Tag Archives: Depression

Tossing and turning in the digital age

By Laurie Meyers May 27, 2014

Branding-DragonFor centuries, poets and playwrights have ascribed a kind of magic to sleep: “We are such stuff as dreams are made on, and our little life is rounded with a sleep,” says Prospero in Shakespeare’s The Tempest. Poet e.e. cummings wrote, “over my sleeping self float flaming symbols of hope, and i wake to a perfect patience of mountains.” Sleep used to be regarded as transcendent and restorative — a place where dreams connected to a better self. But in today’s 24/7 digital age, sleep is often perceived as a thief of time, an elusive lover or even a sign of weakness.

It’s also a biological wonder. A growing body of research is connecting sleep — both its quantity and quality — to a variety of physical and mental health issues. These findings suggest that sleep is no longer a bit player in health prevention and maintenance but a candidate for center stage. Clearly, the digital age needs to tune out, turn off and go to bed. Some counselors are making sleep therapy a significant part of their practices and helping clients learn to get more and better sleep.

Although sleep disturbances have long been associated with mental illnesses, new findings indicate that the link may be more complicated and intertwined than previously thought. For example, insomnia is known as a side effect of depression, but a growing body of research suggests it can precede and perhaps even cause depression. And now there is evidence that specifically targeting co-occurring insomnia can reduce depression symptoms. A recent study at Ryerson University in Toronto found that patients with both depression and insomnia who were successfully treated with cognitive behavior therapy for insomnia (CBT-I) were almost twice as likely to experience significant relief from depressive symptoms. A 2007 study in SLEEP, the peer-reviewed scientific and medical journal of the Associated Professional Sleep Societies, determined that chronic insomnia is not only related to stress but may also cause anxiety disorders. Another SLEEP study, published in a 2013 online supplement, found that insomnia alters the brain’s emotional circuitry. Specifically, it raises the activity level in the amygdala, which plays a significant role in emotional processing and regulation.

In addition to wreaking havoc with people’s mental health, lack of sleep puts stress on the cardiovascular system, suppresses the immune system and can cause endocrine dysfunction. These outcomes cause or are associated with obesity, heart disease, diabetes and dementia.

A recipe for insomnia

Lori Puterbaugh, an American Counseling Association member from Tampa, Florida, believes sleep deprivation is an epidemic in the United States. She says counselors, because of their behavioral training and other skills, can help remedy the problem.

Puterbaugh, a licensed mental health counselor and licensed marriage and family therapist in private practice, asks all of her clients about their sleep habits. At intake, she gives them a short questionnaire that asks about sleep duration and quality, including hours per night spent sleeping, time spent falling asleep, instances of waking up during the night and how rested they feel the next day.

Puterbaugh, who is also a member of the American Mental Health Counselors Association, a division of ACA, finds that many of her clients aren’t sleeping well and often are doing all the wrong things to actually get a good night’s sleep. “Most people’s routine is a recipe for insomnia, and they don’t even realize it,” she says.

In fact, many of the activities people engage in to relax before going to bed, including watching TV, surfing the Internet or interacting with other electronic devices such as smartphones and tablets, are stimulating the brain, Puterbaugh asserts. Even worse, she says, some people are convinced that these habits — their “sleep safety” activities — are actually essential for them to be able to sleep.

Some clients have the right mind-set about attempting activities and routines that promote sleep, but they don’t possess the know-how to follow through properly, says Robert Turner, a licensed professional counselor (LPC) and ACA member from Littleton, Colorado, who devotes part of his practice solely to treating insomnia. “There is a lot of access on the Internet to positive things people can try, but they don’t do it correctly,” he says. “For example, they may try deep breathing, but they actually hyperventilate, or they exercise, but they do it too soon before bed.”

Other people find that the more they chase sleep, the faster it seems to run. “They perpetuate sleep problems by going to bed early, staying in bed longer and napping during the day,” says Kim Restivo, an LPC in Wilmington, North Carolina, who also dedicates part of her practice to the treatment of insomnia.

“People will sometimes say, ‘It takes me awhile to get to sleep, so I will go to bed earlier,’ and that backfires,” says Turner, who has been working with sleep issues for more than 30 years. They instead end up tossing and turning, which adds to their anxiety and makes it even less likely that they will be able to fall asleep.

Puterbaugh says she often has to dispel myths about what qualifies as good sleep. “Many people are under the impression that the normal way to fall asleep at night is that your head hits the pillow and then you’re sleeping peacefully,” she says. They don’t realize that the time it takes to fall asleep varies according to the individual and changes throughout life, she explains.

“Clients sometimes have this idea of sleep as an on/off switch,” adds Turner.

Restivo tries to normalize occasional lack of sleep with her clients. “Everyone has bad nights,” she says. “It doesn’t mean that you are always going to have them.”

Some people also mistakenly think that waking up in the middle of the night should be an aberration, so when it happens to them, they lie there worrying about why they woke up, what is wrong with them and how they’re going to get back to sleep, Puterbaugh says. “I tell them that it’s not that uncommon to wake up to move over, to go to the bathroom or because you’re in the middle of a light sleep cycle and there was a noise,” she says.

“If people aren’t aware of the variations, they sometimes think that it’s just them — that there’s something really wrong with them,” she explains. “Sometimes you can reduce anxiety about bedtime just by giving them that kind of information.”

People often develop a kind of performance anxiety when it comes to sleep, Turner says. Restivo adds that it is important to reduce that anxiety because it often causes catastrophic thinking.

“They’re thinking, ‘Oh my gosh, I’m awake,’” Puterbaugh says. “‘What if I lie here all night and can’t get back to sleep? I’m going to have a horrible day at work tomorrow because I’ll be too tired.’ It’s just this cavalcade of things that are going to go wrong, and [counselors] can help them interrupt that.”

“You want to remove the sense that the bedroom is where you go to fight this dragon,” asserts Turner.

Rest for the weary

To slay that dragon, counselors and clients need to work together to change thinking and behavior.

“It becomes an education process,” Puterbaugh says. “And initially their anxiety levels go up because you are asking them to give up their security blanket [sleep safety activities].”

Puterbaugh and her clients discuss how spending a significant portion of the evening surfing the Internet or watching TV in bed, or other habits such as drinking alcohol or eating right before bedtime, can disrupt sleep. They then explore changes the client could make to promote more and better sleep.

“There’s a difference between having a cup of chocolate ice cream in the evening and having a whole gallon,” Puterbaugh says. “There’s a difference between watching TV in the evening for a little while and watching or falling asleep to it in bed.”

Puterbaugh tells her clients that the changes they make don’t have to be drastic to produce a significant difference. “Can you stop watching TV [or engaging with other electronic devices] an hour before you’re ready to go to bed and use that time to do something quiet under softer lighting?” she asks.

In addition, Puterbaugh advises clients to use relaxation exercises or positive visualization rather than lying in bed feeling anxious as they try to fall asleep or when they wake up during the night.

When working with clients struggling with insomnia, Turner starts with cognitive restructuring. “We shift the focus to ‘how can I manage’ rather than ‘I can’t manage because I didn’t sleep,’” he says.

Turner learned the principles of CBT-I during his time as a guest at the School of Sleep Medicine at Stanford University.  CBT-I uses the tools of cognitive behavior therapy to change sleep behavior. Among the techniques are having clients keep a sleep diary to look for patterns, identifying triggers that make some nights worse than others and establishing good sleep hygiene. In part, that involves ensuring the bedroom is a dark and quiet place that is used exclusively for sleep (and sex).

Turner may also use another CBT-I technique, sleep restriction/sleep scheduling, but he acknowledges this is difficult because it requires the client to stick to a rigid sleep schedule temporarily. The client uses the sleep diary to track his or her sleep for a week to determine the average number of hours of actual sleep time.

“If by the end [of the week] you have averaged five hours, then you get only five hours to sleep, and you get out of bed until you’re having more success,” Turner says. This means staying up until five hours before a client’s normal wake time, whether that is midnight or 3 o’clock in the morning. The idea is to greatly increase the body’s desire for sleep so that when the client goes to bed, he or she actually falls asleep and stays asleep. Once the client is consistently falling asleep on this schedule, the interval is slowly increased until he or she is able to consistently get a full night’s sleep.

By reducing the number of hours spent tossing and turning, sleep restriction helps client to consistently see the bed as somewhere to sleep, not just “try” to sleep, explains Restivo, who also uses CBT-I with clients.

Restivo was trained in CBT-I at a seminar led by Michael Perlis, director of the behavioral sleep medicine program at the University of Pennsylvania. There is no specific certification in CBT-I, but doctoral-level practitioners can become certified in behavioral sleep medicine (go to the American Board of Sleep Medicine’s website at absm.org for more information). Non-doctoral-level clinicians who are actively involved in behavioral sleep medicine clinical care, education or research are eligible to join the SBSM as associate members. Members of SBSM can be listed on the site as behavioral sleep medicine providers.

Not all counselors who work with their clients on sleep issues choose to use CBT-I. Some simply combine their usual counseling methods with the principles of good sleep hygiene, which were originally developed by psychologist and sleep researcher Peter Hauri. According to the National Sleep Foundation, these principles include:

  • Avoid napping during the day because it can disturb the normal pattern of sleep and wakefulness.
  • Avoid stimulants such as caffeine, nicotine and alcohol too close to bedtime. Although alcohol is well known to speed the onset of sleep, it disrupts sleep in the second half of the sleep cycle as the body begins to metabolize the alcohol, causing arousal.
  • Exercise to promote good sleep. Vigorous exercise should be done in the morning or late afternoon. A relaxing exercise, such as yoga, can be done before bed to help initiate a restful night’s sleep.
  • Stay away from large meals close to bedtime. Dietary changes can also cause sleep problems, so if someone is struggling with a sleep problem, it is not a good time to start experimenting with spicy dishes. And, remember, chocolate has caffeine.
  • Ensure adequate exposure to natural light. This is particularly important for older people who may not venture outside as frequently. Light exposure helps maintain a healthy sleep-wake cycle.
  • Establish a regular relaxing bedtime routine. Also avoid emotionally upsetting conversations and activities before trying to go to sleep. Don’t dwell on problems or bring them to bed.
  • Associate your bed with sleep. It is not a good idea to use your bed to watch TV, listen to the radio or read.

Sometimes sleep therapy uncovers other sleep disorders such as sleep apnea, a condition that causes the individual to briefly stop breathing frequently throughout the night. Sleep apnea puts incredible pressure on the cardiovascular system and can be deadly. Restivo, Turner and Puterbaugh emphasize that counselors who are treating clients with sleep problems should advise those clients to see their physicians for a thorough physical checkup.

These counselors say that tracking the quantity and quality of their clients’ sleep and working with them to improve their sleep is an important process because sleep is such an essential part of overall wellness.

Puterbaugh believes that the high incidence of depression, anxiety and attention-deficit/hyperactivity disorder occurring within a sleep-deprived society is no coincidence. “Sleep therapy isn’t going to make everything better,” she says, “but it is a factor — a factor that’s free to treat.”



To contact individuals interviewed for this article, email:

Lori Puterbaugh at puterbaugh@mindspring.com

Robert Turner at turnercounseling@gmail.com

Kim Restivo at krestivolpc@aol.com




Additional information

To read more about cognitive behavior therapy for insomnia (CBT-I), see stanfordhospital.org/clinicsmedServices/clinics/sleep/treatment_options/cbt.html, an online resource developed by the Stanford Center for Sleep Sciences and Medicine.

To learn more about insomnia and other sleep disorders, as well as sleep research, see the National Sleep Foundation’s website at sleepfoundation.org.

In addition, the following publications were mentioned in this article:

  • “Chronic insomnia as a risk factor for developing anxiety and depression,” SLEEP, November 2007
  • “Elevated amygdala activation during voluntary emotion regulation in primary insomnia,” SLEEP, online supplement, 2013



Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.


Letters to the editor: ct@counseling.org



A theological depression

By John A. Wheeler May 22, 2014

In 2004, I experienced what I could only understand as a theological depression. I had recently graduated seminary and should have been at peace with where I was in my life. I was not at peace, however, nor was I at any theological harmony. I had not fully processed my newly acquired philosophy on life, nor had I come to accept my newly acquired theology. This reservation to embrace my new theology created inner conflict. As a result, a depression formed in my life that remained for several years.

depressionAt that time of my life, I was exhausted with anything having to do with the Divine. My relationship with God had reached a place it had never been before. I was mad, I was confused, and I wanted nothing to do with Divinity. As previously stated, I was also depressed, so it took me a while to process what I took with me from seminary. In fact, this was such a significant process that I consider it to be one of the most formative things I have done in my life.

Because this theological depression was so potent in my life, I thought it would be interesting to run it through the psychodynamic, existential, Gestalt, person-centered and cognitive theories of psychotherapy. Theological depression is based on an anti-humanistic perspective, so it does not easily fit into a categorical symptom found in most psychotherapeutic disciplines. As such, I have attempted to go outside of the box in processing this ailment. In doing so, I have processed my perspective, philosophy on life and theology even further. It was good stuff!

Psychodynamic therapy

Alfred Adler might interpret my depression through the idea that I am striving for superiority. He may suggest that I identify theological harmony as the goal for a complete life. The goal of understanding the mind of God is a fictional finalism, with the achievement of that goal equaling the ideal self. Adler might further state that my motivation comes from an inferiority complex in which I identify others as being more intelligent than I am. This may be especially significant as it relates to the perception of older siblings. In addition to the insecurity of intelligence, there is an insecurity of no theological harmony. Longing for harmony with the Divine as seen in others is a motivation.

Adler may explain that my birth order could be significant in determining the origin of my depression. Even though I am the last child of three, I would hold to the traits of a middle child due to the age difference between my first and second sibling and the age difference between my second sibling and myself. I identify with rebel-like characteristics found in the middle child, while simultaneously identifying my older sister, the second sibling, as the pacesetter. Even though, as the youngest of the siblings, I expected to have perpetual attention, I did not recognize that as being the case due to a perceived neglect.

Adler may conjecture that the origin of my depression stems from a perceived sense of neglect by my father. This childhood perception leads me to assume a general sense of defeat in all of my undertakings throughout my adult life. However, in realizing the ideal of self-defeat, I constantly invest major significance in not failing. When failure inevitably occurs, which in this case would be me not understanding the mind of God, it is devastating. This devastation then manifests itself in the form of depression.

To understand the mind of God would be an unreasonable goal. That would need to be articulated and I, as the client, need to understand that. A more reasonable goal would be to accept that having a limited understanding of the Divine could be harmonious in itself. Redirecting the inferiority and compensation outward instead of inward would be quality goals as well.

To assist me in resolving my depression, Adler might suggest bibliotherapy, wherein I would read self-help books. By using the push-button technique, Adler could show that I have more power over the emotion of depression than I had realized. Having me imagine things that bring about feelings of wholeness and contentment, and then creating images that bring about feelings of depression, would prove that the emotion of depression is manageable. Adler would also develop a lifestyle analysis for me in an effort to address my depression.

From a group therapy perspective, Adler might suggest that I join a social interest club or community outreach group that focuses its attention outwardly toward society. Based on my background, Adler could suggest that I involve myself in, or even create, a community outreach program at my church. This community outreach exercise could also include my father as a means of familial therapy.

Adler might disagree with other theoretical disciplines, such as cognitive therapy, that would solely embrace the birth order perspective in defining the source of my depression. These disciplines would not recognize the failure of attainment of the superior self or the failing of the unrealistic goals I had created as relevant in identifying the source of my depression.

Existential therapy

Rollo May would say that my depression is caused by not being authentic. He might expound by conveying that I did not have an authentic relationship with God. An authentic relationship involves absolute trust in the person with whom the relationship exists. The depression may be the result of a failed attempt at knowing the unknown due to distrust. May might suggest that my distrust is a result of my fear of having sinned, as well as a fear of being unaccepted by the Divine. Therefore, I would be “lying for myself,” believing that I would find harmony in my relationship with God by “uncovering” and identifying the true nature of God.

The goal of therapy would be to become authentic by identifying the lie and raising consciousness. Being more conscious of the distrust that was causing the lie would further identify the self-objectification. By no longer seeing myself as an automaton, I would come to the realization that I had individual potency. I would begin to process the concept that I am not merely a pawn, as I had previously internalized in my relationship with God, but a sentient individual who is capable of individual action.

Reality therapy would be productive because it would let me know that I am the one who is responsible for my depression. In an individual or group session, I could be asked what I am doing to make myself depressed. From my response, I could be challenged to realize that I could have made worse decisions that might ultimately have destroyed me, beyond my depression.

The existential therapist might disagree with the psychodynamic therapist regarding the source of my depression. The psychodynamic therapist may see the depression as an inexorable result of my childhood experiences. The existentialist, however, will identify the depression as a self-induced issue formed solely from my will of choice.

Person-centered therapy

Carl Rogers would interpret my depression as a result of seeking conditional love from God instead of pursuing a normal actualization tendency. He would propose that my self-concept exists around my understanding of what my relationship with God is. As such, a need for positive regard has developed and is understood by my interpretation of life events. Positive life events equal positive regard from God and, conversely, negative life events correlate to negative regard from God. Being that positive regard can potentially be more powerful than organismic values, the consistently perceived negative events could lead to depression.

The goal or objective of therapy would be to adjust my self-concept. This adjustment would focus on what a healthy relationship might look like. Identifying my original, rigid understanding of relationships and moving toward a more fulfilling understanding of what a relationship can be would help promote a healthy actualizing tendency. For this to happen, the therapist would have to utilize unconditional positive regard. Furthermore, the therapist would have to be genuine and capable of providing empathy and reflective listening.

As is the case with psychodynamic therapy and existential therapy, many of the concepts of person-centered therapy have been assimilated into the mainstream of psychotherapy. Unfortunately, this assimilation is not typically acknowledged, nor is credit given to the person-centered discipline. Nonetheless, the significance of the relationship between the therapist and client is generally recognized as being paramount across the landscape of psychotherapy. In dealing with my depression, the person-centered relationship with the therapist would be extremely effective.

Rogers might disagree with a psychoanalytic, who would perceive my depression being the result of being stuck in one of Freud’s psychosexual stages — perhaps the phallic stage. Regardless, the psychoanalytic will see the depression as a result of some parental neglect or overindulgence, whereas the Rogerian will see it as a result of swaying away from a healthy actualization process.

Experiential therapy

Fritz Perls might interpret my depression as an immaturity, wherein I am stuck in a childish pattern of dependency on God. Rather than identifying my parents as the objects from which I draw sustenance, Perls might suggest that I have placed God in that role instead. In so doing, I placed God in an overly significant role to attend to my dependence. With that being the case, and on the basis of my negative life experiences, Perls would suggest that I was at an impasse, as indicated by my coming out of seminary more confused than when I went in and no longer sensing God the way I had before. Perls might also suggest that I was at a place to operate independently coming out of seminary, but because I had developed a catastrophic expectation of God ostracizing me and condemning me to hell, I chose to refute my seminary education and remain immaturely dependent on God.

The goal of therapy would be to raise my level of consciousness so that I would become more aware of the phobic level of psychopathology I inhabited. By raising my consciousness, I would also address the catastrophic expectation that I was using for not embracing my post-seminary theology.

To address my depression, Perls might use an empty chair exercise in both individual and group settings, wherein I might “let the dogs out.” My Top Dog persona would address the Underdog, demanding to know why I had stopped cherishing life and had allowed myself to remain depressed for so long. My Underdog persona might respond by expressing its fear that changing its theology coming out of seminary would jeopardize the immortal soul. Unfortunately, the Underdog would explain, embracing the seminary theology had caused the depression because the newly embraced theology often was in direct conflict with the theology taught throughout his life prior to attending seminary.

This might lead up to an empty chair exercise with God. I might ask God why I felt led by Him to go to seminary, but afterward felt as if the seminary experience had jeopardized my soul. Because I see God as omnipotent, I would also ask why He allowed me to be depressed in the first place. Perls might then put me in God’s seat and have me respond to each question. From this perspective, I would come to understand what my theology truly was and find peace and acceptance from that understanding.

Cognitive therapy

Albert Ellis might interpret my depression as the result of embracing a faith-based or even mystical perception of life. By not following a natural, humanistic tendency to be logical or empirical, my depression has become the result of inner conflict. Ellis might see my activating event as the acceptance of a new theology that is in conflict with a lifelong, prior theology. He may then interpret my belief from that event — that accepting a new theology will condemn my soul — as irrational. This irrational belief could be based in the concept of feeling that I must have the approval of my perceived authority figures, such as my mother or aunts, whom I have designated as maternal figures, or the authority figure of God, whom Ellis might consider mythical. Ellis might suggest that my theology, or belief learned in childhood, is no longer an adequate guide for a post-seminarian adulthood.

The goal of therapy would be to identify my irrational beliefs and dysfunctional attitude and then to modify those traits to a more harmonious union with myself by acknowledging my catastrophized ideals. These ideals include the concept that I will go to hell because I believed something different from what I was taught as a child. I would have to process that flawed perception. This goal for me might be difficult for Ellis because, like many psychotherapists, he may see my entire faith-based philosophy as the dysfunction in my life. Nonetheless, with my faith-based philosophy remaining, the ultimate goal would be to develop a more rational belief in the context of theology.

If Ellis were to work under the perspective of my reality, which revolves around Divine recognition, he might challenge my hopeless perception. Ellis could ask me to explain where it is written in the Bible that I will go to hell for believing in a more loving, and less condemning, God. Furthermore, because of my previous stance that the Bible was inerrant, Ellis may challenge me to find where it is written in the Bible that one has to believe the entire contents of the Bible literally or go to hell for not possessing such a literal belief. In a group setting, Ellis might have me teach what I have learned about my irrational perceptions. In so doing, I might be able to draw out more understanding concerning why I embraced my previous theology in the first place.

My culture of faith-based individuals would be challenged by Ellis’ cognitive behavior therapy (CBT). The humanistic stance that one’s psychopathology can be rectified solely from within, and by oneself, is in direct conflict with the concept of Divine dependency. For CBT (and many other theories of psychotherapy) to be inclusive of such a population, it would need to be modified in a way that suggests a more tolerant perspective. If the varied perspectives of psychotherapy were to express that change can be created within oneself due to the power of the divinely created self, then the spiritual and religious culture would be more accepting of secular therapy.



John A. Wheeler is a former Navy Seal and a doctoral candidate at Mercer University. Contact him at theofrog5326@gmail.com or john.a.wheeler@live.mercer.edu.


The impact of community on postnatal depression

Heather Rudow February 13, 2013

CCU_MeAttendees of next month’s 2013 American Counseling Association Conference & Expo in Cincinnati will be treated to a new series of conference sessions aimed at shedding light on research gathered by ACA members on topics that uniquely benefit clients. 

Called the Client-Focused Research Series, these 30-minute presentations aim to increase awareness of research that focuses on improving the services that professional counselors provide to clients. 

In the weeks leading up to the conference, Counseling Today is speaking with some of the presenters about their research and why they believe it enhances the work of the profession. Next up is counseling student and public health advocate David Jones, who will be presenting on “Advocacy Outside the Box: A Multilevel Spatial Analysis of First-Time Mothers With Postpartum Depression.”

What would you like attendees to take away from your session? 

A greater knowledge of individual and community risk factors associated with postnatal depression (PND). Additionally, they will have an expanded conceptualization and tools for working with their clients and community.

Why is it important for counselors to learn the difference between community and individual risk factors associated with postpartum depression?

From an ecological perspective or other social models, there is a conjugal dance between individual and community risk factors. To effect lasting change, the counselor needs to see within but also beyond the individual risk factors toward the context: community. This context is a powerful influence on the individual’s affect, mood, cognition and behavior. Further, the individual’s choices have collateral. This collateral affects the family, which impacts neighborhood, which influences the community and vice versa.

How did you get involved with this subject?

My career is in public health, but I am also a counseling student. Through my work at Cincinnati Children’s Hospital and Medical Center and my studies emerged a passion around improving the outcomes of children.

Further, counseling and public health have a natural marriage: prevention. Therefore, through the lens of life course theory, the best approach is to intervene before the birth of the child to change the trajectory of lifelong outcomes for the child. Hence, a counselor seeks interventions before womb, secondarily when the child is in the womb and, tertiary, postpartum.

What inspired you to present this session at the conference?

It is a desire to bring about awareness and advancing the field of counseling. I believe that research is imperative for improving the health of our clients and their communities. Furthermore, there is a call for the counseling profession to get more serious about research. By doing so, it will advance our identity as counselors. 

Did anything surprise you as you were compiling information for your session?

The sample was drawn from a home visiting program for first-time mothers. The program contracts with seven agencies within Hamilton County, Ohio, to conduct their services. Each agency provides services in a specific catchment based on ZIP code. What was of particular interest was the severity of these rates and that the majority had rates higher than the national averages [of] 10 to 15 percent. Yet, conversely, the Hamilton County rate was high as well.

When looking at the individual risk factors, several became salient. For example, race and ethnicity were significantly different between those at risk for PND  (EPDS score < 10) than those not at risk. Another risk factor associated with the risk of PND was years of education.

Besides these finding above, what was remarkable was the many risk factors that were not found to be significant. This study linked the home visitation client record data with hospital discharge data, Ohio birth certificate data and 2010 Census tract data. After the linkage, there were over 300 variables associated with each case. Through analysis, no significant association was found for preterm birth and infant loss among others.

When examining the area level (Census tract) variables, it was a surprise that median home value was not significant. Yet, other area level variables did have an association such as percent of vacant housing units, percent on SNAP and GINI Index score.

This is the initial step in our investigation. Our study group plans on digging deeper into the data and looks forward to seeing what we will find.

Who do you feel is the best audience for this session?

This is important for a variety of audiences. One is the counselor who works with this specific population. Others that become prominent are counselors who take prevention and community outreach to heart, such as those who are passionate about social justice. It is relevant for counselors-in-training to expand their conceptualization of their profession. Finally, based on ACA’s call, it is imperative for all counselors [to take part] in a concerted effort to advance the counseling profession’s presence in research.

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.

Q&A with Brandon Ballantyne: From aspiring tornado chaser to counseling teens

Heather Rudow February 7, 2013

OLYMPUS DIGITAL CAMERABrandon Ballantyne, 28, a licensed professional counselor at Reading Hospital in Reading, Pa., has found a way to use his passion for the arts to help his teenage clients. Ballantyne, a member of the American Counseling Association and the Pennsylvania Counseling Association, has been a drummer for more than 15 years. He incorporates music, along with other creative interventions such as art and journaling, to help his adolescent clients express sometimes difficult thoughts, feelings and experiences. The teens with which Ballantyne works are typically admitted into the hospital’s inpatient psychiatric unit after episodes of self-injury, psychosis, suicidal ideation, suicide attempts, aggression or homicidal ideation. Still, Ballantyne believes that utilizing creative interventions is important for every counselor to practice, regardless of the client population. 

Why did you first decide to work with adolescent patients? 

Many people have asked me this question, and I have given most people the same interesting, honest response. Originally, I wanted to become a tornado chaser. However, I took a psychology class in high school and really enjoyed the material and concepts. I decided that the tornado-chasing idea was a little too risky, so I chose to pursue a career in working with teenagers.

Yes, these two career pursuits are very different, but maybe not as different as one would think. While working with adolescents as a counselor, you can encounter various challenges and obstacles to the therapeutic process. The therapeutic process itself is something that has always been very rewarding for me to be a part of. In therapy, we should not “chase” the challenges. And we should not fear the challenges. We should embrace them and be open to them. We should accept them as an important part of the therapeutic process.

If you know what I am talking about, then you can understand why I chose to work with adolescents. I believe that adolescents have an incredible ability to utilize their resilience and potential. As a counselor, I feel that you have the option of working with many aspects of a teen’s individuality, which includes but is not limited to their sense of humor, skills, hobbies, talents, aspirations, family and creativity.

Why did you think that creative interventions would be helpful for them?

Creative interventions are helpful for adolescents because it provides them with a safe, less intimidating outlet to express their thoughts, feelings and self-concept. From my personal experience, creative interventions allow adolescents to access their strengths more effectively in the therapy session. With the combination of art, music, journaling and talk therapy, the adolescent is able to experience various styles of self-expression. They also experience the autonomy of working with a counselor who allows them as an individual to choose which therapeutic outlet is most beneficial.

How long have you been using creative interventions with these patients? What results have you seen?

I have been using a combination of art, music, journaling and talk therapy with adolescents for approximately six years. Most of my work has been done on an acute inpatient psychiatric unit. I have noticed that when art is combined with journaling and cognitive therapy, the adolescents appear more comfortable disclosing thoughts and feelings. It seems as if they perceive support from both the counselor and the protective platform that their artwork creates.

What is a typical session like with your patients?

Initially, I start the session by inviting the patient to complete a drawing. I typically ask my patients to use colored pencils because I feel it gives them more opportunity to add more detail to their picture. For example, I may ask the patient to draw a picture of a volcano. Now, we all know that sometimes a volcano is just a volcano. However, each volcano is different. And each volcano has different characteristics.

Next, I would ask the patient to create a story about [his or her] picture. I would be sure to communicate that the plot of the story is completely up to them. However, it must include their volcano in some way. I also invite them to include a description of their volcano in the story as well.

After the story is complete, we are about 20 to 30 minutes into the session. Next, I invite them to share their picture and story with me. I have found that the stories that adolescents create to go along with their pictures are usually either really creative and intricate, or very brief and concrete. However, as a counselor, I pay most attention to the themes they include in their story as well as the description of their volcano. They might describe their volcano as explosive, or simmering, or quiet, or maybe even violent. The theme of their story might represent similar dynamics. The goal is to invite them to compare the characteristics of their drawing and creative story to themes in their actual life. Maybe their preference to express emotions is similar to the way they imagine their volcano erupting.

I think that if the patient is able to connect their own interpersonal preferences to the characteristics in their creative work, insight can be grown. I believe that once the adolescent discovers insight, they are able to experience more awareness of how situations and relationships in life influence them. I find that, sometimes, this type of insight is hard to grow in a classic talk therapy session.

Adolescents are unique individuals with unique ideas and perceptions. Using a creative intervention such as the one [I] described can provide them with an opportunity to discover new insight into their self-concept. By the end of group, a volcano will not just simply seem like a volcano anymore. I imagine you could facilitate the same intervention using tornadoes.

The specific object that they choose to draw is just as important as the themes and characteristics brought out in the story. This creative intervention is a less intimidating, safe platform that can be used to assess interpersonal themes, coping skills, relationships, self-esteem and more. I think it is important to end the [session] by making connections between their drawing and their real-life situations. This is the point in the session where insight can occur.

I believe that it is also important to offer a homework assignment as well. Inviting the patient to complete homework assignments reinforces a sense of responsibility to themselves and their treatment. For example, I might ask my patients to write a paragraph about what they feel they learned during the session and invite them to share it with me the next day. This also increases the flow of therapy and creates continuity from session to session, thus providing the patient with a fluid, consistent therapeutic experience.

Have you found any interventions to be more effective than others?

I have used art as a single intervention, journaling as a single intervention, talk therapy as a single intervention and music as a single intervention. All of these provide a unique platform for the patient to express thoughts and feelings, as well as build insight. However, it seems that the most progress has been made by using a combination of art, journaling and talk therapy [as part of] one creative activity. I feel that music is a good complementary item to utilize either at the beginning or at the end of the session. I tend to use soft rock/acoustic music to help the patients ground their mood both at the beginning and the end of the session. This is something that can be applied to both group and individual therapy.

What kinds of counselors do you feel would benefit from using these types of interventions?

I believe that all counselors can benefit from creative interventions. My priority as a counselor is to create a safe environment for my patients to express their thoughts and feelings. I feel that music, art, journaling and talk therapy can provide a client-centered environment that reinforces the patient’s autonomy to invest in treatment. I believe that the best progress is made when the patient is able to access their personal strengths, talents and creativity. 

Is there anything else you would like to add?

I believe that at the very root of all adolescents, there is a sense of resiliency that patients can access with the help of creative outlets. I encourage all counselors to consider the use of creative interventions when working with patients who seem to gravitate toward that kind of platform. Creative interventions may not be helpful for all adolescents. However, it is our professional and ethical duty as counselors to take a flexible approach with patients. We have to be willing to explore various styles of counseling and work with the patient to determine which styles are most beneficial. Allow your adolescent to have autonomy and control in your session, while at the same time providing assignments to reinforce accountability. As a counselor, you should not feel like a tornado chaser. Instead, maybe more like a tornado embracer.


Record number of military suicides begs questions about the path forward

Heather Rudow February 1, 2013

8410502197_b2223c9814_zDespite recent efforts from the Department of Defense to stem the rise in military suicides, the number of service members who took their own lives last year appears to have topped the number of troops killed in combat.

Despite the Pentagon’s recent efforts to hire more mental health workers, begin a long-term study of mental health for military personnel and expand the reach of mental health services for service members and their families, there were 349 active-duty suicides in 2012 — a record high.

Art Terrazas, grassroots advocacy coordinator for the American Counseling Association, believes if it were easier for licensed professional counselors to join in the Pentagon’s efforts, then the rising military suicide numbers would have a better chance of decreasing.

“The news is deeply saddening and, at the same time, troubling,” Terrazas says. “Any loss of life is tragic, and that tragedy is compounded when someone falls victim to suicide. What is also troubling is that despite the fact that mental health in the military has gained more attention in the past year and more efforts have been made to address mental health care, we continue to fall short of meeting the goal, which is reducing or eliminating suicides among our service members.”

Last year, ACA conducted an aggressive outreach campaign to various media markets to highlight the fact that the Department of Veterans Affairs fell behind in its efforts to recruit and obtain all available mental health clinicians, specifically licensed professional counselors.

ACA’s Public Policy Department believes the DOD has still not done enough to get military personnel the mental health services they need.

“From our point of view, if you are going to do all that you can to meet the mental health care demands of the troops, then that means you are going to utilize all the tools at your disposal,” Terrazas says. “[The DOD] is not doing that. They are sidelining thousands of counselors from working with our military members because of rules that they have created. The DOD is putting up its own barriers when it comes to recruiting every mental health clinician to combat this very serious problem.”

Terrazas says he hears from counselors across the United States almost every day who are being denied work at VA facilities.

“Many of these counselors are veterans themselves,” he continues. “Counselors have not been given the chance to help combat this problem simply because the government hasn’t allowed them to be part of the solution.”

ACA member David Fenell is one of those counselors who has been on both sides of the fence. As a colonel and behavioral sciences officer with the U.S. Army and Army Reserve, he retired in 2009 after 26 years of service, which included tours in Afghanistan and Iraq. Since then, he has counseled soldiers returning from deployments on how to fit back in with their families at home.

When Fenell first heard the news of the suicide numbers, he says he “felt sad that so many of our warriors were so desperate and in such pain. I was sad that they found no options, other than suicide, to relieve that pain and desperation. We try to prepare our soldiers to be resilient and provide them with tools to face adversity, but that training does not seem to have helped those who took their lives.”

Fenell believes the DOD has a lot of helpful programs for military personal in need. “Unfortunately, these programs were either not accessed by the struggling warriors or were not effective if used,” he says. “I know the DOD is currently reassessing its suicide-prevention strategies.”

Fenell points to a Dec. 24 issue of Army Times, which, he says, “reported that about half the 301 service members who committed suicide in 2011 had accessed a mental health provider or received inpatient care before committing suicide. About a third of these had received services within 90 days of their deaths. Over 50 percent of the service members who committed suicide had no known mental health diagnosis. Over 70 percent were drug- and alcohol-free at the time of their death.”

Part of the problem continues to be stigma, Fenell says.

“Service members may seek help but may not fully disclose the depth of their pain because they don’t want to appear weak,” he says. “Also, military mental health care, because of the intense demand for services, can be sporadic. So a client whose depression deepens may not have an appointment scheduled and may be unwilling to call emergency services.”

Lynn Hall, dean of the College of Social Sciences at the University of Phoenix and author of the book Counseling Military Families: What Mental Health Professionals Need to Know, agrees.

“My thoughts go to what are we not doing for these service members and how can life seem so hopeless [for them],” she says. “We talk about moving beyond the concept of the stigma of seeking help, but doesn’t this indeed suggest that we haven’t done enough to decrease this stigma?”

Hall, a member of ACA, says she has found through her research that three conditions are typically present when a suicide occurs:

  • A weapon is available and the individual has been trained to use it.
  • The individual has experience or some level of comfort with death.
  • The individual has a fear of being a burden on others.

With members of the military, Hall says, the first two conditions are present. “Military are trained to use weapons and have weapons available and, at least for those in combat, have experienced death. Therefore, it is only the third condition that perhaps we have not focused on enough in the mental health world.”

The most common characteristics of military life are change and transition, Hall says, and with any change or transition comes grief and loss. The power of accumulated grief over time to lead to high levels of distress is often not recognized, Hall says. “Every person in a military environment must learn how to make healthy transitions, and perhaps everyone going into the military needs to be assessed for prior loss and unfinished grief.”

The relevant questions then become, Hall says, “Does something in the military experience trigger this fear of being a burden on others? Is this what pushes service members over the edge? Being a burden on their families and/or their communities because of their emotional state or even their physical injuries?” If so, Hall says, “might we not focus on this aspect of ‘healing’ for all in the military, or possibly focus more on preventative measures in military training?”

Terrazas believes utilizing counselors is one of the only ways to reduce the number of suicides in the armed forces.

“Federal agencies have made the decision to place barriers that keep counselors from treating service members, military families and veterans,” Terrazas says. “Even though past congresses and presidents have clearly stated that counselors should be part of the effort to treat invisible wounds of war, there seems to be an effort in several agencies to promulgate rules that keep counselors from working [with] the VA and the DOD. Those rules need to be changed so that we can start getting as many mental health clinicians as we can into this fight. It wouldn’t require an act of Congress, it wouldn’t require a lot of hoops to jump through. All it would take is for the administration to [make] some common sense changes so we can get people the help they need. [Counselors] have not been given a chance to help solve the problem.”

Fenell, too, thinks counselors could play a much greater role in the effort to reduce military suicides.

“Licensed professional counselors are trained to establish effective and continuing therapeutic relationships with their military clients,” he says, “and many suicidal service members need a stable, ongoing, supportive relationship to help get through the darkest periods of their depression. Counselors can effectively provide that type of intervention.”

Additionally, Fenell points again to the Army Times issue which states that the most noted causes of military suicide were broken relationships, workplace problems and financial problems. “Licensed professional counselors can be effective in helping in each of these problem areas,” he says.

Hall says she believes that on a local level, “Every single counselor, social worker, psychologist, even physician, who sees a service member must be screening for suicide ideology. This is not something that should happen only when there is a crisis or major loss, but with everyone. We in the mental health world are perhaps not paying close enough attention to the accumulation of grief/loss issues and assume that if someone ‘looks’ healthy because they are capable of functioning, that they are indeed healthy.”

She also questions whether society has the responsibility of raising boys in a less stereotypical way, teaching them that “being a warrior with all its ingrained messages about being dependable, not needing help, being strong, not being weak or invincible is not the ultimate demonstration of being male. The military is, for some young men, the exaggeration of this stereotype, and we may not have enough up-front assessment of our young people to determine the reasons why someone joins.”

It is ACA’s hope that the suicide rate will go down to zero next year. But unfortunately, Terrazas says, there is no indication that will happen.

“The RAND Corporation told us that in 2009, we lost more service members to suicide than we lost in combat in either Iraq or Afghanistan, and 2012’s numbers are higher than they were in 2009,” Terrazas says. “While there has been a lot of work and a lot of resources have been dedicated towards ending this terrible problem, we as a country are still failing and we as a country need to do more. We just hope that both the Department of Defense and the VA will finally listen to recommendations that ACA has made over the past year so that we can get more counselors where they’re needed. And we hope that we all remember this and remind ourselves that this is part of the true cost of war. This is part of the price that we pay when we activate the members of our armed services, and it’s a cost that we should never forget.”

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.