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