Chronic fatigue syndrome

Chronic fatigue syndrome (CFS), also known as post-viral fatigue syndrome (PVFS) and myalgic encephalomyelitis (ME) (Lewis, Cooper, & Bennett, 1994), is a clinically defined disorder with an ambiguous etiology characterized by severe debilitating fatigue and a combination of other somatic and neuro-psychiatric systems (Farrar, Locke, & Kantrowitz, 1995). The importance of recognizing CFS and its functional limitations is recognized by the Centers for Disease Control (CDC), which added it to the list of priority one new and emerging diseases in 1994 (Reeves, 1995). Although controversy continues concerning its symptomatology, management, and prognosis; some agreement has been reached in the medical community about diagnostic criteria (Lewis et al., 1994). In addition, the term chronic fatigue syndrome is usually preferred to refer to the symptoms commonly associated with this disorder (Lewis et al., 1994, Wessely, 1995). The original case definition describes CFS as the "new onset of persistent or relapsing, debilitating fatigue severe enough to reduce or impair average daily activity below 50% of the patient's premorbid activity level for a period of at least six months" (Holmes et al., 1988, p. 388). Neither physical nor psychological explanations alone can define the complexities of this disorder (Lewis et al., 1995).

CFS is not a rare or homogeneous disorder. Approximately 1 to 3 persons per 1000 have CFS, with almost 70% being female (Wessely, 1995). The disorder is more dominant among White middle class persons (Royal Colleges, 1996), occurs frequently among adolescents but rarely among children under 10 years of age (Jordan, 1996), and is associated with allergies (Klonoff, 1992). The onset of CFS is typically abrupt, and individuals with this disorder often have feelings of powerlessness, fear, bewilderment, and frustration. In the most dramatic cases, a healthy, highfunctioning person becomes severely impaired without apparent cause, and the individual's quality of life is drastically altered (Friedberg & Jason, 1998). Anderson and Ferrans (1997) found that CFS resulted in "profound and multiple losses in jobs, relationships, financial security, future plans, daily routine, hobbies, stamina and spontaneity" (p. 362).

Often physicians do not find a psychological explanation for the fatigue symptoms of this disorder. Individuals with CFS are often dismissed as being hypochondriacal, depressed, phobic or non-legitimate (Friedberg & Jason, 1998; Shorter, 1995). Significant stigmatization is frequently associated with CFS. Individuals with CFS vary considerably in their clinical presentations and often report a number of different medical and psychiatric symptoms. Because of this ambiguity, rehabilitation counselors may be called upon to play a critical role not only in the rehabilitation of, but also in detecting unsuspected cases of CFS among rehabilitation consumers (Albrecht & Wallace, 1998). Therefore, rehabilitation counselors need information to help them recognize and understand the symptoms, signs, and effects of CFS.

The purpose of this article is to provide rehabilitation counselors with an overview of chronic fatigue syndrome that will allow them to skillfully inquire about and understand the consequences of this disorder. Rehabilitation counselors are continually expected to incorporate new information about the functional limitations of disabling conditions and expand their existing knowledge base without compromising the continuity and quality of services for their consumers. Understanding CFS requires an understanding of the interrelationships between psychological/ affective and biological/medical variables. Information is presented in the following sequence: (a) etiology and symptomatology, (b) diagnoses and treatment, (c) functional limitations, and (d) rehabilitation implications and recommendations. The information is synthesized to assist rehabilitation counselors to better understand and serve their consumers with chronic fatigue syndrome.

Etiology and Symptomatology

Chronic fatigue syndrome is considered to have an ambiguous and a multifactoral etiology. Several hypotheses have been advanced to explain CFS: viral, immunologic, psychiatric, and neurologic (Pliolpys & Pliolpys, 1995). Lewis et al. (1994) reported that stress is implicated in CFS and that "vulnerability to disease is influenced by certain behavioral patterns, coping styles and social resources" (p. 662). According to Albrecht and Wallace (1998), "CFS typically begins abruptly with a flu-like illness. Less frequently it follows physical trauma (e.g., automobile accident) or surgery" (p. 184). Although CFS is linked with mental health problems (Kruesi, Dale, & Straus, 1989; Lane, Manu & Mathews, 1991; Wessely et al., 1996), the literature equally supports the independence of the disorder from mental dysfunction (Bruce-Jones, White, Thomas, & Clare, 1994; Lewis et al., 1994; Wearden & Appleby, 1996). Other predisposing factors associated with CFS include personality, biological characteristics, and other medical conditions (Friedberg & Jason, 1998). Friedberg and Jason explained that while the research does not identify unique characteristics as antecedents or consequences of CFS, high levels of emotionality and neuroticism may act as predisposing factors. For biological factors, Lanham and Lanham (1994) and Abbot et al. (1996) found high rates of autoimmune diseases in families of individuals with CFS. Indeed, even diagnosed cases of CFS may turn out to have other causes when studied over time (Albrecht & Wallace, 1998).

Chronic fatigue syndrome has a constellation of psychological, neuropsychological, and physical symptoms along with extreme fatigue. According to Freidberg and Jason, CFS definitional symptoms have a composition of variability, severity, continuation, and ambiguity (Friedberg & Jason, 1998). A diagnosis of CFS includes two major criteria and eight minor symptom criteria. The first major criterion involves medically unexplained chronic fatigue, experienced for at least 6 months, is of new or definite onset, is not substantially alleviated by rest, is not the result of ongoing exertion, and results in substantial reduction in occupational, educational, social, and personal activities. Anxiety disorders, somatoform disorders, and nonpsychotic or nonmelancholic depression are not exclusionary (Fukuda et al., 1994). However, if present, the following conditions exclude a diagnosis of CFS. The conditions include: (a) past or recurrent major depression with melancholic or psychotic features, (b) delusional disorder, (c) bipolar disorders, (d) schizophrenia, (e) anorexia nervosa, (f) bulimia, and (g) alcohol or substance abuse within two years of onset of CFS (Fukuda et al., 1994). The second major criterion includes the concurrent occurrence of two or more of the symptoms listed below, which must be persistent or recurrent during six or more months of the illness and do not predate the fatigue (Fukuda et al., 1994). The eight minor symptom criteria that help define CFS include: (a) self-reported persisted or recurrent impairment in short-term memory or concentration severe enough to cause substantial reductions in previous levels of occupational, educational, social, or personal activities, (b) sore throat, (c) tender cervical or axillary lymph nodes, (d) muscle pain, (e) multiple joint pain without joint swelling or redness, (f) headaches of a new type, pattern, or severity, (g) unrefreshing sleep, and (h) postexertional malaise lasting more than 24 hours (Fukuda et al., 1994).

In addition to these symptoms, specific physical signs are often present in individuals with CFS. These signs include inapproproate sweating, unusual skin tone, motting (e.g., splotchy or spotting) of arms and hands, and unusual thirst (Albrecht & Wallace, 1998). Specific neuropsychological complaints include: (a) inability to concentrate, (b) forgetfulness, (c) confusion, (d) difficulty thinking, (e) excessive irritability, (f) depression, (g) sensitivity to light, and (h) temporary visual blindness or dark spots (Holmes et al., 1988). CFS follows a variable course with exacerbations and partial remissions, relapses, and varied duration.

Diagnosis and Treatment

There is no conclusive diagnostic test for CFS. Friedberg and Jason (1998) suggested that because CFS is a "multidimensional behavioral construct rather than a precisely delineated disease entity, sophisticated behavioral assessment is crucial" (p. 49). Emphasis is placed on assessing the full spectrum of symptom severity, not the mere presence or absence of symptoms (Friedberg & Jason, 1998). It is critically important to distinguish any degree of comorbidity of CFS with psychiatric disorders (Albrecht & Wallace, 1998; Friedberg & Jason, 1998). In addition to behavioral assessment, a detailed physical examination (e.g., chemistry screen, blood count, arthitic profile, hepatitis B, HIV screen, urinalysis, tuberculin skin test, anterior-posterior and lateral chest x-ray, sleep studies, electrocardiogram, immunoglobulin levels, serum cortisol determination, and other appropriate tests) is required (Farrar et al., 1995; Friedberg & Jason, 1998; Wessely, 1995). Because fatigue levels constitute a prominent and defining feature of CFS, symptom charting (e.g., quantitative data collection on symptom severity through the use of rating scales) is useful in confirming the presence of ongoing illness. Symptom charting can also provide feedback about the impact of an individual's coping strategies and assist in the successful management and treatment of CFS (Friedberg & Jason, 1998).

Although there are various scales for rating fatigue (see Friedberg & Jason, 1998 for discussion of rating scales), Friedberg and Jason recommended the use of fatigue scales that "(a) have been diagnostically validated in CFS and depression samples, (b) assess several factorially distinct dimensions of fatigue, and (c) are easy to administer and score" (p. 77). In the clinical setting, the Fatigue Severity Scale (FSS) (Krupp, La Rocca, Muir-Nash, & Steinberg, 1989) and Multidimensional Assessment of Fatigue (MAF) (Belza, 1995; Belza, Henke, Yelin, Epstein, & Gillis, 1993; Tack, 1990a, b) are recommended for use because they provide a rapid assessment of fatigue-related impairments (Friedberg & Jason, 1998). In the initial validation study of the FSS, the internal consistency was r =.68 (Krupp et al., 1989). In addition to its psychometric properties, the FSS is a practical tool because of its brevity and ease of administration and scoring (Friedberg & Jason, 1998). However, a "ceiling effect" in the FSS (Friedberg & Krupp, 1994) "may limit its utility to assess severe fatigue-related disability, and therefore, the true association between the FSS and other health-related measures may be underestimated" (Friedberg & Jason, 1998, p. 72). In two validation studies the MAF showed strong concurrent validity (r [is greater than].75) and divergent validity (r [is greater than or equal to] -.60), and two of the MAF items showed strong face validity (Belza, 1995; Belza et al., 1993). In addition, the MAF covers a comprehensive range of impairments, thus minimizing ceiling effects for respondents who are severely disabled (Friedberg & Jason, 1998). Conversely, "the construct validity of the five dimensions of the MAF has not been confirmed with factor analysis, an essential task in the development of any multicomponent measure" (Friedberg & Jason, 1998, p. 73). Nevertheless, the MAF is both brief and thorough in scope. An appropriate assessment and diagnosis of CFS encompasses differential diagnoses that distinguish CFS, stress symptoms, psychiatric symptoms, and syndromes that may overlap with CFS (e.g., fibromyaliga, lyme disease, multiple chemical sensitivity, and irritable bowel syndrome) (Friedberg & Jason, 1998). Moreover, a differential diagnosis is the prerequisite for establishing treatment protocol.

There is no known cure for CFS and no universally related treatments have been established. The majority of therapies are either experimental or untested (Friedberg & Jason, 1998). The most common interventions include pharmacological treatment (e.g., antidepressant medication, blood pressure medication, and antiviral and immumomodulatory drugs), dietary regulation intervention (e.g., vitamin, mineral, and amino acid supplementation), and cognitive-behavioral counseling (e.g., combination of cognitive restructuring, coping skills training, stress management, and behavior modification) (Goodnick & Sandoval, 19993; Kodama, Kodama, & Murakami, 1996; White & Cleary, 1997). Cognitive-behavioral interventions may include relaxation techniques, pleasant mood induction and maintenance, activity pacing, daily life restructuring and graded activity, cognitive coping, social, support, and memory assistance (Friedberg & Jason, 1998). In 1994 Friedberg and Krupp presented patient rankings of treatment effectiveness of medical and alternative therapies for individuals with CFS. Their results indicated that an anti-allergy diet and anti-yeast diet were more highly rated than the majority of pharmacological therapies. LeRoy, Haney-Davis, and Jason (1996) found non-pharmacological interventions such as stress reduction and rest yield the best results. These findings are consistent with earlier results (e.g., Berne, 1992) in which individuals with CFS reported that reducing stress and increasing rest are two of the best strategies for reducing and controlling symptoms (Berne, 1992).

Friedberg and Jason (1998) suggested that the ability to adjust psychologically to CFS is an important element of any intervention. Furthermore, individuals with CFS need "to pace their activity in order to conserve energy and avoid overexertion and relapse" (Friedberg & Jason, 19998, p. xi). This energy conserving approach is referred to as the "envelope theory" and informally, is known as the "fifty-percent solution" (Collinge, 1993). According to Collinge, the envelope theory provides a testable hypothesis that predicts that individuals with CFS can avoid relapse while increasing their tolerance to activity if the individual's perceived energy and expended energy are properly balanced. In other words, people with CFS can prevent relapses, and over time, possibly increase their energy levels if they make efforts to keep their expended energy (e.g., energy used) and perceived energy (e.g., energy they think they have) approximate to each other (e.g., contained in the envelope). For example, under the envelope theory, individuals with CFS that continually overexert themselves should cut back on activities and reserve their energy, but those who are severely disabled and inactive for prolonged periods should be encouraged to gradually increase activity as tolerance develops (Friedberg & Jason, 1998). The envelope theory does not advocate for either increased rest or activity universally to all individuals with CFS. Rather, the envelope theory mediates as a midpoint between the rest and activity continuum. Under this model each individual receives an individualized assessment. "Thus, envelope theory promotes the use of moderation and energy conservation based on individualized treatment programs" (Friedberg & Jason, 1998, p. 151).

Treatment for CFS must be individualized, address coexisting conditions, and be founded on common sense. Individuals with CFS should be presented with information about their condition, encouraged to join a support group, and instructed in ways to keep a diary of their symptoms, behaviors, and daily activities. Questions should be posed in order to prescribe treatment for individuals with CFS. Examples of such questions include: Does the individual experience the minor or major CFS criteria more frequently? Depending on the answer to the question, one should proceed to the appropriate category and criteria (e.g., minor or major) and assess symptoms and functional limitations. How frequently is each of the minor CFS criteria present in individuals who meet the major criteria? (Komaroff et al., 1996).

Diagnosis and treatment for CFS is a lengthy process that requires exclusion of other conditions that might cause the same or similar symptoms. Any understanding of CFS has to take into account the complex interactions between physical, emotional, and psychological components. Therefore, any condition with symptoms whose primary basis is fatigue should be evaluated with caution because CFS could be only one of several possible culprits (Albrecht & Wallace, 1998).

Functional Limitations

Individuals with CFS experience a host of functional limitations. Even with reduced symptoms, many individuals still experience exacerbation during periods of stress and minor illness, and a significant minority of individuals experience progressive worsening of symptoms (Friedberg & Jason, 1998). The limitations presented in this article are not in any particular order of severity nor are they exhaustive. Moreover, not all individuals with CFS have all of these limitations. One functional limitation may be neurally mediated hypotension (NMH) (Rowe, Bou-Holaigh, Kan, & Calkins, 1995). Neurally mediated hypotension is a chronic condition in which prolonged standing or sitting causes reduced blood flow to the brain, resulting in episodes of near fainting. For individuals with CFS, NMH episodes are followed by prolonged fatigue, blurred vision, muscle and joint pain, unusual thirst, the need to lie down, and craving for salt (Albrecht & Wallace, 1998).

Individuals with CFS complain of difficulties with concentration and memory, but they do not suffer gross deficits in cognitive functioning (Wearden & Appleby, 1996). Wearden and Appleby explained that "everyday cognitive tasks may require excessive processing resources leaving the individual with diminished spare attention capacity or flexibility" (p. 197). Individuals with CFS may show signs of slower performance and slower information processing (Scheffers, Johnson, Grafman, Dale, & Straus, 1992; Smith, Behan, Bell, Millar, & Bakheit, 1993) where tasks are more difficult and complex (Deluca, Johnson, Beldowicz, & Natelson, 1995). Individuals with CFS commonly report that they have word block (e.g., difficulty retrieving specific words to convey a thought, complete sentence, or carry on a conversation) (Friedberg & Krupp, 1994). Because of their inability to recall a specific word or phrase, the individual with CFS may become frustrated and discontinue a conversation (Friedberg & Jason, 1998).

Because of physical problems (e.g., muscle pain, joint pain, headaches, etc.) the individual with CFS frequently experiences restrictions in social and physical activities. Physical inactivity limits the individual's employment options, social functioning, and relationships with family members and peers (Friedberg & Jason, 1998). For example, significant others may perceive the individual with CFS as being too tired to do anything and therefore may decline social invitations on behalf of themselves and the person with CFS. This may result in problems in the spousal unit and family functioning. Individuals with CFS may have coexisting physical and psychological conditions such as depression or pain and it is important to differentiate those with a primary diagnosis of major depressive disorder or physical pain from CFS. Jason et al. (1997) noted that it is possible for individuals with depression or other physical problems to also have CFS. The case criteria for CFS require that fatigue and other symptoms not be a product of other conditions. Thus, it is advisable to deal with other conditions before referring the individual for possible CFS (Albrecht & Wallace, 1998).

Emotions such as self-anger, guilt, and discouragement are prevalent among individuals with CFS. Because of the limitations imposed by CFS, affected individuals may have low levels of self-esteem. Depression is the most commonly diagnosed psychological disorder in CFS (Friedberg, 1996), and discouragement or demoralization "arises from the sense of reduced competence to manage vocational, marital, family, and social activities. Discouragement can have a profound effect on well-being" (Friedberg & Jason, 1998, p. 159). In addition, because of experiences with medical rejection their concerns and fears may escalate to anger, and the anger may affect individuals with CFS functioning and compromise their immune systems (Friedberg & Jason, 1998).

Finally, individuals with CFS experience low frustration tolerance often characterized by the perception that one should have total control of the illness or disorder and somehow overcome the disability by sheer will (Friedberg & Jason, 1998). Failure to maintain control exacerbates the individual's irritability level. Increased irritability detracts from the individual's interpersonal and vocational functioning.

Implications for Rehabilitation Counselors

Ferrari and Jason (1997) suggested that CFS has become a new and difficult challenge for the field of counseling. This challenge is even more relevant for rehabilitation counselors. Although rehabilitation counselors are not expected to assume the responsibility of making a medical diagnosis, they may be in a position to assist consumers with CFS in dealing with symptoms and functional limitations associated with the disorder. While not all rehabilitation counselors work with the population, those who do must expand their knowledge to include information about CFS and be aware of its vocational, psychological, and social effects.

Of relevance to rehabilitation counselors is the fact that individuals with CFS usually do not appear sick (Albrecht & Wallace, 1998). Because doctors do not diagnose them as "sick," many individuals with CFS may dramatize their condition in an effort to be perceived as having a genuine illness (Friedberg & Jason, 1998). While it is not uncommon for those with more severe symptoms to have suicidal ideations (Collinge, 1993), counselors must avoid uncritical acceptance of individuals with CFS as having emotional problems. In addition, lack of treatment response is a warning sign that the individual may have been misdiagnosed. For example, "when depression does not improve more than marginally with treatment, or when it improves but leaves residual symptoms," the rehabilitation counselor needs to consider the possibility that some or all of the symptoms emanate from a physical problem (Albrecht & Wallace, 1998, p. 187). It is not uncommon for rehabilitation counselors to arrive at several different conclusions when a consumer does not improve. One conclusion is that as a counselor, he or she should have done a better job. A second conclusion is that treatment has failed because the consumer did not cooperate fully. Finally the counselor may believe that the consumer should be referred to someone else who might use a different approach (Albrecht & Wallace, 1998). According to Alberecht and Wallace (1998), counselors should avoid applying inappropriate diagnostic labels to or reaching inaccurate conclusions about individuals with CFS. In order to do this rehabilitation counselors must acquire a working knowledge of the psychosocial, medical, and physical aspects of CFS and other medical conditions (especially those that may be confused with or disguise CFS).

One way in which rehabilitation counselors' knowledge of CFS may be increased is through in-service training and/or curricular changes that include CFS as part of courses on medical and psychosocial aspects of disability. In addition, when rehabilitation counselors refer consumers for medical examinations they can request that the consulting physicians screen for CFS. The screening effort may be facilitated by a checklist of symptoms that is developed through collaboration of rehabilitation counselors and medical professionals in which counselors can use during their intake interview or at any stage of the rehabilitation process with consumers. In addition, rehabilitation counselors and physicians, along with the consumer with or suspected of having CFS, should confer to develop an educational/informational format to assist these individuals with understanding and regulating their behavior and symptoms.

Fennell (1995) developed a four-stage model of CFS that provides a framework for consumers to understand the consequences of their disorder. During Stage One, onset of CFS, the individual utilizes denial as a functional coping mechanism. As symptoms become more disabling the following changes may occur (a) denial may give way to an escalating crisis of emotional isolation and bewilderment, (b) family, significant others, and friends may or may not be supportive, and (c) vocational functioning may be compromised if the illness severity limits performance (Friedberg & Jason, 1998). In Stage Two, receiving a diagnosis of CFS, the individual exhibits disappointment, desperation, and fear about the lack of effective treatment or cure. This stage is characterized by (a) erosion of self-confidence as routine physical and cognitive tasks are performed with increasing difficulty, (b) social networks may become more distant as the persistence of the illness continually frustrates the support network, and (c) impairments may lead to a leave of absence from work and risk of job loss (Friedberg & Jason, 1998). Stage Three, illness plateau and relapses, is characterized by (a) frequent relapses as the individual attempts to engage in normal tasks, (b) greater abandonment by friends and significant others, (c) increased feelings of isolation and stigmatization, and (d) further work reductions or terminations (Friedberg & Jason, 1998). At Stage Four, illness plateau or improved health, individuals may (a) emphasize personal efforts to achieve greater control of their lives as they lose faith in medical interventions, (b) reassess their values and develop new standards of living or continue their attempts to sustain the roles they held before CFS began, (c) find new social connections and forms of support, and (d) continue work with modifications in work schedule or jobs or completely abandon their job for an entirely different type of work (Friedberg & Jason, 1998). As an educational tool, the four-stage model provides the individual with CFS with knowledge, validation, and the ability to cope with the disorder. Counselors may find this model useful in working with their consumers with CFS (Fennell, 1995).

As part of job development and job placement process rehabilitation counselors must evaluate both general employability and specific capacity of individuals with CFS to function in a particular occupation or work situation (Friedberg & Jason, 1998). Friedberg and Jason suggested that for evaluation of specific capacity rehabilitation counselors have to consider such factors as general concentration and attention, ability to attend to the task at hand, ability to attend to detail, stress tolerance, fatigability, emotional and physical endurance, and general work stamina. As for general employability of individuals with CFS, rehabilitation counselors must weigh the strengths and weaknesses of these individuals to become and remain employed. Geist and Calzaretta (1982) referred to this process as "placeability" of the individual. Therefore, rehabilitation counselors will need to develop a placeability checklist to assess the job readiness of individuals with CFS with consideration given to punctuality, abseteeism, interpersonal interactions (Friedberg & Jason), physical stamina, behavioral stability, and overall function. These considerations are particularly important competencies for the rehabilitation counselor because individuals with CFS need professional assistance in negotiating with their employers for accommodation and assistance with career change (Heiman, 1994).

Rehabilitation counselors should help individuals with CFS to "avoid overstimulation caused by too much activity based on a `do-everything' work ethic" (Friedberg & Jason, 1998, p. 167). Friedberg and Jason suggest that activity levels that were acceptable prior to CFS onset may now cause cognitive overload. This possibility is particularly relevant to counselors because they will need to take this into consideration for the job development and job placement process. Rehabilitation counselors must develop job sites that include flexibility. Jobs with intense physical requirements, a typical workday (e.g., eight hours), or tasks with multiple or complicated steps are not good placements for those with CFS unless the jobs can be modified. Practical accommodations might include home-based employment, part-time employment, job sharing, and employment with flextime. Appropriate jobs could include those that (a) allow extra time to complete activities, (b) minimize distractions, (c) establish a routine for daily activities that will minimize the stress on fragile cognitive capacities, and (d) permit schedule relaxation time to reduce confusion and improve attention (Friedberg & Jason, 1998). Because individuals with CFS are often chemically sensitive, the environment in which they work must be relatively chemical-free (e.g., odors and scents) (Albrecht & Wallace, 1998; Friedberg & Jason, 1998).

Rehabilitation counselors may need to assist the individual with CFS to deal with the psychosocial aspects of their condition. Others may question the severity of the person's illness. A common response to this disbelief is anger and hurt. According to Friedberg and Jason (1998), it is important to allow individuals to express this anger in counseling sessions because it may not be well received by others. The counselor's understanding and tolerance of the anger is an important element of gaining trust and rapport building (Friedberg & Jason, 1998). Moreover, the counselor can help the individual understand the thinking of skeptics. That is, "healthy people's" disbelief is oftentimes an attempt to psychologically distance themselves from chronically ill individuals in an effort to believe that their health is not at risk (Friedberg & Jason, 1998).

In addition to having a knowledge base about CFS, the rehabilitation counselor must be knowledgeable about community, technological and interpersonal resources for individuals with CFS. Support groups can be a valuable intervention strategy for those with CFS. Schlaes and Jason (1996) conducted a study of the effectiveness of a buddy-mentor system involving people with CFS. The buddy was a person who agreed to spend I hour per week making home visits and the mentor engaged in 2 hours of phone contact each month providing informational and emotional support. The results indicated that individuals with CFS who received a buddy-mentor experienced significant declines in fatigue severity and reported improvements in positive thinking. Conversely, individuals with CFS who did not receive the intervention experienced increased fatigue and decreased levels of positive thinking.

Finally, rehabilitation counselors should assist the individual with CFS to focus on controlling his or her attitude and behavior, rather than attempting to control the illness itself (Friedberg & Jason, 1998). For example, rehabilitation counselors may consider implementing a behavioral contract in which the consumer's behaviors are identified and strategies are specified for self-monitoring and behavior control. The behavioral contact can be implement as either part of guidance and counseling services or as part of the individualized employment plan (IPE). Friedberg and Jason referred to this process of self-control as therapeutic coping. Moreover, terminology is important because for many individuals, "adapt" or "tolerate" has a more constructive connotation than "accept" because it emphasizes personal control (Fennell, 1995). It is particularly important to involve the individual with CFS in the planning of interventions. This involvement empowers the individual to become a better problem solver, reinforces an important sense of validation about the legitimacy of CFS, and provides a means for the individual to see and appreciate gains he or she has made and may provoke positive illness management (Fennell, 1995; Friedberg & Jason, 1998).

Conclusion

Chronic fatigue syndrome is a relatively common disorder occurring in 1 to 3 persons per 1000, with the majority being female, white, and middle class. CFS impedes social, physical, psychological, and vocational functioning. It is often undiagnosed or misdiagnosed by physicians who may be skeptical about legitimacy of the disorder. Individuals with CFS experience a variety of functional limitations including difficulties with concentration and memory, physical fatigue and inactivity, low frustration tolerance, and a host of physical problems and pain. Intervention strategies must be individualized, focused on regulating and controlling behavior, and continually reassessed so that they are beneficial to individuals with CFS. It is important to include individuals with CFS in the planning of interventions in order to empower them and provide them with a sense of validation about the disorder.

The debilitating effects of CFS reach far beyond the individual with the disorder. The impact is felt by significant others, employers who may lose a good worker, and society may lose the financial and intellectual contributions of individuals with CFS. A major consideration for rehabilitation counselors working with individuals with CFS is to understand the nature of the disorder, the attitudes and behaviors of those who are skeptical about it, and the psychosocial dynamics of the dysfunctional aspects of CFS. Clearly, if those who have CFS are to regain and maintain comparable premorbid functional levels a comprehensive, persistent approach to treatment is essential.

Rehabilitation counselors are in a position to play a critical role in the psychosocial, physical, emotional, and vocational adjustment of individuals with CFS. Although rehabilitation counselors are not expected to make any type of medical diagnosis, they are expected to have a working knowledge of the signs and symptoms and functional limitations of CFS, and knowledge about community, technological, and interpersonal resources. Given the adverse effects of CFS, counselors must work closely with these individuals and medical professionals to gain an understanding of both real and perceived limitations of the disorder. In addition, rehabilitation counselors must possess competencies in job development and job placement, workplace accommodations, negotiation skills with employers to provide accommodations, basic assessment skills about general employability and specific capacity, and behavioral guidance skills at they pertain to individuals with CFS. Overall, rehabilitation counselors have the responsibility to collaborate with medical professionals, employers, other human and community service providers, and consumers with CFS to develop more sensitive diagnostic and treatment strategies to facilitate optimal recovery of limitations associated with the disorder.

In conclusion, rehabilitation counselors should avoid inaccurate and biased characterizations of consumers with CFS. Making sense of this disorder requires rehabilitation counselors to expand their knowledge base and counseling skills to work with consumers with CFS. Clearly, possessing accurate information and an understanding of CFS are prerequisites for rehabilitation counselors' effectiveness in the development and implementation of guidance and counseling services, individualized employment plans, job development and job placement services, and post-employment follow up services.

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Debra A. Harley, Ph.D., CRC, CPC, Department of Special Education and Rehabilitation Counseling, University of Kentucky, 219 Taylor Education Building, Lexington KY 40506-0001. Email: DHARL00@pop.uky.edu.

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