Tag Archives: Depression

Talk therapy less effective for depression than once thought

By Bethany Bray December 2, 2015

No one – especially professional counselors – would dispute the fact that psychotherapy is an effective way to help people deal with depression. However, a recent study claims that the benefits of traditional “talk therapy” are less effective than once thought.

According to the co-authors of a recent peer-reviewed article in the Public Library of Science’s PLOS ONE journal, the benefits of psychotherapy treatment for depression have been historically overestimated by roughly 25 percent because studies with negative results often go unpublished, thus skewing the data pool.

This same overestimation occurs with data about the effectiveness of antidepressant drugs used in the treatment of depression. This, too, is due to “publication bias,” say the article’s authors, a cohort of professionals in neuroscience and psychology departments at universities in the Netherlands and the United States.

“Our findings indicate that psychological treatment is efficacious and specific, but, as is the case for antidepressants, less than the published literature conveys,” the authors write in the study’s conclusion. “Clinicians, guidelines developers and decision-makers should be aware of [the] overestimated effects of the predominant treatments for major depressive disorder.”

Depression is one of the most common mental illnesses in the United States, affecting more than 6 percent of American adults, according to the National Institutes of Health.




View the full PLOS ONE journal article at bit.ly/1L6N83u





Related reading: See Counseling Today’s August cover story “Treating depression and anxiety





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: facebook.com/CounselingToday

Counseling, football, recovery and triumph

By Bethany Bray September 28, 2015

In a life of ups and downs, football has been a constant for Chris Harris, a 34-year old limited licensed professional counselor (LLPC).

Among the struggles Harris has faced was a battle with severe depression that threatened to derail his life at a young age. Football served as a saving grace for him during some of his darkest periods — times when life didn’t seem worth living.

Chris Harris, LLPC

Chris Harris, LLPC

Harris’ example of how football can change lives for the better was featured in the National Football League’s “Together We Make Football” campaign in 2013. He was one of 10 finalists from across the United States featured in nationally televised video clips on Thanksgiving Day.

In the NFL’s three-minute video, Harris explained how football had been a lifesaver for him, in addition to providing him with an opportunity to become a leader and peer counselor on a newly established club team at Oakland University in Michigan.

When he was younger, “I couldn’t see myself living to even be 20 [years old],” Harris says, citing his struggles with alcohol addiction, depression and fitting in with peers. “Anytime I got really down, football would come knocking. That’s why I love football.”

Harris says football will always be a central part of his life, even though his playing days may be behind him. He graduated from Oakland University this year with a master’s degree in counseling.

Harris wants to build a platform from which he can reach people who are wrestling with some of the issues he has struggled with, including depression, anger, alcoholism, bullying and finding focus and direction in life.

He has established a private practice and hopes to eventually specialize in sports counseling and youth development and mentoring. He would also like to become a public speaker.

“I’ve always had a natural passion for helping people,” he says. “With my personal experience with mental illness and trauma, I know how that impacts people. … I have a passion to be a bridge builder.”

When Harris speaks about the potential for recovery and triumph, it’s personal. Counselors should never underestimate the power of growth and development to change a person’s life, he says.

“Even if a client doesn’t see it in that moment, have the vision of them yourself growing and developing to achieve the life that they want for themselves,” he says. “As a counselor, make sure you maintain that vision of them getting healthy, recovering and achieving the triumph that they would like, because it is possible.”


‘I would have never imagined myself being here’

The 6-foot-5-inch Harris played football as a youngster growing up in Detroit. At age 19, he made the roster of the Motor City Cougars and played semi-professionally for four years.

ChrisHarris_1Playing with the Motor City Cougars pulled him out of a downward spiral he fell into after high school, including a bout of depression, alcohol dependency and grief over the death of his grandfather.

He fell into another dark depression in 2009 when he was six months shy of earning an undergraduate degree in social work at Wayne State University in Detroit.

Although his 2009 mental health crisis was as a breakdown, it also marked a breakthrough for him, Harris says. Since that time, he has been able to rise above his struggles and make a 180-degree turn, he says.

He has completed bachelor’s and master’s degrees at Oakland University, where he also was a leader on the school’s club-level football team.

“At my darkest time, I would have never imagined myself being here,” says Harris, a national certified counselor (NCC). “But guess what? I did the work, I sacrificed, I made the decisions, and it happened. I know it sounds cliché, but if I can do it, anybody can do it.”

Harris is starting a yearlong internship this fall with Michigan College Access Network, an organization that works to boost the percentage of Michigan residents who go to college. The organization places particular focus on students from families with low incomes and students who would be the first in their families to seek postsecondary education. Harris will be working in a local high school, where he will advise students on everything from choosing a college or academic major to applying for financial aid.

James Hansen, a professor and coordinator of the mental health specialization within Oakland University’s counseling department, describes Harris as a bright, warm, accepting and curious person.

“He glows with those qualities, and his clients will certainly benefit from that, as [will] the others in the counseling profession he encounters,” says Hansen, who is a member of the American Counseling Association.

“I admire his courage,” Hansen says of his former student. “His own journey informs his empathy and his ability to be an excellent helper. … He has a sincere desire to help others. I admire what he’s gone through.”


Trust and team building, on and off the field

Much like football, counseling is based on building relationships and trust with those you work with, says Harris. The relational aspect of counseling is what ultimately drew him to the profession, he says.

“[Counseling] has techniques and theories. However, it’s all about the relationship, the therapeutic alliance,” he says. “I feel in my heart that it’s the truth – relational health is central.”

As a counselor, Harris would like to work with athletes – a natural fit with his personal experience and with the profession’s relational approach.

“I understand the mentality of an athlete,” he says. “The same things that make them successful on the field of play can get them in trouble off the field – aggression, being strong, being a leader. It’s difficult for athletes to channel that in the right way. You can’t get rid of it (anger, competitiveness, etc.). It’s what you do when you’re angry that gets these people in trouble. I’d like to use my experience as a platform.”

Athletes are hard-wired to understand the give-and-take, trust and relationships that are part of being a tight-knit team, Harris explains. Counselors can leverage these skills when working with clients who are athletes, he adds.

Athletes will especially understand and respond when given a finite task or job to do, Harris says, because that’s what they’re used to in team sports. For example, athletes are used to having to go home and learn their playbook, he says. In counseling, this could translate to the “homework” assignments that counselors often give to clients, such as journaling or communication exercises.

“In sports, you’re used to a script [or playbook], following directions and doing your job,” Harris says. “If [a counselor] can sit down with an athlete, or anyone, and lay the foundation for the relationship to gain and earn their trust – after that, your counseling skills, the ability to sense patterns, read body language, etc., will benefit.”

“Counselors should listen first. Listen to your client speak about what inspires them, what drives them and what they desire,” he says. “Once you’re comfortable and know the client well enough, then you can begin to engage them from that perspective. Bring their struggle back to their strengths.”





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


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Treating depression and anxiety

By Laurie Meyers July 22, 2015

According to the National Institute of Mental Health (NIMH), approximately 25 percent of U.S. adults struggle with depression, anxiety or some combination of both. In any given year, approximately 6.9 percent of American adults — about 16 million people — live with depression. Approximately 18.1 percent — about 42 million — live with anxiety.

NIMH estimates that an even greater percentage of adolescents ages 12-18 struggle with depression and anxiety — approximately 9.1 percent and 25.1 percent, respectively. The precise Treating-Depressionincidence in children is unclear.

These numbers are staggering but perhaps not as eye-opening as another number. According to NIMH, 50 to 60 percent of those living with anxiety and depression receive no mental health services.

But what about those who do seek help? What works? Which treatments should counselors know about? Counseling Today asked several practitioners to discuss the steps they’re taking to help clients who are engaged in struggles with anxiety and depression.

Letting go 

Beth Patterson, a licensed professional counselor (LPC) with a private practice in Denver, uses an eclectic mix of mindfulness practices, epigenetics and, in some cases, eye-movement desensitization and reprocessing (EMDR) to help clients with depression and anxiety. “I see a mix of depression and anxiety. They’re really closely related. The same brain chemicals are involved,” she says.

Depression and anxiety also share an essential psychological component — namely, pushing people away from living in the present moment. Individuals with anxiety are continuously worried about the future, while people with depression are often focused on what has happened in the past, explains Patterson, a member of the American Counseling Association.

Although she uses the same basic methods to treat both depression and anxiety, Patterson says it is essential to discern what clients are saying to themselves to help them address their negative self-talk. For example, she says that people dealing with depression ask a lot of “why” questions of themselves, such as “Why did I … ?” People struggling with anxiety, on the other hand, tend to use statements indicative of fear of future events, such as “I’m really worried about what’s going to happen with …”

Patterson helps her clients recognize when they’re having negative or anxious thoughts. She also gives them homework, instructing them to focus on noticing their self-talk. Patterson says she also teaches visualization as a tool to “bring them back down to their bodies” and out of the constant cycle of negative thoughts. Clients learn methods such as the “tree meditation,” in which they imagine themselves as a tree that is growing from the ground and sprouting branches. Another technique she uses is to have clients breathe in and out while visualizing that they are drawing breath through their feet. Patterson also meditates with her clients, teaching them to focus on their breathing and center their bodies instead of always living in their heads.

Another mindfulness technique is known as the driving meditation. “When you are in the car, drive,” Patterson tells her clients. “Turn off the radio [and] your cell phone and feel the road. When you get to a stop sign, stop and notice whether you’re driving or making a shopping list.” Over time, Patterson explains, these tools help clients become more aware of their thoughts and recognize when they are ruminating or engaging in negative self-talk. Once clients start recognizing negative thought patterns, they can then use visualization or other mindfulness practices to break the cycle, she says.

Clients often feel ashamed of having anxiety or depression and tell themselves that they must be weak to be susceptible to the condition, Patterson says. One of the ways she helps her clients see the fallacy behind this thinking is by asking them to build a family tree to find out whether depression, anxiety or trauma runs in the family. She talks with them about epigenetics, or chemical changes that alter a person’s genome and affect whether certain genes are expressed. Some researchers believe that life experiences can cause these changes and that the alterations can be passed from generation to generation.

For instance, Patterson says that depression runs in her family. She believes that a great trauma — her grandmother’s flight from the Russian pogroms at the turn of the 20th century — caused a change in DNA that was handed down in the form of depression.

Patterson also probes for trauma in the backgrounds of her clients because she believes it is common in people with depression and anxiety. “There are all kinds of trauma,” she says. “There is large ‘T’ trauma and small traumas.” Sometimes, the accumulation of small traumas can also cause psychological damage, she asserts.

Patterson often sees clients with trauma-related depression. For those cases, she uses EMDR as part of the treatment. She sometimes also uses EMDR for anxious thoughts. Developed by psychologist Francine Shapiro, EMDR uses bilateral stimulation, or stimulation on each side of the body, to help alleviate the emotional distress caused by traumatic memories. The most common method of EMDR uses eye movement, but it can also be performed through physical stimuli, such as buzzers or tapping, explains Patterson, who uses hand-held buzzers with her clients.

Patterson’s overall strategy in treating depression and anxiety is to use self-awareness techniques to help clients escape the thoughts and feelings that are holding them back. After clients learn to recognize their negative self-talk, she says, they can use the other tools she has given them, such as meditation and visualization, to ultimately banish their negative thoughts and the anxiety or depression that accompanies them.

Balancing the brain

Lori Russell-Chapin believes that neurocounseling — which combines traditional counseling with an understanding of how the structure and functions of the brain affect behavior and emotion — can deliver the most effective treatment for depression and anxiety.

In neurocounseling, clients are taught about the brain’s structure and chemical processes and how they influence a person’s emotions, she explains. Clients then learn that they can change some of these processes through neurotherapy.

“Neurotherapy is anything that changes or neuromodulates any of our neurons. That could be counseling, it could be neuro- or biofeedback, or it could be exercise,” says Russell-Chapin, a licensed clinical professional counselor (LCPC) at Chapin and Russell Associates in Peoria, Illinois.

Russell-Chapin, an ACA member, begins counseling with a complete assessment of the client. Because she is probing for neurological and physiological factors, her assessments cover elements such as a client’s medical history all the way back to birth. For example, Russell-Chapin wants to know whether there was any trauma during the client’s birth, such as oxygen deprivation or the use of forceps. These details help reveal potential sources of brain dysregulation, or an unhealthy alteration of the brain’s activity, explains Russell-Chapin, who is also a professor of counselor education at Bradley University in Peoria and co-director of the university’s Center for Collaborative Brain Research. This dysregulation is at the heart of clients’ mental health problems, she asserts.

For instance, she says, depression is related to frontal asymmetry — a condition in which the left frontal lobe, which is associated with positive affect and memory, is underactivated. In cases of anxiety, she adds, the right frontal lobe usually has excessive activity.

This dysregulation shows up in clients’ brain waves and can be treated through neurofeedback, Russell-Chapin says. The process begins with an initial electroencephalogram (EEG), which will reveal where the brain is dysregulated and the corresponding imbalance of brain waves.

Neurofeedback sessions are designed to change specific brain wave activity, Russell-Chapin says. “During the session, an [electroencephalograph] tracks the client’s brain waves. The neurotherapist sets a clinically needed threshold, and when the EEG indicates the desired brain wave activity, the brain is ‘rewarded’ with music or video activity,” she explains. “For example, a client with depression may have an underactivated left frontal area —not enough alpha — and an overactivated right frontal area — too much beta. Over time, the principles of learning win over, with the reward system ‘training’ the client’s brain. The sessions continue until the client’s EEG is consistently showing the desired — or properly regulated — wave activity and the symptoms of depression begin to dissipate.” The process usually takes 20 to 40 sessions, according to Russell-Chapin.

To make neurocounseling more effective, Russell-Chapin usually begins by teaching clients basic biofeedback skills such as controlling their breathing, heart rate and skin temperature. “I think [this] gives people great freedom and power,” she says. “[They think], ‘If I can control this, I can control anything.’”

Russell-Chapin also emphasizes to clients the importance of diet, exercise and sleep because they all have a significant effect on brain regulation.

“I had a client in my office who was drinking eight cups of caffeinated coffee a day. So we’re going to have to withdraw some of that caffeine,” she says. “I had another client who drinks maybe six or seven Cokes a day. Do you know how much sugar is in them?”

Russell-Chapin firmly believes that all counselors should take a similarly holistic approach with their clients. “What I am trying to do in my private practice and teach my students is that we now more than ever need to teach clients this holistic approach and that they can impact their physiology and brain and corresponding behaviors,” she says. “There’s really this underpinning of physiology underneath most of our mental health problems. We can do so much to help with this dysregulation.”

Brain-based psychoeducation 

Humans are hard wired to have negative thoughts, says Vanessa McLean, and that is something she emphasizes to clients with depression and anxiety. McLean, an LPC with The Westwood Group, a group practice in Richmond, Virginia, that offers a wide variety of therapies, has found that teaching people about the physiology of their emotions with intense brain-based psychoeducation can be very effective for treating depression and anxiety. Learning that the tendency to react with fear or sadness is in part biologically driven helps to lessen the shame that often accompanies depression and stress, she says.

“That initial emotional response, we often can’t control, but it’s what we do with it. Do we feed it?” asks McLean, whose areas of specialization include anxiety and mood disorders.

Although anxiety and depression involve overreactions or underreactions in different parts of the brain, McLean doesn’t base her counseling on a diagnosis. “I don’t really treat anxiety or depression — I treat people,” she says. “They [depression and anxiety] are the same kind of feelings, just manifested differently.”

McLean talks to clients about their personal histories and how they have traditionally reacted to and coped with negative emotional responses. She helps them understand that struggling with negative thoughts is normal, but they can learn to reinterpret or not dwell on these emotions.

“A lot of times, people spend all day living in their heads,” McLean observes. She urges clients who might be struggling with depression or anxiety to distract themselves with exercise and other activities that they find enjoyable or that give them a sense of meaning and purpose.

She also talks to clients — particularly those with anxiety — about how the body and brain can create a kind of tension loop. “If the body is tense, the brain thinks something is wrong,” McLean explains. “A lot of people with anxiety don’t know what it feels like to be relaxed.”

To short-circuit this loop, she teaches clients deep breathing techniques and progressive muscle relaxation. She also asks them about other activities that have helped calm them in the past.

When clients are open to it, McLean may also discuss spirituality with them and get them to talk about what gives them meaning and purpose. As one element of her practitioner profile, McLean identifies herself as a Christian counselor, so sometimes people seek her out because of that. However, she doesn’t limit herself to clients of a particular religion. She believes that everyone is a spiritual being in one way or another, and she helps clients explore their beliefs — whatever they may be — to impart a sense of hope.

Something that McLean doesn’t embrace is the medical model — the view that mental health issues are illnesses. She believes that calling depression or anxiety an illness encourages people to think that they can’t do anything about their symptoms.

Lisa Jackson-Cherry has a counseling practice in a medical setting — the Chester Regional Medical Center in Chester, Maryland — and often receives referrals from physicians. She doesn’t reject the concept of mental health problems as illnesses, but she believes that psychotropic drugs are rarely the answer to treating those issues.

“I believe that the majority of individuals can overcome their anxiety and depression with counseling,” says Jackson-Cherry, an LCPC and a member of ACA. “I have found people want a quick fix [through medication] because they do not want to feel the uncomfortable feelings.”

Although the process may take longer, Jackson-Cherry thinks that the tools clients acquire through counseling will bring longer lasting relief and will also help individuals cope should symptoms of depression or anxiety later resurface.

Although she often uses cognitive strategies to help clients, Jackson-Cherry, who is also an associate professor of psychology at Marymount University in Arlington, Virginia, doesn’t use a predetermined script. She believes that depression and anxiety are inextricably linked to a client’s life experiences.

“My experience is that anxiety and depression often interfere with life goals, sense of purpose and meaning issues,” Jackson-Cherry says. “I believe many individuals have irrational beliefs or cognitive distortions. However, some of those ineffective cognitions are so enmeshed into their lives [that] listening to their … struggles and stories is an important aspect [of treatment].”

Talking to clients about their experiences helps Jackson-Cherry to individualize their therapy, she says. For example, talking about the root of a client’s anxiety may reveal that it comes from not feeling protected or safe in the wake of a sexual assault, she explains. In that case, Jackson-Cherry might use not just cognitive therapies but also behavioral therapy, such as talking about how the client can feel safer and more in control.

The gender gap

Research has shown that women are two to three times more likely than men to experience depression. Approximately 1 out of every 5 women in the United States will experience depression at some point in her lifetime. This is largely, though not entirely, due to hormonal factors, according to ACA member Laura Hensley Choate, an associate professor at Louisiana State University in Baton Rouge. She adds that this stark gender gap does not appear until puberty and then disappears after menopause.

“There are no gender differences between boys and girls until about age 12,” she explains. “Then, at the onset of puberty, it [depression] spikes in girls. Puberty is a particularly vulnerable time.”

In fact, between the ages of 12 and 15, the depression rate in girls triples, growing from about 5 percent to 15 percent of all girls, says Choate, who has written extensively about girls’ and women’s mental health, including two books published by ACA (Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions and Eating Disorders and Obesity: A Counselor’s Guide to Prevention and Treatment). This rapid increase in depression incidence is related not only to a surge in hormones but also to factors that accompany the onset of puberty, she explains.

“Girls are more likely to experience multiple stressors at once,” Choate continues. “They’re going through puberty, they’re changing schools [going from elementary to middle school], they’re having to deal with romantic relationships … so everything’s hitting them all at once.”

Girls who go through puberty early are at even greater risk for depression, Choate says, in part because their emerging physical maturity often pushes them into situations that they are not emotionally ready to handle, such as older boys becoming interested in them sexually. These girls may also find themselves pulled in socially by older students and encouraged to experiment with drugs and alcohol, which further sets them up for depression, she explains.

Boys, on the other hand, go through puberty about three years later, which gives them time to become settled in school and adjust to the challenges of adolescence, Choate says. In essence, they have more life experience before they face the hormonal surge of puberty.

Another factor in the early gender gap with depression is that girls place more importance on relationships than boys do, Choate notes. “That’s another big issue [as puberty hits],” she says. “They’re more sensitive to disruptions in their relationships, like fights with friends or fights with romantic partners.”

And then there is the monthly hormonal shift that girls and women face with their menstrual period, Choate points out. Counselors should be aware that not only can PMS exacerbate depression symptoms, but in some cases, she continues, what looks like major depression may actually be premenstrual dysphoric disorder (PMDD), a condition that was added to the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders.

If depressive symptoms seem to appear for only part of the month, a counselor should screen for PMDD by helping the client track her moods over time, Choate says. If PMDD is present, making dietary changes such as decreasing alcohol, fat, salt and caffeine and increasing complex carbohydrates may help. If antidepressants are needed, they may be necessary for only part of the month, Choate notes. Counselors can also help clients evaluate their options for lessening the symptoms of PMDD. For example, if a client decides she wants to consult her gynecologist or primary care physician, the counselor can help her come up with questions to ask to be fully informed about her options, Choate says.

It is also important for counselors to encourage female clients to focus on self-care during their symptomatic days, she emphasizes. Women need to be told that it is OK to slow down, plan a less hectic schedule and take care of themselves when they are feeling bad. “We know through CBT [cognitive behavior therapy] that just decreasing [self-] expectations can help,” Choate says.

In fact, CBT is often regarded as the “go-to” treatment for depression by mental health professionals, but counselors should also consider interpersonal psychotherapy (IPT), especially if CBT doesn’t work, Choate says.

IPT can be very effective for women and, in particular, girls, Choate asserts. “It works not just on depression but also on social skills, building up relationships and self-esteem,” she says.

IPT assumes that regardless of depression’s cause, it is intertwined with personal relationships, Choate explains. In IPT, counselors start by taking an interpersonal inventory of the client’s life: Whom can she count on? Who supports her emotionally? Is she dealing with any relationship issues, including unresolved grief?

Role transitions, such as from childhood to adolescence or the transition into motherhood, are also important because they raise questions about loss, Choate says. For example, when she becomes a mother, a woman is gaining a child, but she may also question what she is losing, such as a degree of personal freedom. The uncertainty that accompanies transitions can trigger depression.

Because women are more likely to view relationships as central to their emotional well-being, supportive interpersonal relationships can help them cope with the emotional aspects of transitions. Conversely, interpersonal conflict may exacerbate feelings of anxiety or depression, Choate explains. Therefore, identifying negative and positive interpersonal factors in a woman’s life can be essential to treating depression, she says.

Pregnancy and depression

The childbearing years are also a prime time for depression in women, Choate says. Part of that involves issues such as deciding whether to become a mother or becoming a mother and learning to juggle family, work and life.

However, pregnancy itself poses a depression risk that counselors may not be aware of, Choate cautions. Postpartum depression has become a familiar concept, but women can also become depressed during pregnancy, she explains. Women who have a history of depression are at very high risk for developing pregnancy-related depression. But prepartum depression can mimic normal pregnancy symptoms such as fatigue, loss of appetite and not wanting to participate in previously pleasurable activities, Choate explains. To help distinguish between normal pregnancy symptoms and depression, Choate advises counselors to ask their clients who are pregnant whether they would want to go out and do what they used to do if their physical symptoms such as nausea and fatigue disappeared. Most pregnant women would say yes, but those who are depressed would generally answer no, she explains.

Depression during pregnancy — whether it is preexisting or prepartum — can also raise the particularly difficult question of whether to take antidepressants, she says. The answer is not simple. Untreated depression is bad for the mother, and research indicates that once the child is born, a mother’s state of mind can have a significant impact on the child.

But the other side of the argument is also valid. “In the past, doctors have prescribed [antidepressants] without considering the risk, and the research really is mixed,” Choate says. “So counselors can help [pregnant clients] weigh the risks of untreated depression versus an antidepressant. … This is an emotionally charged issue, so counselors need to help the client and also check their own biases.”

Although not conclusive, some research has indicated that antidepressants are associated with low birth weight, preterm delivery and pulmonary hypertension in newborns. Antidepressants may also be associated with spontaneous abortions and preeclampsia. However, many of these complications have also been associated with depression itself.

After the child is born, a mother experiencing depression will have to make another related decision: whether to take antidepressants and nurse, to nurse without taking antidepressants or to continue drug therapy and rely on formula to feed the child. Again, says Choate, the research on the implications of these choices is mixed.

There is also significant medical and social pressure for mothers to breastfeed, so female clients who are dealing with depression will need support gathering and considering all the variables to make a decision. Counselors can play a valuable role in helping clients formulate the right questions, Choate says.

As women leave their childbearing years behind, they also face increased risk of depression. “Women are more vulnerable to depression during the years leading up to menopause,” Choate says.

Then there are the issues that women face related to aging in today’s society, she continues. Women are valued for their youth, beauty and fertility, and as they grow older and no longer reproduce, they lose societal status, Choate says. These changes are especially difficult if a woman’s self-identity is closely tied to her looks, she says.

So, Choate concludes, although hormonal factors are certainly a contributing factor, counselors should be aware of all the sociocultural influences that make women and girls more vulnerable to depression.



To contact the individuals interviewed for this article, email:




Additional guidance 

The American Mental Health Counselors Association, a division of the American Counseling Association, was chartered in 1978. It represents mental health counselors and advocates for client access to quality services within the health care industry. Visit its website at amhca.org.

For more information on treating depression and anxiety, counselors can also access the following webinars and podcasts on the ACA website:

Webinars (counseling.org/continuing-education/webinars)

  • Depression: New and Emerging Treatment Strategies
  • Neuroscience: The Cutting Edge of Counseling’s Future

Podcasts (counseling.org/knowledge-center/podcasts)

  • Assessing and Treating Perinatal Mood and Anxiety Disorders
  • Suicide Assessment: Sharpen Your Clinical Skills




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

Letters to the editor: ct@counseling.org

The Hope Chest: Unpacking the hurt

By Kim Johancen-Walt August 19, 2014

When I first met Ally, 17, she surveyed the seating arrangement in my office and chose the chair closest to my door. Obviously guarded, she sat with both arms and legs crossed looking at me with green eyes slightly camouflaged by blond wispy bangs. Ally’s mother had been trying to get box_unpackingher to come to therapy in recent months because of Ally’s deepening depression. Her mother believed Ally’s depression was due to an abortion Ally had had several months prior to our first meeting. The mother had only insisted on therapy after reading a journal entry in which Ally had made it clear she was thinking about suicide.

As I began to ask Ally some questions during our initial visit, she stated that she did not need therapy and expressed anger at her mother for forcing her to come to my office. Although Ally knew I was aware of the journal entry and the abortion, I honored her resistance by staying in shallow waters, asking only about things such as hobbies, school and friends. I purposefully avoided the topic of loss. At first she answered questions but became increasingly quiet and then stopped talking all together. Counselors working with teens dread these moments, wondering how we will get through the hour when our young clients refuse to talk to us despite our best efforts to connect, create safety and begin the therapeutic process.

By the time many kids get to my office, they have come to believe that most of the adults in their lives cannot help them. They feel misunderstood, sometimes blamed, and tend to find their own emotion overshadowed by the emotion of others. They are also desperate for relief. I strive to educate these kids about the connections between unresolved grief, loss and suicidal behavior, about how therapy can help them manage pain differently and how to cultivate hope and resiliency along the way.

Sitting in silence, I explained to Ally that I actually did not need to know much about her to know that she was in incredible pain due to her suicidal thoughts. I told her that I knew I was looking at the tip of a very large iceberg. It is important to communicate to kids our knowledge of what may fuel suicide, that we take it seriously but are comfortable talking about it, and that we do not judge them for their thoughts and actions. I told Ally I knew she was doing the best she could to take care of herself as she dealt with unbearable pain.

Not believing that they can (or should) seek support and care from others, many kids come to believe that they must be fully self-reliant. Otherwise, they think they will risk more injury to themselves or become even more burdensome to those around them. Add to this the developmental (and oftentimes skewed) belief about the need to seek independence, and many teens retreat completely into themselves. Affected deeply by the things that happen in their lives, these teens believe they are mainly (if not solely) responsible for their losses, their pain and their inability to cope. Rather than asking for help, many of these teens become increasingly desperate as they find themselves drowning, with little or no ability to swim to the surface.


The overflow

When working with suicidal teens, I have found it useful to tell them about the invisible box that we each carry. It is a place where we store the painful events or losses in our lives, packaging them tightly to avoid the feelings associated with those events. Although this process of stuffing may work for a while, over time our boxes can begin to fill up, leaving us little room or tolerance for added stressors. I remember vividly the reaction of one of my 16-year-old male clients who, after I explained the box metaphor, stated, “If that is true, then I have a field of boxes buried in the ground.”

Once full, we find ourselves frantically trying to keep the lid on the box tightly sealed. But regardless of how hard we try, it is at this point of distress that painful content may begin to leak over the sides. When there is no room left in the box, many teens find themselves spilling over into what I term the “Overflow.” Desperate, they may turn to self-injury, substance abuse or suicidal behavior. After using this metaphor to explain the connections between my clients’ feelings and behaviors, most begin to understand the importance of making room so they can stay out of the Overflow. They become primed for therapy and ready to cautiously explore methods of healing and more effective ways of coping.

Although the unpacking is necessary, it is also a tender process. After a few sessions spent building both trust and safety, Ally started discussing the details of the abrupt and painful breakup with her boyfriend that occurred soon after her pregnancy. She cried quietly as she talked about his cruelty, along with how her mother had also abandoned her, “forcing” her to have an abortion and telling her she was irresponsible and an embarrassment to the family.

Ally believed she was fully to blame for the pregnancy, for having disappointed her parents through her reckless behavior and for her boyfriend leaving. Furthermore, she believed that her inability to cope and “just get over it” were signs of a flawed character. She believed she was weak and selfish for having aborted her baby. She continued talking about what happened, looking into the deep well of grief over having lost a child.

Throughout her process, I seized every opportunity to listen, understand and treat her with love and compassion. We discussed how her coping was outstripped trying to deal with complicated grief and that her suicidal feelings were the result of what had happened. In other words, I told her that her depression and increasing suicidal thoughts made sense.

Many of my clients have dealt with multiple losses and are unaware that each new wound can awaken others that are tucked away in dark corners. Overwhelmed with grief, most of these clients do not realize that the only way to make room is to unpack their losses one by one. And, sometimes, one explosion can be followed by several other mini blasts. For example, if our clients are not met with love, support or compassion after the initial bomb goes off, then their injuries can deepen, their framework distorted by multiple losses. They come to expect loss, perhaps blaming themselves and losing hope. Ally not only lost her child, but she also felt abandoned by some of the most important people in her life. She couldn’t stop the bleeding despite her best efforts to avoid stepping on additional land mines.


Handle contents with care

When I discuss the box metaphor with teens, I assure them that they are in charge of what content they choose to remove. Not wanting these young clients to feel further overwhelmed, it gift1is critical to move forward at a gentle pace and to focus on the importance of making room rather than what is actually emptied. After explaining the therapeutic process in this way, many kids naturally begin looking at what is taking up the most space in their containers, knowing that the bigger objects are what contribute to their inability to handle added stressors.

We do not want our clients to empty everything at once, and each container must be handled with care. I want kids to know they are in control of their therapy, but I also want them to be aware that the unpacking is necessary if they are going to make room, build tolerance and effectively stay out of the Overflow. Throughout therapy, we assess safety and coping constantly, knowing that without careful attention to the process, speed and wounds touched, we may inadvertently push our young clients closer to the edge rather than away from it. We find ourselves dipping in and out of raw material.

Through our conversations, Ally slowly began building confidence in her ability to handle painful feelings. Gradually, we were ready to invite her mother into session to discuss what had happened. Both women cried together as Ally’s mother discussed feeling deep remorse for how she had handled the situation and for not considering Ally’s feelings surrounding the abortion. Through her own accountability, Ally’s mother opened the door to begin repairing the cherished relationship between mother and daughter. And in addition to cultivating compassion for herself, Ally was able to begin finding compassion for her mother. She came to realize that her mother had also done the best she could at the time and acted in what she believed to be the best interests of her daughter.

Through therapy, we help our young clients to uncover new pathways that were previously out of their view. We celebrate their victories and watch them gain confidence not only in their ability to cope but also in their ability to heal. And as we end therapy, we remain aware that they may have more work to do. Whether they collect new losses over time or whether older losses begin to reemerge, we know that future excavation may be needed — although that process may not happen with us.

We have done our job if we have given our young clients a new framework to work through the inevitable human experience of grief and loss, if we have taught them the importance of seeking help from caring others and if we have helped them learn how to effectively stay out of the Overflow. Through our work, these teens leave therapy with a new definition of healthy independence rather than one that finds them overwhelmed and in dependence. Through our connections with caring others, we are reminded that even in times when things are not OK, we will be OK.





Kim Johancen-Walt writes “The Hope Chest” column exclusively for CT Online. She is a licensed professional counselor with almost 20 years of experience. Her clinical experience includes working as a therapist for La Plata County Human Services, where she helped develop a treatment model for adolescents in Durango, Colorado. She has presented her clinical work at mental health conferences nationally, including at the annual conference for the International Society for the Study of Self-Injury. Additional clinical experience includes a position as assistant training director and senior counselor in the Counseling Department at Fort Lewis College. She currently operates a full-time private practice in Durango. Contact her at johancenwaltks@gmail.com.


Read her previous column, “The Hope Chest: The GIFT of therapy,” here:  ct.counseling.org/2014/06/the-hope-chest-the-gift-of-therapy

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