Tag Archives: chronic illness

Attending to tummy troubles

By Lauren Mirkin September 24, 2015

Most of our clients come to us for help with relationship difficulties, work-related stress, persistent anxiety, chronic depression or other well-researched and commonly encountered challenges. Most of us feel that our education and experiences have effectively prepared us to deal with these conditions. Armed with a time-tested array of evidence-based strategies, we confidently set out to help our clients work toward productive relationships, satisfying work experiences and greater equanimity.

But in talking to other counselors, I have found that many of them feel ill equipped to help clients who present with more physically based concerns that are interfering with their quality of life. What about clients who are frequently late to work or don’t feel they can go out with friends because they never know when they will need to find a bathroom immediately? What about the 25-year-old client who has a little-known condition called gastroparesis? How would you help her balance the need to puree or blend all of her food with her desire for an active dating and social life?

The previous examples illustrate a cluster of disorders known as functional gastrointestinal disorders, or FGIDs. These are problems marked by persistent, recurring symptoms — such as gas, bloating or loose stools — that result from abnormal function of the gastrointestinal (GI) tract without any underlying physiological problem such as a growth or hormone imbalances.

How can counselors help? There are several ways.

Clarify and validate: Many clients with FGIDs are sent to a therapist by their medical practitioners when medication, procedural or surgical treatment options have not helped or are not indicated for their condition. The unspoken message is, “I, as your doctor, cannot find anything medically wrong with you, so it must be in your head.” The subtle — or sometimes not-so-subtle — implication is that this person has stomach troubles because she or he is so stressed out and overwhelmed by life.

Medical professionals do not often educate patients about the nature of FGIDs or point out the existence of evidence-based psychological treatments that may help them manage the condition. Mental health professionals, on the other hand, have a different view. Psychologist Barbara Bradley Bolen, author of the book Breaking the Bonds of Irritable Bowel Syndrome, writes, “Despite the prevalence of IBS [irritable bowel syndrome], most people feel fairly alone in their suffering. The effort to cover up symptoms and the corresponding feelings of shame and embarrassment can serve to further exacerbate those very symptoms and the discomfort that goes along with them.”

To help clients over these difficult feelings of doubt, counselors can work to validate and normalize clients’ symptoms and experiences, educate them about the nature of FGIDs and suggest strategies to help alleviate their suffering. I have had clients who have broken down in tears of relief during our first session, happy that they have finally found someone who understands what they are going through and who is prepared to offer workable solutions to ease their distress and misery.

Acknowledge the mind-body aspect: In their groundbreaking book Trust Your Gut, physician Gregory Plotnikoff and health psychologist Mark Weisberg write about the new science of psychoneuroimmunology, the study of mind-body interactions. Their work reflects a growing recognition in recent years among medical experts of the interconnectedness of the body and mind. They write, “We approach the treatment of gut issues from the premise that the mind and body are all part of an integrated system. … The most surprising insight is that our brain does not distinguish between what is physical and what is psychological. It creates the same neurohormonal responses either way. This new perspective allows a completely different way of looking at the problems of gastric distress. More important, it makes it possible to find new solutions.”

Many clients and, unfortunately, many medical professionals, think only in a linear and one-dimensional way about FGIDs. Here is a common line of advice offered by doctors: “First, try medication. Then add fiber or a fiber supplement. If that doesn’t work, go to a dietician so she or he can ‘fix the problem’ by providing a regimen of food restrictions.” The flaw in this approach is that a functional disorder always has both physical and psychological components.

In addition to being a licensed clinical professional counselor, I am a clinical nutritionist. In that role, I help patients with supplement or dietary recommendations that may be indicated for their FGIDs. When wearing my counselor hat, however, I have seen firsthand how some clients with FGIDs feel embarrassed about being encouraged to seek out a mental health professional for what they perceive to be a physical problem. Therefore, it is important to help clients understand that FGIDs, like many other health problems, are multifaceted and must be approached from various angles, including the angle of mental health. By looking at the problem in this way, clients ideally will come to understand that the mental health professional may be only part of the solution and that their nutritionist, physician and perhaps other team members might have roles to play as well. In the great majority of cases, a team approach is most effective.

That said, counselors who are trained in empathic listening and who practice Carl Rogers’ unconditional positive regard can be hugely beneficial to clients with FGIDs. Many of these clients have been talked down to, lectured at and even blamed for their gastro distress. Many have been told it is all in their head and that they are simply too stressed or overwhelmed. Many have felt attacked or accused by family members, friends, colleagues or health professionals. A counselor who is paying attention with compassion, seeking to understand the person’s discomfort and attempting to connect both emotionally and cognitively with the distressed client can be a wonderful catalyst, providing the healing space needed to help the client begin to get well.

Teach self-monitoring skills: Within the therapeutic relationship, the counselor can provide information to help destigmatize the FGID, which reaffirms for the client that it is perfectly normal to feel stressed about symptoms that seem unresponsive to medical treatment. Additionally, counselors can play an important role in helping clients establish an effective and personalized style of self-monitoring that will aid them in developing more insight and objectivity related to their condition. This is valuable in helping clients identify factors that increase or decrease their symptoms. Self-monitoring in this way can be analogous to using worksheets or logs to help a client with depression or anxiety. Margaret Wehrenberg, in her book The 10 Best-Ever Depression Management Techniques, recommends identifying triggers as the first technique to use with clients who are struggling with depression. A similar approach, applied in the context of the steps mentioned previously, may be appropriate for FGIDs.

Jeffrey Lackner, a research psychologist at the University of Buffalo Behavioral Medicine Clinic, has written a self-help book called Controlling IBS the Drug-Free Way in which he suggests that clients first track their symptoms in a daily IBS diary. Specifically, he recommends that clients should note when symptoms occur and what triggers them. In addition, he recommends that clients use a daily stress worksheet to write down stressful situations, thoughts related to what was happening during the situation and techniques that were used to cope. He believes it is important for clients to monitor their symptoms for several reasons. “Tracking your symptoms will help you identify more subtle triggers of your symptoms and how you respond to them,” he writes. He then adds, “Monitoring creates a little distance between you and your symptoms so that you can see the big picture more clearly.”

Recommend relaxation training: Another way counselors can support these clients is by introducing, demonstrating and helping to monitor a regular program of relaxation training. Lackner suggests controlled breathing, muscle relaxation and visualization exercises.

Many clients with FGIDs have a chronically activated fight-or-flight stress response. As Lackner writes, “Diaphragmatic breathing … activates the part of the nervous system that puts a brake on the fight-or-flight response. It’s impossible to be physically relaxed and stressed at the same time, so that by controlling your breathing patterns you override the physical part of stress that can aggravate bowel symptoms.”

The authors of Trust Your Gut also include relaxation in their programs and recommend that patients work on getting grounded, a term they define as “being calm, centered, relaxed and focused.”

Offer or recommend hypnosis: Counselors can also assist clients with FGIDs through the use of hypnosis. Clinical psychologist Olafur Palsson, an expert in hypnosis for gastrointestinal disorders, writes, “Clinical hypnosis is a method of inducing and making use of a special mental state where the mind is unusually narrowly and intensely focused and receptive. In such a state, verbal suggestions and imagery can have a greater impact on a person’s physical and mental functioning than otherwise is possible.”

Palsson also states that during the past 15 years, research has shown that hypnosis can influence gastrointestinal functioning in powerful ways and is particularly effective in helping patients with IBS. In a study at the University of Sweden, for example, researchers found a 40 percent reduction in symptoms of IBS and observed long-term relief even for the most severe symptoms. What intrigued the researchers was not only the high percentage of patients who got relief but also the cost-effectiveness of the intervention. The hypnosis sessions took place in a regular health center, so there was no need for patients to attend a specialized treatment center.

Palsson offers an encouraging outlook on hypnosis for gastrointestinal functioning: “This benign and comfortable form of treatment will hopefully become a more popular treatment option for GI patients — especially for those who have not received much relief from standard medical management.”

Offer cognitive behavior therapy: Charles Burnett, nationally known for his work with patients suffering from chronic illness, says, “Cognitive behavioral therapy [CBT] is not a cure for functional gastrointestinal disorders, but the tools and skills developed during therapy can dramatically reduce the stress of coping with a chronic condition.” Importantly, Burnett points out, “CBT helps to shift functional GI symptoms to the background, so patients can experience decreased depression, reduced anxiety and improved quality of life.”

Furthermore, in a 2013 review study published in the World Journal of Gastroenterology, the researchers concluded, “There is increasing evidence for the efficacy of CBT in alleviating the physical and psychological symptoms of IBS, and it has been recommended that it should be considered as a treatment option for the syndrome.”

Note that studies have found not only psychological benefits from CBT but physical ones too. Again, the mind-body connection is paramount. Here’s an example of how this can play out: Many people who suffer from FGIDs worry about finding a bathroom in time to avoid an embarrassing accident in public. CBT can give these clients tools to help lessen their stress, which in turn may ease their actual physical symptoms.

In particular, CBT is often used in cases of IBS — one of the most common forms of FGIDs — because it enables clients to overcome cognitive distortions related to their symptoms. To help clinicians recognize all-or-nothing or absolutistic thinking, Bolen offers the example of a client who maintains the irrational thought that her symptoms are completely unpredictable and unmanageable. Bolen suggests that once this person learns to identify triggers, she will better understand when and how her IBS is likely to manifest, and she will be better equipped to deal with the unpleasant symptoms.

Most counselors are trained in the basic tenets of CBT and should be able to effectively help FGID sufferers with this therapy. In recognition of this, a 2007 review article in Psychosomatics emphasized the “great need” for FGID behavioral specialists.

Conclusion

My hope is that as a result of this article, counselors will feel more confident in helping clients with FGIDs by drawing upon evidence-based therapies ranging from relaxation training to CBT. It is gratifying to know that we possess the knowledge, training and skill to help alleviate the suffering of those coping with this debilitating and frequently misunderstood health condition.

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Lauren Mirkin is a licensed clinical professional counselor and licensed dietitian/nutritionist. Contact her at laurenmirkin@gmail.com.

Letters to the editor: ct@counseling.org

Techniques for counseling clients who have chronic pain

By Betsy Farver-Smith July 27, 2015

Clients or patients facing chronic pain require a special counseling approach that can be applied universally, no matter their source of pain or the number of months or years they have tried to deal with the pain. We have honed and practiced these techniques at the Betty Ford Center in Rancho Mirage, California, because many of the patients we see for addiction treatment also experience chronic pain.

Chronic pain and addiction do not necessarily co-occur, but there are some strong correlations. Unfortunately, because pain medication can be addictive, it is common (but not certain) to find patients with the combined condition of chronic pain and addiction. All people who abuse alcohol or other drugs experience chronic emotional pain. According to an article published by Jennifer Sharpe Potter and colleagues in the Journal of Substance Abuse Treatment in 2010, chronic physical pain affects approximately 60 percent of those struggling with alcoholism or addiction.

At the Betty Ford Center, we have a special treatment program, developed by Dr. Peter Przekop, for both chronic pain and addiction. Regarding chronic pain alone, we have learned several critical counseling techniques that help patients move forward.

Determining if an individual has chronic pain issues

Treatment, of course, begins with an assessment and diagnosis. Sometimes clients or patients will not present their chronic pain as a factor in the reason they are seeking counseling. However, certain markers will help you identify whether the person is dealing with chronic pain. Look for:

1) Symptoms of depression

2) A history of adverse events, including physical abuse, emotional abuse, sexual abuse, a bad accident or a high level of past stress

3) High present stress

4) Anxiety

5) A catastrophizing mindset — a belief that if things can go wrong, they will go wrong

A key part of your assessment is to understand any and all physical pain issues. This detailed inquiry will aid the development of your treatment plan.

There is likely to be related emotional pain as well. Often that emotional pain has early life trauma as its origin. Your assessment and treatment must take this into account. In a national survey of 1,009 chronic pain sufferers completed in 2014 by the Hazelden Betty Ford Foundation, we found a disturbing, though not unexpected, correlation between early life trauma and chronic pain. The chart below lists the top incidents of early life trauma among the survey participants.

One of the most dramatic findings in the national survey was that 97.1 percent of chronic pain sufferers had experienced at least one instance of physical or emotional trauma prior to their chronic pain. We believe this early trauma experience often trains the person’s brain to be more receptive to future chronic pain in a way that does not lead easily to treatment relief. Therapy that helps the chronic pain patient understand, accept and forgive these earlier traumas may help heal the pain center of the brain and make it less receptive to chronic pain.

Counseling techniques

1) Practice being patient with those who are dealing with chronic pain. Inexperienced counselors should know that it is not easy to sit with someone in chronic pain. Many of us in this profession can be caretakers. With clients or patients who have chronic pain, we can tend to want to take away their pain right away. Be prepared instead for a lengthy process. The longer you can comfortably tolerate sitting in session with a client or patient in chronic pain without trying to fix it, minimize it or talk about something else, the more that person will build trust with you. The client or patient will begin to feel that you don’t regard his or her pain as either imaginary or a burden, as the person may have sensed that others have done.

Extended acknowledgment of the pain and listening for the roots of the trauma or concurrent emotional pain builds a capacity within the client or patient for self-exploration and self-awareness. This longer process also helps the client or patient look inward instead of outward, which will benefit the overall therapy process.

2) Offer clients (or refer them to) group therapy in addition to your individual counseling. Unfortunately, a frequent characteristic of people with chronic pain is a tendency to isolate themselves. Because the pain has lingered and feels severe, these individuals talk about it often and intensely with family members and friends. In turn, they have likely eventually experienced being “tuned out.” These clients decide that nobody can relate to what they have gone through. Worse, they may reach an unhealthy conclusion: “My pain is imagined. I’m a wimp. I must be crazy.”

Group therapy, particularly in a community of others dealing with chronic pain, can reduce these clients’ or patients’ sense of loneliness, shame and isolation and help them feel they are not alone. By seeing other chronic pain sufferers who are further along in the process of emotional recovery, your client or patient will gain hope that the day might come when he or she will experience less pain.

Individual counseling provides a different benefit, which is why I recommend both types of therapy concurrently. I begin by recognizing with the patient that pain is pain. By this I mean that our minds and bodies are one unit, and pain will register as pain regardless of whether it is physical or emotional. Emotional pain is just as valid and just as much a contributor to chronic pain as is a medical condition that affects the body. For example, chronic knee pain can be influenced by the pain of unresolved emotional pain.

In this way, it becomes the primary focus of individual therapy to gather information from the client about unresolved emotional pain. As a counselor, you must witness that emotional pain and validate it. Out of this discussion emerges a real gift for the client: a new level of positive self-acknowledgment and self-esteem.

3) Consider adding mindfulness exercises. In addition to traditional emotional counseling, we provide mindfulness training to our patients at the Betty Ford Center who are experiencing chronic pain. Patients spend time in group settings each day becoming aware of how chronic pain has changed their way of thinking, coping and judging themselves and others. Patients learn how to restore normal brain function, in part by working on planned movement exercises that have been taken from the disciplines of tai chi, qigong, kung fu and yoga. Manual medicine and acupuncture also are key parts of the treatment mix. These additional treatment approaches allow patients to learn to refocus attention and help them gain strength, flexibility and confidence. Mindfulness exercises also allow the patients to slow down their minds, control their thoughts and gain a sense of presence. Pain literally steals this ability from people.

Group settings for mindfulness exercises can be helpful as chronic pain sufferers share new skills on how not to focus on the physical pain. Mindfulness helps these patients know where in their bodies they tend to carry the emotional pain from the past. Is it in the same place where they feel the physical pain or elsewhere, such as in the stomach? Patients will come to the realization, for example, that they have internalized and physicalized emotional pain.

4) Help clients learn not to judge the pain. Physical pain is intensified by the person’s judgment of the pain. For example, if your client or patient has a “bad back” and suddenly feels a twinge in the back muscle, that person could spend a significant amount of emotional and mental energy assessing or judging that pain. How much did that hurt? Will it come back? How does it compare with past pains? If you teach clients not to judge or assess the pain, but rather to move on and refocus on something positive, it can actually lessen the sensation of physical pain.

5) Look for signs of chemical addiction. As mentioned earlier, there is, unfortunately, a strong correlation between chronic pain and addiction. Often the addiction is attributable to the pain medication. Your clients or patients may be reluctant to address this issue. I have heard patients say, “I can’t possibly be addicted. After all, these medications were prescribed to me by a doctor.” Or they will say to me, “Addicts live under bridges. I am far from that!” Remember, denial and resistance are typical responses of addicted personalities.

In our 2014 national survey, 48.2 percent of those studied were taking at least three concurrent pain medications prescribed for their chronic pain situation. More than one-third (35 percent) thought they were drug dependent because of the chronic pain treatment. Given that people are reluctant to admit addiction, this number likely is underreported.

The most common drugs prescribed for chronic pain are opioids, which are highly addictive. Likewise, there are more negative consequences for opioid use than for any of the other prescribed pain drugs. For instance, our study showed that half of patients taking opioids for chronic pain said they had suicidal thoughts. Opioid use (through legal prescriptions) reportedly caused multiple problems that counselors should understand and address with their clients who are dealing with chronic pain. The chart above, taken from our national survey, lists some of those negative consequences.

6) For follow-up as counseling ends, consider recommending more group therapy. As mentioned earlier, group therapy is an excellent treatment for patients with chronic pain because it puts them in contact with others who are learning ways to cope with the pain. For this reason, after concluding individual counseling with a client or patient, a good ongoing support to suggest would be a chronic pain group.

When making recommendations, avoid two specific types of chronic pain groups. The first is a group in which members are still reliant on medication. We have seen too many patients come to the Betty Ford Center addicted to their pain medication yet still in chronic pain. Medication complicates and often defeats recovery from chronic pain. The second is a group focused on one specific type of pain. In these groups, patients may end up comparing symptoms and aches and pains rather than continuing to move forward with emotional self-exploration and learning new coping skills.

If your clients or patients have chemical addiction issues, I recommend that they participate in a 12-step recovery group. This group will help them focus on recovery from substance abuse, while simultaneously helping them heal related emotional pain issues that pertain to chronic pain.

A proven approach

We use these counseling techniques at the Betty Ford Center. We possess the benefit of treating the patient daily for anywhere from 45 to 60 days, compared with typical counseling schedules of once or twice weekly. We believe this intensity of treatment leads to exceptional results. Retrospective case reviews show that 74 percent of our pain management patients report being free of pain a year after concluding treatment.

This is why we feel so strongly about these suggested counseling techniques for chronic pain. Even if the counseling sessions you provide are less frequent, we believe these techniques will promote healing of the chronic pain and make your clients more emotionally available to address other issues that are causing them difficulty in life.

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Betsy Farver-Smith holds a master’s degree in addiction counseling from the Hazelden School of Addiction Studies. She has been with the Betty Ford Center for 13 years. Her positions include serving as the executive director of clinical services, and she was recently appointed executive director of philanthropy for the Hazelden Betty Ford Foundation. Contact her at bfarver@hazeldenbettyford.org.

Letters to the editor: ct@counseling.org