Monthly Archives: March 2018

@TechCounselor: Creating email signatures

By Adria S. Dunbar March 22, 2018

We’ve all heard that a first impression is incredibly important, so we get dressed up, pay attention to our choice of words and do everything we can to present our most professional selves to the world.

Sometimes, however, we don’t have the opportunity as counselors to put our best foot forward in the literal sense. Instead, we must rely on digital communication for a first meeting. Believe it or not, your email signature says a lot about who you are. I will keep this article short and sweet, just like your email signature should be.


Here are some tips for creating an effective email signature:


  • Think carefully about the photo you upload. Make sure it is a recent photo, a high-quality image and appropriate for your professional setting. If you don’t have a photo you like, perhaps you can choose a logo instead.
  • Link to your social media, but only if it is up to date. No one wants to read your tweets from 2009!
  • Do not include your email address. If recipients have your email signature, they have your email address.
  • Lead people to what you want them to learn about you. This might be your Twitter account, but it could be your webpage or your Instagram instead.
  • Think about using a booking site (Adria uses so that people can book an appointment with you from your email signature.


Your email signature should be simple, effective and functional. Here is an example that Adria created with WiseStamp, a free email signature creator.







Adria S. Dunbar is an assistant professor in the Department of Educational Leadership, Policy and Human Development at North Carolina State University in Raleigh. She has more than 15 years of experience with both efficient and inefficient technology in school settings, private practice and counselor education. Contact her at


@TechCounselor’s Instagram is @techncounselor (




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.

When help isn’t helpful: Overfunctioning for clients

By Kathleen Smith March 19, 2018

“Erin” came to counseling with all the signs of depression. She was unhappy with her career, her health and her family. Her mother was distressed, her father was distant and her disabled brother was sick.

Erin spent a lot of energy calming and directing her family, and she complained about how little her family supported her in return. She increasingly relied on sugar to calm herself down, and she struggled to end this dependence.

Erin’s anxiety was high, and as a newbie counselor, I struggled to operate outside of it. She cried through many of our meetings, and she grew increasingly critical of our work together.

She said she wanted to stop focusing on her family dynamics, so I switched topics.

She wanted to focus more on her eating habits, so I focused on that.

Then she said I wasn’t giving her enough tools, so I gave her more tools.

I dreaded meeting with her every week, knowing that she’d find some reason to be unhappy with me. I’ll admit that I was relieved when she decided to switch to a different counselor.

It would be very easy for me to look back on my work with Erin and label her as a difficult or resistant client — someone who simply wasn’t ready to change. But now I know better.

You see, I’m a student of Bowen family systems theory. One of the big ideas in Bowen theory is that relationships are reciprocal. Each person plays a part, and these parts are complementary. When you look at the individual and not the relationship, then you miss seeing this reciprocity. The therapeutic relationship is no exception.

Murray Bowen wrote, “When the therapist allows himself to become a ‘healer’ or ‘repairman,’ the family goes into dysfunction to wait for the therapist to accomplish his work.”

Erin was looking for someone to take responsibility for her problems, and I quickly dove in and volunteered as a way to calm down the room and avoid her anger. Looking back, I think about how our relationship might have been different if I hadn’t begun to overfunction for Erin and had refrained from “teaching” her how to fix her depression. I decided that Erin wasn’t willing to change, and I never stopped to think about how my actions were supporting her ambivalence and helplessness.

Have you ever heard an interview with a successful person who grew up in an intense family situation? These individuals always have at least one variable in common. Someone took an interest in them. Often, it was a teacher, a coach, a grandparent or a clergyperson. Someone was curious about their capabilities, and they thrived from this interest.

I truly believe that the opposite of anxiety is curiosity. If I can stay curious about counseling clients who are challenging, they will often do better. When I jump in and try to fix, I am communicating to those clients that they aren’t capable of solving a problem — that their thinking isn’t useful and that they should borrow mine instead. In such instances, I am more concerned with calming everything down than letting clients take responsibility for themselves.

I am very fortunate to have a curious counseling mentor who does not prop up my own incapacity to direct my life. Even though we have been meeting for years, I could probably count the number of times she has made a suggestion to me on one hand. I can see how by simply asking good questions and helping me develop my thinking, she has allowed me to take responsibility for my own functioning.

My job as a counselor is to help people see the reciprocity in their relationships. Like when a client wonders why his mother is financially irresponsible when he’s spent years bailing her out of debt. Or when someone wonders why her partner doesn’t share more when she’s constantly asking him to manage her own distress. When we focus on the other person in a relationship, we’re missing 50 percent of the picture. In fact, we’re missing the 50 percent that we can actually control. By focusing on Erin and what I thought was her “fault,” I missed seeing my part in our relationship.

When anxiety is high in the counseling room, it’s incredibly difficult to shift the focus back on yourself. Difficult, but not impossible. So when a person is distressed, instead of fixing or reassuring, I try to relax my posture, take some deep breaths and access my best thinking. I try to pay attention to when I’m slipping into my default mode of overfunctioning. When a person asks me how I think they’re doing, I challenge them to trust their own ability to evaluate themselves. I try to do this for any relationship, whether it’s with a counseling client or with a friend.

I think I’m getting a little bit better each day with noticing the reciprocity in my relationships. By seeing my part, I’m taking responsibility for myself and allowing others to do the same. In exchange, these relationships bring so much more joy into my life. If I can stay focused on myself around my most anxious clients, then, often, they end up being some of the most rewarding ones I see.

It’s funny how when we treat people as though they can take responsibility for themselves, they are likely to rise to the occasion. I hope that Erin found a counselor who saw her as the capable young woman she was.



Kathleen Smith is a licensed professional counselor and writer in Washington, D.C. Read more of her writing at



Related reading by Kathleen Smith, from the CT archives: Facing the fear of incompetence

Self-doubt often nags at the minds of counselors, but the practice of vulnerability might offer both a powerful antidote against unrealistic expectations and a prescription for forming stronger connections with clients.




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.


Five strategies to develop mental health models in schools

By Dakota L. King-White March 12, 2018

Over the past 13 years, I have dedicated my career to developing mental health services and models within the academic setting as a school counselor, mental health therapist and now as an assistant professor in counselor education, where I engage in community action research to develop mental health models in schools from pre-K through 12th grade. From my research and experiences, I have observed that students’ ability to learn is significantly affected by their mental health.

Many of our nation’s students have been exposed to traumatic events and regular life stressors that act as barriers to their success. Exposure to violence and other traumatic experiences can have a lifelong effect on academic achievement. Within the school setting, this can be manifested in a number of ways, including trouble concentrating, low grades, a decline in test scores and students avoiding school or dropping out of school entirely.

Making an investment in prevention and intervention services can help to address students’ overall development and thus enhance their ability to succeed socially, emotionally and academically. The school setting is an ideal place to provide mental health support to students. However, it is extremely important for schools to align mental health support with academic achievement goals. This calls for greater collaboration among mental health professionals, teachers, administrators, parents, students, staff and other stakeholders in school settings.

Based on the work I have done in developing mental health models in schools, as well as guidance from the American School Counselor Association (ASCA) National Model, I believe that the following five components are key to effectively supporting both the mental health needs and academic achievement of our students.

1) Create mental health programming based on data-driven decisions.

2) Collaborate to address the mental health needs of students.

3) Provide a tiered system of mental health support.

4) Evaluate mental health services to ensure they are addressing the academic achievement gaps.

5) Communicate the outcomes to key stakeholders.

Make data-driven decisions

Developing mental health models in schools is a preventive measure by which mental health professionals analyze data ahead of time and design programming based on need. This approach allows stakeholders to assess the needs and develop services that truly address the academic, social and emotional gaps. Schools have an obligation to create programming based on their students’ needs.

When developing mental health models in schools, it is imperative to analyze data from several sources. One key component involves looking at data that focus on academic achievement. Report cards, test scores and other instruments that measure academic achievement must be considered. The main priority when addressing mental health issues in schools is to identify barriers that are affecting students’ academic achievement.

Once the needs have been identified, the next step is to create measurable goals to address the gaps. This step involves a collaborative approach that should include school counselors, mental health therapists, parents, teachers, administrators and students. Measurable goals provide a means for stakeholders to evaluate programming and help to ensure that it is supporting academic achievement.

Collaborate to address student needs

In a 2010 article for the Journal of Interprofessional Care, Elizabeth Mellin and colleagues identified collaboration among colleagues as being imperative when developing mental health models in schools. School counselors, mental health therapists, school psychologists and school nurses are the professionals most often tasked with delivering mental health services to students in schools.

School counselors are an excellent resource to support mental health models in schools. Quite often, however, school counselors are still labeled as “guidance counselors” in educational settings and are not always considered when schools are developing mental health services and models. Administrators and other stakeholders must be informed that the practice of school counseling has evolved, with “guidance” being only one component of the services that school counselors provide. According to the ASCA Ethical Standards for School Counselors, the school counselor’s role is to address all students’ “academic, career and social/emotional development needs.” School counselors must actively engage and advocate to inform stakeholders of their titles and responsibilities, which are based on their skill set and training. Their skill set and training include addressing many of the social and emotional barriers that affect the ability of students to succeed academically.

Mental health therapists are another valuable resource. When licensed as a clinical counselor or social worker, these professionals are able to diagnose mental health disorders and provide treatment to students. Another invaluable component of their skill set that often goes untapped is an ability to provide consultation to staff, teachers, parents and administrators. It is also important that mental health therapists collaborate with teachers, administrators, other staff members and families to demonstrate the correlation between mental health and academic achievement.

School psychologists are integral to the collaboration process when developing mental health models in schools. According to the National Association of School Psychologists, the school psychologist’s role includes providing assessments, providing interventions to address mental health concerns and working with teachers, staff, administrators and other stakeholders to create programming to address gaps. As noted by Joni Williams Splett and Melissa Maras in their 2011 Psychology in the Schools journal article, school psychologists who are trained as research practitioners offer a unique skill set that contributes to bridging the gap of research and actual practice of services to support academic achievement.

School nurses can also play a central role in developing mental health models in schools. Quite often, school nurses have mental and physical health records provided by school personnel, parents and outside health care providers. Because of the time these professionals spend with students addressing other health concerns, they are frequently able to screen for mental health concerns. This relationship provides school nurses opportunities to develop rapport with students. It is during these interactions that school nurses can detect changes in a student’s physical or mental health. School nurses can also provide insight to their colleagues about the mental health concerns they have observed within the school setting.

Teachers and administrators are additional important contributors to the development of mental health models in schools and must be equipped to identify mental health concerns in the school setting. In an effort to ensure that all school stakeholders are collaborating and properly equipped, regular meetings are essential. The more collaboration that takes place among the mental health team, teachers, parents, students and administrators, the more likely it is that students will succeed.

Provide a tiered system of support

Kelly Vaillancourt and colleagues described the benefits of a tiered system of mental health support in their 2013 article for the National Association of School Psychologists and the National Association of School Nurses. A tiered system of support for delivering mental health services also provides different levels of care to support students to succeed academically. Keep in mind that schools must use evidence-based strategies. This ensures that the most effective, empirically supported practices available are being used to help students succeed.

Tier one is the universal level of support in which all students have access to mental health services in a school setting. Within tier one, trauma-informed classroom methods are introduced to teachers, administrators and staff. Tier one includes implementation of a social/emotional curriculum for all students that is preventive in nature and that supports academic achievement by addressing social and emotional barriers. It is also imperative to use a strengths-based approach that looks at the positive attributes of the students and builds upon those attributes to provide services for the students. To further support students, families should be made aware of the services and information being taught at school.

Tier two is where targeted interventions are identified for students who need additional mental health support to eliminate barriers that are affecting them academically. Selective interventions are provided to students who exhibit behaviors that are hindering them. Mental health and other services provided at the tier-two level consist of small groups, classroom behavior management strategies for teachers and staff, individual counseling and additional professional development for stakeholders related to social and emotional barriers to academic achievement. Collaboration among the team is extremely important.

The third tier is the most personalized, with intensive strategies provided based on the student’s needs. Typically, this is done through a comprehensive process in which key stakeholders gather to collaborate and strategize about the needs of the student. The team should consist of the mental health team members, the student, the student’s parents or guardians, teachers, administrators and outside agencies that work with the student and family. As highlighted by Kenneth Messina and colleagues’ 2015 article in The Family Journal, family buy-in is crucial at this level because of the importance of collaboration between home and school to support the student’s academic achievement and to identify the student’s strengths. Mental health and related services at this level include, but are not limited to, individual counseling provided by a mental health therapist, crisis intervention, outside counseling services, small group counseling, behavior plans and additional professional development for stakeholders.

Evaluate and communicate

In an effort to improve academic achievement, mental health services provided in the schools must be based on data-driven decisions and evaluated to ensure that progress is being made to address the needs. Vaillancourt and colleagues noted that an effective mental health model includes consistent monitoring of student and program outcomes. This includes reviewing outcome data and analyzing the data to measure gaps, successes and areas of limitation. Evaluation of services is a continuous process.

Once programming or services are provided, it is critical to analyze the data and review the goals that were established for the student. It is imperative to have an outside reviewer provide feedback on the data and assess the outcomes of programming. The outside reviewer could be a mental health professional, teacher, curriculum director, administrator, local college professional or another professional within the district who has experience analyzing data.

Once the data are analyzed, it is vital to communicate the results to the stakeholders. Communicating the results to stakeholders has been found to build rapport and transparency among the team. Communication also allows for stakeholders to understand the impact and correlation between mental health and academic achievement.


There is a need to develop effective mental health models in schools because of the mental health challenges that affect students academically, socially and emotionally. Students will continue to be faced with these challenges, but it is important that schools address the barriers that affect students’ academic achievement. Mental health professionals, teachers, parents, students, administrators and school staff play a vital and collaborative role in the development, implementation and evaluation of mental health services aimed at maximizing students’ academic success. Through the five strategies discussed in this article, I believe that school districts will realize the success of mental health models being implemented within schools to support academic achievement.




Dakota L. King-White is an assistant professor in counselor education at Cleveland State University in Ohio. She is a licensed school counselor and licensed professional counselor. Her areas of research include the development of mental health models in schools, children of incarcerated parents and 21st-century school counseling. Contact her at


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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.

Why neurocounseling?

Compiled by Bethany Bray

Decades ago, you might have gotten some funny looks or raised eyebrows if you used the word “neurocounseling” in a professional setting. In recent years, however, counselors have become increasingly interested in using concepts from neuroscience to inform and support their work with clients.

What makes professional counseling compatible with neuroscience? How can it help counselors gain insights into human behavior and the challenges that clients bring into counseling sessions?

Counseling Today asked three practitioners for whom neurocounseling is an area of expertise, Thomas A. Field, Laura K. Jones and Lori A. Russell-Chapin, what draws them to this topic.

The trio are co-editors of the ACA-published book Neurocounseling: Brain-Based Clinical Approaches. Field is an associate professor in the master’s counseling program at the City University of Seattle; Jones is an assistant professor at the University of North Carolina at Asheville; and Russell-Chapin is professor of counselor education at Bradley University in Illinois.


Q+A: Why neurocounseling?


Laura Jones: Coming into the field with graduate degree in cognitive neuroscience, I have always playfully said that I do not know how to be a counselor without considering what is happening in the brains and bodies of my clients — both the physiological factors that have led to their struggles and resilience as well as the neurophysiological corollaries of their growth. As a counselor-in-training and later a student in counselor education, I could find very little work discussing this connection and became passionate about trying to bridge the two fields.

One of my foremost professional endeavors is to facilitate the intentional and informed integration of neuroscience into our field in a way that honors our professional identity (as I am also quite passionate about professional advocacy as well) and in doing so enrich and increase accessibility to training in this area. I am endlessly excited by the emerging science that can, has and will continue to influence the mental health field. For example, how can we ignore research that suggests that levels of certain gonadal hormones (steroids) have the potential to influence an individual’s susceptibility to suicidal ideation and attempts, drug relapse, responses to traumatic stress, etc., or the burgeoning research that implicates dysbiosis (imbalance) of our gut microorganisms (e.g., bacteria) in our mental health, or the fact that our body’s immune response has implications on mental and emotional wellbeing.

Although Descartes’ mind-body dualism has long been disproved, we (mental health and medical practitioners alike) often still function, largely implicitly, from this paradigm. Each and every day, researchers are substantiating just how complex this connection truly is, thereby underscoring how we can no longer work in health silos. This integrative perspective is the future of mental health.

Counselors have the opportunity to learn from other fields and use this information to strengthen our work with clients and our field as a whole. I firmly believe that counselors are well positioned to provide valuable and unique contributions to broader deliberations, research initiatives and policy efforts in the national mental health sector, and in doing so, secure our position as a leader among the mental health professions.

Another reason that I have become so passionate about this work stems directly from clinical experiences, much of which has centered around work with trauma survivors and individuals struggling with substance use disorders. I cannot express how powerful and empowering it has been for clients with whom I have worked to understand how processes in brain and body may be contributing to their struggles. The phrases, “So, you mean I’m not crazy?” “It makes so much sense!” and “Can you please explain that to my family?” have been used more than once. As counselors, we also are well aware of the pervasive and damaging stigma shrouding mental health challenges and those who are struggling. Most individuals with clinically diagnosable disorders never get the help they need, owing largely to this stigma.

Providing a physiological rationale for mental health challenges can significantly reduce mental health stigma; make mental health, often considered an enigmatic concept, more tangible; and alleviate the blame and shame that those who are struggling frequently experience.



Thom Field: Neuroscience attracts me for several different reasons. First, I think neuroscience provides a scientific basis for understanding important foundational concepts about human development, the impacts of oppression and marginality and the centrality of the counseling relationship. It has already provided us with significant insights into why certain problems develop at different stages (e.g., why the emerging adulthood years make a person susceptible to develop bipolar disorder or schizophrenia; see Seth Grant’s genetic lifespan calendar). Second, certain clinical issues are better understood and addressed through the lens of neuroscience, such as traumatic brain injury, posttraumatic stress, substance use, autism, attention-deficit/hyperactivity and even depression. One of my close family members has a diagnosis of schizophrenia and another autism, so understanding how to prevent and treat these conditions is important to me personally. Third, neuroscience helps to explain why we respond to certain events, such as why our physiological systems become activated in response to threats in the environment, leading to quick and often automatic decision-making and action such as aggression. I am part of a team that has developed a therapy model around this concept (neuroscience-informed cognitive behavioral therapy (CBT); see the website for more information). Fourth, many of my fellow counselors and students continue to underprioritize Maslow’s basic needs like sleep, and sometimes do not ask about this during the first meeting with a client/student. Fifth, and perhaps most important, neuroscience offers promise for the discovery of new information about the brain and body that can make us more effective professionals.

Most psychotherapy research is limited by self-reported data (which is largely unreliable) and has largely failed thus far to distinguish specific behaviors and interventions on the part of the counselor that lead to more effective client outcomes. For example, meta-analyses have found that most counseling theoretical approaches are equivalently effective, and component studies have found that specific components of a model (e.g., the trauma narrative in trauma-focused CBT) are relatively unimportant to overall effectiveness. Thus, while psychotherapy generally appears to be effective, we still have little clue as to what factors make counseling more/less effective.

I believe that the objectivity of brain imaging and measures of neurological activity may help us to better measure what makes counseling more/less effective in the future.



Lori Russell-Chapin: I have been teaching and practicing counseling for at least three decades. It seems that many clients are searching for methods to help them feel better. So many of my clients have been to several counselors who have been helpful, but the clients are needing, wanting and searching for “one more thing” to help with their psychological and physiological concerns. Neurocounseling, or bridging our brain to behaviors, is the missing piece or “thing” of the puzzle.

As I teach students, clients and other helping professionals about neurocounseling, an all-encompassing phenomenon seems to occur. Without exception when people begin to learn more about the brain and body connections, they often comment, “If I can control my breathing or heart rate or skin temperature, then perhaps I can control so much more in my life!” Offering people self-regulation skills teaches intrinsic locus of control and personal accountability. Neurocounseling strategies demonstrate on an individual basis quantitative measures to show counseling efficacy measures. An example of this is a client who enters the counseling office with a skin temperature of 75 degrees. With one skin temperature imagery exercise, the client may be able to raise the skin temperature 5 to 10 degrees. I have had clients literally skipping out my office because they have learned this simple but essential biofeedback tool. This is an outcome measure at every counseling session.

Another fun example of neurocounseling: I wear biofeedback/temperature control nail polish. I am constantly getting feedback about what is going on in my day. This is a constant reminder for me to diaphragmatically breathe, slow down and self-regulate!

Teaching others about neurocounseling doesn’t just help them with situational symptom reduction, but it teaches a unique approach to wellness, life and a method for adapting and regulating through life’s difficulties.





Related reading, from the Counseling Today archives:






Want to connect with other counselors who are interested in neuroscience? Join ACA’s Neurocounseling Interest Network. Contact Lori Russell-Chapin at or visit






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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.






Assessing depression in those who are chronically ill

By Cathy L. Pederson, Kathleen Gorman-Ezell and Greta Hochstetler Mayer March 7, 2018

You receive a referral for a new client from a local physician. Great! As you review the materials, it is clear that the physician thinks the client’s issues are “all in her head.” Perhaps she is depressed. A good strengths-based and ecologically grounded counselor is just what she needs.

On the day of the first appointment, you wonder about this 24-year-old woman. You make a quick assessment upon meeting. Diane is pale, thin and has bags under her eyes. She looks exhausted and almost fragile. Yet she is neatly dressed in jeans and a T-shirt, and her light brown hair is pulled into a ponytail. She is not wearing makeup and is naturally pretty. She has an easy smile and is quite pleasant.

As you begin your work with Diane, you realize that a number of her complaints sound like the somatization of depression. She clearly suffers from fatigue. She has also struggled with insomnia the past several months, adding to her exhaustion. Diane reports a decreased appetite and has lost 10 pounds in the past couple of months without effort. Furthermore, she suffers from neuropathic pain in her legs — a chronic pain condition from abnormalities in the sensory nerves that often results in constant pain that may feel like explosions, stings or burning aches. In addition, she frequently has abdominal pain and headaches.

Because of these symptoms, Diane was often absent at work and was subsequently fired. She now relies on her parents for financial support and has moved back home. Diane is clearly depressed … or is she?

Overlapping symptoms

Many people suffering from invisible illnesses such as chronic fatigue syndrome, myalgic encephalomyelitis, Ehlers-Danlos syndrome, fibromyalgia, Lyme disease, mast cell activation disorder, postural orthostatic tachycardia syndrome (POTS) and Sjögren’s syndrome are first diagnosed, often incorrectly, as suffering from depression. Although troubling, this is understandable because the symptoms for these chronic illnesses overlap with somatic complaints associated with depression.

Many people in the general population who are depressed suffer changes in appetite, sleep and weight, and have increased fatigue and pain. Among individuals in the chronic illness community, these are common symptoms related to their physical illness. They may also suffer from other symptoms that make gainful employment or social relationships difficult. These symptoms include brain fog that makes concentration and processing of information challenging, orthostatic intolerance (increased symptoms when standing), exercise intolerance, joint subluxations and dislocations, severe allergic reactions to foods or chemicals, hot flashes, and muscle and joint stiffness or pain.

Many current depression screening instruments have at least a third of their questions related to somatization of depression. This can artificially elevate the depression score in those individuals with a chronic, invisible illness because of the physical symptoms they experience.

For instance, consider the free version of the Beck Depression Inventory. The last seven questions of this popular instrument ask about physical, rather than psychological, changes. Thinking about those with chronic invisible illnesses, imagine their scores for the following somatization of depression items.

  • I can work about as well as before (0). … I can’t do any work at all (3).
  • I can sleep as well as usual (0). … I wake up several hours earlier than I used to and cannot get back to sleep (3).
  • I don’t get more tired than usual (0). … I am too tired to do anything (3).
  • My appetite is no worse than usual (0). … I have no appetite at all anymore (3).
  • I haven’t lost much weight, if any, lately (0). … I have lost more than 15 pounds (3).
  • I am no more worried about my health than usual (0). … I am so worried about my physical problems that I cannot think of anything else (3).
  • I have not noticed any recent change in my interest in sex (0). … I have lost interest in sex completely (3).

There are 21 questions total on the Beck Depression Inventory, each ranging in point value from 0 to 3, with the higher numbers reflecting an increased possibility of depression. For how many of the seven questions above do you think that Diane might report a 2 or a 3 because of her physical ailments? If she chose the most severe response (a score of 3) for each of these seven questions, this would give her 21 points — placing her in the category of moderate depression on the Beck Depression Inventory — without even considering the first 14 questions on the survey.

It is important to realize that some clients who might appear moderately, severely or extremely depressed on a screening instrument such as the Beck Depression Inventory are actually suffering from an undiagnosed physical illness. We urge counselors to explore these somatic symptoms with their clients, particularly if the counselor notices an imbalance in the affective versus somatic parts of the instrument. With an integrated conceptualization of the person within her or his environmental context, counselors can go beyond addressing surface symptomology to explore underlying concerns.

Taking time to build a therapeutic alliance is critical, especially as many in the health care industry feel pressure from insurance companies to conduct quick patient exams. Unfortunately, many health care practitioners don’t get reimbursed for really listening to their patients and probing these multifaceted issues to arrive at a correct diagnosis. As counselors, you have the opportunity to give your clients something that they have been lacking — someone who is willing to take the time to truly listen and piece together the complexity of their problems.

Chronic illness and depression can be comorbid

Just as someone with chronic illness may not have depression, comorbidity of depression with chronic illness is possible and must be ruled out. There is a known link between chronic medical illness and depression for people with heart disease, cancer and a variety of other well-understood medical issues. Approximately 50 percent of people with chronic invisible illnesses also suffer from clinical depression. The trick is to separate those individuals with elevations purely from physical symptoms from those individuals who are truly depressed. There is a paucity of literature to guide clinical practice in this area.

Chronic illness encompasses more than just the physical symptoms. Many clients/patients become socially isolated because they can’t work or go to school. Friends and family members may slowly drift away as the illness drags on for months, years or decades. In the case of invisible illnesses, these clients often look “normal,” so it is not uncommon for people to completely dismiss their affliction. Many of these disorders are not well-understood, and a stigma can be attached to them that adds shame and guilt for being ill.

Poor treatment from health care workers can compound the problem. Many people with these illnesses have perfectly normal blood and urine tests, electrocardiograms and MRIs. If the tests are normal, then the symptoms must be “all in the person’s head,” right? Can people truly be suffering when traditional testing can’t find the cause? Many individuals working in the health care professions would say no. As a result, many of these patients are labeled as being high maintenance, and their own physicians may not believe that they are truly ill. Even for those individuals with a chronic or invisible illness who are not depressed, counseling can be important to increase their hope, improve their quality of life, help them gain perspective and help them work through social issues as they learn to deal with their new reality.

Properly diagnosing clinical depression for people with chronic illnesses is important, just as it is in the general population. Interestingly, not all people in the chronic illness community who die by suicide are clinically depressed. Research has shown that individuals with chronic invisible illnesses, particularly women, are at an increased risk for suicide. Some studies have reported that nearly 50 percent of people with POTS or fibromyalgia report suicidal ideation. Among those with chronic fatigue syndrome and myalgic encephalomyelitis, approximately 20 percent are at high risk for suicide. These are staggering numbers.

Although most counselors routinely assess for suicide, it is important to know that individuals with chronic invisible illnesses often do not present with the same symptomatology. Whereas most people in the general population who are suicidal tend to have comorbid depression, people with chronic invisible illnesses may not present this way.

Suicide risk factors for individuals with chronic invisible illness include loneliness, perceived burdensomeness and thwarted belongingness. The acquired capability for lethal self-injury is a critical area of risk to explore for those with chronic invisible illness due to repeated exposure to painful or fearsome experiences. These risk factors should be routinely assessed and worked into the treatment plan to target the underlying suicidality and reasons for living. Determining specific goals and objectives on the treatment plan, as well as providing regular check-ins on these topics, may help to decrease the risk of suicide.

The individual’s support system, including the treating physician, should also be made aware of the link between these risk factors and suicide. By facilitating this conversation between clients who are chronically ill and their support systems, some of the concerns related to loneliness, perceived burdensomeness and thwarted belongingness may be addressed proactively and conversely serve as protective factors rather than risk factors.

Counseling clients who are chronically ill

Many individuals with chronic illnesses need a safe place to vent their frustrations while receiving validation for their emotional, social and physical suffering, even if they are not clinically depressed. You may be the only person who believes them as they explain their symptoms and how the chronic illness impacts their daily life.

The therapeutic relationship and the ability to establish rapport are imperative to initiating change in the treatment process. Individuals with chronic invisible illnesses may benefit from individual therapy, couples or family-based interventions, multidisciplinary case coordination and group therapy with other people who are chronically ill. Integrating teletherapy or online therapy can ensure that these individuals, particularly those who are partially or completely homebound, have access to the care that they need.

Some people with chronic invisible illnesses struggle to get through the day. Because of their physical struggles, they often miss activities that they enjoy and may feel disconnected from their social circles. Feelings of loneliness and isolation may develop. As their illness progresses, individuals may require more assistance to perform tasks of daily living (e.g., showering, cooking, cleaning, shopping), which can lead to feelings of burdensomeness. As counselors, it is important to help these individuals find strong support networks and to provide psychoeducational information to the significant people in their lives. It is also crucial to assure these clients that they are resilient and have inherent value that is untouched by their illness.

Many individuals with chronic invisible illness are accurately diagnosed later in life. This fact illustrates how the course of chronic illness can impact the developmental process and quality of life at different stages. The diagnosis and ensuing disability can alter many of these individuals’ plans for the future, including college, career, family life and, at times, independence. This may cause them to redefine themselves within the scope of their chronic illness. Often, they must develop new roles in school, at work and within their families and friendships as they live within the confines of their health issues. As a result, their self-esteem and identity may be negatively impacted and must be addressed within the therapeutic context at different points in time.

This may be done by challenging negative self-talk, focusing on intrinsic motivation and using techniques such as radical acceptance, acceptance and commitment therapy, mindfulness-based stress reduction and a strengths-based, ecological perspective. By focusing on these individuals’ strengths, counselors may empower them to create new roles that will provide joy while also embracing the changes in their physical abilities.

In addition to the physiological changes that they are experiencing, clients who are chronically ill may simultaneously be going through the grief process. It is important for counselors to work with these clients to acknowledge the reality of the loss of their physicality, address feelings associated with their loss and help them to adjust to a new “normal.” Magical thinking often accompanies the process of grief and loss and occurs when an individual creates an improbable theory or belief system (often self-deprecating) around why a loss might have occurred. This often serves as an initial defense mechanism but can become detrimental over time. As a result, it is important for counselors to work with chronically ill patients to challenge any magical thinking that may be in place.

Finding normalcy after loss takes time. It is important to remind those with chronic invisible illnesses that there will be good days and bad days, while simultaneously working with them to instill hope for the future. Counselors can play a valuable role in helping people with chronic invisible illnesses to accept their physical limitations, while also empowering them to live rewarding and fulfilling lives.



Cathy L. Pederson holds a doctorate in physiology and neurobiology. She is a professor of biology at Wittenberg University and is the founder of Standing Up to POTS ( Contact her at

Kathleen Gorman-Ezell holds a doctorate in social work. She is a licensed social worker and an assistant professor of social work at Ohio Dominican University. Contact her at

Greta Hochstetler Mayer holds a doctorate in counselor education and is a licensed professional counselor. She is CEO and initiated suicide prevention coalitions for the Mental Health & Recovery Board of Clark, Greene and Madison Counties in Ohio. Contact her at


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Related reading, from the Counseling Today archives: “The tangible effects of invisible illness” by Cathy L. Pederson and Greta Hochstetler Mayer




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