On Friday, November 21, 2008, Dr. David B. Feldman addressed attendees at the SCV-CAMFT luncheon held at Michael’s at Shoreline. The subject was “Post-Traumatic Stress Disorder At The End Of Life: What Therapists Need To Know.”

The end of life is something we all have to deal with, but has been a taboo topic. We are now beginning to recognize End of Life (EOL) as a separate phase of life distinct from old age. There is very little information available about the prevalence of Post-Traumatic Stress Disorder (PTSD) at the end of life, however Dr. Feldman asserted that it is fairly common for people in EOL to have PTSD, whether from old wounds, or from the realization that their illness is terminal and death is approaching.

Rates of PTSD are well-documented in other populations: cancer patients 35%; rape 40%; combat veterans 30%. Dr. Feldman suggested that a patient with a diagnosis of a terminal disease may be traumatized, and/or that the trauma of this diagnosis may trigger or reactivate old, buried PTSD.

Is EOL PTSD different from “ordinary” PTSD? First, a review of the diagnostic criteria for PTSD:

• Experienced trauma
• Re-experiencing symptoms, including: intrusive recollections, nightmares, flashbacks
• Avoidance symptoms, including: avoidance of thoughts/feelings/conversations; of activities, places, people; emotional numbness
• Increased arousal symptoms, including: insomnia, irritability and angry outbursts, hypervigilance, increased startle response

PTSD affects the EOL client differently, and significantly impairs the client’s quality of life. PTSD symptoms sabotage the client’s ability to deal with EOL issues in the following ways:

EOL Issue: Reliance on family/social support

PTSD Symptom: Isolation/detachment (If the client has isolated self and numbed emotionally, she or he is unlikely to have reliable family/social support.)

EOL Issue: Importance of life review, resolving unfinished business

PTSD Symptom: Avoidance of trauma memories and unfinished business (If the client cannot think about his or her life, he or she cannot review it, or resolve unfinished business.)

EOL Issue: Need for good doctor-patient communication

PTSD Symptom: Hypervigilance, distrust in authority, need for control (If the client does not trust the doctors, she or he cannot have good communication.)

EOL Issue: Need for acceptance of death

PTSD Symptom: Avoidance of trauma reminders (If the client cannot think about his or her approaching death, he or she cannot accept it.)

Why treat somebody who’s dying anyway? Why alter your established and familiar methods? These clients are suffering, often severely, and are at an extremely vulnerable time in their lives. Their PTSD symptoms reduce their already-compromised quality of life. If you don’t adapt your treatment to their needs, you may not help them during their final weeks or months.

Two Common PTSD Therapies

Cognitive-Behavioral:

• Treatment mechanisms: exposure and cognitive restructuring
• Number of sessions: 8-16 (60-90 minutes each)
• Efficacy: leads to decrease in symptoms

EMDR:

• Treatment mechanisms: bilateral stimulation, exposure, reprocessing of trauma memories
• Number of sessions: 8-12 (90 minutes each)
• Efficacy: leads to decrease in symptoms

Problems with the Above Standard Therapies:

• Require too much time and too much patient stamina (often, a very ill or aged client simply doesn’t have the strength to sit up in session for 60 to 90 minutes)
• Often lead to short-term distress
• Focus on long-term outcome (with a dying client, you need to focus on short-term outcome)
• Can ignore important symptoms such as isolation, anger, and guilt
• Do not address EOL issues
• Have little role for family or caregivers
• Less effective in older adults due to cognitive deficits

Problems with Pharmacotherapy:

Antidepressants (SSRIs and TCAs) may be useful in relieving PTSD symptoms. However, they may take six to eight weeks to take effect and may lead to increased agitation. Furthermore, in an aged client, the effects of prescription medications may be less predictable than in the general population.

In this Situation, You Need a Method of Therapy that:

• Does not require multiple sessions
• Does not require long sessions or lead to fatigue
• Has immediate benefits
• Does not cause short-term distress
• Addresses guilt and anger
• Addresses influences of PTSD on dying
• Includes family
• Is suitable for geriatric populations

Feldman proposed a therapeutic model more suitable for this population. The staged model for treating EOL PTSD is much like what you do now but in a different order.

Stage I: Palliate immediate discomfort. If this works, stop now! If not, continue to Stage II, assuming the client is healthy enough, and likely to live long enough, to do it.

Stage II: Enhance coping skills and social supports. If this works, stop now! If not, continue to Stage III, again assuming the client is healthy enough, and likely to live long enough, to do it.

Stage III: Treat specific trauma issues.

Details of Each Stage of Treatment

Stage I. Methods for palliating immediate discomfort:

• Active listening — use empathy and validation
• Reassurance (e.g. providing information to soothe patient’s anxiety)
• Direct assistance in solving practical problems (Don’t bother “teaching a man to fish” when he does not have a future lifetime to exercise his new fishing skills.); Solve problems for the client if you can, keeping boundaries clear and maintaining good ethical relations
• Educating healthcare providers and family about how to avoid triggering PTSD symptoms (e.g. talk to hospice nursing staff)
• Mediating discussions with medical providers (e.g. go to the doctor with your client, and intervene if necessary)
• Mediate family conflicts and address concrete concerns with family

Stage II. Ways to provide coping skills and social supports (“teaching the client to fish,” assuming there is time):

• Provide psychoeducation regarding PTSD symptoms with patient and family
• Teach concrete coping skills (relaxation, breathing, mindfulness, thought-stopping, etc.)
• Provide problem-solving interventions (teach the client to come up with his/her own solutions)
• Improve communication and social skills
• Work with family members on above skills

Stage III. Suggestions for treating specific trauma issues (do not bring up trauma in Phase I or II):

• Don’t use prolonged exposure
• Use a reminiscence-based approach
• • Treatment should be patient-paced, probably with frequent, short sessions
  • Provide a safe environment
  • Use active listening (reflect, clarify, validate)
  • Facilitate reframing and meaning-making
  • Encourage forgiveness of self and others

Note that the above model of treatment probably doesn’t work as well as the standard model, overall — but it does decrease chances of making matters worse. Remember: “First, do no harm.”

During the question and answer period, members of the audience asked several important questions.

One question asked how to recognize if Stage I “works?” Feldman looks for indicators that it is not working, i.e. lack of symptom reduction and decrease in distress. If you get 80% success with symptom reduction in Stage I (palliation), perhaps that’s enough, and you may not need to move on to Stage II.

Feldman remarked that as a therapist working with this population, it’s best to stay with natural empathy, rather than focusing on all the therapeutic tricks we know and applying good-but-mismatched techniques. Be aware of your own fear of death. If you have it at a conscious level, you have a better chance of talking about it; but if you have it submerged, you will probably miss opportunities to address important concerns.

Another question asked how does one deal with resistance? (“I don’t need a shrink, I don’t have any mental problems!”) A good response is something like, “Okay, my purpose is to see if I can make your life better. How can I help? What would you like to talk about?”

David B. Feldman is an assistant professor of counseling psychology at Santa Clara University, Santa Clara, California. He holds a Ph.D. in clinical psychology from the University of Kansas and completed a fellowship in hospice and palliative care at the Veterans Administration Palo Alto Health Care System.

Author:  Melissa Miller, MFT
Presented by: David B. Feldman, Ph.D.