People with common medical disorders who visit their primary care physicians have high rates of behavioral health concerns, including diabetes, chronic pain, obesity, sleep disorders and heart disease. Obesity is one of the biggest drivers of preventable chronic diseases and health care costs in the United States. Currently, estimates for these costs range from $147 billion to nearly $210 billion per year. The annual cost of chronic pain is estimated to be as high as $635 billion a year, which is more than the yearly costs for cancer, heart disease and diabetes.
Clearly, there are far more serious outcomes and higher health care costs if these problems aren’t addressed in a unified way. This is where counselors can play a very important role. Consider the following scenario.
Alfonso, a 36-year-old Hispanic male, was referred to you for counseling for depression. He has had increasing depression for the past 10 years. He reports a history of severe physical and emotional abuse from both parents when he was young. He is unmarried, has no close relationships and says, “I always feel alone.” He has no suicidal thoughts or plans, but he describes feelings of hopelessness, lack of energy and thoughts of discouragement and despair. He has been on antidepressant medication for seven years and says it “helps a little.”
Alfonso is 5 feet 10 inches tall and weighs 310 pounds. This equates to a body mass index (BMI) of 44.5 (a BMI of 30 or greater is considered obese). He ingests a large amount of fast food each day. Alfonso previously worked in construction but noticed that even with his active job, he was frequently “dog-tired” all day long and felt like he would “just love to sleep.” His average total sleep time is four to five hours per night.
About three years ago, Alfonso fell on his job site and injured his lower back. He has had several back surgeries but claims that they “didn’t help at all.” He reports still feeling moderate to severe pain every day. He is currently taking oxycodone, an opioid pain medication, at 15 milligrams every six hours and is on long-term disability.
Alfonso has no hobbies or interests, and because he is not currently working, he spends most of each day watching television and drinking beer. By his estimate, he drinks “six to eight beers a day.” He is not a smoker and says that he does not use other drugs.
During your initial interview with Alfonso, he appears very tired and generally unmotivated for treatment. He asks, “Why am I seeing a counselor and not a real doctor?” He appears to have average intelligence but very little insight into how his health problems may be affecting his depression and his life in general. He feels very little control over his health and thinks that he just needs “some new medicine” to help him.
The biopsychosocial perspective
How many times have you seen clients such as Alfonso and gotten so involved in their abuse histories, psychological issues and diagnoses that you ignored the obvious? Sometimes the “mental health” or “psychosocial” view of counseling gets in the way of assessing the biopsychosocial aspects of our clients. (For more information on the biopsychosocial perspective developed by George Engel and John Romano, see tinyurl.com/mcqdyqb.)
If you see clients privately or at any facility, you are bound to encounter people with stories similar to Alfonso’s. Although his scenario may seem exaggerated, the reality is that behavioral health problems often have a substantial impact on clients.
Consider the following facts and figures.
Sleep: According to the National Sleep Foundation’s inaugural Sleep Health Index, 45 percent of Americans report disrupted sleep patterns that have negatively affected their daily life over the past seven days. Some of the study’s biggest takeaways: Among 74,571 adult respondents in 12 states, 35.3 percent (more than 26,000 people) reported getting less than seven hours of sleep during a typical 24-hour period; more than 35,000 reported that they snored; and almost 29,000 reported falling asleep during the day at least once over the past month. More than 3,500 respondents acknowledged either drifting off or falling asleep while driving.
According to Harvard Medical School, chronic sleep problems affect 50 to 80 percent of patients in a typical psychiatric practice and are particularly common in patients with anxiety, depression, bipolar disorder and attention-deficit/hyperactivity disorder. Chronic sleep problems may raise the risk for, and even directly contribute to, the development of some psychiatric disorders.
Pain: Nearly 50 million American adults have significant chronic pain or severe pain, according to The Journal of Pain. New research suggests that people who have chronic pain are also more likely to suffer from problems such as depression, anxiety, lack of sleep and trouble focusing.
Obesity: According to the annual report The State of Obesity, a project of the Trust for America’s Health and the Robert Wood Johnson Foundation, 35.7 percent of U.S. adults are considered to be obese, and more than 1 in 20 (6.3 percent) have extreme obesity. For
state-by-state data, see stateofobesity.org/adult-obesity.
Obesity is frequently accompanied by depression. In fact, the two can trigger and influence each other. Although women are only slightly more at risk than men for being obese, they are much more vulnerable to the obesity-depression cycle. In one study, obesity in women was associated with a 37 percent increase in major depression, according to the American Psychological Association. There is also a strong relationship between obesity in women and more frequent thoughts of suicide. For more information on this research, see cdc.gov/nchs/products/databriefs/db167.htm.
Given the findings in each of these areas, it is vitally important for counselors to have the tools available to help their clients thrive. Returning to the scenario of Alfonso, we will see how integrated behavioral health care can bring more clarity to his situation.
Best office practices
This is my toolbox of practices that I have found most useful with clients.
Motivational interviewing: Motivational interviewing is loosely defined by the Motivational Interviewing Network of Trainers as “a particular kind of conversation about change.” It refers to a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. Motivational interviewing is nonjudgmental, nonconfrontational and nonadversarial. For integrated care, this style of interviewing has many benefits, including instilling hope, confidence and action in our clients. It empowers clients to take a more active role in their health, far removed from the passivity that the usual “doctor’s advice” elicits.
I use motivational interviewing techniques daily in both my office and in hospital settings. I have found them to be very useful for helping clients reduce ambivalence and take more responsibility for important behavior changes. The main goals of motivational interviewing are to engage clients, elicit change talk and evoke motivation to make positive changes from clients. For example, change talk can be elicited by asking the client questions such as “How might you like things to be different?” or “How does ______ interfere with things that you would like to do?”
The spirit of motivational interviewing can be summarized as follows:
1) Motivation to change is elicited from the client and is not imposed from outside forces.
2) It is the client’s task, not the counselor’s, to articulate and resolve the client’s ambivalence.
3) Direct persuasion is not an effective method for resolving ambivalence.
4) The counseling style is generally quiet and elicits information from
5) The counselor is directive in that he or she helps the client to examine and resolve ambivalence.
6) Readiness to change is not a trait of the client but rather a fluctuating result of interpersonal interaction.
7) The therapeutic relationship resembles a partnership or companionship.
The four general processes involved in motivational interviewing are:
1) Engaging: Used to involve clients in talking about issues, concerns and hopes, and to establish a trusting relationship with the counselor.
2) Focusing: Used to narrow the conversation to habits or patterns that clients want to change.
3) Evoking: Used to elicit client motivation for change by increasing clients’ sense of the importance of change, their confidence about change and their readiness to change.
4) Planning: Used to develop the practical steps that clients want to use to implement the changes they desire.
For more information, go to motivationalinterviewing.org.
The role of self-monitoring: Self-monitoring is an important technique in all of the areas this article discusses because it a) gives clients the responsibility to actively observe and record their behavior, b) makes clients more aware of the effects of interventions on the variable being monitored and c) puts clients more in control.
There is strong research evidence that the mere act of self-monitoring and recording can significantly change behavior. In my practice, I always find something for the client to track (behaviors, thoughts or emotions) on a regular basis. As is the case with motivational interviewing, this gives more of the responsibility for behavior change to the client.
Measuring self-efficacy: Albert Bandura’s concept of self-efficacy can be applied quite well to clients who need to focus on changing some important aspects of their behavior, including exercise, smoking, alcohol use, sleep management and behavior changes, to reduce pain.
Self-efficacy refers to the degree to which a person feels confident, effective and successful in managing his or her health or life. My contention is that motivational interviewing should increase a client’s self-efficacy, so I often use the simple measure shown below (in the box below) to track the client’s motivation, confidence and readiness to change. I frequently request that the client fill this out on a daily basis for two weeks.
Results from this scale can provide a realistic benchmark of client progress and can be shared with other members of the behavioral health care team.
Sleep problems are often the most common symptoms that clients discuss with their primary care physicians. Optimal sleep duration for adults of all ages is 7.5 to 8.5 hours per night. Adolescents need a bit more and older adults a bit less. The average American adult gets only about six hours of sleep per night.
Poor sleep can be a result of any combination of physical conditions, psychological disorders, work shift changes or poor sleep habits. People who are sleep deprived may have profound daytime sleepiness and often fall asleep immediately when they go to bed.
Integrated health care team: Sleep disorders center, primary care physician, counselor
Alfonso’s view: We already know that Alfonso estimates his sleep at four to five hours per night. He admits to profound daytime sleepiness and feels “tired all the time.” He doesn’t understand the causes of his poor sleep.
Assessment for Alfonso: Many clients presenting with depressive or anxiety disorders have coexisting sleep issues that can easily make their symptoms worse. Alfonso might have insomnia, partly because of his depression or pain, or he might have obstructive sleep apnea (OSA), which is often related to being overweight or obese. In fact, sleep apnea has been observed in as many as 95 percent of obese males. A complete sleep study should be performed for Alfonso.
I always ensure that clients are screened for OSA prior to further intervention. If no OSA is present, it is important to ask these clients a few general questions about their sleep patterns, such as how long they sleep on the average night, whether they feel rested during the day and if they are concerned about sleep. Sleep problems are not that obvious, so it is always important to ask about them, especially during your initial evaluation with clients. Sleep problems can be either a cause or an effect of other biopsychosocial conditions.
To pursue this further, you might suggest that clients keep a simple sleep log. Have them keep daily records of these sleep-related events for one week:
1) Physical exercise (type/duration/timing)
2) Naps (number and total time)
3) Medication for sleep (drug and amount)
4) Time they went to bed
5) Minutes to fall asleep
6) Number of awakenings
7) Wake-up time
8) Total hours asleep
9) Sleep quality rating (on a scale of 0-10, with 0 being the worst possible and 10 being the best possible)
10) Daytime alertness rating (on a scale of 0-10)
11) Obsessing about sleep (on a scale of 0-10)
Potential interventions: After obtaining Alfonso’s data for a week or more, go over it with him, paying particular attention to challenging areas. The most important part of this intervention is to educate Alfonso regarding some rules of healthy sleep, including continuing to self-monitor his sleep, reducing his caffeine and alcohol use, maintaining a regular sleep schedule, increasing his physical activity (especially later in the day), controlling his sleep environment and taking some time to “unwind” his brain in the evening. In addition, the most popular evidence-based intervention for this issue is cognitive behavior therapy for insomnia (for more information, see sleepfoundation.org/sleep-news/cognitive-behavioral-therapy-insomnia).
It can sometimes be difficult to identify if clients are having sleep problems, but clients with chronic pain are usually much more forthcoming and their issues with pain are obvious. Acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself, but chronic pain is different. Chronic pain persists — pain signals keep firing in the nervous system for weeks, months or even years. This kind of pain often continues well after the normal healing time for any injury or tissue damage that might have occurred.
Chronic pain can be mild or excruciating, episodic or continuous, merely inconvenient or totally incapacitating. The clients we see as counselors are much more likely to have chronic pain. Research suggests that 40 to 50 percent of chronic pain clients suffer from depressive disorders.
In his important analysis, Dr. John Loeser described the four major components of pain: nociception, pain, suffering and pain behaviors. Nociception is the sensory process that provides the signals that lead to pain. This occurs through nociceptors, which are primary sensory neurons that are activated by stimuli that cause tissue damage. Pain, as described by the International Association for the Study of Pain, is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”
It is suffering, not pain, that brings patients into doctor’s offices in hopes of finding relief. Chronic pain is far more than a sensory process, however, so we must maintain the biopsychosocial model of chronic pain if we are to provide effective health care to our patients and clients. Pain behaviors may communicate to others that a person is experiencing pain. These behaviors include resting, shifting positions, guarding, grimacing, asking for help, taking medication and other observable behaviors.
As Loeser has pointed out, every client with chronic pain may be unique in his or her presentation. For instance, many chronic pain sufferers demonstrate pain behaviors without having any physical findings of tissue damage. There are also many cases of people who show pain and suffering without nociception (for example, phantom limb pain).
In the case of chronic pain, many studies have shown that gradual increases in physical activity can actually improve a person’s functioning and reduce his or her pain.
Integrated health care team: Pain physician, physical therapist, primary care physician, counselor
Alfonso’s view: Since his injury, Alfonso has undergone several surgeries to his lower back with no apparent benefit. He feels moderate to severe pain “all the time.” Opioid medication and rest seem to be the only things that help. Alfonso is very inactive and isolated and has “nobody to talk to.”
Assessment for Alfonso: Because it sounds like Alfonso has chronic benign pain, it is important to observe him closely as you talk with him. Does he grimace, shift positions, guard parts of his body or look uncomfortable?
Have Alfonso self-monitor his daily pain levels over the next week or two. Does he show variations in that level at different times of the day or during various activities?
You might also have Alfonso assess his level of self-efficacy. A high level of self-efficacy is beneficial when people are confronted with acute or chronic pain. One reason for this is that individuals who are highly self-efficacious may be more motivated to engage in health-promoting behaviors and adhere better to treatment recommendations because they have higher expectations of performance success. They are also less likely to give up an activity when facing barriers (e.g., pain), which may prevent them from becoming trapped in the negative spiral of activity avoidance, physical deconditioning, loss of social support and depression. Finally, perceived self-efficacy can positively affect the body’s opioid and immune systems.
Potential interventions: Given that Alfonso received no benefit from surgery and is stuck on fairly high doses of opioid pain medications, you might consider several options for psychosocial interventions. Weight loss often helps people with pain, so this might be an early goal. You might suggest a strategy to help Alfonso slowly increase his physical activity, perhaps including use of a wearable activity monitor. You could also work with his pain physician to develop a schedule of gradual “fading” or reduction of Alfonso’s opioid drugs, accompanied by training Alfonso in muscle relaxation, imagery and cognitive behavioral strategies for pain reduction. You can assist the health care team by suggesting nonmedical approaches.
Obesity may be the most important focus of attention in Alfonso’s complex case. We have seen that obesity affects sleep dramatically, and extra weight only makes pain problems worse. Given that all three of these problems contribute directly to depression, it is important to select one issue for intervention.
Integrated health care team: Bariatric physician, primary care physician, dietitian, counselor
Alfonso’s view: Alfonso shows little concern about his weight, claiming that he comes from a “fat family.” His sedentary habits and consumption of fast food and beer can be important targets here.
Assessment for Alfonso: Asking Alfonso to keep a journal of his eating and exercise patterns would be a reasonable starting point. Weekly monitoring of weight is also important.
Potential interventions: Motivational interviewing is a very powerful tool for discussing areas of change. In Alfonso’s case, this might include taking small steps toward healthier eating and increasing his level of exercise. Because of Alfonso’s isolation, simply developing a helping relationship with him may be beneficial in and of itself.
Putting it all together
Clients who present with primary psychological problems and issues often have underlying behavioral health problems that may have an effect on their psychological functioning. Using the biopsychosocial model, it is possible to identify those problems and offer focused counseling that involves motivational interviewing, client self-monitoring and assessment of self-efficacy.
In Alfonso’s case, there were many areas of concern — obesity, sleep problems, pain, social isolation and alcohol/drug misuse — that could be improved through counseling. Regardless of the complexity of the case, these areas are always worth exploring carefully.
Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.
David Engstrom is a board-certified health psychologist in Scottsdale, Arizona. He trained and supervised counselors and counseling psychologists for 20 years at the University of California, Irvine. Currently, he is a full-time core faculty member in counseling at the University of Phoenix, where he teaches integrative health care, motivational interviewing and mindfulness meditation techniques to counseling students. Contact him at email@example.com.
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