Tag Archives: Depression

For such a time as this: A plan of action for general anxiety and depression

By Esther Scott June 8, 2020

[Editor’s note: This is the first of four articles in a series on action plans for different areas of life during the COVID-19 pandemic. The next three articles will be posted on subsequent Mondays in June.]

With the coronavirus pandemic, everything has changed, from the hygiene habits of washing our hands more frequently to the physical distancing that we must now maintain. For many, the financial stress and rapid changes brought about by the pandemic can be just as scary as the virus itself. Business closures, income reduction and the uncertainty of what might be ahead once we return to “normalcy” has increased stress levels for all of us, and many people are even experiencing symptoms of depression. Understanding what is happening in our brains and having a plan of action can help us manage these new challenges in the different areas of our lives.

Through this four-part series, we will look at a plan of action that can help the rational brain feel in control again and view the new challenges we now face as opportunities to develop our resilience.

Let’s start with a plan of action to help reduce anxiety and prevent depression symptoms.

1) Write down specific worries.

The first step to solving a problem is understanding what is happening. Why are we so stressed out? Perceived lack of control.

Uncertainty produces hypervigilance in the brain. Our brains are on high alert, increasing our levels of stress. Stress is an automatic defense mechanism that prepares us to face a threat, whether hypothetical or real. It is regulated by the hypothalamus and pituitary gland (in the brain) and the adrenal gland (above the kidneys).

In the face of danger (uncertainty), the hypothalamus activates the alert system (increased heart rate, respiratory rate and muscle tone) and produces cortisol — the stress hormone — secreted by the adrenals, which maintains this physiological alert as long as necessary. If it is perpetuated too long, stress can become a health problem that leads to increased risk of anxiety, depression, substance use and other maladaptive behaviors.

The brain likes organization and predictability. That is why we organize information in categories known as bias or stereotypical organization. Therefore, the first step to overcoming anxiety and depression is making a list of the worries you have about how the coronavirus pandemic has disrupted your life. Examine your worries, aiming to be realistic in your assessment of the actual concern and your ability to cope. Try not to catastrophize; instead, focus on what you can do. Your life is going to be different for a while, but identifying what worries you have and focusing on what you can control will make the difference.

2) Make a list of possible solutions.

Think of all possible options. This is the all-familiar “brainstorming” technique. Include whatever possibilities come to mind that could help you get by, even if it is not your ideal option. The goal is to focus on concrete things that you can problem-solve or change. A solution-focused approach will help you focus on your strengths instead of your weaknesses.

Think about how you have been able to cope with difficulties in the past by asking yourself questions such as “How have I managed to carry on?” or “How have I managed to prevent things from becoming worse?” After you have evaluated your options, accept your new reality and develop a plan.

Remember, anxiety comes from not knowing what will happen, and depression comes from believing there is nothing we can do to change it. Having a plan will move you from paralyzing anxiety to action. Practicing physical distancing, getting enough sleep and doing other activities to support your immune system are examples of positive actions that you can take immediately. Put your attention on your strengths and abilities, and imagine yourself coping and adapting.

3) Know your emotional triggers.

Pinpoint what your emotional triggers are and how you react to them. It is natural to feel stressed about what may happen if our income does not cover our obligations, or if someone we love gets sick, or if we must quarantine longer. In fact, feeling down from time to time is a normal reaction to life’s stressors. But when hopelessness and despair enter the picture or take hold and just will not go away, then we need to pay closer attention because it may be a sign of depression.

Depression is more than just sadness in response to struggles or setbacks. Depression changes your perception and the way you feel, bringing you feelings of emptiness and doom. It impacts your ability to sleep, work, eat, and enjoy your life.

It is also important to remember that the feelings of hopelessness or helplessness we may experience are symptoms of depression, not the reality of the situation. There is hope. There is a solution. Even if we cannot see it right now.

4) Conduct a strength inventory.

Resilience is the ability to withstand, recover and bounce back in the midst of stress, chaos and ever-changing situations. It is the capacity to recover quickly from difficulties, the courage to come back.

Conducting a strength inventory can help you feel stronger and more resourceful. Identify what negative thought you struggle with. Replace or reframe how you are viewing your challenges. The situation you are facing is hard, but is there something you can learn from it or some other silver lining? If you have been through difficult situations in the past — and most of us have been through those at some point in our lives — identify what got you through them, and use it to your advantage.

5) Practice kindness.

Studies have shown that people who consistently help others experience less depression, greater calm and fewer pains. Kind people create joy and satisfaction through helping others. People who can give and accept support in a tough situation tend to feel less depressed.

Kindness toward others can translate into kindness to you. Seek support from your family and friends or a professional mental health provider if you need it. It can help you deal better with hard times.



Esther Scott, LPC

Esther Scott is a licensed professional counselor in Arlington, Texas. She is a solution-focused therapist. Her specialties include grief, depression, teaching coping skills and couples counseling. Contact her through her website at positiveactionsinternational.com.




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Going beyond sadness

By Bethany Bray October 21, 2019

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

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

Signs and symptoms

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

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

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

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

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

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

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

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

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

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

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

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

Depression through a behavioral and Latinx lens

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Depression through an older adult lens

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

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

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

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

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

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

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

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

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

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

Depression through a systems lens

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Depression through an African American lens

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

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

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

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

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

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

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

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

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

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

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

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

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




Treating depression with or without medication

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

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

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

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



Additional resources

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

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


Contact the counselors interviewed for this article:



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

Letters to the editor: ct@counseling.org




Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Challenging the inevitability of inherited mental illness

By Lindsey Phillips August 29, 2019

With a family history that famously includes depression, addiction, eating disorders and seven suicides — including her grandfather Ernest Hemingway and her sister Margaux — actress and writer Mariel Hemingway doesn’t try to deny that mental health issues run in her family. She repeatedly shares her family history to advocate for mental health and to help others affected by mental illness feel less alone.

And, of course, they aren’t alone. Mental health issues are prevalent in many families, making it natural for some individuals to wonder or worry about the inherited risks of developing mental health problems. Take the common mental health issue of depression, for example. The Stanford University School of Medicine estimates that about 10% of people in the United States will experience major depression at some point during their lifetime. People with a family history of depression have a two to three times greater risk of developing depression than does the average person, however.

A 2014 meta-analysis of 33 studies (all published by December 2012) examined the familial health risk of severe mental illness. The results, published in the journal Schizophrenia Bulletin, found that offspring of parents with schizophrenia, bipolar disorder or major depressive disorder had a 1 in 3 chance of developing one of those illnesses by adulthood — more than twice the risk for the control offspring of parents without severe mental illness.

Jennifer Behm, a licensed professional counselor (LPC) at MindSpring Counseling and Consultation in Virginia, finds that clients who are worried about family mental health history often come to counseling already feeling defeated. These clients tend to think there is little or nothing they can do about it because it “runs in the family,” she says.

Theresa Shuck is an LPC at Baeten Counseling and Consultation Team and part of the genetics team at a community hospital in Wisconsin. She says family mental health history can be a touchy subject for many clients because of the stigma and shame associated with it. In her practice, she has noticed that individuals often do not disclose family history out of their own fear. “Then, when a younger generation person develops the illness and the family history comes out, there’s a lot of blame and anger about why the family didn’t tell them, how they would have wanted to know that, and how they could have done something about it,” she notes.

Sarra Everett, an LPC in private practice in Georgia, says she has clients whose families have kept their history of mental illness a secret to protect the family image. “So much of what feeds mental illness and takes it to an extreme is shame. Feeling like there’s something wrong with you or not knowing what is wrong with you, feeling alone and isolated,” Everett says. Talking openly and honestly about family mental health history with a counselor can serve to destigmatize mental health problems and help people stop feeling ashamed about that history, she emphasizes.

Is mental illness hereditary?

Some diseases such as cystic fibrosis and Huntington’s disease are caused by a single defective gene and are thus easily predicted by a genetic test. Mental illness, however, is not so cut and dry. A combination of genetic changes and environmental factors determines if someone will develop a disorder.

In her 2012 VISTAS article “Rogers Revisited: The Genetic Impact of the Counseling Relationship,” Behm notes that research in cellular biology has shown that about 5% of diseases are genetically determined, whereas the remaining 95% are environmentally based.

The history of the so-called “depression gene” perfectly illustrates the complexity of psychiatric genetics. In the 1990s, researchers showed that people with shorter alleles of the 5-HTTLPR (a serotonin transporter gene) had a higher chance of developing depression. However, in 2003, another study found that the effects of this gene were moderated by a gene-by-environment interaction, which means the genotype would result in depression if people were subjected to specific environmental conditions (i.e., stressful life events). More recently, two studies have disproved the statistical evidence for a relation between this genotype and depression and a gene-by-environment interaction with this genotype.

Even so, researchers keeps searching for disorders that are more likely to “run in the family.” A 2013 study by the Cross-Disorder Group of the Psychiatric Genomic Consortium found that five major mental disorders — autism, attention deficit/hyperactivity disorder (ADHD), bipolar disorder, major depressive disorder and schizophrenia — appear to share some common genetic risk factors.

In 2018, a Bustle article listed 10 mental health issues “that are more likely to run in families”: schizophrenia, anxiety disorders, depression, bipolar disorder, obsessive-compulsive disorder (OCD), ADHD, eating disorders, postpartum depression, addictions and phobias.

Adding to the complexity, Kathryn Douthit, a professor in the counseling and human development program at the University of Rochester, points out that studies on mental disorders are done on categories such as major depression and anxiety that are often based on descriptive terms, not biological markers. The cluster of symptoms produces a “disorder” that may have multiple causes — ones not caused by the same particular genes, she explains.

Thus, thinking about mental health as being purely genetic is problematic, she says. In other words, people don’t simply “inherit” mental illness. A number of biological and environmental factors are at play in gene expression.

Regardless of the genetic link, family history does serve as an indicator of possible risk for certain mental health issues, so counselors need to ask about it. As a genetic counselor, Shuck, a member of the American Counseling Association, admits that she may handle family history intake differently. Genetic counseling, as defined by the National Society of Genetic Counselors, is “the process of helping people understand and adapt to the medical, psychological and familial implications of genetic contributions to disease.” It blends education and counseling, including discussing one’s emotional reactions (e.g., guilt, shame) to the cause of an illness and strategies to improve and protect one’s mental health.

Thus, Shuck’s own interests often lead her to ask follow-up questions about family history rather than sticking to a general question about whether anyone in a client’s family struggles with a certain disorder. If, for example, she learns a client has a family history of depression, she may ask, “Who has depression, or who do you think has depression?” After the client names the family members, Shuck might say, “Tell me about your experiences with those family members. How much has their mental health gotten in the way? How aware were you of their mental health?”

These questions serve as a natural segue to discussing how some disorders have a stronger predisposition in families, so it is good to be aware and mindful of them, she explains. Discussing family history in this way helps to normalize it, she adds.   

Everett, who specializes in psychotherapy for adults who were raised by parents with mental illness, initially avoids asking too many questions. Instead, she lets the conversation unfold, and if a client mentions alcohol use, she’ll ask if any of the client’s family members drink alcohol. Inserting those questions into the discussion often opens up a productive conversation about family mental health history, she says.

Environmental factors

Mental disorders are “really not at all about genetic testing where you’re testing genes or blood samples because there are no specific genetic tests that can predict or rule out whether someone may develop mental illness,” Shuck notes. “That’s not how mental illness works.”

Shuck says that having a family history of mental illness can be thought of along the same lines as having a family history of high blood pressure or diabetes. Yes, having a family history does increase one’s risk for a particular health issue, but it is not destiny, she stresses.

For that reason, when someone with a family history of mental disorders walks into counseling, it is important to educate them that mental health is more than just biology and genetics, Shuck says. In fact, genetics, environment, lifestyle and self-care (or lack thereof) all work together to determine if someone will develop a mental disorder, she explains.

One of Shuck’s favorite visual tools to help illustrate this for clients is the mental illness jar analogy (from Holly Peay and Jehannine Austin’s How to Talk With Families About Genetics and Psychiatric Illness). Shuck tells clients to imagine a glass jar with marbles in it. The marbles represent the genes (genetic factors) they receive from both sides of their family. The marbles also represent one’s susceptibility to mental illness; some people have two marbles in their jar, while others have a few handfuls of marbles.

Next, Shuck explains how one’s lifestyle and environment also fill the jar. To illustrate this point, she has clients imagine adding leaves, grass, pebbles and twigs (representing environmental factors) until the jar is at capacity. “We only develop mental illness if the jar overflows,” she says.

Behm, an ACA member, also uses a simple analogy (from developmental biologist Bruce Lipton) to help explain this complex issue to clients. She tells clients to think of a gene as an overhead light in a room. When they walk into the room, that light (or gene) is present but inactive. They have to change their environment by walking over and flipping on a switch to activate the light.

As Everett points out, “Our experiences, drug use, traumas, these things can turn genes on, especially at a young age.” On the other hand, if someone with a pervasive family history of mental disorders had caregivers who were aware and sought help, the child could grow up to be relatively well-adjusted and healthy in terms of mental health, she says.

In utero epigenetics is another area that illustrates how environment affects our genes and mental health, Douthit notes. The Dutch Hongerwinter (hunger winter) offers an example. In 1944-1945, people living in a Nazi-occupied part of the Netherlands endured starvation and brutal cold because they were cut off from food and fuel supplies. Scientists followed a group who were in utero during this period and found that the harsh environment caused changes in gene expression that resulted in their developing physical and mental health problems across the life span. In particular, they experienced higher rates of depression, anxiety disorders, schizophrenia, schizotypal disorder and various dementias.

Why is this important to the work of counselors? If, Douthit says, counselors are aware of an environmental risk to young children, such as the altered gene expression coming from the chronic stress and trauma associated with poverty, then they can work with parents and use appropriate therapeutic techniques such as touch therapy interventions in young infants and child-parent psychotherapy to reverse the impact of the harmful
gene expression.

Behm uses the Rogerian approach of unconditional positive regard and “prizing” the client (showing clients they are worth striving for) to create a different environment for clients — one that is ripe for change.

Counseling interventions that change clients’ behaviors and thoughts long term have the potential to also change brain structure and help clients learn new ways of doing and being, Behm continues. “It’s the external factors that are making people anxious or depressed,” she says. “If you get yourself out of that situation, your experience can be different. If you can’t get yourself out of it, the way you perceive it — how you make meaning of it — makes it different in your brain.”

The hope of epigenetics

Historically, genes have been considered sovereign, but genetics don’t tell the entire story, Behm points out. For her, epigenetics is a hopeful way to approach the issue of familial mental illness.

Epigenetics contains the Greek prefix epi, which means “on top of,” “above” or “outside of.” Thus, epigenetics includes the factors outside of the genes. This term can describe a wide range of biological mechanisms that switch genes on and off (evoking the prior analogy of the overhead light). Epigenetics focuses on the expression of one’s genes — what is shaped by environmental influences and life experiences such as chronic
stress or trauma.

Douthit has written and presented on the relationship between counseling and psychiatric genetics, including her 2006 article “The Convergence of Counseling and Psychiatric Genetics: An Essential Role for Counselors” in the Journal of Counseling & Development and a 2015 article on epigenetics for the “Neurocounseling: Bridging Brain and Behavior” column in Counseling Today. In her chapter on the biology of marginality in the 2017 ACA book Neurocounseling: Brain-Based Clinical Approaches, she explains epigenetics as the way that aspects of the environment control how genes are expressed. Epigenetic changes can help people adapt to new and challenging environments, she adds.

This is where counseling comes in. Clients often come to counseling after they have struggled on their own for a while, Behm notes. The repetition of their reactions to their external environment has resulted in a certain neuropathway being created, she explains.

Clients are inundated with messages of diseases being genetic or heritable, but they rarely hear the counternarrative that they can make changes in their lives that will provide relief from their struggle, Behm notes. “Through consistent application of these changes, [clients] can change the structure and function of [their] brain,” she adds. This process is known as neuroplasticity.

Behm explains neuroplasticity to her clients by literally connecting the dots for them. She puts a bunch of dots on a blank piece of paper to represent neurons in the brain. Then, for simplicity, she connects two dots with a line to represent the neuropathway that develops when someone acts or thinks the same way repeatedly. She then asks, “What do you think will happen if I continue to connect these two dots over and over?” Clients acknowledge that this action will wear a hole in the paper. To which she responds, “When I create a hole, then I don’t have to look at the paper to connect the dots. I can do it automatically without looking because I have created a groove. That’s a neuropathway. That’s a habit.”

Even though clients often come in to counseling with unhealthy or undesirable habits (such as responding to an event in an anxious way), Behm provides them with hope. She explains how counseling can help them create new neuropathways, which she illustrates by connecting the original dot on the paper with a new dot.

Of course, the real process is not as simple as connecting one dot to another, but the illustration helps clients grasp that they can choose another path and establish a new way of being and doing, Behm says. The realization of this choice provides clients — including those with family histories of mental illness — a sense of freedom, hope and empowerment, she adds.

At the same time, Behm reminds clients of the power exerted by previously well-worn neuropathways and reassures them that continuing down an old pathway is normal. If that happens, she advises clients to journal about the experience, recording their thoughts and feelings about making the undesirable choice and what they wish they had done or thought differently.

“The very act of writing that out strengthens the [new] neuropathway,” she explains. “Not only did you pause and think about it … you wrote about it. That strengthened it as well.”

In addition, professional clinical counselors can help bring clients’ subconscious thoughts to consciousness. By doing this, clients can process harmful thoughts, make meaning out of the situation, and create a new narrative, Behm explains. The healthy thoughts from the new narrative can positively affect genes, she says.

Protective factors

When patients are confronted with a physical health risk such as diabetes or high blood pressure, they are typically encouraged by health professionals to adjust their behavior in response. Shuck, a member of the National Society of Genetic Counselors and its psychiatric disorders special interest group, approaches her clients’ increased risk of mental health problems in a similar fashion: by helping them change their behaviors.

Returning to the mental illness jar analogy, Shuck informs clients that they can increase the size of their jars by adding rings to the top so that the “contents” (the genetic and environmental factors) don’t spill over. These “rings” are protective factors that help improve one’s mental health, Shuck explains. “Sleep, exercise, social connection, psychotherapy, physical health maintenance — all of those protective factors that we have control of and we can do something about — [are] what make the jar have more capacity,” she says. “And so, it doesn’t really matter how many marbles we’re born with; it’s also important what else gets put in the jar and how many protective factors we add to it to increase the capacity.”

Techniques that involve a calming sympathetic-parasympathetic shift (as proposed by Herbert Benson, a pioneer of mind-body medicine) may also be effective, Douthit asserts. Activities such as meditation, knitting, therapeutic massage, creative arts, being in nature, and breathwork help cause this shift and calm the nervous system, she explains. Some of these techniques can involve basic behavioral changes that help clients “become aware of when [they’re] becoming agitated and to be able to recognize that and pull back from it and get engaged in things that are going to help [them] feel more baseline calm,”
she explains.

In addition, counseling can help clients relearn a better response or coping strategy for their respective environmental situations, Behm says. For example, a client might have grown up watching a parent respond to external events in an anxious way and subconsciously learned this was an appropriate response. In the safe setting of counseling, this client can learn new, healthy coping methods and, through repetition (which is one way that change happens), create new neuropathways.

At the same time, Shuck and Douthit caution counselors against implying that as long as clients do all the rights things — get appropriate sleep, maintain good hygiene, eat healthy foods, exercise, reduce stress, see a therapist, maintain a medicine regime — that they won’t struggle, won’t develop a mental disorder, or can ignore symptoms of psychosis.

“You can do all of the right things and still develop depression. It doesn’t mean that somebody’s doing something wrong. … It just means there happened to have been more marbles in the jar in the first place,” Shuck says. “It’s [about] giving people the idea that there’s some mastery over some of these factors, that they’re not just sitting helplessly waiting for their destiny to occur.”

Shuck often translates this message to other areas of health care. For example, someone with a family history of diabetes may or may not develop it eventually, but the person can engage in protective factors such as maintaining a healthy body weight and diet, going to the doctor, and getting screened to help minimize the risk. “If we normalize [mental health] and make it very much a part of what we do with our physical health, it’s really not so different,” she says.

Bridging the gap

Shuck started off her career strictly as a genetic counselor. As she made referrals for her genetics clients and those dealing with perinatal loss to see mental health therapists, however, several clients came back to her saying the psychotherapist wasn’t a good fit. Over time, this happened consistently.

This experience opened Shuck’s eyes to the existing gap between the medical and therapeutic professions for people who have chronic medical or genetic conditions. Medical training isn’t typically part of the counseling curriculum, often because there isn’t room or a need for such specialized training, she points out.

Shuck decided to become part of the solution by obtaining another master’s degree, this time in professional counseling. She now works as a genetic counselor and as a psychotherapist at separate agencies. She says some clients are drawn to her because of her science background and her knowledge of the health care setting.

Behm also notes a disconnect between genetics and counseling. “I see these two distinct pillars: One is the pillar of genetic determinism, and the other is the pillar of epigenetics. And with respect to case conceptualization and treatment, there aren’t many places where the two are communicating,” she says.

Douthit, a former biologist and immunologist, acknowledges that some genetic questions such as the life decisions related to psychiatric genetics are outside the scope of practice for professional clinical counselors. However, helping clients to change their unhealthy behaviors and though patterns, deal with family discord or their own reactions (e.g., grief, loss, anxiety) to genetically mediated diseases, and create a sympathetic-parasympathetic shift are all areas within counselors’ realm of expertise, she points out.

An interprofessional approach is also beneficial when addressing familial mental health disorders. If Behm finds herself “stuck” with a client, she will conduct motivational interviewing and then often include a referral to a medical doctor or other medical professional. For example, she points out, depression can be related to a vitamin D deficiency. She has had clients whose vitamin D levels were dangerously low, and after she referred them to a medical doctor to fix the vitamin deficiency, their therapeutic work improved as well.

Another example is the association between addiction and an amino acid deficiency. Behm notes that consulting with a physician who can test and treat this type of deficiency has been shown to reduce clients’ desires to use substances. Even though counselors are not physicians, knowing when to make physicians a part of the treatment team can help improve client outcomes,
she says. 

Another way to bridge the gap between psychotherapy and the science of genetics is to make mental health a natural part of the dialogue about one’s overall health. “Mental illness lives in the organ of the brain, but we somehow don’t equate the brain as an organ that’s of equality with our kidneys, heart or liver,” Shuck says. When there is a dysfunction in the brain, clients deserve the opportunity to make their brains work better because that is important for their overall well-being,
she asserts.

Facing one’s fears

Having a family history of mental illness may result in fear — fear of developing a disorder, fear of passing a disorder on to a child, fear of being a bad parent or spouse because of a disorder.

“Fear is paralyzing,” Shuck notes. “When people are fearful of something … they don’t talk about it and they don’t do anything about it.” The aim in counseling is to help clients move away from feeling afraid — like they’re waiting for the disorder to “happen” — to feeling more in control, she explains.

Some clients have confessed to Everett that they have doubts about whether they want or should have children for several reasons. For instance, they fear passing on a mental health disorder, had a negative childhood themselves because of a parent who suffered from an untreated disorder, or currently struggle with their own mental health. For these clients, Everett explains that having a mental health issue or a family history of mental illness doesn’t mean that they will go on to neglect or abuse their children. “With parents who have the support and are willing to be open and ask for help … [mental illness] can be a part of their life but doesn’t have to completely devastate their children or family,” she says.

Shuck reminds clients who fear that their children could inherit a mental illness that most of the factors that determine whether people develop a mental disorder are nongenetic. In addition, she tells clients their experience with their own mental health is the best tool to help their child if concerns arise because they already know what signs to look for and how to get help.

Even if a child comes from a family with a history of mental illness, the child’s environment will be different from the previous generations, so the manifestations of mental illness could be less or more severe or might not appear at all, Douthit adds.

The potential risk of mental illness may also produce anger in some clients, but as Shuck points out, this can sometimes serve as motivation. One of her clients has a family history that includes substance abuse, addiction, hoarding, anxiety, bipolar disorder, OCD, depression and suicide. The client also experienced mental health problems and had a genetic disorder, but unlike her family, she advocated for herself. When Shuck asked her why she was different from the rest of her family, the client confessed she was angry that she had grown up with family members who wouldn’t admit that they had a mental illness and instead used unhealthy behaviors such as drinking to cope. She knew she wanted a different life for herself and her future children.

Defining their own destiny

Everett doesn’t focus too heavily on client genetics because she can’t do anything about them. Instead, her goal is to encourage clients to believe that they can change and get better themselves. She wants clients to move past their defeated positions and realize that a family history of mental illness doesn’t have to define them.

Likewise, Behm thinks counselors should instill hope and optimism into sessions and carry those things for clients until they are able to carry them for themselves. To do this, counselors should be well-versed in the science of epigenetics and unafraid of clients’ family histories, she says. Practitioners must believe that counseling can truly make a difference and should attempt to grow in their understanding of how the process can alter a client’s genes, she adds.

From the first session, Behm is building hope. She has found that activities that connect the mind and body can calm clients quickly and make them optimistic about future sessions. For example, she may have clients engage in diaphragmatic breathing and ask them what they want to take into their bodies. If their answer is a calming feeling, she tells them to imagine calm traveling into every single cell of their bodies when they breath in. Alternately, clients can imagine inhaling a color that represents calm. Next, Behm asks clients what they want to let go of — stress or anxiety, for example — and has them imagine that leaving the body as they exhale.

Hope and optimism played a large role in how Mariel Hemingway approached her family’s history of mental illness. She recognized that her history made her more vulnerable. Determined not to become another tragic story, Hemingway exerted control over her environment, thoughts and behaviors. Today, she continues to eat well, exercise, meditate and practice stress reduction.

Hemingway’s story illustrates the complexity of familial history and serves as a good model for counselors and clients, Douthit says. “Whether it’s genetic or not, it’s being passed along from generation to generation,” Douthit says. “And that could be through behaviors. It could be through other environmental issues. It could be any number of modifications that occur when genes are expressed.”

Shuck says she often hears other mental health professionals place too great an emphasis on the inheritance of mental illness. A family history of mental illness alone does not determine one’s destiny, she says. Instead, counselors and clients should focus on the things they do have control over, such as environmental factors and lifestyle.

“We have to emphasize wellness [and protective factors] much more than the idea that ‘it’s in my family, so it’s going to happen to me,’” she says. “We have to look at those things we can do as an individual to enhance those aspects of our well-being to make [the capacity of the mental illness] jar bigger.”




Lindsey Phillips is a contributing writer to Counseling Today and a UX content strategist living in Northern Virginia. Contact her at hello@lindseynphillips.com or through her website at lindseynphillips.com.

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Study: Genetic wiring as a ‘morning person’ associated with better mental health

By Bethany Bray February 11, 2019

Are you a morning person or a night owl?
Most people consider themselves to be one or the other, with a natural inclination for productivity either in the morning or after sunset.

Not only are these tendencies wired into our genes, but they have a correlation to mental well-being, according to a study published Jan. 29 in the journal Nature. A cohort of researchers found that the genetic tendency toward being a morning person is “positively correlated with well-being” and less associated with depression and schizophrenia.

“There are clear epidemiological associations reported in the literature between mental health traits and chronotype [a person’s ‘circadian preference,’ or tendency toward rising early or staying up late], with mental health disorders typically being overrepresented in evening types. … We show that being a morning person is causally associated with better mental health but does not affect body mass index (BMI) or risk of Type 2 diabetes,” the researchers wrote.

A person’s tendency toward what the researchers refer to as “morningness” is wired into the genes that regulate our circadian rhythm. In addition to sleep patterns, the body’s circadian rhythm affects hormone levels, body temperature and other processes.

Using data from more than 85,000 people, the researchers found that the sleep timing of those in the top 5 percent of morning persons was an average of 25 minutes earlier than those with the fewest genetic tendencies toward morningness.

The study also highlights the connection, reported by previous research, between schizophrenia and circadian dysregulation and misalignment, as well as the increased frequency of obesity, Type 2 diabetes and depression in people who are night owls.

“One possibility which future studies should investigate is whether circadian misalignment, rather than chronotype itself, is more strongly associated with disease outcomes,” wrote the researchers. “For example, are individuals who are genetically evening people but have to wake early because of work commitments particularly susceptible to obesity and diabetes?”




Read the full study in the journal Nature: nature.com/articles/s41467-018-08259-7


From the Australian Broadcasting Corporation: “Early birds have a lower risk of mental illness than night owls, genes show




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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.


Talking about menopause

By Laurie Meyers January 7, 2019

Sleepless nights. Sudden temperature spikes and night sweats. Fluctuating moods. Brain fog. Sudden hair loss (head). Sudden hair growth (face). Dry skin, leaky bladder, pain during intercourse.

This litany of symptoms may sound like the signs of a mysterious and slightly terrifying disease, but they’re actually all possible side effects of a normal, natural life transition: menopause.

Menopause is an inevitable part of life for women — or, more precisely, people with ovaries — but chances are, many clients who show up to counseling know little about it. “The Change,” as it is sometimes called, isn’t taught in sex education classes and is rarely brought up by doctors. Even friends don’t always tell other friends about it. Unprepared for this disruption that usually coincides with a life stage already known as a major time of transition, clients may turn to counselors for help navigating this natural biological process.

Understanding the process

Therein lies the first lesson: Menopause is part of a process. Menopause refers to a specific point 12 months after a person’s last menstrual cycle. Perimenopause, which can begin up to 10 years before menopause, is the transitional time during which most menopausal symptoms occur. Perimenopause usually begins in a person’s 40s but can start as early as a person’s mid- to late 30s.

“During these years, most women will notice early menopausal symptoms such as hot flushes, night sweats, sleep disturbance, heart palpitations, poor memory and concentration, vaginal dryness and … depression,” says American Counseling Association member Laura Choate, a licensed professional counselor (LPC) who has written extensively about issues that affect women and girls.

According to the National Institutes of Health, other perimenopausal symptoms include irregular menstrual periods, incontinence, general moodiness and loss of sex drive. Some people also experience aches and pains and weight gain, particularly in the abdominal area, although experts are unsure whether these effects are tied directly to perimenopause or are instead caused by aging.

LPC Stacey Greer, whose practice specialties include assisting clients with issues related to perimenopause/menopause, says that many clients show up to her office because they’ve been feeling “off” or “not like themselves.” Some of these clients may even have received a perimenopause diagnosis, but most still are unaware of the symptoms and don’t understand the process, she says.

Both Greer and Choate believe that knowing what to expect in perimenopause can in itself ease some of the discomfort of the transition. Choate notes that for those who are unaware of the signs of perimenopause, many of the symptoms can be alarming. Some clients’ symptoms may be mild, but for others, they are severe and can significantly interfere with clients’ functioning and quality of life, Choate says. She adds that symptoms usually peak about a year before the last menstrual period and begin to ease significantly in the second year of postmenopause.

Is it hot in here?

Knowing what to expect from perimenopause is all well and good, but in this case, forewarned doesn’t mean forearmed. Clients still have to live through the symptoms.

Counselors can help with that. Greer says that charting is an excellent tool. She gives clients a chart listing perimenopausal symptoms and asks them to note all the ones that they experience over the course of a month. This allows her to identify and focus on a client’s specific problems.

Hot flashes, night sweats and trouble sleeping are some of the most common complaints. Choate says research has shown that cognitive behavior therapy (CBT) can help with hot flashes and night sweats. She recommends the techniques contained in Managing Hot Flushes With Group Cognitive Behavioral Therapy: An Evidence-Based Treatment Manual for Health Professionals by Myra Hunter and Melanie Smith. The book highlights the importance of identifying and reframing thoughts that occur during a hot flash.

When hit with a hot flash, instead of thinking, “Not other one!” or “I am going to pass out” or “This will never end,” clients can tell themselves, “It will pass” or “Menopause is a normal part of life” or “The flashes will gradually go away over time,” Choate explains.

“In addition to changing self-talk, it is helpful to have an attitude of calm acceptance, mindfully accepting the hot flash instead of trying to push it away or become upset by it,” she says. “There is evidence that mindful acceptance and allowing the flash to ‘fall over you’ helps women cope more effectively. Also, using paced breathing to elicit the relaxation response helps women cope as they focus on their slowed breathing instead of the discomfort that accompanies a hot flash.”

Many people also experience problems sleeping during perimenopause. According to the National Sleep Foundation (NSF), this is not only because of nighttime hot flashes but because of decreasing levels of progesterone, which promotes sleep. The NSF recommends the following for menopause-related sleep problems:

  • Stay cool. Keep a bowl of ice water and a washcloth near the bed for quick cool-offs when awakened by a hot flash. Also maintain a cool, comfortable bedroom temperature (ideally between 60 and 67 degrees), and keep the room well ventilated.
  • Choose the right bedding. Skip thick, heavy comforters and fleece sheets and go for bedding made from lighter materials, such as breathable and fast-drying cotton. This prevents overheating.
  • Eat soy. Eating soy products such as tofu, soy milk and soybeans may help combat dropping estrogen levels. Soy products contain phytoestrogens, which have weak, estrogen-like effects that may ease hot flashes.
  • Consider a natural remedy. Natural hot-flash helpers include botanicals such as evening primrose and black cohosh. Make sure that clients consult a physician before taking these or any other supplements because they are not regulated and may interfere with other medications.
  • Try acupuncture. This ancient Chinese remedy uses tiny needles to unblock energy points in the body and may help balance hormone levels to ease hot flashes and trigger the release of more endorphins to offset mood swings.
  • Balance hormones. Clients should consult a physician for sleep problems that last for more than a few weeks. A physician might recommend hormone replacement therapy (HRT), which helps stabilize decreasing hormone levels and lessen the severity of hot flashes. Other medication options such as low-dose antidepressants and even some blood pressure drugs have also been shown to alleviate menopausal symptoms.

Good sleep hygiene habits are also important. The NSF recommends the following:

  • Get earplugs or a sound conditioner to maintain a quiet environment. Extraneous noise in the bedroom can disrupt sleep.
  • Keep overhead lights and lamps in the home dim (or turn off as many as possible) in the 30 to 60 minutes before going to bed.
  • Position the alarm clock so that it’s difficult to see from bed. Watching the seconds and minutes of a clock tick on and on while trying to fall asleep can increase stress levels, making it harder to get back to sleep when awakened.
  • Keep a consistent sleep schedule. Going to bed and waking up at the same time every day — even on the weekends — reinforces the natural sleep-wake cycle in the body.
  • Develop a bedtime routine. Running through the same set of habits at night helps the body recognize that it is time to unwind.
  • Stay away from stimulants such as nicotine and caffeine at night. Avoid drinking tea or coffee, eating chocolate or using anything containing tobacco or nicotine for four to six hours before bedtime. Alcohol can also disrupt sleep, so avoid more than a single glass of liquor, beer or wine in the evening.
  • Get regular exercise, but not too close to bedtime.

Greer also recommends relaxation techniques. She works with clients to help them focus on the things they can control and let go of the things they cannot control.

Many people find significant relief from hot flashes, sleep problems and mood disturbances by taking HRT or antidepressants, but clients often need help sorting through their options, Greer says. It’s not uncommon for clients to come to counseling with a whole sheaf of information from their OB-GYN, much of which can be difficult to understand. Greer helps clients navigate the material and identify any follow-up questions they have for their physicians. “This can help them feel more empowered and have a voice in their treatment,” she says.

“Speaking to a trusted medical and mental health professional is important at this time,” says Joanna Ford, an LPC whose practice specialties include assisting clients with issues related to menopause and perimenopause. If her clients don’t already have a physician, she suggests that they ask family members and friends or even consult social media for recommendations. In fact, some of Ford’s clients have created circles on social media that offer recommendations on physicians and treating menstrual issues.

Depression risk

Choate, who is currently writing a book on depression in women across the life span, says that depression is a common perimenopausal symptom. “There is an increase in depressive symptoms, first-time episodes of major depressive disorder (MDD) and … risk of recurrence of MDD in women who have a history of MDD,” she says. “Symptoms of depression occur at a 40 percent greater rate [among perimenopausal women] than in the general population, and the prevalence of depression increases 2-14 times in women during perimenopause versus the premenopausal years.”

Interestingly, perimenopausal depression presents slightly differently than depression as defined in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. In perimenopausal depression, clients are more likely to be irritable or hostile, have mood lability or anhedonia, and have a less depressed mood than is commonly seen in MDD, Choate explains. “Therefore, without a predominantly depressed mood, depression during the transition can be overlooked or misdiagnosed,” she says.

“Counselors can help women focus on self-compassion and self-care during this time, as studies show that there is an increase in negative life events for midlife women compared to other times in their lives,” Choate continues. “This could include children leaving home, caring for aging parents, the death of parents, personal illness, divorce or separation, [and] loss of social or financial support. With the increase in stressful life events, paired with the biological changes of perimenopause, women are more likely to experience distress.”

But all hope is not lost, Choate says. “I think it is helpful to be aware of studies that indicate that while women do experience a decrease in their mental health during these years, recent longitudinal studies show that depressive symptoms decrease as women age out of the perimenopausal years and enter their late 50s, 60s and 70s,” she says. “It is helpful to view this time as a window of vulnerability that does dissipate as women age and as they learn to view mid- to later life as a time of renewal and vitality.”

Sense of self and sexuality

It is not uncommon to feel grief about the menopausal transition. Greer says that some of her clients describe feeling “old” and struggle with their identity as women. “I try to help them work through the grieving process and work toward an acceptance of what is happening to their body,” she says. “It [the transition] does not change who they are, just how they see themselves.”

It isn’t difficult to understand why perimenopausal women feel old. As Choate notes, in Western cultures, youth is viewed as highly desirable, particularly for women, who continually receive the message that signs of aging should be avoided and obscured as much — and as long — as possible.

“The anti-aging industry is designed to perpetuate the myth of eternal beauty — that women can and should maintain a youthful, thin appearance regardless of their age,” Choate says. “The myth implies that women should exert the energy needed to conceal signs of aging, and if they don’t, then they are to blame.”

Women are socialized to prevent or repair skin changes such as wrinkling, sagging and age spots, all of which are natural signs of the aging process. Thinning and graying hair and weight gain are other results of aging that are considered undesirable, Choate notes.

Women “are taught that as they lose their youth, they will also lose their physical beauty, their sexual appeal, their fertility and their overall use to society,” she says. “In contrast, in cultures in which older age is revered, women report fewer symptoms during the menopausal transition. Cross-cultural studies show us that when older women are valued for their wisdom and contributions, they have more positive expectations about aging and menopause, and they also experience few menopausal symptoms. The message from these cross-cultural studies is that when women welcome aging as a natural process, not a disease, and accept naturally occurring changes to their weight, shape and appearance, they are less likely to experience negative symptoms associated with menopause.”

Women may know all of this intellectually, but the societal message is hard to ignore: Youth = beauty = power. Even women who habitually kept these weapons sheathed may feel the shift as they enter the perimenopausal transition.

“Body issues are important to address during this transition time,” emphasizes Ford, a member of ACA. “Aging is part of every life. The culture that we are surrounded by may impact our image of ourselves and our self-value. If we can increase our awareness about how we speak to ourselves about our bodies, it is possible we can accept the changes instead of fighting them.

“People may feel invisible before entering perimenopause, and it can increase feelings of depression and isolation. It is imperative to find a support system that encourages an individual’s values based on a variety of things, such as personal interests, skills, spiritual or religious beliefs, occupation, artistic or creative pursuits or any topic people can connect through.”

Body image issues can become part and parcel of the sexual changes that accompany perimenopause. “Menopause is reached upon the cessation of a woman’s menstrual cycles for 12 consecutive months. This means that menopause culminates in the loss of fertility,” Choate says. “For many women, this is a difficult role transition, particularly if they have based their identity upon a youthful appearance, which is often associated with fertility. For other women, the end of the childbearing years is a welcome change, as they become free from monthly menstrual cycles and also gain freedom from the need for birth control and other pregnancy concerns. They may experience negative biological sexual changes but may be more motivated to seek treatment for these changes as they begin to explore their sexuality apart from its association with childbearing.”

“Women often report a decrease in libido during this time,” Choate continues. “Some of this is due to physical factors — pain during intercourse, vaginal dryness — and some is due to psychological factors, including poor body image, beliefs and expectations about aging and sexuality, stress, fatigue from night sweats, and sleep disruption.”

Estrogen replacement therapies can help with many of the physical factors, but addressing the psychological factors is equally important.

“CBT is also helpful in examining a woman’s expectations for menopause, aging and her sexuality now that her sexuality is no longer linked to fertility and youth,” Choate says. “She might need to change her beliefs about women and aging, viewing menopause as a natural process that occurs to all women but does not indicate a disease, nor does it necessitate a view of herself as an aging, asexual woman. She might benefit from discussing her concerns with her partner to clear up any miscommunication about her partner’s expectations or attitudes toward the changes that are occurring in her body.”

It is essential — but sometimes difficult — to talk about those negative biological sexual changes, Ford notes. “Testosterone and estrogen levels are decreasing at this time and can lead to a change in libido or discomfort during intercourse,” she explains. “I do think people have to ‘re-envision’ their sexuality because hormonal changes are always happening.”

Of course, sex does not mean just intercourse, Ford continues. Embracing different ways of sexual expression can be helpful if intercourse becomes painful. People for whom intercourse is painful may also want to consult their physicians about lubrication or hormonal therapies, she says, adding that she recommends clients read The V Book: A Doctor’s Guide to Complete Vulvovaginal Health by Elizabeth G. Stewart and Paula Spencer.

Ultimately, counselors can help clients see not just the losses associated with menopause but also the opportunities.

“Now that you are entering a new life stage, what new opportunities do you want to seek out for yourself?” Choate asks. “What can you explore and enjoy during this next life phase? Research shows that while women do experience increased unhappiness during their early 50s, longitudinal studies show that they are happier than ever in their mid-50s and into their 70s and benefit from decreased caregiving and work responsibilities in their later years.”

Greer reassures clients that even though the menopausal process may sometimes seem as if it will go on forever, the stage is temporary. “There is life after menopause,” she emphasizes.




Laurie Meyers is the senior writer for Counseling Today. Contact her at lmeyers@counseling.org.

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