Certified counselor Nicola Kruger has developed a fatigue-sensitive counseling method that she conducts entirely online to support clients across South Africa.
A counseling session might begin with the client being in bed. It could include a break, a shorter conversation, or an activity postponed because pain or exhaustion made it too burdensome. For certified counselor Nicola Kruger, such adjustments are key in supporting people living with fatigue and chronic illnesses.
These approaches help manage the pressure clients may bring into the session: the feeling of needing to prove their exhaustion so that someone takes it seriously. Kruger stated: 'I aimed to present a fatigue-sensitive, centered approach so that clients feel comfortable coming into the counseling space without the pressure of having to validate their fatigue.'
She noted that fatigue is often perceived as a normal occurrence, yet it can have a huge impact on many aspects of a person's well-being. This impact can extend to relationships, work, and self-identity. Chronic illness can also cause grief, anger, isolation, and a sense of detachment from one's own body, much of which goes unnoticed by others.
Kruger emphasized: 'These difficulties are often 'invisible' or underestimated.' Her goal is to provide support in all aspects of emotional state, regardless of whether the person was recently diagnosed or further along in their journey.
Fatigue-sensitive counseling starts with discussing the person's needs and how sessions can meet those needs. The conditions remain open to change as symptoms and circumstances shift.
Kruger explained that this involves discussing communication methods, tools, or checks that will be used to prevent overexertion, what current issues they would like to address, and how they will handle difficult days. In practice, this might mean breaking tasks into smaller parts, alternating activities, taking breaks, or shortening the session. The client can join from bed or another comfortable place.
'The focus is not on what you can do on 'good days'; it is about determining how much work can be done in sessions without causing exhaustion or flare-ups,' said Kruger. The work also includes examining expectations regarding strength and productivity, including the belief that rest must be earned or that overcoming difficulties means fighting pain. Kruger insisted: 'The focus is on consistency, not intensity. Small changes over time matter. Sometimes the mere fact of the client showing up in the state they are in on any given day is a powerful tool.'
The process is guided by the client's understanding of their condition. A diagnosis can provide useful information, but it cannot describe every individual's experience. Kruger stressed: 'The client is always the expert in their own life, and how they identify with their condition will form the basis and framework of our counseling sessions.'
Support may include practicing communicating with healthcare providers, setting boundaries, preparing for difficult days, or finding ways to manage daily demands. At other times, the priority is having a space where feelings can be expressed without managing other people's reactions. Kruger also warned against assuming that illness must dominate the conversation. She added: 'A person with a chronic illness may come to counseling not to focus on their condition, but because they know it affects their life.'
Loss of health can also mean the loss of routine, independence, or expectations about the future. Such losses can be hard to explain, especially when others primarily associate grief with the loss of a loved one. Kruger stated: 'Grief is a genuine emotional response to the loss of everything that mattered to you.'
Instead of viewing grief as a sequence of stages, Kruger described an approach that allows for unpredictable cycles and individual responses. She clarified: 'Grief is not just a strong form of sadness; it can also include feelings of guilt, anger, envy, or even positively associated emotions, such as gratitude or hope.'
Acknowledging invisible loss begins by naming it, without comparing it to others' suffering. Clients can choose a personal ritual or another meaningful act of acknowledgment. Kruger concluded: 'People are complex, life is complex, emotions are complex, therefore, grief is complex. It is a multifaceted experience that will differ for everyone.'
Kruger's decision to create a fully online practice was partly driven by financial reasons: it was more manageable when starting an independent practice. Online sessions also allow clients across South Africa to attend sessions without traveling to a counseling room.
She noted that online counseling helps solve problems of tight schedules, long commutes, mobility limitations, and immunocompromise, but access to mental health services remains a fundamental issue. The screen can eliminate some practical barriers, but building trust requires attention. Initial sessions involve discussing expectations, confidentiality, technical issues, and any concerns about the process. Kruger usually starts the first session by asking how the client feels today, and she takes this very seriously. This allows her to understand how comfortable, uncertain, or nervous the client feels, and she dedicates as much time as needed to alleviate any concerns, answer questions, or start the conversation.
Clients retain control over what they disclose and whether they continue the process. Kruger emphasized: 'Clients are free to share what they are comfortable with, respect their boundaries, and pause or exit the process at any time.' Collaboration continues after the first appointment, with regular opportunities to review goals and session structure. She encourages clients to report which approaches and activities work for them and why.
Expectations regarding achievement and self-identity are also present in Kruger's work with adolescents. Young people try to figure themselves out while facing pressure to conform, achieve academically, and secure an uncertain future. Kruger noted that navigating this situation is very difficult, as many teenagers feel simultaneously undervalued and responsible for something very serious, sometimes without necessary support: it is a time of contradictory expectations.
Social media can foster connection and self-expression, but it also amplifies comparison and dependence on external approval. 'Today's teenagers face an unprecedented level of digital and social media use, a world governed by 'feedback metrics' and unattainable standards,' said Kruger. Sessions often feature academic pressure alongside issues related to post-school opportunities. She observed a rise in academic pressure among adolescent clients in the context of competition, achievement-based values, fear of unemployment, limited university spots, and fear of failure. Kruger's background in English literature and gender studies aids in discussing the personal and social expectations clients carry. However, exploring these expectations must start with what the client wants. Kruger stressed: 'It is important that it comes from the client themselves.'
For clients wishing to revise their personal narratives, questions might include: 'Is this my story? Or is it society's story about me? Has the story changed? Do I want to rewrite this story?'
For relatives and friends, support begins with understanding how the person experiences their condition. Knowledge about the illness can help, but it should not replace listening. People with chronic illnesses often experience significant cognitive and emotional exhaustion, especially due to the need to explain their condition and its impact on life. Some people appreciate being asked how they feel every day, while others prefer to bring up their health topic themselves. Discussing these preferences can make support more helpful and less intrusive. Kruger advises: 'Always listen to learn, to understand, and to support, not to focus on 'fixing' ideas.'
Practical help can include attending medical appointments, preparing comfort items, or adapting social plans as problems arise. 'Preventive help can be extremely significant, as it is often hard to ask for support and help,' she said. It is important to continue including someone in plans, even if the person's condition makes attendance unpredictable. 'When it comes to planning, keep your loved ones included and remind them there is no pressure: be understanding and flexible; chronic illnesses are unpredictable.'
Beyond individual practice, Kruger called for increased investment in psychiatric care and a more integrated community approach with stronger directions and broader representation. She stated: 'More training, more representation, more diversity, and more screening. This means mental health must be a priority in funding and resource allocation.'
Certified counselors play a special role in this system. Kruger described her work as typically short-term, focused on prevention, intervention, and psychosocial well-being, with screening for referral being an important duty. 'Certified counselors provide psychoeducation, offer basic psychometric assessment, but do not diagnose or conduct in-depth psychological evaluations,' she explained.
In connection with Heritage Month, Kruger also asserted that psychiatric care in South Africa must interact more closely with the communities it serves. 'Contextually relevant mental health practices must incorporate representative knowledge systems and healing practices that reflect the lived experiences, languages, belief systems, and reference points of South Africans.'
In the counselor's office, attention to personal experience begins by listening to what a person can endure, what they have lost, and what they need. For someone accustomed to explaining or defending their exhaustion, belief in it is part of the work. As Kruger said, the goal is to provide 'a space that validates the legitimacy of the person's experience, without any pressure to explain or meet expectations.'
}, {