End of life and ACT

What do we mean by end of life?

In the context of acceptance and commitment therapy (ACT) or psychological practice, “end of life” typically refers to the period of time leading up to an individual’s death. This could encompass the physical, emotional, psychological, and social experiences and challenges they face as they approach the end of their life. It might also include the time when an individual is dealing with a terminal illness, or their life expectancy is limited due to medical or natural circumstances.

For practitioners, working with clients in their end-of-life phase often involves helping them find meaning, connection, and peace in their remaining time. It can include supporting them to process their emotions, come to terms with their mortality, and identify what matters most to them. Within the ACT framework, this work often focuses on helping clients live in alignment with their values, even in the face of pain or uncertainty, and finding ways to accept what cannot be changed.

How do people approaching end of life often feel when they attend therapy?

When individuals come to therapy at the end of life, they are often experiencing a complex and deeply personal mix of emotions, thoughts, and concerns. While everyone’s journey is unique, there are recurring themes and feelings that tend to emerge during this profoundly challenging time. Understanding these can help practitioners provide compassionate and effective support.

Common emotional and psychological experiences

• Fear and anxiety: Many individuals feel fear about the unknown, including what happens after death, the process of dying, or leaving loved ones behind. They may also experience anxiety about physical pain, loss of independence, or how their loved ones will cope after they’re gone.
• Grief and sadness: Grief is common, not only for the loss of life but also for the loss of future dreams, relationships, and roles. Individuals may mourn the life they had or regret not having more time to accomplish certain goals. Sadness about leaving loved ones and missing out on future moments (e.g., seeing children grow up) often surfaces.
• Regret or guilt: Some people reflect deeply on their lives and may feel regret about certain choices, missed opportunities, or unresolved conflicts. Guilt about past actions or the impact of their illness on loved ones can also weigh heavily on their minds.
• Anger or frustration: Anger may arise as individuals come to terms with their mortality. They might feel frustrated about the unfairness of their situation, the limitations imposed by illness, or the loss of control over their lives.
• Isolation and loneliness: Even with loved ones around, many people feel isolated in their experience of dying. They may believe that no one truly understands what they’re going through. Physical limitations or being confined to a hospice or hospital can also contribute to loneliness.
• Search for meaning: As individuals confront their mortality, there is often a deep desire to find meaning in their lives and their current experience. They may question what their life has stood for, what legacy they will leave behind, or how to make their remaining time meaningful.
• Acceptance and peace: For some, especially those who have had time to process their situation, there may be feelings of acceptance or even a sense of peace. This often comes from aligning with their values, resolving conflicts, or finding closure in relationships. However, this stage can be fleeting and may coexist with other emotions.

Why they seek therapy

People at the end of life often come to therapy because they are struggling to cope with these overwhelming emotions, or they feel stuck in patterns of fear, regret, or despair. They may seek therapy to:

• Process their emotions: To talk openly about their fears, sadness, or regrets in a safe space.
• Find meaning: To explore their legacy and connect with what matters most to them.
• Strengthen relationships: To resolve conflicts or reconnect with loved ones.
• Cope with suffering: To find ways to manage emotional or physical pain and improve their quality of life.
• Prepare for death: To come to terms with their mortality and feel at peace with their journey.

Therapists working with individuals at the end of life often play a critical role in helping them navigate these challenges. Using approaches like ACT, practitioners can support clients in embracing their emotions, clarifying their values, and finding meaning and connection in their remaining time.

Ways that ACT therapy can support people at end of life

Acceptance and commitment therapy (ACT) can offer profound support to individuals at the end of life. By focusing on acceptance, values, and mindfulness, ACT helps people navigate the emotional, psychological, and existential challenges that arise during this time.

Here are some ways ACT can support individuals at the end of life:

• Embracing emotions rather than suppressing them: ACT encourages individuals to acknowledge and make space for painful emotions such as fear, sadness, grief, or regret, rather than trying to suppress or avoid them. This can reduce the struggle with these emotions and allow the person to focus their energy on what matters most in their remaining time.
• Supporting relationships and connection: ACT emphasises living in alignment with values, and for many people, relationships are a central part of this. Practitioners can help individuals nurture meaningful connections with loved ones, express gratitude, or resolve conflicts as part of their end-of-life journey. Other values might include leaving a legacy, creating meaningful experiences, or finding peace. By identifying and acting on these values, individuals can find purpose and connection even in their final days.
• Managing physical discomfort and limitations: While ACT does not address physical pain directly, it can help individuals respond more flexibly to the emotional and psychological aspects of physical suffering. For example, mindfulness and acceptance techniques can help reduce the struggle with pain, allowing individuals to focus more on what they care about. Mindfulness techniques also help individuals stay in the present moment. This can be especially powerful at the end of life, as it allows people to savour meaningful interactions despite their limitations, letting them connect deeply with loved ones, and experience moments of peace amidst the uncertainty.
• Reducing the struggle with mortality: Many individuals confront existential fears and thoughts about death at the end of life. ACT supports them in accepting the reality of their mortality, while also helping them shift their focus to living fully in the time they have left, rather than being consumed by fear or regret. End-of-life often involves a process of letting go, whether of relationships, roles, or the future they had envisioned. ACT helps individuals work through this process by encouraging acceptance and self-compassion, and by helping them to focus on the aspects of life they can still engage with meaningfully.
• Legacy and meaning-making through compassion: ACT supports individuals in reflecting on the legacy they wish to leave behind and how to create meaning in their remaining time. This might involve conversations about how they want to be remembered, engaging in creative or relational activities, or considering the positive impact they have already made. This can help them reframe their identity in a way that transcends their illness or limitations. Rather than seeing themselves only as a “patient” or someone “dying”, they can reconnect with a broader sense of who they are, focusing on their values, life story, and the impact they have had on others.
• Empowering choice and autonomy: Even at the end of life, ACT emphasises the importance of choice. By focusing on values and committed action, individuals can make empowered decisions about how they spend their time, ensuring that their final days align with what truly matters to them.

ACT offers a compassionate, flexible framework for working with individuals at the end of life, helping them navigate this profound transition with dignity, meaning, and connection. It’s about acceptance of the things they cannot control, while empowering them to take action in areas they can, all in alignment with their values.

For individuals:

If you are facing end of life and struggling to cope with overwhelming emotions, our ACT trained therapists are here to support you.

For professionals:

If you would like to learn more about how to use ACT to support people during end of life take a look at our current training courses. We also offer free resources or further insight on our blog.

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