COUNSELING CLIENTS WITH ENVIRONMENTAL SENSITIVITIES: A GUIDE FOR THERAPISTS

COUNSELING CLIENTS WITH ENVIRONMENTAL SENSITIVITIES – A GUIDE FOR THERAPISTS PAMELA REED GIBSON

◦ A condition where persons become sensitized to levels of chemicals in ambient air. ◦ They are then subject to symptoms when exposed to those chemicals in environments that others take for granted. ◦ A simple trip to the grocery store can result in illness that may last for several days. ◦ People steadily lose environments that they can access. Work, relationships, finances, and identity all need readjusting.

WHAT IS MULTIPLE CHEMICAL SENSITIVITY (MCS)?

â—Ś Symptoms can affect any organ system (respiratory, neurological, cardiovascular, digestive, urinary, etc.) â—Ś The most problematic symptoms rated by 254 persons with MCS were tiredness/lethargy, difficulty concentrating, muscle aches, memory problems, and long-term fatigue (Gibson & Vogel, 2008). Most of these affected the nervous, musculoskeletal, and gastrointestinal systems.

WHAT SYMPTOMS OCCUR IN MCS?

◦ A portion of persons with MCS also evidence electrical hypersensitivity (or electrohypersensitivity) (EHS). Some persons have EHS without the chemical sensitivity. Those with the EHS are unable to be around computers, cell phones, florescent lighting, or high-tech medical equipment. Johansson (2015) estimates that 230,000 to 290,000 Swedes of 9 million have EHS. ◦ Johansson cites prevalence estimates from a variety of countries between 1.5% and 3.5%, except for Taiwan, where the estimate is 13.3%. ◦ Johansson points out that the EMFs are harming animals and other aspects of nature in addition to people, and thus constructs EMF sensitivity as an environmental issue. I view MCS similarly. ◦ Johansson sees EHS as a kind of irradiation damage, as cell permeability is affected, allowing toxics to cross the blood-brain barrier; mast cells then degranulate and release histamine. The Swedish government recognizes EHS, though this does not guarantee citizens appropriate access or treatment. ◦ I will use the term Environmental Sensitivities to include both MCS and EHS.

WHAT IS ELECTROHYPERSENSITIVITY?

◦ MCS WORLDWIDE ESTIMATES ◦ 12.6% of US population (Caress & Steinemann, 2003) ◦ 33% of US population with 3.9% becoming ill every day

(Meggs, Dunn, Bloch,

Goodman, & Davidoff, l996)

◦ 20% of a US sample taken in waiting rooms for family medicine clinics (Katerndahl, Bell, Palmer, & Miller, 2012)

◦ 27% of Danish population (Berg, Linnegarg, Dirksen, & Elberling, 2008) ◦ 16.4% in Korean adults (Jeong, Kim, Park, Roh, & Park, 2014). ◦ 33% of a Swedish community; 19% affected more substantially

(Johansson,

Brämerson, Millqvist, Nordin, S& Bende, 2005)

◦ 15.6% of Swedish teenagers (Andersson, Johansson, Millqvist, Nordin, & Bende, 2008)

◦ EMF ESTIMATES ◦ 1.5% -3.5% in a variety of countries; 13.3% in Taiwan (Johansson, 2015)

HOW PREVALENT ARE MCS AND EHS?

MCS TRIGGERS The most problematic triggers rated by 254 people included pesticides, formaldehyde, fresh paint, new carpet, diesel exhaust, perfumes, and air “fresheners� (Gibson & Vogel, 2008).

Among Japanese people with MCS, insecticide, paint/paint thinner, cleaning products, fragrance, nail polish/hair spray, and tobacco smoke were cited as most problematic (Hojo, Ishikawa, Kumano, Miyata, & Sakabe, 2007).

EHS TRIGGERS Respondents in our research have cited computers, electrical equipment, cell phones, florescent lighting, cell towers, and medical equipment to be among the most dangerous triggers for them.

WHAT TRIGGERS CAUSE SYMPTOMS?

Data from a number of studies in our lab show: 20-21% cite one large chemical exposure, 53-59% a series of low-level exposures, 5-6% a physical illness, 1% a psychological stressor, and 8-15% are uncertain regarding what initiated their sensitivity (Gibson, Elms, & Ruding, 2003; Gibson & Vogel, 2008).

WHAT INITIATES MCS?

◦ For the same reasons that others go – to work out personal issues. ◦ Because they do not know what is wrong with them. People may be experiencing symptoms that make no sense to them.

It is important that therapists have a working knowledge of the problem in order to guide people who may not know that they have been sensitized. ◦ Because they have applied for disability benefits and have been mandated to see a therapist. Courts will often attempt to contextualize MCS or EHS as a mental problem because they are uneducated about it. ◦ Because they know that they are sensitive and need help with coping.

WHY WOULD SOMEONE WITH ES GO TO A THERAPIST?

WHAT MIGHT A CLIENT WITH ES GO THROUGH BY THE TIME THEY SEE A THERAPIST?

◦ Gibson, Elms, and Ruding (2003) found that people with MCS consulted many health practitioners with a great drain on their finances. Only a quarter of these providers were helpful. ◦ The mean amount spent on health care for 305 people with MCS was over $50,000 (Gibson et al., 2003). ◦ Medical providers encouraged people with MCS to expose themselves to chemicals to “deprogram” themselves from believing that chemicals made them ill. One could well make the case that this was malpractice.

Iatrogenic harm from poorly educated providers included harm from drugs, delay in diagnosis, treatment for the wrong condition, invasive testing , unnecessary surgeries, and even electroshock (Gibson et al., 1996). ◦ Unmet medical needs are common in persons with disabilities Jarzynowskab, & Shortt, 2010). For those with MCS, this is certainly true.

(McColl,

◦ Gibson, Leaf and Komisarcik (2016) interviewed 19 people with MCS and/or EHS and found that people struggled even to gain access to potential care, to be seen as legitimate, and to find practitioners who didn’t attempt to force them into standard protocols designed for other conditions. Conventional medicine’s lack of even a paradigm for treating them, was their impetus to give up seeking help and try to become as self-sufficient as possible.

THEY MIGHT STRUGGLE TO FIND MEDICAL HELP.

◦ Physicians admit to being unfamiliar with MCS (93% reported some level of unfamiliarity) and only 6% say they have a treatment protocol for the condition (Gibson & Lindberg, 2011). ◦ Yet good medical help is crucial. Gibson (2014) found in a study of 209 persons with MCS, that persons who were in a downward health spiral at time 1 were less likely to report improvement 2 years later. It should be the goal of providers to help interrupt the negative trajectory that leads to unemployment, loss of friends and family, and a poor home environment. ◦ Gibson, Kovach, and Lupfer (2015) found that over 25% of respondents avoided health care to avoid harm from EMFs. High levels of unmet needs were reported due to a lack of knowledgeable providers, exposures in the medical arena (both chemical and EMF), inability to pay, and not even feeling well enough to go out. Those with poorer health and lower income reported higher unmet needs. In the previous year, of 465 persons, 281 had unmet general medical needs, 203 dental, 133 opthalmic, 106 sexual health, 100 dermatological, 104 gastrointestinal, and 116 had unmet mental health needs.

MEDICAL HELP CONTINUED

◦ Gibson, Cheavens, and Warren(1996) found that over ¾ of 305 MCS respondents had lost employment due to their health, with only 7% currently working in safe conditions. Additionally, of those made ill by 1 large exposure, over half were sensitized in the workplace. 151 of these 305 people had to apply for disability benefits, a process that is long and stressful. ◦ Losing employment may mean losing health insurance, life insurance, retirement benefits, social interaction and even ones’ home. ◦ ”Employment was for many participants lost to the limits of spatiality” (Gibson, Sledd, McEnroe, & Vox, 2011). The challenge of accessing spaces to work and interact with others is constant and demands ongoing watchfulness, i.e., If someone arrives wearing perfume, the sensitive person must leave. ◦ Workplace harassment was common both for those still working and had been common for those forced out of the workplace, with harassment likely one of the pressures that forces people out of employment. Even those who received work accommodations worked with difficulty due to ongoing obstacles, including the refusal of co-workers to honor the accommodations (Gibson & Lindberg, 2008).

THEY MIGHT STRUGGLE TO KEEP A JOB

◦ If persons do not receive work accommodations, they have the right to file a complaint with the Equal Employment Opportunity Commission (EEOC). However, Vierstra, Rumrill, Koch, and McMahon (2007) found that MCS filings with the (EEOC) were less likely to be resolved in the worker’s favor than those of persons with other disabilities. ◦ Vierstra et al. believe that gender discrimination may be a factor, as the cases they studied were 63.7% female. Women have historically been seen as not reliable reporters of their own symptoms.

JOB CONTINUED

◦ Given that making a safe space to live in and avoiding chemicals are the highest rated interventions for MCS, the importance of housing is clear. In our 1996 life impact study, persons reported having spent a mean of over $27,000 making their homes safe.

40.6% said that their home was either mostly safe or very safe. ◦ Even if people are able to do this, they are still at risk from neighbors’ pesticides, dryer sheets, and others chemicals. ◦ In each of our studies, a portion of respondents has been homeless, or reports having lived through a period of homelessness.

Gibson, Cheavens, and Warren (1996) found that 2/3 of their 305 respondents had lived in “unusual circumstances” (homeless, in a car, on a porch, or in a tent or trailer) at some point. Currently, 38% were living housebound, 4% in cars, 3% in tents, 2% in trailers or campers, 1% on patios, 1% in cleaned out garages, and 1% in porcelain trailers or totally outdoors. One woman lived in her horse trailer for a year. ◦ The Environmental Health Coalition of Western Massachusetts found that 10% of their 49 respondents had lived in such circumstances.

THEY MIGHT STRUGGLE TO FIND AND KEEP SAFE HOUSING

â—Ś Gibson et al. (1996) found that income plummeted a mean of over $17,000 after developing MCS Those granted disability income received a mean of $12,000, which took two years to get and cost the person a mean of over $2,500. Many were forced to accept psychological labels for disability income, rather than live completely without means.

THEY MAY STRUGGLE WITH FINANCES

Gibson, Cheavens, and Warren (1998) found that perceived social support in those with MCS was lower than published samples of persons with other illnesses and that women had higher scores than men. Some people report that family and friends are not willing to give up fragrances or do not believe that the person has a true illness. Small numbers (1-3%) were extruded, ostracized, or even deliberately exposed to chemicals by family!

Gibson Sledd, McEroe, and Vos (2011) found that 26 interview respondents reported problems in maintaining relationships, as others simply did not understand the invisible threat they faced. At times, “friends” even tested people by exposing them to the chemicals that harmed them.

Lipson (2004) commented on persons being absent in public when not feeling well and thus disappearing from others’ purview. Even when present, their disability does not manifest in a sensory or cognitive way and others do not perceive it.

THEY MIGHT STRUGGLE TO KEEP RELATIONSHIPS AND SOCIAL SUPPORT

◦ They report more disruption from illness than that of most other samples reported, including spinal injury, stroke, cancer, ankylosing spondylitis, chromic back pain, and Crohn’s Disease (Gibson & Vogel, 2008). ◦ Partly due to the marginalization, those with MCS report low satisfaction with life – lower than that of most published samples and only somewhat higher than veterans currently hospitalized. ◦ The most disrupted life areas on the Sickness Impact Profile for those with MCS were work, alertness behavior, and leisure. Eating, body care and movement, ambulation, and communication were least disrupted (Gibson & Vogel, 2008).

◦ Levels of hope were lower than that reported for all healthy or older adults, and higher only than elderly widowed populations (Gibson, 1999). ◦ One fifth of 305 persons with MCS considered suicide, 8.2% had made a plan, and 3.3% had made an attempt (Gibson, Cheavens, & Warren, 1996). ◦ Persons with SHR (a form of chemical sensitivity that mimics allergy or asthma) reported lower quality of life in a number of domains compared with published reference groups for other illnesses as measured on the The Nottingham Health Profile (NHP) and the ShortForm 36 Health Survey (SF-36) (Kristofferzon, & Ternesten-Hasséus, 2013).

STIGMA CAN CAUSE POOR QUALITY OF LIFE

◦ Larsson and Martensson (2009) found 4 themes in an interview study of 12 person with Sensory Hyper Reactivity (SHR): ◦ 1) “Limitations in one’s life situation.” ◦ 2) “Lack of understanding from others.” ◦ 3) “Concern that the symptoms will transition into a serious disease.” ◦ 4) “Disparagement of one’s own personal experience.”

QUALITY OF LIFE CONTINUED

◦ In 2010, Gibson found that of 100 respondents with MCS, 52% could not access higher education, 45% houses of worship, 40% community meetings, 29% homes of extended family, 24% homes of friends or dentists’ offices, 15% public libraries, 13% public parks and grocery stores, and 12% could not go to medical offices. Perfumes, cleaning products, lack of ventilation, carpet and air “fresheners” are the most significant barriers to buildings and pesticides and exhausts are the insurmountable barriers to parks (Gibson, 2008). High tech medical equipment is a barrier for those with electromagnetic hypersensitivity. ◦ Gibson, Suwal, and Sledd (2009) found that even Centers for Independent Living (CILs), set up “by and for” those with disabilities, were less than helpful to those requesting aid for MCS or EHS. Only 17 of 41 who requested help received any services. Advocates wore scents, and 25 of the 41 felt that their treatment at a CIL was not reasonable. One person was told she was mentally ill. Most needed services were safe housing, counseling, home assistance, work accommodation, formal recognition of their condition, and advocacy.

THEY MIGHT STRUGGLE TO ACCESS COMMUNITY RESOURCES

◦ Gibson, Placek, Lane, Brohimer, and Lovelace (2005) found two overarching themes regarding the effects of having MCS on identity: ◦ 1) Loss involved loss of a sense of self and of self-positioning.

People mourned the loss of who they “were,” and occupation, community position, and other contextual losses. ◦ 2) Response to loss included emotional suppression to meet others’ expectations, redesigning the planned life, forced personal growth, adjustments to interpersonal support, spiritual support, and identity reconciliation.

THEY MAY FACE IDENTITY CHANGES

◦ Gibson, Horan, and Billy (2016) interviewed 20 women growing older with MCS and or EHS. Respondents described a theme of “balancing on a tightrope without a net.” Persons with these conditions live their lives without a safety net, as mainstream institutions are almost completely inaccessible to them (though people around them are oblivious to this fact). There is a traumatic knowing for the experiencer regarding the lack of a net, and what access they do mange to muster is that of “going through the cracks.” This means that they must find very creative ways of surviving, socializing, and acquiring health care. ◦ Industrial culture’s economic model resists the recognition of illness caused by technology, whether chemicals or electromagnetic fields.

Dumit (2006) had called illnesses such as MCS and chronic fatigue syndrome (CFS) “illnesses you have to fight to get,” meaning that there is great resistance to getting a proper diagnosis, given that these illnesses do not have official codes.

THEY MIGHT FACE AGING WITH A STIGMATIZING ILLNESS

◦ Gibson, Lockaby and Bryant (2016) asked 60 people with ES about their experience with mental health providers. Most sought counseling or a disability evaluation, but also sought were help for depression, medication reviews, validation that their condition was physical, and help understanding their chemical reactions. ◦ Only 7% saw their providers as highly knowledgeable. More commonly, they saw providers as not knowledgeable (41.7%), or only somewhat knowledgeable (45%). Most (65%) said their providers were not experienced with MCS. ◦ Respondents complained of receiving psychological diagnoses and having to receive services in unsafe environments. ◦ Respondents wanted a fragrance-free environment or a chemical-free room, to avoid waiting rooms (with others’ fragrances), an open window, no fluorescent lighting, to be alerted regarding fresh paint, and other small accommodations.

HOW HAVE THERAPISTS DONE SO FAR WITH MCS CLIENTS?

WHAT DO PEOPLE WITH MCS OR EHS NEED FROM A THERAPIST?

◦ Counseling skills used with general clients are also useful with clients with sensitivities. Good listening, respect, inquisitive behavior, and rapport will go a long way. ◦ People with sensitivities are used to being disbelieved, to encountering numerous obstacles to accessing public spaces, and to going home sick from many outings. ◦ If you can make your office scent and chemical-free, you will have taken the first step toward supporting your sensitive clients. Cleaning supplies should be natural and scent free, air “fresheners” should not be used. Paint should be zero VOC (volatile organic compound). Other clients should be asked to come scent-free so as not to poison the air for clients with MCS. ◦ For clients with EHS, florescent lights should not be used, cell phones and all wifi should be turned off, and your office should be away from any medical equipment. ◦ If you can do a little reading and have some understanding of MCS and EHS ahead of time, you will save your client the trouble of educating you.

SUPPORT

◦ If you (meaning not the client) discovered that the client has MCS and/or EHS, your client has to educate themselves in order to cope and function. Resources are listed at the end of this PPTX. ◦ People will likely have received psychological labels, which ignore the origin of their problem (Swaboda, 2006). ◦ Gibson (2016) found that persons with ES were often given the label of somatization disorder. Those who wore masks to evaluations were labeled psychotic or delusional.

INFORMATION AND VALIDATION

To acquire disability benefits, clients must have a clear description of their limitations from a physician. The provider who knows the client best is supposed to be given the most credibility. However, this may not occur. Often, “Independent Medical Examiners,� who are completely unfamiliar with environmental sensitivities, are asked to examine a client and their word may be given priority. Not surprisingly, their assessments often include psychological labels.

As their therapist, your support in writing may be helpful in refuting some of these automatic psychogenic labels. Gibson and Bryant (2009) found that psychological evaluations for either people with ES included labels of somatization disorder, delusional disorder, conversion disorder, mixed personality disorder, depression, and anxiety. Evaluators were almost completely without knowledge regarding sensitivities. The problem is made all the more abhorrent by the fact that one of the clients was a book author.

Some of our research respondents in our lab have used creative means to illustrate their disabilities to Administrative Law Judges (at the third stage, the person often appears before a judge). For example, one person videotaped themselves during a reaction.

HELP IN APPLYING FOR DISABILITY BENEFITS

â—Ś Having a disability or chronic illness does not make you happy! It is normal for people with health problems to experience some anxiety or depression. Many studies show that people with sensitivities are NOT any more anxious than those with other chronic illness. But it does help to acknowledge and support people while they deal with these problems. â—Ś You could even say that it might make sense to develop trust issues when dealing with needs that are rarely met. Sorting out what is secondary to MCS or EHS or both is a significant part of coming to terms with living with sensitivities.

THERAPY FOR SECONDARY REACTIONS TO MCS

◦ Know that the level of sensitivity will determine the lifestyle. Some people will simply have to avoid strong scents. Others will have to revamp their entire way of living. ◦ Providers may have to be flexible regarding meeting place and fee. ◦ Know that some reactions to incitants may mimic psychiatric symptoms. This does not mean that the reaction is psychologically caused. You may have to work with the client to unpack the incitant reaction from any co-morbid psychiatric issues. ◦ It helps to validate the client’s knowledge. They are the expert on their own life and body. ◦ Help the client with future planning. They may have to let go of impossible goals and focus on what is attainable ◦ Do not force cures on people. There are literally hundreds of supplements and programs and no one can try them all. ◦ Help the client navigate constant challenges and changes in their health and environment. Mourning losses is ongoing. ◦ Support any activism that the client chooses. Many persons with sensitivities are able to find ways to help others with the same or similar conditions.

RULES FOR PROVIDING THERAPY

◦ Gibson (2009) called for: ◦ 1) Some safe zones and accommodations for those with limited access. E.g., health care and education could allot chemical-free zones for sensitive people. ◦ 2) Education for health care providers and advocates of Centers for Independent Living and other social service agencies. ◦ 3) Understanding of the context of Environmental sensitivities, meaning how chemicals damage people and then predispose them to more socioeconomic and health care oppressions. Yet chemicals are central to our industrial lifestyle. ◦ Ishikawa and Miyata (2000) called for: ◦ 1) Training of physicians and counselors. ◦ 2) Cooperation with public health centers. ◦ 3) Guidelines to regulate implicated chemicals. ◦ 4) Money for epidemiological research. ◦ 5) Creation of a database of MCS literature. ◦ 6) Animal study models. ◦ 7) Public relations with media and public. ◦ 8) Delivery of research findings to chemical companies.

WHAT DO RESEARCHERS RECOMMEND ?

REFERENCES FROM ESRT ◦ Gibson, P.R. (2019). Waking up to the environmental crises. In press at Ecopsychology for June, 2019 issue. ◦ Gibson, P.R. (2017). Living on the margins with access denied: Introduction to special issue on environmental sensitivities. Ecopsychology, June, 2017 ◦ Gibson, P.R., Coronado-Prieto, Y., & Cook-Smith, A. (2016). Access to community based advocacy services for persons with multiple chemical sensitivity. World Journal of Social Science Research, 3(3), 331339. ◦ Gibson, P.R. (2016). Extruded: A review of the life impacts of environmental sensitivities. Internal Medicine Review, May 2016. Invited paper. http://internalmedicinereview.org/index.php/imr/issue/view/2 ◦ Gibson, P.R. (2016). The hidden marginalization of persons with environmental sensitivities. Ecopsychology 8(2), 131-137. ◦ Gibson, P.R. (2015). Surviving with environmental sensitivities in the long emergency. Ecopsychology, 7(4), 224-230. DOI: 10.1089/eco.2015.0017 ◦ Gibson, P.R. (2014). Life Indicators, illness characteristics, and psychosocial concomitants of self-reported multiple chemical sensitivity: A two-year longitudinal study. Journal of Nursing Education and Practice 4(3), 204-216.

REFERENCES FROM ESRT ◦ Giibson, P.R. (2010). Of the world but not in it: Barriers to community access and education for persons with environmental sensitivities. Health Care for Women International, 31(1), 3-16. ◦ Gibson, P.R. (2009). Chemical and electromagnetic exposures as disability barriers: Environmental sensitivity.

Disability & Society, 24(2), 187-199.

◦ Gibson, P.R. (2006). Multiple chemical sensitivity: A survival guide, 2nd Edition. Earthrive Books. Can be ht to get: Facts as forces in uncertain, emergent illnesses.

Social Science & Medicine, 62, 577-590. PMid:16085344 http://dx.doi.org/1 accessed at www.arthrivebooks.com or www.mcsresearch.net ◦ Gibson, P.R. (2002). Understanding and accommodating multiple chemical sensitivity in independent living. A 57-page guide published by IL NET, a cooperative National Training and Technical Assistance Project of the Independent Living Research Utilization (ILRU) Program and the National Council on Independent Living.

Available at www.ilru.org. ◦ Gibson, P.R. (l997). Multiple chemical sensitivity, culture and delegitimization: A feminist analysis. Feminism & Psychology, 7(4), 475-493. ◦ Gibson, P.R. & Vogel, V.M.R. (2009). Sickness related dysfunction in persons with self-reported multiple chemical sensitivity at four levels of severity. Journal of Clinical Nursing, 18, 72-81. ◦ Gibson, P. R. (2002). Understanding and accommodating multiple chemical sensitivity in independent living. A 50-page guide published by IL NET, a cooperative National Training and Technical Assistance Project of the Independent Living Research Utilization (ILRU) Program and the National Council on Independent Living. http://www.ilru.org/understanding-accommodating-people-with-multiple-chemical-sensitivity-independentliving

REFERENCES FROM ESRT CONTINUED ◦ Gibson, P.R. (l999). Social support and attitude toward health care delivery as predictors of hope in persons with multiple chemical sensitivity. Journal of Clinical Nursing, 8, 275-283. ◦ Gibson, P.R. (l997). Multiple chemical sensitivity, culture and delegitimization: A feminist analysis. Feminism & Psychology, 7(4), 475-493. ◦ Gibson, P. (l993). Multiple chemical sensitivities/environmental illness: Invisible disabilities. Women and Therapy, 14, 171-185.

Also printed as a chapter in M.E. Willmuth & L. Holcomb (Eds.). (l994). Women with disabilities: Found voices. NY: Haworth Press. ◦ Gibson, P.R. & Bryant, J.M. (2009). Psychological reports and chemical intolerance: Evaluation or “delegitimization?” Paper delivered at the Southwest Conference on Disability, September 30 – October 2, Albuquerque, New Mexico. ◦ Gibson, P.R., Cheavens, J., & Warren, M. L. (l998). Social support in persons with self-reported sensitivity to chemicals.

Research in Nursing & Health, 21(2), 103-115. ◦ Gibson, P.R., Cheavens, J., & Warren, M. L. (l996). Multiple chemical sensitivity/environmental illness and life disruption.

Women & Therapy, 19, 63-79. ◦ Gibson, P.R., Elms, A.N.M., & Ruding, L. A. (2003). Perceived treatment efficacy for conventional and alternative therapies reported by persons with multiple chemical sensitivity. Environmental Health Perspectives, 111, 1498-1504. http://dx.doi.org/10.1289/ehp.5936

REFERENCES FROM ESRT CONTINUED ◦ Gibson, P.R., Kovach, S., & Lupfer, A. (2015). Unmet healthcare needs for persons with environmental sensitivity. Journal of Multidisciplinary Healthcare, 2015:8 59–66. http://dx.doi.org/10.2147/J MDH.S61723 ◦ Gibson, P.R. Leaf, B., & Komisarcik, V. (2016). Unmet medical care needs in persons with multiple chemical sensitivity: A grounded theory of contested illness. Journal of Nursing, Education, and Practice, 6(5), 75-83. ISSN 1925-4040 E-ISSN 19254059 ◦ Gibson, P.R. & Lindberg, A. (2011). Physicians’perceptions and practices regarding patient reports of chemical sensitivity.

ISRN Nursing,1-5. PMid:22007328 http://dx.doi.org/10.5402/2011/838930 ◦ Gibson, P.R. & Lindberg, A. (2007). Work accommodation for people with multiple chemical sensitivity. Disability & Society, 22(7), 717–732. http://dx.doi.org/10.1080/09687590701659576 ◦ Gibson, P.R., Lockaby, S.D., & Bryant, J.M. (2016). Experiences of persons with multiple chemical sensitivity with mental health providers. Journal of Multidisciplinary Healthcare, (in press). ◦ Gibson, P.R., Placek, E., Lane, J., Brohimer, S.O., & Lovelace, A.C.E. (2005). Disability induced identity changes in persons with multiple chemical sensitivity. Qualitative Health Research, 15(4), 502-524. http://dx.doi.org /10.1177/1049732304271960 ◦ Gibson, P.R., Sledd, L.G., McEnroe, W.H., et al. Isolation and lack of access in multiple chemical sensitivity: A qualitative study. Nurs Health Sci. 2011; 13: 232-237. PMID:20390633 http://dx.doi.org/10.1111/j .1442- 2018.2011.00606.x ◦ Gibson, P.R., Suwal, S., & Sledd, L.G. (2009). Services requested and received by consumers with chemical sensitivities at the Centers for Independent Living. Disability Studies Quarterly. 29(2), p. 10. ◦ Gibson, P.R. & Vogel, V.M. (2009). Sickness related dysfunction in persons with self-reported multiple chemical sensitivity at four levels of severity. Journal of Clinical Nursing, 18, 72-81. PMid:19120734 http: //dx.doi.org/10.1111/j.13652702.2008.02439.x

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PMid:16085344 http://dx.doi.org/10.1016/j.socscimed.2005.06.018 ◦ Evans J. (2010). Chemical and electrical hypersensitivity: A sufferer's memoir. Jefferson, NC and London: McFarland & Company. ◦ Goodheart, C.D., & Lansing, M.H. (l997). Treating people with chronic disease: A psychological guide. Washington, D.C.: American Psychological Association

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