Counseling Today, Cover Stories

Going beyond sadness

By Bethany Bray October 21, 2019

Major depression is one of the most ubiquitous mental illnesses in the United States, affecting slightly more than 7% of all adults in the past year, according to statistics from the 2017 National Survey on Drug Use and Health. Not surprisingly, depression is also one of the most common issues that bring clients to counseling, regardless of practitioner specialty or setting.

Although professional clinical counselors regularly turn to tried-and-true methods such as cognitive behavior therapy (CBT) to help clients who have depression, it is worth emphasizing that treating depression should never become a paint-by-numbers affair. Certain methods and tools may be more helpful with some client populations than with others. Clinicians must remain sensitive to the individual needs and experiences of the client in front of them. Because depression manifests differently in each client, it is vitally important that counselors truly listen when the client describes what he or she is — or isn’t — feeling and experiencing.

Signs and symptoms

Occasional feelings of sadness, irritability or pessimism are a normal part of life. Depression may be indicated, however, if these feelings occur regularly for two weeks or longer and begin to interfere with daily life. Research suggests that depression is caused by a combination of factors, including genetic, biological, psychological and environmental influences.

Major depressive disorder, the most commonly diagnosed form of depression, is the leading cause of disability in the United States for those ages 15 to 44. The median age of onset is 32.5, according to the Anxiety and Depression Association of America.

On the basis of prevalence data from the National Survey on Drug Use and Health, it is estimated that more than 17 million American adults experienced a major depressive episode lasting two weeks or longer in 2017. The prevalence of major depressive episodes among adult females was 8.7% (compared with 5.3% of adult males). Among adults, those ages 18 to 25 were most likely to have experienced a major depressive episode in the past year, with a prevalence of 13.1%. In a comparison among different races and ethnicities, adults who reported two or more races had the highest prevalence of major depressive episodes at 11.3%.

Although many people associate depression primarily with feeling sad or “down,” the disorder often involves a range of symptoms. According to the National Institute of Mental Health (NIMH), these symptoms can include:

  • Physical aches and pains, including digestive issues and headaches
  • Fatigue and loss of energy
  • Difficulty sleeping
  • Loss of interest in hobbies or activities enjoyed previously
  • Feelings of hopelessness, anxiousness, restlessness, irritability or “emptiness”
  • Feelings of guilt, worthlessness or helplessness
  • Difficulty concentrating, remembering or making decisions
  • Changes in appetite or weight
  • Moving or talking more slowly
  • Thoughts of death or suicide

The mental health literature and commonly used assessment tools such as the Beck Depression Inventory list sets of symptoms and client questions that can be helpful to counselors. However, it is paramount that professional counselors also consider each client’s context when asking assessment questions, stresses Azara Santiago-Rivera, a counselor educator whose research focus includes depression and Latinx adults.

“Be very much aware that the manifestation of symptoms [for depression] are not the same across cultures. One needs to carefully look into that with a client,” says Santiago-Rivera, professor emeritus at Merrimack College in Massachusetts and an adjunct professor in the counseling program at William Paterson University in New Jersey. “It’s not just sadness. Explore what is underneath that sadness through the lens of their cultural values and beliefs. … Their symptoms could be culturally bound and very much associated with an individual’s background and culture.”

Latinx clients may experience depression differently than what is typically expected and may even use different language in counseling sessions to describe what they are going through, she says. For example, these clients might not exhibit some of the typical behaviors that counselors normally associate with depression, such as staying in bed all day. Instead, they may be more likely to experience the somatic problems that accompany depression, such as severe stomachaches or leg and back pain.

Depression can also manifest differently across the life span, sometimes in unexpected ways. For example, in children and adolescents, symptoms of depression might include irritability or acting out, notes Matthew Paylo, a licensed professional clinical counselor and co-author of the American Counseling Association’s practice brief on depressive disorders in youth.

“Irritability is a central symptom in youth with depression. Therefore, counselors should adequately assess acting-out and aggressive behaviors [in young clients],” says Paylo, an associate professor and counseling program director at Youngstown State University in Ohio. “For example, acting-out behaviors in young boys, while often associated with behavioral disorders — attention-deficit/hyperactivity disorder, oppositional defiant disorder — can sometimes be depressive disorders that have been overlooked without an identifiable negative stressor. This concept of masked depression is the presentation of acting out, aggressive behaviors, school refusal and/or somatic complaints which are thought to be concealing underlying feelings of depression. These youth will often present more overt depression later in life. Counselors must adequately assess acting-out behaviors in youth [because they] could be behavioral disorders, trauma-related, or even associated with underlying depression.”

Similarly, depression might manifest differently in older adults and can easily be overlooked by practitioners, says Mary Chase Mize, a provisionally licensed counselor who is in the doctoral counseling program at Georgia State University. Later in life, depression often occurs without depressed mood or sadness. Instead, withdrawal behaviors and a lack of interest in activities that were previously enjoyed might be more prevalent, explains Mize, an American Counseling Association member with a master’s degree from Georgia State’s Gerontology Institute.

“Make sure your assessment is as thorough as it can be, and don’t look solely at depressed mood or sadness [as indicators for depression]. That is often what goes into misdiagnosis,” Mize says. “If you’re encountering an older adult who has lost their zest for life but they’re not feeling sad, [depression] won’t be as easy to recognize. … Depression with someone who is 75 looks very different than in someone who is 25.”

Depression through a behavioral and Latinx lens

Santiago-Rivera and Paylo both find behavioral activation therapy (BAT) particularly useful for addressing depression in clients. Counselors using BAT set goals and offer positive reinforcement for clients as they engage (or re-engage) in activities that have been put on the back burner because of lost interest, lack of energy, depressed mood, isolation, physical pain or other symptoms of depression. These activities might range from something as basic as keeping up with personal hygiene to something more involved, such as maintaining social relationships.

With BAT, counselors work with clients to plan activities that can help them feel better and break depression’s cycle of isolation, explains Paylo, an ACA member and the co-author of several books, including Treating Those With Mental Disorders: A Comprehensive Approach to Case Conceptualization and Treatment. To increase the likelihood that clients will follow through with activities discussed with a counselor, it may be helpful to map out a schedule with these clients before they leave sessions, Paylo says.

“Since depressive symptoms tend to lead individuals to isolate and avoid various situations that could provide enjoyment and growth, this approach moves toward increasing and challenging clients to participate in more desirable and pleasurable activities — and, in turn, begin to experience a more positive affect,” Paylo explains. “This change can and should ultimately impact their depressive symptoms. … Ultimately, targeting these avoidance behaviors can allow clients to reconnect with sources of positive reinforcement and decrease aversive conditions such as boredom, insomnia and complaints. Often, counselors will need to assist clients in identifying a hierarchy of potential activities and assist them in planning to address potential obstacles and challenges to engage in these tasks.”

Santiago-Rivera was part of a team that received an NIMH grant several years ago to study the treatment of depression at a community-based mental health agency in Milwaukee. Many of the agency’s clients came from a low-income, Latinx background, so Santiago-Rivera’s team worked to adapt BAT to be culturally appropriate for that population, including translating materials and offering treatment in Spanish.

A range of stressors contributed to the clients’ depression, including traumatic memories from their immigration experiences, hostile/anti-immigrant sentiment in their new home country, and, for some, the stress of navigating life as undocumented immigrants, Santiago-Rivera shares. Ultimately, the team found that BAT was more effective at keeping these clients in therapy than was the nonbehavioral treatment methods the clinic had used previously.

BAT is “a very concrete, specific, short-term treatment approach,” says Santiago-Rivera, an ACA member. “It worked well [for this population] because it wasn’t long term and it focused on the here and now, their current experiences. … The focus is on getting active again in healthy ways. Behaviors often reinforce depression, and this gets them active in behaviors that eventually lead to reduction in depressive behaviors.”

At the same time, counselors must ensure that the behavioral goals they are suggesting to clients are culturally appropriate, Santiago-Rivera stresses. For example, physical activity can play an important role in depression treatment, but setting a goal of going to the gym may not be feasible for Latinx clients with limited income. Instead, practitioners might suggest alternative behavioral goals to these clients such as going to church on Sundays or spending a weekend afternoon in a local park with family.

“They’re more apt to do it if they find the activities relevant and understandable,” Santiago-Rivera says. “Think of their cultural values and what activities [are applicable]. Many don’t have the resources to pay for a gym membership. Instead, maybe they can take a short walk with a family member around the block, attend a cultural event happening in their neighborhood, or attend a Spanish-language movie with a friend.”

Counselors should check in with clients regularly to talk about which activities they are finding meaningful and then think of ways to build on those behaviors. Counselors should also ensure that clients are equipped with a plan of behaviors to fall back on should their depression begin to worsen, says Santiago-Rivera, who presented on depression treatment for Latinx clients at ACA’s 2017 conference.

Family typically plays an important role in Latinx culture, so these clients may respond well to behavioral goals that involve family activities, Santiago-Rivera says. At the same time, she cautions, clients who are recent immigrants may be separated from their families, and the suggestion of family activities may only worsen the sting. Counselors can ensure that BAT goals are appropriate by asking about a client’s family life and support systems beforehand.

“Clinicians needs to contextualize the diagnosis of depression,” Santiago-Rivera says. “They need to get a better understanding of the contributing factors to depression because it can be complicated in Latinx culture. Connecting with other people in your group and culture is such a significant factor in coming-of-age. There is a sense that family is very important, and if there isn’t a sense of family, they can feel marginalized and isolated, which can lead to depression and related issues. As clinicians, we should know more about these nuanced factors that can contribute to stress and depression that we wouldn’t [necessarily] think about … [or] ask about.”

Additionally, counselors using translated materials with clients should ensure that the translation is sound and culturally appropriate. Translated materials can miss the mark if they use words and phrases that are unfamiliar to the client, Santiago-Rivera notes.

Counselors must also carefully consider the words they are using with clients and simultaneously keep their ears open for clues to help them understand the client’s experience, even (or especially) if the client doesn’t use the typical descriptors that the counselor might be used to.

“Even the words used to describe depression can vary because of the many dialects in the Spanish language. [For] the word ‘depressed,’ the literal translation deprimido, [clients] may not understand what you mean. They may use triste, which means sad, not deprimido,” Santiago-Rivera explains. “Really listen to what they’re describing. … They may use different words to describe their manifestation of symptoms [of depression].”

As a whole, clients will respond best to clinicians who are open to learning more about their culture, Santiago-Rivera asserts. “You won’t necessarily have all the tools in your toolkit and sufficient knowledge about a client’s background, but if you introduce cultural humility into your framework, that will go a long way. Be clear and humble that you don’t have all the answers but are willing to learn,” she says. “The most effective therapists have an openness [and] are personal, active, inquisitive and interested in the individual in a family context. All of those things seem to matter, beyond whatever therapeutic approach they use. Those are the [counselors] who keep clients in treatment longer.”

Depression through an older adult lens

The Centers for Disease Control and Prevention reports that rates of depression in older adults (those ages 65 and older) who live in mixed-age communities are lower than the rates found among the general population.

However, depression in older adults can be complicated — and thus harder for medical and mental health practitioners to pinpoint — because it often dovetails with instances of grief or loss, chronic pain, Parkinson’s disease, or other medical diagnoses and life issues that frequently co-occur for this population.

Mize co-presented a session at ACA’s 2018 conference with Laura Shannonhouse titled “Combating Ageism and Understanding Depression With Older Adults at Risk of Suicide.” The two are currently working on a federally funded research grant project on suicide and aging adults. One easy mistake that counselors can make, Shannonhouse and Mize agree, is to assume that depression in later life is just part of the aging process. They encourage counselors to explore their own beliefs about older clients and the aging process; counselors’ own death anxiety has been found to contribute to internal (and often unconscious) bias, according to Shannonhouse.

“There’s a difference between going through the challenges of aging and being depressed,” Mize says. “Depression is prevalent in all stages of the life span, but in older adults, it’s often concurring with other medical issues. But it’s the same as with other ages: If it’s treated, it can get better. It’s totally false to assume that because someone is old, depression is natural.”

Shannonhouse, an ACA member and an assistant professor in the Counseling and Psychological Services Department at Georgia State University, notes that CBT, interpersonal therapy, medication, relapse prevention-focused methods, and psychoeducation about depression with the client and client’s family are common treatments. But she says that older adults can also benefit from including Adlerian life review and early recollections analysis in treatment for depression. Exploring clients’ early lives and memories provides insight into how older adults make sense of themselves, others and life in general, she says.

Clinicians can help older clients uncover and rewrite mistaken meanings that they have ascribed to particular life events, Shannonhouse explains. Analysis of early recollections leads to the identification of patterns or rules that can be problematic. Counselor educator Arthur Clark’s work has revealed that early recollections pulled after therapy are often different than the memories pulled beforehand. It’s not that clients’ memories have changed, however; it’s that they are pulling different memories as their view of themselves, others and life in general shifts. These types of reminiscent therapies have been proposed as being respectful and helpful for older adults with depression, Shannonhouse says.

It is also important to screen clients for suicidal ideation, notes Shannonhouse, affiliate faculty at Georgia State’s Gerontology Institute. Indicators for suicidal ideation and depression can overlap, including perceiving oneself to be a burden to others, feeling hopeless, or lacking a sense of belonging. Although depression and suicide risk do co-occur, one does not necessarily indicate that the other is present; this is something for counselors to discern through assessment, Shannonhouse emphasizes.

Charlene M. Kampfe, in her ACA-published book, Counseling Older People: Opportunities and Challenges, lists a multitude of depression symptoms that older adults may exhibit, ranging from decreased socialization and lack of motivation to finding fault in others, loss of appetite, and compulsive gambling. In a counselor’s office, behavioral signs may include strained muscles around the mouth and eyes, poor eye contact, slowed movements and speech, excessive crying, and slumped posture, Kampfe writes.

In addition to thorough assessment for depression, counselors should ask older adult clients whether they are receiving regular, ongoing medical care, Mize adds. Many medical conditions, including heart attacks, can elevate a client’s risk for depression. Also, somatic issues such as chronic pain can keep people from getting out of the house and lead to isolation, which can exacerbate depression and spiral into a cycle of further withdrawal and worsening symptoms.

“Older adults may have a difficult time identifying depression [in themselves], which can lead to poor health outcomes,” Mize says. “An older adult may not be able to describe what they’re feeling in mood-related terms or psychological language. What we [counselors] need to do when working with older adults is make sure that we’re aware of these challenges and make sure we’re not treating the diagnosis of depression the same as [with] other clients across the life span.”

Depression through a systems lens

ACA member Sean Newhart urges counselors to look at the big picture when treating clients for depression. A person’s system, including family, social and cultural connections, can have a significant impact on the individual’s experience and ability to make change, says Newhart, a certified clinical mental health counselor and a lecturer at Johns Hopkins University in Maryland.

Professional counselors’ go-to approach for clients with depression is typically individual counseling, and there are good reasons for that, Newhart concedes. “But I would argue that there’s a lot of research that points to the importance of family and systems support. It’s important to consider that and incorporate it into treatment,” he says. “We need to broaden the way that we see depression and different mental health issues. Instead of focusing on how the individual can change, take it to a macro level approach and [think of] how to intervene as a whole.”

Newhart urges professional clinical counselors to explore clients’ systems — getting beyond the basic questions usually asked at intake — and consider including key members of their systems in therapy. When appropriate, and with a client’s permission, a counselor could arrange to have family members or other members of the client’s system come into a counseling session. The counselor would then act as moderator as the parties talk through issues and behavioral patterns that may be contributing to or exacerbating the client’s depression, Newhart explains.

For example, a college student struggling with depression and in conflict with a roommate can address only so much in counseling without involving the other person. If the counselor and client were to involve the roommate in a session, the two parties could talk through their issues in a safe setting, highlighting each person’s needs and the behavioral patterns that could be beneficial to change, Newhart says.

Of course, there are some scenarios in which it could be harmful to involve members of a client’s system, such as inviting a person to participate who might become aggressive, accusatory or manipulative toward a client in session, or situations where abuse or abandonment has taken place. Newhart and his co-authors, Patrick Mullen and Daniel Gutierrez, explored this in more depth in a July Journal of Counseling & Development article titled “Expanding Perspectives: Systemic Approaches to College Students Experiencing Depression.”

There are also situations in which involving members of a client’s system will not work because the client is not in favor of the idea and declines to grant permission. However, exploring clients’ systems in therapy, regardless of whether other people are involved, will help practitioners to better understand their clients’ experiences with depression, Newhart asserts.

“Sometimes this requires a shift of perspective [by the counselor]. This isn’t just you [the client], depressed. There are all these factors that are influencing that, and how do we address them? No one ever is truly an isolated individual,” Newhart says.

Before diving into a therapeutic intervention for a client’s depression, the counselor should help the client map out his or her family history, relationships, and support systems, Newhart advises. Questions that can be beneficial to ask include:

  • Who supports you?
  • Who can you turn to when you’re struggling?
  • How is your relationship with your parents and siblings?
  • Who would you say are your friends?
  • Who do you look up to?
  • Who do you confide in?
  • Do you feel like you’re getting support from your friend group?
  • What about these relationships are important to you?

Systems can either mitigate or exacerbate a person’s depression, Newhart says. For some clients, healthy relationships with friends and family can serve as a buffer and support them through their depression. On the flip side of the coin, a variety of negative connotations involving their systems, from past trauma and abandonment to manipulation or feelings of guilt or shame, can contribute to clients’ struggles with depression and even stall their progress in counseling. Counselors should always explore how clients perceive their support systems, which may be different than it appears at face value, Newhart adds.

Clients who are distanced from the positive effects of their systems, such as moving to a new town or going away to college, may experience a worsening of depressive symptoms.

“Some theories say depression is a product of feelings of abandonment, isolation and feeling disconnected. Depression can be affected [positively] by interpersonal factors but can be caused by them as well,” Newhart says. “The symptoms of depression typically lead to isolation from other people, which decreases social support, which increases isolation. So, it’s a vicious cycle. [Research indicates that] social support buffers these impacts of depression.”

Counselors can work with clients (such as college students) who are distanced or removed from their systems to help them establish new connections and build interpersonal skills. Engaging in goal setting with a counselor and taking small steps such as attending a social event on campus can deter clients’ instincts to isolate themselves when they are feeling depressed, Newhart says.

“Those with depression might not have a lot of friends,” he says. “Talk [with them] about building interpersonal skills, confidence in approaching people, and navigating situations that might be anxiety-provoking.”

Previously a doctoral student at William & Mary in Virginia, Newhart aims to set up a private counseling practice in Maryland once he settles into his new job at Johns Hopkins. He completed his doctoral dissertation on how family systems affect college students’ mental health.

Exploring systems issues with clients is a good fit for counselors because “it’s part of our professional disposition to go beyond the client in a multitude of ways,” Newhart says. “The charge of going beyond the client in the room and helping them in a holistic way, that’s already happening a lot. Perhaps it’s meeting clients where they are, in their home or where their systems already are. If we can break down the barriers to treating the client in a way that works best for them, that fits our professional duties and the idea of what professional counseling is.”

Depression through an African American lens

A multitude of factors — from a lack of culturally competent mental health practitioners to a cultural mistrust of treatment due to a history of misdiagnosis — make treating depression in the African American community a complicated endeavor, says Renelda Roberson, a licensed professional counselor (LPC) in private practice in the Houston area.

Bernadine Duncan, an LPC who is the director of Student Counseling Services and the Women’s Center at Prairie View A&M University in Texas, finds that the adage “you don’t know what you don’t know” rings true for many of the African American college students who come to her counseling center. Treatment often begins by explaining just what depression is and confirming that it is a common disorder that can be treated. Many of the counseling center’s clients are first-generation college students who have grown up among family with undiagnosed or untreated depression, so they view these struggles as normal, Duncan says.

Roberson and Duncan are ACA members who co-presented a session on stereotypical attitudinal behaviors and depression in African American college women at ACA’s 2017 conference.

Duncan organizes group counseling and large, women-only discussion sessions at Prairie View A&M, a historically black university. She finds that these sessions appeal to students who wouldn’t necessarily have sought out individual counseling on their own beforehand. She also gives talks to clubs, sororities and other student groups on campus about mental health issues and how counseling can help to address them.

“We can put flyers up all over campus and information on social media, but what I’ve found that can help an individual come to counseling is to talk to them where they are,” says Duncan, president of the Texas University and College Counseling Directors Association.

Among the tools Duncan finds useful with clients struggling with depression are relaxation techniques, reality therapy, role-play exercises, and the Gestalt empty chair technique. Relaxation techniques, in particular, can help in session when clients need to deal with anger connected to their depression, she says. But there is no one tool or technique that is an automatic fit for every client.

“First, you have to meet clients where they are,” Duncan says. “Keep in mind that African Americans are not a monolithic group. Talk with [a client] to determine their perspective and tailor [your] treatment from there. Relaxation techniques can help with some individuals, but not all [people of color] embrace relaxation; some may see it as a form of voodoo,” Duncan says. “Some have pushed their feelings so far down inside that they don’t know how to talk about them. But once rapport is formed, things come out. When they trust the counseling relationship, we can work more effectively with them.”

Roberson, an adjunct professor in the master’s-level counseling programs at Texas Southern University and Houston Baptist University, finds CBT beneficial for quelling negative thought patterns in clients with depression. It also serves as psychoeducation about how thinking influences behavior, she says. Discussions about a client’s sleep patterns, nutrition and activity level can also be helpful, she adds, as can connecting clients to local resources such as an African American faith community.

“You want to make sure you’re familiar with whatever resources are available for your client. They may not take you up on it, but you want to be able to offer it in the moment instead of saying, ‘Let me get back to you,’” Roberson observes. “Be able to have that conversation [because] that may be your only chance to see that individual. What they do with it is up to them, but at least they have it when they leave the office.”

Roberson and Duncan also urge counselors to ensure that African American clients who have depression are connected to medical care and have an opportunity to have medicine prescribed, if needed. Beyond that, compassion from a counselor, cultural competency, and rapport-building are key with this client population, Duncan emphasizes.

“We have to remember that we’re going into their world, which is not our world. We have to be unbiased, no matter what their reality is. We have to see how they’re surviving,” Duncan says. “Don’t pretend to know all about what they’re going through. If you come up against something you’re unsure about, ask the client. Really listen to what they say, and repeat what you’ve heard them say. Don’t act like you’re the know-all, end-all. That can be the difference between them returning to counseling or never coming back.”

Roberson says that in her work with people of color and depression, a focus on empowerment has gone a long way. From the very first session, she emphasizes that she is the client’s ally and that counseling is an open, safe, nonjudgmental and nonbiased environment.

“One of the first statements that I always end my first session with is, ‘How can I help you in this journey that you are on?’ They light up [when I say], ‘I’m here to assist you to help you become the person you are,’” Roberson says. “Sometimes in the lives we live, we don’t believe that.”

 

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Treating depression with or without medication

It is estimated that 1 in 6 adults in the United States has a prescription for a psychiatric drug. Although professional clinical counselors cannot prescribe medication, practitioners who are helping clients with depression must be open to — and even proactive about — having discussions regarding psychiatric medications.

Ample research exists supporting the use of antidepressants, especially if a client has previously had a positive response to antidepressants, has moderate to severe symptoms of depression, has significant sleep or appetite disturbances, or is in maintenance therapy for depression, says Matthew Paylo, an associate professor and counseling program director at Youngstown State University.

“Counselors should be knowledgeable and aware of the types of medications utilized for depressive disorders while realizing that they are not in a role of prescribing or advocating for a specific medication or dosage. Therefore, counselors should assume a supportive, psychoeducational role that is aimed at educating and empowering clients to seek and utilize mediations — if they desire to do so,” Paylo says.

“Consistently, there has been empirical research to support the use of counseling alone or in combination with antidepressants as an effective treatment for major depressive disorder, with many meta-analyses suggesting that counseling with antidepressants is superior to medication alone,” Paylo continues. “With that being said, research also suggests there are a range of psychotherapies that are as effective as medications, such as cognitive behavior therapy, mindfulness-based cognitive therapy, behavioral activation therapy, and interpersonal psychotherapy. Some adjunct therapies such as electroconvulsive therapy, bright light therapy, neurofeedback, transcranial magnetic stimulation, and vagus nerve stimulation are beginning to show significant strides in symptom relief and maintenance of overall wellness and should or could be considered as part of a comprehensive and individualized treatment approach.”

 

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Additional resources

For more information on depression, access the American Counseling Association’s webpage of resources at counseling.org/knowledge-center/mental-health-resources/depression.

CT Online also offers a variety of past articles on the topic, including:

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Contact the counselors interviewed for this article:

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Bethany Bray is a senior 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.

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