Tag Archives: Adult Development & Aging

Midcourse corrections

By Stacy Notaras Murphy September 24, 2014

Picture a female client facing a bleak employment market, stressing out about finding a new living space and struggling to find a boyfriend who wants the same things she does. She also suffers from low self-esteem and has been dabbling in some disordered eating.

Based on that description, perhaps you are envisioning a millennial in her mid-20s. In fact, this client could just as easily be 60 years old and confronting the same complicated issues that we typically Lady-Smallassign to younger people. Women in “midlife,” defined for our purposes as age 45 and beyond, may face career issues, changes in their primary coupling, challenges parenting adult children and becoming caregivers to their own parents — all at a time of life when Hollywood tells us they should either be enjoying complete success or be thoroughly ignored as popular culture trains its spotlight on ever younger role models.

Counselors serving this population can help put today’s struggles in the context of the woman’s entire life, assisting her with making sense of the past and deciding whether a new lens could be used to process her current circumstances. These counselors must be capable of navigating a variety of topics, from sexuality to career development, often while bumping into lifelong stereotypes about women’s self-worth and poor boundary-setting skills. The rewards are manifold for counselors who can work in this space, and the experience can enrich their own understanding of development across the life span.

Carolyn Greer, a longtime American Counseling Association member and an adjunct professor at Texas A&M University-Central Texas, was inspired by the major transitions women in midlife often face, including moves, divorce, the death of loved ones and new family arrangements. She and a counseling colleague developed a workshop to help women facing these circumstances explore some of the new pathways before them, while also considering the mental, physical and social changes associated with these changes. Greer highlights her own personal interest in an evolving approach to adult development.

“As I have aged and dealt with many personal situations, I have gained better insight into what Erik Erikson proposed with his stages of adult development, a theoretical approach I learned in my counselor training and have continued to teach in my counseling courses,” says Greer, who adds that her membership in other organizations studying adult development deepened her interest in questioning old thinking about aging.

“As life expectancy extends, the expected ideas about what individuals will look like, feel like and be doing by middle age continue to be questioned,” she says. “Erikson called ages 35 to 60 middle age, with an expectation that the adult would be at a point midway of having many accomplishments that lead to the personal life dream. However, what once was midlife, with all the preconceived thoughts, no longer fits the picture.”

“The life expectancy in 1900 was 47 years, but in 2000, it was 77 years. So, what is middle age?” Greer asks. “Adding to changes in this picture, what one looks like as an aging adult is [changing] as more and more effects from improved medicine, exercise and environment tend to lead to a more youthful life and outlook. There is an accepted premise that the current 50-year-old is the previous 40-year-old, and the changing age concept continues upward. Adding to these phenomena, the fastest-growing population group in our country is 85-plus, with an ever-increasing number of adults living to 100 and above.”

Changing relationships

With such a wide definition of midlife, counselors must be able to walk with these women through an array of topics that can have an impact on mental health. Jean Dixon, a licensed professional counselor with private practices in Houston and The Woodlands, Texas, leads several groups that help empower women facing life transitions. Noting that at age 42, she also is experiencing transitions unlike those earlier in her life, Dixon says she understands the immense change and growth occurring in midlife.

“It’s like adolescence all over again but with the added advantage of wisdom,” she says. “[Women at midlife] are often experiencing emotions that are deeper than they have experienced in the past. Due to increased awareness of themselves, others [and having more] experience, this new stage of life can be trying but also very exciting. It’s a lot for them to take in and process.”

For some women, midlife becomes a time to consider past unresolved issues that they did not have the time or energy to address previously. Dixon says these clients often feel that they need direction and a dedicated space to process their feelings. In her experience, empowerment is a very popular topic for this population.

“These women are often successful in life but continue to feel a sense of low self-worth,” she says. “Many … are wanting to work after being at home with children [but] are facing self-esteem and self-worth issues related to being out of the workforce, feeling inferior to younger women and sometimes even to their own [adult] female children who are not always supportive. … These younger women can be critical, as they have their own self-centered desire to keep mom as mom.” 

Dixon mentions a client who attended one of her women’s empowerment groups. “She talked about how her grown girls would comment to her, ‘Why do you need that group, Mom? You don’t struggle with empowerment.’ Their concept of her as ‘Mom’ was that she was in charge, and she was of them, but they did not see what she felt about herself.”

Carol Boyer, an ACA member in private practice in Montclair, New Jersey, mainly works with women ages 25 to 60. She advises counselors to be on the lookout for relationships as a key component of many of the struggles women face in midlife. For example, she recalls one of her clients who ended a romantic relationship.

“It was her choice to end it, but now she feels like she lopped off her arm and is having trouble moving forward,” Boyer says. “One of the things she brought up was, ‘I’m 60, and I don’t want to start with someone new.’ As we get older, if we’re not in a stable, continuing relationship, I think it can hit us harder when we break up. We are not as resilient as we were in our 20s. The stakes are higher. We aren’t as comfortable in looking for the next one. Meanwhile, we are bringing more baggage to the situation.”

Dixon has found that her clients in midlife possess great interest in discussing their sexuality, often for the first time in their lives. Some are struggling with the way their bodies are changing, while others have accepted those changes but are noticing that sex has a different meaning for them at this stage.

“They often come to therapy asking for help being more open-minded with sex or wanting to help their partners develop a healthier and mature relationship with sex,” Dixon says. She notes that often these women are with partners whose sex drive has decreased, while their own libido is stronger than it was at earlier stages of their life. Dixon works with these women to adjust to the changes and helps them develop the communication skills to address the shifts with their partners.

The women’s husbands or partners often have difficulty adjusting to the changes, at least initially, Dixon says. “I have heard my clients comment that at first, their partners did not really like hearing them speak [up] or share their opinion, and that this would create power struggles,” she says. “But in time, most of them come to appreciate it and can see that the power equality feels more intimate and increases their enjoyment of each other. The intimacy actually encourages other types of intimacy as well and can rekindle old flames.”

Continued career development

With longer life expectancy comes the desire or need to continue investing in a career. As such, career development issues often work their way into therapeutic discussions of life satisfaction and meaning-making. But the career development needs of women in midlife may be quite different from what career counselors typically see.

Jill Dustin, an ACA member and assistant professor in the Department of Counseling and Human Services at Old Dominion University in Norfolk, Virginia, specializes in career development. She has found that women in midlife often exhibit a strong desire to embark on new career-related adventures, such as tackling long-held goals or changing careers entirely. But at the same time, they also have financial concerns and struggle with work-life balance, just like younger workers often do. She notes that women in midlife also struggle with barriers to career success that may be structural or even related to their physical and mental health changes at this stage. Finally, women in midlife may be recognizing career dissatisfaction and a loss of self-identity.

Boyer has witnessed this struggle in her own office. “Some people at this midlife point say to themselves, ‘This is the best I’m ever going to feel, ever going to do. This is the most money I’m going to make.’ People get stuck when thinking that forward motion is not an option anymore,” she explains. “There’s a loss when we believe we’ve reached the end of our promotional ability. People find themselves a little depressed that life is kind of over and that things are just going to start getting worse. It can become a self-fulfilling prophecy.”

Boyer could cite herself as an example of why that line of thinking is too limiting. “For me, I went to grad school at 45, and I’m about to turn 57,” she says. “My career is still on the ascendancy. While chronologically I’ve reached midlife, professionally, I consider myself quite young in the profession. It’s all relative.”

When teaching counseling students how to help women with midlife career development issues, Dustin emphasizes that each woman is unique and comes to the process with diverse experiences and challenges. “It is very important that counselors working with women in midlife do not stereotype their clients,” she advises. “For example, counselors should not assume that since their client is in midlife, she is experiencing a ‘crisis.’ This certainly is not the case. Many women experience midlife as an exciting time of transition in which they can redesign their lives and explore careers that hold greater meaning for them.”

Career development is often viewed as a separate entity from personal counseling, but in reality, Dustin says, it is very personal and can be transformative. For that reason, she encourages counselors to include career development as part of their work with female clients in midlife.

“I would urge [counselors] to actively engage their clients in their career development,” she says. “This can be achieved by supporting, encouraging and empowering women throughout their journeys and assisting them in discovering and uncovering their strengths, barriers, types of support, goals, fears, abilities, values and desires.”

Methods in midlife

While the counseling methods applied to working with midlife women may not be too different from those used with other populations, the enthusiasm these clients show for trying new things can be inspiring. From empowerment workshops to psychoeducational book groups, psychodynamic analysis to mindfulness, women in midlife are often accepting of diverse approaches.

Greer has witnessed this herself. She explains that her workshop for midlife women in transition was not designed to be a clinical experience. But the end result is that many of the participants evaluate their own lives and set out in new directions that were mostly unknown to them at the beginning of the class.

Boyer also agrees, noting that she has used mindfulness techniques to help women connect with their bodies and become more aware of how they experience stress — something many women go through life never truly understanding. She recalls a 51-year-old client whose menopausal symptoms brought her into counseling. But the client’s mother was also in a nursing home, and on top of that, she was managing the stress of a change in her workplace review process and a complicated issue in her marriage.

“She is managing the aging aspect while she’s in a situation caring for her mother because she is an only child. Meanwhile, she’s trying to do an impossible job professionally and trying to save a marriage at the same time,” Boyer reflects. “She’s feeling misunderstood and it’s overwhelming to have to deal with these things all at the same time. Her energy level is different than it has been in the past, her moods are more labile [and] she doesn’t have the same kind of resources to bring to the other issues in her life.” Working with clients to simply name the stressors can be a major turning point for those who have spent decades ignoring their own needs, Boyer says.

Assertiveness training and building decision-making skills are other common techniques used with these clients. Dixon adds that basic decision-making can be a challenge for women in midlife who have rarely felt heard by their families or communities. She explains that they struggle with saying “no” without feeling guilty, often viewing themselves as one-dimensional beings: mothers, wives, workers or children of aging parents.

“Long-standing roles as ‘doers’ and caretakers take a toll,” Dixon says. “These women often report feeling depressed and lonely and very often just not knowing who they are or what they want. For example, often these women even struggle with deciding where they want to go to dinner. They are afraid to make the wrong decision. Having someone angry or disappointed with them is a big deal and creates such anxiety that they would rather just leave decisions to others.”

Dixon also finds that many of these women are afraid of being alone or being left by a partner. “Their sense of self and self-confidence is so low that we work on basic skills and communication, as well as self-talk and self-acceptance, for quite awhile,” she says.

She advises counselors to be sensitive to the client’s past experiences when working with current struggles, noting that understanding how the client managed transitions in her past can offer good direction today. She also suggests asking the client about current resources and supports, as well as what supports she may have possessed in the past. Then ask how her life is similar or different as she transitions through this current stage or challenge. For example, Dixon notes that women in midlife may suffer from anxiety or depression as their bodies age and they face new medical challenges. Being able to connect current frustrations to old struggles that they may have overcome — an eating disorder, for instance — can be transformative, Dixon says.

Dixon’s love of working with women in midlife comes from the joy she finds in helping them finally release their inner voices. “To help someone value and learn to listen and respond to themselves is the greatest gift I receive from my work, and these women have it in them so strongly it can’t be stopped,” she says.

However, Dixon acknowledges, fear of change is the main obstacle to making progress. “Change is hard, and the work it asks of us can often seem insurmountable,” she says. “That is why I spend so very long sometimes just working on the value of the person, improving and uplifting [the women’s] belief in themselves as they ready for the work it will take to change. But many times, luckily, the beauty of working with these women … [is that] they are ready for the work. They actually love the work because it is so very self-satisfying and serves their confidence, and they see their worth increase steadily. It is very satisfying work.”

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Contributing writer Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. To contact her, visit stacymurphyLPC.com.

Letters to the editor: ct@counseling.org

Ages and stages

By Laurie Meyers March 24, 2014

ForrestAmericans live in a youth-obsessed society. Advertisers, the media and even the job market send the message that it pays to be young — or at least look young. But looking beyond the airbrushing and the nip/tucking, there is a stark reality: The population of adults 65 and older in the United States is increasing rapidly.

According to Stanford University’s Center on Longevity, during the next 30 years, the U.S. population of those 65 and older will double from 40 million to 80 million. By the time the last baby boomer turns 65 in 2029, one in five Americans will be 65 or older. By 2032, there will be more people 65 and older than the total number of children under the age of 15.

These numbers are more than just statistics; they represent actual people who will be going through major life changes. These potential transitions and challenges could include a second career (whether by choice or out of necessity), the need to give care or be cared for, reduced income, personal loss, physical illness or pain, depression or other mental illness, cognitive decline, terminal disease, facing one’s own mortality and confronting ageism.

It is not hard to connect the dots then that as the aging population increases, so does the need for counselors who can help clients with these transitions. “Professional counseling is focused on healthy development over the life span,” says Suzanne Degges-White, president of the Association for Adult Development and Aging (AADA), a division of the American Counseling Association. “This includes working with older adults as they move through both the normal transitions in life and with unexpected difficulties. As adults move into each new developmental stage — and development doesn’t just stop at 18 — they may experience a need for support, guidance and normalization of the emotional responses to each stage. Personal and professional transitions are important at any age.”

Despite the demonstrable need for help throughout this transitional period, many counselors do not focus on engaging with this population. Catherine Roland, AADA’s representative to the ACA Governing Council and editor of Adultspan Journal, says it can be very uncomfortable for some counselors to explore late-in-life issues with older adult clients because it forces counselors to confront their own mortality, which can be a difficult process. “It’s like looking in a mirror,” Roland says.

However, counselors should be aware that working with aging adults is not all doom and gloom. Surveys and research have found that life satisfaction and happiness increase for many people as they approach their 60s. Older adults also possess more life experience and in many instances have accumulated more wisdom and confidence that contribute to greater overall well-being.

When considering aging adults, counselors need to remember that they are not one homogenous population, says Christine Moll, an ACA member and professor of counselor education at Canisius University in Buffalo, N.Y. “There are several generations. We have the boomers, the youngest of whom just turned 50 and the oldest are 68 or 69, and then we have Depression-era and World War II babies, people over 69 and up to 100,” she says. “It’s probably the widest range within the life span of development. We’ve got 40-plus years of people that we call ‘older adults.’”

What do I do with the rest of my life?

One of the first — and sometimes most challenging — life changes this group faces is change in job status. Older adults between the ages of 60 and 70 — or, as Moll likes to call them, the “new aged” — may be considering retirement, transitioning to part-time work, embarking on a new career altogether or trying to remain in their current position.

Their decisions may be driven not just by personal preference, but also by economic circumstances related to the recession and a changing global economy, Roland says. “Whenever the economy goes bad, people at or later than retirement age are really harmed [financially],” she points out. “They don’t have the ability to go back and make up savings.”

In many cases, even when these older adults developed a plan for setting aside money for retirement, the rules changed on them, notes Tom Christensen, a licensed mental health counselor and doctoral candidate at the Warner School of Education at the University of Rochester. As an example, he points to employer-funded pensions shrinking or being taken away entirely. “After a lifetime of planning, how do you rearrange things to account for sudden changes in retirement accounts?” he asks.

Aging adults who are still in the workforce also face the dual realities of downsizing and evolving job requirements. And when their jobs are outsourced, Christensen says, older adults often have less flexibility and fewer options. “It’s harder to just up and relocate to where the jobs are because you have a house or obligations and family ties. Maybe you are even needed to provide child care for your grandchildren,” he says. “And how easy is it really to bear the cost of going back for retraining?”

“In the past, a person’s age matched their wage and worker loyalty garnered longer tenure,” adds Rich Feller, a past president of the National Career Development Association, a division of ACA. “Globalization, technology and a winner-take-all performance system have imploded later-life expectations. Fewer opportunities exist to transfer older skills, dated habits or traditional and repetitive performance skills that pay livable wages.”

However, the situation is not hopeless, emphasizes Feller, an author and professor of counseling and career development at Colorado State University’s Institute for Learning and Teaching. Many employers do still appreciate the professionalism and experience that older workers offer, he says. One important task for career counselors is to show older adult clients how to reframe their experiences and work histories to match available positions, Feller says. He asserts that older workers can overcome the biases they sometimes face by highlighting their demonstrable skills.

Simply applying to positions in response to postings on job boards is not enough, he says. Instead, aging adults need to work with their professional and personal networks to connect with hiring managers. Meeting decision-makers face to face gives aging adults the opportunity to transcend being simply an “older résumé” by demonstrating their maturity and accumulated wisdom in person, Feller says.

On the flip side, even when aging adults are ready to retire, the transition can pack more of a punch than most people realize. “Work provides structure, relationships and relevancy,” Feller says. “Without work, finding purpose is hard. Seeking meaning, contributing and mattering is especially important in the new adult phase where we live 30 years longer than our parents.”

Degges-White delves into this life transition further. “Older adults experience this passage with such a diverse range of responses,” she says. “Some individuals embrace the new freedoms of retirement with great ease, while others may see their transition out of the workplace as a huge blow to self-esteem and identity. Counselors are able to help individuals make sense of these types of transitions and help clients develop a new sense of self and purpose in their lives.”

Feller says aging adults need to know they are not alone in their experience — that others have gone through this transition and regained a sense of meaning in their lives. Counselors can help these clients see that they have other talents and are more than the sum of their careers. Retiring can bring time to “redefine” their lives by exploring new interests, developing new hobbies or spending more time with their family members.

Giving care

Retirement is not the only challenge aging adults will begin — or continue — to face. The “new aged” group in particular may find themselves confronting family issues such as the need to provide some level of care to grandchildren or even coping with an adult child who has returned home, Moll notes.

Degges-White recounts the story of a female client who was 70-plus and suddenly found herself raising a grandchild. “This woman was trying to figure out the best way to handle her responsibilities as primary caregiver to her 7-year-old granddaughter,” Degges-White says. “This young girl was diagnosed with an assortment of learning disorders, behavior disorders and emotional challenges. The young girl’s mother, who was the daughter of the older woman, had been a drug addict and ‘lost soul,’ but her mother recognized that the granddaughter should not be lost in the system. When our country’s older adults are coping with raising the children of their own children, they have a difficult time facing their own concerns. Counselors of children and adolescents may need to intervene when these kids are being cared for by already overwhelmed or vulnerable older adults.”

Aging adults may also be the primary caregivers for a parent or spouse. Counselors need to remain aware of how much stress these caregivers are under and intervene by helping them find strategies to cope.

ACA member Rebecca Cowan, a counselor and instructor at Eastern Virginia Medical School, provides counseling to caregivers at a weekly senior clinic that takes place at the medical school’s Portsmouth Family Medicine. “We often ask caregivers to come in with the elder to their visit. The geriatrician, nurse practitioner or medical resident will complete a physical exam on the elder, while I talk in a separate room to the caregiver,” she explains. “We spend the majority of our time discussing caregiver burnout. If a caregiver is feeling particularly stressed and strained, we brainstorm ways to increase support, whether it be contacting other family members for respite or exploring community supports. We also do some very brief relaxation exercises such as diaphragmatic breathing or guided visualization.”

Older adult clients may not currently be facing caregiving issues or having trouble transitioning into retirement, but there is one experience that everyone must eventually face: loss. Although that experience is certainly not restricted to the older adult population, it does become more common as people age.

“One big thing that counselors can help clients with is loss,” Roland says. “Even if you’re healthy and have enough money to age comfortably, people around you are passing — spouses, friends and, in some cases, even children, and that is devastating. It’s not something that you are prepared for.”

Health effects

As adults move through the “new aged” stage, they share similar challenges, but in certain circumstances, Moll says, the aging path really starts to diverge. Although most people who reach older adulthood have some kind of health complaint, the “well-aged” (as Moll terms them) generally have minor or manageable conditions. They may have arthritis and other wear and tear, she explains, but they are as healthy as can be expected for their age group.

On the other hand, aging adults in poor health are starting to reach the point — if they are not there already — of becoming seriously disabled. In many cases, these aging adults have a “biological” age that is older than their chronological age, Moll says. She adds that counselors should be cognizant of these differences and watch for the depression and anxiety that often accompany a loss of ability.

Some counselors, such as Cowan, are working with other health professionals to meet the needs of the ill and aging. In concert with a geriatrician, nurse practitioner and family medicine physician resident, Cowan helps aging adults with complex health issues. Primary care providers send aging adults with common geriatric issues such as dementia, depression, frequent falls and poor nutrition occurring with comorbid chronic illnesses such as obstructive pulmonary disease, heart failure or diabetes to the medical school’s senior clinic for assessment.

“The purpose of our clinic is not to follow these elders long term,” Cowan explains. “We see them for one-hour appointments once or twice or, in some cases, three times to develop a comprehensive management plan which we give to their primary care provider.”

Cowan’s principal role is to screen these aging adults for mental health issues such as cognitive decline, depression and anxiety. “When elders present with anxiety or depression, having me right there in the clinic during their medical visit reduces the stigma of seeking therapy,” she says. “Many elders are resistant to therapy because they fear they will be labeled with having a ‘mental illness’ and, therefore, do not seek mental health treatment. They are usually more comfortable with the idea of engaging in a therapeutic relationship right there in their physician’s office. I often administer brief assessments such as the Geriatric Depression Scale, which gives us a nice starting point to discuss these difficult topics.”

Cowan also contributes to the team’s overall treatment assessment. One common issue is aging adults who take numerous medications and are confused about when and how to take them. “It is imperative that their medications are taken correctly,” Cowan says. “Taking too much or too little can significantly impact health outcomes. This is often a primary focus, and I use motivational interviewing techniques to encourage medication adherence.”

Sometimes, however, the team decides it would be better for a patient’s family member or caregiver to manage the medication schedule. “The team may use me to deliver the news in a sensitive way,” Cowan says. “I have found that the use of empathy is imperative. Most of the time, elders are concerned about losing their independence and autonomy. With motivational interviewing techniques, the elders often open up about these fears, and we can process them together. … For instance, I might say, ‘It must be terrifying to feel like you are losing your independence, and I’m wondering how I can help you feel more in control.’”

Cowan also assists in delivering upsetting medical information to patients and then helps them to deal with the news. She has the flexibility to remain with patients beyond their scheduled 10- to 15-minute medical visits at the senior clinic, and she is also available to provide additional counseling outside of the senior clinic to help patients process and cope with their diagnoses. Cowan believes the integrated structure of the senior clinic provides patients a level and breadth of physical, mental and emotional care that would be difficult to find elsewhere.

Cowan recalls an 85-year-old female patient with a history of breast cancer who came to the clinic with swelling in her upper arm. “Her daughter and son often accompanied her to her senior care clinic appointments, and I was able to begin to develop a relationship with both the patient and her children during that very first visit,” she says. “At a subsequent visit, she was diagnosed with breast cancer, and I was able to provide counseling to both the patient and her family members. This is something that may not take place in a typical medical clinic, as there is often a rush to move on to the next patient.” Cowan notes that patients and caregivers genuinely seem to appreciate this additional support during their medical visits.

Aging and marginalized 

Health and wealth aren’t the only factors that affect how people age, says Karen Mackie, an ACA member and assistant professor of counseling and human development at the Warner School of Education at Rochester University. She contends that elements such as race, gender, ethnicity, sexual orientation and even historical context — being born in a time of war versus a time of peace, for instance — color the aging process.

“Over time, people tend to accumulate advantage or disadvantage,” Mackie says. “Over the life course, people who are advantaged seem to become more advantaged, and those who are disadvantaged become more disadvantaged. If you think of life as a kind of V shape, we start closer together, but throughout life we diverge, and the greatest disparity gap appears toward the end of life.”

For instance, older adults who are lesbian, gay, bisexual or transgender (LGBT) can face difficulties that their heterosexual counterparts are, in a sense, protected from.

“This [issue] reminds me of a story that a woman shared with me many years ago,” Degges-White says. “She mentioned that she and her best friend envied lesbians because they were less likely to become widows as early as a straight woman might. Therefore, she and her best friend were already making plans to set up house together if they outlived their husbands.”

“True, straight women tend to outlive their male partners, but they also are often more socially integrated into their communities, churches and other support networks,” Degges-White continues. “Depending on age and communities, some lesbian couples may still be living relatively isolated lives. This sense of isolation can present significant challenges when one partner or the other is dealing with health-related concerns or when a partner dies. Without a healthy support system — no matter what your sexual orientation might be — older adulthood is much more difficult.”

“There are other vital issues and needs that can present difficulties, such as shared retirement accounts and Social Security, that straight couples — due to the advantages conferred by being legally married — are not likely to face,” she adds.

Because of that reality, LGBT older adults need to put financial plans in place for any future needs. At the same time, Degges-White says, counselors should be aware of these issues and encourage their clients to consult a financial planner to organize estate planning.

All aging adults should seek connection with others, she says, but it is especially important for clients from marginalized populations to solidify or build networks with their extended families, close friends, community organizations or faith-based institutions so they will have supports in place to help them face later-life difficulties.

Faith-based, family and community connections are essential to meeting the mental health needs of older adult persons of color and other diverse ethnicities, says SeriaShia Chatters, an ACA member and assistant professor of counselor education at Penn State’s College of Education. “Many older adults from diverse populations may be skeptical of the therapeutic process and are more likely to divulge their personal issues to someone in their religious community or neighborhood,” she observes. Oftentimes, it is a suggestion from someone in the aging adult’s religious community or other personal network that encourages the person to visit a counselor’s office, Chatters says.

Counselors must also keep in mind that context is crucial, especially with older adult clients from diverse populations, Chatters says. “I think counselors should be aware of indigenous healing practices and their impact on their client’s culture and belief system,” she says. “I also think counselors need to be aware of and open to various belief systems and understand how to incorporate these beliefs into the therapeutic process if they are helpful and positively impact mental health.”

Chatters notes it is also important for counselors to understand the acculturation process and the divisions it can cause within different generations of the same family. Family therapy can be very useful in these situations if it is something with which the older adult is comfortable, she says.

Still a story to tell

An ageist society tends to stop seeing older adults as individuals, regardless of whether those adults are advantaged or disadvantaged, asserts Mackie, who references the idea of a “mask of aging.”

“People get related to on the basis of their appearance,” she explains. “But, actually, they carry internally multiple stories and identities and senses of who they are. Part of training counselors to work with aging [adults] is to understand what new developmental aspects aging might bring to people.”

“For instance,” Mackie continues, “they may never have had a physical illness before, or they may not have been as isolated before or as economically unstable, so aging brings assaults and crises for them, but at the same time, they are who they have always been. They have this rich background that we have to tap into in order to find those resources to help people cope.”

It is essential for counselors to recognize that aging people still have a story to tell, Mackie emphasizes.

Donald Redmond, an ACA member and assistant professor of counseling at Mercer University in Atlanta, agrees. He proposes narrative therapy as a particularly useful technique for working with aging adults.

“Narrative approaches to counseling center people as the experts in their own lives and view problems as separate from people,” Redmond explains. “This technique assumes that people have many skills, competencies, beliefs, values, commitments and abilities that will assist them to reduce the influence of problems in their lives. ‘Narrative’ refers to the emphasis that is placed upon the stories of people’s lives and the differences that can be made through reauthoring these stories in collaboration with a counselor.”

Redmond notes he has found that many people — aging adults in particular — are more likely to be open to discussing their lives if the term narrative is used rather than counseling or therapy. “We all have a desire to make sense of our lives,” he says, “and with older adults or others facing mortality, this means integrating the different parts of our life — finding ‘integrity.’ In my opinion, this need makes a narrative approach particularly useful for older adults.”

Simply having someone listen to the older adult’s story can be a kind of therapy in and of itself, Redmond asserts.

Christensen’s years of experience counseling nursing home residents has taught him that it’s hard to overestimate the difference that listening and understanding can make. “I had one female patient who had been a refugee during World War II, and during her stay at the nursing home, she had to change rooms,” he recounts. “She reacted to that room change as if she had been abducted against her will at knifepoint. She was so terrified that she was constantly talking about war-related things such as the danger of the communists coming at night. People really had trouble relating to her because they couldn’t see what she was experiencing.”

“I talked with her and listened to her story,” Christensen continues. “And we then tried to build on that experience based on her strengths. We would talk about things like her needlework, and she would tell me about how back in her native country, her grandmother taught her needlework, and this helped her remember that bond. She would also tell me about the meanings of the pattern’s colors. For example, how the black thread was like the very rich soil they used to grow their food, and the reds and yellows were the colors of the wildflowers, and how the green represented hope. Bringing all of that life back helped her let go of a lot of those fears and … some of the war themes and really expand the range of her conversation.”

The resulting change was so dramatic that the woman’s daughter called the nursing home wondering what had happened to her mother. She was suddenly, once again, the mother she remembered, says Christensen.

There is a small concentration in gerontological counseling at the Warner School of Education, but Christensen and Mackie see an urgent need for more programs that focus on meeting the needs of older adults.

“It’s really important that counselor education programs have faculty that identify as gerontology specialists, that they have specialized course work and are performing research,” Christensen says, “because without those sustaining resources, I don’t know how effective an education program can be in this area. So many gerontological counseling programs have withered for lack of student interest. What example is being set?”

As it relates to counselors advocating for, supporting and providing services to the older adult population, Mackie draws one last conclusion: “There is a huge social justice need.”

 

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Medicare: Advocates needed

As the population ages, so does the counseling profession’s client (or potential client) base. And that poses a significant issue. Unless they have private resources, most adults over 65 are on Medicare and depend on this coverage when seeking physical and mental health care. However, Medicare does not currently cover licensed professional counselors (LPCs).

The American Counseling Association and its division, the Association for Adult Development and Aging (AADA), are leading advocacy efforts for the inclusion of counselors under Medicare, which is the nation’s largest health insurance program. According to numbers compiled from the 2010 U.S. Census, Medicare covers roughly 40 million older Americans (ages 65 and older) and approximately 8 million Americans with disabilities. The program was established in 1965.

As an ACA position paper explains: “Medicare has covered psychologists and clinical social workers since 1989, but does not cover licensed professional counselors. Many Medicare beneficiaries live in mental health professional shortage areas, and there are more than 120,000 licensed professional counselors across the country ready to provide needed treatment. Lack of access to outpatient mental health treatment harms beneficiaries and contributes to overutilization of more expensive inpatient care. It also increases the costs of treating chronic medical conditions such as diabetes or congestive heart failure, since many individuals with these conditions have a comorbid depressive disorder.”

Art Terrazas, the director of government affairs for ACA, emphasizes that Medicare reimbursement for LPCs is unlikely to be achieved without a significant amount of advocacy from individual counselors in the field. Terrazas encourages all ACA members to contact their congressional representatives to urge legislative action on behalf of older adults.

“Not only do we need to have counselors call their congressional members, but we need their friends and families to call as well,” Terrazas says. “Many times representatives don’t know about these issues, and it’s up to their constituents to educate them. With the rapid growth in the older population, we are going to see a serious increase in the need for mental health providers, and Medicare is sidelining 40 percent of the providers at a time when we need them the most.”

For more information on ACA’s efforts regarding Medicare coverage of LPCs, contact Terrazas at aterrazas@counseling.org, and read Washington Update on page 10 of the April issue of Counseling Today.

To learn about AADA’s “Day on the Hill” event taking place in July, contact AADA President-Elect Bob Dobmeier at rdobmeie@brockport.edu.

 

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Approaches to counseling older adults

Because older adults often are on tight budgets and because counselors aren’t currently covered under Medicare (see sidebar, above), SeriaShia Chatters, an assistant professor of counselor education at Penn State, says it is essential for counselors to provide treatment that is effective and that can produce results in a relatively short period of time.

She believes cognitive behavior therapy (CBT) should be at the core of care for these clients. “CBT offers techniques that, when used properly, can effectively reduce symptoms of depression and anxiety in many clients in fewer sessions than some other therapeutic techniques,” she says.

Chatters also thinks strengths-based counseling is important. “In the older adult populations, some of our clients may be faced with declining physical health and/or cognitive ability,” she says. “It is important to focus on their strengths and abilities and draw from their ability to overcome previous challenges. [I] also advocate for the use of the word challenge in place of the word problem. Changing the terms we use in therapy can also provide hope.”

In addition, Chatters says it is important for counselors to challenge some of the myths of aging. Although it is true that some cognitive decline is common among older adult populations, she says advances in neuroscience indicate that older adults “can still change their brains and maintain healthy cognitive function.”

To help preserve cognitive function in older clients, counselors need to discuss exercise, nutrition and the importance of sleep with these clients, she says.

 

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To contact individuals interviewed for this article, email:

Christine Moll at moll@canisius.edu

Catherine Roland at caroland@gru.edu

Tom Christensen at thomas.christensen@warner.rochester.edu

Karen Mackie at kmackie@warner.rochester.edu

Rich Feller at rich.feller@colostate.edu

Suzanne Degges-White at sdeggeswhite@niu.edu

Rebecca Cowan at cowanrg@evms.edu

SeriaShia Chatters at sjc25@psu.edu

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Laurie Meyers is a staff writer for Counseling Today. Contact her at LMeyers@counseling.org

Letters to the editor: ct@counseling.org

The impact of community on postnatal depression

Heather Rudow February 13, 2013

CCU_MeAttendees of next month’s 2013 American Counseling Association Conference & Expo in Cincinnati will be treated to a new series of conference sessions aimed at shedding light on research gathered by ACA members on topics that uniquely benefit clients. 

Called the Client-Focused Research Series, these 30-minute presentations aim to increase awareness of research that focuses on improving the services that professional counselors provide to clients. 

In the weeks leading up to the conference, Counseling Today is speaking with some of the presenters about their research and why they believe it enhances the work of the profession. Next up is counseling student and public health advocate David Jones, who will be presenting on “Advocacy Outside the Box: A Multilevel Spatial Analysis of First-Time Mothers With Postpartum Depression.”

What would you like attendees to take away from your session? 

A greater knowledge of individual and community risk factors associated with postnatal depression (PND). Additionally, they will have an expanded conceptualization and tools for working with their clients and community.

Why is it important for counselors to learn the difference between community and individual risk factors associated with postpartum depression?

From an ecological perspective or other social models, there is a conjugal dance between individual and community risk factors. To effect lasting change, the counselor needs to see within but also beyond the individual risk factors toward the context: community. This context is a powerful influence on the individual’s affect, mood, cognition and behavior. Further, the individual’s choices have collateral. This collateral affects the family, which impacts neighborhood, which influences the community and vice versa.

How did you get involved with this subject?

My career is in public health, but I am also a counseling student. Through my work at Cincinnati Children’s Hospital and Medical Center and my studies emerged a passion around improving the outcomes of children.

Further, counseling and public health have a natural marriage: prevention. Therefore, through the lens of life course theory, the best approach is to intervene before the birth of the child to change the trajectory of lifelong outcomes for the child. Hence, a counselor seeks interventions before womb, secondarily when the child is in the womb and, tertiary, postpartum.

What inspired you to present this session at the conference?

It is a desire to bring about awareness and advancing the field of counseling. I believe that research is imperative for improving the health of our clients and their communities. Furthermore, there is a call for the counseling profession to get more serious about research. By doing so, it will advance our identity as counselors. 

Did anything surprise you as you were compiling information for your session?

The sample was drawn from a home visiting program for first-time mothers. The program contracts with seven agencies within Hamilton County, Ohio, to conduct their services. Each agency provides services in a specific catchment based on ZIP code. What was of particular interest was the severity of these rates and that the majority had rates higher than the national averages [of] 10 to 15 percent. Yet, conversely, the Hamilton County rate was high as well.

When looking at the individual risk factors, several became salient. For example, race and ethnicity were significantly different between those at risk for PND  (EPDS score < 10) than those not at risk. Another risk factor associated with the risk of PND was years of education.

Besides these finding above, what was remarkable was the many risk factors that were not found to be significant. This study linked the home visitation client record data with hospital discharge data, Ohio birth certificate data and 2010 Census tract data. After the linkage, there were over 300 variables associated with each case. Through analysis, no significant association was found for preterm birth and infant loss among others.

When examining the area level (Census tract) variables, it was a surprise that median home value was not significant. Yet, other area level variables did have an association such as percent of vacant housing units, percent on SNAP and GINI Index score.

This is the initial step in our investigation. Our study group plans on digging deeper into the data and looks forward to seeing what we will find.

Who do you feel is the best audience for this session?

This is important for a variety of audiences. One is the counselor who works with this specific population. Others that become prominent are counselors who take prevention and community outreach to heart, such as those who are passionate about social justice. It is relevant for counselors-in-training to expand their conceptualization of their profession. Finally, based on ACA’s call, it is imperative for all counselors [to take part] in a concerted effort to advance the counseling profession’s presence in research.

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.

Understanding bulimic dissociation to create new pathways for change

Rebecca Heselmeyer & Eric W. Cowan December 1, 2012

Given the extensive research on eating disorders, motivated clients and a gold standard treatment — cognitive behavior therapy — it is perplexing that recidivism rates remain so high for bulimia. It behooves us as counselors to investigate possible hindrances to effective treatment and adjust our approach accordingly for those clients with bulimia who have not achieved long-term resolution. It is notable that, despite the substantial evidence linking dissociation and bulimia, many counselors remain unaware of this connection. Further, the nature of the relationship has not been sufficiently explored. In this article, we apply principles from self-psychology to bulimic dissociation and use this new understanding to inform clinical practice.

When I (Rebecca) first met Sonya, she sat across from me tearfully expressing the shame she felt about her binging and purging and the feeling of defeat she experienced from failed efforts: to stop thinking about food, to stop scrutinizing her body, to stop mindlessly gorging on food and then rushing to vomit. Sonya presented as many clients with bulimia do — she expressed a desire to change and a willingness to try whatever therapeutic assignments I may assign to her. Rather than engage with her in familiar and expected territory by focusing on food (nutrition, food journals and so on), I turned my attention to a different part of Sonya’s experience, inviting into our conversation the part of her identity that up until then had likely been unacknowledged and invalidated repeatedly. We have labeled this the dissociated bulimia identity (DBI). To explain our reasoning for yet another coined term with a nifty initialism, let’s shift gears and look at the underlining theory.

Self-psychology and the vertical split

Heinz Kohut proposed that children need specific interactions and feedback from caregivers to formulate cohesive, integrated selves. An important part of this process involves mirroring, in which caregivers demonstrate accurate, empathic affective attunement with the child. For example, a child may cry out upon seeing shadows in a dark bedroom at night. An attuned care provider might respond by giving language to what the child is experiencing (“You are afraid”) and comforting the child. Through such interactions, the child not only learns language for his or her affective state, but also learns that he or she can be afraid and still be loved. Gradually, with additional interactions in which the caregiver reflects the child’s fear in a nurturing manner, this affective state becomes identified and integrated into the child’s sense of self.

Assuming the care provider responds to the multitude of emotional experiences with validating, reflective attunement, the self then develops into a cohesive being where all affective states — love, joy, fear, grief, discouragement, excitement, loneliness and so on — have an identified and accepted place. The child has been welcomed into the world of shared meanings and connections and has formed a cohesive sense of self composed of, to use Harry Stack Sullivan’s language, “reflected appraisals.” Further, the process that enables identification and integration also teaches the child about self-care; the nurturing and soothing interactions with the caregiver over time become internalized so that the child develops the ability to self-soothe and manage emotional experiences without relying on the caregiver’s presence.

Now imagine the same child in the frightening, dark bedroom, crying out at the lurking shadows. In this house, the caregiver responds with taunts, calling the child a scaredy-cat and snapping at her to go back to sleep “or else.” Continued interactions of this nature also identify the affective state while invalidating the experience of it. The child is taught that fear is not allowed and is shamed for experiencing it. There is no comforting hug or lullaby to internalize; there is only the message of rejection. There is a disconnect between the child and others, which results in a parallel disconnect from internal thoughts and feelings. Dependence on the caregiver is crucial for survival, so anything that might threaten this relationship is sacrificed. Consequently, affective states met with invalidation become disavowed and denied integration into the “socially acceptable self.” But where do these affective states go?

Kohut proposed that lack of adequate and empathic mirroring results in a “vertical split” — a metaphor for the partition between self-experiences integrated into the “normal” self and disavowed affects and frustrated developmental needs. Repression can be understood as a horizontal split, with unconscious desires tucked away deep in the psyche and blocked from the rest of the aware mind and body. The vertical split, on the other hand, designates a chasm between selves: the integrated affects and being states that were met with empathic mirroring and those that were sacrificed in an attempt to maintain the essential relationship with primary caregivers.

Therefore, for clients with bulimia, validated affective states become integrated into the normal, socially acceptable self, while invalidated affective states are sequestered on the other side of the split, forming the unacknowledged, rogue DBI. Acknowledging this part of the self-experience has been deemed threatening and forbidden. Perhaps more important, the child never learns to effectively acknowledge, self-soothe and manage this part of self-experience. Needless to say, mere ignoring cannot relieve the emotional demands of loneliness, lust, anger, guilt, despair and other feelings. When the DBI demands attention, the now-adult client may address it in the one way she or he knows how — with food.

Media teach us time and again that food is a source of comfort, pleasure and love. The absurdity of media campaigns goes so far as to sexualize food. Jean Kilbourne, in her “Killing Us Softly” lectures, observes the potency of a variety of media messages, including ones that offer food as a substitute for relationships. Food is also culturally anchored in our experiences: family gatherings, celebrations and times of mourning. Our bodies respond physically and physiologically to eating. In the most basic sense, food literally fills a void within us. Binging provides momentary relief and escape, and the process at work is twofold.

Dissociative symptoms are present throughout the binge-purge cycle, with peaks occurring during the binge and immediately after the binge. Dissociation is commonly thought of as an escape from painful psychological experiences. Dissociative symptoms are on a continuum ranging from minor alterations in perceptual functioning to significant disruptions, such as a dissociative fugue. The dissociation associated with bulimia is primarily categorized as mild to moderate. Clients may feel out of control or have a detached experience of watching themselves binge.

Let’s explore the dual process at play, using Sonya as an example.

Dissociation, revisited

Sonya would often report the quick onset of the urge to binge. As she began, her feelings of disconnectedness and lack of control grew, enabling her to eat beyond capacity by blunting both the physical and emotional discomfort she would otherwise experience. Psychologically, the dissociative symptoms she experienced also provided temporary relief from the triggering affective state. At the same time, the dissociative experience allowed Sonya to “jump” the vertical split and access the very region housing the unmet need that was triggering the binge — in her case, a deep sense of helplessness. This dis-integrated part of her self-experience that was reproached during her development has shown up in her adult life, but she lacks the ability to effectively identify, manage and attend to it.

The binge-purge behavior brings with it dissociative processes that temporarily provide Sonya with both an escape from pain and access to the region where she can acknowledge and soothe that otherwise denied self-aspect. The function of dissociation is to “escape” to a very specific and important place: her DBI. In other words, while Sonya is desperately (and ineffectively) seeking physical comforts, her psychological self is likewise seeking to self-soothe the neglected and needy DBI. She is momentarily allowed access to this outlawed part of the self and can attend to the very real need for nurturing and validation.

With the conclusion of the binge also comes the conclusion of dissociative symptoms. Sonya becomes more aware of her physical self — and simultaneously is returning to her socially acceptable, normal psychological self — and is swept by feelings of shame and guilt. Physically she feels great discomfort and embarrassment at the quantity of food she has consumed, while psychologically she has trespassed to visit and comfort the forbidden DBI. She has broken the rules — physically by food consumption and psychologically by traversing the vertical split. Guilt reigns supreme, and she purges to expunge herself of the harm done.

Through this lens, the functionality of the binge-purge behavior and dissociation can be seen as the client’s best effort to attend to a disorganized self-experience. For many clients, including Sonya, bulimia is a clinical presentation that, at its core, is a disorder of self rather than being fundamentally rooted in body image concerns. The clients’ repeated attempts at self-care through the use of food fail because the core unmet developmental needs are never brought out of exile and given their rightful place in the integrated “normal” self. Symptom-focused counseling that serves largely as behavior management — food journals, nutritionists, love-my-body activities — prove ineffective for these clients because there is no room for the underlying disorder of self to emerge in the therapeutic dialogue. For this to happen, there needs to be a shift in the counseling mindset and conversation.

Clinical applications

If I had partnered solely with Sonya’s desire to extinguish her bulimic behaviors, I would also have partnered solely with her “socially acceptable” self  — that part of her that genuinely does want to stop binging and purging. Concurrently, I would have communicated to her that her DBI was not welcome.

The DBI relies on the function of her behaviors for much-needed psychological care, so there is likely a very substantial part of Sonya that wants to binge and purge and has no intention of giving this up. Focusing the counseling conversation on ways to extinguish and change behavior, without also addressing the purpose of the behavior and offering an alternate way of accomplishing the function, invalidates the part of the client’s experience that appreciates and needs the behavior. If approached in this manner, the client’s DBI is likely to “go into hiding” for fear that successful counseling will result in its extinction (rather than integration). In effect, this guarantees an unsuccessful long-term counseling outcome.

Instead, I invited Sonya to tell me about the part of her that wants to binge and purge. This is a potentially shame-laden and socially ostracized part of Sonya’s being, so it is important for me to seek it out and welcome it rather than assume it will enter the therapeutic dialogue without active and sometimes repeated invitation. Counselors need to provide an experience in which all parts of the client’s experience — both the desire to cease behavior and the desire to maintain it — are welcomed and validated. We encourage counselors to address the DBI directly (“Tell me about the part of you that needs to keep doing this”) or by using third-person language (“Tell me about her — the part of you that defies your attempts to control her”). In addition, use language that demonstrates an appreciation for the adaptive function of bulimia that is, in a sense, trying to help.

Occasionally, it may serve as a powerful paradoxical intervention for the counselor to urge the client not to give up the binge-purge behavior too quickly. Clearly, this intervention is not appropriate when working with clients who have significant health risks. But for clients in relative physical good health, and especially for those who have had extensive counseling, an intervention of this sort likely will be unexpected and get beyond psychological resistance by “siding” with the DBI against the socially conforming self. You can observe to clients how cruel they are to their bulimic selves when they use disparaging language (“I’m such a fatso loser when I binge”).

Once it is established in the therapeutic dialogue that all parts of the client’s experience are welcomed and validated, new pathways for healing can emerge because the client, with the counselor’s support, can begin to acknowledge and express the frustrated developmental needs that are the driving force behind the bulimic behavior. An important part of this approach is keeping the therapeutic conversation focused on the client’s inner world of needs, feelings and thoughts, particularly those that are outside the client’s normal experience, so the client can expand self-reflective awareness.

Once clients gain insight into the role their bulimia has served in managing emotions and needs, a powerful experiential process unfolds as the counselor provides the empathic mirroring response that was previously withheld during the client’s childhood development. Counseling provides the repeated, accurate, empathic attunement that the client’s caregivers failed to supply. Just as over time the child internalizes the caregiver’s ability to soothe and comfort, the client’s new awareness of emotional triggers, coupled with the empathic, attuned response from the counselor, allows the client an opportunity to begin addressing and meeting her or his needs in a new, direct way. The ongoing process of welcoming the formerly forbidden self-experiences into the counseling relationship gradually breaks through the wall of the vertical split, allowing a merging of selves into a now fully integrated self. As this happens, the need for bulimic behaviors diminishes and, without a purpose, the behaviors eventually cease.

Similar to the experiences of other clients, the turning point for Sonya came when she felt at liberty to speak about the part of her that could not imagine life without binging and purging. Gradually, Sonya’s sense of inner connectedness and connection with others grew, and she became skillful at recognizing her emotional needs and attending to them in healthy ways. Her binging and purging has subsequently tapered.

We hope you will find this conceptualization and the suggested techniques enriching to your counseling practice.

“Knowledge Share” articles are based on sessions presented at American Counseling Association Conferences.

Rebecca Heselmeyer is a staff counselor in residence at the James Madison University (JMU) Counseling and Student Development Center, adjunct instructor for the JMU Counseling Programs and a member of the Rockingham Memorial Hospital Psychiatric Emergency Team. Contact her at heselmrj@jmu.edu.

Eric W. Cowan is a professor in the Department of Counseling and Graduate Psychology at JMU and the author of Ariadne’s Thread: Case Studies in the Therapeutic Relationship. Contact him at cowanwe@jmu.edu.

Eyes wide open

Lynne Shallcross November 1, 2012

Melancholy piano music plays in the background as people flash back to times in their lives when they felt happiness. Returning to the present, we see individuals in obvious emotional pain. A voice asks, “When you’re depressed, where do you want to go? Nowhere. Who do you feel like seeing? No one. Depression hurts in so many ways.”

If you watch TV, you’ve no doubt seen this commercial advertising one of the growing number of antidepressants now on the market. Regardless of how you feel about these medications, statistics suggest the message from that commercial — that depression can be debilitating and rob people of their sense of joy — likely resonates with millions of viewers. In fact, the World Health Organization calls depression “common,” affecting about 121 million people across the globe. According to the Centers for Disease Control and Prevention, nearly 1 in 10 U.S. adults reports symptoms of depression.

American Counseling Association member Katherine Walker has a private practice in Wake Forest, N.C., and one of her counseling specialties is treating depression. She says clients dealing with depression often feel stuck or overwhelmed with some aspect of
their lives.

“Some may be experiencing a significant loss such as loss of a job, loss of previous status or esteem, loss of a significant relationship or the death of a loved one. Others may be dealing with some internal conflict — body image, poor self-esteem, etc. — or experiencing conflict in their relationships with others. We know that depression can either be situational or recurrent, lasting hours, days, weeks, months or even years. It can affect them not just mentally and emotionally but also physically, relationally, vocationally and spiritually. Regardless, these clients often describe their depression on a continuum ranging from feeling blue or ‘in a funk’ to experiencing overwhelming emptiness and despair. They feel helpless, hopeless and victims to whatever they are experiencing,” says Walker, who has also worked as a counselor in an outpatient physical rehabilitation setting and as part of an employee assistance program.

Having trouble concentrating, feeling a lack of desire to do anything and feeling a general sense of malaise are also common among those experiencing depression, says Gary Gintner, an associate professor and program leader of counselor education at Louisiana State University and a past president of the American Mental Health Counselors Association, a division of ACA.

We all hit bumps in the road of life. The question is why these bumps land some people “in the ditch,” while others seem to power through without losing course. Walker points to genetics and the individual’s environment as two major factors that determine the likelihood of depression. Those individuals with a family history of depression — especially a biological parent who has struggled with depression — are more likely to experience depression at some point in their own lives, she says. Moving beyond genetics, a history of abuse, stressful life events, loss of previous status or role, conflict in interpersonal relationships and loss of loved ones can also increase a person’s likelihood of living with depression, Walker says. Certain medications such as beta-blockers and medical problems such as cancer can also increase depression risk, she adds.

Says Richard Hazler, a professor of counselor education at Penn State University and a member of ACA, “No different than most disorders, genetics appear to make some people more likely to suffer from depression and some less, but it is the environment that tends to trigger reactions [and] make the depression less severe or more severe.”

Certain clients who seek counseling will present with clear symptoms and be “painfully in touch with their depression,” Walker says, making it relatively easy for the counselor to determine what is going on. “For others,” she says, “it might be more insidious, especially for individuals who may be unaware and not in touch with themselves, are in denial of their symptoms or tend to be more stoic in nature and put up a front for fear of being perceived as being weak or a failure.”

In searching for clues of depression in clients, Walker says counselors should pay close attention to the following symptoms:

  • Reported or observed signs of sadness, including poor eye contact, strain in the facial muscles around the eyes and mouth, slowed movement and speech, slumped posture, crying in session and reported bouts of tearfulness
  • Wanting to withdraw and hide from responsibilities and relationships
  •  Feeling either overwhelmed or underwhelmed in life roles
  • Experiencing a loss of appetite or engaging in emotional eating
  • Experiencing decreased sex drive
  • Having sleepless nights or sleeping excessively
  • Feeling helpless and hopeless
  • Feeling fatigued and achy
  • Having trouble remembering, concentrating or making decisions
  • Feeling a loss of pleasure for previously enjoyable or meaningful activities and apathy for things once important to them
  • Feeling worthless
  • Feeling a general lack of direction, meaning, purpose or motivation

Asking clients whether or how their habits have changed can also provide possible indicators of depression, Hazler says. For instance, if clients say their sleeping patterns have changed recently, their eating habits have changed recently and their interactions with friends and family have changed recently, those might be warning signs of depression, he says.

Different paths to treatment

Gintner says three approaches are empirically supported for treating depression across the general population: behavior therapy, cognitive therapy and interpersonal therapy. Behavior therapy is often a good initial treatment, Gintner says, because it is fairly straightforward and encourages clients to make changes in their activities or lifestyle. Cognitive therapy is beneficial when the main component of a client’s depression is connected to his or her thoughts, he says. Interpersonal therapy fits well with clients experiencing a significant number of interpersonal problems related to their depression, Gintner says.

From his experience, Hazler believes a counselor’s best route is to follow his or her own preferred clinical approach. “If you are a good counselor and you have a solid theoretical viewpoint and it works consistently, that’s what you should be doing,” Hazler says. “All the research shows that the core relationship and counseling skills have the greatest impact on client outcomes, and those skills are used across all major counseling theories. We have counseling theories — plural — because no one theory has proven to be perfect or uniformly better than others. The combination that seems most important is a counselor with basic skills and a sound belief in and ability to implement a theory that will do the best job.”

Walker deems her theoretical orientation a bit “eclectic,” combining rational emotive behavior therapy and solution-focused therapy with mindfulness and awareness, and that is the treatment path she follows with clients struggling with depression as well. Walker says her goal with these clients is to help them live more authentically rather than always striving to be what others expect them to be.

“I work with clients to help them uncover their true potential and to [live] life more assertively, meaningfully and adaptively, and to do so mindfully with awareness,” Walker says. “I try to help them make sense and find meaning out of what may feel [like] insurmountable circumstances or traumatic events they have had to endure. While we can’t change difficult situations of the past, we can work to better understand and resolve challenges in our life by realizing our true potential to be our own change agent. By applying complementary therapy approaches and techniques, I work with clients to unearth long-standing behavior patterns or negative perceptions that may be holding them back from experiencing a more fulfilling and meaningful life. I believe as counselors, we need to help our clients identify areas where they feel stuck, establish reasonable and attainable goals, break [from] feeling victimized by their circumstances, and feel more empowered and be more adaptive and resilient in their lives.”

In certain cases, these counselors say, medication can aid clients in rebounding from depression. “Medication is mostly used to ease the depressive thoughts and feelings so that the client can more appropriately consider cognitions and take actions that will be productive,” Hazler says.

Walker thinks an antidepressant may be an important adjunct to therapy for some clients. That’s especially true, she says, in cases in which clients are dealing with pervasive depressive symptoms, have a family or personal history of depression, have a history of suicide ideation or attempts, or have a serious medical condition, chronic pain or disability. “However,” Walker says, “I do not necessarily see medications as being the end-all-be-all and believe that a whole-body approach will provide greater efficacy in the treatment of depression. I frequently encourage clients to schedule an appointment with their general practitioner or internist for a full physical and blood work to determine if an underlying medical condition may be contributing to their depression.”

In addition to the chosen counseling approach and possible medications, Walker says wellness is a key ingredient in fighting depression. “[I] have found that when clients engage in a good self-care program, which includes better nutrition, a regular moderate exercise program and keeping a consistent and reasonable sleep-wake cycle, they often report that the intensity, frequency or duration of their [depression] symptoms diminishes,” she says. “I also believe it is important that clients engage in meaningful and productive activity and daily responsibilities, be fully present and engaged in relationships with important others, and participate in leisure activities and recreation to help mitigate their depressive symptoms.”

“Wellness comes apart during depression,” Hazler says, adding that many people experiencing depression tend to decrease healthy life habits such as good eating, exercise, spirituality and sociability. “Not only does not doing these things change body chemistry, [but] the person also knows they’re not doing them, and they feel bad about it,” which can further deepen the depression, he says.

Encouraging wellness is one piece of a holistic approach to helping clients combat depression, Hazler says. “In action, [a holistic approach] means that you deal with the client’s cognitions, work with their actions/behaviors and consider all aspects of the client’s environment, culture [and] the various aspects of wellness,” he says. “Depression is not one-dimensional. It impacts and is impacted by all aspects of the client’s genetics [and] environment and all the aspects of a wellness model that support a healthy life and lifestyle.”

Invisible no more

When it comes to diagnosing depression, says Carlos Zalaquett, professor and coordinator of the clinical mental health counseling program at the University of South Florida, adolescents and older adults are often the most “invisible” populations. Why? With adolescents, symptoms of depression are frequently chalked up to teenage moodiness, while among older adults, the symptoms are often mistaken as a normal part of aging, says Zalaquett, a member of ACA who has conducted research on depression in both groups.

Especially troubling when it comes to depression being overlooked in these two groups — by doctors, by mental health professionals, by loved ones and even by the clients themselves — is that both populations are known to be at high risk for depression, Zalaquett says. According to the National Alliance on Mental Illness, depression affects more than 6.5 million adults age 65 and older in the United States, or more than 18 percent of that population. Information from the National Institute of Mental Health (NIMH) indicates that about 11 percent of adolescents have a depressive disorder by age 18.

Zalaquett, who has trained school counselors throughout Florida on how to separate adolescent moodiness from depression, says counselors need to stay alert for signals that a teenager might be depressed. These signals can include attendance issues, behavior problems, academic problems, inability to concentrate, irritability, withdrawing from classmates and friends, and any expressions of suicide or death wishes. Most adolescents won’t show these symptoms for an extended period of time, but if they do, Zalaquett says, counselors need to get involved or make a referral.

According to NIMH, adolescent girls are even more likely than boys to experience depression. Laura Choate, associate professor of counselor education at Louisiana State University, says major depressive disorder is rising among adolescent girls, perhaps because they are reaching puberty earlier than in the past, are facing life stressors earlier and are less prepared to manage those stressors and pressures. Between the ages of 12 and 15, rates of depression among girls triple, according to Choate. By age 18, she says, 1 in 5 girls will have experienced an episode of major depression, and 1 in 10 will have had at least one suicide attempt.

Adolescent girls are under more pressure today than in the past, says Choate, author of the book Girls’ and Women’s Wellness: Contemporary Counseling Issues and Interventions, published by ACA. Not only are their bodies growing and their hormones changing, but they are also facing pressure to achieve academically and socially and to measure up to often-unattainable ideals fostered in the popular media. Choate says adolescent girls also soak up a message perpetuated by society that they should succeed and be competitive, while simultaneously receiving another message that they should be kind, take care of others and show compassion. So, Choate says, these girls may worry about their friends’ feelings even as they try to compete against them in athletics or academics, for instance.

Girls also are prone to excessive empathy, Choate says. “If their friend is going through a hard time, they allow the friend’s problem to affect them, and they feel it [too],” she says. “That can put them at risk for depression.”

Another factor is that girls are more likely to engage in corumination, repeatedly obsessing over problems verbally with their friends, Choate says. “Yet they’re less likely than boys to problem solve and take action,” she says. “Instead, they just ruminate and talk about the problem, and this process contributes to depression.”

Although most adolescent girls will experience a depressed mood from time to time, Choate points out that the criteria for major depression as set forth in the Diagnostic and Statistical Manual of Mental Disorders (DSM) include having at least five of the nine following symptoms that persist for two weeks or more: depressed mood, loss of interest or pleasure in usual activities, appetite disturbance (decrease or increase), sleep disturbance (insomnia or hypersomnia), psychomotor agitation or retardation, fatigue or loss of energy, feelings of worthlessness or guilt, concentration problems or indecisiveness, and suicidal ideation or gestures. These symptoms must represent a change from previous functioning in the adolescent, Choate says, and must produce impairment in relationships or in the performance of typical activities.

Early intervention

Choate says cognitive behavior therapy (CBT) is the theoretical approach for depressed adolescent girls that is most effective and most highly recommended by research. “It really addresses girls’ negative core beliefs about themselves, negative core beliefs about others and negative beliefs about the future that things will never be better,” she says. CBT techniques also address coping skills and problem-solving skills. Choate particularly recommends that counselors check into what she calls the most studied program for adolescent depression — Coping With Depression-Adolescents. Its manual and more information about the approach are available online, she says.

In discussing the possible role of medication in treating depression, Choate points to the Treatment for Adolescents With Depression Study (TADS), a randomized, controlled clinical trial that evaluated the effectiveness of CBT on its own, the medication fluoxetine on its own and therapy involving a combination of both CBT and fluoxetine. In a 36-week study, Choate says adolescents treated with CBT plus medication had the greatest recovery rates. “The TADS researchers reported that combination treatment reached maximum benefit at Week 18 with a response rate of 85 percent,” she says.

When fluoxetine alone and CBT alone were compared, Choate says the medication produced symptom reduction more quickly, but adolescents who received only medication were twice as likely to report suicide ideation. “This concerning finding led researchers to conclude that clinicians may want to begin treatment with CBT alone to avoid risk of antidepressant-induced suicidality and only [add] medication to the treatment regimen if the response to CBT is inadequate,” Choate says. “By starting treatment with CBT, there is no increased risk for suicidality, and adding CBT to medication helps protect from suicidality because it helps the client learn skills for managing stressful events, family conflicts and negative affect.”

In making treatment decisions regarding depression with adolescent clients, Choate suggests that counselors consult with appropriate medical professionals and consider the recommendations provided by the American Academy of Child and Adolescent Psychiatry Practice Guidelines for Child and Adolescent Depression.

Early intervention needs to be a primary focus for counselors, Choate says, especially because providing girls with the skills to prevent the onset of depression during adolescence can protect them from many of the negative outcomes associated with battling depression throughout their lifetime. Among important areas of training for girls are emotional literacy and regulation, stress reduction, social skills, problem solving, cognitive skills, building positive support systems, participation in pleasant events, awareness of mental health issues and knowledge of how to access services, Choate says.

Among the other recommendations Choate provides for working with adolescent girls who are dealing with depression:

  • “Take the depressive symptoms seriously,” she says. “Don’t buy into the stereotype that adolescent girls are just moody and that symptoms should be dismissed as typical teenage behavior if the depressive symptoms are persistent.”
  • Regardless of the theoretical approach taken, address the adolescent girl’s relationships with significant others in her life, including family, peers and romantic partners.
  • Assess her level of activity online. “While most girls report that social networking and texting help them feel closer to their friends, they also report that it can cause them to feel jealous, depressed or sad when others do not respond to their communication in the way they expected,” Choate says.
  • Include her family in treatment. “At this age, she is embedded in her family system,” Choate says. “Family communication, her role in the family and overall family functioning should be addressed in treatment.”
  • Check out prevention programs such as the Penn Resiliency Program, which is an evidence-based program for the prevention of depression in adolescents ages 10-14.

‘Depression is not mandatory’

On the other end of the human development continuum, older adults’ depression symptoms are often passed off as something to be expected as people age, Zalaquett says. “As a society, we value youth, vigor, enterprise and agency, among other characteristics,” he says. “Therefore, the declines in mobility and perceptual skills, as well as in intellectual speed, plus health issues, emptying of the nest and loss of relationships due to death, make observers feel that older adults are unhappy and that later years are depressive years. Moreover, many professionals and nonprofessionals view depression as a condition naturally associated with older age. This is not true, and depression is not mandatory for older age.” As with all other groups of people, Zalaquett says, the diagnosis of major depressive disorder among older adults is determined by classification tools such as the DSM and the International Classification of Diseases.

Although depression should not be viewed as a “normal” condition among older adults, Gintner acknowledges a number of life stressors that often accompany aging can contribute to its onset. For example, he says, older adults are often dealing with medical issues, the loss of loved ones and social support, potential cognitive impairment and life transitions such as retirement.

Gintner says it is also important to point out that undiagnosed and untreated depression can have serious consequences for older adults, including potentially complicating any medical issue and even predicting a shorter life. However, studies have shown that psychotherapy is very effective at treating major depression among older adults, he says.

What is tricky, Gintner says, is separating some of the typical physical problems and symptoms of aging from the symptoms of depression, because they often can mimic each other. For example, he says, adults might automatically attribute forgetfulness, fatigue, loss of interest in activities or loss of appetite to aging. But in fact, those are also symptoms of depression.

In diagnosing depression among older adults, Gintner says counselors must pay close attention and screen carefully. Many older adults grew up in a time when psychiatric symptoms were minimized and hidden, especially if you were a man, Gintner says, so they might remain hesitant to discuss those issues today. Counselors should also be aware of how depressive symptoms might vary at different ages, he says. For instance, among older adults, depression is more likely to be indicated by a loss of interest in certain activities rather than by significant depressed mood.

Gintner says cognitive therapy, behavior therapy and interpersonal therapy each have been shown effective in treating depression in older adults. Cognitive therapy looks at the older adult’s dysfunctional thoughts and beliefs; behavior therapy might aim to increase the frequency of a client’s pleasant events while decreasing the frequency of negative events; and interpersonal therapy would examine how a client’s interpersonal relationships affect his or her mood, Gintner explains.

Medication is also an option for treating depression among older adults, Gintner says, although it is often used more with adults whose depression is in the moderate to severe range rather than in the mild to moderate range. Choosing to add medication to the treatment regime is a matter of preference for clients, Gintner says, and counselors should respect whatever the client’s preferences are.

Whoever prescribes the medication should also be aware of the differences between older and younger adults in terms of the side effects a medication might have, Gintner says. And, of course, antidepressants might also affect or interact with other medications that older clients are already taking. “Counselors need to be aware of the benefits of medication for the elderly but also [be aware of] potential risks so that they can advocate for their clients if they need to,” Gintner says. The obvious benefit of psychotherapy, he adds, is that it has no medical side effects.

Building on client strengths and focusing on wellness are other keys when working with older adults, Zalaquett says. He suggests that counselors talk with clients about healthy eating, age-appropriate exercise, improvement of cognitive skills, maintenance or re-establishment of social and family relationships, and how to find meaning in life.

Gintner recommends that counselors interested in working with older adults on the topic of depression check out their area Council on Aging, make contacts with nursing homes and develop relationships with physicians known to work in gerontology.

Depression during pregnancy

Prenatal women may be considered yet another partially invisible population as it concerns depression. Choate, who co-authored an article on prenatal depression with Gintner for ACA’s Journal of Counseling & Development last year, says postpartum depression has become more well known in part because of media coverage of women who have acted violently toward their children while suffering from postpartum depression. But depression among women who are pregnant is just as common as depression among women who recently have given birth, according to Choate.

The highest rate of depression for women occurs during childbearing years between the ages of 25 and 44, Choate says. It used to be thought that pregnancy offered protection from depression, Choate says, but it has since been found that just as many women are depressed during pregnancy as are depressed after or outside of pregnancy.

It is not known for certain whether biological factors such as hormones play a role in depression among pregnant women, Choate says, but a previous history of depression does make a woman more likely to have a depressive episode during pregnancy, as does a family history of depression. Pregnant women also tend to be processing a variety of potentially emotional topics, Choate says, such as resolving thoughts about the upcoming transition, regardless of whether they are becoming a mother for the first time or becoming a mother again. They may also be dealing with interpersonal issues with their partners, external stressors such as finances and even grief over a perceived loss of independence, especially if the pregnancy was unwanted.

What makes prenatal depression challenging to diagnose and treat, Choate says, is that many of the symptoms of depression mimic pregnancy symptoms, including fatigue, trouble sleeping, mood swings and trouble concentrating. What might help counselors determine if prenatal depression is present, Choate says, is asking a question such as, “If you did experience an increase in energy or you were able to get better sleep, would you be interested in doing the things you normally do?”

Research has not been conducted on CBT techniques specifically with prenatal women, but Choate believes CBT is likely a good approach to use because of its effectiveness with depression in the general population. A manualized form of interpersonal therapy for pregnant women, called interpersonal therapy for pregnancy (IPT-P), does exist. It focuses on interpersonal skills and on the client being able to resolve issues in her personal relationships, Choate says. IPT-P places emphasis on the skills women need as new mothers, such as communicating with their partners, parenting, getting medical care, building a strong support system, resolving issues from their past and preparing to transition into their new role. Preparing for the transition may involve the mother-to-be addressing what she is giving up as well as what she will gain, Choate says.

Counselors treating prenatal clients with more severe depression might want to suggest that these women talk with their physicians and possibly be evaluated for medication. In such cases, Choate recommends that counselors offer to consult with the physician so that all three parties — counselor, client and physician — can weigh the potential side effects of medication to the baby versus the risk to the child if the mother remains depressed.

Building relationships with physicians is important even before a counselor sees a prenatal client, Choate says. She suggests reaching out to doctors and offering to collaborate with them and take referrals if their pregnant patients appear depressed. Women might believe they are automatically supposed to be happy during pregnancy, she says, and feel embarrassed or ashamed when they feel depressed instead. In such cases, they might not seek out a counselor directly.

Counselors who see depressed prenatal clients should be careful not to impose their values or assume that pregnancy is necessarily a happy time for all women, Choate says. “Try to understand her worldview, her role as a future mother and the pregnancy,” she says. “Make sure that you understand the different stressors that are operating in her life. Look at her holistically, not just as a depressed woman or a pregnant woman. Consider all the stressors and strengths in multiple life areas.”

The threat of suicide

All counselors, regardless of specialty or the population with which they work, should understand that depression is a prominent risk factor for suicide. A new report from the American Journal of Public Health revealed that more Americans now die by suicide than die in car crashes. According to health officials, almost 100 people die by suicide every day in the United States.

In September, U.S. Surgeon General Regina Benjamin in September introduced a new suicide-prevention plan with the goal of saving 20,000 lives in the next five years. Medicare has begun covering depression screenings, and Medicare and Medicaid now reward doctors who screen depressed patients for suicide risk.

Choate points out that adolescent girls are at especially high risk for suicide. “Counselors should definitely assess for suicide if the client is taking antidepressant medication,” she says. “Treatment should include helping her become aware of the relationship between her thoughts and feelings and should help her learn skills for distress tolerance, emotion regulation, coping with stressors and problem solving. This will help her better manage suicidal thoughts if they should emerge.”

According to NIMH, older Americans are “disproportionately likely to die by suicide.” Data from 2009 noted by the American Association of Suicidology shows that adults older than 65 made up almost 13 percent of the population but almost 16 percent of all suicides. “Suicide is a significant concern among older adults,” Zalaquett says. “This group has [a higher] rate of suicide [than] any other age group, particularly among men. Counselors working with older adults should assess for depression and suicide risk. We should not take these symptoms lightly or assume they are a necessary component of aging.”

The first step in combatting suicide with any depressed client, regardless of age or stage, is to understand that he or she is in intense psychological pain and wants to get as far away from that pain as possible, Walker says. “It is imperative that counselors listen openly and calmly with their clients who feel depressed and demonstrate that they care,” she says. “Don’t ignore the threats, and don’t be afraid to talk about suicide or the problems that have caused the desire to commit suicide. If a counselor communicates a fear of talking about it, [the counselor] will inadvertently convey to the client that it isn’t OK for them to talk about it either. Sweeping the problem under the rug may cause the client to feel guilty, misunderstood or unaccepted.”

Walker says counselors should assess for suicide risk factors, including the following:

  • History of chronic physical or emotional illness
  • Family history of attempted and completed suicides
  • Losing a significant other or close friend to suicide
  •  Increased anxiety, agitation, rage and emotional outbursts
  • Social isolation, relationship loss or stress, or perceived lack of emotional and tangible resources
  • Isolating and withdrawing from relationships and responsibilities (for example, missing important family events or absenteeism at work)
  • History of impulsivity, poor decision-making or risk-taking behavior
  • History of mental illness
  • History of drug and/or alcohol use or abuse
  • Pervasive and unwavering feelings of hopelessness, worthlessness, helplessness, guilt and/or despair

Walker suggests that counselors also attempt to find out clients’ intent, plans and means to carry out suicide; the frequency, duration and intensity of clients’ feelings; previous suicide attempts, if any; and how hopeless clients feel (using a measurable scale). Counselors can also aim to find out how specific, lethal, available and proximate the suicide plan is, she says. For example, using over-the-counter drugs might be lower risk than using a gun.

“Use closed-ended questions that involve ‘yes’ or ‘no’ answers so you can get a thorough assessment of specific plan and intent,” Walker says. For example, “‘Have your problems been getting you down so much lately that you’ve been thinking about harming yourself?’ and ‘Have you been feeling so hopeless that you’ve been thinking of killing yourself?’ If the answer is yes, the counselor must assess the degree of risk very quickly. Do not ask, ‘Why would you kill yourself?’ Instead ask, ‘How would you kill yourself?’ Talking about it with them will most likely help to bring down the agitation and lower the lethality.”

Help clients verbalize their difficulties and make an “options” list, prioritizing those options from best to worst, Walker suggests. “If they can’t think of anything, help them create alternative options,” she says. “If they absolutely insist on listing suicide as an option, try to get them to list it last. Additionally, help build a network for them and get them to do a verbal … and written contract with you that they will call a crisis hotline before they decide to do anything.”

Hazler warns counselors not to lose sight of the suicide threat as a client’s depression improves. Sometimes, he says, therapy or medication actually provides individuals the little added energy they were previously missing to carry out a suicide attempt.

Offering a lifeline

Walker recalls a depressed older male client she counseled while working at a rural community agency. “[He started] off his first session with me with intense anger,” Walker remembers, “shaking his cane in the air, pounding it into the ground [and] saying, ‘No one wants to help me, no one cares about me, and I have nothing left to live for.’ He didn’t want to be there, but he had nowhere else to turn and knew he needed help. He was at the end of his rope. The week prior to his first session with me, he made the devastating decision to put his dog down because he couldn’t afford to feed it, and [he] felt so alone and lost in life. He had not talked to his adult children in months. He was living with chronic pain, could no longer work and had to survive on meager disability assistance. He felt helpless, hopeless and worthless. He had a definite plan to take his own life and the means to carry it out.”

Walker did a substantial amount of active listening and supporting during that first session. The client could tell she cared tremendously, and he began to trust that she was not going to give up on him. “As a counselor, I believe in the power of human potential and in helping my clients learn to overcome life challenges and trust in their own resiliency,” she says. “I believe in hope and our ability to create meaning in our lives instead of being victims to it.”

Counselors often serve as guides, teachers, coaches, mentors, mediators or lifelines, Walker says. “For this client, I was the lifeline he needed. One test of strength and resiliency was the fact that he had been 20 years actively sober from alcohol. However, as he struggled with his loss of identity as a worker and wage earner, he found himself … in the depths of abject despair. Believing that no one cared and that he was a fraction of a man due to his pain, disability and loss of identity, he had pulled away from his family, friends and the support network he had in Alcoholics Anonymous and with his sponsor.”

Encouraged by Walker, the client agreed to give his gun, which was part of his suicide plan, to a family member, and the family member agreed not to give it back to him. “We tapped into his support network to help serve as a buffer to his emotional pain,” Walker says. “He committed himself to figuring out a way to make sense of it all and to re-create meaning in his life. He began to spend time with his children and grandchildren. He re-engaged in life and reached out to his friends. He resumed weekly AA meetings and began meeting regularly with his sponsor. He began to focus on what he still had in his life and what he could still do with it instead of focusing on what he had lost. Throughout our work together, he learned to not give up on himself and to trust the resources he already had and the resources he could tap into to make it through in life. As he felt stronger, he felt better and began to believe in himself again.”

Walker continues, “There is a great quote by an unknown author that says, ‘When the world says, “Give up,” Hope whispers, “Try it one more time.”’ As a counselor, I believe in hope and I believe in client resiliency, and I believe as counselors, that is our mandate.”

The following individuals interviewed for this article invite readers to contact them:

Want to read more? Click here for an online exclusive Q&A with Carlos Zalaquett on diversity’s role in depression.

Lynne Shallcross is the associate editor and senior writer for Counseling Today. Contact her at lshallcross@counseling.org.

Letters to the editor: ct@counseling.org