Tag Archives: integrated care

Integrated interventions

By Laurie Meyers May 25, 2018

W hen people think about integrated care, they may imagine a mental health care professional (or two) working in the same building with a physician or other medical professional and following a mutual agreement to refer cases to one another as needed. Others might picture a specialized setting, such as a pain clinic or cancer treatment center, where mental and emotional health concerns are addressed in relation to the medical or physical issue. However, multidisciplinary integrated care teams can now be found in hospitals, outpatient medical centers and community mental health clinics. Professional counselors who operate in these settings say that working in concert with other medical, mental and physical health professionals is the best way to provide clients with whole-person care.

Integrated care facilities are often in medical settings such as primary care clinics, but this doesn’t have to be the rule. Sherry Shamblin is chief of behavioral health operations for Hopewell Health Centers, a group of nonprofit community primary care and behavioral health clinics with 16 locations in southeast Ohio. She helped to develop a system that features primary care facilities in which counselors can conduct brief behavioral interventions and centers that focus principally on mental health but also offer primary care resources.

Shamblin’s thinking is that clients who already are struggling to manage serious mental health issues are often too overwhelmed to seek medical care. “If you’re depressed, you don’t really take care of yourself,” says Shamblin, a licensed professional clinical counselor with supervision designation. “You’re not valuing self-care and taking care of your [physical] health.” In addition, many psychotropic medications have side effects such as weight gain, which can increase clients’ chances of developing diabetes and other chronic illnesses, she notes.

“When you physically feel better, your mood improves, your energy is better, [you] feel more like tackling things that seem overwhelming and your overall coping improves,” says Shamblin, a member of the American Counseling Association. “Although mental and physical [health] have been separated for a long time … [the division] is artificial. It’s all connected.”

Counselors at the mental health clinics ask clients at intake whether they have a primary care physician and, if so, who that person is and when the last time was that the client saw their physician. Counselors will also try to get clients’ permission to access their medical records. That way, counselors can work with clients’ physicians to help ensure that clients are getting the health care they need, Shamblin explains.

If mental health clients don’t have a primary care physician or only go when they are feeling really ill, the counselor talks to them about health and wellness and the importance of receiving regular checkups. “We try to help them view it [regular health care] as another component of staying well,” Shamblin says.

If Hopewell Health Centers’ clients don’t have a primary care physician but would like to start taking better care of their health, they don’t have far to go — the mental health care facilities have exam rooms and primary care providers on-site. Having these resources readily available not only makes it easier for clients to access health care but also allows them to receive it in a setting in which they already feel comfortable, Shamblin says. The counselor (or other mental health professional) and onsite primary care provider then become a team dedicated to maintaining the client’s physical and mental health.

In Hopewell Health’s primary care clinics, counselors (who are called behavioral health consultants, or BHCs) play several roles. In some cases, the BHC is brought in to help the client manage a chronic illness. For example, Shamblin says, a primary care physician might see someone whose diabetes or high blood pressure is not under control despite treatment. This would provide an opportunity for the physician or nurse to explain that they have a colleague on the team who might be able to help the patient with this struggle. They would then ask if the patient would like to meet with the BHC.

The BHC would then try to determine the factors that are keeping the patient from progressing. For instance, is the person not taking medicine consistently or not watching their diet? If treatment adherence is a problem, the BHC assesses whether patients are ready to change their behavior and, if so, works with them to set goals and offers ongoing support. If patients are not open to making a change in a particular lifestyle area — such as diet, for example — the BHC would work with them to identify another positive lifestyle change they could make, such as stopping smoking or getting more exercise, Shamblin explains.

In other cases, the BHCs working in the primary care clinics conduct brief interventions with patients. The primary care physicians screen patients by asking questions that assess for signs of depression or substance abuse. If the physicians get an answer that concerns them — perhaps a patient saying that they have been feeling overwhelmed or depressed, for example — they ask the patient whether they can bring in someone who might be helpful, Shamblin says. The BHC will then ask brief questions to help determine whether the patient needs intervention.

Sometimes patients feel better just being given the opportunity to have a short conversation about their worries, Shamblin says. In such cases, the BHC will ask if it is OK to check in with the patient the next time the person returns to the clinic. In some cases, the BHC will ask the patient to come back for a few brief counseling sessions. In other instances, the BHC determines that patients need more intensive mental health care and will refer them to the clinic’s mental health professionals who oversee long-term care, Shamblin explains. The BHC then becomes the liaison between the primary care and mental health providers and will check in with the patient periodically to see how the person is doing, she says.

Hopewell Health Centers was created in 2013 when two organizations, Family Healthcare Inc. and Tri-County Mental Health and Counseling Services Inc., merged in order to provide integrated care. Shamblin notes that the frequency of Hopewell Health Centers’ screenings and treatment of substance abuse has gone up with the introduction of the integrated care model. Some data have suggested that the area of Ohio where the clinics operate has the lowest depression rates in the state, she says.

Leading the way in integration

Wake Forest Baptist Medical Center in Winston-Salem, North Carolina, is a leader in hospital and outpatient integrated care. Just ask ACA member Laura Veach, who explains that the Wake Forest system has moved beyond the concept of integrated medicine being simply “co-located” care. In fact, the system is so integrated that Veach, a counselor educator, is a full professor in the Department of Surgery in the Wake Forest School of Medicine, a position that Veach thinks may be unique. Veach is also the director of counselor training at Wake Forest Baptist Medical Center. Though affiliated with Wake Forest University, the center also works with other counselor educator programs.

Veach has played a crucial role in the medical center’s emphasis on integrated care. She says she feels particularly fortunate because she works with a group of surgeons “who get it and want the best for patients.”

“We [counselors] are embedded in the medical team,” Veach explains. “We started in surgery in the specialty of trauma surgery and began to test the feasibility of doing counseling and screening and intervention at the bedside and [then] became a training site. Now we include posttraumatic stress disorder [PTSD] intervention work, crisis intervention and grief and loss work with trauma patients who have suffered the loss of a loved one in a trauma incident that brought them to the hospital. That led to the pediatric trauma unit, where we work with families of children who are traumatically injured, as well as the children themselves.”

Counselors are also part of integrated care efforts in the facility’s burn center, which is one of the only certified burn centers in North Carolina. Those efforts include providing ongoing counseling sessions in the burn intensive care unit and the step-down unit. Wake Forest Baptist Medical Center has also expanded integrated care into medical inpatient units, where people come in for issues such as pancreatitis, infections, pneumonia and so on.

Wake Forest Baptist Medical Center has a system that scans medical records to help identify patients who might need counseling help. For instance, when patients come through the emergency room, nurses ask them about depression, anxiety, suicidal thinking or past suicidal behavior. Other patients may receive bloodwork that shows elevated blood alcohol content or urine drug screens. Veach emphasizes that these are not for legal use but to help the medical center provide better integrated care. Some people may have elevated liver enzymes, which can be a sign of alcohol abuse, she continues. The medical records also include the physician’s account of what the patient’s complaint is. The chart-scanning system analyzes all of this information to help identify and prioritize who the counselors and other mental health professionals on staff should see first, she says.

Counselors introduce themselves as part of the team to patients and let them know that they are there to support the patients’ recovery and health. They then ask if the patients are open to the counselor spending some time with them. The counselors are rarely turned away, according to Veach.

After reviewing informed consent and confidentiality policies with each patient, the counselors simply listen, Veach emphasizes. “We try to just be present with them, to not ask questions, to hear what they are struggling with,” she says.

Veach notes that most of the medical center’s patients have never been to see a counselor before. So the counselors and counseling graduate students who work on the integrated teams at Wake Forest Baptist Medical Center are essentially educating these individuals about what counseling can provide. They tell patients they are prepared to listen to whatever the patients most want to talk about or need help with.

“What we find most often is that people have a lot to share,” Veach says. “We’re not someone who’s coming to do something to them; we’re someone who is coming to be with them. They might say, ‘I really want to talk to my family about this, but they’ll worry.’ A counselor or addictions specialist can be there and not be judgmental.”

In the medical center’s trauma and burn units, counselors stay on the alert for signs of acute stress or PTSD in patients, Veach says. After being released from the medical center, patients return for medical follow-up visits for the next six months, and counselors continue to check in and evaluate their recovery during this time. In certain cases, the counselors set up extended mental health therapy sessions with patients (scheduled adjacent to their medical visits) or recommend that they see a trauma specialist, such as someone trained in administering eye movement desensitization and reprocessing therapy.

When Veach first started working in integrated care, it was common for surgeons to state that they didn’t need or want to know about patients’ emotional issues — they just needed to know how to repair individuals surgically. “In the past decade, we’ve seen a big shift to asking how do we more fully treat this person to help them have a better chance of healing and without experiencing more trauma,” Veach says. “I think more trauma surgeons [today] know that if we don’t address [these emotional issues] now, we’re going to see them here again.”

Many people undergoing medical treatment aren’t aware of the types of issues that counseling or addictions treatment can help them address, or they don’t know how to access those services themselves, so having counselors as part of the team at Wake Forest Baptist Medical Center is particularly valuable, Veach says. Counselors on staff can make recommendations and point patients toward other resources. For instance, Veach says, families may have been struggling for years to get a loved one into treatment for substance use; counselors on staff at the medical center can offer information on which addictions centers in the area offer family support.

In the trauma and intensive care units, the teams offer dedicated support time for families two days per week. Counselors are on hand during these times to offer snacks and encouragement, Veach says. The integration of mental health into the hospital also extends to support groups, including a weekly trauma survivors’ network, a family member support group and a peer-led burn survivors group, she adds.

Veach has been helping to implement brief intervention counseling services at Wake Forest Baptist Medical Center for a decade. As counseling services have expanded to be included in more and more of the center’s departments, she has been surprised at how receptive medical patients are to counseling. She says she has witnessed “a deeply heartfelt responsiveness” on the part of patients to being heard and understood. In addition, surgeons have begun to tell Veach how valuable counselors are to the team. They tell her they are heartened to see patients getting care from counselors that they, as surgeons, can’t provide themselves.

Putting people first

Marcia Huston McCall, a national certified counselor and doctoral student in counseling and counselor education at the University of North Carolina at Greensboro (UNCG), spent several decades in health care management before becoming a counselor. She worked in the finance department at Massachusetts General Hospital and then became the business director of several different departments in an academic medical center in Winston-Salem, North Carolina.

McCall, an ACA member, says she went into health care management as a means of helping patients. She thought her business acumen was her strongest skill set and her best way of contributing. Over time, however, she became convinced that the business side of health care was moving farther and farther away from helping patients. “Health care management got so corporate,” she says. “I felt separated from the patients, and I wanted to have that contact.”

McCall realized that the people part of her job was what she loved best and decided that a career shift into counseling would be a better fit. She entered the counselor education program at Wake Forest University and completed her practicum and internship hours in inpatient integrated care at Wake Forest Baptist Medical Center. UNCG also has a relationship with Wake Forest Baptist Medical Center, so McCall completed her doctoral internship there and continues to work at the center as a graduate assistant.

McCall has worked in both the outpatient clinic and the inpatient section of the medical center. She says it is crucial for counselors to be full members of the team by participating in rounds and team huddles. “Having the counselor as part of the team when all the patients are being discussed is really important because you’re not only offering perspective but also picking up on things that might be issues,” she says. “They’re talking about patients you might not see [in the outpatient clinic], but you can pick up on patients that you do need to see.”

“In inpatient, we screen patients ourselves, so we review all the new admissions to our floors and identify the patients we think [will] need our services,” says McCall, a member of ACA. If she notices a history of substance abuse or other mental health issues, McCall brings this up before rounds or in the team huddle.

McCall and the other mental health professionals at the medical center conduct brief assessments with patients for signs of substance abuse, depression, anxiety, suicidality and delusions. In some cases, they conduct brief treatment and perhaps even see the patient a few times, depending on the length of stay. McCall also refers patients for further psychiatric or substance abuse care if needed.

Counselors working in integrated care settings frequently need to use their skills to build rapport with patients. For example, a physician might see signs indicating that a patient has possible substance abuse issues and call a counselor in for an assessment. In many cases, patients will not have sought treatment for substance abuse previously and may have avoided acknowledging that they have a problem.

“We’re walking in, and they may not be very interested in talking about their substance issues, particularly with a stranger,” McCall says. “We have to approach resistant patients in an indirect way and try to understand what their issues are and what they want to do about them,” she explains.

In such instances, McCall says that she rolls with the resistance. Friends and family members have likely been asking these individuals to seek help, but the patients haven’t been ready to acknowledge that they need treatment. McCall validates their resistance by verbalizing the arguments they are making against getting help. She says these patients often respond to her validation by saying, “Yeah, but I really do need help.” She then asks them what they are willing to do to get that care. If these patients voice a desire to pursue substance abuse treatment, counselors at the medical center connect them with specialty resources outside of the inpatient or clinic setting.

“We help them find that treatment and do as much as possible to ensure they actually get there — that everything is set up,” McCall says.

Counselors serve as consultants for the medical team at Wake Forest Baptist Medical Center but also act as advocates for the patients, McCall says. A lot of bias still exists among medical personnel about mental health issues, she explains, so counselors are there to help ensure that patients are seen as human beings who have needs, no matter what they have been through.

Counselors may also get called in when a physician is questioning whether a patient might need psychiatric services. The medical center doesn’t have many psychiatrists on staff, so the physicians are hesitant to call them for a consultation if there is no need for immediate inpatient treatment, McCall explains.

By working in integrated care, McCall says she gets to be a kind of ambassador for the counseling profession. “I have the opportunity to work not just with physicians and nurses, but residents, medical students, pharmacy students and physician assistant students,” she says. “[I] really have the opportunity to interact with people who aren’t used to having counselors as part of the team.”

McCall would like to bring even more of the counseling perspective into integrated care. She contends that “behavioral health” is too narrow of a designation and believes that counselors should define their own roles and use terminology that is more appropriate to the counseling profession. McCall says she wants her team, as well as other medical personnel working in different integrated care settings, to be aware that professional counselors are not just behaviorists but also possess many other skills. For example, McCall envisions counselors having a central role to play in helping patients who have gotten a shocking diagnosis or who are struggling with the inherent vulnerability of being in the hospital.

McCall also cautions counselors entering the field to be aware that supervision in integrated care settings is rarely provided by other counseling professionals. It is vital for counselors to maintain their professional identity while operating within integrated care, she emphasizes, even if that means pursuing additional supervision outside of the integrated care setting. Receiving ongoing supervision when working in integrated care is critical because the work can be intense and overwhelming, McCall says. Peer support and supervision can help counselors deal with stress and avoid burnout, she concludes.

Training students in integrated care

Some counseling students interested in integrated care are adding medical knowledge to their counseling skills. Rachel Levy-Bell, assistant professor of psychiatry and associate program director and director of clinical training in the mental health counseling and behavioral medicine program at Boston University School of Medicine (BUSM), teaches and trains counseling students to work in integrated care. The program at BUSM focuses not just on counseling but also behavioral medicine, so students take integrated care courses, learn about psychopharmacology and human sexuality, and get bedside training in getting to know the patient beyond the disease, says Levy-Bell, a member of ACA. She supervises practicum and internship students working in Boston University-affiliated clinics and other Boston community centers.

As part of practicum, Levy-Bell trains small groups of counseling students to conduct biopsychosocial interviews. Each week, the 10-member group receives a list of patients and their medical issues. As the counseling students visit the patients, they take turns being the lead interviewer. Students ask patients about what brought them to the hospital and deduce whether they fully understand their condition and how their disease affects their lifestyle, relationships and work. They also ask how patients physically manage their disease, how they cope with its demands and whether spirituality or religion plays a role for them. They also assess for substance abuse.

At the end of the interview, Levy-Bell asks the patients how they felt the students performed. Many patients share that they like that the students spent more time with them than the medical personnel typically do and also comment that the students are better at maintaining eye contact with them when talking and listening. Afterward, the group goes back to class to evaluate and discuss the interviews: What went right? What do they need to improve? What did they learn?

Part of the training process is getting counseling students used to working in medical settings and grappling with issues such as how to build therapeutic rapport when the patient has a roommate or when medical equipment is everywhere and beeping noises are constant, Levy-Bell says. Students are also exposed to things that they’ve never seen before. These experiences might make them uncomfortable, but they have to learn to control both their verbal and nonverbal reactions to ensure that they aren’t indicating discomfort, she says. Levy-Bell also focuses on practical aspects such as teaching students not to faint — or, at a minimum, fainting away from the patient. She also teaches students to wear light clothing (hospitals are hot), to stay hydrated, to make sure they eat and to take a break if they feel unsteady — but to always come back.

Sara Bailey, an ACA member who works at Wake Forest Baptist Medical Center as part of her postdoctoral fellowship, says that regardless of whether counselors plan to go into integrated care, working in a behavioral health setting provides excellent training. In integrated care, counselors-in-training get the chance to see how other professionals such as doctors, nurses and other mental health practitioners work and handle challenges, she says. They also quickly become aware that all practitioners encounter individuals with alcohol or substance abuse problems.

“In a perfect world, this would be required,” Bailey says. “You get to hone your reflection and rapport-building skills and have to learn to do your best in a short amount of time.”

 

 

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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)

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

  • “Integrated Care: Applying Theory to Practice” with Russ Curtis & Eric Christian (HT030)

ACA Interest networks (counseling.org/aca-community/aca-groups/interest-networks)

  • ACA Interest Network for Integrated Care

 

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Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@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 counselor’s role in assessing and treating medical symptoms and diagnoses

By Jori A. Berger-Greenstein April 4, 2018

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

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

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

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

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

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

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

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

Understanding context

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

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

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

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

The process of assessing for mental health symptoms

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

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

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

Collaboration

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

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

Providing care

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

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

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

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

Transtheoretical model (stages of change)

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

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

Concrete needs and specific skills

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

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

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

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

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

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

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

Getting started

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

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

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

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

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

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

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

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

Ethics

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

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

 

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

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

Letters to the editorct@counseling.org

 

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

Talking through the pain

By Laurie Meyers January 30, 2018

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

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

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

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

Treating chronic pain

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Taking away pain’s power

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

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

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

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

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

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

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

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

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

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

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

Teamwork and support

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

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

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

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

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

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

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

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

 

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

Letters to the editor: ct@counseling.org

 

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

 

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.