Tag Archives: integrated care

Bringing CBT into the doctor’s office

By Bethany Bray September 12, 2018

When you get your annual physical, does your primary care physician ask if you’ve been feeling atypically sad or anxious lately?

Primary care doctors are often the first professional a person will tell about symptoms related to depression or other mental health issues. With this in mind, two Pennsylvania counselors have created a presentation on coping skills and takeaways from cognitive behavior therapy (CBT) that medical doctors can use with their patients.

When Brandon Ballantyne and Kevin Ulsh spoke to the primary care physicians and other medical personnel at Tower Health in Reading, Pennsylvania, recently, they found an interested and engaged audience. The medical practitioners were particularly interested in learning more about how to help patients who present with anxiety and related problems during medical appointments.

Ulsh and Ballantyne are mental health therapists in the inpatient and partial hospitalization programs, respectively, at Reading Hospital, which is part of the Tower Health system. Ballantyne is also a licensed professional counselor and American Counseling Association member.

How can aspects of CBT be translated for use in the medical professions? CT Online asked Ulsh and Ballantyne some questions to find out more.

 

How did this come together? Did you reach out to the doctors, or did they invite you to come?

We have always been interested in the concept of extending coping skills practice and implementation into primary care settings. We believe that the primary care setting is where most individuals first report problems associated with anxiety, stress, depression and so on. In many situations, the primary care physician is the first provider to address such issues.

Recently, we have observed a growing trend to integrate primary care and behavioral health services. We decided to take these observations and build a coping skills lecture that can assist providers in the primary care setting with addressing stress and anxiety, along with other mood-related problems with the patients they serve. We developed an outline for a presentation and broadcast the idea to the primary care Tower Health continuing education team, who then gave us an invitation to present it as a part of their lecture series.

 

How did it go? Were the doctors open to your message? What were some of the things they asked or commented about?

The lecture went well. The doctors in attendance were attentive and interested. They asked several questions about how to address behaviors particularly associated with adolescent anxiety such as school avoidance and oppositional defiance. We addressed these questions by referring back to the cognitive model, which we highlighted as a foundation of our lecture.

We think it was important to have a discussion with the doctors about the clinical indicators of avoidance versus defiance. Utilizing a cognitive philosophy, we emphasized that avoidance typically shows itself as a behavior which prevents an individual from doing something that they would like to be able to do or would want to be able to do if not affected by anxiety. The anxiety that drives avoidance is typically a product of some anticipated fear. … The individual has cognitively come to the conclusion that the fear itself is an already established fact or guarantee.

Defiance, on the other hand, is a behavior that is driven by the desire to maintain control by resisting demands and expectations to comply with things that are simply undesirable. In other words, in the cognitive process that drives defiance, an individual may think, “If I don’t like it or don’t want to do it, then I don’t have to, and it doesn’t matter what anyone says.”

Therefore, primary care physicians may be able to get a better handle on what it going on with the patient, clinically, simply by asking about their thinking.

 

From your perspective, how could CBT be helpful in a medical setting? Please talk about why you chose to focus on CBT when you spoke to the doctors.

We chose to focus on cognitive behavior therapy when providing this lecture because CBT is an evidence-based approach that has been shown to be an effective form of treatment for multiple psychological problems across various populations. We believe that in the primary care settings, patients will benefit most from socialization to the cognitive model, so that they can gain a clear understanding of the difference between a thought and an emotion.

Once an individual understands the relationship between a thought, an emotion and a behavior, they acquire control over regulating their mood and reactions in a positive way. CBT-based skills are goal-oriented, problem-focused and able to be introduced and taught to individuals dealing with a wide range of psychological problems.

In the fast-paced primary care setting, brief psychological education and skills practice can be a piece of the treatment puzzle that not only addresses the emotional problems of the patient, but also offers skills that they can continue to utilize and benefit from outside of the office (such as deep breathing, sleep hygiene, behavioral activation, disputing cognitive distortions, thought journals, activity scheduling, etc.).

 

From your perspective, what are the benefits to this kind of collaboration? In other words, benefits not only for the professionals involved, but for the patients/clients too.

There are multiple benefits to this kind of collaboration. We believe that in most cases, the first call that patients make when they are not feeling well is to their family doctor. On some occasions, they are being seen by their family doctor for a physical health issue. However, in the midst of assessment, they may reveal an emotional problem or talk about a significant stressor that is causing psychological distress.

This is because for the most part, individuals attend treatment with a primary care doctor whom they trust. Maybe they have been seeing this doctor for most of their life. They have learned to confide in this doctor quite often. Therefore, they may be more open to acknowledging emotional problems within that office setting.

The type of collaboration that we facilitated reinforces the importance of integrating psychological education and coping skills practice into a primary care setting. For professionals, it improves the continuum of care and reduces the stigma of mental health problems. Ongoing behavioral health collaboration, and having a behavioral health component to primary care treatment, implies that psychological distress is a natural area of assessment which patients might otherwise be hesitant to acknowledge or discuss. In this way, patients can become more open to behavioral health support and more accepting of their need to seek outpatient therapy to further resolve symptoms.

 

What advice or tips would you give to counselors who might want to collaborate with medical professionals, like you did, in their local area?

We would suggest that mental health professionals in all parts of the country consider developing a presentation on one particular area of therapy and/or psychological education that you feel passionate about [and] which you also utilize with the clients you serve. The goal is to develop a component of that theoretical orientation that is applicable to a primary care setting. It has to be something that primary care physicians can utilize within the short amount of time that they have with their patients.

We found that in our lecture, doctors were most interested in the practical applications of CBT as it pertains to the acute management of anxiety. We assume that other helpful topics may be closely related to dialectical behavior therapy [and] concepts such as mindfulness, distress tolerance and opposite action.

 

Is this something you think that counselors could or should do more of? What did you learn through this process?

As a result of providing this lecture, we learned that primary care doctors are very much interested in behavioral health support and assistance. It seems as though there has been an increase of patients presenting to family physicians with emotional problems. The doctors that we spoke with were very thankful for the background on CBT and the skills practice that we provided. In fact, they practiced some of the skills with us.

It reminded us that regardless of the [health] profession, we all will be most effective [with] our patients if we are also taking good care of ourselves. Integrating behavioral health support, psychological education and coping skills practice into a primary care setting reinforces the importance of seamless multidimensional treatment, ultimately helping patients to receive effective care that addresses their physical and emotional needs, and offers the safety to accept the behavioral health treatment that they may otherwise be hesitant to pursue.

 

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Ballantyne and Ulsh can be contacted via email:

Brandon.Ballantyne@towerhealth.org

Kevin.Ulsh@towerhealth.org

 

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Related reading, from Counseling Today:

Integrated interventions

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

When brain meets body

 

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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.

 

Group counseling with clients receiving medication-assisted treatment for substance use disorders

By Stephanie Maccombs September 6, 2018

Holistic care, or the integration of primary and behavioral health care along with other health care services, is becoming more common. In my experience as a mental health and chemical dependency counselor in an integrated care site, I have come to value the benefits that such wraparound services offer.

I now have the opportunity to consult with primary care providers, medication-assisted treatment providers, dentists, early childhood behavioral health providers and our county’s Women, Infants and Children team about their perspectives and hopes for clients. Every client has a treatment team, and each team member is only a few feet from my office door. I quickly realized the significant positive impact that close-quarters interdisciplinary collaboration has for many clients, and particularly those receiving medication-assisted treatment (MAT) and counseling services for substance use disorders.

MAT is a treatment model that lends itself to the integrated care setting. As described by the Substance Abuse and Mental Health Services Administration (SAMHSA), MAT is the use of prescribed medications with concurrent counseling and behavioral therapies to treat substance use disorders. MAT is used in the treatment of opioid, alcohol and tobacco use disorders. The medications, which are approved by the Food and Drug Administration, normalize brain chemistry to relieve withdrawal symptoms and reduce cravings. MAT is not the substitution of one drug for another. When medications in MAT are used appropriately, they have no adverse effects on a person’s mental or physical functioning.

Medications used in MAT for alcohol use disorder include disulfiram, acamprosate and naltrexone. Those used for tobacco use disorders include bupropion, varenicline and over-the-counter nicotine replacement therapies. Medications used in MAT for opioid use disorders include methadone, buprenorphine and naltrexone — each of which must be dispensed through a SAMHSA-certified provider. Naltrexone is the only medication of the three that does not have the potential to be abused. Federal law mandates that those receiving MAT for opioid use disorder also receive concurrent counseling.

Embracing the advantages of integrated care

The combination of medication and therapy offers a holistic approach to treatment that is easily implemented in integrated care settings. The hope offered by the integration of services is embodied in an extraordinary case involving one of my clients who relapsed and arrived to counseling intoxicated, holding their chest. I was able to immediately consult with the client’s MAT provider, who ruled out the physical causes of chest pain after performing an electrocardiogram. Within 30 minutes, I was able to proceed with de-escalation of the client’s panic attack. The MAT provider educated the client on the next steps for care and on the dangers of using substances while taking MAT medications.

In a nonintegrated site, my only recourse would have been calling an ambulance for the client and a long wait at the hospital emergency room — and possibly a client who discontinued services. It is heartening when I can instead walk a client with symptoms of withdrawal across the hallway to the MAT provider or primary care provider, who can in turn offer targeted expert medical advice and medications to alleviate the symptoms.

Despite the substantial advantages that integrated care offers, however, most mental health and chemical dependency counselors are not adequately trained to provide effective counseling in integrated care settings for substance use disorders. In my experience, clients have better outcomes when receiving counseling services in conjunction with MAT. MAT alone can be effective, but the underlying thoughts and emotions that perpetuate use are not addressed unless concurrent counseling services are offered.

According to SAMHSA’s Treatment Improvement Protocol (TIP) No. 43, counseling for clients in MAT programs:

  • Provides support and guidance
  • Assists with compliance in using medications in MAT appropriately
  • Offers the opportunity to identify additional areas of need
  • May assist with retention in MAT programs
  • Offers motivation to clients

Although individual counseling is valuable, I am focusing on group counseling in this article because it offers similar benefits to individual counseling and is typically more cost-effective. In addition, TIP No. 43 notes that group counseling in MAT programs reduces feelings of isolation, involves feedback and accountability from peers, and enhances social skills training.

Resources for group counseling with MAT clients, or group counseling in integrated care settings, may not be easily accessible to many counselors-in-training or to practicing counselors. My goal is to share tips and resources with mental health and chemical dependency counselors that may be helpful in enhancing group counseling services for clients receiving MAT in integrated care settings. These tips and resources may also be useful to those providing group counseling services to MAT clients in settings that do not offer integrated care.

Tips and resources

1) Holistic education: MAT and integrated care are relatively new concepts for counselors, and we are still adapting. If it is new for us, it is new for our clients too. In the initial sessions of psychoeducational or process groups, the inclusion of education about MAT, the benefits of counseling in conjunction with MAT, and treatment in integrated care settings is essential.

Having access to a range of service providers is a benefit that clients should understand and utilize. Treatment team members can speak to the group about their role in client care and how their role may relate to the counseling group. For example, a dentist might help with appearance and self-esteem issues; an early childhood care provider might help the children of clients process situations arising from parental drug use; a primary care or MAT provider might link the client with hepatitis C treatment in addition to MAT. Such education can answer many questions that the group may have and help clients benefit from quality holistic care.

2) Dual licensure and continuing education: Many chemical dependency counselors refer out to mental health counselors and vice versa. In integrated care, it is ideal for counselors to be dually licensed. Dual licensure and training can assist counselors in identifying and addressing a variety of dynamics that may arise in group counseling with MAT clients.

For example, one client might have major depressive disorder and be using MAT for alcohol recovery, whereas another client might have symptoms of mania and be receiving MAT for opioid recovery. The way that counselors assist these clients may differ based on their knowledge of mental health diagnoses and the substance being used. Furthermore, counselors who are knowledgeable about these differing yet comorbid disorders will be better equipped to provide education to the group about the individualized and shared experiences of each member in recovery.

Some states have a combined mental health and chemical dependency counseling licensure board, whereas others have separate licensing boards. For more information about licensure, contact your state boards. If dual licensure is not plausible or desirable, I strongly recommended seeking continuing education in both mental health and chemical dependency counseling, as well as their relation to MAT.

3) Cognitive behavior therapy (CBT) and solution-focused brief therapy (SFBT) techniques: According to SAMHSA’s webpage about medication and counseling treatment, by definition, MAT includes counseling and behavioral strategies. The combination of MAT with these strategies can successfully treat substance use disorders.

One of SAMHSA’s recommended therapies is CBT, an evidence-based practice that has been shown time and time again to be effective in the treatment of substance use disorders. In an extensive review of the literature about the efficacy of using CBT for substance use disorders, R. Kathryn McHugh, Bridget A. Hearon and Michael W. Otto (2010) outlined a variety of interventions shown to be effective in addressing substance use disorders in both individual and group counseling. Those interventions included motivational interviewing, contingency management, relapse prevention interventions and combined treatment strategies.

Combined treatment refers to the use of CBT alongside pharmacotherapy, which includes MAT. Although some studies the authors reviewed indicated that MAT alone could be effective in treating substance use disorders, others demonstrated that combined treatment was most effective. Given SAMHSA’s recommendation, the literature review and my own personal experience, I believe that CBT may best benefit a group of MAT clients with substance use disorders in an integrated care setting.

Although CBT is suitable, I have learned that integrated care sites are much more fast-paced than the typical behavioral health counseling agency. Primary care and MAT appointments are as short as 15 minutes. In my work with our on-site behavioral health consultant, I noticed her quick and effective use of SFBT with individual clients. Although there is some research discussing the use and efficacy of SFBT in the treatment of substance use disorders, there is little information about using SFBT in groups with MAT clients in integrated care. This is a much-needed area for future research.

4) SAMHSA: SAMHSA has been mentioned various times throughout this article. That is a tribute to the value I place on the agency’s importance and usefulness. SAMHSA, in my opinion, is the best resource for exploring ways to enhance groups for clients receiving MAT. SAMHSA offers educational resources about a variety of substance use disorders; forms of MAT for different substances; comorbidities; and evidence-based behavioral health practices. SAMHSA is up to date, provides a variety of free resources for counselors and other professionals, and also has information about integrated care for professionals and clients.

According to SAMHSA’s TIP No. 43, groups commonly used with MAT clients include psychoeducational, skill development, cognitive behavioral and support groups. Suggested topics for individual counseling with MAT clients, which easily can be translated to group format, include feelings about coping with cravings and a changing lifestyle; how to identify and manage emergencies; creating reasonable goals; reviewing goal progress; processing legal concerns and how to report a problem; and exploring family concerns. Visit SAMHSA’s website (samhsa.gov) to enter a world of helpful information and resources for both personal professional development and client development.

5) Professional counseling organizations: Whereas SAMHSA offers information about substance use disorders, comorbidities, MAT, and individual and group counseling, the counseling profession’s codes of ethics and practice documents are crucial to the ethical provision of group counseling in this challenging field. Among the resources to consider are the 2014 ACA Code of Ethics, the Association for Specialists in Group Work (ASGW) Best Practice Guidelines (which clarify application of the ACA Code of Ethics to the field of group work) and the Association for Lesbian, Gay, Bisexual and Transgender Issues in Counseling’s (ALGBTIC’s) competencies for providing group counseling to LGBT clients. ASGW also has practical resources to augment your group counseling skills through its Group Work Experts Share Their Favorite Activities series. Combining these resources with information acquired from SAMHSA and the tips in this article should prove helpful in designing and running effective groups for clients in MAT in integrated care settings.

Conclusion

As integrated care becomes more widespread, counselors must adapt their practice of counseling to the environment and to the full range of client needs. It is a counselor’s duty to utilize the benefits that integrated care has to offer, such as immediate and continual collaboration with treatment team members.

For clients in MAT, group counseling in integrated care can provide a multitude of benefits, including the opportunity to learn from each treatment team member, the opportunity to build community in the journey to recovery and accountability. To enhance group counseling in these settings, counselors might consider:

  • Including education from each service provider in the early stages of the group
  • Seeking dual licensure or relevant continuing education opportunities
  • Implementing theories that are suitable for the client issue and the setting
  • Using resources made available by SAMHSA and professional counseling organization such as ACA, ASGW and ALGBTIC

Implementing these tips and resources will result in a fresh and efficient group counseling experience for clients in MAT in integrated care settings.

 

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Stephanie Maccombs is a second-year doctoral student in the counselor education and supervision program at Ohio University. She is a licensed professional counselor and chemical dependency counselor assistant in Ohio. She has worked as a home-based addiction counselor and currently works in a federally qualified health center providing mental health and chemical dependency counseling services to adults participating in medication-assisted treatment. Contact her at sm846811@ohio.edu.

 

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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.

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.