AMITY INSTITUTE OF BEHAVIOURAL HEALTH AND ALLIED SCIENCES

SEMINAR: EVIDENCE-BASED PSYCHOTHERAPY APPROACHES IN

TERMINAL ILLNESS

DATE: 09.11.2023

PRESENTED BY: SUPERVISED BY:

SHAHELI MUKHERJEE Ms. AVISIKTA BASU
M.Phil. trainee (2nd year) Assistant Professor,
AIBHAS, AIBHAS,
Amity University, Kolkata Amity University, Kolkata

Aims of the Seminar

 To understand subjective experience of patients with terminal illness and clinician’s
perspective
 To understand terminal illness and the various key concepts
 To understand distress due to physiological, psychological, and spiritual changes and
scope for management
 To get a brief overview of Kubler-Ross’s stages of grief
 To understand considerations in Breaking Bad News
 To get a brief overview of scales/ assessment tools
 To understand how psychotherapy for terminally ill patients is different from ‘typical’
psychotherapeutic interventions for psychiatric disorders
 To understand how psychotherapy interventions for end-of-life care are planned and
conducted
 To understand the ways of managing grief in family members

Introduction
Terminal illness is used to describe patients with advanced disease and a drastically reduced
lifespan, with perhaps months or weeks to live. Inevitably the range and severity of physical
symptoms will have increased, and will be having a profound effect on how the patient lives
his life.
Examples of some illnesses which can be terminal include:

 advanced cancer
 dementia (including Alzheimer's)
 motor neurone disease (MND)
 lung disease
 neurological diseases, like Parkinson's
 advanced heart disease.
 HIV/ AIDS
Common symptoms of patients with a terminal illness:
1. Fatigue
2. Weight Loss
3. Confusion & Dementia
4. Nausea & Vomiting
5. Insomnia –

Distress due to physiological, psychological and spiritual changes

Patients approaching death experience physical symptoms along with psychological, spiritual,
and existential distress for which appropriate psychotherapeutic intervention can have
significant impact. The challenges faced by the dying patient are potentially overwhelming.
These challenges include physical pain, depression, a variety of intense emotions, the loss of
dignity, hopelessness, and the seemingly mundane tasks that need to be addressed at the end of
life. An understanding of the dying patient's experience should help clinicians improve their
care of the terminally ill.
Pain, and the fear of pain, often drives the behavior of patients at the end of life. In a survey
of 310 patients with life-limiting illness, “freedom from pain” ranked most important in their
considerations of the end-of-life process (Rao, 2004).
Anxiety and depression frequently accompany pain, and addressing this is pivotal to alleviating
“total pain.” Depression is one of the most common mental health problems faced by
individuals with terminal illness. Approximately 14% of patients receiving palliative care meet
criteria for an anxiety disorder, with many more experiencing decreased quality of life or
deteriorating emotional well-being caused by anxiety about death. Helping clinicians
recognize and treat depression at the end of life has significant implications for patients’ and
families’ quality of life. Undertreated depression and anxiety can reduce treatment adherence,
increase physical symptoms, and hamper the developmental tasks of dying (e.g., pursuit of
meaning and connection and saying goodbye).
The threatened and experienced losses faced by patients at the end of life are also associated
with anticipatory grief and fear of death. Spiritual distress can be a component of existential
suffering, and might manifest in the form of inability to find a meaning in life or purpose to
work towards.
The loss of previous roles, meaninglessness, decreased sense of control, and subjective
incompetence have been identified as key factors in demoralization of patients with terminal
illness (Kissane,et. al., 2001). Dignity has gained increasing attention as a vital component of
quality of life and quality of end-of-life care.

Kubler-Ross’s Stages of Grief

Denial
Anger
Bargaining
Depression
Acceptance

Breaking the Bad News

An optimal adjustment also depends on how bad news is delivered, and how the various
reactions to this are managed.
Assessment tools and Scales
The process of assessment is important in case conceptualization and treatment planning. For
the purpose of monitoring symptoms, level of distress, to understand progress, cognitive
functioning, neuropsychological profile, various relevant scales and assessment tools are
applicable.

Psychotherapy at the End of Life

Psychotherapy at the end of life includes the foundation of a strong therapeutic relationship
that is based on trust, therapist empathy, presence, and unconditional positive regard for the
patient and his or her emotional distress (Norcross & Lambert, 2018). They must also be
mindful of a diminished and often unpredictable time frame for therapy and the need for
flexibility in scheduling.

Cognitive Behavioural Therapy (CBT)

CBT has a solid evidence base for use among patients receiving palliative care and may be
particularly helpful in managing common symptoms of depression and anxiety in addition to
physical discomfort. Cognitive restructuring related to specific maladaptive anxious or
depressive thoughts and behavioral management of physical (e.g., pain and dyspnoea) and
psychological symptoms can be helpful. Diaphragmatic breathing, progressive muscle
relaxation, guided imagery, and clinical hypnosis can all be useful to aid in coping, self-
management, and management of pain. These approaches can be adapted as needed for
individual patients’ physical and cognitive constraints (Turk & Feldman, 2009).

Acceptance and Commitment Therapy (ACT)

Emerging evidence supports acceptance and commitment therapy (ACT) as an efficacious
intervention for patients with a terminal illness, particularly for the understudied and
difficult-to-target symptom of anticipatory grief. In ACT, psychological distress is thought to
arise from an unwillingness to engage with unpleasant thoughts, sensations, feelings, and
memories (i.e., experiential avoidance). ACT targets unhelpful control and avoidance
behaviors while empowering psychological flexibility.

Mindfulness-Based Cognitive Therapy

MBCT is a third-wave treatment that is based on mindfulness, as a receptive and
nonjudgmental awareness of the present moment. It consists of a combination of the main
techniques of CBT and mindfulness. Mindfulness meditation activates the regions of the
brain that are responsible for positive emotions and thus has a beneficial effect on immune
functions of the body. This process allows individuals to make less painful sense of present-
moment events.

Dignity Therapy (DT)

Dignity therapy is an established intervention for terminally ill populations, with demonstrated
efficacy in enhancing end-of-life experience (Chochinov, 2002; Chochinov & Kristjanson,
2011). Harvey Chochinov, a Canadian psychiatrist who specializes in palliative care, is widely
credited with putting forth the theory behind—and the practice of—dignity therapy. It is a brief
psychotherapy based on an empirical model of dignity that begins with reflection on why some
patients with advanced disease wish to die, while others find serenity and a desire to enjoy their
last days.

Meaning-Centered Psychotherapy (MCP)

Spiritual well-being and sense of meaning are important concerns for clinicians who care for
patients with cancer. The Meaning-Centered Psychotherapy (MCP) addresses the need for
brief interventions targeting spiritual well-being and meaning for patients with advanced
cancer. MCP is a manualized brief, structured psychotherapeutic intervention, based on the
existential perspectives put forth by Viktor Frankl, to help patients suffering with loss of
meaning around illness. Research studies have shown a significant decrease in levels of
demoralization (despair), anxiety, depression, and emotional distress among patients.

Managing Grief in Family Members

As the dying process progresses, psychotherapy with the individual patient may become limited
by cognitive and speech deficits. It is at this point that the focus of supportive
psychotherapeutic interventions shifts primarily to the family.

Conclusion
In conclusion, the utilization of evidence-based psychotherapy interventions in patients with
terminal illness represents a compassionate approach to improving their overall well-being and
quality of life during this challenging phase of their journey. Through a review of the existing
literature and clinical studies, it becomes evident that CBT, meaning-centered therapy, and
mindfulness-based interventions tailored to the unique needs of these patients can effectively
alleviate psychological distress, enhance coping, and provide a sense of emotional support.
Another crucial aspect of such approaches and interventions is the collaboration between health
care providers and family members.

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