Depression is a common mental health disorder and affects people from every walk of life, regardless of their age, race, ethnicity or socioeconomic background. According to the National Alliance on Mental Illness, approximately “21 million adults in the United States — 8.4% of the population — had at least one major depressive episode in 2020.”
Common treatments for depression often include cognitive behavioral therapy (CBT) and psychotherapies that focus primarily on a client’s past. However, they are not the only approaches counselors can use. Solution-focused brief therapy (SFBT) and acceptance and commitment therapy (ACT) are evidence-based counseling approaches that have also been found to be effective in treating depression. Counseling Today asked six counselors to discuss the effectiveness of these two clinical approaches for treating clients with depressive symptoms.
Fostering hope through SFBT
By Foley L. Nash
For me, one factor in the effectiveness of SFBT is the set of themes that runs through its basic tenets. The main themes are building exceptions to the presenting problem and making rapid transitions to identify and develop solutions intrinsic to the client or problem. These themes resonate well with clients, particularly those experiencing depression, as well as with a subset of depressed clients who experience comorbid anxiety, which can occur in as much as 70% of depression cases.
In treating depression, the emphasis of a solution-focused approach is to counter hopelessness, which is an important and common factor related to the frequently present risk of suicide. SFBT benefits depressed clients by engendering hope for the possibility of finding solutions in ways that are tied to the following basic tenets:
- A focus on competence, not pathology (emphasizing the client’s power and hope)
- The goal of finding a unique solution for the individual client (not a cookie-cutter approach)
- The use of exceptions to the problem to foster optimism (hope)
- The use of past successes to support/increase client confidence (hope)
- The view of the client as the expert (acknowledging the client’s power)
- The use of goal setting in charting a path to change (scaling questions are important in goal setting)
- A shared responsibility for change between client and therapist (supportive partnership)
In SFBT, the emphasis shifts from problems to solutions, which empowers clients by allowing them to access their own internal resources, strengths and prior successes.
The following are the aspects of SFBT that appeal to me:
- It’s an evidence-based practice (EBP) and its proven effectiveness has been documented. As a managed care clinical director, I see increased emphasis on EBP providers by large payers. In my private work, employee assistance programs also like the use of EBPs for the greater likelihood of faster change in their shorter treatment episodes.
- It’s largely focused on the skillful use of language for therapeutic purposes. As the Greek philosopher Epictetus said, “People are disturbed not by things, but by the views they take of them.” Helping clients to see things differently is one of the useful functions of SFBT, which allows clinicians to ask questions such as, “How did you make that improvement happen during that time?” or “What would your best friend say you did differently when things were better?”
- As a former language teacher/linguist who now conducts therapy in English and Spanish, I ascribe to the outlook that language is the tool of thought. SFBT can be immediately helpful in guiding clients to think differently about potential solutions. Instead of accepting that clients are as helpless as they may feel, counselors can try asking about how they have managed to achieve and sustain some of the times when the problem was absent or less severe. It’s helpful for the therapist to have some affinity for fluency in language and in the SFBT tools. As counselors study some of the SFBT principles, strategies and techniques, they will encounter many examples of questions that use language in helpful ways to change a client’s perspective, and they can become more skilled, thoughtful and proactive about how to use language to bring about a shift in a client’s perspective.
- I’ve found over time that SFBT and its tools are also very helpful in helping clients become “unstuck” and breaking an impasse.
SFBT focuses on helping the client to reframe the situation, develop second-order change that supports solutions, and see the situation as something they can manage and change by using their own strengths and abilities. While first-order change is behavioral, as in doing things differently (sometimes described as matter over mind), second-order change is conceptual (often described as mind over matter) and involves helping a client to see things differently. This type of change can help a client with depressive symptoms to be more readily able to make the desired behavioral change to move toward a modified or new solution.
I have also found that SFBT is effective in treating depression along with comorbid anxiety. In my practice, clients frequently present with both depression and anxiety. It’s useful to focus initially on whichever condition is creating the most significant impairment in functioning for the client. This can provide a quick initial improvement and encourages the client to continue to address the less problematic condition, which, in my experience, is usually the anxiety.
Comorbid anxiety and its occasional panic attacks often engender fear in clients, especially the fear of the next panic attack after an initial one, as well as the corresponding sense of fear about the loss of control. By providing hope to clients, SFBT has treatment application for both depression and anxiety.
— Foley L. Nash is a licensed professional counselor supervisor with a private practice in Baton Rouge, Louisiana. He works mostly with adults and often provides short-term employee assistance program services. Contact him at firstname.lastname@example.org.
Working toward a solution-focused goal
By Marc Coulter
Jeremy (a hypothetical client) was hopeful and enthusiastic early in life, but after a cross-country move and a long-term relationship ended just before the pandemic, he had difficulty coping.
Some days, Jeremy couldn’t get out of bed to work. Other days, he showed up, but he felt dark and hopeless and didn’t care whether he lived. Jeremy’s depression continued through the pandemic and medication didn’t help.
When working with severely depressed clients such as Jeremy, SFBT practitioners maintain a stance of optimism and hope, knowing that a client’s past experiences and feelings of depression do not determine future outcomes.
A solution-focused perspective directs the course of therapy toward solutions, rather than focusing on problems, and guides the questions we ask. With empathy, compassion, respect, curiosity and hopefulness, we acknowledge and honor whatever agonizing feelings, or perhaps the lack of feelings, clients such as Jeremy experience while co-creating a preferred future.
SFBT counselors often explore what gives depressed clients hope. In Jeremy’s case, what gave him hope was knowing that change was possible. Sometimes clients live their lives and show up to counseling sessions despite not feeling hopeful. SFBT counselors explore how clients show up and participate in their lives despite the lack of hope. In session, we reaffirm what they’ve said is meaningful in their lives and why it may be important to keep moving forward despite the lack of hope.
In the book Tales of Solutions: A Collection of Hope-Inspiring Stories, Insoo Kim Berg, who along with Steve de Shazer co-founded SFBT, and Yvonne Dolan wrote that SFBT counselors begin therapy with a detailed description of a client’s desires. Clinicians can then explore possible times when these desired outcomes may have been present, even in small ways, to find solutions to their problems. The solution-building process for Jeremy might include questions such as “How might you want to cope given your circumstances? How have you been able to manage up until now? What helps even a little? What helps you make it through the day?”
If Jeremy couldn’t imagine even one small movement toward feeling better, the counselor might ask, “What helps prevent it from getting worse?”
Focusing on Jeremy’s best hopes for therapy, the counselor might also say, “Suppose you’re walking away from our last session together and you’re thinking to yourself, ‘That was a really good use of my time, energy and money.’ What would you be walking away with that would make a difference?” Jeremy might respond, “Maybe I would feel less depressed.” The counselor could then ask, “Yes, of course, and if you felt less depressed, what might you feel instead?” Jeremy might say, “I guess lighter, more hopeful.”
The miracle question
When working with a client who is overwhelmed, depressed and suicidal, solution-focused counselors often ask the “miracle question,” a concept co-developed by Berg and de Shazer. The miracle question includes components of what the client has determined is a meaningful and important solution to their problem. In Jeremy’s case, that was “feeling lighter, more hopeful.”
Using this technique, the counselor could ask Jeremy if it would be a miracle to feel this way, and Jeremy would agree. The counselor could ask him to imagine that while he was asleep the night before, a miracle happened. He would feel lighter and more hopeful, but because he was sleeping, he would have no idea the miracle happened.
The counselor could then ask Jeremy, “What might be the first thing you notice upon waking that would let you know that something was different?” After a pause, he might reply, “I would get up and not stay in bed.” The counselor and Jeremy could then explore how this would make a difference to him and the important people (and even pets) in his life. They could continue to slowly explore Jeremy’s miracle morning and the differences he and others had noticed.
The counselor could also use scaling questions, an SFBT tool, which can help to ground the miracle day for Jeremy in the reality of his life. For example, a scaling question might be, “On a scale of 1 to 10, with 10 being that miracle day and 1 being life prior to beginning counseling, where are you right now?” Jeremy may reply and say a 2. The counselor could then ask why he was that high (why he didn’t choose 1 or even -12) and explore what he was doing in his life that put him at that level rather than a lower one. Jeremy might name things like engaging with colleagues and taking care of his dog. Next, the counselor could ask him to imagine what he could do that would put him just a little higher on that scale, maybe even a half a point, and what difference that might make?
— Marc Coulter is a licensed professional counselor in Lakewood, Colorado. He is a member of the American Counseling Association and past president of the Colorado Counseling Association. Contact him at email@example.com.
The benefits and limitations of SFBT and CBT
By Nicole Poynter
SFBT and CBT are both effective in treating depression, but in different ways. Here are some of the benefits and limitations of both.
If a client’s purpose for coming to therapy is to find a solution to a problem, then SFBT may be the right therapeutic approach. SFBT usually lasts for six to 10 weeks and focuses on a client’s strengths and capabilities. SFBT pays attention to the client’s problems in the present. In counseling, we believe that individuals have the inner resources, strengths and skills that are needed to help them to achieve their goals and overcome difficult life situations. The purpose of SFBT is for therapists to focus on a clients’ capabilities. This therapeutic technique focuses on problem-solving, generating solutions and moving toward a goal.
The benefits of using SFBT for treating depression include the fact that it is short term and that is more cost effective than long-term therapy. Another benefit is that the counselor uses compliments in therapy, such as “That is amazing to hear,” when a client talks about a goal that has been met or a strength that was used, which can help to motivate clients to work toward their therapeutic goals. SFBT is also future-oriented, so clients do not get stuck in the past. The therapist focuses on what the client thinks their life will be like once the concern is resolved.
However, there are some limitations for choosing SFBT as a therapeutic model of choice. Some clients take more time to open up in therapy, so having only a few weeks for treatment does not make it easy to solve problems. This modality also focuses on the present, and it does not investigate the past and past traumas, which often contribute to unhealthy behaviors in the present. In addition, the counselor must trust the client and accept what the client desires for treatment, even if their goals are not beneficial. SFBT relies heavily on the therapist and client working together and works on the assumption that the client is willing to do the work to achieve their goal.
CBT helps clients look at problems differently and encourages them to think in healthier ways. This approach focuses on thoughts, feelings and behaviors and how they are all connected. If a client has a negative thought, it can lead to a negative emotion, which can lead to unhealthy behaviors. In a CBT session, the counselor focuses on the client’s negative thinking, or cognitive distortions. Counselors help clients look for evidence to support a thought and evidence to support their thought distortions. After clients determine that they have more evidence against a negative thought, then they can work with the counselor to turn it into a more positive thought.
There are some also some disadvantages to using CBT to treat depression. This approach is not intensive, so it is better for people with mild depressive symptoms. CBT has a high client dropout rate, which can be due to the hard work that is required in therapy or because it is not a quick fix. Although CBT is the strongest evidence-based treatment for depression, it takes a commitment to make it work. Clients must continue to use the skills they have learned to help prevent relapses.
Neither one of these modalities is easy for clients. Homework is vital for both approaches, so clients can practice what they have learned in session. Change is gradual and takes time to manifest. There is no one-size-fits-all treatment for improving mental and emotional well-being.
Both therapeutic treatments are effective in treating depression, so how does one know which one to use in practice? Talk to clients to understand their goals and preferences. Clarifying goals for therapy with a client will help determine what treatment modality is most appropriate. Being a therapist who is empathetic, client-centered and supportive is what is most important, regardless whether they use SFBT or CBT.
— Nicole Poynter is a licensed professional clinical counselor at Avenues of Counseling and Mediation LLC in Medina, Ohio. She works with children, adolescents, adults, and families and specializes in anxiety, depression, LGTBQIA+ issues, attention-deficit/hyperactivity disorder, parenting concerns, relationship distress, anger management and adjustment issues. Contact her at firstname.lastname@example.org.
Rekindling connection to self and others through ACT
By Lottena Wolters and Caitrin McKee
Since I (Lottena) began my D.C.-based private practice in 2016, new clients have increasingly presented with a profound loss of faith, but not in the religious sense.
Theirs is a loss of faith in personal safety, which is included in the second level of Maslow’s hierarchy of needs, along with law and order, physical security and economic stability. Some of my clients have also lost faith in themselves and their fellow human beings and feel acutely disconnected from the communities outside their inner circles. This loss of faith is the primary and most persistent symptom of their depression.
How do we help our clients feel connected and experience joy when they are bombarded with stressors such as news of political division, the ongoing COVID-19 pandemic and the worsening impacts of climate change? It can be deeply distressing to realize we lack the power to change the turmoil in the world, especially for our clients who are experiencing depression.
But what if the goal of therapy is not to change our clients’ emotions or reduce their depressive symptoms, but instead enable them to compassionately accept their feelings while engaging less with self-bullying thoughts? ACT is an evidence-based mental health approach that helps clients learn to accept what is out of their personal control and commit to actions that improve satisfaction with their quality of life.
Some of the most meaningful outcomes of ACT for depressed clients are increased resilience, a measure of one’s overall wellness that can reduce the risk of depression, and greater self-compassion. Self-compassion allows us to experience negative events and emotions with acceptance, which leads to a reduction of suffering.
At the onset of treatment, I (Lottena) have clients complete a resiliency questionnaire, a stress inventory and the Valued Living Questionnaire (VLQ). The VLQ is an ACT self-directed tool used to help clients assess their values across 10 domains of living (family, marriage/couples/intimate relations, parenting, friendship, work, education, recreation, spirituality, citizenship and physical self-care) and evaluate how successfully they have lived in accordance with those values in the past two weeks. Clients are asked to rate the 10 domains on a scale of 1 to 10, with 1 being “not at all important” and 10 being “very important.”
I (Lottena) find that clients who are experiencing depression often rank themselves at a 2 or 3 in the domains that are most valuable to them. These clients will also score low on resiliency and high on external stressors. This was the case for one of my former clients, who I will refer to as “Mr. A.”
Soon after rapport was established in therapy, Mr. A completed the resiliency questionnaire, stress inventory and VLQ. He scored high on stress and low on resiliency. The VLQ illustrated that Mr. A felt he was unable to prioritize his life, primarily his marriage, work and family. He ranked himself between a zero and a 2 for how successful he had been at living in accordance with his values during the previous two weeks. This client could not fathom how to get above a 5, and he felt that he should be a 10 in each domain.
Mr. A’s hopelessness was so intense that he would either disconnect from his feelings to function professionally and socially or drown himself in his sadness. Mr. A woke up with feelings of dread and felt hopelessly unmotivated about work, often arriving at least an hour late for his job. He socialized only when he was intoxicated, and he avoided conversations with his family. Mr. A reported that his wife complained he was only present in body but not in spirit. His depression impacted all areas of his life.
After using ACT therapeutic interventions (such as the willingness and action plan and exercises that incorporate mindfulness practices) in session, this client began to rank his success in these domains at a minimum of a 6, and usually higher, for most two-week periods. His faith in himself and his loved ones was seldom below a 5, even when he experienced an episode of depression. And he could connect to his feelings of optimism, pride and joy.
Mr. A’s depression now has significant periods of remission, and when he experiences depressive symptoms, they rarely cause major problems for him at work, home or socially. The acceptance of both his depressed symptoms and new positive emotions allows him to treasure and protect his joyful experiences. He has undergone a profound transformation through his dedication to the ACT process.
Thus, counselors should be open to trying ACT, which is sometimes overlooked as a therapeutic approach. I (Lottena) have utilized ACT for over 14 years as a clinician, and I often recommend it during supervision sessions with newly licensed therapists and graduate students. I find that ACT is flexible enough for both younger clinicians and more experienced clinicians who treat clients reporting increased feelings of hopelessness and persistent depression. And I can say that both the research and my own personal experience demonstrate its effectiveness with depressed clients.
— Lottena Wolters is a licensed professional counselor and founder of the F.L. Wolters Group in Washington, D.C. She works with young adults and adults struggling with anxiety, mood disorders and attention-deficit/hyperactivity disorder. Contact her at email@example.com.
— Caitrin McKee is a registered yoga teacher and the patient care coordinator at the F.L. Wolters Group in Washington, D.C.
Helping clients become unstuck with ACT
By Jared Torbet
In the initial assessment, Camie (pseudonym) presented as depressed, unmotivated and indecisive, and she ruminated on her insecurities, which are all common symptoms of depression. She also used humor and a noticeable dismissal or minimizing of her feelings. Once I noticed these avoidant strategies, I felt ACT would be a good fit for this client.
At our next session, I helped Camie notice and name her internal experiences, including her thoughts, feelings and sensations; this is a basic mindfulness skill that Steven Hayes, the psychologist who founded ACT, believes is the most important mindfulness skill one can master. Camie’s internal world came into view as she began to notice and name that world in the present moment with ease.
We progressed to working with those internal experiences in a more helpful and workable way than she was accustomed to. Before I go further, let me share a warning label that comes with ACT. As therapists, we must do ACT, not explain ACT. It was vital that I guide Camie through an experiential journey, not a psychology lesson. Camie had a hard time differentiating herself from her depression, insecurities and fears. She was stuck.
I asked her to hold her depression, insecurities and the reality of being stuck in her hands and imagine it as an object. She described it to me as a big, heavy, lava-red, smokey, hot, smooth, oval-shaped sphere that was about 2 feet wide and 1 foot tall. “Where do you feel this object?” I asked. She replied, “Right here on my chest.”
Together, we playfully engaged with the object. We handed it back and forth. I had her set it on the coffee table between us and walk to the other side of the room. I said, “If this stuff is sitting here on this table, and you’re standing over there, what does that tell us?” She replied, “I’m not that stuff.”
She noticed a feeling of freedom and motivation from this exercise. This led us to discuss the range of her values, including relationships and career goals, as well as her fears and doubts. I guided her through an expansion exercise. We both breathed deeply while widening our arms and imagining making room for values, goals, fears and doubts. I asked how much of her energy is spent on these important things. She said, “Pretty much none.”
“You spend so much time and energy trying to figure out, or get rid of, this heavy, red sphere,” I told her. “What would happen if you spent that time and energy on the things that matter the most to you?” She replied, “I would probably be a lot further in my life.” I asked, “Where would you be?” Without hesitation, she told me, “I would be teaching English as a second language (ESL) overseas.”
I said, “Wow, that sounds amazing! What is stopping you from going?” She smiled and replied “this” while she simulated holding the heavy, red sphere. So I asked, “What if you packed it in your suitcase, and just took it with you?”
I could see the wheels turning. This was our segue into her accepting and allowing fear and doubt to be there. I taught her that her fear, which shows up as anxiety, is just trying to protect her. When she imagined her fear/anxiety, it took the form of her child-self.
I used the analogy of her being the captain of her own ship, with her thoughts, feelings and sensations being her deck mates. It felt right to offer the choice of inviting her child-self on board as co-captain. This helped her to organically embrace self-compassion and self-love. I told her that she cannot control all her deck mates, but she can guide the ship and build tolerance for those on board. And as long as she’s traveling in the direction of her values, her deck mates won’t cause as much ruckus, and some will even help her, especially her co-captain.
Camie, through her dedication to therapy and her hard work in session, was able to notice her thoughts, feelings and sensations. She was able to see the difference between her internal experiences and herself. She was able to defuse, or unhook, from unproductive thoughts, while bravely accepting her emotions and sensations. She learned to align her choices and actions with what mattered most to her, such as teaching ESL overseas, which she eventually did.
ACT is not for everyone. In my experience, ACT requires a client to be able to practice mindfulness and engage in mental imagery. Clients with aphantasia (the inability to voluntarily create mental images in one’s mind), for example, would most likely benefit from a different modality. Also, in cases where the client is at risk of suicide, homicide, child/elder abuse, domestic abuse, trafficking and other high-risk behaviors, including self-harm, more immediate and tangible interventions should be considered with safety as top priority. These are situations that should not be accepted but avoided and reported.
— Jared Torbet is a licensed professional counselor and owner of Anxiety & Depression Clinic of Columbia in Missouri. He specializes in adults and teens who struggle with anxiety, depression or attention-deficit/hyperactivity disorder. Contact him at firstname.lastname@example.org.
ACT: The mindful approach
By Katy Rothfelder
ACT is an empirically supported and evidence-based treatment for individuals experiencing depression, yet it is an approach many clinicians are not trained or fully comfortable exploring. For clients experiencing depression and the clinicians who use ACT to treat them, we must first come in contact with the totality of human suffering. From this place, we can bear witness to the suffering within our clients in the here and now. It is from this willingness to let suffering come close, to see it as one of the many thousands of threads forming one cloth of the client, that we as clinicians can form a workable framework for the way in which internal and external experiences are woven to diminish valued living, as noted by Kelly Wilson and Troy DuFrene in their book Mindfulness for Two: An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy.
ACT moves beyond the language composed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This approach, which includes self as context as one of its core processes, defies labels such as “depressed client,” and instead appreciates the unique, narrow and broad experiences of the client. It takes the language and behaviors the client exhibits, such as “there’s no point,” and looks to transform those overt and covert behaviors into valued, flexible ways of being.
Mindfulness practice is a critical part of ACT. It can be argued that mindfulness, as it is understood in contemplative practices, is the totality of many of ACT’s six core processes — acceptance, defusion, self as context, values, committed action and contact with the present moment. And ACT’s core process of contact with the present moment is what we might contextualize as modern-day mindfulness. According to Jon Kabat-Zinn in his book Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, mindfulness is “paying attention in a particular way: on purpose, in the present moment, nonjudgmentally.”
Unique to ACT is the way in which the six core processes interact, merge and flow with one another. They are not mechanistic in form, but rather are existent within a particular context and in service of creating psychological flexibility.
Lindsay Fletcher and Steven Hayes, in their 2005 article “Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness” published in the Journal of Rational-Emotive and Cognitive-Behavior Therapy, defined psychological flexibility as “contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values,” which can also be considered a workable definition of mindfulness.
Psychological flexibility is a practice and the outcome we continuously return to in ACT. Rather than seeking to get rid of unwanted, unpleasant thoughts or experiences, ACT aims to support individuals in living full, rich and meaningful lives without defense, while also engaging in the moment with what is most important to them. With many clients experiencing depression, as well as other experiences such as anxiety or trauma, contacting the present moment in a particular way can be helpful in reconnecting with valued living.
Contacting the present moment involves commitment and deliberate action, drawn from one’s values, with an awareness of the self as containing thoughts, emotions, roles, bodily states and memories. In essence, ACT supports individuals in experiencing their “wholeness,” with flexibility and persistence in valued living.
ACT is not done to a client, but rather is experienced with and between the client and clinician, moment to moment, in a flexible, processed-based practice.
— Katy Rothfelder is a licensed professional counselor associate who is supervised by John Hart at the Anxiety Treatment Center of Austin in Texas. She specializes in obsessive-compulsive disorder and related disorders, anxiety, depression, trauma and neurodiversity. Contact her at email@example.com.
Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at firstname.lastname@example.org.
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.