Adjustment Related to Physical Loss or Chronic Illness | NCMHCE Exam Review

Hey there, everybody, and welcome to this presentation on adjustment related to chronic physical disability. This is part of the NCMHCE exam review. I'm your host, Dr. Donnellice Snipes. In this video, we're going to explore common disabilities and identify bidirectional pacer that is physical, affective, cognitive, environmental and relational interactive impacts and interventions to address them. Approximately one in four adults, or about 26% of people living in the United States, or 61 million people, report living with at least one disability. In 2018, 51.8%, or about 129 million adults, were diagnosed with at least one of 10 selected chronic conditions. And nearly 16% or 41 million individuals reported having autoimmune issues. So there are a lot of people that are struggling with chronic physical disabilities. And if you've watched some of my other classes, you know that stress, chronic stress, adverse childhood experiences, trauma, those things can cause disruption in the or dysregulation in the HPA axis, which can lead to chronic inflammation and stress related physical disorders. So it is intertwined. Not only can stress cause physical problems, but physical problems can cause stress and mood disorders. So what are we talking about here? Now, this list is not all inclusive. I could have gone on for a long time. But some of the more common ones that we're going to see include autoimmune disorders, including Crohn's disease, lupus, multiple sclerosis, rheumatoid arthritis, and psoriasis. Now, a fundamental component of autoimmune disorders is inflammation. And we know that stress contributes to inflammation and inflammation contributes to stress. So people with autoimmune disorders are going to need assistance potentially with managing their stress and anxiety and learning to regulate or down regulate their HPA axis if it's hyperactive. Lyme disease is becoming more and more common and that has a whole host of symptoms that look a lot like depression for a lot of people, but also include things that are inflammatory, like joint pain and other things. Chronic pain. Now this can encompass a lot of things. People can have an injury, maybe get into a car accident and get injured, and they have chronic pain henceforth. Some people, after they have a bone marrow transplant or donate bone marrow or even have an epidural, they have struggle with chronic pain. Another cause of chronic pain is fibromyalgia. Now, fibromyalgia at its root does not have necessarily the symptom of inflammation, so it's actually not categorized as an autoimmune disorder, but it does cause chronic widespread pain and it's Important for us to recognize how this pain impacts people in all areas of their life. Amputation is another area that we're going to need to talk about because people who have an amputation often go through a grieving process due to the loss of that limb or that body part. They have sometimes self esteem issues regarding feeling self conscious about the loss of that limb. They have frustration as they learn how to use their new, their new limbs once they're able to get a prosthesis. So there are issues and prostheses are not necessarily always effectively fit the first time. A lot of times they've got to be adjusted so there can be some pain in that initial break in period. People who experience paralysis due to an injury, like a car accident or a parachuting accident or something, or a stroke also will struggle. They will also, like a lot of these issues will have to go through or will often go through a grieving process because they are losing the functionality, if you will, or the body that they knew. They are sometimes losing some dreams that they thought they had had, you know, a dream to live pain free every day. Their dreams of being able to do certain things may be squashed by their condition. So there's, there are a lot of things that may need to be grieved. And we're, again, we're going to talk about that as we go through this presentation. Diabetes is another chronic condition that people have to make major life adjustments to a lot of times. And it can be very overwhelming, not only managing their blood sugar, but giving themselves injections if they don't have a pump installed. There are a lot of things that may require not only cognitive adjustment, but emotional adjustment too. Dementia, people who have a stroke, Alzheimer's disease or Wernicke's encephalopathy may develop dementia. And a lot of people who develop dementia are aware of the fact that they're starting to forget things. People with Alzheimer's disease are often diagnosed before they get to the point where they are unaware. So they are anticipating the onset of dementia and there is an anticipatory grief and anxiety that may go along with that. Cardiovascular disease like heart disease or COPD can prevent people from engaging in certain activities. They may have to wear oxygen around. It can contribute to mood symptoms if their oxygen levels are not being adequately maintained. POTs or postural orthostatic Tachycardia syndrome is a syndrome that is relatively new but is basically the result of a dysfunctional autonomic nervous system. So people's heart rate will spike. They have A variety of different symptoms. But a lot of people with POTS are unable to sit or stand or walk for extended periods of time, which means work, for example, may not be a possibility, especially, you know, upright work, like sitting at a desk all day long. And there are a lot of accommodations that need to be made. I have a video on the YouTube channel on POTS if you want to learn more about that, because it actually is estimated to impact up to 1% or 1 out of 1, 1 out of every 100 adolescents. Osteoarthritis. Now, this is different than rheumatoid arthritis, which is autoimmune in nature. Osteoarthritis can happen when the bones start rubbing on each other, the cartilage is worn away, and people start having joint pain. And it's still pain, and it still can be limiting to what people do if they're experiencing significant pain with walking or even sitting for long periods of time. Time. HIV is another condition that people may experience. It's a physical condition that is going to be lifelong. Now, the medications and treatments have come a long, long way in the past 20 years. So people with HIV often can live a very long, productive life. It's not like it was, you know, 20 or 30 years ago when where the virus would progress very rapidly. However, a lot of people don't realize this. They need to understand the advances that we've made in treatment. They need to understand what they can do. And they will also need a lot of help interpersonally with adjustment issues because there's still a whole lot of stigma and ignorance about hiv. HIV transmission and where we're at with being able to prevent and treat the disease. Hepatitis C and cirrhosis of the liver are other issues that may present in people who have alcohol use disorders, but they can also present in people who don't have addictive behavior. So you don't want to assume that just because somebody has hep C that they have an addiction in their history. They may, but they may not. What we need to know is that the liver is our main filter for toxins. And when the liver quits working as well, then toxins can build up. It can take longer to clear, medications, toxins, other things. And if the liver becomes really non functional, then some of those toxins may back up and cause something called health hepatic encephalopathy, which is inflammation of the brain because the toxins backed up in the system. So we need to be aware of that. Hepatitis C can cause a fair amount of pain in people as well, and there's also, again, a stigma associated with having hepatitis. So there is a certain amount of education that we may need to do. And finally, kidney failure is another one of the common issues that we see. And kidney failure can be a side effect of diabetes. It can be caused by a variety of other issues, but it is a progressive disease. And people have to adjust their diet when their kidneys are failing. They may get to the point where they've got to be on dialysis and sometimes on a transplant list. So there are a lot of things that they've got to cope with in addition to, you know, the side effects from medications, just like people with hepatitis and HIV may be struggling with. So let's talk about some of these issues we need to consider. When we're working with somebody who has a chronic physical condition, we want to look at their circadian rhythms and sleep. When people sleep is when their body can rest, rebalance, restore. It's when all of the immune system workers, if you will, go through the body, clear out all of the debris from the day, all of the free radicals that cause oxidative stress, and fine tune the machinery, so to speak. So when the body factory opens in the morning, it can function effectively. If people are not sleeping well, if they don't have good, solid circadian rhythms, it's going to impact their immunity. There is a lot of research that shows that sleep deprivation and circadian rhythm disruption can exacerbate, can make worse inflammation as well as cognition, chronic HPA axis activation. Now, this is one that's a little bit harder to assess, but we do want to evaluate it. If somebody is under chronic stress or they have a history of trauma or adverse childhood experiences, we want to recognize that they may have a HPA axis that's dysregulated. And a lot of times, one of the easiest symptoms to identify that by is emotional dysregulation. So the person goes from feeling kind of flow flat, you know, getting along, not, you know, feeling great, to an extreme emotion. And that is their body surging those fight or flight chemicals. There is a physiological underpinning. It's not that they're, quote, overreacting. It is their brain giving them a super dose of the fight or flight chemicals because it is trying to protect them, and it's informed by their prior trauma and stress alterations in the gut microbiome. This is another thing that, you know, we can't really assess very accurately, but it's important for people to eat a healthy diet, preferably with fiber, and, you know, vegetables and probiotics like from, from fermented foods, as well as things like yogurt. In order to keep their gut microbiome healthy, more than 90% of certain neurotransmitters are made in the gut. And an unhealthy gut communicates to the brain through the gut brain axis, the vagus nerve, and says, hey, we are not functioning at full capacity. And the brain alters neurotransmitters accordingly. When people experience physical issues, they often experience stress. Stress alters the gut microbiome, not just what you eat, but how you feel. The environments that you're in alter that microbiome. So it's important to encourage a healthy lifestyle in order to help their gut be as healthy as possible. Medications can also alter the gut microbiome. You know, antibiotics, antivirals, anti inflammatories, any of those antis in there are going to alter the gut microbiome, even antidepressants. So it is important to recognize that when we take things, when our gut gets disrupted for whatever reason, it can have an impact on energy levels, mood and immunity. Increased pain. Some conditions come with a syndrome or characteristic of either hyperalgesia or allodynia. And hyperalgesia is when something that would normally feel painful feels super, super painful. And allodynia is when people are feeling things, registering things as painful that other people wouldn't normally register as painful. So they're finding pain from a lot more things. And that can make the environment very scary and traumatic. And we want to recognize that this is something that's very, very real to people. They're not making it up, they're not malingering. Their body is actually responding to sensory stimuli differently, and that can lead to increased inflammation. It can be caused by increased inflammation. But ultimately, think about it. If things cause you extreme pain or lots of things cause you pain, it's going to feel very exasperating and depressing and you may feel hopeless and helpless. So there's a lot of stuff that goes along with chronic pain that we may need to address. And a lot of conditions have pain associated even after an amputation. Some people have what they call phantom pain, pain in the limb that's no longer there. And that can be exceedingly frustrating because it's not like you can rub it or, you know, take anti inflammatories and make it go away. It's the nervous system misresponding to what's going on. And it's important. If people, for example, have phantom pain they're probably working with a neurologist and or a physical therapist. It's important to loop them in to the treatment plan to make sure you get can most effectively help the person deal with that pain. Medication side effects and I have on this documented and client report because if you go to like drugs.com and look at medication side effects, you'll have a whole list of side effects that are common. But some people experience other side effects or more significant side effects from certain medications like doxycycline. Not supposed to make people sleepy according to the documentation, but repeatedly I have talked to people who have had to take it because they have gotten bitten by a tick and there's been a concern of Lyme disease and it has made them exhausted and as soon as they quit taking it, they felt better. So doxycycline is a. Or client report is another thing that you want to consider. If they say I started taking this medication and you know, within hours or the next day I started having these symptoms, there's something to look at and something to consider. Not that we're going to tell them to D.C. their medication, of course not. That is something that they have to talk to their doctor about. But for example, with Lyme disease, if people are taking the doxycycline prophylactically to prevent it as soon as they get a bite, even if they're not sure if they've got Lyme disease, if they start feeling exhausted and having and doxycycline also tears your stomach up. But having those symptoms, flu like symptoms, those are also symptoms of Lyme disease. So a lot of times people get very panicked when they start taking it because they feel like, oh my gosh, maybe, you know, I already got it. So it's really important to refer them back to their physician if they start having side effects that are worrisome to them. Nutrition. We want to help them assess their diet and they can download an app like SparkPeople on their phone and track what they're eating and the nutrients that they're getting in order to get a general idea based on the usrda, whether they're getting all of the nutrients they need on a daily basis. If they're not, then we can make a referral to a registered dietitian. But nutrients are what our body uses to make the hormones, neurotransmitters and tissues. Our body needs all of them. It needs proteins to, for example, make neurotransmitters. But in order to break those neurotransmitters down or Break those proteins down into usable products. To create serotonin, it needs a variety of different vitamins and minerals. So a well rounded nutrient profile is really important. We also want to consider absorption. If somebody has celiac disease, for example, or irritable bowel syndrome, or they had gastric bypass, or they're really stressed right now and food's just going right through them, they are not absorbing food in the same way as somebody who has an adequately functioning GI system. So they may still be eating a great diet, but if they're not absorbing the nutrients, it doesn't do them a whole lot of good. Again, this is call for a referral in order to see what can be done to enhance nutrient absorption. Gonadal hormones, testosterone, estrogen, progesterone are the three biggies. Oxytocin, a little bit. They are involved in affecting the availability of certain neurotransmitters. Estrogen in adequate amounts, not too much, not too little. So estrogen in moderation is neuroprotective. If people have an imbalance in their gonadal hormones, which often happens just as a byproduct of aging, because our body quits making as much once we get to middle age and beyond, they may start experiencing symptoms that are depressive, like in nature. No amount of talk therapy is going to help them reach their maximal quality of life if they have imbalanced gonadal hormones or imbalanced thyroid hormones. And finally, some people complain of fatigue. And there are so many different causes of fatigue. But if people experience chronic pain or chronic stress, both of those are going to keep them from getting adequate quality sleep. So that adenosine that builds up in the brain during the day is a byproduct of thinking and living doesn't get completely cleared out. So people wake up in the morning, they feel groggy, they end up relying on caffeine in order to get them through the day, which impairs their sleep at night. And they wake up repeating the same process because they're not getting that good sleep that they need. So we do want to evaluate sleep hygiene as well as other contributors to fatigue, affective and cognitive aspects that we need to consider. Low health literacy is one of those things that comes up a lot, because a lot of times doctors don't spend a lot of time educating people about their condition. So it's important to help people figure out where they can go to get adequate, reliable, accurate health information that is understandable to them, whatever their cognitive level is. So hiv, hepatitis, autoimmune diseases, diabetes, Lyme disease, all those things we talked about. Most people have a very low level of information about and in order to help them be as treatment compliant as possible and in order to help allay some of the anxiety they may feel because they don't understand exactly what it is or what tool expect, enhancing their health literacy is important. We want to explore anxiety. A lot of times when people are diagnosed with a chronic health issue or disability, they may experience a variety of types of anxiety. They can experience health anxiety, they're worried that it's going to get worse, or every time they start to feel feel a new symptom, they're worried that things are getting worse, they start having a headache and they think that oh my gosh, you know, the disease is progressing when it may just be they've got a headache. So we do need to help them use some cognitive behavioral tools to evaluate the facts in order to assess their health anxiety in order to cope with it. Sometimes assessing the facts is going to say, hey, I need to call the doctor. But we do need to empower them to use that feeling of anxiety. Not to sit with it and nurture it and dwell on it, but to say, okay, let me do something about it, let me figure out, is it a problem and what do I need to do about it. People also, when they experience a disability or a chronic condition, may fear abandonment or rejection. Their relationships and interactions with other people may need to change. They may not be able to go on 40 mile bike rides with their best friend like they used to anymore. So the time they spend with that person may suddenly like shrink considerably. And that can feel isolating and it can feel like rejection. So it's important to figure out how can you maintain the relationships that are important to you and have this condition. Living in the and is one of the things that Hayes refers to in acceptance and commitment therapy. And some people fear rejection. They fear that their significant others and their friends are going to be angry with them because they can't do things like they used to. Or they may fear that if anybody finds out what they have that they may be rejected or criticized or blamed for their condition. So it's important to assess all of those self esteem and abandonment rejection related issues. As I mentioned earlier, most people, when they get a diagnosis of a chronic condition, whether it's chronic mental health or physical health, go through a grieving process. And this is where, you know, denial, anger, bargaining, depression and acceptance. We need to help people understand the grief process, understand what it looks like for them, and process their Depression and their anger as many times as it comes up. Because remember, we don't just go through it and say, you know, go through it once and we're done. Sometimes they'll get depressed first and then angry. Sometimes they'll get angry first and then depressed. But a lot of times people bounce back and forth between anger and depression, sometimes having them simultaneously until they process it to the degree that they reach acceptance. And there are a lot of things that are involved in the grieving process process, you know, in how many different ways does it impact their life? They have this initial loss, this physical loss or diagnosis, but what else does that mean? Does that mean they're going to lose their, their job? Maybe people can't do the their job like they used to, so they have to find a different job. Does it mean that they're going to lose friends? Does it mean that they're going to lose, you know, years off their life? What is it? How many different losses, secondary losses, do they experience as a result of the primary loss? And each one of those losses may need to be grieved. People may have guilt when they're diagnosed with a chronic condition. Sometimes they blame themselves for getting it. Either they did something that caused it, or they feel like they're being punished in some way, or they may feel guilty that they can't do the things that they used to. This kind of goes up with the anxiety in their family or at work. They may feel guilty that they can't, they don't have the energy or the ability to, you know, be it be at every basketball game that their kid has anymore. So processing those guilt feelings and helping them identify how they feel and how much of their guilt and their self anger about this situation is mind reading. They assume people are angry at them because they can't do these things. Concentration when you're not getting good sleep, when your circadian rhythms are out of whack, when your nutrient absorption is crappy. There are a lot of different things that can contribute to poor concentration, aside from having some sort of cognitive issue. So it's important to help people recognize that what they can do to improve their concentration, like eliminating distractions, doing stuff that requires a lot of concentration at certain times of the day that are better for them, but also helping them develop strategies like writing things down and chunking what they do into 15 minute or 30 minute segments, whatever works for them so they don't feel frustrated. Because every time they lose their concentration and they get frustrated and angry with themselves, that HPA axis goes off. They flood themselves with adrenaline and impair their concentration further. So concentration is something we can help people work on. And a lot of times during the grief process, concentration's in the crapper. And it's important to normalize that for people and say, you know, this is an adjustment process and your brain and your body are trying to find the new normal. And during this process, concentration may be difficult. So what can you do to mitigate those difficulties until you get back on your A game? Going along with concentration is memory. During the adaptation process, memory is also often poor. So remembering what you need to pick up at the store or remembering to do something may be more difficult. That's when push notifications and notes come in really handy. And, and anybody when they're under stress or sleep deprived is likely going to have difficulty with memory. And we want to help people recognize that, normalize that, and provide interventions. Hopelessness and helplessness often arise when people get a diagnosis of a chronic condition or a permanent condition. And a lot of times it's because of an overall sense of disempowerment. You know, whatever happened, they didn't have any control over, and they may not be. They can't make it go away. It's there. So we do want to help people focus on what aspects of this can you control and what aspects of this, you know, are out of your control to help them regain a sense of personal power over their body, over their life, over their relationships. And polarized thinking. When people are in crisis, when people are grieving, a lot of times their cognitions become very dichotomous, very polarized, and that's normal. But we do want to help people be mindful of their self talk and of their cognitions so they can address that polarized thinking instead of saying, I am never going to feel better or this always happens. You know, helping them address some of those extreme words with things that are more temporal. You know, right now, you know, it's going to be a while before I'm not in pain or whatever the case may be. But helping them use cognitively restructure in a more helpful way, environmentally. When people are diagnosed with a chronic physical issue, there may be housing instability because it's expensive. Medical bills are really expensive. They may have to change jobs because they can't do what they used to. If they used to be a cop or a firefighter, and all of a sudden something happens and they lose vision in one eye, they may not be able to do that job anymore, or if they lose the ability to use their dominant hand. They may not be able to do that job anymore, which could mean that they are making a lower wage at whatever job that they do end up getting, which could contribute again to inability to maintain stable housing in some cases. And I put home loss here, I didn't know how to put it. But in some cases people may be unfortunately rejected by their family and put out because their family feels very strongly. And a lot of times this surrounds things that are more like HIV and hepatitis where there's a stigma surrounding it and a lot of fear and very low levels of health literacy. And the family may be very angry about that and blame the person for their condition and therefore evict them, if you will. I've seen it happen, you know, unfortunately I have. Working in addictions for many years, I've seen a lot of people whose family has blamed their addiction for the development of other issues and used that as an excuse to kick them out. So we need to make sure they've got stable housing. That's really what it comes down to. And we need to look at if they are on the cusp of housing instability, what might be causing that and what interventions are available. Employment changes may happen. If they have a short term disability, it may be six months where they can't go to work. Well, when people are not going to work and a lot of us experienced that during the pandemic where we weren't able to interface with our colleagues on a regular basis. And it can feel very isolating and depressing and, you know, oppressive sometimes. So we want to examine that. I mean, the whole, well, it's just a short term thing, you'll be back to work in no time. That just invalidates their feelings. So we want to recognize that if somebody's on short term disability, you know, it may have a significant impact on their finances and on their mood and their relationships and other things. If people are on long term disability, it means they're not going to be able to regain certain functions which may result in job changes or the need for accommodations or both. Now you can go to Jan, I believe it's Jan.org the job accommodation Network to find identified accommodations for a lot of different issues. The only one I haven't ever that I've gone on there and I haven't found has been for pots. Ergonomics and accessibility is also important. People who have chronic issues, whether it's POTS or paralysis or amputation, may have needs for changes in the environment or even Alzheimer's that cost money. And it's important to identify what needs to be done in order to make the home safe and accommodating for that person so they can engage in their ADL's as independently as possible. And how can they pay for it if they can't afford it out of pocket? Are there resources available to help them pay for it? And we want to recognize also accessibility. If they live in a third story apartment that has no elevator and they're in a wheelchair now, you know that's not going to work. If they work in a, a building somewhere that is not accessible, and especially if they work for a small business, it is possible that that's the case. You know, what needs to happen, what can happen in order to help them have as high a quality of life as possible. When I talk about ergonomics, you know, I'm talking about being able to get in and out of the bathtub, being able to use the toilet, being able to take a shower, being able to cook your own meals and access things because a regular counter height is too high for someone in a wheelchair most of the time. So all of these things are necessary to consider. And a lot of times a case manager will work on that. But talking with clients, if they're having difficulties with their ADL's or they're having difficulties doing their job at work, then it's important to explore what sorts of accommodations might you need. Ergonomics also applies to pain. And people with pain conditions may need special seating, they may need special cushioning, they may need special beds in order to accommodate their particular condition. So it is important to understand the ergonomic implications of different conditions and sensory input. For some people, sensory input can become more painful. People with chronic migraines and. I know I didn't mention that one earlier, I told you the list wasn't all inclusive. And people with pots tend to be more become more sensitive to sensory input. So lights, sounds, smells and even temperatures can become excruciating very easily. And so it's important to recognize that and help them figure out how can they mitigate those things in their environment so they are not assaulted by overly intense stimulus input on a regular basis. Relationally, people often experience changes in self concept when they develop a long term disability or have a permanent physical change. And as I've mentioned multiple times, they're going to have to grieve that process or grieve that loss and develop this a new self concept that embraces or at least acknowledges this new condition. So writing the narrative description of the protagonist in the story, you know, how is this new condition going to impact the person and how does it play out in this person's life? And hopefully it plays out in a way that is empowering and inspiring and not something else. There are often changes in self efficacy. When people are learning to deal with a new condition or they're learning about a condition that they only have partial control over, they may have a lack of a sense of self efficacy or ability to control what's going on. We want to help them see and hone in on those aspects that they can control for as long as they can. But sometimes, you know, like after an amputation, some people may lack self efficacy during that adjustment period because they're not sure what they can do anymore. And it's going to be important for them to work with whatever multidisciplinary team member is appropriate to reestablish their sense of personal efficacy and control over their life, their ability to do those day to day activities, activity of daily living things, altered interpersonal activities. I alluded to earlier, sometimes that can be due to disability. You know, they can't run marathons anymore, or energy levels or autonomic nervous system dysfunction. There are a lot of different reasons that a person's daily activities and things they enjoy doing may have to be altered or adjusted. And if those are things they used to do with other people, then those relationships are going to fundamentally change. And that may involve a grieving process and a readjustment process. Not everybody's comfortable coming out and saying, hey, I've got this condition, so I can't do this anymore. So how are they going to navigate those relationships? There's a need to connect with others with similar conditions to normalize, destigmatize and validate what they're going through. Support groups are so helpful. And I know with pots, for example, and dementia caregivers, there are two really good groups on Facebook, one for each of those, where there is a lot of amazing empathy and support and validation. So even if people can't go to a support group, or maybe they don't want to actually go to a face to face support group, there are a lot of avenues online where people can connect with others with similar issues and get the validation on a regular basis for how they're feeling and get insight from others who are further along in the process about, you know, what does this progression look like and what can I expect next month or, you know, three months from now? They may need help dealing with the reactions of their significant others. Significant others, like clients, often have low levels of health literacy about particular issues. So we may need to educate the significant others or educate the client so they can educate their significant others about the condition. In order to allay the anxiety of the significant others, significant others may have to go through a grieving process because, you know, if you have a child, for example, who is diagnosed with a long term disability, there is a grieving process because you hurt for your child, you hurt for them not being able to have a, you know, perfect, pain free, 100% healthy life forever and always, which probably isn't realistic anyway, but there's a grieving process and you may need to grieve or they may need to grieve the change in the relationship with that person. Like I mentioned, if you and your best friend used to run marathons together and you can't do that anymore, they may have to grieve the loss of their running buddy. And I know that sounds petty, but it is a significant alteration. Significant others may have difficulty understanding or empathizing with the person. They may feel or believe that the client is exaggerating or malingering or you know, there are a lot of negative words that can be used that basically amount to why can't they just get over it. So it's important to help significant others understand the grieving process and, and encourage them provide strategies to help them empathize with what it's like for that person. Resentment can happen. You know, if somebody used to do something all the time and they can't do it anymore, then whoever has to pick up the slack may resent the fact that they are having to do more work because that person can't do it anymore. And overprotectiveness. Sometimes significant others go the opposite way. Instead of being rejecting, they become hovering because they want to do whatever they can to make it easier for that person in order to help them recover. And they really have the best intention to, but it can be overwhelming sometimes and disempowering because sometimes they become so overprotective that they quit permitting that person to feel their feelings, to take risks, to, you know, grow and adjust to this new situation. And finally, sometimes there's attachment changes. And remember, attachment can be summarized by craves, consistency, responsiveness, attention, validation, encouragement and support. We need to help people understand how they can be consistently aware of their own needs and responsive to them. With this new condition, we need to encourage them to do things that are positive, that make them happy, give them self positive attention and recreation. We need to help them learn how to validate how they're feeling instead of saying, I shouldn't feel this way or I should be able to do this. Just validating how they feel and where they are and provide them self encouragement and support. That's the first step. And then we want to help their significant others also be able to be helpfully responsive, not overprotective, not rejecting, you know, that helpful right there in the middle. Responsiveness. Help them figure out, okay, well, what can we do now if we can't do what the things we used to do together, what can we do that is positive? So there's positive attention, there are positive interactions that the person is still involved in. And through health literacy education about the condition, the significant others in the person's life are going to be more effective at providing validation, encouragement and support spiritually. When people are diagnosed with a chronic issue, a lot of times their spirituality, their sense of connectedness and kind of thrown for a loop. So their sense of connectedness to others in the world may change. They may feel disconnected, they may feel isolated, their source of hope may change, or they may not have any hope. And that hopelessness can be very oppressive to people. So it's important for us to help them identify, you know, where are their sources of hope. And hardiness was something proposed by Kielbasa back in the 70s. And the first C in hardiness is commitment and helping people recognize, okay, you have this aspect of your life right now where this disability is. And yeah, it's probably going to impact a lot of the other aspects, but what aspects of your, your life are going well right now and what aspects give you hope for the future? You know, you have to deal with this. But what other things, you know, you may be struggling with an autoimmune issue right now and struggling with adapting to that and life adjustments. And you have a child who is getting ready to go to college or have a baby themselves or something else that give you hope for the future, something that you're looking forward to. Sources of hope about their condition, you know, educating themselves about. Okay, you know, they're probably going to go look for worst case scenario. But what's the best case scenario? And what actually happens is probably somewhere in between. But where is their hope? Where is there. Are there models of people living with this condition like Parkinson's disease? Michael J. Fox is a perfect example of someone who inspires hope, a sense of purpose. Their sense of purpose may change radically depending on their diagnosis and how it impacts their activities of daily living and their hopes and dreams for the future. Future, you Know if it alters what they can do for their occupation, if it alters significant areas of their life, it also may impact their sense of purpose and they may feel like they're floundering. You know, if they used to have a great sense of purpose from their job and they can't do that anymore, okay, so where are they going to find their sense of purpose? When my mom recommended retired, she had a lot of sense of purpose from her job. And when she retired, you know, the first couple of months were kind of grand. But very quickly she started to feel like she was floundering and purposeless. So she threw herself into volunteering and she found a purpose in helping people learn about the problems with illiteracy and improving literacy in her three county catchment area. People may struggle finding meaning in events, or they may only see the negative aspects of meaning in events. They may not understand why things are happening, that life is unfair. And that can be very challenging. Because as humans we generally want to understand why. Why. You know, think about children, they have all those why questions. Why is the sky blue? Why do dogs bark? Why? Why this? At our very core, we want the answer to that question, why? And sometimes there is no answer. And that can be untenable for people. And encouraging them to talk about that and their frustration, frustration and figure out how they are able to resolve that. Cognitive dissonance is going to be important. Some people have a belief in a higher power or a universal energy that is supportive and can help heal them or that is punishing them and causing this condition. Not everybody has that belief. Some do. And we do want to understand how they're spiritual beliefs factor into their current situation. Does it give them hope or does it make them feel like they are being punished? Or maybe both. Sometimes it's a punishment that can be cured by that same higher power. And the ability to partake in spiritual activities like church and various other religious rituals may be altered by people's physical condition. Can they get to church? Can they sit through an entire hour or three hours of church, depending on what kind of church you go to. Are they able to partake in certain activities? And I know various churches have different activities, like in the Catholic Church, there's a lot of standing, sitting, sitting, kneeling. People who have arthritis may not be able to do all of those different gyrations. Some religions have other rituals like sweat lodges and things that, for example, someone with pots who is super sensitive to heat can't participate in. So we want to explode how this current condition impacts their ability to be involved to nurture their spirituality. Chronic physical conditions can impact every area of a person's life. Even though the behavioral health professional focuses on the affective, cognitive, and relationship dimensions and sometimes spiritual, it's vital to understand the impact of these issues also on physical functioning of the individual as well as the environment and how the physical aspect and the environment impact behavioral health.