Counseling Today, Features

A light in the darkness

By Bethany Bray October 30, 2017

Erin Wiley, a licensed professional clinical counselor in northwestern Ohio, once had a client tell her that seasonal depression was like diving into a deep, dark pond each fall. Wiley understands the comparison. With seasonal depression, “you have to prepare to hold your breath for a long time until you get across the pond, reach the other side and can breathe again,” she says.

Wiley routinely sees the effects of seasonal depression in her clients — and in herself — as summer wanes, with the days getting shorter and the weather getting colder. Ohio can be a hard place to live when daylight saving time takes effect and the sun starts setting just after 4 p.m., she says.

Seasonal depression “feels like a darkness that’s chasing you. You know it’s coming, but you don’t know when it’s going to pin you down,” says Wiley, a member of the American Counseling Association. “[It’s like] getting pinned down by a wet blanket that you just can’t shake, emotionally and physically. … For those who get it every year, you can have anxiety because you know it’s coming. There is a fear, an apprehension that it’s coming. [You need] coping skills to have the belief that you have the power to control it.”

For Wiley, the owner of a group practice with several practitioners in Maumee, Ohio, this means being vigilant about getting enough sleep and being intentional about planning get-togethers with friends throughout the winter months. Keeping her body in motion also helps, she says, so she does pushups and lunges or walks a flight of stairs in between clients and leaves the building for lunch. If a client happens to cancel, “I will sit at a sunny window for an hour, feel the sun on my face, meditate and be mindful,” she adds.

Seasonal depression, or its official diagnosis, seasonal affective disorder (SAD), can affect people for a large portion of the calendar year, Wiley notes. Although there is growing awareness that some people routinely struggle through the coldest, darkest months of the year, it’s less well-known that it can take time for these individuals to start feeling better, even once warmer weather returns in the spring. According to Wiley, seasonal depression can linger through June for her hardest-hit clients.

“It takes that long to bounce back,” she says. “They’re either sinking into the darkness or coming out of it for half the year.”

Symptoms and identifiers

SAD is classified as a type of depression, major depressive disorder with seasonal pattern, in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. According to the American Psychiatric Association, roughly 5 percent of adults in the U.S. experience SAD, and it is more common in women than in men. The disorder is linked to chemical imbalances in the brain caused by the shorter hours of daylight through the winter, which disrupt a person’s circadian rhythm.

People can also experience SAD in the reverse and struggle through the summer, although this condition is much rarer. Wiley says she has had clients who find summers tough — especially individuals who spend long hours inside climate-controlled, air-conditioned office environments with artificial lighting.

Regardless, a diagnostic label of SAD isn’t necessary for clients to be affected by seasonal depression, say Wiley and Marcy Adams Sznewajs, a licensed professional counselor (LPC) in Michigan. Sznewajs says that SAD isn’t a primary diagnosis that she sees often in her clients, but seasonal depression is quite common where she lives, which is less than 100 miles from the 45th parallel.

“I live in a climate where it is prevalent. I encounter it quite a bit and, surprisingly, people are like ‘Really? This makes a difference [with mental health]?’” says Sznewajs, an ACA member who owns a private practice in Beverly Hills, Michigan, and specializes in working with teenagers and emerging adults. “We change the clocks in November, and it’s drastic. It gets dark here at 4:30 in the evening, so kids and adults literally go to school and go to work in the dark and come home in the dark.”

Likewise, Wiley says that she frequently sees seasonal depression in clients who don’t have a diagnosis of SAD. “I notice it with my depressive clients,” she says. “I have been seeing them once a month [at other times of the year], and they ask to come in more often during February, March and April, or they need to do more intensive work in those months. It’s rare for someone to be healthy the rest of the year and struggle only in the winter. It’s [prevalent in] people who struggle already, and winter is the final straw. They need extra help in the winter and reach out [to a mental health professional] in the winter.”

In other instances, new clients begin to seek therapy because life events such as the loss of a job or the death of a loved one push them to a breaking point during a time of the year — typically winter — when they already feel at their lowest, Wiley notes.

Cindy Gullo, a licensed clinical professional counselor in O’Fallon, Illinois, says that she doesn’t encounter clients who have the SAD diagnosis very often. However, she says that roughly 2 out of every 10 of her clients who have preexisting depression experience worsening mood and exacerbated depression throughout the fall and winter months.

The symptoms of SAD mimic those of depression, including loss of interest in activities previously enjoyed, oversleeping and difficulty getting out of bed, physical aches and pains, and feeling tired all of the time. What sets seasonal depression apart is the cyclical pattern of symptoms in clients, which can sometimes be difficult to see, Sznewajs says. If a client presents with worsening depressive symptoms in the fall, counselors shouldn’t automatically assume that seasonal depression is the culprit, she cautions. Instead, she suggests supporting the client through the winter, spring and summer and then monitoring to see if the person’s symptoms worsen again in the fall.

“If they show improvement [in the spring/summer], and then I see them in October and they start to slide again, that’s when I have to say it could be the season. And certainly if they point it out themselves — [if] they say, ‘I’m OK in the summer, but I really struggle in the winter.’ It’s really when you start to notice a pattern of worsening mood changes in November and December [that alleviate] in the summer.”

Sznewajs recalls a female client she first worked with when the client was 13. She saw the client from October through the end of the school year, and the young woman showed significant improvement. The client checked in with Sznewajs a few times during the summer, but Sznewajs didn’t hear from her much after that. Then, when the client was 16, she suddenly returned to Sznewajs for counseling — in the wintertime. In recounting the prior few years, the young woman noted that her struggles usually seemed to dissipate around April each year, even though the pressures of the school year were still present at that point.

“‘I don’t know what’s going on with me,’” Sznewajs remembers the client remarking. “‘I’m a mess right now.’ It was very evident that there was a pattern [of seasonal depression] with her.”

Wiley notes that clients with seasonal depression often describe a “heaviness” or feelings of being weighed down. Or they’ll make statements such as, “It’s just so dark,” referring both to the lack of sunlight during the season and the emotional darkness they are enduring, Wiley says.

Gullo, an ACA member and private practitioner who specializes in working with teenagers, keeps an eye out for clients who become “very flat” and engage less in therapy sessions in the fall and winter. Other typical warning signs of seasonal depression include slipping grades (especially among clients who normally complete assignments and are high achievers at school), changes in appetite, sluggishness, weepy or irritable mood, and withdrawal from friends and family. For teens, the irritability that comes with seasonal depression can manifest in anger or frustration, Gullo says. For example, young clients may have an outburst or become agitated over small things that wouldn’t bother them as much during other times of the year, such as a parent telling them to clean their room, Gullo says.

John Ballew, an LPC with a solo private practice in Atlanta, estimates that up to one-third of his clients express feeling “more grim,” irritable or unhappy as winter approaches. He contends that the winter holidays “are a setup to make things worse” for clients who are affected by the seasons.

Overeating and overconsumption of alcohol are often the norm during the holidays, and this is typically coupled with the magnification of family issues through get-togethers, gift giving and other pressures, notes Ballew, a member of ACA. In addition, many coping mechanisms that clients typically use, such as getting outside for exercise, may be more difficult to follow in the winter. And although many people travel around the holidays, that travel is often high stress — the exact opposite of the getaways that individuals and families try to book for themselves at other times of the year.

“It’s a perfect storm for taking the ordinary things that get in the way of being happy and exacerbating them,” Ballew says. “People feel heavily obligated during the holidays, more so than in other seasons. It means that we’re not treating ourselves as well, and that can be a problem.”

[For more on helping clients through the pressures and stresses of the holiday season, see Counseling Today‘s online exclusive, “The most wonderful time of the year?https://wp.me/p2BxKN-4TI]

In the bleak midwinter

The first step in combating seasonal depression might be normalizing it for clients by educating them on how common it is and explaining that they can take measures to prepare for the condition and manage their feelings.

“Educating [the client] can give them control,” Sznewajs says. “People often feel shame about depression. Explain that you can take steps to treat yourself, just like you would for strep throat. You can’t will yourself to get better, but you can do things to help yourself get better. When you know what’s causing your depression, it gives you power to take those steps.”

Ballew notes that many of his clients express feeling like a weight has been lifted after he talks to them about SAD. “Many of them won’t think they have [SAD], but they will say, ‘Winter is a hard time for me’ or ‘I get blue around the holidays.’ They’re caught off guard by this unhappiness that seems to come from nowhere. People seem to feel a certain amount of relief to find that it’s something they will deal with regularly but that they can plan for and be cognizant of. It doesn’t mean that they’re defective or broken. It’s just that this is a stressful time. That helps us take a more strategic and problem-solving approach.”

Many counselors find cognitive behavior therapy (CBT) helpful in addressing seasonal depression because it combats the constant negative self-talk, catastrophizing and rumination that can plague these clients. CBT can assist clients in turning around self-defeating statements, finding ways to get through tough days and taking things one step at a time, Sznewajs says.

Gullo gives her teenage clients journaling homework (she recommends several journaling smartphone apps that teenagers typically respond well to). She also encourages them to maintain self-care routines and social connections. For instance, she might request that they make one phone call to a friend between counseling sessions.

Wiley guides her clients with seasonal depression in writing a plan of management and coping mechanisms (or reviewing and updating their prior year’s plan) before the weather turns cold and dark. She types out the plan in session while she and the client talk it over. Then she emails it so that the client will have it on his or her smartphone for easy access. The plans often include straightforward interventions — such as being intentional about going outside and getting exposure to natural light every day — that clients may not think about when dealing with the worst of their symptoms midwinter.

“It sounds simple, but those [individuals] who are down may not realize that the sun is shining and they better get outside to feel it on their face,” Wiley says. “We list exercises that are feasible. You might not join the gym, but what can you do? Can you walk the staircase at your house five times a day? Or, what’s one [healthy] thing you can add to your diet and one thing you can take away, such as cutting down to having dessert once per week, cutting out your afternoon caffeine or drinking more water. And what’s one thing you can do for your sleep routine? [Perhaps] take a hot shower before bed [to relax] and go to bed at the same time every night.”

Wiley also reminds clients to simply “be around people who make you feel happy.” She suggests that clients identify those friends and family members whom they enjoy being with and include those names on their therapeutic action plans for the winter.

All of the practitioners interviewed for this article emphasized the importance of healthy sleep habits, nutrition and physical activity for clients with seasonal depression. “All of these things are really hard to do when you feel lousy, so that’s why the education [and planning] piece is so important,” Sznewajs says. “Let them know that this [the change in seasons] is why you feel lousy, and it’s not your fault. But there are ways to feel better.”

Sznewajs typically begins talking with clients about their seasonal action plans in early fall and always before the change to daylight saving time. One aspect of the discussions is brainstorming how clients can modify the physical activities they have enjoyed throughout spring and summer for the winter months.

One of the cues Wiley uses to tell if clients might be struggling with seasonal depression is if they mention cravings for simple carbohydrates (crackers, pasta, etc.), sugars or alcohol when the days are dark and cold. They don’t necessarily realize that they are self-medicating in
an attempt to boost their dopamine, Wiley says.

Of course, exercise is a much healthier way of boosting dopamine levels. “Exercise is important, but it’s really hard to get depressed people to exercise,” Wiley acknowledges. “Telling them to join the gym won’t work when they just want to cry and lay in bed. So, turn the conversation: What is something you can do? If you already walk your dogs out to the corner, can you walk one more block? Take the stairs at work instead of the elevator, or park farther away from the grocery store.”

Effectively combating seasonal depression might also include counselor-client discussions about proper management of antidepressants and other psychiatric medications. Gullo recommends that her clients who are on medications and are affected by seasonal depression set up appointments with their prescribers as winter approaches. Sznewajs and Wiley also work with their clients’ prescribers, when appropriate, to make sure that these clients are getting the dosages they need through the winter.

Wiley will also diagnose clients with SAD if the diagnosis fits. “For someone who is really struggling and could benefit from [psychiatric] medication, the prescriber is often thankful for a second opinion. It adds weight and clarity to what the client is saying and what the doctor is hearing,” Wiley says. “It also helps the client to have a diagnosis so they don’t just wonder, ‘What’s wrong with me?’ It removes the blame and shame for people who are really struggling.”

Seeking the light

Many factors contribute to seasonal depression, but a main trigger is the reduced amount of daylight in the winter. It is vitally important for clients with seasonal depression to be disciplined about getting outdoors to feel natural light on their faces and in their eyes, Wiley says. She coaches clients to be disciplined about making themselves bundle up and get outside on sunny days or, at the very least, sit in their car or near a window for extra light exposure.

Wiley cautions clients against using tanning beds as a source of warmth and bright light to fend off seasonal depression. However, she acknowledges that she has seen positive results with tanning beds in severe cases of seasonal depression in which individuals were verging on becoming suicidal. In those extreme cases, counselors must weigh the long-term risks of using a tanning bed versus the more immediate risks to the client’s safety, Wiley says.

In addition to encouraging those with seasonal depression to get outdoors, Gullo and Sznewajs have introduced their clients to phototherapy, or the use of light boxes. Roughly the size of an iPad, these boxes have a very bright light (more than 10,000 lumens is recommended for people with seasonal depression) that clients can use at home.

Sznewajs recommends that clients use a light box first thing in the morning for at least 30 minutes to “reset their body,” increase serotonin and boost mood. If a client responds positively to phototherapy, it also serves as an indicator that he or she has SAD (instead of, or in addition to, nonseasonal depression), she notes.

Neither Gullo nor Sznewajs require clients to purchase light boxes. Instead, they simply introduce the idea in session and suggest it as something that clients might want to try. Insurance doesn’t typically cover light boxes, but they can be purchased online or at medical supply stores.

Gullo does keep a light box in her office so she can show clients how it works. She also recommends “sunrise” alarm clocks, which feature a light that illuminates 30 minutes before the alarm sounds. The light gradually becomes brighter and brighter, mimicking the sunrise. Gullo uses this type of alarm clock at home and finds it helpful.

The light box and sunrise alarm clock “are game changers,” Gullo says, “and a lot of people don’t know they exist.”

Powering through

In The Lion, the Witch and the Wardrobe, the second book in C.S. Lewis’ The Chronicles of Narnia series, characters struggle through never-ending cold that is “always winter but never Christmas.” Grappling with seasonal depression can feel much the same way: an uphill battle in a prolonged darkness in which occasions of joy have been snuffed out.

The key to making it through is crafting and sticking to a plan. Sznewajs says she talks with clients in the early fall to help them prepare: Yes, winter is coming, and you’re probably going to feel lousy, but it won’t last forever, and there are ways of getting through it.

“People need to understand that this is a totally predictable kind of concern,” Ballew concurs. “It’s not weak or self-indulgent [to feel depressed]. This is a hard time of year for many people, and you need to plan for it. … We [counselors] are in a great place to validate clients’ concerns, but also help them to strategize beyond them.”

 

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To contact the counselors interviewed for this article, email:

 

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Bethany Bray is a staff writer and social media coordinator for Counseling Today. Contact her at bbray@counseling.org.

Letters to the editor: ct@counseling.org

 

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

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