Unanswered chatroom questions from September 22
I am curious, has DT been monetized by anyone? One could potentially dedicate a career to this.
I am aware of people who have made this part or the entirety of their practice. What people are direct billing patients depends on where this is taking place, and the overall organization of healthcare funding.
Can one title themselves a "Dignity Therapist" without being registered with a governing body?
At this time, there is not a formal governing body that registers therapists; perhaps this is something that I should consider. So for now, I believe people who should call themselves Dignity Therapists are those who have received some training, read and studied the key literature—especially my book, Dignity Therapy: Final Words for Final Days (which is still the most detailed description of how to conducted Dignity Therapy to date), and have put in the time to practice in order to gain mastery. The idea of conducting Dignity Therapy may sound easy and straight forward, but as the workshop demonstrated, there are many nuances that need to be paid attention to.
Did you have experience doing DT for a person who do not speak English as their 1st language?
Good question. You need to determine the language the participant wants the document written in. You also need to keep in mind that the transcriptionist needs to be fluent in the language of the Dignity Therapy participant, or the translator if one is being used. Of course, this can add time and complexity; but so long as all parties are invested in making this happen, solutions can be found. Good luck with the Indonesian translation; and as we discussed in our last session, be sure that the language translation is also informed by a cultural translation.
When or would it be appropriate to share the original transcript with the family (or whoever). I so worry that when editing, the Pt's essence/true voice may be lost.
Unless this has been discussed with the patient and consent to do so has been obtained, the recording and original transcript are not shared with the family. The transcript provides the raw material used to create the legacy document. Often people sense that their wandering responses, or responses interspersed with things that veer off of a generativity focus, will yield something that is inaccessible or unengaging. In my experience, the editing process allows for the revelation of the patient’s essence or true voice. Editing does not mean introducing our own voice, but clearing the way for the voice of the respondent to be heard.
It will take me sometime to feel confident deleted the person's words.
Your caution and reticence mean that you care and take the process seriously. That is exactly as it should be. The commitment to help the patient produce a part of their legacy that that want to share with loved ones, current and in the future, is also a vital one. While editing, I don’t ever feel like I am ‘deleting’ their words, but rather, providing clarity that allows their stories and messages to be heard.
I worry about my own use of adjectives/adverbs such as precious memory or leaping from mountain top.
We very rarely would add adjectives/adverbs—particularly if those have not been used by the respondent elsewhere—as those kinds of embellishments can change the style and voicing of the document, resulting in a distorted version of how they would choose to tell their story.
How do you weave the stuff that relatives add into the text?
Typically, Dignity Therapy is done only with the patient, and no input from relatives/other informants. However, there are three ways in which I’ve seen the voice of a third party become part of the Dignity Therapy document. 1) In cases of more advanced dementia, when the patient is unable to participate in a meaningful way, I have seen Dignity Therapy be conducted by proxy i.e., a third party becomes the primary informant; 2) a third party has helped facilitate the patient’s responses to the interview i.e., they may have posed questions of their own, and offered reminders for the patient to embellish on (“Do you remember attending your daughter’s wedding”? “What about the times you took the children camping”? etc.). In these instances, the voice of the family member doesn’t appear in the document, and very much like the voice of the interviewer, serves to facilitate the patient’s responses without being seen; 3) a family member provides responses concurrent with the patient’s. I’ve seen this when the patient is particularly fragile, such that both respondents become the co-creators of this legacy document. In those instances, I label each individual person separately i.e., interviewer, patient, family member (for the later two, using the name by which they wish to be referred to).
Have you even given back an edited document and had a client become upset with the work done?
The final document is often emotionally evocative. I am currently involved in a situation where the edited document arrived back with the husband of a patient s few days after she died (she had put off doing Dignity Therapy many times as her condition was deteriorating, and then afterwards had a precipitous decline). I spoke with him yesterday, and he is afraid to read the document for fear of his intense grief and emotional response. We’ve brain stormed about the right timing to look at this, including having her sisters look at it, or him coming to the hospital for us to read it together.
I’ve never had a situation where someone reads it and becomes upset with the work they’ve done. Occasionally people are self-critical and want to change/edit/revisit what they have done. This is the exception, not the rule; for the most part, working with people in a spirit of cooperation, understanding and support leads to outcomes that patients are happy with.
Would you consider cutting and pasting somewhere under lessons learned from life: When you are feeling down you just remember how you will have bright times.
Dignity Therapy is about facilitating the telling of stories, lessons, and sharing words that the patient feels need to be conveyed. I understand the inclination to want to direct people towards ‘good stories’ (recall we discussed good, sad, and ugly stories). I have learned to respect the patient’s needs, even when that leads to an agenda that may be more challenging, such as the revelation of regret, disappointment, words of apology or explanations for perceived missteps along the way. Reflecting on the bright times in their past may not capture the essence of what they feel they want to say and suggesting that there are bright times ahead may not resonate with someone facing dire uncertainties of where life and illness are about to take them.
Are there plans to provide this workshop via Zoom again/on an ongoing basis? This is a great option for us to train our staff/volunteers, without the added cost and time of travel?
This is the first time that we have offered this on-line, and the first time we have tried to broaden the focus from strictly Dignity Therapy to Dignity in Care. We will be looking at the evaluations to determine if we’ve been successful. Certainly, the feedback within the chat all seem very positive; and the virtual platform has allowed us to enroll far more attendees than we’ve been able to train with in person workshops. At this point, Lori and I have discussed repeating this training next year, making whatever tweaks are necessary—based on group feedback—to make this even better.
Would be VERY interested in hearing if, and how, hospices in Canada may be considering or have implemented a DT program
Unfortunately, I don’t have my finger on the pulse of what programs are being offered across Canada. I think we are making headway with more and more psychosocial professionals working in palliative care and oncology being exposed to/becoming familiar with Dignity Therapy. Offering more training opportunities, especially using on-life platforms, would seem to me an important part of a knowledge dissemination strategy.
Do the qualifications of the provider mark the difference between a life review and Dignity Therapy?
The qualifications of the provider offer both unique opportunities and challenges with respect to providing Dignity Therapy. People bring skill sets that allow them to make connections, read emotional tone, understand psychological process and subtext to varying degrees, based on their professional experience and disciplinary affiliations. This can often serve the process well. However, where people run into difficulties is when they feel focusing that focusing on generativity requires that they relinquish their usual mode of practice. For instance, Dignity Therapy is not insight oriented psychotherapy, it’s not about fostering new psychological understandings or relaying dynamic interpretations; despite the inclination to do so, especially in the context of a trusting therapeutic connection. All of those approaches have tremendous merit, but recording how those unfold in the service of generativity simply doesn’t work.
As for life review versus Dignity Therapy, the differences lie in the approach and particulars of the processes involved rather than who is implementing the intervention. Here is a reference that may be on interest:
Vuksanovic D, Green HJ, Dyck M, Morrissey SA. Dignity Therapy and Life Review for Palliative Care Patients: A Randomized Controlled Trial. J Pain Symptom Manage. 2017 Feb;53(2):162-170.e1. doi: 10.1016/j.jpainsymman.2016.09.005. Epub 2016 Nov 1. PMID: 27810568.