While working as a Clinical Supervisor for the evening Intensive Outpatient Program for Centerpointe Hospital in St. Louis, Mo, we served a predominantly high functioning group of men and women with a variety of dual diagnosis - many of whom would report self medicating with a range of legal and illegal substances, for what they believed were their underlying issues of depression and anxiety. While technical clinical diagnosis of their presenting problems, as an Acute Therapist II, was limited to the DSM-IVTR/DSM-V classifications for both medical and billing purposes, client reporting of their own perceptions of their physical and mental status, and external psycho-social factors, was always an important part in providing a personalized treatment plan. Perhaps, in some cases, more important than the technical diagnostics.
Human beings, while we all share many of the same physical and systemic characteristics, are not simply a collection of standardized terms and codes. Though none of us can escape certain processes, such as the Law of Thermodynamics, or how our physical systems interact on a cellular level, our minds and bodies are not simple products of these traits. Even on a systemic and cellular level, internal and external factors do not only affect how the systems work, but modern research into trauma and perception (including imagination), has been shown to not only change our psychological makeup - but the physiological as well.
Modern science has supported the idea of brain-body connection for well over a century, as stated in the journal article, Gut feelings: the emerging biology of gut–brain communication by Emeran A. Mayer, “A major scientific breakthrough in understanding the interaction of the nervous system with the digestive system occurred with the discovery of the so-called enteric nervous system (ENS) in the middle of the nineteenth century1–4 (BOX 1). Even though it is now considered the third branch of the autonomic nervous system, the ENS has been referred to as the ‘second brain’, based on its size, complexity and similarity — in neurotransmitters and signalling molecules — with the brain5.” (NATURE REVIEWS: NEUROSCIENCE, VOL. 12, AUGUST 2011, p. 453). However, this work has subsequently been expanded to show that the bidirectional nature of the communication between the gut and the brain, specifically through the ENS and the autonomic nervous system, and parts of the brain which regulate emotion, social relationships, and the ancient limbic brain (which regulates distress reaction, sex drive, and hunger/satiety), is not only rooted in the bottom-up affective movement of hormones from the gut to the brain, but is also moderated by the top-down effective communication of our brain to our gut. This means that not only does our gastro-intestinal health contribute to our overall health, but so to does the physical and mental health of the brain.
When working with clients, either as a Clinical Therapist, or as a Physical Health Coach, it is therefore important to address not only the physical health of the body, but to take into consideration all levels of psycho-social and behavioral beliefs and habits that our clients present with. This means a full profile “snapshot” of the clients’ past and present will provide a deeper insight into the creation of a personalized program that will better fit that client’s specific needs and “buy in” to commit to the program. While it is important to note that Clinical Therapists can provide diagnosis along with a treatment plan to specifically identify and work through underlying behavioral and emotional problems, Physical Health Coaches will still benefit from this information as it will allow them to better serve each client with a general understanding of how to create a bespoke program for each. It can also help the Coach determine whether or not to refer a client to a Clinician for specialized behavioral health work that will enhance the client’s ability to reach their goals.
(NOTE: The following case study is fictitious and for the purposes of this training.)
In the case of our current study, our client presents with possible past trauma and current behavioral and psychological patterns. This 50-year-old executive level professional male states that he has suffered a “sensitive stomach” for years, and that he recalls vomiting when his parents fought, or when he would ride in a car, when he was a child. He also states, “I’m still a worrier”, and reports that his current job is highly stressful. His physical symptoms are alternately diarrhea, constipation, heartburn, indigestion, and stomach bloating. His GP has ruled out serious pathology and diagnosed with IBS. He reports that he does not want to be on medication for the rest of his life and has a concern that, “I hear some of those drugs give you heart attacks”. Current behavioral patterns are irregular eating habits, such as skipped meals, late work nights, and a low priority to eat when he is working. Sxs are worse on weekdays, and later in the day.
As this client’s self-perception of the presenting problem seems to be rooted in his idea that he has always “been a worrier”, I would want to ask more questions about his career choice and to help him identify why he places such a high priority on his work, and to assess whether or not he might need some work with a Clinical Therapist to address deeper psychological issues such as childhood trauma or self image. He mentioned that he felt his wife “might divorce him” due to his bloating and gas, but I also wonder the nature of their relationship, so I might either ask him for further insight on his support systems, or invite him to bring her in for a session so I can observe their interactions and assess whether or not they might need a referral for either individual or couples counseling to help enhance the overall process of change. However, there are still many factors here that a Physical Health Coach could easily use to help this client reach his goal of diminishing bowel irritation and feeling better, physically.
I would also explore more about his specific goals so that we can work on a plan of action that is a joint effort. This client’s current job as an executive, and his dismissal of the Doctor’s diagnosis, “My doc says IBS; I say BS”, shows that he is both used to managing others and is uncertain of his own beliefs about the cause and effect of his current symptoms. However, his fear of taking drugs that might cause significant side effects, while valid, and the fact the has come for nutrition help, also shows that despite his lack of total acceptance of his problem he is open to asking for and accepting help. Sharing research with him on the current research on IBS and gut-brain duality, as well as inviting him to help problem solve out the factors that he is in control of that might be worsening (or even causing) his symptoms could help him feel as though he does not have to “lose control” in order to accept the help he desires.
One specific action would be to use the Able, Willing, Ready assessment in order to prioritize and process through some of the external factors and choices he has made in terms of his career, as well as his level of commitment to learn to re-prioritize food thoughts. His statement that he doesn’t “always have time to grab something healthy… or something at all” and the fact that his Sxs are worse on work days tells me that he might have a black and white concept of foods either being healthy or not, and that he only abstractly connects his nutrition (or lack, thereof) with his symptoms. Jumping directly into behavior changes might not be effective if these his underlying thoughts are in opposition to change. While we want to eventually introduce and practice Somatic behaviors such as slow eating, and body awareness, the client might not be compliant with the changes if his thinking is not aligned with the behaviors.
Another consideration would be learning his client learning type and having him complete a behavior log for at least 3 days, which we would use to talk through his insights in the following session. As we’ve already established he is a professional executive, it’s likely that he is higher in logical and social intelligences, and his lack of insight into his eating and sleep hygiene and causation of his stomach distress shows he is likely very low in kinesthetic and natural learning styles. Having him work through the logical process of writing down food, sleep, symptoms, and stress will hopefully help him see the correlation between his habits and his discomfort. Again, bringing him onboard as a participant and not an passive learner will cater to his personality, as well as giving him the power to learn to make the long term sustainable changes he needs to heal.
As we can see, helping clients understand and connect their internal systems, as well as historic and present external behaviors and psychosocial beliefs and experiences, enhances the client-centered coaching process by bringing the client into the planning and execution of change.