Counselling Dilemma: A Highly Stressed Client
A client comes to you having had to quit work due to a degenerative visual impairment. He has a 3 year-old child and his wife is expecting another baby. His sight may continue to deteriorate or it may remain at the current level. He is suffering stress, feelings of grief and loss and anxiety about the future.
How would you go about helping this client?
The main issues are: stress; anxiety; loss and grief; loss of employment; and possible further deterioration of eyesight. Each of these issues could have underlying problems that may need to be explored.
Stress and anxiety will hinder the client?s ability to find solutions to the other issues. Therefore the first thing to do, is to teach the client relaxation methods and the importance of practicing them on a regular basis. Untreated stress can lead to other health problems, which could escalate the problem. If the client can learn to relax, then other issues will not seem quite as overwhelming and finding solutions will be much easier.
His feelings of loss and grief need to be handled carefully, I would therefore use a person-centred approach to allow full expression of the multitude of feelings he is experiencing. With careful observation, you can judge when he is ready to move on and explore options for dealing with the more practical issues he is facing. At this time, a solution-focused approach may be more suitable.
I would only use influencing techniques when absolutely necessary, in order that the client is allowed to find their own solutions. Whilst this is important in most counselling situations, in this particular case it is even more so. This client has lost control over his eyesight, his health, his employment and his dreams for the future. He needs to be given back a sense of having some measure of control over his own life.
It is possible that the disease is hereditary. I would therefore explore whether a relative of the client had to deal with this problem. The client?s fears about his own situation could be linked with that situation. For instance, if his father had the disease and lacked support services, the client may be afraid that he will face the same issues, without realising that services may well have improved. He may also be afraid that the disease will affect his children later on.
If he has never encountered this problem before, he may have a lot of unanswered questions and if I can give him this information, this could ease some of his anxiety. I would obtain this information by talking to his doctor or some other medical person, after obtaining the client?s permission to do so.
Furthermore, I would research what services are available to assist him with his eyesight-related issues. Retraining may be available to either enable him to continue in his former employment or to find a new direction.
In summary, I would focus on the client?s strengths by exploring how he has coped with adversities in the past and use reframing skills to assist him to see his family, including the expected child, as an asset, rather than a part of the problem.
There would be several steps involved in helping this client and the best counselling service outcomes may be achieved by taking a case management approach. In the first assessment appointment I would ask the client to tell me about the visual disorder, any visual changes over time, the way in which he found out about the impairment and the effects that it has had on his life to date.
In subsequent assessment appointments I would be finding out how the visual impairment had impacted on him emotionally and psychologically, any anxiety history, relationship problems, effects the vision impairment has had upon his relationship with his wife and child, and his attitude towards his impairment and the future. It would be important that a positive approach to the client and his future, based on his abilities, would be adopted, and demonstrated towards the client, as the approach taken by all significant carers will influence the way he responds to his circumstances.
If the client is experiencing low vision, time would be taken to discuss appropriate support networks and he would be helped to find suitable services and to make contact with them. The state based Blind Association, for instance, may be able to assist this client and his family with financial concerns or practical services such as visual aids or a reading service. The client would be encouraged to contact a specialist visual rehabilitation centre, available in larger hospitals or universities (such as the Queensland University of Technology), for a multi-disciplinary assessment.
At such centres the client may access an optometrist, social worker and occupational therapist who together can provide an assessment of the client?s activity management. Information, advice and aids that may assist the client to maintain an independent lifestyle or improve life quality would also be provided. As with most degenerative disorders the client will benefit from having accurate and comprehensive information about his prognosis to enable psychological adjustment, planning and direction for rehabilitation efforts.
A Low Vision Support Group, available in capital cities and regional centres, or a telephone service such as the Vision Information Line, would provide emotional support. The client would be encouraged to contact Commonwealth Rehabilitation Services Australia, which assists people with injuries or other problems to rejoin the workforce. This service is free to people receiving a Centrelink benefit.
The client would also benefit from a medium term counselling program. The client would be asked to set his own goals in relation to his anxiety, stress management and grief reactions. These specific and measurable goals would be clarified, reality tested and discussed within a preliminary session alongside a discussion of counselling expectations, explanations and requirements. The client would be asked to participate in homework assignments including cognitive behavioural techniques of ?mood monitoring? (evaluating mood on a numerical continuum and recording extremes and time of day), daily thought journal and activity journals.
This information would be particularly valuable in helping the client to manage his anxiety. Cognitive assessment would facilitate stress management also in helping the client to understand what thoughts and behaviours, triggers or experiences may coincide with the increase in stress symptoms.
Stress management techniques such as breath control, progressive muscular relaxation, guided visualisation, thought distraction and thought stopping would be taught to the client and the client would be encouraged to practice the techniques he finds most helpful. He would be encouraged to talk about his feelings of grief, his experience would be normalised or legitimised and the grief process would be discussed. The client would be encouraged to disclose his thoughts, feelings and experiences in a context of non-judgemental respect and acceptance, with appropriate challenging of feelings of hopelessness or helplessness.
After the relationship has been developed and the primary focus established the possibility of referral to relationship counselling would be explored. The adjustments required to manage stressful life circumstances, particularly one with far-reaching financial, occupational and family consequences, is likely to impact upon the client?s relationships and the wellbeing of the family.
Ongoing monitoring of the counselling process would be a consultative approach, with the client examining life situation and outcomes against counselling goals. The termination of the counselling process would also be carefully evaluated, as it is vital that the client understands that his visual impairment does not limit personal responsibility or coping ability. The termination process would commence when the client is displaying signs of being able to manage anxiety and stress symptoms independently, and has become more purposeful in future planning.
From a lay person viewpoint the second scenario is probably the best. Having worked with vision impaired and blind clients establishing a secure base of support is the only way to go. Via Centrelink if they have been found to be “legally blind” they are entitled to a Disability Blind Pension which is not means tested thus allowing them to earn a wage on top of the pension. This at least initially provides financial support.
Via organisations such as Vision Australia there are a raft of support functions available to them, Independence in the Community – orientation and mobility training – adaptive technology training – Independence in the Home – occupational therapist assistance managing inthe home – Independent Living Services – face to face and phone conferencing sessions with a facilitator and people that have been in the same position.
Support via Vision Australia Employment Services to help them retain their present employment or to obtain employment. The Government through Job Access for a job in jeopardy provides assistance to purchase whatever is required in the way of technology, training, alterations etc to help someone retain their position. Consultants can offer wage subsidies to employers and provide support by negotiating changes in work roles.
There are also a number of courses available via registered training organisations supported by the Government’s Productivity Placement Program which enables a person to undertake retraining at no cost to them. I have had clients who spent their entire working lives in the construction industry undertake training in avenues which were totally opposed and are now working as community workers, with the disabled and in aged care who have stated they have never been happier and are finally enjoying their working lives.
Of course loosing your sight rapidly or even slowly causes all sorts of stress, anger, sense of hopelessness particularly in the case of a male who has been responsible for the support of the family via income. There will be a period of grief as well as a period of anger, depression and anxiety. But there will come a period where that person comes to realise that perhaps all this takes is a change of direction and with the right support that change can be made in a positive way. My question is always “what is your passion” and then we simply set about satisfying that.
The last thing any of my clients want is for someone to “do” everything for them. This is sometimes the biggest problem I face in that daughters, sons, mothers, sisters, wives and girlfriends often don’t take the time to allow the vision impaired person to “do” for themselves and step in and “do” it for them.
Regards
Perry Quinton
Yeah it sucks! I lost all that you could possible loose in this situation except my eyesight. We can walk through it all together. You may or may not loose further eyesight. Give yourself time to adjust having lost your job first. Perhaps another job could come up better than the last one that caters to the loss no matter how severe. Your wife will not love you any less. She vowed to love you in sickness and in health and you don’t give her cause for grief in anything else. You will get by and work it out together even if it turns out to be the worse case senario. All you can do is focus on your wife that she doesn’t stress. Let her know you are willing to step outside usual expectations and stay home minding the children while they are young and perhaps get your sister in to help get this started. Your wife as I understand is a qualified … Perhaps look at scaling down your housing needs and family before the birth to releive the pressure financially until you are certain of an outcome. Be encouraged through all the things that come your way that you are capable to deal with it and work at finding a solution with your loved ones even if it is not in line with your plan A dreams. Plan Bs can be just as satisfing.
Perry, your ‘expert’ reply was timely and practical to me personally. I have a husband who is experiencing aspects of the case scenario mentioned. He has partially lost sight during the aftermath of heart surgery. He is presently facing the prospects of trying to remain in the workforce with the possibility of his sight deterioating further. Even though I am a professional counsellor, I have understandably found it hard to remain objective in the situation. I have been able to present your practical suggestions to my husband to consider. I am praying now that I will not make the same mistake you mentioned of ‘taking over’. Thank you Perry and thank you AIPC.