Tag Archives: Depression

A light in the darkness

By Bethany Bray October 30, 2017

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

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

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

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

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

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

Symptoms and identifiers

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

In the bleak midwinter

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Seeking the light

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

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

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

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

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

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

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

Powering through

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

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

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

 

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To contact the counselors interviewed for this article, email:

 

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

Letters to the editor: ct@counseling.org

 

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

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.’”

 

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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’

 

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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.

 

 

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

 

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.

 

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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.

 

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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.

Letters to the editor: ct@counseling.org

 

Validating the quarter-life crisis

By Lynne Shallcross April 22, 2016

More than a decade ago in the song “Why Georgia,” musician John Mayer put words to a phenomenon that many 20-somethings sense all too well.

“I rent a room and I fill the spaces with/ Wood in places to make it feel like home/ But all I feel’s alone/ It might be a quarter-life crisis/ Or just the stirring in my soul/ Either way I wonder sometimes/ About the outcome/ Of a still verdictless life/ Am I living it right?”

Despite its inclusion in a hit pop song, the quarter-life crisis isn’t always taken seriously by society at large. “Nobody questions the midlife crisis,” points out Cyrus Williams, an associate professor in the Branding-Images_quarter-lifeSchool of Psychology and Counseling at Regent University, but the same isn’t always true of the quarter-life crisis, which Williams defines as a period of significant life and career transitions for young adults between the ages of roughly 22 and 30.

“As a culture, we all think that age 25 is the best stage of your life — these folks are happy, they’re doing everything they want and it’s a great time of life,” says Williams, an American Counseling Association member who has been studying and speaking about the quarter-life crisis for more than five years.

In the counseling session, however, the quarter-life crisis — a developmental time period of potentially high anxiety — needs to be given the same level of respect and attention as the midlife crisis rather than being dismissed out of hand, Williams says. “We really need to acknowledge and not minimize this time period,” he emphasizes.

Decisions, decisions, decisions

In their early 20s, many young adults are graduating from college and find themselves faced with a deluge of life transitions, Williams explains. There are choices and changes swirling around them in almost every major area of life.

They are deciding where to live, whether moving to their own apartment (or a shared living space) in a new city or back into their parents’ home. They want to pursue a career but sometimes find themselves stuck in entry-level jobs that don’t pay their bills or student loans. They wonder whether they should already be in a committed relationship headed toward marriage and a family. They question whether and how they will develop new friendships while hanging on to old ones from their high school or college days.

All of those issues can lead to feelings of anxiety, fear, instability and an existential crisis of “Who am I?” Williams says. “There are too many choices, too many decisions to make, and it’s scary,” he says.

This time in life can also dredge up self-doubt, says Melissa Nelson, a doctoral candidate in counselor education and supervision at Regent University who has been researching the quarter-life crisis with Williams. For example, some young adults might see that a peer has landed a successful job and become financially stable and start wondering why they haven’t been able to follow the same timetable. This can make young adults question themselves, their decisions and their abilities, says Nelson, a member of ACA. “Did I major in the right thing? Is there something wrong with me?”

It isn’t uncommon for clients in their 20s to present in the counseling session with feelings of depression and anxiety, says Katherine Hermann, an assistant professor in the Department of Counselor Education at the University of Louisiana at Lafayette. The idea of leaving a close-knit community, whether the town where someone grew up or the circle of friends an individual developed at college, can be isolating, says Hermann, who has presented on transitions in adulthood. The search for a romantic partner can also feel isolating and provoke anxiety, she points out.

Young adults in this stage may also feel a sense of betrayal, Williams says. Many of these individuals have grown up being told by parents, teachers and others that if they follow the rules and check all the boxes they’re instructed to, life will work out as it is supposed to. When things don’t fall into place that seamlessly, Williams says, these young adults feel lied to.

In such cases, Williams says, it can be helpful if counselors talk through those feelings of betrayal with clients, allowing them to express why things feel unfair and then working together to move forward past those feelings.

All of the anxious feelings that are normally experienced at this time of life can be exacerbated by social media, Williams adds. For instance, on Facebook and Instagram, people tend to post messages and photos documenting only their best experiences, which doesn’t translate to a realistic account of life. “That is one of the things that other generations didn’t have to deal with,” Williams says. “They [didn’t] have to have this in their face every day of ‘Wow, my friend is having a great life and I’m not.’”

Nelson agrees. It is easy for people in this stage of life to get caught up in comparing themselves to peers who post photos or messages related to career success, romantic adventures or starting a family. “What does that mean for an individual who doesn’t have those things yet?” Nelson asks.

One key is for counselors to talk with these clients about how social media rarely shows the day-to-day reality of people’s lives, Williams says. That simple action can help young adults begin to put things in the proper perspective, he adds.

Keep your ‘therapeutic antennae up’

With all those choices and transitions hurtling toward young adults in rapid succession, how can counselors help most? “I wish there was a magic answer,” says Hermann, a member of ACA. Short of that, developing a strong therapeutic relationship is perhaps most important, she says, along with gathering and attempting to understand the perspective of the client as much as possible.

“I think having your therapeutic antennae up is one of the most important things,” says Hermann, who adds that the client’s presenting problem isn’t always the real problem. Get to know these clients and work on the issues they present with, she says, but also be open and attentive to exploring other issues of which they may not even be aware.

Counselors should also know that these clients aren’t afraid to walk through your door, Williams says. “This generation is not like generations in the past,” he explains. “There’s not a stigma involved in mental health issues [with them]. They’ll come in to your office and they’re like, ‘Listen, I’m stressed out, I’m anxious. I need some help.’”

In return, Williams says that he stands ready to help these clients identify what they are experiencing. He specifically uses the term quarter-life crisis with young adult clients because he says it is empowering for them to hear a phrase that defines their experience. “It’s liberating for them,” Williams says. “They’re like, ‘Holy crap. OK. I get it. This is what I’m going through right now.’ So normalizing this is very important.”

Nelson agrees, adding that 20-somethings are reading magazine articles and self-help books on this topic as a way of finding support and normalizing their experience. “If we as counselors and therapists don’t do the same in normalizing this and recognizing this,” Nelson says, “then we’re not providing the comprehensive services that we need [to].”

Even if career counseling is not a counselor’s specialty, being well-versed in career counseling topics is imperative when working with these clients, Nelson says, because career issues are intricately tied to many other areas of life, from identity to finances to relationships. For example, Nelson says, paying for a house or paying for child care is tied to family and partner relationships, but it is also dependent on career decisions. That means that even if a counselor doesn’t specialize in career or academic counseling, it is critical to have a basic understanding of those areas of counseling, she says.

On the flip side, Nelson says, career counselors might have young adult clients come in for help writing résumés, only to discover that their parents are pressuring them to create the “perfect” résumé in order to find the “perfect” job. Or perhaps a counselor working with a couple in premarital counseling might find that one member of the couple is struggling with career and financial worries. Nelson suggests that counselors try to look holistically at everything going on in these clients’ lives.

Williams points out that, of course, not every 20-something is going to experience a full-blown “crisis.” But the potential is there for these various life transitions to lead to crisis if young adults don’t have the coping skills and supports in place to weather changes in a healthy way, he says.

Counselors would be wise to do assessments with these clients at the outset of counseling, Williams says, especially to help determine whether they might be experiencing clinical depression or anxiety. Then, he says, counselors should hear these clients out and try to understand where they’re coming from.

Williams often explores existential questions such as “Who am I?” and “What do I want to do with my life?” with clients in this age group. He also reminds these clients that the answer to what they want to do with their lives doesn’t necessarily have to be related to their jobs; a job can pay the bills without necessarily “satisfying” or defining every aspect of the person. Williams prefers a holistic perspective, asking clients to think about what things in life make them happy, bring them meaning and help them make sense of the world.

No one right approach

When working with clients on quarter-life crisis issues, Williams suggests that practitioners remember to keep the counseling brief. Although these clients tend to be more willing than generations past to seek out counseling, they also generally want a faster route to a solution, not years of sessions, he observes.

“They come to counseling, but they don’t stay in counseling,” Williams says. Brief, solution-focused and existential approaches are often the best alternatives with these clients, he says. At the same time, many young adult clients aren’t afraid of doing work toward arriving at the solution, he adds, so counselors shouldn’t hesitate to suggest books for them to read, questions for them to ponder or other homework for them to do between sessions.

When deciding which interventions to use with these clients, Nelson suggests that counselors familiarize themselves with the literature on evidence-based practices related to life transitions, such as the school-to-work transition or the transition of becoming a family. Because the quarter-life crisis is a newer area of study that hasn’t yet been extensively researched, Nelson says it is hard to pronounce whether one counseling approach would be more effective than another. She believes almost any evidence-based approach can be effective with these clients, although she tends to lean toward existential-based approaches.

Williams came up with an intervention that he calls the “NEEDS” approach. The “N” stands for normalize, which all three counselors interviewed for this article highly recommend trying to do with clients confronting a quarter-life crisis.

The first “E” stands for empower. Williams says counselors can do this by arming these clients with anything from books to YouTube videos that will help them feel less alone and more confident that what they are experiencing is real.

The second “E” stands for taking an existentially focused approach. Williams says this involves helping clients explore who they are, what their calling is and the “why” behind it. For example, if young adult clients are focused on landing a particular job or moving out of their parents’ house, Williams will ask them to examine the “why” behind those desires.

The “D” stands for a developmental approach, in which Williams encourages clients to explore the “long continuum” of their lives, and also the decision-making skills that are required at this time in life. The decisions that 20-somethings make can have consequences that extend into their later years, he points out. For example, some young adults make the decision to run up their credit card debt so they can rush to move out of their parents’ home, while others decide to get married and have children before they are truly ready.

The “S” stands for screening and assessment, which Williams says is a must in determining whether clients are experiencing a normal transition or if their experience has crossed over into crisis mode.

Prevention where possible

Although counselors must be prepared to help 20-somethings who already find themselves in the midst of a quarter-life crisis, Nelson says practitioners should be thinking with a preventive mindset whenever possible. For example, she says, counselors who work with college students can help those students better prepare for what lies ahead by engaging them in exercises to build their self-esteem and raising their awareness of the challenging decisions and transitions that might pop up in the near future.

University counseling centers might be able to offer graduating students continued career counseling services until they land jobs, Nelson says. If such services aren’t feasible, she suggests that college counselors ensure that their clients who are graduating leave the school equipped with referral sources. She encourages college counselors to add website resources for recent graduates “who are feeling the heat of the quarter-life crisis.”

Nelson says counselors must do what they can to arm graduating students with the tools they need before they actually need them. “Getting the information out there and the resources out there before it becomes a problem is really important,” she says.

In preparing to work with clients on issues related to the quarter-life crisis, Nelson says it is crucial for counselors to be aware of changing cultural dynamics. For example, she says, counselors should understand how social media can further complicate life transitions for young adults and how changes in unemployment rates and student loan rates can have “very real implications” during an already frightening time period for 20-somethings.

Counselors who desire to work with young adult clients should read more about this generation, Williams says. Understand what makes them culturally unique, what is significant to them and what has shaped their lives. Among the resources that Williams suggests is the 2001 book Quarterlife Crisis: The Unique Challenges of Life in Your Twenties by Alexandra Robbins and Abby Wilner.

“Cultural shifts of parenting style and expectations are one of the greatest mitigating factors in understanding millennials,” Williams says. “Concepts such as positive reinforcement rather than punishment, or self-esteem building rather than tough love, became popular during the millennials’ formative years. Millennials were revered by parents and sheltered from the world, developing unrealistic expectations of self and never learning skills necessary for survival in the ‘real world.’ Often they have been sheltered so much that they have not been allowed to learn to survive on
their own.”

“In addition to the confounding dynamics such as parental influence, millennials have come to age during a period of significant corporate downsizing, unemployment, underemployment and outsourcing,” Williams continues. “The estimated unemployment rates for young adults are more than double that of overall unemployment rates. As a result, young adults face increased financial stressors, often resulting in an inability to pay student loans, save for retirement or maintain independent living. It is estimated that approximately 44 percent of recent college graduates are currently experiencing underemployment, working in fields and positions in which they are overqualified. Like many other generations, work is a crucial aspect of one’s identity and expression of self. Consequently, when employment aspirations and ideals are not met, crises of personal identity may result.”

Hermann agrees. “Understanding the culture of this population will be important to sustained treatment success,” she says. “I think a systemic perspective is very important, and understanding the individual within [his or her] environment, especially as it pertains to relationships — family of origin, intimate, social, professional — is imperative to treatment.”

Hermann recommends two journals published by ACA divisions to counselors who might be working with this population. One is Adultspan Journal (published by the Association for Adult Development and Aging), which includes topics relevant to young adults. The other is the Journal of Creativity in Mental Health (published by the Association for Creativity in Counseling) “because of the innovative, therapeutic applications that engage and challenge clients to think differently,” she says.

Expert wisdom

To help counselors better prepare to work with clients undergoing a quarter-life crisis, Counseling Today asked these experts to weigh in with their best advice and guidance. Here are their top tips.

  • Don’t minimize the quarter-life crisis, Nelson says. “Far too often, that’s one of the reasons that an individual is there [in counseling] in the first place.” In many cases, parents, peers or co-workers have minimized what these 20-somethings are experiencing, which only ends up increasing the pressure on them, Nelson says.
  • Do focus on wellness, decision-making and the future, Williams says, not pathology.
  • Don’t make assumptions, Hermann says. “Every client has a different past and goals for the future. Focus on the individual,” she says. Although counselors develop models and frameworks to understand patterns, “every person is a unique human,” Hermann reminds her colleagues.
  • Do your research, Nelson says. Become aware of factors outside of your counseling specialty or area of practice that may be affecting young adults. “Awareness is half the battle,” she says.
  • Do make it clear to these clients that this is short-term counseling, Williams says, “because you lose Generation Y if you are going to ask them to come back for 15 sessions. They really need to see the end from the beginning.”
  • Don’t rely solely on clinical intuition, Williams adds. “I love the fact that we are intuitive, but we have instruments and science out there that can help us,” he says.
  • Do consider group therapy. “If you are working in a setting that has the ability to utilize group therapy and group counseling interventions, I would say go for it,” Nelson says. “I think that group counseling can really help that process of normalizing the crisis [and] developing a support network for individuals beyond their counselors.”
  • Do take the time to explore the individual’s relationships, including family relationships, intimate relationships, friendships and work relationships, Hermann says. “This exploration will give counselors an understanding of the individual and also the depth and capacity of [his or her] support group. In addition, so many of the changes that occur during this developmental period are connected to changes in relationships, so having a complete understanding of the relational aspects of an individual can be helpful in understanding and focusing a treatment plan.”
  • Do encourage these clients to address their relationship with their parents, Williams says. It is a relationship that has likely changed now that these young adults are in their 20s, but it is a relationship and an influence that has long been paramount to them, he says.
  • Do normalize the crisis, Nelson says. Point clients toward books or other resources to help them recognize that they are not alone in experiencing these struggles and challenges.
  • Do explore identity development with clients, Hermann says. What is meaningful to them, and how do they create meaning?
  • Do give these clients resources, books to read and homework to do, Williams says. They are typically used to being on the computer and doing research, so they are likely to engage in the homework related to their own counseling, he says.
  • Do ask questions and then address any issues that become apparent from the answers, Nelson says. “Is it stressful to pay your student loans each month? Is it stressful to be pressured by your parents to be married and to have children, and how are you dealing with that?” Nelson suggests asking. “I don’t think that counselors need to be afraid and shy away from addressing the quarter-life crisis.”

 

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To contact the individuals interviewed for this article, email:

 

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Lynne Shallcross, a former associate editor and senior writer at Counseling Today, works for Kaiser Health News as a web producer. Contact her at lshallcross@gmail.com.

Letters to the editor: ct@counseling.org