Jo is a 23-year-old undergraduate student. She is very sociable and admits to enjoying a drink fairly frequently. Six months ago she got involved in a “scuffle” while out and ended up in her local A&E department. While there she had a blood test which showed abnormal liver function. Follow up tests revealed she had cirrhosis but with only a small part of the liver affected at present.
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Consequently, Jo has been advised to quit drinking completely and has been referred to her local community alcohol team. However, she has not attended any sessions with them. She did go to one session with the AA which she found out about on the Web but did not return as she felt the people attending were so unlike her – “I’m not an alcoholic”.
Recently, Jo has been to see her GP and said that, as her condition is so mild, and is not causing her any problems at present, she doesn’t see why she should totally give up drinking. She claims to have reduced her drinking slightly – going out only 4 nights a week and reducing the alcohol she drinks at home, and believes that this is enough. She admits to not telling any of her family or friends about her diagnosis. Her GP has now referred her to her local psychology service to see if “you can make her see sense”. How might a health psychologist go about helping Jo?
Issues
Jo has been diagnosed with having cirrhosis of the liver and has been advised by her GP to stop drinking alcohol. During early stages of cirrhosis there can be very few symptoms (Wright, 2009), and Jo does not seem to have experienced any physical aggravation that would indicate problems with her liver function. Therefore her diagnosis initially seemed inconceivable for Jo to comprehend. After a chronic disease is diagnosed, patients can be in a state of crisis and psychological disequilibrium (Taylor, 2006). Moos and Schaefer (1984, cited in Bennet, 2000) suggested that following a diagnosis of a chronic illness an individual can feel that their future plans, social identity and support network is threatened. She has decided not to tell her friends or family, and is avoiding the implication of her health through denial (Taylor, 2006) until she is more accustomed to the diagnosis.
After prolonged inflammation of the liver due to excessive alcohol abuse Jo has cirrhosis on the liver. This is when normal healthy liver cells are damaged and replaced by scar tissue, reducing the number of cells remaining to perform its many important functions (Wright, 2009). Cirrhosis is the final stage of alcoholic liver disease, which is an incurable, progressive and potentially fatal (Wright, 2009). Alcoholic cirrhosis is a multi-factorial disease and is not only a result of high dependency to alcohol (alcoholism) (Addolorato et al, 2009; Day, 2009). Research have found a low dependency of alcohol in patients with cirrhosis (Smith, 2006 cited in Addolorato et al, 2009), and it is known that gender, genetic and nutritional factors can influence the disease progression to cirrhosis (Addolorato et al, 2009). Therefore alcoholic cirrhosis could develop in susceptible individuals whose life style of heavy alcohol abuse has predisposed them to their illness. Jo’s dependency to alcohol will be established and considered throughout her treatment process, as this could affect the length and stringency of the treatment approach to achieve the best response (Kadden, 1998).
Due to the progressive nature of liver cirrhosis in is imperative that Jo eliminates her alcohol intake, as this would worsen her condition (Wright, 2009). The ability to maintain abstinence from alcohol requires a change in lifestyle, accepting the responsibility of one’s actions and being aware of the consequences of drinking behaviour (Farid, Clark & Williams, 1997). Once Jo establishes this belief and takes responsibility that her behaviour influences her health, she will hold an internal locus of control (Farid et al, 1997). However currently believing that she has reduced her alcohol consumption to an adequate level, and doesn’t believe her behaviour has an influence on her health status, she currently ender an external locus of control. Without acknowledgment of this link to her health, Jo might lack the motivation to stop drinking (Farid et al,1997). To alter and educate Jo’s current beliefs the information and advice given will need to match the appropriateness for her needs (Brunt, 1993).
After her diagnosis Jo could be feeling a great deal of anxiety, fear and uncertainty (Berry, 2003), which would make the processing of advice and treatment information difficult. There is a danger that the individual can be left uneducated, which then adversely affects her coping methods and adherence to treatment (Silverman, 2005). Careful consideration must be made to their treatment of individuals who suffer from alcohol related illness as they tend to differ in their ability to function due to depression (Bianchi et al, 2005), raised anxiety (Bolden, 2009; Kim et al, 2005) and fatigue (Blackburn et al, 2007; Sogolow et al, 2007). There are also multiple psychological factors that contribute to this difference such as elevated levels of stress, inadequate coping mechanisms and reinforcement of alcohol use from other drinkers (Bolden, 2009; Bianchi, 2005; Constant, 2005). Psychological support could help Jo overcome any avoidant coping style and associated psychological distress preventing adverse response to illness (Taylor, 2006). As this could have a detrimental effect on the progression of liver disease (Jin-Cai & Xu-Ru, 2002) and act as a predictor for depression (Bianchi, 2005).
Majority of the side effects for cirrhosis are treatable with adequate medical management of the patients affected by alcoholic cirrhosis (Addolorato, 2009). Despite damage to the liver, the liver can still perform some of its functions. Jo currently only has a small part of her liver affected and complete abstinence of alcohol is the only way to prevent further damage that could lead to the gradual recovery of liver function (Addolorato, 2009). However it is likely that end-stage liver failure will result in the patient being assessed for a liver transplant (Georgiou, 2003). Therefore, it is imperative that Jo has documented evidence of the length of time she has been abstinence from alcohol, has sound psychological wellbeing and a strong support network, imperative whilst on the waiting list for a replacement liver (Georgiou, 2003; Pereia, 2000) all in which are considered to reduce the risk of relapse both before and after the liver transplantation.
A health psychologist can help Jo to employ effective strategies into different aspects of her life to prevent further alcoholic liver damage. Her current psychological wellbeing will be considered as she is adapting to various lifestyle changes, and therefore psychological intervention will help avoid or reduce psychological suffering (Blackburn, 2007; Kim, 2005). A health psychologist will educate Jo to tackle her current beliefs and develop effective coping mechanisms (Taylor, 2006). Having a wider support network would greatly benefit her treatment process (Georgiou, 2003), which would require her to involve family and friends for extra social support. Together with suitable nutritional advice (Merli et al, 2009) and exercise programme (Petrides et al, 1997) could reduce the effect of liver cirrhosis and could lead to the gradual recovery of liver function.
Intervention
From the start of the intervention it is important that Jo feels like she is being treated like an individual and that her health psychologist understands the impact of having diagnosed with liver cirrhosis will have on her life (Kadden, 1995), and that they may feel that their identity will be defined by their disability (Charmaz, 1995). A good patient-doctor relationship is important for the adherence and success of the intervention (Kadden, 1995). To establish a good rapport Jo’s health psychologist must display empathy and belief with good interpersonal skills (Kadden, 1996). He or she must be familiar with the material and function as an active teacher to import the skills successfully (Kadden, 1995). To further strengthen a positive patient-doctor relationship Jo must be encouraged to be involved in the decision-making of her treatment, as this could increase the likelihood of Jo being motivated to comply (Longabaugh, 1999).
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Jo will complete a Patient Knowledge Questionnaire (PKQ) to assess the knowledge of her disease, and also a CAGE screening test for alcohol dependence (Kadden, 1995), which will set a guide line for the health psychologist of the problems being addressed. Her current beliefs and perceptions of how her illness will affect her life can be further be explored by using open-ended questions (Kadden, 1995). Together with constant emotional support (Kadden, 1995) would improve her psychological wellbeing. Once Jo’s beliefs have been established, meaningful information can be given and educational programs can be incorporated. Jo requires learning necessary skills to change her problem behaviour, for this reason the information should be given alongside cognitive behavioural therapy (CBT), which views alcohol abuse as a learned behaviour which can be reversed (Lonabaugh & Morgenstern, 1999).
Jo will need to be aware that any negative feelings towards the diagnosis are normal and reassured that following the intervention she will learn adequate coping skills that will help her take control of her illness (Taylor, 2006). The first part will gain acceptance of the purpose, content and plan of the therapy. Information will be presented about the severity of her liver disease, and abstinence of alcohol clearly identified as the desired goal. The patient should elect a person (family member, friend) willing to act as a source of support. A motivational interviewing style should be used to throughout to promote self-efficiency and better understanding in a nonthreatening fashion (Georgiou et al, 2003). Secondly it is important to identify and develop sufficient coping skills and plan how they can occupy their time with social activities that do not involve alcohol. Potential high-risk situations for drinking will have been identified, and the third part of the therapy would require the individual to identify how they will avoid and cope with relapse.
Jo’s psychologist should use the PKQ and CAGE results as a guideline to predict the length and stringency of the treatment (3-12 weeks), depending on level of alcohol dependence (Kadden, 1995), which should be constantly reviewed. Jo has shown positive response to cope with her diagnosis by looking for support on the internet. This provides support for the CBT approach as the success of this therapy will require active participation from the patient (Kadden, 1995). Jo did not enjoy the AA meeting she attended, and may have had difficulty comprehending their belief that an individual is unable to alter their drinking behaviour without the aid of religious intervention (Longabaugh & Morgenstern, 1999). This would provide further support for the CBT approach having an underlying assumption that it is within the individual’s power to change (Longabough & Morgenstern, 1999). Attendances to alternative support group will be encouraged as researches have associated this with positive drinking outcomes (Longabough, 1999). Jo might benefit from a group who share the underlying assumption that alcohol is learned maladaptive behaviour that they can change (SMART cited in Longabough, 1999).
Total alcohol abstinence represents the most effective strategy for alcoholic patients affected by cirrhosis (Tilg & Day, 2007 cited in Addolorato, 2009). Even low doses of daily alcohol intake are associated with increased risk of cirrhosis. Continuing alcohol abuse can lead to compilations such as hepatocellular carcinoma (Addolorato, 2009). Consequently, achieving total alcohol abstinence should be the main aim in the management of Jo’s liver cirrhosis. This could become complex if Jo is diagnosed with alcohol dependence (Sussman, 2004). Medical recommendations and/or brief interventions may not be sufficient to achieve and maintain alcohol abstinence when a diagnosis of dependence is present. There may be a need to add pharmacological approaches, like naltrexone, acamproste and bacolfen which have been shown to reduce alcohol craving and intake (Addolorato, 2009), to prevent relapse and further damaging Jo’s liver.
Malnutrition is frequently present in cirrhotic patients, and considered to be a predictive factor for increased morbidity and mortality (Merli et al, 2009). Exercise and nutritional intervention could improve and prevent inter-related conditions such as obesity, diabetes and insulin resistance (Catalano, 2008), which may worsen her condition. Good nutrition has been shown to improve liver regeneration, recommending an intake of about 2000 calories per day to correct deficiencies and promote hepatic repair (Addolorato, 2009). It is generally assumed that patients with chronic liver disease should be encouraged to engage in exercise, as this will maintain or improve their physical well-being. This could have beneficial effects on body composition, muscle strength (Andersen et al, 1998) and glucose tolerance (Petrides, 1996) and may reduce symptoms of depression (Rot et al, 2009) and fatigue (Blackburn, 2007; Sogolow, 2008). However strenuous exercise is not recommended as this might increase risk of internal bleeding (Petrides, 1996). There aren’t many researches available on the long-term functional outcome of nutritional and physical well being, however malnutrition (Merli, 2009), depression (Bianchi, 2005) and fatigue (Blackburn, 2007) have been shown to increases complications in liver disease.
In conclusion forming a good report with the health professional throughout the sessions will promote the underlying success of the intervention. Jo’s determinants and high risk situations that are likely to lead to alcohol will be assessed. It is important to incorporate healthy interests to her lifestyle and involve her friends and family throughout the cognitive behavioural treatment, where Jo will learn the necessary coping-skills to unlearn old habits associated with alcohol abuse. She should receive psychological support counselling for a long as required and be encouraged to maintain nutritional and physical well-being, which will overall reduce disability and psychological distress.
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