As health professionals, every day we are invited to face patients presenting different problems and which need various solutions or therapies such as medical treatment, information giving, teaching, counseling, etc. I am a trained nurse in dialysis and renal pathologies management and I work in dialysis unit of our hospital. My main role is to receive patients with renal pathology and lead them to the Nephrologist, to plan and to execute prescribed treatment for those who are diagnosed with renal failure. That treatment concerns in general renal replacement therapies like hemodialysis or peritoneal dialysis. For the following work, I have chosen one of our patients because of the following reasons:
He is a patient suffering of end stage renal disease and undergoing dialysis treatment since 2 years, he passed the first year under peritoneal dialysis but after developed chronic peritonitis and for this he has been transferred for hemodialysis.
He is waiting for renal transplantation but now lacks fund needed for the process
Because of peritonitis he has received painkiller drugs for a longtime to relieve pain but he finished by developing addiction to painkillers. Still now he continues to claim for painkillers while there is no valuable reason.
He presents signs of anxiety and depression
IDENTIFYING THE PROBLEM
Identifying client’s problem is the key of the success of counseling process. Problem exploration is an important step, because it permits counselor-client initial contacts and to map out the client’s problem. For this, all the process has to be well prepared. The preparation concerns the client and the environment in which counseling will be given. Concerning my client preparation, to get his consent, I have before all explained him what is counseling and what its benefits are for people undergoing it. Concerning the environment, all counseling sessions have taken place in our service, in one of our offices that I have chosen because it’s calm, well illuminated and aerated and where distracting conditions have been eliminated. We used chairs permitting to have various positions but every time it was possible, I arranged them in manner to permit face to face interaction. This arrangement permits us to avoid distractions and to have a full opened interaction. Counseling sessions were arranged to have place before each hemodialysis session, and I tried to avoid they went over 30 minutes. This has the purpose to permit my client to begin quietly his hemodialysis session.
My client MV is a young adult presenting various problems. After a careful analysis, I found that my client has various problems which need to be resolved by himself or through assistance from other people. Here, I found that neededassistance could be categorized as following:
Problem necessitating other help than counseling
Treatment of End stage renal disease: the management of that condition is accomplished primarily by medication, diet therapy and renal replacement therapy. The initiators of the treatment are Physicians (Fink et al., 2001).
Problems which may find solution with counseling
Addiction to painkiller drugs: treatment by painkiller began while my client was treated by peritoneal dialysis. He developed chronic peritonitis with intolerable abdominal pain. For the pain he received painkiller each time he claimed it. After stopping peritoneal dialysis and starting hemodialysis, my client continues to ask painkiller although we don’t see a real reason for it. We concluded that he has developed dependency to painkillers. Understanding a variety of models and theories of addiction and other problems related to substance use, describing helping strategies for reducing the negative effects of substance use, abuse, and dependency are among competencies of a counselor in addiction (U.S CSAT, 2005).
Problem which may find solution in combination of medical assistance and counseling:
Anxiety and depression which according to my assessment are due to:
Waiting a long time the renal transplantation without hope to find financial assistance for the process.
Thinking to be useless for the family
Anxiety and fear of the future: before he felt sick, he was going to begin university studies and has been obliged to stop them
Brusque stop of painkiller treatment
Cucor D. et al, (2007)recognized that depression is one of common mental health problem for people with End-stage renal disease. According to them, depression is one of factors influencing morbidity and mortality rates among those people.
Various medications are used to fight anxiety and depression but to be more effective, medication need to be combined with other therapies like behavioral therapies. When associated, both medical and behavioral therapy, patient benefits from better decrease in symptoms and a lesser risk of setback (http://helpguide.org/mental/anxiety_types_symptoms_treatment.htm).
The client has developed dependency on painkillers drugs and has been obliged to stop them without any psychological assistance to help him to do gentle withdraw from drug taking. According to my assessment and a long time passed with the client, it’s for that problem that my client needs to be helped firstly and it’s about it I have chosen to work with him as also he has wished. It may be a hard task, but this will help the client and will help me to get more experienced because we are lacking experienced counselors.
TRANSCRIPT OF PART OF MY COUNSELLING INTERACTION WITH MY CLIENT
During counseling sessions, the counselor uses various techniques to interact with his client. Communication and interaction management skills are used during counseling interaction and their use depends on how the session is going. Here below is a short transcript of one session I had with my client.
Myself: you come just to present me problems which are stressing your life, could you tell me now about the intensity of each problem?
Here I have used questioning skills to help my client to express himself and explore issues concerning his problems.
Client: As I told you in the last session, I have been suffering from chronic renal failure there are now more than 3 years. As you see it, I am young and I was about to begin my university studies when I felt ill. At the beginning, I was confident even though my doctor had told me that I will need long term treatment. Now when I think about my future, I feel hopeless. My studies stopped, I lost a lot of money with medical treatment, and I don’t have money for renal transplantation, and for my unluckiness although he knows that I am suffering the doctor has stopped my injections of painkiller.
Myself: I understand you feel overburden by all those problems; according to you which problem is mostly troubling your life? What are your main concerns?
Client: actually it’s my continuous unrelieved pain.
Myself: Can you briefly speak about that pain?
Here, focusing skills to bring my client to give a clear definition of the problem for which he needs our help.
Client: as you know it, I have started treatment with peritoneal dialysis. After 5 months of treatment I developed peritoneal infection which was causing me serious pain. Other patients who had the same problem in the past advised me to ask to my doctor to prescribe me Pethidine which relieves pain and permits to sleep.
Here, active listening skills helped me to show to my client that I am attentive to what he is telling me.
Myself: how did you appreciate the treatment with Pethidine?
Here also I used questioning skills to get full information which can help me to analyze the relationship between my client’s problems and his medical history.
Client: at the start it was wonderful to not feel pain and I was again able to close my eyes and sleep.
Myself: and after?
Client: after, it became impossible for me to sleep without my injection and one injection a day was not sufficient for me. For this, all the day I was harassing my nurse to provide me Pethidine.
Myself: You told me that when you begin treatment with Pethidine everything was ok, no pain and you were able to sleep. So, how did you take it when the Nephrologist decided to stop Pethidine injection for you?
Here I used summarizing skills to help my client to stay fixed on our subject; ‘pain’. I asked him that question as a challenge to see if he will continue to tell me that he still needs Pethidine injection.
Client: it has been a bad moment for me and up to now I don’t understand him because I am still feeling pain.
Myself: how do you feel when you are at your home?
His family members have told me that he is quite at home and claims to feel pain only when he arrives in medical facilities. I wanted to get deep information about his pain.
Client: Not very bad. I feel exaggerated pain when I come for treatment.
In this work, I have been using the client-centered approach. That approach of counseling has been conceptualized by Carl Rogers (1946). The fundamental belief turns around the idea that each individual innately strives towards self actualization, in the other words to be the best that he can.
Essentially the person or child centered approach extends the central conditions of empathy, no conditional positive regard and congruence to the client, facilitating, in a reflective and non directive way the client’s exploration and harmonizing of his emotional and personal issues that have been arisen from his life’s experiences.
The target is, to help the client to give up the personal image which he has built around his individual experiencing (Mearns D. & Thorne B, 2000 p5).
This approach considers a client as an active agent, able to take responsibility for his own condition. Palmer reinforces this when he notes ” clients are encouraged to explore their most intimately held opinions and values, in order to discover for themselves, what it is that really matters to them, what it is worth living for or what would be worth dying for” (Palmer, 1996:p31).
The respect of client is essential in this approach. According to Corey (1977) the strength of this approach come from its capacity to focus on preferences and pathways headed for personal growth. Emphasis is on freedom, responsibility and the person’s ability to redesign his life through attentive choice.
The counselor-client relationship is also essential to good practice of client-centered approach. To participate effectively in counseling, Freshwater (2003) claims that nurses necessitate to recognize the client as an equal, though as clients often view nurses as experts it can make this relationship difficult to obtain.
Through this work I have been using the theories of motivational interviewing counseling, in which the main objective of the counselor is to identify and work with the client’s motivation to change. Motivational interviewing builds on Carl Rogers’ optimistic theories about people’s capabilities for exercising free choice and changing through a process of self-actualization (Alcohol answers, 21.8.2009).
The therapeutic relationship counselor-client is a reciprocal partnership. The counselor’s role in motivational interviewing is directive, with a goal of eliciting self-motivational statements and behavioral change from the client in addition to creating discrepancy to enhance motivation for positive change (Miler and Rollnick, 1991).
As healthcare providers, we are often asked to act as change agent for our patients, students, and colleagues. When we play that role we try to help people make necessary behavior changes by instructing them in the whys and hows of making them. We may have been trained to believe that if we simply teach our patients what they need to do to change and do it effectively enough; they will change (Ellen R. Glovsky, and Gary R., 2007).
In our daily work, tendency is to think that our clients need only medical assistance, but when we try to analyze the situation, we may find that we are wrongful. All clients’ needs are not answered by medicines or other medical and nursing interventions. Most of the time, we ignore the socio-psychological aspect of the problem. This is remarkable with chronic renal diseases like end stage renal failure, diabetic nephropathy, cancer, etc.
Sensky (1993), in his work, showed how renal failure impacts on person’s life. The impact doesn’t only concern the physical condition but the whole person. With renal failure, various alterations come in the life; the patient has to learn new skills and strategies which can help him to cope with his condition. The patient has to attempt to adapt to his chronic illness and the necessity to deal with dependence on dialysis machine or other else’s kidney to continue to live.
In their works, (Levenson, 1991; Kimmel, 1993, and Finkelstein, 2002) recognize that anxiety and depression are the most common psychological problems in dialyzed patients. The same idea can be found in the work of Chilcot and his colleagues. They found 20% to 30% of End stage renal disease patients with signs of depression at various levels (Chilcot, & Al., 2008).
The other problem found in patients undergoing long term dialysis is a possible addiction on pharmaceutical drugs like painkillers (Manjula, Bennett, Chertow, 2003).
Addiction is defined as a state characterized by impaired controlover the use of chemical substance and/or behavior. This lead the addict to seeking and abuse of drugs, a need to continue to take drugs to which some one has become habituated following a repetitive utilization because it produces some special effects like euphoria and other types of mental status alteration. Clinical manifestations occurbeside physical, psychosocial and spiritual dimensions (College of Physicians and Surgeons of Saskatchewan, 2008).
Addicted substances are like alcohol, stimulant substances like cocaine, heroine, marijuana, and medicines like tranquilizers and painkillers.Others may habitually mix prescribed drugs with alcohol to numb the mind from staying on disappointments or personal conflicts. Many people persist in taking medications to feel better physical or psychologically even when no ailments are present; and some insist that they can’t function without them. Statistics indicate that, the number of visits in emergency room for prescription and illegal drugs overdoses are the same and that individual abusing medical drug like codeine can be just as addicted as the one who abuses of illegal drug like cocaine. While prescribe medicines is absolutely legal, ethical and moral laws prohibits the use of medicines for purposes other than the original aim. Addicted people need therapists specialized in chemical dependence counseling and who can help them to recover from the addiction by reviewing past medical history and patterns of substances abuse. Most of the time counselors discover that long term abuse has produced undesirable psychological and physical effects. The case presented above concern a patient addicted to Pethidine, a painkiller of opioids pharmacological family. Addiction to opiates like morphine can occur after chronic pain suffer is given dosages to control acute discomfort, and continues its use long after pain has collapsed (ChristiaNet, 2009).
Many people with long-lasting pain receive treatment by opioids. But, there are evidence throwbacks and side effects that may follow this treatment. Developing tolerance to drugs is one major risk, sometimes at short time. The second major risk is the development of addiction. Addicted people to painkillers becomeso fixated on getting more of them that the obsession prevail over the medical target of relieving pain (Media Planet, 2009).
COUNSELING IN ADDICTION
The focus of individual drug counseling is on the symptoms of substances addiction. It also relates areas of weakened function and the structure and content of the client’s ongoing rehabilitation program. The first target of counseling in addiction is to support the addict to achieve and maintain abstinence from addictive substances or behavior. The second target is to aidthe addict to recover from damages which have caused by addiction in his life (Delinda E. & Georges W., 1999).
The addict’s counselor works firstly by helping the client to be aware of the reality of a problem and the connected unfounded thinking. In the next steps, client is stimulated to achieve and uphold abstinence from addicted substance or behavior. This can help to develop needed psychosocial abilitiesand spiritual growth to remain in recovery process (Delinda E. & Georges W.).
ADDICT INDIVIDUALIZE COUNSELING PROCESS
Counseling as a helping process consists of 3 main phases. Each phase has its distinct aims although the same skills may be used in those 3 phases. Those three main phases are:
Exploration, assessment and planning phase
In this phase, the main objectives are to apprehend the client as a whole person, to plan counselor’s interventions, and to arrange an agreement between counselor and client.
Rehabilitation counseling and goal achievement phase
Counselor’s objectives in this phase are the initiation and implementation of his treatment plan in collaboration with his client.
Termination and evaluation phase
In the closing phase, objectives are to conclude treatment process and deliberate its outcome with the client, and to arrange agreement on upcoming actions.
Rehabilitation and relapse prevention
In addiction counseling, the objectives of the all process are to rehabilitate the client from the addicted substance or behavior and to prevent the relapse.
Rehabilitation may be defined as the process consisting in recovering the capacities that have been reduced due to injuries or illness. The recovery is sustained only when there is no relapse or return back to addicted substance or behavior. Here, the goal of counseling is to lead the client to a full reintegration into his community as dynamic and valued person. Each time it’s possible, detoxification comes first, and after can be started the laying of the basis of rehabilitation process. Abstinence from addicted substance or behavior is not enough in itself. The addict has to see the profits of staying abstinent; otherwise he can relapse at short or long term (United Nations International Drug Control Program, 2003).
Individual addiction counseling doesn’t only focus on stopping or reducing addicted substance or behavior. It will also address the other related domains of impaired functioning and those are such as social relations, illicit activities, employment status, etc. When additional helps are needed, the counselor is advised to refer the client (U.S National institute of Health, 2009).
Above, I have mentioned that counseling process has to help client to maintain abstinence after the recovery period, otherwise the client can relapse and return back in addiction.
What is a relapse?
There is a relapse when, a client in recovering period or in post recovery, returns to the addicted substance/behavior or becomes addicted to a new substance.
Prevention of relapse in counseling process
Preventing relapse is a very important element of recovery. When the client becomes able to establish some constancy in abstinence, he could begin to develop skills to put off future relapse to addicted substance/behavior. To prevent relapse, the addict has to be taught how to identify in advance, when he is headed near a relapse and to modify course of events. Through counseling process, by education, the addict can identify indicators of coming up relapse. Those indicators are like negatives changes in client’s behavior, feelings and attitudes. Once the client became conscious of the environment of relapse process, his next mission is to build up the skills to intervene and change any occurring negative behavior or feelings (Delinda E. & Georges E.)
I am not a professional or trained counselor. I am only a student in nursing studies who is trying to apply learnt counseling skills. I have chosen to work with my client about his addiction. I know it’s a very complicated subject for a beginner in counseling, more experience is needed. Difficult to handle that subject has stimulated and encouraged me to do further reading and researches concerning addiction; what is it, its causes, its management by a combination of counseling and other ways of help like pharmacotherapy. During my counseling process, in my client’s needs assessment; I was more influenced by medical side of my client’s problems. The social situation of the patient has not been full analyzed and I think that this can a bit weaken the problem exploring process. The second difficult is to know borderline between intervention domains of a professional counselor and a health professional who applies counseling skills to help a client. We may think that it’s easy but in practice it’s very complicated. You ask yourself: “Does the client’s problem need a professional counselor or a skilled health professional can help?”
This can lead us to be fluctuating in our practice. I suggest here to insist on this point during elaboration of “Professional practice and counseling skills module”. My strength now reside in fact that I can now lead counseling process without apprehension, methodically and without asking about the beginning or next stages. To help my client, I didn’t consider medical data as enough to conclude that my client is addict. I have spoken with my client but it was necessary to know what his family thinks about him. For this, I had discussion with some members of his family about my client’s problems and needs. From the family I received information reinforcing the medical diagnosis of addiction. I consider this as a positive point, because we have to check the all environment of client to get real and full information which can help us during counseling process. Not long time after the beginning of my counseling sessions, my client begins to withdraw progressively from his constant obsession to receive Pethidine injection and stop to advise other patients to ask that drug. He was suffering from end stage renal disease; a chronic condition so we had many counseling sessions to prevent relapse. We didn’t continue to work together; he died before the termination of our counseling process; but all this process has been helpful for him and full of experience for me.