10/8/2018. Behavioral Health For End of Life Care. Angela M. Williams Schroden, MS, LADC, LPCC Elli Reginek, MSW, LICSW

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1 Behavioral Health For End of Life Care Angela M. Williams Schroden, MS, LADC, LPCC Elli Reginek, MSW, LICSW Disclosures: None Angela M. Williams Schroden, MS, LADC, LPCC Staff Psychotherapist for the St. Cloud Hospital, CentraCare Health System has been working for the St. Cloud Hospital for over eight years with over ten years of experience doing therapy. Angela obtained her Bachelor of Arts degree in psychology from The University of St. Thomas and her Master s of Science degree in clinical psychology from St. Cloud State University. Angela is currently working as a behavioral access staff psychotherapist at the St. hospital amongst the behavioral health consultation liaison team. Angela specializes in working with peripartum patients including antepartum mothers, patients receiving perinatal care, postpartum mothers and families of Neonatal Intensive Care Unit (NICU) patients. Angela also sees pediatric patients, those who struggle with chemical dependency issues and patients on the general medical floors who need behavioral health services. Elli M. Reginek, MSW, LICSW Staff Psychotherapist at the St. Cloud Hospital, CentraCare Health System, amongst the behavioral health consultation liaison team. Elli obtained her Bachelor s and Master s degree in Social Work from Minnesota State University, Mankato. Elli brings over 11 years of experience and has largely spent her career providing services within the geriatric population, particularly with Hospice and end of life care. Elli provides clinical behavioral health services on the general medical floors at the St. Cloud Hospital in addition to providing psychotherapy for Palliative Care patients and their families. WA1 Psychologists can contribute to end of life care before illness strikes, after illness is diagnosed and treatments begin, during advanced illness and the dying process, and after the death of the patient, with bereaved survivors. Kleespies (2004) Behavioral Health for end of life care is not just for those approaching the end of their life, it is also for their family members, friends and caregivers. A terminal illness and/or a period of serious illness, pain and/or discomfort may cause many reactions including: Pain and discomfort Fear and loneliness Concern about family and friends Anxiety about the future Objective: Identify benefits of psychotherapy Identify psychotherapeutic interventions to patient care. 1

2 Interesting Points 1 in 5 U. S. adults aged 18 or older experience mental illness in a given year An estimated 1 in 10 adults report having depression Depression and anxiety are the most common mental health disorders in America Average delay between onset of symptoms and seeking treatment is 10 years Mental health problems lead to more than 150 million visits to doctor s offices, clinics and hospital outpatient departments each year Psychotherapy has fewer side effects and lower instances of relapse when discontinued Psychotherapy is cheaper and more effective than medications for many of the problems that lead people to seek treatment. Estimates of psychotherapy's effectiveness, based on hundreds of empirical studies, are that it works approximately 75 80% of the time. Psychotherapy is cheaper than prescription medications particularly when you consider the impact on your ability to achieve life long goals. Hospital Based vs. Outpatient Psychotherapy Psychotherapy can help eliminate or control troubling symptoms so a person can function better and can increase well being and healing. Hospital Based Psychotherapy Integrated Behavioral Therapy) Brief psychotherapy Sessions are generally shorter Psychotherapy is conducted between one and ten sessions The goal is to produce emotional or behavioral change within a minimal amount of time. Psychotherapy is more active and directive Goals are generally limited and more specific Consults are placed by the medical provider and are generally seen the same day and followed through discharge. Outpatient Services Can be brief or more long term psychotherapy Individual, family, marital or group Outpatient visits may vary: 2x week, weekly, bi weekly, monthly or as needed. Some treatment plans such as EMDR, DBT, TF CBT among others require more sessions. (Rosenstein, 2011) Mindfulness Breathing Exercise minute breathing meditation 2

3 Psychotherapy Psychotherapy, or talk therapy, is a way to help people with a broad variety of mental illnesses and emotional difficulties. There are several different types of psychotherapy and some may work better than others depending on the individual and situation. Psychotherapy may be used in combination with medication or other therapies. Psychotherapy may be conducted in an individual, family, couple or group setting. Psychotherapy may help with: Psychosocial stressors Depressive symptoms Anxious symptoms Panic attacks Medical illnesses Pain management Adjustment Chemical dependency Emotional Distress Relationship discord Caregiver burden stress Grief/ loss Trauma Suicidality t2khky Psychotherapeutic Benefits Increased comfort and support for individuals and families nearing the end of life Improved communication amongst patients and their family Treatment of anxiety, depression and other mental health distress Better understanding of patient s concerns and values Improved coping skills and daily living Reduced emotional distress Improved relationships Improved pain management, symptom reduction Improved quality of life Decreased suicidality/self injurious behavior Mental Health and Decision Making Patients and their caregivers are frequently faced with treatment options Depression may have an impact on decision making Making choices is particularly difficult when decision making is impacted by physical discomfort, psychosocial stressors or depression. A patient s decision to discontinue active treatment is a common trigger for a depression assessment. (Rosenstein, 2011) 3

4 Psychotherapeutic Models There are many psychological/ psychotherapeutic approaches to psychotherapy. Evidenced based approaches and non evidence based approaches are used Two of the main goals behind evidence based practice are increased quality of treatment, as well as increased accountability, so that patients only pay for and undergo treatments which have been proven effective (Spring 2007). Research has shown that Evidence Based Therapy is indeed cost effective (Emmelkamp et al. 2014). This makes sense since clients undergoing Evidence Based Therapy likely spend less time receiving treatment than those undergoing treatment plans which have not been proven Cognitive Behavioral Therapy Helps people identify and change thinking and behavior patterns that are harmful or ineffective, replacing them with more accurate thoughts and functional behaviors. Helpful in treating depression, anxiety, trauma related disorders and eating disorders Interpersonal Therapy Short term form of treatment. Helps people understand underlying interpersonal issues that are troublesome, like unresolved grief, changes in social or work roles, conflicts with significant others and problems relating to others. Most often used to treat depression Acceptance & Commitment Therapy Stems from traditional behavior therapy and cognitive behavioral therapy. Clients learn to stop avoiding, denying, struggling with their inner emotions Accept that these deeper feelings are appropriate responses to certain situations that should not prevent them from moving forward in their lives. Dialectical Behavioral Therapy (DBT) Specific type of CBT to help regulate emotions to help with chronic suicidality and to learn new skills to help people take personal responsibility to change unhealthy or disruptive behaviors. Utilizes eastern philosophies like mindfulness Helpful for people with borderline personality disorder, eating disorders, PTSD and other behavioral or interpersonal problems Psychodynamic Therapy Derived from psychoanalytic therapy/ psychoanalysis Insight orientated therapy focused on unconscious processes and how they affect current behavior Based on the idea that behavior and mental well being are influenced by childhood experience and inappropriate repetitive thoughts or feelings that are unconscious. Used to improve self awareness and to change old patters so he/she can more fully take charge of his/ her life. 4

5 Supportive Therapy Guidance and encouragement to help patients develop their own resources. Build self esteem, reduce anxiety, strengthen coping mechanisms and improve social and community functioning. To help deal with issues related to their mental health conditions which in turn affect the rest of their lives. Person Centered Therapy Based on the belief that clients are resourceful persons capable of taking responsibility for their lives and solving their own problems. Emphasizes honoring and preserving clients' autonomy and choice, as well as the client's role as an active participant in all aspects of therapy. Being person centered means to create a therapy that fits the unique person of the client, so therapists consider clients as experts on what works best for them and thus engage clients as co therapists. Existential Humanistic Therapy The approach emphasizes a person s capacity to make rational choices and to develop their maximum potential. Emphasizes not only the concepts of freedom and responsibility, but experiential reflection, in which clients experience their problems in session through a process of checking in with their affective and bodily sensations. The goal of this therapy is to help clients free themselves from selfimposed limitations and come to a deeper understanding of their authentic life goals, versus those imposed by others or by a rigid sense of self. Dignity Therapy Invites patients to discuss issues that matter most or that they would most want remembered. Addresses psychosocial and existential distress among terminally ill patients. Newer therapeutic approach to instill a sense of meaning and purpose Patients/ clients are offered the opportunity to address issues that matter most to them or speak to things they would most want remembered as death draws near. Sessions are often recorded/ transcribed and edited with a final version returned to the patient/ client for them to share with family/ friends Addresses: generativity, continuity of self, role preservation, maintenance of pride, hopefulness, aftermath concerns, and care tenor. (Chochinov et al., 2005) Psychotherapist Qualities Possession of a sophisticated set of interpersonal skills. Ability to help you feel you can trust the therapist. Willingness to establish an alliance with you. Ability to provides an explanation of your symptoms and can adapt this explanation as circumstances change. Commitment to developing a consistent and acceptable treatment plan. Communication of confidence about the course of therapy. Attention to the progress of therapy and communication of this interest to the client. Flexibility in adapting treatment to the particular client's characteristics. Inspiration of hope and optimism about your chances of improvement. Sensitivity toward your cultural background. Possession of self insight. Involvement in continued training and education. (Norcross 2011) 5

6 Psychotherapy Blind Spots Transference Transference was a word coined by Sigmund Freud to label the way patients "transfer" feelings from important persons in their lives, onto the psychotherapist. Countertransference When a psychotherapist unconsciously transfers his/ her own feelings onto a patient. According to Freud, "countertransference" can interfere with successful treatment. The psychotherapist experiencing countertransference should rid himself/ herself of such feelings by having further analysis himself/ herself. Perceptions/ Assumptions Bias Lack of insight Therapy interfering behaviors Ethical issues Reference: streetpsychiatry/201003/countertransference overview References. (2005). The role of psychology in end of life decisions and quality of care. Washington, DC.. (2012). Has psychotherapy taken a back seat to medication. Washington, DC. (2018) Breitbart, W., Gibson, C., Poppito, S. R., Berg, A. (2004). Psychotherapeutic Interventions at the end of life: a focus on meaning and spirituality. Foti ME. Do It Your Way: End of Life Care for Persons with Serious Mental Illness A Massachusetts Demonstration Project. The Journal of Palliative Medicine, 6: , 203. Haley, W., Larson, D., Kasl Godley, J., Neimeyer, R., & Kwilosz, D. (2003). Roles for Psychologist in End of Life Care: Emerging Models of Practice. Professional Psychology: Research and Practice, Vol. 34, No. 6, pp Rosenstein, D. L. (2011). Depression and end of life care for patients with cancer. Clinical Research, Chochinov, Hack, Hassard, Kristjanson, McClement & Harlos. (2005). Dignity Therapy: A Novel Psychotherapeutic Intervention for Patients Near the End of Life. Journal of Clinical Oncology, 23: Norcross, J. C. (2011). Psychotherapy relationships that work (2nd ed.). New York: Oxford University Press. Summers, R.F., Barber, J.P. (2012). Psychodynamic Therapy: A Guide To Evidence Based Practice. New York: The Guilford Press. Spring, B. (2007). Evidence based practice in clinical psychology: What it is, why it matters; What you need to know. Journal of Clinical Psychology, 63(7), doi: /jclp Emmelkamp, P.M.G., David, D., Beckers, T., Muris, P., Cuijpers, P., Lutz, W., Andersson, G., Araya, R., Rivera, R.M.B., Barkham, M., Berking, M., Berger, T., Botella, C., Carlbring, P., Colom, F., Essau, C., Hermans, D., Hofmann, S.G., Knappe, S., Ollendick, T.H., Raes, F., Rief, W., Riper, F., Van der Oord, S., Vervliet, B. (2014). Advancing psychotherapy and evidence based psychological interventions. International Journal of Methods in Psychiatric Research, 23(S1), doi: /mpr