Recognition and treatment of physical factors in psychotherapy clients

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Content: Recognition and Treatment of Physical Factors in Psychotherapy Clients Martha Sanbower, MA1
As therapists and counselors we are taught to see things from a psychological perspective. Psychopathology develops, we are told, because of such things as unresolved unconscious conflicts (Freud, 1950), unsatisfied basic needs (Maslow, 1970), irrational thinking (Beck, 1979) or emotionally threatening environments (Horney, 1939). These theories rest on the notion that emotional and mental difficulties occur because of emotional or mental wounding. When psychological problems are behind our emotional symptoms then applying these theories to our psychotherapy is appropriate. However, these theories are limited in scope because they are based upon the assumption that our minds are separate from our bodies. They cannot help us deal with a client whose emotional symptoms stem from a physical source. In truth, our minds and our bodies are inextricably linked. Research dealing with physical illness is revealing important information about the intricate relationship between our minds and our bodies. Psychological factors have been connected to a variety of physical illnesses including cancer (Goodkin, Antoni, & Blaney, 1986; Leshan & Worthington, 1956), heart disease (Rosenman et al, 1975), migraine headaches (Rees & Linford, 1974), and even the common cold (Totman, Kiff, Reed, & Craig, 1980). It is important that we do not minimize the fact that this relationship goes two ways: just as our minds affect our bodies, so do our bodies affect our minds. While psychological problems may be complicating factors, there are a variety of physical problems that can cause mental and emotional symptoms, and can easily be passed off as neurotic or psychotic. Endocrine disorders, immune system problems and Nutritional deficiencies are
among the physical problem areas that can affect our emotional balance. Symptoms as varied as mood swings, mental fogginess, anxiety, depression and psychosis can be physically based. Many individuals who suffer from physically based emotional symptoms have been told that their problems are "all in your head", when doctors cannot pin down their complaint with a concrete diagnostic label. Often they will be referred for psychiatric care or counseling. It is the purpose of this paper to clarify our role as therapists in recognizing and dealing with complicating physical problems in our clients. We will overview some of the physical problems that may be affecting our clients. From a holistic point of view, we will discuss the ways in which we can act as health advocates for our clients. And we will look at some psychotherapeutic issues involved in working with chronically ill clients. In order to understand the connection between our minds and our bodies, it is important that we understand the concept of stress. Contrary to common understanding, stress is not just emotional pressure. According to noted stress researcher Hans Selye (1978), stress is "the nonspecific response of the body to any demand" (p. 472). Actually, all situations to which we must adapt, even positive life changes, cause stress in our bodies (Pelletier, 1977). We must understand that just as a poor relationship with our boss can be the source of stress, so can each of the health conditions described further on in this paper. Any time our bodies are taxed by anything the result is stress, and whatever it's source, stress is a physical reality. Affecting the entire body, stress can disrupt our nervous systems, damage our internal organs, and suppress our immune systems (Pelletier, 1977; Selye, 1978).
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While we may cope effectively with one or two stressors (that which causes stress) there is a limit to our coping resources, and when our resources are over-taxed, we become ill (Brown, 1984; Pelletier; Selye). It does not matter if the stressors which pushed us into illness are psychological, environmental, or physical; they all result in stress. And illness itself is a stressor that maintains a constant state of stress in our bodies. When the effects of stress are combined with our own unique body chemistry, our psychological and genetic make-up, and the effects of the specific stressor, the result is our own particular set of symptoms or type of illness. Stress frequently causes emotional symptoms. (See Appendix A for a list of common symptoms of stress.) There is a group of illnesses which typically produce mental and emotional symptoms. The examples overviewed here were chosen because they tend to be commonly overlooked by doctors. These examples are nutritional deficiencies, hypoglycemia, hypothyroidism, premenstrual syndrome, allergies, and chronic candidiasis. These illnesses involve subtle biochemical changes rather than clear cut organic pathology, and tend to be difficult to test for. Also, while pioneering physicians recognize and treat these problems, many closed-minded doctors do not accept these as legitimate illness, finding it easier to label sufferers as hypochondriacs and neurotics. As therapists we are likely to encounter clients with these health problems. And if we miss these potentially vital physical components, we could be doing a harmful disservice to our clients. The following information is not meant to be an exhaustive list of illnesses which have emotional ramifications. Nor is it meant to be an in depth analysis of the physiological aspects of these health problems. Instead, this material is given to provide a general picture of the way in which various physical problems can manifest emotionally, with the purpose of making us wary of automatically assuming a purely psychological base for the kinds of issues which we encounter as therapists. Malnutrition It is not a recent discovery that emotional symptoms can be caused by malnutrition.
For example pellagra, a vitamin B3 deficiency has long been known to cause an array of mental and emotional changes (Spies, Aring, Gelpering & Bean, 1938). However, as a gross case of deficiency, pellagra may not be diagnosed for five years after psychotic symptoms have first appeared (Fredricks, 1976). Until it becomes extreme, nutritional deficiencies may be difficult to pick up with standard lab tests; however, even mild deficiencies may have marked emotional effects (Hoffer & Walker, 1978). Among the common causes of nutritional deficiency are extreme individual needs for certain nutrients, and our modern diets of highly processed, nonnourishing "junk" foods. Noted Orthomolecular psychiatrist, Abram Hoffer states that "every tissue of the body is affected by nutrition. Under condition of poor nutrition the kidney stops filtering, the stomach stops secreting, the adrenals stop secreting, and other organs follow suit. Unfortunately, some psychiatrists labour under the false belief that somehow brain function is completely unaffected by nutrition" (Hoffer & Walker, 1978, p. 28). However, a wide variety of emotional and mental symptoms including depression, psychosis and anxiety, can be traced to nutritional deficiencies. In his book Nutritional Therapy, Dr. Jonathan Wright, MD (1979) cites many examples of individuals with emotional symptoms due to nutritional deficiency. Typical of the kind of case that we may find among our therapy clients is a depressed 36 year old woman called Mrs. Action. Despite years of psychotherapy and drug treatment, Mrs. Action's depression was relentless. In addition, Mrs. Action suffered from physical symptoms including constipation, excessive gas and fatty deposits around her eyelids. After determining that Mrs. Action was suffering from a vitamin deficiency, Dr. Wright treated her with B12 injections. According to Dr. Wright, "her response was striking ... Mrs. Action's mental attitude was entirely different with B12. She reported she had 'energy and ambition' (and felt that) she could control her emotion 'for the first time in years'. Her depression lifted, and tension dissipated. (Her outbursts of rage) became a thing of the past'' (p. 56), and her physical symptoms cleared up.
Recognition and Treatment of Physical Factors in Psychotherapy Clients
Hypoglycemia Because sugar is our brain's primary source of fuel, when our blood sugar drops below an optimum level for our brains, we may be prone to experiencing a confusing array of mental and emotional symptoms (Hoffer et al, 1978). Among those symptoms attributed to low blood sugar, or hypoglycemia, are nervousness, irritability, depression, mental confusion, phobias, and anxiety (Fredericks, 1976). A number of factors can interfere with our sugar balance and bring on hypoglycemia. These factors include prolonged stress, caffeine and sugar consumption, poor absorption of sugar, excessively slow or fast metabolism, and allergies (Fredericks). In his book Nutritional Therapy, Wright (1979 cites a case of a depressed truck driver named William. William had suicidal thoughts and his temper flared up over the smallest problem. William's physical symptoms were a clue to the diagnosis of hypoglycemia. Describing his symptoms he said the "last few months, driving, I've started to have practically blackout spells ... After a couple of those spells, I got real nervous and shaky. I used to drive all day without eating. Now if I eat something it helps" (p. 63). With treatment for his hypoglycemia William's depression, anger and dizzy spells cleared up. Hypothyroidism In its extreme form, thyroid deficiency or hypothyroidism is a disease called myxedema. Myxedema is a fairly rare endocrine (i.e. hormonal) disorder which causes psychotic symptoms (Berkow & Talbott, 1977). However, according to Barnes & Galton (1976), mild to moderate cases of hypothyroidism are quite common and often undetected. Many patients with hypothyroidism have been labeled hypochondriacs and they are told that their problems are psychologically based. Some common physical and emotional symptoms of hypothyroidism are headaches, skin problems, menstrual disturbances, memory and concentration difficulties and depression. Latent hypothyroidism can manifest itself at any age when there is high stress in life (Barnes & Galton).
Dr. Martha Schon (as cited by Barnes & Galton, 1976, p. 79) studied a group of patients with hypothyroidism and concluded that they could easily be mistaken for neurotics. Along with varied physical symptoms, these patients complained of fatigue, irritability, and nervousness. They were described as emotionally expressive with oppositional tendencies; while regretting their behaviour, they could not control themselves. Upon treatment with thyroid hormone Dr. Schon found that most of the physical and emotional symptoms cleared up. Premenstrual Syndrome Another common female disorder which may be labeled neurotic is premenstrual syndrome or PMS. Also called cyclic distress, PMS can produce a wide variety of symptoms which appear regularly each month at the same phase of a woman's menstrual cycle (Weiss & Hendrickson, 1986). There are several possible reasons for PMS including hormonal imbalances (Barnes, 1976; Dalton, 1979; Weiss et al), vitamin B6 devidiency (Wright, 1976), or immune-system problems (Crook, 1985; Truss, 1982; Weiss et al). While symptoms vary with individuals, common symptoms include irritability, mood swings, depression, bloating, bladder and bowel dysfunction, fatigue, headaches, uncontrolled eating binges, and alcohol cravings (Weiss et al). In a therapy group for women with chronic illness, one of my clients suffered from severe PMS. On Sarah's good days she was a warm, smiling and interactive member of our group. However for two weeks out of each month Sarah became another person. It took all her effort just to make it to our sessions due to the agoraphobic feelings she experienced during those days, and when she did come in, she was withdrawn and sullen in group. She also looked different without her usual smile, her face bloated and pale. Sarah's central problem during her good phase was her dread of the possibility of committing suicide during her "bad" days. Sarah knew that her ups and downs were due to PMS, and she gained helpful coping skills and boosted self-esteem from having the physical aspects of her problems acknowledged within our group.
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Allergies From the fields of Clinical Ecology and Orthomolecular Psychiatry, we have learned that allergies can beat the root of a myriad of emotional and mental symptoms. Respected researcher and Clinical Ecologist, Dr. Theron Randolph (Randolph & Moss, 1980) uses the term "allergy" broadly to mean any pathological reaction to any encountered substance. When our immune systems are over-taxed, we can develop allergies to common allergens such as pollens and molds. Other substances such as foods, chemicals, and environmental pollution can also be a source of problems. When the central nervous system is affected by allergies, the sufferer may experience a variety of mental or emotional symptoms including mood swings, memory and concentration problems, and psychosis. These responses, known as cerebral reactions, generally go along with a host of physical symptoms which may be as varied as the standard "wheeze and sneeze" reaction, insomnia, headaches and joint pain, and all types of gastrointestinal disturbances (Philpott & Kalita, 1980; Randolph et al). Scented products of all sorts, such as soaps, perfumes, or deodorants, are chemicals which frequently cause sensitive individuals trouble. One of my chemically-sensitive clients, whom I will call June, experienced a dramatic example of an allergically induced mood change. June had been feeling fine one day until she went to a beauty shop to have her hair trimmed. By the time the haircut was finished, June's mood was radically altered; she felt suicidally depressed. We realized that June's nervous system had reacted to the chemicals in the beauty shop. Her depression gradually wore off over the next few days as June's body detoxified from the chemicals. Now June avoids beauty shops and has her hair cut at home. Another client, Cindy, was a college student when she began to experience mental symptoms due to chemical allergies. Cindy was taking a chemistry class when fatigue and depression began to interfere with her studies. Describing herself as feeling "foggy headed", confused and shaky, she noticed that she felt the worst in her chemistry lab where she found herself
dropping and spilling things and forgetting experimental procedures. In addition, she suffered from headaches, insomnia and respiratory problems. She began to think that she was losing her mind but, like June, Cindy was suffering from cerebral reactions to chemical allergies. After dropping her chemistry class, Cindy consulted a Clinical Ecologist who told her to avoid chemical exposures, and helped her work out a regimen to rebuild her weakened immune system. Gradually, Cindy's symptoms disappeared. Chronic Candidiasis The extensive research of Dr. Orian Truss (1982), has singled out an ubiquitous pathogenic yeast, Candida Albicans, as a prime cause of many emotional symptoms. Candidiasis is a chronic yeast infestation that results in a weakened immune system. Our 20th century high-sugar diets, birth control pills, and extended use of antibiotics are all factors which promote yeast growth. Wreaking biochemical havoc in the bodies of sufferers, chronic candidiasis can cause a host of problems including many of the disorders mentioned in this paper. If we become victims of chronic candidiasis, the yeast may affect our brains in various ways. The chronic yeast infection weakens our immune systems, leaving us vulnerable to developing allergies to all sorts of substances. When the reacting organ to these substances is the brain, we can experience such symptoms as depression, concentration and memory problems, and even psychosis. In a related way, the yeast toxins released into the blood can directly cause cerebral reactions. Furthermore, by colonizing our Digestive systems, the yeast hampers absorption thereby robbing our bodies of vital nutrients. The resulting state of malnutrition has a debilitating effect upon the entire body, and can add to our central nervous system problems (Crook, 1985; Truss). My own story illustrates the effects of chronic candidiasis. Beginning with a bout of bad bronchitis, which was treated with antibiotics, my life became a nightmare of emotional and physical problems.
Recognition and Treatment of Physical Factors in Psychotherapy Clients
I was nineteen years old when I was diagnosed as having colitis, and I was told this was a psychosomatic illness that I would have for the rest of my life. Along with the colitis, my moods began bouncing from ecstatic highs to suicidal lows and I was diagnosed as "manic-depressive". After the birth of my two children, my health rapidly deteriorated. I was constantly sick with one infection after another, and I always seemed to be on antibiotics. Exhaustion and depression became my constant companions; my memory was hopeless, and my mind seemed filled with fog. In addition, I seemed to be developing allergies to everything in my environment. In my quest for healing I tried all sorts of treatments, both traditional and alternative, but at best they seemed to keep me from getting worse. Among the diagnoses I received were hypoglycemia, hypothyroidism, and PMS. Doctors attributed my overwhelming exhaustion and other complaints to the stress of being a young mother: it was normal to feel as I did, they told me, and they suggested I seek counseling. I began to believe that a horrible unconscious conflict lay at the heart of my problems, and I wondered if I had repressed hatred for my role as mother or wife. Fortunately, I discovered the source of my problem. At a workshop I attended, an Orthomolecular Psychiatrist spoke about biochemical problems which can cause both physical and emotional distress. I sat this doctor down and shared my health/mental health history with him and he urged me to check Candida as a possible reason for my problems. The Candida treatment has given me back both my physical and emotional health. My mood swings are gone, as are the other symptoms of my illness. Through the best teacher that there is, experience, I have learned that our bodies can affect our minds. Clearly as therapists, we are not expected to be medically trained. It is not our job to diagnose and treat these problems. However, we can learn to recognize the various "red flag" symptoms that may suggest an underlying physical problem. Because stress is involved in all illnesses, many of the common symptoms of Hypoglycemia, Candidiasis, Hypothyroidism and the other health
problems described in this paper are the same as that of a general state of stress. A familiarity with the list in Appendix A will give us a good overview of these "red flag" symptoms. We must be careful not to assume that all stressors are psychological. While psychological factors may be involved, the origin of the stress may be physical. We must be ready to help our clients pinpoint the stressors in their lives in other realms than just the psychological. And we must know how to proceed if we suspect that our client's problems may have a physical component. A Holistic Viewpoint As we learn to stop taking psychological explanations for our clients' problems for granted and learn to think more holistically, it becomes clear that we need to work with other health care professionals as part of a healing team. To more adequately fill our role as therapists, it is important that we understand the holistic approach to health. In his book, The Mechanic and the Gardner, Lawrence Leshan (1982) says "there is no such thing as a holistic technique or modality. There is only a holistic attitude" (p. 127). Basic to the holistic attitude is a rejection of the single-cause theory of disease. Instead, the holistic viewpoint is that many factors contribute to our state of health. In holistic thinking, our self-healing capacities are acknowledged and worked with as a crucial part of the prevention and cure of illness. According to Kenneth Pelletier (1979), a basic premise of the holistic approach to health is a belief that a "patient's life-style and willingness to participate in the healing process can significantly affect the course of his or her health" (p. 214). The holistic approach to health demands that we take responsibility for our health through active involvement with and understanding of any treatment we undergo. The holistic attitude accepts that we are each individuals and must be met and responded to as such. Seen holistically, we are more than just a body or a mind; according to Leshan (1982), we "must be seen as existing on many equally important levels" (p. 53), including our
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bodies, minds, emotions, spirits, and social and Physical Environments. In his guidelines to the development of a holistic-health program, Leshan (1982) states that no one program will be effective for everyone, and every program will take careful planning and work. According to Leshan, various modalities can help specific types of problems. In addition to medical doctors, other health care professionals including chiropractors, massage therapists, and acupuncturists should be utilized as part of a holistic-healing team. In the words of Kenneth Pelletier (1979), "health never has been and never will be the sole responsibility of doctors but increasingly that of the consumer working in concert with medical, psychological and environmental counselors" (p. 6). While we as therapists are an integral part of the health-care team, we must not think that we have the exclusive answer, but must view psychotherapy as part of a total holistic approach to health. As therapists we are in a prime position to help our clients develop and coordinate their holistic-health programs. We should be aware of various therapeutic modalities besides those in the psychological area to help us sort out and work with physical components to our clients problems. And it is important that we have a list of competent referral sources of practitioners among these various modalities. In addition, as therapists we can act as health care advocates for our clients. We can check with our clients to make sure that the health care they are receiving is meeting their needs. We can encourage our clients to be assertive health care consumers, making certain that all questions get asked and answered satisfactorily. We can use our skills to educate our clients about the effects of stress, and help our clients gain awareness of the stressors in their lives. We can teach our clients coping skills to deal more effectively with the stressors in their lives. And when physical illness is present, helping our clients face and deal with their health can be an intense psychotherapeutic task. Implications for Psychotherapy For people with illnesses such as those described in this paper, the search for an
answer to their problems may take many years. Because they constantly feel sick they tend to lose trust in their ability to function in their lives. Coping with jobs and maintaining relationships can become unbearable. Often targets of abusive in-sensitivity, they have been misdiagnosed, belittled, and treated with suspicion by the traditional medical community. Psychiatric labels are often placed upon these people which damage self-esteem and cause feelings of hopelessness. No matter how hard they may work on their "emotional" issues the same problems -- depression, exhaustion, low libido, anxiety, etc. -- still plague them. In working with people who suffer from PMS, environmental illness, and chronic candidiasis, I have noted that these diagnoses bring their own set of problems. Generally requiring strict dietary restrictions and other major lifestyle changes, treatment for these illnesses can be quite difficult. The recovery process may take years of hard work, and sometimes even with the best treatment certain individuals may never completely regain their health. Furthermore, due to lack of understanding of these conditions, many sufferers have little support from family and friends. And in addition, it may be hard for these people to find qualified health care professionals to work with them. Regardless of the difficulties, proper physical diagnosis is the most important first step toward healing. Only after a thorough assessment is performed and a clear diagnosis is made can a focused treatment program be formulated. After treatment has begun people generally start to feel better physically, and they begin to have the strength to look more deeply into psychological issues which may be adding to their chronic stress load. For the chronically ill client, the psychotherapy process can be a consuming one. Body awareness is crucial for these people, and it is necessary to work on this throughout therapy. It is common for these people to feel obsessed with their bodies for a period of time as they learn to tease apart their physically based reactions from those that have a truly emotional origin. This will eventually allow them to "step back" from those physical reactions, rather than becoming emotionally overwhelmed by them.
Recognition and Treatment of Physical Factors in Psychotherapy Clients
While we must be careful not to assume that emotional issues are causing our clients' problems, we need to be aware that psychological factors may be complicating the physical problems and hindering the healing process. Facing emotional stressors such as "adult children of alcoholic" issues, co-dependency or chemical dependency, abuse or incest may be a need for some clients (Kritsberg, 1988; Whitfield, 1987). Physiological problems with food may be complicated by emotional food issues (Bruch, 1973; Chernin, 1985), which will need to be resolved. Shame (Fossom & Mason, 1986; Kaufman, 1980), low self-esteem, and perfectionism (Burns, 1980) are among the psychological issues that may need to be worked through. Also, just dealing with chronic illness can be an extremely hard emotional as well as physical struggle. When facing the loss of health, individuals go through a grieving process. The five grief stages associated with facing death -- denial, anger, bargaining, depression and acceptance (KublerRoss, 1978) -- also apply to those dealing with chronic illness (Pereira, 1984). In addition to these five classic stages, I have added a sixth stage called transformation. It is important for us as therapists to be aware of these stages, and the issues that present themselves during the grieving process. Each of these stages will be discussed in turn. As with any stage theory, we need to remember that within our clients these stages become a living process, not a rigid lock step progression. Stages can overlap, and elements from several stages may be present at once. People may also return to stages they have already worked through, perhaps due to the need to process this stage at a deeper level, to deal with an onslaught of new symptoms, or to grieve a reoccurrence of problems thought to be healed. As a flexible tool to help us be aware of how to work with chronically ill clients, this grief model is quite useful. The denial stage can be particularly strong in people faced with illness. These people often go for long periods of time ignoring their bodies' distress signals.
Despite feeling sick, they may force themselves, like taskmasters, to operate full tilt. For many people the thought of having a physical weakness can be scary and can throw them into denial. Even after diagnosis, there is a tendency for people to minimize or deny their problems. The individuals that I work with suffer primarily from environmental illness, chronic candidiasis and PMS. The lack of support from the traditional medical community, and lack of understanding from family and friends, tends to feed the denial that accompanies these diagnoses. For those who have been used to seeing themselves as hopelessly emotionally ill, adjust-ing to a new self image can seem overwhelming and can spark denial. In addition, the difficult dietary restrictions and life style changes that need to be made to treat these disorders can be avoided through denial. As therapists, helping our clients through their denial is an important first step towards healing. When clients express doubts about their diagnosis, directing them back to the evidence within their bodies can be very reassuring. Questions such as "what does your body say when you east as you must for your health?" or, "what does your body do when you go off your diet?" can help clients move through this level of denial. Learning to read and accurately interpret the body's signals is a fundamental need for people with chronic illness and must be worked with on an ongoing basis throughout therapy. Techniques such as bioenergetics (Lowen, 1958, 1967, 1975), and focusing (Gendlin, 1981) can allow people to get more in touch with their bodies and help them let go of their denial. Psychological factors often underlie the need to deny illness, and moving out of denial frequently involves working through fear and shame issues (Fossom & Mason, 1986; Kaufman, 1980). For individuals who have a driving need to be perfect, illness can be extremely shaming. In exposing their weaknesses and imperfections, illness is a threatening state which can be avoided through denial. People avoid dealing with fears of helplessness, abandonment, or loss of control by denying problems. Facing the need to make changes can also be very scary, and may be put
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off through denial. Among individuals with chronic illness, denial is frequently operating in varying degrees throughout the next three grief stages: anger, bargaining and depression. Denial will halt the grieving process and inhibit healing. When denial is present in our clients, we must be able to spot it, and get to the underlying issues. In the anger stage of grief people recognize that they have a health problem. Acknowledging illness brings up pain and anger and as therapists, we need to encourage our clients to express these feelings. When these emotions are accepted and worked through people can begin to take responsibility for their healing. However, blame can be a trap, keeping people stuck in the anger stage. Funneling anger into blaming others bolsters denial and feeds helplessness by keeping people's focus on external factors rather than on themselves. In thinking back over their history, people with chronic illness often see times when the help they needed was not available, when incorrect diagnoses were made, or when health care was actually harmful to their bodies. They may also realize that they damaged themselves through unhealthy habits such as poor diets, drugs and cigarettes, or lack of rest. The common reaction to these types of realizations is anger and pain. Amy, one of my clients who suffered from chronic candidiasis, had routine antibiotic prescriptions for almost every childhood cold she had. As an adolescent, she was put on long term antibiotics for acne. When she finally connected the chronic yeast infections and other symptoms that plagued her to the antibiotics, Amy felt furious. She was angry at the "damned doctor" who prescribed these drugs, she was angry at her mother for carting her off to the doctor at the slightest sniffle, and she was angry at herself for having a sick body. In therapy, Amy learned to own and experience her anger, rather than get stuck blaming her illness on external forces which were now beyond her control. In the third stage of grieving chronic illness people use bargaining to avoid taking active responsibility for their health and healing. Bargaining is often characterized by an impulsive
quest for healing. Bargainers may hop from doctor to doctor in search of someone who will take their illness away, or they may dive into each of the latest treatment fads hoping to find an instant sure-cure. In opposition to the impulsive approach, are bargainers who are unable to trust that anyone or anything could actually help them. Feeling overwhelmed by their belief that they must fend totally for themselves, they become frozen and unable to make any decisions regarding their health care. The following list is presented to give examples of bargaining statements made by chronically ill individuals: · "If my parents were more understand, then I could take care of myself." · "If I had more information, I would know what to do." · "If I stay perfect on my diet for this week, I can blow it during the holidays but I'll be ok." · "Someone told me about this vitamin (or any other treatment possibility) that they're using for my problem. I know that's what I've been waiting for." For individuals who suffer from the health problems described in this paper there is a healthy counterpart to bargaining which I call "testing the water". Health problems such as PMS, chronic candidiasis and environmental illness have no easy instant cures. Nor is there one treatment plan that will work for everyone. To find treatment programs and health care providers for their needs, people have to "test the water". That is, they need to learn about and possibly sample various treatments, then check in with their bodies to see which approach feels right to them. And they will also need to "shop around" to find health care providers that they feel they can trust and have rapport with. "Testing the water" is useful throughout the healing process for rechecking limits, or identifying the need to change or add to treatment regimens. For people to learn to "test the water" they must first understand that they are the ones who are responsible for making their health care choices; they have the ultimate authority with their bodies. When people are unable to accept this responsibility they may have underlying
Recognition and Treatment of Physical Factors in Psychotherapy Clients
psychological issues such as fear of failure or lack of self trust that need to be worked through. Often, chronically ill individuals must work through their grief to the stage of acceptance before they can take active responsibility for themselves. When chronic illness creates the need for major life changes, depression often follows the bargaining stage. In the depth of depression these people may become suicidal, believing there is nothing left to live for. For example, people with environmental illness often become overwhelmed with the belief that there is no place they can go, there is nothing they can eat, and there is nothing they can do without becoming sick. While it is true that environmentally ill people will have limitations because of their illness, the all or nothing thinking (Burns, 1980) in the example above distorts reality and feeds depression. When our clients have invested their identity in things that are external to themselves, a tremendous loss of identity ensues when those things are no longer there. The therapeutic task at this grieving stage involves helping our chronically ill clients establish a new identity. This may involve working to restructure distorted negative messages (Beck, 1967,1976; Burns, 1980) such as "I'm worthless if I'm not productive," "I can't live this way," or "No one can understand this." Working on self esteem and shame issues (Fossom & Masson, 1986; Kaufman, 1980) may also be necessary at this stage. Pat had invested her identity and her self esteem in her job. When illness made it impossible for her to continue to work she thought that there was no reason to go on with her life because of her belief that she was nothing without her job. When Pat began to deal with her shame and her perfectionism she was able to work towards building a new identity for herself. She began to see herself as inherently worthwhile apart from external standards. When denial has been lifted, anger has been vented, bargaining has been given up, and depression has been worked through, people can begin the process of acceptance. In acceptance chronically ill people acknowledge the reality of their situation no matter how grim. Without
judgment or loss of hope the accepting person can say "This is where I am right now." In acceptance people maintain their self esteem despite their physical state, and they can nurture and care for themselves. Acceptance differs from resignation in that resignation is a passive state whereas acceptance is an active one. In resignation people feel their choices have been taken from them and they passively submit to their fate. In acceptance people acknowledge where they stand while maintaining their ability to choose their path. Resignation halts the healing process whereas acceptance is the first true step towards healing. The final stage of transformation is the end result of the positive resolution of the grieving process. Transformation is a process of gaining wisdom about life and one's place in the world. Not all people reach this stage, but those who do have made peace with their bodies. While physical healing is not necessarily part of the transformation process, working through the grief process can have a beneficial effect on the physical health as well as the emotional health. In certain cases, there may have been too much physical damage for complete healing to occur; however people can come to terms with the state of their health. People in transformation are able to grow and live full lives regardless of handicaps. Ultimately a spiritual process, reaching the transformation stage creates a hero's journey (Campbell, 1949) out of the grieving process. Like a hero, the chronically ill person must face his or her situation with honesty, and struggle through difficult places to gain the reward of transformation. Despite it's painfulness, people in transformation are able to see the process they have been through as a blessing from which they have learned and grown. These people develop a greater sensitivity to the suffering of others and become more tolerant of their own and other's weaknesses. In transformation, the qualities that people have struggled to learn such as self-love, patience, forgiveness, and honesty become available in all areas of their lives. They reconnect with their childhood awe towards life, and become more whole as people. In this way,
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dealing with illness becomes not only a journey through grief, but also a journey towards healing. Further Considerations The chronically ill individuals that I have had the privilege to work with who have been able to move through the grief process, develop a "growth orientation" towards life. These growth oriented people are able to accept responsibility for their health. They take charge of their lives, rather than play the victim role, and they tend to actively educate themselves about their disease. They develop strong support systems, and are able to ask for help when they need it. In addition, they see themselves as more than just sick people, and they tend to work towards goals that are separate from their illnesses. People who are effective in dealing with life's difficulties have been described similarly. In Pathfinders, Gail Sheehy (1981) says that individuals who overcome and grow from crises rarely feel victimized by life. And in The Road Less Traveled, Scott Peck (1978) says that personal growth requires an ability to confront and resolve problems in our lives, and a willingness to accept responsibility for ourselves. It is interesting to note that the characteristics of the growth oriented person are similar to those of the stress-resistant personality described by researchers and clinicians. Among the attributes of the stress-resistant personality are an acceptance of responsibility for one's self, an ability to avoid feeling helpless and victimized by situations, and a willingness to actively engage in life (Selye, 1974; Shaffer, 1982). In locus of control research, the internal locus of control orientation has consistently been found to be more stress resistant than the external locus of control orientation (Johnson & Sarason, 1978; Sandler & Lakey, 1982; Silver, Auerbach, Vishniavsky & Kaplowitz, 1986). A central characteristic of internals is a belief in their ability to effect their environment rather than seeing themselves as helpless victims of fate (Phares, 1979). Research has been done by Kobasa (Kobasa, Maddi & Courington, 1981; Kobasa, Maddi, Pucceli & Zola, 1985) on a cluster of personality traits known as hardiness, which have been found
to buffer stress and decrease the chance of illness. According to Kobasa, hardy people are committed to their lives, seeing life as a challenge rather than a threat. They are curious about life's experiences, finding them meaningful rather than alienating. And rather than feeling powerless, hardy people believe they have control over their lives. Others have described similar patterns of traits claiming that these qualities are crucial to regaining health. In Love Medicine and Miracles, Bernie Siegal, M.D. (1986) describes his experiences treating "exceptional" cancer patients. Siegal says that exceptional patients are willing to take charge of their lives rather than play the victim role, and they are willing to work hard to achieve health and peace of mind. Exceptional patients tend to live longer and recover more often than other more passive patients with similar diseases. In his book, Anatomy of an Illness, Norman Cousins (1979) describes his healing process from a lethal disease called ankylosing spondylitis. Basic to Cousin's recovery was his willingness to accept responsibility for his health. Refusing to take a passive role, Cousins learned everything he could about his disease. Using his doctor as a support person, he took charge of his treatment, and helped heal himself. While most of our clients will not come into therapy with the tools to respond to illness as Norman Cousins did, these tools that make up the growth orientation can be developed. In working through the grieving process towards acceptance and transformation, people learn to grow regardless of what life brings, and to care for themselves regardless of their physical state. They learn that their self-worth is separate from external standards, and they learn to accept responsibility for those aspects of their lives over which they have control. By going through the grieving process, people learn the growth orientation towards life and gain the tools that can help in their healing. Conclusion As we let go of our rigid one-way image of the mind/body connection we can come to a more balanced holistic view of people.
Recognition and Treatment of Physical Factors in Psychotherapy Clients
Without letting go of respect for the potent influence that our minds have over our bodies, we must learn to acknowledge with equal respect, the force that our bodies can exert over our minds. And we must learn to use our recognition of the two-way street of mind/body interaction with our therapy clients. While we work to help our clients create a healthier psychological environment, we must not ignore their physical environment. We must have an understanding of the dynamics of stress. We must have an awareness of specific physical illnesses which may produce emotional symptoms. We must be trained to screen for possible physical components to our clients' problems. We must have a list of competent referral sources for our clients' holistic-health needs. And we must be aware of the emotional dynamics involved in illness. As we become aware of the multiplicity of forces acting upon ourselves and our clients, it becomes clear that health is more than just the absence of disease. Health is not a static state, but is a process involving all facets of our lives; health is a way of life. Looking more closely at the growth orientation towards life may deepen our understanding of the nature of health. And a clearer understanding of what health is will guide us in the development of more effective, health promoting psychotherapeutic strategies. Appendix A Common Symptoms of Stress General irritability, hyperexcitation or depression associated with unusual aggressiveness or passivity; pounding of the heart; dry throat; impulsive behaviour; urge to cry or run and hide; inability to concentrate; feelings of unreality, weakness, dizziness; fatigue; free floating anxiety; emotional tension and alertness "keyed up"; trembling, nervous tics; tending to be easily startled; high-pitched, nervous laughter; stuttering or other speech problem; bruxism; insomnia; hypermotility; sweating; frequent need to urinate; diarrhea, indigestion, queasiness and even vomiting; migraine headaches; PMT (premenstrual tension) or missed period; pain in neck or low back; loss of or excessive appetite; increased smoking; increased drug use (legal prescription drugs); alcohol and drug addiction; nightmares; neurotic behaviour; psychosis;
accident proneness. Adapted from Hans Selye's book The Stress of Life (Selye, 1978). * While these symptoms are of ten labeled psychosomatic or hypochondriacal, they may indicate a physical disorder and should not be ignored. References 1. Barnes B & Galton L (1976): Hypothyroidism: The Unsuspected Illness. New York: Thomas Y. Crowell Co. 2. Beck A (1976): Cognitive therapy and the Emotional Disorders. New York: New American Library. 3. Beck A (1967): Depression: Causes and Treatment. Philadelphia: University of Pennsylvania Press. 4. Berkow R & Talbott J (eds.) (1977): The Merck Manuel, 13th Ed. Rahway, N. J.: Merck Sharp & Dohme Research Laboratories, p. 1260. 5. Brown B (1984): Between Health andlllness. Boston: Houghton Mifflin Co. 6. Bruch H (1973): eating disorders: Obesity, Anorexia Nervosa and the Person Within. New York: Basic Books Inc. 7. Burns D (1980): Feeling Good: The New Mood Therapy. New York: Signet Books. 8. Campbell J (1949): The Hero With a Thousand Faces. New Jersey: Princeton University Press. 9. Chernin K (1985): The Hungry Self: Women, Eating and Identity. New York: Random House Inc. 10. Cousins N (1979): Anatomy of an Illness. New York: Bantam Books. 11. Crook W (1985): The Yeast Connection. Tennessee: Professional Books. 12. Dalton K (1979): Once a Month. California: Hunter House Inc. 13. Fossum M & Mason M(1986): Facing Shame: Families in Recovery. New York: W. W. Norton & Comp. Inc. 14. Fredericks C (1976): Psycho-Nutrition. New York: Grosset & Dunlap. 15. Freud S (1950): The Question of Lay Analysis. New York: Norton &: Co. 16. Goodkin K, Antoni M & Blaney P (1986): Stress and hopelessness in the promotion of cervical intraepithelial neoplasia to invasive squamous cell carcinoma of the cervix. Journal of Psychosomatic Research, 30, 67-76. 17. Hoffer A& Walker M(1978): Orthomolecular Nutrition. Connecticut: Keats Publishing Inc.
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18. Homey K(1939): New Ways in Psychoanalysis. New York: W. W. Norton & Co. 19. Johnson J & Sarason I (1978): Life stress, depression and anxiety: Internal-external control as a moderator variable. Journal of Psychosomatic Research 22, 205-208. 20. Kaufman G (1980): Shame: The Power of Caring. Cambridge, Massachusetts: Schenk-man Publishing Co. 21.Kobasa S, Maddi S & Courington S (1981): Personality and constitution as mediators in the stress-illness relationship. Journal of Health and Social Behavior, 22, 368-378. 22. Kobasa S, Maddi S, Pucceli M & Zola M (1985): Effectiveness of hardiness, exercise and social support as resources against illness. Journal of Psychosomatic Research, 29, 525-533. 23. Kritsberg W (1988): The Adult Children of Alcoholics Syndrome. New York: Bantam Books. 24. Kubler-Ross E (1978): On Death and Dying. New York: Macmillan Pub Co. 25. Leshan L & Worthington R (1956): Personality as a faxtor in the pathogenesis of cancer: A review of the literature. British Journal of Medical Psychology, 29, 46-56. 26. Leshan L (1982): The Mechanic and the Gardner. New York: Dell. 27. Lowen A (1958): The Language of the Body. New York: Collier Books. 28. Lowen A (1967): The Betrayal of the Body. New York: Collier Books. 29. Lowen A (1975): Bioenergetics. Dallas: Offset Paperback. 30. Maslow (1970): Motivation and Personality, 2nd ed., New York: Harper & Row. 31. Peck S (1978): The Road Less Travelled. New York: Simon & Schuster. 32. Pelletier K (1977): Mind as Healer, Mind as Slayer. New York: Dell Publishing Co. 33. Pelletier K (1979): Holistic Medicine: From Stress to Optimum Health. New York: Dela-corte Press. 34. Pereira B (1984): Loss and grief in chronic illness. Rehabilitation Nursing, 9, 20-22. 35.Phares E (1976): Locus of Control in Personality. Morristown, N.J.: General Learning Press. 36. Philpott W & Kalita D (1980): Brain Allergies. Connecticut: Keats Publishing, Inc.
37. Randolph T & Moss R (1980): An A Iternative Approach to Allergies. New York: Lippincott & Crowell. 38. Rees & Linford (1974): Personality and psycodynamic mechanisms in migraine. Proceedings of the Second Congress of the International College of Psychosomatic Medicine, Amsterdam, 1973, 23, 111-122. 39. Rosenman R, Brand R, Jenkins C, Friedman M, Straus R & Wurm M (1975): Coronary heart disease in the Western Collaberative Group Study: Final follow-up experience of eight and one half years. Journal of the American Medical Association, 233,872-877. 40. Sandler I & Lakey B (1982): Locus of con trol as a stress moderator: The role of control perceptions and social support. American Journal of Community Psychology, 10(1), 65-80. 41. Selye H (1978): The Stress of Life. Revised edition, New York: Mcgraw-Hill Book Co. 42. Selye H (1974): Stress Without Distress. New York: J. B. Lippincott Co. 43. Shaffer M (1982): Life After Stress. New York: Plenum Press. 44 .Sheehy G (1981): Pathfinders. New York: Bantam Books. 45. Siegel B (1986): Love, Medicine and Miracles. New York: Harper & Row. 46. Silver P, Auerbach S, Vishniavsky N & KaplowitzL(1986): Psychological factors in recurrent genital herpes infection: Stress, coping style, social support, emotional dysfunction and symptom recurrence. Journal of Psychosomatic Research, 30, 163-171. 47.Spie T, Aring C, Gelpering N & Bean W (1938): The mental symtoms of pellegra. American Journal of Medical Science, 196, 461. 48. Totman R, Kiff J, Reed S & Craig W (1980): Prediction of experimental colds in volunteers from different measures of recent life stress. Journal of Psychosomatic Research, 24, 155-163. 49. Truss C (1982): The Missing Diagnosis. Alabama: Orian C. Truss MD. 50. Weiss R & Hendrickson S (1986): Who Am I? PMS Handbook. Minneapolis, MN: PMS Awareness. 51. Whitfield C (1987): Healing the Child Within. Florida: Health Communications Inc. 52. Wright J (1979): Dr. Wright's Book of Nutritional Therapy. Pennsylvania: Rodale Press.

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