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Counseling Clients with Medical Conditions in Private Practice
Paula S. van Rein, PhD Psychology, Health Psychology
Walden University, November, 2010
Abstract
This paper’s focus is on counseling clients with medical conditions in private practice. In the first section, I review approaches to medical crisis counseling and the main issues that need to be addressed in sessions with clients who face life-changing or chronic illnesses. Then I look at the psychosocial interventions that can be used in an individual counseling setting. Throughout this essay my focus is on the role and style of the therapist. In the discussion, I argue that a personal mix of approaches may work best for medical clients. When counseling these clients, the therapist needs an approach with a flexible balance between the heart and the mind, between supportive psychotherapy and insight-oriented and directive modalities.
Counseling Clients with Medical Conditions in Private Practice
Since medical technology extended humanities possibilities to survive with serious diseases, there are more people with chronic illness. Because of this development we see is a growing need for psychosocial treatments of people with medical conditions (Schein, Bernard, Spitz, & Muskin, 2003). Illness causes stress, including the fear that accompanies the threat of death, the anxiety the treatments brings, and the emotions brought on by the loss of work or other social rolls. The individual’s response to this stress may in turn contribute to the progression of the illness. Medical crisis counseling offers clients with medical conditions an effective psychosocial treatment modality that provides both support and guidance and is aimed at teaching the client to adjust to the illness and to more effectively cope with the stress it creates.
Medical Crisis Counseling Approaches
Various approaches have been proposed to work with individuals with medical conditions, Pollin’s approach is a practical one, based on her experience with clients and their families and care-givers (Pollin & Baird Kanaan, 1995). Integrative medicine (Frenkel, 2008) and supportive psychotherapy (Viederman, 2008) propose a different, holistic, more compassion-focused view. Livney and Parker (2005) offer an alternative way of looking at the client’s experience that offers counselors yet another approach to medical crisis counseling.
Pollin’s Medical Crisis Counseling
When discussing the counseling of individuals with chronic illness or disabilities (CIDs) in private practice, the psychosocial treatment model of Pollin appears to be an important source of practical information. This “medical crisis counseling” (MCC) model, presented in her seminal book offers a framework for short-term interventions for mentally healthy individuals who face the serious psychosocial challenges of living with a long-term or life-threatening medical condition (Pollin & Baird Kanaan, 1995).
The most important feature that distinguishes Pollin’s MCC intervention from other psychotherapeutic interventions is its focus on the client’s medical condition and its consequences in the clients’s life. Instead of curing the disease or solving the problem, MCC seeks to enhance the sick person’s ability to cope with whatever the illness confronts him/her with (Pollin & Baird Kanaan, 1995). The interventions in MCC are in that sense directed at acceptance and adjustment rather than elimination or change.
A chronic illness has a distinct and powerful influence on a person’s life; a diagnosis and the illness bring about a number of changes and uncertainties the client has to learn to deal with. MCC counseling is a safe place to explore the frightening feelings that accompany the confrontation with the demands of a CID. It is extremely important to let the client know that his/her responses to the medical crisis are quite normal and not psychopathological. The client benefits from understanding that facing problems and talking about their tangled emotions might actually make them less overwhelming (Pollin & Baird Kanaan, 1995).
When clients share their feelings and explore solutions and different perspectives, problems become more amendable to problem solving. Fears and anger, even depression, are validated as normal and natural dimensions of the reaction to the stress. MCC explicitly promotes the enhancement of positive coping skills that the client already possesses; the goal of therapy is to strengthen the client’s ability to adjust to the changes prompted by the medical condition and to invite him/her to be an active participant in the healing process.
MCC is meant to be a low-threshold model for brief (i.e., ten sessions or less), structured and complementary (or even adjunctive) psychological care sessions for individuals with medical conditions. The time-limited structure is intentional, giving clients a positive sense of closure and control, as opposed to the open-endedness of their medical condition (Pollin & Baird Kanaan, 1995). The time of diagnosis, moment of release from the hospital, and period of exacerbation of the illness are the three crisis points in the disease-related process that are most relevant to MCC interventions. Experience shows that MCC is most effective when implemented as early as possible after each crisis point.
The underlying goal of MCC is to prevent the development of negative long-term psychological states like anxiety, depression, and adjustment disorders and to supply anticipatory guidance. MCC focuses on (a) the illness and its treatment (i.e., the medical crisis is the governing factor), (b) emotions and coping skills, and (c) family relationships (Pollin & Baird Kanaan, 1995). MCC Counselors offer an approach that explores a careful balance between support and the necessary confrontation.
Integrative Medicine
The integrative medicine approach focuses on the whole person, emphasizes the importance of the relationship between patient and healthcare professional, and is willing to explore all therapeutic options (i.e., also outside the conventional realm) to achieve optimal wellbeing for the patient (Frenkel, 2008). This author discussed the need of an open and trustful dialogue between patient and health professional(s). He pointed to the importance of empowering the patients and encouraging them to engage in the decision-making process and the choice of therapeutic management strategies.
Frankel (2008) listed the most important element s in integrative medicine counseling as follows: (1) empathic communicating with empathy, compassion and care; (2) providing information/education about the treatments they are undergoing or interested in; (3) providing psychological, social, and spiritual support; (4) empowering patients and care-givers; and (5) assisting with coping strategies. Frankel argues that for the involved interaction, the interaction he deems most effective with patients going through an existential crisis, empathy and active compassion are critical ingredients. Frankel (2008) defines empathy as the emotional understanding of feelings or state of mind of another person, and active compassion as compassion with a determination to help alleviate suffering. For clients with medical conditions the presence of the therapist as a fellow human being seems as important as his/her presence as a professional consultant.
Supportive Psychotherapy
Viederman (2008) discussed an active supportive approach in which the therapist engages in a dynamic interaction with the client by communication his/her understanding of the client’s predicament and, in a sense, shares the experience to a certain extend. He argues that the aim of the greater affective responsiveness and activity from the counselor is to more fully engage the client in his/her therapeutic process.
Cognitive-behavioral therapies target dysfunctional thoughts and behaviors, identifying, challenging, and changing negative cognitions. Supportive counseling on the other hand, seeks to bring relief to the emotional distress of the client by discussing experiences, interacting with empathy and compassion, and unconditionally supporting choice-making, problem solving, and attempts at coping. Gilbert (2009) pointed to the effectiveness of a compassionate mindset to alleviate the negative consequences of self-critique and threat-based thinking. Being compassionate (i.e., open to the suffering of others and willing to relieve it) and supportive helps clients to feel milder towards themselves, their disease-related shortcomings, and their surroundings.
There is not much research done about the association between the therapist’s compassion and its impact on the effectiveness of counseling, although several therapy models point to compassion as an essential aspect of therapy (Vivino, Thompson, Hill, & Ladany, 2008). Research shows that compassion motivates therapists to engage more easily in interactions with clients who are in pain, helps them to understand the client more deeply, and to express sentiments about this understanding to the client (Vivino et al., 2008). Compassion may, in that way, create a therapeutic environment that is safe enough for the client to deeply explore and experience anxiety and suffering and may facilitate change by modeling a different emotional experience; helping the clients to become nonjudgmental observers of their own cognitive, emotional, or behavioral responses. These researchers suggested that the attitude of genuine warmth, support and acceptance that are expressed in compassion may counteract experiences of abandonment and isolation, inspiring clients to reconnect to themselves and others.
Dimensionality and Self-Organization
Livney and Parker (2005) proposed to use insights from chaos and complexity theory to find new way to help CID patients with psychosocial adaptation. After receiving the diagnosis of CID, they argued, most patients will suffer from a psychic disequilibrium. Their normal processes (e.g., cognitive, emotional, and behavioral) are disrupted and their normal functioning, or “core of functional complexity” (p. 24), is threatened. These researchers remarked that these patients experience a shift in dimensionality, which they described as a narrowing of life’s focus to a present-oriented and space-restrained framework (p. 24). For these patients the crisis forces their attention to the here and now of the immediate surroundings and present situation in which their physiological health and survival is all they can see and think of. When this symptom in a medical crisis is acknowledged as a dimensionality issue, the counselor may concentrate on regaining functional complexity by working on expanding the diminished dimensionality by a conscious orientation towards goals (future), skill acquisition, and for instance efforts that stimulate connections with others.
The impact of a CID is influenced by functional limitations, residual abilities, and the environments (i.e., dimensions) in which the patient physically and socially finds him/herself (Livney & Parker, 2005). Patients with CIDs could benefit from interventions that are aimed at extending functional dimensionality through modification and mastery of the environment and community in which the person lives and works. The researchers argued that a focus on strategies that increase dimensionality may invite clients to explore adaptive coping modalities that are future-oriented and more flexible. In this way these clients may address changing circumstances more effectively and be more creative in problem solving and using environmental-based coping resources (e.g., education, social support, funding).
Livney and Parker (2005) also explored the use of strategies for promoting self-reorganization. A CID may interrupt the homeostasis that exists between the person (i.e. self) and the environment. The medical crisis counselor has tools, for instance experiential interventions (e.g., role play, Gestalt) or cognitive-behavioral modalities, to help the client to develop alternative cognitive schemas, explore new adaptive measures, and adopt more effective ways of coping.
Expectable Issues
Pollin and Baird Kanaan (1995) formulated eight distinct areas of problems that clients with CID normally face; the eight “expectable issues”: control, self-mage, dependency, stigma, abandonment, ager, isolation, and death. In their book, they discussed each of these issues: how they present in counseling and the objective, role and stance of the counselor in the context of these issues. As these “expected issues” provide an important framework for the issues that need to be addressed in the MCC sessions with clients with CIDs, I will shortly introduce them here as they are presented by Pollin and Baird Kanaan.
Control
Research shows that the ability to create a sense of personal control is an important factor in the adaptation process to a chronic illness or disability. The client experiences an internal struggle with the illness, a struggle for power it seems, in which he/she seeks to gain mastery over his/her illness (Pollin & Baird Kanaan, 1995). In MCC the client is invited to verbalize fears and concerns about aspects that create a sense of powerlessness. An assessment can be made to distinguish actual and current from possible and future worries. A realistic reevaluation of the issues that bother the client may reduce the intensity of the anxiety and release some of the tension. Often it is helpful to reassess the client’s beliefs and attitudes toward the illness and the treatment and education/knowledge of the medical specifics and procedures can help the client to become a better participant in the discussions with primary care physicians.
Self-Image
A medical condition often requires considerable sacrifices in terms of physical agility, strength, and appearance. This means that for an individual with CID the existing image of self almost always needs to be adjusted to integrate the losses and changes that are the consequences of the disease this person is suffering from. People, who were used to being healthy, strong, and invulnerable, need to learn to live with the loss of these valued attributes.
Pollin and Baird Kanaan (1995) emphasized the importance of acknowledging, identifying, and grieving these losses. With time, a client then learns to accept and possibly even value a modified version of him/herself in which other attributes, those that remained or developed because of the illness, are strengthened. It may help a client to change perspective (e.g., asking “how would you perceive someone with your disease”) or explore beliefs and assumptions about lost attributes.
Dependence
Other, sometimes less noticeable or even conscious, sacrifices need to be acknowledged and integrated. An individual who suffers from a chronic disease may become dependent on many levels; emotionally, physically, but also practically. With CID patients it is important to keep in mind that, although they must accept a certain level of dependence, it is in the interest of the patient and caregiver(s) to remain a maximum level of self-reliance. We already saw that perceived control is an important adaptive quality; when possible the patient should feel stimulated to hold onto their independence, especially in areas in which their dependence is not compromised.
The MCC counselor needs to address the objective realities (e.g., the availability of help, financial limitations) and practical demands of the limitations the illness poses. It is also important to balance personality factors that influence the day-to-day functioning of the patient and his/her relation to caregiver(s), family, and others concerned (Pollin & Baird Kanaan, 1995). A counselor may want to assure that all parties are and remain consciously aware that it is the illness that creates the burden, not the patient. It is his/her responsibility to show those concerned that open and respectful communication helps to find solutions that work best.
Stigma
In our societies, people still have a hard time treating people who are different in a normal and respectful way. Especially those with physical handicaps or visible manifestations of their illnesses are often avoided or discriminated (Pollin & Baird Kanaan, 1995). For individuals with CIDs it is necessary to develop an adequate level of self-acceptance and social skills to deal with these attitudes of others. As we already saw in our discussion about self-image, the client must explore his/her own assumptions about his CID and it is essential to distinguish projections and personal prejudices from what others might really think.
MCC interventions focused on coping skills (e.g., how to communicate when discriminated in real life situations, finding alternative transportation) can be beneficial for clients with CIDs. Pollin and Baird Kanaan (1995) mentioned that a healthy level of detachment may be helpful, as may a developed sense of humor. Most important, it seems, is to grief losses and integrate the illness into the reality of self.
Abandonment
Clients, who are diagnosed with a CID and go through treatments and consequent stages of the disease-related process, experience various, often contradictory, thoughts. They know that they will need care, but they do not want to be a burden. They know they depend on their loved ones, but they are not willing to cause hardship to a caregiver. The caregivers, on the other hand, struggle with their willingness to help and, at the same time, experience feelings of inadequacy, frustration, or, in many instances, exhaustion. The interactions between patient and caregiver can suffer from these ambiguities and the tensions they cause (Pollin & Baird Kanaan, 1995). Again, both parties need to understand that it is the illness, and not the person being sick, that is the real problem. It is essential for a balanced cooperation that patient and caregiver both realize that they are facing this problem together. An early and honest discussion about these problems and the feelings surrounding them, separating practical decisions to make them discussable, help to prevent worst fear scenarios to become reality.
Anger
It is quite natural to be angry when confronted with a CID; the loss of one’s health is often a confrontation with aspects of life that seem unfair and cruel. The patient often does not recognize the feeling as anger or does not want to express it as such. Unacknowledged anger can lead to depression. MCC should therefore be aimed at identifying and releasing this anger and to give the client relief from the emotional pain it causes. Anger can be also closely associated with the loss the individual is suffering from. As we saw, the grieving of loss is essential to the adjustment to a chronic illness.
Pollin & Baird Kanaan (1995) learned from their experience with CID patients, that through interventions that seek the source of feelings of frustration and anger, a counselor can present ways to release and redirect their reconstructive energy. They called this transformation of “trapped energy” a vital part of the MCC treatment (p. 82), and surprisingly effective in relieving physical symptoms and turning the mood of the patient towards positive action.
Isolation
When confronted with a chronic illness most people will need some time to themselves to get used to the idea of being ill and to adjust to the many changes in their lives. For some it is also extremely difficult to “come out” with the news of their illness to family, friends, or people in their workplace. It is quite normal to withdraw during this phase; it takes courage to face the world as a person with a CID. Pollin and Baird Kanaan (1995) suggested considering and discussing the choice of a good moment to tell others about the CID in MCC. They argued that the timing of expressing this life-changing information may be an important factor in relationships that are crucial to the patient. In the examples these authors gave, isolated patients first needed to establish secure enough relationships before taking the risk of telling the truth about their medical condition.
Some patients will feel a tendency to withdraw from contact with others and some will feel the need to cut ties with the world they used to live in. Isolation however, is mostly a maladaptive way of coping. Research shows, that withdrawing from contact with other people may have a direct negative impact on health (Charmaz, 2008). In MCC a counselor will invite a client to look honestly at the perceived (versus real) barriers to social interactions and address assumptions that block the client from engaging in them.
Prior important personal relationships should normally be cherished and encouraged. Any difficulties a client encounters in maintaining these relationships should be identified and compassionately scrutinized. A confrontation with a chronic disease can put any relationship under pressure. In MCC a client should feel save enough to acknowledge and mourn the reality of deteriorating of relationships and friendships and be encouraged to search for and celebrate new ones.
Support and sharing groups can be an important way of sharing emotions and feelings that are more difficult to share with people who are not suffering from the same disease. Others in these groups can model behaviors that the client wants to learn. The therapist however, may feel the need to assess the client’s involvement in the group. When necessary it is his/her task to alert the client of the risks of exclusively interacting with these groups and emphasize the importance of a personal support system among the people they live with such as family, friends, neighbors, and their community (e.g., work-related or religious).
Death
Death is on the minds of people with medical conditions and needs to be addressed in any form of counseling that is offered, according to Pollin & Baird Kanaan (1995). Counselors should prepare themselves (e.g., by volunteering in a hospice) to be comfortable with the subject of death, be willing to talk about it, and be compassionate but also at ease around people who are dying.
In MCC sessions, clients who are dying need to be able to discuss their fears and worries freely. They should feel supported in grieving the anticipated losses and stimulated to examine if there are things they want to do or resolve in order to feel at peace. For some it may be essential to explore beliefs about death and life, and find meaning in things that happened. In the final stages of life, Pollin and Baird Kanaan (1995) emphasized, it is still essential to focus on the quality of life, to discover ways to enjoy the moment, and strive to live the life that is to the fullest.
Medical Crisis Counseling Interventions
Counseling interventions should be designed to address the psychological, emotional, and spiritual impact of a medical crisis on a patient’s wellbeing. Roberts, Kiselica, and Fredrickson (2002) argued that it is essential to acknowledge that the psychosocial responses that the afflicted person experiences are normal rather than pathological. These researchers considered the treatment of the complications (e.g., anxiety, fear, depression) of a CID as important for the patient’s health as the medical treatment of the disease itself.
Bishop (2005) researched the impact of a CID and explored the association between the adaptation to a CID and the perceived quality of life (QOL) of the patient. She hypnotized that the responses an individual experiences when confronted with the physical problems of a chronic illness, can be seen as an attempt to restore his/her QOL. Bishop found a significant, positive correlation between psychosocial adaptation to a CID and QOL. From these findings, she concluded that, because the inter-individual variations in terms of response appears to be unrelated to the severity of the illness/disability; these variations can probably be attributed to psychosocial factors.
Every person will react differently to a chronic illness; the psychosocial treatment of medical crisis requires a flexible and personalized approach. Ulman (2003) pointed to the importance to choose psychosocial interventions on an individual basis, depending on personal considerations and taking into account the severity, stage, and type of illness. Because a collaborative interaction between patient and clinician is considered to be more effective in most cases, Ulman argued that the final decision about the treatment should preferably be a choice made by the patient and clinician together.
First Aid Medical Crisis Interventions
In contact with an individual in medical crisis situations, a counselor should be concerned with psychological “first aid”, a term Reyes and Elhai (2004) used for the counseling interventions they suggested when first meeting the client with a CID. They proposed a number of measures to secure a safe environment for the client, providing him/her with emotional support, and helping him/her to regain a sense of equilibrium. An assessment should be made of the client’s situation, as well as his/her responses to it. For instance: how overwhelmed, confused, or emotionally unstable is this person? What short-term (time sensitive) actions and decisions need to be taken; and what personal or community resources are available? Reyes and Elhai added that the counselor should use a more directive stance during crisis interventions, and first focus on systematic problem solving and model constructive coping.
Cognitive-Behavioral Interventions
Individuals ordinarily live with a system of assumptions about their world and beliefs about their place in this reality. Most have ideals, goals, and ideas about their direction. A chronic illness confronts a person with serious limitations that can change life’s circumstances drastically. Prior assumptions and immediate goals are no longer attainable or even valid. The gap, the perceived discrepancy, between the actual new situation and the one that was perceived as desirable under the old assumptions influences the impact of the CID.
When first confronted with a CID, the cognitive response to it will generally be characterized by pessimism, negative rumination, intrusive feelings of despair and loss and the consequent psychological stress. Tedeschi and Calhoun (2008) reported, however, that in the next phase, healthy individuals will disengage gradually from the beliefs and goals that are no longer valid, and start the process of restructuring their cognitive structures (schemas), thus reducing the deviation between inner cognitive structures and outer reality. In counseling, the therapist can assist clients with this cognitive processing en restructuring, and help them to integrate the illness or physical limitations of it into their daily lives and make behavioral adaptations.
Seligman (2002) posed that an individual requires the impetus of a true challenge to fully engage inner strengths and virtues. For some, a CID may present such a challenge to change their perspectives and learn to appreciate life, daily pleasures, and their relationships with loved ones in a different, more meaningful way (Armstrong, 2007). A MCC counselor should create opportunities to stimulate a positive, proactive attitude in clients in order to evoke a willingness to see opportunities for growth from the CID experience. After establishing a supportive environment, therapists may inspire clients to consider conscious choices to appreciate what is good in their lives and to find opportunities to make the best of their situation.
Benefit-finding and positive reframing can be seen as essential aspects of cognitive behavioral therapy for patients with medical conditions because both have adaptive significance (Affleck & Tennen, 1996). When working with people under traumatic circumstances, personality characteristics that may promote these adaptive coping strategies merit attention. Affleck and Tennen argued that optimistic and hopeful individuals, people with a positive perspective on the present and a hopeful look towards the future, can perceive positive aspects in living with their chronic illnesses and limitations with more ease than less optimistic individuals can. More cognitive complex persons tend to perceive the opportunities for change (e.g., changing their priorities) easier because of their greater flexibility and ability to create alternative goals. A MCC counselor could stimulate a positive outlook by discussing realistic possibilities for change and proposing strategies to achieve attainable goals.
Self-Management
As many of the expectable issues in the coping process of a CID patient are concerned with the perceived individual functioning of the patient in his/her life (e.g., control, dependency, isolation etc.), self-management is an important, but complex topic in any therapy in the context of chronic illness; a multitude of social and cultural factors are involved. Gazzola and Muskin (2003) emphasized that sick people must often relinquish a great deal of control and often have no choice but to delegate tasks concerning their treatment (e.g., making decisions, planning) to health professional and care-givers. For a counselor, it may be necessary to assess “who is in charge” in various the client’s health-related situations (e.g., at home, in the decision-making context) and to determine what the patient’s position is in each of these situations. An open and truthful communication is highly recommended and the patient should be encouraged to participate and exercise control where possible.
Townsend, Wyke, and Hunt (2006) studied people with chronic illnesses and found that patients use self-managing coping strategies aimed at handling symptoms and maintaining pre-morbid functioning. Often individuals try to appear stronger and healthier than they really are because they feel morally bound to show a positive attitude. Self-management seems focused on identity management and keeping up appearances (e.g., social roles and familiar identities), even if they risk aggravating their illness. “Being a good mum trumps being a good patient” (p.191). Although these coping strategies enable patients to hold onto their sense of self, the culturally enforced need to function “normally” creates tension and ambivalence.
Counseling could help these patients to acknowledge their maladaptive coping strategies and invites them to reevaluate their priorities. It seems important to create a therapeutic environment in which clients can learn to allow themselves to accept the limitations the illness imposes on their lives, so that meaningful adaptation and integration of the CIDs can occur. An honest, realistic, and pragmatic perspective on what they can reasonably expect from themselves can help clients to set appropriate goals and be happier with their own functioning. For care-givers and family, this may also be a relief.
A sense of personal control seems to help a patient to adjust to the psychological distress of illness. Henselmans et al. (2010) found mastery to be the only characteristic that significantly predicted the trajectory of adjustment to a chronic illness. Perceived personal control over life (mastery) seemed to have a protective effect on psychological distress because of the different way in which women who felt they were in control appraised threats and coped with a sense of self-efficacy. Because having a CID lowers one’s sense of control, regaining a sense of control may be considered an important aspect in the adjustment to illness.
Research shows a significant relationship between perceived control and psychological stress. Ranchor et al. (2010) found that declines in control are maladaptive; individuals who were able to maintain their levels of perceived control reported better outcomes on their assessments of psychological distress, independent of prognosis. They argued that active efforts to exert control may be beneficial for individuals with chronic diseases. Ranchor and al. distinguished between primary control strategies, including the ability to exert control over treatment choices and other aspects of the disease process and secondary control strategies, like for instance cognitive reconstruction. An understanding of the adaptive value of control mechanisms could have decisive implications for clinical practice and therapeutic interventions. It would be helpful, in an individual setting, to assess the level of perceived control for clients and explore how the sense of personal mastery could be increased.
Social Support
Partners, friends, and members of the family can be an important factor in a patient’s response to medical treatment and his/her adjustment to a chronic illness. These people are also affected by the patient’s disease and may sometimes benefit from psychological support or help. Psychosocial interventions that incorporate a spouse or another family member appear to be an attractive treatment option. Gazzola and Muskin (2003) suggested issues that are important to evaluate when assessing the support potential of a client who faces medical problems: level of well-being of patient, primary care giver, and support providers; family structures; marital roles; employment and financial situation; and community, religious, and cultural expectations and demands (pp. 374-376).
Martire (2005) reviewed research that compared different forms of cognitive-behavioral interventions. She found that many studies report that family interventions, targeting a close family member as well as the patient, showed promising positive effects and meaningful improvements for patients in terms of symptomatology, stress, and self-efficacy. Cognitive-behavioral approaches seemed to work well in a dyad setting, with both patient and care-taker, where lifestyle changes, as necessary with diabetes or heart disease, were required. These finding suggest that exchanges of emotional support between partners enhances the effect of the intervention. Especially with female patients, the family-oriented interventions seemed to be more effective. In private practice the counselor may consider working with clients and their partners; a flexible approach, showing willingness to invite primary care-givers to join for relevant sessions, seems desirable.
Self-disclosure and other forms of expression of thoughts and feelings in a supportive social context, soon after a traumatic event such as the diagnosis of a CID, have positive effects on health outcomes (Ulrich & Lutgendorf, 2002). Sharing of personal ruminations was found to be helpful, even more so in instances where the patient was asked to explicitly talk or write about the positive aspects in his/her thinking. Especially patients who tend to ruminate excessively benefit from social interactions; talking with others may be an effective way to avoid depression. Nolen-Hoekstra and Larson (1999) suggested that cognitive processing is sometimes inhibited when people are unable to share their thoughts or when they feel that social support is lacking. In individual therapy, a counselor invites clients to talk about their thoughts and emotions. It is useful to explore other forms of expression too; for example a daily journal to write down thoughts and feelings about the traumatic diagnosis or experienced anxiety, or role play.
Psycho-educational Interventions
As discussed above, patients with chronic illnesses often express a desire to be involved in the management of their health; they want to understand the basic mechanisms of their disease, the clinical consequences of their test results, and the reasons why certain medications or treatments are chosen (Thorpe, 2008). In the same way, clients benefit from knowing more about their psychosocial responses to their illness. Patients may feel the need to become experts on managing their personal health (Sollod, 2002).
Another advantage of psychoeducation is that the client gradually deepens the personal experience that a proactive participation effectively helps to feel better. This experience can engender an incentive to become more involved, for instance in decision-making, self-management, or positive goal setting. Ulman (2003) recommended psychoeducation as a first psychosocial intervention with medical patients. The cognitive framework helps clients to reduce their anxiety and promotes a sense of control. In this view, the knowledge that, although the stress response can influence the illness and may interfere with recovery, there are options for managing its impact, can increase the patients’ motivation to actively cooperate in seeking effective interventions. Sheridan and Radmacher (2003) emphasized the importance of educating patients about the use of coping strategies in order to equip them to deal more effectively with health problems, make better decisions concerning their treatment, and take appropriate actions to enhance the quality of their lives.
Stress Management
It is important in MCC to address the stress the patient is experiencing. Brown, Tennant, Dunn, and Pollard and colleagues (2005) suggested a “vicious cycle may exist between stressors and disease progression” (p. 480). When the homeostatic response to terminate the acute stress reaction fails or the stress endures, the prolonged stress-response exacts an adaptive cost: the allostatic load (Lovallo, 2005). It is the price the human body, including the brain, pays for adapting to the challenges of stress. The allostatic load can seriously impair health and cause additional diseases and psychological disorders to develop.
Stress-reducing interventions, such as stress-management, mindfulness, and cognitive therapy, may be combined with interventions that reduce susceptibility to stress-related physical decline (e.g., exercise and diet). Stress-preventing strategies, including coping skills training, can help patients to cope with the excessive stress they are experiencing. A combination of these interventions may influence the course of the disease and improve prognosis (Brown et al., 2005).
Stapleton, Lating, Kirkhart, and Everly (2006) reviewed research into the effect of early individual crisis interventions in medical contexts. They found that these interventions had the strongest effect on anxiety symptoms and posttraumatic stress but that the effect on depressive symptoms was less pronounced. These researchers suggested that a multiple components approach was most effective: coping-related interventions seemed to be highly effective but counseling sessions that combine these stress-management interventions with interventions that focus on feelings of grief and guilt, target other individual depressive symptoms, and built resilience proved to be more effective. The findings showed that multiple sessions were of more value to the patient than single sessions without follow-up, and that a higher level of specialized training of the counselor was associated with significantly better results. For counselors who work with clients with medical conditions in private practice this means that they should not only focus on coping, but also on the emotional aspects of the CID.
Counselors may assess the ability of a client to cope with stress by looking for certain characteristics. A more optimistic person who seems resourceful and flexible and tends to be practical would normally cope better than a person with a more pessimistic, inflexible, and intolerant disposition (Gazzola & Muskin, 2003). People respond differently to a crisis or an illness. Some clients will feel guilt and view the illness as a punishment, others will feel anger and ask “why me?”, or react with emotions that show signs of depression. Counseling interventions need to be adapted to these specific emotions.
Personality style should also be assessed and understood in order to determine how best to approach stress, because personality may also play a role in how a person responds to illness (Gazolla & Muskin, 2003). A compulsive person, for example, might have a tendency to ask questions repeatedly. For this patient, it would be helpful to give adequate details and allow him/her to actively participate in planning. For a paranoid person, who fears to be harmed, it would be best to explain beforehand what is to be expected in every step of the procedure (p386-390).
Charney (2004) discussed resilience and vulnerability in the context of the neurobiological responses to extreme stress. In order to understand why some people are able to cope more effectively with stress than others, he proposed to identify the responses that relate to psychobiological allostasis. In individual therapy session, it may be valuable to explore with clients what behaviors have served them in the past to maintain their normal functioning. As Pollin (1995) suggested, prior coping strategies can be helpful in dealing with the new situation.
Complementary Therapies and Alternative Interventions
In recent years, the popularity of complementary and alternative medicine (CAM) has increased, and research shows that people with chronic illness or chronic pain are 50% more likely to use CAM treatments than those without a chronic condition (Saydah & Eberhardt, 2006). Although the reasons why people use CAM are not always clear, these authors suggested that most are not satisfied with their conventional treatments or feel that these treatments are too expensive, too invasive, or not congruent with their worldviews, life philosophy or values. Another addition reason could be that patients with chronic diseases may manifest a need for personal control and a desire for self-care; these patients tend to seek information on different treatments and are more open to alternative therapies that might bring them relief. Less than 30% of CAM users report talking about it to their physicians (Saydah & Eberhardt, 2006).
The categories grouping the CAM practices are (a) natural products, for instance herbal or botanical medicinal products, supplements, and probiotics (live microorganisms); (b) mind-body medicine, including meditation, hypnosis, yoga, and acupuncture; and (c) manipulative and body-bases practices like spiral manipulation and massage therapy (NIH, 2006). Frenkel (2008) proposed to explore why people want to use CAMs and what beliefs and expectations they associate with the therapies they use because they play an important role in the decision-making process and might influence treatment adherence.
Thorpe (2007) argues that most people are motivated to use CAM because they perceive biomedicine to be limited and desire more control over the management of their illness. A further advantage of CAM is its holistic approach to health and well-being, as opposed to, the more pathogenic focus of biomedicine. A pragmatic approach seeking the treatments that are most effective and manageable when necessary combining conventional and complementary therapies, seems to be the best strategy that suits most clients.
Mindfulness-based stress reduction (MBSR) uses mindfulness meditation to alleviate suffering and increase perceived quality of life. Research shows that MBSR helps with chronic diseases; it engenders better coping with symptoms, enhances health outcomes, and improves overall well-being (Merkes, 2010). Because mindfulness meditation is a technique that can easily be taught in counseling sessions and practiced at home (i.e., in almost any setting, with a minimum of time, and no particular attributes), it can be explored in a private practice setting. Although the MBSR was first designed to reduce stress, mindfulness meditation itself seems to have other advantages. Research shows that meditation practices increases the levels of mindfulness which in turn improve psychological symptoms. Mindfulness seems to reinforce the patient’s sense of mastery, enhances well-being, and increases the perceived quality of life Carmody & Baer, 2008).
In my practice, I have often recommended clients with high levels of emotional stress and depression to experiment with exercise (e.g., tai chi or yoga), relaxation (e.g. massage), or meditation practices. For some self-hypnosis or guided imagery helped, others found more equanimity in a meditation practice (e.g., mindfulness). I think it is important to support people to find what works for them, but I witnessed some amazing results from these techniques.
End of Life Counseling
Counselors can help their clients with medical conditions, where needed, to develop better relationships with their primary physicians by addressing the problems that occur in their interactions with these health professionals. Clear communication decreases ambiguity; an honest discussion and the sharing of relevant information about the patient’s condition (e.g. about the futility of medical interventions) are among the most important needs of patients and families in end-of-life decision-making. Bartels and Faber-Langendoen (2001) emphasized the importance of respect, care and compassion.
In situations where the family of a patient plays an active role in the care and monitoring of the patient, it seems essential hearing what they have to say and helping them to negotiate meaning for the reality of the situation. Patients and their families benefit from an open discussion with health professionals. The goal of the interaction is a thorough understanding of the decision-making options and a mutual agreement on the division or sharing of decision-making responsibilities. Patients or their surrogates need to feel comfortable in either making choices or otherwise in following the recommendations of the physician in charge (Winzelberg et al., 2005).
Psychotherapy; exploring one’s attitude towards life, suffering, and dying can also be valuable for those confronted with chronic disease and death. Breitbart, Gibson, Poppito, and Berg (2004) urged counselors to use more meaning-centered approaches and focus on the promotion of personal agency and responsibility. Existential interventions are particularly relevant in end-of-life counseling; they involve issues surrounding meaning and spirituality, and may explore the client’s ideas concerning the “why” of their existence, to help them to accept and embrace the choices they have made in their lives (p. 369). Most individuals will feel a need for closure, especially when relationships with important others are troubled or unresolved. A counselor should be willing to address these issues with compassion and enough detachment to do what is possible but should refrain from feeling challenged to work miracles.
Discussion
During the MCC course and while researching the topic of counseling clients with medical conditions in private practice, I realized how valuable it is to have experience, personal or from contact with others, with chronic illness and death. Can anybody learn MCC solely from scientific literature or textbooks? As Pollin and Baird Kanaan (1995) suggested, counselors in MCC should feel comfortable with sickness, disabilities, and death. They should consciously prepare themselves for the emotional burden clients may bring to their practices. Apart from the academic knowledge and skills, psychotherapists could learn from listening to and reading about people who lived with life threatening or chronic illnesses (Sollod, 2002). MCC therapists need to invest effort and time in the development of their ability to counsel with empathy and compassion (Gilbert, 2009).
The research on MCC has revealed that it is important to offer clients counseling that is tailored to their specific needs (Roberts, Kiselica, & Fredrickson, 2002). A combination of cognitive-behavioral interventions, psycho-education, and complementary approaches seems to be the most appropriate and effective way to treat most of the symptoms of these medical patients. A flexible, but structured course of action in a supportive setting will more effectively invite clients to pay attention to their internal experience, their physical sensations, thoughts, and feelings, in relation to external events (Pollin and Baird Kanaan, 1995). The ability to observe their inner responses will allow clients to behave and adapt with more awareness when confronted with the expected difficulties (Ulman, 2003, p. 412). The goal of this kind of counseling is to teach the clients to optimally adapt to the changing circumstances the CID brought to their lives.
Although various authors remarked that a pragmatic, problem-focused approach seems to be more effective than emotion-focused strategies, counselors should complement problem-focused interventions with supportive, emotion-focused interventions that address the emotional adaptation to the changes brought on by the illness (Sheridan & Radmacher, 2003). In most illnesses the stressors are hardly controllable. Because the loss of control seems difficult to cope with for clients, potential avenues for effective interventions lie in an approach that emphasizes a transformation of perspective, enabling the clients to better handle distressing emotions accompanying the loss of control. The therapist’s empathy and compassion seem to be an important factor in this process (Gilbert, 2009). In private practice, a counselor is able to create a safe and supportive therapeutic environment that facilitates change.
The conscious reevaluation and reconstruction of basic personal cognitive structures, schemas that are overthrown by the confrontation with a medical crisis, can provoke processes that may be perceived as psychological growth (Aldwin, 2007). Counselors should be aware of the opportunities for positive transformation as a result of the experience of the medical crisis. With guidance, clients can emerge from a medical crisis with a new sense of self that integrates abilities and insights that will enable them to face future challenges. These insights, Tedeschi and Calhoun (2004) argued, go beyond an intellectual understanding, but develop from the transformative experience itself, which invites individuals to explore what is really important and inspires them to grow as human beings. The clients’ awareness of vulnerability, combined with the inner knowing of their ability to cope in spite of it, often empowers clients and inspires them to engage more deeply in life. It would be rewarding for a counselor to motivate and assist clients in their efforts to psychologically grow from their experience with a medical condition.
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