Tag Archives: Depression

The ‘storm and stress’ of adolescence and young adulthood

By Laurie Meyers October 25, 2018

For much of human history, the idea of adolescence being a distinct life stage was nonexistent. True, in the Middle Ages, children were recognized not merely as “mini” adults but as distinct beings with different needs. However, the years from ages 13 to 19 were not considered part of childhood until the turn of the 19th century. Instead, the “teen years” were the time when one began to assume adult responsibilities such as making a living and starting a family.

During the late 1800s, changes in child labor laws and the push for universal education for those under the age of 16 began to influence society’s perspective on when adulthood began. G. Stanley Hall, the first president of the American Psychological Association (APA), is credited with the modern “discovery” of adolescence, defining it in a 1904 book as a new developmental stage — created by societal changes — in which children grow into adults. Hall described adolescence as a time of “storm and stress” and, unlike later researchers, ascribed this life stage as lasting from ages 14-24 (rather than today’s generally accepted range of 13-19).

Although adolescence is still considered to be synonymous with the teen years, Hall’s instinct to single out the early 20s as different from later “adult” years was prescient. In the past decade, neurological research has discovered that the brain does not fully mature until one’s mid-to-late 20s. This revelation has spurred many researchers, particularly in mental health fields, to call for a separate developmental stage that is generally referred to as “young” or “emerging” adulthood.

Adding more than a soupçon of complication to both the recognition of emerging adulthood and the established research on adolescence is the reality that being a teen or 20-something in the information age is, in many ways, significantly different — and arguably more difficult — than it was for previous generations.

Stressed and depressed

An abundance of research indicates that teens and young adults are experiencing increased levels of stress and depression. In recent years, APA’s annual “Stress in America” survey has gathered data only on adults. However, in the survey released in 2014, “Stress in America: Are Teens Adopting Adults’ Stress Habits?” young people ages 13-17 were also included.

Survey respondents reported that during the school year, they had a stress level of 5.8 on a 10-point scale. During the summer break, teens reported a slight decrease in stress levels — 4.6 on a 10-point scale. Furthermore, 31 percent of survey respondents said that their stress levels had increased over the past year. In response to their high levels of stress, 40 percent of respondents reported feeling irritable or angry, 36 percent reported feeling nervous or anxious, 36 percent reported feeling fatigued or tired, and 31 percent reported feeling overwhelmed.

Depression is another significant concern among adolescents. According to the National Institute of Mental Health, in 2016 (the most recent year for which statistics are available), an estimated 3.1 million adolescents ages 12-17 experienced at least one major depressive episode. That number represented 12.8 percent of the U.S. population in that age bracket.

Although most mental health surveys do not specifically target “young” or developing adults, data are available relating to college students. Among the more than 31,000 college students who completed the 2017 American College Health Association National College Health Assessment, 39.3 percent reported being so depressed that they found it hard to function at some point during the previous 12 months. Anxiety levels among respondents were even higher: 60.9 percent reported feeling overwhelming anxiety at some point during the prior year.

The high levels of anxiety and depression indicated in these studies are part of a national pattern of significantly increasing distress. A national poll published in May by the American Psychiatric Association noted a sharp increase in American anxiety levels over the past year. On a scale of 0-100, this year’s “national anxiety score” was a 51 — a five-point jump since 2017. A study published in the June 2018 issue of the journal Psychological Medicine found that rates of depression rose across all age brackets of Americans for those 12 and over from 2005 to 2015. Most significantly, among those ages 12-17, depression rates increased from 8.7 percent in 2005 to 12.7 percent in 2015.

Under pressure

Some researchers are eager to blame technology — particularly social media — for the increase of depression and anxiety among teenagers and young adults. The reality is more complex and involves myriad factors.

It is undeniable that some people do find their lives lacking when compared with what they see on social media. Carefully curated Facebook feeds can suggest to them that their friends are happier and more successful than they are. Celebrity photos on Instagram — most of which are professionally produced and heavily filtered — can encourage unrealistic expectations about body image and personal appearance. However, when one considers the role that social media plays in the quest for perfection, it may be something of a chicken-and-egg scenario.

A 2017 study on perfectionism that appeared in the journal Psychological Bulletin found that beginning in the 1980s, a culture of “competitive individualism” in the United States, Canada and the United Kingdom steadily increased the quest for personal perfection. So, is what we see on social media pushing us toward unattainable standards of perfection, or is it a reflection of the pressure we put on ourselves? At this point in time, we may be caught in a reinforcing loop. The study found that current generations not only feel intense societal pressure to be perfect but also expect perfection from themselves and others. The study’s authors also believe that this rise in perfectionism may be linked to an increase in myriad psychological problems.

Today’s teenagers and young adults are unquestionably subject to high expectations and demands. Licensed mental health counselor David Flack, who has worked with adolescents and young adults for 20 years, says he has seen a significant increase in anxiety related to academic performance among his clients.

“It is not uncommon for teens I meet with to have three, four or even more hours of homework most days,” he says. This reality creates significant pressure and is particularly stressful for students who are predisposed to anxiety. Flack, a member of the American Counseling Association, also believes that such heavy academic workloads are interfering with important social and developmental processes because many teenagers may be spending more time doing homework than socializing and engaging in extracurricular or other age-appropriate activities.

Licensed professional counselor (LPC) Sean Roberts, an ACA member who specializes in working with young adults, says he has witnessed a precipitous increase in anxiety among clients. He thinks this is strongly, though not solely, linked to teenagers and young adults feeling increased pressure to succeed.

Not coincidentally, the anxiety they experience makes it only more difficult for them to achieve. “Anxiety has a neurological effect,” explains ACA member Amy Gaesser, an assistant professor of counselor education at the State University of New York at Brockport whose research focuses on the social and emotional well-being of students in school. “The survival part of the brain activates and shuts off or interferes with the parts of the brain that help us think clearly.”

This can have a significant effect on academic performance, says Gaesser, a certified school counselor in New York who gives presentations and offers private consultations with parents. For example, some students can study extensively and be fully prepared for a test, but because of their anxiety, can have trouble accessing that information while taking the test. Anxiety can also interfere with the ability to take in and synthesize information, Gaesser says. Students become frustrated with their seeming inability to “get it,” which affects their feelings of self-efficacy and can even make them question their level of intelligence. Once a pattern of academic difficulty tied to anxiety is established, the problem can become self-perpetuating.

Disrupting the cycle is vital, says Gaesser, who recommends the emotional freedom technique (EFT) as an effective method of interrupting the stress response and downregulating the brain. In EFT, participants respond to stressful thoughts or situations by visualizing an alternative outcome while taking their hands and tapping acupuncture points on the body that have been linked to stress reduction. Students can go through the whole sequence of body points or just use the areas they find work best for them, she says.

Gaesser also recommends the “4-7-8” breathing method as a quick way to interrupt the stress response. This involves breathing in for four seconds, holding the breath for seven seconds and then breathing out for eight seconds. Students can practice this method themselves, but Gaesser thinks that teachers should also use it in their classrooms as a way to begin class.

Peter Allen, an LPC based in Oregon who specializes in counseling young adults and adolescents, used to work with teenagers in a wilderness therapy setting. Most of his clients were struggling with a variety of issues, including substance abuse, conduct problems (although not usually at the conduct disorder level) and mood disorders, principally depression and anxiety. In most cases, Allen says, the core elements of the wilderness setting were effective in helping these clients address their various presenting issues.

In part, he believes that’s because the pressures of school, family and social life were stripped away, leaving these teenage clients to focus on the basics, such as securing food and shelter. Surviving in the wilderness also required working together and building a community, which helped teach clients new communication skills. Participants also got daily exercise, ate healthy meals and were required to follow a regular sleep schedule, all of which had a calming and stabilizing effect. “Once diet, sleep and exercise have been regulated, about half of the problems disappear right away,” Allen says.

Many wilderness therapy clients also benefit from what Allen calls “expanding the size of their world. … If you are a 15-year-old kid and doing bad at school, arguing with your parents, your world is tiny.” The wilderness program not only provided literal wide-open spaces, but also introduced clients to people from different places and adults who didn’t have the same expectations as the teenagers’ parents or teachers did.

The wilderness can also serve as a mirror for clients, says Roberts, who has also worked in wilderness therapy, or, as he says it is becoming more commonly known, outdoor behavioral health care. For instance, when clients who struggle with executive function and organization encounter bad weather for which they are not prepared, the experience can be a vivid demonstration of the importance of working on those problem areas. Another example: Someone who is struggling with distress tolerance will need to get used to having to build a fire after hiking all day.

Information overload?

Although none of the counselors interviewed for this article view social media or technology as inherently negative, they agree that living in the information age is complicated. The current generation of teens and young adults is awash in an unprecedented flood of information, asserts Roberts, clinical director at Cascade Crest Transitions, a program that provides support to young adults struggling to launch their independence by attending college or obtaining a job. He maintains that this technological bombardment not only is difficult to assimilate but also can encourage the tendency to “get stuck” in one’s own head.

Allen adds that in the age of the internet, children and adolescents are exposed to a lot of information and knowledge at an earlier age than previous generations were. In certain cases, it is information that they may not have the maturity to handle. For example, most children and adolescents who grew up in the latter half of the 20th century had to somehow get their hands on a copy of Playboy or another adult magazine to satisfy their sexual curiosity. Today’s children and teens are exposed online to myriad genres of easy-to-access pornography, which not only present unrealistic ideals of sexuality but also can include disturbing practices such as bestiality and pedophilia. Children and young adolescents today are also more likely to be exposed to media coverage of frightening or horrific events before they have the ability to contextualize all that they are taking in, Allen says. He believes this early exposure is contributing to a kind of “nonspecific existential dread” that he says he commonly sees in his clients.

Roberts says that technology offers many positive benefits, but it also sometimes provides adolescents and young adults with a means to avoid their problems. He stresses the need for counselors to learn more about the draw of technology so that they can help clients evaluate whether they are using it in positive or negative ways. Roberts gives gaming as an example. For those who know little about it, gaming may seem like an excuse to “do nothing.” In reality, he says, it is a legitimate hobby that can provide enjoyment, stress release and even a sense of community while boosting problem-solving skills. However, like any other activity, when gaming gets in the way of schoolwork, chores or getting out of the house, it becomes a problem to be addressed, he says.

Another complicated aspect of online life is social media. For all the potential benefits, social media feeds have made it so that virtually no part of life is private anymore, Allen says. Many adolescents may not fully understand that by making everything public, the internet is, in essence, “forever” or grasp the potential ramifications of that reality, he says. In addition, he notes, social media feeds can encourage social contagion.

ACA member Amanda LaGuardia, a former private practitioner whose research focuses on self-harm, agrees. Much of the social media content targeted to young girls is focused on body image, says LaGuardia, a licensed professional counselor supervisor in Texas and a licensed professional clinical counselor supervisor in Ohio. Many of her former clients talked about the images they saw on Instagram, such as already-thin celebrities discussing “thigh gap” (as part of a supposedly “perfect” body, women and girls must have thighs that don’t touch each other) and other unrealistic physical standards. Such posts are usually popular, garnering a large number of likes and admiring comments, which gives girls the impression that this is what their bodies should look like, she says.

However, such standards are unrealistic for most females and are simply unachievable for girls with developing bodies, continues LaGuardia, an assistant professor at the University of Cincinnati. Regardless, these images are presented as the feminine ideal, presuming to highlight all of the elements that will make women attractive to men. At the same time, girls are often subject to sexual harassment at school and too often told by those in authority “that’s just how boys are” (boys will be boys) and that girls just need to find a way to deal with it, she says.

All of these messages about how girls should look and act and what they should accept come at a time when they are already struggling to figure out who they are. It is overwhelming, and self-injury is becoming a more common way to cope with the distress. Self-harm used to be most common in the eating disorder population, but according to LaGuardia, social media has introduced it to a wider audience. It isn’t necessarily that self-injury is presented as a positive behavior online. Most people who talk about it on social media are seeking support, she says. However, the widespread nature of the discussion has created social contagion.

The best thing counselors can do to help is listen and affirm, LaGuardia emphasizes. When adolescents talk about their experiences, some counselors focus on helping them feel better about themselves, but that is not what they need most, she asserts. Instead, adolescents need to express what they are going through and to process their confusion verbally. Counselors should respond, she suggests, by saying things such as, “That sounds really difficult” and “I’m here and I’m listening.”

“So many of the messages they [adolescents] are receiving are controlling,” LaGuardia explains. “They need to feel in control.”

As these clients become more comfortable, they will begin to talk about how they are coping with their turmoil. LaGuardia explains that these clients view self-injury as a means of surviving what they are currently experiencing, not a solution. “I ask clients, ‘Is this something you see working for you for the rest of your life?’ I’ve never had anyone say yes.”

Usually, LaGuardia notes, clients will say that they hope not to engage in self-harm forever, but at the current time, they don’t know what else to do. At that point, counselors can ask whether this coping method is something the client is ready to change. LaGuardia says the first step is finding out what the client needs help coping with and then exploring ways that will allow the client to cope without self-harm.

The most common underlying problem for clients who self-harm is conflict with a parent or sibling, LaGuardia says. In such cases, she works with the whole family on communication skills. She starts with the adolescent clients, teaching them how to express their needs without self-injury. She asks the adolescents to think about their most stressful conflicts and what they would like their parents to know. Then, through role-play, LaGuardia helps these clients practice asking for what they need.

Often, LaGuardia will also bring in the parents and have the adolescent express the source of conflict. As the parents and adolescent talk, things can get heated, so LaGuardia is there to help redirect the conversation. She also tries to educate parents about what adolescents need, which includes being treated as independent young adults and given space to grow, while at the same time knowing that their parents are always there to listen to them regardless of
the circumstances.

Adult transitions

Allen is the program director at College Excel, a residential, coaching-based college support program. The program’s clients are typically young adults who are coming out of high school and looking for extra support to succeed in college or those who previously attended college but dropped out because of a mental health issue or learning disability.

Many of the students have some level of anxiety and depression and often struggle with executive function deficits. College Excel provides the students with mental health support and coaching on life and study habits. Allen says he tries to run the program through the lens of good mental health practices. Calling on his background in wilderness therapy, he also encourages students to eat well, follow a consistent sleep schedule and get regular exercise. College Excel staff do not live on-site, but the program does provide students with housing, which helps them establish a sense of community and support — elements that are common among those who successfully adjust to college life, Allen points out.

Allen says that many of the program’s clients struggle with attention-deficit disorder and organization. College Excel staff teach students basic organizational skills such as using their attention strategically. For example, with students who struggle with memory and retaining information, Google Calendar can be a particularly useful tool. It can tell students where they need to be at any given moment, freeing up their attention and memory for other tasks.

Allen also talks with students about the importance of a clean workspace and provides them with practical tips on organization. For example, he says, students who constantly misplace things can save time and frustration by designating a space for pens, papers and other basics so that they will always know where to find them.

Students also work on developing good study habits. For example, rather than growing frustrated with their struggles to focus on what they’re reading for long periods of time, clients learn to study in 15- to 20-minute chunks, with five-minute breaks in between.

Roberts’ program is geared toward young adults who are coming from inpatient treatment and are ready to enter college or find a job. In addition to receiving ongoing mental health treatment, these clients take classes that focus on interpersonal skills, stress regulation, goal setting, time management and money management. They are also encouraged to exercise, and all students are matched with a case manager who helps them focus on sleep hygiene, peer interaction, health and nutrition, and, in some cases, dating.

Clients are required to attend one individual and one group counseling session per week. Counselors are also on-site five days a week, which allows them to give feedback outside of sessions. For example, a counselor might say to a student, “You say that you want to socialize, but you’re constantly retreating to your room or on the phone.” This opens up a discussion about why the student isn’t following through on counseling goals and allows the counselor and client to work on solutions together, Roberts says.

The students are usually enrolled in college or working when they start Roberts’ program. The coaching and classes take place around the students’ schedules, and staff members are available to help clients through whatever challenges they are facing in school or at work. Clients typically remain in the program about nine to 12 months. During the last six months, they move out of program housing and into their own apartments or college dorms.

Allen closes by noting that today’s adolescents and young adults — the oft-discussed millennials — are very much aware that older generations generally view them in a negative light. He believes this widespread maligning carries a psychic weight for this generation and can contribute to limiting their self-efficacy and sense of options.

Because this negative image of adolescents and young adults is so prevalent, Allen believes that even counselors may fall prey to it. “You can’t hold them in contempt and do good work,” he emphasizes. “The best thing we could be doing for them is stoking the fire of creativity.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books and DVDs (counseling.org/publications/bookstore)

  • Youth at Risk, sixth edition, edited by David Capuzzi and Douglas R. Gross
  • A Contemporary Approach to Substance Use Disorders, second edition, by Ford Brooks and Bill McHenry
  • Active Interventions for Kids and Teens, by Jeffrey S. Ashby, Terry Kottman and Don DeGraaf
  • Suicide Assessment and Prevention, DVD, presented by John S. Westefeld

ACA Mental Health Resources (counseling.org/knowledge-center/mental-health-resources)

  • Suicide Prevention
  • Substance Use Disorders and Addiction
  • LGBTQ Resources

Webinars (aca.digitellinc.com/aca/pages/events)

  • “Depression/Bipolar” with Carmen S. Gill (CPA22120)
  • “Trauma/OCD/Anxiety” with Victoria E. Kress (CPA22118)
  • “Substance Abuse/Disruptive Impulse Control/Conduct Disorder” with Shannon Karl (CPA22116)
  • “Counseling Students Who Have Experienced Trauma: Practical Recommendations at the Elementary, Secondary and College Levels” with Richard Joseph Behun, Julie A. Cerrito and Eric W. Owens (CPA24339)

 

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

Letters to the editor: ct@counseling.org

 

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

When panic attacks

By Bethany Bray July 30, 2018

Kellie Collins, a licensed professional counselor (LPC) who runs a group private practice in Lake Oswego, Oregon, experienced her first panic attack when she was 14. She remembers suddenly feeling cold, losing sensation in her hands and her heart beating so rapidly that it felt like it was going to leap out of her chest — all for no readily apparent reason.

“I thought I was dying. That’s what it felt like,” Collins says. “It was the worst experience of my life up to that point. It felt like it lasted forever, even though it was just a few minutes. Afterward, I was left with a feeling that I had no control.”

When Collins subsequently experienced more panic attacks, the situation was exacerbated by a close family member who didn’t understand what was happening. The family member suggested that Collins might be having the panic attacks on purpose, to get attention.

Collins’ life changed for the better in high school, when she began seeing a counselor. She learned not only that her panic attacks were manageable but also that she wasn’t to blame for their occurrence.

“Hearing that I didn’t cause this and that it wasn’t my fault set me on the path to get better. It made all the difference,” says Collins, a member of the American Counseling Association. “The biggest thing [counselors can do] is to validate the client’s experience. What they experience is real and not under their control in that moment — and it’s terrifying.”

‘Fear of the fear’

In addition to overwhelming feelings of fear, panic attacks are usually marked by shortness of breath or trouble breathing and a rapid heartbeat. Other physical symptoms can include sweating (without physical exertion), a tingling sensation throughout the body, feeling like your throat is closing up or feeling that you’re about to pass out, explains Zachary Taylor, an LPC and behavioral health director at a health center in Lexington, Virginia. Symptoms vary, however. “I’ve never had two patients describe it the same way,” he says. (Taylor refers to patients instead of clients because he works at a medical health center.)

According to the National Institute of Mental Health (NIMH), an estimated 4.7 percent of adults in the United States experience panic disorder at some point in their lives. The past-year prevalence was higher among females (3.8 percent) than among males (1.6 percent).

Panic disorder is marked by recurring, unexpected panic attacks (or, as NIMH describes, “episodes of intense fear” that are “not in conjunction with a known fear or stressor”). People who experience panic disorder typically worry about having subsequent attacks, even to the point of changing behavior to avoid situations that might cause an episode.

“It’s such a jarring and uncomfortable experience, and it feels so much like a real medical emergency, that they begin to fear the sensations themselves. This fear of the fear is what drives panic disorder,” explains Taylor, a member of ACA. “If it gets too bad, they begin to arrange their life around trying not to experience anything that might resemble or trigger any of those feelings that are associated with a panic attack, and it becomes a vicious cycle.”

At the same time, panic attacks can occur in people who do not have a panic disorder diagnosis. Although panic attacks are often coupled with stress, trauma or anxiety-related issues, they can also occur in clients without complicating factors, says Collins, who notes that she has seen clients who experienced their first panic attack in their 50s or 60s.

“They can happen even when life is going well and have no apparent reason. … Some people have them for a period of time in life and then never have them again, while others will have them throughout life,” she says. In addition, significant life changes, such as getting married, starting retirement or having a child, can trigger recurrences in clients who previously were able to manage their panic attacks, Collins adds.

Among clients with mental illness, panic attacks can co-occur with depression, anxiety, bipolar disorder, posttraumatic stress disorder, obsessive-compulsive disorder, specific phobias (particularly emetophobia, or fear of vomiting) and other diagnoses. Taylor says they can also be associated with a medical or physical issue.

“One of the most overlooked problems that can lead to developing panic is chronic sleep deprivation or insomnia,” he says, explaining that a lack of sleep can overexaggerate the fearful thoughts related to panic. When treating panic attacks, counselors should ask clients about their sleep habits within the first few sessions, Taylor advises. Counselors can also remember the acronym CATS and ask clients about their consumption of caffeine, alcohol, tobacco and sugar — all of which can worsen the feelings associated with panic attacks, he adds.

Learning coping skills and identifying triggers

Clients who come to counseling after experiencing a panic attack may start therapy without understanding the complexity of panic attacks or harbor feelings of shame or embarrassment about succumbing to panic seemingly out of the blue, Collins says.

It is sometimes helpful to explain to clients that during a panic attack, their body is launching into the fight-or-flight mode that is part of their biological wiring, Collins says. However, in this case, there is no tiger chasing them.

“I like to say that [a panic attack] is tripping the sensor, like when a leaf falls on your car and the alarm goes off. It trips the sensor, but your car doesn’t know” that there isn’t any actual danger, she explains. Collins says it also can be helpful to assure clients that “it will never be as bad as those first few times when you didn’t know what was happening to you.”

To identify triggers, Collins suggests walking clients through the months, days and hours that led up to their first panic attack — but only when the individual is ready to relive the experience, she adds. Some triggers can be easily identifiable, such as a spike in work-related stress or the loss of a loved one. Other triggers may be less obvious, meaning more work will need to be done to unpack the experience later in therapy.

“I like to make sure clients have really solid coping skills before they work on the underlying stuff that might be contributing” to their panic attacks, such as trauma, Collins says. “Spend the first few sessions identifying what’s been going on. Once they’re confident and capable of managing and getting through an attack, then ask about what might be contributing” to the attacks occurring.

Outside of session, counselors can encourage clients to devote time to journaling, relaxation, deep breathing and counting exercises that can boost self-reflection and change negative thought processes, Collins suggests.

Counselors can also equip clients with coping mechanisms such as mindfulness to help them remain calm and feel more in control in the event of a panic attack. Collins often gives her clients a small stone to carry with them and hold in their hand when a panic attack strikes. She tells them to focus on the stone and describe it to themselves — is it rough, smooth, cold, heavy? This can help divert their attention from the panicky sensations, she explains. The same technique can be followed using car keys, a coffee mug or whatever else clients can hold in their hands that wouldn’t readily draw undue attention from others, she adds.

Clients can also develop mantras to remind themselves in the moment that even though a panic attack feels all-consuming, it is a finite experience. Among the phrases Collins suggests as being helpful:

  • “I’ve gotten through this before.”
  • “This is only temporary.”
  • “Even though this feels like it’s going to last forever, it will end; it always does.”

Collins acknowledges, however, that “once it gets to a certain point, these things don’t work. You have to accept it for what it is when you’re in the middle of an attack. You have to ride the wave, accepting that it will be temporary and it will go away.”

“Sometimes, even getting angry at the panic attack can help,” she adds. “When [people] allow themselves to accept that anger, it takes away some of the power of the attack itself. Admit that it stinks but it’s something you can get through.”

Uncomfortable but not dangerous

Thinking that a panic attack can be halted or avoided by using breathing or relaxation techniques is a misconception, according to Taylor. Those methods are often the first choice of well-meaning practitioners, but Taylor argues that “it sends a subtle message to the patient that what you’re experiencing is dangerous and we need to do something to prevent it.”

“The first thing you need to do is teach [clients] that what [they are] experiencing is uncomfortable but not dangerous,” he says. “It’s your avoidance of the uncomfortable feelings, and trying to stop it, that has unintentionally made it worse. When it comes to symptoms of panic, trying to suppress or avoid those symptoms is the exact opposite of what you want to do.”

Diaphragmatic breathing and other relaxation techniques can be helpful to manage anxiety, Taylor clarifies, but they won’t stop the symptoms of a panic attack altogether. “The only way to truly stop it is to become accustomed to the feelings” and to understand that a panic attack is not dangerous, he adds.

Taylor finds the DARE method developed by author Barry McDonagh particularly helpful. The technique focuses on overcoming panic with confidence rather than employing futile attempts to calm down, Taylor says. The four tenets of DARE are:

  • Diffuse: Using cognitive diffusion, counselors can teach clients to deflect and disarm the fearful thoughts that accompany panic attacks. The thoughts that flood people’s minds during these episodes are just that — thoughts — and are not dangerous, Taylor explains. “Teach them to say ‘so what?’ to their thoughts: ‘What if I embarrass myself or pass out or throw up? So what?’ Take the edge off that thought by not only demoting it but separating ourselves from the thought: ‘It’s not me. I didn’t put it there.’ Teach patients to say to themselves, over and over, ‘This sensation is uncomfortable but not dangerous.’ Think of it like a hiccup. It’s uncomfortable but not dangerous. There’s nothing medically wrong. The more you focus on it, the more uncomfortable it gets.”
  • Allow for psychological flexibility: It is more important that individuals allow and become comfortable with their negative associations than it is to try to get rid of them, Taylor says.
  • Run toward the symptoms: Moving toward feelings of discomfort is antithetical to human instinct, but in the case of panic attacks, it can actually be an effective tactic. Taylor teaches people who deal with panic attacks to tell their bodies to “bring it on. Ask your heart: ‘Give me more. Let’s see how fast you can beat.’ One of the fastest ways to stop a panic attack, ironically, is to ask for more and try and make it worse. It’s the resistance to the sensations that makes it stick around.”
  • Engage: Teach clients to engage in the moment once the panic attack has peaked and is starting to wind down. This is when grounding and mindful exercises can be helpful, Taylor says. “What’s important is to focus on right here and right now. That will help you continue to move forward and get unstuck,” he adds.

An attachment approach

All of the counselors interviewed for this article noted that cognitive behavior therapy (CBT) is an effective, tried-and-true method to support clients who experience panic attacks by helping them refocus the fearful and overexaggerated thoughts that accompany the experience.

Linda Thompson, an LPC and licensed marriage and family therapist in Florida, finds that using CBT through the lens of attachment theory can be particularly helpful in addressing panic attacks. That holds especially true for clients who struggle with feelings of abandonment or rejection or have experienced attachment trauma, including the loss of a loved one or caretaker. Counselors can identify clients who might benefit from attachment work by asking questions at intake regarding past relationships and loss, Thompson says.

“If they are the kind of person who is very relationship-oriented and attachment is very important to them or there is trauma there, that has to be brought into the conversation,” says Thompson, an associate professor at Argosy University with a private practice in the Tampa area.

Thompson suggests that counselors invite someone to whom the client is attached, such as a partner or a spouse, into the therapy sessions (with the client’s consent). The practitioner can prompt discussion that helps the client share some of the inherent fears that he or she is harboring. Often, Thompson says, the partner’s response to this sharing is “I had no idea you felt that way. How can I help?”

From there, counselors can introduce techniques that the client and the client’s attachment figure can use together when the client is feeling anxious, Thompson says. Eye contact, hand holding and other physical connections can be particularly helpful. “It’s making it about connecting,” she explains.

Once they understand that their loved one’s worry and panic are spurred by issues related to relationships or a fear of isolation, friends and family members can be better prepared to respond differently when the person begins to struggle. If the client is willing, counselors can play a role in training the individual’s support system to help with attachment-oriented responses. For example, if a client wakes up in the middle of the night feeling panicked, a spouse or partner could respond by rubbing the person’s back or whispering affirmations such as “You’re not alone,” “I’m here” or “We’re going to get through this together,” Thompson says.

Attachment-oriented clients may also benefit from learning to do breathing techniques with someone to whom they are attached, Thompson adds. For example, a client may start to feel the symptoms of a panic attack while driving. Relying on techniques learned in session, the client would pull the car over and focus on their child in the backseat — holding the child’s hand, making eye contact and breathing together. The physical touch will boost oxytocin, a hormone connected to social bonding and maternal behavior, Thompson explains.

Thompson also suggests that these clients try yoga to help with relaxation and self-control. She says the practice is more beneficial if it involves a social aspect, so she recommends that clients practice yoga in a class with other people instead of alone at home.

Similarly, Thompson suggests helping attachment-oriented clients build a “tribe” or circle of support beyond the counselor. This is especially important for those who have lost a spouse or partner and those who are more susceptible to isolating themselves. Counselors can guide clients in finding connections that are personally meaningful to them, whether that is through participation in spiritual or religious activities, volunteer work or other community groups such as a book club. Focusing on relationships rather than the physical symptoms of a potential panic attack can help these clients feel less vulnerable, says Thompson, a past president of both the Pennsylvania Counseling Association and the International Association of Addictions and Offender Counselors, a division of ACA.

Thompson recalls one client who struggled so acutely with panic attacks and a fear of losing her loved ones that it kept her from leaving the house for two years. CBT alone wasn’t helping, so Thompson added attachment techniques to their therapy work together.

After a substantial amount of in-session exploration, Thompson discovered that the client’s panic attacks were tied to family-of-origin issues. The physical feelings the client experienced during her panic attacks were in the same part of the body where one of her parents had experienced a significant health problem.

In addition to conducting one-on-one therapy, Thompson included the client’s husband in sessions. They worked together on attachment-focused techniques, and, eventually, the couple was able to go outside of the home for the first time in a long while to celebrate their anniversary.

To prepare, they created notecards with attachment-focused feelings and reminders, such as what their first date felt like. They referred to the notecards throughout the evening and connected consistently via holding hands and making eye contact.

After the date, the client reported to Thompson that instead of thinking of where the exits were in the restaurant, as she would have done previously, she remained focused on the man — her husband — in front of her.

Thompson urges counselors to remain open to adding attachment theory or other complementary methods on top of go-to techniques such as CBT to reach clients who are experiencing panic attacks. “Expand your toolbox,” she says. “A person’s fear, the fear that is triggering panic, can have multiple origins. Help the client to find the source of their fear, and work on that. … Broaden your perspective to recognize that human beings have to be attached with people, no matter what the disorder. Ask, ‘How do I make sure the social needs of my client are being met?’”

Controlled exposure

Taylor knows firsthand how terrifying a panic attack can feel. He began experiencing anxiety in his teens and early 20s that intensified to the point of daily panic attacks.

When things were at their worst, he would often go to the emergency room of his local hospital. He wouldn’t register as a patient but would simply sit in the waiting room, knowing that those uncomfortable, uncontrollable feelings would eventually overtake him again. “Sometimes [I would go] because I was having a panic attack, or other times it was just because I felt I might have a panic attack,” Taylor recalls.

Eventually, Taylor did check himself into the hospital, and a doctor explained that he was going to be OK. That was the life-changing encounter that put him on the path to getting help; he credits medication and therapy for helping him overcome his panic attacks. The experience also inspired him to become a counselor.

This personal history plays into his work with clients. As a specialist in treating chronic anxiety and panic, he often emphasizes to clients that feelings of fear and excitement share the same neurological pathways. “It’s just our perception that makes them different. … You have to be able to ride the waves of panic without resisting it,” he says.

In addition to teaching clients to tolerate and deflect the invasive thoughts and physical symptoms that accompany panic attacks, Taylor finds exposure therapy to be a powerful treatment for panic. In fact, Taylor believes that exposure, or intentionally bringing on a panic attack in a controlled setting (such as the counselor’s office), must necessarily play a large role in overcoming the episodes.

“Patients are not moved by information; they’re moved by what they believe is possible, and they’re moved by new experiences. Just giving them the information [that panic attacks are survivable] is about as good as baptizing a cat,” he says. “If you give them the experience of exposure work in your office, they walk out a changed person. The focus should not be on staying calm but [on knowing] that no matter how hard their heart beats or [how much] they feel a sense of doom, they’re actually safe. It’s just a brain hiccup.”

Inducing a panic attack in the safety of a counselor’s office can prove to clients that what they might experience is uncomfortable but far from fatal, Taylor says. “When a counselor is doing exposure therapy with a patient and inducing panic-like symptoms in the office with them, we as counselors need first to be confident that a panic attack truly is not dangerous to the patient,” he explains. “If they start to panic and then we get scared and try to calm them down, the exposure will fail. We have to be able to stay with it, let the panic attack fully develop and subside on its own, so the patient learns that their fear of having a heart attack, passing out or losing control won’t happen. And unless we can really allow them to go all the way through a panic attack and come out the other side, the exposure just won’t work. They will continue to believe that a panic attack is dangerous and continue to try to suppress and avoid them.”

A good amount of therapeutic work may be required before clients are ready for exposure techniques, Taylor says. Once they are, counselors should begin the experience by asking clients to verbalize the worst thing they can imagine happening to them as the result of a panic attack, he says. Fears that clients typically voice include passing out, vomiting or even having a heart attack.

Taylor says the counselor’s response could be, “OK, are you ready to test that out” in the safety of the counselor’s office?

To induce the elevated heart rate and rapid breathing that accompany panic attacks, the counselor might suggest that the client do jumping jacks, run up and down the stairs or breathe through a straw for an extended period of time. As the panic symptoms swell and peak, the counselor will remain close by to remind the client of the cognitive diffusion and other techniques previously mentioned by Taylor.

Afterward, the counselor can talk about how the things the client feared happening as the result of a panic attack did not actually come to pass. The moment clients realize that they can endure panic attacks without their worst fears materializing is the moment they can begin to overcome the attacks, Taylor says.

Conquering avoidance

Individuals who have experienced panic attacks will sometimes start avoiding situations or places where a prior attack occurred. Often, this includes public places such as shopping malls. If this inclination is left unchecked, it can spiral into the person missing work and social engagements or engaging in other isolating behaviors, Collins says. On top of that, avoidance will serve only to make things worse, she notes.

“That fear of having another panic attack can be crippling,” she says. “One of the fears a lot of people have is having an attack in front of people or being in a place where they can’t escape, such as an airplane or a meeting at work.”

When Collins broaches this subject with clients, she frames it as taking their power back and not letting panic attacks control their lives. “We talk about starting small and [taking] baby steps, especially if they’ve been terrified of a place for a while,” she says.

Counselors can begin by having clients visualize in session the place they have been avoiding. Ask them to describe it and talk about how their body feels as they think about that location, Collins suggests. This process may need to be repeated several times before clients feel comfortable and confident enough to make a plan to actually go to the places they have been avoiding, she adds.

When they do go, make sure the client takes a friend or other trusted person with them for support. Clients should also be directed to stick to the plan they have created and talked through in their counseling sessions, Collins says.

For example, if a client has been avoiding going to a shopping mall out of fear of having a panic attack, a first step in the client’s plan might be simply driving to the mall, parking the car and sitting inside it for five minutes before leaving. The client might even need to repeat that step of the process multiple times, Collins says.

After that, the client can move on to walking through the doors of the mall and then leaving immediately. On the next visit, the client might enter the mall and go into a store, and so on. The idea is to continue going until the client no longer associates that place with feelings of fear.

Often, after repeated visits, “people will say, ‘OK, I don’t need baby steps. I want to go now,’” Collins says.

Above all, compassion

Counselors can provide a holistic approach to addressing panic attacks that clients might not have experienced previously with medical professionals or other mental health practitioners. Most of all, Collins says, counselors should offer empathy to clients who are confronting such a distressing, overwhelming and, often, seemingly unexplainable experience.

“That validation is the most powerful thing I’ve seen that helps people,” she says. “Clients get better with the relationship, the validation, the compassion. Compassion: That’s the No. 1 thing to remember.”

 

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Contact the counselors interviewed for this article:

 

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Learn more:

ACA Practice Brief on panic disorder: counseling.org/knowledge-center/practice-briefs

 

Zachary Taylor recommends these resources for counselors who want to learn more about the treatment of panic attacks:

  • DARE: The New Way to End Anxiety and Stop Panic Attacks by Barry McDonagh
  • Anxious Kids, Anxious Parents: Seven Ways to Stop the Worry Cycle and Raise Courageous and Independent Children by Reid Wilson and Lynn Lyons
  • Interview, “Maximizing Exposure Therapy for Anxiety Disorders” with Michelle Craske, professor of Psychology, Psychiatry and Biobehavioral Sciences and director of the Anxiety and Depression Research Center at the University of California, Los Angeles: sscpweb.org/craske
  • Article, “Get Excited: Reappraising Pre-Performance Anxiety as Excitement” by Allison Brooks, assistant professor, Harvard Business School: apa.org/pubs/journals/releases/xge-a0035325.pdf
  • Dr. Andrew Weil’s 4-7-8 Breathing Method: drweil.com/videos-features/videos/the-4-7-8-breath-health-benefits-demonstration/

Linda Thompson recommends these resources for counselors wanting to learn more about attachment-focused responses:

 

 

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

Letters to the editorct@counseling.org

 

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

Is depression lurking in your medicine cabinet?

By Bethany Bray July 16, 2018

An estimated one in three American adults are taking one or more medications that can – and often do – cause depression.

A recent Journal of the American Medical Association (JAMA) study found that many common medications that Americans take regularly, such as drugs for acid reflux or high blood pressure, have the potential to cause depression as a side effect.

The study, published in JAMA‘s June 12 issue, analyzed federal health survey data collected from U.S. adults between 2005 and 2014. Of the more than 26,000 participants, 7.6 percent who were regularly taking one medication reported having depression — and this doubled in those who were taking three or more medications.

“The estimated prevalence of depression was 15 percent for those reporting use of three or more medications with depression as an adverse effect, vs 4.7 percent for those not using such medications,” wrote the article’s co-authors.

The study also found that the number of Americans who regularly take medications that carry depression as a side effect has increased from 35 percent to 38.4 percent between 2005 and 2014. The percentage of people taking three or more these medications concurrently increased from 6.9 to 9.5 percent over the same timeframe.

American Counseling Association member Dixie Meyer says these findings only affirm the importance for counselors to familiarize themselves with medical diagnoses and commonly prescribed medicines. Also, counselors should routinely screen for depression in clients who take medications with depressive side effects, as well as those in at-risk groups, such as minorities, clients with low socio-economic status or who identify as LGBTQ.

As the evidence for the intertwined nature of the medical and mental health fields continues to accumulate, it becomes increasingly important for counselors to bring themselves up to speed on medical research that may inform clinical practice, says Meyer, an associate professor in the medical family therapy program in the department of family and community medicine at the St. Louis University School of Medicine. This can happen both through individual professional development and a profession-wide focus.

“We know that for professions to succeed, there needs to be a continual adaption. For the counseling field, counselor training programs need to include not only counseling but medical research evaluation,” Meyer says. “Counselors need to be trained in understanding the relationship between physical and mental health disorders. For example, trauma increases the likelihood for chronic health conditions.”

Meyer is also the director of the Relationships and Brain Science Research Laboratory at the St. Louis University School of Medicine. She frequently gives presentations to counselors on the importance of understanding their clients’ medications, including at ACA’s 2016 conference in Montreal. She recommends that all counselors have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. Counselors can also refer to resources like Medscape.com for updates on the latest medical research that may inform clinical practice.

“Because this [JAMA] research is not a clinical trial or a prospective study that can inform the reader of temporal implications, we should interpret the results with caution as they are correlational in nature,” says Meyer. “It is not uncommon for physicians to prescribe, at the onset of treatment or later concurrently with treatment, a medication intended to manage side effects. While the sample with the 15 percent increased risk were taking three or more medications with the depression side effect, we can still expect the majority of individuals using these medications will not experience an increase in depression. Thus, any preventative care could be needless without symptoms present.”

 

 

When it comes to counselors, clients and medication, Meyer suggests the following:

  1. Intake forms should include use of both prescription and over-the-counter medications. The form should specify that he or she should include medications taken periodically or on an as-needed basis.
  2. Counselors should implement regular, monthly checks to assess if medication usage has changed.
  3. In addition to counselors systematically assessing how clients perceive the effectiveness of their psychotropic medication and side effect evaluation, the medication management component of counseling should include an assessment of those medications associated with depression risk, like anti-hypertensives, hormonal contraceptives and other hormone replacement therapy and proton pump inhibitors (commonly used to treat acid reflux).
  4. Clients being treated for depression, those in at-risk groups (LGBTQ, racial minorities, women, low-income) and those taking medications with depressive side effects need to be routinely screened for depression. A monthly screen for depression using widely available tools like the PhQ-2 or PHQ-9 can easily be incorporated into clinical practice without being too cumbersome for clients.
  5. Counselors need to monitor both the mood and somatic symptoms of depression in high-risk groups. Many of the symptoms of depression are somatic; thus, clients may be experiencing depressive symptoms that go unnoticed because they are unrelated to mood changes.
  6. Counselors need to be well-versed in who is at risk for depression. The [JAMA] research reported that the medications with potential depressive side effects were more likely to be given to those individuals already at an increased risk for depression (e.g., female, widowed, older populations and those with more chronic health conditions). Not only does this make it difficult to determine if the research is uncovering depression prevalence already present or if vulnerable populations are being placed in a position that increases their depression risk. Thus, counselors need to understand what the research tells us about who is at risk for depression — and counselors need to identify if these individuals are also taking medications with this potential side effect.
  7. Counselors need to encourage self-monitoring of mood symptoms and discuss with clients taking medications with depressive side effects how to intentionally monitor their mood at home. For example, smart phone apps designed to track mood are widely available.

 

 

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Find out more

 

Read the full JAMA article: jamanetwork.com/journals/jama/article-abstract/2684607

 

From NPR, “1 In 3 Adults In The U.S. Takes Medications Linked To Depression

 

From the Counseling Today archives:

The counselor’s role in assessing and treating medical symptoms and diagnoses

Healthy conversations to have” (on discussing psychiatric medication usage with clients)

 

 

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

 

 

Follow Counseling Today on Twitter @ACA_CTonline and on Facebook at facebook.com/CounselingToday.

 

 

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

 

 

 

Finding balance with bipolar disorder

By Laurie Meyers April 24, 2018

Licensed professional counselor (LPC) John Duggan didn’t plan on bipolar disorder becoming one of his specialties, but providing emergency room support gave him a close-up view of the consequences when the disease was left uncontrolled. Duggan, who is also a licensed clinical professional counselor (LCPC), noticed the escalation in manic and hypomanic crises that accompanied the increased light and time change in spring. He also saw people who had been diagnosed with depression but whose manic or hypomanic symptoms had gone undetected until they ended up in the emergency room with full-blown mania, psychosis or dysphoria.

Some of these individuals had no one to help them remain stabilized after leaving the hospital. Seeing the need for, as Duggan puts it, “boots on the ground,” he began seeing more and more clients with bipolar disorder in his private practice in Silver Spring, Maryland. Duggan, who is now the manager of professional development at the American Counseling Association, says some of those clients came as referrals from counselors who didn’t feel qualified to work with individuals struggling with bipolar disorder.

It is not uncommon for counselors to be hesitant to take on clients with a bipolar diagnosis, according to practitioners who specialize in the disorder. At the same time, there are many individuals with bipolar disorder who truly need the support of counselors and other mental health professionals to help them manage their condition. Although the public — and perhaps even some mental health professionals — may think that the disease is rare, the National Institute of Mental Health (NIMH) estimates that approximately 2.8 percent of U.S. adults currently have bipolar disorder and that 4.4 percent will experience it in their lifetime. NIMH also estimates that approximately 2.9 percent of adolescents currently have bipolar disorder.

Some mental health practitioners may buy in to the stereotype that clients with bipolar disorder are volatile and resistant to treatment, whereas others may be daunted by the disorder’s elevated risk of suicide. The Substance Abuse and Mental Health Services Administration estimates that for those with bipolar disorder, the lifetime risk of suicide is at least 15 times higher than it is for the average person. However, Duggan and others who treat bipolar disorder say that counselors have a crucial role to play in helping clients manage the disease.

Bipolar basics

Counselors are already trained to obtain a detailed client history that includes, among other things, emotional symptoms, family history and sleep and lifestyle habits, all of which can be crucial to spotting bipolar disorder.

“Bipolar clients often seek help only when depressed. Because of this, their manic or hypomanic symptoms are often not reported or observed,” explains Valerie Acosta, an LPC who counsels a number of clients with bipolar disorder in her Richmond, Virginia, practice.

A first step is for counselors to educate clients. Although they may be familiar with the symptoms of depression, they are much less likely to know how mania or hypomania present, adds Acosta, a member of ACA. Many clients think mania involves feeling very “up” and happy, but symptoms actually include intense irritability, anxiety and distraction, she explains.

Sleep patterns are also instructive when looking for evidence of mania or hypomania, says Regina Bordieri, a licensed marriage and family therapist in New York who specializes in bipolar disorder. “If they’re not sleeping, are they feeling energetic or tired?” she asks. Most people feel tired after a short night’s rest, but in hypomanic or manic phases, those with bipolar disorder feel energized despite very little sleep, Bordieri explains.Bordieri also asks clients about times when they weren’t depressed. Did they have high levels of energy and feel like they could get a lot done? Depressed moods that alternate with periods of intense activity and feelings of almost limitless energy may be signs of bipolar disorder.

Because it can be difficult for individuals to recognize their mood and behavioral shifts, family members and partners can also play a significant role when it comes to identifying and gauging symptoms, Bordieri says. Then, of course, there is the other role that family plays in diagnosis — namely, family history. Bipolar disorder is strongly tied to genetics, so clients with a family history of bipolar disorder are more likely to develop the disease.

Duggan urges counselors who are treating clients with bipolar disorder to work closely with medical professionals. Consulting a client’s primary care physician (with the client’s permission) is particularly crucial during diagnosis so that physical causes such as sleep disorders, thyroid disorders or a reaction to medication won’t be mistaken as symptoms for bipolar disorder.

Counselors — and clients — should also be aware of their ideas concerning which symptoms and forms of bipolar disorder are most debilitating, say Acosta and Bordieri.

“Bipolar II is not a milder form of bipolar I, but a separate and different diagnosis,” Acosta explains. “Bipolar I is also not necessarily more difficult to treat. … While the manic episodes in bipolar I can be severe and dangerous, the depressive episodes associated with bipolar II can be longer lasting, causing severe impairment to the individual. While clients with bipolar II have hypomania and not full manic episodes, their depressive episodes can be more debilitating than the depressive episodes of bipolar I.”

Although the depression of bipolar II may take a greater overall toll and be harder to treat, the mania inherent in bipolar I comes with its own set of “baggage.” In the popular imagination, mania — especially more extreme episodes — is the phase most associated with bipolar disorder and contributes to the perception that those who have the disorder are “crazy.” Mania is also extremely disturbing for clients and is highly stigmatized, especially when it leads to hospital stays, Bordieri says.

Ultimately, however, each client’s experience of bipolar disorder is different, Acosta says. “A therapist might be working with two people with bipolar II, and these individuals may present with very different symptoms,” she says. “Helping clients and their families to understand the individual’s unique symptoms, and have a variety of tools and strategies for managing their moods and specific symptoms, is essential for recovery.”

Managing medication

The counselors interviewed for this article stress that because of the neurobiological nature of bipolar disorder, medication is an integral part of treatment. Cheryl Fisher, an LCPC practicing in Annapolis, Maryland, whose specialties include bipolar disorder, says that counselors should work closely with a psychiatrist when treating these clients. In fact, when Fisher sees new clients with bipolar disorder who are working with a primary care physician, she strongly urges them to begin seeing a psychiatrist. Fisher, a member of ACA, believes that psychiatrists possess the specialized psychopharmaceutical knowledge necessary for prescribing the medication “cocktail” that works best for each individual with bipolar disorder. And because counselors see clients more often (and for longer chunks of time) than their physicians do, Fisher thinks that counselors are in a better position to track the effectiveness and side effects of clients’ prescriptions.

Counselors can also help clients become better self-advocates, says ACA member Dixie Meyer. Sometimes clients aren’t comfortable speaking up at the doctor’s office or are unaware that they are even experiencing side effects, she says. Counselors are in a position to spot such problems.

Meyer gives the example of a client who was showing signs of lithium toxicity. “I asked him when was the last time he had his blood levels checked [lithium requires regular blood testing to guard against toxicity]. He asked me what I was talking about. Somehow, he never knew he needed to have levels checked regularly.”

Meyer, an associate professor in the medical family therapy program at the St. Louis University School of Medicine’s Relationships and Brain Science Research Laboratory, says counselors should also be aware that clients with bipolar disorder might be given antidepressants for depression that can cause the onset of mania or hypomania.

“Clients might feel like, ‘Wow, I’m really starting to have a good mood,’” she notes. “They don’t really think to bring that up to the doctor, but the counselor can easily recognize the difference between remission of depression symptoms versus the development of manic symptoms. [Clients] might become more impulsive, snippier, their motor behavior more agitated … Counselors and family members are often the best [resources] to spot mood shifts.”

Sometimes clients don’t want to take medication for bipolar disorder because they have experienced unpleasant side effects, says Meyer, who frequently gives presentations to counselors on the importance of understanding their clients’ medications. She urges counselors to talk through this decision with clients. Meyer informs her clients with bipolar disorder that all medications have side effects, some of which may be temporary. She then asks these clients to give the medications some time and encourages them to talk to their physicians about which side effects might be permanent.

If the side effects of the medication aren’t going to go away, Meyer talks with clients about whether the side effects are something they can live with. In some cases — especially with medications that cause significant weight gain — the client’s answer is no. In those situations, Meyer says that she, the client and the physician go back to the drawing board and look for other medications or explore whether lifestyle changes might help reduce the side effects.

Meyer says all counselors should have a copy of the Physicians’ Desk Reference on hand so that they can quickly look up any medication. She also recommends Drugs.com as an excellent online resource.

Sometimes clients with bipolar disorder get stabilized and decide that they don’t need to take their medications anymore. When that happens, Acosta says that she “reflects back” what happened the last time the client stopped taking his or her medication. (Spoiler alert: It wasn’t good.)

Fisher tries to educate clients about bipolar disorder, emphasizing that a biochemical reaction underlies their mood shifts and that the medication helps buffer that process.

Medication, however, is not the only tool in the box to help individuals with bipolar disorder. Counselors can provide the emotional and lifestyle keys that help clients manage and, hopefully, decrease their mood and behavior shifts.

Prevention and stabilization

Multiple research studies continue to demonstrate the link between the circadian rhythm and bipolar disorder. Researchers are still teasing out the specifics, but what is clear is that maintaining a schedule — particularly a sleep schedule — that hews to the circadian rhythm plays a key role in controlling the disease.

Research has shown that insomnia is not just a symptom of depression but can also cause it. Likewise, Bordieri says, disturbed sleep can be either a symptom of hypomania/mania or the trigger for an episode.

Sleep is one of the first things that Fisher investigates with all clients, but it is particularly important in those with bipolar disorder. “I ask them what their sleep routine is,” she says. “How do you end your day? How do you prepare your body to rest? What is your sleeping environment like?” Fisher talks about how the blue light from devices such as smartphones and tablets disrupts sleep and advises clients to establish total darkness in their bedrooms.

Some clients reveal that a racing brain regularly prevents them from going to sleep. For these clients, Fisher recommends tools such as guided meditation or performing what she calls a “brain dump” — emptying the mind by writing down all of the thoughts that are keeping clients awake.

Acosta encourages clients with bipolar disorder to go to bed at the same time every night, wake up at the same time every day and take their medications at the same time daily. She has found this routine has a stabilizing effect.

Fisher and Duggan both believe sleep is so essential to mental and physical health that if good sleep hygiene isn’t working, they advise clients to get a sleep aid from their physician.

Duggan has found that the changing of the seasons can also have a profound effect on bipolar disorder. It’s a component of the bipolar resiliency program he came up with called SMART.

S — (Control) stress, sleep, maintain a schedule, seasons: Duggan asks clients with bipolar disorder to track their moods and sleep. He also teaches sleep hygiene and makes note of clients’ responses to the different seasons. Summer, when there is a lot of activity going on and plenty of sun, is usually a good time for many clients with bipolar disorder. But as the season draws to a close, Duggan reminds them that once fall arrives and there is less light, they are likely to start feeling less upbeat and may feel overwhelmed. He urges these clients not to overschedule themselves in summer and to step up their self-care efforts when the calendar turns to September.

M — Medication as prescribed

A — Adjunctive treatment such as yoga, acupuncture, massage or other complementary or alternative practices: Duggan says these are all areas that are outside of his expertise but that clients have found helpful. He also works with clients on self-soothing techniques and meditation. If a client is going through a severe manic or depressive phase, however, he strongly recommends against mindfulness. “I don’t want them to ‘be’ with the bad depression or the bad mania,” he explains.

R — Recreation and relationships: Duggan urges clients with bipolar disorder to stay engaged socially and to “do things that bring you joy, that you love, that give you a sense of flow.”

T — Therapy and counseling as needed

Fisher is a proponent of what she calls “nature therapy.” Research has shown that nature has a beneficial effect on mental health, so she urges clients to find a way to get outside — even if only for a short time — every day.

“Encouraging clients to track their moods can be a very valuable tool,” Acosta adds. “There are a wide variety of apps that clients can download to help with tracking their moods. Daylio is one that a lot of my clients like to use. By recording this information over time, clients learn about how their moods cycle, and this helps them to better understand the nuances of their moods, their triggers, and what helps and does not help with stabilizing their moods. I routinely review data from these apps — or paper mood charts — with my clients. I also routinely review symptom charts with my clients to help them monitor their symptoms.”

Some of Acosta’s clients have also had their own highly personal methods of tracking problematic mood changes. One client monitored her mood elevations by the number of packages that appeared for her in her apartment lobby (overspending). Another client could connect his manic symptoms to times when he would spend several days engrossed in building things (an increased focus on goal-directed activities).

Developing this degree of self-awareness can be beneficial for clients with bipolar disorder. “Linking symptoms to behaviors, thoughts and triggers can help to foster recovery,” Acosta says.

Meyer also teaches clients to spot patterns. She has premenopausal women chart their menstrual cycles so they will be aware, for example, that three days before their periods begin, they will feel more depressed. Meyer instructs clients to note their moods throughout the day and record what was going on. She believes that when clients can identify these patterns and recognize that there was a specific reason they were particularly manic or depressed, it provides them a greater sense of control.

Meyer teaches clients to self-soothe on hard days by going for a walk, going to the park and sitting on a bench or doing whatever else makes them feel good in a healthy way. 

“It’s really important … that our clients be empowered with a strategy for their symptoms,” Fisher says. For instance, if clients with bipolar disorder are having a down day and feel as though they are shifting toward a depressive episode, they could start to manage the switch by making a plan to get together with a friend or even just calling someone close to them.

Acosta tries to equip clients with bipolar disorder against life stressors. “They need to find healthy ways to cope with stress,” she says.

Acosta teaches clients mindfulness meditation and gives assignments outside of session, such as trying yoga or a new form of exercise. She believes that physical activity helps rein in racing thoughts. Acosta also recommends music for relaxation.

Seeking support

In addition to individual therapy, Acosta has found that group therapy is very effective for clients with bipolar disorder. She runs a monthly support group for adults over 18. “Some participants have been living with bipolar disorder for decades, and some have just been diagnosed,” Acosta says. “This is an open group, so members are constantly joining and leaving the group. On average, we have three to 10 participants per group. Because this is a therapy group, participants bring in and discuss any issue that they’re currently dealing with in their lives. Some of the topics of discussion include challenges such as the struggle to be on time for work or losing a job because of their bipolar symptoms, relationship conflicts, the side effects of medication, healthy strategies for managing symptoms, grieving the losses in their lives caused by their illness and building healthy living strategies.”

Acosta also provides education as needed in the group on topics such as understanding symptoms, exploring apps to track mood and locating resources for further education and support. She believes the peer support is what is most helpful to group participants.

“Many people have never met someone else with bipolar disorder, and learning that they are not alone or the only person dealing with the challenges of bipolar disorder can be extremely comforting and helpful,” she says. “Seeing peers recover, build healthy relationships and obtain their goals and dreams is most powerful.”

Support for these clients is essential, agrees Meyer, who recommends that counselors help recruit family members and romantic partners as a kind of support team whenever possible. Loved ones can be there when counselors can’t and are often the first to spot mood changes, she explains. “We also know when clients are in good, healthy relationships, it helps stress levels, and that helps keep them in good health,” Meyer adds.

Sometimes support can come from the strangest of sources, notes Fisher, relating the story of a woman who was in particular need of connection. “I had a client who had a trauma history in addition to bipolar disorder, and she was engaging in really unhealthy behaviors and self-loathing. She was just not in good shape,” Fisher says. “She came in one day, I did a checkup, and she showed really high levels of depression.”

Fisher didn’t think the client was in immediate danger, but she felt bad leaving her without another source of support, particularly because it was a Friday and Fisher was going away for the weekend.

“I asked, ‘Who can you be with? Who can you talk to?’’ Fisher says. “The client said, ‘No one. There is no one.’”

The woman was estranged from her family, and her only “network” involved her sexual hookups.

Suddenly, Fisher had an idea. She had just bought a betta fish for her office, so she asked the client to watch it for her over the weekend.   

Fisher saw the client the following Monday — sans fish — and asked how she was doing. The client replied that she was feeling better and more upbeat.

“Then she started talking about her weekend and spending time with ‘Olive’ and watching TV with ‘Olive,’” Fisher continues.

She asked the client who Olive was. Olive was the name the client had bestowed on the betta fish. The client had neglected to bring Olive back because she didn’t want to leave the fish in the car but promised to return her later in the week.

Fisher told the woman to keep the fish but was curious as to why she had named her Olive. The client said that Olive made her think of hope — like the olive leaf the dove brought back to Noah’s Ark to show the waters were finally receding after the Great Flood described in the Bible.

What lesson did Fisher take away from this experience? “We have to get our clients to connect — even if it’s just with a betta fish,” she says.

Fisher urges counselors to overcome any reservations they might harbor about treating clients with bipolar disorder. “Get more training if you’re uncomfortable,” says Fisher, who encourages counselors to ask themselves why they might be uncomfortable and then to address those reasons.

Counselors already possess the skills needed to empower these clients, Fisher adds. “We have clients who are walking in the door with this diagnosis and identifying it with who they are,” she says. “Bipolar disorder is not who they are — their diagnosis is not their identity. People think, ‘My body is betraying me. I feel like crap. I’ve alienated all my friends — I am the monster.’ Counselors can exorcise the demon of the [bipolar] diagnosis.”

 

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Additional resources

To learn more about the topics discussed in this article, take advantage of the following select resources offered by the American Counseling Association:

Counseling Today (ct.counseling.org)

Books (counseling.org/publications/bookstore)

Podcasts (counseling.org/knowledge-center/podcasts)

  • “Bipolar Resiliency Program” with John Duggan (HT056)

Webinars (aca.digitellinc.com/aca)

  • “Depression/Bipolar” with Carman S. Gill

Practice briefs (counseling.org/knowledge-center/practice-briefs)

  • “Counseling Adults Who Have Bipolar Disorders” by Victoria Kress, Stephanie Sedall and Matthew Paylo

 

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

Letters to the editor:ct@counseling.org

 

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

 

Assessing depression in those who are chronically ill

By Cathy L. Pederson, Kathleen Gorman-Ezell and Greta Hochstetler Mayer March 7, 2018

You receive a referral for a new client from a local physician. Great! As you review the materials, it is clear that the physician thinks the client’s issues are “all in her head.” Perhaps she is depressed. A good strengths-based and ecologically grounded counselor is just what she needs.

On the day of the first appointment, you wonder about this 24-year-old woman. You make a quick assessment upon meeting. Diane is pale, thin and has bags under her eyes. She looks exhausted and almost fragile. Yet she is neatly dressed in jeans and a T-shirt, and her light brown hair is pulled into a ponytail. She is not wearing makeup and is naturally pretty. She has an easy smile and is quite pleasant.

As you begin your work with Diane, you realize that a number of her complaints sound like the somatization of depression. She clearly suffers from fatigue. She has also struggled with insomnia the past several months, adding to her exhaustion. Diane reports a decreased appetite and has lost 10 pounds in the past couple of months without effort. Furthermore, she suffers from neuropathic pain in her legs — a chronic pain condition from abnormalities in the sensory nerves that often results in constant pain that may feel like explosions, stings or burning aches. In addition, she frequently has abdominal pain and headaches.

Because of these symptoms, Diane was often absent at work and was subsequently fired. She now relies on her parents for financial support and has moved back home. Diane is clearly depressed … or is she?

Overlapping symptoms

Many people suffering from invisible illnesses such as chronic fatigue syndrome, myalgic encephalomyelitis, Ehlers-Danlos syndrome, fibromyalgia, Lyme disease, mast cell activation disorder, postural orthostatic tachycardia syndrome (POTS) and Sjögren’s syndrome are first diagnosed, often incorrectly, as suffering from depression. Although troubling, this is understandable because the symptoms for these chronic illnesses overlap with somatic complaints associated with depression.

Many people in the general population who are depressed suffer changes in appetite, sleep and weight, and have increased fatigue and pain. Among individuals in the chronic illness community, these are common symptoms related to their physical illness. They may also suffer from other symptoms that make gainful employment or social relationships difficult. These symptoms include brain fog that makes concentration and processing of information challenging, orthostatic intolerance (increased symptoms when standing), exercise intolerance, joint subluxations and dislocations, severe allergic reactions to foods or chemicals, hot flashes, and muscle and joint stiffness or pain.

Many current depression screening instruments have at least a third of their questions related to somatization of depression. This can artificially elevate the depression score in those individuals with a chronic, invisible illness because of the physical symptoms they experience.

For instance, consider the free version of the Beck Depression Inventory. The last seven questions of this popular instrument ask about physical, rather than psychological, changes. Thinking about those with chronic invisible illnesses, imagine their scores for the following somatization of depression items.

  • I can work about as well as before (0). … I can’t do any work at all (3).
  • I can sleep as well as usual (0). … I wake up several hours earlier than I used to and cannot get back to sleep (3).
  • I don’t get more tired than usual (0). … I am too tired to do anything (3).
  • My appetite is no worse than usual (0). … I have no appetite at all anymore (3).
  • I haven’t lost much weight, if any, lately (0). … I have lost more than 15 pounds (3).
  • I am no more worried about my health than usual (0). … I am so worried about my physical problems that I cannot think of anything else (3).
  • I have not noticed any recent change in my interest in sex (0). … I have lost interest in sex completely (3).

There are 21 questions total on the Beck Depression Inventory, each ranging in point value from 0 to 3, with the higher numbers reflecting an increased possibility of depression. For how many of the seven questions above do you think that Diane might report a 2 or a 3 because of her physical ailments? If she chose the most severe response (a score of 3) for each of these seven questions, this would give her 21 points — placing her in the category of moderate depression on the Beck Depression Inventory — without even considering the first 14 questions on the survey.

It is important to realize that some clients who might appear moderately, severely or extremely depressed on a screening instrument such as the Beck Depression Inventory are actually suffering from an undiagnosed physical illness. We urge counselors to explore these somatic symptoms with their clients, particularly if the counselor notices an imbalance in the affective versus somatic parts of the instrument. With an integrated conceptualization of the person within her or his environmental context, counselors can go beyond addressing surface symptomology to explore underlying concerns.

Taking time to build a therapeutic alliance is critical, especially as many in the health care industry feel pressure from insurance companies to conduct quick patient exams. Unfortunately, many health care practitioners don’t get reimbursed for really listening to their patients and probing these multifaceted issues to arrive at a correct diagnosis. As counselors, you have the opportunity to give your clients something that they have been lacking — someone who is willing to take the time to truly listen and piece together the complexity of their problems.

Chronic illness and depression can be comorbid

Just as someone with chronic illness may not have depression, comorbidity of depression with chronic illness is possible and must be ruled out. There is a known link between chronic medical illness and depression for people with heart disease, cancer and a variety of other well-understood medical issues. Approximately 50 percent of people with chronic invisible illnesses also suffer from clinical depression. The trick is to separate those individuals with elevations purely from physical symptoms from those individuals who are truly depressed. There is a paucity of literature to guide clinical practice in this area.

Chronic illness encompasses more than just the physical symptoms. Many clients/patients become socially isolated because they can’t work or go to school. Friends and family members may slowly drift away as the illness drags on for months, years or decades. In the case of invisible illnesses, these clients often look “normal,” so it is not uncommon for people to completely dismiss their affliction. Many of these disorders are not well-understood, and a stigma can be attached to them that adds shame and guilt for being ill.

Poor treatment from health care workers can compound the problem. Many people with these illnesses have perfectly normal blood and urine tests, electrocardiograms and MRIs. If the tests are normal, then the symptoms must be “all in the person’s head,” right? Can people truly be suffering when traditional testing can’t find the cause? Many individuals working in the health care professions would say no. As a result, many of these patients are labeled as being high maintenance, and their own physicians may not believe that they are truly ill. Even for those individuals with a chronic or invisible illness who are not depressed, counseling can be important to increase their hope, improve their quality of life, help them gain perspective and help them work through social issues as they learn to deal with their new reality.

Properly diagnosing clinical depression for people with chronic illnesses is important, just as it is in the general population. Interestingly, not all people in the chronic illness community who die by suicide are clinically depressed. Research has shown that individuals with chronic invisible illnesses, particularly women, are at an increased risk for suicide. Some studies have reported that nearly 50 percent of people with POTS or fibromyalgia report suicidal ideation. Among those with chronic fatigue syndrome and myalgic encephalomyelitis, approximately 20 percent are at high risk for suicide. These are staggering numbers.

Although most counselors routinely assess for suicide, it is important to know that individuals with chronic invisible illnesses often do not present with the same symptomatology. Whereas most people in the general population who are suicidal tend to have comorbid depression, people with chronic invisible illnesses may not present this way.

Suicide risk factors for individuals with chronic invisible illness include loneliness, perceived burdensomeness and thwarted belongingness. The acquired capability for lethal self-injury is a critical area of risk to explore for those with chronic invisible illness due to repeated exposure to painful or fearsome experiences. These risk factors should be routinely assessed and worked into the treatment plan to target the underlying suicidality and reasons for living. Determining specific goals and objectives on the treatment plan, as well as providing regular check-ins on these topics, may help to decrease the risk of suicide.

The individual’s support system, including the treating physician, should also be made aware of the link between these risk factors and suicide. By facilitating this conversation between clients who are chronically ill and their support systems, some of the concerns related to loneliness, perceived burdensomeness and thwarted belongingness may be addressed proactively and conversely serve as protective factors rather than risk factors.

Counseling clients who are chronically ill

Many individuals with chronic illnesses need a safe place to vent their frustrations while receiving validation for their emotional, social and physical suffering, even if they are not clinically depressed. You may be the only person who believes them as they explain their symptoms and how the chronic illness impacts their daily life.

The therapeutic relationship and the ability to establish rapport are imperative to initiating change in the treatment process. Individuals with chronic invisible illnesses may benefit from individual therapy, couples or family-based interventions, multidisciplinary case coordination and group therapy with other people who are chronically ill. Integrating teletherapy or online therapy can ensure that these individuals, particularly those who are partially or completely homebound, have access to the care that they need.

Some people with chronic invisible illnesses struggle to get through the day. Because of their physical struggles, they often miss activities that they enjoy and may feel disconnected from their social circles. Feelings of loneliness and isolation may develop. As their illness progresses, individuals may require more assistance to perform tasks of daily living (e.g., showering, cooking, cleaning, shopping), which can lead to feelings of burdensomeness. As counselors, it is important to help these individuals find strong support networks and to provide psychoeducational information to the significant people in their lives. It is also crucial to assure these clients that they are resilient and have inherent value that is untouched by their illness.

Many individuals with chronic invisible illness are accurately diagnosed later in life. This fact illustrates how the course of chronic illness can impact the developmental process and quality of life at different stages. The diagnosis and ensuing disability can alter many of these individuals’ plans for the future, including college, career, family life and, at times, independence. This may cause them to redefine themselves within the scope of their chronic illness. Often, they must develop new roles in school, at work and within their families and friendships as they live within the confines of their health issues. As a result, their self-esteem and identity may be negatively impacted and must be addressed within the therapeutic context at different points in time.

This may be done by challenging negative self-talk, focusing on intrinsic motivation and using techniques such as radical acceptance, acceptance and commitment therapy, mindfulness-based stress reduction and a strengths-based, ecological perspective. By focusing on these individuals’ strengths, counselors may empower them to create new roles that will provide joy while also embracing the changes in their physical abilities.

In addition to the physiological changes that they are experiencing, clients who are chronically ill may simultaneously be going through the grief process. It is important for counselors to work with these clients to acknowledge the reality of the loss of their physicality, address feelings associated with their loss and help them to adjust to a new “normal.” Magical thinking often accompanies the process of grief and loss and occurs when an individual creates an improbable theory or belief system (often self-deprecating) around why a loss might have occurred. This often serves as an initial defense mechanism but can become detrimental over time. As a result, it is important for counselors to work with chronically ill patients to challenge any magical thinking that may be in place.

Finding normalcy after loss takes time. It is important to remind those with chronic invisible illnesses that there will be good days and bad days, while simultaneously working with them to instill hope for the future. Counselors can play a valuable role in helping people with chronic invisible illnesses to accept their physical limitations, while also empowering them to live rewarding and fulfilling lives.

 

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Cathy L. Pederson holds a doctorate in physiology and neurobiology. She is a professor of biology at Wittenberg University and is the founder of Standing Up to POTS (standinguptopots.org). Contact her at cpederson@wittenberg.edu.

Kathleen Gorman-Ezell holds a doctorate in social work. She is a licensed social worker and an assistant professor of social work at Ohio Dominican University. Contact her at gorma111wnek@ohiodominican.edu.

Greta Hochstetler Mayer holds a doctorate in counselor education and is a licensed professional counselor. She is CEO and initiated suicide prevention coalitions for the Mental Health & Recovery Board of Clark, Greene and Madison Counties in Ohio. Contact her at greta@mhrb.org.

 

Letters to the editor: ct@counseling.org

Counseling Today reviews unsolicited articles written by American Counseling Association members. To access writing guidelines and tips for having an article accepted for publication, go to ct.counseling.org/feedback.

 

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Related reading, from the Counseling Today archives: “The tangible effects of invisible illness” by Cathy L. Pederson and Greta Hochstetler Mayer

 

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