Tag Archives: chronic illness

Rebuilding after brain injury

By Bethany Bray May 31, 2022

“I just want to feel useful again, like I have some purpose.”

“I just want to know is there anything I can do?”

“I just want to know I’m not going crazy.”

“I want to be happy again, have friends again and feel satisfied in relationships.”

These are among the heartbreaking responses Herman Lukow, a licensed professional counselor (LPC) and licensed marriage and family therapist, receives from clients who have experienced a traumatic brain injury (TBI) when he asks what they want and need from counseling.

Individuals who have experienced a TBI often find themselves facing change and challenge in nearly every aspect of life. Depending on the severity of the injury and their recovery trajectory, TBI survivors can experience memory loss, personality changes and difficulty with language, comprehension, impulsivity, anger and decision-making. This is in addition to physical issues such as having challenges with balance, coordination and mobility. Individuals with a TBI may no longer be able to work in the field or job they once had. They may lose the independence to do things such as drive a car, and their friends and loved ones may struggle — or even give up on — maintaining a relationship with this new, changed person.

These clients might come to counseling after experiencing a hospitalization and lengthy rehabilitation process involving countless appointments with a variety of medical specialists. Brain injury survivors “are so steeped in the medical environment,” Lukow says, that they’re used to practitioners telling them what to do. Professional counselors can be the first to flip that narrative and ask the client what they want and need.

Lukow, who spent three years as a postdoctoral fellow researching TBI at Virginia Commonwealth University’s (VCU’s) Traumatic Brain Injury Model System program, says he has had clients break down in tears because he was the first professional to ask them about their wants and needs since their injury.

A professional counselor can be the one to “honor what they want and empathize with them and help them understand this huge shift in their life that has occurred in a blink of an eye,” Lukow says. “This work takes a lot of patience, a lot of reframing. But some of my most appreciative clients have been TBI survivors.” In counseling, “they’ve finally found someone who doesn’t make them feel like a burden or judged.”

A difficult road

The Centers for Disease Control and Prevention estimates that on any given day, roughly 176 people die and 611 people are hospitalized in the United States because of a TBI.

The Brain Injury Association of America (biausa.org) defines TBI as an “alteration in brain function, or other evidence of brain pathology, caused by an external force.” One of the most common causes is falls, but TBI can also result from motor vehicle accidents, sports/recreation or workplace injuries, child abuse or intimate partner violence, blast injuries during war or disaster, or acts of violence such as assault or gunshot wounds. Nontraumatic (or acquired) brain injury can occur from a stroke, seizure, meningitis, lack of oxygen, exposure to toxins, pressure from a tumor, drug overdose and other scenarios.

Research suggests that certain populations are more likely to be affected by TBI, including veterans and members of the military, racial and ethnic minorities, survivors of intimate partner violence, those who live in rural areas and people who have experienced incarceration or homelessness. According to a recent article published in JAMA Network Open, it’s estimated that between 9% and 28% of U.S. soldiers who served in the conflicts in Iraq and Afghanistan experienced a TBI.

Not only do the causes and severity of brain injury vary, but each survivor will also have a different recovery trajectory and array of symptoms depending on which areas of the brain were affected, the person’s age, the support and treatment they received during recovery, and numerous other factors.

TBI “is anything but cookie-cutter,” stresses Michelle Bradham-Cousar, a licensed mental health counselor and certified rehabilitation counselor who recently completed a doctoral dissertation on counseling clients with TBI.

Not only will these clients’ needs and presenting concerns differ, but their therapeutic expectations, outcomes and what can be counted as “successes” will also vary, says Bradham-Cousar, who has a private counseling practice in Tampa, Florida. For one client, success may be returning to work full time; for another, it may be learning to calm down to keep from getting into fights with other residents of their group home (as was the case for one of Bradham-Cousar’s TBI clients).

“Success needs to be measured differently for each client — and it won’t look the same as your last client” with TBI, she emphasizes.

Lukow agrees, noting that benchmarks or signs that counselors may associate with improvement or growth in their other clients may not be apparent — or appropriate — with clients who have experienced a brain injury. Also, what might seem to be resistant behavior in this client population is often not intentional, he stresses. They may miss sessions or be hard to contact, but this is more likely to be caused by the memory and cognitive challenges they live with (e.g., confusing what day it is) rather than resistance.

Bounce forward

People who have experienced a brain injury will often hear well-meaning friends, family members, caregivers and even medical and other practitioners reference “bouncing back” when talking about their recovery. Lukow urges counselors to avoid using the phrase “bounce back” with these clients because there is no way for them to fully return to the life they had before their brain injury. Not only is such language unhelpful, but it can also give the recipient a sense of false hope.

Lukow instead uses the phrase “bounce forward” with his TBI clients. “In many cases, they can’t go back; they can only bounce forward,” says Lukow, who lives in Tennessee and works remotely as a staff counselor at a private practice in Williamsburg, Virginia.

Although these clients can’t go back to the way things were prior to their injury, they can work to move forward and make the most of their life with impairments through the support they receive and the skills they learn in counseling, Lukow says.

And these clients don’t always want or need encouragement, Lukow adds. At times, TBI clients may feel that the work they’re doing in counseling sessions only emphasizes what they have lost.

“Don’t always be a cheerleader,” Lukow urges. “Sometimes they don’t need to hear ‘that’s alright, you’ll get through it’ [from a counselor], but instead, ‘that really sucks.’”

Lukow specializes in counseling clients who have experienced TBI. He estimates that 10% to 20% of his current client caseload is recovering from a brain injury. During his time as a researcher at VCU, he developed resilience-based interventions for mental health practitioners to use with couples and individuals after a TBI.

It’s not uncommon for individuals recovering from a brain injury to be told by medical personnel, rehabilitation specialists and others that recovery ceases after a few years. An often-repeated message is that the only gains a person will make after a TBI are those made in the first two years, he says.

Although that may be true for some of the physical aspects of TBI recovery, growth and progress in other arenas — especially the emotional and psychological aspects — can continue for years and even decades, Lukow says. He has seen TBI clients make strides many years after their injury, especially in coming to accept that they may never get some of their abilities back and will need to rely on aids, such as memory reminders, for the rest of their life. Learning and growth can also happen years later for clients related to their social skills and in responding to awkward questions and assumptions made by others. (Lukow explains that these situations occur because TBI is often an “invisible” injury and people misjudge or misunderstand the actions or challenges of survivors because they don’t look disabled.)

Hillel Goldstein, an LPC with a private counseling practice embedded within the Brain Injury Foundation of St. Louis, agrees that recovery can occur long after the period of intensive treatment TBI survivors receive immediately after their injury. Goldstein once counseled a client who developed aphasia (language difficulty) after a TBI. This client, with the help of a speech therapist, was still relearning and mastering new words 10 years after his injury, Goldstein recalls.

“The good news is that brain plasticity is much better than we once thought it was,” Goldstein says. “But people are still told that they have a year to improve or a limited time.”

Asking the right questions

Individuals can experience an array of symptoms and difficulties after a brain injury that dovetail with mental health or the client’s presenting concern in a wide variety of ways. Because brain injury varies from person to person and there is no one concise set of symptoms, professional counselors must know some of the more common symptoms (e.g., memory loss) and — perhaps, more importantly — how to ascertain whether a client may have experienced a brain injury in the past.

Brain injury is nuanced and complicated, and there is a good deal of misunderstanding about it among the general population, Lukow asserts. Clients may come into counseling without realizing that their presenting concern (such as trouble maintaining relationships) could be tied to an unacknowledged brain injury or one that happened in the past.

Lukow points out that a person wouldn’t necessarily have needed to be hospitalized or even received a blow to the head for a brain injury to have serious consequences. A car accident, for example, can cause a person’s head to move so forcefully that the brain impacts against the skull without the head touching any part of the car.

Or clients may not realize that brain injury can be cumulative (e.g., “I had a few concussions back when I played lacrosse …”) and affect them later in life, Lukow says. He advises counselors to ask clients not only if they have had any brain injuries but also whether they have experienced any related issues such as a loss of consciousness, cognitive difficulty, a head or sports injury, or a fall.

Bradham-Cousar, a clinical assistant professor in the Department of Counseling, Recreation and School Psychology at Florida International University, urges counselors to listen for client language that may indicate they have had head trauma, including phrases such as “concussion,” “woke up a little while later,” “unconscious,” “got stitches,” “car accident” and “slipped and fell.”

Past brain injury can cause behavior and other deficiencies that are hard to pinpoint or connect to a diagnosis or for which psychiatric medicine doesn’t seem to help. Bradham-Cousar  provides examples such as a person who has trouble understanding social cues but does not have autism spectrum disorder, someone who has reading difficulties but does not have a learning disorder, and someone who struggles with attention span and focus but does not have attention-deficit/hyperactivity disorder. In other examples, an individual may struggle with anger, self-control, problem-solving, object recognition or articulating what they’re trying to say and not realize that a past brain injury could be the root cause, she adds.

Goldstein advises counselors not to overlook issues that the client feels are “minor,” such as a concussion, because these could be contributing to their mental health challenges. Counselors should also be aware that in some cases, TBI can cause violent behavior or the urge to self-medicate with alcohol or other substances. So, Goldstein says, practitioners need to be comfortable screening for substance use and be familiar with the reporting protocol for their state in case a client discloses violent behavior (including when the client is a spouse or a family member of a TBI survivor).

TBI survivors sometimes turn to alcohol or other substances to temporarily escape or “slow down” from impulsivity and other challenges, Goldstein notes. However, “one drink for someone with TBI is not the same as it is for someone without [a brain injury]. Their symptoms will be amplified by any substance use, including alcohol,” he explains. “Brain injury and substance use don’t mix. It’s one of the worst things they can do to themselves, but it’s commonly seen among those with TBI.”

Complicating factors

The counselors interviewed for this article note that TBI can co-occur with common challenges that bring clients into counseling, most notably depression, anxiety and issues that correspond with loss and relationship problems. And sometimes there can be a chicken-and-egg debate about which of these issues came first, which adds a layer of complication for practitioners trying to assess and plan treatment for a TBI survivor in counseling.

For example, isolation, loneliness, and a loss of meaning and purpose — the classic markers for depression — are common after TBI and the related challenges that come with it, Lukow says. 

In these situations, Bradham-Cousar notes that depression is often a secondary diagnosis to a client’s TBI that becomes co-occurring.

At the same time, it’s not uncommon for TBI survivors to be misdiagnosed with a mental illness because some post-injury symptoms can mimic those associated with other disorders, Goldstein adds. Brain injury can cause people to experience hallucinations, hear voices or have severe personality changes, impulse control problems and erratic moods that can resemble mania. This can lead to diagnoses such as personality disorders, psychosis, bipolar disorder or even antisocial personality disorder, Goldstein says.

“I call it [TBI] the great imposter,” Goldstein says. “Mental health [symptoms] are only part of the story. Sometimes it’s the tip of the iceberg, and sometimes it’s not at all what’s going on.”

Because of this, Goldstein recommends that counselors begin work with each client by first ruling out brain injury as the root cause of their mental health challenges. He stresses not to automatically assume that a client’s symptoms are psychiatric in origin. When it comes to mental health diagnoses and TBI clients, false negatives and false positives are very common, he says.

This challenge can be compounded when a client doesn’t recognize or disclose that they’ve had a brain injury (e.g., a concussion that they weren’t hospitalized for), Goldstein says. It’s also likely that the practitioner who referred a client to counseling — whether a medical or mental health professional — hasn’t ruled out TBI as the root of the individual’s symptoms because the connection between brain injury and mental health is simply not on the radar of most professionals.

“Even if a client has a big fat DSM diagnosis, don’t assume, and keep an open mind,” Goldstein says. “I implore [counselors] to rule out brain injury, and even if you think you’ve ruled it out, revisit it. Don’t assume the person that you’re seeing, no matter how they were referred, has a mental health diagnosis.”

Goldstein recommends that in addition to conducting a thorough intake process, counselors screen clients for brain injury by asking for access to their medical records and the ability to confer with the other professionals they are being treated by, such as a neurologist.

“Keep your mind open, and consult, consult, consult with people who are experts in areas that can help you tease apart where these symptoms are coming from,” Goldstein says. “Don’t assume that what you’re seeing is due to a mental health disorder. Your default should be that their brain has been injured.”

Helping clients adjust to loss and change

The crux of what many clients who have experienced a brain injury need in counseling is help adjusting to change and processing loss. Most professional counselors already have an array of tools that can help in this realm, from coping mechanisms and goal setting to the therapeutic relationship itself. 

“Often, they need [empathic] listening from a counselor and a large amount of time just to talk about their situation, what they need and what they’re struggling with,” Lukow says.

Any counseling technique or method that builds coping skills or helps clients deal with life changes and loss would be appropriate and helpful to use with clients who have experienced TBI, Lukow notes. This population may also need grief counseling and help with managing emotions and improving communication and social skills. Seemingly small skills, such as being able to politely ask someone to slow down or repeat themselves when they are outpacing the client’s cognition abilities in a conversation, can go a long way to boost the person’s self-esteem, rebuild their relationships and, in turn, reduce isolation, Lukow says.

Stress recognition and management are also important skills for brain injury clients to learn, Lukow adds. Techniques such as diaphragmatic breathing, muscle relaxation, guided imagery and mindfulness, as well as activities such as walking or exercising, painting, coloring, and listening to white noise or ambient sounds, can help these clients learn to calm themselves.

“[Brain injury] survivors are ‘allergic’ to stress,” Lukow says. “When their stress gets worse, their impairments get worse.”

Occasionally involving a client’s spouse, partner or loved ones in individual counseling sessions can also be beneficial for both parties. They provide comfort and moral support to the client in session, Bradham-Cousar explains, and in turn are better able to understand the client’s needs and therapeutic goals. For TBI clients who struggle with memory challenges, having another person in session can also serve to provide them with reminders of what was said and what was assigned as homework.

TBI clients’ loved ones can also benefit from group counseling. The counselors interviewed for this article agree that the supportive environment that group counseling provides can be extremely helpful for this client population and their family/caregivers. (For more on this topic, read the article “Life after traumatic brain injury: Lessons from a support group.”)

Bradham-Cousar specializes in counseling clients who live with disabilities, including cognitive difficulties from a brain injury, stroke or dementia. A large part of what these clients need, she says, is therapeutic work to move them toward acceptance of the change in their lives, including the things they can no longer do. She often uses cognitive behavior therapy and a working

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alliance approach to foster trust with clients who are brain injury survivors and adjust their thought patterns and perspective. Counselors can also help the client see the opportunity to gain new skills; they’re not just losing things but gaining them as well, she says.

Grief counseling and psychoeducation about grief can also help this client population process the many losses they have experienced, including the loss of a part of themselves, Bradham-Cousar adds.

“Counselors can help these [clients] to grow and understand their regenerated self and look at it [through] the eyes of a new opportunity, a new chance. They still have a life to live,” says Bradham-Cousar, a past president of the Florida Counseling Association and the American Rehabilitation Counseling Association. “It’s a transformational process. … They need to move forward to accept that they’re not as they used to be.”

Similarly, Lukow finds that using a solution-focused approach, as well as equipping clients with coping mechanisms and skills that can boost their self-esteem and resiliency, is helpful for clients who have experienced brain injury. For instance, a counselor might suggest that a client who struggles with memory issues set up a “launch pad” — a spot in a visible area of the home, such as a kitchen counter, to keep their keys, wallet and other essential items they need when going out so that they’re less likely to forget or lose them.

Much of this work, Lukow says, is supporting clients as they navigate the learning curve of trying new skills, abandoning things that aren’t working for them and finding solutions and workarounds to live life.

For example, a TBI survivor who is unable to drive may struggle with this loss of independence and feel like a burden for having to ask for rides from others. A counselor can help the client process these feelings so that it’s easier for them to ask for help and find solutions that boost their self-worth.

One such solution could be supporting the client as they learn how to take the bus, Lukow suggests. “Help them find a [bus] schedule and look together, asking, ‘Which stop is closest to your house?’ ‘How much does it cost?’ etc. Something as little as looking up a bus schedule can be a success. And with it, a shift in thinking: ‘Yeah, I can’t drive anymore, but it doesn’t mean I can’t get around.’”

Goldstein notes that motivational interviewing can be useful in helping TBI clients to focus on adjusting to change. Influenced by Irvin Yalom and Viktor Frankl, Goldstein also uses an existential approach to guide clients to make meaning of their new circumstances.

This client population “is searching for new meaning in a hugely altered life. They need to construct new meaning, and it’s sometimes not the meaning that they were hoping to construct,” Goldstein says. “These folks need to adjust to ‘the new me.’ They’re forever changed. As with big changes in our lives that are negative, there’s grief, and if we don’t work through the grief, it metastasizes.”

Language workarounds 

Brain injury often affects a person’s ability to speak. Counselors who work with this population must be knowledgeable of and comfortable using adaptive technology or creative workarounds to communicate with clients who may not be able to respond verbally.

Bradham-Cousar sometimes uses a speech-generating app such as UbiDuo 3 with clients because it allows them to type responses to counseling prompts on a smartphone or other device. She also has an extra keyboard linked to a computer monitor in her counseling office for clients to use to type and display their thoughts during sessions.

Bradham-Cousar suggests that counselors use a collaborative approach by asking clients (during the intake process) to identify adaptive tools or supports they are comfortable using. Counselors can also find information on meeting these clients’ adaptive needs by searching for “brain injury” on the Job Accommodation Network’s website at askjan.org.

In addition to specializing in psychotherapy for brain injury, Goldstein’s subspecialty is helping clients with aphasia. He says that counselors need to be comfortable not only with using different modalities and tools to communicate with TBI clients who struggle with speech but also with long periods of silence in counseling sessions. This can be hard for some practitioners.

Goldstein urges counselors to become sensitive to the wealth of information communicated through a client’s body language and leverage what skills a client does possess. Remember, he says, that these clients have the same range of needs and emotions that verbal clients have; they know what they want to say, but it just won’t come out.

Goldstein sometimes uses a method he calls “facilitated therapy.” He invites another professional who is working with the client (such as a speech and language pathologist) to consult or co-treat with him or come to counseling sessions to serve as a mediator/facilitator until he has forged a bond with the client and learned to “speak their language,” even if it’s nonverbal.

This was the case for one client whose speech was severely limited after his brain injury. However, the client was a gifted artist and would draw pictures during sessions to communicate. When Goldstein began working with this client, he involved the client’s vocational rehabilitation counselor in sessions because she had been working with him for a while and understood the nuances in the way he expressed himself.

“He had his own language,” Goldstein recalls. “He communicated wonderfully; it was just not via speech.”

Once Goldstein established a relationship with this client, they were able to communicate and do one-on-one sessions without the other professional. In addition to drawing and art, the client would play songs he had saved in an extensive library on his phone to express how he was feeling.

Counselors may have to get creative because these clients [can] have speech limitations and cannot do traditional talk therapy,” Goldstein says. “Look for the gifts they have and use it, use it, use it.”

Team approach

Counselors working with clients who have experienced TBI also need to be comfortable reaching out to, consulting with and co-treating with a number of professionals in different fields. Depending on the severity of their injury, TBI survivors may be treated by surgeons, neurologists, speech and language pathologists, occupational and physical therapists, social workers and vocational/career professionals, among others.

Goldstein recommends counselors build connections with a base of these types of professionals in their local area so they can consult and ask questions when facing a challenge or sticking point with a TBI client. When treating clients who have experienced TBI, “don’t fly solo,” Goldstein urges. “In this work, it’s not a two-way street [with other practitioners]; it’s a superhighway.”

The counselors interviewed for this article emphasize that counselors should resist the urge to refer TBI clients to a specialist right away. Counseling this client population can be complicated and challenging and it requires lots of patience, but the empathic listening and supportive relationship that a counselor provides can make a world of difference for these individuals and their families.

Goldstein encourages those counselors who are interested in this client population or who thrive working in multidisciplinary teams to think about specializing in counseling TBI clients. “Brain injury is scary, and it puts a lot of therapists off,” he says. “If you see someone with a brain injury and you’re baffled, pat yourself on the back, because you should be. And if you’re intrigued and interested [in this topic], consider it as a specialty.”

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Contact the counselors interviewed in this article:

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Related reading, from Counseling Today:

 

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Counseling after brain injury: Do’s and don’ts

By Bethany Bray May 20, 2022

Traumatic brain injury (TBI) is complicated.

Counseling practitioners may work with brain injury survivors who struggle with impulsivity, anger, despair, personality changes, memory loss, language or cognitive difficulties and a range of other symptoms. Not only do post-injury symptoms and recovery differ from person to person but the way these challenges dovetail with their mental health, relationships and overall wellness also varies.

Here are 12 important do’s and don’ts for mental health practitioners to keep in mind when counseling clients who have experienced a brain injury:

 

1) Do devote a lot of time to listening. One of the most important and beneficial things a counselor can offer a brain injury survivor is empathic and nonjudgmental listening. Having a space to talk about what they’re going through and struggling with and what they need without feeling like a burden can make a world of difference for these clients, says Herman Lukow, a licensed professional counselor (LPC) and licensed marriage and family therapist who spent three years as a postdoctoral fellow researching TBI at Virginia Commonwealth University’s Traumatic Brain Injury Model System program.

 

2) Don’t equate struggle with resistance. What might seem to be resistant behavior in this client population is often not intentional. They may miss sessions or be hard to contact, but it’s more likely to be caused by the memory and cognitive challenges they live with (e.g., confusing what day it is) rather than resistance, Lukow says.

 

3) Do be comfortable with silence in counseling sessions. Brain injury survivors may struggle with speaking or finding the right words to express themselves. Practitioners need to resist the urge to fill periods of silence, and they may also need to get creative to find other nonverbal methods or adaptive tools to communicate with these clients, notes Hillel Goldstein, an LPC with a private counseling practice embedded within the Brain Injury Foundation of St. Louis.

 

4) Don’t go it alone. Counselors can best treat these clients by collaborating, co-treating and consulting with professionals from a range of other disciplines who have expertise in helping brain injury survivors, including speech and language pathologists, occupational therapists, rehabilitation specialists and others, says Goldstein.

 

5) Do adjust your pace and expectations of progress. The therapeutic expectations, outcomes and what can be counted as a “success” will vary with clients who are TBI survivors, notes Michelle Bradham-Cousar, a licensed mental health counselor and certified rehabilitation counselor who recently completed a doctoral dissertation on counseling clients with TBI. The benchmarks or signs that counselors may associate with improvement or growth in clients may not be apparent — or appropriate — with clients who have experienced brain injury.

 

6) Don’t be a cheerleader. Life after a brain injury is hard, and survivors may feel that conversations in counseling only emphasize what they’ve lost, says Lukow. A constant stream of positivity or messages such as “you’ll get through this” from a counselor may turn these clients off; instead, they need honesty from a practitioner and validation that what they’re going through is rough.

 

7) Do ask clients if they’ve ever had a brain injury or related issues such as falls, sports injuries or loss of consciousness. Clients may not disclose past brain injury or realize that it can be connected to their mental health or presenting concern, so it’s important to ask at intake. It’s equally important for counselors to realize that a past brain injury — even if a client doesn’t think it was serious — can lead to or exacerbate mental health symptoms, Lukow adds.

 

8) Don’t forget these clients’ loved ones and caretakers. The mental and emotional burden that comes with caring for a brain injury survivor is heavy, yet caretakers often put themselves last, Goldstein notes. The loved ones of TBI survivors can also benefit from therapy, particularly the supporting environment that group counseling can provide.

 

9) Do dig deep into your counseling toolbox. The crux of what brain injury survivors need in counseling is help dealing with loss and change, says Lukow. And counselors already have an arsenal of tools and methods to help in this realm, from cognitive behavior therapy to the therapeutic relationship itself.

 

10) Don’t think of life after brain injury only in terms of loss. Post-injury recovery is also an opportunity to gain new skills and find new ways of doing things. A client may not be able to work in a job or field they used to, for example, but a counselor can help them reframe this loss as a chance to look for a new occupation that fits with the skills they do have, notes Bradham-Cousar.

 

11) Do consider this as a specialty. There are not many professional counselors who specialize in psychotherapy for brain injury, but it’s an important and much-needed expertise, says Goldstein. It could be a good fit for counselors who are interested in this client population or who thrive working in multidisciplinary teams.

 

12) Don’t assume that recovery ceases within a few years of a brain injury. Survivors can still make gains with emotional, social and psychological challenges long after — even decades after — brain injury, says Lukow, especially when supported by helping professionals who provide patient, empathic care.

 

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Read more on counseling clients who have experienced a brain injury in an in-depth feature article in Counseling Today’s June magazine.

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Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Integrating substance dependence and pain management into counseling approaches

By Geri Miller November 5, 2020

In the United Sates, 2000-2010 was labeled the “decade of pain.” In 2011, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education stated that the prevalence of chronic pain in our country exceeded the prevalence of diabetes, heart disease and cancer combined.

Unfortunately, this prevalence of pain has continued, and because of that, counselors need to be aware that substance dependence and pain management may be an issue for their clients — even if it is not a “problem” as presented by clients themselves. Clients may be particularly vulnerable to substance dependence specific to opioids because they (or others in their lives) may view these drugs as the best treatment for pain (i.e., a “quick fix”).

There is a great deal to know about substance dependence and pain management. Because of this, counselors can easily become overwhelmed and hesitate to work with these issues. I am writing this article to help counselors see that they can readily integrate some basic substance dependence and pain management approaches into their current counseling practices and still be practicing within their area of competence.

Because of the prevalence of substance dependence and pain management in the United States, it would serve counselors well to always “wear the lenses” of both of these areas as they assess and treat their clients. However, it is probably most important for counselors who are working with clients specifically on either one of these two areas (substance dependence or pain management) to also intentionally explore the area not presented as a problem so that the potential relationship between the two is examined. For example, when counseling someone who struggles with chronic pain, a counselor would be well advised to also ask about their substance use. The same exploration needs to happen when a client struggles with substance dependence; a counselor should ask about any issues with pain and its management.

While this exploration is important, it is also imperative for counselors to be able to readily fuse these “lenses” into their existing clinical approaches. Five suggestions on the general process of incorporating these two perspectives follow.

First, counselors need to accept the reality that there is a lot to know about substance dependence and pain management and make sure that they work within their area of competence. One method for exploring and addressing these areas with their clients (while still practicing in their area of competence) is to use the “HOW” approach. This acronym encourages counselors to be honest, open and willing to discuss substance dependence and pain management issues with their clients. For example, a counselor can be honest about not knowing much about the client’s experience of pain, be open to being educated about the client’s perspective and be willing to discuss the pain experience with the client.

Second, counselors can anchor their approach in the discussion with respect for and genuineness toward the client. This client-centered approach inherently invites the client’s story of their pain (including the ways they try to handle the pain, such as opiates).

Third, counselors can assess and treat the pain using their typical counseling approaches and continue reassessment throughout the treatment process. Counselors should operate as gatherers of information about the pain and, as appropriate, consult with others (e.g., mentors, supervisors, colleagues, medical professionals) concerning appropriate ways to address the pain.

Fourth, counselors need to be aware of countertransference related to their own and their loved ones’ experiences with pain management and substance dependence. An awareness of their countertransference can enhance counselors’ effectiveness in addressing these overlapping areas.

Finally, counselors need to work within the realistic resource limitations that both they and their clients experience. For example, both counselors and their clients have limitations on the amount of time, energy and money they can invest in learning about and addressing the issues of substance dependence and pain management. Maintaining such a realistic perspective can cultivate more humane and practical counseling interventions that will result in less frustration for both the counselor and client.

An overview of chronic pain

In 2011, as stated previously, the Institute of Medicine’s Committee on Advancing Pain Research, Care and Education reported that chronic pain exceeded the combination of diabetes, heart disease and cancer in terms of prevalence in the United States. These historical statistics, in which the current issues of substance abuse and pain management are anchored, underscore the likelihood that many of our counseling clients are experiencing chronic pain but have not mentioned it or its impact on their lives in session. This prevalence should serve as an invitation for counselors to discuss pain and pain management with their clients.

In 2019, Beth Darnall, a pain scientist and director of the Stanford Pain Relief Innovations Lab, summarized the following information on chronic pain in her book Psychological Treatment for Patients With Chronic Pain. By definition, chronic pain is pain that lasts longer than three months or that extends beyond the expected time it should take to heal. Breakthrough pain is an acute version of chronic pain and centers on days or times when the pain is worse.

Although Darnall called chronic pain a “harm alarm” that tells the person to escape the pain to survive, she said the “riddle of chronic pain” is that it is impossible to escape. This knowledge needs to be fused into the perspective of how the pain experience is affecting our counseling clients in a biopsychosocial manner. This biopsychosocial exploration of the relationship between the overlapping areas of substance abuse and pain management can be facilitated by the core suggestions presented in the following section.

Core suggestions

I offer seven core suggestions that counselors can use as a guide in addressing substance dependence and pain management from a biopsychosocial perspective.

1) Work out of a systems perspective. From this perspective, the counselor looks at the systemic interactions that result separately for addiction and pain, as well as their overlap systemically. This means that the counselor is aware of the internal and external contributing factors for both addiction and pain and that the client may have developed an addiction in response to their pain or vice versa. The addiction may have resulted from prescribed medication following surgery, or the pain may have resulted from an accident that occurred while the client was under the influence of alcohol or drugs.

2) Watch for prescribed and nonprescribed substance use. This suggestion means that the counselor obtains information from the client about any prescribed medication of substances (such as medication-assisted treatment) in response to their pain or substance dependence as well as the client’s nonprescribed usage of opiates and marijuana for pain. Such an inclusive gathering of information provides the counselor with a broader view of the client’s treatment responses to managing the pain.

3) Practice “compassionate accountability.” This phrase means that the counselor has compassion for the client and simultaneously holds the client accountable for their behavior. For example, I can have compassion that my client has an addiction resulting from their use of opiates in response to chronic pain that prevents the client from performing activities of daily living. However, I also need to hold the client accountable for their behavior, such as stealing prescription opiates from a friend’s medicine cabinet.

4) Use firm, direct, honest communication. This is complementary to exercising compassionate accountability because this form of communication avoids enabling behaviors related to both pain management and addiction. No matter what, clients are responsible for the choices they make, and counselors need to be clear with clients about what they see.

5) Consider a harm-reduction perspective. This perspective means that the counselor walks the fine line of not enabling the client’s substance use while at the same time not requiring the client to suddenly commit themselves to abstinence. Instead, the counselor works within the reality of the client’s willingness and ability to change without encouraging the client to remain at the same level of change.

6) Complete assessment and treatment plans for both addiction and pain. This involves the counselor examining both areas in a broad way that includes the client’s fear of the pain returning and their psychological withdrawal from pain medication.

7) Watch for behavioral indicators of pain during the session. A significant amount of information can be gathered when the client is actively experiencing pain. The client’s pain experience can be processed in the moment, and the resulting information can assist both the assessment and treatment processes.

Assessment

Counselors can use a simple anchoring assessment prompt to elicit each client’s story: “Tell me the story of your pain.”

That open-ended prompt has the power to draw out narratives that clients have perhaps not spoken about previously. These clients may be accustomed to closed questions or scaling questions regarding their pain, but they may never have had anyone ask about and then carefully listen to the actual story of their pain.

This motivational interviewing approach can readily draw out information about the impact of community, culture, family and multicultural factors on the individual’s self-report. For example, the client may talk about how pain is simply not discussed in their family and culture. As a result, they have learned not to reach out for support to address their pain. The counselor could then help the client develop skills to reach out to others who will be supportive of them as they live with their pain, or the counselor might refer the client to a group that discusses pain management approaches.

Another assessment approach is to have clients keep diaries or logs pertaining to their pain, sleep and nutrition. These logs can assist in obtaining information about pain patterns and contributing factors to pain. Such record-keeping also needs to focus on what the client is doing “right” as well as what they are doing “wrong,” in addition to times when the areas of pain, sleep and nutrition are going well for the client. The collection of this information is solution-focused and strength-based. It can become the cornerstone on which healing treatment is built.

The assessment of pain also needs to be considered within the context of addiction. So, although the client has pain, this does not mean that it is necessary for them to use substances to cope with that pain. Neither does the existence of pain prevent the client from being confronted about their addiction as a “stand-alone” diagnosis.

Thus, the message is twofold:

1) The client can learn to live with pain without the use of substances.

2) The client may need to be confronted solely on their use of substances.

Treatment

Treatment for pain can involve various therapy modalities such as individual, group or family counseling. The counselor and client can choose the modality that seems to best fit the needs of the client, in combination with the resources available related to client income, agency resources and community resources.

Specific therapy approaches can include motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and grief counseling (because when dealing with chronic pain, clients frequently have issues of loss). It is within these forms of therapy where clinicians can legitimately practice counseling in their areas of competence by simply anchoring themselves in their treatment approach (e.g., therapy modalities, specific therapy approaches) and adding the lenses of “pain” and “substance abuse” by asking about information in the assessment process that broadly addresses these areas. Such broad assessment can assist the counselor in knowing whether the treatment of pain and substance use can be readily integrated into treatment or whether a more specific assessment and focused treatment of these areas are required.

Treatments that change the client’s relationship with the pain by focusing on the present (e.g., mindfulness, yoga, biofeedback, acupuncture) are also potential resources. In such cases, clients may remain aware of the pain but work with the knowledge that the intensity of their pain ebbs and flows and learn how to live with that process. They may also find techniques to reduce their pain.

Another treatment approach, described by Kirsten Weir in 2017 in Monitor on Psychology, encourages the client to practice self-care of the body through diet, exercise and sleep. It uses the metaphor of a stool with three legs. I developed the diagram above for the fifth edition of my book Learning the Language of Addiction Counseling (currently in press) to illustrate this metaphor.

The three-pronged stool is precariously balanced, which illustrates that self-care is not a static entity but rather one that needs to fluctuate depending on the client and the context. Each leg of the stool (diet, exercise, sleep) is needed to keep the overall stool (self-care) in balance. In other words, each leg has an impact on the others. For example, the experience of pain may negatively affect a client’s sleep, which then inhibits them from exercising and tempts them to eat unhealthy comfort foods. In contrast, a client who gets enough sleep may experience diminished pain, thus encouraging them to exercise and practice healthy eating. Counselors need to remind clients, however, that “pretty good” self-care is good enough; one does not have to practice “perfect” self-care to reap the benefits.

A final treatment approach involves counselors viewing themselves as part of a health management team. Such a team can consist of different health care professionals in which each professional has an important perspective on the unique aspects of the individual client’s pain and pain management. The unique components of the client’s pain determine the composition of such a team and the treatment system in which the team exists (e.g., hospital setting, private practice). Whether the team is formally or informally established by the counselor or by the system in which the counselor works, the counselor provides a critical mental health perspective that is needed for a holistic treatment approach.

As part of such a team, counselors familiarize themselves with any prescribed medications that the client is taking for chronic, active disorders. Counselors then play a role in the planned and gradual reduction of medications being taken. Counselors do not need to be experts in pain management or medications to be part of such a team or to be assigned to a formal team. The team approach can be extremely effective in serving the welfare of clients.

The counseling perspective offers important contributions to such teams, including a heightened sensitivity for clients’ pain stories and a commitment to advocating for clients. Such a perspective can result in an effective and humane approach to pain management and the use of prescription drugs. Additionally, this perspective can prevent clients from feeling like they are being dehumanized on a “medical assembly line” during the treatment process.

Conclusions

Clinicians can work effectively with clients by integrating pain management and substance use approaches into their already-existing counseling approaches. Awareness of the prevalence of chronic pain and its potential interaction with substance use can assist counselors during the assessment and treatment process.

Chronic pain and substance use frequently overlap, but they are areas that can easily be missed in terms of their impact on clients’ presenting problems. Simply by integrating the lenses of pain management and substance use into their counseling — asking questions and intervening as necessary — clinicians can offer a more holistic approach to their clients.

The development of these lenses can be enhanced through continuing education, ongoing training and staying informed on current research. There are some excellent resources (see below) that counselors can add to their clinical toolboxes. Counselors who commit to more deeply examining the areas of pain management and substance use can improve their overall treatment effectiveness and, thus, act in the best interests of their clients.

Recommended resources

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Learn more: ACA has produced a series of webinars with Miller on this topic. See more at ACA’s Professional Development Center: https://imis.counseling.org/store/catalog.aspx#

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Geri Miller is a licensed professional counselor, licensed clinical addiction specialist, certified clinical supervisor, master addiction counselor, licensed psychologist, diplomate in counseling psychology and a professor in the Department of Human Development and Psychological Counseling at Appalachian State University. She has worked in the counseling profession since 1976 and in the addictions field since 1979. She has published and presented research on counseling, and the fifth edition of her book Learning the Language of Addiction Counseling is currently in press. Contact her at millerga@appstate.edu.

 

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

A counselor’s journey to healing from chronic pain

By Douglas Guiffrida July 8, 2020

From 2005-2007, I suffered from excruciating back and leg pain. My pain was so bad that I was unable to sit for nearly a year. The only time I would sit was to drive myself to work, and the pain during that drive was so intense that there were several times I had to crawl out of my car once I arrived.

An MRI revealed a herniated disc, so I began a series of medical interventions that included seeing two chiropractors (a second after the first failed to help), two different types of physical therapists with two different approaches, and an acupuncturist, and receiving three cortisone shots, to name just a few of my treatments. Although I occasionally experienced relief, it never lasted long, and my pain got worse. I reluctantly decided to undergo back surgery.

To help deal with my pain as I awaited surgery, I began exploring nontraditional approaches and came across a book by Dr. John Sarno called Healing Back Pain: The Mind-Body Connection. In the book, Sarno, a physician, outlined a radical approach to curing back pain that he had developed through observing his own chronic pain patients for decades. He theorized that pain such as mine was caused not by structural abnormalities or injuries but rather by oxygen deprivation and faulty neuropathways in the brain. Furthermore, Sarno argued that the brain can actually create physical pain as a means of protecting people from experiencing painful emotions such as anger, rage and guilt. He labeled this condition tension myositis syndrome (TMS).  

Learning about my pain

This isn’t to suggest that chronic pain is not real or is “all in your head.” On the contrary, Sarno believed that TMS pain was real and could be excruciating. However, because chronic pain is often not caused by structural abnormalities, Sarno argued, it could not be cured by focusing solely on the body. In other words, surgery, manipulations, injections, stretches and so on cannot cure the pain because the pain originates in the mind, not the body. Even for me, a licensed mental health counselor, this theory sounded crazy at first. After all, I had an MRI that proved I had a bulging disk.

At the same time, there was also something that resonated with me about Sarno’s ideas. First, he described how people with TMS tended to have shifting pain that could manifest in different ways and move to other areas of the body. This could include experiencing migraines, heartburn and other digestive issues, knee and shoulder pain, and so on. These were all things I had suffered from since I was a child, but none was occurring now that I had back pain.

Second, Sarno outlined how people with TMS often experienced more severe pain under times of stress and how that pain could diminish during less stressful times. This was certainly true for me. At the time, I was working very hard to earn tenure as a professor at the University of Rochester, and my wife and I were raising two small children. It was among the most stressful times in my life. I also noticed that my pain would sometimes subside during less stressful times such as vacations.

Third, Sarno outlined a series of personality characteristics that are consistent with people who suffer from TMS. Not only do TMS patients tend to ignore their own emotional reactions, but they are incredibly hard on themselves (i.e., they are perfectionistic, highly driven, tend not to seek out help, etc.). These personality characteristics fit me perfectly. Furthermore, Sarno argued that an MRI would reveal structural abnormality in almost all patients over the age of 30 — but most people don’t experience any pain as a result. In other words, if Sarno was to be believed, my herniated disk wasn’t the cause of my pain; rather, it was my personality.

I decided that Sarno’s approach was worth a try, so I delayed back surgery, stopped physical therapy and seeing chiropractors, and began working on my emotions. I found a therapist who worked from a psychoanalytic approach designed to help clients uncover repressed emotions, and I began therapy. I also began engaging in psychoeducation, behavioral interventions and mindfulness (which I will describe in more detail later).

Miraculously, after just a few weeks of practicing this integrative mind-body intervention, I was free of pain. Not only was I able to avoid back surgery, but I was able to heal a number of other chronic health issues with which I had suffered for years. To this day, my back remains pain free, and I am able to engage in physical activity without any restrictions.

In 2017, I began advanced training and research in mind-body therapies, and later that year, I opened a private practice focused on helping clients who are in chronic pain. Since then, I have helped dozens of people overcome a variety of chronic pain conditions, including back, neck, shoulder, knee and hip pain; fibromyalgia; migraines; and chronic nerve pain. Like me, most of my clients suffered for years and were not able to find cures from mainstream medical approaches. Several of them were on disability from work or school but have now resumed normal life activities.

In this article, I provide an overview of the mind-body counseling approach I use with clients who are in chronic pain and provide suggestions to counselors interested in integrating this approach into their work.

Integrating a mind-body approach

When I began my own healing journey, few resources about this intervention existed beyond Sarno’s books. Thankfully, things have changed. The advent of social media has allowed the hundreds of people healed by Sarno to share their stories (many presented in the documentary All the Rage), and a growing body of research now supports the efficacy of Sarno’s ideas.

This increased awareness and popularity have led to numerous options for professional counselors to receive additional training in this modality. Although I highly recommend that counselors pursue this additional training through workshops and clinical supervision, many of the mind-body counseling interventions are consistent with skills that counselors already possess.

To begin, counselors must carefully screen clients to ensure they are appropriate for the intervention. Most importantly, clients must be screened by their physicians for serious medical conditions such as cancer, heart disease or broken bones that require medical attention and cannot be cured by mind-body counseling. Second, as with all counseling interventions, the mind-body approach is most helpful to those who believe in it, are familiar with the process, and are committed. While most clients arrive with some skepticism (like I did), those who are completely closed to the idea (e.g., clients who attend only to appease someone else) are not likely to be helped and can often become frustrated with the process. In addition to posting information about my approach on my website, I also conduct extensive phone consultations with prospective clients to explain the approach in detail and assess their potential fit.

Once clients are screened, several counseling interventions can be used in ways that effectively integrate Sarno’s strategies. These interventions include:

  • Psychoeducation about the nature of chronic pain
  • Behavioral techniques to build confidence and reduce fear
  • Mindfulness to help clients become more comfortable with uncomfortable physical and emotional sensations
  • Intensive short-term dynamic psychotherapy (ISTDP) to allow clients to become aware of and express painful emotions
  • Social support from other mind-body clients

Psychoeducation

The first step in integrating this mind-body approach to healing chronic pain is to provide clients with psychoeducation regarding the relationship between their minds and their pain. In addition to Sarno’s books, a number of other recent books by mind-body experts such as Howard Schubiner, Allan Abbass, Nicole Sachs, David Clark, Steve Ozanich and spine surgeon David Hanscom review scientific evidence that supports and extends Sarno’s ideas about mind-body connections to many forms of chronic pain. These resources expose clients to research that shows:

1) Most people with healthy (i.e., pain-free) backs, knees, shoulders and hips show structural abnormalities that should cause pain, supporting the notion that human bodies naturally change with age in ways that look structurally problematic but do not cause pain.

2) There are relationships between childhood trauma and physical health, including many forms of chronic pain.

3) fMRI research has established links in neuropathways responsible for physical and emotional pain.

4) There are strong relationships between chronic pain and the inability to be aware of, experience and express painful emotions such as anger and guilt.

Familiarizing clients with research showing that their pain is not likely of a structural origin, which is contrary to what they have been told by other health care providers, and providing them a path for recovery can instill hope and reduce fear. This process alone can begin to reverse the fear-pain-fear cycle that can activate and reinforce pain neuropathways in the brain. 

Behavioral therapy

At the same time clients are learning about mind-body connections to chronic pain, counselors should also begin engaging them in behaviorist interventions designed to reduce fear and encourage reengagement in their normal activities. Well-meaning health care providers frequently instruct people with chronic pain to discontinue physical activities that they enjoy in order to allow their bodies to heal. This is great advice for injuries such as broken bones or sprained ligaments but extremely problematic for mind-body ailments. Several health care professionals told me to swim laps instead of playing basketball. After several weeks of swimming (which I hated), a chiropractor then told me that swimming was the worst thing I could do for my back because of all the twisting and bending involved. He instructed me to disengage from all activity. In reality, the less activity I engaged in, the more depressed and hopeless I felt, and the worse my pain became.

As clients become educated about mind-body connections to their pain, they are encouraged to gently reengage in physical activity without fear of harm the next day. Counselors can facilitate this process by encouraging clients to engage in daily affirmations to reduce their fears of physical activity. This could include declarative statements such as “I am strong, and my body is capable of engaging in this activity” or “There is nothing structurally wrong with me, so doing this can’t hurt me.”

Clients should also be instructed to chart their progress as they reengage in life activities. Often, clients can become discouraged and feel hopeless when minor setbacks occur. Logs that indicate their overall progress over time can help clients sustain optimism during these setbacks.

Counselors should also encourage clients with chronic pain to engage in somatic tracking. These clients often arrive at counseling having already devoted extensive time to seeking potential relationships between their pain levels and physical activities (e.g., exercise, household chores) or the foods they eat. This process can become incredibly frustrating because many of the activities or foods they once associated with their pain often are disproved over time. Counselors integrating this mind-body approach should instead encourage clients to document relationships between their physical pain and their emotional states. 

A very common example is that people suffering from chronic pain can experience reductions in pain during less stressful times in their lives such as vacations. Traditional structural models of pain often seek to correlate these improvements to things such as nice weather, changing humidity levels or even the quality of the mattress at the hotel. However, counselors operating from a mind-body approach should encourage clients to document their emotional states when feeling free from pain. This same process is used when pain increases.

For example, pain that went away during vacation often returns or becomes even worse when the client returns home. It is tempting to attribute this increase in pain to uncomfortable travel conditions (e.g., car or airplane seats) or weather changes. However, clients should be encouraged instead to explore problematic interpersonal issues to which they may be returning at home. Sometimes these answers can be very clear; other times, the answers are hidden from view, especially when they involve traumatic events or emotions that clients feel guilty about having toward others. In these cases, ISTDP is central in uncovering hidden emotions related to pain flare-ups.

Counselors can also help clients consider, without judgment or fear, the secondary gain that their pain potentially provides them, particularly regarding what their pain gets them out of doing or feeling. Chronic pain often requires people to become confined to their homes and, therefore, to miss out on potentially stressful interpersonal encounters. These can include social events that they may be dreading, conflicts with colleagues or family members, or even having to provide care for children, partners or aging parents.

Understandably, clients are often resistant to exploring these possible relationships because it may feel like they are being blamed for their pain or accused of it all being in their heads. Counselors need to continually reassure their clients that mind-body pain is real and not “created” on purpose. In fact, it is often a result of people trying to subconsciously protect others from their feelings toward them.

Counselors should encourage clients to create logs of what they miss out on during severe pain flare-ups. This may reveal correlations between their pain and their hidden (but potentially powerful) feelings of fear, anger and guilt. Sometimes, the patterns that emerge, although difficult to recognize initially, can become too prevailing for clients to ignore. Once these patterns are identified, ISTDP can be particularly useful in assisting clients with unpacking and understanding the complex relationships between their pain and their hidden emotions toward others.

Mindfulness-based therapy

Mindfulness-based stress reduction, first introduced into Western medicine by Jon Kabat-Zinn, has been used for over 30 years to treat chronic pain. While research indicates that mindfulness shows only moderate effects in alleviating chronic physical pain, the approach has proved highly effective in improving psychological symptoms associated with chronic pain, such as depression and anxiety, and reducing physical limitations associated with the pain.

From my experience, mindfulness is also extremely useful in helping clients become more comfortable with uncomfortable emotions. This can greatly enhance the effectiveness of the behavioral approaches mentioned previously as well as emotional-focused therapies such as ISTDP.

A detailed description of mindfulness is beyond the scope of this article. Counselors interested in effectively implementing this mind-body approach should seek training in mindfulness and mindfulness-based therapy. However, even counselors without training in mindfulness can encourage their clients to participate in mindfulness workshops and to develop regular mindfulness practices outside of their counseling sessions.

ISTDP

While Sarno argued that many people could heal themselves through psychoeducation and behavioral approaches alone, he also realized that some people (like me) needed psychotherapy to assist them with recognizing, experiencing and expressing repressed painful emotions that might be causing pain. Specifically, Sarno advocated that people with chronic pain engage in ISTDP, which is an attachment-based, emotion-focused somatic therapy developed by psychiatrist Habib Davanloo.

Through extensive research over several decades, Davanloo identified a series of core defenses some people have developed, often since childhood, to block uncomfortable feelings and repress traumatic experiences. While these defenses can often be adaptive when people are children, Davanloo found that they create tremendous emotional and physical suffering later in life.

Chronic pain, from an ISTDP perspective, is an unconscious attempt to protect (or distract) people from experiencing uncomfortable emotions and harmful impulses toward others, particularly loved ones, as well as the guilt they carry for harboring these negative feelings and impulses. Counselors conducting ISTDP therapy help clients notice strategies (or defenses) that they have developed to prevent themselves from becoming close to others and experiencing emotions toward them. Counselors also integrate experiential techniques that help clients become aware of, experience and express these painful, repressed emotions toward others and to recognize and even act out potentially threatening impulses associated with these painful feelings.

This process of skillfully pressuring and challenging client defenses can result in what Davanloo referred to as an “unlocking” of repressed emotions, where defenses are loosened and waves of painful feelings are experienced consciously. When partially or fully experienced in therapy, an unlocking can result in dramatic improvements in both physical and psychological well-being.

ISTDP is a complex and powerful approach to therapy that requires years of supervised training to implement. Even after completing extensive reading on ISTDP, attending numerous conferences and workshops, and participating for several years in a core training group and individual supervision with an expert ISTDP practitioner, I still feel like a novice. Even so, leading mind-body physicians such as Sarno and Schubiner have suggested that all health care professionals, including those without formal training in ISTDP, should integrate aspects of this approach into their mind-body practice. Specifically, they advocate for people in chronic pain to journal about their feelings toward others and to engage in meditations designed to help them connect their emotions to their bodies.

More information about ISTDP, including how to integrate elements of the approach into health care practice, can be found in Abbass and Schubiner’s book Hidden From View: A Clinician’s Guide to Psychophysiologic Disorders.

Social support

When I began this process as a client 15 years ago, I remember feeling very alone in my journey. The few attempts I made to discuss these ideas with health care providers, or even friends and family members, were usually met with skeptical or condescending looks and remarks. Now, having counseled many others, I have learned the power of social support in the success of this process. A consistent comment I hear from clients in my pain groups is how integral the support they receive from their fellow group members is to their success.

Engaging in pain groups may not be possible for everyone, but a number of online communities are available through Facebook and other social media platforms that can provide opportunities for clients with chronic pain to connect with others like them. There are also several podcasts, including The Mind and Fitness Podcast, hosted by former chronic pain sufferers who share their own and others’ success stories overcoming various forms of chronic pain through the mind-body process. These stories usually detail their struggles with chronic pain; their frustrations with health care professionals who performed costly and unnecessary tests and medical procedures; their mind-body healing journeys, including how they overcame setbacks; and their quality of life since becoming free of chronic pain.

Such connections provide clients not only with role models, but with continual support from others. This can enhance the effectiveness of the intervention, especially during times of struggle. There is even an app called Curable that is specifically designed to provide people in chronic pain with resources, activities and social support in ways consistent with Sarno’s approach.

Summary and conclusions

The integrative mind-body approach outlined in this article is a powerful and underutilized approach to helping clients heal from chronic pain. The approach is particularly well suited to clients who have been cleared of serious health conditions and who have exhausted traditional medical interventions with no relief.

While many of the intervention strategies align well with traditional counseling approaches, counselors who are interested in specializing in this work should engage in professional development by attending mind-body trainings and workshops and participating in an ISTDP core training group. Among the ISTDP master clinicians who offer core training are Allan Abbass, Patricia Coughlin, Marvin Skorman and Jon Frederickson. Counselors may also consider enrolling in the University of Rochester’s advanced certificate program in mind-body healing and wellness (see tinyurl.com/Mind-BodyCert). It is the first program of its kind to provide advanced-level training in this type of mind-body intervention.

 

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Douglas Guiffrida is professor, counseling program director, and director of the mind-body healing and wellness program at the Warner Graduate School of Education and Human Development at the University of Rochester. He is a licensed mental health counselor and a national certified counselor. To learn about his private practice or to contact him, visit DouglasGuiffrida.com.

Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

From pain to empowerment: Lessons learned through physical therapy

By Jane E. Buckingham July 20, 2019

A number of years ago, I gradually and almost imperceptibly began to have lower back problems. Eventually, simple daily activities caused me great pain: lifting a grocery bag, taking a casserole out of the oven, rolling over in bed, getting out of a chair, vacuuming the house (that last one I didn’t really care about). I had to give up things I loved, such as swimming laps and working in my garden. The more my back hurt, the less I did.

As it turns out, that’s one of the worse things you can do in situations like mine, but I didn’t know that at the time. I had been through an extreme amount of stress not long before my back started acting up. As anyone who has a health condition (ranging from a cold to cancer) can attest, friends, family and even perfect strangers feel free to provide you with unsolicited diagnoses and treatment suggestions. So, people kept telling me that my condition was stress related, emotional. I think there may have been some truth to that, but I also knew deep down that there was a structural element that needed to be addressed.

Eventually I got X-rays, which showed that I had not only long-term scoliosis but also erosion at the sites of a couple discs and some arthritic changes in my spine. I didn’t want to relegate my existence to painkillers or a reduced quality of life, so I accepted a referral for physical therapy. I was fortunate to find a wonderful practitioner to whom I returned again and again in the years that followed for a variety of issues — not only my lower back but also an injured shoulder, a knee problem and an unstable cervical area in my neck.

Upon conducting the initial assessment of my back situation, my physical therapist announced, “Jane, you have no core!” She meant physically, not psychologically, but nonetheless the pronouncement sounded dire, so I really took her words to heart. And, indeed, I had been using my back muscles inappropriately because no one had ever explained to me how to strengthen core muscles and why it was important to do so. To this day, I still do most of the exercises my physical therapist taught me as a way to manage my back condition, and I have resumed all the activities I was unable to do previously, including (unfortunately) vacuuming.

So, why this essay about what I learned from physical therapy? Because I believe the lessons and approaches presented in the PT model of conducting therapy, albeit in the physical realm, apply in very concrete ways to our work as professional counselors. Here are my takeaways.

 

Assessment

  • A thorough initial assessment sets the frame for successful treatment. In physical therapy, there was paperwork but not too much. A good portion of the evaluation was my own self-report, along with some objective measurements and observations on the part of the therapist. The preassessment consisted not only of rating my level of pain but also a functional analysis of my ability to perform tasks of daily living. This set the stage for an accurate post-treatment assessment.
  • In terms of diagnosis, instability can be just as concerning as outright pain, but it doesn’t get as much attention. We often hope that those initial warning signs, whether physical or emotional, will go away. However, stabilizing a condition before it becomes painful can help avoid serious problems down the line.

 

Goals

  • In my various experiences with physical therapy, the goals of our work together were very clear and established by me during that first intake session, thus creating a contract for therapy. Usually, one or two goals were sufficient and were completely measurable. Sometimes a goal was merely to reduce (not eliminate) pain and to regain my ability to engage in a particular activity again. My physical therapist estimated the number of sessions I would need, so the work had a beginning and an end, but it always included an invitation to return for a consult if needed.

 

Relationship

  • Trust is essential and was developed through the therapist’s active listening and sincere invitation to provide her with feedback. She had the expertise but understood that I was the expert on myself. Encouragement and honesty went hand in hand. If something wasn’t helping, we decided together to regroup and start fresh. I never really liked anything that involved props such as big rubber balls or elastic bands. She didn’t judge me for this but instead worked with my preferences.
  • My physical therapist was not just a good listener but also genuinely wanted to know how I was doing. In my most recent round of physical therapy for a neck condition, I wasn’t experiencing the results that either of us would have liked. I was feeling discouraged and frustrated that I wasn’t making progress. No problem. She instructed me to forget all the exercises I’d been given so far so that we could start all over at the beginning. We began anew with a different approach and set of practices, and they worked. It’s important to note that, to switch gears like this, total honesty on my part was essential, but it was her nondefensive response that allowed us to find a more effective approach.

Action

  • A little goes a long way. We started very slowly. Each week my physical therapist introduced one or two exercises that I was to practice in between sessions. In fact, my participation and practice outside the sessions were where the real work happened (just like in psychotherapy). The requirements and expectations were so minimal — most exercises involved only 10-15 repetitions one or two times a day — that it was easy to do them, and this led to a sense of accomplishment. My therapist gave me handouts with written instructions and diagrams so that I could refer back to them if needed. I came to understand that when humans are confronted with change on a big scale (even if the change is something we invite into our lives), the organism can set up resistances in both subtle and significant ways. When change is small and gradual, the protective functions of the amygdala don’t get activated, and barriers to change don’t have a chance to develop.
  • Visualization was a primary tool for the physical therapist. When she asked me to locate and tighten muscles I didn’t even know I had, she used imagery and mental practice to get me started. “Just see yourself in your mind’s eye doing the exercise.” “Imagine guy wires attached to your abdomen pulling the muscles tight.” “Bend from the waist, keeping your back straight, like a waiter taking a bow.” “Press your feet to the floor as if trying to keep an egg from rolling away without breaking it.” “Try this with a light touch, like kitten whiskers.”

 

Outcome

  • The results of physical therapy were not instantaneous, but changes became evident in a few short weeks. Stabilization came first, and then strengthening. Small gains were encouraging and kept me motivated. Armed with a menu of exercises to practice on my own, I felt resourced with an increased sense of agency. Slowing down and paying attention with mindfulness became solidified as tools that were readily available (these tools were also transferable to other life situations).
  • If something can’t be cured, at least it can be managed, functioning can be restored, and quality of life can be enjoyed. I felt empowered to continue the maintenance work on my own but also encouraged to come back if past problems resurfaced or new ones arose later on.

 

Final thoughts

Each of the concepts and suggestions I incorporated from physical therapy can be applied to our work in mental health counseling. Some of them are common sense, whereas others reflect what is established as best practice. But organizing them into a frame that is parallel to physical therapy provides a different portal into our therapeutic work.

I have used all of these ideas with clients and found them to be useful. My back continues to be stable, and I have discovered that I do have a core after all.

 

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This essay is dedicated to BB with gratitude.

 

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Jane E. Buckingham is a licensed clinical mental health counselor, national certified counselor, certified clinical mental health counselor and mental health consultant in Brattleboro, Vermont. Contact her at janebuckingham@yahoo.com.

 

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