Grief while natural can go many different directions and become in some cases pathological. There are many unique singularities that can make one loss different than another and transverse normal and healthy trajectories into abnormal and pathological trajectories. Grief Counselors can play a key role in guiding clients and helping identify possible clues that can lead to complications in grief. While pastoral counselors who are grief certified can help those along normal trajectories, only licensed and clinical counselors can help those with complications.
Grief can become pathological. Please also review AIHCP’s Grief Counseling Certification
Please also review AIHCP’s Grief Counseling Certification and see if it matches your academic and professional goals. The program is online and independent study and open to qualified professionals seeking a four year certification in grief counseling. AIHCP certifies both clinical as well as pastoral professionals within the Human Service professions. as well as others within the healthcare fields.
Licensed counselors, Human Service professionals, and other specialized behavioral health therapists can help the bereaved through advanced therapies. Cognitive Behavioral Therapy or CBT is one such example, but there are other humanistic approaches that are also patient centered in design. Gestalt Therapy is one such humanistic approach that avoids psycho-analysis and looks to the present state of the person. It looks for the fullness and wholeness of the entirety of the person and issue instead of reviewing merely smaller parts. Designed by Fritz Perls. his wife, Laura Perls and John Goodman in the early 1940s, this approach helps individuals face and cope with emotion in the present moment (Good Therapy, 2018, p.1).
In regards to the bereaved, Gestalt can be an excellent way to help the grieving come more into contact with the emotions they are feeling in the present moment. It can help the depressed focus on the emotions of the now moment and help them find resolution and self-awareness about these feelings. This can usher forward a inner healing for some and help one find resolution with the present moment. The important theme of Gestalt Therapy is that it focuses on the now and how one is feeling in the moment not how one felt in the past or the issues of the past.
Gestalt Therapy
Gestalt focuses on the current emotional state of the client and emphasizes discussion of those emotions
Gestalt Therapy focuses on the now. This is one of its defining qualities. The counselor or therapist will help the client focus on what the client is experiencing in the moment and how to address those emotions in the now moment. This now moment involves a mind and body connection and an awareness within the body of these feelings (Lindsey, 2022). A strong counselor-client connection is important for the client to feel comfortable enough to identify these emotions and discuss them. Furthermore, the Gestalt has a strong phenomenological emphasis on experiencing the process of emotion itself and exploring and evaluating it within the session. This brings one closer to true feeling. Within Gestalt, one is not so much looking for change, but acceptance and understanding of self to better cope and push forward in a productive and non-maladaptive way.
Fritz Perls wished for clients to find more self-awareness of oneself. He hoped one to become more attune with one’s feelings and to better cope with them by identifying and feeling them (Guy-Evans, 2022). Gestalt pushes for the here and now of the moment. It emphasizes that the past cannot change, but the present exists now and can produce transformation. Hence, even past emotions are encouraged to be expressed in the present moment (Guy-Evans, 2023). By understanding the emotion now, one can conclude the unfinished business of the past.
Gestalt Techniques
Gestalt Therapists will utilize a variety of techniques to help the client experience present emotion. Many counselors encourage clients to utilize “I” statements. When discussing an emotion such as anger, instead of stating “they made me angry”, the counselor encourages the client to say “I feel angry when”. This again emphasizes the importance of individual emotion within the moment (Langmaid, 2024).
In addition to this, Gestalt therapists will identify various bodily manifestations correlated with emotion. A person may clench a fist, look downward, raise one’s voice, tap their foot against the ground, twitch, or frown. When these physical manifestations appear, the counselor will help the client identify these manifestations with the emotion felt. Counselors should encourage the client to exaggerate these manifestations during the session. This process in Gestalt is referred to as exaggeration (Good Therapy, 2018, p. 1). This will help clients become more aware of their emotions and how to better regulate them in the future.
The empty chair is perhaps the most famous Gestalt technique. It involves an empty chair where the client is able to speak to the person who is the source of the client’s frustration, abuse, or source of emotion. It could represent an abuser, ex spouse, deceased family member, or even be a conversation between the self (Guy-Evans, 2023). This permits the client to express present emotion but also allows the client to better understand that the power to heal does not depend upon another person but the power is within oneself.
Empathetic confrontation is sometimes a technique employed by therapists as well within Gestalt. This was more widely common in its earlier phases, but in recent times is not as employed. The purpose was to confront the false emotion or shield and help the true emotion to emerge.
Goals and Benefits of Gestalt Therapy
The primary goal of Gestalt is to help clients become more self aware of present emotion and how that emotion is affecting one’s life. It helps to push one to become more self aware and regulating of emotion and to find resolution by accepting the emotional reality that exists. This promotes responsibility on the part of the client to accept certain emotions and work through them.
Guy Evans lists these benefits from Gestalt
Improved sense of self-control
Increased awareness of needs
Improved ability to monitor and regulate emotions
Improved communication skills
Increased tolerance for negative emotions
Improved mindfulness
Increased emotional understanding
Improved ability to view things from another perspective
Increased self-esteem
Increased decision-making skills
Increased interpersonal skills
Increased empathy for others
(Guy-Evans, O. (2023). “Gestalt Therapy: Definition, Types, Techniques, And Efficacy”. Access here
Conclusion
Gestalt is another tool for the counselor. It does not necessarily work for everyone. It may need to be utilized with other therapies. In some cases, clients who wish for more structure, or wish to focus on the past, may find it unhelpful. While others who are still too traumatized by emotion, may find it disturbing. It can definitely bring up strong emotions, so it should only be utilized in a secure setting with a strong client/counselor relationship. Obviously, those who are only pastoral or only certified in grief counseling but lack a professional and clinical license in counseling should not utilize this therapy.
Please also review AIHCP’s Grief Counseling Certification and if it matches your academic and professional goals
For many though, it can help individuals find peace with the present moment and express emotion in a healthy and safe way. It can help a person transform and move beyond past negative emotions and find new resolutions in life to move beyond the pain. In grief, this is especially true. It can provide for the bereaved an outlet to express current emotion and also sort through feelings and emotions with the deceased.
Please also review the American Academy of Grief Counseling’s Grief Counseling Certification and see if it meets your academic and professional goals. The program is online and independent study and open to qualified professionals seeking a four year certification as a grief counselor.
Additional Resources
“Gestalt Therapy”. (2018). Good Therapy. Access here
Langmaid, S. (2024). “How Does Gestalt Therapy Work?” WebMD. Access here
Guy-Evans, O. (2023). “Gestalt Therapy: Definition, Types, Techniques, And Efficacy”. Simple Psychology. Access here
Lindsay, C. (2022). “All About Gestalt Therapy”. PsychCentral. Access here
When dealing with grief, individuals deal with the immediate emotions of the loss itself but at the same time, the pain of dealing with secondary losses. Unfortunately, life does not stop while grieving, so the dual process model addresses how a person faces both fronts of loss while grieving. One must face how one is dealing with one’s own pain as well as dealing with life itself.
Grief Counselors many times utilize the Dual Process Model to help others face grief and loss
The video below deals with the Dual Process Model and how grief counselors utilize it. Please also review AIHCP’s Grief Counseling Certification and see if it meets your academic and professional goals. The program is online and independent study and open to qualified professionals.
Grief is a universal and unbiased in who it afflicts. Unfortunately, children suffer in this fallen world of pain and loss. Throughout the world, children are plagued with horrible images that adults in many nations would never imagine. Children are victims of war, bombings, loss of family and many traumatic incidents. Children are abused in every corner of the world and face horrible trauma. Beyond the most traumatic events, children experience loss at early ages. The loss of a grandparent, or family member, or even a beloved pet. No loss is too small for a child.
Licensed counselors who specialize in children psychology and have training in Play Therapy can help children face trauma, grief and loss. In addition, many licensed professionals and human service professionals earn additional certifications to help children. Some may even specialize in Child and Adolescent Grief Counseling and have a greater understanding of children and the nature of loss. Licensed professionals with specialties and additional training certificates can help children process emotional pain because they are trained to identify and communicate to children. Play Therapy is one type of advanced counseling technique that counselors can utilize to help children.
Children express themselves in play. Please also review AIHCP’s Child and Adolescent Grief Counseling Certification
Children grieve differently from adults due to their brain development. Many children are so young that many communicate skills have yet to develop. Children sometimes do not know how to say what emotionally hurts or what is bothering them because they do not know how to articulate it. Children are more right brain developed and many of the feelings, traumas and losses associated with them are experienced in the lower areas of the brain. The Amygdala, Hippocampus, and Thalamus are non-verbal areas of the brain and with children, one must engage in non-verbal ways. In addition, while children have billions of brain cells still forming and becoming more complex within their first five years, these neural pathways are still not complex enough to effectively communicate. The Pre-Frontal Cortex of the adult brain possesses the ability to better communicate, while the child’s less developed area to communicate still needs time. Hence counselors who deal with children, utilize a variety of non-verbal ways to help the child express. Understanding that communication and judgement are operations of the higher parts of the brain, counselors look for signs from the lower areas of the brain that are more primal in expression.
It is because children have less verbal communicate abilities that counselors must look for visible manifestations of emotion within children which can be displayed during play. Among the most common types of physical signs of emotional distress in children, Melinda points out tension, fidgeting, repetitive movements, aggression, self harm, low energy, increased heart rate, hyperactivity, somatic pains, and rapid breathing as things to watch for with children as a way they express emotional distress (2018). These types of physical signs can manifest in counseling, play therapy, or at school or home in children experiencing emotional issues. Many children brought to therapy are already manifesting various social outbursts or behavioral issues that are merely ways of attempting to express difficult emotions due to loss, trauma, or grief.
Play Therapy and Grief
Alan Wolfelt points out that helping children grieve is not just about therapy but is a companioning experience that involves actively participating in the child’s healing (p.1, 2012). Play Therapy involves actively entering into the child’s world, earning the child’s trust, creating a safe place for the child to express in his/her own way and being able to translate those expressions and help the child heal.
Play Therapy owes its origin to Hermine Hug-Helmuth who in 1921, first introduced ideas of allowing children to express themselves in play with toys and other games. Melanie Klein, as well, was a pioneer in the field who discovered that play was a doorway into the child’s subconscious mind. Later in 1938, David Levy would utilize toys and other objects chosen by the child as a way to identify past trauma and relive the traumatic event via play. This became known as Release Therapy. Joseph Solomon employed Active Play as a way to allow children to express emotions such as a fear and anger in a controlled way to help them become more able to interact later socially
Counselors utilize Play Therapy as a way to be build relationship with the child to earn a way into their inner mind according to Anna Freud. Carl Rogers also saw Play Therapy as a way to center the therapy around the needs of the child and build genuine and trustful relationships. These are all critical elements in helping the child express. It is time consuming but necessary to help the child trust and be able to learn the language of the child during play.
Play Therapy helps the counselor understand the language of the child
During Play Therapy, the counselor wants to give the child controlled freedom. The child is allowed to choose the toys in the room or games. The counselor does not look to push serious questions but instead observes and plays with the child. Usually sitting at eye level with the child, the counselor will ask the child about the toys or games the child likes and enjoys. Many times, the counselor will reflect and repeat what the child says and encourage the child to name the toys and express how the toys make them feel. To the foreign eye, it may seem as nothing is occurring but the counselor is attempting to not only gain trust, but is also engaging the child at symbolic and non-verbal way looking for cues of the child’s behavior. In other ways, the counselor is attempting to help the child better express verbally by granting the child freedom of labeling and naming toys. Some counselors may approach with a more directly with more interaction, while others may be less direct.
The room itself is a play room with numerous options for the child to choose from. This includes miniature figures, dolls, doll houses, stuffed animals, puppets, legos, building materials, and other sporting equipment. The toys are a doorway to the child’s symbolic mind and help facilitate healthy expression. Counselors may utilize other ways to express and open creative mindsets through songs and music, story telling or through uses of art, drawing, clay and painting. The key is to help the child tell his/her story, find healing, and discover other ways to find outlets and creative ways to express and rediscover oneself.
Some children who may be grieving, may use dolls or action figures as a way to reflect the life of family members around them. This symbolic expression correlates with their inability to express verbally but through play and expression instead. A child who may be experiencing grief over the loss of a family member, may play out death with a doll or action figure. In addition, certain toys or games or songs may trigger within the child physical symptoms of discomfort that the counselor may identify and notate. During certain activities, children may share information that otherwise would never emerge in an adult conversation.
Conclusion
All people grieve and children are no exception. When children are emotionally hurting, they sometimes do not act logically. To help children grieve and express emotion, counselors need to understand the language of the child. Due to brain development that is not as verbal in children, Child Grief Counselors need to understand the symptoms of emotional distress in children via Play Therapy. Play Therapy helps the child find safety and trust in expressing issues in the child’s own special way during play. Child Grief Counselors who specialize in Play Therapy can help children heal during play by allowing them to express in conducive and healthy ways.
Please also review AIHCP’s Grief Counseling and Child and Adolescent Grief Counseling Certifications and see if it matches your academic and professional goals
AIHCP offers a specialty certification in Child and Adolescent Grief Counseling for the American Academy of Grief Counseling’s certified Grief Counselors. This certification trains and educates Grief Counselors in the knowledge of grief in children. While pastoral and non licensed counselors can help individuals with grief, only licensed counselors with grief background, child psychology and training in Play Therapy are permitted to treat children suffering from emotional damage. Pastoral counselors trained in Grief Counseling and Child Grief Counseling, if not licensed, should refer children to clinical professionals with Play Therapy training.
AIHCP’s Child and Adolescent Grief Counseling Certification is online and independent study and open to qualified pastoral and clinical human service professionals, as well as those in the healthcare fields.
References and Additional Resources
Wolfelt, A. (2012). “Companioning the Grieving Child”. Companion Press
Cognitive Behavioral Therapy or CBT can help the bereaved reassess and reframe negative schemas or feelings surrounding the loss. Clinical counselors can help individuals via CBT to correct and reframe the ideas the bereaved shares and properly understand the loss. If someone is angry or experiencing unneeded guilt, the counselor can help the individual see the situation in a different light. CBT can also help the person face these negative feelings and express them so that they can be properly understood and interpreted.
CBT can be a very useful therapy in grief counseling. Please also review AIHCP’s Grief Counseling Certification
Pastoral counselors or limited in grief therapy and CBT is reserved for grief counselors who are clinical in practice, but pastoral counselor can use aspects of CBT to help the bereaved understand grief that is following normal trajectories.
Please also review AIHCP’s Grief Counseling Certification and see if it matches your academic and professional goals. The program is online and independent study and open to qualified professionals seeking a four year certification in grief counseling. The program is open to both pastoral and clinical counselors or those in the Human Service and Healthcare fields.
Carl Rogers, the famous psychologist and counselor, in the 1950s presented a far different approach than past Freudian psychological views that emphasized psycho-analysis and subconscious treatments. Like others, he wanted to approach counseling and the patient differently. He emphasized a more Humanistic approach that involved patient or client-centered therapies that addressed the feelings that existed now within the client. In an earlier blog, AIHCP discusses in a broader stroke the Humanistic approach to grief and counseling, but in this short blog, we will instead focus more solely on Rogerian concepts in helping individuals express feelings, in particular feelings associated with depression. Please also review AIHCP’s numerous counseling certifications for Human Service professionals.
Rogerian Theory
While Cognitive Behavioral Therapy looks to restructure and reframe illogical and negative emotional schemas with healthy and positive thoughts to alter behavior, Rogerian approaches look to address the the feelings of the client him/herself with unconditional love, genuineness, empathy and support. It looks to transform and strengthen the person. The term “client” is utilized instead of “patient” to remove stigmas that the person is sick or ill but merely needs love and guidance for life altering change. The counselor guides the client but the client ultimately has more control in the sessions and is able to express and discuss his/her feelings within a far less structured environment. Narrative is key. The counselor does not look to confront, but to listen.
Rogerian approaches in counseling are client centered and focuses in an empathetic and non-judgmental way the feelings of the client. Please also review AIHCP’s Grief Counseling Certification
Roger’s goal was to help the client reach self-actualization of what the person can become through a process of helping the client see him/herself as he/she is, wishes to be and how to become. Within this, a client learns to discover one’s self worth. The counselor also helps the client distinguish between self image and real image and how to reach the ideal image. When dealing with many individuals suffering with depression, self worth is something that is greatly damaged. Many depressed individuals feel they have very little worth or value. Whether this is due to something that occurred or merely depression without correlation to direct loss, the person feels a blanket of darkness over him/herself. Allowing the client to express these emotions, both positive and negative are key in Rogerian approaches. The counselor listens to these concerns with congruence and empathy, allowing the client to express and discuss the sadness and low self worth. The counselor helps the client direct the session into accurately describing how he/she feels and also views oneself. Many who are depressed also possess a very low self image. In many cases, this self image is not properly balanced with reality. Various distortions will emerge that are tied to the person’s feelings. It is not necessarily the role of the Rogerian approach to reframe these immediate concerns as in CBT, but to help the client understand the feelings and empathetically listen and restate these feelings to help the client re-discover where this false self image and true image lie. The counselor’s ultimate goal is help the client find a genuine understanding of his/her real self despite feelings. The counselor then looks to help the client find the ideal self. In this way, one’s self image and ideal self can become congruent and tied together.
Once congruence is established where the depressed individual is able to find self image and ideal image as a true reality, Rogers speaks of the possibility of self actualization where the person is able to thrive and exist again in an emotionally healthy way. Rogers listed five particular qualities of a fully functioning person who has tied self image and ideal together via self actualization. First, he pointed out that the person is open again to new experiences. Many depressed individuals are afraid to move on or seek out new things. A healthy functioning individual is able to seek out and find new meanings through new experiences. Second, Rogers spoke of existential living, where the person lives in the present and is able to experience the present in new fresh ways without prejudice or fear of the past. Many times, depressed individuals cannot untie themselves from the past and are unable to experience the present. Third, Rogers remarked that those who are functioning at a healthy level trust their feelings. Individuals are able to make decisions with certitude without doubt and not second guess oneself. Depressed individuals usually labor with decisions and fear what others may think or if they may fail. Fourth, Rogers pointed out that individuals should be creative without fear and able to move forward and share thoughts and ideas without fear of fallout from others. Depressed individuals lack the confidence to create or stand out. Finally, Rogers illustrated the idea of a fulfilled life where an individual is able to live life to its fullest. The person is able to find satisfaction in decisions, goals and challenges. Depressed individuals are unable to find joy in little things, much less have the energy for goals or the ability to face challenges.
These five qualities of a fully functional person are critical to overcoming the depressed state. When individuals are able to express these points within life, then they are again functional and free of the dark grip of depression. We will now in the next half of the blog look at how to implement Rogerian concepts and put them into practice. This will involve reviewing and understanding the basics of client-centered attending and responding skills.
Rogerian Practice
It is once congruence occurs and emotions are faced that the client is able to reach this type of fulfillment. The long process of helping the client discover this congruence and self-actualization is the key . While those who study the Rogerian approach understand the theory, it is the practical approach from person to person that is key.
Attending and Responding Skills are imperative in Rogerian Counseling. Please also review AIHCP’s Grief Counseling Certification
The counselor within the Rogerian approach utilizes a variety of micro counseling skills discussed in previous AIHCP blogs. Within Rogerian practice, basic attending skills are critical in helping the client discuss emotions and properly relate those emotions back. The counselor attends the client with empathetic listening. Rogers believed that genuine and empathetic listening was the first key in learning the story of the client. This involved active and intense focus on the client. The counselor should not only listen but show intense interest via eye contact, gestures, and physical positioning. In regards to response, the counselor looks not to judge the feelings of the client, but instead to restate or paraphrase them to the client. This helps the client not only understand that the counselor is listening but also to hear these feelings out loud. Sometimes, speaking about negative feelings also needs hearing them back to begin to decipher the false reality of those negative feelings. In essence, the empathetic approach of active listening and responding creates not only trust between client and counselor but also creates a safe zone where the client is able to fully express inner feelings. The counselor helps create this environment through multiple sessions and active and empathetic support for the client. The client feels he/she exists in a safe zone where no judgement or confrontation exists. It allows the client to take center stage and control and with the help of the counselor, unravel the negative emotions and find the real and possible ideal self that depression has hidden from the client. Rogers refers to this type of empathetic environment as one of unconditional love. It is place where feelings are not questioned or given positive or negative value, but only spoken about and understood within the context of the session. The counselor helps foster this environment because the counselor is not judging or giving qualitive value to the feelings. Instead the counselor is allowing the client to direct and discover value to the feelings.
Hence, how the counselor presents him/herself, listens, responds and creates a safe environment is critical to the success of Rogerian approaches. While the practice itself takes more time, seems unstructured, and is more about the now of emotion, it does have success with many patients facing depression and negative emotions. Obviously, sometimes supplemental approaches may be need introduced, as well as pharmaceutical remedies when issues beyond behavior exist such as neurological or hormonal, but overall, Rogerian approaches are very common place in counseling. The humanistic approach is very classical and non evasive for many individuals with already low self esteem issues that feel an abundance of negative emotions.
Those facing loss and depression need an empathetic ear and voice to help them heal. The emotional release and discussion of issues is a key part of grief healing. Through these discussions and release of emotions, the client can begin much of the grief work required that goes through the various emotional stages of denial, emotion, anger, and bargaining. The grief counselor utilizing Rogerian approaches will be able to listen as the person works through his/her grief and also notate any maladaptive emotions such as guilt that may appear. Through a non judgement zone, the counselor will be able to help the person come to grips with these emotions and help the person self-actualize beyond the loss or depression and find new hope.
Conclusion
Rogers client-centered care in the 1950s revolutionized counseling and forever changed how counselors approached clients. Humanistic approaches are in many ways the classical counseling sessions that individuals imagine where one speaks of feelings and the counselor paraphrases and asks how this makes one feel? It directly and openly deals with emotion without judgement and with complete empathy. This is a very important aspect to consider when dealing with depressed populations who may not be ready to deal with confrontations in counseling or face fast changes. Instead, the Rogerian approach gives the client control to discuss feelings and work them out. It slowly helps the client sort out negative feelings and replace them with positive vibes. The key is to help the client move forward in a productive and healthy life style that is congruent and true to self.
The counselor utilizes different micro counseling skills. The counselor refrains from direct reframing, or empathetic confrontations that may upset the client. Instead the counselor becomes more passive in direction and gently moves the client through good attending and responding skills that create a safe and no judgement zone. Depressed individuals, especially, need this type of environment to regain their voice and ability to move forward.
Please also review AIHCP’s numerous Human Service related certifications in counseling ranging from just not grief but also from stress to anger and crisis to spiritual counseling
Ultimately, as counseling continues, different techniques may need added to fit particular clients, or maybe even the necessity of medication, but overall, the initial Rogerian approaches will help the client feel safe and help form a strong bond between counselor and client.
If you would like to learn more about grief counseling, then please review the American Academy of Grief Counseling’s certification program in Grief Counseling. The program is online and independent study and open to qualified professionals seeking a four year certification as a grief counselor. AIHCP certified both pastoral counselors as well as clinical counselors. Bear in mind, certified grief counselors who are not licensed or clinical do face restrictions in what therapies they may utilize as well as treating complicated versions of grief that lead down trajectories that include depression.
AIHCP also offers a broad range of other Human Service counseling certifications that revolve around Anger Management, Crisis Intervention, Stress Management and both Spiritual Counseling and Christian Counseling.
References and Additional Resources
Mcleod, S. (2024). “Carl Rogers Humanistic Theory And Contribution To Psychology”. Simple Psychology. Access here
Bottaro, A. (2024). “Everything to Know About Person-Centered Therapy”. Very Well Health. Access here
Joseph, S. (2015). “Carl Rogers’ Person-Centered Approach”. Psychology Today. Access here
Hopper, E. (2018). “An Introduction to Rogerian Therapy”. Thoughtco. Access here
Miller, K. (2019). “Carl Rogers’s Actualizing Tendency: Your Ultimate Guide”. Positive Psychology. Access here
Counseling is about the person and the person’s story. Like so many things in life, everything is not usually black and white. There are a variety of shades of color from multiple perspectives in life that can make the story of the client incomplete. For starters, the client has his/her own subjective experience with the events within the story. The unique experience of the client may very well be true from the client’s point of view due to the subjective factors and information available. In addition, the client may possess a variety of blinders to certain truths that may be painful to accept or realize. In other cases, the client may have various personality disorders that completely distort the reality of the events. Whether purposeful or not, these distortions can cause larger issues in the healing, changing and transformational process.
Counselor help clients tell their story but also help them see the real story and how to find the right story
Throughout the blogs on counseling techniques, we have discussed numerous skills a counselor must utilize to help a client find change. This blog will bring many of these skills together in helping forge the client’s initial story into the real and right story (Egan, 2019, p. 270). Egan guides the counselor in addressing the story told, but also how to help push the client forward into telling the real and right story. This helps the client enter into a state of self discovery so that as the story progresses, the client not only heals but also changes and transforms with the reality of the story.
Of course, as a counselor, one cannot make a client change, nor can a counselor sometimes ruthlessly correct or tell a client he/she is wrong. The skills of counseling help the counselor with empathy and patience, gently nudge and guide the client to truth and help the client choose to pursue that truth. This stems first by forming a strong relationship of trust with the client. It involves basic attending skills of empathetic listening, observing and responding to help understand the client and better address the issues. Through empathetic listening and excellent observations, one can begin to see if any discrepancies exist within the story and how to better empathetically confront the client to recognizing the real story and then challenging the client to the right story and course of action, all the while, supplying the client with resources and encouragement to move forward.
The Story
Egan emphasizes that when helping the client tell the story that the counselor needs to make the client feel safe in the encounter. Egan also encourages counselors to understand the styles between different cultures and how different cultures may express stories. Some clients divulge and talk, others are more quiet, while others supply numerous details and others are vague. Some clients may tell the core of the story and leave out secondary issues, while others may approach the story the opposite direction. Some clients may go off topic, while others may stay on topic (Egan, 2019, p. 274-275). This is why it is important to identify what is going on or what the client is feeling at the moment, identify what the client wants and how to get what the client needs. In this regard, counselors can help clients identify key issues and help them discuss the past but in a productive way that helps the past not define them but help them learn (Egan, 2019, p. 181). Egan also points out it is imperative to identify the severity of the initial story. Will this client need basic counseling or require crisis counseling? Clinical counselors may be able to better handle the issue presented or see the need for a specialist. Pastoral counselors dealing with issues beyond basic loss and grief, may identify something more severe and need to refer the client to a clinical counselor.
Sometimes when helping a client tell their story, it can also be useful to utilize Narrative Therapy which helps differentiate the person from the issues. At the end of the blog, there are links to better understand Narrative Therapy and its role in telling the story.
The Real Story
After identifying the key elements of the story, counselors can help clients start to see the real story by exposing with empathy any discrepancies or any blinders a client may possess. Through empathetic confrontation, a counselor can help a client see both sides or different angles to the story that the client may not had seen initially. In this way, the counselor challenges the client in the quality of their perception and participation in the story (Egan, 2019, p. 289). In dealing with the real story, Egan also points out that counselors can help clients understand their own problems and be better equipped to own their own problems and unused opportunities. When a client is gently nudged to the realities of the real story, a counselor can help the client see that the real issue is not impossible to rectify and begin to present problem maintenance structures which help clients identify, explore and act properly with their real issues (Egan, 2019,p. 292). Challenging and encouraging like a coach, can help clients move forward to begin to make the right story in their life.
The Right Story
In telling the right story, the client is pushed to new directions. The client no longer denies the need to change, but has to some extent acknowledged it. In previous blogs, we discuss issues that correlate with change in a client. When the client is ready to change, the client still requires guidance and help. The counselor helps the client choose various issues that will make a true difference in his/her life. When looking at these issues, the counselor helps the client set goals. The goals should be manageable at first and lead to bigger things but only after smaller steps to avoid let down. The counselor can help the client choose from various options and cost benefits, as well as helping the client make proper choices (Egan, 2019, p. 299-301). The counselor, like a coach, helps the client push forward and improve in life. Within the phase of telling the right story, the counselor helps the client with goals but also helps the client see the impact new goals can give to life as well as the needed commitment to those goals to ensure a continued transformation. In previous blogs, we discuss the importance of helping clients face change and develop goals. In essence, goals are developed and strategies are conceived to meet those goals
Stages of Change
Throughout the process, Egan points out that the process involves three stages. First, telling the story so that it transforms into the real and right one. Second, helping the client design and set forth problem managing goals and third and finally, setting into motion those plans with strategies (Egan, 2019). These phases involve various skillsets that the counselor must employ at different phases and stages. It involves the counselor being a listener, advisor, encourager and coach. The counselor applies basic attending skills, in previous blogs, and utilize those attending skills in productive responses and when necessary confrontations. Everything is accomplished with empathy and patience but the skills, built upon trust, allow the counselor to awaken the client to new realities. Following these earlier discussions, the counselor becomes and advisor and coach in helping the client find ways to change and implement new goals and strategies. The counselor uses encouragement skills, coaching skills, and directive skills to help the client discover the power to choose wisely and act in a more healthy fashion. Ultimately it is about the client discovering his/her own inner abilities to not only change but to sustain change.
Conclusion
No client is the same and many will have different innate virtues or vices, talents or deficiencies, strengths or weaknesses. It is up to the counselor to help cultivate what is best in the client and help the client become his/her very best. Through individual skills, the counselor can help within each session, but the counselor must try and fail with multiple different theories and therapies that work best for his/her client. This involves realizing that each case is unique and different people will respond differently to different practices or approaches. A counselor must forever remain creative and flexible in approaches and adhere to the standards of empathy which helps establish trust with clients.
Counselors play the role of listener, advisor and coach. Please also review AIHCP’s numerous mental healthcare certifications for Human Service and Healthcare professionals
A counselor can utilize a basic structure of identifying the problem, helping the client see where he/she wishes to be and help the client find ways to do it. This involves working the client through the story and helping them see the real and right story moving forward. It involves then goal setting and moving forward with action. It makes the counselor more than a listener and advisor but also a coach.
Please also review AIHCP’s numerous counseling programs for those in the Human Service and Healthcare fields. While clinical counselors have more ability to help clients deeper with issues, pastoral counselors in Human Service can also help. This is why AIHCP offers these certifications to both clinical and non clinical Human Service professionals. The programs in mental health include a Grief Counseling Certification, as well as a Christian Counseling Certification, Crisis Counseling Certification, Stress Management Consulting Certification and Anger Management Specialist Certification. The programs themselves are online and independent study and open to qualified professionals seeking a four year certification. Please review AIHCP’s numerous certification programs.
Reference
Egan, G. and Reese, R. (2019). “The Skilled Helper: A Problem Management and Opportunity-Development Approach to Helping” (11th Ed.) Cengage.
Additional Resources
Ackerman, C. (2017). “19 Best Narrative Therapy Techniques & Worksheets”. Positive Psychology. Access here
Bates, D. (2022). “Storytelling in Counseling Is Often the Key to Successful Outcomes”. Psychotherapy.net. Access here
Guy Evans, O. (2023). “Narrative Therapy: Definition, Techniques & Interventions”. Simply Psychology. Access here
“Narrative Therapy”. Psychology Today. Access here
Mental Health should receive the same care as physical health. Please also review AIHCP’s numerous healthcare based certifications
Mental health is health. Too many stigmas exist that prevent individuals from seeking help when signs of mental illness occur. Unlike physical symptoms of sickness that are addressed immediately, mental illness falls to the side due to stigmas and embarrassment. It is important to notice changes in emotional and mental health that persists longer than 2 weeks. Many minor things as OCD, ADHD, or minor stress and depression issues can be resolved through professional care.
Please also review AIHCP’s numerous mental health certifications within Grief Counseling, Crisis Counseling Spiritual/Christian Counseling, Anger Management and Stress Management Programs. The programs are online and independent study and open to qualified professionals. Remember only those within the clinical side of Human Services can treat mental illness. Pastoral counselors can refer or help others in non pathological issues.
When clients experience stress, grief or loss, sometimes meaning is critical to understand. The emotions and feelings need to find meaning in relation to the issue. Counselors need to have the helping skills to aid the client in finding meaning again. This is essential especially in Grief Counseling. In grief and loss, the individual needs to find meaning in the loss and be able to connect the past with the present to move forward to the future. New meanings in relationship to the loss help the person connect the dots and knit together the chapters of life into a logical story. When meaning is not found and emotions rage without direction, then the stressor or loss can lead to grief pathologies of depression or prolonged grief. Hence it is important for the counselor to be able to navigate the person through the emotion and find meaning. This is more than understanding the process of grief and loss, or dealing with stress, but also being able to help the client find meaning through good counseling techniques that help the client find meaning.
In previous blogs, we discussed the importance of meaning re-construction, as well as Cognitive Behavioral Therapy or CBT, as key ways to help clients tie together pass loss or trauma to the present to move forward. In this blog we will focus more on the micro skills and probing that is necessary to help clients find meaning via interaction, reframing and interpretation skills, and how to relate to the client. Obviously, many of the other micro skills of attending the client, observation, focusing, responding, challenging and confronting are all implied within this blog and found in other previous blogs.
Please also review AIHCP’s multiple counseling blogs as well as certification programs in Grief Counseling, Stress Management, Crisis Intervention or Christian and Spiritual Counseling.
The Importance of Meaning
Finding meaning is critical to life. When bad things happen, counselors can help clients discover meaning
Meaning is essential to human existence. This is why it is so important for individuals suffering from trauma, or abuse, or loss, or any situation to find meaning in their situation. Sometimes it involves regaining it because it has been taken away, other times, it is discovering it for the first time.
Logotherapy is a type psychotherapy that helps individuals find meaning. It is based off Victor Frankl, the famous Holocaust survivor, who utilized meaning in life, even in its darkest hours, as a prisoner in a Nazi camp, to find hope. Frankly administered to many of his fellow prisoners and helped them find also meaning despite the evil and trauma and abuse that surrounded them under Nazi rule.
Frankly believed everyone had a will to meaning. This meaning is what pushes all in will and action and even helps one endure suffering and pain. These beliefs persist in the value and uniqueness of each human person. It also is a platform for a person to move forward in life. This has numerous applications in counseling and helping others. It involves understanding purpose in life despite pain, but the importance to define and push forward. It involves understanding that life is far from fair but one can still find meaning through it. Purpose is beyond bad things (Waters, E., 2019).
Frankly summarized his philosophy in six basic tenets. Humanity is comprised of mind, body and soul but it is through the soul that we experience and find meaning. He continued that life has meaning in all circumstances, good or bad. He stated as well that humans have a will to meaning that pushes them. He also listed humans also have freedom to access this meaning no matter the situation. He stated in addition that true meaning is not merely an statement but something concrete that correlates with life and one’s values and beliefs. Finally, he emphasized that all human beings are unique (Waters, E., 2019).
From Frankl and his classic work, “Man’s Search for Meaning”, counselors, but especially grief counselors have an excellent way to help reconstruct meaning to clients and cultivate true change in a client’s life.
Obviously, much of the work associated with David Neimeyer and meaning reconstruction are found from the ideas of Frankl.. Meaning helps tie together past, present and future into something that matters to the individual. It helps make sense of the loss and allows the chapters of one’s life, even the bad ones, to have meaning to the overall story and book. Obviously, counselors play a key role in helping clients evolve the story told initially into telling the right story that correlates with reality. This involves intense counseling and sorting out feelings, but eventually these feelings can lead to a true meaning. Reflecting and reframing are keys in achieving this for a client.
Reflection
When individuals are discussing feelings and emotions, it is essential eventually, not initially, to guide them to meaning. In the very beginning, it is important to allow raw emotion to be expressed, felt and processed, but it needs to eventually find meaning within the grieving process. Counselors can help clients reflect on the emotion. Ivey refers to the term “reflection on meaning” as a way to help clients find deeper understanding regarding issues, purpose, feelings and behaviors (2018, p. 258). Ivey also points to the importance of interpreting and reframing these feelings. Interpretation helps the clients understand their feelings and add meaning to them through a variety of perspectives or multicultural or psychodynamic ways. The client is able to find new meaning, while the counselor provides the necessary reframing to explore new interpretations (2018, p. 258).
The counselor through reframing, can with empathy begin to offer different interpretations of the event itself, One skill a counselor can utilize is linking. Linking helps the client tie together two or more things that enables them to find new insight (Ivey, 2018, P. 265). A counselor can tie family history, values and talents to the client in relationship to the issue, or tie the event to psychodynamic issues that exist within the client. The linking helps the client find new perspectives on the issue at hand.
Counselors can help clients link and find self discovery through a variety of approaches. Some counselors may utilize decisional theory that presents outcomes and alternatives for action. Decisions need to be understood and made with the client understanding outcomes (Ivey, 2018, p. 268). Another approach is person centered. Linking is utilized to tie the problem together with the person’s strengths. CBT is another way to help individuals review old ways of thinking, acting and behaviors and re-interpret them. Reframing and linking can also be utilized with psycho-dynamic theories that help the person understand the person’s deeper subconscious past. Finally, multicultural therapy can help a person link to and also reframe an issue with ones’ own ethnic and cultural backgrounds
Reframing
A counselor’s response is key in helping one reframe and interpret meaning. In previous blogs, we discussed first attending the client, with basic responses, such as paraphrasing or summaries. How one reflects how one feels helps open new dialogue and understanding. Other ways to help discuss emotions and help build meaning and cultivation to change involves disclosures, feedback and consequences.
Counselors can help clients reframe and reinterpret events and emotions and help them find new meanings moving forward
Disclosures are excellent ways to involve oneself by sharing an appropriate story of one’s own life, but usually it involves oneself utilizing the phrase ” I think or I feel” in relationship to one’s issue or feeling or intended action. Feedback is also critical in cultivating change. It can be confirmatory or corrective. When corrective, it looks to help align a person back on track. It involves empathy and nonjudgment when being applied but helps the client again find the proper perspective and route. Remember, the client remains in charge and review how the client responds. Empathetic confrontational approaches should be utilized. Finally, logical consequences can be employed to help a client. It summarizes the possible positive and negative consequences of a particular action. The common phase includes “If you do…then…will possible result” (Ivey, 2018. p. 302).
Employing psychoeducation and instruction is also a key way to help push individuals to change and reframing. By making the client understand the science and philosophy of their feelings, one can better take ownership to change.
Whatever link the counselor can utilize through whichever therapy, or phrasing is good. Each individual is different. The key is to help the person find a new perspective on the emotion, situation, stressor or loss. This enables the person to form a new meaning which can help them tie the past with the present and into the future.
Fostering Resiliency
Through any change and new discovery, counselors need to foster resiliency. This helps the person emotionally and physically push forward into the new change and maintain the new meaning he/she has found. This can be accomplished through a multitude of stress management techniques that involves multicultural approaches, psychoeducation, social skill training, assertiveness training, conflict resolution, bio or neurofeedback, positive reframing, CBT, time management, relaxation management and active planning techniques (Ivey, 2018, p. 288). Ivey also lists the importance of Seven Therapeutic Lifestyle Changes. He includes exercise, nutrition, sleep, social relations, cognitive challenges, meditation and cultural health. Within these, he also lists the importance of prayer, hobbies, positive thinking, social outreach and avoidance of negative substances (2019, p. 288).
Egan, emphasizes that in cultivating change, counselors need to help client discover their own resilience. Egan points out the difference between process resilience and outcome resilience. In counseling, the counselor should be able to encourage clients to change in face of challenges, but also note outcomes. With outcome resilience, the counselor comments on the change and how one has returned to one’s own self (Egan, 2019, p. 263). Like a coach, the counselor hence cheers the person’s progress and ability to overcome. Counselors need to also help clients identify resources for resiliency, within family, friends or other social support systems. A counselor should help a client find ways to make better connections with families and friends as well. In pushing forward, a counselor can help a person reframe issues, such as challenges or crisis as ways to grow and to understand that change is part of life (Egan, 2019, p. 265). A client must continue, especially after loss, or trauma, to continue to keep things in perspective, maintain a healthy outlook, find new ways for self discovery and maintain care of oneself (Egan, 2019, p.265). A counselor can help a person maintain this progress.
Recall also, the previous blog which discusses the change scale in clients and how it is essential that the counselor discovers the level of acknowledgement and commitment to change a client may possess, as well as helping the client implement first order or second order changes depending on their situation. The counselor can help the client with goals to implement the change and also be aware of possible setbacks and pitfalls.
Conclusion
Please also review AIHCP’s multiple mental health certifications, including AIHCP’s Grief Counseling Certification
In helping clients change, reflection and reframing are key in helping the client link and find meaning in the trauma or loss. As time progresses, the client will be able to find meaning and connect the incident into one’s life narrative. Counselors can help this transition through a variety of skills mentioned in this blog and throughout other blogs written for AIHCP. These skills help the client understand the emotion and find linking to it. This helps them discover new meaning and ways to reinterpret the event. Furthermore the counselor helps the client move forward by fostering resiliency and helping the client continue to move forward.
Please also review AIHCP’s various mental health certifications. These certifications are granted to professionals in the health care field and human service field. Some may be licensed professionals while others may be pastoral in nature. Obviously such licensures or lack of, grant or prohibit the extent of certain counseling therapies and techniques.
AIHCP’s programs include Grief Counseling, Crisis Counseling, Stress Management Consulting, Anger Management Consulting and also Christian Counseling and Spiritual Counseling. The programs are online and independent study.
References
Egan, G. & Reese. R. (2019).”The Skilled Helper: A Problem Management and Opportunity-Development Approach to Helping” (11th Ed). Cengage
Ivey, A. et, al. “Intentional Interviewing and Counseling: Facilitating Client Development in a Multicultural Society” (9th Ed( (2018). Cengage.
Additional Resources
Morin, A. (2023). “How Cognitive Reframing Works”. Very Well Mind. Access here
Caraballo, J. (2018). “Reframing is Therapy’s Most Effective Tool, Here’s Why”. TalkSpace. Access here
Ackerman, C. (2018). “Cognitive Restructuring Techniques for Reframing Thoughts”. Positive Psychology. Access here
Waters, E. (2019). “Logotherapy: How to Find More Meaning in Your Life”. PsychCentral. Access here
Treatment Resistant Depression can make one lose hope. Please also review AIHCP’s Grief Counseling Certification
Depression, a debilitating mental health condition, significantly impacts the lives of millions worldwide. Among its most challenging forms is resistant treatment depression, where patients do not respond to traditional therapies. This complexity underscores the critical need for a deeper understanding of treatment resistant depression treatment options, guiding patients towards improved mental health outcomes. As the prevalence of this condition poses significant challenges to both patients and healthcare providers, exploring innovative methods and therapies becomes imperative.
The subsequent discussion in this article aims to shed light on various facets of resistant treatment depression, starting with a thorough understanding of what characterizes treatment-resistant depression and how it can be identified. It will delve into the risk factors associated with the development of this form of depression and examine both medication options and non-medication therapies and interventions. Furthermore, the role of psychotherapy in managing resistant treatment depression will be highlighted, alongside innovative and experimental treatments that hold promise for those affected. Lastly, the creation of personalized treatment plans will be discussed, emphasizing the tailored approach required to address the unique needs of each individual facing resistant treatment depression. This comprehensive exploration aims to equip readers with the knowledge to navigate the complexities of treatment-resistant depression treatment, advocating for a proactive and informed approach to mental health care.
Key Takeaways
Treatment-resistant depression (TRD) occurs when at least two different antidepressants fail to improve symptoms.
TRD affects about 30% of individuals with major depressive disorder.
There are multiple treatment strategies for TRD, including optimization, switching, combination, augmentation, and somatic therapies.
Non-pharmacological treatments such as psychotherapy, electroconvulsive therapy (ECT), and transcranial magnetic stimulation (TMS) can be effective.
Early diagnosis and personalized treatment plans are crucial for managing TRD effectively.
Also, please feel free to review AIHCP’s Grief Counseling Certification and see if it meets your academic and professional goals.
Understanding Treatment-Resistant Depression
Definition and Overview
Treatment-resistant depression (TRD) is a subtype of major depressive disorder (MDD) characterized by inadequate response to standard antidepressant therapies. Patients with TRD have undergone at least two different first-line antidepressant treatments without sufficient relief during a depressive episode. This condition is not only prevalent but also poses significant challenges in mental health care, affecting approximately 30% of individuals diagnosed with MDD. TRD often requires a comprehensive evaluation to understand the underlying factors contributing to its persistence. This may include reviewing the patient’s medical history, current medications, and adherence to prescribed treatments. Specialists might also explore other mental health conditions that could influence the depression’s responsiveness to treatment, such as bipolar disorder or personality disorders.
There are several misconceptions about TRD, including the belief that it is synonymous with “no hope.” In reality, there are multiple treatment options available, including medications and procedures like electroconvulsive therapy (ECT). Understanding these options can help dispel myths and encourage patients to seek comprehensive care.
The complexity of treatment-resistant depression requires a nuanced understanding and a personalized approach to treatment.
Prevalence and Impact on Individuals
The prevalence of treatment-resistant depression is alarmingly high, with estimates suggesting that at least 30% of persons with depression are affected by this condition. In some populations, such as those covered by Medicaid, the prevalence can be as high as 44.2%. The impact of TRD extends beyond the individual, affecting societal costs and healthcare utilization significantly. Individuals with TRD often experience more severe symptoms, longer depressive episodes, and a greater number of lifetime depressive episodes compared to those with non-resistant MDD. Additionally, TRD is associated with higher indirect costs due to increased disability benefits, workplace absenteeism, and the burden on caregivers. The healthcare costs and unemployment costs attributable to TRD are disproportionately high, reflecting the intensive treatment and support required for managing this condition. Furthermore, the rate of suicidality, including completed suicides, is markedly higher among populations with TRD, underscoring the urgent need for effective interventions and support systems.
Identifying Signs of Treatment-Resistant Depression
The biggest sign of treatment resistant depression is not feeling better
Lack of Improvement despite Treatment
Individuals experiencing treatment-resistant depression often find that standard treatments such as antidepressants or psychotherapy do not alleviate their symptoms effectively. Despite undergoing multiple treatments, their symptoms might not improve, or they may experience only temporary relief before their symptoms return. This persistent lack of response to conventional treatments is a hallmark of treatment-resistant depression, necessitating the exploration of alternative therapeutic approaches.
Persistent Symptoms and their Severity
Treatment-resistant depression is characterized by more severe symptoms compared to typical major depressive disorder. Individuals may suffer from prolonged depressive episodes and exhibit symptoms such as anhedonia, which is a reduced ability to experience pleasure. The severity of these symptoms often leads to significant impairment in daily functioning and quality of life. Additionally, individuals with treatment-resistant depression are more likely to experience increased anxiety and have a higher risk of suicidal ideation and behavior. These persistent and severe symptoms underscore the critical need for effective management strategies tailored to this challenging condition.
Clinical Evaluation
Treatment-resistant depression can be hard to diagnose. Sometimes, other conditions or problems can cause similar symptoms. So when you meet with your doctor, they will want to:
Review your experience with psychotherapy (talk therapy) and if it has helped manage depression.
Assess physical health conditions that can sometimes cause or worsen depression, like thyroid disease and chronic pain.
Assess issues like substance use problems.
Consider if a different mental health condition more accurately describes your symptoms, like bipolar disorder or a personality disorder.
Diagnostic Tools
Depression is a clinical diagnosis, based on the history and physical findings. No diagnostic laboratory tests are available to diagnose major depressive disorder. However, healthcare providers may use various screening tools and questionnaires to aid in the assessment.
Challenges in Diagnosis
The diagnosis of treatment-resistant depression isn’t clearly defined. But most healthcare providers diagnose TRD if your depression symptoms haven’t improved after trying at least two first-line antidepressant medications. Most providers consider the following to be first-line depression medications:
SSRIs
SNRIs
Bupropion
Mirtazapine
Accurate diagnosis is crucial for effective treatment planning and management of treatment-resistant depression.
Risk Factors for Developing Treatment-Resistant Depression
Genetic Predispositions
Genetic factors play a significant role in the development of treatment-resistant depression (TRD). Research indicates that first-degree relatives of individuals with TRD are at an increased risk for developing the condition themselves. This familial tendency suggests that genetic predispositions are influential in the resistance to antidepressant treatments. Furthermore, specific genetic polymorphisms, such as those found in the serotonin transporter (5-HTT) and the brain-derived neurotrophic factor (BDNF), have been linked to variations in treatment response. Polymorphisms in the 5-HTT promoter region and BDNF gene affect neurogenesis and the serotonergic system, which are crucial in the pathophysiology of depression and its treatment. Genetic predisposition plays a significant role in the development of treatment-resistant depression (TRD). Studies have shown that individuals with a family history of depression are at a higher risk of developing TRD. Specific genetic markers and variations can influence how patients respond to antidepressant medications, making it crucial to consider genetic factors in treatment planning.
Environmental and Lifestyle Factors
Environmental and lifestyle factors also contribute significantly to the risk of developing TRD. Patients with TRD often report a higher number of stressful life events, such as severe health conditions, financial stress, or significant interpersonal relationship problems. Additionally, lifestyle choices, such as moderate to heavy alcohol consumption, have been associated with poorer responses to treatment. Adverse childhood experiences, including trauma and bullying, have also been reported frequently among those with TRD, indicating that early life stressors can increase vulnerability to later life stressors and potentially lead to treatment resistance.
Patients with depression who have some medical illnesses—such as thyroid disease and chronic pain—are at greater risk for TRD. Other conditions associated with TRD include substance abuse and eating and sleep disorders, which have the potential to make you more prone to being resistant to treatment with antidepressants.
A depressed person’s overall health can also play a role. Addressing these comorbid conditions is essential for improving treatment outcomes in TRD.
By understanding the complex interplay between genetic predispositions and environmental factors, healthcare providers can better identify individuals at risk for TRD and tailor interventions that address these specific risk factors.
Exploring Medication Options
Switching Antidepressants
When patients exhibit poor response or intolerable side effects to an initial antidepressant, switching to another may be necessary. It is crucial for clinicians to be well-versed in the pharmacodynamics of each drug, aware of potential drug-drug interactions, and the expected timeline for the onset of the new medication’s effectiveness. Studies have shown that approximately 9% of patients undergoing antidepressant monotherapy switch to another antidepressant during treatment.
Pharmacological treatment strategies for treatment-resistant depression (TRD) involve a multi-faceted approach to manage symptoms effectively. Different antidepressants work in different ways to affect specific chemicals (neurotransmitters) that send information along brain circuits that regulate mood. If a current medication isn’t helping enough, other drugs might be considered.
First-Line Medications
First-line medications typically include selective serotonin reuptake inhibitors (SSRIs) and serotonin-norepinephrine reuptake inhibitors (SNRIs). These medications are often the initial choice due to their efficacy and safety profile. However, if these medications do not yield the desired results, other classes of antidepressants may be explored.
Combination Therapy
Combining antidepressants can offer a synergistic effect, enhancing efficacy or tolerability. For example, combining SSRIs, which extensively inhibit serotonin reuptake, with agents like trazodone or nefazodone that block 5-HT2A receptors can reduce agitation and insomnia, allowing for higher dosages and increased efficacy. Moreover, combinations like SSRIs with bupropion, which also targets noradrenaline and dopamine reuptake, have shown greater improvement in treatment-resistant depression. The use of lithium as an adjunct to antidepressants like TCAs, MAOIs, and SSRIs has been shown to enhance response rates and prevent early relapse by affecting various neurotransmitter systems and neuroplastic changes.
Novel Medications and Approaches
Esketamine, a component of ketamine, represents a novel approach in treating resistant depression. Approved as a nasal spray, it must be administered under clinical supervision due to potential side effects such as dissociation and extreme relaxation. Esketamine acts on the glutamate neurotransmitter system, differing from traditional antidepressants that primarily affect serotonin. This allows for the formation of new neural pathways, potentially preventing the recurrence of depression. Patients may notice rapid improvements, often within days, especially when esketamine is used in conjunction with traditional antidepressants.
Innovative combination therapies have also shown promise. For instance, the combination of the SSRI fluoxetine with olanzapine has been superior in treating resistant depression compared to either treatment alone. Similarly, augmentation strategies like adding triiodothyronine (T3) to TCAs have accelerated response times and have been particularly effective in women. The β-adrenergic/5-HT1A receptor antagonist pindolol has been used to enhance the effects of SSRIs by binding to 5-HT1A receptors, although results have been mixed.
Through a deeper understanding of these medication options and their mechanisms, clinicians can better tailor treatments to meet the unique needs of individuals with treatment-resistant depression.
Non-Medication Therapies and Interventions
Grief therapists can help individuals with a variety of therapies to help the person through the depression when medications fail to work
Psychotherapy Techniques
Psychotherapy remains a cornerstone in the management of treatment-resistant depression, offering various techniques tailored to individual needs. Cognitive-behavioral therapy (CBT) and interpersonal psychotherapy (IPT) have shown efficacy in treating mild to severe nonpsychotic major depression and, based on limited research, offer comparable benefits to medications in treatment-resistant cases. The integration of psychotherapy with usual treatment has been found to moderately improve outcomes compared to usual treatment alone, with effect sizes similar to those seen in adjunctive pharmacotherapies. Psychotherapies provide unique advantages, particularly for patients whose depressive episodes are linked to specific outlooks, symptoms, or stressors. Unlike medications, psychotherapies help patients structure their lives, enhance self-understanding, and improve interpersonal functioning.
Electroconvulsive Therapy (ECT) and Other Neuromodulation Therapies
Electroconvulsive therapy (ECT) is highly effective for severe depression and has a significant advantage over antidepressant medications in treatment-resistant cases. ECT involves administering electrical currents to induce a controlled seizure, significantly reducing depressive symptoms and enhancing response rates. The procedure’s safety has improved with the use of general anesthesia, muscle relaxants, and modern monitoring techniques. Other neuromodulation therapies such as repetitive transcranial magnetic stimulation (TMS) and deep brain stimulation (DBS) also offer promising results. TMS has consistently outperformed sham treatments in major depressive disorder, providing a non-invasive option with minimal side effects like transient headaches. DBS, though more invasive, targets specific brain areas with electrical impulses to alter neural activity and alleviate depression.
Lifestyle Changes and Complementary Therapies
Addressing lifestyle factors plays a critical role in managing treatment-resistant depression. Regular physical activity, adherence to a Mediterranean diet, maintaining good sleep hygiene, and ensuring sufficient sunlight exposure are recommended as part of a comprehensive treatment plan. These interventions not only support overall health but also directly impact depression symptoms by reducing stress, improving sleep, and enhancing mood. Complementary approaches such as acupuncture, although less effective in treating depression directly, may offer additional health benefits. The use of supplements like omega-3 fatty acids, and St. John’s wort has shown mixed results, necessitating careful consideration of potential interactions and benefits. Moreover, light therapy can be particularly beneficial for those experiencing seasonal exacerbations of depression.
The Role of Psychotherapy in Managing Treatment-Resistant Depression
Cognitive Behavioral Therapy (CBT)
Cognitive Behavioral Therapy (CBT) is a prevalent form of psychotherapy that addresses the interconnections between thoughts, feelings, and behaviors that affect mood. It is specifically designed to identify and modify distorted or negative thinking patterns and teaches individuals skills to respond positively to life’s challenges. This therapy is particularly effective for those suffering from treatment-resistant depression, as it provides them with tools to manage their depressive symptoms actively. The therapy focuses on altering negative thought patterns, improving interpersonal relationships, and developing coping strategies.
Other Therapeutic Approaches
Several other psychotherapeutic approaches play crucial roles in managing treatment-resistant depression. Acceptance and Commitment Therapy (ACT), a branch of CBT, encourages patients to accept their thoughts and feelings rather than fighting them, promoting positive behavioral changes even in the presence of negative thoughts. Interpersonal Psychotherapy (IPT) focuses on resolving interpersonal issues contributing to depression, helping patients improve their relationship dynamics.
Family or marital therapy involves the patient’s family members or partners in the therapeutic process. This approach is beneficial as it addresses and works through relationship stress that may be impacting the patient’s depression. Dialectical Behavioral Therapy (DBT) is another effective method, particularly for those with chronic suicidal thoughts or behaviors associated with treatment-resistant depression, as it combines acceptance strategies with problem-solving skills.
Group psychotherapy offers a unique environment where individuals with depression can interact with others facing similar challenges, facilitated by a psychotherapist. This setting can enhance support and sharing of coping strategies among participants.
Mindfulness and Behavioral Activation are also valuable in the treatment arsenal against resistant depression. Mindfulness encourages individuals to be present and non-judgmental about their thoughts and feelings, which can help manage stress and depressive symptoms. Behavioral Activation helps patients engage in activities that improve mood and reduce isolation, gradually reversing the withdrawal that often accompanies depression.
Each of these therapies provides distinct benefits and can be tailored to meet the specific needs of individuals dealing with treatment-resistant depression, underscoring the importance of a personalized approach in psychotherapeutic interventions.
Innovative and Experimental Treatments
Ketamine and Esketamine
Esketamine, approved by the US Food and Drug Administration (FDA) and European Medicines Agency (EMA) in 2019, is a novel pharmacological agent recognized for its glutamatergic neuromodulatory properties. It functions through non-selective, non-competitive antagonism of N-methyl-D-aspartate (NMDA) receptors, which are crucial for mood regulation and emotional behavior. This antagonism results in a transient increase in glutamate release, stimulating further neurotransmitter activity that is vital for combating depressive symptoms. Esketamine’s rapid onset is linked to its ability to stimulate the mammalian target of rapamycin complex 1 (mTORC1), promoting synaptogenesis and enhancing brain-derived neurotrophic factor production, which are essential for effective treatment outcomes in treatment-resistant depression (TRD).
The intranasal form of esketamine is particularly noted for its quick action, often showing antidepressant effects shortly after administration, which is critical for patients with severe depression or those at imminent risk of suicide. However, its use must be carefully monitored due to potential psychotomimetic effects, and it is generally administered in a clinical setting to manage these risks effectively.
Psychedelic-Assisted Therapy
In recent years, there has been a significant resurgence of interest in the use of psychedelic compounds, such as psilocybin, for treating mental disorders like TRD. Psilocybin, found in magic mushrooms, has been studied in various clinical settings, often in conjunction with supportive psychotherapy. It has demonstrated substantial antidepressant effects in both open-label and randomized controlled trials, although these studies often face limitations such as small sample sizes and lack of rigorous control conditions.
Psilocybin’s effects are believed to stem from its activation of serotonin 2A (5-HT2A) receptors, leading to altered states of consciousness, or the ‘psychedelic trip,’ which is central to its therapeutic potential. Current research is exploring whether these effects can be separated from the psychedelic experience, with studies like the proof-of-concept randomized controlled trial combining psilocybin with risperidone to block the psychedelic effects and assess the antidepressant potential in isolation.
Moreover, patient feedback suggests the need for more personalized approaches in psychedelic-assisted therapy, emphasizing trust-building, individualized preparation, and the possibility of multiple treatment sessions to optimize the therapeutic outcomes for TRD. This patient-centered feedback is crucial for refining treatment protocols and enhancing the adaptability of psychedelic therapies in clinical practice.
The future of treating depression lies in the continuous exploration of new therapies and the rigorous testing of their effectiveness and safety.
Creating a Personalized Treatment Plan
Working with a Specialist
When experiencing persistent symptoms of depression despite ongoing treatment, it is crucial to consult a specialist who can provide a comprehensive review and adjustment of the current treatment plan. Specialists, such as psychiatrists or psychiatric nurse practitioners, are equipped to assess the effectiveness of current treatments and make necessary changes. They may review the patient’s medical history, inquire about life situations impacting the depression, and consider any physical health conditions that could influence symptoms. Additionally, they might adjust medications, suggest different therapeutic approaches, or recommend advanced treatments like repetitive transcranial magnetic stimulation (rTMS) or electroconvulsive therapy (ECT) if standard therapies are ineffective.
Evaluating and Adjusting the Treatment Plan
Creating an effective treatment plan for depression involves continuous evaluation and flexibility to adapt to the patient’s evolving needs. This may include altering the treatment setting, the types of medications used, and the psychological treatments applied. Patients and caregivers should be actively involved in this process to ensure that the plan remains practical and applicable to the patient’s specific circumstances. Regular follow-ups with the healthcare provider are essential to assess the treatment’s effectiveness and to make timely adjustments. This collaborative approach helps in maintaining a strong therapeutic alliance, which is vital for encouraging patient adherence and ultimately improving treatment outcomes.
Support Systems and Self-Care Strategies
Incorporating support systems and self-care strategies into the treatment plan is fundamental for individuals with treatment-resistant depression. Engaging in regular physical activity, maintaining a balanced diet, and ensuring adequate sleep are critical components that enhance the overall effectiveness of medical treatments. Patients are encouraged to manage stress through mindfulness and relaxation techniques, which can significantly alleviate symptoms of depression. Support from family, friends, and community resources also plays a crucial role in recovery. Educational programs about depression can help patients and caregivers recognize early signs of relapse and seek prompt treatment, reducing the risk of complications.
By integrating these approaches, a personalized treatment plan for depression not only addresses the medical and psychological aspects of the condition but also empowers individuals to take proactive steps towards their mental health and well-being.
Management and Long-Term Care
Long term care is sometimes required to help someone with treatment resistant depression
Personalized Treatment Plans
Management of treatment-resistant depression (TRD) requires personalized treatment plans tailored to the individual needs of each patient. These plans often involve a combination of pharmacological and non-pharmacological strategies to address the complex nature of TRD. Regular assessment and adjustment of the treatment plan are crucial to ensure its effectiveness and to minimize side effects.
Monitoring and Follow-Up
Continuous monitoring and follow-up are essential components of managing TRD. This includes regular appointments with healthcare providers to evaluate the patient’s progress and to make necessary adjustments to the treatment plan. Monitoring should also involve tracking any side effects and the overall impact of the treatment on the patient’s quality of life.
Patient and Family Support
Support from family and caregivers plays a significant role in the long-term management of TRD. Providing education about the condition and involving family members in the treatment process can enhance the effectiveness of the treatment plan. Additionally, support groups and resources can offer emotional and practical assistance to both patients and their families.
Effective management of treatment-resistant depression requires a comprehensive approach that includes personalized treatment plans, continuous monitoring, and robust support systems.
Living with Treatment-Resistant Depression
Living with treatment-resistant depression (TRD) presents unique challenges that require a multifaceted approach to manage effectively. Arriving at the right treatment can take some trial and error. However, persistence and a comprehensive, patient-centered approach can lead to significant improvements in quality of life.
Ethical and Societal Considerations
Access to care for individuals with treatment-resistant depression is a significant ethical concern. Disparities in healthcare access can exacerbate the condition, particularly in low- and middle-income countries. Ensuring equitable access to innovative treatments is crucial for global health equity.
Stigma surrounding mental health remains a pervasive issue. It can deter individuals from seeking help and contribute to the worsening of symptoms. Combatting stigma requires a multifaceted approach, including public education and policy changes.
Effective policy and advocacy are essential for addressing the needs of those with treatment-resistant depression. This includes advocating for responsible supply bases and supplier-enabled innovation to ensure that new treatments are both ethical and accessible. Policymakers must consider the psychiatric and legal considerations for novel treatments to ensure they are implemented responsibly.
Addressing ethical and societal considerations is not just a medical challenge but a moral imperative. It requires collaboration across sectors to create a supportive environment for those affected by treatment-resistant depression.
Prevention and Early Intervention
Identifying early warning signs of treatment-resistant depression is crucial for timely intervention. Early detection can significantly improve treatment outcomes and reduce the disease recurrence rate. Common early warning signs include persistent sadness, loss of interest in activities, and changes in sleep patterns.
Preventive strategies play a vital role in managing treatment-resistant depression. These strategies include:
Regular mental health screenings
Stress management techniques
Healthy lifestyle choices, such as regular exercise and a balanced diet
Building strong social support networks
Primary care providers are often the first point of contact for individuals experiencing depressive symptoms. They play a critical role in early intervention by:
Conducting thorough clinical evaluations
Utilizing diagnostic tools to assess the severity of depression
Referring patients to mental health specialists when necessary
Effective collaboration between primary care providers and mental health specialists is essential for comprehensive care.
By implementing these preventive strategies and recognizing early warning signs, healthcare professionals can better manage and treat treatment-resistant depre
Conclusion
Please also review AIHCP’s Grief Counseling Certification and see if it meets your academic and professional goals
Throughout this exploration of resistant treatment depression, we’ve traversed a vast landscape of innovative methods and therapies that spotlight the pressing need for personalized and comprehensive approaches. From the nuances of identifying treatment-resistant depression, understanding its risk factors, to the meticulously discussed medication options and non-medication therapies, the article offers a beacon of hope for those navigating this challenging condition. It underscores the crucial role of psychotherapy, alongside the promising horizon of experimental treatments like esketamine and psychedelics, in crafting a tailored treatment plan that resonates with the unique experiences and needs of each individual.
The journey towards conquering treatment-resistant depression is a testament to the resilience of both patients and healthcare providers in the face of adversity. It is a reminder of the importance of continuing research, patient-centered care, and the amalgamation of traditional and novel therapies to enhance mental health outcomes. By fostering a deeper comprehension of this condition and advocating for a multifaceted approach to treatment, we pave the way for more effective management strategies and a future where the shadows of resistant treatment depression are illuminated by the light of hope and healing.
Please also review AIHCP’s Grief Counseling Certification. Licensed counselors as well as pastoral counselors can both earn a Grief Counseling Certification to aid in their pastoral ministry or in licensed field of counseling. Remember, grief counseling outside the licensing arena cannot go beyond pathology. Hence pastoral counselors cannot help clients with depression and need to refer them to clinical and licensed counselors. AIHCP’s program covers numerous aspects of grief as well as depression but the certification itself is not a licensure and does not provide the rights that correspond with a licensed counselor. So when dealing with depression issues, pastoral counselors need to be careful not to treat but to refer.
AIHCP’s program in Grief Counseling is online and independent study and leads to a four year certification.
Frequently Asked Questions
What is treatment-resistant depression?
Treatment-resistant depression (TRD) is a type of major depressive disorder that does not respond to at least two different antidepressant treatments of adequate dosage and duration. The most effective management strategy for treatment-resistant depression often involves a combination of psychotherapy and medication. This approach not only addresses the chemical imbalances in the brain but also helps uncover and tackle underlying issues contributing to the depression. Through therapy, individuals can learn practical behaviors and strategies to combat their depression.
How common is treatment-resistant depression?
Treatment-resistant depression affects about 30% of people diagnosed with major depressive disorder.
What are the primary symptoms of treatment-resistant depression?
The primary symptoms include persistent feelings of sadness, loss of interest in activities, and difficulty concentrating, despite treatment efforts.
What are the treatment options for treatment-resistant depression?
Treatment options include optimizing current medications, switching medications, combination therapies, augmentation strategies, and non-pharmacological treatments like psychotherapy and electroconvulsive therapy (ECT). The latest advancement in treating treatment-resistant depression is Transcranial Magnetic Stimulation (TMS). This innovative, non-invasive method involves using gentle pulses of magnetic fields to stimulate nerve cells in the brain. It offers a different mechanism of action compared to traditional antidepressants like serotonin reuptake inhibitors (SSRIs) and does not come with their common side effects, including weight changes and sexual dysfunction.
What are the risk factors for developing treatment-resistant depression?
Risk factors include genetic predisposition, environmental influences, and comorbid conditions such as anxiety or substance abuse.
How is treatment-resistant depression diagnosed?
Diagnosis typically occurs after a patient has not responded to two different first-line antidepressant medications taken for a sufficient duration, usually six to eight weeks.
Are there non-medication options for treating treatment-resistant depression?
Yes, non-medication options include psychotherapy approaches, electroconvulsive therapy (ECT), and transcranial magnetic stimulation (TMS).
What should I do if I suspect I have treatment-resistant depression?
Consult with a healthcare provider who can perform a thorough evaluation and work with you to develop a personalized treatment plan. There is new hope for individuals struggling with treatment-resistant depression. The Treatment-Resistant Depression (TRD) Neuromodulation Clinic is at the forefront of offering innovative treatments such as repetitive Transcranial Magnetic Stimulation (rTMS) and esketamine. These treatments are specifically designed for veterans and others whose depression has not improved after several attempts with traditional antidepressant medications.
Additional Resources
“Treatment-Resistant Depression: What We Know and How To Manage It”. (2022). Cleveland Health Essentials. Cleveland Clinic. Access here
Bruce, D. (2023). “Treatment-Resistant Depression” WEBMD. Access here
Meissner, M. (2021). “What To Do When Your Antidepressant Isn’t Helping Enough”. PsychCentral. Access here
“How to Manage Treatment-Resistant Depression” (2023). Healthline Medical Network. Healthline. Access here
