The “Acceptance” in the Elaboration of Mourning in Oncological Diseases: Definition, Theoretical Models and Practical Applications: Needs Analysis and Subjective Oncological Reality

The “mourning” is the feeling
of intense pain that one feels for the loss, in general, of a loved one


Definition, Theoretical Models and Practical Applications
Definition and Clinical Context: The "mourning" is the feeling of intense pain that one feels for the loss, in general, of a loved one, but it can also extend to all those hypotheses of the conclusion of an emotional and sentimental relationship with lasting and stable relationships or even to relationships that -beyond timepresent clear elements of relational dysfunction. Consequently, the "elaboration of mourning" consists in the work of assumption of emotional awareness of the meanings, of the experiences and of the social processes linked to the loss of the "relational object", that is of the person (relative or friend) with whom one was developed a significant emotional bond, interrupted by the death (or loss) 3) Negotiation Phase: "Overcoming this moment will make me stronger", "If I go out, I swear I won't make the same mistakes again". The third phase is one in which the person begins to take note of the irreversibility of the loss and to hypothesize, even in the alternation of moments of despair and hope, ways and It was developed in 1969, from experience with people at the end of their lives and their families and operators.

2.
The feelings experienced are typical responses to suffering.

3.
The way to deal with pain is unique and subjective.

4.
The phases are not stages. Therefore, there is no predetermined order, being able to alternate, recur or overlap. and attention is given to the body, with the loss that appears to be a malfunction of the body; after 5 years, death continues to be conceived as something external to the individual (e.g. a phantom man who takes away and makes disappear); around 9/10 years, the concept of death becomes more biological and realistic, practically permanent [1].

Practical Applications
In the practical sphere, it is necessary to distinguish three main hypotheses [2]: a) The oncological patient during his therapeutic course, in an evolution phase with a favorable diagnosis; b) The cancer patient during his therapeutic course, in an evolutionary phase with an unfavorable diagnosis; c) The cancer patient during the final stage of the oncological disease, on a slope of poor diagnosis.
In the first hypothesis [2], the patient is in a time-lapse between the reception of the diagnosis and establishment of clinical treatment, in the presence of a probable favorable evolution, due to the specific elements of the case. In this hypothesis, the most suitable psychological treatment involves support to the patient to favor and increase (if necessary) his level of awareness of the disease and the role of the patient in the general picture. Also, in this hypothesis, it is not said that the patient's family needs support, even if an indepth interview is always recommended, in order to disseminate also the typical contents of primary and secondary prevention. In the second hypothesis [2], the patient finds himself in a time-lapse that always elapses between the receipt of the diagnosis and the establishment of clinical treatment, in the presence of a probable or certain unfavorable evolution, due to the specific elements of the case. In this hypothesis, the most suitable psychological treatment provides support to the patient to favor and increase (if necessary) his level of acceptance of the disease and the role of the patient in the general framework, in order to accompany him on his journey in the most serene and conscious as possible. Also, in this hypothesis, the need for a widening of the psychological support to the whole family of the patient is useful, in order to better facilitate the network of relations around the patient and disseminate the typical contents of primary, secondary and tertiary prevention.
In the third hypothesis [2], the patient is experiencing the last phases of his oncological pathology, with an undoubtedly unfavorable prognosis and is often approached to the "Palliative Care Centers" (Hospices) to help him concretely in the daily management of his personal and clinical needs. In this hypothesis, the most suitable psychological treatment involves supportive support for the patient, to accompany him to death in the most serene way possible. In this hypothesis, on the other hand, the need for a widening of the psychological support to the whole family of the patient, affected by the imminent loss of the loved one, is evident. And while on the one hand the patient and his needs are the main priority, on the other it is essential to pay attention to the management of human and professional dynamics related to the personnel working in the "Palliative Care Centers": in fact, <<(...) it is widely acknowledged that work in contact with suffering and death is a professional experience that involves operators on a personal, before a professional level [7][8][9]. Consequently, it is possible that more or less conscious identification processes are activated with the patient which, if not recognized and adequately managed, can favor the development of a form of emotional fatigue, described in literature as "compassion fatigue", or of a loss of sense with respect to one's work ("moral distress") or result in a more complicated condition of psycho-physical exhaustion, known as "burnout syndrome" [10][11].
The scientific literature has often questioned whether the confrontation with death the primary source of stress for palliative care workers and the studies is published in the last twenty years have produced conflicting results. An interesting review of the literature on the subject although dated, has shown that operators active in this area report less overall work stress when compared to other health workers who work with serious diseases, even if not necessarily terminal ones [12]. With the same work setting it was also shown that clinicians who feel insufficiently trained in communication and managerial skills have higher levels of stress than those who consider themselves more prepared in these specific areas; even insufficient confidence in patients 'psychological care has been more associated with physicians' burnout levels than the comparison with death has shown. An Australian study has suggested that the limited impact of the "death" factor on work stress is due to the fact that it is a problem that is mostly "taken on" by the Palliative Care organization model. It can be assumed that the specific organizational model of Palliative Care, as well as the training paths of the operators, perform an essential function of prevention or containment of stress-related work. More recent research has focused on the analysis of the relationship established between the Palliative Care operator and his / her work environment, identifying some specific factors that play a significant role in determining work-related stress.  [7][8][9][10][11][12][13][14].
The case of an assisted person and the relative assistance pathway are analyzed within the group in order to evaluate the answers provided by the team to the complex needs of the patient and family members and the communicative-relational methods used.
Crucial is the identification of any critical issues that have emerged actively participating in these debriefings report a more exceptional ability to manage to grieve and maintain professional integrity [16].    "is an integral part of the assistance plan and deserves the same attention paid to physical problems ". Attention to these needs and the interventions related to them also serve to help the patient rediscover the value and meaning of things, to find the meaning both of himself and of belonging to others, even when the disease with its progressive addiction and disability makes it difficult. can evolve up to self-punitive behaviors such as rejection of the treatments, the denial of the illness, or to underline resignation and passive behaviors. In fact, as [17]. reports, one of the psychological needs of the advanced cancer patient is precisely the need for safety [18]. indicate that one of the primary needs of the cancer patient in the advanced stage of illness is the need for safety, which is combined in the feelings of not feeling abandoned, of not feeling cheated, of receiving adequate assistance and that the care staff pay attention to on the specific difficulties of their situation

Psycho-Educational
Psychological problems can be anxious, depressive, organic, of anger and consequent to alterations of the body image " [18]. In this phase of illness, "anguishes of isolation, separation and death are exasperated" [18]. give and receive [18] actively. This specific need is also mentioned by as the primary need of the cancer patient in the advanced stage of illness and expresses itself with the feeling of being appreciated, in the possibility of being able to maintain his own roles and in having decision-making power in his own path of illness [12].  [18]. In close connection with many of the needs referred to above, there is also the need for self-realization of the cancer patient at an advanced stage of illness, which is expressed through being able to express one's own projects (such as the future and the latest provisions) and the reassessment of one's existence [18][19].

The Central Role of Active Listening
To construct a plan of care shared with the patient, to identify realistic goals for it, and to be able to discuss its emotional reactions in front of the clinical picture, one must start primarily by creating a listening space, where the client can report his or her knowledge, its degree of awareness, its need for information, its expectations and its values. Only with a listening space, the patient has the possibility of being able to express and express their emotions.
The manifestation and expression of emotions are crucial for the patient in order to adapt and accept the disease, but above all, to establish a relationship with reality and with others. In fact, if this externalization is lacking, there is a risk that the accumulation of internal feelings of tension and discomfort considerably worsens the patient's discomfort. The need to belong [17] is reported in the advanced stage of illness and can be expressed in having the possibility of being able to express one's thoughts and emotions, both the need for understanding, not only of symptoms and illness, but also in general of death and the possibility of obtaining a moment to discuss them [17]. Patients often experience difficulty in expressing their feelings and expressing and managing their own psychological needs (in fact many reports that they want help to identify and manage them). Furthermore, cancer patients report that they have often The best tool to ascertain the psychological state of the patient is, therefore, the interview. Within this intervention, it is possible to discover the emotions that the patient experiences, but also the needs, problems and representations that characterize his experience. Moreover, the interview allows explaining not only what the needs of the patient are, but also which are the ones for which the latter wants help. In the context of a patient-centred approach to care, needs are self-defined and reflect the inconsistency that exists between the individual's perception of the supportive patient considered necessary and the real support provided by the healthcare team. Communication cannot exist if no one is willing to listen [18].
"Hearing is a physical act; listening is an intellectual and emotional action". Those who hear the sounds recognize the words, but the listener understands their meaning. To be considered an expert in interpersonal relationships, and therefore to be a specialist in the establishment of significant relationships, the specific skill required to possess is listening. It is essential in the advanced stage of illness to be close to the patient, to sit next to him and listen to his particular needs, even more so than to dialogue, so that he can express his fears, his worries, remember and relive One of the primary psychological needs of the cancer patient at an advanced stage of illness is necessarily the need for acceptance "regardless of mood, social relationships and appearance". Accepting the patient also means welcoming his feelings without falling into judgment, thus giving the impression to the patient of the validity of his emotional and psychological expressions and highlighting our support. The patient must feel secure within the patient-caring relationship and must feel free to express himself without being judged. Only in this way will it be possible to create a satisfactory and useful therapeutic alliance for the purpose of continuity of care.
Also, even silence can be active and creative when it is characterized by intimacy and harmony, which allow the patient to feel at ease and to be able to deepen his own self and that of the carer with greater awareness. Furthermore, silence can encourage the patient to continue talking without being interrupted, allowing him to tell his story with his rhythm and encourages the creation of a safe space where the person can express himself without being blocked or hindere.
However, silence can also be harmful, and therefore passive,

The Emotional Relationship Between "Acceptance" and "Resignation"
Terminologically, the two words under consideration may seem synonymous; however, their differences are more than substantial [20][21][22][23][24]. Rogers, the father of humanistic psychology, argued that change was possible only after reaching full acceptance of who we are. "Acceptance" intended as a preparation for change and not for immobility. On this assumption the typical differences between these two states of mind are evident: in "acceptance", the subject is at peace with himself and the surrounding environment, does not experience negative emotional states such as anger or frustration and is ready to rise to a different level determined by the change of inner status; in the "resignation", the subject is not at peace with himself or with the surrounding environment, he still experiences negative emotional states such as anger or frustration which he nevertheless tries to suffocate by suffering the consequences and is not ready to rise to a different level (in how much is still linked to one or more components of the event that destabilized it).
In psychotherapy with a cognitive-behavioural approach, a series of indications are used that refer to the model called "Acceptance and Commitment Therapy" (ACT), where "acceptance represents one of the six fundamental processes that favour psychological and existential well-being, as opposed to experiential avoidance which is related to psychological rigidity and malaise. In the avoidance of one's own painful internal experiences, on the other hand, one often has the sensation of feeling better but immediate relief is associated with the escape or suppression of an emotion, a situation or an aversive interaction is such a seductive prize that almost all Human beings often fall into experiential avoidance. It is no coincidence that Russ Harris, one of the leading exponents of the ACT, uses the word "accretion" instead of acceptance, precisely to emphasize its development potential.
Thanks to acceptance, the energies used in a useless and counterproductive struggle against unpleasant emotions can be released, so that they can be used in actions that are useful and consistent with your values.
The six key processes underlie two macro-areas. The two macro-areas in question are: 1.
The "processes of mindfulness and acceptance"; and 2.
The "processes of behavioural modification and action committed according to values". Also, so: A.
The crucial first target process of the ACT intervention is experiential avoidance. Experiential avoidance is that set of strategies that we implement to control or alter our internal experiences (thoughts, emotions, feelings or memories), even when this causes behavioural damage. Attempts to control anxiety, thoughts to control other thoughts (e.g., brooding), to try in every way not to think or not to remember a pain through harmful and dysfunctional behaviours. Experiential avoidance also materializes in attempts to escape or control external experience, such as avoiding anxiety, avoiding conflicts or expressing anger. The functional equivalent of experiential avoidance in the ACT is called "Acceptance" and can be defined as "leaving space" or "opening up to the experience" of painful emotions and painful thoughts and memories. In this sense, the ACT therapy aims to promote some acceptance trends: a) not to judge our internal (and external) experiences with a malicious look by the inquisitor of ourselves; b) welcome the emotional states and give them the "informative" importance they deserve; c) weaken the power of thoughts about our behavior and our daily experience.

B.
The second fundamental process for the ACT is cognitive fusion. In the ACT, the term "cognitive fusion" refers to the tendency of human beings to be captured, "harnessed" by the contents of their thoughts. The principle that justifies the dysfunctionality of this "connection to thoughts" is summarized in the following sentence: It is not so much what we think about creating problems and suffering but the way in which we relate to what we think. When we are "fused" with our thoughts, especially the dysfunctional ones, we forget that we are interacting with thought and not with a real event, a bit as if our thoughts and our assessments of reality lived in our place. The virtuous counterpart of cognitive fusion, in the ACT, is the Defusione. Therefore, it is of primary importance to intervene not on the contents of dysfunctional thoughts, but on how the individual relates to his own thoughts. In this way, we focus on the attitude towards our thoughts and not on the thoughts themselves.

D. The crucial fourth process of Acceptance Commitment
Therapy is the "Conceptualized Self". We could define the conceptualized self as a set of "fusions" of definitions of ourselves that the mind of each of us tells us. These definitions usually touch on nuclear and relevant aspects for the definition of oneself and of oneself in relation to others. When this process is very present and can be harmful, one is strongly identified with the contents of one's mind. There are various forms that the conceptualized self can take in our daily lives. Some of the most frequent may be the "labels" we give ourselves. Let's think, for example, of being "the sick", "the unfortunate", "the nerd". On other occasions, the conceptualized self assumes the content of rigid fixations on specific problems, a block that leads to failing to grasp the evolution of experience.
On other occasions, the conceptualized self can be characterized by "mergers" with some rigid and abstract/evaluative aspects of oneself. The self-conceptualized is a mask so glued to the skin of our face that we forget we are wearing it, and it becomes our eyes, our ears and our mouth. The conceptualized self contains an elaborate description of ourselves, to which we have become attached and which soon becomes so crystallized that we mistake it for absolute reality. So, a problem like an anxiety problem (but really right for any kind of difficulty) turns into the conceptualized self "I am an anxious", and no matter how many experiences I do where I did not experience that loud and frightening anxiety, I continue to describe myself verbally with "I am an anxious". What the ACT suggests as a functional counterpart of the conceptualized self is the Self as proposal lies in the concept of "committed action": the term is used to define the personal action guided by one's own values; instead it foresees that the individual "reckon" with his own difficulties and fragility. Accepting and making contact with one's own frailties and guiding one's actions starting from one's own personal values allows one to pursue a meaningful and productive life, not without suffering, but satisfying and choice. In particular, it is essential for the Acceptance and Commitment Therapy the concept of workability, of "feasibility". An action committed and guided by its own purposes must also be feasible, actionable. In other words, the committed action consists of continually choosing to engage in actions in the direction of one's personal values, despite the difficult emotions that may be encountered along the way.

Conclusion
It is clear that acceptance, in cancer patients, represents both distress -be they supportive or more specifically psychotherapeutic (individual, group, couple, family) -is therefore fundamental for the patient and his family [24]. Active listening, therapeutic talk, the use of standardized psychometric tools, targeted pharmacological therapies and psychotherapeutic counselling, mindfulness, biofeedback and hypnosis techniques seem to be the winning weapons to accompany the patient (and his family) in the steep path which will see him active.