Tag Archives: Depression

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 (standinguptopots.org). Contact her at cpederson@wittenberg.edu.

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 gorma111wnek@ohiodominican.edu.

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 greta@mhrb.org.


Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.



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




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.


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.”




To contact the counselors interviewed for this article, email:




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




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.

The most wonderful time of the year?

By Bethany Bray October 23, 2017

Counselors can help clients prepare for the pressures that come during the holiday season, from a barrage of parties and social events to the temptation to compare themselves with the happy, near-perfect holiday scenes in movies, advertisements or friends’ social media posts.

For clients with seasonal depression, it can all be overwhelming — just at a time when people are expected to be happy and joyful, says John Ballew, a licensed professional counselor (LPC) with a private practice in Atlanta. Financial stresses, relationship concerns, grief over the loss of a loved one and other life challenges can feel more intense.

“This can be exactly the time that’s going to press on an old wound,” says Ballew, a member of the American Counseling Association.

Cindy Gullo, an ACA member and licensed clinical professional counselor in O’Fallon, Illinois, says she also notices an uptick in depression symptoms in her teen clients during the unstructured weeks of school break for the holidays, as well as anxiety over the return to school in the new year. She coaches clients to create and maintain structure over holiday breaks, including getting up at the same time in the morning and keeping up with the tasks they normally do while in school, such as completing reading assignments or practicing a musical instrument.

For Ballew’s adult clients, setting boundaries — from limiting their party RSVPs and holiday overeating to avoiding toxicity on social media — is often key to navigating the holidays. He also talks about the difference between self-care and self-indulgence with clients when preparing for the season.

“The adage that ‘No is a complete sentence’ is very applicable here,” Ballew says. “Especially if they have social anxiety, three hours at a party can feel totally overwhelming. Plan to go for 20 minutes, say hello to at least three people, then leave and admit you’ve done something difficult.”

On the flipside, clients who don’t receive any holiday invitations can sink into isolation or self-pity. Ballew says he works with clients to challenge themselves. Are they sitting at home waiting for the phone to ring? If so, they can be the one to call friends and initiate get-togethers. They can volunteer. They can choose to attend concerts and other local events on their own.

The holidays — from Thanksgiving to Valentine’s Day — can also be a struggle for clients who are single and unhappy about it. Again, Ballew says he challenges these thought patterns with clients. “For people who are alone, it’s learning to love being alone and make peace with it,” he says. “Reassess old patterns and beliefs and let go of things that aren’t working. What activities can you do alone? What beliefs do you have that keep you from enjoying things alone?”

Conversations with clients about setting boundaries can also be helpful in preparing for the family pressures and get-togethers that crop up during the holidays. For clients with particularly toxic or unhealthy family situations, this may mean limiting their involvement or staying away altogether, Ballew says. It may even be helpful to create their own new traditions during the holidays.

Sometimes, Ballew coaches clients to think of family visits as a trip to the zoo: What behavior might you see? What can you expect? What responses can you have ready for when family members make inappropriate or triggering comments?

When appropriate, he will create a “family bingo” board with clients, listing predictable patterns and negative behaviors that they can track in their minds. Although they wouldn’t bring the board to family gatherings, its creation is a way to prep for managing potentially challenging situations, Ballew explains.

“Approaching things with a sense that it doesn’t need to be that serious can be helpful,” he says. “With other folks, if the family is seriously dysfunctional, they just need to set boundaries. For example, if dad gets drunk, they don’t need to wait around to be berated. Have a [plan and] a place to go so you aren’t as vulnerable as when you were younger.”

Marcy Adams Sznewajs, an ACA member and LPC with a private practice in Beverly Hills, Michigan, specializes in working with teenagers and emerging adults. Like Ballew, she works with clients to prepare for family interactions over the holidays, with focus placed on empathy and listening skills.

“We do a lot of role-play in anticipation of family events,” she says. “What would happen if your uncle goes down this path and you respond in this way? How might that end? How would you like it to end? What are some different ways you can approach the situation? Teens don’t always have the ability to step back and say, ‘Just because someone doesn’t understand me doesn’t mean that I need to spout off my opinion at all times or respond.’”

“We also talk about understanding other people’s perspectives and life experiences,” she continues. “If they can look at a [family member’s] actions and behaviors from a place of empathy, sometimes it’s easier to sit through a conversation. Or, sometimes, it’s so horrible that all they can do is take a deep breath and get through it. Then we talk about management, mindfulness and ‘this too shall pass.’

“I tell them, ‘I can’t always help fix this, but I can help you cope, and you are strong enough to deal with this.’”




READ MORE about supporting clients through seasonal depression in the article, “A light in the darkness” in Counseling Today‘s November magazine: https://wp.me/p2BxKN-4V1


From the Counseling Today archives: “Unhappy holidays: Helping clients through the ‘holiday blues’




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


Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.





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.


Helping clients realize their daily potential

By Brandon S. Ballantyne June 7, 2016

I often think about the pursuit of potential and try to imagine what “reaching potential” would look like exactly. I think about how it could be helpful to assist my clients in identifying their beliefs about personal potential and then developing a navigational tool to assist them in moving toward that potential. The concept is fascinating to me.

For a few moments, I’d like you to sit back and think about what it might be like to have GPS navigation aimed at routing you to your potential as a human being. My theory is that, as counselors, in a lot ways, we help individuals do just that.

All of us acquire beliefs about our potential from what we are told as children. We also acquire beliefs about our potential from what we observe as children. Our families, friends, caretakers and siblings all contribute to this cognitive framework of the ideal image of ourselves that we GPS navigation in carcontinuously pursue. I believe that when individuals experience a traumatic event, or suffer a significant loss or endure a situation that provokes emotional struggle, it can interfere with their ability to effectively navigate the pursuit of their personal potential. In other words, this is depression.

I believe a key component to helping clients work through their depression is assisting them in the identification, exploration and challenging of beliefs related to individual potential and its pursuit. I believe there is certain “word choice” in our thoughts that increases what I refer to as “internal pressure.” What is internal pressure? It is simply increased emotional distress.

Being trained in cognitive theory, I believe it is important to help clients examine their word choices in thought. For example, the word “should” can be reflective of a rigid demand. Therefore, “should” will likely intensify emotional distress by creating a strong sense of guilt for being unable to continuously achieve the imagined rigid demand.

I work in a partial hospital setting. Often, I work with clients who are struggling with continued depressive symptoms due to repeated thoughts of “I should be better than this.” I believe this thinking interferes with their ability to effectively pursue their desired level of individual potential.

I remind and educate my clients that emotional response is a normal human experience. I tell them that when considering the history of events leading to their treatment, it would be “understandable” if they were struggling with levels of depression at this time in their lives. Therefore, it might not be totally fair to assume that they “should” be better (emotionally) than they are at this time.

In defining the legitimacy of their emotional struggles, we can help clients access some self-validation and acknowledge the need to take the necessary time to patiently work through their current experience with depression. In doing so, we create a less rigid view of their achievable potential “at this time” in life.

I think that individual potential is something that changes. My individual potential today might be different from my individual potential tomorrow.

Potential is a belief system. Potential is a series of thoughts. As human beings, we have thoughts in response to events and emotions in response to thoughts. If we can help clients focus on examining their “daily” potential, we will help them to increase self-esteem and self-confidence through the implementation of daily achievable goals and assignments. They will become the sole directors of their individual potential each day, using their “evidence of success” (accomplishments) from prior days to achieve tomorrow’s tasks.

Our job as counselors is not to increase clients’ potential for them. It is to offer a less rigid framework for balanced thoughts and considerations. This in itself serves as the client’s GPS navigation for reaching individual potential. The difference is that in the beginning, these clients might have felt extreme emotional pressure to “be better right away.”

My hope is that my personal approach will allow other therapists to help clients take beliefs about individual potential that were once rigid, extreme and demanding, and modify them into expectations, goals and daily achievable tasks that will increase self-esteem. This approach can also provide a foundation for continued growth (progress) by suggesting alternative routes rather than assuming that all detours lead to increased distress or misery.

By the way, it is always OK to stop and ask for directions (help) despite what your belief system tells you that you “should” or “should not” do.




Brandon S. Ballantyne, a licensed professional counselor and national certified counselor, has been practicing clinical counseling since 2007. He currently practices at Reading Health System in Reading, Pennsylvania, and Advanced Counseling and Research Services in Lancaster, Pennsylvania. He has a specialized interest in using cognitive theory to help his clients enhance their abilities to recognize and change problematic thought patterns to achieve more desirable emotions and healthier behavioral responses. Contact him at Brandon.Ballantyne@readinghealth.org.

The tangible effects of invisible illness

By Cathy L. Pederson and Greta Hochstetler Mayer April 26, 2016

A variety of invisible illnesses can greatly impact both the physical and mental health of individuals. Some of these illnesses are debilitating, preventing participation in the normal activities of daily living. Examples include chronic fatigue syndrome/myalgic encephalomyelitis, Ehlers–Danlos syndrome, fibromyalgia, lupus, Lyme disease, multiple sclerosis, myasthenia gravis, postural orthostatic tachycardia syndrome (POTS), regional complex pain syndrome and Sjogren’s syndrome.

These disorders disproportionately affect women and are not well understood by the health care Branding-Images_invisibleestablishment or the general community. Lack of understanding can lead to feelings of alienation and hopelessness for those suffering from these disorders.

Such was the case for Natalie (case study used with permission). Seemingly overnight, she transformed from a vivacious teenager at the top of her eighth-grade class to being virtually bedridden with fatigue, dizziness and chest pain. She visited a series of doctors in search of relief. A few months later, at age 15, Natalie’s life changed forever when she was diagnosed with POTS and Ehlers–Danlos syndrome, neither of which is curable or easily managed medically.

POTS is a disorder of the autonomic nervous system in which blood pressure, heart rate, blood vessel and pupil diameter, peristaltic movements of the digestive tract and body temperature are affected. Natalie’s Ehlers–Danlos syndrome caused additional pain — her connective tissues were weak and her joints would easily dislocate. During her freshman year of high school, Natalie was bound to a wheelchair. But as a sophomore, her dizziness and other symptoms were better controlled, so she went roller-skating with friends. She broke her wrist and injured her neck that evening, and her fall triggered debilitating migraines.

Although not widely studied, rates of suicide are believed to be higher in people with chronic or terminal illness. It is unclear if physical illness alone leads to risk of suicide or whether having an illness increases the chances of developing depression or hopelessness, which then increases suicide risk.

Painful, chronic illnesses and illnesses that interfere with a person’s everyday functioning are believed to be risk factors for suicide, especially among older adults. Some illnesses associated with increased suicide risk are AIDS, certain forms of cancer, Huntington’s disease and multiple sclerosis.

Risk of suicide is often linked with co-occurring mood, anxiety and substance use disorders in this population. However, people with invisible illnesses may not necessarily be clinically depressed or anxious; instead they may feel hopeless about their prognosis, experience real and anticipated future losses, and suffer from chronic pain — all of which are potent risk factors for suicide. The basic science of these individuals’ physical condition is not well understood, which makes developing medications to treat them difficult. Most treatments are aimed at individual symptoms rather than the root cause of the problem.

It takes Natalie three times more energy than normal just to stand because of her POTS. Even making minor movements around the house and engaging in daily routines, including eating meals and showering, can be exhausting for her and increase her symptoms. Her quality of life is similar to those with congestive heart failure or chronic obstructive pulmonary disease.

At 16, Natalie endured weeklong hospitalizations for headaches and other POTS symptoms. Medications didn’t offer relief. An honor student, Natalie missed more than 70 days of school during the last half of her sophomore year. She was no better by the end of her junior year and eventually dropped out of high school. She was behind in her work and struggled to complete projects and tests that would have been easy for her when she was healthy. “It was heartbreaking,” said Natalie’s mother about seeing her daughter transform from high achiever to high school dropout.

Natalie’s family had done everything right. They took her to see physicians, followed all prescribed treatment regimens, put her in counseling and supported her through her illness. Unfortunately, medical help was evasive and mental health care was marginal. Over time, Natalie’s friends drifted away. She couldn’t be physically active, participate in community events or hold a job. Eventually, she confronted insidious suicidal thoughts.

Working with those who are chronically ill

Many chronic illnesses are not terminal conditions, but they can severely impact a person’s quality of life for decades. For example, imagine that you have POTS. You feel lightheaded every time that you stand, and you faint several times per day. You experience neuropathic pain that feels like bees stinging your arms and legs. Hot flashes arrive without warning, and you begin to sweat. Despite possessing above-average intelligence, you have difficulty concentrating and analyzing problems. Simply taking a shower drains your energy, and it doesn’t replenish itself. Your physical isolation and illness create feelings of being misunderstood and not belonging.

These feelings only increase when you finally venture out of the house. People congratulate you on your “recovery.” Friends tell you how good you look. Distant relatives offer advice about how to get better. Even worse, you are bullied, called a faker or are the target of other derogatory comments. Your boss suggests that you would feel better if you only ate right and exercised. Even your spouse says, “Just get over it!”

Counselors should not fall into these traps when working with these clients. For someone who is chronically ill, even hearing “you look good” might be equivalent to “I don’t believe that you are really sick.” Normal niceties take on special meaning and ring hollow for those with chronic illnesses.

For most people, a doctor’s visit will result in control of their illness and restoration of their health. This isn’t true for many individuals suffering from chronic, invisible illnesses. Not only are they grieving their loss of health because of their physical condition but, often, they also feel dismissed and even traumatized by their health care practitioners.

Many with chronic illness feel ignored or abandoned by doctors and nurses. Some individuals have even been told to stop fainting or to bring down their heart rate, as if they are making choices meant to curry attention. Many physicians aren’t educated about these debilitating illnesses, and specialists in these fields often have waiting lists that are years long. Imagine how such repeated, negative experiences might erode hope for recovery and lead to suicidal thinking. What is a patient to do? In the case of those with POTS, the incidence of mental illness is the same as is found in the general population. The seemingly paranoid behavior these individuals demonstrate related to their health can be the result of medical mistreatment and neglect, and it is often justified and understandable.

Sadly, invisible illness can put even the strongest relationships in jeopardy. As days turn to months and years, the constancy of chronic illness can wear on marriages, friendships and family relationships. Missed holidays, birthdays and other social events leave loved ones feeling betrayed and wondering if the person who is chronically ill could make more of an effort to be present. Friends and family members often doubt whether their loved one is sick. Some acquaintances become confrontational with the person who is chronically ill, whereas others turn passive-aggressive. Because a person’s hair doesn’t fall out with chronic fatigue syndrome, no skin lesions appear with multiple sclerosis and no significant weight loss takes place with fibromyalgia, it is easy to forget the internal battles being waged every day by those with chronic illness.

Counseling professionals are well-positioned to address the fallout of living with chronic illness. Counseling can provide something that those with chronic illness who are feeling suicidal desperately need but are often missing — a safe place where they can be heard, validated and comforted. Most important, counselors are particularly skilled at uncovering suicide risk, advocating for underserved populations and providing clinical management of complex cases.

In Natalie’s case, she was depressed from grieving her loss of physicality, friends and school. She had found some relief through the use of an antidepressant and went to counseling regularly. In the midst of a flare, her physician switched Natalie to Prozac, which she had taken previously, without considering the fact that it might increase suicidal ideation in teenagers. Natalie never mentioned the suicidal thoughts to her family or doctor. Shortly after titrating to 30 milligrams, the 17-year-old attempted suicide.

Consider physical illness part of the problem

Many people with debilitating and invisible chronic illnesses are told that it is all in their heads. As a counselor, you may be the first person who truly listens and tries to understand what is happening in the individual’s life. Don’t be afraid to suggest that someone who has especially dry mouth and eyes (Sjogren’s syndrome), fainting episodes and difficulty thinking (POTS), debilitating fatigue that can’t be attributed to known causes (chronic fatigue syndrome/myalgia encephalomyelitis, POTS, fibromyalgia, lupus) or chronic pain (complex regional pain syndrome, fibromyalgia, POTS) should get a thorough checkup with a good physician.

Consider working collaboratively with these physicians as a multidisciplinary team. Recommend someone who is a knowledgeable problem-solver to investigate underlying physical causes for the person’s anxiety or depression. In addition, assess regularly for suicide risk, especially during transitions in levels of care, and take all warning signs and risk factors seriously. Labeling a person’s symptoms as part of a recognized disorder will often be a great relief to the person psychologically.

Physical limitations and their effect on counseling

As a result of chronic illness, routine activities can cause debilitating fatigue. Standing, walking, showering, riding in the car and even attempting to focus on a conversation can quickly exhaust those with chronic illness. As their fatigue increases, brain fog also tends to increase.

As counselors, it is important to understand and recognize the effort it takes for these clients to walk through your office door. Offering small encouragements will reinforce the proactive effort they have taken to maintain their mental health and improve their quality of life.

Also note that many people with invisible illness are particularly sensitive to light, noises and smells. This is particularly true when they are flaring. Simple gestures such as closing the blinds or turning off fluorescent lights may help them conserve their energy for their work with you. Similarly, avoiding the use of candles, strong scents or incense can be helpful.

Differentiating the physical from the psychological

When working with clients who are chronically ill, differentiating their physical issues from their psychological issues can be difficult. Consulting with knowledgeable health care specialists is essential. Taking the time to learn about a client’s chronic illness can greatly increase empathy, provide authentic understanding and help in guiding the person to proper medical care.

Counselors should be aware that the coping skills people use to deal with symptoms of chronic illness can look like warning signs for depression or suicide. For example, coping skills to manage many invisible illnesses, such as staying in bed and avoiding the shower, may be unrelated to depression or risk of suicide.

In addition, dysregulation of the autonomic nervous system causes surges of norepinephrine that can lead to insomnia, anxiety or panic attacks. A person’s lack of appetite can be related to gastroparesis (paralysis of the stomach) or other digestive motility issues. Debilitating fatigue and difficulty focusing/concentrating are also common problems connected to many invisible illnesses.

At the same time, it is important to remember that individuals with chronic illnesses that involve functional impairment and chronic pain are at greater risk for suicide, so warning signs such as suicidal thoughts and threats, previous suicide attempts and hopelessness must be taken seriously. In Natalie’s case, she had confided her suicidal thoughts to her counselor. Unfortunately, her parents and doctors were unaware of the extent of Natalie’s overwhelming emotional pain until she attempted suicide.

Follow-up care after hospitalization is critical

Pursuing inpatient hospitalization for people at serious risk of suicide can be a life-saving step. However, the current health care environment poses challenges to accessing timely, quality care when needed, even for those at imminent risk for suicide. Inpatient stays are difficult to secure, and lengths of stay are minimal at best.

Individuals often transition from an inpatient level of care to outpatient settings before their stabilization, and this is not easy for individuals with chronic illness or their families. In addition, being hospitalized for mental health problems can be further stigmatizing and demoralizing for the person with chronic illness.

The period immediately following hospital discharge is particularly dangerous for people at risk for suicide. Counselors operating from a multidisciplinary framework can mitigate this risk (with permission of the person with chronic illness) by coordinating care with hospital staff, medical specialists and key family members.

Providing continuity of care also helps with stabilization, engagement and retention in aftercare. Long-term counseling is necessary to strengthen the person’s reasons for living and to uncover the problematic situations and underlying psychological vulnerabilities that led to the suicidal crisis.

“After 12 inpatient days and nine partial hospitalization days, I’m starting to feel confident that she is on the road to recovery,” Natalie’s mother reported. Natalie’s medications were changed, and she passed the GED test in lieu of her high school diploma. She is now on the road toward college. We hope that sharing her story can help to prevent suicide attempts in other young adults with chronic illness.




Cathy L. Pederson holds a doctorate in physiology and neurobiology. She is a professor of biology at Wittenberg University and founder of Standing Up to POTS (standinguptopots.org). Contact her at cpederson@wittenberg.edu.

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

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