Working With Clients With Multiple Sclerosis
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Multiple sclerosis (MS) is a complex, unpredictable, and chronic neurologic disorder that can affect numerous bodily systems and result in minimal symptoms or in significant disability. There is no known cause or cure. The role of the mental health professional has been well recognized in evidenced-based treatment of individuals living with MS. There is no definitive psychological theory or treatment. However, a multimodal approach that includes the management of stress, fatigue, pain, cognitive deficits, and psychological diagnoses is recommended. This approach also works toward increasing resilience and ability to self-manage symptoms, building a viable healthcare and wellness plan, and strengthening interpersonal relationships.
Jasmine, a 35-year-old, married, black mother of two, asked her neurologist for a referral because of her struggles with increasing symptoms from relapsing-remitting multiple sclerosis (RRMS). She was initially diagnosed three years ago after several years of reported symptoms were ignored or misdiagnosed. Jasmine states that she wants to learn better ways to cope with MS. She describes balance issues, fatigue, pain, restless sleep, worry, and difficulty with concentration and memory. She appears anxious as she describes the struggles she has encountered in her position as an administrator. She feels overwhelmed and has lost self-confidence. She, however, reports having a supportive husband and manager. She also expresses guilt that she is not living up to the expectations as a wife and mother of two young children. Jasmine reports previously feeling relatively happy, optimistic, and social, but she now participates less in family, social, and church activities. Jasmine appears motivated and reports no prior mental health issues. She appears to be a good candidate for self-management interventions. Will stress, pain, and fatigue management strategies be a good starting point? Will success with these interventions decrease her anxiety and feelings of being overwhelmed? Will physical and cognitive accommodations be necessary in therapy? How do religious beliefs about illness and disability play a role in her coping with MS? How are anxiety and sleep disturbance affecting her MS symptoms and quality of life?
Nature of Multiple Sclerosis
Multiple sclerosis is a complex disease, and it can be difficult to diagnose and treat. It is not uncommon that initial symptom reports are dismissed or mislabeled. A final diagnosis can be delayed, leading to increased frustration, anxiety, and sometimes a distrust of medical professionals (Traboulsee et al., 2015).
MS is an immune-mediated disorder, where the body’s immune system misbehaves and mistakenly attacks healthy cells. The immune system incorrectly recognizes healthy nerve tissue as foreign, which leads to inflammation, demyelination, and nerve damage. MS impacts the central nervous system (i.e., brain and spinal cord) as well as other select areas, such as the optic nerves. RRMS is the most common subtype. The course of the disease involves unpredictable flare-ups of symptoms interspersed with periods of stability, often prompting re-adjustment over time (Bogosian et al., 2017).
Overall, MS is not a “one size fits all” disease. In MS, immune cells destroy myelin, the protective covering of nerve fibers. These random attacks are commonly referred to as relapses, exacerbations, or flare-ups. A broad spectrum of clinical signs and symptoms, which vary from person to person, may include fatigue, sensory problems (e.g., visual disturbances, reduced sensation, numbness/tingling), incontinence, motor difficulties (e.g., problems with walking, balance, and coordination), cognitive dysfunction, and changes in mood and behavior. These changes and losses can have a significant impact on functioning and quality of life.
Incidence, Prevalence, and Course of MS
It is estimated that one million adults are living in the United States with MS (Wallin et al., 2019). This may be a low estimate, as underdiagnosis is probable because of limited access to neurological evaluation services and because MS is not an infectious disease that must be reported to the Centers for Disease Control and Prevention (CDC). Most individuals are diagnosed with MS between 20 and 50 years of age. MS is diagnosed 2–3 times more frequently in women than men.
The clinical presentation and course of the disease is characterized by uncertainty and unpredictability. Partial or complete remission of symptoms can occur. MS is clinically divided into relapsing and progressive subtypes (Lublin et al., 2014). The course of the disease can be described as intermittent, episodic, chronic, and progressive.
When living with MS, a person’s time and energy can be consumed by the symptom(s) and resulting assessment and treatment. Physical and/or cognitive difficulties can challenge autonomy, particularly during the acute phase or as significant symptoms accumulate over time. The experience may also increase anxiety and fatigue in supportive others who provide primary assistance (e.g., coordinating urgent medical visits and addressing the increased need for practical and emotional support). The individual and/or family may notice a preoccupation with distress and anticipatory grief about the unpredictable nature of the course and prognosis.
There is no cure for MS, as noted. Disease modifying therapies are the primary treatment approach. These are geared to reduce inflammatory disease activity and slow worsening disability (Moss, Rensel, & Hersh, 2017). In addition to conventional pharmacologic therapy, there is growing support for psychological intervention as well as interest in the use of lifestyle strategies (e.g., exercise, nutrition, smoking cessation). Complementary and alternative medicines to support wellness and mitigate disease-related complications in MS are also expanding (Moss, Rensel, & Hersh, 2017).
Nature of MS Symptoms
The most common MS-related symptoms are fatigue, pain, sleep disturbance, balance difficulties, and cognitive issues. Many of these symptoms are referred to as “invisible” because they are not readily apparent to others. Some examples of invisible symptoms include vision disturbance, fatigue, weakness, pain, prickly or tingling sensations, heat sensitivity, dizziness, and cognitive difficulties. White et al. (2008) found that the MS-related invisible symptoms of pain and depression were the most significant predictors of heightened distress. A client with such invisible symptoms may be told “but you look so good,” which gives an implicit message that they are not measuring up to expectations.
Fatigue is considered by many to be the most disabling MS symptom (Induruwa, Constantinescu, & Gran, 2012), affecting up to 75% of individuals (Kos et al., 2008). Fatigue can manifest as a manageable difficulty or it can lead to significant disability. Fatigue can impact independence and engagement in meaningful activities, as well as home and work responsibilities. There are successful fatigue management techniques a psychologist can introduce. Such interventions utilize psychoeducation, exercise, relaxation, and energy budgeting. There are also several medications that a neurologist may suggest.
Pain is another prevalent symptom associated with MS, with as many as 65% of people with MS reporting pain or discomfort (Kerns, Kassirer, & Otis, 2002). Pain may be caused directly by the disease acting on the nervous system or indirectly through a functional impairment. Research has established a relationship between pain and depression (Amtmann et al., 2015). This underscores the need to assess and address potential depression. As with fatigue, there are a number of pain management techniques a psychologist can introduce as well as some medical interventions that a neurologist may recommend.
Rates of cognitive impairment have been estimated to range from 40% to 70% (Amato, Zipoli, & Portaccio, 2006; Chiaravalloti & DeLuca, 2008). Cognitive dysfunction in MS was initially thought to be present only in those individuals with severe and obvious physical difficulties. We now know that cognitive deficits may appear at any point of the disease process. There is considerable variability in type and degree of cognitive difficulties. Cognitive difficulties may reflect a magnification of pre-existing weaknesses or a marked change in ability. Not all cognitive problems result directly from the disease process. They may be caused or compounded by stress, depression, fatigue, sleep disturbance, pain, medication side effects, and normal aging. Initial and periodic screening of cognitive functioning is recommended. Grief and acceptance are often closely tied to the client’s level of awareness of cognitive difficulties and their ambivalence about utilizing cognitive compensatory strategies. Cognitive dysfunction can negatively influence the quality of engagement in health interventions, including psychotherapy. For instance, memory problems, such as difficulty retrieving information, can challenge the carryover of information from counseling sessions to daily life. Reduced executive functions—such as poor initiation and problems with prioritizing, problem-solving, and reasoning—can affect treatment-related decision-making.
Mood Disorders in MS
Depression has been reported as the most common psychiatric disorder (Minden & Schiffer, 1990), with lifetime prevalence around 40% to 60% (Caine & Schwid, 2002). Depression is more common in MS than in other chronic illnesses, including other neurologic disorders (Lobentanz et al., 2004). A quarter of clients with MS report suicidal ideation, and the risk of suicide is 5–10 times higher than in the general population (Feinstein, 2002). Given the high incidence of depression in people with MS, it is important to continue to evaluate even if clients do not initially endorse depressive symptoms.
Anxiety is a salient issue in individuals living with MS. In general, those living with MS face anxiety about their current and future functioning and quality of life. Perceptions of increased psychosocial stressors and decreased social support in response to the disease may underly development of a comorbid anxiety disorder (Korostil & Feinstein, 2007). Those who experience relapses were shown to have the highest levels of anxiety compared with those in remission (Kalb, 2007). Anxiety is commonly treated with psychotherapeutic interventions and medication if indicated.
Inter-Relationships of Symptoms
There are often reciprocal and complex inter-relationships between MS-specific symptoms and other symptoms. For instance, insomnia can be secondary to spasticity, pain, or bladder issues. Depression, anxiety, and other negative emotions adversely influence health-related quality of life and work productivity (Glanz et al., 2012). These mood states can magnify problems with fatigue, cognition, adherence to healthcare recommendations, and sexual function and can alter perception of health (Moss, Rensel, & Hersh, 2017). The relationship between psychological disorders and sleep disturbances is bidirectional (Caminero & Bartolomé, 2011)—insomnia can contribute to depression, anxiety, and cognitive difficulties and vice versa. Cognitive dysfunction frequently coexists with depression and pain. Higher pain is associated with worse depressive symptomatology, which suggests the possibility that the presence of one condition amplifies the presence of the other (O’Connor et al., 2008).
Individuals with MS are often faced with adjusting their self-image from invulnerable or healthy to one that includes living with a chronic illness (Werfel, Durán, & Trettin, 2016). Identity issues may include self-doubt, self-criticism, and the loss of one’s sense of self-image, attractiveness, and capabilities. Psychosocial consequences can influence numerous areas of life, with distress related to disruptions to life goals, employment, finances, independence, relationships, and activities of daily living. Social role and relationship difficulties in MS are associated with lack of social support, isolation, and social withdrawal. Therapists can help clients identify changed and/or lost abilities and alternative methods to meet their needs.
Another salient psychosocial issue is the intersectionality of identities. The scope of diversity is broad, including demographic factors such as gender, sexuality, religion, ethnicity, race, education, social class, and age. Each of these can influence how one experiences MS and interacts with healthcare professionals. Those with a chronic, disabling illness often experience marginalization. If they are already a member of another marginalized group, they experience compounding effects.
Culture is just beginning to be recognized as an important part of effective treatment for people living with chronic illnesses and disabilities like MS. An individual’s cultural and familial context can influence all aspects of health, including health beliefs and health behaviors, symptom expression, and sources of social support (Werfel, Durán, & Trettin, 2016). Assessing a client’s religious beliefs may give a better understanding of the conceptualization of diagnosis (see Pargament, 1997, for more detail). Similarly, religion can provide a source of support or strife and influence coping mechanisms.
Stress and MS
Meta-analysis of research on stress and MS documents a relationship between stress and clinical exacerbation (Mohr et al., 2004; Lovera & Reza, 2013). Mohr et al. (2012) argued that a purely causal relationship, in which stressful events alone trigger exacerbation, was unlikely. However, Mohr (2007) found data to suggest that more effective coping strategies may influence the relationship between stress and MS inflammation. In a meta-analysis of stress management interventions for those with MS, most studies indicated positive changes (Reynard, Sullivan, & Rae-Grant, 2014). Stress management is currently considered to be an important component of managing MS.
Living with MS often amplifies the more common stressors of relationships, family, work, or money. The daily and long-term unpredictability of the disease, managing medical appointments and medications, adjusting to increasing or fluctuating disability, and navigating daily life tasks with multiple MS symptoms can become overwhelming. Therefore, a person with MS navigates a double bind—living with MS is stressful, and stress can increase symptoms (Werfel, Durán, & Trettin, 2016).
Two potential stressors are microaggression and microinvalidation. Sue (2010) has expanded his original definition of microaggression to include everyday verbal, nonverbal, and environmental slights, snubs, or insults, whether intentional or unintentional, that communicate hostile, derogatory, or negative messages to target persons based solely on their marginalized group membership. Sue states that the most detrimental forms of microaggression are usually delivered by well-intentioned individuals who are unaware that they have engaged in harmful conduct toward a socially devalued group.
Research indicates that microaggressions have a powerful impact on psychological well-being and affect the standard of living of marginalized groups by creating inequities in health care, education, and employment (Sue, 2010). For example, in Olkin’s study on microaggressions toward people with disabilities, they noted that one of the most frequent microaggressions, the right to equality being denied, is also the most bothersome. They further noted that the most common reported microaggression was someone downplaying the effects of disability on an individual’s life (Olkin, 2017). People with MS who have previously encountered microaggression owing to their ethnicity or sexual orientation may now have an additional stressor of microaggression focused on disability. This life experience can affect every aspect of a person’s effort to achieve wellness.
MS can significantly impact interpersonal relationships. The client may need to become more open with others about the effect of the disease and potential ways MS can affect a relationship. They may, however, want to avoid talking about MS from fear of potentially “burdening” others, out of concern that they will be treated differently than they were prior to discussing their MS, or due to potential risks of disclosure at work. Without open communication, symptoms may be misattributed. For instance, fatigue may be incorrectly identified as laziness or disinterest in the relationship. Alternatively, others may assume that limitations exist when there is actually no evidence to support such a conclusion.
Working Clinically with Individuals with MS
As clinicians, we must be cognizant of the lens through which we view psychological diagnosis for someone with MS. For example, if symptoms are evaluated primarily from the perspective of mental health, fatigue, normative grieving, and loss of identity can be misdiagnosed as depression. Likewise, invisible symptoms can cloud the therapist’s conceptualization of the client. For instance, fatigue or cognitive dysfunction may be misinterpreted as disinterest, resistance, or reduced awareness. We also run the risk of misattributing symptoms of depression, substance abuse, and other mental health diagnoses to MS. The problem is bi-directional, and it must be kept in mind when working with clients with MS.
Another important consideration is the therapist’s own attitude toward disability and chronic illness. Some people with MS are successful professionals and highly valued employees with very full and meaningful lives, while others will experience increasing disability that significantly challenges their quality of life. The therapist will need to be flexible: support clients when they are meeting challenges with strength and creativity and support clients when challenges overwhelm them. A disability-affirmative approach to therapy that focuses on developing a positive disability identity will more likely result in self-empowerment (Olkin, 2017). However, viewing the client as “suffering,” or “inspirational,”—or other concepts that are disempowering and imply that a client is inferior—are common microaggressions that impede a positive therapeutic outcome.
Reitman and Kalb (2012) noted common emotional responses to living with MS that include grief, resentment, guilt, shame, self-blame, fear, distrust, anger, frustration, confusion, and feeling overwhelmed. As a person adjusts to the MS diagnosis or experiences changes in abilities, identity issues may emerge. Given the unpredictable nature of the disease, many individuals face considerable uncertainty and anxiety, leaving them feeling overwhelmed. MS will compound challenges that arrive with each developmental stage. A clinician needs to consider a person’s premorbid functioning, coping mechanisms, level of functioning, MS symptomatology, and normative adjustment process—along with the presenting manifestation of mental health issues.
People with disabilities are at risk of physical, emotional, and financial abuse by caregivers. Independent living skills are impacted by cognitive and physical disabilities. Ongoing assessment and amelioration of safety risks is recommended.
Any form of psychotherapy that involves compassionate listening and support can be helpful to someone living with MS. However, a skillful psychotherapist can offer a great deal of MS-specific support. Both the National Multiple Sclerosis Society and the Consortium of Multiple Sclerosis Centers recognize the importance of comprehensive care for those living with MS, which includes a focus on wellness and the inclusion of numerous professionals on the client’s treatment team. People living with MS will encounter normative challenges and successes with life, work, and family, so the focus of therapy will not always be on MS.
People with MS typically see their neurologist every 3–12 months. The role of the psychologist will include assisting clients with problem-solving and advocating within the healthcare system, reducing anxiety about medication choices and side effects, addressing other psychological sequelae of the disorder, increasing resources, solidifying trust in the treatment team, and coordinating and maintaining a viable healthcare team.
Psychotherapy sessions may focus on health and wellness, clinical concerns, and/or safety issues (Werfel, Durán, & Trettin, 2016). This incorporates addressing the MS diagnosis, building resilience and ability to self-manage, increasing support networks, managing symptoms, exploring the intersection of disability identity with other identities, and developing a wellness plan. In addition, sessions will often focus on processing grief, assessing and treating depression and anxiety, evaluating and increasing coping skills, resolving premorbid trauma, adaptation, and addressing family issues.
Research with CID (Chronic Illness and Disability) indicates that the self-management model is effective for increasing self-efficacy, improving health status, and decreasing pain (Meade & Cronin, 2012). Self-management refers to the ability of individuals to manage their health and its physical and psychosocial consequences. However, not all clients will have the ability to self-manage. For example, clients with chronic pain and/or cognitive challenges may have difficulty with self-management and therefore rely more on professionals and/or supportive others to assist with management of symptoms. A self-management model incorporates psychoeducation, skill building, problem-solving, communication, and relaxation. Self-management is associated with perceived control. Bishop, Frain, & Tschopp (2008) found that both perceived control and self-management can mediate the impact of MS on quality of life. A self-management scale for MS has been developed (Bishop & Frain, 2011).
Starting the Therapeutic Relationship
When initiating treatment with a client with MS, the psychologist can start by jointly assessing the client’s therapeutic needs and safety risk and introducing the concept of self-management. The psychologist should assess a client’s knowledge of MS and ability (and readiness) to self-manage, address symptoms with the treating neurologist, and self-educate through reliable resources such as the National MS Society.
Reported MS symptoms should be evaluated based on their impact on quality of life and the client’s emotional reaction to such symptoms. The psychologist should reassure the client that psychotherapeutic techniques and/or medical interventions can be utilized in managing symptoms such as pain, fatigue, stress, and depression and/or anxiety. If the client and psychologist are from differing ethnicities, the client’s comfort level with working with the psychologist should be discussed. Even if a client does not recognize this as issue, future discussion should be invited by acknowledging that differences in ethnicity or privilege might influence the therapeutic relationship. It is important that both the client and the therapist feel comfortable bringing up this and other issues that could compromise the work.
The psychologist should discuss the client’s healthcare plan. Is the client comfortable with and confident in their neurologist? Are they tolerating the medication, infusions, or injections well? What additional healthcare referrals have been made and are any lacking? For example, referrals to a physical therapist for mobility challenges or fatigue management or a neuropsychologist for cognitive issues and depression risk may not have been made by the treating physician. MS affects the whole family, so family sessions may be recommended.
Pain and stress levels, depression, and anxiety should be routinely evaluated for their impact on daily living and quality of life. There are many interventions for the management of stress, anxiety, fatigue, and physical discomfort that could be introduced during the course of therapy and utilized between sessions (e.g., CBT, simple breathing exercises, hypnosis, imagery, Somatic Experiencing, mindful meditation).
If the client is willing and able, the psychologist can introduce assignments such as experimenting with symptom management techniques at home and beginning a log of activities, symptoms, stress, pain and fatigue levels, sleep, exercise, and eating habits. Tracking symptoms and behavior allows clients to provide better reports to their neurologists and notice patterns that might help with self-management. Attitudes toward disability, health, and healing should be explored. This included religious, cultural, and familial beliefs.
If a client is challenged with fatigue, psychoeducation about time usage and energy budgeting can help with management. It may be necessary for a client to reduce household, work, or social responsibilities. Adjusting, coping, and strategizing how to discuss this at work and with adult and child family members will often be a therapy focus. Children need to be educated about changes in the parent’s behavior so that it is not perceived as disinterest or withdrawal. New self-care activities can be incorporated into family routines. For example, the parent can invite children to listen along to relaxation recordings. Other low-energy activities can also be incorporated into the daily or weekly routine, if needed, so that family interaction time is not decreased.
Ongoing evaluation of a client’s coping mechanisms, wellness behaviors, and quality of life is recommended. In addition to cognitive and affective symptoms that can be related to disease progression, affective responses to the diagnosis itself should be assessed, as well as responses to the onset of new symptoms or medical procedures. The impact of such symptoms and their management on activities of daily living should be assessed and monitored. If there is progression, the client’s identification as a person with increasing levels of disability should be addressed, along with any financial issues associated with disease progression. For those with a trauma history, medical visits and procedures can elicit re-traumatization, which will also need to be processed. A form of sabotage is also expected and can occur when a client is disheartened by increasing symptoms or during periods when the client reports “feeling good” but is burned out on doctor’s appointments and wellness activities. This is a time to evaluate wellness or treatment plans.
Neuropsychological Assessment and Consultation
Evaluation by a neuropsychologist with specific experience in working with MS is recommended for individuals who report cognitive difficulties. Initial and periodic cognitive assessment can be used as a baseline screening, to assess for treatment effects, to evaluate progression of cognitive impairment, and/or to screen for new onset of cognitive problems (Kalb et al., 2018). An evaluation is particularly recommended when the client questions their capacity to maintain employment or requires workplace accommodation, as well as when they apply for disability due to cognitive impairment. The differential diagnosis of a mood disorder, stress, fatigue, sleep disorder, and a consideration of pre-existing learning difficulties or attention deficit disorders versus MS-related cognitive impairment can clarify treatment goals and inform the psychotherapist about contributing factors that can impede the therapeutic process.
A neuropsychological evaluation will systematically examine cognitive function, mood, and behavior in the context of all interacting health, social, and psychological factors. It will, of course, include in-depth assessment of affective disorders (e.g., depression, hypomania/mania, anxiety), pseudobulbar affect syndrome (marked by mood lability and affective expressions that do not correspond with underlying mood), and neurobehavioral symptoms (e.g., reduced insight, agitation). Suicide risk assessment is highly recommended. Exploration of fatigue, psychomotor retardation, decreased concentration, and insomnia are center to differentiating the overlapping symptoms of clinical depression and MS itself.
Standardized neuropsychological measures will be used to quantify and measure specific cognitive functions. The most commonly affected cognitive domains in MS include information processing speed and the acquisition phase of memory (Rao et al., 1991). Other frequently reported cognitive difficulties may include attention difficulties, problems with multitasking, word-finding problems, visuospatial perception difficulties, and reduced executive functions, such as organization, planning, problem-solving, and initiation difficulties (Chiaravalloti & DeLuca, 2008). Some clients may report difficulty keeping up with the flow of conversation, the details of which need to be assessed (e.g., hearing problem or reduced processing speed).
Compassionate discussion between the neuropsychologist and the client/family regarding their concerns about changes in cognition, mood, and behavior can engender awareness of potential contributing factors and inform a plan to improve functioning. The neuropsychologist can also assist the client/family in identifying resources within the community that may be beneficial, such as cognitive and adaptive rehabilitation therapies, job accommodation resources, and MS-related organizations (e.g., National MS Society and Can Do Multiple Sclerosis) that provide education and support.
There can be an emotional risk associated with neuropsychological assessment for some clients. The findings may document areas of neurocognitive and/or neurobehavioral difficulty that can trigger a client’s worry and apprehension about the future. A grief reaction can be experienced given that maintaining one’s autonomy and identity can potentially be challenged when deficits are uncovered. However, even subtle cognitive changes and/or neurobehavioral symptoms that are not clearly identified and addressed can result in lowered self-evaluation, insecurity, heightened distress, and misattribution (e.g., mislabeling attention problems for disinterest).
The client must be empowered to be an active participant in the assessment through the open sharing of thoughts and impressions; a relationship that views the client as an active partner throughout the entire process of interviewing, testing, and feedback. The neuropsychologist must be mindful of the client’s emotional experience and provide feedback in a manner that does not overwhelm the person with information or diminish their coping abilities (Pepping & Ehde, 2005). In addition, either referral to a mental health provider or feedback to a treating mental health provider can help the client process the emotional reaction.
The neuropsychological evaluation can provide useful information to the client, their family, and the therapist. The assessment can help individuals identify and capitalize on their strengths and address vulnerabilities. Such evaluation can provide clues for clarifying needed treatment goals. The results can be used to guide interventions to support and maximize overall functioning. Findings may clarify whether reduced engagement in self-management is related to diminished motivation, a byproduct of depression, the interference of pain on daily functioning, and/or cognitive dysfunction. The neuropsychologist can provide recommendations for cognitive compensatory strategies, determine if the client is an appropriate candidate for cognitive rehabilitation, and share fatigue management strategies. These strategies can be incorporated into psychotherapy sessions.
Psychotherapy can provide further processing of emotions and problem-solving surrounding topics initially explored and discussed by the neuropsychologist with the client (and possibly the family). These topics may include changing roles within the family, communication in relationships, and whether or not the client should disclose their cognitive difficulties to employers (as well as requests for formal workplace modifications, or informal suggestions to improve work performance such as requesting an email follow-up of minutes from a meeting).
The neuropsychological consultation can also provide strategies that the mental health provider may use in session, such as speaking in shorter sentences, asking clarifying questions to ensure that information has been processed accurately, and reiterating the main points of a session. It is often helpful to encourage the client to take notes on session themes and assignments in a journal.
Key Points to Remember When Working with Individuals with MS
Routinely assess and address stress and anxiety that can result from living with the unpredictability of MS symptoms.
Collaborate on strategies to manage invisible symptoms (e.g., depression, fatigue, pain, cognitive dysfunction) and explore disclosure in personal and workplace relationships.
Provide strength-based interventions that support self-management, self-advocacy, and autonomy.
Support the client in developing a comprehensive healthcare team, which requires referrals and collaboration between the psychotherapist and the treating physicians.
Refer to a neuropsychologist when the client reports cognitive challenges or you (as the treating psychotherapist) have concerns that cognitive difficulties are impacting psychotherapy and other areas of a client’s life.
Consider and explore the challenges that individuals with a disability and chronic illness face in an able-bodied dominant society, including common microaggressions that increase stress.
Be mindful of your own attitudes toward disability and chronic illness (and self-care needs).
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