Cognitive Behavior Therapy: Palliative Care

Cognitive Behavior Therapy alleviator C beIndividuals that accommodate been deemed by their medical team to gull serious disorders that are resistant, nonresponsive or have failed reasonable interferences are often referred to specialists for comfort measures wholly. According to the World Health Organization, Palliative tuition is the active agree care of patients whose disease is non responsive to curative treatment. Control of wound, of other symptoms, and of psychological, affable and spiritual problems is par criterion. The goal of lenitive care is the achievement of the best practicable quality of life for patients and their families (WHO, 1990). The National Center for Health Statistics (1996) estimated that 20% of all deaths and 30% of the deaths of elderly individuals extendred in extended care facilities. Extended care facilities are but single place where end-of-life issues are a common fact of daily life. However, regardless of the stage setting, each ind ividual faces the end of life with his or her induce view of life, death and the dying wait on.The estimated number of patients in alleviatory care varies ascribable to the difficulty in capturing the actual numbers from hospitals, primary care practitioners, families and fatality rooms. The estimate of patients receiving the Medicare benefit for hospice and palliative care is approximately million, and it is estimated that, in 2000, approximately 20% of patients dying in the United States certain hospice or palliative care services. It should be noted that although m each, if not close to, individuals in hospice/palliative care settings are age 85 or honest-to-god, this level of care is not limited to older adults. Motor vehicle accidents, post-traumatic incidents, drug overdoses and other physiologicly devastating dis holy orders whitethorn result in permanent damage to the younger body as puff up as the older body. Mortality values at a young age for those with psychi c illnesses is decreasing therefore it is estimated that by 2030 there will be 15 million individuals with mental illness residing in long term care facilities (SAMHSA, 2004).This chapter will focus on the diminution or modification of autonomic, psychiatric, or sensory symptom experience of these individuals through use of cognitive behavioral therapy. Cognitive behavior therapy (CBT) uses a structured and collaborative approach while lot individuals to recognize, evaluate and restructure the relationships between their thoughts, touchings and behaviors. Through a process of targeted interventions, the therapist serve ups individuals to identify, monitor and cognitively restructure the dysfunctional thoughts and/or to modify behaviors that are maladaptive, ineffective or even harmful (Beck, 1976 Turk, Meichenbaum, Genest, 1987 Freeman Freeman, 2005). CBT involves a range of both cognitive and behavioral techniques such as heartsease, head imagery/visualization, biofeedb ack, behavioral experiments, guided discovery, stress palmment, cultivation in upset or stress management strategies, and cognitive restructuring for dysfunctional thinking and many others. Although there is a paucity of query on the use of CBT in palliative care settings, CBT is effective for many of the psychological issues that are prevalent in palliative care including, first, perplexity, pain management, and insomnia. The finding of this chapter is to provide an overview on the use of CBT for assessment and treatment of psychological distress in palliative care settings.Assessment of Emotional Functioning in Palliative worryThere are many challenges to the assessment of musical mode disorders in palliative care settings. An initial challenge is the myth that psychological distress is a normal re carry out to end of life. Despite expectations, approximately individuals in palliative care settings do not have symptoms of anxiety, depression or madness. Many individuals generate at this stage of their lives or illnesses with a sense of calm resignation, if not expectations of relief and of going home to God, heaven or family members waiting for them in the hereafter. therefore those individuals that are experiencing symptoms that require intervention whitethorn achieve monumental benefit from the interventions. The most common presentations are those of depression, anxiety, pain management failures with exhaustion and anguish, and rest disorders. The wellness care provider requires tools necessary to classify major depression from anger, sadness, and anxiety associated with the symptoms of an untreatable or chronic illness.Assessment of preparatory affliction and depression. Another obstacle to the assessment process is simply overcoming the challenges of differentiating symptoms from normal melancholy of the illness itself. Differentiating between preparatory grief and depression is a key component to the proper(a) assessment of depressio n in palliative care and has important treatment implications. Preparatory grief kindle be defined as what an individual must undergo in order to prepare himself for his final separation from this world (Kubler-Ross, 1997). Symptoms of preparatory grief acknowledge 1) Mood waxes and wanes with time, 2) Normal self-esteem, 3) Occasional fleeting thoughts of suicide, and 4) Worries virtually separations from loved ones (Periyakoil and Hallenbeck, 2002). Preparatory grief is a normal, not pathological, life cycle event (Axtell, 2008 Periyakoil and Hallenbeck, 2002).Major depression is defined as five or to a greater extent than of the following symptoms during the same dickens week period depressed mood, marked diminish in recreation, weight neediness or gain, insomnia or hypersomnia, psychomotor agitation/retardation, fatigue/loss of energy, feelings of slowness or inappropriate guilt, lack of concentration/indecisiveness, and recurrent thoughts of death and suicidal thoughts or plans (APA, 1994). Table 1 provides a symptom list. The list is not think to be all inclusive however it gives the clinician an overall view of symptoms that may be observed in the individual dealing with depression in a palliative care setting.Although some symptoms of grief and depression overlap, there are ways to distinguish between grief and depression. Table 2 summarizes the ways to differentiate symptoms of grief versus depression according to temporal variation, self-image, hope, anheonia, response to bridge over, and active desire for an early death (Periyakoil Hallenbeck, 2002).The first step to proper recognition of depression involves the realisation of possible venture factors (Wilson, Chochinov, de Faye, and Breitbart, 2000). Certain demographic characteristics, such as younger age, poor social support, limited financial resources and family history of a mood disorder, as hygienic as a personal history of previous mood disorders place individuals at a greater risk for developing depression or anxiety in end of life situations. Risk for developing a mood disorder in like manner is elevated with certain types of diagnoses, including pancreatic cancer and thinker tumors, and particular medical interventions such as radiation therapy (Hirschfeld, 2000). Symptoms of the illness, including poor symptom control condition, physical disability, and malnutrition also place individuals at higher risk.The second step to the proper assessment of depression includes utilization of appropriate assessment tools. Many time it is the degree and persistence of symptoms that provide the information necessary when considering major depression. Major depression, which is estimated to occur in fewer than 25% of patients in end of life care, may be best screened with targeted questions such as How much of the time do you feel depressed? In addition, for those individuals that have a difficult time describing their symptoms or history, asking family members to provide information about a previous history of depression or a family history can be very useful.Although studies validating assessment tools vary greatly, many of the self- calculate measures have been shown to be effective in palliative care patients. The most common utilized tools in palliative care settings frequently omit physical symptoms of depression. Many symptoms of depression overlap with the terminal disease process (Noorani Montagnini, 2007). Examples of self- compensate measures that omit somatic symptoms include the Beck Depression Inventory II (Beck, Steer, and Brown, 1996), Hospital Anxiety and Depression Inventory (Zigmond Snaith, 1983), and the Geriatric Depression Scale (Yesavage et al., 1983). The convert and Lohse Non-Verbal Depression Scale (Hayes, Lohse, and Bernstein, 1991) is a third party observational measure that can be completed by staff, family, or friends to assist with the diagnostic process. terminally Ill Grief or Depression Scale (TIGDS), c omprising of grief and depression subscales, is the first self-report measure designed and validated to differentiate between preparatory grief and depression in adult inpatients (Periyakoil et al., 2005).Assessment of anxiety. The symptoms of anxiety may differ in individuals in the palliative care environment. Many times symptoms of anxiety have a physiologic component. For example in those individuals with chronic preventative pulmonary diseases difficulty breathing, low group O levels and overall compromised respiratory function causes air thirstiness which is experienced as anxiety and even panic. Table 3 lists some of the common anxiety symptoms jiben in this population.Family members are often at a loss as to what they can do to assist their loved one that is experiencing anxiety, and especially fearfulness. It is often useful to provide profound others with a checklist of items that are important to report to the healthcare provider. Involving the family has the benefi t of giving them a structured guide for response which boil downs their own anxiety in response to the patient. In addition the patient may relax more knowing that a family member is involved with their care in an approved, helpful manner. An example of a list of items for family members to watch for and report to the healthcare team is listed in Appendix 1.Cognitive Behavioral Interventions in Palliative CarePsychological intervention in the palliative care setting includes those aspects of treatment that would provide relief from senseal distress while an individual is dying. Often this time period includes depression, anxiety, grief and organic brain dysfunctions such as dementia and/or cerebral vascular diseases. Individuals and their family members are both considered the patient during these times. Many of these individuals are suffering from chronic, unremitting pain conditions which negatively impact their emotional health. Treatments for pain and chronic conditions also p lay a part in the individuals mental status. The use of Cognitive Behavior Therapy (CBT) is extremely useful for these individuals. Cognitive Behavioral Therapy has the strongest experiential support of any psychological intervention for the management of symptoms typically seen in a palliative care setting.The most common presentations of psychological distress in the dying patient include anxiety, depression, hopelessness, guilt over perceived life failures and remorse. Persistence of these thoughts and feelings interfere with functioning, makes the person generally miserable as wellhead as those around them and can severely affect his/her quality of life. Medical treatments, such as antidepressants, anxiolytics and cholinesterase inhibitors, exist for these problems however supportive psychotherapy such as relaxation training, imagery, distraction, skill training, and negative thought restructuring rectifys the possibility of remission. CBT can also improve the symptoms of spi ritual distress that may include feelings of disappointment, guilt, loss of hope, remorse, and loss of identity.CBT for depression. Symptoms of depression are common in end of life care. It can be one of the most distressing groups of symptoms an individual can experience and may interfere importantly with daily tasks of life. few experts have estimated that up to 75% of patients with terminal illnesses experience symptoms of depression. Amelioration of some of the symptoms of depression can emergence the amount of pleasure and importee in life, as well as add hope and peace. Treatment for depression can reduce the experience of physical pain as well as general misery and suffering. In addition, reduction of the symptoms of depression may improve the treatment of coexisting illnesses more effective. Most importantly, given that one of the most serious symptoms of depression is suicidal ideation, it makes sense to treat depression in order to prevent successful suicidal outcomes.Th ere is a paucity of literary productions in the area of the use of CBT with depression in Palliative Care, due to the high attrition rate resulting from physical morbidity and mortality (Moorey et al., 2009). Therefore, these factors pose epoch-making barriers to conducting randomized clinical mental testings in Palliative Care to address these components. The following is a review of the sparse literature on CBT in Palliative Care with depression.In an attempt to address this problem, Moorey et al., conducted a cluster randomized controlled mental testing in order to determine if it was possible to teach nurses CBT techniques in order to reduce anxiety and depression symptoms in patients with mature cancer (2009). Eight nurses were trained in CBT by attending several 1- and 2-day workshops and then were rated on the Cognitive Therapy first gear Aid Rating Scale (CTFARS) for CBT competence. Seven nurses did not receive training and served in the control group. A total of 80 ho me care patients entered the trial however most of these participants were excluded due to being too ill to participate. A total of 16 patients were in the CBT group and 18 patients were in the control group. The participants received home care nursing visits in which assessments were conducted at 6-, 10-, and 16-week intervals. The individuals who received CBT reported lower anxiety scores over time, but no effect of the training was found regarding depression. It was noted that both groups experienced lower rates of depression over the course of the study. The authors noted the heterogeneity of the sample and the high attrition rate due to physical morbidity and mortality presented several barriers to conducting the study and may have played in a role in the findings (Moorey et al., 2009).Cole and Vaughan (2005), in their review on the feasibility of using CBT for depression associated with Parkinsons disease (PD), found that it is a promising option. The authors noted that depres sed inviduals with comorbid PD experienced a meaning(a) reduction in depressive symptoms and negative cognitions. In addition they experienced an increased perception of social support over the course of treatment (Cole Vaughan, 2005). The recommended course of action for individuals in this setting included stress management training, relaxation training, behavioral modification techniques for sleep hygiene, and cognitive restructuring. Modification of life stressors contributing to depressed mood should be place and plans made to minimize stress and maximize quality of life. The use of thought restructuring is recommended in order to maintain a sense of figure and fulfillment through meaningful activity and to ad skilful expectations of self and others. Individuals are also encouraged to return to previously enjoyed activities in order to maximize feelings of pleasure and happiness. Through systematic defocusing on physical conditions the person is able to experience more plea sant activities, which are also encouraged. likewise, Dobkin et al, conducted a study which explored the effects of modify CBT for depressed patients with PD, in conjunction with a dismantle social support intervention for caregivers (2007). The patients received 10-14 sessions of limited CBT, while caregivers attended trine to four separate psychoeducational classes. The modified CBT sessions were comprised of the same components of the previous Cole Vaughan, (2005) study, such as, stress management training, behavioral modification techniques for sleep hygiene, relaxation training, cognitive restructuring, modification of life stressors, and increase engagement in pleasurable activities. The classes were targeted at providing caregivers with ways to respond to the patients negative thoughts and beliefs, as well as, strategies to offer appropriate support. As in the previous study, the modified CBT sessions were comprised of training in stress management, behavioral modificatio n, sleep hygiene, relaxation techniques, and cognitive restructuring. Participants reported a significant reduction in their depressive symptoms and cognitions and increased perception of social support at treatment termination and one-month post-treatment.CBT for anxiety. Along with depression, anxiety is a common mental health problem in palliative care settings and also appears to be alleviated with CBT interventions. In a small feasibility study examining the use of cognitive behavioral therapy techniques for mild to moderate anxiety and depression in hospice patients, four sessions of CBT techniques was found to significantly reduce anxiety and depression in a majority of patients (Anderson, Watson, Davidson, and Davidson, 2008). Overall, participants in the study found the CBT techniques acceptable, helpful, and qualitatively reported alter mood. A significant reduction in anxiety symptoms also was seen in a randomized controlled trial of CBT administered by home care nurses in patients with advanced cancer (Moorey et al., 2009).CBT techniques are particularly effective to assist with the management of anxiety related to breathing difficulties commonly seen with pulmonary diseases, such as chronic obstructive pulmonary disease (COPD). In a group of individuals with COPD, six sessions of guided imagery, a CBT relaxation technique, was found to significantly increase the partial percentage of oxygen saturation, which is a physiological indicator signaling more effective breathing (Louie, 2004). In another study, as little as 2 hours of CBT group therapy yielded a decrease in depression and anxiety among older patients with COPD, but there was no change in physical functioning (Kunik et al., 2001).CBT for pain management. Pain is not simply a biological response to unpleasant stimuli. It is a complex phenomenon that includes biological, psychological, behavioral and social factors that interact in complex ways to influence the pain experience. Some of the factors that can influence a persons experience of pain include a) previous pain experiences, b) biologic and genetic predispositions, c) mood disorders such as anxiety and depression d) their beliefs about pain, e) fear about the pain experience, f) their individual pain threshold and pain tolerance level, and f) their skill with coping methods. Cognitive-Behavioral Therapy has the most empirical support for the management of chronic pain, especially when used as part of an interdisciplinary treatment approach to manage pain symptoms (Turk, Swanson, Tunks, 2008).Cognitive behavioral techniques can be used independently to assist with pain management or integrated into a comprehensive cognitive-behavioral case conceptualization framework to address pain (Turk, Swanson, Tunks, 2008). The three components to CBT for pain management are 1) Education and rationale for the use of CBT, 2) Coping skills training, and 3) Application and maintenance of CBT skills (Keefe, 1996). Useful beha vioral interventions to assist with pain management include goal setting, relaxation strategies, such as deep breathing and guided imagery, and activities scheduling. Cognitive interventions would include increasing problem-solving skills and addressing an individuals maladaptive thoughts related to pain management. Examples of maladaptive thoughts include 1) Ive tried every pain management intervention with no success, 2) I cannot do any of the things that I used to do, 3) nothing will help manage my pain, and 4) no one can help me feel better. CBT for pain management has demonstrated efficacy in various diagnoses often addressed in palliative care. CBT has been found to be efficacious in the management of cancer-related pain in single studies (Syrjala, Donaldson, Davis, et al., 1995) as well as in systematic reviews (Abernethy, Keefe, McCrory, Scipio, Matchar, 2006).CBT for sleep hygeine. Insomnia, sleep duration and quality are major concerns for people with pain disorders such as osteoarthritis (Vitiello, 2009). Approximately 60 percent of individuals with chronic pain disorders report frequent nighttime awakening due to pain during the night. Disrupted sleep patterns exacerbate chronic pain intensity and experience which in turn causes more disturbance of the sleep/wake cycle. Successful treatment of interrupted sleep may reduce the pain experience as well as improve the overall quality of life for these individuals. Psychotherapeutic techniques that target sleep disturbances are easily incorporated indoors behavioral and cognitive management of other co-occurring disorders as well.Sleep disorders are common in patients who suffer from Parkinsons disease (PD) (Stocchi, Barbato, Nordera, Berardelli and Ruggieri, (1998). Specifically, insomnia, nightmares, REM sleep behavior disorder, sleep attacks, sleep apnea syndrome, excessive daytime sleepiness, and periodic weapon movement in sleep result from changes in sleep structure, movement disturbances in sl eep, disturbances in neurotransmission and medications. Individuals who are sleep deprived are at risk to develop infections, cardiovascular disease, hypertension, diabetes, depression, and require increased time to recover from stress (Schutte-Rodin, Broch, Buysse, Dorsey, and Sateia, 2008). CBT improves sleep by addressing unhelpful beliefs regarding sleep and misperceptions about the amount of sleep that one sees. Many misperceive the amount of time they are actually asleep. People who suffer from insomnia actually sleep more than they are aware of because they are only attentive of when they are awake. Furthermore, many people believe they require 8 hours of sleep in order to be able to function during the day and any amount of sleep that is less is insufficient and will result in reduced ability to function during the day. Therefore, these beliefs and misperceptions can increase ones stress level about sleep and a stress response may result when one thinks about going to sleep . Clearly, a heightened stress response is not conducive to sleeping. CBT increases ones control over their unhelpful and inaccurate beliefs and enables them to replace them with more helpful and accurate beliefs (Whitworth, Crownover, and Nichols, 2007).CBT also addresses the behavioral components of ones sleep routine or patterns that interfere with ones ability to obtain restful sleep. Exercising, smoking, or drinking caffeinated drinks just prior to bedtime can interfere with ones sleep. All of these activities are stimulants that energize the body. Also, not having a bedtime routine, a regular sleep-wake pattern, or taking naps may interfere with ones ability to get restful sleep. Increasing ones sleep hygiene by developing positive habits that influence sleep such as, having a bedtime routine to prepare ones mind and body for sleep, regular exercise several hours before one intends to prepare for sleep, and avoiding coffee, alcohol, and smoking in the evening, as well as, incr easing activities that produce relaxation (e.g., taking a hot bath one to two hours before going to bed, meditation, deep breathing, or muscle relaxation) can increase the likelihood of obtaining restful sleep. Another behavioral strategy utilized in CBT is sleep restriction. This technique attempts to match ones actual sleep requirement with the amount of time one spends in his/her bed. The theory behind this approach is that reducing the amount of time spent in bed without sleep will increase ones desire to sleep (Harvey, Ree, Sharpley, Stinson, and Clark, 2007).Results of a study by Vitiello showed that treatment improves both immediate and long-term self-reported sleep and pain in older patients with osteoarthritis and comorbid insomnia without in a flash addressing pain control (2009). This study included 23 patients with a mean age of 69 years were randomly assigned to CBT, while 28 patients with a mean age of 66.5 years were assigned to a stress management and wellness contr ol group. Participants in the control group reported no significant improvements in any measure while Individuals treated with CBT reported significantly decreased sleep latency (onset of sleep) by an average of 16.9 transactions and 11 minutes a year after treatment. Interruptions in sleep after sleep onset decreased from an average of 47 minutes initially to an average of 21 minutes after one year. Pain symptoms improved by 9.7 points initially to 4.7 points. Sleep efficacy (how rested does the person feel upon awakening) initially increased by 13 percent and 8 percent a year after treatment. The improvements remained robust in 19 of 23 individuals at a one-year follow up visit.Furthermore, while many older adults experience insomnia, it is reported that up to two-thirds of those who experience these symptoms have limited knowledge regarding available treatment options. Sivertsen (2006), conducted a randomized controlled trial to compare the efficacy of non-benzodiazepine sleep medications with CBT. This study included 46 patients with a mean age of 60.8 years who were diagnosed with chronic primary insomnia. Participants were randomly assigned to every the CBT intervention (information on sleep hygiene, sleep restriction, stimulus control, cognitive therapy, and progressive relaxation), sleep medication (7.5 mg zopiclone each night), or placebo medication. Treatment lasted 6 weeks, and the CBT intervention and sleep medication treatments were followed up at 6 months. Data regarding total wake time, total sleep time, sleep efficiency, and slow-wave sleep was collected utilizing sleep diaries, and polysomnography (PSG monitors physiological activity during sleep). Results revealed that total time spent awake improved significantly more for those in the CBT group compared to the placebo group at 6 weeks and the zopiclone group at both 6 weeks and 6 months. In comparison, the zopiclone group did not reveal significant results from the placebo group (Sivertsen , 2006). The CBT group experienced a 52 percent reduction in total wake time at 6 weeks compared with 4 percent and 16 percent in the zopiclone and placebo groups respectively. A statistically and clinically significant finding was that participants receiving CBT improved their PSG-registered sleep efficiency by 9 percent at posttreatment, opposed to a decline of 1 percent in the zopiclone group. measure sleep time increased significantly between 6 weeks and 6 months for the CBT group. The zopiclone group showed improvements at 6 weeks and maintained these improvements at 6 months, but did not show further improvements. The CBT group showed significant improvements compared to the zopiclone group in total wake time, sleep efficiency, and slow-wave sleep total sleep was the only area that did not yield a significant difference (Sivertsen, 2006).ADAPTING CBT TO THE PALLIATIVE CARE SETTINGOverview of CBT in Palliative CareCognitive-behavioral therapy is effective for many of common me ntal health issues seen in palliative care and often augments the success of pharmacological interventions. In addition to the individual with the terminal illness, their family members, as well as multiple health providers are considered integral members to the success of the collaborative relationship. Use of a CBT case conceptualization framework and various components offer flexibility, which makes the CBT approach feasible to implement within a palliative care setting. The following section provides an overview of the components of cognitive-behavioral therapy and necessary adaptations to palliative care settings.Collaborative RelationshipAs mentioned in previous chapters in this book, a collaborative relationship is a core component of an effective cognitive-behavioral intervention. In a palliative care setting, the collaborative relationship often involves more than just the client and the therapist. The interdisciplinary treatment team works with the individual to develop an individualized treatment plan that is central to the case conceptualization and goal setting of CBT. A variety of disciplines, such as nursing and social work, use CBT techniques in palliative care settings. Individuals receiving palliative care often need avail with CBT interventions as their illness progresses. Individuals receiving palliative care often need assistance from the treatment team with practicing skills, such as relaxation techniques, and adapting CBT interventions as goals of care change.Some individuals in the Palliative Care setting may not be facing death in the near future, and if they are facing impending death, they may not be aware of it. In these cases the primary patient may be the family member or significant other. It is also common practice for most individuals to seek help for mental health problems from their family practitioner even though the typical family practitioner has very little training in psychiatric/mental health assessment, diagnosis and treatment. In cases where the family is relying on an under-trained health care provider it may be incumbent upon the mental health provider to negotiate the suspension between family and medical care.Case Conceptualization and Goal SettingTherapy with the dying person should begin with having the person identify, explore and determine outcome goals regarding the issues at hand. Similarly to the primary care setting, case conceptualization and goal setting need to occur almost immediately. The therapist uses the Socratic Dialogue to explore the persons concerns and worries. This gives the individual more of a sense of control over what will be happening in the therapy session. Once this sense of control is established it becomes easier to explore other, more emotion laden topics.Goals should be small, obtainable and proximal to the session to be most effective. For example, Mrs. Jones I will be back to see you tomorrow. One of the things you have fixed to practice is your deep bre athing at least twice tonight and again in the morning. When I return I will check with you to see how you are doing with the practice. In palliative care setting, it may be necessary to discuss how other people involved in care can assist with reaching goals. For example, nurses might remind individuals to practice relaxation strategies during wakeful periods, as well as talk an individual through the relaxation technique when experiencing a high level of pain.Behavioral InterventionsPleasant Events Scheduling. Activities scheduling is a useful intervention to assist with mood disorders, pain management, and sleep hygiene issues seen in a palliative care setting. Engaging in pleasant events distracts an individual from negative thoughts and provides experimental evidence to support more adaptive thinking styles. Often times in palliative care the first barrier to overcome is identifying pleasant events that can occur in a palliative care setting due to health limitations. Pleasant events need to be person-centered, meaningful, and feasible activities that can be built into a daily routine.Meaningful pleasant events can be identified through both clinical interview and self-report methods. Clinical interview queries should include taking a history of an individuals daily schedule and identify activities the individual enjoyed amiable in on a routine basis prior to their illness. From the generated list of previously enjoyed pleasant events it needs to be determined which activities the individual can elapse to enga