The ultimate test of a counselor and any health care delivery system should be their adequacy in the face of suffering. This article starts from the premise that most treatment programs and therapists fail that test.
In far too many cases today, we treat the disease, while suffering inevitably involves the person. Bodies do not suffer. People suffer. This may be another way of saying that with our emphasis in counseling and medicine today on science and technology, evidence-based medicine, we are in danger of losing touch with the personal side of sickness and suffering. We need a systematic and disciplined approach to the knowledge that arises from the counselor’s experience rather than the artificial division of clinical and medical knowledge into science and/or art. There is not, and never will be, a substitute for the counselor as a person.
Medicine has arrived at the false dichotomy that anything that is not a specific manifestation of disease is “psychological” and thus is seen as perhaps “self-inflicted,” “subjective,” and inherently “uncertain.” Medicine and science seeks certainty. Diagnosis supposedly eliminates uncertainty. If one test does not reveal whatever is going on for the person, then another will. Unfortunately, the human body and psyche live with levels of certainty and uncertainty. As Einstein said, not everything that can be counted counts and not everything that counts can be counted. So, what is needed are counselors who are actively trained to be masters of their science and technology (evidence-based practices), not its servants.
The unique nature of disease
Disease theory (the foundation of modern medicine) says the purpose of the clinician is: the discovery of the illness in the sick person; its unique causes; and to provide proper diagnostic and therapeutic actions accordingly. The disease approach has dominated how we look at counseling and treatment, even of addictions. There are two weaknesses to disease theory: the concept that any disease has one and only one causation; and the belief that disease is rooted in structures (such as the anatomy of the heart, the brain and the psyche), and that changes in function therefore imply changes in structure. Yet, mental disorders, despite psychiatry’s enormous efforts, almost never fit into the neat, classical criteria of diseases. In fact, if medicine is truly honest about it, neither do most “physical illnesses” because every disease occurs in a unique individual, with unique causes, at a unique time in his or her life, with individual setting, cultural, lifestyle and emotional variables.
Let me illustrate. Two women are told by their doctors they have breast cancer, both requiring the same treatment. How each women responds to the diagnosis and treatment is greatly influenced by her attitudes, values, lifestyle and many individual variables. One might experience a far different form of suffering than the other, depending on her attitude and approach to the diagnosis and treatment. Sickness cannot be completely understood apart from the person, her social setting, etc. If, after all, diseases are simply entities — things that affect the body or psyche — then why should the overall health of poor people be any different? There are many factors affecting diseases and our approach to suffering: housing, education, availability of preventive and palliative medical care, family structure and poverty, all playing a part in the complex structure called “the human.”
In sum, we do not treat diseases; we treat people who happen to be “patients.” The same disease in different individuals may have a different presentation, course, treatment and outcome, depending on individual and group differences.
What’s driving medicine and counseling?
Financial and economic considerations have become the dominant (even ahead of technology and science) forces shaping the nature of our practice. The influence of economics permeates every aspect of what we do, from research, education and training, and even the doctor-patient relationship. Unfortunately, medicine and psychotherapy has become a commodity to be bought and sold in a highly competitive managed care marketplace. A dominant conceptual force in contemporary treatment, evidence-based or science-based practice (EBP), involves the conscientious and judicious use of current best evidence from clinical care research in the management of the patient. All well and good. Who could argue against using best practices?
However, by definition, science seeks generalities, taking into account multiple variables and deriving standardized responses. Yet, nowhere in the formulations of EBPs does there seem to be an acknowledged place for the individual differences between patients, their illnesses, or variations in the experience of the skills of the practitioner. A uniform practice makes for uniform commodities, and the result can be deadening when it ends up in depersonalized treatment. Patients are not generalities. They are individuals and there is, by definition, no science of individuals.
Today we are trying to provide services directed at individual needs, desires, beliefs, concerns and fears, employing the most up-to-date EBPs and technological advances, in as inexpensive and sufficiently uniform manner so that fixed pricing for services makes sense. These may be mutually incompatible goals. Yes, we speak of “individualized treatment plans,” for patients, yet far too often, one size in treatment fits all. In the end, instead of focusing on evidence-based therapies we will focus on evidence-based therapists. Why is it that two counselors, with the same training and experience, using the same EBPs might have different outcomes with patients? What is that X factor that differentiates outcome?
There are many practitioners who love their profession and are caring professionals. I meet them daily in my classes and at treatment centers worldwide. Treatment is fundamentally a moral enterprise because it is devoted to the welfare of the patients it treats, where one person helps another who cannot help themselves, and are critically vulnerable at that time. Where else in life other than medicine would you find yourself walking into a strange, new room, meet a person, and within minutes be standing their partially naked, with the stranger putting their finger into uncomfortable places? Where else in life, other than counseling, would you walk into a group of strangers and be asked to reveal your deepest, darkest, untold stories?
EBPs should never dominate what we do because it is in the service of something larger than itself. EBPs, properly understood, must be conceived as being as fully responsive to human needs as possible. What is needed is for us to constantly understand the goals of treatment, the nature of suffering, and the implications for relief of pain and suffering.
The nature of pain and suffering
The words “pain” and “suffering” are often coupled together. While they are not synonymous, physical pain remains a major cause of human suffering and is the primary way we think about suffering. Yet, we must reject the dualism of the mind and body approach to healing. The “person” is not his mind or body alone. For example, for readers who have experienced childbirth, pain can be extremely severe and yet be considered uplifting, not suffering. Pain is experienced as suffering when three conditions are met: when the pain is so severe that it is virtually overwhelming; when the person believes the pain cannot be controlled; and when the pain seems endless. The meaning we ascribe to the pain affects whether we see it as suffering.
Our beliefs, values and worldviews affect how we view pain. Two examples might be how an individual hears the word “chemotherapy,” and their expectations of related suffering from treatment. Another example might be how a Christian might see physical pain as God testing their resolve or faith, as in the case of Job in the Bible.
When a person recovers from loss without succumbing to suffering it’s called resiliency. For some, this means borrowing the strength of others to sustain them until their own resources kick in. Counselors, in this sense, lend clients’ strength. Transcendence is another aspect of how one experiences pain, wherein the client locates the pain in a larger landscape of meaning.
Chronic illnesses, such as asthma, diabetes, hypertension and substance abuse, are all characterized with varying degrees of changes in the patient’s social world, self-esteem and self-conflict, disharmony, disorder, discord and denial. In other words, in complex a world such as chronic illness, the individual is rarely “of one mind,” even within themselves. How one views their pain and suffering greatly impacts the outcome of treatment. Or stated otherwise, chronic illness is a thing apart from chronic disease.
This means that no scientifically-controlled study can ever fully account for the diversity of persons, problems and prognoses. Add to these variables, the mysterious relationship between doctor and patient, counselor and client, and we see the complexity of treatment. When we as caregivers place ourselves in the midst of a patient’s pain and suffering, we need to be aware of our feelings so we can empathically experience the client’s feelings; discipline our own feelings in the presence of the strong feelings of the client; and subordinate our own issues so we can reasonably, clearly, make decisions and offer help.
The technologies we have from EBPs have no power in and of themselves. Humans acquire power by employing the technology. We are people who, because of our knowledge, training and experience, are empowered by the patient to act by virtue of the trust given us by them. Together, we are bound in a reciprocal relationship of trust. This means one of the skills in the art of a good counselor is in coming as close as ethically possible to intimacy, for access to the patient, while maintaining independence of action. Therein lays the capacity for maximum therapeutic power, not in the technologies we employ.
Evidence-based practices
The promise of science-based medicine and counseling is that the knowledge we have through random clinical trials does the work. EBPs arise from the belief that clinical decisions should be guided by evidence that comes from the best research, clinical trials of new treatments, adhering to strict research and statistical methods available. From these trials we derive practice guidelines. The emphasis on basing treatment decisions on good evidence cannot be faulted. It is what good healers have been doing all along. The marked improvement in the quality of clinical research is a major advance in the field.
However, it is impossible to base sound clinical decisions solely on scientific evidence because, as stated above, evidence is derived from generalities and patients are individuals. EBPs need to be adapted to patients through the agency of the caregiver. The extent to which the patients in the clinical trials were like your patient, the special circumstances of their illness, you as a clinician, the treatment setting variables, etc., all influence how the evidence is applied to your unique treatment. This might seem self-evident, but unfortunately, decisions are too often made currently in slavish adherence to practice guidelines.
Lost in this process are a number of variables that influence randomized clinically- controlled trials: biases introduced by the investigator, by the patient, the placebo effect, other prior therapies, the stage of the disease, the patient’s associated behaviors (smoking, exercise, lifestyle, treatment compliance), the caregiver’s attitudes about the patient, and demographic characteristics (age, gender, social status, etc)., which even when controlled for, affect outcome. Although EBPs speak of fidelity to a particular therapeutic intervention/model and adaptation to the uniqueness of the situation, this must always be done in the context of a multi-faceted relationship of doctor and patient.
Every illness and every sick patient has its own unique story. If persons’ stories are all different, so too are their diseases. Thus, we need to view illness as a process, a narrative being told every time we hear the stories, rather than as a clinical event. The single most important tool that reveals a person is his or her story as he or she tells it “in his or her own language.” We know our patients through their narratives, not through the lens of science. It requires a great degree of skill and practice for the clinician to be a truly attentive listener, able to hear what a person says apart from an interpretation of what that person means. We must somehow separate ourselves from our judgments about a person from the information on which the judgments are based.
In sum, the objective “facts” of science and EBPs, as essential as they are, are in themselves insufficient to the clinician’s task. We treat particular patients in particular circumstances at a particular moment in time and this requires information that particularizes the individual and the moment.
To illustrate this point, I have a condition called Barrett’s esophagus, for which I take “the little purple pill.” I go regularly to see my gastroenterologist. Recently, at my annual check-up, my GI guy spent five minutes poking and doing all the things doctors do. We then spent 45 minutes discussing my life, where I travel to and my lifestyle. Afterwards, I asked the doctor why he did that. He said something profound. “First of all,” he said, “I enjoy talking to my patients. I like and care for my patients. I learn so much about myself, life and them. Second, when I stop listening to them, I stop caring. Then, I am more likely to misdiagnose their problem.” Now, my GI guy is about as “meat and potatoes” a doctor as one can find. Yet, he “gets it.” He understands that listening to the patient’s story and taking the time to show caring contribute to good medicine and ultimately, to the patient’s well-being. If only we in the counseling field had such an understanding. (And, oh, by the way, perhaps even managed care).
For years I have stated that counseling is both an art and a science. I am only partially correct. Counseling is not about relationship without skills and EBPs. EBPs are neutered when they omit the curative element of the doctor-patient therapeutic alliance. It is not an either/or question but a both/and issue. Plus, a third element, the unique experiences of the patient and all of their affected others, and the provider, and all related care giving elements.
Our task is to use the best practices science gives us, to be attuned to our own value systems and experiences, to listen to the person and all dimensions of their unique experience, and to apply our best skills and knowledge to care for this person. One does not learn this skill by studying a manual, and maybe not even in a classroom. Attentive listening is attained through training, repetition, experience and self-awareness. Key to effectiveness in practice is in the relationship of the use of EBP knowledge to the experience of the individual patient.
David J. Powell, PhD President, International Center for Health Concerns, Inc., is an internationally recognized lecturer and trainer, and author of Clinical Supervision in Alcohol and Drug Abuse Counseling. His most recent book is Playing Life’s Second Half: A Man’s Guide for Turning Success into Significance. For further infor-mation, contact
This e-mail address is being protected from spambots. You need JavaScript enabled to view it
or www.ichc-us.org.
|
