2. Identify coping strategies and take into account interpersonal communication styles of the patient.

There are perhaps as many styles of coping as there are individual personalities. It may be useful to elicit information about the ways in which the patient faced challenges that occurred in the past to plan treatment strategies for the present and certainly for the future. There may be underlying emotional, spiritual, intellectual, and cultural factors that interfere with adequate communication, understanding of the disease process, and the successful integration of coping strategies. The patient's reaction to a diagnosis that is terminal is akin to the reaction observed in individuals experiencing trauma. Denial may be observed, or patients may insist that they are coping well, when in fact they may not be. Although this defense mechanism is inordinately useful to the patient (it enables an individual to maintain a sense of competence in the face of actual incompetence [11]), the healthcare team would be wise to recognize that this coping strategy is frequently used. It also has been advised that the healthcare team should not force the acceptance of a frank or poor prognosis or confront denial directly (11). Instead, one should recognize that denial is a common reaction, understand its positive and negative effects, emphasize the patient and family's strengths, and encourage alignment with the medical team. An awareness and understanding of the patient's patterns of coping; current functioning; psychological status, including cognitive change and impairment; and spiritual and cultural orientation can help to facilitate that alignment. Reframing through the utilization of the positive aspects of denial and emphasizing of concerns of safety will orient the patient and family toward reality and help them view the diagnosis of ALS as a challenge and not a crisis situation (12).

3. Identify coping mechanisms, strategies, and interpersonal communication styles of the patient's family.

Relationships with the patient's primary caregivers should be actively pursued. This effort may lead to insight into the system of family interdependence (13) and identification of the members that will be the most influential in effecting change and supporting the use of certain assistive devices. Cultural factors may be important determinants of a successful relationship, as for example when the eldest son of an affected father holds the most influence in a family because of the cultural norms. Language barriers may hamper interpersonal communication, for example, when English is not the primary language spoken at home. In our experience, family members may not openly express helplessness, frustration, anger, fear, and concern about the patient in front of the patient or to all members of the interdisciplinary team. The technique ofreframing (14) (again emphasizing the positive aspects of denial and concerns of safety always orienting toward reality) may be useful in ALS family support groups. Group facilitators are mindful that the emphasis is not what is happening to the family but how the family is relating to what is happening (12).

4. Ensure that an analysis of interdisciplinary treatment goals has been conducted to ascertain how psychosocial support might complement the medical plan of care.

The provision of psychosocial support can be facilitated or diminished by the behaviors and treatment goals of the interdisciplinary team. It is important for team members to share common goals and establish close communicative ties. Any tendency of the family to manipulate or split the team should be made apparent to all concerned and put into perspective.

5. Ensure that the coping strategy and interpersonal communication of health professionals are continually self-assessed and open to outside counsel.

Healthcare professionals should be aware of their own behaviors. Just as the patient and family are asked to meet the diagnosis of ALS as a continual challenge, so should the healthcare team. One manner of self-assessment is to ask a set of related questions. Have our behaviors promoted problem-solving and positive adaptation or dependency in patients with ALS and other progressive motor illness? Whose psychological needs are being met-the patient's or ours? Are we being realistic in our behavioral self-assessment? Have we been creative in our approach to alternative treatments? Do we need supportive guidance from a psychiatric nurse clinician, psychologist, or psychiatrist in responding to a patient and their family, particularly when psychological dysfunction is evident? Are we aware of our own psychological functioning, dysfunctioning and maladaptive patterns? Have we promoted collegiality and collaboration among all our team members?

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