Tag Archives: Depression

Seasonal affective disorder and the summertime blues

By Samantha Cooper July 28, 2023

A worried, sad, depressed person sitting beside the seaside


For many people, summer is a happy time, filled with pool parties, barbeques, and vacations, but people who experience seasonal affective disorder (SAD) during the summer months often find themselves dreading the heat and longer days.

Dr. Norman Rosenthal, a clinical professor of psychiatry at Georgetown University School of Medicine, is credited with describing and naming SAD, a mood disorder that is most often associated with the winter months because of the link between reduced sunlight and depression.

Rosenthal sent out a survey to find out more about people with winter SAD and got thousands of responses. Many people reported that their moods dropped during the winter, confirmed his assumption about winter SAD, but he noticed that several people also reported their moods were affected in the summer. “That really made us realize there were other kinds of seasonal problems [than] winter SAD,” he says. And it led to him discovering summer SAD.

Diagnosing summer SAD

Winter SAD and summer SAD are each entities in their own right; aside from the time of year they occur, the two present differently, notes Rosenthal, author of the forthcoming book Defeating SAD (Seasonal Affective Disorder): A Guide to Health and Happiness Through All Seasons.

“With winter SAD, people are sluggish. They need more sleep. They overeat, especially sweets and starches, and they gain weight. In contrast, with summer SAD, people tend to eat less, and they may lose weight. Instead of [being] sluggish, they’re rather agitated and antsy,” he says.

In Defeating SAD, Rosenthal discusses two ways that summer SAD differs from winter SAD:

Summer SAD can often be confused with general depression, which affects people year-round, notes Ashley Lowe-Simmons, a licensed clinical social worker who has spoken about summer SAD previously and has worked with clients with this condition. She says that the best way to differentiate the two is by recognizing patterns in a client’s history.

In a blog post about summer SAD, Rosenthal lists symptoms that people with summer SAD are more likely to report:

  • Sleeping less
  • Feeling overactivated and easily agitated
  • Having a smaller appetite
  • Having increased suicidal thoughts
  • Being bothered by heat or light

Although some of these symptoms could indicate general depression, if they consistently occur around summer and are not an issue during the rest of the year, then it may indicate the person is suffering from summer SAD.

“It’s important for the mental health professionals to ensure that they get complete and thorough evaluations when assessing individuals,” Lowe-Simmons stresses.

The fear of missing out in the summer

People often have an idealized view of summer — one gleaned from pop culture and social media—and think they should be having nonstop fun. They imagine themselves enjoying the warmer weather and spending lots of time outdoors. But this perception can make it challenging for those struggling with summer SAD to recognize their condition, says Alyssa Mairanz, a licensed mental health counselor who specializes in depression.

Summer is often a time filled with vacations and outdoor activities. Kids and young adults are often out of school, and many people try to spend a little less time in the office. But people with summer SAD might not be able to enjoy the extra time off. Going to the beach may sound like a terrible time to them, for example, but avoiding it may mean spending less time with their loved ones, which can make them feel even worse, Mairanz notes.

They feel as though they’re missing out, she says. In the winter, many people stay inside and aren’t as active in the summer, so those with winter SAD don’t experience the same anxiety around missing out on activities, Mairanz explains.

Seeing people be more active during the summer can make those suffering from summer SAD feel like an outsider, and they often judge themselves harshly for not being able to join in, she adds.

Treating triggers for summer SAD

Temperature and light are major factors for those suffering from summer SAD. They feel as though they suffer from getting too much light in the summer. People “can’t bear the dazzling light,” says Rosenthal, to the point where the light is painful for them.

Counselors can help clients with summer SAD by helping them adjust their exposure to lights in the summer. Rather than adding more lights to their routine, they reduce some of the lighting in their homes by dimming lights, closing blinds or adding blackout curtains, Rosenthal says.

Heat in the summer may also be an issue. Some people who suffer from SAD in the summer have issues with heat regulation (i.e., they are less tolerant to hot weather), and others find themselves more irritable during the summer months.

Mairanz often recommends clients use air conditioning and cold baths or showers to help with temperature regulation. Going to the movies, where it’s dark and often much cooler, is a great way to have fun outside the home while still staying out of the sun, she says.

Although it might seem like a good idea to stay inside during the summer, Mairanz cautions clients against this because it could cause the person to further isolate themselves and worsen their mood. Instead, she advises clients to go outside and build up their tolerance to the sun and heat by taking short walk outside with a small fan and sunglasses, or if that isn’t a good fit for them, then she recommends they find things they can do indoors with loved ones, rather than spending time alone.

“It’s a matter of doing all the little things that you can do to help yourself,” Mairanz says. Having a support system can be extremely helpful, to ensure the person doesn’t fall into complete isolation, she adds.

Medications such as antidepressants may be helpful for some clients, Rosenthal adds. Counselors can work with psychiatrists and other medical professionals to figure out the best plan for the client and how clinical therapies can work in conjunction with any medication the client may need.

Rosenthal is concerned that issues related to heat tolerance and summer SAD might increase with rising temperatures worldwide. This summer has been one of the hottest on record, and experts agree that summer temperatures will continue to rise. “It’s becoming more and more of an issue so I think we have to be more cognizant,” he adds.


Samantha Cooper is a staff writer for Counseling Today. Contact her at scooper@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.

Treating depression by focusing on solutions and acceptance

Compiled by Lisa R. Rhodes November 21, 2022

Tanongsak Panwan/Shutterstock.com

Depression is a common mental health disorder and affects people from every walk of life, regardless of their age, race, ethnicity or socioeconomic background. According to the National Alliance on Mental Illness, approximately “21 million adults in the United States — 8.4% of the population — had at least one major depressive episode in 2020.” 

Common treatments for depression often include cognitive behavioral therapy (CBT) and psychotherapies that focus primarily on a client’s past. However, they are not the only approaches counselors can use. Solution-focused brief therapy (SFBT) and acceptance and commitment therapy (ACT) are evidence-based counseling approaches that have also been found to be effective in treating depression. Counseling Today asked six counselors to discuss the effectiveness of these two clinical approaches for treating clients with depressive symptoms. 


Fostering hope through SFBT

By Foley L. Nash 

For me, one factor in the effectiveness of SFBT is the set of themes that runs through its basic tenets. The main themes are building exceptions to the presenting problem and making rapid transitions to identify and develop solutions intrinsic to the client or problem. These themes resonate well with clients, particularly those experiencing depression, as well as with a subset of depressed clients who experience comorbid anxiety, which can occur in as much as 70% of depression cases.

In treating depression, the emphasis of a solution-focused approach is to counter hopelessness, which is an important and common factor related to the frequently present risk of suicide. SFBT benefits depressed clients by engendering hope for the possibility of finding solutions in ways that are tied to the following basic tenets:

  1. A focus on competence, not pathology (emphasizing the client’s power and hope)
  2. The goal of finding a unique solution for the individual client (not a cookie-cutter approach)
  3. The use of exceptions to the problem to foster optimism (hope)
  4. The use of past successes to support/increase client confidence (hope)
  5. The view of the client as the expert (acknowledging the client’s power)
  6. The use of goal setting in charting a path to change (scaling questions are important in goal setting)
  7. A shared responsibility for change between client and therapist (supportive partnership)

In SFBT, the emphasis shifts from problems to solutions, which empowers clients by allowing them to access their own internal resources, strengths and prior successes.

The following are the aspects of SFBT that appeal to me:

  • It’s an evidence-based practice (EBP) and its proven effectiveness has been documented. As a managed care clinical director, I see increased emphasis on EBP providers by large payers. In my private work, employee assistance programs also like the use of EBPs for the greater likelihood of faster change in their shorter treatment episodes.
  • It’s largely focused on the skillful use of language for therapeutic purposes. As the Greek philosopher Epictetus said, “People are disturbed not by things, but by the views they take of them.” Helping clients to see things differently is one of the useful functions of SFBT, which allows clinicians to ask questions such as, “How did you make that improvement happen during that time?” or “What would your best friend say you did differently when things were better?” 
  • As a former language teacher/linguist who now conducts therapy in English and Spanish, I ascribe to the outlook that language is the tool of thought. SFBT can be immediately helpful in guiding clients to think differently about potential solutions. Instead of accepting that clients are as helpless as they may feel, counselors can try asking about how they have managed to achieve and sustain some of the times when the problem was absent or less severe. It’s helpful for the therapist to have some affinity for fluency in language and in the SFBT tools. As counselors study some of the SFBT principles, strategies and techniques, they will encounter many examples of questions that use language in helpful ways to change a client’s perspective, and they can become more skilled, thoughtful and proactive about how to use language to bring about a shift in a client’s perspective. 
  • I’ve found over time that SFBT and its tools are also very helpful in helping clients become “unstuck” and breaking an impasse.

SFBT focuses on helping the client to reframe the situation, develop second-order change that supports solutions, and see the situation as something they can manage and change by using their own strengths and abilities. While first-order change is behavioral, as in doing things differently (sometimes described as matter over mind), second-order change is conceptual (often described as mind over matter) and involves helping a client to see things differently. This type of change can help a client with depressive symptoms to be more readily able to make the desired behavioral change to move toward a modified or new solution.

I have also found that SFBT is effective in treating depression along with comorbid anxiety. In my practice, clients frequently present with both depression and anxiety. It’s useful to focus initially on whichever condition is creating the most significant impairment in functioning for the client. This can provide a quick initial improvement and encourages the client to continue to address the less problematic condition, which, in my experience, is usually the anxiety.

Comorbid anxiety and its occasional panic attacks often engender fear in clients, especially the fear of the next panic attack after an initial one, as well as the corresponding sense of fear about the loss of control. By providing hope to clients, SFBT has treatment application for both depression and anxiety.

Foley L. Nash is a licensed professional counselor supervisor with a private practice in Baton Rouge, Louisiana. He works mostly with adults and often provides short-term employee assistance program services. Contact him at foley1@foleynash.com.


Working toward a solution-focused goal

By Marc Coulter 

Jeremy (a hypothetical client) was hopeful and enthusiastic early in life, but after a cross-country move and a long-term relationship ended just before the pandemic, he had difficulty coping. 

Some days, Jeremy couldn’t get out of bed to work. Other days, he showed up, but he felt dark and hopeless and didn’t care whether he lived. Jeremy’s depression continued through the pandemic and medication didn’t help.

When working with severely depressed clients such as Jeremy, SFBT practitioners maintain a stance of optimism and hope, knowing that a client’s past experiences and feelings of depression do not determine future outcomes. 

A solution-focused perspective directs the course of therapy toward solutions, rather than focusing on problems, and guides the questions we ask. With empathy, compassion, respect, curiosity and hopefulness, we acknowledge and honor whatever agonizing feelings, or perhaps the lack of feelings, clients such as Jeremy experience while co-creating a preferred future.


SFBT counselors often explore what gives depressed clients hope. In Jeremy’s case, what gave him hope was knowing that change was possible. Sometimes clients live their lives and show up to counseling sessions despite not feeling hopeful. SFBT counselors explore how clients show up and participate in their lives despite the lack of hope. In session, we reaffirm what they’ve said is meaningful in their lives and why it may be important to keep moving forward despite the lack of hope.

Solution building

In the book Tales of Solutions: A Collection of Hope-Inspiring Stories, Insoo Kim Berg, who along with Steve de Shazer co-founded SFBT, and Yvonne Dolan wrote that SFBT counselors begin therapy with a detailed description of a client’s desires. Clinicians can then explore possible times when these desired outcomes may have been present, even in small ways, to find solutions to their problems. The solution-building process for Jeremy might include questions such as “How might you want to cope given your circumstances? How have you been able to manage up until now? What helps even a little? What helps you make it through the day?” 

If Jeremy couldn’t imagine even one small movement toward feeling better, the counselor might ask, “What helps prevent it from getting worse?”

Focusing on Jeremy’s best hopes for therapy, the counselor might also say, “Suppose you’re walking away from our last session together and you’re thinking to yourself, ‘That was a really good use of my time, energy and money.’ What would you be walking away with that would make a difference?” Jeremy might respond, “Maybe I would feel less depressed.” The counselor could then ask, “Yes, of course, and if you felt less depressed, what might you feel instead?” Jeremy might say, “I guess lighter, more hopeful.”

The miracle question

When working with a client who is overwhelmed, depressed and suicidal, solution-focused counselors often ask the “miracle question,” a concept co-developed by Berg and de Shazer. The miracle question includes components of what the client has determined is a meaningful and important solution to their problem. In Jeremy’s case, that was “feeling lighter, more hopeful.” 

Using this technique, the counselor could ask Jeremy if it would be a miracle to feel this way, and Jeremy would agree. The counselor could ask him to imagine that while he was asleep the night before, a miracle happened. He would feel lighter and more hopeful, but because he was sleeping, he would have no idea the miracle happened.

The counselor could then ask Jeremy, “What might be the first thing you notice upon waking that would let you know that something was different?” After a pause, he might reply, “I would get up and not stay in bed.” The counselor and Jeremy could then explore how this would make a difference to him and the important people (and even pets) in his life. They could continue to slowly explore Jeremy’s miracle morning and the differences he and others had noticed.

Scaling questions 

The counselor could also use scaling questions, an SFBT tool, which can help to ground the miracle day for Jeremy in the reality of his life. For example, a scaling question might be, “On a scale of 1 to 10, with 10 being that miracle day and 1 being life prior to beginning counseling, where are you right now?” Jeremy may reply and say a 2. The counselor could then ask why he was that high (why he didn’t choose 1 or even -12) and explore what he was doing in his life that put him at that level rather than a lower one. Jeremy might name things like engaging with colleagues and taking care of his dog. Next, the counselor could ask him to imagine what he could do that would put him just a little higher on that scale, maybe even a half a point, and what difference that might make?

Marc Coulter is a licensed professional counselor in Lakewood, Colorado. He is a member of the American Counseling Association and past president of the Colorado Counseling Association. Contact him at marcjcoulter@liveyoursolution.com.


The benefits and limitations of SFBT and CBT

By Nicole Poynter

SFBT and CBT are both effective in treating depression, but in different ways. Here are some of the benefits and limitations of both. 

If a client’s purpose for coming to therapy is to find a solution to a problem, then SFBT may be the right therapeutic approach. SFBT usually lasts for six to 10 weeks and focuses on a client’s strengths and capabilities. SFBT pays attention to the client’s problems in the present. In counseling, we believe that individuals have the inner resources, strengths and skills that are needed to help them to achieve their goals and overcome difficult life situations. The purpose of SFBT is for therapists to focus on a clients’ capabilities. This therapeutic technique focuses on problem-solving, generating solutions and moving toward a goal. 

The benefits of using SFBT for treating depression include the fact that it is short term and that is more cost effective than long-term therapy. Another benefit is that the counselor uses compliments in therapy, such as “That is amazing to hear,” when a client talks about a goal that has been met or a strength that was used, which can help to motivate clients to work toward their therapeutic goals. SFBT is also future-oriented, so clients do not get stuck in the past. The therapist focuses on what the client thinks their life will be like once the concern is resolved.

However, there are some limitations for choosing SFBT as a therapeutic model of choice. Some clients take more time to open up in therapy, so having only a few weeks for treatment does not make it easy to solve problems. This modality also focuses on the present, and it does not investigate the past and past traumas, which often contribute to unhealthy behaviors in the present. In addition, the counselor must trust the client and accept what the client desires for treatment, even if their goals are not beneficial. SFBT relies heavily on the therapist and client working together and works on the assumption that the client is willing to do the work to achieve their goal. 

CBT helps clients look at problems differently and encourages them to think in healthier ways. This approach focuses on thoughts, feelings and behaviors and how they are all connected. If a client has a negative thought, it can lead to a negative emotion, which can lead to unhealthy behaviors. In a CBT session, the counselor focuses on the client’s negative thinking, or cognitive distortions. Counselors help clients look for evidence to support a thought and evidence to support their thought distortions. After clients determine that they have more evidence against a negative thought, then they can work with the counselor to turn it into a more positive thought. 

There are some also some disadvantages to using CBT to treat depression. This approach is not intensive, so it is better for people with mild depressive symptoms. CBT has a high client dropout rate, which can be due to the hard work that is required in therapy or because it is not a quick fix. Although CBT is the strongest evidence-based treatment for depression, it takes a commitment to make it work. Clients must continue to use the skills they have learned to help prevent relapses. 

Neither one of these modalities is easy for clients. Homework is vital for both approaches, so clients can practice what they have learned in session. Change is gradual and takes time to manifest. There is no one-size-fits-all treatment for improving mental and emotional well-being. 

Both therapeutic treatments are effective in treating depression, so how does one know which one to use in practice? Talk to clients to understand their goals and preferences. Clarifying goals for therapy with a client will help determine what treatment modality is most appropriate. Being a therapist who is empathetic, client-centered and supportive is what is most important, regardless whether they use SFBT or CBT. 

Nicole Poynter is a licensed professional clinical counselor at Avenues of Counseling and Mediation LLC in Medina, Ohio. She works with children, adolescents, adults, and families and specializes in anxiety, depression, LGTBQIA+ issues, attention-deficit/hyperactivity disorder, parenting concerns, relationship distress, anger management and adjustment issues. Contact her at npoynter@avenuesofcounseling.org.


Rekindling connection to self and others through ACT

By Lottena Wolters and Caitrin McKee

Since I (Lottena) began my D.C.-based private practice in 2016, new clients have increasingly presented with a profound loss of faith, but not in the religious sense. 

Theirs is a loss of faith in personal safety, which is included in the second level of Maslow’s hierarchy of needs, along with law and order, physical security and economic stability. Some of my clients have also lost faith in themselves and their fellow human beings and feel acutely disconnected from the communities outside their inner circles. This loss of faith is the primary and most persistent symptom of their depression. 

How do we help our clients feel connected and experience joy when they are bombarded with stressors such as news of political division, the ongoing COVID-19 pandemic and the worsening impacts of climate change? It can be deeply distressing to realize we lack the power to change the turmoil in the world, especially for our clients who are experiencing depression.

But what if the goal of therapy is not to change our clients’ emotions or reduce their depressive symptoms, but instead enable them to compassionately accept their feelings while engaging less with self-bullying thoughts? ACT is an evidence-based mental health approach that helps clients learn to accept what is out of their personal control and commit to actions that improve satisfaction with their quality of life.

Some of the most meaningful outcomes of ACT for depressed clients are increased resilience, a measure of one’s overall wellness that can reduce the risk of depression, and greater self-compassion. Self-compassion allows us to experience negative events and emotions with acceptance, which leads to a reduction of suffering. 

 At the onset of treatment, I (Lottena) have clients complete a resiliency questionnaire, a stress inventory and the Valued Living Questionnaire (VLQ). The VLQ is an ACT self-directed tool used to help clients assess their values across 10 domains of living (family, marriage/couples/intimate relations, parenting, friendship, work, education, recreation, spirituality, citizenship and physical self-care) and evaluate how successfully they have lived in accordance with those values in the past two weeks. Clients are asked to rate the 10 domains on a scale of 1 to 10, with 1 being “not at all important” and 10 being “very important.”  

I (Lottena) find that clients who are experiencing depression often rank themselves at a 2 or 3 in the domains that are most valuable to them. These clients will also score low on resiliency and high on external stressors. This was the case for one of my former clients, who I will refer to as “Mr. A.” 

Soon after rapport was established in therapy, Mr. A completed the resiliency questionnaire, stress inventory and VLQ. He scored high on stress and low on resiliency. The VLQ illustrated that Mr. A felt he was unable to prioritize his life, primarily his marriage, work and family. He ranked himself between a zero and a 2 for how successful he had been at living in accordance with his values during the previous two weeks. This client could not fathom how to get above a 5, and he felt that he should be a 10 in each domain.

Mr. A’s hopelessness was so intense that he would either disconnect from his feelings to function professionally and socially or drown himself in his sadness. Mr. A woke up with feelings of dread and felt hopelessly unmotivated about work, often arriving at least an hour late for his job. He socialized only when he was intoxicated, and he avoided conversations with his family. Mr. A reported that his wife complained he was only present in body but not in spirit. His depression impacted all areas of his life.

After using ACT therapeutic interventions (such as the willingness and action plan and exercises that incorporate mindfulness practices) in session, this client began to rank his success in these domains at a minimum of a 6, and usually higher, for most two-week periods. His faith in himself and his loved ones was seldom below a 5, even when he experienced an episode of depression. And he could connect to his feelings of optimism, pride and joy. 

Mr. A’s depression now has significant periods of remission, and when he experiences depressive symptoms, they rarely cause major problems for him at work, home or socially. The acceptance of both his depressed symptoms and new positive emotions allows him to treasure and protect his joyful experiences. He has undergone a profound transformation through his dedication to the ACT process. 

Thus, counselors should be open to trying ACT, which is sometimes overlooked as a therapeutic approach. I (Lottena) have utilized ACT for over 14 years as a clinician, and I often recommend it during supervision sessions with newly licensed therapists and graduate students. I find that ACT is flexible enough for both younger clinicians and more experienced clinicians who treat clients reporting increased feelings of hopelessness and persistent depression. And I can say that both the research and my own personal experience demonstrate its effectiveness with depressed clients.

Lottena Wolters is a licensed professional counselor and founder of the F.L. Wolters Group in Washington, D.C. She works with young adults and adults struggling with anxiety, mood disorders and attention-deficit/hyperactivity disorder. Contact her at lottena@flwoltersgroup.com.

Caitrin McKee is a registered yoga teacher and the patient care coordinator at the F.L. Wolters Group in Washington, D.C.


Helping clients become unstuck with ACT

By Jared Torbet

In the initial assessment, Camie (pseudonym) presented as depressed, unmotivated and indecisive, and she ruminated on her insecurities, which are all common symptoms of depression. She also used humor and a noticeable dismissal or minimizing of her feelings. Once I noticed these avoidant strategies, I felt ACT would be a good fit for this client. 

At our next session, I helped Camie notice and name her internal experiences, including her thoughts, feelings and sensations; this is a basic mindfulness skill that Steven Hayes, the psychologist who founded ACT, believes is the most important mindfulness skill one can master. Camie’s internal world came into view as she began to notice and name that world in the present moment with ease.

We progressed to working with those internal experiences in a more helpful and workable way than she was accustomed to. Before I go further, let me share a warning label that comes with ACT. As therapists, we must do ACT, not explain ACT. It was vital that I guide Camie through an experiential journey, not a psychology lesson. Camie had a hard time differentiating herself from her depression, insecurities and fears. She was stuck.

I asked her to hold her depression, insecurities and the reality of being stuck in her hands and imagine it as an object. She described it to me as a big, heavy, lava-red, smokey, hot, smooth, oval-shaped sphere that was about 2 feet wide and 1 foot tall. “Where do you feel this object?” I asked. She replied, “Right here on my chest.” 

Together, we playfully engaged with the object. We handed it back and forth. I had her set it on the coffee table between us and walk to the other side of the room. I said, “If this stuff is sitting here on this table, and you’re standing over there, what does that tell us?” She replied, “I’m not that stuff.” 

She noticed a feeling of freedom and motivation from this exercise. This led us to discuss the range of her values, including relationships and career goals, as well as her fears and doubts. I guided her through an expansion exercise. We both breathed deeply while widening our arms and imagining making room for values, goals, fears and doubts. I asked how much of her energy is spent on these important things. She said, “Pretty much none.” 

“You spend so much time and energy trying to figure out, or get rid of, this heavy, red sphere,” I told her. “What would happen if you spent that time and energy on the things that matter the most to you?” She replied, “I would probably be a lot further in my life.” I asked, “Where would you be?” Without hesitation, she told me, “I would be teaching English as a second language (ESL) overseas.”

I said, “Wow, that sounds amazing! What is stopping you from going?” She smiled and replied “this” while she simulated holding the heavy, red sphere. So I asked, “What if you packed it in your suitcase, and just took it with you?” 

I could see the wheels turning. This was our segue into her accepting and allowing fear and doubt to be there. I taught her that her fear, which shows up as anxiety, is just trying to protect her. When she imagined her fear/anxiety, it took the form of her child-self.

I used the analogy of her being the captain of her own ship, with her thoughts, feelings and sensations being her deck mates. It felt right to offer the choice of inviting her child-self on board as co-captain. This helped her to organically embrace self-compassion and self-love. I told her that she cannot control all her deck mates, but she can guide the ship and build tolerance for those on board. And as long as she’s traveling in the direction of her values, her deck mates won’t cause as much ruckus, and some will even help her, especially her co-captain.

Camie, through her dedication to therapy and her hard work in session, was able to notice her thoughts, feelings and sensations. She was able to see the difference between her internal experiences and herself. She was able to defuse, or unhook, from unproductive thoughts, while bravely accepting her emotions and sensations. She learned to align her choices and actions with what mattered most to her, such as teaching ESL overseas, which she eventually did.

ACT is not for everyone. In my experience, ACT requires a client to be able to practice mindfulness and engage in mental imagery. Clients with aphantasia (the inability to voluntarily create mental images in one’s mind), for example, would most likely benefit from a different modality. Also, in cases where the client is at risk of suicide, homicide, child/elder abuse, domestic abuse, trafficking and other high-risk behaviors, including self-harm, more immediate and tangible interventions should be considered with safety as top priority. These are situations that should not be accepted but avoided and reported.

Jared Torbet is a licensed professional counselor and owner of Anxiety & Depression Clinic of Columbia in Missouri. He specializes in adults and teens who struggle with anxiety, depression or attention-deficit/hyperactivity disorder. Contact him at hello@comoclinic.com. 


ACT: The mindful approach 

By Katy Rothfelder

ACT is an empirically supported and evidence-based treatment for individuals experiencing depression, yet it is an approach many clinicians are not trained or fully comfortable exploring. For clients experiencing depression and the clinicians who use ACT to treat them, we must first come in contact with the totality of human suffering. From this place, we can bear witness to the suffering within our clients in the here and now. It is from this willingness to let suffering come close, to see it as one of the many thousands of threads forming one cloth of the client, that we as clinicians can form a workable framework for the way in which internal and external experiences are woven to diminish valued living, as noted by Kelly Wilson and Troy DuFrene in their book Mindfulness for Two: An Acceptance and Commitment Therapy Approach to Mindfulness in Psychotherapy.

ACT moves beyond the language composed in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders. This approach, which includes self as context as one of its core processes, defies labels such as “depressed client,” and instead appreciates the unique, narrow and broad experiences of the client. It takes the language and behaviors the client exhibits, such as “there’s no point,” and looks to transform those overt and covert behaviors into valued, flexible ways of being.

Mindfulness practice is a critical part of ACT. It can be argued that mindfulness, as it is understood in contemplative practices, is the totality of many of ACT’s six core processes — acceptance, defusion, self as context, values, committed action and contact with the present moment. And ACT’s core process of contact with the present moment is what we might contextualize as modern-day mindfulness. According to Jon Kabat-Zinn in his book Wherever You Go, There You Are: Mindfulness Meditation in Everyday Life, mindfulness is “paying attention in a particular way: on purpose, in the present moment, nonjudgmentally.”

Unique to ACT is the way in which the six core processes interact, merge and flow with one another. They are not mechanistic in form, but rather are existent within a particular context and in service of creating psychological flexibility. 

Lindsay Fletcher and Steven Hayes, in their 2005 article “Relational frame theory, acceptance and commitment therapy, and a functional analytic definition of mindfulness” published in the Journal of Rational-Emotive and Cognitive-Behavior Therapy, defined psychological flexibility as “contacting the present moment fully as a conscious human being, and based on what the situation affords, changing or persisting in behavior in the service of chosen values,” which can also be considered a workable definition of mindfulness. 

Psychological flexibility is a practice and the outcome we continuously return to in ACT. Rather than seeking to get rid of unwanted, unpleasant thoughts or experiences, ACT aims to support individuals in living full, rich and meaningful lives without defense, while also engaging in the moment with what is most important to them. With many clients experiencing depression, as well as other experiences such as anxiety or trauma, contacting the present moment in a particular way can be helpful in reconnecting with valued living.

Contacting the present moment involves commitment and deliberate action, drawn from one’s values, with an awareness of the self as containing thoughts, emotions, roles, bodily states and memories. In essence, ACT supports individuals in experiencing their “wholeness,” with flexibility and persistence in valued living. 

ACT is not done to a client, but rather is experienced with and between the client and clinician, moment to moment, in a flexible, processed-based practice. 

Katy Rothfelder is a licensed professional counselor associate who is supervised by John Hart at the Anxiety Treatment Center of Austin in Texas. She specializes in obsessive-compulsive disorder and related disorders, anxiety, depression, trauma and neurodiversity. Contact her at katy@anxietyaustin.com.



Lisa R. Rhodes is a senior writer for Counseling Today. Contact her at lrhodes@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.

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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