Monthly Archives: October 2019

Procrastination: An emotional struggle

By Lindsey Phillips October 24, 2019

Procrastination is a common issue — one that people often equate with simply being “lazy” or having poor time-management skills. But there is often more to the story.

William McCown, associate dean of the College of Business and Social Sciences and professor of psychology at the University of Louisiana at Monroe, cites a case example of a man in his mid-30s with a degree in chemical engineering who was procrastinating about applying to graduate school. The client reported just not being able to “get it together.” Through therapy, however, the man discovered that he had an emotional block. His parents supported his choice to get another degree, but their own lack of formal schooling often led them to make detractive comments, such as the father stating that when his children thought they were as smart as him, he would just die. The client came to realize that comments such as these sometimes incited him to self-sabotage his career.

According to Joseph Ferrari, a psychology professor at DePaul University in Chicago, “Everyone procrastinates, but not everyone is a procrastinator.” His research indicates that as many as 20% of adults worldwide are true procrastinators, meaning that they procrastinate chronically in ways that negatively affect their daily lives and produce shame or guilt.

According to McCown, a pioneer in the study of procrastination and co-author (along with Ferrari and Judith Johnson) of Procrastination and Task Avoidance: Theory, Research, and Treatment, procrastination becomes problematic when it runs counter to one’s own desires. “We all put things off,” he notes. “But when we put off things that are really in our best interest to complete and we do it habitually, then that’s more than just a bad habit or a lifestyle issue.”

McCown finds that clients with chronic procrastination often come to counseling for other presenting concerns such as marital problems, depression, work performance issues, substance use, attention-deficit/hyperactivity disorder (ADHD) and anxiety. He has noticed, however, that younger generations are starting to seek counseling explicitly to work on procrastination.

McCown says that among Gen Xers and particularly among baby boomers, tremendous stigma existed around procrastination. But that largely changed with the Great Recession, he contends, because people realized that having a procrastination problem hurt them at work — a luxury they could no longer afford.

Managing emotions, not time

A growing body of research suggests that procrastination is a problem of emotion regulation, not time management. Julia Baum, a licensed mental health counselor (LMHC) in private practice in Brooklyn, New York, agrees. “Poor time management is a symptom of the emotional problem. It’s not the problem itself,” she says.

Nathaniel Cilley, an LMHC in private practice in New York City, also finds that chronic procrastination is often a sign of an underlying, unresolved emotional problem. People’s emotional triggers influence how they feel, which in turn influences how they behave, he explains. However, clients may incorrectly assume that procrastination is their only problem and not connect it to an underlying emotional issue, he says.

People procrastinate for various reasons, including an aversion to a task, a fear of failure, frustration, self-doubt and anxiety. That is why assessment is so important, says Rachel Eddins, a licensed professional counselor and American Counseling Association member who runs a group counseling practice in Houston. “There’s not one answer to what procrastination is because [there are] so many things that lead to it,” she says.

Procrastination can also show up in conjunction with various mental health issues — ADHD, eating disorders, perfectionism, anxiety, depression — because it is an avoidance strategy, Eddins says. “Avoidance strategies create psychological pain, so then that leads to anxiety, to depression, and to all these other things that people are calling and seeking counseling for,” she explains.

Sometimes, procrastination may even mask itself initially as another mental health issue. For example, overeating in itself is a procrastination strategy, Eddins says. She points out that if certain people have a hard task they are avoiding, they may head to the refrigerator for a snack as a way of regulating the discomfort.

If a client comes to counseling because he or she is binge eating and procrastinating on tasks, then the counselor first has to determine the root cause of these actions, Eddins says. For example, perhaps the client isn’t scheduling enough breaks, and the stress and anxiety are leading to binge eating. Perhaps food acts as stimulation and provides the client with a way to focus, so counselors might need to explore possible connections to ADHD. Maybe the client is rebelling against harsh judgment, or perhaps the root cause is related to the client experiencing depression and feeling unworthy.

One approach Eddins recommends for finding the root cause is the downward arrow technique, which involves taking the questioning deeper and deeper until the counselor uncovers the client’s underlying emotion. For example, if a client is avoiding cleaning his or her house, the counselor could ask, “What does it mean to have a messy house?” The client might respond, “It means I can’t invite people over.” The counselor would follow up by asking, “What does that mean?” These questions continue until the client and counselor get to the issue’s root cause — such as the client not feeling worthy.

Eddins and Cilley both find imaginal exposure helpful for accessing clients’ actual memories and experiences and discovering the underlying cause of procrastination. For instance, if a client is procrastinating over writing an article, Cilley may have the client imagine sitting at his or her desk and staring at the blank computer screen. Cilley would ask, “What’s going on in this moment? Where are we? What is around you? How are you feeling emotionally at the thought of writing this article?” The client might respond that he or she feels anxious about it, which means the underlying cause is emotional.

“Imagination is really great with drumming up emotions,” Cilley notes. “The emotion starts to come into the session when [clients visualize what they are avoiding].”

Addressing irrational thoughts

“You can do all the time-management skills in the world with someone, but if you haven’t addressed the underlying irrational beliefs fueling the anxiety, which is why they’re procrastinating, they’re not going to do [the task they are avoiding],” notes Cilley, an ACA member who specializes in anxiety disorders.

As described by Cilley, the four core irrational beliefs of rational emotive behavior therapy (REBT) are:

  • Demands (“should” and “must” statements such as “I should go to the gym four times a week”)
  • Awfulizing (imagining a situation as bad as it can be)
  • Low frustration tolerance, which is sometimes referred to as “I-can’t-stand-it-itis” (belief that the struggle is unbearable)
  • Self-downing (defining oneself on the basis of a single aspect or outcome, such as thinking, “If I mess up one work project, then I am a failure”)

“When we’re having procrastination problems, a lot of times we awfulize about the task and have abysmally low frustration tolerance about the energy required to do it,” observes Cilley, a certified REBT therapist and supervisor and an associate fellow at the Albert Ellis Institute. “And we disproportionately access how bad it would be to do it or to be put through it and minimize our ability to withstand or cope with it.” Put simply, sometimes when people think something will be too difficult, they don’t do it.

Another common reason people procrastinate is a fear that they could fail, and they interpret failure to mean that something is inherently wrong with them, Cilley says.

For example, imagine a client who comes to counseling because he procrastinates responding to work emails out of fear that he will answer it incorrectly and his co-workers will realize he is a failure. To first identify the root cause, Cilley would ask a series of open-ended questions to the client’s statements regarding procrastination: I am avoiding responding to emails at work. What would it mean if you responded to the emails? I’m afraid I would do it incorrectly. What if you did respond incorrectly? My boss would think I’m an idiot. What would that mean to you? That I’m no good at my job. I’m a bad employee.

A self-label of “bad employee” causes the client to filter everything through that lens, including minimizing the good that he does, Cilley points out. In addition, the man will act as if he is a “bad employee,” which reinforces this label and makes him more prone to procrastination, Cilley says.

One technique that Cilley uses with clients to challenge unhealthy thinking and break the vicious cycle is the circle exercise. He draws a big circle, and at the top he writes the client’s name. At the bottom, he writes the negative thought in quotes — “I’m a bad employee.” Then, he places six plus signs and six minus signs inside the circle and asks the client to think of six things that he or she does poorly at work. The client might respond, “I procrastinate on tasks, I show up late, I make mistakes when I respond to emails” and so on. Next, Cilley has the client name six things that he or she does well. For example, the client could say, “I care about the work I do, I stay late if needed, and my co-workers can depend on me.”

If clients respond by saying that they don’t have any positive qualities at work, then Cilley will ask them to think about what positive things another co-worker would say about them (even if the clients don’t believe the statements themselves).

Next, Cilley circles one of the statements in the minus category and asks the client if this one negative statement erases the other six positive statements. To emphasize the flawed logic, he may also ask if one positive trait causes all of the negative ones to go away and makes someone a “perfect” employee.

This exercise challenges black-and-white thinking and helps clients separate their identities from their actions or the task they messed up on, such as sending an incorrect email, Cilley explains.

Even after clients identify their irrational beliefs and create rational coping statements (positive beliefs used to replace the negative and irrational ones), they still may not believe the rational ones. When this happens, Cilley uses an emotiveness exercise he refers to as “fake it till you make it.” He asks clients to read the rational beliefs out loud 10 times with conviction — as if they were Academy Award-winning actors and actresses who wholeheartedly endorse and embrace the beliefs.

If clients are going to rebut thoughts such as “I am a failure” and “I can’t do anything right,” then a monotone voice won’t help them change their thoughts or calm down, Cilley notes. “Anyone can go up on stage and read a speech,” he says. “The emotion and conviction behind your voice is what moves the audience, and that’s what we have to do to ourselves when we’re trying to convince ourselves of the rational beliefs.”

Even though clients may not initially believe what they are saying, by the eighth or ninth time they repeat it, they are finally internalizing the beliefs, Cilley says. On the 10th time — when clients are starting to actually believe what they are saying — he records them repeating the rational beliefs. Clients are then instructed to listen to this recording three times per day throughout the week as a way of talking themselves into doing whatever they have been procrastinating over, he says.

Cilley has also used role-play to help clients put stock in more rational thoughts. He does this by adopting the client’s irrational belief (e.g., “I am a failure” or “I am unworthy”) and then asks the client to try to convince him of more rational thoughts. By doing this, the clients start to convince themselves. Even though clients often laugh at this exercise, Cilley has found it to be one of the quickest ways to change clients’ irrational thoughts.

REBT and other short-term therapy techniques are not just effective but also efficient for clients who procrastinate, notes Baum, a rational emotive and cognitive behavior therapist and supervisor, as well as an associate fellow at the Albert Ellis Institute. With procrastination, clients often want to see results quickly, she says. They want to finish the work project, clean their house or get to the gym next week, not next year. REBT helps clients quickly “take responsibility for their behavior and recognize that they have agency to change it,” Baum emphasizes.

Learning to tolerate discomfort

Often, people procrastinate to avoid discomfort, Eddins notes. This discomfort comes in many forms. Maybe it’s procrastinating on beginning a complex task at work out of fear of failure, or avoiding having a difficult conversation with a friend.

The first step is helping clients become aware of the discomfort they are avoiding, Eddins says. “When we suppress our feelings, that’s when the procrastination and avoidance habits emerge,” she adds.

Eddins often uses the “name it to tame it” technique. She will first ask clients what they are feeling when thinking about the task they are avoiding. Clients may not have a word for this discomfort, so she will ask them to identify what they are feeling physically, such as a tightness in their chests.

Baum, a member of the New York Mental Health Counselors Association who specializes in helping creative professionals and entrepreneurs overcome procrastination, helps clients learn to cope with feelings of discomfort through imaginal exposure. First, Baum teaches clients coping skills such as breathing exercises to use when they experience discomfort. She also helps them identify, challenge and replace irrational thoughts that contribute to emotional distress and self-defeating behaviors. Then, she asks them to imagine walking through the scenario they have been avoiding.

For example, a man procrastinates about going to the gym because he feels ashamed of being out of shape. The client thinks to himself, “I’m out of shape. I won’t fit in at the gym. I’m no good because I let myself go.” These thoughts and his fear of others judging him prevent him from going to the gym despite the health benefits.

To address this emotional problem, Baum would have the client imagine walking into the gym and getting on the treadmill as others stare at him. During this exercise, she would guide the client to breathe slowly to keep his body calm and have him practice rational thinking, such as accepting himself unconditionally regardless of the shape he is in or what others may think. This will help him overcome his shame and productively work toward a healthy fitness routine.

Eddins also uses a mindfulness-based technique called “surfing the urge” to help clients. She instructs clients to stop when they feel the urge to procrastinate and ask themselves what the urge feels like in their bodies and what thoughts are going through their heads. For instance, clients may notice having an urge to get up and grab a snack rather than work on their task. This technique helps them learn to sit with their discomfort and face the urge rather than distracting themselves from it or trying to change it, she explains.

The power of rewards and consequences

Cilley finds rewards and consequences a useful motivational tool for those clients who are good at identifying irrational beliefs and who already possess coping and emotion-regulation skills yet are still procrastinating when faced with certain tasks (or even their therapy homework). For example, clients could reward themselves by watching their favorite show on Netflix after they complete the task. The ability to watch the show could also become a consequence — they would withhold watching the show until they complete the task.

Counselors may need to help clients determine appropriate rewards. McCown, a clinical psychologist at the Family Solutions Counseling Center in Monroe, Louisiana, finds that clients sometimes want to use grandiose rewards that really aren’t helpful motivators. For example, a client may decide that he or she will take a trip to Europe after finishing writing a novel. McCown notes that the likelihood of this motivating the client to make progress on the novel isn’t as strong as if the client used smaller rewards, such as going out with a friend or taking a walk to celebrate completing 300 words of their novel.

If clients are having trouble enforcing rewards or consequences themselves, counselors can become the enforcers — but only as a last resort, Cilley says. For example, Cilley had a client who was procrastinating when it came to taking steps toward starting a side business because he feared he would do it imperfectly, and that would make him a “failure.” After learning how to identify his irrational thoughts and how to regulate his emotions, the client still needed one final push to start his business. The client was a gamer, so both he and Cilley agreed that if he didn’t start his business that week, Cilley would change the client’s PlayStation 4 password so that he couldn’t play video games until after the business was launched.

“You want to make sure you have a good working alliance with the client and that they feel safe to be vulnerable and that [you] can laugh about this [with them] because it’s kind of unorthodox. But sometimes that’s what works for some people. They need that accountability,” Cilley says. “Just laughing about how silly the consequence is in therapy can make it more of a fun challenge.”

Giving yourself permission

Eddins finds that shame is a big factor with people who procrastinate. “Somehow we learned that shame [is] a way of motivating — ‘If I’m just hard on myself, then maybe I’ll get it done’ — and that for sure backfires and leads to procrastination,” she says.

For some people, their inner critic is shaming them constantly with “should” statements (e.g., “I should work out four times a week”). Procrastination is their way of rebelling against this harsh judgment, Eddins explains.

Self-compassion is one way to address critical thoughts and shaming, Eddins says. For example, the critical inner voice that declares a client lazy if he or she doesn’t go to the gym could be changed to use more motivating statements such as “It feels good when I go outside and move my body.”

In addition, if critical thoughts start to surface when clients are trying to complete a task, they can use a self-compassionate voice to remind themselves that they will feel better after they take a break, Eddins advises. In fact, the act of giving oneself permission to take a break, practice some self-care, and rest and relax can sometimes break the cycle of procrastination, Eddins says.

A 2010 study found that students who forgave themselves for procrastinating when studying for a first exam were less likely to procrastinate when studying for the next one. The researchers concluded that self-forgiveness allows people to move past the maladaptive behavior and not be burdened by the guilt of their past actions.

At the same time, Eddins advises counselors to be careful with the technique of giving permission. Clients with black-and-white thinking may interpret that as the counselor telling them it is OK to be “lazy.” Instead, she recommends that counselors use this strategy within a context that the client will accept.

Eddins had a client who put off meal planning each week because it was stressful. When Eddins asked why it was stressful, she discovered the client was preparing up to three different meals each night to accommodate each family member’s personal preferences. Eddins knew that if she told this client to give herself permission to cook only one meal each night, the client would engage in black-and-white thinking: “Well, that would make me a bad mom.”

So, instead, Eddins said, “No wonder you are exhausted. You are trying to do everything for everyone else but not for yourself. This doesn’t work for you. You have permission to take care of yourself and do what works for you. And that does not make you a bad mother.”

Strategies for success

Procrastination does offer momentary relief and reward, which only reinforces the behavior and continues the cycle of avoidance, Eddins notes. So, the more times that an individual avoids a task, the more difficult it becomes to stop the cycle of procrastination.

In counseling, clients can learn strategies that are more effective than avoidance. One therapeutic technique that Eddins likes involves breaking tasks into smaller ones that are realistic and obtainable. For instance, an individual who hasn’t formally engaged in exercise in the past year might be tempted to set a goal of working out four times a week. This person has created an ideal “should,” but because the goal is overwhelming, he or she is likely to continue avoiding exercising, Eddins points out.

Should this happen, Eddins might explore why the client is procrastinating on the goal: “Tell me about the last time you worked out. When was that?”

When the client responds that it was a year ago, Eddins would suggest establishing a smaller goal to ensure success and build motivation. For example, the client could start by exercising one day a week for 10 minutes and build from there.

“I want [clients] to take the smallest possible step because I want to [help them] build success,” Eddins says. “That is actually reinforcing in the brain because … it gives you that sort of reward and that success, and then that allows people to achieve the goal.”

McCown points out that “the rehabilitation of a severe procrastinator is almost like working with a severely depressed person: Once they are able to … do anything, they will feel better about themselves, and they’ll have more self-efficacy.” That’s why it is important to get these clients to succeed at some task, even if it is a small and relatively meaningless one such as going to the grocery store or getting the car washed, he says.

Counselors can also help clients who procrastinate to create specific — rather than generic — goals, Eddins says. For example, a goal of “meal planning” would become “planning four meals for dinner on Sunday afternoon.” The counselor can then collaborate with these clients to identify the specific actions they will need to take to meet that goal: What typically happens on Sunday afternoons? What could get in the way of this task? How can you make time on Sunday afternoons? What do you need to prepare in advance? What steps will you take to complete this task?

Some clients, especially those with perfectionist tendencies, may resist setting a small goal or task because they don’t see it as “good enough” or as an effective way of achieving their larger goal, Eddins says. In these cases, counselors may need to address the client’s black-and-white thinking and the role it can play in procrastination, she adds.

Counselors can also help clients identify optimal times to complete tasks that they have been procrastinating on, Eddins says. For instance, clients might tell themselves they will complete an unpleasant task right after getting home from work. But if the counselor knows the client doesn’t like his or her job and will likely need some time to decompress after getting home, the counselor can point that fact out and note that it increases the likelihood of the client avoiding the task, she says.

Shifting clients’ focus to what they will do — rather than what they won’t do — is another way to motivate clients, Eddins says. For example, counselors can encourage clients to think along the lines of “I’m going to come home, get a glass of water, put on my tennis shoes, go out for a 10-minute walk, and then come home and fix dinner” rather than “I’m not going to sit on the couch this evening and watch television.” Trying to avoid procrastination or its underlying emotional root makes procrastination more active and powerful in one’s mind, Eddins points out.

All of these strategies can aid clients in addressing the deeper emotional problems connected to their procrastination. McCown stresses that procrastination won’t go away by itself. “Joe Ferrari phrases it quite beautifully: ‘It’s not about time.’ It’s often something deeper,” McCown says, “and I think counselors are in a great role to figure out whether it’s just simply a bad habit or whether it’s something a little more serious.”




Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist. Contact her at or through her website at

Letters to the editor:




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.

Voice of Experience: Looking for honesty in the supervisory relationship

By Gregory K. Moffatt

Sitting in a workshop for supervisors at the American Counseling Association’s annual conference in 2018, I listened to the presenter discuss cases of ethical violations by licensed counselors around the country. All of us in the room were stunned at some of the flagrant violations that had occurred. Among the examples presented were counselors sleeping with their clients, marrying past clients, and seeing clients regularly in social settings. Some of these counselors were disciplined by their state licensing boards, while others voluntarily surrendered their licenses and left the profession.

It’s a good thing that none of them lived in Georgia, the state where I practice, or they could have gone to jail. In Georgia, it is a felony to sleep with your client or to terminate with a client for the explicit purpose of engaging in a sexual relationship.

The 25 or so supervisors in the room were surprised at the risks these counselors had taken. The obvious question was: “How did it get that far?” We were stunned that any professional would throw all of their education and training away so casually, not to mention the damage they might have done to their clients.

Around the same time, I was managing a situation in which one of my supervisees had committed an unintentional ethical violation right before being fully licensed. This counselor, whom I’ll call Pat, had made a mistake and realized the error within a few days. Without hesitating, Pat called me to ask how to correct it.

We worked through the scenario and came up with a plan. Then came the question I had anticipated from Pat: “What does this mean in regard to you signing my paperwork next month for licensing?”

The harsh answer was that I would not be able to sign off on the paperwork at the time. This particular ethical violation served as clear evidence that Pat wasn’t ready yet for a license, or else the lapse wouldn’t have occurred. Such a scenario is exactly why we undergo supervision as counselors. Supervision isn’t a formality.

My decision wasn’t the end of the line for Pat though. Pat accepted the consequences of the breach and the remediation that I required. As a result, just a few months later, I was happy to sign off. Pat is now fully licensed and in a successful private practice, and I haven’t an iota of concern that Pat will make such a blunder again.

Sitting in that ACA workshop, I realized how fortunate I was that Pat had trusted me enough to risk a delayed license by telling me what had happened. I realized that I must have done something right as a supervisor, although it wasn’t deliberate in regard to Pat’s particular issue.

After that incident, I started speaking more overtly with all of my interns and supervisees about what they would do should they commit an ethical violation that might delay them getting their license. I told them I was wondering whether I had created an appropriate environment (as I must have done with Pat) so that they would be willing to tell me about any violations. This opened up a discussion that continued for several weeks.

My story here isn’t meant only for supervisors. If you are currently a graduate student or counselor in supervision, I hope that you have a trusting relationship with your supervisor. If you don’t — if you couldn’t go to her or him and say, “I messed up,” even when knowing that your licensing process may slow down — you need to either adjust that relationship or find another supervisor.

If you are a supervisor, you must make this an overt part of your discussions with supervisees. Since that 2018 ACA Conference, I have had conversations about this issue on a regular basis with all of my new supervisees and interns, and I believe it has strengthened their trust in me. My situation with Pat was one of only a very few serious ethical issues I have had to manage as a supervisor. Even so, we must be prepared for them, and we must prepare our future counselors for them.

Perhaps most importantly, if you are licensed, you must have a confidant or mentor in the field whom you trust enough to confide in when you make mistakes. This person can guide you through sticky ethical situations and must also be willing to tell you when you have messed up. This brings the risk of being reported to a licensing board, but taking that risk is crucial to our professionalism as counselors. The greater risk in an ethical breach is to the client. What it costs us is secondary.



Gregory K. Moffatt is a veteran counselor of more than 30 years and the dean of the College of Social and Behavioral Sciences at Point University. His monthly Voice of Experience column for CT Online seeks to share theory, ethics and practice lessons learned from his diverse career, as well as inspiration for today’s counseling professionals, whether they are just starting out or have been practicing for many years. His experience includes three decades of work with children, trauma and abuse, as well as a variety of other experiences, including work with schools, businesses and law enforcement. Contact him at



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.

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.”




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.”



Additional resources

For more information on depression, access the American Counseling Association’s webpage of resources at

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


Contact the counselors interviewed for this article:



Bethany Bray is a senior writer and social media coordinator for Counseling Today. Contact her at

Letters to the editor:




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.

From Combat to Counseling: Comprehensive mental health in the military-affiliated population

By Duane France October 17, 2019

Often, when talking about mental health in the military-affiliated population, the first thing that comes to many people’s minds is posttraumatic stress disorder (PTSD). This is true of mental health professionals as well.

Once, a colleague asked me how many deployments I had in my military career. When I told her that I had five combat and operational deployments, she said, “Well, of course you have PTSD!” In reality, the number of deployments doesn’t dictate the level of traumatic events to which a service member has been exposed. A client could have multiple deployments and not have experienced anything worse than separation from family, whereas another client could have experienced only one very serious and traumatic deployment.

It is important to understand what we are talking about when we discuss mental health in the military-affiliated population. It is critical to understand the culture of the military and to understand who we are talking about. However, as mental health professionals, it is equally important to understand the potential psychological impacts that our clients have experienced.



Although PTSD is not representative of everything that service members deal with after the military, it is a condition that any counselor working with the military population must understand. It has been described in a number of different ways throughout history, including “soldier’s heart” in the Civil War, “shell shock” in World War I, and “battle fatigue” in World War II and the Korean War. After the Vietnam War, the symptoms that would come to signify PTSD were called “post-Vietnam syndrome.” It wasn’t until the third edition of the Diagnostic and Statistical Manual of Mental Disorders, published in 1980, that PTSD became an official diagnosis.

There are a number of PTSD diagnostic criteria outlined in the DSM-5, the most significant of which is that the service member must have been exposed to an event that resulted in death, threatened death, actual or threatened serious injury, or sexual violence. The service member or veteran must have been exposed either through direct exposure, witnessing the trauma, learning that a relative or close friend was exposed to such trauma, or experiencing indirect exposure to details of the trauma in the course of professional duties. This is significant. Just because a service member was deployed to a combat zone does not mean that the service member was exposed to an event that meets this criterion; this was certainly true for three of my five deployments. Being able to differentiate between PTSD and other psychological conditions is critical to supporting the client.



Another condition emerging as an important consideration is traumatic brain injury (TBI), which is also known as a concussion or mild, moderate, or severe TBI. Military equipment and medical response have improved significantly over the past 50 years, resulting in greater survivability on the battlefield. Injuries that previously might have been fatal are now being treated quickly and effectively. While this development has reduced the mortality rate in recent conflicts, it has led to an increase in the number and severity of catastrophic injuries.

Further complicating TBI is the fact that many of its symptoms overlap with those of PTSD, and many of the conditions that could cause TBI also meet criterion A for PTSD. Whether it is a blunt force trauma concussion from a direct blow to the head or a diffuse TBI caused by blast overpressure from an explosion, the causes of TBI could also be causes for PTSD (and vice versa).



Addiction is another important mental health consideration in the military-affiliated population. This of course includes substance use. Many of us who served know that the military is a drinking culture. Drinking is normalized and used to relax, to celebrate, to memorialize. Regardless of rank or branch of service, alcohol is acceptable and available.

It is problematic, however, when the reason for alcohol use changes from celebration to self-medication, or using alcohol to reduce discomfort from psychological concerns. Additionally, the opioid epidemic in the veteran population typically begins during active duty. Because of the extreme chronic pain that results from multiple injuries, pain management is a necessary consideration, and painkillers are readily available.

In addition to substance use, it is also imperative to explore process addictions in the military-affiliated population. Whether it involves gambling, viewing pornography, compulsive eating or shopping, compulsive and addictive behaviors can cover the veteran’s or service member’s underlying concerns.


Photo by U.S. Army Sgt. Victor Perez Vargas/

Emotional dysregulation

Difficulty tolerating and managing emotions is another significant aspect of mental health for the military-affiliated population. While there are certainly emotional components to PTSD, TBI and addiction, it is also possible for emotional challenges to exist apart from substance use, trauma exposure or physical injury. For many service members and veterans, the typical dysregulated emotions are depression, anxiety and anger.

Among the nontraumatic causes for an inability to manage these emotions are toxic leadership and systemic harassment. An inability to escape from an adverse situation can lead to feelings of helplessness and hopelessness. I will emphasize again that there are many situations in the military that could cause anger, anxiety and depression that have nothing to do with exposure to traumatic events. It is necessary to determine whether emotional dysregulation or substance use is the result of traumatic exposure or another cause.

These aspects of mental health are not unique to the military of course. Combat trauma is not the only cause of PTSD, and any significant blow to the head can cause TBI. Addiction is not a problem just for the military population, and emotional concerns such as depression and anxiety are widespread. Additionally, these conditions follow the medical model of mental health; there is a diagnosis for each of them and corresponding medications for each of them. Although these conditions can be debilitating in and of themselves, there are other factors unique to the military population that can complicate attempts to treat service members, veterans and their families.


Meaning and purpose

Although service in or affiliation with the military can be difficult, it can also be extremely satisfying. There is a collective effort toward a common goal, a sense of shared culture and community, and a feeling that the work you’re doing is important. Many veterans, upon leaving the service, struggle to find the same satisfaction in their post-military careers. Many are able to build a meaningful life after the military, but it is not automatic.

There is also the challenge of navigating an identity shift. Whether it’s for four years, 14 years or 24 years, the service member’s identity is closely tied to the military. We were Soldiers, Airmen, Sailors, Marines, or Coast Guardsmen literally 24 hours a day. Even if not serving full time, as is the case in the National Guard or Reserve components, service members are always aware of a type of double life. When we leave the service, many of us ask ourselves, “Who am I if I’m not a soldier?” A friend of mine, a medically retired Green Beret, expressed this quite well when he stated, “The Army said I couldn’t be me anymore. What do I do now?


Moral injury

Another concept that has emerged over the past 25 years is moral injury. PTSD, at a very basic level, is an injury of the behavior. It is classic conditioning: When a triggering event occurs, a certain reaction is initiated. It is, of course, more complicated than that, but a significant aspect of PTSD is stimulus response. TBI, on the other hand, is a physical injury of the brain. Moral injury can be described as an injury of the soul: What a service member believes to be right and wrong with the world has been fundamentally changed.

In one of the first articles to fully develop an explanation of moral injury, Brett Litz and colleagues described moral injury as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations.” There is some disagreement as to whether moral injury is an aspect of PTSD or its own distinct condition. the fact is that one can have a morally injurious event that is not traumatic, and there are a number of traumatic events that are not morally injurious. Regardless, it is beneficial for anyone interested in working with the military population to familiarize themselves with moral injury and to at least explore the concept with these clients.


Needs fulfillment

The military is a highly connected communal society where tasks are divided among its members. When I was in Iraq and Afghanistan, I didn’t have to worry about where my food and water would come from because there were other service members or contractors who provided that. When my family and I arrived at a new duty station, we were provided housing, and there were people on base who gave us guidance on schools for our children.

Of course, when service members leave the military, those same needs still have to be fulfilled, but now it must be done in different ways. This isn’t to suggest that service members aren’t capable on their own, but challenges related to employment and housing — those lowest levels of Maslow’s hierarchy of needs — are widely known in the veteran population. Even our psychological needs, such as belongingness and esteem, are part of the military framework. Our peer group is provided for us; like them or love them, the people you serve with are your family. Your effort is recognized with rank or reward. Outside of the military, however, we have to learn how to meet those old needs in new ways … and for some service members, that can be difficult.



The final aspect of mental health in the military-affiliated population that I’ll discuss is relationships. Our mental health affects our interactions with others, and our interactions with others affects our relationships. Whether it is frequent separation, moving households every three or four years, or relationships with people who are literally on the other side of the world, the relationships of those in the military population are necessarily different from those who have never served.

When considering how military service impacts relationships and vice versa, it is important to understand that this doesn’t just refer to intimate relationships such as spouses and children, or even parents and siblings. This also includes peer relationships (friends and acquaintances) and work relationships. Understanding how to integrate into a community that has a different cultural orientation than you do is difficult. Even if none of the other psychological concerns mentioned in this article are prominent, adapting relationships to a new lifestyle can be challenging.


Considering all aspects of psychological wellness

It can be daunting to consider how these various aspects may interact to provide an almost never-ending combination of circumstances for members of the military-affiliated population. One thing is clear though: The more of these areas that the service member, veteran, or military family member has difficulty in, the more at risk they are.

As professional counselors, we need to be able to understand the complexity of our clients’ conditions. We need to ensure that we have a full picture of their needs and then address those needs if possible. If an area is outside of our expertise — if we are not trained in an evidence-based practice for PTSD, for example — then we have an ethical responsibility to refer that client to someone who can meet their needs.

In this way, we are providing the best possible care for those who serve, those who have served, and those who care for them.




Duane France, LPC

Duane France is a retired U.S. Army noncommissioned officer and combat veteran who practices as a licensed professional counselor in Colorado Springs, Colorado. He is the director of veteran service for the Family Care Center, a private outpatient mental health clinic specializing in service members, veterans and their families. He is also the executive director of the Colorado Veterans Health and Wellness Agency, a 501(c)3 nonprofit that is professionally affiliated with the Family Care Center. In addition to his clinical work, he writes and speaks about veteran mental health on his blog and podcast at Contact him at



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.

Maldistribution: Mental health care in America

By Bethany Bray October 14, 2019

Access to mental health care varies greatly depending on where one lives in the United States. This variance is so great that Mental Health America (MHA) referred to the situation as a “maldistribution” of behavioral health providers in a recent report.

In Massachusetts, there is a mental health provider for every 180 residents, which marks the best ratio in the nation. On the other end of the spectrum is Alabama, which has the nation’s worst ratio at 1,100 residents for every one mental health provider. Texas, West Virginia, Georgia, Arizona, Tennessee, Mississippi and Iowa are the others states that have ratios of 700:1 or worse.

MHA, a Virginia-based nonprofit advocacy organization, compiles a report of mental health indicators each year from nationwide survey data, including information from the Substance Abuse and Mental Health Services Administration and the Centers for Disease Control and Prevention. In tabulating its ratios, MHA included counselors, psychiatrists, psychologists, licensed clinical social workers, marriage and family therapists, and nurses specializing in mental health care in its definition of mental health provider.

MHA’s report, The State of Mental Health in America, was released in September.

When weighing access to mental health care and insurance against prevalence of mental illness, substance abuse, suicidal ideation and other factors, MHA ranked Pennsylvania, New York, Vermont, Rhode Island and Maryland as the top five states (in that order) for mental health in its most recent report. Nevada was ranked last in MHA’s list, preceded by Oregon, Idaho, Utah and Wyoming.

The organization also recognized Rhode Island as rising from 27th to fourth in its overall rankings over the past six years. In contrast, Alaska has gone from 17th to 46th, Kansas from 18th to 42nd, and North Carolina from 16th to 35th during that same time period.

MHA tracks a number of other mental health indicators in its annual report, including statistics on youth and adults with substance use disorders, depression and suicide, as well as insurance coverage and rates of treatment and other data. MHA notes that rates of overall mental illness (defined as “having a diagnosable mental, behavioral or emotional disorder, other than a developmental or substance use disorder”) among American adults have remained relatively stagnant, increasing from 18.19% to 18.57% between 2012 and 2017. However, suicidal ideation among adults rose from 3.77% to 4.19% over those six years.

Of note is a more than 4% increase in prevalence of past-year major depressive episodes in youth ages 12 to 17 (an increase of 8.66% to 13.01% from 2012 to 2017).

“While ensuring that youth with mental health conditions have greater access to care is vitally important, the only way to address the rising prevalence of mental health conditions in youth is to address the upstream causes on a population level,” wrote MHA. “States must invest time and resources into researching and understanding the causes for this drastic worsening of mental health in youth ages 12-17 and generating meaningful and effective policies and programs to address mental health concerns before they reach the point of becoming a diagnosable mental health condition.”




Mental Health America’s The State of Mental Health in America 2020

When it comes to mental health, how does your state stack up?

View the full report and state rankings at

State-by-state ranking of adult mental health factors (page 16 of MHA’s report;




CT Online’s recap of MHA’s 2019 report: “America’s mental health disparities





Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at




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.