a child discovered the healing effect of music. When I was a teenager, research on intrauterine hearing had just come to the fore. I was fascinated and became interested in music therapy. At the University of Zurich, I studied educational psychology, psychopathology, and ethnomusicology.
The deepest influences on my therapeutic work with dying patients came from several accidents and longer periods of personal illness. As a patient, I experienced what I later called a transformation of perception. I discovered two different states of being: In one, I suffered great pain, and in the other state, I had none. In the one state, I was present and in control, and in the other painless state, I was somehow far away from time and space but very clear. I looked deeper into this phenomenon when writing my doctoral dissertation on primordial trust and primordial fear under Professor Heinz Stefan Herzka. This was the very beginning for my later research on perception and development of consciousness. Years later, I studied theology to better understand patients’ spiritual distress. My theologic dissertation dealt with redemption from early behavioral imprinting.
From Music Therapy to Palliative Care
How did you become involved in palliative care at Cantonal Hospital?
Before I entered the field of psycho-oncology, I had a private practice and worked as a music therapist with children and adults. I felt that the long-term therapies were unsatisfying and inefficient. I closed my practice and applied for a position in the Department of Oncology of the Cantonal Hospital of St. Gallen, feeling that my keen interest in crisis intervention would be useful here.
At that time (1998), the hospital did not offer psycho-oncology therapy yet, just music therapy. I was entrusted with building the Psycho-oncology Department; I developed a multidimensional therapy approach for cancer inpatients and outpatients. The approach combines illness-coping strategies, dream interpretation, family support, spiritual care, trauma therapy, and music therapy. My special focus is music-assisted relaxation combined with active imagination.
Over the years, my therapeutic approach has been so successful that there has been a fourfold increase in demand for this therapy at our hospital. Meanwhile, we have developed a whole team including a psychiatrist. We use multidimensional approaches, but each member has his or her own focus. In regular intervision meetings, we discuss casework; thus, everyone in the team learns several techniques.
For end-of-life care and support of dying patients, I have developed an educational program together with the Head of Palliative Medicine at our hospital, Dr. Daniel Bueche. As a result, I supervise members of the palliative care nursing team to support dying patients psychologically and spiritually.
An Author’s Insights
Please tell the readers about your recently published book.
Dying: A Transition introduces readers to the “inside” of dying processes. During the dying process, all automated ego-based thinking and ego-centered perception fall away. The process brings us to another state of consciousness, a different state of sensitivity, and an alternative dimension of spiritual connectedness.
This transformation of perception, called transition, seems to be the main mental and emotional process in dying and often the background of visible changes, such as from fear to trust, from struggle to peace, from denial to acceptance. The transformation of perception can also explain why family problems and the need for reconciliation are urgent at first but gradually fade.
Understanding the transformation of perception as a key to many other symptoms, such as increasing fear and total pain, may improve care. Thus, pain medication and sedation can be reduced and used selectively, when needed. Dying: A Transition is based on 17 years of work with terminally ill cancer patients and research with 680 dying patients.
Past and Current Research
Please describe your current research.
Our current study, “Dying Trajectories,” investigates dying processes of 80 terminal cancer patients, whether from a phenomenological perspective, dying is a structured process with periods of crises and peace. It addresses the following themes: fear, pain, denial, and spiritual experiences. Are there any interrelations between them? When do they erupt or subside? Based on our former research, we hypothesize a correlation between fear, pain, and denial. And we expect that spiritual experiences (eg, seeing a light) occur in stages of peace and may facilitate the ongoing process. We also observe alterations in time, space, body awareness, and social connectedness as possible indicators of a transformation of perception.
In addition to our former research, we now include a parameter pain scale. We are also involving the whole palliative care team of two palliative units. Members of the team first have short sensitivity training. We are assessing patients’ previous spiritual attitudes and current fears followed by participant observation of the dying process over a period of 2 to 28 days. We will analyze our data by interpretative phenomenological analysis. A panel of international experts of several disciplines will then discuss the results.
The Swiss National Cancer Strategy
Please tell the readers a bit about the state of palliative care in Switzerland.
Communication skills training has become mandatory for all Board-certified oncologists. Further, cancer palliative care interventions—delivered by both oncologists and palliative care teams—are increasingly integrated into routine clinical care. Both of these clinical approaches represent an achievement.
National oncology services are on a high level, but equal access to optimal care still depends on where people live. Therefore, the Swiss National Cancer Strategy is establishing more quality and efficiency by fostering networks in all major fields of cancer and prevention throughout Switzerland.
Closing Thoughts
Any closing thoughts you’d like to share with our readers?
I would like to point out the importance of a particular “hearing sensitivity” in the dying process. Even a small noise can be overwhelmingly loud.
Next, I would like to bring into the clinical discussion a new approach to spiritual care. Spirituality includes more than just giving a response to a patient’s spiritual attitude. Spiritual needs as well as patients’ consciousness and communication are changing during the dying process. Spirituality in dying, as perhaps in near-death experiences, has to do with an altered connectedness and consciousness.
Spiritual experiences are powerfully independent from religious attitudes, as our second study with 251 palliative cancer patients shows. Last but not least, I think that by understanding the phenomenon of primordial fear, we could reduce pain management and sedation therapy. ■
Disclosure: Dr. Renz reported no potential conflicts of interest.
