patient counselling case study

Case Examples

patient counselling case study

I would not exchange or trade the honor and privilege I have had helping individuals, couples and families since 1987. Along this journey, I experienced many situations of success and seeing people grow and share their positive outcomes.

Below you will find a sample of cases where a client has given me permission to share their experience. Identifying information has been changed to protect confidentiality.

Dr. Chen is a good therapist.  He has helped me clarify perceptions that have blocked my growth and development.  I have been able to resolve the feelings that have grown from the misperceptions.  In counseling, I have learned new attitudes and language to help improve my marriage and family relationships.  The barriers I have built up over the years are being removed.  This process takes a long time, but I think it has moved at an appropriate pace.  Other counselors have taken much longer to help me even begin the healing process.  I have made great progress while working with Dr. Chen.

Dear Dr. Chen,

I am writing to express my appreciation for your knowledge and understanding in helping us deal with our teenager’s issues. We were very distraught when we learned about our child’s problems. As with any parent, we were concerned for our child and feared for the worst. We didn’t know what to expect or how to help our child.

Your extensive knowledge and expertise helped us understand what was going on and provided comfort and reassurance. Your expertise and ability to relate to our situation helped us get through a very difficult time.

Thank you for the competence and calm demeanor you displayed as you helped reassure us during this critical time. I firmly believe that others facing similar problems would greatly benefit from your services.

Thanks again, Bruce L.

After suffering with trichotillomania for 15 years, I felt trapped by my constant urges to pull my hair.  3 weeks after seeking professional help from you, I was able to greatly reduce the amount I pulled my hair.  By using the tools I learned in therapy, I can go several days at a time without pulling and am continually improving.

Thank you! Kelsey

Alcoholic Alan

Not long ago a client (Alan) came in seeking help for drug and alcohol abuse. He was in his mid 30’s and had been using marijuana, cocaine and methamphetamine since his late teenage years. He started drinking alcohol before he was a teenager.

Alan finished high school and began working in retail. He changed jobs or was fired every couple years but was able to work his way up into a manager position. He was married and had three children. His drinking had a negative impact on his family and occasionally he yelled at his wife and kids. Often he spent time by himself at home watching T.V. or surfing on the Internet.

He wasn’t very satisfied at work and occasionally got into arguments with his assistant manager.  During therapy, it became evident that Alan used drugs and alcohol to cover up his feelings of anger, frustration and at times low self-esteem.

He was able to learn new coping skills and reduce his use of drugs and alcohol. His marriage improved and he enjoyed his kids more. Even his relationship with his assistant manager improved.

Co-dependent Cathy

Cathy had been married for 14 years to her high school sweetheart. Things started out good but as their family grew to four children the first five years, their marital relationship gradually deteriorated. Her husband, a sales manager traveled almost every week. When he was home, he tended to ignore her and the kids.

Cathy would occupy herself with housework, church duties and helping neighbors and other relatives. Most people thought Cathy had a good marriage, but inside she felt empty and trapped.

Feelings of frustration and anger would occasionally rise to the surface, but most of the time she just kept it all inside.

When Cathy started therapy, she had just discovered her husband had an addiction to pornography. She was surprised, hurt, angry and didn’t know whether she wanted to stay in the marriage or leave. She was concerned about the kids.

The therapy focused on a pattern of behavior called co-dependency. Cathy discovered that her husband was in many ways like her father, who was an alcoholic. She tried to control her family growing up and now she was trying to control her husband.

Gradually Cathy developed a healthy mental separation from her husband and as she began to get healthy, her husband admitted he had a problem with pornography and decided to get help himself.

Anxious Ann

Ann was in her late 20’s and had been working in a secretarial position since graduating from high school. She was nervous and anxious most of the time. She rarely dated but desperately wanted to get married.

However, Ann was afraid to socialize and had few friends. Most evenings she would read a book at home or talk on the phone to her parents or other relatives.

By the time Ann came to therapy, she had begun to have panic attacks and at times she thought she might die. Therapy began by exploring why Ann was not dating. It was discovered that she had been sexually abused by a baby sitter when she was 7 years old. This abuse continued over a two year period. She had never told her parents. Later she was also sexually abused by an uncle.

Ann had strong feelings of anger toward men but also wanted to develop a relationship with a man and eventually get married. Her feelings of ambivalence had developed into anxiety which lead her to isolate and avoid men.

During therapy Ann was able to work through the trauma of the two different periods of sexual abuse. Her anxiety disappeared and then therapy focused on helping her develop appropriate social skills. Ann began dating and recently became engaged.

Depressed Donna

Donna was in her mid 40’s, a typical mother of 4 children, married for over 16 years and active in the community and church.}

She had her first depression with the birth of her first child, and her family doctor prescribed an anti-depressant.

Her husband was supportive and made a decent income, yet money always seemed tight. It was a challenge taking each of the four children to music lessons, dance, football practice and the like, not to mention all the church activities.

Donna never felt like there was any time for herself. In fact, if she did take time to do something she enjoyed, she felt guilty.

She tried to talk to her church leader once, but that didn’t seem to help. She knew there were other women who were depressed and taking medication, but she still felt like no one understood what she was going through.

When she finally came to therapy, she felt hopeless but wanted to change her life. In therapy, she learned to develop some positive thinking skills, not just think happy thoughts, but really challenge some of her long held beliefs that kept her from finding the peace and happiness she knew she had always sought.

She began to enjoy life more and her husband even commented how much happier she seemed. The best compliment was from one of her children who said “mommy, you don’t seem like you’re mad at me anymore”. Donna almost cried. The mixture of joy and sadness she had; joy that she could connect better to her husband and children, and sadness that she hadn’t sought help sooner.

Career Confusion

Tom was in his late 40’s and ready for a new challenge in his life. He had worked in the computer industry for over 20 years and was recently let go from one of the major computer companies.

He first got into the computer industry because it was exciting and new developments were happening all the time. But over the years he became upset by the lack of loyalty that large companies showed their employees.

This was the third time he was a “victim” of a downsizing and he was ready to bail out of computers. But he didn’t have a clue what to do.

When Tom came to career counseling, the first question he asked was “What else am I good at?” He took a battery of assessments and found that he had natural abilities in the science and technology areas. The more he explored, the more interested he became in fixing scientific devices. He enrolled in a course designed to help technicians fix medical devices.

During this course he met another entrepreneur and together they developed a business plan. Tom had found a new challenge and was ready to move forward.

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Issue Cover

Article Contents

Introduction, research design and method, opening of the encounter: developing a reciprocal relationship, active listening: power sharing, vision of the future: emphasizing the positive, conclusions.

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Empowering counseling—a case study: nurse–patient encounter in a hospital

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Tarja Kettunen, Marita Poskiparta, Leena Liimatainen, Empowering counseling—a case study: nurse–patient encounter in a hospital , Health Education Research , Volume 16, Issue 2, April 2001, Pages 227–238, https://doi.org/10.1093/her/16.2.227

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This study illustrates practices that a nurse uses in order to empower patients. The emphasis is on speech formulae that encourage patients to discuss their concerns and to solicit information about impending surgery. The study is a part of a larger research project and a single case was selected for presentation in this article because it differed from the rest of the data by manifesting empowering practice. A videotaped nurse–patient health counseling session was conducted in a hospital and transcribed verbatim. The investigator interviewed the nurse and the patient after the conversation, and these interviews were transcribed as well. The encounter that is presented here as a case study is a concrete example of a counseling session during which the patient is free to discuss with the nurse. The empowering practices that the nurse employed were as follows: encouraging the patient to speak out, tactfully sounding out the patient's concerns and knowledge of impending surgery, listening to feedback, and building a positive vision of the future for the patient. We suggest that nurses should pay attention to verbal expression and forms of language. This enables them to gain self-awareness and discover new tools to work with.

In recent literature, empowerment has become an important concept of health education ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ), health promotion ( Labonte, 1994 ; Tones, 1994 , 1995 ; Williams, 1995 ; McWilliam et al. , 1997 ) and health counseling ( Poskiparta et al. , 2000 ). The process of empowerment has been related more to community and organizational levels than to micro levels of practice ( van Ryn and Heaney, 1997 ) where it is constantly crucial ( Tones, 1994 ). In addition, operationalization of the concept of empowerment has been relatively vague. According to Tones ( Tones, 1994 ), empowerment is a major goal of health promotion. This article focuses on health counseling as a means of interpersonal health education practice and uses health promotion as an umbrella term.

Empowerment is as much a process as an outcome of developing the skills and perceptions of clients. It is not only something that happens but a process that is facilitated. In interpersonal health counseling, the primary goal is not to change clients' behavior and seek their compliance with the presented message but rather to raise critical awareness through learning and support, to give clients tools for making changes on their own. The aim is personal empowerment, control and choice, which means that patients become aware of changes in their knowledge and understanding, decision-making skills, enhanced self-esteem/sense of personal control, and development of various social, health and life skills ( Labonte, 1994 ; Tones 1994 ; Anderson et al. , 1995 ; Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 ; Kar et al. , 1999 ).

The basic point of departure for empowerment is taking into consideration the interactive nature of the individual and the environment: people are not completely controlled by their environment nor can they fully control their physical, social or economic circumstances ( Tones, 1994 ). Empowering health counseling is based on recognizing clients' competence, resources, explanations of action styles of coping and support networks. Client initiative, clients' realizations and clients' expressions of their opinions and interpretations are the basis on which clients can approach health issues in collaboration with professionals. They are of crucial importance for their decisions on future action ( Anderson, 1996 ). All this supports the notion that empowering health counseling is significant.

Because learning about personal health is complex, the key issue of empowering health counseling is partnership and reciprocal conversation in a confidential relationship. This means that clients not only analyze their situation but also have an opportunity to plan what to do next, and how to go on and to construct their own solutions to health issues. In this type of hospital health counseling, either patients raise the issues (i.e. determine the topics) or the nurses do so in a sensitive and non-threatening manner ( Poskiparta et al. , 2000 ). Nurses recognize and respect patients' experiences, knowledge and skills, and make their own professional knowledge and expertise available to them ( Williams, 1995 ; McWilliam, et al. , 1997 ), which are important aspects of nurse–patient relationships that are also reported by patients ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Lindsey and Hartrick, 1996 ; Wiles 1997 ). The emphasis is placed on patient-driven [see ( Lindsey and Hartrick, 1996 )] health counseling, where patients' life situations are respected, patient-initiated actions are supported, and shared knowledge and deep understanding are nurtured.

The nurse's institutional task is not only to facilitate patient participation but also to promote patients' awareness of their routines and preconceptions as they are revealed to both interlocutors. This should lead to the aim of interaction, which is to activate self-reflection and re-evaluation and reorganization of patients' activities. The assumption is that new knowledge is gained in this process as a result of empirical realization and deliberation ( Feste and Anderson, 1995 ), which means that both patients and nurses have linked new knowledge to existing knowledge. Thus, patients learn to interpret and outline even familiar health problems in new ways that conform to their worldview [ cf . ( Mattus, 1994 )]. As for nurses, empowerment calls for not only sensitivity but also an ability to accurately perceive patients' messages.

From this point on, the focus is on the content of the interactive process. Tones ( Tones, 1994 ) discusses empowerment theoretically, Labonte ( Labonte, 1994 ) expresses ideas for practice in general, while Feste and Anderson ( Feste and Anderson, 1995 ) provide three empowerment tools for facilitating patients' empowering process: using questions, behavioral language and storytelling. According to them, questions maintain the process of pursuing wisdom, i.e. exploring the meaning of health problems in the context of everyday life. This kind of questioning involves broad questions that relate to one's personal philosophy and lifelong dreams. In addition, it includes practical, day-to-day issues of successfully integrating into one's personal, family, social and professional life. Behavioral language means using words such as `list', `describe', `identify', `decide', etc., in order to encourage patients to act and make choices instead of being satisfied with receiving information. Stories help to facilitate the process of self-discovery because diseases affect all areas of life and each individual's health status is unique.

Van Ryn and Heaney ( Van Ryn and Heaney, 1997 ) pay attention to interpersonal relations by suggesting concrete strategies and examples for empowering practice. In their article, they demonstrate two principles of interaction: (1) provide clients with unconditional positive regard and acceptance, and (2) facilitate client participation. Both principles include several practical strategies (Table I ).

However, the authors pay less attention to empirical findings ( Northouse, 1997 ). The present article describes some linguistic realizations of empowering practice. This article describes a nurse's empowering speech formulae during her efforts to give a patient information about an impending surgical operation and to strengthen her feelings of security by providing her with an opportunity to discuss her concerns. This study adopts a holistic approach to interaction and does not focus on isolated sentences or dialogue structure. The relationship of language and context in comprehension, as well as non-verbal communication, are also discussed.

This article describes a single case derived from qualitative data collected from a total of 38 counseling sessions in a Finnish hospital. Nurse–patient encounters were videotaped and transcribed verbatim. Interviews with the nurses and the patients after the sessions were transcribed as well. All participants volunteered to take part in the research, signed a research license and granted permission for the transcribed data to be used in publications. Nineteen nurses participated in this study. Each nurse conducted two videotaped counseling sessions with different patients. There was only one male nurse while the patient group consisted of 24 female and 14 male patients. The research material took shape as nurses volunteered in the hospital and it was found to be adequate for qualitative analysis. The length of the nurses' careers varied from 1 to 25 years. The ages of the nurses were between 24 and 50 years (mean age 36.9 years) while the patients' ages ranged from 18 to 70 years (mean age 47.9 years). The researcher did not attend the counseling sessions, which lasted from 5 to 45 min. The participating patients were experiencing diverse health problems. Various surgical problems, e.g. knee surgery, hernia operation, breast surgery, hip operation, back operation, post status of brain bleeding and post care of bypass surgery, were among the most representative. In addition to the health problems that had led to hospitalization, many patients also suffered from chronic diseases, such as hypertension, asthma, rheumatic illnesses or diabetes. Many patients also found themselves in an insecure situation when a chronic disease had suddenly been manifested or they were undergoing examinations. There were also some mothers in the group who had delivered recently and had no health problems.

The health counseling sessions were genuine counseling situations that were related to the patients' treatment. A single video camera was used, which meant that the observation of non-verbal communication was limited to examining the session as a whole, including only eye contact, smiles, laughter, tone of voice, gestures and, to some extent, facial expressions. Consequently, the emphasis of this study was examining verbal communication. Separate interviews with the nurses and the patients where both parties were encouraged to express their evaluations of the health counseling were used for partial support of the interpretations, e.g. when describing the patients' opinions about health counseling. We also checked if there were any nurses or patients who were nervous about the videotaping.

This article concentrates on videotaped data. When we examined all of the data we found many encounters that involved some empowering features from time to time, but there were none that were consistently empowering. In this article, we present a single case from the data. This particular encounter was selected because it differed from the rest of the data ( Stake, 1994 ) by manifesting empowering practice most widely. In order to study the interactive nature of communication, the coding and analysis of the videotaped data was based on principles of Conversation Analysis ( Drew and Heritage, 1998 ). The videotapes were transcribed word by word, including stammering, etc. At the same time, additional data were added to the transcriptions, such as pauses during and between turns, onset and termination of overlapping talk, intonation information, and some non-verbal communication. The following transcription symbols were used to indicate this information:

ha+ hands support speech

vo+ rising voice

vo– falling voice

[ ] at the beginning and end of overlapping speech, words enclosed

(( )) transcriber's comments, e.g. smile, laughter, body movements

(.) small but detectable pause

underlining emphasis

… omission of text

=no interval between the end of prior and start of next speech unit

°speech° speech in low volume, words enclosed

`speech'pitch change, words enclosed

The analysis was carried out on a turn-by-turn basis. The principle behind this analysis was to examine how turns were taken with regard to other participants' speech and what sequential implications each turn had for the next. After reading the transcript and watching the recording several times, we discovered a number of empowering expressions in the nurse's speech and concluded that this case was the one which best manifested empowering action in the data.

The particular case describes at the individual level information about the patient's situation, the nurse's interview after the encounter, an in-depth description of the nurse–patient conversation and the observational data derived from it. Pearson ( Pearson, 1991 ) and Patton ( Patton, 1990 ) indicate that a case study can be used, for example, for examining how different concepts emerge or change in particular contexts. However, an even more important question is what can be learned from a single case. Stake ( Stake, 1994 ) suggests that one should select a case that seems to offer an opportunity to learn and contributes to our understanding of specific phenomena. Here, a detailed single case analysis illustrates how empowerment may be practiced during health counseling and demonstrates how new working tools for empowerment can be developed on the basis of a single encounter ( Laitakari, 1998 ). The present study describes the speech of a nurse when she helped a patient to deal with anxiety and to receive information about surgery in an empowering way.

The nurse anesthetist has come to see a patient who is scheduled to have surgery the next day. The encounter involves, besides interviewing, producing a lot of information about the operation, counseling on the preparations for the surgery and advising how to manage after the surgery. The encounter takes place at a table, with the nurse and the patient facing each other. Both are women; the nurse is 50 and the patient 41 years old. The patient had had problems with her back for 10 years and was suddenly admitted to the hospital because of these problems. The patient has recently been examined and a decision has been made to operate on her the next morning. The interviewing session lasted 14 min.

At the beginning of a conversation the participants evaluate each others aims and concerns, and the communication situation as a whole, and this evaluation directs the entire discussion because the participants base their actions on it (Goffman, 1982). In a hospital, it is typical that nurses initiate a discussion ( Leino-Kilpi, 1991 ) and that is what happened in this case ( Extract 1 ). Professional dominance common in medical encounters ( Fairclough, 1992 ) is not so obvious in this conversation. After greeting the patient, the nurse refers to the goal of the discussion and individualizes it by using familiar `you' (line 1) instead of the formal, plural form of `you'. This form of address can be viewed as an act of communicating an appropriate degree of informality. It implies intimacy and mutual respect when a relationship is established ( van Ryn and Heaney, 1997 ).

1 N: Hello, Rose (.) you are going to have surgery 
 2 tomorrow…but now I would like to ask you 
 3 you well about the operation tomorrow if 
 4 there is (.) something that would influence 
 5 the preparations for your operation (.) and 
 6 then you ((ha+)) can bring things up ask well 
 7 er if something is unclear to you ((nod+)) If 
 8 you want to know anything about what's 
 9 going to happen to you tomorrow ((vo–))

((at first the nurse looks at papers on the table, while she speaks she turns her eyes to the patient and nods))

This opening was not typical of the other interviews in the data set, because in the data these encounters were usually initiated with the nurses' brief statements about the impending operation. They explained that they interviewed patients in advance in order to get information and that they could provide information to the patients as well. Nurses usually used formal, plural forms of address when speaking. When referring to the preoperative encounter, they used the plural, institutionalized form `we' [see ( Drew and Heritage, 1998 )], instead of first person singular `I', and plural `you', instead of the singular, when addressing the patient. Other nurses did not individualize their speech. On the contrary, they maintained a distance from the patients. In this particular case, a familiar mode of address reduces social distance, which is very important in health education practice [ cf . ( van Ryn and Heaney, 1997 )]. We explain our interpretations in more detail below.

The nurse uses the verb `ask' (line 2), but her remark further on (line 6–9) `then you can bring up ask well er if you were unclear about something if you want to know something about what's going to happen to you tomorrow' introduces a context for the discussion. Even though the nurse goes on to ask a question about previous operations, the interview becomes an interactive dialogue, with the patient actively participating. On her own initiative the patient discloses symptoms that she has experienced during the last few months, what happened when she needed to come to the hospital and the doctor's decision to perform surgery.

Thus, the nurse introduces the context of the discussion with her opening words [ cf . ( Peräkylä, 1995 )]. She expresses her acceptance by offering collaboration [ cf . ( van Ryn and Heaney, 1997 )] when asking questions. The verb form `would like to' (line 2) gives the discussion an air of voluntariness. The conditional form softens the notion of the necessity of the questions, and the verbal mode implies respect for the patient. At the beginning of the session (lines 1–9), the nurse combines two topics into a single long sentence, which also encourages (lines 6–9) the patient to clarify matters that are unclear to her. The nurse's words leave room for the patient's own thoughts and invites her to look for a personally meaningful way to connect the nurse's questions about the preparations (line 5) for the operation to her lack of information (lines 7–9). Encouraging statements can stimulate the patient to think in a way that is personally meaningful to her and to participate in the conversation ( van Ryn and Heaney, 1997 ; Tomm, 1988). Here, encouragement takes a form that is different from what Feste and Anderson ( Feste and Anderson, 1995 ) suggested; it is given in a more sophisticated manner. The opening words ( Extract 1 ) correspond with the goal that the nurse states later during the interview: `that the patient would receive the information she needs, what she wants to know and that she would feel safe to come, that at least those worst fears would be like forgotten. That she would feel safe'.

An encounter can threaten a patient's need for autonomy and freedom because it gives the nurse the legitimate power to request information about the patient's private life ( van Ryn and Heaney, 1997 ). Here, the nurse is mitigating her power by avoiding threatening terms and using tentative formulations (`would like to, well er, you you'), the emphasis being on the patient's needs. The opening of the interview by the nurse plays an important role in the development of the atmosphere. The act has been planned in advance but is not thoroughly thought out. In addition to conveying information, the main consideration in setting the goal for the discussion is to help the patient deal with her concerns. These are issues that have also been stressed in earlier studies ( Häggman-Laitila and Åstedt-Kurki, 1994 ; Breemhaar et al. , 1996 ; Leinonen et al. , 1996 ; Lindsey and Hartrick, 1996 ; Otte, 1996 ).

Tactful exploration: activation of reflection

Later during the interview, the patient mentions having thought about the impending surgery, which the nurse interprets as an indication of fear for the operation ( Extract 2 ). She indirectly gives the patient an opportunity to deal with her fears. The patient's words (lines 1, 3, 5 and 7) are related to the previous topic and her status during the operation and conclude the discussion. The nurse changes the subject (line 9) by praising the doctor's skill. The nurse and the patient look at each other.

1 P:mmm[think about during the day]= 
 2 N:[of] course ((nod+)) 
 3 P:=what's going to happen and (.) 
 4 N:right ((nod+)) 
 5 P:°like[that]° (.) 
 6 N:[mmm] 
 7 P:°it's[okay]° ((nod+, vo–)) 
 8 N: [that's] right (.) ((glance at papers: doctor's 
 9 name)) is is an excellent surgeon so in that 
 10 respect you can definitely (.) ((vo–)) feel 
 11 safe ((nod+)) that 
 12 P:yes of course I am 
 13 N:mmm 
 14 P: and and absolutely 110% (.) I trust that (.) 
 15 the thing is that (.) this is small case for 
 16 him but this is a horribly big thing for me…

The nurse's comment about the operating surgeon contains an allusion to fear of surgery. Instead of soothing the patient by telling her not to be afraid or asking if the patient is scared, the nurse indirectly comments on the doctor's professional skill (line 9) and emphasizes the expertise as a guarantee of success (line 10 and 11). Thus, the nurse allows the patient to save face when she leaves her to interpret her words. Her indirectness implies politeness and gives the patient options: if she does not want to deal with her fear, she may choose not to take the hint [see ( Brown and Levinson, 1987 )]. Here, politeness can also be linked to and interpreted through empowering practice, where the nurse holds the patient in high regard [ cf . ( van Ryn and Heaney, 1997 )].

The extract might have been interpreted as an example of the nurse cutting the patient off if one had not seen the videotape. Our interpretation is supported by a number of factors. First of all, the entire conversation until this extract has been tranquil and calm, the nurse has spoken and asked questions at a gentle pace, with pauses, and she has explored the patient's experiences. In this extract, the situation is similar, and she looks at the patient and nods. She speaks quite slowly, and her voice is low, friendly, and convincing ( van Ryn and Heaney, 1997 ). We can also see that the patient completes her speech by pausing (lines 3 and 5) and lowering her voice (lines 5 and 7). Therefore, after the nurse's words (lines 8–11), the patient presents her fear for discussion (lines 15 and 16) and also returns to the matter later during the interview. The extract shows how the issue has been constructed together by the nurse and the patient. The nurse raises the theme in a sensitive and non-threatening manner, and the patient continues the same topic. It also shows that the relationship is confidential enough for the patient to disclose her concerns and become aware of her own understanding, and thus contributes to empowerment. Salmon ( Salmon, 1993 ) has stressed that the main goal in the discussions between nurses and patients before surgery is not to reduce the patients' fears but to help them to deal with them.

Indirectness is a polite feature of discourse. There is `strategic indefiniteness' in indirectness that offers patients an opportunity to continue a discussion according to their own wishes ( Brown and Levinson, 1987 ). In general, nurses' empowering acts are mostly manifested in the form of questions ( Poskiparta et al. , 2000 ). In some cases, an indirect comment by a nurse, instead of a question, may encourage patients to talk about topics that they fear. Here it generates reflection in the patient. After disclosing her concerns, the patient analyzes the situation and recounts the conversation that she had with the doctor who explained the reason for her back surgery ( Extract 3 ).

Extract 3 .

1 P:this morning ((doctor's name)) said that 
 2 N:`this morning' ((surprised)) 
 3 P:this morning 
 4 N:that's recent for sure 
 4 P:yes 
 5 N:well it happened so 
 6 P: so it happened suddenly because yesterday 
 7 it became evident that (.) there was in the 
 8 X-ray ((doctor's name)) said that there was 
 9 a cause when I asked if there was anything 
 10 that caused the pain or if I was just imagining 
 11 it (.) so he said that yes there was a 
 12 genuine cause…

The amount of information given always depends on the situation and the nurse needs to continually evaluate the patient's needs: what it is that the patient knows, wants to know and how much she does want to know. This is also important because there are several persons that the patient sees before surgery ( Breemhaar et al. , 1996 ). Furthermore, nurses and doctors may deal with the same issues in their counseling. In Finland, the doctors, the surgeon and the consultant anaesthetist inform patients about the medical facts, risks, and benefits of operations. The patient also has an interview with a nurse on the surgical ward and, in addition to these encounters, there will occasionally be an encounter with a nurse anesthetist.

The nurse's empowering approach is manifested in how she raises issues or questions from time to time as if with hesitation. A pause precedes questions [`I don't have any (.) questions to ask you any more but do you—you have anything to ask from me like such things about tomorrow that worry you') ((looks at the patient))]. She asks the questions more quietly than normal and looks at the patient. According to Beck and Ragan's ( Beck and Ragan, 1992 ) study, nurses' softening words and their hesitant and tentative manner of speaking indicate discretion and tact and are aimed at not embarrassing patients. In our data, slow and hesitant speech also encourages the patients to comment more than nurses' more usual and brief question does: `Do you have any questions?'.

The nurse's tentative manner of asking questions makes it easier for the patient to start dealing with her concerns. She repeatedly pauses briefly and, in addition to the closed questions in the medical history questionnaire, she asks open-ended questions that explore the patient's experiences: `What kind of memories do you have of previous operations?' `Is there anything else you remember (.) is there something?'. Open-ended questions encourage the patient to speak and participate, e.g. in the naming and solving of a problem [ cf . ( Feste and Anderson, 1995 ; van Ryn and Heaney, 1997 )]. In this particular case, indirectness and hesitation are polite speech formulae that help the patient to save face ( Fairclough, 1992 ). They can also serve as empowering strategies that provide unconditional positive regard and acceptance for patients.

Despite these quite extensive empowering acts, the nurse subsequently evaluated her information skills only. She indicated how difficult it was for her to decide what kind of information to give to the patient:

I wondered if I should have maintained a more professional role, I mean more facts, if the patient got all that she wanted. Because this is not really medical science, you know, that's up to the doctor. It has to happen on the patient's terms, what she wants to know. I tried to check the patient's needs several times.

The content of the session satisfied the patient as well:

I got enough information about the operation, things that occupied my mind, so I didn't, she even told me before I asked. There's nothing to find out any more. As I said to her, I'm terribly afraid but I'll go ahead with confidence.

The nurse's way of posing questions builds up interaction. With her questions she steers the discussion thematically. This is how she controls the conversation. On the other hand, it is the patient who determines the content of the discussion. Her answers are reflective and bring up new issues. When the patient speaks, the nurse supports her with various feedback (e.g. Extracts 2 and 3) `mmm, right, of course, yes, exactly' and sometimes by paraphrasing. She nods a lot, bends toward the patient and looks at her. The feedback also occasionally includes completing the patient's sentences. According to van Ryn and Heaney ( van Ryn and Heaney, 1997 ), such non-verbal cues signal acceptance and, according to Caris-Verhallen et al. ( Caris-Verhallen et al. , 1999 ), they are patient-centered. With her feedback the nurse shows that she is there to listen to the patient, that she does not want to interrupt. Her feedback encourages the patient to speak in a similar way as in the doctor–patient conversation of an alternative medical interview described by Fairclough ( Fairclough, 1992 ). The patient interprets the feedback as encouragement, goes on to discuss the matter, and indicates her intention to continue by using the expressions `What I have been wondering…', `I did that when…' and `on the other hand, it's…'. This is how the nurse supports the patient's right to speak, which is not necessarily typical of a medical conversation ( Fairclough, 1992 ). The nurse's multi-facetted listening feedback is empowering, and this can be seen here and there in the data [see also ( Poskiparta et al. , 2000 )]. In this encounter, the feedback is exceptional because it disregards the participant's status. Generally, this type of feedback is directed to the dominant person ( Hakulinen, 1989 ). In a medically oriented environment, the hospital staff are viewed as superior to patients in knowledge ( van Ryn and Heaney, 1997 ; Tones, 1994 ). In this particular case, the nurse's listening feedback manifests power sharing.

When the patient discusses the reason for her admission to the hospital, the nurse builds up a positive, healthier vision of the future through other patients' experiences ( Extract 4 ). She makes her professional knowledge and expertise available to the patient ( Williams, 1995 ; McWilliam et al. , 1997 ). This lends a touch of reality and possibly builds on the patient's strengths ( van Ryn and Heaney, 1997 ) in this situation. The nurse attempts to dispel the patient's concerns about the risks of the operation. Her tone is convincing, and her non-verbal messages also inspire confidence: she looks at the patient, reinforces her message by nodding her head and gestures with her hands. Encouraged by the nurse, the patient can have a vision of her postoperative future.

Extract 4 .

1 N:these these ((ha+)) back operations are 
 2 like such that patients in them are usually 
 3 really grateful ((nod+)) after the operation 
 4 because if the operation like succeeds and 
 5 something is found (.) then the pain will be 
 6left in the operating room (.) ((ha+)) and 
 7 in that in that this is like like different from 
 8 other operations (.) and then because the 
 9 woundpainisinthebacksomehowit's 
 10 different than in here if the wound was here 
 11 inthestomach(ha+))andit'snotthatthat 
 12bad when it is if[you]= 
 13 P:[yeah] 
 14 N:=afterthosestomachoperationsyouoften 
 15 often hear that these patients who have had 
 16their back operated are such fortunate 
 17((nod+)) cases in the sense [that]= 
 18 P:[yeah] ((nod+)) 
 19 N:= because the pain will be left in the 
 20 operating room and and that's it then 
 21 ((nod+/ha+))

The nurse encourages the patient to examine her life at some hypothetical future point of time when the operation will have succeeded. Hypothetical questions encourage patients to discuss issues that they fear [ cf . ( Peräkylä, 1995 ; Tomm, 1987 )], while a hypothetical positive situation encourages patients indirectly. In this case, discussing the past would not calm the patient but rather lead her thoughts to the incident that caused her hospitalization. The vision of the future that the nurse provides to the patient with may help relieve her. A positive example is an empowering message and displays the nurse's understanding of the patient's anxiety. This vision can tap new resources in the patient for facing the future that is suddenly uncertain [ cf . ( van Ryn and Heaney, 1997 )]. Some manifestations of this can be seen in the patient's words: `…I'm very happy that if it's going to be over (.) yes I'm ready though I feel nervous' or `…I'm going ahead with confidence…'. A skilful use of future focus by the nurse helps the patient to find new solutions to her problems [ cf . ( Tomm, 1987 )]. As Atwood ( Atwood, 1995 ) suggests, confining the clients' thoughts to their problems is not sufficient in therapy work (focus on the past). In addition, we need to assist clients to expand their outlook by re-visioning their lives (future focus).

The encounter that is presented here as a case study demonstrates empowering nursing practice in hospital. It is a concrete example of a discussion during which the official and formal nature that characterizes the role of an institutional nurse is not emphasized. It actually emphasizes partnership and reciprocal conversation [ cf . ( van Ryn and Heaney, 1997 ; Poskiparta et al. , 2000 )], with the nurse's social interaction skills at the heart of the encounter [ cf . ( Wiles, 1997 )]. The patient is free to discuss her thoughts, concerns, experiences and even fears with the nurse, and the nurse adopts an empowerment strategy in order to facilitate the patient's participation. This encounter included the following empowering practices: (1) opening the session in an encouraging and constructive manner, which improves the atmosphere, (2) tactful exploration when examining the patient's need for information and concerns for surgery, (3) active, power sharing listening, and (4) building up a positive vision of the future.

The descriptions of empowerment strategies reported by van Ryn and Heaney ( van Ryn and Heaney, 1997 ) support our findings. However, we agree with Northouse's ( Northouse, 1997 ) criticism that the reported strategies are not completely separated. In our study, empowerment was manifested through intimacy and mutual respect. The nurse's encouragement of the patient's participation and her attempt to share power signaled acceptance, and perhaps gave the patient new insights for controlling her feelings about the impending surgery. Furthermore, the perceptions of active listening feedback and questioning are consistent with our previous studies ( Poskiparta et al. , 1998 , 2000 ; Kettunen et al. , 2000 ), where we found them to be a means of activating patients' self-evaluation and self-determination. In this study, we did not find evidence for empowering stories or questions that relate to patients' personal philosophy, as mentioned by Feste and Anderson ( Feste and Anderson, 1995 ). In addition, the nurse's encouragement was more sophisticated than what Feste and Anderson suggest with their empowering tools.

Our research data consisted of only one videotaped session per patient. Thus we have no evidence about how patients' decision-making skills develop or their self-esteem improves. During the interviews we did not ask the patients' opinion on the effects of counseling and that is why the patients evaluated conversations at a quite general level. In this particular case, the patient said that an encounter was ` illuminating ' for her. She mentioned that she received enough information and again spoke about her fears but used the same words as the nurse did when she emphasized a positive vision of future (see Extract 4 , lines 5, 6, 19 and 20): `if it's a fact that the pain will be left in the operating room, if it really is possible…that there's going to be an operation and they'll do it tomorrow, then that's how it's going to be'. This could, perhaps, signify some kind of relief or new resources to face an uncertain future. During the interview it also became evident that the patient's fears had not been diminished, but she talked about them and stressed a strong reliance on the professionals and on the operation as a whole: `I believe what I'm told'. This is in line with the perspective of Salmon ( Salmon, 1993 ), who emphasized that patients' anxiety about surgery should not be seen as a problem but rather as a normal phenomenon, a sign of patients' emotional balance, of an ability to feel fear. Thus, the nurse's task is not to diminish the patient's fears but to facilitate the patient's disclosure and offer help for dealing with fear.

With caution, we can speculate on the factors behind this kind of empowering practice, which became evident during the subsequent interviews. There was no evidence that nurses' or patients' age, education or work experience influenced the format of the counseling. What makes this case different from traditional rigid counseling sessions is that the nurse had a goal that she had planned in advance and pursued flexibly. This indicates that she had reflected on the significance of this situation from the patient's perspective. In most cases, nurses approached counseling without any goal or the hospital provided a detailed agenda based on professional knowledge of diseases, their care and prevention. Then, different kinds of institutionalized health counseling packages seemed to restrict nurses' communication, and health counseling often followed the standard institutional order of phases mentioned by Drew and Heritage ( Drew and Heritage 1998 ).

This study highlights empowering opportunities that arise in actual situations and that nurses can consciously use in their work. The results of this study can be applied to other health counseling practices and we would argue that every nurse should consider how (s)he initiates discussion. The analysis of the encounter shows that a tentative discussion style gives the patient a chance to deal with her concerns and to absorb the information that she needs. Thus, the patient has an opportunity to participate more actively in the discussion from the beginning than she could in the case of filling out a questionnaire in a strict predetermined order.

Clearly there are limitations to the generalizability of these findings. For example, both interlocutors were women, and this could in part explain the nature of the conversation since the highest levels of empathic and positive behavior occur between females [see ( Coates, 1986 ; Roter and Hall, 1993 ), p. 63]. There is also some concern whether the nurse may have been subject to a performance bias because she was aware of being videotaped and possibly behaved differently. However, we think that this was limited because only two nurses discussed this type of bias in the interviews afterwards and other nurses did not even notice the camera or did so only briefly at the beginning of counseling [see also ( Caris-Verhallen et al. , 1998 )]. Techniques to enhance the credibility of the findings included data and methodological triangulation of research data ( Patton, 1990 ; Stake, 1994 ; Begley, 1996 ), and acquiring data that included both verbal and non-verbal communication from the videotaped health counseling sessions and the subsequent interviews. In addition, team analysis sessions (investigator triangulation) ensured the accuracy of data interpretation (Polit and Hunger 1995). Different expertise helped us to get more complete picture from this case and empowerment philosophy when we discussed interpretations together.

However, in the last analysis, the effect of an empowering encounter could be checked after the operation by checking the patient's perspective, e.g. her satisfaction, recovery rate, etc. Evidence from nursing and medical staff might also be offered as additional evidence. Further research from larger numbers of patients is needed and more evidence from different settings will be required for a more extensive description of empowering practice. We will continue our research, and, for example, present qualitative analysis of interaction by describing how power features and patients' taciturnity are manifested in nurse–patient counseling. In addition, we will investigate how student nurses make progress in empowering counseling.

We suggest that nurses should pay attention to verbal expression and forms of language, in addition to non-verbal messages, because then they can empower patients by opening new and important perspectives for them. Nurses' every question, remark or piece of advice leads to individualized understanding and interpretation by the patient. It is important to remember that each communication situation is a unique, dynamic and transforming process. Nurses should observe what figures of speech they use and thus gain self-awareness and discover new tools to work with. We suggest a training program where the development of health care professionals' empowering skills can occur in practical, dynamic communication situations, be videotaped and transcribed for later theoretical, conscious and instructive evaluation. Analyzing the transcripts of video or tape-recorded counseling sessions opens up the possibility of an exact evaluation of empowering skills.

In health counseling, it is important that patients are able to maintain and strengthen a positive image of themselves as communicators. Positive experiences build up patients' self-esteem and increase their confidence in their ability to influence their care. The mere opportunity to discuss one's opinions and interpretations or different health concerns with a nurse may have the effect of unlocking patients' mental resources. This article demonstrates particularly how unconditional acceptance and facilitation of participation can be used in interpersonal counseling [see ( van Ryn and Heaney, 1997 )]. The empowering practices that are presented in this article should not be regarded as rigid and formalistic, rather they should be adapted to one's personal style.

Empowering principles of interpersonal practice ( van Ryn and Heaney, 1997 )

This study was supported by the Ministry of Health and Social Affairs of Finland and by the Finnish Cultural Foundation. We are sincerely grateful to all that participated in this study.

Anderson, J. M. ( 1996 ) Empowering patients: issues and strategies. Social Science and Medicine , 43 , 697 –705.

Anderson, R. M., Funnell, M. M., Butler, P. M., Arnold, M. S., Fitzgerald, J. T. and Feste, C. C. ( 1995 ) Patient empowerment. Results of randomized controlled trial. Diabetes Care , 18 , 943 –949.

Atwood, J. D. ( 1995 ) A social constructionist approach to counseling the single parent family. Journal of Family Psychotherapy , 6 , 1 –32.

Beck, C. S. and Ragan, S. L. ( 1992 ) Negotiating interpersonal and medical talk: frame shifts in the gynaecologic exam. Journal of Language and Social Psychology , 11 , 47 –61.

Begley, C. M. ( 1996 ) Using triangulation in nursing research. Journal of Advanced Nursing , 24 , 122 –128.

Breemhaar, B., van den Born, H. W. and Mullen, P. D. ( 1996 ) Inadequacies of surgical patient education. Patient Education and Counseling , 28 , 31 –44.

Brown, P. and Levinson, S. C. (1987) Politeness. Some Universals in Language Usage. Cambridge University Press, Cambridge.

Caris-Verhallen, W. M. C. M., Kerkstra, A., van der Heijden, P. G. M. and Bensing, J. M. ( 1998 ) Nurse–elderly patient communication in home care and institutional care: an explorative study. International Journal of Nursing Studies , 35 , 95 –108.

Caris-Verhallen, W. M. C. M., Kerkstra, A. and Bensing, J. M. ( 1999 ) Non-verbal behaviour in nurse–elderly patient communication. Journal of Advanced Nursing , 29 , 808 –818.

Coates, J. (1986) Women , Men and Language. A Sociolinguistic Account of Sex Differences in Language. Longman, New York.

Drew, P. and Heritage, J. (1998) Analyzing talk at work: an introduction. In Drew, P. and Heritage, J. (eds), Talk at Work. Interaction in Institutional Settings. Cambridge University Press, Cambridge, pp. 3–65.

Fairclough, N. (1992) Discourse and Social Change. Polity Press, Cambridge, pp. 134–168.

Feste, C. and Anderson, R. M. ( 1995 ) Empowerment: from philosophy to practice. Patient Education and Counseling , 26 , 139 –144.

Goffman, E. (1967/1982) Interaction Ritual. Doubleday, New York, pp. 5–45.

Hakulinen, A. (1989) Keskustelun luonnehtimisesta konteksti- ja funktionaalisten tekijöiden nojalla. [Characterizing the conversation according to contextual and functional factors]. In Hakulinen, A. (eds), Kieli 4 Suomalaisen Keskustelun Keinoja I. Helsingin Yliopiston Suomen Kielen Laitos, Helsinki, pp. 41–72.

Häggman-Laitila, A. and Åstedt-Kurki, P. ( 1994 ) What is expected of nurse–client interaction and how these expectations are realized in Finnish health care. International Journal of Nursing Studies , 31 , 253 –261.

Kar, S. B., Pascual, C. A. and Chickering, K. L. ( 1999 ) Empowerment of women for health promotion: a meta-analysis. Social Science and Medicine , 49 , 1431 –1460.

Kettunen, T., Poskiparta M. and Liimatainen, L. (2000) Communicator styles of hospital patients during nurse–patient counseling. Patient Education and Counseling , in press.

Labonte, R. ( 1994 ) Health promotion and empowerment: reflections on professional practice. Health education quarterly , 21 , 253 –268.

Laitakari, J. ( 1998 ) How to develop one's counseling—demonstration of the use of single-case studies as a practical tool for evaluating the outcomes of counseling. Patient Education and Counseling , 33 , S39 –S46.

Leino-Kilpi, H. ( 1991 ) Good nursing care—the relationship between client and nurse. Hoitotiede , 3 , 200 –206.

Leinonen, T., Leino-Kilpi, H. and Katajisto, J. ( 1996 ) The quality of intraoperative nursing care: the patient's perspective. Journal of Advanced Nursing , 24 , 843 –852.

Lindsey, E. and Hartrick, G. ( 1996 ) Health-promoting nursing practice: the demise of the nursing process? Journal of Advanced Nursing , 23 , 106 –112.

Mattus, M.-R. (1994) Interview as intervention: strategies to empower families of children with disabilities. In Leskinen, M. (ed.), Family in Focus. New Perspectives on Early Childhood Special Education. Jyväskylä Studies in Education, Psychology and Social Research 108. Jyväskylä University Printing House, Jyväskylä, pp. 87–107.

McWilliam, C. L., Stewart, M., Brown, J. B., McNair, S., Desai K., Patterson, M. L., Del Maestro, N. and Pittman, B. J. ( 1997 ) Creating empowering meaning: an interactive process of promoting health with chronically ill older Canadians. Health Promotion International , 12 , 111 –123.

Northouse P. G. 1997 . Effective helping relationships: the role of power and control. Health Education and Behavior , 24 , 703 –706.

Otte, D. I. ( 1996 ) Patients' perspectives and experiences of day case surgery. Journal of Advanced Nursing , 23 1226 –1237.

Patton, M. G. (1990) Qualitative Evaluation and Research Methods. Sage, Newbury Park, CA, pp. 388–390.

Pearson, P. ( 1991 ) Clients' perceptions: the use of case studies in developing theory. Journal of Advanced Nursing , 16 , 521 –528.

Peräkylä, A. (1995) AIDS Counselling. Institutional Interaction and Clinical Practice . Cambridge University Press, Cambridge.

Polit, D. F. and Hungler, B. P. (1995) Nursing Research. Principles and Methods. Lippincott, Philadelphia, PA.

Poskiparta, M., Kettunen, T. and Liimatainen, L. ( 1998 ) Reflective questions in health counseling. Qualitative Health Research , 8 , 682 –693.

Poskiparta, M., Kettunen, T. and Liimatainen, L. ( 2000 ) Questioning and advising in health counseling. Results from a study of Finnish nurse counselors. Health Education Journal , 95 , 47 –67.

Roter, D. L. and Hall, J. A. (1993) Doctors Talking with Patients/Patients Talking with Doctors . Greenwood, Westport, CT.

van Ryn, M. and Heaney, C. A. ( 1997 ) Developing effective helping relationships in health education practice. Health Education and Behavior , 24 , 683 –702.

Salmon, P. ( 1993 ) The reduction of anxiety in surgical patients: an important nursing task or the medicalization of preparatory worry? International Journal of Nursing Studies , 30 , 323 –330.

Stake, R. E. (1994) Case studies. In Denzin, N. K. and Lincoln, Y. S. (eds), Handbook of Qualitative Research. Sage, Newbury Park, CA, pp. 236–247.

Tomm, K. ( 1987 ) Interventive interviewing: part II. Reflexive questioning as a means to enable self-healing. Family Process , 26 , 197 –183.

Tones, K. (1994) Health promotion, empowerment and action competence. In Jensen B. B and Schnack, K. (eds), Action and Action Competence as Key Concepts in Critical Pedagogy. Studies in Educational Theory and Curriculum . Royal Danish School of Educational Studies, vol. 12, pp. 163–183.

Tones, K. ( 1995 ) Editorial. Health Education Research , 10 , i –v.

Wiles, R. ( 1997 ) Empowering practice nurses in the follow-up of patients with established heart disease: lessons from patients' experiences. Journal of Advanced Nursing , 26 , 729 –735.

Williams, J. ( 1995 ) Education for empowerment: implications for professional development and training in health promotion. Health Education Journal , 54 , 37 –47.

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Counselling Case Study: An Overwhelmed Client

Chris came to counselling because he was experiencing increasing feelings of being stressed, overwhelmed and weighed down by his commitments in life. He has been particularly concerned about his negative thoughts and attitude at work and at home and would like to change this. Chris has been seeing a Professional Counsellor for three sessions and together they have been using an eclectic approach using Cognitive Behavioural Therapy, some Solution Focused Therapy and Gestalt techniques. For ease of writing the Professional Counsellor is abbreviated to “C”.

Background Information

Chris is a husband of three years to Michelle and father to 18-month-old James. He is 45 years of age and a nurse at a local hospital. He has also been studying part time for his Masters degree in Nursing for three years. His wife is also a nurse and together they work shift-work in order to look after James. Chris states he enjoys his job but it can be demanding and physically tiring at times. He has previously enjoyed his studies but is now finding it difficult to finish the work with the responsibilities of a small baby. For financial reasons he has not been able to complete his studies full-time.

Chris has recently found the demands of being a husband, a nurse, a father and a student to be taxing on his physical and emotional health and he has found himself to be snappy, irritable, exhausted and unmotivated at home and at work. He has noticed that his relationship with his wife Michelle has become strained and he has begun to resent her for asking him to complete even minor chores around the home. He is feeling unloved and taken for granted by his wife. He has started questioning whether he wants to finish his studies and whether he wants to stay in the marriage.

Chris was prompted to come to counselling at the suggestion of his doctor. Chris presented to his doctor’s surgery complaining of an itchy rash covering his arms and torso, and of throbbing headaches at night and in the morning. Chris stated that medical tests revealed no physical reason for these complaints and his doctor suggested that working through some of the demands and pressures Chris had in his life may relieve the symptoms, as they may be directly related to stress and tension. Chris was happy to do this as he stated he was unhappy with his reactions and attitude at this time, as he had always been a happy, positive sort of guy.

Previous Sessions

In the first three sessions, C worked through identifying the above issues and asked Chris what he felt was the most important issue requiring attention. Chris identified this as his negative thought patterns and pessimistic way of looking at each day in the morning.

C worked to immediately change this by using Ellis’ Rational Emotive Behaviour Therapy ABC model. Using this framework to identify the behavioural and emotional consequences of his thought patterns, Chris chose to work on his attitude to going to work everyday. Before using the ABC model, Chris’ thoughts and behaviours looked like this:

A – Alarm rings every morning at 7am B – Chris says to self “Oh, no. I hate my job. This is going to be another horrible day” C – The behavioural consequence here is that Chris is often late for work because he procrastinates about going and then is often reprimanded by his supervisor. D – The emotional consequences are that Chris has a sense of despair about his ability as a nurse

After applying the ABC model to change his irrational beliefs (in B), Chris has found the following pattern when his alarm rings in the morning:

A – Alarm rings every morning at 7am B – Chris says to self “I can do this. Every day is a new day. I will work well today” C – The behavioural consequence has meant that Chris has not been late for work and therefore not in trouble from his supervisor – in fact he has been praised for his promptness in front of other staff (thus reinforcing his behaviour to be on time!)
D – The emotional consequences for Chris have included a greater sense of satisfaction with his work, a feeling of being appreciated at work, and more importantly, the knowledge and evidence that he is in control of his own thoughts.

Current Session Content

After Chris had noticed some considerable improvements in his thought processes and felt more in charge of his meditating thoughts about work, he and C moved onto discussing the feelings he was having about his studies and his marriage.

Chris had noticed that his more positive attitude at work had certainly influenced his mood at home, but something was still not right. He also noted that his rash and headaches in the morning had somewhat subsided, although he was still suffering throbbing pain in his temples at night after work. C began asking questions:

Extract, Counsellor and Client

Counsellor: “Chris, you talked in our first session about wanting to leave your marriage and maybe not finish your Masters, how do you feel about this now we have worked on your positive thinking?”

Client: “You know, as much as the positive thinking has helped with getting up each day and getting through work, I don’t know if it has changed my other feelings. I dunno, I still don’t know whether I want to finish my Masters. I mean, I feel better about my marriage, but I still find myself lying awake at night wondering at the “why” of everything. Know what I mean?”

C: “Tell me more about the “why”. Just your marriage and studies?”

Client: “Well, not really just that. I mean, I’m 45 now. I have a son and a wife and a job, but something just doesn’t seem right. Like maybe something’s missing.”

C: “Chris, can I just ask a question for a moment?”

Client: “Sure”.

C: “If I could wave a magic wand and you could wake up tomorrow and everything was worked out, everything was the way you wanted, what would it be like?”

Client: “It would be great!”

C: “Great, how?”

Client: “Well, I guess I would be happy. Everyday.”

C: “So would your marriage be any different? Your studies?”

Client: “Probably not. I mean, Michelle isn’t really asking more of me than when we first got together. It just seems more. The studies stay the same no matter how I feel.”

C: “So..?”

Client: “Oh, I get it. It’s not really the stuff is it? It’s me. I’m the one who has changed.”

C: “Is that how you feel?”

C proceeded to show Chris that while some things at home and work were the same as when they first married, other factors had changed. C wanted to make sure that Chris was not going to be too hard upon himself for realising that much of his own thoughts and feelings were under his own control. C pointed out elements of stress and how it works, and again they surveyed Chris’ life to examine the external factors.

Counsellor: “Chris, I just want to go back a step to the work we did around your thoughts and taking control”

Client: “Mmmmm…”

C: “Are you familiar with the word stress?”

Client: “Sure”

C: “I don’t just mean the bad form of stress, where you want to rip your hair out, but other forms too”

Client: “I’m confused”

C: “So am I! What I mean is, anything in your life that causes a change, causes stress. So when you find your dream wife and get married, this is stress. When you break your leg, this is stress. There are different types of stress, but mostly it is a word that means any change in your life.”

Client: “Ok. Where are we going?”

C: “When we look at your life and you say that things are still basically the same as when you married, you might be right on the surface, but underneath lots of things have changed that may have caused forms of stress.”

Client: “Ok”

C: “What if we have a look at exactly what is going on in your life right now and see if it makes more sense?”

C showed Chris a copy of the Holmes Rahe Stress Scale (available easily on the Internet for use – try www.teachhealth.com ) and together they identified different things that were in his life over the past 12 months, which he may not necessarily have thought of as forms of stress.

Some examples from the Holmes Rahe Scale which Chris identified included: a mortgage, change in the health of a family member (Chris disclosed that his mother had recently been diagnosed with cancer and he hadn’t really thought of this as playing an active role in the physical symptoms he was having), changes in his responsibilities at work, chronic allergies, and a change in the number of family get togethers (these had decreased due to Chris and his wife’s work and study commitments).

C helped Chris realise that there was a great deal going on in his life and that someone else in the same position may feel just as overwhelmed. This exercise served to help Chris acknowledge the forms of stress, understand how they impacted upon him and avoid falling into the trap of believing that he was the only one who had changed and everything was his fault.

Satisfied with Chris’ grasp on these concepts, C moved back to the issue of Chris being unsatisfied in life generally and searching for answers to the “why” of it all. Together they examined more closely what Chris was feeling and he surprised himself by breaking down and crying in one of these sessions. Chris talked about his own upbringing and not feeling that he had ever been good enough for his father, who had since passed away.

He discussed that his father had been a Doctor and had wanted Chris to follow the same. Chris’ grades had prevented him from achieving this and so he had chosen nursing as the next best thing. Chris was surprised at this realisation as he and C explored this issue, and he then started to examine whether nursing was really his chosen profession. C used a visual technique to examine this and coupled it with the Gestalt technique of using an empty chair because Chris’ father had died, in order to give Chris a chance to express his thoughts and feelings.

Extracts include:

Client: “I think what it means is that somewhere I knew I was never going to be as good as him and nursing was a bit of a cop out too. Even though I didn’t get the grades to get into medicine.”

C: “Would it be possible that you may have subconsciously manipulated the situation to avoid the scrutiny or pressure of studying medicine and being a doctor?”

Client: “Yeah, you know I think that’s it. It all adds up. I mean, I like nursing, but I think I’ve always felt there was something more that I didn’t achieve, for some reason.”

C: “We call it self-sabotaging, where subconsciously a person might do the very thing they are avoiding or vice versa.”

Client: “How bizarre.”

C: ‘Would it be ok if we explored your choice of nursing further with a visual exercise?”

Client: “Sure. Whatever works.”

C asked Chris to close his eyes and using a brief relaxation technique they had employed in the earlier sessions using CBT, C asked Chris to imagine the first day he had started work as a Nurse, after graduating. C specifically asked Chris to watch the scenario as it unfolded, from an outsider’s point of view. C did not want Chris to be drawn into the scene, but wanted him to be able to note his own feelings and behaviours from a distance.

Client: “I can remember it like it was yesterday. It was such a busy day and I had no idea what I was doing.”

C: “Chris, can you imagine yourself somewhere in the middle of the day, with things happening around you?”

Client: “Yep, there was this patient who was crying in the waiting room and I went over to help.”

C: “You seem a little sad.”

Client: “Well, she was waiting for her child who was in emergency. I think there was an accident or something. It was so hard to sit there and just watch, waiting you know.”

C: “Run the scene before you until you get to the end of that situation. Watch yourself handle it.”

Client: “I know I look helpless but in the end, she came and thanked me for just being there. Her daughter was alright.”

C: “That’s a smile.”

Client: “Well, it was such a good feeling on that day because in the middle of all the chaos, I sat with her and just kinda talked about stuff, to take her mind off it, and she thanked me in the end. I really felt like I did nothing.”

C: “But as you watch now…”

Client: “I think it felt good. When I see myself now, I know I handled it ok, for the first day and all, and I guess I felt I could make it.”

Chris noted that in that moment of starting work after his studies, he felt okay as a nurse. This helped him clarify that while he was not a doctor, his work was appreciated and valued as a nurse. Together he and C explored the notion of still becoming a doctor, but Chris said he felt secure in his current role. He noticed over the next few sessions since this realisation, that his feelings at work continued to improve, and that he felt happier and more valued as a staff member; and that his patients benefited from this. Despite the progress Chris had made with these feelings, it still left the issue of his unresolved feelings towards his father.

Through more discussion, Chris came to realise that the unresolved childhood event of not feeling as though he had lived up to his Father’s expectations, was still having an impact on his feelings of emptiness and unfulfilment. C explained the concept of the Empty Chair technique to Chris and he agreed to give it a try, although he was finding it difficult to put his feelings towards his father into words. As a brief explanation, here the client is asked to put feelings or thoughts into action.

For example, C encouraged Chris to use a kind of role playing (in this case, speaking to an empty chair because Chris’ father was not present). He was encouraged to tell his father how he felt about the expectations he felt as a child. Enactment here is intended as a way of increasing awareness, not as a form of catharsis and in the case of Chris he had difficulty expressing his feelings into words in front of C. Instead of badgering Chris to continue, C took a step back and changed the angle slightly and tried some integrating and body techniques.

Integrating techniques bring together processes the patient doesn’t bring together or actively keeps apart (splitting). The client might be asked to put words to a negative process, such as tensing, crying or twitching. Or when the client verbally reports a feeling, that is, an emotion, they might be asked to locate it in their body.

Another example is asking a client to express positive and negative feelings about the same person. The body techniques include any technique that brings clients’ awareness to their body functioning or helps them to be aware of how they can use their bodies to support excitement, awareness and contact. In this case C observed Chris sitting tightly and rigidly in the chair after trying to express his feelings to his father in the Empty Chair technique.

C: “Would you be willing to try another experiment?”

Client: Nods

C: “Take some deep, deep breaths and each time you exhale, let your jaw loosely move down.”

Client: Breathes deeply, lets jaw drop on the exhale

C: “Stay with it”

Client: Starts melting, crying, then sobbing

At this point Chris was more able to speak about his feelings and loudly started to express how he hated his father, and how angry he was. C let Chris vent his feelings, which had been suppressed for many years. This was a huge breakthrough for Chris, even more so because this issue had not been foremost in his mind when he entered counselling.

This powerful technique involving role-playing may sound artificial and might make some people feel self-conscious as it did for Chris in the beginning, but it can be a powerful way to approach buried feelings and gain new insight into them. While Chris still had some way to go in working through these feelings, this session was useful for him to open to the idea of working on self-awareness.

Session Summary

In summary, Chris’ counselling focused on a number of issues:

  • His initial complaint of negative thought patterns and pessimistic attitude to work and life
  • The number of stressors in Chris’ life
  • His feeling of being empty and unfulfilled in life which expanded into the issues of not living up to his father’s expectations and sacrificing a medical career

The techniques of CBT helped Chris rapidly get a hold on his negative thought patterns and he was able to implement these in his life quite quickly. Visualisation techniques helped Chris explore his notion that perhaps he still wanted to be a doctor instead of a nurse. Finally, Gestalt techniques helped Chris begin to understand his unresolved feelings towards his father.

After the session involving the Gestalt technique of the empty chair, Chris opted to change his weekly sessions to fortnightly for 2 sessions, and then visited monthly for two more sessions. He stated at this time that life had settled back down to “normal”, meaning that he was coping well at work, had mapped out a timetable to finish his nursing studies and that his marriage was happy. He discussed that Michelle constantly pointed out the positive changes in him and this made him feel even more in control of his feelings, thoughts and behaviours.

Chris stated that the feelings of anger and resentment towards his father had subsided although he found himself pondering his childhood a little more now than he used too. He said that the counselling had worked to a degree with this issue, but because he had not realised it when he came into counselling, he was still coming to terms with his feelings.

He and C discussed this being a normal phenomenon, and the notion that if in the future the issue proved too difficult to handle, or started to again interfere in Chris’ life, then future sessions might be necessary. Chris described that he was particularly positive about his future, about spending more time with his son and wife, and felt more in control than he had ever been before.

Author: Peta Hartmann

Related Case Studies: A Case of Stressful Life Change , A Case of Low Self Esteem , A Case of Using a Person-Centred and Cognitive-Behavioural Approach to Burnout

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Trust and respect in the patient-clinician relationship: preliminary development of a new scale

Paul crits-christoph.

University of Pennsylvania, 3535 Market St (Room 650), Philadelphia, PA 19104 USA

Averi Gaines

Mary beth connolly gibbons, associated data.

The dataset used and analyzed curing the current study are available from the corresponding author on reasonable request.

Trust and respect may be an important component of client-provider relationships. This study aimed to develop and report preliminary psychometric analyses of a new brief measure to evaluate a patient’s level of trust and respect for their clinician. The scale was designed to be applicable in multiple healthcare contexts, with a particular focus on mental healthcare.

Adult patients completed the study survey in an academic outpatient psychiatric clinic waiting room. Classical and Item Response Theory (IRT) analyses were utilized to examine the adequacy of scale items. Validity was examined in relation to the patient-therapist alliance and to willingness to share private information (social media content) with one’s clinician.

Beginning with 10 items, a final 8-item version of the measure was created with an internal consistency reliability of .91. Principal components analysis indicated that the scale was best viewed as capturing one overall dimension. A Graded Response Model IRT model indicated that all items contributed information on the latent dimension, and all item curves were not flat at any region. The correlation of the trust/respect total score with the alliance was .53 when respect-related items were deleted from the alliance score. The trust/respect scale was significantly associated with patient willingness to share social media posts with their clinician but the alliance was not.

Conclusions

The brief measure of patient trust and respect towards their clinician was unidimensional, showed good internal consistency, and was not redundant with existing measures of the alliance. The scale has the potential to be used in a wide variety of healthcare settings.

Trust has been described as perhaps the most important ingredient for the development and maintenance of happy, well-functioning relationships [ 1 ]. Indeed, major theories of human psychosocial development such as Bowlby’s [ 2 ] attachment theory and Erikson’s [ 3 ] theory of stages of development emphasize the idea that trusting relationships early in life build a foundation for better functioning in adulthood. Despite the prominence of Bowlby’s and Erikson’s theories, and the importance of trust within such theories, there has been surprisingly little empirical research on trust in close relationships. The existing empirical studies on trust in the personality and social psychology literature have provided evidence that degree of trust in close relationships maps onto attachment patterns. For individuals with a secure attachment style, compared to those with an insecure attachment style, greater trust is associated with more constructive coping strategies where there is a violation of trust in love relationships [ 4 ]. In addition, within close relationships, individuals develop trust in their partners when they perceive that their partners have demonstrated pro-relationship behaviors rather than only behaviors that show self-interest [ 5 ].

Such findings from personality and social psychology have clear potential relevance to patient-provider relationships, particularly the relationship between patients and psychotherapists. For example, level of patient trust in the therapist may be critical to working through ruptures in the therapeutic relationship. Extrapolating from the findings of Wieselquist et al. [ 5 ], it seems likely that therapist actions that are perceived by the patient as pro-relationship such as self-disclosure, fee reductions, and referrals for additional services, might be particularly useful for building trust in psychotherapy. However, there has been little research specifically on the patient level of trust toward psychotherapists.

Relevant to the concept of trust is the literature on the therapeutic alliance in therapy. In his seminal paper defining the alliance, Bordin [ 6 ] discusses the bond component of the alliance in the following way: “Some basic level of trust surely marks all varieties of therapeutic relationships, but when attention is directed toward the more protected recesses of inner experience, deeper bonds of trust and attachment are required and developed” (p. 254). Consistent with Bordin’s [ 6 ] discussion of the bond, virtually all alliance scales contain at least one item referring to mutual trust. “Mutual trust” is likely overlapping, but not identical to, the patient’s individual level of trust towards the therapist. Moreover, such scales also include, and are actually primarily composed of, items not specifically related to trust. For example, the following items are included within the Bond subscale of the Working Alliance Inventory (WAI) [ 7 ] client long-form version, in addition to mutual trust: comfort with therapist, mutual understanding, liking of therapist, genuine concern by therapist, therapist appreciation, importance of relationship, feeling cared about, and feeling that if one says or does the wrong things the therapist would stop working with the patient. Thus, while the WAI Bond scale includes an item on mutual trust, the scale is not geared toward more specifically investigating patient level of trust in their therapist.

Still, given the inclusion of trust items within alliance scales, the empirical alliance literature has some bearing on the role of trust in psychotherapy. Although some research has suggested that, at least within the context of cognitive therapy, agreement on tasks and goals is the critical aspect of the alliance that leads to positive outcomes [ 8 ], other research has emphasized the importance of the bond component as a predictor of psychotherapy outcome [ 9 ].

Such findings regarding the bond component of the alliance are consistent with Bordin’s [ 6 ] theorizing on the importance of mutual trust in therapeutic relationships. However, it is not clear from the existing literature which facet of that bond is critical to positive treatment outcomes. Many studies only focus on the total alliance as an amalgamation of many relationship qualities, rather than on specific subcomponents of that relationship. As described above, the Bond scale of the WAI includes a diverse (though correlated) set of items, and its subscales are composed of a mixture of items that have a focus on mutual feelings (e.g., mutual trust) and items that highlight individual feelings (e.g., patient’s view of the therapist’s honesty). Thus, the extent to which the patient’s feelings/beliefs towards the therapist, versus a sense of mutual feelings/beliefs, is critical in the process and outcome of therapy is not clear when using alliance scales, including the WAI.

Beyond the alliance, a few studies have focused more specifically on trust in the patient-therapist relationship. One study of 17 clinicians and 48 patients by Peschken and Johnson [ 10 ] used a modified version of the Dyadic Trust Scale [ 11 ] that was developed for measuring trust among intimate partners. The study found that therapist ratings of trust in their clients correlated positively with therapist ratings of facilitative conditions, and that client ratings of trust in their therapists correlated positively with client ratings of facilitative conditions. But, therapist ratings of trust did not correlate with client ratings of trust, and neither set of ratings correlated significantly with current symptom levels. Limitations of this study include the fact that clients and therapists rated trust in general, not current (i.e., session or weekly) level of trust, the use of a modified scale designed for use with intimate partners without validation for use in therapy, and the lack of examination of trust in relation to outcome of treatment. The lack of a significant relationship between therapist trust of their client and client trust of their therapist is of particular interest, as it suggests that these two constructs should be measured separately. Along these lines, an early study found that therapist self-disclosure, which one can hypothesize is likely more common when the therapist trusts the client, actually has a negative association with client trust of the therapist in an analogue therapy interaction [ 12 ].

Another measure of client trust of their therapist is the “trustworthiness” subscale included within the Counselor Rating Form (CRF) [ 13 ]. The CRF has been used by observers rating tapes of psychotherapy (e.g., [ 14 ]) and by patients in treatment rating their counselor (e.g., [ 15 ]). Two studies, however, have concluded that a separate trustworthiness factor is not apparent in the CRF [ 16 , 17 ], further suggesting that existing measures are not sufficient in capturing the construct of patient trust in their therapist. In addition, the CRF has been found to correlate very high (0.78) with the alliance [ 18 ]. Though some degree of overlap with the alliance is to be expected, ideally a scale measuring patient trust and respect towards their clinician would not be redundant with alliance scales that measure agreement on tasks, agreement on goals, and strength of the bond as defined as mutual trust, respect, and liking.

Separate from research on psychotherapy, there has recently been considerable attention paid to trust in the patient-clinician relationship within the context of primary care and other medical interactions [ 19 , 20 ]. Trust in physicians in the United States is notably a concern. A survey found that the United States was tied for 24th place internationally in terms of the proportion of adults who agree with the statement, “All things considered, doctors in [your country] can be trusted” [ 21 ], with only 58% of adults in the U.S. agreeing with the statement. Over the years, a variety of scales have been developed for measuring trust in the context of medical care interactions (e.g., [ 22 – 24 ]). The items of these scales, however, often focus on characteristics of medical doctors that might further trust (e.g., “sometimes you worry that your doctor’s medical decisions are wrong,” “your doctor has better medical skills than most other doctors in his or her field”). Such scales may be measuring aspects of provider competence that may, or may not, further trust in the relationship, rather than directly measuring the interpersonal and emotional dimension of trust. One can imagine a provider who competently accomplishes needed tasks for a patient, but for whom the patient still does not have a strong feeling of trust towards. Moreover, the types of behaviors that primary care doctors perform (reflected in items such as “your doctor would never prescribe the wrong medicine for you”) have less applicability to psychotherapy, especially when conducted by non-M.D. providers.

A related construct to trust is respect. In general healthcare settings, the patient’s perception of whether their doctor displays respect towards them has been found to be the best predictor of patient’s overall rating of their view of their doctor [ 25 ]. In psychotherapy, the importance of a therapist adopting a respectful view of their patients can be traced back to Carl Roger’s [ 26 ] central concept of unconditional positive regard. Surprisingly, few quantitative studies of psychotherapy have explicitly focused on the patient’s reported respect for their therapist. However, a review of 13 qualitative studies found that disrespectful behaviors by therapists were one important barrier to the formation of a positive therapeutic relationship [ 27 ]. Thus, measuring patient respect for their clinician might provide a window into the development of a positive relationship and consequently better outcomes.

Most alliance scales contain one or two that specifically focus on respect. The WAI has an item on mutual respect that is included within the Bond scale. Given the definition of respect as “a feeling of deep admiration for someone or something elicited by their abilities, qualities, or achievements” [ 28 ], one can imagine a patient who respects a clinician (e.g., because the clinician has received training from the best Universities, written books, received accolades, etc.), but has no idea as to whether that clinician in turn respects them and therefore mutual respect is not rated highly on the WAI. Furthermore, it might well be the case that some patients have some level of respect for their clinician based on professional credentials and accomplishments alone, but a high level patient personal respect for that clinician may or may not be present. Whereas the “bond” between patient and therapist, as reflected in mutual trust and respect, is likely to be an essential ingredient for successful psychotherapy, it may also be the case that certain research, and perhaps clinical, agendas would be better served with a scale that focuses directly on the patient’s level of trust and respect for their clinician. For example, impairment in trust within interpersonal relationships is a central feature of borderline personality disorder (see [ 29 ] for a review). Monitoring levels of trust over the course of treatment among patients with borderline personality disorder might be a way to track improvement in this aspect of the disorder.

The goal of the current project was to propose a new scale to measure patient trust and respect for their clinicians. Our aim was to develop a scale that could be applied to psychotherapy as well as other patient-clinician contexts (e.g., medication management, case management), and be used repeatedly (e.g., at every visit) to measure changes in trust and respect over time. We report psychometric analyses of the new scale using both classical and item response theory methods, along with preliminary validity data. In regard to validity, we explored the overlap of the new scale with a measure of the alliance and the relation of the trust/respect scale to patients’ willingness to share private information with their clinician.

Initial development of scale

We generated items for the new scale by attending initially to the definitions of trust and respect provided by dictionaries. Because our goal was to develop a scale that might be used at every visit, brevity was essential. Items were chosen and refined during multiple group meetings of clinicians and researchers. A set of 10 items, five for trust (key words: reliable, truthful, trust, confidence in, count on) and five for respect (key words: respect, admire, have high opinion of, hold in high esteem, appreciate), were identified through these discussions for initial testing, with the potential aim of reducing to four items each for trust and respect, should the psychometric evaluation suggest that some items were less than desirable and an adequate scale could be created with the reduced number of items. Each item is rated on a 1 ( strongly disagree ) to 7 ( strongly agree ) scale, with half of the items negatively worded. The final list of items is provided in the Additional file 1 and is available for public use at no charge. After item generation, the 10-item scale was administered to patients currently in treatment at an academic-based psychiatry outpatient clinic. If patients saw more than one clinician at the clinic, they answered the questions related to the clinician they were seeing the day of the assessment.

Participants (aged 18 or above) were recruited by research assistants in the waiting room of the outpatient psychiatry clinic. All patients were eligible regardless of the types of services they were currently receiving (i.e., medication management, psychotherapy, or both). Patients received no compensation for participation. All patients provided written informed consent and the study was approved by the University of Pennsylvania Institutional Review Board committee #8. Patient responses were anonymous and were not shared with their clinicians.

The academic-based outpatient clinic provides psychiatric services to individuals 18 or above. Services offered include diagnostic evaluations, delivery of evidence-based psychotherapies, medication management using evidence-based decision support, and group therapies. The clinic offers specialized treatment of bipolar disorder, treatment resistant depression, anxiety disorders, substance abuse, psychosis, geriatrics, and medical-psychiatric conditions. Approximately 500 new patients each year seek services at the clinic. The clinic is staffed by 15 psychiatric residents, six attending physicians, five full-time staff psychologists, and four part-time psychologists.

A measure of the patient-therapist alliance was included to determine if the new trust/respect scale was redundant, particularly with the bond component of the alliance. The revised short-form client version of the Working Alliance Inventory (WAI-SR) [ 30 ] was used to assess the alliance. The total score of the WAI-SR has been previously reported to have an internal consistency (Cronbach’s alpha coefficient) in the range of .91 to .92 [ 30 ]. In the current study, the WAI-SR total score had an alpha coefficient of .92. Internal consistency of the 3 subscale scores were as follows: Bond: .86; Agreement on Tasks: .81; Agreement on Goals: .86. We also created a modified Bond scale, deleting the two WAI-SR items that addressed respect (“My therapist/doctor and I respect each other” and “I feel that my therapist/doctor appreciates me”) and retaining the two items that did not (“I believe my therapist/doctor likes me” and “I feel my therapist/doctor cares about me even when I do things that he/she does not approve of”). The internal consistency of this modified Bond scale was .82.

Willingness to share social media posts with clinician

To assess construct validity, we included an assessment of whether or not the patient was willing to share information not typically shared with a clinician as part of treatment. We hypothesized that patients would be more willing to share such information when they have higher levels of trust and respect for their clinicians. Patients were asked if they would be willing (“yes” or “no”) to share their social media posts (assuming they make such posts) with their therapist if their therapist was concerned about how they were doing.

Statistical analyses

Initial analyses included descriptive statistics, principal components analysis to examine dimensional structure, internal consistency using Cronbach’s alpha, and corrected item-total correlations. A unidimensional Item Response Theory (IRT) method was then used to further investigate the psychometric properties of the scale using the SAS (version 9.4) IRT procedure. We implemented the Graded Response Model (GRM), which is appropriate for analyzing polytomous Likert style item responses. Within IRT, the amount of information that each item, or the test as a whole, provides is not evenly distributed across the entire continuum of the latent construct. The amount of information provided by each item is quantified in terms of the value of the slope parameter. A slope value below 1.0 was used as a threshold for detecting less discriminating items [ 31 ]. Finally, construct validity was examined by evaluating correlations between the new scale, the alliance, and patient willingness to share social media post information with their clinician. The relations of demographic variables (age, gender, minority status) to the new scale were also examined.

The set of questionnaires was completed by 218 outpatients. Women comprised 60.6% of the sample. The age range was 18 to 84, with an average age of 40.3 ( SD  = 16.0). The racial composition of the sample was 70.2% White, 23.9% Black/African American, 2.3% Native American or Alaska Native, 2.8% Asian, and 3.2% “Other or Unknown” (percentages add to more than 100% because respondents could endorse more than one race). Hispanic ethnicity was endorsed by 6.0% of the sample. Of the 218 patients, 74 (33.9%) were receiving medication management only, 32 (14.7%) were receiving psychotherapy only, and 112 (51.4%) were receiving both medication and psychotherapy services from the clinic.

The internal consistency of the total score for the initial 10 items was .91 and all items had satisfactory corrected item-total correlations, ranging from .58 to .77 (Table  1 ). Because brevity was a goal, we examined the internal consistency of an 8-item scale by deleting the two items with the lowest corrected item-total correlation. The internal consistency of the 8-item scale was also .91 and, therefore, we proceeded with the eight items. A principal components analysis of the eight items revealed only one eigenvalue greater than 1, with this first component explaining 74% of the overall variance. It was therefore concluded that the 8-item scale was best viewed as capturing one overall dimension. The overall mean (SD) for the total of the 8 items was 49.6 (7.9).

Item Means, Standard Deviations, and Corrected Item-Total Correlations

N  = 209. Items 2, 3 (deleted in final version), 6, 7, and 10 are reverse scored

Table  2 shows the slope parameters when a unidimensional GRM IRT model was fitted to the eight items. All items had slope coefficients that were considerably above the 1.0 minimum threshold rule of thumb, indicating that all items contributed information on the latent dimension and, thus, no items should be dropped. We inspected the item information curves and found that all curves were not flat at any region, which suggests that the items are reliable across the range of the latent variable. The test information curve is shown in Fig.  1 . The curve peaks between − 2 and − 1 standard deviations below the mean with another small peak at the mean. Above the mean, the curve goes steeply down between the mean and about +.5 standard deviations, and at a very high level (z scores above 2.0), there is no information provided by the scale to differentiate respondents.

Item Slopes from Item Response Theory Graded Response Model

An external file that holds a picture, illustration, etc.
Object name is 40359_2019_347_Fig1_HTML.jpg

Test Information Curve for Total of 8-Item Trust/Respect Scale

For assessing concurrent validity, we examined correlations of the total of the 8-item trust/respect scale with the alliance (Table  3 ). Although moderate in strength, correlations with the WAI-SR total score and subscale scores were well below the reliability of the 8-item trust/respect scale. In particular, the correlation with the WAI-SR Bond scale was .55, which reduced to .53 when WAI-SR items related to respect were deleted from its Bond scale. Among patients receiving psychotherapy, a small to moderate, but significant, correlation ( r  = .28; p  = .004; N  = 106) was apparent between trust/respect for one’s clinician and willingness to share social media posts with one’s clinician. The correlation between the WAI and willingness to share social media posts was not significant ( r  = .16, p  = .09).

Correlations of 8-Item Trust/Respect Total with Other Measures

WAI Working Alliance Inventory

** p  < .001

* p  < .005

Age ( p  = .99) and gender ( p  = .23) were not significantly associated with the total trust/respect score. However, higher trust/respect scores were apparent for White patients compared to all other patients who did not self-identify as White ( r  = .19, p  = .009). This effect of lower trust/respect scores was particularly strong for a comparison of Black patients to all others ( r  = −.25, p  < .001).

This article reports the development and validity of a trust/respect scale of patients for their clinicians. Though developed in the context of patients receiving treatment at an outpatient psychiatric clinic, the scale items were worded to have broad patient-clinician use. The final 8-item single dimension scale showed good internal consistency and reliability, and all items contributed information to the total score.

The result that a single latent dimension was mostly evident, rather than separate dimensions related to (a) trust and (b) respect, raises the question of whether the scale is primarily measuring a patient’s positive overall view of their clinician, rather than more specifically assessing their levels of trust and respect. A so-called “good guy” effect (i.e., the tendency for patients to view their therapists as generally good or bad) was hypothesized to account for the high intercorrelations among the subscales of the Counselor Rating Form by Corrigan and Schmidt [ 32 ]. To some degree, this seems likely with our new scale as well. However, the fact that the total trust/respect scale was only modestly correlated with the alliance, including the Bond scale, suggests there is a dimension partly independent of the alliance that is captured by the new trust/respect scale. In addition, the small-to-moderate association of the trust/respect scale with patient willingness to share information not normally shared with one’s clinician (social media posts), taken together with the lack of a significant association of the alliance with willingness to share social media posts, suggests that the new scale is measuring something related to trust and not simply a “good guy” effect or alliance dimension.

It is important to note that the IRT analyses revealed that more reliable information is obtained from patients that rate their trust/respect lower than the average patient. For scales with high mean scores such as the current scale (i.e., average item rating of 6.2 on a 1 to 7 scale), it is expectable that there is little reliable information in the high range. However, it is the low range of the scale that would be of more interest to clinicians and researchers. The critical question is: what is going with patients who are reporting impairments in trust/respect towards their clinician, and how can such impairments be addressed? The ability of the scale to discriminate between very positive and extremely positive trust/respect responses likely has little clinical relevance.

Scores on the trust/respect scale were not associated with age or gender. However, there was a tendency for patients who self-identify racially as White compared to other racial groups to have higher trust/respect scores. Those who racially identified themselves as Black were particularly likely to have relatively lower trust/respect scores towards their providers, a result consistent with findings of lower levels of trust towards physicians evident for non-Hispanic Blacks compared to Whites [ 33 ]. Such differences in trust can have clinical implications. For example, Black women with high blood pressure who trusted their health care providers were found to be more adherent to their prescribed antihypertensive medications than those who did not trust their health care providers [ 34 ]. With regard to mental health, lack of trust has been identified as one possible barrier for Black patients in seeking mental health services.

The new trust/respect scale opens up a number of questions that can be investigated empirically. For example: Is the combination of a positive alliance and positive patient trust/respect for their provider particularly predictive of treatment outcome? To what extent does trust/respect change over the course of treatment? What therapist actions, or clinician behaviors in other contexts besides psychotherapy, contribute to the formation and maintenance of positive trust and respect? Can alerting clinicians to negative patient reports, or ruptures, in the level of trust/respect assist such clinicians in restoring adequate trust/respect?

The current results are only preliminary and several limitations are important to note at this stage. For one, more extensive examination of the validity of the new scale is warranted. The extent to which scores are influenced by social desirability will be important to assess. Another major limitation is that we have proposed that the scale be used in a variety of patient-clinician settings, but thus far has only been investigated in the context of mental health services. A further limitation is that responsiveness to change has not been examined in the current study.

With these limitations in mind, the current report provides promising preliminary data on a new, brief, trust/respect scale. The development of this scale will permit further investigation of these central, but relatively overlooked, aspects of patient-therapist and patient-doctor relationships.

Supplementary information

Acknowledgements.

The authors acknowledge and thank the patients, who participated in this study, and the staff of the outpatient clinic, who facilitated the data collection.

Abbreviations

Authors’ contributions.

PCC designed the study, analyzed and interpreted the data, and was the major contributor in writing the manuscript. AR collected the data and assisted in writing the manuscript. AG assisted in data collection and assisted in writing the manuscript. MBCG assisted in designing the study and writing the manuscript. All authors have read and approved the manuscript.

Research reported in this publication was supported by the Robert Wood Johnson Foundation. The content is solely the responsibility of the authors and does not necessarily represent the official views of the Robert Wood Johnson Foundation, which had no role in the design of the study, data collection, data analysis, interpretation of data, or in writing the manuscript.

Availability of data and materials

Ethics approval and consent to participate.

This study was approved by the University of Pennsylvania IRB. Participants provided written consent before participating.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary information accompanies this paper at 10.1186/s40359-019-0347-3.

Case study: management and counselling of a patient with rheumatoid arthritis

Exploring questions to be considered when managing a patient with rheumatoid arthritis.

Managing a patient with rheumatoid arthritis. In the image, close up of the hands of a senior woman with rheumatoid arthritis

Shutterstock.com

Case scenario

Mrs PJ is a 67-year-old woman with rheumatoid arthritis. Her current prescription includes:

  • Salazopyrin EN 500mg twice a day;
  • Diclofenac 50mg three times a day;
  • Paracetamol 1g up to four times a day when required.

She collected her first prescription for sulfasalazine two weeks ago. She has returned to the pharmacy and asks to speak to you. She has several problems with her medication which she wishes to discuss. First, she complains that her medication is not working properly and she tells you that she has not noticed any benefit from it. She asks you whether you think she should make an appointment with her GP to discuss this.

Case discussion

patient counselling case study

Pharmacy Case Studies by Soraya Dhillon and Rebekah Raymond. Pp 471 £29.99. London: Pharmaceutical Press; 2009. ISBN 978 0 85369 724 4

This discussion, adapted from Pharmacy Case Studies [1]   published by Pharmaceutical Press, highlights the main questions to be considered in managing Mrs PJ’s case. 

How is the dose of sulfasalazine normally initiated and titrated?

The patient should start with one tablet daily, increasing their dosage by a tablet a day each week until one tablet four times a day, or two tablets three times a day are reached, according to tolerance and response.

Why is the dose increased gradually?

Nausea may be a problem for some patients, hence the dose is titrated up gradually to avoid this.

What advice would you give Mrs PJ in answer to her question? 

Mrs PJ should be informed that the onset of effect of sulfasalazine is slow and an initial benefit may not be seen for 4–16 weeks. It would be useful to check what instructions Mrs PJ has been given regarding the titration of her medication. She is currently on a dose at the lower end of the titration scale.

You could ask Mrs PJ when her follow-up appointment with the prescribing doctor is due. If she has an appointment in the very near future, her dose may be increased at that consultation. 

If Mrs PJ has not been given a titrating dose, it may be worth suggesting that she contacts her prescribing doctor to confirm the instructions given to her at the initial appointment. It is important to reiterate that the onset of action of the sulfasalazine is slow.

Mrs PJ also mentions that she has to go to her practice nurse for some blood tests but she’s not sure why. The British National Formulary recommends that liver function tests, full blood counts and renal function tests are carried out regularly.

How often should the above tests be performed?

Close monitoring of the full blood count and liver function tests is necessary initially and then at monthly intervals for at least the first three months of treatment. Renal function tests may be performed periodic­ally, as recommended by the manufacturers.

Why should these tests be performed?

Side effects of sulfasalazine include blood dyscrasias which usually occur in the first 3–6 months of treatment. The full blood count should be checked regularly so that any haematological abnormalities can be ­identified at an early stage. 

There have been reports of hepatitis and renal dysfunction in patients taking sulfasalazine, therefore liver function tests and renal function tests should be performed at regular intervals.

In the course of the conversation, Mrs PJ tells you that since she has started taking her new medication, she has been experiencing stomach discomfort about half an hour after she has taken her tablets. 

What do you think could be the cause of this problem?

As the symptoms initially appear to be related to her medication she may be experiencing gastric irritation as a result of her diclofenac or she may be suffering from nausea due to the sulfasalazine. Ask Mrs PJ whether she is suffering from any alarm symptoms like gastrointestinal bleeding, unintentional weight loss, difficulty swallowing, abdominal swelling or persistent vomiting. If Mrs PJ is experiencing any of these symptoms, she should be referred to her GP urgently.

What suggestions could you offer Mrs PJ to help resolve this problem?

With further questioning, it may be possible to clarify the symptoms and to ascertain whether one of the drugs is likely to be causing the problem. You should check that Mrs PJ is taking her diclofenac with food so as to reduce the risk of gastric irritation. If you decide that the problem is likely to be dyspepsia, in most cases an antacid may help. In this case, however, an antacid could not be taken at the same time as either sulfasalazine or diclofenac. This is because both are enteric-coated tablets and the presence of an antacid may lead to the premature dissolution of the coating due to the presence of an alkaline pH. Therefore, the use of an antacid would not be a suitable suggestion.

As this is a suspected adverse drug reaction, it would be prudent to suggest to Mrs PJ that she returns to her GP to discuss this issue with them.

What alternative medication might a doctor prescribe to help Mrs PJ with her upset stomach?  

If the doctor decided that the cause of Mrs PJ’s upset stomach may be non-steroidal anti-inflammatory drug (NSAID)-induced dyspepsia, it would be usual to stop NSAID treatment. However in the case of Mrs PJ, this might not be possible due to her concurrent medical history of rheumatoid arthritis. 

The doctor may decide to stop the NSAID and see how Mrs PJ ­manages without the diclofenac or may consider adding in a proton pump inhibitor, in line with Clinical Knowledge Summaries guidance [2] , to manage the incid­ence of NSAID-induced dyspepsia. If it is felt that the problem is related to the sulfasalazine and the nausea does not abate, the doctor may try an alternative treatment. As Mrs PJ is currently only on a low dose of sulfasalazine it would not really be possible to reduce the dose and still maintain efficacy.

Four months later, Mrs PJ returns to your pharmacy. She says that she still has not had much benefit from her sulfasalazine despite the fact that her dose has been titrated to an appropriate level.

What are the goals of therapy when treating rheumatoid arthritis?

When treating rheumatoid arthritis, the goals of therapy are to reduce the symptoms of the disease, slow progression of the disease and limit the amount of joint deformation, while improving the patient’s quality of life.

Please list the alternative treatments that may be used in the management of rheumatoid arthritis and briefly discuss when an alternative treatment would be tried.

When a drug has been titrated to the maximum dose that can be tolerated and the level of disease control is still unacceptable, therapy may be switched to an alternative agent or another drug may be added in. Other treatments available for managing rheumatoid arthritis include:

  • methotrexate
  • gold injections
  • antimalarials
  • leflunomide
  • penicillamine
  • ciclosporin
  • azathioprine
  • cyclophosphamide
  • cytokine modulators
  • corticosteroids

Nicola Parr , BPharm (Hons), MSc, MRPharmS is senior pharmacist, Addenbrooke’s Hospital, Cambridge and Tracy Garnier , BSc (Hons), PhD, PgCert, MRPharmS is principal lecturer in pharmaceutics, School of Pharmacy, University of Hertfordshire.

[1]   Pharmacy Case Studies by Soraya Dhillon and Rebekah Raymond. Pp 471 £29.99. London: Pharmaceutical Press; 2009. ISBN 978 0 85369 724 4

[2]  Clinical Knowledge Summaries (2015) Dyspepsia. Available at:  http://cks.nice.org.uk/dyspepsia-unidentified-cause#!scenario:2

General reference

Bryant DM & Alldred A. Rheumatoid arthritis and osteoarthritis (2007). In: Walker R and Whittlesea C (Eds)  Clinical Pharmacy and Therapeutics , 4th edn. Edinburgh: Churchill Livingstone.

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A Case Demonstrating Person Centred Therapy

Author: Jane Barry

Michael has made an appointment to see his School Counsellor. He is due to finish school this year and is undecided about what direction he should take once he leaves school. Michael is a high achiever and his parents want him to make the most of his opportunity to enter University and study Law or Medicine. Whilst Michael is interested in Medicine, he feels that his interests at the moment are directed towards working and travelling abroad. He wants to discuss his preferences with the School Counsellor and to talk about the pressure he has been experiencing.

For ease of writing, the Professional Counsellor is abbreviated to “C”.

Essential Case Information

“C” has known Michael for the last 18 months and has developed a rapport with him. Michael and his parents have visited “C” a few times to discuss Michael’s career options and the subjects that would benefit him the most. From these meetings, “C” has ascertained the following information. Michael’s parents would like him to achieve a high OP score and are encouraging him to pursue science and maths subjects to allow him access to University to study Law or Medicine. Michael’s father is a Barrister and would like to see his son follow on in his professional footsteps. Michael’s mother wishes for Michael to have a professional career, but she has also encouraged his interest in arts, history and travel.

Both parents have contributed considerable time and energy into Michael’s education and Michael is very grateful for their support. As he has a very close relationship with his parents, Michael feels a great deal of pressure to follow the goals that they have set for him. Whilst he would like to follow a career in Medicine, he is not sure that he has the life experience to make such an important decision. After the last meeting, Michael confided to “C” that he did not want to go into university straight after school. If he could have his own way, he would prefer to take some time off from study and travel for a while. He has a close group of friends who are interested in welfare work. Together they have plans to travel and work voluntarily. These dreams with his friends seem exciting and challenging to him and would allow him some time to come to a decision about his career.

Michael has talked to his parents about travelling, particularly to his mother. She is understanding of his need to see the world and to experience a different side to life, however she is also concerned that he is still very young and inexperienced. She would prefer to see him enter University first and travel when he gets a little older. Michael’s father is also concerned about Michael’s preferred directions. He fears that if Michael doesn’t undertake University at this age, he may spend his life wandering around the world, without any substantial training to fall back on. Michael’s older sister (Theresa) has dropped out of her studies and has spent the last 5 years travelling. Michael’s father does not want to see his son follow the same direction as his sister. He has offered to finance his son’s further education if he enters university directly after school.

“C” has previously administered a Personality Need Type Profile for Michael, and has found him to have moderate type C/D needs. After some discussion with Michael, “C” believes that he has fairly high need gratification through his school work and home life, however the disagreement with his parents has been causing him some discomfort, particularly because of his security needs.

Session Content

“C” has decided to use a person-centred approach with Michael. “C” believes that Michael has the resources to come to his own decision about his life. Because of the rapport that already exists between “C” and Michael, “C” suspects that Michael may look to him to acknowledge his right to choose his own path. Because of “C’s” respect for both Michael and his parents, “C” believes that a person centred approach would be of benefit, to ensure that the responsibility for the decision remains with Michael.

When Michael arrives, “C” begins the session by making him comfortable and asking some questions about his sports interests. Both “C” and Michael are interested in touch football, and it is a topic that they have discussed in some detail in the past. As this conversation draws to a close, “C” asks Michael about his reasons for making the appointment.

As Michael explains the difficult decision he has to make, “C” pays close attention to Michael’s body language and his description of feelings. “C” attempts to make Michael feel listened to by making eye contact with him and by sitting forwards, in a more active listening position.

“As you know, Mum and Dad are really keen for me to go to University next year, but I really don’t like the idea. I’m not looking forward to more years of study yet,” Michael explained. “I’m getting to the point where I don’t want to do any more study after this year, I’d rather hang out with Paul and Mica. Their parents don’t put the same pressures on them to study and they don’t mind if they travel after leaving school. Compared to them, I feel like I’m wrapped up in cotton wool.”

“C” paraphrased Michael’s comments, focussing on his feelings, “so your feeling that you haven’t got as much freedom as your friends do.” “Well, yeah,” replied Michael, “I’ve always gone along with what Mum and Dad wanted, and so I’ve never had any reason to really disagree with them, and I’ve always kinda wanted what they wanted anyway. But now I don’t. Sure it will be great to go to University one day, it’s not like I’m going to be like my sister and never come home, but Dad is really paranoid about it.”

“C” responded, “It sounds like you’ve got some plans of your own, that are different to your sister’s and your fathers, is that right?”

“Definitely,” Michael said with emphasis. “Definitely,” “C” replied, “you said that with a lot of conviction!” “Yeah,” Michael replied, “you know, I’ve got some really good ideas of where I want to go and what I could do with my life.” “That’s great,” responded “C”, “I’d really like to hear about them.”

As Michael describes his plans for the future, “C” listened carefully and felt proud of the goals Michael was setting himself. “C” appreciated the strength of character that Michael demonstrated, for someone of such a young age. “C” felt that Michael had both the conviction and determination to create meaningful goals for himself and to carry them through.

Michael felt excited and elated to talk about his plans so candidly with someone. He felt that “C” had a deep appreciation of his needs, which inspired confidence in himself and the goals that he dreamed about. Michael was surprised and heartened by the depth of his convictions and the strength of his belief in his goals. Having someone listen to him so intently made him feel special and worthwhile. He genuinely felt that his world was an exciting and challenging place to be.

“C” expressed some of his thoughts to Michael, so as to further convey his genuine concern for Michael. “You certainly seem to have some very clear goals for yourself. From what I know of you, you’re a very determined young man and you’ve achieved very well at the subjects that you’ve taken on. I am sure that you can achieve all of your goals if you keep your determination. It takes a lot of maturity, and a certain type of person to be able to identify your goals so clearly. I can imagine that it must be frustrating to experience some obstacles to reaching your dreams.”

“Yes…I’m not sure what to do about that,” replied Michael. “I know that my parents mean well and are worried for me, but, I think that I want them to support me in other ways now.” “How is their support of value to you,” inquired “C”.

“Probably more valuable than what I realise! You know, they’ve done a lot for me. I’ve always been into a lot of things and they seemed to have sensed that and tried to give me lots of opportunities. In some ways we’re a well suited family, you know? They want a son who achieves well, and I just want to achieve. Up until this point, we’ve mostly agreed about what I achieve at. My sister is different though, she is happier to just accept life as it comes along and she never used to like Dad pressuring her to do stuff. They used to argue a lot and sometimes I think she saw going overseas as a way to escape and be herself.”

“Dad was pretty upset when she went, I think he took it personally. I know he would just go crazy if he thought that I was going to do the same thing. I just wonder if I can ever get him to see that the decisions Theresa made and the ones I want to make have got nothing to do with him. I really don’t want him to think that I’m ungrateful or doing it to spite him.”

“C” reflected, “it sounds like your pretty grateful to your father and that you respect him. It also sounds like you are trying to find some ways to tell him about your plans, whilst still respecting him.”

“Yeah, though I’m still afraid that he won’t agree to my plans,” replied Michael.

“C” responded, focussing on his feelings, “can you tell me more about your fears?” “Well,” Michael replied, “I don’t know, I guess I fear that he’ll back off and not offer me any more chances to go to University.”

“How would you feel if that happened,” inquired “C”. “Really let down, and angry too. I mean, he’s got to let me make my own life now. I’m not just a kid any more,” Michael responded, frowning.

“C” reflected Michael’s meaning back to him. “You’re feeling angry about your lack of freedom and you want your father not to treat you like a kid any more. You want to go to University some day, but you’d like to have a break from study and travel with your friends. You’re afraid that your father will not accept your decisions and you will lose respect for each other. Does this sound right to you?”

Yeah, Michael sighed, “so what am I supposed to do? Why won’t Dad give me some credit for my own sense? Does he think that I’m going to be a kid for the rest of my life? I deserve to make my own plans,” complained Michael.

“C” nodded and responded, “they’re all important questions Michael, what do you think some of the answers might be?” “I don’t know,” replied Michael, “I thought that you could help me out there.” “Hmm,” said “C”, “that’s a tough one. I can see why you’re having such difficulty in making a decision. On the one hand, you’ve got some very exciting plans of your own that you want to fulfil. On the other hand, your trying to consider the plans that your parents are offering you, to get a tertiary education. I’m also wondering how you’ll make a decision.”

“Ultimately, I’d like to do both,” said Michael. “C” nodded and remained silent for a period. Michael also sat silently, thinking to himself. After a period, Michael replied, “I think I need to think about it some more. I need to talk to my parents some more too. I’ve been a bit afraid to talk about it directly, in case they definitely say ‘no’. I was thinking that I have to put in my selection for university soon, so perhaps I could apply for Medicine, but then defer for a year. It might be easier for Dad to accept, if I did this. What do you think about that?”

“C” replied, “discussing some of your options with your parents is a good idea. Perhaps you might think about how you would approach them. How might you feel if they still did not accept your proposals?”

“I’d feel let down and angry. I think I’d want to leave home if that happened. I wouldn’t want to make a scene, but I do want to live my own life. I think that I would have to leave.”

“C” replied, “that is a serious move, leaving home. Your goals must be very important to you indeed.”

“They are!” Michael exclaimed.

“C” probed further into Michael’s feelings about the choices he wanted to make. In particular he asked Michael about approaching his parents to discuss his goals. “C” focussed in on what Michael would say to his parents to let them know the seriousness of his intentions. “C” also asked Michael to consider how his parents might react to his news. From this, Michael developed some strategies for himself to use when telling his parents of his intentions.

In summary, “C” expressed his appreciation of Michael’s world and experiences. “C” validated Michael’s feelings and goals and complemented Michael on his mature strategies to explain his goals to his parents. Michael’s decisions included setting a time with his parents to discuss his goals, to suit everyone. He thought that they might go out for dinner one evening, to mark it as an important event. Michael would ask his parents to think about their goals for him and discuss these over dinner. In this way Michael would be allowing for his parents to contribute to his plans and hopefully influence them to listen to and respect his own ideas.

As a finishing point “C” asked Michael how he had felt about the session in general. Michael had appreciated the opportunity to talk about his issues and goals so completely to someone. He said he felt clearer about the direction he wanted to take in his life and was beginning to consider how to explain his goals to his parents. He thought that “C” had really appreciated him for who he was and it made him feel more mature in himself. He had hoped that “C” would have offered him some more direct advice about what to do, but understood that it was his own responsibility to decide.

End of Session

Some points to consider with Person Centred Therapy are as follows:

This therapy focuses on the quality of the client / counsellor relationship . It assumes that clients are basically trustworthy and have the inner resources to find solutions to their own problems. It is a less directive therapy on the counsellor’s behalf, meaning that clients are free to set their own goals and create the conditions that will allow themselves to explore their needs and behaviours.

Therapists themselves contribute to the client’s growth by providing a warm, positive, trusting, and open relationship with the client . The three important qualities the counsellor should possess are congruence (genuineness), unconditional positive regard (acceptance and caring) and accurate empathetic understanding (ability to deeply grasp the world of another person).

There are no fixed techniques that apply to Person Centred Therapy, rather there are a set of principles for counsellors to be guided by. Some of these are as follows:

  • The client is experiencing a discrepancy between the way they perceive themselves, the ideal picture of themselves and the reality of their situation. They may feel helpless and unable to make a decision, or direct their own life.
  • Whilst the client may look to the counsellor for direction, the emphasis will be upon the client to take responsibility for their own decisions and to learn to use the therapeutic relationship to increase their self-understanding.
  • The therapist should attempt to understand the client’s world through listening, empathising, respecting and accepting them; and in doing so, the counsellor will be integrating themself into the relationship with the client.
  • The therapist should try to experience genuine care and acceptance of their client, otherwise, the client may feel that the counsellor is feigning interest and will not fully disclose their feelings.
  • As clients experience the therapist listening to them and accepting them, they learn how to accept themselves. As they find the counsellor caring for them, they start to experience themselves as worthwhile and valuable. When they experience realness from the counsellor, the client is encouraged to shed their pretences with themselves and others.

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Counseling a Cancer Patient-Case Study

Case presentation of cancer patient.

The client, who would be referred as Lucy, is a 62-year-old Caucasian lady, who was referred to the counselor by her physician. The lady was being treated by an oncologist as she was diagnosed of throat cancer. During the treatment period, she had also suffered from coughing , weakness , painful swallowing, difficulty in talking and change in voice quality.

The treating physician felt the need for counseling and referred her to the counselor. The counselor was one of Lucy’s acquaintance, due to which initiation of the counseling process was easy.

Counseling a Cancer Patient-Case Study

Presenting Complaints of Cancer Patient

Lucy presented with complaints of increased irritability and occasional emotional outbursts as she was getting frustrated about her health condition. Since cancer had been identified, it was difficult for her to accept her condition. After assessing the case, the counselor suggested counseling and psychotherapy sessions for the lady.

Objective of Counseling Cancer Patient

The basic aim of counseling cancer patient was:.

  • To minimize her emotional outbursts
  • To enable her to bear a positive attitude towards life.

Counseling Plan For Cancer Patient

Counseling sessions for cancer patient (Lucy) of one hour duration once in a week was planned. Approximately four sessions per month spreading over a period of two months would be required initially. Further following initial two months, one session once in a fortnight may be sufficient.

History of Cancer Patient

Lucy was a good looking lady, who had served as a professor for more than 30 years. She had been a very good cook and was appreciated by all for her multi-talented personality. She and her husband had been separated since 10 years. She missed her husband, who occasionally visited her.

She had a son who stayed abroad with his family and she missed him a lot. She stayed with her daughter, who was a medical professional and took good care of Lucy.

At the time of referral Lucy was retired and felt that her talents were no longer useful. She was getting frustrated that she was not able to perform those activities, which she used to earlier. Also, she thought that her looks no longer remained as they were before.

She felt miserable about herself and was extremely worried about the prognosis of her condition. She felt her condition was worsening and became more and more anxious. This added to her dissatisfaction, which resulted in emotional outbursts and clashes with her daughter.

Cancer Counseling Sessions

The initial two cancer counseling sessions were focused on enabling Lucy to narrate her story along with her feelings. She seemed to dwell much in the past and had a combination of worries related to her future. It was important for her to express her emotions before beginning to realize the present.

The next two sessions dealt with making her understand the present condition and feel positive towards life. This was to allow her to understand her present emotions and relations with others. She actually missed her husband and son and also missed being away from work after retirement. There was a vacuum created in her life and the news of cancer added to her emotional disturbance. She began realizing and expressing her real emotions to the counselor.

In the next sessions, she started feeling better about herself after free expression of feelings, but still needed much support. Her emotional outbursts were not given much attention; instead only the positive thought was acknowledged. This helped her remain focused on free expression and living in the present.

Lucy was given simple cooking activities that she had always enjoyed to remain focused on the present. In the next sessions, she was asked to write down about her present feelings whenever possible or whenever she felt sad.

Counselor’s Role in Dealing with Cancer Patient

The counselor comforted her and enabled her to vent her feelings by expressing her emotions. During her narration, the counselor, kept on the positivity of the counseling approach and intervened whenever she had to be kept on track. The counselor was understanding and empathetic about Lucy’s condition and emotions. The counselor encouraged her to act out a role play of her situation and that of her husband and son staying away. This helped her clarify her thoughts and feelings and also their emotions.

The counselor used the principle of instrumental conditioning and suggested some techniques to Lucy’s daughter, who was the primary care taker. She was asked to ignore Lucy’s negative remarks or unnecessary emotional outbursts, while carrying out all the other regular nursing activities.

The counselor encouraged her at every step and helped her gain confidence that she can still perform well within the limits of her health condition.

Outcome Of Counseling Of Cancer Patient

After a month of counseling, Lucy had begun to feel relieved and had slowly started to realize the present. She felt relieved and was happy to see that she could still perform the cooking activities very well and began taking interest in life. She was asked to continue writing about her feelings.

This gradually reduced her outbursts and she too began to see the brighter side of her life. She also started getting a clear idea of her present emotions and relations. The counseling sessions continued till she improved to a satisfactory level without any emotional outbursts.

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Wait, how many? —

German man got 217 covid shots over 29 months—here’s how it went, it conflicts with concerns of repeat boosters, but authors warn against hypervaccination..

Beth Mole - Mar 5, 2024 7:40 pm UTC

German man got 217 COVID shots over 29 months—here’s how it went

A 62-year-old man in Germany decided to get 217 COVID-19 vaccinations over the course of 29 months —for "private reasons." But, somewhat surprisingly, he doesn't seem to have suffered any ill effects from the excessive immunization, particularly weaker immune responses, according to a newly published case study in The Lancet Infectious Diseases .

The case is just one person, of course, so the findings can't be extrapolated to the general population. But, they conflict with a widely held concern among researchers that such overexposure to vaccination could lead to weaker immune responses. Some experts have raised this concern in discussions over how frequently people should get COVID-19 booster doses.

In cases of chronic exposure to a disease-causing germ, "there is an indication that certain types of immune cells, known as T-cells, then become fatigued, leading to them releasing fewer pro-inflammatory messenger substances," according to co-lead study author Kilian Schober from the Institute of Microbiology – Clinical Microbiology, Immunology and Hygiene. This, along with other effects, can lead to "immune tolerance" that leads to weaker responses that are less effective at fighting off a pathogen, Schober explained in a news release.

The German man's extreme history of hypervaccination seemed like a good case to look for evidence of such tolerance and weaker responses. Schober and his colleagues learned of the man's case through news headlines—officials had opened a fraud investigation against the man, confirming 130 vaccinations over nine months, but no criminal charges were ever filed. "We then contacted him and invited him to undergo various tests in Erlangen [a city in Bavaria]," Schober said. "He was very interested in doing so." The man then reported an additional 87 vaccinations to the researchers, which in total included eight different vaccine formulations, including updated boosters.

The researchers were able to collect blood and saliva samples from the man during his 214th to 217th vaccine doses. They compared his immune responses to those of 29 people who had received a standard three-dose series.

Throughout the dizzying number of vaccines, the man never reported any vaccine side effects, and his clinical testing revealed no abnormalities related to hypervaccination. The researchers conducted a detailed look at his responses to the vaccines, finding that while some aspects of his protection were stronger, on the whole, his immune responses were functionally similar to those from people who had far fewer doses. Vaccine-spurred antibody levels in his blood rose after a new dose but then began declining, similar to what was seen in the controls.

His antibodies' ability to neutralize SARS-CoV-2 appeared to be between fivefold and 11-fold higher than in controls, but the researchers noted that this was due to a higher quantity of antibodies, not more potent antibodies. Specific subsets of immune cells, namely B-cells trained against SARS-CoV-2's spike protein and T effector cells, were elevated compared with controls. But they seemed to function normally. As another type of control, the researchers also looked at the man's immune response to an unrelated virus, Epstein-Barr, which causes mononucleosis. They found that the unbridled immunizations did not negatively impact responses to that virus, suggesting there were no ill effects on immune responses generally.

Last, multiple types of testing indicated that the man has never been infected with SARS-CoV-2. But the researchers were cautious to note that this may be due to other precautions the man took beyond getting 217 vaccines.

"In summary, our case report shows that SARS-CoV-2 hypervaccination did not lead to adverse events and increased the quantity of spike-specific antibodies and T cells without having a strong positive or negative effect on the intrinsic quality of adaptive immune responses," the authors concluded. "Importantly," they added, "we do not endorse hypervaccination as a strategy to enhance adaptive immunity."

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  • Case report
  • Open access
  • Published: 02 March 2024

Inguinal endometriosis: a case series and review of the literature

  • Ameneh Haghgoo   ORCID: orcid.org/0000-0002-7248-6199 1 ,
  • Ali Faegh   ORCID: orcid.org/0000-0002-5033-8435 2 ,
  • Seyyed Reza Saadat Mostafavi 3 ,
  • Hamid Reza Zamani 4 &
  • Mehran Ghahremani 5  

Journal of Medical Case Reports volume  18 , Article number:  83 ( 2024 ) Cite this article

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Inguinal endometriosis is one of the most common forms of endometriosis. The present study introduces 8 cases of inguinal endometriosis and discusses probable theories of inguinal endometriosis by reviewing the literature.

Case presentation

8 Iranian cases of inguinal endometriosis with a mean age of 36 years were presented. Catamenial groin pain and swelling were the most common complications. Also, patients usually had accompanying symptoms such as pelvic pain and dysmenorrhea. One-half of patients had a history of previous abdominal surgery. Ultrasound was diagnostic in 4 patients (50%), and magnetic resonance imaging was used in two patients (25%). Among 6 patients who underwent hormonal therapy, 4 experienced an endometriosis size increase. Inguinal endometriosis was right-sided in 87.5% of patients, and among 4 patients who underwent surgery, 75% had proximal site involvement of the round ligament.

According to the rarity of inguinal endometriosis, it is more likely to be a misdiagnosis with other inguinal disorders such as inguinal hernia. Inguinal endometriosis should be considered in patients who undergo inguinal herniorrhaphy, with suspected findings such as thickening of the hernia sac wall, bloody fluid inside the sac, or thickening of the extraperitoneal round ligament during the surgery.

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Endometriosis is a common gynecological disorder among women of reproductive age with about 10 to 15% prevalence [ 1 , 2 ]. Ovaries are the most common site of endometriosis, although it can be identified in unconventional sites, such as the inguinal region, which accounts for 0.3–0.6% of all endometriosis [ 3 , 4 , 5 ]. 133 cases of inguinal endometriosis (IEM) have been reported until 2022 in the literature [ 6 ]. However, many inguinal IEM patients are not diagnosed because they undergo herniorrhaphy by general surgeons without any consideration for endometriosis [ 7 ]. IEM can co-exist with other groin disorders, such as inguinal hernia [ 8 ]. So, IEM is divided into three types: 1, IEM of inguinal hernia sac or hydrocele of canal of Nuck; 2, round ligament IEM; and 3, superficial IEM [ 9 ]. IEM’s diagnosis is challenging according to the wide range of differential diagnoses, such as inguinal hernia, inguinal lymphadenopathy, etc., so it can be misdiagnosed with other inguinal disorders commonly [ 10 ]. Female individuals with groin swelling or pain with menstruation-associated exacerbation (catamenial symptoms) should be assessed for IEM [ 6 ]. Although, a definitive diagnosis of IEM is usually made through histopathological examination [ 5 ]. Surgical resection is the standard treatment of IEM; nevertheless, the role of medical therapy is still controversial [ 10 ]. This study presents 8 cases of IEM who presented to the author’s office from 2017 to 2022. Also, it discusses probable theories of IEM by reviewing the literature.

Patient’s characteristics and symptoms

Eight Iranian cases of IEM, as well as one case of inguinal hernia with superficial implantations of the endometriosis surrounding the entrance of the hernia sac, were included 1 . The mean age was 36.3 years (standard deviation: 6.78, ranging between 30 and 51). Five patients were nulliparous, and the other 3 were multiparous. Visual analog scale (VAS) was used to assess the patient’s symptoms better. Patients with VAS ≥ 4 were considered to have the symptoms. Seven patients (87.5%) had complaints of inguinal swelling or pain, and six mentioned exacerbations in their menstrual period (catamenial symptoms). Also, seven patients (87.5%) had dysmenorrhea, 6 (75.0%) had dyspareunia, and 6 (75.0%) had pelvic pain. Footnote 1

Two patients had a history of primary infertility. Two had a history of inguinal herniorrhaphy, and four had a history of previous abdominal surgery. Also, six patients were diagnosed with pelvic endometriosis before presenting to the author’s office. The patient’s characteristics, symptoms, and history are summarized in Table  1 .

Physical examination and laboratory tests

Right and left inguinal mass was detected by physical examination in 6 patients (75.0%) and 1 patient (12.5%), respectively. Six patients had tenderness in the right groin and one on the left side. The Valsalva maneuver did not lead to an increase in the inguinal masse’s size. As shown in Table  1 , the CA-125 value was measured in 4 patients. It was higher than the normal range in only 2 patients.

Imaging assessment

Inguinal ultrasound revealed IEM in 6 patients. Trans-abdominal and transvaginal ultrasounds were performed on two patients because they have symptoms associated with pelvic endometriosis. Also, two patients (25.0%) were misdiagnosed previously by ultrasound, one with inguinal hernia and the other with inguinal lymphadenopathy. IEM size increase was assessed for 2 patients. In one patient, IEM size increased about 17 × 1 mm during 4 years with an average growth of (4 × 0.25 mm) per year despite medical treatment with progestin and GnRH agonists. In another patient, the IEM size was decreased, but notably, she underwent medical treatment with progestin during those 2 years. Also, two patients underwent magnetic resonance imaging (MRI). It revealed IEM in both patients. As shown in Fig.  1 , MRI in patient 2 revealed 29 × 51 mm growths during 9 months despite taking an oral contraceptive. We used imaging #Enzian classification to describe imaging assessment results better. Imaging’s findings are summarized in Table  1 .

figure 1

Comparison of inguinal endometriosis size in magnetic resonance imaging. A first magnetic resonance imaging (35 × 9 mm); B second magnetic resonance imaging 9 months later (61 × 60 mm)

Treatment and surgical methods

As shown in Table  1 , medical treatment by progestin, GnRH agonist, and Dydrogesterone was performed on 6 Patients, leading to IEM size decrease in 2 of them; however, IEM size increased in 4 patients, and their pain got worse.

Laparoscopic surgical intervention was performed on 5 patients. Four underwent IEM resection surgery. Under general anesthesia, they secured a Trendelenburg position. A central umbilical trocar (12 mm), 2 lateral trocars (5 mm), and a suprapubic trocar (5 mm) were inserted. Intraoperative CO 2 pressure was established at 13 mm Hg. First, endometriosis abdominal and pelvic exploration was performed. Then, inguinal canal exploration was performed. Inguinal mass was resected with a safe margin in these patients. In addition, in patient 5, IEM was adherent to the femoral, external iliac, and inferior epigastric vessels. So, surgery was performed by a multidisciplinary team, including an expert vascular surgeon and a gynecologist. IEM was resected with a safe margin without any vascular injury. Then, a skin incision was conducted in the groin. In patients with involvements, IEM mass was resected from the external oblique, transversus abdominis, internal oblique muscles, and Scarpa facia. IEM lesion and resected part of the round ligament were pulled out via a skin incision. The abdominal wall defect was repaired by Prolene 3-0 suture in all patients. Also, to avoid an incisional hernia, a PROLENE Mesh was placed on the inguinal canal and fixed with Prolene 3-0 suture for patient 5. Also, a Hemovac drain was established to prevent post-surgical collection in this patient. After abdominal wall repair, the peritoneal defect was repaired via laparoscopy to avoid gas leakage, subcutaneous emphysema formation, and intestinal hernia. In cases with co-existing inguinal hernia, Inguinal hernia sacs and IEM were resected, and the abdominal wall defects were repaired. Then, abdominal-pelvic laparoscopic exploration was performed, and endometriosis lesions were removed in patients with other endometriotic lesions.

Patient 6 underwent pelvic endometriosis laparoscopic surgery due to pelvic endometriosis diagnosis. Nevertheless, mild-size endometrioid implantations were identified accidentally surrounding the entrance of the inguinal hernia sac during laparoscopy (Figs.  2 and 3 ). As mentioned, she had no IEM, so she was excluded from statistical analysis.

figure 2

Pre-operative imaging assessment and intraoperative findings of case 5. A groin palpable mass; B inguinal endometriosis in ultrasound; C rectum endometriosis in transvaginal ultrasound; D inguinal endometriosis in magnetic resonance imaging; E inguinal bulging was seen during abdominal exploration; F uterosacral ligament endometriosis; G round ligament, external iliac artery, and vein after making incision; H pulling out inguinal mass via skin incision after resection with safe margin; I placing PROLENE Mesh on the external orifice of the inguinal canal; J peritoneal defect repairment; K inguinal endometriosis; L rectum endometriosis and inguinal mass; M Hemovac drain on inguinal site and corrugated drain on the anastomosis

figure 3

Abdominal view of inguinal endometriosis and pulling out inguinal mass via skin incision. A inguinal canal and round ligament involvement by endometriosis (patient 1); B endometriosis implantations on the internal orifice of the inguinal canal (patient 3); C superficial endometriosis surrounding the entrance of inguinal hernia sac (patient 6); D inguinal endometriosis and round ligament remove via skin incision (patient 2)

Surgical findings

Among patients who underwent surgical interventions for IEM, three patients (75%) had proximal part of the inguinal canal and round ligament involvement by IEM. However, in one patient (25%), the proximal part was not involved, and IEM involved the distal portion of the round ligament near the labia majora and pubic symphysis. Also, two had co-existing inguinal hernia. The surgical #Enzian classification was used to better describe the patients’ surgery findings. Surgical interventions and findings are summarized in Table  1 .

Histopathological examination and follow-up

Histopathology examination revealed IEM in all four patients who had inguinal lesions. Also, it demonstrated abdominal wall endometriosis for patient 6 (Fig.  4 ).

figure 4

Histopathological appearance of inguinal endometriosis. A glandular and stromal endometrial tissue surrounded by fibromuscular tissue × 40 LPF; B glandular and stromal endometrial tissue surrounded by fibromuscular tissue × 400 HPF

As shown in Table  1 , during a long-time follow-up (> one year) for five patients who underwent surgery, patients had no complaints and suspected symptoms of IEM recurrence. The results of the statistical analysis are summarized in Table  2 .

Discussion and conclusion

Clinical manifestations and differential diagnoses.

This study discussed 8 cases of IEM with a mean age of 36. Five were nulliparous, so it seems there is no relationship between IEM and parity history. Catamenial groin pain or swelling was the most frequent symptom. Also, patients usually had accompanying symptoms such as pelvic pain and dysmenorrhea. One-half of patients had a history of previous abdominal surgery. Ultrasound was diagnostic in 4 patients (50%), and MRI was used in two patients (25%). Among 6 patients who underwent hormonal therapy, 4 (66.6%) experienced IEM size increase. IEM was right-sided in 87.5% of patients, and among 4 patients who underwent surgery, 75% had proximal site inguinal involvement.

About 133 cases of IEM were reported in the literature until 2022. The mean age is about 36 years old, and the largest number of the reported instances belongs to Japan [ 6 ]. Right-side IEM is more frequent than left-side; therefore, right inguinal swelling with pain exacerbation in the menstrual cycle is the typical clinical manifestation. Nevertheless, cases of bilateral or left-side IEM and cases without catamenial symptoms were reported [ 6 ]. Dysmenorrhea, dyspareunia, and pelvic pain are accompanying symptoms. However, in patients without these symptoms, IEM is not a diagnosis of exclusion [ 11 ]. Also, about 30% of IEM cases have a previous operation [ 6 ].

There are various causes for an inguinal mass, such as inguinal hernia, hydrocele of the canal of Nuck, inguinal lymphadenopathy, hemangioma, and malignancies [ 12 , 13 , 14 ]. Also, endometrial-like tissue can be identified in the sac of the inguinal hernia or the hydrocele of the canal of Nuck [ 13 , 15 ]. So, about 20% of patients with IEM have Co-existing inguinal hernia or canal of Nuck hydrocele [ 6 ]. Several cases of IEM are misdiagnosed as an inguinal hernia due to the greater prevalence of inguinal hernia, less consideration of general surgeons for endometriosis, and insufficient post-operative histopathological assessments [ 10 ]. According to the wide range of differential diagnoses of inguinal swelling, diagnosis of the IEM is challenging and requires careful investigations. MRI is the most sensitive and specific imaging modality for IEM diagnosis. MRI identifies iron particles in the hemosiderin, in contrast with computed tomography. Therefore, MRI has more sensitivity and specificity than computed tomography. MRI shows IEMs as hyperechoic lesions on T1 images and hypoechoic on T2 images [ 11 , 16 , 17 , 18 ]. However, ultrasound is valuable and diagnostic in most patients [ 6 , 13 , 19 ]. Abdominal ultrasound has been used to diagnose IEM in about 74% of patients [ 6 ]. Ultrasound is an appropriate modality for detecting cystic peritoneal implants in contrast to small peritoneal implantations. Still, the sensitivity and specificity of the ultrasound for the diagnosis of round ligament endometriosis have not been evaluated due to the limited number of studies [ 20 ].

A high CA-125 level is not identified in all cases of IEM, even though there are several cases of IEM with increased CA-125 [ 6 ]. Two patients (25%) among our study population had CA-125 levels higher than the normal range. In one of them, the CA-125 level was near the upper normal limit (36.96 U/Ml), and only one had a CA-125 high level (12.5%). In highly suspected cases of IEM, fine-needle aspiration cytology can confirm the IEM diagnosis before the operation, but it is not performed commonly [ 17 ].

Pathophysiology

Some theories describe the pathophysiology of endometriosis, including retrograde menstruation (Sampson theory), lymphatic or hematogenous benign metastasis, and Mullerianosis theory [ 21 , 22 , 23 ]. Dissemination of endometrial cells along the round ligament from the abdominal cavity is the more acceptable theory in cases with co-existing pelvic endometriosis. In these patients, endometriosis usually can be seen in the proximal part of the round ligament and inguinal canal [ 10 ]. Although, in isolated IEM without pelvic endometriosis, IEM nodules are usually seen on the distal part of the round ligament and not on the proximal portion. We hypothesize that Mullerianosis seems to be the most favorable theory in these patients. The round ligament involvement pattern can help to describe the appropriate theory in each patient better. Also, we hypothesize that the isolated distal part of the round ligament involvement by endometriosis is against retrograde menstruation theory and advocates for the Mularianosis theory in patients without co-existing pelvic endometriosis.

Peritoneal fluid circulates clockwise because of gravity and diaphragm respiratory movements [ 24 ]. Although, endometrial free cells in the peritoneal fluid spread in the abdominal cavity. The sigmoid colon prevents the entrance of the peritoneal fluid to the left inguinal canal [ 10 ]. The right-side canal does not have this support, so the round ligament plays a role as a transmitter of endometrial cells to the groin. It can be an appropriate explanation for IEM cases with co-existing pelvic endometriosis [ 10 ]. According to these two facts, the right-side dominancy of the IEM can be described [ 25 ].

Surgical excision of the inguinal mass with inguinal canal exploration is the most common treatment [ 6 ]. The operation can be achieved by both open and laparoscopic approaches [ 26 ]. Due to the proximity of IEM lesions, external iliac and femoral vessels, complete resection of the inguinal mass with a safe margin without vessel wall damage is the most critical issue that should be considered during surgical excision. In case of co-existing inguinal hernia or canal of Nuck hydrocele, excision of the hernia sac and abdominal wall repairment by Mesh is required [ 10 , 26 ]. Laparoscopic pelvic and abdominal cavity exploration is probably needed in case of co-existing pelvic or abdominal endometriosis. Patients who undergo inguinal herniorrhaphy with suspected findings (such as thickening of the hernia sac wall, bloody fluid inside the sac, or thickening of the extraperitoneal round ligament) during the surgery by general surgeons should refer to gynecologists for more assessments about other sites of endometriosis [ 10 ].

The sufficiency of hormonal therapy for IEM is not strongly acceptable and requires more investigation due to the limited number of patients undergoing medical treatment [ 6 ]. Post-operation hormonal therapy is often performed to prevent endometriosis recurrence [ 27 ]. Nevertheless, despite the slight recurrence rate of IEM, the benefits of hormonal treatment should be investigated [ 6 ]. However, for patients with IEM, enough time should be considered to choose the best surgical team and plan due to the low velocity of IEM growth.

Definitive diagnosis of IEM is based on post-operative histopathological examination [ 5 ]. Post-operative histopathological examination is crucial due to variations of histopathological findings, such as uterus-like tissue and malignant clear-cell carcinoma [ 6 , 28 ].

In conclusion, IEM is a rare condition requiring precise diagnosis assessments. In case of an inguinal mass with aggravated swelling or pain in the menstrual period, IEM should always be considered. MRI is the most sensitive modality of IEM diagnosis. Also, ultrasound has been used for diagnosis. However, because ultrasound is an operator-dependent modality, suspected patients for IEM should be referred to an expert sonologist with enough experience in endometriosis diagnosis. Due to a wide range of differential diagnoses of groin masses, IEM can be misdiagnosed commonly. A more precise post-operative histopathological examination is required about inguinal masses. In cases that undergo inguinal herniorrhaphy and diagnosis with IEM during or after the operation, a gynecological consultant is necessary to investigate the other sites of endometriosis.

Availability of data and materials

Further information about this study is available by contacting the corresponding author.

Patient 6 has mild-size superficial endometriosis implantations surrounding the entrance of the inguinal hernia sac, which was identified accidentally during laparoscopic abdominal and pelvic exploration for endometriosis, but she had no IEM, so she was excluded, and then statistical analysis was performed on 8 patients with IEM.

Abbreviations

Inguinal endometriosis

Visual analog scale

Magnetic resonance imaging

de Graaff AA, D’Hooghe TM, Dunselman GAJ, Dirksen CD, Hummelshoj L, Simoens S, et al . The significant effect of endometriosis on physical, mental and social wellbeing: results from an international cross-sectional survey. Hum Reprod. 2013;28:2677–85.

Article   PubMed   Google Scholar  

Mehedintu C, Plotogea MN, Ionescu S, Antonovici M. Endometriosis still a challenge. J Med Life. 2014;7:349–57.

CAS   PubMed   PubMed Central   Google Scholar  

Lee HJ, Park YM, Jee BC, Kim YB, Suh CS. Various anatomic locations of surgically proven endometriosis: a single-center experience. Obstet Gynecol Sci. 2015;58:53.

Article   CAS   PubMed   PubMed Central   Google Scholar  

Blanco RG, Parithivel VS, Shah AK, Gumbs MA, Schein M, Gerst PH. Abdominal wall endometriomas. Am J Surg. 2003;185:596–8.

Jena SK, Begum J, Kumari S, Kar C. The groin endometriosis: a great mimicker of common groin conditions. J Gynecol Surg. 2020;36:30–3.

Article   Google Scholar  

Dalkalitsis A, Salta S, Tsakiridis I, Dagklis T, Kalogiannidis I, Mamopoulos A, et al . Inguinal endometriosis: a systematic review. Taiwan J Obstet Gynecol. 2022;61:24–33.

Zihni İ, Karaköse O, Özçelik KÇ, Pülat H, Eroloğlu HE, Bozkurt KK. Endometriosis within the inguinal hernia sac. Turk J Surg. 2020;36:113–6.

Article   PubMed   PubMed Central   Google Scholar  

Prodromidou A, Pandraklakis A, Rodolakis A, Thomakos N. Endometriosis of the canal of nuck: a systematic review of the literature. Diagnostics. 2020;11:3.

Niitsu H, Tsumura H, Kanehiro T, Yamaoka H, Taogoshi H, Murao N. Clinical characteristics and surgical treatment for inguinal endometriosis in young women of reproductive age. Dig Surg. 2019;36:166–72.

Li S-H, Sun H-Z, Li W-H, Wang S-Z. Inguinal endometriosis: ten case reports and review of literature. World J Clin Cases. 2021;9:11406–18.

Hagiwara Y, Hatori M, Moriya T, Terada Y, Yaegashi N, Ehara S, et al . Inguinal endometriosis attaching to the round ligament. Australas Radiol. 2007;51:91–4.

Article   CAS   PubMed   Google Scholar  

Yang DM, Kim HC, Ryu JK, Lim JW, Kim GY. Sonographic findings of inguinal endometriosis. J Ultrasound Med. 2010;29:105–10.

Cervini P, Mahoney J, Wu L. Endometriosis in the canal of nuck: atypical manifestations in an unusual location. Am J Roentgenol. 2005;185:284–5.

Fujikawa H, Uehara Y. Inguinal endometriosis: unusual cause of groin pain. Balkan Med J. 2020;

Albutt K, Glass C, Odom S, Gupta A. Endometriosis within a left-sided inguinal hernia sac. J Surg Case Rep. 2014;2014:rju046–rju046.

Licheri S, Pisano G, Erdas E, Ledda S, Casu B, Cherchi MV, et al . Endometriosis of the round ligament: description of a clinical case and review of the literature. Hernia. 2005;9:294–7.

AlSinan FM, Alsakran AS, Foula MS, al Omoush TM, Al-Bisher H. Inguinal endometriosis in a nulliparous woman mimicking an inguinal hernia: a case report with literature review. Am J Case Rep. 2021;22.

Gaeta M, Minutoli F, Mileto A, Racchiusa S, Donato R, Bottari A, et al . Nuck canal endometriosis: MR imaging findings and clinical features. Abdom Imaging. 2010;35:737–41.

Kamkarfar P, Shahriyaripoor R, Rokhgireh S, Mostafavi SRS, Chaichian S, Mehdizadeh KA. Comparison of diagnostic values of transvaginal sonography with laparoscopic and histological results in the evaluation of uterosacral ligaments’ involvement in endometriosis patients. Caspian J Intern Med. 2022;13:705–12.

PubMed   PubMed Central   Google Scholar  

Bazot M, Daraï E. Diagnosis of deep endometriosis: clinical examination, ultrasonography, magnetic resonance imaging, and other techniques. Fertil Steril. 2017;108:886–94.

Sampson JA. Peritoneal endometriosis due to the menstrual dissemination of endometrial tissue into the peritoneal cavity. Am J Obstet Gynecol. 1927;14:422–69.

Pergialiotis V, Lagkadas A, Polychronis O, Natsis S, Karakalpakis D, Giannakopoulos K. Endometriosis-associated ovarian cancer. Presentation of a case report and review of the literature. Eur J Gynaecol Oncol. 2011;32:682–5.

CAS   PubMed   Google Scholar  

Batt RE, Yeh J. Müllerianosis: four developmental (embryonic) mullerian diseases. Reprod Sci. 2013;20:1030–7.

Sun Z-J, Zhu L, Lang J-H. A rare extrapelvic endometriosis: inguinal endometriosis. J Reprod Med. 2010;55:62–6.

PubMed   Google Scholar  

Burcharth J. The epidemiology and risk factors for recurrence after inguinal hernia surgery. Dan Med J. 2014;61:B4846.

Hwang B, Bultitude J, Diab J, Bean A. Cyst and endometriosis of the canal of Nuck: rare differentials for a female groin mass. J Surg Case Rep. 2022;2022.

Lee SE, Jo DH, Moon SH, Chong HI, Shin SI, Kim HG, et al . A case of inguinal endometriosis in the absence of previous gynecologic surgery. Korean J Obstet Gynecol. 2008;51:261–4.

Google Scholar  

Seki A, Maeshima A, Nakagawa H, Shiraishi J, Murata Y, Arai H, et al . A subserosal uterus-like mass presenting after a sliding hernia of the ovary and endometriosis: a rare entity with a discussion of the histogenesis. Fertil Steril. 2011;95:1788.e15-1788.e19.

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Ameneh Haghgoo

School of Medicine, Alborz University of Medical Sciences, Karaj, Iran

Department of Radiology, Hazrat-e-Rasoul Hospital, Iran University of Medical Sciences, Tehran, Iran

Seyyed Reza Saadat Mostafavi

Department of Radiology, Imam Hossein Medical and Educational Center, Shahid Beheshti University of Medical Sciences, Tehran, Iran

Hamid Reza Zamani

Iranian Society of Pathology, Tehran, Iran

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AH contributed to the conception, design, and supervision of the study. AF, HZ, and SM performed material preparation, data collection, and analysis. AF wrote the first draft of the manuscript. MG performed the manuscript reviewing and editing. All authors read and approved the final manuscript.

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Haghgoo, A., Faegh, A., Mostafavi, S.R.S. et al. Inguinal endometriosis: a case series and review of the literature. J Med Case Reports 18 , 83 (2024). https://doi.org/10.1186/s13256-024-04400-x

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A 62-year-old man in Germany intentionally got 217 doses of  COVID-19 vaccines within 29 months. The vaccinations occurred outside of a clinical study, and after hearing about the "hypervaccinated" man, medical researchers in Germany reached out to him to run tests.

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Staying up to date with  COVID-19 vaccinations  is recommended for everyone ages 6 months and older in the U.S. There are three types of COVID-19 vaccines available in the U.S. — two mRNA vaccines from Moderna and Pfizer, and a protein subunit vaccine from Novavax — and there is no preferential recommendation of one over the other, according to the CDC.  The CDC has a table with information  on the number of recommended doses based on your past vaccinations.

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This study illustrates practices that a nurse uses in order to empower patients. The emphasis is on speech formulae that encourage patients to discuss their concerns and to solicit information about impending surgery. The study is a part of a larger research project and a single case was selected for presentation in this article because it differed from the rest of the data by manifesting empowering practice. A videotaped nurse-patient health counseling session was conducted in a hospital and transcribed verbatim. The investigator interviewed the nurse and the patient after the conversation, and these interviews were transcribed as well. The encounter that is presented here as a case study is a concrete example of a counseling session during which the patient is free to discuss with the nurse. The empowering practices that the nurse employed were as follows: encouraging the patient to speak out, tactfully sounding out the patient's concerns and knowledge of impending surgery, listening to feedback, and building a positive vision of the future for the patient. We suggest that nurses should pay attention to verbal expression and forms of language. This enables them to gain self-awareness and discover new tools to work with.

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Abortion pill studies cited in ruling set for Supreme Court are retracted

Two of the studies cited in a ruling that suspended federal approval of the abortion pill mifepristone were retracted by a medical journal earlier this week.

Sage Publishing said it issued the retractions from the journal Health Services Research and Managerial Epidemiology because of methodology issues and conflicts of interest. The Supreme Court is hearing oral arguments in March on the case -- about access to mifepristone, the drug used in medication abortions -- which cited the studies.

Medicated abortions account for about half of all abortions, according to according to Guttmacher Institute , an organization committed to advancing reproductive rights.

U.S. District Judge Matthew Kacsmaryk cited these now-retracted studies in his decision to suspend the Food and Drug Administration's authorization of mifepristone . A federal appeals court overturned parts of the ruling, only keeping restrictions that prohibit patients from receiving the pill in the mail.

Kacsmaryk primarily cited one of the studies from 2021 to justify that anti-abortion rights medical groups and physicians had a right to bring their case to the court. In his order, he wrote that they have that right because "they allege" that the effects of "chemical abortion drugs" can put a lot of pressure on doctors during complications and emergencies. Along with some other key findings, the cited study alleged that "chemical abortion significantly increased the risk of an emergency room visit."

A 2022 study that Kacsmaryk also used in his order is based on the same dataset as the 2021 study and has most of the same authors. It analyzes the increased risks of concealed medical abortion during an emergency room visit. The judge used the study to illustrate what he argued were the dangerous side effects of the approved drug.

Both studies analyzed Medicaid data that tracked patients' emergency room visits 30 days after having an abortion.

The FDA has said that "mifepristone is safe when used as indicated and directed."

Alliance Defending Freedom, a Christian conservative legal advocacy group working to outlaw abortion, filed the initial lawsuit that Kacsmaryk ruled on. Its legal counsel said the group isn't concerned about the retractions’ impact on the case.

"ADF has never relied on these studies for the issues that are currently before the Supreme Court," ADF Senior Counsel Erik Baptist said to ABC News in an email. "So this will not have any impact on the court's consideration."

Mary Ziegler, University of California, Davis law professor and expert on law, history and politics of reproduction, said the study retractions likely won't impact the case headed before the Supreme Court next month.

"I don't think the fact that it was retracted would necessarily even change the justices' reasoning," she said.

There's already been suspicion in some parts of the court about the academic data and reasoning, Ziegler said.

"This is likely to be sort of a non-story for the justices and for Judge Kacsmaryk, because it's sort of baked in for a lot of people that there's going to be differing perception of fact," she said.

Sage referred to "fundamental problems" with the methodology, errors in the analysis of the data and "misleading presentations of the data," that served as the basis for the retractions. The publisher noted in the retraction notice that those findings “invalidate the authors’ conclusions in whole or in part.”

In addition to those issues, Sage found that most of the authors, including principal author James Studnicki, were affiliated with Charlotte Lozier Institute, an anti-abortion rights advocacy organization. The initial peer reviewer was also affiliated with the same institute. These conflicts of interest were not disclosed when the study was first released, according to Sage's notice.

In an email statement to ABC News, Studnicki, vice president and director of data analytics at Lozier Institute, said they "fully complied with Sage's conflict disclosure requirements" and didn't withhold any information they were required to share.

He added that Sage hasn't required authors from pro-abortion rights organizations, including the Guttmacher Institute, to report their employment affiliations as conflicts of interest.

Journal "editors rely on the authors to self-declare" their potential conflict of interest, a Sage spokesperson told ABC News in an email. "If a reader inquires about an author's potential conflict of interest in a published article," Sage conducts an investigation to look into those concerns, which is what happened in this case, according to the retraction notice.

Abortion pill studies cited in ruling set for Supreme Court are retracted

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  30. Abortion pill studies cited in ruling set for Supreme Court are ...

    Both studies analyzed Medicaid data that tracked patients' emergency room visits 30 days after having an abortion. The FDA has said that "mifepristone is safe when used as indicated and directed."