MEDICAL CONDITION

BEHAVIORAL DEFINITIONS

1. A diagnosis of a chronic illness that is not life-threatening but necessitates changes in living.
2. A diagnosis of an acute, serious illness that is life-threatening.
3. A diagnosis of a chronic illness that eventually will lead to an early death.
4. Sad affect, social withdrawal, anxiety, loss of interest in activities, and low energy.
5. Suicidal ideation.
6. Denial of the seriousness of the medical condition.
7. Refusal to cooperate with recommended medical treatments.

LONG-TERM GOALS

1. Accept the illness and adapt life to necessary changes.
2. Resolve emotional crisis and face terminal illness's implications.
3. Work through the grieving process and face the reality of own death with peace.
4. Accept emotional support from those who care without pushing them away in anger.
5. Resolve depression, fear, and anxiety, finding peace of mind despite the illness.
6. Live life to the fullest extent possible even though time may be limited.
7. Cooperate with the medical treatment regimen without passive-aggressive or active resistance.
SHORT-TERM OBJECTIVES THERAPEUTIC INTERVENTIONS
1. Describe history, symptoms, and treatment of the medical condition. (1, 2, 3) 1. Establish rapport and a working alliance with the client and parents using appropriate process skills (e.g., active listening, reflective empathy, support, and instillation of hope).
2. Gather a history of the facts regarding the client's medical condition, including symptoms, treatment, and prognosis; assess the emotional, cognitive, and behavioral impact of the medical condition.
3. With informed consent and appropriate releases, contact the treating physician and family members for additional medical information regarding the client's diagnosis, treatment, and prognosis.
2. Disclose any history of substance use that may contribute to and complicate the treatment of the medical condition. (4) 4. Arrange for a substance abuse evaluation and refer the client for treatment if the evaluation recommends it.
3. Provide behavioral, emotional and attitudinal information toward an assessment of specifiers relevant to a DSM diagnosis, the efficacy of treatment, and the nature of the therapy relationship. (5, 6, 7, 8, 9) 5. Assess the client's level of insight (syntonic versus dystonic) toward the “presenting problems” (e.g., demonstrates good insight into the problematic nature of the “described behavior,” agrees with others' concern, and is motivated to work on change; demonstrates ambivalence regarding the “problem described” and is reluctant to address the issue as a concern; or demonstrates resistance regarding acknowledgment of the “problem described,” is not concerned, and has no motivation to change).
6. Assess the client for evidence of research-based correlated disorders (e.g., oppositional defiant behavior with ADHD, depression secondary to an anxiety disorder) including vulnerability to suicide, if appropriate (e.g., increased suicide risk when comorbid depression is evident).
7. Assess for any issues of age, gender, or culture that could help explain the client's currently defined “problem behavior” and factors that could offer a better understanding of the client's behavior.
8. Assess for the severity of the level of impairment to the client's functioning to determine appropriate level of care (e.g., the behavior noted creates mild, moderate, severe, or very severe impairment in social, relational, vocational, or occupational endeavors); continuously assess this severity of impairment as well as the efficacy of treatment (e.g., the client no longer demonstrates severe impairment but the presenting problem now is causing mild or moderate impairment).
9. Assess the client's home, school, and community for pathogenic care (e.g., persistent disregard for the child's emotional needs or physical needs, repeated changes in primary caregivers, limited opportunities for stable attachments, persistent harsh punishment, or other grossly inept parenting).
image4. Verbalize an understanding of the medical condition, its consequences, and effective cognitive behavioral coping. (10) 10. Encourage and facilitate the client and parents in learning about the medical condition, cognitive behavioral factors that facilitate or interfere with effective coping and symptom reduction, the realistic course of the illness, pain management options, and chance for recovery (see Chronic Illness in Children and Adolescents by Brown, Daly, and Rickel; Psychological Interventions in Childhood Chronic Illness by Drotar).image
image5. Comply with the medication regimen and necessary medical procedures, reporting any side effects or problems to physicians or therapists. (11, 12, 13) 11. Monitor and reinforce the client's compliance with the medical treatment regimen.image
12. Explore and address the client's misconceptions, fears, and situational factors that interfere with medical treatment compliance (or assign “Attitudes About Medication or Medical Treatment” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
13. Therapeutically confront any manipulation, passive-aggressive, and denial mechanisms that interfere with the client's compliance with the medical treatment regimen.image
image6. Adjust sleep hours to those typical of the developmental stage. (14) 14. Assess and monitor the client's sleep patterns and sleep hygiene; intervene accordingly to promote good sleep hygiene and sleep cycle (or assign “Sleep Pattern Record” in the Adult Psychotherapy Homework Planner by Jongsma).image
image7. Eat nutritional meals regularly. (15) 15. Assess the teen's eating habits and intervene accordingly to plan and establish a well-balanced and nutritious eating schedule.image
image8. Share feelings triggered by the knowledge of the medical condition and its consequences. (16) 16. Assist the client in identifying, sorting through, and verbalizing the various feelings and stresses generated by his/her medical condition (or assign “Coping With Your Illness” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
image9. Verbalize acceptance of the reality of the medical condition and its consequences while decreasing denial. (17, 18) 17. Gently confront the client's denial of the seriousness of his/her condition and of the need for compliance with medical treatment procedures.image
18. Reinforce the client's acceptance of his/her medical condition.image
image10. Share fearful or depressed feelings regarding the medical condition and develop a plan for addressing them. (19, 20, 21) 19. Explore and process the client's fears associated with deterioration of physical health, death, and dying.image
20. Normalize the client's feelings of grief, sadness, or anxiety associated with his/her medical condition; encourage verbal expression of these emotions.image
21. Assess the client for and treat his/her depression and anxiety using relevant cognitive, physiological, and/or behavioral aspects of treatments for those conditions (see the Unipolar Depression and Anxiety chapters in this Planner).image
image11. Family members share with each other the feelings that are triggered by the client's medical condition. (22) 22. Meet with family members to facilitate their clarifying and sharing possible feelings of guilt, anger, helplessness, and/or sibling attention jealousy associated with the client's medical condition (or assign “Coping With a Sibling's Health Problems” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
image12. Family members share any conflicts that have developed between them. (23, 24, 25) 23. Explore how each parent is dealing with the stress related to the client's illness and whether conflicts have developed between the parents because of differing response styles.image
24. Assess family conflicts using a conflict resolution approach to addressing them.image
25. Facilitate a spirit of tolerance for individual difference in each person's internal resources and response styles in the face of threat.image
image13. Family members verbalize an understanding of the power of one's own personal positive presence with the sick child. (26) 26. Stress the healing power in the family's constant presence with the ill child and emphasize that there is strong healing potential in creating a warm, caring, supportive, positive environment for the child.image
image14. Identify and grieve the losses or limitations that have been experienced due to the medical condition. (27, 28, 29, 30) 27. Ask the client to list his/her perception of changes, losses, or limitations that have resulted from the medical condition (or assign “Coping With Your Illness” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
28. Educate the client on the stages of the grieving process and answer any questions (or suggest that the teen read Good Grief by Westberg).image
29. Suggest that the client's parents read a book on grief and loss (e.g., Good Grief by Westberg; How Can It Be All Right When Everything Is All Wrong? by Smedes; When Bad Things Happen to Good People by Kushner; or Teen Grief Relief: Parenting with Understanding, Support, and Guidance by Horsley and Horsley) to help them understand and support their teenager in the grieving process.image
30. Assign the client to keep a daily grief journal to be shared in therapy sessions.image
image15. Parents implement consistent positive parenting practices to facilitate adaptive responding of child to the medical condition. (31) 31. Assess the parents' understanding and use of positive reinforcement principles in child-rearing practices; if necessary, teach the parents operant-based child management techniques (see the Parenting chapter in this Planner).image
image16. Identify and replace negative self-talk and catastrophizing that is associated with the medical condition. (32, 33) 32. Assist the client in identifying the cognitive distortions and negative automatic thoughts that contribute to his/her negative attitude and hopeless feelings associated with the medical condition (or assign “Bad Thoughts Lead to Depressed Feelings” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
33. Generate with the client a list of positive, realistic self-talk that can replace cognitive distortions and catastrophizing regarding his/her medical condition and its treatment (or assign “Replacing Fears With Positive Messages” in the Adult Psychotherapy Home- work Planner by Jongsma).image
image17. Decrease time spent focused on the negative aspects of the medical condition. (34, 35) 34. Suggest that the client set aside a specific time-limited period each day to focus on mourning the medical condition; after the time period is up, have the client resume regular daily activities with agreement to put off thoughts until next scheduled time (or assign “Worry Time” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis).image
35. Challenge the client to focus his/her thoughts on the positive aspects of his/her life and time remaining, rather than on the losses associated with his/her medical condition; reinforce instances of such a positive focus.image
image18. Learn and implement calming skills to reduce overall tension and moments of increased anxiety, tension, or arousal. (36, 37, 38) 36. Teach the client cognitive and somatic calming skills (e.g., calming breathing; cognitive distancing, decatastrophizing, distraction; progressive muscle relaxation; guided imagery); rehearse with the client how to apply these skills to his/her daily life (or assign “Progressive Muscle Relaxation” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); review and reinforce success while providing corrective feedback toward consistent implementation.image
37. Utilize electromyography (EMG) biofeedback to monitor, increase, and reinforce the client's depth of relaxation.image
38. Assign the client and/or parents to read and discuss progressive muscle relaxation and other anxiety coping strategies in relevant books or treatment manuals (e.g., The Relaxation and Stress Reduction Workbook by Davis, Robbins-Eshelman, and McKay; or The C.A.T. Project Workbook for the Cognitive Behavioral Treatment of Anxious Adolescents by Kendall et al.).image
image19. Parents and child learn and implement personal and interpersonal skills for resolving conflicts effectively. (39) 39. Teach the client and parents tailored, age-appropriate personal and interpersonal skills including problem-solving skills (e.g., specifying problem, generating options, listing pros and cons of each option, selecting an option, implementation, and refining), and conflict resolution skills (e.g., empathy, active listening, “I messages,” respectful communication, assertiveness without aggression, compromise) to improve personal and interpersonal functioning; use behavioral skills-building techniques (e.g., modeling, role-playing, and behavior rehearsal, corrective feedback) to develop skills and work through several current conflicts.image
image20. Engage in social, productive, and recreational activities that are possible despite the medical condition. (40, 41, 42, 43) 40. Sort out with the client activities that can still be enjoyed alone and with others.image
41. Assess the effects of the medical condition on the client's social network; facilitate the social support available through the client's family and friends.image
42. Solicit a commitment from the client to increase his/her activity level by engaging in enjoyable and challenging activities (or assign “Show Your Strengths” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); reinforce such engagement.image
43. Engage the client in “behavioral activation” by scheduling activities that have a high likelihood for pleasure and mastery, are worthwhile to the client, and/or make him/her feel good about self; use behavioral techniques (e.g., modeling, role-playing, role reversal, rehearsal, and corrective feedback) as needed, to assist adoption in the client's daily life (or assign “Home, School, and Community Activities I Enjoyed” in the Adolescent Psychotherapy Homework Planner by Jongsma, Peterson, and McInnis); reinforce advances.image
image21. Establish a regular exercise schedule. (44) 44. Develop and encourage a routine of physical exercise for the client.image
image22. Learn and implement relapse prevention skills. (45) 45. Build the client's relapse prevention skills by helping him/her identify early warning signs of relapse into negative thoughts, feelings, and actions; reviewing skills learned during therapy; and developing a plan for managing challenges.image
23. Attend a support group of others diagnosed with a similar illness, if desired. (46) 46. Refer the client to a support group of others living with a similar medical condition.
24. Parents and family members attend a support group, if desired. (47) 47. Refer family members to a community-based support group associated with the client's medical condition.
25. Client and family identify the sources of emotional support that have been beneficial and additional sources that could be sought. (48, 49) 48. Probe and evaluate the client's, siblings', and parents' sources of emotional support.
49. Encourage the parents and siblings to reach out for support from each other, church leaders, extended family, hospital social services, community support groups, and personal religious beliefs.
26. Implement faith-based activities as a source of comfort and hope. (50, 51) 50. Draw out the parents' unspoken fears about the client's possible death; empathize with their panic, helplessness, frustration, and anxiety; reassure them of their God's presence as the giver and supporter of life.
51. Encourage the client to rely upon his/her spiritual faith promises, activities (e.g., prayer, meditation, worship, music), and fellowship as sources of support and peace of mind.

image indicates that the Objective/Intervention is consistent with those found in evidence-based treatments.

DIAGNOSTIC SUGGESTIONS

Using DSM-IV/ICD-9-CM:

Axis I: 316 Psychological Symptoms Affecting (Axis III Disorder)
309.0 Adjustment Disorder With Depressed Mood
309.24 Adjustment Disorder With Anxiety
309.28 Adjustment Disorder With Mixed Anxiety and Depressed Mood
309.3 Adjustment Disorder With Disturbance of Conduct
309.4 Adjustment Disorder With Mixed Disturbance of Emotions and Conduct
296.xx Major Depressive Disorder
311 Depressive Disorder NOS
300.02 Generalized Anxiety Disorder
300.00 Anxiety Disorder NOS
Axis II: V71.09 No Diagnosis

Using DSM-5/ICD-9-CM/ICD-10-CM:

ICD-9-CM ICD-10-CM DSM-5 Disorder, Condition, or Problem
316 F54 Psychological Factors Affecting Other Medical Conditions
309.0 F43.21 Adjustment Disorder, With Depressed Mood
309.24 F43.22 Adjustment Disorder, With Anxiety
309.28 F43.23 Adjustment Disorder, With Mixed Anxiety and Depressed Mood
309.3 F43.24 Adjustment Disorder, With Disturbance of Conduct
309.4 F43.25 Adjustment Disorder, With Mixed Disturbance of Emotions and Conduct
296.xx F32.x Major Depressive Disorder, Single Episode
296.xx F33.x Major Depressive Disorder, Recurrent Episode
311 F32.9 Unspecified Depressive Disorder
311 F32.8 Other Specified Depressive Disorder
300.02 F41.1 Generalized Anxiety Disorder
300.09 F41.8 Other Specified Anxiety Disorder
300.00 F41.9 Unspecified Anxiety Disorder

Note: The ICD-9-CM codes are to be used for coding purposes in the United States through September 30, 2014. ICD-10-CM codes are to be used starting October 1, 2014. Some ICD-9-CM codes are associated with more than one ICD-10-CM and DSM-5 disorder, condition, or problem. In addition, some ICD-9-CM disorders have been discontinued, resulting in multiple ICD-9-CM codes being replaced by one ICD-10-CM code. Some discontinued ICD-9-CM codes are not listed in this table. See Diagnostic and Statistical Manual of Mental Disorders (2013) for details.