Dear Editor, Re: Time to Recognize End-of-Life Traumatic Stress Disorder (JPM Vol 11 No 7, 2008 Gil Porat, MD)

) Gil Porats heart is in the right place when he writes about our responses to family and patient grief but I am concerned about his proposed response, in formulating an End of Life Traumatic Stress Disorder. If we assume that families and patients degree of distress is likely to show a (kind of) normal distribution, then it follows that some people will exhibit high levels of distress, irritability and other symptoms - whereas others will be more relaxed, controlled and not hyperaroused. The key is how we choose to respond to these people; particularly those who present us with more pronounced distress that sometimes is described as crazy, difficult, or unrealistic. These individuals may require more input, and as Porat suggests in his example, lengthy discussion is helpful. But I am concerned that the use of a diagnosis (ETSD) in this area would not necessarily encourage the empathic communication that is needed. My view of people who show more pronounced signs of distress is that they need more a more empathic approach; one that acknowledges and validates their individual experience, making them feel understood (Clark, 1991) This creates a relationship that is reassuring for them, and less difficult for us. I remember a patients wife being described to me as a controlling, blunt woman yet, when I met her, I very quickly recognized that she was scared, frustrated, and needed to be listened to. She was indeed blunt and sometimes challenged people, including me but this was in no way pathological. It was a valid response to a major stressor. As Porat admits, it should be expected. However, he goes on to suggest that, if we identify these reactions as a disorder, then more effective forms of treatment might emerge as a result of research. He also suggests that healthcare professionals might communicate more effectively using helpful language. I think the real solution should be more radical that people involved in end-of-life care should be encouraged (even trained) to separate their own feelings from those of the people they deal with. Effective communication comes much more naturally if we really try to understand (empathise with) someone elses experience. There is a wealth of literature on the pros and cons of diagnostic labelling. Its interpersonal, political and philosophical implications, particularly in the psychiatric field, are widespread. Labelling (explicit or implicit) has a dramatic effect on how we treat people as human beings (Laing 1967, Steiner 1985). Thinking about ETSD, we run the risk of pathologizing the experience of people suffering real distress who need an empathic response from us. Ian Argent, BSc (Hons), MSc (TA Psych), CTA (P), Dip. Psychotherapy Transactional Analysis Psychotherapist

Laing, R. D. (1967). The politics of experience. New York: Ballantine. Steiner, C (1985) Principles of Radical Psychiatry. In Handbook of Innovative Psychotherapy, Corsini (ed), Wiley Clark, B. D. (1991). Empathic Transactions in the Deconfusion of Child Ego States. Transactional Analysis Journal, 21, 92-98