Tag Archives: chronic illness

Supporting clients through the anxiety and exhaustion of food allergies

By Bethany Bray November 27, 2018

The diagnosis of a food allergy is life-changing, not just for the individual but for those who love and live with that person. In addition to avoiding exposure to certain foods, the condition requires that these families and individuals explain, over and over again, the seriousness of the allergy at schools, restaurants, social gatherings, workplaces, daycare facilities and countless other places.

It can all be exhausting, says Tamara Hubbard, a licensed clinical professional counselor whose son was diagnosed with a peanut allergy six years ago. Families receiving a new allergy diagnosis face steep learning curves that can cause them to worry and to overthink every detail of what their child or other loved one eats or might be exposed to.

“It’s almost like Russian roulette. You don’t know when an [allergic] reaction will happen, even when you take precautions,” Hubbard explains. “There’s a constant level of fear and anxiety at all times in the background that parents and caregivers need help managing.”

Food allergies affect an estimated 4 to 6 percent of children in the United States, according to the U.S. Centers for Disease Control and Prevention. Between 1997 and 2007, food allergies increased 18 percent among American children and adolescents younger than 18.

A food allergy reaction sends someone in the United States to the emergency room every three minutes, reports the nonprofit organization Food Allergy Research & Education (FARE).

Counselors can help clients work through the anxiety and other mental health issues that food allergies sometimes exacerbate, but they can also be a source of support simply by serving as a listening ear. Clients may come to a counselor’s office worn out from the self-advocacy and constant vigilance that a food allergy requires, explains Hubbard, who has a private practice in the suburbs of Chicago that specializes in supporting clients (and their families) with food allergies.

With food allergies, there is sometimes “a constant feeling of having to fight in every conversation to get your point across,” she says. “Just being an empathic, listening ear [as a counselor] and wanting to learn, that makes a huge difference in their anxiety level and ability to release tension.”

At the same time, counselors should research and learn about food allergies to become a competent support to clients, Hubbard emphasizes. For example, they should know that an intolerance or sensitivity to a food is very different from a diagnosed allergy.

With a food allergy, the immune system views the allergen — for example, wheat, shellfish or peanuts — as an invader and overreacts whenever it enters the body. Someone who ingests a food that he or she has an intolerance or sensitivity to will experience discomfort but not the potentially life-threatening reaction that comes with an allergy, Hubbard explains.

Counselors who understand the biological and mental health implications of food allergies can help these clients to live fuller lives, Hubbard says. Although the most important thing counselors can do is learn about and understand food allergies, exercising compassion is also essential, she says.

“Sometimes, even medical professionals aren’t good at that part. They send [people] off with an EpiPen and say, ‘Come back in six months.’ In a perfect world, they would send them off with a list of resources for mental health and wellness,” says Hubbard, an American Counseling Association member. “Counselors can play a very important part to fill in that gap, even if it’s just an empathic ear. That is incredibly therapeutic in itself.”

 

Tempering the uncertainty

The anxiety that families and individuals with food allergies often experience is more complex than simply worrying about possible exposure to an allergen, Hubbard says. Anxiety can spike over everything from sending a child to school and worrying that the staff won’t follow allergy-safe protocols to second-guessing whether a food product might contain nuts, even when the label says it doesn’t.

In the United States, companies are required to note on food labeling whether a product contains one or more of the eight most common allergens. These potential allergens are:

  • Milk/dairy
  • Eggs
  • Fin fish (e.g., salmon, flounder, cod)
  • Shellfish (e.g., crab, lobster, shrimp)
  • Tree nuts (e.g., almonds, walnuts, pecans)
  • Peanuts
  • Wheat
  • Soybeans

However, U.S. companies are not required to disclose whether a product is made in a facility or on equipment that is or was exposed to those eight allergens, Hubbard notes.

With that in mind, navigating grocery stores, restaurants and social gatherings involving food can be anxiety-provoking for those with food allergies — and especially for newly diagnosed families, Hubbard says. Some parents react by restricting their child’s activity to reduce the risk of exposure.

Allergy diagnoses are sometimes given after a person has experienced one initial anaphylactic reaction. This can create uncertainty concerning how much of the allergen is too much. For example, is it OK to be near someone else who is eating the food to which the person is allergic?

“There is fear of the unknown: ‘How much of the allergen will it take for my child to react?’ There are different layers to the anxiety, and it’s important [for counselors] to understand each layer,” Hubbard says. “Also, the anxiety affects each member of the family; they will all feel it. There’s a lot to unpack when you are assessing a client who is dealing with food allergies.”

Counselors who understand the complexity of the issue can help clients find balance and equip them with tools to manage the anxiety, Hubbard notes.

“Ultimately, the goal is to help the client — whether it’s the allergic person themselves or a caregiver — assess the risk for every situation they’re going to be in. Is their anxiety based on fact or emotion? We can tell ourselves that everything is unsafe, or we can navigate [the risk] and take precautions,” she says.

 

Finding balance

There is a balance between living in fear and frustration because of food allergies and still enjoying a good quality of life, Hubbard stresses. “Understand that in many cases, when someone is newly diagnosed, especially if it’s a young child, the person or family may be very overwhelmed initially,” she says, “as there can be a steep learning curve when your lifestyle needs to suddenly change due to a food allergy diagnosis. Some people navigate this well, while others need support and guidance. I typically encourage people to remember that it will take time to get used to the diagnosis and gain all of the necessary knowledge to live a well-balanced life between food allergy fears and empowerment. I also encourage those who are newly diagnosed to learn the basics at first and, over time, as they feel ready, branch out to other related food allergy topics, such as potential treatments, research and advocacy.”

Here are some tips for counselors to keep in mind related to food allergies:

> Prepare for an emotional roller-coaster: Food allergies can be life-threatening, so it’s understandable when individuals (or their families) experience strong emotions such as fear, sadness, anger or guilt connected to the diagnosis. Of course, these emotions can eventually lead to becoming overwhelmed or burning out, Hubbard says.

“If a child has a [allergic] reaction, the parents can feel strong emotions of ‘what did I do wrong?’ At the same time, they could have done everything 100 percent right,” Hubbard says. “The reality is that it’s a big deal, but that doesn’t mean it has to be a … crisis every day.”

Equipping clients with coping mechanisms will not only help them manage their own anxiety and strong emotions but will also keep them from transferring those feelings to the child or family member with the allergy, Hubbard says.

Counselors can also help clients work through their feelings of loss concerning what their life (or their child’s life) might have been like without the limitations of a food allergy. For example, they may yearn to eat at a restaurant without having to ask about the establishment’s allergy protocols or to eat lunch with friends in the school cafeteria instead of sitting at a separate table or worrying about what foods they could be exposed to.

“These children [with food allergies] have to grow up a little quicker in some respects. They have to learn to speak up for themselves and make decisions,” Hubbard says. “It’s about managing the feelings and finding ways to help them empower themselves and advocate to come through with some balance.”

> Move toward acceptance: One of the most important things counselors can do is help clients reach acceptance of the food allergy diagnosis, Hubbard says. This can have similarities to grief work, including helping clients come to terms with the fact that they can’t change the situation, she explains. Narrative therapy can assist clients in reframing their feelings and taking control of their story.

Role-play can be beneficial for clients of all ages because it helps them learn to navigate their feelings and the language they will need to use to advocate for themselves. (For example, how will they explain that they can’t eat the cake at an upcoming birthday party?) Hubbard says she also finds play therapy, mindfulness and cognitive behavior therapy helpful for clients with food allergies.

Above all, she says, counselors should make sure their approaches are tailored to and appropriate for the individual client. “For kids, it’s not appropriate to talk about the risk of death [involved with food allergies], but coping with their feelings and worry is appropriate,” she notes.

Counselors can also model acceptance for clients in session, Hubbard adds. It can be a relief to find that “they don’t have to walk into a session defending themselves,” she says. “They can learn that not every conversation has to be fight-or-flight. It’s a marathon, not a sprint, for sure, just as with any chronic illness. Help clients pace themselves.”

> Find the right words: An individual with food allergies (or the parents of a child with food allergies) will need to explain the allergy to everyone from school staff to well-meaning relatives who are hosting a holiday dinner. Be aware that there can be cultural and generational differences in levels of understanding and flexibility surrounding food allergies, Hubbard advises.

“This can be hard for people who aren’t comfortable speaking up. If they’re not a natural advocate, it will now fall to them to educate [others] and advocate,” she says. “A counselor can help them manage the feelings around that, [including] frustration, burnout and exhaustion.”

> Guide children (and parents) as they grow up: Parents may find themselves growing anxious as their child with food allergies ages, develops more independence and spends more time away from home. Counselors can offer support as these families navigate the child’s developmental milestones. This might include encouraging the family to gradually give the child more freedom and responsibility to make safe choices independently.

For example, teenagers who are beginning to date may have to inform their love interests that they shouldn’t kiss for a while after the person has eaten something containing an allergen. “For every phase of life, there will be an additional need to explain and educate [about the allergy], and that can be exhausting,” Hubbard says.

> Be aware that “relapses” are possible: Clients who have made progress on accepting a food allergy and managing the emotions that come with it can “go back to ground zero” anytime they experience an allergic reaction or exposure scare, Hubbard says. Counselors shouldn’t be disappointed if these clients sometimes backslide on the progress they have previously made in therapy.

> Work with the allergist: Professional counselors shouldn’t hesitate to contact a client’s allergist (if the client grants permission). Counselor practitioners can learn a lot about the specifics of a client’s needs from the allergist, Hubbard says. For example, some food allergies are milder, whereas others can cause a reaction even from airborne exposure (for example, peanut dust). “Each client will have a specific set of data [regarding his or allergy],” Hubbard explains. “It’s important to stay connected with their allergist and check in to help you better understand.”

> Be cognizant that allergy-related bullying does happen: Being aware of allergy-related bullying is especially important for counselors who work in school settings or with children and adolescents in their practice, Hubbard notes. Up to one-third of children with food allergies have faced bullying, according to FARE.

This can include overt bullying, such as taunting or threatening a classmate with an allergen. But allergy-related bullying can also come in less obvious forms, such as when an adult (teacher, sports coach, etc.) points out the individual with an allergy and labels them as the “reason” the class or team can’t have certain foods. This type of scenario can make individuals feel bad about their allergies and the inconveniences they may present, Hubbard says.

 

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The Food Allergy Counseling Professionals Networking Group

Started by Tamara Hubbard, this group is open to counselors who work with clients who are managing food allergies. Connect with them on Facebook: facebook.com/groups/FoodAllergyCounselingProfessionals/ to share resources and network with other professionals who specialize in this area.

 

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Contact Tamara Hubbard and find resources at her website: foodallergycounselor.com

Hubbard also writes a blog on allergy-related issues, including a series titled “Four things counselors should know about food allergies.”

 

 

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Related reading

Hubbard suggests the following resources for counselors or clients looking to learn more about food allergies and their connection to mental health:

 

 

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

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

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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.

 

The counselor’s role in assessing and treating medical symptoms and diagnoses

By Jori A. Berger-Greenstein April 4, 2018

Take a moment to imagine the following scene, with you as the protagonist: A few days ago, you woke, went for a run, had breakfast and headed to work, where you attended a committee meeting. The next thing you remember is lying in a hospital bed and being told that you had a stroke. You seem unable to move or feel one of your legs.

You are in a double room with an elderly man who has had many relatives and friends visit, although he seems not to be doing well. You’re not sure, however, because you feel foggy. Is this a side effect of the medication they keep giving you?

You are dressed in a hospital johnny and confined to bed. A nurse checks your vital signs on the hour, often waking you when you’re sleeping. An intravenous tube in your arm is connected to a bag with some sort of liquid in it, and you are hooked up to monitors, although you’re uncertain of what they are monitoring. Beepers sound regularly, prompting the nurses to come check you, look at the monitors or change out the bag.

A doctor visits in the mornings, along with a group of medical students, reminding you of Grey’s Anatomy, complete with looks back and forth and eye-rolling. They talk among themselves as if you aren’t there, using medical jargon that you don’t understand. Your family members are anxious and tearful. You hear them talking to the doctor about transferring you to another facility because your insurance won’t continue to cover your stay in the hospital. You also hear your spouse on the phone with relatives who live across the country but want to come see you.

As the patient, how might you be feeling? What might you be thinking?

Now imagine that instead of being the patient, you are a mental health provider called in to assess the patient for depression. How might you respond?

The above scenario and others similar to it are commonplace for many providers who operate in the field of behavioral medicine, which the Society of Behavioral Medicine defines as the “interdisciplinary field concerned with the development and integration of behavioral, psychosocial and biomedical science knowledge and techniques relevant to the understanding of health and illness, and the application of this knowledge and these techniques to prevention, diagnosis, treatment and rehabilitation.”

As recognition of the psychological and behavioral factors involved in medical illness has increased, so has our ability as mental health counselors to serve a valuable function in patient care. Providers and researchers alike now recognize the importance of approaching health care more holistically rather than compartmentalizing medical versus psychological well-being.

Understanding context

Primary care providers, the first stop for most people’s health-related complaints, operate under ever-increasing pressures to provide care for more people in less time. The average visit lasts 10 to 15 minutes, with the goal of assessing presenting symptoms (typically while simultaneously entering patient information into a computer system) to ascertain their cause and thereby provide information about how to treat them. There often isn’t time to gather the context of these symptoms, increasing the likelihood that important details can be missed. Likewise, there isn’t sufficient time to fully discuss the pros and cons of treatment options, the potential barriers to treatment and whether a patient is willing or able to follow through on the treatment recommendations.

In contrast, mental health providers often have the luxury of coming to understand patients/clients more fully. This includes understanding and appreciating the contexts in which patients/clients find themselves, understanding how these individuals are coping and making meaning of what is happening, and forming a trusting relationship with them, which is consistently demonstrated to be predictive of adherence to care and improvements in health-related parameters.

As Thomas Sequist, assistant professor of health care policy at Harvard Medical School, stated in a New York Times article in 2008, “It isn’t that [medical] providers are doing different things for different patients, it’s that we’re doing the same thing for every patient and not accounting for individual needs.”

It can be said that medical providers are trained to identify and treat symptoms in order to identify disease so that a patient can be effectively treated — which is, in fact, their role. In contrast, mental health providers are trained to treat people and illness — illness being one’s experience of disease rather than just a compilation of symptoms or diagnostic labels.

The process of assessing for mental health symptoms

A variety of mental health conditions are characterized by symptoms that overlap with those attributable to medical conditions. For example, symptoms of an overactive or underactive thyroid mimic anxiety and depression, respectively. Psychosis can mimic neurological conditions, mood disorders can mimic endocrine disease, anxiety can mimic cardiac dysfunction and so on.

Through training mental health clinicians to identify symptoms that may indicate a medical cause and knowing how to assess for the possibility of a medical workup, we can make earlier referrals for medical care. This, in turn, helps us to identify diagnoses more quickly, leading to easier/more efficacious treatment and better validating concerns.

One’s cultural identity and the resonance of cultural norms are also important to assess and monitor. For instance, a patient may be reluctant to engage with an English-speaking provider, may have a vastly different conceptualization of illness as punishment (in stark contrast to the Westernized biopsychosocial model) and may need validation for his or her reliance on faith and spirituality.

Collaboration

Collaborating as mental health clinicians directly with medical professionals toward the common goal of helping those who need our care can be invaluable. Examples include ruling out mental health disorders, identifying appropriate treatments in the case of comorbidities, providing emotional support to patients who have been diagnosed with a medical disorder and supporting physicians who may be overwhelmed. For instance, medical treaters may not know or understand the presentation of symptoms associated with trauma or the intricacies of providing trauma-informed care.

Being knowledgeable as mental health clinicians about medical-related symptoms, the language and jargon of medicine, and strategies for navigating the medical system provides us with critical credibility. This credibility can make or break our ability to collaborate as mental health clinicians.

Providing care

At its best, behavioral medicine functions as a prevention-focused model with three levels of care:

1) Primary prevention refers to preventing a problem from emerging to begin with. Examples of this might be establishing obesity prevention programs in public schools for young children or working with high-risk families to promote safety practices. The idea is to work with groups that may be more vulnerable to risks at some point in the future and to prevent those outcomes from occurring.

2) Secondary prevention involves working with people who have developed a problem of some sort, with the goal of preventing it from worsening or becoming a larger problem. Examples include working with people who are prehypertensive in order to prevent hypertension and subsequent cardiovascular disease or stroke, and working with people with HIV to increase their adherence to antiretroviral medication to reduce viral load, making them less infectious to others and providing them with more healthy years of life.

3) Tertiary prevention refers to helping people manage an already-existing disease. This might involve increasing quality of life for people enduring a condition that won’t improve, such as a spinal cord injury, multiple sclerosis or late-stage renal disease, and supporting people in the later stages of a disease that is imminently terminal.

Transtheoretical model (stages of change)

Although mental health clinicians may be familiar with efficacious interventions for a given condition, we may not be perceived as credible if we do not understand and respect the client’s/patient’s motivation. No mental health provider’s repertoire is complete without an understanding of the transtheoretical model and how to utilize it to increase an individual’s motivation for positive change.

Assessing where a client/patient might be in the stages of this model (precontemplation, contemplation, preparation, action, maintenance) helps us to better target our interventions in a respectful way by taking context into consideration. Clients/patients in the precontemplation stage might benefit most from education and are less likely to be receptive to recommendations for lifestyle changes, whereas those in the action stage may not need as much of an emphasis on motivation. For a thorough description of the transtheoretical model, I would refer readers to William Miller and Stephen Rollnick’s seminal work, Motivational Interviewing: Helping People Change.

Concrete needs and specific skills

The majority of causes of death and disability in the United States are those caused or treated, at least in part, by behavior. Nationally, the top 10 causes of death, according to the Centers for Disease Control and Prevention (2015), include cardiovascular and cerebrovascular disease, cancer, pulmonary disease, unintentional injuries, diabetes, Alzheimer’s disease and suicide. Changes in lifestyle, knowledge/education and interpersonal support can be successfully utilized as part of all three levels of prevention. In fact, these are areas in which mental health providers can be extremely valuable.

Primary prevention: Data suggest that the single most preventable cause of death is tobacco use, which can dramatically increase the risk of developing cancer, pulmonary disease and cardiovascular disease. Comprehensive smoking-cessation programs can be quite effective in managing this, as can education to prevent young people from initiating cigarette use.

Sedentary behavior (and, to a lesser extent, lack of exercise) is also strongly associated with health problems, perhaps most commonly cardiovascular disease and cancer. Concrete strategies for introducing nonsedentary behaviors (using the stairs, standing up once an hour, walking) can be incorporated into one’s lifestyle with less effort than a complex exercise regimen.

Getting proper nutrition, practicing good dental hygiene and consistently wearing sunscreen, helmets and seat belts are other examples of primary prevention in behavioral medicine. Motivating people who have not (yet) experienced the negative consequences of their risk behaviors is an approach that mental health providers are trained to provide.

Secondary prevention: The rates of obesity have risen dramatically in the past decade and are associated with a wide variety of serious medical complications, including diabetes, cardiovascular disease, stroke and cancer. If treated effectively, the risk of such complications can be reduced significantly. Examples of interventions found to be useful include aerobic exercise, dietary change (such as adhering to a Mediterranean diet and managing portions) and monitoring weight loss.

Although the specifics of these interventions may be most appropriately prescribed by dietitians and physical therapists, mental health providers can add value by helping to increase clients’/patients’ motivation and adherence, providing more thorough education about recommendations and collaborating with other providers.

Tertiary prevention: Spinal cord injury, most often caused by motor vehicle accidents, falls or violence, can have a devastating effect on a person’s life. These injuries are not reversible, but mental health providers can prove valuable in tertiary prevention efforts. These efforts might involve providing existential support; helping patients to navigate the medical system and ask for/receive support from significant others; and identifying strategies for improving quality of life and accessing tangible resources to sustain some aspects of independence.

Getting started

So, how might clinical mental health counselors “break into” the system? The ideal is an integrated care model in which mental health providers are colocated within the medical setting. This serves a dual function of facilitating mental health referrals and making it easier for patients/clients to see us because we’re just down the hall or up a flight of stairs from the medical providers. It also ensures that we remain visible to medical providers and allows for us to easily demonstrate our value.

Short of this, and for those who are less interested in focused work in behavioral medicine, the following suggestions may be helpful:

1) Attend trainings. This is a crucial first step before mental health counselors can ethically market themselves as being knowledgeable about behavioral medicine. As an example, with rates of diabetes increasing, and associated adjustment and psychological sequelae common, learning all you can about the disease and strategies for managing it provides you with some expertise and a valuable referral option. This is consistent with current recommendations for branding a practice.

2) Develop a niche. Your services can be all the more compelling if you have developed a niche for yourself that fills a gap. Research your area and the specialties that mental health providers are marketing. Is there something missing? For instance, many providers may be offering care for people who are terminally ill, but are there providers specializing in working with young people in this situation? Are people who specialize in working with pediatric cancer also advertising services to treat siblings or affected parents?

3) Being mindful of your competence and expertise, connect with medical providers and let them know that you are accepting clients. For instance, if you work with children or adolescents, consider reaching out to pediatricians. Research consistently finds that the only linkage to care someone with mental illness may have is through his or her primary care physician. Providing these physicians with literature about your services makes it easy for them to pass along your information to anyone they think may benefit. Mental health counselors can connect with medical providers via personal visits to physicians’ offices or through direct marketing to professional organizations. Note that approaching small practices may be the better option because they are less likely to already be linked with another service (hospitals often have their own behavioral health clinics/providers).

4) Connect with specialty care providers. These providers tend to have greater need of mental health professionals who are familiar with a given diagnosis.

5) Don’t be afraid to contact a medical provider treating one of your clients. This can provide a means for collaborative care and could also serve to gain you credibility, while indicating that you are glad to take referrals. Clearly, this should be done only if clinically indicated and only with the client’s permission.

6) Finally, be prepared to describe your experience, training and competency areas in a brief fashion. In the busy world of medicine, time is quite valuable. Mental health providers’ skills in waxing poetic can get in the way of communicating the essence of what we want to get across.

Ethics

This article would be incomplete without a mention of ethics. Behavioral medicine is a field rife with ethical concerns. Perhaps the most salient of these is competence. From an ethical lens, it is critical that we, as mental health counselors, recognize the limits of our competencies — that is, we are not trained in medicine and thus cannot ethically diagnose a medical condition, recommend treatments that could be potentially harmful or assure patients/clients that medical evaluations or treatments are unnecessary. All of these actions require the input and monitoring of medical treaters, who can guide our efforts in care. Patients/clients also need to be clearly informed of both our benefits to and limitations in their care. The world of medicine changes rapidly, and the half-life of training in medicine and medical care is short. Ongoing education is critical.

Let’s return to the scenario described at the beginning of this article. The shared goal for all providers — medical, psychological and other — is to provide efficacious and meaningful care in a way that improves the patient’s health and quality of life. By utilizing our respective areas of training, competencies and strengths, we can better understand the context of symptoms, which can guide our care. This is the cornerstone of providing ethical care.

 

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

Jori A. Berger-Greenstein is an assistant professor at the Boston University School of Medicine and a faculty member in the mental health counseling and behavioral medicine program. She is an outpatient provider in adult behavioral health at Boston Medical Center, where she serves on the hospital’s clinical ethics committee. She also maintains a private practice. Contact her at jberger@bu.edu.

Letters to the editorct@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.

Assessing depression in those who are chronically ill

By Cathy L. Pederson, Kathleen Gorman-Ezell and Greta Hochstetler Mayer March 7, 2018

You receive a referral for a new client from a local physician. Great! As you review the materials, it is clear that the physician thinks the client’s issues are “all in her head.” Perhaps she is depressed. A good strengths-based and ecologically grounded counselor is just what she needs.

On the day of the first appointment, you wonder about this 24-year-old woman. You make a quick assessment upon meeting. Diane is pale, thin and has bags under her eyes. She looks exhausted and almost fragile. Yet she is neatly dressed in jeans and a T-shirt, and her light brown hair is pulled into a ponytail. She is not wearing makeup and is naturally pretty. She has an easy smile and is quite pleasant.

As you begin your work with Diane, you realize that a number of her complaints sound like the somatization of depression. She clearly suffers from fatigue. She has also struggled with insomnia the past several months, adding to her exhaustion. Diane reports a decreased appetite and has lost 10 pounds in the past couple of months without effort. Furthermore, she suffers from neuropathic pain in her legs — a chronic pain condition from abnormalities in the sensory nerves that often results in constant pain that may feel like explosions, stings or burning aches. In addition, she frequently has abdominal pain and headaches.

Because of these symptoms, Diane was often absent at work and was subsequently fired. She now relies on her parents for financial support and has moved back home. Diane is clearly depressed … or is she?

Overlapping symptoms

Many people suffering from invisible illnesses such as chronic fatigue syndrome, myalgic encephalomyelitis, Ehlers-Danlos syndrome, fibromyalgia, Lyme disease, mast cell activation disorder, postural orthostatic tachycardia syndrome (POTS) and Sjögren’s syndrome are first diagnosed, often incorrectly, as suffering from depression. Although troubling, this is understandable because the symptoms for these chronic illnesses overlap with somatic complaints associated with depression.

Many people in the general population who are depressed suffer changes in appetite, sleep and weight, and have increased fatigue and pain. Among individuals in the chronic illness community, these are common symptoms related to their physical illness. They may also suffer from other symptoms that make gainful employment or social relationships difficult. These symptoms include brain fog that makes concentration and processing of information challenging, orthostatic intolerance (increased symptoms when standing), exercise intolerance, joint subluxations and dislocations, severe allergic reactions to foods or chemicals, hot flashes, and muscle and joint stiffness or pain.

Many current depression screening instruments have at least a third of their questions related to somatization of depression. This can artificially elevate the depression score in those individuals with a chronic, invisible illness because of the physical symptoms they experience.

For instance, consider the free version of the Beck Depression Inventory. The last seven questions of this popular instrument ask about physical, rather than psychological, changes. Thinking about those with chronic invisible illnesses, imagine their scores for the following somatization of depression items.

  • I can work about as well as before (0). … I can’t do any work at all (3).
  • I can sleep as well as usual (0). … I wake up several hours earlier than I used to and cannot get back to sleep (3).
  • I don’t get more tired than usual (0). … I am too tired to do anything (3).
  • My appetite is no worse than usual (0). … I have no appetite at all anymore (3).
  • I haven’t lost much weight, if any, lately (0). … I have lost more than 15 pounds (3).
  • I am no more worried about my health than usual (0). … I am so worried about my physical problems that I cannot think of anything else (3).
  • I have not noticed any recent change in my interest in sex (0). … I have lost interest in sex completely (3).

There are 21 questions total on the Beck Depression Inventory, each ranging in point value from 0 to 3, with the higher numbers reflecting an increased possibility of depression. For how many of the seven questions above do you think that Diane might report a 2 or a 3 because of her physical ailments? If she chose the most severe response (a score of 3) for each of these seven questions, this would give her 21 points — placing her in the category of moderate depression on the Beck Depression Inventory — without even considering the first 14 questions on the survey.

It is important to realize that some clients who might appear moderately, severely or extremely depressed on a screening instrument such as the Beck Depression Inventory are actually suffering from an undiagnosed physical illness. We urge counselors to explore these somatic symptoms with their clients, particularly if the counselor notices an imbalance in the affective versus somatic parts of the instrument. With an integrated conceptualization of the person within her or his environmental context, counselors can go beyond addressing surface symptomology to explore underlying concerns.

Taking time to build a therapeutic alliance is critical, especially as many in the health care industry feel pressure from insurance companies to conduct quick patient exams. Unfortunately, many health care practitioners don’t get reimbursed for really listening to their patients and probing these multifaceted issues to arrive at a correct diagnosis. As counselors, you have the opportunity to give your clients something that they have been lacking — someone who is willing to take the time to truly listen and piece together the complexity of their problems.

Chronic illness and depression can be comorbid

Just as someone with chronic illness may not have depression, comorbidity of depression with chronic illness is possible and must be ruled out. There is a known link between chronic medical illness and depression for people with heart disease, cancer and a variety of other well-understood medical issues. Approximately 50 percent of people with chronic invisible illnesses also suffer from clinical depression. The trick is to separate those individuals with elevations purely from physical symptoms from those individuals who are truly depressed. There is a paucity of literature to guide clinical practice in this area.

Chronic illness encompasses more than just the physical symptoms. Many clients/patients become socially isolated because they can’t work or go to school. Friends and family members may slowly drift away as the illness drags on for months, years or decades. In the case of invisible illnesses, these clients often look “normal,” so it is not uncommon for people to completely dismiss their affliction. Many of these disorders are not well-understood, and a stigma can be attached to them that adds shame and guilt for being ill.

Poor treatment from health care workers can compound the problem. Many people with these illnesses have perfectly normal blood and urine tests, electrocardiograms and MRIs. If the tests are normal, then the symptoms must be “all in the person’s head,” right? Can people truly be suffering when traditional testing can’t find the cause? Many individuals working in the health care professions would say no. As a result, many of these patients are labeled as being high maintenance, and their own physicians may not believe that they are truly ill. Even for those individuals with a chronic or invisible illness who are not depressed, counseling can be important to increase their hope, improve their quality of life, help them gain perspective and help them work through social issues as they learn to deal with their new reality.

Properly diagnosing clinical depression for people with chronic illnesses is important, just as it is in the general population. Interestingly, not all people in the chronic illness community who die by suicide are clinically depressed. Research has shown that individuals with chronic invisible illnesses, particularly women, are at an increased risk for suicide. Some studies have reported that nearly 50 percent of people with POTS or fibromyalgia report suicidal ideation. Among those with chronic fatigue syndrome and myalgic encephalomyelitis, approximately 20 percent are at high risk for suicide. These are staggering numbers.

Although most counselors routinely assess for suicide, it is important to know that individuals with chronic invisible illnesses often do not present with the same symptomatology. Whereas most people in the general population who are suicidal tend to have comorbid depression, people with chronic invisible illnesses may not present this way.

Suicide risk factors for individuals with chronic invisible illness include loneliness, perceived burdensomeness and thwarted belongingness. The acquired capability for lethal self-injury is a critical area of risk to explore for those with chronic invisible illness due to repeated exposure to painful or fearsome experiences. These risk factors should be routinely assessed and worked into the treatment plan to target the underlying suicidality and reasons for living. Determining specific goals and objectives on the treatment plan, as well as providing regular check-ins on these topics, may help to decrease the risk of suicide.

The individual’s support system, including the treating physician, should also be made aware of the link between these risk factors and suicide. By facilitating this conversation between clients who are chronically ill and their support systems, some of the concerns related to loneliness, perceived burdensomeness and thwarted belongingness may be addressed proactively and conversely serve as protective factors rather than risk factors.

Counseling clients who are chronically ill

Many individuals with chronic illnesses need a safe place to vent their frustrations while receiving validation for their emotional, social and physical suffering, even if they are not clinically depressed. You may be the only person who believes them as they explain their symptoms and how the chronic illness impacts their daily life.

The therapeutic relationship and the ability to establish rapport are imperative to initiating change in the treatment process. Individuals with chronic invisible illnesses may benefit from individual therapy, couples or family-based interventions, multidisciplinary case coordination and group therapy with other people who are chronically ill. Integrating teletherapy or online therapy can ensure that these individuals, particularly those who are partially or completely homebound, have access to the care that they need.

Some people with chronic invisible illnesses struggle to get through the day. Because of their physical struggles, they often miss activities that they enjoy and may feel disconnected from their social circles. Feelings of loneliness and isolation may develop. As their illness progresses, individuals may require more assistance to perform tasks of daily living (e.g., showering, cooking, cleaning, shopping), which can lead to feelings of burdensomeness. As counselors, it is important to help these individuals find strong support networks and to provide psychoeducational information to the significant people in their lives. It is also crucial to assure these clients that they are resilient and have inherent value that is untouched by their illness.

Many individuals with chronic invisible illness are accurately diagnosed later in life. This fact illustrates how the course of chronic illness can impact the developmental process and quality of life at different stages. The diagnosis and ensuing disability can alter many of these individuals’ plans for the future, including college, career, family life and, at times, independence. This may cause them to redefine themselves within the scope of their chronic illness. Often, they must develop new roles in school, at work and within their families and friendships as they live within the confines of their health issues. As a result, their self-esteem and identity may be negatively impacted and must be addressed within the therapeutic context at different points in time.

This may be done by challenging negative self-talk, focusing on intrinsic motivation and using techniques such as radical acceptance, acceptance and commitment therapy, mindfulness-based stress reduction and a strengths-based, ecological perspective. By focusing on these individuals’ strengths, counselors may empower them to create new roles that will provide joy while also embracing the changes in their physical abilities.

In addition to the physiological changes that they are experiencing, clients who are chronically ill may simultaneously be going through the grief process. It is important for counselors to work with these clients to acknowledge the reality of the loss of their physicality, address feelings associated with their loss and help them to adjust to a new “normal.” Magical thinking often accompanies the process of grief and loss and occurs when an individual creates an improbable theory or belief system (often self-deprecating) around why a loss might have occurred. This often serves as an initial defense mechanism but can become detrimental over time. As a result, it is important for counselors to work with chronically ill patients to challenge any magical thinking that may be in place.

Finding normalcy after loss takes time. It is important to remind those with chronic invisible illnesses that there will be good days and bad days, while simultaneously working with them to instill hope for the future. Counselors can play a valuable role in helping people with chronic invisible illnesses to accept their physical limitations, while also empowering them to live rewarding and fulfilling lives.

 

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Cathy L. Pederson holds a doctorate in physiology and neurobiology. She is a professor of biology at Wittenberg University and is the founder of Standing Up to POTS (standinguptopots.org). Contact her at cpederson@wittenberg.edu.

Kathleen Gorman-Ezell holds a doctorate in social work. She is a licensed social worker and an assistant professor of social work at Ohio Dominican University. Contact her at gorma111wnek@ohiodominican.edu.

Greta Hochstetler Mayer holds a doctorate in counselor education and is a licensed professional counselor. She is CEO and initiated suicide prevention coalitions for the Mental Health & Recovery Board of Clark, Greene and Madison Counties in Ohio. Contact her at greta@mhrb.org.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Related reading, from the Counseling Today archives: “The tangible effects of invisible illness” by Cathy L. Pederson and Greta Hochstetler Mayer

 

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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.

 

Talking through the pain

By Laurie Meyers January 30, 2018

By the time the 43-year-old man, a victim of an industrial accident, limped into American Counseling Association member David Engstrom’s office, he’d been experiencing lower back pain for 10 years and taking OxyContin for six. The client, whose pain was written in the grimace on his face as he sat down, was a referral from a local orthopedic surgeon, who was concerned about the man’s rapidly increasing tolerance to the drug.

“He often took twice the prescribed dose, and the effect on his pain was diminishing,” says Engstrom, a health psychologist who works in integrated care centers.

The man’s story is, unfortunately, not unusual. According to the National Institutes of Health, 8 out of 10 adults will experience lower back pain at some point in their lives. As the more than 76 million baby boomers continue to age, many of them will increasingly face the aches and pains that come with chronic health issues. And as professional counselors are aware, mental health issues such as depression, anxiety and addiction can also cause or heighten physical pain.

Those who suffer from chronic pain are often in desperate need of some succor, but in many cases, prescription drug treatments or surgery may be ineffective or undesirable. Fortunately, professional counselors can often help provide some relief.

Treating chronic pain

At first, the client had only one question for Engstrom: “I’m not crazy, so why am I here?”

Although the man’s physician did not think that the pain was all in the man’s head, it is not uncommon for sufferers of chronic pain to encounter skepticism about what they are experiencing. “It was important … to defuse the idea that I might think he was imagining his pain,” Engstrom says. “So I [told him] that I accepted that his pain was real and that all pain is experienced from both body and mind. I told him that we would be a team and work on this together.”

Engstrom and the client worked together for five months. As they followed the treatment plan, the man’s physician slowly eased him off of the OxyContin.

Engstrom began by teaching the client relaxation exercises such as progressive muscle relaxation. “When in pain, the natural inclination of the body is to contract muscles,” Engstrom explains. “In the long term, this reduces blood flow to the painful area and slows the healing process. Contracted muscles can be a direct source of pain.”

Engstrom also began using biofeedback to promote further relaxation. In biofeedback sessions, sensors are attached to the body and connected to a monitoring device that measures bodily functions such as breathing, perspiration, skin temperature, blood pressure, muscle tension and heartbeat.

“When you relax, clear your mind and breathe deeply, your breathing slows and your heart rate dips correspondingly,” Engstrom explains. “As the signals change on the monitors, you begin to learn how to consciously control body functions that are normally unconscious. For many clients, this sense of control can be a powerful, liberating experience.”

As Engstrom’s client learned to control his responses, he began reporting a decrease in pain following the relaxation exercises.

Engstrom also used cognitive behavior therapy (CBT) methods, including asking the man to keep a daily journal recording his pain level at different times of the day, along with his activity and mood. Through the journal, the man started recognizing that his pain level wasn’t constant. Instead, it varied and was influenced by what he was doing and thinking at the time.

Engstrom highly recommends CBT for pain treatment because it helps provide pain relief in several ways. “First, it changes the way people view their pain,” he says. “CBT can change the thoughts, emotions and behaviors related to pain, improve coping strategies and put the discomfort in a better context. You recognize that the pain interferes less with your quality of life and, therefore, you can function better.”

In this case, the client was trapped by thoughts that “the pain will never go away” and “I’ll end up a cripple,” Engstrom says. He and the client worked on CBT exercises for several months, keeping track of and questioning the validity of such negative future thoughts. They also practiced substituting more helpful thoughts, including “I will take each day as it comes” and “I will focus on doing the best I can today.”

Chronic pain often engenders a sense of helplessness among those who experience it, Engstrom says, so CBT also helps by producing a problem-solving mindset. When clients take action, they typically feel more in control of their pain, he says.

CBT also fosters new coping skills, giving clients tools that they can use in other parts of their lives. “The tactics a client learns for pain control can help with other problems they may encounter in the future, such as depression, anxiety or stress,” Engstrom says.

Because clients can engage in CBT exercises on their own, it also fosters a sense of autonomy. Engstrom often gives clients worksheets or book chapters to review at home, allowing them to practice controlling their pain independently.

Engstrom notes that CBT can also change the physical response in the brain that makes pain worse. “Pain causes stress, and stress affects pain-control chemicals in the brain, such as norepinephrine and serotonin,” he explains. “By reducing arousal that impacts these chemicals, the body’s natural pain-relief responses may become more powerful.”

Although Engstrom acknowledges that he could not completely banish the discomfort his client felt, he was able to lessen both the sensation and perception of the man’s pain and give him tools to better manage it.

Taking away pain’s power

Mindfulness is another powerful tool for lessening the perception of pain, says licensed professional counselor (LPC) Russ Curtis, co-leader of ACA’s Interest Network for Integrated Care.

Mindfulness teaches the art of awareness without judgment, meaning that we are aware of our thoughts and feelings but can choose the ones we focus on, Curtis continues. He gives an example of how a client might learn to regard pain: “This is pain. Pain is a sensation. And sensations tend to ebb and flow and may eventually subside, even if just for a little while. I’ll breathe and get back to doing what is meaningful to me.”

Engstrom agrees. Unlike traditional painkillers, mindfulness is not intended to dull or eliminate the pain. Instead, when managing pain through the use of mindfulness-based practices, the goal is to change clients’ perception of the pain so that they suffer less, he explains.

“Suffering is not always related to pain,” Engstrom continues. “A big unsolved puzzle is how some clients can tolerate a great deal of pain without suffering, while others suffer with relatively smaller degrees of pain.”

According to Engstrom, the way that people experience pain is related not just to its intensity but also to other variables. Some of these variable include:

  • Emotional state: “I am angry that I am feeling this way.”
  • Beliefs about pain: “This pain means there’s something seriously wrong with me.”
  • Expectations: “These painkillers aren’t going to work.”
  • Environment: “I don’t have anyone to talk to about how I feel.”

By helping people separate the physical sensation of pain from its other less tangible factors, mindfulness can reduce the suffering associated with pain, even if it is not possible to lessen its severity, Engstrom says.

According to Engstrom, mindfulness may also improve the psychological experience of pain by:

  • Decreasing repetitive thinking and reactivity
  • Increasing a sense of acceptance of unpleasant sensations
  • Improving emotional flexibility
  • Reducing rumination and avoidant behaviors
  • Increasing a sense of acceptance of the present moment
  • Increasing the relaxation response and decreasing stress

Curtis, an associate professor of counseling at Western Carolina University in North Carolina, suggests acceptance and commitment therapy (ACT) as another technique to help guide clients’ focus away from their pain.

“ACT can help people revisit what their true values are, whether it’s being of service, having a great family life or creating art,” he notes. Encouraging clients to identify and pursue what is most important to them helps ensure that despite the pain they feel, they are still engaging in the things that give their lives meaning and not waiting for a cure before moving forward, Curtis explains.

Teamwork and support

In helping clients confront chronic pain, Curtis says, counselors should not forget their most effective weapon — the therapeutic relationship. Because living with chronic pain can be very isolating, simply sitting with clients and listening to their stories with empathy is very powerful, he says.

Counselors have the opportunity to provide the validation and support that clients with chronic pain may not be getting from the other people in their lives, says Christopher Yadron, an LPC and former private practitioner who specialized in pain management and substance abuse treatment. The sense of shame that often accompanies the experience of chronic pain can add to clients’ isolation, he says. According to Yadron, who is currently an administrator at the Betty Ford Center in Rancho Mirage, California, clients with chronic pain often fear that others will question the legitimacy of their pain — for instance, whether it is truly “bad enough” for them to need extended time off from work or to miss social occasions.

Curtis says it is important for counselors to ensure that these clients understand that the therapeutic relationship is collaborative and equal. That means that rather than simply throwing out solutions, counselors need to truly listen to these clients. This includes asking them what other methods of pain relief they have tried — such as supplements, over-the-counter painkillers, physical therapy, yoga or swimming — and what worked best for them, Curtis says.

The U.S. health care system has led many people to believe that there is a pill or surgery for every ailment, Curtis observes. This makes the provision of psychoeducation essential for clients with chronic pain. “Let them know there’s no magic bullet,” he says. Instead, he advises that counselors help clients see that relief will be incremental and that it will be delivered via multiple techniques, usually in conjunction with a team of other health professionals such as physicians and physical therapists.

Curtis, Yadron and Engstrom all agree that counselors should work in conjunction with clients’ other health care providers when trying to address the issue of chronic pain. Ultimately, however, it may be up to the counselor to put the “whole picture” together.

A 60-something female client with severe depression was referred to Engstrom from a pain clinic, where she had been diagnosed and treated for fibromyalgia. After an assessment, Engstrom could see that the woman’s depression was related to continuing pain, combined with social isolation and poor sleep patterns. The woman was unemployed, lived alone and spent most of her day worrying about whether her pain would get any better. Some of her previous doctors had not believed that fibromyalgia was a real medical concern and thus simply had dismissed her as being lonely and depressed. Despite finally receiving treatment for her fibromyalgia, the woman was still in a lot of pain when she was referred to Engstrom.

Engstrom treated the woman’s depression with CBT and taught her to practice mindfulness through breathing exercises and being present. Addressing her mood and sleep problems played a crucial role in improving her pain (insomnia is common in fibromyalgia). By dismissing the woman’s fibromyalgia diagnosis, discounting the importance of mood and not even considering the quality of her sleep, multiple doctors had failed to treat her pain.

Engstrom points out that in this case and the case of his client with lower back pain, successful treatment hinged on cognitive and behavioral factors — manifestations of pain that medical professionals often overlook.

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@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.

 

When brain meets body

By Laurie Meyers February 22, 2017

Chinese medicine has always acknowledged the link between the body and the mind. In Western medicine, from the time of the ancient Greeks through the Elizabethan era, the thinking was that four bodily humors (black bile, yellow bile, phlegm and blood) influenced mood, physical health and even personality. Shakespeare built some of his characters around the characteristics of the humors (such as anger or depression). It sounds faintly ridiculous, but the idea that good health came from a balance of the humors — in essence, that the physical and the mental were closely related — was not so far off the mark. Then along came René Descartes and dualism — the school of thought that says that mind and body are separate and never the twain shall meet, essentially.

In the past few decades, however, Western medicine has once again begun to acknowledge that the body and mind don’t just coexist, they intermingle and affect each other in ways that researchers are only beginning to understand.

Counselors, of course, are well-aware of the mind and body connection, but it is becoming increasingly evident that a person’s thoughts can directly cause changes in physiological processes such as the regulation of cortisol. This cause-and-effect relationship suggests that in some cases, symptoms typically considered psychosomatic in the past might actually be indicators of physical changes that are having or will have an effect on the client’s physical health.

Take, for instance, something that most people have experienced at some point in their lives: a “nervous” stomach. It turns out that having a “gut feeling” and “going with your gut” are not just metaphors. Researchers have begun to refer to the stomach as the “second brain” and the “little brain.”

Although no one is going to be making reasoned decisions or solving algebra equations with the little brain anytime soon, the enteric nervous system (ENS) does possess some significant brainlike qualities. It contains 100 million neurons and numerous types of neurotransmitters, including serotonin and dopamine. In fact, researchers have found that most of the body’s serotonin (anywhere from 90 to 95 percent) and approximately half of its dopamine are found in the stomach. The main role of the ENS is to control digestion, but it can also send messages to the brain that may affect mood and behavior.

Researchers are still teasing out whether (and how) the gut-brain conversation causes emotion to affect the gastrointestinal system and vice versa, but a major area of focus is the microbiome — the vast community of bacteria that dwell primarily within the gut. So far, research suggests that these bacteria affect many things in the body, including mood. Gut bacteria may directly alter our behavior; they definitely affect levels of serotonin. (For more discussion of the microbiome and its possible influence on mental health, read the Neurocounseling: Bridging Brain and Behavior column on page 16 of the March print issue of Counseling Today.)

The bacteria in the gastrointestinal system may also play a role in depression and anxiety. Digestive issues such as irritable bowel syndrome and functional issues such as diarrhea, bloating and constipation are associated with stress and depression. Some researchers believe a causal connection may exist that is bidirectional — meaning it is not always the psychological that causes the gastrointestinal problems but perhaps vice versa. Interestingly, research has shown that approximately 75 percent of people who have autism have some kind of gastro abnormality such as digestive issues, food allergies or gluten sensitivity.

Most people have heard the injunction to “think with your heart, not your head.” And in Western culture, the notion of heartbreak is commonly understood not just as an emotional metaphor but as an actual sensation of physical pain. Once again, these aphorisms and metaphors represent an instinctive understanding of another significant connection: that between emotion and the heart.

Coronary artery disease (CAD) is linked to emotion and mental health — depression in particular. Research indicates that 25 to 50 percent of people with CAD have symptoms of depression. Some experts believe not only that depression can cause CAD, but that CAD may cause depression. Increased activity in the amygdala is associated with arterial inflammation, and inflammation is a factor in CAD.

Research indicates that inflammation in the body plays some kind of role in many chronic diseases, including asthma, autoimmune disorders, chronic obstructive pulmonary disease, obesity and type 2 diabetes. Some researchers believe that inflammation may also be a causative factor in mental illness.

Letting go

If physical and mental health are so tightly bound, what role do counselors play in balancing the two? A vital role, believes licensed professional counselor (LPC) Russ Curtis, co-leader of the American Counseling Association’s Interest Network for Integrated Care.

Yes, counselors can help clients manage chronic health conditions and cope with stress and mental illness, Curtis says, but it’s the client-counselor relationship — the therapeutic bond — that he views as the most important element. He believes the simple act of listening, taking clients’ concerns seriously and becoming their ally can help jump-start their healing process. “Once you sit down and build a rapport with clients and treat them with respect and dignity, you are helping them heal,” says Curtis, an associate professor of counseling at Western Carolina University in North Carolina.

Curtis, who has a background in integrated care, doesn’t equate “helping” with “curing.” But he does believe that inflammation in the body strongly affects mental and physical health, and he says that counselors possess the tools to help clients ameliorate the factors that may contribute to inflammation.

For example, gratitude and forgiveness, and particularly letting go of anger, are essential to emotional wellness, and in some studies, Curtis says, they have been shown to have a physical effect. In one study, participants were instructed to jump as high as possible. Those who thought of someone they had consciously forgiven despite being wronged by them in the past were able to jump higher than participants who received no such instruction, he says. Another study found that cultivating forgiveness by performing a lovingkindness meditation produced a positive effect on participants’ parasympathetic systems.

Curtis, who also researches positive psychology, asks clients in his small part-time private practice to keep gratitude journals, which is something that he also does personally. In addition, he uses motivational interviewing techniques to help clients develop forgiveness.

If a client isn’t ready to forgive, the counselor might explore the ways in which anger may be affecting the person’s emotional and physical health and functioning in daily life, Curtis says. If the client is still resistant to the thought of issuing forgiveness, then the counselor can broach the idea of the client at least letting go of his or her anger, he adds.

Anger is particularly toxic to personal well-being, stresses Ed Neukrug, an LPC and licensed psychologist who recently retired from private practice, where he focused in part on men’s health issues. “Anger is a difficult topic for many clients to understand and address appropriately,” he says. “Usually, individuals who have angry outbursts have not learned to monitor their emotions appropriately. They most likely have had models who had similar outbursts. These individuals need to obtain a better balance between their emotional states and their thinking states.”

“Oftentimes, just teaching clients about mindfulness can be helpful because it begins to have them focus on what they are feeling,” continues Neukrug, a member of ACA and a professor of counseling and human services at Old Dominion University in Virginia. “Once they begin to realize that they have angry feelings, they can then talk to the person who they are angry at in appropriate ways, to reduce the anger and resolve the conflict early on. If they wait too long, they are likely to have an outburst.”

Anger, like stress, can cause physical changes in the body, such as a surge in adrenalin, cortisol and other stress hormones; raised blood pressure; and increased heart rate and muscle tension. Over time, as the body is constantly put into this “fight or flight” mode, the immune system may treat chronic stress or anger almost like a disease, triggering inflammation.

To help ameliorate the effects of toxic emotions, Neukrug recommends that counselors teach clients how to sit and engage in quiet contemplation. He notes that many people don’t realize that they are involved in a constant, almost unconscious, running mental commentary throughout the day. By taking time for self-reflection, clients can become better aware of how they are reacting to these thoughts, both emotionally and physically, and can then engage in stress reduction techniques such as progressive relaxation and mindfulness exercises.

Neukrug also recommends what he calls “life-enhancing changes” such as exercising, eating healthfully, journaling, confronting and resolving personal conflicts, and getting enough sleep. He also is a big proponent of nurturing personal relationships, taking regular breaks from work and going away on vacations to lessen the effects of stress.

Healthy habits

David Engstrom, an ACA member and health psychologist who works in integrative health centers, teaches his clients mindfulness exercises and recommends that they engage in daily gratitude journaling. But he also emphasizes a factor that is often overlooked despite its unquestioned importance to physical and mental well-being: sleep.

“It’s the first thing I focus on [with new clients],” he says. “There are few people who can be real short sleepers,” meaning less than six hours per night. “Most of us if we are [regularly getting] under seven hours a night have a higher risk of diabetes, obesity, heart disease, hypertension, chronic cardiovascular problems, depression and anxiety.”

Engstrom has his clients keep a sleep log detailing information such as the number of hours of sleep they get each night, when they went to sleep, how often they woke up in the night and the overall quality of their sleep. He also has them track their alcohol intake and physical exercise. He notes that exercise can vastly improve sleep quality, whereas drinking any alcohol after about 5 p.m. hinders sleep.

For clients who are having trouble falling asleep, Engstrom recommends mindfulness techniques such as being still and present in the bedroom and practicing deep breathing. He also sometimes gives clients MP3 files and CDs that contain guided mindfulness activities.

Counselors also can also play a role in changing clients’ health behavior for the better through psychoeducation, Curtis says. He recommends the use of simple cards that list information such as the benefits of smoking cessation or strategies for preventing or controlling diabetes. Curtis believes that clients are best served physically and mentally by integrated health care, a model in which a person’s physical and mental health needs can be attended to in one location by multiple professionals from different disciplines, such as LPCs and primary care physicians. He currently serves on two integrated care advisory boards for local mental health centers and also supervises students serving internships in integrated care settings.

When he practiced in integrated care, Curtis says a significant percentage of the clients he saw had not just mental health issues but also serious physical issues such as diabetes or cancer. “I was part of providing real support,” he says. “Instead of just having a 20-minute session with the doctor and being told what to do, clients were able to sit with me and process their fears and what they were feeling. I was also making sure that they understood what to take, where to go for bloodwork and making sure they didn’t feel lost [in the process].”

Neukrug uses a structured interview intake process in which he asks clients about their medical histories, any past or current issues with substance abuse and any experiences of major trauma. He has found that many clients are more likely to reveal issues such as a history of trauma or concerns about their physical health in written form rather than verbally. He notes that men in particular can be hesitant to raise common health-related issues with which they are struggling, such as erectile dysfunction, sexually transmitted diseases and prostatitis.

“Men [are] fragile about their egos,” he says. “If they have a disease that affects how they view their manliness or impairs them, they may just not want to talk about it. But any of these diseases can impact their relationships, their ability to earn an income, which is related to male identity and being the provider, so counselors just need to have that attitude that they are open to hearing about anything.”

Trauma’s toll on the body

Examining the health of adults who have experienced childhood abuse and neglect paints a particularly vivid portrait of the connection between physical and mental health. A large body of research — most of it using information gathered from the joint Centers for Disease Control and Prevention-Kaiser Permanente study “Adverse Childhood Experiences” (ACE) — has demonstrated that early exposure to violence and trauma can lead to significant illness later in life.

The initial study was conducted in 1995-1997 and surveyed 17,000 patients at Kaiser’s Health Appraisal Clinic in San Diego. Participants answered detailed questions about childhood history of abuse (emotional, physical or sexual), neglect (emotional or physical) and family dysfunction (for example, a parent being treated violently, the presence of household substance abuse, mental illness in the household, parental separation or divorce, or a member of the household who was engaged in or had engaged in criminal behavior). Respondents who reported one or more experiences in any of the “adverse” categories were found to be more likely to develop chronic conditions and diseases such as heart disease, obesity, cancer, chronic obstructive pulmonary disease, liver disease, depression, anxiety and other mental illnesses. The risk of developing these health problems also increased in correlation with the number of adverse incidents the study participants reported experiencing.

Although some of the health problems developed by adult survivors of trauma can be traced directly to injury or neglect, in many cases, specific cause and effect cannot be established. Nevertheless, the correlation between trauma and illness is significant, and some research findings — such as an increased incidence of autoimmune diseases among adult survivors of child abuse and neglect — suggest that the connection can be systemic and affect the entire body.

Causation versus correlation aside, clients who have experienced long-term trauma are often living with both mental and physical complaints, and the number of prospective clients who have a background of adverse childhood events may surprise some clinicians, say trauma experts. More than half of the ACE respondents reported experience with one adverse category, and one-fourth of participants had been exposed to two or more categories of adverse experiences.

Given the prevalence of traumatic exposure, ACA member Cynthia Miller, an LPC who has a private practice in Charlottesville, Virginia, believes it is important to ask about early childhood experiences as part of her intake process, and she urges other clinicians to do the same. She has clients fill out a written scale based on the questionnaire used in the ACE study. If clients indicate a history of abuse or neglect, Miller uses it as a way to explore how trauma has affected their lives.

“I think counselors need to know that trauma can affect the body in unexpected ways — ways in which the client may not even be aware,” Miller says. “I ask what impact they think these experiences had on their lives and then segue to asking, ‘What effect do you think this has had on your health?’”

Miller focuses on self-care practices for clients. For instance, clients might be using food to self-soothe, which can lead to obesity, diabetes and a whole host of other problems. Miller helps them to examine how the behavior is related to what they have been through and to identify what they are trying to soothe.

Miller also teaches her clients to tune in to their bodies. That can be extremely difficult because trauma survivors often use a kind of dissociation or “tuning out” as a survival mechanism, she explains. Clients who have been through physical trauma often exist, in essence, from the chin up, totally separating themselves from what is happening with their bodies, Miller says.

“Where in your body do you feel that anger?” Miller asks in trying to help them reestablish that whole-body connection. “Where do you feel the stress?”

According to Miller, yoga and mindfulness, particularly progressive muscle relaxation and diaphragmatic breathing, can be very useful for helping clients learn how to self-soothe and pay attention to how their bodies are responding to what they are doing.

On a more basic level, counselors can also play an essential role in ensuring that their clients get proper health care. “A lot of times I’ve found trauma patients don’t even go to the doctor,” Miller says. “Sometimes they may have issues with getting help, such as thinking there’s nothing they can do [to help the situation], and it all feels too hard. One of the questions I routinely ask is, ‘How long has it been since you had a good physical?’ If they say a year or more, I ask, ‘Would you go have one now? If not, why? What are your concerns? How can I help?’”

Miller says counselors can play an essential role in educating clients about the effects of trauma on the body and how that can cause chronic inflammation. Counselors can encourage clients to seek any needed medical care and also talk to them about what they can do personally to help counteract their bodies’ inflammatory responses, she says.

A partner in health

Another area where counselors can help clients with their physical health is by talking with them about why it is important to take medication, Miller says. She notes that in the general population, only about 50 percent of people who are prescribed medications for chronic conditions take them regularly. Counselors can uncover the legitimate concerns that get in the way of treatment compliance, Miller continues, such as the complexity of the regimen, whether the client has adequate access to obtain needed medication or treatment, and whether the client has easy access to the basics such as food, shelter and water.

It is also important for counselors to explore clients’ in-depth thoughts and feelings related to treatment, Miller says. For example, do they even believe in taking medication, or do they simply dislike taking pills?

Once counselors uncover the reasons that a client might not be adhering to medical regimens or engaging in healthy behavior, they should also consider whether the client is even ready to make a change, says Miller, adding that she finds motivational interviewing helpful in this regard.

Counselors can also help clients break down the change into small steps. For instance, Miller says, “When you talk about exercise, people think you are automatically talking about 60 minutes on the treadmill or kickboxing. [But] what is reasonable? If a person is very depressed, maybe you start [the process] in session. If it’s a decent day outside, can you do the session outside and maybe take a walk?”

Clients also need to be made aware that change is often slow, Miller says. If they did five minutes of exercise this week and didn’t exercise the week before, that five minutes is worth celebrating, she says.

Miller also works with clients on sleep hygiene, including tracking how much caffeine they ingest, how late in the day they stop consuming caffeine and the amount of sugar they eat. “Are they setting a sleep time?” asks Miller. “Are they being exposed to blue light? Is there a TV in the bedroom?”

She also helps clients develop a pre-bedtime routine and, if they have trouble going to sleep, encourages them to get up and do something boring until they feel sleepy again.

“If they are still having disrupted sleep and nightmares [even with sleep hygiene], I refer to a physician,” Miller says. “I’m not against someone taking a sleep medication if all other routes have failed because not getting sleep becomes a self-perpetuating cycle.”

Miller, like the other experts interviewed for this story, is an advocate for integrated care because it provides a more complete picture of — and a stronger connection between — clients’ physical and mental health. “If we have counselors who are embedded in primary care, we get a better picture of the client,” she says. “If we are separate, we’re not necessarily going to hear about how long they’ve been struggling with obesity or keeping their blood sugar down. We might not know that they’ve told the doctor that they’re struggling to take medicine regularly.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association.

Counseling Today (ct.counseling.org)

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Wellness” by Dodie Limberg and Jonathan Ohrt
  • “Complex Trauma and Associated Diagnoses” by Greg Brack and Catherine J. Brack

Books and DVDs (counseling.org/publications/bookstore)

  • Relationships in Counseling and the Counselor’s Life by Jeffrey A. Kottler and Richard S. Balkin
  • A Counselor’s Guide to Working With Men edited by Matt Englar-Carlson, Marcheta P. Evans and Thelma Duffey
  • Stress Management: Understanding and Treatment (DVD) presented by Edna Brinkley

Podcast (counseling.org/knowledge-center/podcasts)

  • “The Brain, Connectivity and Sequencing” with Jaclyn M. Gisburne and Jana C. Harr

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

Letters to the editor: ct@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.