Tag Archives: integrated care

Using your integrated behavioral health toolbox

By David Engstrom May 3, 2017

People with common medical disorders who visit their primary care physicians have high rates of behavioral health concerns, including diabetes, chronic pain, obesity, sleep disorders and heart disease. Obesity is one of the biggest drivers of preventable chronic diseases and health care costs in the United States. Currently, estimates for these costs range from $147 billion to nearly $210 billion per year. The annual cost of chronic pain is estimated to be as high as $635 billion a year, which is more than the yearly costs for cancer, heart disease and diabetes.

Clearly, there are far more serious outcomes and higher health care costs if these problems aren’t addressed in a unified way. This is where counselors can play a very important role. Consider the following scenario.

 

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Alfonso, a 36-year-old Hispanic male, was referred to you for counseling for depression. He has had increasing depression for the past 10 years. He reports a history of severe physical and emotional abuse from both parents when he was young. He is unmarried, has no close relationships and says, “I always feel alone.” He has no suicidal thoughts or plans, but he describes feelings of hopelessness, lack of energy and thoughts of discouragement and despair. He has been on antidepressant medication for seven years and says it “helps a little.”

Alfonso is 5 feet 10 inches tall and weighs 310 pounds. This equates to a body mass index (BMI) of 44.5 (a BMI of 30 or greater is considered obese). He ingests a large amount of fast food each day. Alfonso previously worked in construction but noticed that even with his active job, he was frequently “dog-tired” all day long and felt like he would “just love to sleep.” His average total sleep time is four to five hours per night.

About three years ago, Alfonso fell on his job site and injured his lower back. He has had several back surgeries but claims that they “didn’t help at all.” He reports still feeling moderate to severe pain every day. He is currently taking oxycodone, an opioid pain medication, at 15 milligrams every six hours and is on long-term disability.

Alfonso has no hobbies or interests, and because he is not currently working, he spends most of each day watching television and drinking beer. By his estimate, he drinks “six to eight beers a day.” He is not a smoker and says that he does not use other drugs.

During your initial interview with Alfonso, he appears very tired and generally unmotivated for treatment. He asks, “Why am I seeing a counselor and not a real doctor?” He appears to have average intelligence but very little insight into how his health problems may be affecting his depression and his life in general. He feels very little control over his health and thinks that he just needs “some new medicine” to help him.

The biopsychosocial perspective

How many times have you seen clients such as Alfonso and gotten so involved in their abuse histories, psychological issues and diagnoses that you ignored the obvious? Sometimes the “mental health” or “psychosocial” view of counseling gets in the way of assessing the biopsychosocial aspects of our clients. (For more information on the biopsychosocial perspective developed by George Engel and John Romano, see tinyurl.com/mcqdyqb.)

If you see clients privately or at any facility, you are bound to encounter people with stories similar to Alfonso’s. Although his scenario may seem exaggerated, the reality is that behavioral health problems often have a substantial impact on clients.

Consider the following facts and figures.

Sleep: According to the National Sleep Foundation’s inaugural Sleep Health Index, 45 percent of Americans report disrupted sleep patterns that have negatively affected their daily life over the past seven days. Some of the study’s biggest takeaways: Among 74,571 adult respondents in 12 states, 35.3 percent (more than 26,000 people) reported getting less than seven hours of sleep during a typical 24-hour period; more than 35,000 reported that they snored; and almost 29,000 reported falling asleep during the day at least once over the past month. More than 3,500 respondents acknowledged either drifting off or falling asleep while driving.

According to Harvard Medical School, chronic sleep problems affect 50 to 80 percent of patients in a typical psychiatric practice and are particularly common in patients with anxiety, depression, bipolar disorder and attention-deficit/hyperactivity disorder. Chronic sleep problems may raise the risk for, and even directly contribute to, the development of some psychiatric disorders.

Pain: Nearly 50 million American adults have significant chronic pain or severe pain, according to The Journal of Pain. New research suggests that people who have chronic pain are also more likely to suffer from problems such as depression, anxiety, lack of sleep and trouble focusing.

Obesity: According to the annual report The State of Obesity, a project of the Trust for America’s Health and the Robert Wood Johnson Foundation, 35.7 percent of U.S. adults are considered to be obese, and more than 1 in 20 (6.3 percent) have extreme obesity. For
state-by-state data, see stateofobesity.org/adult-obesity.

Obesity is frequently accompanied by depression. In fact, the two can trigger and influence each other. Although women are only slightly more at risk than men for being obese, they are much more vulnerable to the obesity-depression cycle. In one study, obesity in women was associated with a 37 percent increase in major depression, according to the American Psychological Association. There is also a strong relationship between obesity in women and more frequent thoughts of suicide. For more information on this research, see cdc.gov/nchs/products/databriefs/db167.htm.

Given the findings in each of these areas, it is vitally important for counselors to have the tools available to help their clients thrive. Returning to the scenario of Alfonso, we will see how integrated behavioral health care can bring more clarity to his situation.

Best office practices

This is my toolbox of practices that I have found most useful with clients.

Motivational interviewing: Motivational interviewing is loosely defined by the Motivational Interviewing Network of Trainers as “a particular kind of conversation about change.” It refers to a counseling approach developed in part by clinical psychologists William R. Miller and Stephen Rollnick. Motivational interviewing is nonjudgmental, nonconfrontational and nonadversarial. For integrated care, this style of interviewing has many benefits, including instilling hope, confidence and action in our clients. It empowers clients to take a more active role in their health, far removed from the passivity that the usual “doctor’s advice” elicits.

I use motivational interviewing techniques daily in both my office and in hospital settings. I have found them to be very useful for helping clients reduce ambivalence and take more responsibility for important behavior changes. The main goals of motivational interviewing are to engage clients, elicit change talk and evoke motivation to make positive changes from clients. For example, change talk can be elicited by asking the client questions such as “How might you like things to be different?” or “How does ______ interfere with things that you would like to do?”

The spirit of motivational interviewing can be summarized as follows:

1) Motivation to change is elicited from the client and is not imposed from outside forces.

2) It is the client’s task, not the counselor’s, to articulate and resolve the client’s ambivalence.

3) Direct persuasion is not an effective method for resolving ambivalence.

4) The counseling style is generally quiet and elicits information from
the client.

5) The counselor is directive in that he or she helps the client to examine and resolve ambivalence.

6) Readiness to change is not a trait of the client but rather a fluctuating result of interpersonal interaction.

7) The therapeutic relationship resembles a partnership or companionship.

The four general processes involved in motivational interviewing are:

1) Engaging: Used to involve clients in talking about issues, concerns and hopes, and to establish a trusting relationship with the counselor.

2) Focusing: Used to narrow the conversation to habits or patterns that clients want to change.

3) Evoking: Used to elicit client motivation for change by increasing clients’ sense of the importance of change, their confidence about change and their readiness to change.

4) Planning: Used to develop the practical steps that clients want to use to implement the changes they desire.

For more information, go to motivationalinterviewing.org.

The role of self-monitoring: Self-monitoring is an important technique in all of the areas this article discusses because it a) gives clients the responsibility to actively observe and record their behavior, b) makes clients more aware of the effects of interventions on the variable being monitored and c) puts clients more in control.

There is strong research evidence that the mere act of self-monitoring and recording can significantly change behavior. In my practice, I always find something for the client to track (behaviors, thoughts or emotions) on a regular basis. As is the case with motivational interviewing, this gives more of the responsibility for behavior change to the client.

Measuring self-efficacy: Albert Bandura’s concept of self-efficacy can be applied quite well to clients who need to focus on changing some important aspects of their behavior, including exercise, smoking, alcohol use, sleep management and behavior changes, to reduce pain.

Self-efficacy refers to the degree to which a person feels confident, effective and successful in managing his or her health or life. My contention is that motivational interviewing should increase a client’s self-efficacy, so I often use the simple measure shown below (in the box below) to track the client’s motivation, confidence and readiness to change. I frequently request that the client fill this out on a daily basis for two weeks.

Results from this scale can provide a realistic benchmark of client progress and can be shared with other members of the behavioral health care team.

 

Sleep

Sleep problems are often the most common symptoms that clients discuss with their primary care physicians. Optimal sleep duration for adults of all ages is 7.5 to 8.5 hours per night. Adolescents need a bit more and older adults a bit less. The average American adult gets only about six hours of sleep per night.

Poor sleep can be a result of any combination of physical conditions, psychological disorders, work shift changes or poor sleep habits. People who are sleep deprived may have profound daytime sleepiness and often fall asleep immediately when they go to bed.

Integrated health care team: Sleep disorders center, primary care physician, counselor

Alfonso’s view: We already know that Alfonso estimates his sleep at four to five hours per night. He admits to profound daytime sleepiness and feels “tired all the time.” He doesn’t understand the causes of his poor sleep.

Assessment for Alfonso: Many clients presenting with depressive or anxiety disorders have coexisting sleep issues that can easily make their symptoms worse. Alfonso might have insomnia, partly because of his depression or pain, or he might have obstructive sleep apnea (OSA), which is often related to being overweight or obese. In fact, sleep apnea has been observed in as many as 95 percent of obese males. A complete sleep study should be performed for Alfonso.

I always ensure that clients are screened for OSA prior to further intervention. If no OSA is present, it is important to ask these clients a few general questions about their sleep patterns, such as how long they sleep on the average night, whether they feel rested during the day and if they are concerned about sleep. Sleep problems are not that obvious, so it is always important to ask about them, especially during your initial evaluation with clients. Sleep problems can be either a cause or an effect of other biopsychosocial conditions.

To pursue this further, you might suggest that clients keep a simple sleep log. Have them keep daily records of these sleep-related events for one week:

1) Physical exercise (type/duration/timing)

2) Naps (number and total time)

3) Medication for sleep (drug and amount)

4) Time they went to bed

5) Minutes to fall asleep

6) Number of awakenings

7) Wake-up time

8) Total hours asleep

9) Sleep quality rating (on a scale of 0-10, with 0 being the worst possible and 10 being the best possible)

10) Daytime alertness rating (on a scale of 0-10)

11) Obsessing about sleep (on a scale of 0-10)

Potential interventions: After obtaining Alfonso’s data for a week or more, go over it with him, paying particular attention to challenging areas. The most important part of this intervention is to educate Alfonso regarding some rules of healthy sleep, including continuing to self-monitor his sleep, reducing his caffeine and alcohol use, maintaining a regular sleep schedule, increasing his physical activity (especially later in the day), controlling his sleep environment and taking some time to “unwind” his brain in the evening. In addition, the most popular evidence-based intervention for this issue is cognitive behavior therapy for insomnia (for more information, see sleepfoundation.org/sleep-news/cognitive-behavioral-therapy-insomnia).

Pain

It can sometimes be difficult to identify if clients are having sleep problems, but clients with chronic pain are usually much more forthcoming and their issues with pain are obvious. Acute pain is a normal sensation triggered in the nervous system to alert you to possible injury and the need to take care of yourself, but chronic pain is different. Chronic pain persists — pain signals keep firing in the nervous system for weeks, months or even years. This kind of pain often continues well after the normal healing time for any injury or tissue damage that might have occurred.

Chronic pain can be mild or excruciating, episodic or continuous, merely inconvenient or totally incapacitating. The clients we see as counselors are much more likely to have chronic pain. Research suggests that 40 to 50 percent of chronic pain clients suffer from depressive disorders.

In his important analysis, Dr. John Loeser described the four major components of pain: nociception, pain, suffering and pain behaviors. Nociception is the sensory process that provides the signals that lead to pain. This occurs through nociceptors, which are primary sensory neurons that are activated by stimuli that cause tissue damage. Pain, as described by the International Association for the Study of Pain, is “an unpleasant sensory and emotional experience associated with actual or potential tissue damage, or described in terms of such damage.”

It is suffering, not pain, that brings patients into doctor’s offices in hopes of finding relief. Chronic pain is far more than a sensory process, however, so we must maintain the biopsychosocial model of chronic pain if we are to provide effective health care to our patients and clients. Pain behaviors may communicate to others that a person is experiencing pain. These behaviors include resting, shifting positions, guarding, grimacing, asking for help, taking medication and other observable behaviors.

As Loeser has pointed out, every client with chronic pain may be unique in his or her presentation. For instance, many chronic pain sufferers demonstrate pain behaviors without having any physical findings of tissue damage. There are also many cases of people who show pain and suffering without nociception (for example, phantom limb pain).

In the case of chronic pain, many studies have shown that gradual increases in physical activity can actually improve a person’s functioning and reduce his or her pain.

Integrated health care team: Pain physician, physical therapist, primary care physician, counselor

Alfonso’s view: Since his injury, Alfonso has undergone several surgeries to his lower back with no apparent benefit. He feels moderate to severe pain “all the time.” Opioid medication and rest seem to be the only things that help. Alfonso is very inactive and isolated and has “nobody to talk to.”

Assessment for Alfonso: Because it sounds like Alfonso has chronic benign pain, it is important to observe him closely as you talk with him. Does he grimace, shift positions, guard parts of his body or look uncomfortable?

Have Alfonso self-monitor his daily pain levels over the next week or two. Does he show variations in that level at different times of the day or during various activities?

You might also have Alfonso assess his level of self-efficacy. A high level of self-efficacy is beneficial when people are confronted with acute or chronic pain. One reason for this is that individuals who are highly self-efficacious may be more motivated to engage in health-promoting behaviors and adhere better to treatment recommendations because they have higher expectations of performance success. They are also less likely to give up an activity when facing barriers (e.g., pain), which may prevent them from becoming trapped in the negative spiral of activity avoidance, physical deconditioning, loss of social support and depression. Finally, perceived self-efficacy can positively affect the body’s opioid and immune systems.

Potential interventions: Given that Alfonso received no benefit from surgery and is stuck on fairly high doses of opioid pain medications, you might consider several options for psychosocial interventions. Weight loss often helps people with pain, so this might be an early goal. You might suggest a strategy to help Alfonso slowly increase his physical activity, perhaps including use of a wearable activity monitor. You could also work with his pain physician to develop a schedule of gradual “fading” or reduction of Alfonso’s opioid drugs, accompanied by training Alfonso in muscle relaxation, imagery and cognitive behavioral strategies for pain reduction. You can assist the health care team by suggesting nonmedical approaches.

Obesity

Obesity may be the most important focus of attention in Alfonso’s complex case. We have seen that obesity affects sleep dramatically, and extra weight only makes pain problems worse. Given that all three of these problems contribute directly to depression, it is important to select one issue for intervention.

Integrated health care team: Bariatric physician, primary care physician, dietitian, counselor

Alfonso’s view: Alfonso shows little concern about his weight, claiming that he comes from a “fat family.” His sedentary habits and consumption of fast food and beer can be important targets here.

Assessment for Alfonso: Asking Alfonso to keep a journal of his eating and exercise patterns would be a reasonable starting point. Weekly monitoring of weight is also important.

Potential interventions: Motivational interviewing is a very powerful tool for discussing areas of change. In Alfonso’s case, this might include taking small steps toward healthier eating and increasing his level of exercise. Because of Alfonso’s isolation, simply developing a helping relationship with him may be beneficial in and of itself.

Putting it all together

Clients who present with primary psychological problems and issues often have underlying behavioral health problems that may have an effect on their psychological functioning. Using the biopsychosocial model, it is possible to identify those problems and offer focused counseling that involves motivational interviewing, client self-monitoring and assessment of self-efficacy.

In Alfonso’s case, there were many areas of concern — obesity, sleep problems, pain, social isolation and alcohol/drug misuse — that could be improved through counseling. Regardless of the complexity of the case, these areas are always worth exploring carefully.

 

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

David Engstrom is a board-certified health psychologist in Scottsdale, Arizona. He trained and supervised counselors and counseling psychologists for 20 years at the University of California, Irvine. Currently, he is a full-time core faculty member in counseling at the University of Phoenix, where he teaches integrative health care, motivational interviewing and mindfulness meditation techniques to counseling students. Contact him at drengstrom@email.phoenix.edu.

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.

What counselors can do to help clients stop smoking

By Bethany Bray November 29, 2016

Nearly half of the cigarettes consumed in the United States are smoked by people dealing with a mental illness, according to the Substance Abuse and Mental Health Services Administration. The federal agency says that rates of smoking are disproportionately higher — a little more than double — among those diagnosed with mental illness than among the general population.

It is widely accepted that the nicotine in cigarettes is highly addictive, but people struggling with mental health issues often turn to cigarettes for reasons that go beyond their addictive qualities. For instance, many people smoke as a coping mechanism to deal with difficult feelings. In addition, despite their negative health effects, cigarettes are still largely viewed by society as an “acceptable” addiction in comparison with other substances.

The reality? “[Smoking] is a devastating addiction and a difficult one to quit,” says Gary Tedeschi, clinical director of the California Smokers’ Helpline and a member of the American Counseling Association. “This clientele [those with mental illness], in particular, need the encouragement and support to go forward [with quitting], and many of them want to, despite what people might think. … To let people continue to smoke because ‘it’s not as bad’ [as other addictions] is missing a really important chance to help someone get healthier.”

To drive home his point, Tedeschi points to a statistic from the 2014 release of The Health Consequences of Smoking — 50 Years of Progress: A Report of the Surgeon General, which says that more than 480,000 people die annually in the United States from causes related to cigarette smoking. Close to half of the Americans who die from tobacco-related causes are people with mental illness or substance abuse disorders, Tedeschi says.

In Tedeschi’s view, the statistics connecting smoking to mental illness are “so obvious that it’s almost an ethical and moral responsibility to help this population quit.”

Part of a package

Ford Brooks, a licensed professional counselor (LPC) and professor at Shippensburg University of Pennsylvania, says he has never had a client walk in to therapy with a primary presentation of wanting to stop smoking.

Tobacco use “is always part of a package” that clients will bring to counseling, Brooks says. In his experience as an addictions counselor, smoking is often piled on top of a laundry list of other challenges that may include alcohol or drug addiction, depression, a marriage that is on the rocks, the loss of a job or financial trouble.

“They’re on the train to destruction, and their nicotine use, in their minds, is on the back end [in terms of importance]. … Is the smoking related to what their presenting issue is? Chances are it probably connects somehow. Don’t be afraid to bring it up,” advises Brooks, co-author of the book A Contemporary Approach to Substance Use Disorders and Addiction Counseling, which is published by ACA.

Tedeschi, a national certified counselor and licensed psychologist, notes that many people who call the California Smokers’ Helpline are struggling with comorbid conditions or mental illness in addition to tobacco use. The phone line is one in a system of “quitlines” operating in each of the 50 U.S. states, the District of Columbia, Puerto Rico and Guam.

For clients struggling with mental health issues, smoking may serve as a coping mechanism to deal with uncomfortable feelings or anxiety, Brooks says. Years ago, when smoking was still allowed in many indoor spaces, Brooks led group counseling in detox, outpatient and inpatient addictions facilities. “When powerful emotions would come up in group, [clients] would fire up cigarette after cigarette to deal with those feelings and quell anxiety,” he recalls.

With this in mind, counselors should help prepare clients for the irritability, anxiety and other uncomfortable feelings they are likely to experience when they attempt to stop smoking cigarettes. “Talk about what it will feel like to be really anxious and not smoke” and how they plan to handle those feelings, Brooks says. “… If a person has anxiety or depression and stops smoking, what initially happens is they could get more depressed or more anxious without nicotine to quell the emotion.”

The counselors interviewed for this article urge practitioners to ask every single client about their tobacco use during the intake process, no matter what the person’s presenting problem is. “If you’re helping them to get mentally and physically healthier, this [quitting smoking] is a very critical part of the overall wellness picture,” Tedeschi says.

Counselors shouldn’t be afraid to ask their clients whether they smoke, says Greg Harms, a licensed clinical professional counselor (LCPC), certified addictions specialist, and alcohol and drug counselor with a private practice in Chicago. “It can feel weird the first couple of times, especially if this is not your area of expertise,” says Harms, who does postdoctoral work at Diamond Headache Clinic in Chicago, an inpatient unit for people with chronic headaches. “A lot of times, clients have heard all the bad stuff about smoking. A lot of them, deep down, they know they’d be better off if they were to quit smoking. They may have failed so many times in the past that they’re discouraged. They might be hesitant to bring it up because this is a counselor and not the [medical] doctor. If you bring it up, more often than not, the client is going to engage with that. Even if they don’t, if it’s not the right time for them, you’ve planted that seed. … It might come to fruition down the road. I’d much rather plant that seed than not say anything at all.”

When Harms was a counseling graduate student, he completed an internship at the Anixter Center, a Chicago agency that serves clients with disabilities. While there, he worked as part of a grant-funded program for smoking cessation for people with disabilities that was spearheaded by the American Lung Association. He also presented a session titled “Integrating Smoking Cessation Treatment with Mental Health Services” at ACA’s 2013 Conference & Expo in Cincinnati.smoking

If a client doesn’t feel ready to begin the quitting process right away, the counselor can put the topic on the back burner to address again once the client has made progress on other presenting problems or has forged a stronger relationship with the practitioner. However, that shouldn’t mean that the topic is off the table completely, Harms says. A counselor should talk regularly with the client about quitting smoking, even if it’s only for a few minutes each session.

“Give them a little nugget of information [about quitting], and then you can focus on what they’re there for,” Harms says. “Help them find ways to deal with their presenting problem, then they’ll trust you. Once they’re in a better place, revisit [the idea of quitting]. We don’t have to address it and get their buy-in during the first session. It would be fantastic if that was the case, but it’s OK if it’s not. In most cases, time is on our side to develop the relationship, plant the seed and revisit it. If the client is not ready, we can harp on [quitting] all we want, [but] it won’t do anything.”

“You really have to take the client’s lead and go at the pace they’re willing,” Harms continues. “Don’t push. Respect their decision. Even if they’re not ready for [quitting], let them know that [you’re] there for them and respect their autonomy to make that decision.”

Positioned to help

Counselors are particularly suited to help clients quit smoking because the profession has an array of tools focused on behavior modification, Tedeschi asserts. Motivational interviewing, cognitive behavior therapy, acceptance and commitment therapy, and other models can be useful in helping clients stop smoking. But techniques from any therapy model that counselors are comfortable using can be adapted to help clients navigate the challenge of quitting, Tedeschi says, especially when combined appropriately with pharmacologic aids approved by the Food and Drug Administration.

“We’re in the business of helping people change. The principles that a counselor uses to help someone understand an issue and begin to make steps toward change apply to smoking cessation as well,” Tedeschi says. “Counselors help people understand their motivation to change and help them come up with a plan to change.”

Harms agrees, noting that in most cases, a counselor will have significantly more time with a client than a medical professional will. Instead of “hitting [the client] over the head” with the dangers of smoking, Harms says, a counselor can afford to focus on the positive, use a strengths-based approach and build on what the client wants to work toward rather than what he or she wants to avoid.

“We [counselors] are so strengths-based. It’s our natural inclination to tell the client, ‘Yes, you’re strong enough to do this,’ rather than [taking] a scare approach,” Harms says. “We can find their strength and have that unconditional positive regard for them, regardless of how long it’s taking. We have the patience to sit with a client as they’re going through [quitting]. We can build that relationship and be a resource.”

Start small

Tedeschi recommends that counselors use the “five A’s” to discuss smoking with clients. In this approach, a practitioner should:

  • Ask each client about his or her tobacco use
  • Advise all tobacco users to quit
  • Assess whether the client is ready to quit
  • Assist the client with a quit plan
  • Arrange follow-up contact to mitigate relapse

Each of these steps is important, but providing support and follow-up as the client begins to quit is particularly critical, Tedeschi says.

“The first week of quitting is the hardest. If [a counselor] waits for a week to talk to the client, you could lose about 60 percent of people back to relapse,” he says. “If someone is able to quit for two weeks, their risk of relapse drops dramatically.”

If clients resist the idea of quitting or do not feel ready to quit entirely, Tedeschi suggests that counselors work with them to stop smoking for one day or even just an afternoon. During this time, have clients monitor how they felt: How was their anxiety level? What were their cravings like? This technique can introduce the idea of stopping and prepare clients for the quitting process, he says.

Brooks recommends using motivational interviewing to help clients make the life change to quit smoking. “Nicotine is a drug, and it’s no different than if [clients] were to say they want to stop drinking. Work with their motivation to identify what they can possibly do for that,” he says.

Part of the quitting process involves clients going through an identity shift, Tedeschi notes. Clients can be behaving as nonsmokers — abstaining from cigarettes — long before they make the mental leap that they are no longer smokers, he says. It is important for clients to make that mental shift from “a smoker who is not smoking” to a “nonsmoker,” Tedeschi says. Counselors need to work with these clients to identify as and accept the nonsmoker label. “As long as someone calls [himself or herself] a smoker, they will be open to turning back to cigarettes,” he explains.

Kicking the habit

Counselors can use the following tips and techniques to better equip clients to meet the challenge to stop smoking.

Set a quit date. This is an important step, but one that clients must take the lead on and choose for themselves, Tedeschi says. Research shows that simply cutting back without setting a quit date isn’t very effective, he adds. The behavioral patterns that often accompany smoking (for example, smoking after eating or taking smoke breaks at work) make it very hard to keep tobacco use at a low level. Setting a quit date creates accountability and is a “sign of seriousness,” he says. At the same time, be flexible. “For some people, it’s just too hard to think about [sticking to a quit date],” Tedeschi says. “For some — especially those who are struggling with other substances — they need to take one day at a time.”

Be aware of psychotropic medications. Counselors should be aware that if clients are taking prescription medicines for anxiety, depression, bipolar disorder or other mental illnesses, their dosages might need to be adjusted as they quit smoking. Nicotine is a stimulant, so it speeds up a person’s metabolism. This means a person who smokes will burn through psychotropic medications faster than someone who doesn’t smoke, Harms explains. Counselors should be certain to talk this through with clients and work with their doctors to modify their dosages, he says. “This is especially noticeable with mood stabilizers. It’s acute with bipolar disorder,” Harms says.

The same holds true with caffeine, Tedeschi notes. After they quit smoking, clients may notice that they get jittery from caffeine and may need to cut back on their coffee intake.

Use cognitive strategies. Counselors can help clients create a list of personal reasons why they want to stop smoking — beyond the health implications, Tedeschi says. The list doesn’t need to be long, but the reasons need to be compelling and motivating enough to carry clients through a nicotine craving. For example, one of Tedeschi’s clients wanted to quit because his young grandson asked him to. As a reminder, the client kept a toy car that belonged to his grandson in his pocket. “When he had a craving [for a cigarette], he would pull [the toy car] out of his pocket, look at it, hold it and squeeze it,” Tedeschi says. “It helped.”

Turn over a new leaf. As they quit smoking, encourage clients to organize, clean and purge their homes and cars of smoking-related materials such as ashtrays, advises ACA member Pari Sharif, an LPC with a practice in Franklin Lakes, New Jersey. That action will help clients turn a new page mentally and start fresh, she says. Sharif also encourages clients to air out their homes and clean their closets so their clothes and furniture no longer smell like smoke.

On a similar note, if clients have a certain mug that they always use to drink coffee while smoking, Harms suggests that they get a new mug. Or if they always stopped at a certain gas station to buy cigarettes, he suggests that they now change where they buy gas.

When cravings strike, breathe. Sharif, a certified tobacco treatment specialist, introduces breathing techniques to all of her smoking cessation clients. She asks these clients to take measured breaths for roughly two minutes, inhaling while slowly counting to four, then exhaling for four counts.

“Instead of the reflex habit to grab a cigarette, take a moment to stop and ask why. Be more in control of yourself and your mind,” she tells clients. “Pause to do breathing and body scanning from head to toe. Ask yourself, ‘What am I doing? Why do I need this [cigarette] to calm down?’ … [Through breathing exercises,] your breath becomes deeper and deeper. Close your eyes. Your body starts relaxing and your anxiety level goes down.”

Sharif also recommends that clients download a meditation app for their smartphones and use a journal to record how they’re feeling when cigarette cravings strike. This helps them log and identify which situations and emotions are triggering their need for nicotine,
she explains.

Get to the root of it. Asking clients about the circumstances that first caused them to start smoking can help in identifying what triggers their nicotine use and the bigger issues that may need to be addressed through counseling, Sharif says. In some cases, a specific traumatic event or stressor caused the person to start smoking. In other instances, it was a learned behavior because everyone in the household smoked as the client was growing up. “Find out when they started smoking and why,” Sharif says. “Gradually, when they become more aware of themselves, they quit.”

Change social patterns. Cigarettes are often used as a coping mechanism when people experience anxiety in social situations, Harms says, so clients may need to focus on social skills as they start the process of quitting smoking.

“[Cigarettes] are their way to socialize and get out and meet people. If you have social anxiety, you can still go up to someone and ask for a cigarette or ask for a light. It’s programmed socialization,” Harms explains. “It gives you an excuse to be close to people, feel more sociable. If you take away their cigarettes, you’ve got to replace that.”

Brooks agrees, noting that clients who smoke likely have friends who are also smokers. For example, he says, it is not uncommon to see people smoking and talking together outside of Alcoholics Anonymous meetings. Counselors can help clients prepare to avoid situations where smoking is expected and practice asking people not to smoke around them, Brooks says. Counselors can also support clients in creating social networks of people who don’t smoke, including support groups for ex-smokers, he adds.

Break behavioral habits. Similarly, Brooks says, counselors can help clients change the behavioral habits they connect to smoking, such as starting the morning by reading the paper, drinking coffee and smoking a cigarette. Counselors can suggest activities and new rituals to replace the old ones, such as taking a daily walk, he says.

Harms encourages clients to replace their former smoke breaks with “clean air breaks.” They can still take their normal time outside, but instead of smoking, he suggests that they walk around the block, sit and read a book, eat an apple or use their smartphones outdoors. If they had a favorite smoking spot outside, he urges them to find a new place to go instead.

Find comforting substitutes. “The whole ritual of lighting up a cigarette — tapping the pack to pull out a cigarette and flicking the lighter — the behaviors that go with [smoking] can be very comforting,” Harms says. “Sometimes that’s what’s so hard to break — the behaviors that go with it.”

Tedeschi recommends that counselors work with clients to have comforting alternatives ready to go even before the clients attempt to quit smoking. It is hard for people to figure out alternatives in the heat of the moment when a craving strikes, he explains. Tedeschi offers several possible substitutes for consideration: sugar-free gum, beef jerky, cinnamon sticks and even drinking straws cut into cigarette-sized lengths through which clients can inhale and exhale.

If clients are comforted by having something in their hands, Brooks suggests keeping a pen, stress ball or prayer beads nearby. Staying hydrated and carrying a water bottle can also help these clients, Tedeschi adds. Most of all, counselors should work toward the idea of replenishment and filling in where clients feel they are losing something, he says.

Don’t dismiss pharmacotherapy. A wide variety of quitting aids are available, from nicotine patches, lozenges and gum, to prescription pills such as Chantix. The counselors interviewed for this article agree that these stop-smoking aids can be helpful when used alongside counseling. However, Tedeschi says, counselors should work with their clients’ physicians when such medications are being used, or make sure that clients are talking with their physicians. Counselors should also be aware of the potential side affects that these medications can have, such as aggressive behavior.

Brooks notes that none of these options is a magic solution to quit smoking. For example, nicotine gum and other medications can be prohibitively expensive, and some clients can continue to smoke even while using nicotine patches or gum. As for electronic cigarettes, Sharif and Harms agree that they are not a recommended alternative. Electronic cigarettes are carcinogenic, addictive and mimic the “puffing” behavior of regular smoking, Harms notes.

Connect clients with other supports. Counselors should equip clients with resources they can turn to outside of counseling sessions, such as local support groups for ex-smokers or the phone number for their state’s tobacco quitline, Brooks suggests. Nicotine Anonymous (nicotine-anonymous.org) is an ideal resource for clients who are trying to stop smoking, Brooks says. The 12-step method at Alcoholics Anonymous (AA) can also be applied to tobacco use for clients who attend AA meetings already or who don’t have a Nicotine Anonymous support group in their local area, he adds.

Sharif suggests that counselors keep brochures and other information about quitting smoking alongside the materials they might have about depression or suicide prevention in their offices or waiting rooms. It is better for counselors to distribute information that they have vetted themselves rather than having clients search the internet for information on their own, she notes.

 

Try and try again

On average, it takes a smoker 10-12 attempts to fully quit cigarettes, according to Tedeschi. For that reason, it is imperative that practitioners not give up on clients after their first, second or even 10th try, he stresses.

Quitting smoking is hard, Tedeschi acknowledges, but possible with perseverance. “Don’t be discouraged as a clinician if your client relapses. [Quitting] is definitely not a one-time event; it’s a process. … Relapse prevention is important, but it’s equally important to be ready for the relapse,” he says. “One of the best things a counselor can give a client is that reassurance. Any attempt to quit for any length of time is a success rather than a failure. That’s just the reality of this addiction. As long as they keep trying, they’ll get there. The only failure is to stop trying. The most important message a counselor can give a client is to never give up.”

 

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Statistics: Smoking and mental health

  • Roughly 50 percent of people with behavioral health disorders smoke, compared with 23 percent of the general population.
  • People with mental illnesses and addictions smoke half of all cigarettes consumed in the U.S. and are only half as likely as other smokers to quit.
  • Smoking-related illnesses cause half of all deaths among people with behavioral health disorders.
  • Approximately 30-35 percent of the behavioral health care workforce smokes (versus 1.7 percent of primary care physicians).

— Source: U.S. Substance Abuse and Mental Health Administration (see bit.ly/1sEx97a)

 

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Resources

 

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

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.

The tangible effects of invisible illness

By Cathy L. Pederson and Greta Hochstetler Mayer April 26, 2016

A variety of invisible illnesses can greatly impact both the physical and mental health of individuals. Some of these illnesses are debilitating, preventing participation in the normal activities of daily living. Examples include chronic fatigue syndrome/myalgic encephalomyelitis, Ehlers–Danlos syndrome, fibromyalgia, lupus, Lyme disease, multiple sclerosis, myasthenia gravis, postural orthostatic tachycardia syndrome (POTS), regional complex pain syndrome and Sjogren’s syndrome.

These disorders disproportionately affect women and are not well understood by the health care Branding-Images_invisibleestablishment or the general community. Lack of understanding can lead to feelings of alienation and hopelessness for those suffering from these disorders.

Such was the case for Natalie (case study used with permission). Seemingly overnight, she transformed from a vivacious teenager at the top of her eighth-grade class to being virtually bedridden with fatigue, dizziness and chest pain. She visited a series of doctors in search of relief. A few months later, at age 15, Natalie’s life changed forever when she was diagnosed with POTS and Ehlers–Danlos syndrome, neither of which is curable or easily managed medically.

POTS is a disorder of the autonomic nervous system in which blood pressure, heart rate, blood vessel and pupil diameter, peristaltic movements of the digestive tract and body temperature are affected. Natalie’s Ehlers–Danlos syndrome caused additional pain — her connective tissues were weak and her joints would easily dislocate. During her freshman year of high school, Natalie was bound to a wheelchair. But as a sophomore, her dizziness and other symptoms were better controlled, so she went roller-skating with friends. She broke her wrist and injured her neck that evening, and her fall triggered debilitating migraines.

Although not widely studied, rates of suicide are believed to be higher in people with chronic or terminal illness. It is unclear if physical illness alone leads to risk of suicide or whether having an illness increases the chances of developing depression or hopelessness, which then increases suicide risk.

Painful, chronic illnesses and illnesses that interfere with a person’s everyday functioning are believed to be risk factors for suicide, especially among older adults. Some illnesses associated with increased suicide risk are AIDS, certain forms of cancer, Huntington’s disease and multiple sclerosis.

Risk of suicide is often linked with co-occurring mood, anxiety and substance use disorders in this population. However, people with invisible illnesses may not necessarily be clinically depressed or anxious; instead they may feel hopeless about their prognosis, experience real and anticipated future losses, and suffer from chronic pain — all of which are potent risk factors for suicide. The basic science of these individuals’ physical condition is not well understood, which makes developing medications to treat them difficult. Most treatments are aimed at individual symptoms rather than the root cause of the problem.

It takes Natalie three times more energy than normal just to stand because of her POTS. Even making minor movements around the house and engaging in daily routines, including eating meals and showering, can be exhausting for her and increase her symptoms. Her quality of life is similar to those with congestive heart failure or chronic obstructive pulmonary disease.

At 16, Natalie endured weeklong hospitalizations for headaches and other POTS symptoms. Medications didn’t offer relief. An honor student, Natalie missed more than 70 days of school during the last half of her sophomore year. She was no better by the end of her junior year and eventually dropped out of high school. She was behind in her work and struggled to complete projects and tests that would have been easy for her when she was healthy. “It was heartbreaking,” said Natalie’s mother about seeing her daughter transform from high achiever to high school dropout.

Natalie’s family had done everything right. They took her to see physicians, followed all prescribed treatment regimens, put her in counseling and supported her through her illness. Unfortunately, medical help was evasive and mental health care was marginal. Over time, Natalie’s friends drifted away. She couldn’t be physically active, participate in community events or hold a job. Eventually, she confronted insidious suicidal thoughts.

Working with those who are chronically ill

Many chronic illnesses are not terminal conditions, but they can severely impact a person’s quality of life for decades. For example, imagine that you have POTS. You feel lightheaded every time that you stand, and you faint several times per day. You experience neuropathic pain that feels like bees stinging your arms and legs. Hot flashes arrive without warning, and you begin to sweat. Despite possessing above-average intelligence, you have difficulty concentrating and analyzing problems. Simply taking a shower drains your energy, and it doesn’t replenish itself. Your physical isolation and illness create feelings of being misunderstood and not belonging.

These feelings only increase when you finally venture out of the house. People congratulate you on your “recovery.” Friends tell you how good you look. Distant relatives offer advice about how to get better. Even worse, you are bullied, called a faker or are the target of other derogatory comments. Your boss suggests that you would feel better if you only ate right and exercised. Even your spouse says, “Just get over it!”

Counselors should not fall into these traps when working with these clients. For someone who is chronically ill, even hearing “you look good” might be equivalent to “I don’t believe that you are really sick.” Normal niceties take on special meaning and ring hollow for those with chronic illnesses.

For most people, a doctor’s visit will result in control of their illness and restoration of their health. This isn’t true for many individuals suffering from chronic, invisible illnesses. Not only are they grieving their loss of health because of their physical condition but, often, they also feel dismissed and even traumatized by their health care practitioners.

Many with chronic illness feel ignored or abandoned by doctors and nurses. Some individuals have even been told to stop fainting or to bring down their heart rate, as if they are making choices meant to curry attention. Many physicians aren’t educated about these debilitating illnesses, and specialists in these fields often have waiting lists that are years long. Imagine how such repeated, negative experiences might erode hope for recovery and lead to suicidal thinking. What is a patient to do? In the case of those with POTS, the incidence of mental illness is the same as is found in the general population. The seemingly paranoid behavior these individuals demonstrate related to their health can be the result of medical mistreatment and neglect, and it is often justified and understandable.

Sadly, invisible illness can put even the strongest relationships in jeopardy. As days turn to months and years, the constancy of chronic illness can wear on marriages, friendships and family relationships. Missed holidays, birthdays and other social events leave loved ones feeling betrayed and wondering if the person who is chronically ill could make more of an effort to be present. Friends and family members often doubt whether their loved one is sick. Some acquaintances become confrontational with the person who is chronically ill, whereas others turn passive-aggressive. Because a person’s hair doesn’t fall out with chronic fatigue syndrome, no skin lesions appear with multiple sclerosis and no significant weight loss takes place with fibromyalgia, it is easy to forget the internal battles being waged every day by those with chronic illness.

Counseling professionals are well-positioned to address the fallout of living with chronic illness. Counseling can provide something that those with chronic illness who are feeling suicidal desperately need but are often missing — a safe place where they can be heard, validated and comforted. Most important, counselors are particularly skilled at uncovering suicide risk, advocating for underserved populations and providing clinical management of complex cases.

In Natalie’s case, she was depressed from grieving her loss of physicality, friends and school. She had found some relief through the use of an antidepressant and went to counseling regularly. In the midst of a flare, her physician switched Natalie to Prozac, which she had taken previously, without considering the fact that it might increase suicidal ideation in teenagers. Natalie never mentioned the suicidal thoughts to her family or doctor. Shortly after titrating to 30 milligrams, the 17-year-old attempted suicide.

Consider physical illness part of the problem

Many people with debilitating and invisible chronic illnesses are told that it is all in their heads. As a counselor, you may be the first person who truly listens and tries to understand what is happening in the individual’s life. Don’t be afraid to suggest that someone who has especially dry mouth and eyes (Sjogren’s syndrome), fainting episodes and difficulty thinking (POTS), debilitating fatigue that can’t be attributed to known causes (chronic fatigue syndrome/myalgia encephalomyelitis, POTS, fibromyalgia, lupus) or chronic pain (complex regional pain syndrome, fibromyalgia, POTS) should get a thorough checkup with a good physician.

Consider working collaboratively with these physicians as a multidisciplinary team. Recommend someone who is a knowledgeable problem-solver to investigate underlying physical causes for the person’s anxiety or depression. In addition, assess regularly for suicide risk, especially during transitions in levels of care, and take all warning signs and risk factors seriously. Labeling a person’s symptoms as part of a recognized disorder will often be a great relief to the person psychologically.

Physical limitations and their effect on counseling

As a result of chronic illness, routine activities can cause debilitating fatigue. Standing, walking, showering, riding in the car and even attempting to focus on a conversation can quickly exhaust those with chronic illness. As their fatigue increases, brain fog also tends to increase.

As counselors, it is important to understand and recognize the effort it takes for these clients to walk through your office door. Offering small encouragements will reinforce the proactive effort they have taken to maintain their mental health and improve their quality of life.

Also note that many people with invisible illness are particularly sensitive to light, noises and smells. This is particularly true when they are flaring. Simple gestures such as closing the blinds or turning off fluorescent lights may help them conserve their energy for their work with you. Similarly, avoiding the use of candles, strong scents or incense can be helpful.

Differentiating the physical from the psychological

When working with clients who are chronically ill, differentiating their physical issues from their psychological issues can be difficult. Consulting with knowledgeable health care specialists is essential. Taking the time to learn about a client’s chronic illness can greatly increase empathy, provide authentic understanding and help in guiding the person to proper medical care.

Counselors should be aware that the coping skills people use to deal with symptoms of chronic illness can look like warning signs for depression or suicide. For example, coping skills to manage many invisible illnesses, such as staying in bed and avoiding the shower, may be unrelated to depression or risk of suicide.

In addition, dysregulation of the autonomic nervous system causes surges of norepinephrine that can lead to insomnia, anxiety or panic attacks. A person’s lack of appetite can be related to gastroparesis (paralysis of the stomach) or other digestive motility issues. Debilitating fatigue and difficulty focusing/concentrating are also common problems connected to many invisible illnesses.

At the same time, it is important to remember that individuals with chronic illnesses that involve functional impairment and chronic pain are at greater risk for suicide, so warning signs such as suicidal thoughts and threats, previous suicide attempts and hopelessness must be taken seriously. In Natalie’s case, she had confided her suicidal thoughts to her counselor. Unfortunately, her parents and doctors were unaware of the extent of Natalie’s overwhelming emotional pain until she attempted suicide.

Follow-up care after hospitalization is critical

Pursuing inpatient hospitalization for people at serious risk of suicide can be a life-saving step. However, the current health care environment poses challenges to accessing timely, quality care when needed, even for those at imminent risk for suicide. Inpatient stays are difficult to secure, and lengths of stay are minimal at best.

Individuals often transition from an inpatient level of care to outpatient settings before their stabilization, and this is not easy for individuals with chronic illness or their families. In addition, being hospitalized for mental health problems can be further stigmatizing and demoralizing for the person with chronic illness.

The period immediately following hospital discharge is particularly dangerous for people at risk for suicide. Counselors operating from a multidisciplinary framework can mitigate this risk (with permission of the person with chronic illness) by coordinating care with hospital staff, medical specialists and key family members.

Providing continuity of care also helps with stabilization, engagement and retention in aftercare. Long-term counseling is necessary to strengthen the person’s reasons for living and to uncover the problematic situations and underlying psychological vulnerabilities that led to the suicidal crisis.

“After 12 inpatient days and nine partial hospitalization days, I’m starting to feel confident that she is on the road to recovery,” Natalie’s mother reported. Natalie’s medications were changed, and she passed the GED test in lieu of her high school diploma. She is now on the road toward college. We hope that sharing her story can help to prevent suicide attempts in other young adults with chronic illness.

 

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

Greta Hochstetler Mayer holds a doctorate in counselor education and is a licensed professional counselor. She is the 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

 

Advocating for ‘one-stop shopping’ health care: Q+A with ACA’s Interest Network for Integrated Care

Compiled By Bethany Bray April 3, 2014

“One-stop shopping” is viewed as a good thing when it comes to buying groceries, picking up a prescription, grabbing a cup of coffee and filling your gas tank.

Why not do the same when it comes to physical and mental health care? This concept is the focus of the American Counseling Association’s Interest Network for Integrated Care.

integratedcareOne of ACA’s 17 interest networks, the group’s members exchange ideas, advocate for integrated care and discuss current challenges in the field, such as the complications of insurance billing and reimbursement.

Integrating mental and medical health care is a trend in the United States and beneficial to both practitioners and clients/patients, says network co-leader Russ Curtis.

Patients/clients are usually much more comfortable – and more likely to continue treatment – if mental health care is offered from the same office or network as their primary care physician, says Curtis. Therefore, counselors need to know how to work collaboratively and effectively with primary care medical offices.

Curtis, a licensed professional counselor and associate professor in the counseling program at Western Carolina University, co-facilitates the integrated care interest network with Teresa Jacobson, the network’s founder who is working on a doctorate in behavioral health from Arizona State University.

 

Integrated care Q+A

Russ-Curtis[1]

Russ Curtis, co-facilitator of ACA’s Interest Network for Integrated Care

Answers submitted by Russ Curtis, co-facilitator of ACA’s Interest Network for Integrated Care

 

Why should counselors be aware of/interested in integrated care?

First, many counselors will work with clients who are taking medication and/or have comorbid medical conditions, making it imperative for counselors to know how to consult with medical professionals.

Second, the research is clear that clients prefer to receive their mental health care within their primary care providers’ offices.  This type of one-stop shopping ensures better coordination of total health care and reduces the stigma many clients feel when having to go to a mental health center. As such, counselors need to know how to work effectively within primary care medical offices.

 

What are some current issues or hot topics that the network has been discussing?

The inability of LPCs to bill Medicare is a pressing concern which requires constant and creative legislative lobbying.

Another concern is that in some states (i.e., North Carolina, Ohio), LPCs cannot perform Evaluations for Commitment, which, in addition to the Medicare issue, can keep LPCs from working within medical practices and hospitals.

 

What challenges do counselors face in this area?

The inability to bill Medicare can keep LPCs from getting hired within medical practices and hospitals.

 

What’s going on in this area? Any new therapies, legislation, etc.?

Legislatively, all counselors need to call their senators and ask them to support the Seniors Mental Health Access Act [that would allow] LPCs to bill Medicare.

 

What are some trends you’re seeing?

In the early 1990s when I was working in a mental health center, the substance abuse treatment facility was located 5 miles from our center and refused to see our clients. Now it is accepted practice that you must integrate substance abuse and mental health treatment. Not that we will do away with “focused” substance abuse treatment centers, but health care professionals now know we must tend to the total care of clients.

Now, integrating mental with medical health care is a huge trend in the United States and already a staple in many developed countries where socialized medicine is practiced.  In an interview [that ran in the June 2012 issue of Counseling Today], Kathleen Sebelius, the secretary of the U.S. Department of Health and Human Services, mentions the importance of integrating care to increase the quality of care while decreasing costs.

 

What does a new counselor need to know about this topic?

New counselors need to know how to consult with medical professionals. They need to be able to perform brief assessment and provide brief therapy. New counselors need to learn as much as possible about psychotropic medicines, including their side effects, so they can help monitor and distinguish between symptoms and side effects. This type of knowledge and care is valuable to both client and physician.

 

What does a more experienced counselor need to know?

[They should] continue to build and hone their assessment, treatment and collaboration skills. They must also monitor the effectiveness of the services they are providing.

 

What are some tips or insights regarding this area that could be useful to all counselor practitioners?

As mentioned above, build assessment and treatment skills, and set up a system where the effectiveness of services provided can be monitored. I’d recommend that all integrated care counselors collaborate with university researchers to best monitor key client variables.

 

What makes you personally interested in this area?

The separation of mental and medical health care is insane. As such, more and more health care professionals and policymakers recognize the effectiveness of integrating care. I’m interested in this for two primary reasons: 1) clients who are not receiving integrated care are not receiving total care and that is causing much undo stress and frustration, which then, 2) costs this country a ludicrous amount of money in wasted medical tests and procedures. The separation of mental and medical health care truly baffles me.

 

 

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The Interest Network for Integrated Care is one of 17 interest networks open to ACA members. In the coming months, CT Online plans to highlight each network – from sports counseling to traumatology – with an online Q+A article.

For more information on ACA’s interest networks or to get involved, see counseling.org/aca-community/aca-groups/interest-networks.

 

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For more on integrated care:

 

Check out Counseling Today’s October 2013 cover story “Total health care”:  ct.counseling.org/2013/10/total-health-care/

 

Listen to ACA’s podcast with Russ Curtis and Eric Christian:  counseling.org/knowledge-center/podcasts/docs/aca-podcasts/ht030-integrated-care-applying-theory-to-practice

 

NPR article: “Kids Benefit From Counseling At The Pediatrician’s Office”

 

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Bethany Bray is a staff writer at Counseling Today. Contact her at bbray@counseling.org.

Follow Counseling Today on twitter @ACA_CTonline

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