The Need for Counseling Strategies

Counselors are in a unique position to provide education, emotional support, and other types of assistance for clients who have hepatitis and substance use disorders (SUDs). However, most treatment programs do not have components in place to address viral hepatitis. According to the 2007 National Survey of Substance Abuse Treatment Services, only 22 percent of treatment facilities offer onsite screening tests for hepatitis B; 23 percent offer onsite screening for hepatitis C (Office of Applied Studies, 2007). Other studies have shown that only 54 percent of treatment programs provide education about hepatitis, and many counselors are uninformed or misinformed about the disease (Astone, Strauss, Vassilev, & Des Jarlais, 2003).

Depending on the resources available, counselors might be able to implement only some of the strategies presented for supporting clients who have hepatitis. Readers are encouraged to accomplish what they can to improve SUD treatment practices for their clients and to advocate for client access to services that cannot be implemented immediately. Information specific to supporting clients who have co-occurring mental disorders and hepatitis, absent a co-occurring SUD, is provided in Appendix F.

Ensuring Safety

If a client with infectious hepatitis becomes injured and bleeds, staff members are at risk of contracting the infection. Counselors should use universal precautions, such as wearing gloves and other protective gear when exposure to infected blood or other body fluids is possible. Counselors should take care to avoid accidental needle sticks, which can transmit hepatitis and HIV. Counselors should also know their hepatitis status and take cautions to protect clients and coworkers, if necessary.

Counselors can discuss hepatitis in ways that build the therapeutic relationship.

Providing Reliable Information

Providing current, accurate information is an important counseling service. Misinformation obtained by word of mouth or on the Internet can increase clients’ fears and feelings of hopelessness. Counselors can dispel misinformation about hepatitis by providing educational sessions incorporated into treatment programming. Chapter 1 gives an overview of viral hepatitis, and Appendix C provides a list of resources that are available on the Internet.

Building the Therapeutic Relationship

Counselors can discuss hepatitis in ways that build the therapeutic relationship. Clients are more likely to ask questions and express concerns and fears about screening, a diagnosis of chronic hepatitis, and its treatment if the counselor and client have a good working relationship. There are a number of ways in which a counselor can help clients (Astone, Strauss, Munoz-Plaza, Hagan, & Des Jarlais, 2005).

These include:

• Being well informed about hepatitis, especially chronic hepatitis C.
• Talking to clients about their diagnoses and medical treatment with empathy.
• Assuring clients that the counselor will help them negotiate necessary services, either within or outside the treatment program.
• Helping clients overcome possible barriers to hepatitis treatment.
• Interpreting information clients receive from medical care providers, the Internet, family, friends, and other clients.
• Repeating information in different ways until clients understand it.
• Asking about clients’ families’ responses to their diagnoses and helping clients cope with those responses.
• Educating clients about the liver and how to stay healthy with hepatitis and stating that the majority of people who have chronic hepatitis C and who do not use alcohol will not develop life-threatening complications.
• Offering messages of hope about living with hepatitis.
• Emphasizing consistently the importance of clients’ addressing their health-related issues.
• Explaining complex hepatitis treatment and test results or collaborating with medical professionals who can provide necessary explanations to clients.
• Helping to make medical appointments and advocating for clients with medical care providers.
• Helping clients devise strategies for remembering medical and other scheduled appointments.

Helping Clients Understand Their Diagnoses

Clients’ reactions to a diagnosis of viral hepatitis vary. For some clients, the possibility that they might become ill in 20–30 years might be the least of their concerns as they face the immediacy of their potentially life-threatening SUD and other life stressors. For others, a diagnosis might present a crisis. Those who have been in substance abuse treatment for many years, for example, might view a diagnosis as a threat to their hard-won sense of stability (Litwin et al., 2005). New clients might feel overwhelmed by the extra complications placed on the already daunting prospect of recovery. Some might use their diagnoses of hepatitis as an excuse to start using substances again.

Counselors need to be prepared for a range of reactions. Some clients might need to talk through fears and anger many times before moving forward with medical treatment. In these situations, counselors might need to schedule more individual sessions with clients to discuss these issues. Other clients might need prodding to understand their diagnoses and take appropriate steps to reduce their risks of spreading the illness or worsening their prognosis. Clients might be concerned about how to tell loved ones about their diagnoses and worried about transmitting the virus to others. Women might be concerned about pregnancy and hepatitis treatment or viral transmission.

Incorporating Client Needs in Substance Abuse Treatment Planning

Substance abuse treatment planning might be complicated by both hepatitis symptoms and potential side effects of the antiviral treatment. Counselors might need to adjust substance abuse treatment for clients who have hepatitis-related symptoms or antiviral treatment side effects.

Facets of substance abuse treatment might need to be flexible for clients who have hepatitis (within accreditation and licensing guidelines) and allow for the following:

• Individualized, flexible substance abuse treatment planning to permit missed sessions resulting from hepatitis symptoms, antiviral treatment, or medical appointments
• Time for clients to rest
• Time for hepatitis-specific support groups for clients in residential treatment (individual sessions could be scheduled to replace missed group sessions)
• More frequent sessions or more intensive programs
• Longer duration of substance abuse treatment to make up for missed sessions and to provide ongoing support during the hepatitis treatment regimen

Ongoing screening and assessment for depression and other mental disorders are necessary for all clients but are particularly important for clients with hepatitis who are receiving interferon. Depression is a major side effect of interferon treatment, and clients with a history of depression are at particular risk for worsening of symptoms. Treatment plans for clients who have co-occurring substance use and mental disorders should include:

• Periodic screening for depression, referral for evaluation by a mental health professional, and consideration of initiating antidepressant treatment, if warranted.
• Regular medication adherence checks for clients who are taking antidepressant medication.
• Frequent communication among substance abuse, mental health, and medical care providers, with permission of the client.

Developing a Prevention Plan

Clients might continue to put themselves or others at risk for contracting viral hepatitis, especially early in recovery. By identifying a client’s risky past or current behavior, the counselor can help the client create a plan to reduce the chances of contracting or spreading viral hepatitis. The following steps are suggested:

• Identify a specific high-risk incident. Focusing on past behavior might be difficult for a client who feels shame or regret. Discussing one specific incident might be less onerous for the client. Ask the client to describe the “who, what, where, when, and how” of the most recent risky experience. Ask whether the client talked about hepatitis risks with partners. Try to determine whether the client’s patterns of risky behavior are chronic, episodic, or a single incident. Ask, for example, “Was that the first time you let someone inject you?”
• Start where the client is. Keep in mind that some clients will not know how they became infected. Developing a risk-reduction plan for this type of client might require a gradual, supportive approach to identifying risk factors.
• Identify a situation when the client minimized his or her risk. Ask the client to describe what precautions he or she took and why. Offer positive reinforcement, such as “So you refused to share a needle. That must have been hard to do. Good for you.”
• Synthesize patterns of behavior. Identify the client’s pattern of risky behavior and the specific circumstances that lead to the behavior.
• Negotiate a prevention plan. Clients might feel besieged by the many changes they are asked to make. Develop incremental and achievable steps to minimize risk for transmitting viral hepatitis. Put the behavioral change plan in writing, and give a copy to the client.
• Revisit the plan periodically, and assess progress. Check with the client periodically to determine whether new behaviors, stressors, or circumstances need to be addressed in the plan. Renegotiate the plan if necessary.
• Include vaccinations against hepatitis A or hepatitis B and prevention strategies for other infections, such as HIV, that are spread in the same way as different types of hepatitis.

Using Motivational Approaches

Using motivational approaches, the counselor can help clients understand the relationship between good health and recovery (Litwin et al., 2005). Counselors can identify the strengths clients have demonstrated in counseling sessions and encourage clients to develop ways to use those strengths to cope with current health challenges. Appendix G provides sources of information about motivational interviewing and counseling.

Confronting the Social Factors of Hepatitis

Many people who have viral hepatitis report that the social ramifications of a hepatitis C diagnosis are severe (Astone-Twerell, Strauss, & Munoz-Plaza, et al., 2006). Many people who have SUDs and chronic hepatitis feel they are judged as immoral and blameworthy because the infection results primarily from the sharing of contaminated injection drug use equipment (Astone-Twerell, Strauss, Munoz-Plaza et al., 2006). People who have hepatitis C virus (HCV) infection might be viewed by some as having made poor choices because they engaged in dangerous and illegal behaviors that resulted in their illnesses. Negative attitudes about people who have chronic hepatitis remain, even among some medical professionals (Brener, Von Hippel, & Kippax, 2007; Paterson, Backmund, Hirsch, & Yim, 2007; Von Hippel, Brener, & Von Hippel, 2008). Counselors can advocate non-discriminatory treatment for clients who have hepatitis.

For some clients, a diagnosis of hepatitis can generate feelings of low self-worth. Some clients who have viral hepatitis report that their diagnoses caused them to develop a negative sense of self (Astone-Twerell, Strauss, Munoz-Plaza, et al., 2006). The majority of clients reported experiencing fear, shame, and social rejection (Brener et al., 2007; Conrad, Garrett, Cooksley, Dunne, & MacDonald, 2006; Zickmund, Ho, Masuda, Ippolito, & LaBrecque, 2003).

Clients might need to use discretion in revealing their diagnoses. Counselors can help clients decide whom they can tell by encouraging clients to ask themselves the following questions:

• Does this person need to know?

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  Household members need to know, particularly if they are sex partners or likely to share things like razors or hair clippers. Extended family members might not need to know.

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  Under some circumstances employers might need to know. For example, if a client’s work is affected by the illness or if he or she frequently misses work because of illness or medical appointments, a supervisor might need to be told.

• What is the person likely to do with the information? Is this person trustworthy?
• Is this the right time to tell this person?
• What are the risks in telling the person? Is a negative reaction likely?
• What questions might the person have about the client’s diagnosis? Can the client answer those questions?

A diagnosis of viral hepatitis might increase a client’s potential for relapse to alcohol or drug use.

Clients might need help with talking to their families, employers, and friends about their hepatitis. Counselors can help by:

• Role playing with clients, allowing them to practice how they tell various people.
• Offering to be present when clients talk to family members.
• Providing family members and friends with information about the symptoms, treatment, and transmission of the disease.

Addressing Relapse

A diagnosis of viral hepatitis might increase a client’s potential for relapse to alcohol or drug use. The diagnosis might also exacerbate depression and anxiety, which are known triggers for an SUD relapse. Treatment for HCV infection itself also can trigger relapse. The reasons for this are unknown, although the act of injecting medication might trigger cravings in clients who injected drugs. Side effects from antiviral treatment might also mimic withdrawal. Increases in methadone doses might be appropriate (Sylvestre & Clements, 2007).

The counselor can start conversations about relapse by asking the client the following questions:

• “What kinds of things make you think about using again?”
• “Do you consider getting injections during treatment a possible trigger to drug use?”
• “What kinds of things could help you avoid substance use?”
• “Who could support you in these efforts?”
• “How worried are you about the possibility of a relapse?”

Clients might need the counselor’s help in telling family members about a hepatitis diagnosis.

Counselors can give clients the following tips (U.S. Department of Veterans Affairs, 2004):

• “Remind yourself that interferon is working to heal your liver from the damage caused by HCV infection.”
• “Try not to isolate yourself while injecting interferon. It might be helpful to inject interferon around people you trust, such as family members.”
• “Talk openly about your feelings of injecting interferon with members of your support group and other people you trust.”
• “Remind yourself that being abstinent is the best thing you can do to keep yourself healthy when you have HCV infection.”
• “Get help managing side effects. Remember to talk with your doctor if you are experiencing side effects from your HCV treatment.”
• “Do not skip or change doses of interferon. Try to make the injections part of your routine.”

Building Support Systems

Providing Effective Case Management

Clients who have hepatitis might need intensive case management. Some clients receive case management services through their medical care providers, but many do not. Some substance abuse treatment programs have designated case managers to assist clients. Counselors or program nurses sometimes perform these functions. A program’s structure and administrative decisions about staff roles influence the level of case management counselors provide. Counselors should clearly convey the expectations of their programs to clients. If they cannot provide the level of case management a client needs, they should do what they can to connect the client with a case manager in another healthcare or social services system.

Case management for clients who have hepatitis is often the same as that for clients with SUDs, but clients who have hepatitis might need more intensive and specialized help. Some clients who have hepatitis might be unable to work because of illness or hepatitis treatment side effects. Counselors can help by:

• Working with clients on budgeting or referring clients to consumer counseling agencies for debt management.
• Referring clients to local food banks, utility assistance programs, and rent assistance programs.
• Assisting in negotiating short-term disability claims or emergency family assistance.

Clients might need help accessing and navigating medical care systems. Counselors can help by:

• Identifying local providers who treat hepatitis; have experience working with people who have SUDs; and, when relevant, are comfortable treating people in medication-assisted treatment.
• Establishing relationships with clients’ medical care providers and staying abreast of clients’ hepatitis treatment.
• Helping clients understand and complete written documents and consent forms.
• Working with clients to establish procedures that help them remember medical appointments and adhere to medication regimens.
• Ensuring that clients have transportation to medical appointments.

Clients might need help understanding insurance requirements and, possibly, challenging insurers’ coverage decisions. If clients are uninsured, counselors can:

• Identify government sources of healthcare and support benefits (e.g., Medicaid, Medicare, food stamps, unemployment insurance). (See Appendix H.)
• Look for assistance programs in medical centers and clinics.
• Identify local, private nonprofit clinics that offer many types of services; public health departments might be a source of information about community health resources.

Even if clients are insured, co-payments might be very high. Counselors can help clients identify sources of assistance, such as State medication assistance programs and local and national medication assistance programs. Appendix H lists resources for patient financial assistance with medications and transplantation surgeries.

Sources of information on SUD treatment and medical case management procedures include Treatment Improvement Protocol 27, Comprehensive Case Management for Substance Abuse Treatment (Center for Substance Abuse Treatment, 1998) and Case Management Adherence Guidelines, Version 2.0 (Case Management Society of America, 2006).

Chapter Summary

Counselors are in a unique position to provide education, emotional support, and tangible help for clients who have hepatitis.

To be effective, counselors must first be well educated about hepatitis.

Key counselor goals should include:

• Ensuring the safety of clients.
• Providing reliable information to clients and their families.
• Building the therapeutic relationship with clients.
• Helping clients understand their diagnoses.
• Incorporating client needs in substance abuse treatment planning.
• Developing a prevention plan.
• Using motivational interviewing.
• Confronting the social ramifications of hepatitis.
• Addressing relapse issues.
• Building support.
• Providing case management.

Counselors also can help by:

• Being flexible about treatment logistics (e.g., participation, treatment duration), within accreditation and licensing guidelines.
• Being alert to co-occurring mental disorders, particularly depression.
• Assessing clients’ readiness and using motivational approaches to help clients make medical treatment decisions.
• Assessing and mobilizing clients’ strengths.

Counselors can help clients develop social support systems by:

• Providing onsite support groups.
• Helping clients locate community-based support groups.
• Facilitating onsite peer counseling and support programs.
• Facilitating family support through education and counseling.

Counselors can provide effective, targeted case management, such as:

• Helping clients understand and complete written documents and consent forms.
• Helping clients obtain medical care and adhere to medical regimens.
• Helping clients find sources for financing medical treatment and medications for hepatitis.