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Health Counseling: Assessment and Intervention

Perhaps no area of intervention for women offers greater promise of empowerment than counseling services aimed at addressing health-related concerns. This empowerment has been long awaited, as health care traditionally overlooked women's biopsychosocial concerns in favor of a medical model approach to treatment. This model defined all concerns related to women's health, including normal developmental transitions such as menopause, as "medical issues" with a matching medical treatment. In addition, until recently, most health care providers were men, and most of the research that informed health care decisions was predicated on clinical trials that included only male participants. Indeed, it is only recently that large-scale clinical trials, such as the Women's Health Initiative ( www.nhlbi.nih.gov/whi ) and the Study of Women Across the Nation ( www.swanstudy.org ), have placed women's health care and wellness issues at the forefront. Newer developments in medicine and in allied health-provider disciplines have increased the likelihood that health care providers will be sensitive to the range of concerns presented by women, and that a variety of interventions that enhance women's overall health will be available.

This chapter introduces the reader to primary issues in counseling women for health-related concerns. Because other chapters in this volume provide information concerning specific disease entities, our aim is to provide general, but practical, information to facilitate your developing useful treatment plans when working with women who present with health-related issues. We begin with the biopsychosocial model of assessment. Given that health issues are always embedded within the context of a woman's life, this section pays particular attention to the significance of her life roles, examining how her roles may be affected by the diagnosis, the disease process, and the medical treatment of the disease. We also examine the role of culture in her experience, with particular emphasis on multicultural perspectives on health and illness. Next, we discuss treatment planning: identification of suitable treatment goals and establishment of an appropriate plan with the client. A variety of treatment approaches, including those commonly integrated into counseling for health issues, are reviewed. Monitoring compliance and addressing noncompliance are of paramount concern for the provider, and part of this chapter is devoted specifically to this issue.

BIOPSYCHOSOCIAL ASSESSMENT

The biomedical model, which focuses on pathophysiological explanations of disease and health, has slowly begun to be replaced by a more comprehensive perspective. The biopsychosocial model is the typical frame-work used by psychologists working in a medical setting to assess, conceptualize, and treat people with health problems. Initially articulated by Engel (1977), the biopsychosocial model seeks to understand health as a complex interaction of biological, psychological, and social variables. This framework is akin to a feedback loop in which changes in one part of the system produce changes in another part of the system. The premise of this model is that no single factor in isolation can adequately explain health or illness. For instance, biological factors may initially cause physical symptoms, psychological factors affect the appraisal and perception of the physical symptoms, and social factors shape behavioral responses to the perceptions of physical symptoms (Turk, 1996). Thus, the biopsychosocial model offers a useful framework for viewing the client through a broader lens. This framework can be applied to all aspects of the therapy process from assessment to conceptualization, goal setting, and intervention.

Although deemed a comprehensive model by many, it has been argued that the biopsychosocial model does not consider the possible relevance of spirituality to health. Kuhn (1988) suggested the model be renamed the biopsychosocial-spiritual model to take into account such factors. Recent research has shown that spirituality and religion are associated with various physical health outcomes, including lower morbidity and mortality rates, improved coping, better recovery from physical illness, improved medical compliance, and lower medical service use (Koenig, McCullough, & Larson, 2001). Moreover, the majority of Americans identify themselves as spiritual/religious as reported by Gallup data (1995), indicating the importance of assessing such beliefs in the lives of our clients. In this chapter, the term biopsychosocial model is used for the sake of brevity, with the assumption that spirituality is subsumed under the "social" part of the model.

For psychologists and health professionals working in medical settings, the biopsychosocial model is an indispensable framework for providing comprehensive evaluation and care to patients. First, this model allows professionals to address more than the biological aspect of the patient's problem, thoroughly assessing all the factors in a person's life that may be contributing to health status. It has been estimated that approximately 60% of ambulatory care visits involve problems with psychosocial components (Belar, 1996), and up to 80% of medical patients show evidence of significant psychosocial distress (Barsky, 1981). Second, the model recognizes the relationship among health attitudes, beliefs, andhabits; physical illness; and mortality. In 2002, 4 of the top 10 leading causes of death in the United States were chronic health conditions either caused or exacerbated by unhealthy behaviors, such as smoking, poor diet, lack of exercise, excessive substance abuse, and high stress levels (Centers for Disease Control and Prevention [CDC], 2002). Third, a biopsychosocial perspective can guide professionals in developing needed programs that target prevention and behavior change as health care costs continue to increase. Finally, this perspective is compatible with the current trend in medicine toward a greater concern with maintaining quality of life.

Psychologists conducting health counseling are in a unique position to contribute to health and well-being by thoroughly assessing all the factors in a person's life that may be contributing to health status. In fact, a complete biopsychosocial assessment may be the most useful contribution a psychologist can make to a medical team. Prior to planning an assessment strategy, it is useful to articulate the purpose of the assessment. Is it for diagnostic reasons? Is it for initial information gathering to aid in treatment planning? Is it to monitor treatment progress and assess treatment outcome? Is the assessment to answer a consultation question from the patient's physician? Is the assessment needed to screen for particular medical procedures? Pinpointing the purpose of the assessment will help focus the interview.

There are several ways to approach a biopsychosocial assessment. One method generally called "high fidelity" assessment is aimed at specific patient populations (Turk & Kerns, 1985; Van Egeren & Striepe, 1998). These various structured assessments have been created to gather information pertinent to certain illnesses. The Clinical Handbook of Health Psychology (Camic & Knight, 1998) provides specific assessment strategies for medical populations, including cardiac disease, pulmonary disease, chronic pain, diabetes, gastrointestinal disorders, HIV/ AIDS, and oncology/hematology. Focused assessments can also be used to obtain specific information about a patient's candidacy for particular surgeries or organ transplantations. Understanding a person's psychosocial status is useful in such instances because of the relationship between negative affect and poor prognostic outcomes in certain surgeries (Herron, Turner, Clancy, & Weiner, 1986). A second approach to gathering biopsychosocial information is through the use of psychometric tests. Many of the traditional psychometric tests used with mental health populations may be applicable to a medical population; such tests, however, must be used with caution. There is debate regarding the appropriateness of psychiatric norms with medical patients due to overdiagnosis of psychopathology in such populations (Turk & Kerns, 1985). Clearly, the use of instruments designed specifically for medical populations is preferred, although instruments of this type are rare. For thorough reviews of psychometric tests useful in medical settings, see Green (1982), Wright, Johnston, and Weinman (1995), Belar and Deardorff (1995), and Johnston and Johnston (2001).

The type of biopsychosocial assessment described in most detail here is the focused clinical interview because this is the most likely way in which a psychologist will contribute to a patient's care in a multidisciplinary context and is the starting point for care done only by the psychologist. A general framework is presented for conducting an interview that can then be combined with structured questions for specific health populations or with psychometric tests or both. Figure 21.1 provides a biopsychosocial-spiritual flowchart to help clinicians identify the many variables needed to define the complex interplay among physical, psychological, and social factors.

A focused clinical interview with medical patients requires the same basic clinical skills needed to evaluate patients in any setting (Van Egern & Striepe, 1998). The quick establishment of rapport, provision of accurate empathy, and gathering of relevant information are all necessary components. Using the biopsychosocial model as a theoretical framework during the assessment process ensures that information is collected in each of the areas that can then be integrated to produce a comprehensive understanding of the patient.

Physical/Biological

Assessment of this domain can be done through self-report of physical symptoms, previous medical history and treatment, health habits, and current use of medications. Gathering information in this domain can be challenging because relying on patients' self-reports is often not sufficient. A succinct but thorough medical history can be difficult for a patient to articulate or may not be reliable. It must be taken into consideration that many patients do not fully understand their medical diagnosis or, in some cases, may not know their medical status. In addition, patients often may not be able to identify the medications they currently take, especially if they are taking numerous medications.

For psychologists working in a hospital setting, the medical chart can be a source of valuable information and should always be reviewed. When the medical chart is not available, obtaining a release of information to speak with the patient's medical provider is imperative. Medical texts that can be helpful to psychologists in understanding medical terminology, common medical abbreviations, medications, and prognosis and treatment for various diseases include Dorland's Illustrated Medical Dictionary (1999), the Physicians' Desk Reference (2002), and the Merck Manual of Diagnosis and Therapy (1999).

Psychological

Assessing for the presence of mood, anxiety, or adjustment disorders is necessary to understand how a person is coping with physical illness. In addition, gaining a better understanding of a person's personality or any psychopathology present can shed light on how he or she typically adjusts to life stressors. Biopsychosocial assessment differs from a general mental health assessment by making clear the association between how a person's psychological health may be impacting physical health and vice versa. Information not included in a mental health assessment, but useful in a biopsychosocial assessment, includes how patients have been coping with their health problem, attitudes or beliefs about their illness, the meaning of their illness, self-efficacy about health improvement, hopefulness, the presence of learned helplessness, the presence of secondary gains from the illness, and willingness to work with a psychologist regarding behavior change and adjustment.

Although a brief cognitive screen is not routinely done in mental health assessments, it should be included in a biopsychosocial assessment with medical populations. Medical procedures, illness, and the use of medications can impair cognitive status, which in turn can alter adherence to medical treatment regimens and decrease the ability to make complex medical decisions. The modified Mini-Mental State Examination (3MS, an improvement on the commonly used Folstein Mini-Mental State Examination; Teng & Chui, 1987) is a quick and effective screen for moderate or gross impairment of cognitive function (Tombaugh, McDowell, Kristjansson, & Hubley, 1996). The Mini-Mental State Examination is commonly used in hospital settings by a variety of health providers; thus, nonpsychology staff will be more likely to understand a 3MS score than other neuropsychological screening measures. A more thorough neuropsychological battery may be appropriate for patients displaying severe cognitive deficits.

Social

Similar to the psychological domain, the information gathered in the social domain needs to be understood in the context of how it impacts patients' physical health. Patients' social relationships can indicate how they are dealing with their illness and how much support they are receiving in this process. Kerns (1995) noted that health psychology, as a field, has been slow to recognize the role of families in conceptualizations of health and illness. Including a family member in the biopsychosocial interview can be especially helpful for understanding family functioning in relation to illness. Other relationships to explore are those with medical staff, especially if the patient has spent an extended amount of time as an inpatient. Patients' relationships with their health care providers play a major role in how they think about their current health status. Such relationships may be providing needed support or, in some situations, could be increasing the patients' distress levels if the patients are not receiving the care or time they believe they deserve.

Cultural variables and the worldview of the patient likely impact health and are important to assess. In some cultures, it is not acceptable to have psychological symptoms; thus, depression or anxiety may be manifested through somatic symptoms, such as headaches, fatigue, or pain. Rodriguez (1998) suggests that the following information be elicited to enhance assessment in racial/ethnic populations: racial/ethnic identity, acculturation, language, nontraditional family arrangements, support networks, future aspirations, migration history, and socioeconomic issues. Racial/ethnic groups may hold certain beliefs about healing and illness and may prefer to rely on traditional healing systems. When health providers ignore patients' worldview, value system, or subjective culture, patients' decisions to use traditional healing may be labeled as noncompliance. Integrating cultural coping strategies or treatment options more congruent with patients' belief systems is a necessary component of providing culturally sensitive treatment.

An understanding of the importance of spirituality and religion in a person's life should also be part of the biopsychosocial assessment. For many persons, religion/spirituality is a central element of their world-view. Understanding a person's belief system can promote clearer communication and offer contextual information important to the process of treatment (Gorsuch & Miller, 1999). Spirituality/religion can be quickly assessed using the FICA technique (Pulchalski & Romer, 2000). This acronym stands for asking patients about their faith/beliefs, the importance of it in their life, if they are part of a spiritual or religious community, and how to address it in treatment.

The biopsychosocial model provides great utility in understanding the broad health picture. Using it as a framework to gather information from multiple domains will lead to accurate diagnosis, improved treatment planning, better patient care, and positive health outcomes.

ASSESSMENT OF ROLES WITHIN THE FAMILY CONTEXT

Familial, occupational, societal, and personal roles are widely recognized as important life roles to most individuals. Life roles are related to status and social power in most societies (Clemson, Fitzgerald, & Mullavey-O'Byrne, 1999). The appropriateness of holding a particular role and the duties that accompany certain roles are often dictated by societal values, norms, and expectations. Women tend to occupy a wide range of roles, including mother, wife, homemaker, child care provider, religious group member, and employee. Varvaro (2000) notes that for women, not only do life roles help one feel valued and accepted by others but also through life roles women help significant others meet their needs. Multiple life roles, however, can also be a source of stress. Bankoff (1994) studied 379 women seeking psychotherapy concerning their needs in therapy; the number and types of roles of these women differed. Bankoff found that the two most psychologically distressed groups were women with too many roles (e.g., single mothers) and those with too few roles (e.g., those who lacked major roles of spouse, worker, or student).

When women experience health problems, either temporary or permanent, life roles often change. Given that role strain is already a source of stress for many women, role changes resulting from health problems can be particularly challenging. Most researchers agree that the ability to perform duties associated with various roles cannot help but be affected by illness, whether chronic pain (Roy, 1990), head injury (Kneipp, 1991), myocardial infarction (Varvaro, 2000), stroke (Clemson et al., 1999), or spinal cord injury (Chan, 2000). It is likely, however, that most individuals have never considered what life roles they hold and how these overlap with the roles of others in the family (Grahame, 1991); thus, the impact of illness on usual role functioning is a significant disruption.

Role changes affect both the woman and the significant others in her life. Tunks and Roy (1990) describe this as a parallel shift in roles, and they suggest that treating the family or couple together can more directly address the practical implications of role changes. In a study on stroke rehabilitation,

Clemson et al. (1999) recommend that the needs of the entire family should be considered, and the whole family should be considered the "client." Chan (2000) stresses the importance of emotional changes that the unit experiences when roles are altered. A related issue to systemic role changes is that many health problems and conditions are unpredictable and will involve several sequential changes in family roles during the course of the illness. Flexibility, touted by Doherty (1992) as the new postmodern family value, is essential for family adaptation to these unpredictable changes.

Role changes related to health problems and conditions can occur in any capacity of daily functioning. Whatever the role expectations before the onset of illness, the physical, physiological, and psychological elements of illness or disability may make a prior role impossible or simply much more difficult to perform without assistance. In addition to task-related role changes, many individuals with chronic health problems experience a shift in social roles due to various physical and psychological barriers to maintaining prior relationships outside the immediate family (Chan, 2000). Varvaro (2000) describes many role losses for a group of women who experienced a myocardial infarction. Issues raised by these women included loss of comfort over role in the family, feelings of isolation from the family, changes in capacity to perform usual family duties, difficulty in role perception of self in relation to others in family, relegating tasks to others (often at the request of a the physician), managing role reversal, and learning new aspects of changed roles. This study also found reluctance among patients to make lifestyle changes that disrupt roles or routines within the family. In this case, it is not necessarily physical limitations that caused the need for role change but, rather, the need to prevent further health problems.

One role change discussed frequently in the health literature is that of losing the role of provider. Whether one works inside or outside the home, work can fulfill many individual needs in addition to providing financial support, such as altruism, status, respect, security, relationships with coworkers, and an outlet for creativity (Silver, Price, & Barrett, 1991). It is also possible that the provider role may be overemphasized, either by the family or by health care providers. Chan (2000) notes that within some cultures, productivity and money are emphasized over other life tasks; therefore, losing the ability to work may be more devastating and shameful for a family. In other instances, the occupational role is overemphasized as a criterion for rehabilitation outcome, regardless of the family's view of the importance or purpose of work (Tunks & Roy, 1990).

A new and usually unfamiliar role is created during an acute or chronic illness the "sick" role. Clemson et al. (1999) define this as a temporary disengagement from normal roles and occupations in which the patient's primary tasks are focused on the illness. This may be a challenging adjustment for the patient due to an increased dependence on medical professionals. Tunks and Roy (1990) distinguish acute sick role from chronic sick role. This distinction is important because it allows professionals to recognize that some individuals may have an incentive to remain longer in a sick role due to secondary gain. Secondary gains include the receipt of work compensation benefits, attention from others, more affectionate responses from others, or control in what may be perceived as a disempowering situation (Roy, 1990).

Role Assessment

There are several general considerations in considering role assessment for women with health problems. As many family members as possible should be involved in the assessment of family adaptation. Generally, this assessment should include evaluation of family role functions, the nature of the occupational role (i.e., how the patient and family feel about work or work in the home), and how the illness role is viewed (Tunks & Roy, 1990). DePompei and Zarski (1991) stress that individuals or families may be experiencing other normal developmental events while dealing with the illness, and assessment must allow for this as well. Life transitions, such as marriage, birth, children leaving home, and the onset of menopausal changes, may be differentially important to various members of the family. These authors also note that behavioral observations of individual and family reactions to the assessment may provide useful information about family dynamics and attitudes toward potential new roles.

The timing of assessment is also important to take into consideration. Some researchers suggest that if a patient is in rehabilitation or spends an extended time in the hospital, role changes may not become relevant until discharge (Chan, 2000; Varvaro, 2000). Kneipp (1991) labels this time "community reentry" and notes that families and patients feel changes most intensely at this time. Another challenge during this time period is that the family may have found new ways of functioning during the hospitalization and must change again when the patient comes home (Williams, 1991). To address this timing issue, Varvaro recommends addressing role alterations during the discharge phase and then again 6 weeks following discharge. This follow-up assessment allows emotional reactions to certain role changes, such as feelings of guilt or inadequacy that tend to be common for the patient, to be discussed (Chan, 2000). Home visits are considered important as well. Kneipp suggests that home visits should be conducted on a frequent basis to develop sufficient rapport with the family and to gain information on usual family functioning.

Multicultural Considerations

Although traditional gender roles are still prevalent in many communities, individual cultural differences may be another component that makes role change unique to each woman and each family. Clemson et al. (1999) note that gender-related family roles such as division of labor vary greatly within and across cultures and must be considered in the assessment of family roles. These authors suggest that adapting to a chronic illness is similar to the process of adapting to another culture but without the support of others dealing with the same acculturation process. Chan (2000) provides an extreme example from a study on spinal cord-injured individuals living in Hong Kong. Traditional Chinese culture views illness as a weakness that brings shame and guilt on the entire family. Individuals with spinal cord injury are seen as careless, ignorant, and living inappropriately. Although this example is more extreme than may be seen in some Western health care settings, it does highlight the importance of assessing cultural ideas of roles and the perception of disease and illness. Inattention to cultural differences may even hinder functioning if treatment recommendations are rejected due to cultural inappropriateness.

Assessment Tools and Treatment

The Perceived Role Adaptation Scale is a measure of role adjustment that can be used with a wide range of populations (Varvaro, 1991). This scale examines perceived role adjustment and targets the roles of family member, marital/ sexual partner, homemaker, and paid worker. DePompei and Zarski (1991) provide an evaluation of several assessment tools and interview protocols for families dealing with those with head injuries and other illnesses.

Aside from continued assessment of adaptation to new and possibly still changing roles, there appear to be no widely accepted intervention techniques that specifically address role change. Research, however, has suggested general guidelines that may supplement traditional health psychology approaches. Scharloo et al. (1998) conducted a study of role and social functioning in individuals with rheumatoid arthritis, chronic obstructive lung disease, and psoriasis. Strong illness identity, passive coping, belief in long illness duration, and belief in negative consequences were all associated with poorer role and social functioning. These findings suggest that interventions should focus on increasing beliefs of personal control and developing realistic conceptualizations about the course and consequences of illness.

Another consideration presented by Varvaro (2000) is that changes over time may be related to specific time frames. In her sample of cardiac patients, the first year anniversary of the myocardial infarction caused role disruption for many patients because these women believed that they should be out of their "recovery period" and able to return to their previous lifestyle. The treatment group in this study that participated in a nursing intervention to increase adaptation to role changes demonstrated higher adaptation in work and family roles.

Role changes, whether temporary or permanent, are inevitable with the onset of acute or chronic illness. Although many women experience some level of role strain due to multiple life roles and responsibilities, illness adds another strain for the women and their significant others. Addressing individuals within the family unit in assessment and treatment is essential for encouraging the flexibility that is necessary for healthy adaptation to role change.

THE ROLE OF CULTURE IN HEALTH COUNSELING: DIVERSITY ISSUES IN ASSESSMENT AND INTERVENTION

As noted previously, health behaviors and beliefs about illness are often a product of a specific cultural context (Maclachlan, 2000). Western societies base their health beliefs, practices, and treatments on the Western cultural context (Marks, 1996), which typically centered on the values and traditions of White males. As Western societies become increasingly diverse, the framework in which health assessment and treatment have traditionally been conceptualized becomes less relevant (Kazarian & Evans, 2001). Therefore, a chapter focusing on assessment and intervention in health counseling would be incomplete without a discussion of the role of diversity/multiculturalism in the development of health assessment and intervention strategies.

One of the major criticisms of the current training of traditional health psychologists and other health professionals is the lack of attention to the promotion of culturally competent health science and practice (Kazarian & Evans, 2001; Maclachlan, 2000; Marks, 1996). Marks outlined key issues in the field of health psychology with respect to cultural context. Some of these issues emphasize the nature of health psychology's major theories, which are based on social and cognitive theories and have an individualistic bias. These theories, adopted from mainstream psychology and applied to health behavior in an uncritical and unquestioning manner, tend to ignore cultural, sociopolitical, and economic conditions related to health behavior. They have been further criticized for (a) being based on the convenience of medical personnel and not patients, (b) being detached from social policy, and (c) failing to deal with inequalities and disparities in health care of racial minorities and individuals from lower socioeconomic status. Benzeval, Judge, and Whitehead (1995) note that a great deal of attention has been paid to the health experiences of working White males at the expense of women, older people, and ethnic or racial minority groups. In addition, there has been a failure of health psychology to develop appropriate assessment methods for culturally diverse groups. This last criticism is of particular interest because of its relevance to culturally competent health assessment. According to Marks (1996),

Health psychologists place a heavy reliance on self-completion questionnaire instruments, many developed in the United States, frequently with student samples. Problems of measurement incongruence often arise when these instruments are used in other countries, especially with patient or community samples, (p. 15)

Mulatu and Berry (2001) note that health practices in a pluralistic society are complex, consisting of "indigenous and foreign activities aimed at maintaining, promoting, and restoring health" (p. 58). Currently, health psychologists lack appropriate assessments that reflect the diversity of health practices, which include popular, folk, and diverse professional health perspectives. The assessment techniques that are currently employed are based on the Western biomedical system, which takes a mechanistic approach to health care. In contrast, indigenous and traditional health care systems tend to take a more holistic approach to medicine, in which the goal of any assessment or intervention is to promote a harmonious relationship between the elements of the mind, body, and spirit (Mulatu & Berry, 2001). Cultures that favor holistic medicine are generally more collectivistic in nature and rely more on cultural and spiritual communities in the treatment of illnesses. Often, people who favor such treatment options will seek assistance from a traditional healer because of their fear that a health care professional trained in the Western biomedical model will not take seriously their desire to include traditional practices in their treatment. This is one likely explanation for the underuse of health care professionals by ethnic minorities, especially ethnic minority women (Wise et al., 2001).

Health professionals' understanding of cultural factors of health can also have an effect on patients' adherence to treatment. If patients do not believe that their cultural beliefs are being considered by their primary health care professional, they are less likely to adhere to the treatment regimen (Shearer & Evans, 2001). In general, health care professionals and health psychologists are in need of more culturally sensitive and responsive health assessment and intervention strategies.

It is especially important to take into account research on culturally diverse women. Wise, Carmichael, Belar, Jordan, and Berlant (2001) outline many issues concerning cultural perspectives on women's health, although they caution that research focusing on the relationships among culture/ethnic diversity variables and health behavior is sparse due to the fact that women in general have been largely ignored in medical research. There does seem to be limited evidence, however, that women from the four major ethnic groups (Hispanic, Asian, African, and Native American) in the United States and Canada have higher rates of morbidity, mortality from pregnancy, cardiovascular disease, cancer, diabetes, and HIV/AIDS.

As previously discussed, a major factor that may be responsible for the higher risk of health-related problems for minority women is stress from multiple roles. This is especially true for ethnic women. Wise et al. (2001) suggest that common risk factors among women who belong to the four major ethnic groups include increased exposure to psychosocial stressors, such as racism and sexism, and the fact that these women are often the sole source of support for their families. For example, many African American women are responsible for multiple roles, including mother, wage earner, parental care provider, and care provider for grandchildren. In addition to these psychosocial stressors, minority working women often experience workplace health risks, such as exposure to physical, biological, and chemical hazardous materials (Swanson, Piotrkowski, Keita, & Becker, 1997). Wise et al. (2001) argue that several other risk variables may have an effect on minority women's health, such as overrepresentation in lower socioeconomic groups; engagement in high-risk health behaviors, such as smoking, alcohol consumption, and poor diet; and genetic predisposition for certain illnesses, such as heart disease.

Although Wise et al. (2001) call for more research on minority women's health issues, they also warn against creating "health profiles" of each minority group because of the substantial heterogeneity within each of these groups. Their recommendation is that instead of focusing on race/ethnicity as an objective variable, health psychology researchers should examine the "meaning of ethnicity with respect to biological, psychological, and social components" (p. 464).

Despite the paucity of research on the health issues of ethnically and racially diverse women, there have been some attempts to design culturally relevant intervention programs for these women. For example, spiritual and religious interventions have been associated with positive health outcomes for Hispanic and African American women (Musgrave, Allen, & Allen, 2002). Musgrave et al. describe several "faith-based programs" to promote positive health behaviors for African and Hispanic American women. These interventions include programs focused on increasing mammography and breast self-examination (the Witness Program). Another successful program described by the authors is the HIV Prevention Faith Initiative of the CDC, which is a government- and faith-based partnership among several groups (e.g., the surgeon general, the Congressional Black Caucus, and gospel artists) in which the groups work together to dispel myths and encourage audiences to take HIV tests. Musgrave et al. also discuss the popularity of parish nursing, in which nurses promote health and healing "within the context of the values, beliefs, and practices of a faith community" (p. 5). Parish nursing is generally practiced in a church setting in which members of the congregation are able to obtain access to health care in a convenient, interactive, and faith-connected way.

Socioeconomic diversity among minority women is also an important consideration in the development of interventions. Zuckerman, Brennan, Holahan, Kenney, and Rajan (1999) found that lower-income women younger than age 65 do not have the same access to health care as women with higher incomes or those with Medicare benefits. Esser-Stuart and Lyons (2002) conducted a study to identify and describe barriers to seeking health care; to determine perceptions of confidence in health care practitioners; and to explore strategies to enhance, promote, and improve early health care intervention among low-income minority women. Results of this study indicated that participants did feel confident in their health care practitioners and identified few barriers to seeking health care. One explanation for the results of this study is that all the participants were enrolled in a program (Foster Grandparents) that provided some access to health care. The authors identified the importance of connecting low-income women with interventions designed to improve access to health care services, and they identified one national exemplar. The National Breast and Cervical Cancer Early Detection Program (established under the CDC in 1999) involves state and community partnerships that focus on increasing cancer screening for underserved women. Esser-Stuart and Lyons also highlighted the importance of incorporating spirituality and family into any interventions designed to increase positive health behaviors among aging minority women.

Increasing positive health outcomes among underserved and minority women should be a major initiative among counseling health psychologists, considering the health risks that exist for these women. To effectively design interventions that target these women, more research on the contextual and individual variables that determine the health status of women needs to be conducted. We suggest that this begin by examining how race/ethnic background, socioeconomic status, sexual orientation, and gender interact to determine access to health care and positive health behaviors.

DEVELOPING AN INTERVENTION/TREATMENT PLAN

Information obtained using the biopsychosocial assessment delineated previously is the foundation for identifying and implementing effective treatment interventions for a particular client. The plan for treatment will typically be developed collaboratively with the client and should include a set of realistic, measurable therapy goals designed to meet her identified needs. Although the specific goals of treatment will be shaped by a number of interacting forces (e.g., therapist theoretical orientation; therapist multicultural competence; client expectations, style, and needs; client worldview; client-therapist alliance; and managed care restrictions), progress will generally be defined as promoting the client's commitment to a way of life that will allow her to adaptively manage health-related distress. Treatment is intended to help the client adjust to life changes that follow the onset of health concerns (e.g., lifestyle changes, marital adjustment, decrease in physical strength or endurance, restrictions in dietary behaviors, or altered physical appearance) or to cope with preexisting issues exacerbated by the onset of health-related stress.

Women with health concerns present with a wide range of diagnoses and comorbid disorders. These include, but are certainly not limited to, chronic pain, arthritis, breast cancer, menopause, diabetes, asthma, obesity, eating disorders, chronic fatigue syndrome, fibromyalgia, chronic or migraine headache, insomnia, and cardiovascular disease. Here, we provide an overview of several commonly employed treatments, including psychobiological, psychological, and psychosocial interventions, for assisting women in managing symptoms associated with these medical diagnoses. It is important to note that the interventions described here are frequently integrated with other treatment modalities to meet the specific needs of the client. Indeed, many of the treatments supported in the literature are a therapeutic integration of several of the interventions outlined here.

Relaxation Training

Relaxation training procedures are well researched and can be effectively applied across a broad range of women's health issues. Relaxation as a treatment for arthritis, hypertension, tension headache, chronic pain, irritable bowel, chronic fatigue syndrome, and presurgical anxiety has been well documented. Through instruction, demonstration, and rehearsal, relaxation skills can assist clients in moderating physiological arousal, diminishing subjective distress, and enhancing a sense of mastery or control over symptoms. Although several variations of relaxation procedures exist, the most widely used are diaphragmatic breathing, progressive muscle relaxation, and autogenic training (Davis, Eshelman, & McKay, 1988; Ott, 1992).

The use of hypnosis in the treatment of women's health concerns is increasing. With the requisite training, hypnotic procedures facilitate a general sense of relaxation, alter the client's perceptions of a symptom, and evoke insight about symptom onset or symptom etiology. Hypnosis has been used in the treatment of pain, eating disorders, breast cancer, gynecologic cancer, infertility, cardiac disorders, and adjustment to chronic illness (Hornyak & Green, 2000).

Like relaxation, biofeedback targets physiological aspects of a client's distress but often elicits positive modifications within the cognitive and affective domains of client functioning as well. Biofeedback is frequently used in combination with other techniques, such as relaxation, imagery, and diaphragmatic breathing, which are aimed at regulating autonomic nervous system responses. Because the client is able to monitor changes in body functioning, biofeedback procedures facilitate a client's awareness of physiological arousal; teach voluntary control over physiological processes; and enhance perceived control in managing responses to tension, fear, and anxiety. Among the myriad disorders that biofeedback has been found to be effective in treating are anxiety, asthma, and chronic pain. A special form of biofeedback, thermal biofeedback, has also been shown to be effective with tension and migraine headache sufferers (Blanchard, 1998).

Operant Techniques

In health counseling, the central aim of operant conditioning is to increase the frequency of wellness behaviors while decreasing the frequency of illness behaviors, both of which are assumed to a large extent learned or conditioned. Under this paradigm, wellness behaviors are consistently and reliably reinforced either by the therapist or by trained family members, whereas attention is withdrawn during the presence of illness behaviors. For women experiencing chronic pain, for example, behaviors such as increased physical activity or decreased reliance on analgesics may be reinforced, whereas attention is withdrawn during inactivity, bed rest, or facial grimacing (Ott, 1992; Wilkie & Schmidt, 1998). It is important to note that the intention is not to eliminate the client's symptom entirely (e.g., remove the pain) but, rather, to assist the client to adaptively cope with symptoms and to eventually resume a more productive life. Wellness behaviors may be further reinforced by charting the client's progress toward increases in wellness behaviors (e.g., completion of a daily exercise routine) or providing a reward that is contingent on completion of some predetermined goal (Lewis, Sperry, & Carlson, 1993).

Cognitive Methods

The research literature is replete with studies supporting the effectiveness of a range of cognitive interventions. Distraction-based methods, such as the use of imagery to evoke pleasant thoughts that interrupt the client's focus on distressing symptoms, can be useful for clients experiencing headaches and chronic pain. Cognitive restructuring techniques allow the therapist to reframe the client's experience, thus altering her perception or understanding of a symptom, stressor, situation, or attribute. Behavioral pattern identification may facilitate the client's recognition of external events, bodily responses, or thoughts that proceed or follow the onset of symptoms. This skill increases the client's self-awareness and allows her to purposefully modify her environment and initiate useful coping strategies early on. Cognitive stress coping strategies facilitate the client's ability to identify fears or concerns that exacerbate symptoms. Once identified, the client can initiate self-soothing strategies (e.g., thought stopping and positive self-statements) to counter her perceived distress. Skills training interventions have also been identified as an effective intervention. Some clients will benefit from learning and practicing communication and problem-solving skills. Communicating with greater clarity, managing emotions while communicating, expressing needs more directly, using appropriate assertion, and solving problems effectively may be helpful to clients both in their personal relationships and in their interactions within the health care arena.

These strategies are often used in combination with behavioral interventions. Variants of cognitive-behavioral treatments have been found useful in addressing psychosocial aspects of the breast cancer experience (Antoni et al., 2001), chronic fatigue syndrome (Deale, Husain, Chalder, & Wessely, 2001), noncardiac chest pain (Nezu, Maguth-Nezu, & Lombardo, 2001), fibromyalgia (Rossy et al., 1999), insomnia (Espie, Inglis, & Harvey, 2001; Morin & Wooten, 1996), chronic pain (Ott, 1992), and binge eating and obesity (Sammons & Schmidt, 2001).

Supportive Counseling

For women, the counseling relationship can provide needed emotional support, offer a sense of safety, and provide reassurance that they are not alone. Through supportive counseling, clients have the opportunity to be heard and understood. Clients may begin to communicate distress through the creation of a narrative of their health experiences and recognize the normalcy of responses to the experiences.

There are a variety of individual approaches to therapy (e.g., interpersonal, psychodynamic, narrative, existential, and systems focused), and for each of these approaches there is great diversity in how therapy proceeds. Despite these differences, interventions are aimed at establishing a relationship with the client that will facilitate self-discovery, self-regulation, self-care, and the client's search for meaning. Although a large portion of the psychotherapy outcome research uses symptom reduction as the primary outcome measure, the positive effects of psychotherapy go far beyond diminishing symptoms to include a reduction in the amount of medical and surgical interventions used and a decrease in medical care expenses (Rainer, 1996).

Psychoeducation

Psychoeducation has been shown to increase the accuracy of clients' knowledge about their own disorders and to show positive effects on treatment compliance among some patients (Stewart & Stotland, 1993). Mental health providers are in a unique position to assess the accuracy of clients' knowledge about their diseases, supplement this information if deemed appropriate, and dispel misconceptions that may impede client progress. This aspect of treatment may involve didactic interventions during the course of treatment (e.g., the use of books, media, or other forms of information) or directing the client to practical resources to address issues as they emerge.

The information provided may serve to enhance the client's understanding of the typical course of a particular illness, offer a conceptual framework for understanding symptoms, increase awareness of treatment alternatives, or normalize common psychological responses to a particular disease experience. Providing conceptual explanations for pain, such as the gate control theory, stress-pain-stress cycle, muscle tension-pain cycle (Ott, 1992), and blood flow theory for pelvic pain (Steege & Stout, 1993), has been shown to help chronic pain sufferers by validating that their pain is indeed real and by fostering an understanding of pain as multiply determined and within their control. In addition, there is preliminary support for the use of video education in helping breast cancer survivors adjust during each stage of the cancer experience (Hoskins et al., 2002).

Inclusion of an educational component in treatment offers the client anticipatory guidance necessary to continue her progression through successive phases of the treatment process; to confront new, potentially threatening experiences (e.g., medical procedures or seeking a second opinion); and to assist her in developing daily wellness routines (e.g., sleep hygiene for insomnia). It may be helpful to explore past as well as current wellness behaviors and supplement therapeutic interventions with basic health education. Should the information needed by the client extend beyond the psychologist's level of competence, referral and collaboration with other professionals may be necessary (e.g., a nutritionist for a client diagnosed with anorexia nervosa).

Although the interventions previously described can be used in the context of individual and group therapy, it is important to recognize that the group environment offers a number of elements that are not part of the individual therapy experience. Yalom's (1985) research on the dynamics of group therapy identified several valuable elements acquired through the experience. Members develop a sense of cohesiveness, experience altruism, cultivate hope, feel understood, and engage in sharing information. Group members are reminded that they are not experiencing this illness alone, and they model for one another a range of adaptive wellness behaviors. The group provides a socialization experienceone that may actually counteract unconstructive responses received from one's primary support network. The positive effects of group therapy have been demonstrated among breast cancer survivors (Spiegel, Bloom, Kraemer, & Gottheil, 1994), clients with chronic fatigue syndrome (Soederberg & Evengard, 2001), and women with eating disorders (White & Freeman, 2000).

A broader approach may be necessary for some clients, particularly if the therapist identifies pathogenic aspects of the client's life situation that are impeding her progress (Worell, 2001). Interventions can target environmental changes within the family, health care system, or the broader sociocultural context (Belar & Deardorff, 1995). Inviting the client's significant other or family to become involved in treatment is an important consideration. Together, the client and therapist may decide to involve family members, and involvement may range from limited (e.g., a family member completes forms during the assessment phase or attends a single session) to active (e.g., a family member attends several sessions as a "collateral" client, trains as a contingency manager, or engages in family-centered therapy). Conceivably, family members also benefit from receiving timely and accurate information because they may lack information about the client's symptoms, the course of the disease, or the client's primary needs throughout various phases of illness. Family members may be in need of psychological support as they confront their own questions, fears, ambivalence, and confusion concerning the client's health problem. In addition, a couple or family unit may benefit from focused therapy addressing relationship or family-related issues that have been exacerbated by the client's current circumstances, such as changes in sexual activity, financial stability, and child rearing. Many authors have specifically addressed the significance of attending to sexual adjustment issues in counseling women. Wiejmar, van de Wiel, Hahn, and Wouda (1995) identified two provisions, patient information and counseling, as key to assisting women with sexual adjustment following treatment for gynecological and breast cancer, although it seems likely that these two provisions apply more broadly to a variety of health concerns.

In summary, it is becoming increasingly clear that attending to the psychological and psychosocial issues involved in women's health early in the evaluation process, concurrently with the evaluation of organic factors, may lead to greater satisfaction with care and improved outcomes (LeResch, 1998; Rowland, 1998; Steege & Stout, 1993). When possible, clinicians should strive to maintain collaborative relations with providers of medical services offered to women.

COMPLIANCE

Noncompliance is an obstacle that affects both patients and health professionals. Patients who are noncompliant have great difficulty in changing their maladaptive health behaviors. As a result, health professionals who manage such patients are hindered in their ability to facilitate treatment. In treating women with health concerns, it is important to consider variables that may interfere with or enhance adherence to treatment regimens. Variables discussed here are social support, cognitive and emotional components, patient beliefs, and environmental variables.

Social support has been studied extensively with regard to its effect on treatment adherence. A study examining the effects of this and other variables on exercise behavior in older women found that women who had social support specific to exercise behavior were more compliant to the prescribed treatment regimen (Litt, Kleppinger, & Judge, 2002). In another study examining factors related to completion of a substance abuse treatment regimen, those who completed treatment had social support specifically related to the treatment (Kelly, Blacksin, & Mason, 2001). These findings, however, do not discount sources of support that are more general and do not specifically target the patient's desired behavior change. For example, women with high-risk pregnancies who had higher levels of general social support were more accepting of long-term home visitation (Navaie-Wilson, & Martin, 2000). With regard to various forms of social support, close relationships with significant others can serve to increase motivation to comply with certain health behaviors. In a study examining women's likelihood to participate in cervical cancer screening, it was found that those with positive relationships with their husbands were more likely to attend screenings (Wilson & Fazey, 1995).

Compliance is also affected by cognitive and emotional components of patients' experiences. Constructs such as self-efficacy, self-esteem, and patient beliefs can serve to help clinicians understand a patient's hesitance to initiate/maintain a particular treatment regimen. In a study examining exercise behavior in older women, self-efficacy was found to be a significant predictor of those who maintained exercise throughout treatment and at follow-up (Litt et al., 2002). A related concept, self-esteem also helps to increase adherence to treatment regimens, although the mechanisms through which this concept is hypothesized to work continue to be debated. Wilson and Fazey (1995) found that women with higher levels of self-esteem were more likely to get screened for cervical cancer. The authors concluded that this construct, when present, facilitates preventive health behaviors.

Patient beliefs can also serve to challenge clinicians' attempts to facilitate compliance. Noncompliant patients often have irrational health beliefs concerning side effects of treatment (Leung, Haines, & Chung, 2001). In a study of noncompliance in hormone replacement therapy, one fourth of women who did not complete the entire regimen reported that they feared adverse side effects (Leung et al., 2001). In addition, the presence of a psychological disorder is related to poorer adherence in many forms of treatment regimens. For example, women with HIV who reported depressive symptoms had low levels of adherence (Schuman et al., 2001). Safren et al. (2001) report a similar finding in this population in that greater depressed mood was associated with poorer adherence in taking HIV medications. As noted previously, it is important to assess the cultural beliefs of the client and incorporate these beliefs into the treatment process to increase compliance.

Environmental variables should also be assessed by clinicians when dealing with issues of compliance. For example, transportation to and from a clinic can be a major impediment to receiving treatment. In one study, accessibility of treatment facilities influenced treatment acceptance for patients with breast cancer (Simmons & Lindsay, 2001). Arranging breast cancer screening appointments can be an obstacle for some women due to factors such as arranging time off work, organizing transportation, and finding child care (Rutter, 2000). Child care seems to be an especially salient factor in addressing compliance for women. The responsibilities of juggling child care, household, and occupational tasks make adherence to any treatment regimen difficult (Roberts & Johnson, 2000). Roberts and Johnson found that among women with HIV, compliance was of secondary importance to these responsibilities. In another study, women with chaotic family lives that involved high levels of domestic abuse and engagement with child protective services were not able to complete their substance abuse treatment regimens (Kelly et al., 2001).

To increase adherence, Martin et al. (2001) suggest the following: simple and short treatments, maintaining a good relationship with the treating physician, greater accessibility to primary care consultants, and educational interventions. Litt et al. (2002) noted that booster sessions after the initial prescription of a treatment regimen can increase self-efficacy. In addition, all health care providers should explore patients' anxieties about treatment to prevent premature termination (Leung et al., 2001). Finally, enlisting social support specific to the treatment regimen can be helpful because patients who receive this support have a better chance of success (Litt et al., 2002).

CONCLUSION

In this chapter, we considered three aspects of counseling women with health concerns. First, we reviewed assessment, which forms the foundation of the counseling relationship and directs the initial contact with women clients. In some settings, the assessment may be the only "intervention," in which case the counseling psychologist concludes with a report to the referring physician and recommendations to the client. In other settings, the assessment informs treatment planning to be carried out by the psychologist or by other health care providers. In assessment, three spheres of function must be considered: the client, her family and other role contexts, and culture. We reviewed key aspects of each of these spheres.

Specific interventions for various diseases are presented in more detail elsewhere in this volume. We reviewed a variety of basic interventions that will likely be present in most health counseling treatments. It should be noted that each of the interventions we discussed would be tailored to the client and to her treatment setting. Assessment information should inform the specifics of intervention, especially information on the impact of the disease and its treatment and of the cultural context.

Compliance remains the ultimate challenge for psychologists. We can develop assessment plans and treatment goals, but without the client's firm commitment and follow-through, the promise of the plans and goals will not be reached. Thus, each psychologist must consider compliance within both assessment and intervention phases