Finding the Real and Right Story in Counseling

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.


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.




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”.  Access here

Guy Evans, O. (2023). “Narrative Therapy: Definition, Techniques & Interventions”. Simply Psychology.  Access here

“Narrative Therapy”. Psychology Today.  Access here


Resistant Treatment Depression: Innovative Methods and Therapies

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:

  1. Conducting thorough clinical evaluations
  2. Utilizing diagnostic tools to assess the severity of depression
  3. 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


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

Focusing and Empathetic Confrontation in Counseling

Like in previous blogs, attending to the client, empathetically listening and observing, properly responding and encouraging are key elements in basic counseling.  Like a coach training a player or athlete, challenging and encouraging a client to change is like coaching.  It involves the counselor helping the client push forward, and like in coaching, this sometimes involves more than just challenging, but to also focus on the issue that needs addressed and then properly fix it.  A good coach will focus and see a flaw in the mechanics of a player and then challenge and confront the player and help guide the player to fixing it.  Counselors focus on the client’s story and then discover the core issues.  After finding the core issues, they offer empathetic confrontations to help push forward.   These skills represent later measures after basic attending, listening, observing and responding and look in later sessions to help the client find real and true change.  In this blog, we will first look at focusing and then conclude with empathetic confrontation.

Focusing in Counseling

According to Ivey, the skill of focusing is a form of attending of the client that enables a counselor to discover multiple views of the client’s story (2018, p. 221).   It helps the client think of new possibilities during the restory and call to action (Ivey, 2019, p. 221).  A counselor goes well beyond merely the “I” in the story but looks to broaden the story beyond merely the client but into other aspects of the client’s life.  How the counselor responds to the client hence can play a key role in where the story proceeds in the counseling sessions.  Counselors who direct the conversation through selective attention skills can take the “I” conversation into other social and cultural spheres of the client.  These other spheres of influence can be key clues into the client’s mindset. Ultimately, focusing is about helping the client address emotional issues.  It is client based and humanistic in approach.

How a counselor focuses on the multiple aspects of a client’s story is key to understanding the whole story. Please also review AIHCP’s Grief Counseling Certification

Ivey lists seven focus dimensions that counselors can utilize in responding and discussing issues.  The first is to focus on the client him/herself.  This involves direct questions regarding the client’s feelings.  The second involves focusing on the theme .  It involves asking the client about the issue itself and discovering details regarding the theme of the issue and how the client feels in the immediate moment.   The third dimension shifts focus to others within the client’s life.  It delves into questions about significant others, family members, friends or others involved in the issue.  The fourth dimension of focusing looks at mutual aspects of how the client and counselor can work together. It emphasizes “we” and how the counselor and client can find ways to deal with the issue.  The fifth dimension focuses on the counselor.  It involves how the counselor can paraphrase and share appropriate and similar experiences with solutions.  The sixth focus puts into perspective the issue in regards to the client’s cultural or environmental background and how they may play into the current issue.  Finally, focusing on the here and now delves into identifying how the client feels at the moment itself (Ivey, 2018, p. 221).

Focusing on a client’s cultural/religious/ethnic background can play a key in discovering issues that exist in the person.  It can help explain why a particular client responds and reacts a certain way.  It can also be used to find strengths for the person.  Ivey illustrates the importance of Community and Family Genograms that help map out the client’s background (2018, p.212).   A good family genogram will help clients identify issues from a cultural standpoint and understand better their relationship to their surrounding environment and its stressors.  In addition, it can also help clients discover new hidden strengths that exist within their family and culture.   Helping the diverse client take pride in their past and heritage can help build resiliency.  When stressors or issues occur, a client can utilize a term referred to as “body anchoring” where the client reflects upon a voice of a relative, famous individual, or cultural icon to help him/herself find confidence and strength to face the issue (Ivey, 2018, p. 220).  This also helps multicultural clients have the power to name issues that are effecting them.  Using focus on culture can be a very helpful tool when utilized correctly during a counsel session.  This type of focusing helps many diverse populations deal more effectively against microaggressions (Ivey, 2018, p. 248).

Ways to help find a client’s particular cultural awareness during focusing is through the Cross five stage model, named after William Cross (Ivey, 2018, p. 244).  Also referred to as the five stages of cultural identity, Cross identified how diverse populations recognize themselves and respond to confrontation.  Focusing on the stage of a particular client hence can be very beneficial.  The first stage involves the conformity stage.  The individual may be unaware of racial identity and merely conforms to societal expectations.  The second stage involves dissonance where the individual realizes that something does not match or fit.  This can lead to self-appreciation or self doubt.  The third stage results in resistance or emersion.  An individual may become more angry at the injustice or immerse oneself more in one’s own culture.  The fourth phase involves introspection where the individual sees oneself as an individual and part of the cultural group.  The final phase of integrative awareness is the full sense of caring for oneself and one’s cultural heritage.  This leads to appreciation and action but more so due to pride and awareness (Ivey, 2018, p. 245).   Through identification of these phases or stages, counselors can help clients better utilize the client’s heritage and culture to empower the client in various interventions.

Empathetic Confrontation

Empathetic Confrontation looks to help someone understand negative behaviors in a nonjudgmental and empathetic way

A counselor, like a coach, uses a variety of encouragement and challenging strategies to help a client find change.  Within the Problem Management Model, a client is shown the present, perceived view and ways to find the new view.  This involves identifying internal as well as external conflicts.  Sometimes, clients may become stuck in a way of thinking. They lack intentionality to change or lack creativity (Ivey, 2018, p. 229).  Within this state, the client becomes immobile, experiences blocks, cannot achieve goals, lacks motivation and has reached an impasse (Ivey, 2018, p. 229).   In these, cases, like a coach, the counselor needs to help the client face these issues and move forward.   This involves a type of confrontation but this confrontation is not meant to imply aggression or hostile or argumentative behavior but is an engagement for change. According to Ivey, Carl Rogers pushed for the ideal of Empathetic Confrontation, which espouses a gentle listening to the client and then encouraging the client to examine oneself more fully (2018, p. 2029).   Summaries are an excellent way to help confront a client with empathy.  In this way, the counselor can present a two-part summary which states both positions with the connecting phrase “but on the other hand” (Ivey, 2018, p. 229-230).  This presents both views of feelings and allows the client to digest the statement and see any discrepancies or issues of conflict within his/her logic.


Carl Rogers points out that even when presented in these terms, sometimes, the client may feel attacked or confronted. In these cases, he suggests to also hold tight to nonjudgmental attitudes, keeping one’s own beliefs to the side.  Rogers emphasized that individuals with issues who come to counseling do not need judged or evaluated but guided (Ivey, 2018, p. 230).   Within any issue, the counselor confronts but also supports.  This involves first a relationship that must exist.  Without a relationship of trust, the client will not accept any advice from a sterile stranger who he/she may merely see as a paid listener.  When confronting, it is essential when summarizing to state the client’s point of view first, before comparing the opposing view.  In addition, the client must remain in charge of outcomes.  The counselor when confronting is not telling the client what to do but offering suggestions (Ivey, 2018, p. 232).  In conclusion, the counselor must listen and observe for mixed messages and then respond with empathy in a summary that clarifies any internal or external issues.  This should resolve with actions towards resolution of the issue (Ivey, 2018, p. 235).

Egan points out that are multiple ways to challenge and confront clients to life enhancing actions.  Egan differentiates between goals but also strong intention and commitments to a course of action.  The importance of understanding the value of action intentions is key in helping a client carry out a particular again (2019, p, 234-235).    Implementing these instructions, with strong phrases such as “I strongly intend to do x when y occurs” can help clients find tools necessary to incorporate the necessary change (Egan, 2019, p. 235).  Sometimes, a self contract to do a certain thing can be a powerful tool in helping clients galvanize towards change (Egan, 2019, p. 239).

Egan also points out that counselors need to help their clients overcome procrastination.   Egan lists numerous excuses that can include competing daily agendas or short term pains (2019, p. 236).  It is important to guide one’s client between conscious deliberation and procrastination that prevents true change.

Egan reminds counselors to also help clients identify unused resources that can help facilitate change.  Replace “I can’t” with “I can” phrases by helping the client discover unused talents and resources to help one overcome negative thoughts of failure. (Egan, 2019, p.237).

When aiding clients with life enhancing actions, it is important to provide sometimes confirmatory feedback as well as corrective feedback.  Obviously, confirmatory feedback acknowledges progress, but corrective feedback looks to help clients who wandered off from the course of action (Egan, 2019, p. 244).   The spirit of empathy and nonjudgment are again essential in how this is accomplished.  In many ways, it is confronting but in a non hostile way.  Counselors can help clients stay on track through multiple ways via checklists, identification of possible obstacles and helping them identify damaging attitudes.  Such attitudes can be due to a passivity not to take responsibility, a learned helplessness, disabling self talk, or disorganization (Egan, 2019, p. 245-248).  Egan also warns that while helping clients, be aware of entropy and how initial change can gradually break down.  Egan lists false hopes and the natural decay curve as two things that can occur in clients (2019, p.249-250).  Within each, clients may have too high of expectations, or consider mistakes to destroy the entire process.  Give clients the power to make mistakes throughout the process.

Sometimes, as noted, some clients are more resistant to confrontation and change.  Some may become visibly upset if confronted with a discrepancy in life.  Different clients respond to different challenges in different ways.  The Client Change Scale or CCS is a way to measure a client’s reaction to empathetic confrontation (Ivey, 2018, p. 237).  Level 1 involves denial of the issue. Within this level, the story is distorted and the client will look to blame others unfairly.  Level 2 consists of bargaining and partial acceptance of the story.  In this reality, the story is finally changing in a more true direction.  Level 3 involves acceptance of the reality.  The truth is recognized and the story is finally complete.  Level 4 incorporates new solutions to make the story better and finally Level 5 refers to transcendence and the incorporation of the new story into the client’s life (Ivey, 2018, p. 246).  The CCS helps the counselor track each session and see if progress or regression occurs from one session to the next in regards to change.

Egan points out that many individuals are reluctant to change due to variety of issues including fear of intensity of it, lack of trust in the process, extreme shame, loss of hope, or even the cost of the change itself (2019, p. 253-255).  In dealing with these things, counselors need to be realistic and flexible and look to push the client beyond resistance by examining incentives of change (Egan, 2019, 259).  In some cases, when change is identified and the need for it accepted, clients may need time in adjusting or implementing it.  Egan points out that change can exist on two levels.  He refers to these types of changes as first order changes and second order changes.  First order change is operational and a short term solution, while second order change is more strategic and long term.  Egan compares the two with first and second as being compared in these ways.  First order utilizes adjustments to the current situation, while second is systematic, first monitors, while second creates new, first creates temporary, while second creates to endure.  First changes look sometimes to deal with the symptoms while second attacks the causes (Egan, 2019, p. 308).

In some clients, the situation to change may not permit a new paradigm but may requires coping skills.  For instance, a stressed employee may be forced to keep a stressful job but may need to tinker with it due to the financial a loss of finding a new job would incur with a more lasting change, while a battered spouse would require a permanent change and would not be able to cope with the existing abuse.

An interesting model is the GROW model.  John Whitmore, creator of the model utilized the acronym to produce change and to assess one’s willingness to change.  G represents goal or what one wishes to accomplish. R stands for reality and where the client currently exists.  O stands for options and what one can possibly do.  Finally W stands for will, or what one is willing to do.

This model as well the Problem Management Model are ways to help move the sessions and help identify issues and assess how to empathetically confront and challenge individuals to productive change.


How a counselor attends to a client also involves sometimes more than listening but also focusing on particular aspects of the client’s life.  This involves the other aspects of the clients life and in many cases includes cultural and social issues that affect the client.  This can be merely family but also take upon the broader cultural aspect of a person.  Someone of European descent may react quite differently than someone of Asian descent to the same issue.  Hence focusing in on these issues is an essential attending skill.  It is also important to understand where one cultural exists within oneself.  The Cross model can help counselors better gauge one’s cultural awareness and how that plays in one’s particular situation.

Please also review AIHCP’s Grief Counseling Certification as well its Christian Counseling Program.

In addition, this blog discussed the importance of Empathetic Confrontation.  Carl Rogers understood the importance of helping individuals identify problems that were internal or external but he also understood that is was critical to approach confrontation with nonjudgment and empathy.  Employing a two part summary with “on the other hand” can help expose issues and offer good solutions but different individuals react to confrontation to change differently.  The Client Change Scale is an excellent way to gauge and monitor a client’s willingness to change.  Through Empathetic Confrontation, the counselor looks to challenge past themes or schemas of a client’s life and help them find new ways to correct negative behaviors.

Please also review AIHCP’s many mental health certification programs.  AIHCP offers a Grief Counseling Certification, as well as a Christian Counseling Certification. In addition, AIHCP offers programs in Crisis Intervention, Healthcare Life Coaching, Stress Management and Anger Management Consulting.  The programs are online and independent study and open to qualified professionals seeking a four year certification.




Ivey, A. et, al. “Intentional Interviewing and Counseling: Facilitating Client Development in a Multicultural Society” (9th Ed( (2018). Cengage.

Additional Resources

Williams, M. (2018). “Ethnic and Racial Identity and the Therapeutic Alliance”.  Psychology Today.  Access here

Sutton, J. (2022). “How to Assess and Improve Readiness for Change”,  Access here

“Focusing” (2016). Good Therapy.  Access here

“The Technique of Confrontation in Counseling” (2022). Optimist Minds. Access here



Challenging and Encouraging Clients in Counseling

To help transform a person to change, attending, listening and responding are key, but the skilled counselor needs to be able to help instigate change or water the seeds of the healing process within a client.  Whether loss and grief, or merely more daily stressors or emotional issues that are holding the client back from living life productively, the counselor needs to know how to coach the client and help the client find that preferred outcome.  This involves not only identifying the goals and actively pushing towards them but also motivating and challenging them.  Like a coach who is able to abstract the best out of their players on the field, a counselor needs to be able to encourage and challenge his/her clients to produce meaningful change.  Some clients respond better, others may be still facing inner turmoil and self esteem issues.  Some clients may be more resilient naturally, while others may need more prodding and gentle and empathetic guidance.  Each client is unique and different but the general ideas within this short blog complement the previous blogs on attending the client and responding to the client.

Challenging and encouraging a client to change is much like a coach trying to get the best of a player on the field


Some clients may have zero motivation to be challenged.  They may possess some world view or bias that prevents this change.  Some may be forced to attend counseling and feel no need to change.  This can occur with state mandated counseling or clients forced to attend because of family or spouses.  Some clients may feel motivated simply because of guilt and look to foster a positive change.  Some may simply have an interest in the counseling process and wish to see what happens.  In the best case, one will find a client who understands the critical importance of counseling and the changes that need made.  Regardless of the clients motivation level, it is the purpose of the counselor to help bring the best out of the client. This can be easier said then done.




The Counselor as Coach?

Life coaching in itself is a newer field within the Human Service Field.  It is not clinical or requiring of various licensing but it does promote the idea of healthy change and life styles.  It involves a professional who is trained to motivate, direct and help clients meet end goals.  This involves both encouraging and challenging the client.  Whether it is a weight goal, training goal, dieting goal, or health and life style change, life coaches are inherently trained to help produce change through motivation, encouragement and challenging of their clients.  Counselors, whether pastoral or clinical, working in grief counseling or other mental counseling disciplines, through empathetic listening and responding, should have a vested interest in helping their clients meet change, but some may lack the skills to help motivate the client to change.  As counselors, the client is directed and given options, but is never commanded or forced to change, instead, the client is invited to change through an array of options.  Many times, clients need motivated and encouraged and even challenged to push forward through these options. Many times they may fall and need help getting up.  Again, like a coach in sports, it is the counselor’s profession to not only direct, but also to help the client emotionally and mentally push towards that direction.

Challenging for New Behaviors

According to Egan, it is important to challenge clients to change.  He states,

“Help clients, challenge themselves to change ways of thinking, expressing emotions, and acting them mired in problem situations and prevent them from identifying and developing opportunities…become partners with your clients in helping them challenge themselves to find opportunities in their problems, to discover unused strengths and resources, both internal and external, and to commit themselves to the actions needed to make opportunity development happen (2019, p. 190).

In challenging, Egan emphasizes the importance of the counselor and client relationship which is based on trust and partnership.  A counselor, in the eyes of the client, needs to earn the right to challenge.  Once this is established, the counselor needs to ensure that challenges are presented tentatively but not apologetically, with a balance between not being too harsh but not also too passive.  In addition, counselors need to ensure the challenges are clear and specific.  Challenges also should not make demands or be forceful in nature but provide a structural system of choices.  As the term challenge indicates, it is never easy, so help clients utilize unused strengths to help meet the challenges and the ability to build on successful challenges to meet new ones (2019, p. 220-225).  As Egan points out, the counselor should be a “catalyst for a better future (2019, p. 190)”.

Many times, a counselor has to identify what is preventing the person from being able to face a challenge in life

In challenging clients, many times, they have many inherent issues that are already hampering them with the problem and maybe life in general.  To help clients become more resilient and able to create new behaviors, counselors sometimes need to identify blocks and issues within the client.  Egan lists a variety of target areas that negatively affect a client’s ability to respond to challenges and delay productive and healthy change.  Through attending, listening and responding, a counselor is able to identify certain issues that may restrict the ability of a client to respond effectively to challenges.

The first issue Egan lists are what he refers to as self defeating mindsets that include “assumptions, attitudes, beliefs, values, bias, convictions, inclinations, norms, points of view, perceptions of self and the world, preconceptions and prejudices (2019, p. 190-191)”.   Albert Ellis looked at facing irrational beliefs head on with interventions that would challenge irrational mindsets.  According to Ellis, many individuals have flawed misconceptions on life.  Egan lists a few of these ideals.

  • I must only be liked and loved in life
  • I must always be in control in life
  • I must always have my things done my way or no way
  • I should never have any problems
  • I am a victim and not responsible for any of my issues
  • I will avoid things that are difficult
  • I believe my past dictates what I do in the future
  • I do not need happiness in anything or anyone else

(Egan, 2019, p.191)

Ellis considered these mindsets as impediments to change because when something did happen that was bad, the person would tend to “catastrophize” it and become unable to adjust to the problem or even be remotely open to challenges to face it.  In addition to these mindsets, Egan points out that some individuals embrace in four fallacies that hamper change, as according to Sternberg.  Among those listed by Sternberg were egocentrism and taking into account only one’s own interests, omniscience and thinking one knows everything about the issue, omnipotence and feeling one can do whatever one desires and invulnerability and one will never face true consequences (2019, p.192).  Obviously these four fallacies are undesirable characteristics and whether naive or part of a greater personality disorder, they are issues that can prevent true change in the client.

In addition to mindsets, some individuals may have self defeating emotions and feelings that prevent them from achieving goals.  They may possess low self esteem or poor self image.  They may have fears that prevent them doing greater things.  Others may possess various dysfunctional behaviors that are external in nature.  In essence, the person cannot get out of their own way in life.  Their behavior, unknown to them sometimes, continues to create the issues they are trying to escape. Others may possess discrepancies in what they feel and think in regards to what they say and do and how they view themselves versus how they are truly viewed by others. Other times, individuals can be hampered in making true change or answering challenges because of unused strengths or resources (Egan, 2019, p. 194-197).

Other “Blind Spots” within the client preventing and hampering change can include various levels of unawareness.  This can include being blind to one’s own talents and strengths seen by others but not perceived by the self.   Some individuals may be unaware due to self deception itself, or choosing ignorance.  Some individuals will avoid issues and problems because they simply would rather not know because the truth may be too terrifying.  In helping clients challenge themselves to new behaviors, counselors can open clients to new areas of awareness with simple self questions.

  • What problem am I avoiding?
  • What opportunities am I ignoring?
  • What am I overlooking?
  • What do I refuse to see?
  • How am I being dishonest with myself?

(Egan, 2019, p. 204)

As the counselor, but also a coach, it is important to help clients identify these issues and understand why they are unable to move forward.

Helping Clients Identify These Issues and Healthy Challenging

Carl Rogers promoted a empathetic approach. In helping others face hard realities, a fact based empathetic approach is key.  Showing patience and empathy and carefully presenting the issue with assertiveness but compassion is key in helping the client awaken to certain issues.  Of course, timing, tone, and words all play a key role in helping the client become acceptive.  The counselor cannot come across as afraid to address issues but not confrontational.  Sometimes, certain words, may offset a client or labels, and the counselor will need to navigate why and how to discuss the issue.  Also within this process, the counselor cannot simply give a set of directions but present options.  Finally, again, the counselor needs to present the new awareness and challenge to the client without judgment but in a way that creates self awareness and pushes forward change.

Counselors help motivate clients to change through empathy and supplying the client with appropriate level challenges and options to meet

When discovering hindering blind spots and issues, the counselor needs to become a detective in some respects before he/she can truly become a coach.  What is the client truly trying to say, or hinting at, or half saying (Egan, 2019, p.206)?  Counselors need to help clients understand their implicit thoughts and words and make them become more explicit.  In doing so, counselors can help clients understand themes in their stories, make connections with what may be missing and share educated hunches in feedback (Egan, 2019, p. 207-210).  Counselors can through their hunches, help clients see the bigger picture, dig deeper in the story, draw conclusions, open up more, see overlooked aspects, or even own their own story (Egan, 2019, p. 210-211).



Of course how these opinions and disclosures are presented to the client are critical.  They are part of the art of counseling and also the product of good coaching. A good coach is able to present a deficiency in a player’s form or approach and help turn into change and better performance.  This however involves not tearing down the player, but building the player up and giving the player the tools necessary to improve.  As an teacher and encourager, a coach is able to transform the problem and help the player have success on the field.  Likewise, an counselor needs to be able to coach his/her client through approaching a weakness and being able to challenge the person to overcome it and make it a strength in the field of life.  Strength Based Therapies as proposed by Pattoni, (2012) help clients label their strengths and identify them and utilize them in variety of goal setting environments. The process looks to expand hope but also create autonomy in facing issues.

When providing factful information and options to a client, a counselor needs to remain empathetic and tactful in delivering the news.  Some news can be shocking to a client and the client may need time or understanding in the process (Egan, 2019, p. 213).  Hence Egan recommends sometimes sharing one’s disclosures and challenges, but he recommends it to be used with caution.  He recommends being sure to use it sparingly, appropriately and culturally aware.  Timing can be key.  One does not wish to have one’s own disclosure to become a distraction (2019, p.215).

As a counselor and coach, how one gives suggestions and recommendations for better improvements are critical.  Inspired first with empathy and secondly aware of internal issues of the client, a counselor needs to approach and challenge the client without confronting but at the same time presenting clear and factual options to promote change.  These challenges are not easy, so like a good coach, a counselor needs to find ways to provide encouragement during the change process.  Counselors should invite clients to challenge themselves and help them identify specific challenges that will make the best changes.  Like a sports coach, while identifying any issue, the counselor needs to encourage and identify strengths to overcome a particular challenge.  Furthermore, the challenge needs to be evaluated as not to be too intense to be self-demeaning to the client.  Sometimes, success is built upon.  So when identifying challenges, the counselor needs to present them in a fashion that leads to success (Egan, 2019, p. 220).

As a counselor-coach, a counselor identifies changes that are essential and helps the client identify change.  Some clients are more resistant to change.  In another blog, we discuss the Client Change Scale which lists the levels of difficulty for a client to accept change or implement it based on their stage.  It is the counselor’s job to help the client see the necessity of change and help the client find it through encouragement and help.  Some changes will be first order, or deal with the current situation, or others may be second order and more long term or permanent.  This depends on the nature of the issue and the needs of the client.  The counselor like a coach, helps the client implement goals, strategies and plans to implement the change.   The counselor helps the client see his/her possible self, delve into creativity,  and think differently (Egan, 2019, p. 315-318).  In essence, the counselor helps the client see a better future, set goals to attain it and help them put it into action (Egan, 2019, p. 314).



Counselors are like coaches.  They need to challenge their clients by identifying weaknesses and help clients overcome them with appropriate challenges.  This involves active attending and responding to the client and understanding the inner challenges the client faces.  The counselor then is able to better become a catalyst of change in the clients life with setting appropriate challenges to make the client a better person in the field of life.

Please also review AIHCP’s multiple counseling certifications in Grief Counseling, Christian Counseling, Life Coaching, Anger Management, Stress Management and Crisis Intervention Counseling

Please also review AIHCP’s Grief Counseling Certification, as well as its Christian Counseling Certification.  Other mental health certifications for both pastoral and clinical counselors, or those engaged in the Human Service Fields, include Stress Management, Life Coaching, Anger Management, and Crisis Intervention. The programs are online and self study and open to qualified professionals seeking a four year certification in any of these fields.









Egan, G. & Reese. R. (2019).”The Skilled Helper: A Problem Management and Opportunity-Development Approach to Helping” (11th Ed). Cengage

Additional Resources

Sutton, J. (2022). “Motivation in Counseling: 9 Steps to Engage Your Clients”. Positive Psychology.  Access here

Sutton, J. (2022). “How to Perform Strengths-Based Therapy and Counseling”. Positive Psychology. Access here

“The Skill of Challenge in Counselling”(2019). Counseling Tutor. Access here

Voitilainen, L. et, al. (2018). “Empathy, Challenge, and Psychophysiological Activation in Therapist–Client Interaction”. Front Psychol. 2018; 9: 530. National Library of Medicine. Access here


Responding Skills in Counseling

In the previous blog, we discussed listening skills and observing skills of the client.  Good listening and observation set the stage for proper responses.  In this blog, we will shortly review core concepts in turning listening into positive and productive  counselor responses that help the client through the counseling process.  Attending skills are essential in any type of counseling, especially grief counseling.  When these basic skills are absent, the client can feel neglected or misunderstood.  Good grief counselors, whether licensed clinical counselors or non-clinical counselors, are able to incorporate these skills to enhance the therapeutic nature of counseling and keep the client as an active and on going participant in his/her mental health.  Bear in mind, good responses are not necessarily saying the most profound or theory correct statement, but the particular response that is best for the particular stage of counseling and needed comment.  Sometimes the responses may be short or longer, statements or questions, informative or probing, but they all have a particular reason and are the tools of the trade in discovering issues and helping clients find better outcomes.

Identifying Emotions in Counseling

Grief Counselors need to identify emotions when preparing a response or prompt to help the client’s story proceed smoothly

In the last blog, we spoke about the vital importance of observation and how a grief counselor needs to identify verbal but as well as non-verbal cues in a client that can illustrate a particular issue or feeling.  In formulating therapeutic responses, grief counselors and other counselors need to identify the particular emotion of an attending client.  This involves identifying the words associated with the emotion, implicit and unspoken emotions, and any non-verbal cues of the emotion expressed (Ivey, 2018, p., 170).   Based from the core universal feelings across cultures, a counselor should watch for sad, mad, glad and scared (Ivey, 2018. p., 171).   These are root words for all emotions and a grief counselor can build from these words to more complex emotions.

It is crucial to employ empathetic responses.  Like the previous blog, which emphasized empathetic listening, again, the word empathy appears in counseling.  The grave importance of empathy allows the counselor to become involved in the client’s state of being in a true and understanding way that helps the counselor produce productive and positive change.  Empathetic responses help the client feel understood and not judged, or admonished.  Hence, responses to emotions need to be empathetic and caring in nature.   Egan reports three important types of empathy in responding from the work of Arthur Clark.  He first lists subjective empathy, which puts the counselor literally in the client’s life and helps the counselor understand the emotional state of the client.  Second, he lists the term objective empathy which ties to the studies of the counselor and the counselor’s own personal experience in counseling.  Tying these together is a third type of empathy referred to as interpersonal empathy, which ties together the client’s feelings and the way the counselor is able to communicate it as well as any needed information (Egan, 2019, p. 132-133).

Interpersonal empathy involves the ability to perceive the issues, the know how to state it and the assertiveness when to input it (Egan, 2019, p. 134-137).  Grief Counselors need to perceive the emotion on display, the ability to articulate it and the assertiveness to sometimes address it when uncomfortable.  It is important to report what is said back with empathetic accuracy (Egan, 2019., p. 137).  Ivey also emphasizes the importance of accuracy in naming particular emotions.  He points out that counselors should use the words to describe the emotion by the client and also attempt to articulate the emotion with name and when only seen non-verbally as close as possible to what the client is experiencing (2018, p. 171).  Egan continues that is important when naming emotions to remain sensitive when naming them, as well as to not over-emphasize or under emphasize them.  He also encourages counselors to be aware of cultural sensitivities as well when naming particular emotions (2019, p. 139-142).


Prompts in Counseling

Some clients may speak openly about issues of loss, trauma or everyday issues.  They are a flood of information.  Other clients may be more shy, untrusting, or quiet in how they detail their issues.  Obviously, building trust is key within the therapeutic relationship and plays a large role in receiving vital information during the listening phases. However, sometimes it takes various prompts, nudges, or encouragements to help a client discuss difficult issues.  The art of counseling involves keeping a steady dialogue and flow between client and counselor and this falls upon the counselor’s shoulders to ensure this productive process.  According to Egan, probes are extremely beneficial in helping clients engage more fully, especially with more reluctant clients, in identifying experiences, feelings and behaviors.  They further help clients open to other areas of discussion and engage in conversation with more clarity and specifics.  They can also help clients remain on target and on important issues (2019, p. 177).

There are a variety of ways to help a client continue the story through prompts such as paraphrasing, summarizing, or open ended questioning

Some encouragers can be as simple as “uh huh” or a simple phrase of understanding which serves as a bridge for the client to continue speaking (Ivey, 2018, p. 148).  Sometimes, as simple, as saying “I see” or “okay” or “please continue” are strong enough phrases to encourage the client to continue the story. Sometimes the counselor can merely restate the emotion in a particular tone expressed by a client which further facilitates further discussion.  These simple prods can break silence and encourage the client to continue with the story.  Others can be simple non verbal movements, as a nod of the head, a particular look or leaning forward (Egan, 2019, p.161).  Prompts, probes or nudges can also take the form in longer responses.  Counselors can make statements, requests, or ask particular types of questions to better understand the story and also to properly push it forward.

Questions in particular have high value in counseling.  They help the counselor not only understand and clarify points, but they also show the client a sincere interest on the part of the counselor and sometimes can push the client to delve deeper into an issue and find more self discovery.  Questioning, however, for the pure purpose of questioning can be counter-productive and make the client feel they are being interrogated, so questions need to be utilized sparingly and effectively (Egan, 2019, p. 163).   Ivey points out that there are types of questions that are open and closed (2018, p. 124).  Both have their purpose and time but need to be utilized properly in order for the question to be effective.   Open ended questions, as a rule, should be utilized most.  These types of questions do not end with a simple response of “yes” or “no” by the client but look to abstract more information and input from the client.  According to Ivey, most open questions begin with the words “how”, “what”, “where”, “when” or “could” (2018, p. 124). Close ended questions look for a particular concise answer and have value but usually are used when the counselor is looking for a particular answer while the counselor is primarily talking during the session.   Another great question is the “what else question”.  This question looks for any additive elements to the story or if the counselor is missing anything (Ivey, 2018, p. 125).  Remember, if the counselor does not understand something, then questions or statement looking for greater clarity are better than pretending to understand.

Another important prompt involves paraphrasing.  Paraphrasing is a useful tool utilized in responses by counselors to help keep the conversation going or to help the client hear reflectively what the client has stated.  Sometimes the mere power of hearing something back has immense value.  When a counselor paraphrases, the counselor usually states the emotion in a sentence and then concludes with a “because” phrase.  For instance, a counselor may paraphrase to a depressed client by stating, “you are depressed because you no longer feel any energy”.  This paraphrase can illicit additional information or continue the conversation, much in the same fashion as a simple nod, or phrase.  Ivey points out that paraphrasing is not repetition but also adding some of the counselor’s own words (2018,p. 148).  It is important to note that when paraphrasing, if something is worded incorrectly, the counselor should apologize and ask for deeper clarification.  Sometimes, hearing certain things back can trigger an individual, or if worded differently, and the client is not ready to hear the interpretation, the client may respond quickly, or begin to close up.  Cultural issues can sometimes play a key in this.

Finally, Summaries are a critical promoting tool in responding to a client. Summaries are more detailed paraphrases that adds more depth to the conversation.  They are usually utilized to begin an interview to help bridge the previous meeting, or to conclude a meeting, but they have other purposes as well during the session (Ivey, 2018, p. 148).  Egan points out that sometimes a more detailed summary can help during a session when the discussion is not going anywhere.  They can also be utilized to help the client see a new perspective (2019, p. 178-179).   A counselor utilizing a summary for purposes of illustrating a new perspective can state “I’d like to get the bigger picture… or “I’d like to put a few things together” (Egan, 2019, p. 179).   According to Egan, it is also important to help clients create summaries.  The counselor can ask the client to put together the major points or concerns of the issue and to articulate them Egan, 2019, p. 180).

Carl Rogers saw the importance of these ways to respond.  In this Basic Listening Sequence BLS, he saw the skills of the counselor in how he/she responds to be most crucial.  The utilization of open/closed questions, encouraging, reflecting feelings, paraphrasing and summarizing were all critical elements in the empathetic relationship and understanding the story (Ivey, 2019,p.194).

Pitfalls to Avoid When Responding

Responses while helpful can also be detrimental when not properly utilized by the counselor during a session.  A counselor needs to avoid certain responses that derail the process or make the client uncomfortable.  Not responding or asking too many questions are two extremes to avoid.  Not responding can remove merit from a statement or display disinterest to the conversation.  While sometimes silence can be powerful, not saying anything or responding is usually non productive to the counseling session (Egan, 2019.p. 155).  It is also a dis-service merely to respond for the sole purpose of it.  Counselors should avoid parroting or repeating without context  Parroting dismisses any empathetic response (Egan, 2019, P. 156)

Counselors need to avoid distracting questions when working with clients

In addition to not responding, some counselors misuse questioning.  They can either over utilize it and make the session appear as an interrogation, or ask distracting questions that inflame rather than heal.  For instance, instead of responding with empathy, some counselors can ask inflaming and distracting questions that upset the client.  Instead of focusing on the client’s feelings, the question looks at how the client may have responded. “Did you confront him” or ” Did you do anything at all” or “Are you positive you cannot resolve this” (Egan, 2019., p. 155).  These questions again distract from the story and the emotion and can cause irritation in the client as he/she focuses on a personal injustice or slight.

Cliches are another responses that should be avoided.  In grief counseling,  cliches are counter-productive.  In general counseling, they are also counter-productive.  Cliches can minimize the conversation and cheapen it.  They attempt to replace understanding and empathy with a more generic and impersonal response (Egan, 2019, p. 155).  Clients can hear cliches from the next door neighbor, they do not need to hear them from trained professionals that are their to help assist them in resolving issues.

Another pitfall is how counselors advise clients.  In the counselor-client model, most people expect advise from a counselor.  Other cultures may demand it.  However, in counseling, the counselor does not exist to advice a course of action, but presents a host of options for the client to choose. The client is in control and the counseling relationship is one of teamwork and collaboration.  When the client is told what to do, then the counseling relationship strips the client of self discovery and self healing.  The client is not looking for a family member to give un-wanted advice, but a set of options.  Instead of saying what to do, instead utilize “if I was in your situation, here are a few options that I might look into” (Egan, 2019, 156).

Interpretations based on theories and models are also tempting responses that have a time and place but usually not in responses.  A counselor may have a wealth of knowledge to share, but when interpretations and labeling of an client’s state of mind overtake empathetic responses, then the process of counseling can become derailed.  Instead of giving a moralistic interpretation based on past study, respond to the client’s feelings (Egan, 2019. p. 155).

Counselors need to be also honest in their responses to a client.  Pretending to respond with ingenuine “Uh huh” or “Ok” can lead to later issues when the counselor is expected to remember or understand something previously stated by the client.  Hence if, one loses sight, or track of a story, it is far better not to pretend to understand but to ask for clarification.  This is not only polite and professional but it also shows genuine interest and also pushes the client to better explain the issue which alone may be beneficial (Egan, 2019, p. 157).

Finally, a counselor’s response should not be sympathetic and agreeing for the sake of being so.  Empathy is far different than sympathy.  Many times sympathy can drown logic and allow one to lose focus on the facts.  An empathetic counselor while caring remains grounded.  The counselor response is not overtly sympathetic or judgmental but one that addresses emotion and the issue in a caring way.  The client is looking for help beyond a shoulder to cry on (Egan, 2019, p. 157).


A grief counselor’s response to a client is key in helping the client tell the story.  The response is tied to good observation of the client’s emotions.   Good responses are helpful in transitioning the story, moving it forward, but also in in proper feedback about the story.  Empathy is the guiding force in responding.  Grief Counselors can utilize nudges or prompts with verbal and non-verbal responses. Some verbal responses can be one word or a phrase, while some may include paraphrasing or summaries.  Good counselors utilize responses like an artist and interweave them throughout the counseling process.

Please review AIHCP’s multiple mental health certifications including Grief Counseling and Christian Counseling

Please also review AIHCP’s numerous mental health certifications that involve counseling skills.  AIHCP offers a Grief Counseling Certification, as well as a Christian Counseling Certification.  Other topics include crisis counseling, stress management and anger management.  All of the programs are online and independent study and open to qualified professionals seeking a four year certification.








Egan, G & Reese. R. (2019). “The Skilled Helper: A Problem-Management and Opportunity-Development Approach to Helping” (11th Ed). Cengage

Ivey, A. et, al. (2019). “Intentional Interviewing and Counseling: Facilitating Client Development6 in a Multicultural Society” (9th Ed.) Cengage





Additional Resources

Bennett, T. “Empathic responding (or active listening) in counseling: A basic, yet essential response for counselors to master in their practice”. Thriveworks.  Access here

Sutton, J. (2022). “Communication Skills in Counseling & Therapy: 17 Techniques”. Positive Psychology. Access here

“ENCOURAGERS, PARAPHRASING AND SUMMARISING”. Counseling Connection.  Access here

“What Are The Benefits Of Paraphrasing In Counseling”. Processing Therapy.  Access here




Grief Counseling Video on Journaling

Writing about our feelings is an important way to express in a positive and healthy way.  Within CBT it has numerous effects in helping the person reframe and identify troublesome emotions and behaviors. It allows one to express but also cognitively review and respond to the self.

The power of journaling. Please also review AIHCP’s Grief Counseling Certification

Instead of maladaptive coping, journaling helps the individual express without hurting oneself with damaging practices that lead to worst grief responses.  It grants the person privacy in expression but also grants the person control.  The person controls what is written as long within the confines of where the person writes, the person is able to safely release the pain in a positive way.

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.


Please review the video below

Neurotransmitters and Mental Health Video

Neurotransmitters play a big role in our mental health from a physiological view.  They are important chemicals without our brain and body that balance various moods.  Serotonin for example when balanced regulated mood disorders such as depression.  Proper balance and understanding of these transmitters play a key role in mental health.  Sometimes it is diet, other times it may require medication to find balance, but most licensed mental health care professionals can help individuals find the mental help they need if an imbalance occurs.

Neurotransmitters play a key role in mental health. Please also review AIHCP’s Grief Counseling Program


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 seeking a four year certification.  AIHCP also offers a variety of other mental health certifications for other professionals as well.



Please review the video below

Strategies and Prompts in Helping Others Grieve

Grief is a life long process.  Individuals deal with grief or loss to some extent on a consistent basis throughout life. The more significant losses remain with individuals and the ability of the individual to process the loss, understand it, incorporate it and exist with it are key to normal grieving styles.  Those in the field of grief counseling on both the non clinical and clinical side need to sharpen their talents in helping individuals process the loss in a healthy way and be able to find continuing meaning in life.  This involves not only understanding the various therapies on the more broad spectrum of treatment but how to micro handle daily sessions with individuals with minor positive interventions.  Hence while one may employ CBT as the broad approach to help one heal, the daily encounters and how these encounters occur, allow the overall therapy to take root finds its productivity in certain skills and abilities.   Some of these skills deal with how the grief counselor reframes thoughts, repeats words, shows empathy, or other verbal strategies to help emphasize certain parts of treatment, but positive interventions during treatment involve notation of certain parts of the journey within the inner dynamics of whatever treatment.  As the person tells their grief story, finds self, relationship, memories and continuity within the grief story of one’s life, the counselor plays a key role in highlighting these points.

Grief Counselors can help individuals find meaning in loss through various strategies and interventions throughout the process.



Junietta Baker McCall’s text “Bereavement Counseling: Pastoral Care for Complicated Grieving” lists a variety of positive strategies and helpful interventions in chapter 7.  She discusses how the therapists or grief counselors can help guide the person in the person’s grief story, sense of self and relationship, and the building of memories and continued continuity in healing through various prompts and interventions during sessions.  These insights go far deeper than a general discussion of a therapy, or utilization of counselor skills, but look at certain points in therapy at a much more micro level where the grief counselor can better help the person through a particular session and goal.  She states that specific strategies and interventions can be “used to respond to grief … and suggest possible ways to engage the grieving individual (McCall, J. 2012, p. 223).



Strategies in Narrative Therapy

Grief Narrative is a therapy within all overall models of CBT, Psycho Dynamic or Humanistic approaches.  It is the re-telling of the person’s loss and trauma.  It is where everything begins in the healing process.  It permits the person to vocalize the inner feelings and share the loss.  It permits communication and healing and allows for reframing and eventual change in understanding the place of the loss within the person’s life.  Obviously for it to be successful, depends not only the story being told but how the grief counselor is able to guide the individual.

Counselors should utilize the story as a way to develop a caring model relationship that enables them to understand their client.  The story needs to be encouraged to be told no matter the sadness and shared.  In doing so, the grief counselor should grant the person space and time to comfortably tell the story.  The grief counselor should repeat words that need repeated for the person to hear his/her own words echo, as well as show empathy and interest in the telling of the events.   In this way, the grief counselor shows engagement and can later model future healthy grieving models (McCall, J. 2012, P. 225).

Throughout the story, it is important for the grief counselor to accept the therapeutic nature of the grief story.  What matters most is the here and now of the story, not what others think.  At this moment, the important part of healing is the subjective truth of the story to the person.  How does the person feel at this moment in the here and now (McCall, J. 2012, p. 226).  Remain empathetic throughout the story and remain an advocate for the person as the story continues and upon completion of the story within the session, ask the person if the story has been told to the person’s satisfaction.  Upon completion of the story, share observations, address emotions and remain honest in assessments with possible referrals or information to help the person continue the story for next time (McCall, J. 2012, p. 228-229).

With guidance, the story’s initial subjective truths can correlate with objective reality.  The person may recognize various issues within the story, such as blame, or guilt, or anger that once existed that no longer should exist.  In addition, one can begin to reframe the loss within an objective truth as the person heals.

Regaining Self and Connection

Within the grieving process, many times, the person loses sense of self.  One may have had such dependence upon the other that one can no longer function.  Maybe one identified as a spouse, parent or position and when these things are taken, a person loses this important self image.  Again, obviously various CBT or Humanistic Approaches to help cognitively reframe or heal broken images can be utilized, but it is within the smaller bits of communication with the bereaved, where one moves from one point to the next.

It is critical to address and measure a person’s sense of self within sessions.  Asking questions that relate to a person’s self image and how a person may feel since the loss.  Maybe the person is withdrawing from hobbies or no longer finds interests.  These are important notations that can help one measure if one’s sense of self is damaged due to the loss.   McCall recommends utilizing the term loneliness not to just mean when one is alone but a feeling that can occur in any circumstance.  In addition, she uses the term isolation to refer to any inner experience to withdraw from others (2012, P., 237-238).  The grief counselor while helping the person’s self re-find itself, needs to also help the person find relationship with others.  The counselor can describe ways for the bereaved to reach out to others and in what ways

Reclaiming Memories and Meaning

Grief healing occurs when old memories are properly collected, understood, and properly recalled with the present and possible future.  One is able to find meaning of the loss, no matter what it was, and able to tie the loss together within the chapters of one’s life.  The loss has meaning but does not define completely the self or person.  The person continues with the loss, albeit in a healthy way.  The person is able to build new relationships and write new chapters, despite the existence of the loss.

Helping individuals understand memories and how they connect to meaning and healing are important in grief work. Please also review AIHCP’s Grief Counseling Certification


In helping individuals, whether through CBT or Humanistic Approaches, grief counselors can pay close attention to particulars and emphasize and carefully monitor certain aspects of this transition during sessions.  It is important to see the gradual transformation of the bereaved throughout the process.  A good grief counselor will see when certain parts are not lining up and where to intervene and help the client proceed to the next important step of adapting to the loss.

The grief counselor should utilize all mind, body, soul connections tied with ritual and belief.  These ideals within the person can play key roles in anchoring the person with meaning in the loss. It is also at this point to ensure the bereaved understands the value of working through grief and that while the first step is to survive the loss, there is so much more beyond just surviving (McCall, J, 2012, p. 252-256).  McCall points out it is crucial for the person to understand that surviving the loss is vital to growth but it still not quality of life.  As the person recognizes this survival, the person will start to set aside other destructive maladaptive coping habits.  These habits need addressed in any counseling.

The grief counselor can help the person progress by asking the client to discuss how it was before the loss.  In addition, discuss current accomplishments, as well as offer encouragement.  Ask the client to fantasize what one hopes life to be like in the future (McCall, J. 2012,. p. 257).

In remembering, teach clients that memories can be unbearable and that is OK.  Ask the client what the memory means to him/her.  Let the client know some events make no sense in life and cannot be made into order.  Let the client know he/she cannot change the memory or event, but he/she can learn to grow with it.  Use other examples of similar stories of how others coped, or present ways to help put an intrusive thought to the back mind.  Helping individuals focus on issues when it is safe instead of intrusive and inopportune times helps the person handle emotion and bad memories (McCall, J. 2012, p. 260).  As time progresses, help the person reframe bad memories for more positive outcomes and valuable ways to see the past so one may move forward to the future.

Finding meaning in the present and future also means recognizing healing.  So many times, one only focuses on the trauma, but it is equally important to focus on healing and transformation. McCall recommends to help the person focus on the mystery of life.  Let clients know that they have control of their lives and can dictate what the future holds.  Help clients identify healing moments without guilt.  Let individuals know beyond being aware of healing moments to embrace them, pray for them , hope for them and practice gratitude when they occur (2012, p. 265).

It is interesting to note that Aaron Antonovksy famous for his theories on “salutogenesis” which emphasizes health as something more aligned with well being than focus on pathology speaks of the importance of coherence in health.  For well being and health to exist, he points out three key elements that I feel are important to reframing grief and finding meaning.  He first lists comprehensibility as the belief that things/stressors/loss happen in an orderly fashion.  Obviously, world views can be shattered with grief and any type of well being is destroyed initially after loss.  Secondly, Antonosky points out manageability as crucial to well being in the belief that one has the ability and skills to cope with stressors or loss.  In stress, when an organism is over-whelmed, then breakdown begins, so it is not surprising that Antonosky would point out that for well-being, one must be able to manage stressors or loss.  Finally, he lists meaningfulness as source of coherence and well being.  Meaningfulness is what defines a person’s existence and why one pushes forward.  In grief theory, when meaning in life is loss, then well being suffers.  It is the purpose of grief counseling to help the person adjust to loss by again finding meaning in life with the loss.


Helping individuals throughout the grieving process involves identifying issues and helping people one step at a time. Please also review AIHCP’s Grief Counseling Certification and see if it meets your academic and professional goals

Sense of meaning is critical to overall health.  Without a sense of meaning, health itself can suffer.  So when sense of meaning is restored and connected with past, present and future, then true adjustment can occur.  Grief Counselors play a key role in helping individuals regain this balance and sense of health.  It is sometimes in intense sessions where minor observations and interventions occur that grief healing occurs.  It does not occur immediately, but results in multiple months and sometimes years, helping the person adjust to the loss in a healthy way.

Please also review AIHCP’s Grief Counseling Certification.  The program is online and independent study and open to qualified professionals seeking a four year certification in grief counseling.


McCall, J. (2012). ‘Bereavement Counseling: Pastoral Care for Complicated Grieving”. Routledge

Additional Resources

“Salutogenesis”. Wikipedia.  Access here

Sutton, J. 2018. “10 Grief Counseling Therapy Techniques & Interventions”. Positive Psychology.  Access here

“The psychology of grief – applying cognitive and behaviour therapy principles”. InPsych 2011 | Vol 33. APA. Access here

Kelly, L. (2021). “7 Grief Therapy Techniques for Coping”. TalkSpace.  Access here


Grief Counseling: Assessment and Perception Problems for Grievers and Grief Helpers

Whether operating as a pastoral counselor, licensed counselor or a close friend and confidant in the grief process for a bereaved person, certain biases and perceptions from both the griever and grief helper can hamper the healing process or cloud assessment entirely.  In past blogs, we have talked about grief myths, grief bullies and both the griever and the grief helper’s own biases.  In this blog, we will put all together as one core unit in how these issues can culminate in preventing healing and also hamper one’s ability to help the grieving.

Helping others through grief is naturally composed of both healthy and unhealthy perceptions, biases and sometimes myths about loss itself.


Grief Myths

Grief myths exist in society and can attach to a particular griever, grief helper, or grief bully.  They prevent true healing because they mislead about the true nature of normal grieving itself.  They help form bias within the individuals toward a particular grieving process.  In Junietta McCall’s text, “Bereavement Counseling: Pastoral Care for Complicated Grieving” there are various problematic implications that occur due to bad perceptions.  Among them, McCall lists the denial of the necessity of grief work, the fact grief should always be simple, that any type of extended grief is due to immaturity or pathology, that grieving is feeling sorry for oneself or seeking attention and finally that grieving and any outward manifestation displays weakness in character or lack of faith (2012. p. 182-184).  When individuals believe grieving is not normal, or that is an attention seeking process, then these myths become problems that infect the person’s bias in both helper and griever.

Personal Bias

Grief bullies are particular guilty of personal bias.  They set timelines for grief and assert rules for expression of grief.  Most are harboring their own interior issues and cannot grieve properly themselves.  These individuals will assert that individuals are seeking attention, or weak in character.  Some may grow with a bias that “real men do not cry” or that it is simply time to “get over it”,  Others who are less bullies but more observers may dismiss other’s grief due to their own bias and simply state “the person never talks about it, so I leave it be” or “I avoid this person because it will turn into a sad and uncomfortable conversation every time” or “I would rather say nothing instead of bringing up the pain” or “She needs to simply have more faith” (McCall, 2012, p. 179-182).

From this comes a series of problems grievers face in their own perception of their loss.  They may question the amount or lack emotion displayed.  They may question if they have grieved or felt bad long enough or not enough.  Common exclamations such as “I should be over this by now” or “It is time to move on” or “I feel obligated to cry more” are all nagging pains within the person as the person encounters the grieving process over time.  Some may feel a religious obligation to feel happy that the person is in a better place and any crying is selfish or may question other emotions of anger or guilt. Others may feel ashamed they are angry with God or have not shown enough faith that the person is in a better place.

Others may feel conflicted based upon relationships with deceased or the nature of the loss itself.  They may feel guilty for not maybe noticing an illness soon enough, or not paying enough attention to someone who passed away and feel it is partly their own fault. The person may feel guilt for not visiting enough or appreciating the person enough.  This perception as well other perceptions can create future issues in the grief trajectory and how a person heals.  The only way these issues and emotions can be properly diagnosed is through talking and identifying them.

The Pastoral Counselor, Licensed Counselor or Grief Helpers Bias

Many times, even those who work as primary help of the bereaved enter into conversations with their own bias. While grief and loss are objective realities, everyone has  particular unique and subjective experience in their reactions to grief.  This incorporates a history of grieving that has good and bad things.  Some things may also be neutral and worked for oneself while one grieved but may not work for others.  This is not to say sharing experience and coping ideas are bad but it has to be done when invited.  Comparing grief and offering solutions that may have worked for one’s personal self may not work for others.  One should not be upset if one’s particular advice does not lead one to healing but understand that a grief helper is there to listen and sojourn with the bereaved and the griever’s own particular loss in the griever’s own particular way.  Biases of past experience hence can be helpful or detrimental based on a case by case basis.

Yet, biases inherently are part of the care and healing process and when used correctly can supply large doses of wisdom and knowledge to healing. The care process, according to McCall, involves both the griever’s bias and the helper’s bias.  This leads to two sets of perceptions, thoughts, feelings and beliefs (2012, p. 175).   In healthy outcomes, this feedback loop meets the needs of the given grieving situation and promotes healthy healing.

Grief helpers can play key roles in helping identify issues that relate to griever’s bias, beliefs or perceptions due to grief myths or personal complications within the grieving process.  McCall lists numerous ways pastors, counselors or friends can help the bereaved through difficult times.  McCall lists the critical importance of making careful observations, building healthy relationships, furthering necessary treatment and promoting professional and healthy behaviors (2012, p. 186).

Careful observations push the intuitive abilities of a helper to notate issues that may be arising during the grieving process.  This involves not only note taking but also looking for non verbal clues as well as understanding the person’s past history to better identify issues that may be affecting the current grief process.    Three key consultation questions arise.  First, what is the counselor paying attention to and what could he/she be missing or taking for granted? Second, is something unsettling oneself or making oneself uncomfortable about a particular griever and what is it about? And finally, is the counselor helping the person or getting in the way? (McCall, 2012, p,. 196).

Beyond observations emerges the importance of building a healthy and professional relationship with the bereaved.  One that is helpful and not leading to co-dependence but one that is promoting a healing process where the bereaved will be able to again move forward in life.  This involves identifying with the person and forming an understanding of their pain.  It involves empathy, listening, communication and helping the person form connections from past, present and future (McCall, 2012, p. 189-192).

The third key according to McCall is integrating treatment based upon perceptions.  These treatments are unique for each individual griever and may depend on the griever and the nature of the loss.  Treatments can range based on the person but it involves good note taking and documentation of challenges and issues that appear during the grief trajectory.  These notes and documents help the grief counselor make better assessments and plans of action.  Maybe a particular griever needs a particular therapy best performed by a specialist in it, or maybe the griever needs to be seen by a licensed counselor instead of merely a pastoral counselor.  Maybe CBT is a better resource than a Humanistic approach, or psychodynamic approach?  Maybe this individual would benefit from journaling, or instead of journaling, other forms of artistic expression?

Finally, a review of oneself is critical.  It illustrates how one is reacting to the griever and how effective one is being in terms of helping the individual in his/her progress in grieving.  In analyzing oneself, one is better able to see how one has been successful and not with this particular griever and what things may need adjusted or even if one needs to step back and allow another with more experience or expertise to resume the role in the care plan.


The grief process is about human beings.  The griever and helper are on a mutual journey upon the grief trajectory.  Perceptions, bias and process are all part of it.  Some individuals have unhealthy bias and myths about grief and their perceptions are detrimental while others have healthy perceptions which aid in healing.  The dyad process of two individuals and their past, perceptions and ideas all constitute part of the care model and ultimate healthy grieving outcomes.

The care model of helping others through grief is between the bereaved and helper. Please also review AIHCP’s Grief Counseling Certification


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 seeking a four year certification in Grief Counseling.


McCall, J. (2012). “Bereavement Counseling: Pastoral Care for Complicated Grieving”. Routledge.

Additional Resources

“6 Myths About Grief”. PsychCentral.  Access here

Williams, L. (2015). “64 Myths About Grief That Just Need To STOP”. What’s Your Grief.  Access here

Feldman, D. (2019). “Five Myths About Grief You May Believe”. Access here

Haley, E. (2017). ” “I should have known…”: Understanding Hindsight Bias in Grief”. What’s Your Grief. Access here



Humanistic Approach in Counseling and Grief

There are many schools of thought in treatment of individuals facing emotional and mental distress.  Psycho-analysis, behavioral and cognitive schools look at each different human lens of existence to help individuals find balance and happiness.  Psycho-analysis delves deep into the past to find answers to trauma, pain, pathology or issues plaguing a person.  In this venue, we see the seed of Sigmund Freud’s thoughts.   Behavioral strategies look how one’s behavior can be modified to alter mental and emotional issues.  Ivan Pavlov demonstrated the role of classical conditioning on the a person’s behavior.  Cognitive schools emphasized the rethinking aspect to helping others overcome mental and emotional issues. Aaron Beck in the 1960s would combine behavior and cognition as a way to help others via Cognitive Behavioral Therapy.

Another type of way to address human distress is Humanist Therapy.  This type of behavior which has success for many is holistic in nature and looks at the now instead of the past to find healthy balance within a person.  It is far more patient based and subjective in nature.  Due to its greater emphasis on self-happiness and subjective view of self, it focuses more on the person’s emotion in the present and its interaction with others.  It looks to restore and find balance within the person.  It finds its conclusion through authenticity with self and room for self growth in the present and relationships with others (Sherrell, Z,, 2023)

This has many implications within grief.  Grief can shatter a person’s self image and world view.  Humanistic approaches can help restore confidence and hope. It is very sensitive to the needs of the person.  While it may not alone suffice for all cases, it can definitely contribute to specific needs of the grieving person.  In this blog, we will shortly review the nature of the Humanistic Approach for grief, its strengths, its weaknesses, and how it can be incorporated.

Humanistic Approach

Humanistic Therapy is a more holistic and emotional direct therapy that focuses on emotion in the present and how to deal with those emotions in relationship to self and self worth


The idea of meeting human needs to find balance has many strengths in psychological thought.  Abraham Maslow’s famous hierarchy of needs sketched a thorough outline of how when human needs are not met, pathology and dysfunction can occur.    Carl Rogers, however, established the Humanistic school of thought.  Rogers wished to treat the entirety of the human person and felt the imbalance or lack of fulfillment in life constituted the biggest problem to individuals.  He labeled the term congruence to distinguish between healthy balance in life that reflected interior perceptions with the outside world.  When balance occurred, Rogers believed human beings display healthy mental and emotional behaviors.  When incongruence emerged or imbalance between self and the world, then person’s mental and emotional health suffered (Mcleod, S., 2024).

Rogers Humanistic Approach centered upon the needs and desires of the person.  It revolved around the now and the relationships within the person’s realm.  The first key elements were regarding self image and self worth.  A person’s self image correlated with how the person viewed oneself in life, his/her existence and relationship with others and how the person fits (Mcleod. S. 2024).  Self image focuses on a person’s perceived value (Mcleod, S., 2024).   In contrast, the existence of the real self, the actual depiction of the person’s existence can cause distress and imbalance.  Identifying the real self is essential in understanding oneself in all the good and bad that exists within.  It is the starting point to reaching the ideal self.  The ideal self is what one hopes and strive to become.  When the ideal self and self image are imbalanced, congruence is not achieved and a state of incongruence exists that causes unhappiness and discontent as well as unhealthy psychological conditions (Mcleod, S., 2024).

According to Rogers, it is hence important to have a high positive regard with self worth.  Individuals with a high self worth can grow and handle stressors and difficulties, while those with a lower self worth encounter difficulties in life and have a hard time growing from negative events (Mcleod, S., 2024).   Rogers believed that a full functioning person reaches a state of actualization when congruence occurs ands is able to better live a fulfilled life.  He identified five primary characteristics to congruent individual.  He pointed out that one is open to new experiences, living existentially in the moment, trusting one’s feeling, displaying creativity  and living a fulfilled life (Mcleod, S., 2024).

The Humanist Therapist hence needs to help the person cultivate a higher self worth and find congruence.

Humanistic Techniques

In cultivating higher self and congruence, unconditional positive regard is employed that accepts the person for who he/she is and offers little criticism.  Rogers felt that conditional positive regard later put conditions on love or behavior that could negatively shape an individual’s development.  This less structured technique embraces the authenticity of the person and looks at the subjective needs of the person.  It places the Humanist Therapist into a place more of guide and equal than true authority figure in counseling.  The counselor utilizes deep empathy and rephrasing skills to help the person find congruence and balance.

One critical technique employed by the Humanist Therapist is Gestalt Therapy.  Gestalt Therapy focuses on the present and its emotions and how to better understand and grow from them (Dexter. G., 2022).  It helps one be more mindful of current situation and emotions and how emotions interact with current relationships in life.   It helps an individual better identify emotions, utilize them and communicate them with others (Dexter, G., 2022).   Some common themes found within Gestalt Therapy includes the “Empty Chair” where one pretends to speak to someone and role playing with the therapist to communicate emotion (Dexter, G. , 2022).

In addition to Gestalt Therapy, Humanist Therapists utilize a very Patient-Centered approach that acknowledges the needs of the patient and places a great importance on equality between client and counselor.  The counselor plays a key role in building the person’s self worth and avoiding judgement.  The therapy again is focused on the present and is more broad spectrum holistic instead of focusing on one particular issue.

Other techniques include Narrative Therapy which identifies values, Existential Therapy which identifies place in the world, and Logotherapy which focuses on helping individuals cope with difficulties and trials in life (Cherry, K., 2023).

Benefits and Disadvantages

When Humanistic Therapy is utilized there are benefits and disadvantages.  Obviously, helping one’s self esteem can empower someone to retake one’s life and move forward in life.  Self image and how one perceives oneself is essential to mental and emotional well being.  This holistic approach treats the entirety of the human person, helps one find empowerment, self acceptance and confidence, and grants the client an empathetic and non-judgmental guide (Sherrell, Z., 2023). However, there are limitations and possible weaknesses to the therapy.  It has the potential side effect of creating a dependency on the therapist, as well as not addressing acute issues in one’s mental health.  The lack of structure can also be counterproductive to certain personalities, as well as being very intensive emotionally and time consuming than other therapies (Sherrell, Z., 2023). It is also very subjective in nature.  The ontolology towards happiness is not a particular code but instead revolves around what one needs and wants.  This can sometimes create a disordered approach to what is right and wrong versus what makes someone happy.

Humanistic Approach in Grief

I think the approach has many benefits for grieving, albeit, I do not think it should be the only way one works with the grieving.  Obviously, different people need different strategies.  Some grieving individuals may need more cognitive and behavioral guidance with structure, while others may greatly benefit from a unstructured and holistic approach on emotion.  Some may greatly benefit from a mixture and blending of strategies.

Obviously when dealing with depression and emotion, the self image, self worth and the ideal self is key for happiness. Many depressed individuals have major self esteem issues and the techniques and practices in the Humanistic Approach can play a key benefit in helping a grieving individual find congruence and balance.  It can help the person understand the emotions, their connections with others, and how one can grow from loss and find connection again in life.


The Humanistic Approach has many advantages but its ultimate success depends on the needs of the griever and what therapy is best. Please also review AIHCP’s Grief Counseling Certification

I feel the Humanistic Approach is  best utilized in an integrative approach with cognitive and behavioral practices to better help the person not only emotionally but also grant the person ways to cognitively reframe issues.  The grave importance of self image, happiness and balance cannot be overlooked and are essential aspects of finding long term emotional and mental health.  Different individuals have different needs.  Some benefit better from a singular approach, while others from an integrated approach. Ultimately, when helping the grieving, the best therapy for the individual is the one that best meets the needs of the person.  If a licensed counselor is not comfortable or acquainted enough with one therapy, then referrals should be encouraged, but for those with comfort in a particular therapy or multiple disciplines, then one can truly begin to help others from a multi-faceted angle.  The Humanistic Approach is definitely one that all licensed counselors or those in grief theory should be familiar with.

Please also review AIHCP’s Grief Counseling Certification. The program is online and independent study and open to qualified professionals seeking a four year certification in Grief Counseling.



Additional Resources

Mcleod, S. (2024).  “Carl Rogers Humanistic Theory And Contribution To Psychology”SimplyPsychology. Access here

“Different approaches to psychotherapy”. APA. Access here

Sherrell, Z. (2023). “What is Humanist Therapy”. MedicalNewsToday.  Access here

Dexter, G. (2022). “What Is Gestalt Therapy?”. VeryWellHealth.  Access here

“Humanistic Therapy”. Psychology Today.  Access here

Cherry, K. (2023). “What Is Humanistic Therapy?”. VeryWellHealth. Access here