From his experience, Hazler believes a counselor’s best route is to follow his or her own preferred clinical approach. “If you are a good counselor and you have a solid theoretical viewpoint and it works consistently, that’s what you should be doing,” Hazler says. “All the research shows that the core relationship and counseling skills have the greatest impact on client outcomes, and those skills are used across all major counseling theories. We have counseling theories — plural — because no one theory has proven to be perfect or uniformly better than others. The combination that seems most important is a counselor with basic skills and a sound belief in and ability to implement a theory that will do the best job.”
Walker deems her theoretical orientation a bit “eclectic,” combining rational emotive behavior therapy and solution-focused therapy with mindfulness and awareness, and that is the treatment path she follows with clients struggling with depression as well. Walker says her goal with these clients is to help them live more authentically rather than always striving to be what others expect them to be.
“I work with clients to help them uncover their true potential and to [live] life more assertively, meaningfully and adaptively, and to do so mindfully with awareness,” Walker says. “I try to help them make sense and find meaning out of what may feel [like] insurmountable circumstances or traumatic events they have had to endure. While we can’t change difficult situations of the past, we can work to better understand and resolve challenges in our life by realizing our true potential to be our own change agent. By applying complementary therapy approaches and techniques, I work with clients to unearth long-standing behavior patterns or negative perceptions that may be holding them back from experiencing a more fulfilling and meaningful life. I believe as counselors, we need to help our clients identify areas where they feel stuck, establish reasonable and attainable goals, break [from] feeling victimized by their circumstances, and feel more empowered and be more adaptive and resilient in their lives.”
In certain cases, these counselors say, medication can aid clients in rebounding from depression. “Medication is mostly used to ease the depressive thoughts and feelings so that the client can more appropriately consider cognitions and take actions that will be productive,” Hazler says.
Walker thinks an antidepressant may be an important adjunct to therapy for some clients. That’s especially true, she says, in cases in which clients are dealing with pervasive depressive symptoms, have a family or personal history of depression, have a history of suicide ideation or attempts, or have a serious medical condition, chronic pain or disability. “However,” Walker says, “I do not necessarily see medications as being the end-all-be-all and believe that a whole-body approach will provide greater efficacy in the treatment of depression. I frequently encourage clients to schedule an appointment with their general practitioner or internist for a full physical and blood work to determine if an underlying medical condition may be contributing to their depression.”
In addition to the chosen counseling approach and possible medications, Walker says wellness is a key ingredient in fighting depression. “[I] have found that when clients engage in a good self-care program, which includes better nutrition, a regular moderate exercise program and keeping a consistent and reasonable sleep-wake cycle, they often report that the intensity, frequency or duration of their [depression] symptoms diminishes,” she says. “I also believe it is important that clients engage in meaningful and productive activity and daily responsibilities, be fully present and engaged in relationships with important others, and participate in leisure activities and recreation to help mitigate their depressive symptoms.”
“Wellness comes apart during depression,” Hazler says, adding that many people experiencing depression tend to decrease healthy life habits such as good eating, exercise, spirituality and sociability. “Not only does not doing these things change body chemistry, [but] the person also knows they’re not doing them, and they feel bad about it,” which can further deepen the depression, he says.
Encouraging wellness is one piece of a holistic approach to helping clients combat depression, Hazler says. “In action, [a holistic approach] means that you deal with the client’s cognitions, work with their actions/behaviors and consider all aspects of the client’s environment, culture [and] the various aspects of wellness,” he says. “Depression is not one-dimensional. It impacts and is impacted by all aspects of the client’s genetics [and] environment and all the aspects of a wellness model that support a healthy life and lifestyle.”
When it comes to diagnosing depression, says Carlos Zalaquett, professor and coordinator of the clinical mental health counseling program at the University of South Florida, adolescents and older adults are often the most “invisible” populations. Why? With adolescents, symptoms of depression are frequently chalked up to teenage moodiness, while among older adults, the symptoms are often mistaken as a normal part of aging, says Zalaquett, a member of ACA who has conducted research on depression in both groups.
Especially troubling when it comes to depression being overlooked in these two groups — by doctors, by mental health professionals, by loved ones and even by the clients themselves — is that both populations are known to be at high risk for depression, Zalaquett says. According to the National Alliance on Mental Illness, depression affects more than 6.5 million adults age 65 and older in the United States, or more than 18 percent of that population. Information from the National Institute of Mental Health (NIMH) indicates that about 11 percent of adolescents have a depressive disorder by age 18.
Zalaquett, who has trained school counselors throughout Florida on how to separate adolescent moodiness from depression, says counselors need to stay alert for signals that a teenager might be depressed. These signals can include attendance issues, behavior problems, academic problems, inability to concentrate, irritability, withdrawing from classmates and friends, and any expressions of suicide or death wishes. Most adolescents won’t show these symptoms for an extended period of time, but if they do, Zalaquett says, counselors need to get involved or make a referral.
According to NIMH, adolescent girls are even more likely than boys to experience depression. Laura Choate, associate professor of counselor education at Louisiana State University, says major depressive disorder is rising among adolescent girls, perhaps because they are reaching puberty earlier than in the past, are facing life stressors earlier and are less prepared to manage those stressors and pressures. Between the ages of 12 and 15, rates of depression among girls triple, according to Choate. By age 18, she says, 1 in 5 girls will have experienced an episode of major depression, and 1 in 10 will have had at least one suicide attempt.
Adolescent girls are under more pressure today than in the past, says Choate, author of the book Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions, published by ACA. Not only are their bodies growing and their hormones changing, but they are also facing pressure to achieve academically and socially and to measure up to often-unattainable ideals fostered in the popular media. Choate says adolescent girls also soak up a message perpetuated by society that they should succeed and be competitive, while simultaneously receiving another message that they should be kind, take care of others and show compassion. So, Choate says, these girls may worry about their friends’ feelings even as they try to compete against them in athletics or academics, for instance.
Girls also are prone to excessive empathy, Choate says. “If their friend is going through a hard time, they allow the friend’s problem to affect them, and they feel it [too],” she says. “That can put them at risk for depression.”
Another factor is that girls are more likely to engage in corumination, repeatedly obsessing over problems verbally with their friends, Choate says. “Yet they’re less likely than boys to problem solve and take action,” she says. “Instead, they just ruminate and talk about the problem, and this process contributes to depression.”
Although most adolescent girls will experience a depressed mood from time to time, Choate points out that the criteria for major depression as set forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM) include having at least five of the nine following symptoms that persist for two weeks or more: depressed mood, loss of interest or pleasure in usual activities, appetite disturbance (decrease or increase), sleep disturbance (insomnia or hypersomnia), psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, concentration problems or indecisiveness, and suicidal ideation or gestures. These symptoms must represent a change from previous functioning in the adolescent, Choate says, and must produce impairment in relationships or in the performance of typical activities.
Choate says cognitive behavior therapy (CBT) is the theoretical approach for depressed adolescent girls that is most effective and most highly recommended by research. “It really addresses girls’ negative core beliefs about themselves, negative core beliefs about others and negative beliefs about the future that things will never be better,” she says. CBT techniques also address coping skills and problem-solving skills. Choate particularly recommends that counselors check into what she calls the most studied program for adolescent depression — Coping With Depression-Adolescents. Its manual and more information about the approach are available online, she says.
In discussing the possible role of medication in treating depression, Choate points to the Treatment for Adolescents With Depression Study (TADS), a randomized, controlled clinical trial that evaluated the effectiveness of CBT on its own, the medication fluoxetine on its own and therapy involving a combination of both CBT and fluoxetine. In a 36-week study, Choate says adolescents treated with CBT plus medication had the greatest recovery rates. “The TADS researchers reported that combination treatment reached maximum benefit at Week 18 with a response rate of 85 percent,” she says.
When fluoxetine alone and CBT alone were compared, Choate says the medication produced symptom reduction more quickly, but adolescents who received only medication were twice as likely to report suicide ideation. “This concerning finding led researchers to conclude that clinicians may want to begin treatment with CBT alone to avoid risk of antidepressant-induced suicidality and only [add] medication to the treatment regimen if the response to CBT is inadequate,” Choate says. “By starting treatment with CBT, there is no increased risk for suicidality, and adding CBT to medication helps protect from suicidality because it helps the client learn skills for managing stressful events, family conflicts and negative affect.”
In making treatment decisions regarding depression with adolescent clients, Choate suggests that counselors consult with appropriate medical professionals and consider the recommendations provided by the American Academy of Child and Adolescent Psychiatry Practice Guidelines for Child and Adolescent Depression.
Early intervention needs to be a primary focus for counselors, Choate says, especially because providing girls with the skills to prevent the onset of depression during adolescence can protect them from many of the negative outcomes associated with battling depression throughout their lifetime. Among important areas of training for girls are emotional literacy and regulation, stress reduction, social skills, problem solving, cognitive skills, building positive support systems, participation in pleasant events, awareness of mental health issues and knowledge of how to access services, Choate says.
Among the other recommendations Choate provides for working with adolescent girls who are dealing with depression:
- “Take the depressive symptoms seriously,” she says. “Don’t buy into the stereotype that adolescent girls are just moody and that symptoms should be dismissed as typical teenage behavior if the depressive symptoms are persistent.”
- Regardless of the theoretical approach taken, address the adolescent girl’s relationships with significant others in her life, including family, peers and romantic partners.
- Assess her level of activity online. “While most girls report that social networking and texting help them feel closer to their friends, they also report that it can cause them to feel jealous, depressed or sad when others do not respond to their communication in the way they expected,” Choate says.
- Include her family in treatment. “At this age, she is embedded in her family system,” Choate says. “Family communication, her role in the family and overall family functioning should be addressed in treatment.”
- Check out prevention programs such as the Penn Resiliency Program, which is an evidence-based program for the prevention of depression in adolescents ages 10-14.
‘Depression is not mandatory’
On the other end of the human development continuum, older adults’ depression symptoms are often passed off as something to be expected as people age, Zalaquett says. “As a society, we value youth, vigor, enterprise and agency, among other characteristics,” he says. “Therefore, the declines in mobility and perceptual skills, as well as in intellectual speed, plus health issues, emptying of the nest and loss of relationships due to death, make observers feel that older adults are unhappy and that later years are depressive years. Moreover, many professionals and nonprofessionals view depression as a condition naturally associated with older age. This is not true, and depression is not mandatory for older age.” As with all other groups of people, Zalaquett says, the diagnosis of major depressive disorder among older adults is determined by classification tools such as the DSM and the International Classification of Diseases.
Although depression should not be viewed as a “normal” condition among older adults, Gintner acknowledges a number of life stressors that often accompany aging can contribute to its onset. For example, he says, older adults are often dealing with medical issues, the loss of loved ones and social support, potential cognitive impairment and life transitions such as retirement.
Gintner says it is also important to point out that undiagnosed and untreated depression can have serious consequences for older adults, including potentially complicating any medical issue and even predicting a shorter life. However, studies have shown that psychotherapy is very effective at treating major depression among older adults, he says.
What is tricky, Gintner says, is separating some of the typical physical problems and symptoms of aging from the symptoms of depression, because they often can mimic each other. For example, he says, adults might automatically attribute forgetfulness, fatigue, loss of interest in activities or loss of appetite to aging. But in fact, those are also symptoms of depression.
In diagnosing depression among older adults, Gintner says counselors must pay close attention and screen carefully. Many older adults grew up in a time when psychiatric symptoms were minimized and hidden, especially if you were a man, Gintner says, so they might remain hesitant to discuss those issues today. Counselors should also be aware of how depressive symptoms might vary at different ages, he says. For instance, among older adults, depression is more likely to be indicated by a loss of interest in certain activities rather than by significant depressed mood.
Gintner says cognitive therapy, behavior therapy and interpersonal therapy each have been shown effective in treating depression in older adults. Cognitive therapy looks at the older adult’s dysfunctional thoughts and beliefs; behavior therapy might aim to increase the frequency of a client’s pleasant events while decreasing the frequency of negative events; and interpersonal therapy would examine how a client’s interpersonal relationships affect his or her mood, Gintner explains.
Medication is also an option for treating depression among older adults, Gintner says, although it is often used more with adults whose depression is in the moderate to severe range rather than in the mild to moderate range. Choosing to add medication to the treatment regime is a matter of preference for clients, Gintner says, and counselors should respect whatever the client’s preferences are.
Whoever prescribes the medication should also be aware of the differences between older and younger adults in terms of the side effects a medication might have, Gintner says. And, of course, antidepressants might also affect or interact with other medications that older clients are already taking. “Counselors need to be aware of the benefits of medication for the elderly but also [be aware of] potential risks so that they can advocate for their clients if they need to,” Gintner says. The obvious benefit of psychotherapy, he adds, is that it has no medical side effects.
Building on client strengths and focusing on wellness are other keys when working with older adults, Zalaquett says. He suggests that counselors talk with clients about healthy eating, age-appropriate exercise, improvement of cognitive skills, maintenance or re-establishment of social and family relationships, and how to find meaning in life.
Gintner recommends that counselors interested in working with older adults on the topic of depression check out their area Council on Aging, make contacts with nursing homes and develop relationships with physicians known to work in gerontology.
Depression during pregnancy
Prenatal women may be considered yet another partially invisible population as it concerns depression. Choate, who co-authored an article on prenatal depression with Gintner for ACA’s Journal of Counseling & Development last year, says postpartum depression has become more well known in part because of media coverage of women who have acted violently toward their children while suffering from postpartum depression. But depression among women who are pregnant is just as common as depression among women who recently have given birth, according to Choate.
The highest rate of depression for women occurs during childbearing years between the ages of 25 and 44, Choate says. It used to be thought that pregnancy offered protection from depression, Choate says, but it has since been found that just as many women are depressed during pregnancy as are depressed after or outside of pregnancy.
It is not known for certain whether biological factors such as hormones play a role in depression among pregnant women, Choate says, but a previous history of depression does make a woman more likely to have a depressive episode during pregnancy, as does a family history of depression. Pregnant women also tend to be processing a variety of potentially emotional topics, Choate says, such as resolving thoughts about the upcoming transition, regardless of whether they are becoming a mother for the first time or becoming a mother again. They may also be dealing with interpersonal issues with their partners, external stressors such as finances and even grief over a perceived loss of independence, especially if the pregnancy was unwanted.
What makes prenatal depression challenging to diagnose and treat, Choate says, is that many of the symptoms of depression mimic pregnancy symptoms, including fatigue, trouble sleeping, mood swings and trouble concentrating. What might help counselors determine if prenatal depression is present, Choate says, is asking a question such as, “If you did experience an increase in energy or you were able to get better sleep, would you be interested in doing the things you normally do?”
Research has not been conducted on CBT techniques specifically with prenatal women, but Choate believes CBT is likely a good approach to use because of its effectiveness with depression in the general population. A manualized form of interpersonal therapy for pregnant women, called interpersonal therapy for pregnancy (IPT-P), does exist. It focuses on interpersonal skills and on the client being able to resolve issues in her personal relationships, Choate says. IPT-P places emphasis on the skills women need as new mothers, such as communicating with their partners, parenting, getting medical care, building a strong support system, resolving issues from their past and preparing to transition into their new role. Preparing for the transition may involve the mother-to-be addressing what she is giving up as well as what she will gain, Choate says.
Counselors treating prenatal clients with more severe depression might want to suggest that these women talk with their physicians and possibly be evaluated for medication. In such cases, Choate recommends that counselors offer to consult with the physician so that all three parties — counselor, client and physician — can weigh the potential side effects of medication to the baby versus the risk to the child if the mother remains depressed.
Building relationships with physicians is important even before a counselor sees a prenatal client, Choate says. She suggests reaching out to doctors and offering to collaborate with them and take referrals if their pregnant patients appear depressed. Women might believe they are automatically supposed to be happy during pregnancy, she says, and feel embarrassed or ashamed when they feel depressed instead. In such cases, they might not seek out a counselor directly.
Counselors who see depressed prenatal clients should be careful not to impose their values or assume that pregnancy is necessarily a happy time for all women, Choate says. “Try to understand her worldview, her role as a future mother and the pregnancy,” she says. “Make sure that you understand the different stressors that are operating in her life. Look at her holistically, not just as a depressed woman or a pregnant woman. Consider all the stressors and strengths in multiple life areas.”
The threat of suicide
All counselors, regardless of specialty or the population with which they work, should understand that depression is a prominent risk factor for suicide. A new report from the American Journal of Public Health revealed that more Americans now die by suicide than die in car crashes. According to health officials, almost 100 people die by suicide every day in the United States.
In September, U.S. Surgeon General Regina Benjamin in September introduced a new suicide-prevention plan with the goal of saving 20,000 lives in the next five years. Medicare has begun covering depression screenings, and Medicare and Medicaid now reward doctors who screen depressed patients for suicide risk.
Choate points out that adolescent girls are at especially high risk for suicide. “Counselors should definitely assess for suicide if the client is taking antidepressant medication,” she says. “Treatment should include helping her become aware of the relationship between her thoughts and feelings and should help her learn skills for distress tolerance, emotion regulation, coping with stressors and problem solving. This will help her better manage suicidal thoughts if they should emerge.”
According to NIMH, older Americans are “disproportionately likely to die by suicide.” Data from 2009 noted by the American Association of Suicidology shows that adults older than 65 made up almost 13 percent of the population but almost 16 percent of all suicides. “Suicide is a significant concern among older adults,” Zalaquett says. “This group has [a higher] rate of suicide [than] any other age group, particularly among men. Counselors working with older adults should assess for depression and suicide risk. We should not take these symptoms lightly or assume they are a necessary component of aging.”
The first step in combatting suicide with any depressed client, regardless of age or stage, is to understand that he or she is in intense psychological pain and wants to get as far away from that pain as possible, Walker says. “It is imperative that counselors listen openly and calmly with their clients who feel depressed and demonstrate that they care,” she says. “Don’t ignore the threats, and don’t be afraid to talk about suicide or the problems that have caused the desire to commit suicide. If a counselor communicates a fear of talking about it, [the counselor] will inadvertently convey to the client that it isn’t OK for them to talk about it either. Sweeping the problem under the rug may cause the client to feel guilty, misunderstood or unaccepted.”
Walker says counselors should assess for suicide risk factors, including the following:
- History of chronic physical or emotional illness
- Family history of attempted and completed suicides
- Losing a significant other or close friend to suicide
- Increased anxiety, agitation, rage and emotional outbursts
- Social isolation, relationship loss or stress, or perceived lack of emotional and tangible resources
- Isolating and withdrawing from relationships and responsibilities (for example, missing important family events or absenteeism at work)
- History of impulsivity, poor decision-making or risk-taking behavior
- History of mental illness
- History of drug and/or alcohol use or abuse
- Pervasive and unwavering feelings of hopelessness, worthlessness, helplessness, guilt and/or despair
Walker suggests that counselors also attempt to find out clients’ intent, plans and means to carry out suicide; the frequency, duration and intensity of clients’ feelings; previous suicide attempts, if any; and how hopeless clients feel (using a measurable scale). Counselors can also aim to find out how specific, lethal, available and proximate the suicide plan is, she says. For example, using over-the-counter drugs might be lower risk than using a gun.
“Use closed-ended questions that involve ‘yes’ or ‘no’ answers so you can get a thorough assessment of specific plan and intent,” Walker says. For example, “‘Have your problems been getting you down so much lately that you’ve been thinking about harming yourself?’ and ‘Have you been feeling so hopeless that you’ve been thinking of killing yourself?’ If the answer is yes, the counselor must assess the degree of risk very quickly. Do not ask, ‘Why would you kill yourself?’ Instead ask, ‘How would you kill yourself?’ Talking about it with them will most likely help to bring down the agitation and lower the lethality.”
Help clients verbalize their difficulties and make an “options” list, prioritizing those options from best to worst, Walker suggests. “If they can’t think of anything, help them create alternative options,” she says. “If they absolutely insist on listing suicide as an option, try to get them to list it last. Additionally, help build a network for them and get them to do a verbal … and written contract with you that they will call a crisis hotline before they decide to do anything.”
Hazler warns counselors not to lose sight of the suicide threat as a client’s depression improves. Sometimes, he says, therapy or medication actually provides individuals the little added energy they were previously missing to carry out a suicide attempt.
Offering a lifeline
Walker recalls a depressed older male client she counseled while working at a rural community agency. “[He started] off his first session with me with intense anger,” Walker remembers, “shaking his cane in the air, pounding it into the ground [and] saying, ‘No one wants to help me, no one cares about me, and I have nothing left to live for.’ He didn’t want to be there, but he had nowhere else to turn and knew he needed help. He was at the end of his rope. The week prior to his first session with me, he made the devastating decision to put his dog down because he couldn’t afford to feed it, and [he] felt so alone and lost in life. He had not talked to his adult children in months. He was living with chronic pain, could no longer work and had to survive on meager disability assistance. He felt helpless, hopeless and worthless. He had a definite plan to take his own life and the means to carry it out.”
Walker did a substantial amount of active listening and supporting during that first session. The client could tell she cared tremendously, and he began to trust that she was not going to give up on him. “As a counselor, I believe in the power of human potential and in helping my clients learn to overcome life challenges and trust in their own resiliency,” she says. “I believe in hope and our ability to create meaning in our lives instead of being victims to it.”
Counselors often serve as guides, teachers, coaches, mentors, mediators or lifelines, Walker says. “For this client, I was the lifeline he needed. One test of strength and resiliency was the fact that he had been 20 years actively sober from alcohol. However, as he struggled with his loss of identity as a worker and wage earner, he found himself … in the depths of abject despair. Believing that no one cared and that he was a fraction of a man due to his pain, disability and loss of identity, he had pulled away from his family, friends and the support network he had in Alcoholics Anonymous and with his sponsor.”
Encouraged by Walker, the client agreed to give his gun, which was part of his suicide plan, to a family member, and the family member agreed not to give it back to him. “We tapped into his support network to help serve as a buffer to his emotional pain,” Walker says. “He committed himself to figuring out a way to make sense of it all and to re-create meaning in his life. He began to spend time with his children and grandchildren. He re-engaged in life and reached out to his friends. He resumed weekly AA meetings and began meeting regularly with his sponsor. He began to focus on what he still had in his life and what he could still do with it instead of focusing on what he had lost. Throughout our work together, he learned to not give up on himself and to trust the resources he already had and the resources he could tap into to make it through in life. As he felt stronger, he felt better and began to believe in himself again.”
Walker continues, “There is a great quote by an unknown author that says, ‘When the world says, “Give up,” Hope whispers, “Try it one more time.”’ As a counselor, I believe in hope and I believe in client resiliency, and I believe as counselors, that is our mandate.”
The following individuals interviewed for this article invite readers to contact them:
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Lynne Shallcross is the associate editor and senior writer for Counseling Today. Contact her at firstname.lastname@example.org.
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