Category Archives: Depression

Suicide assessment mistakes


Yesterday’s post was about suicide. Counselors sometimes fail to adequately evaluate suicidal ideation, plan, or intent in their counselees. Some years ago, I ran across a research study looking at the most common mistakes made by 215 masters level counselors when dealing with suicidal clients. I’ve lost the bibliographic data for the article and couldn’t find it easily in Psychlit…

Here are some of the mistakes (in no particular order):

  • Superficial reassurance (“you have so much to live for”
  • Avoidance of strong emotions (not allowing client to express strong despair–usually with first bullet point)
  • Professionalism (cold and distant, possibly seen as uncaring in assessment)
  • Inadequate assessment (failure to explore fully because of nervousness or fear of asking)
  • Failure to identify precipitating causes (most suicides have both current and historical precipitating events. Counselors may identify historic event (e.g., divorce 4 years ago) but miss the current precipitant.)
  • Passivity; failure to be empathic (25% took this stance)
  • Insufficient directness. No contract to not harm, no next steps
  • Overbearing advice. Counselee needs to be involved in the planning for safety
  • Stereotyping response (“She’s just a borderline!”)
  • Defensiveness (usually about whether hospitalization is necessary)

Every counselor worries about how they will perform when addressing the serious problem of suicide risk assessment. We do well to review (a) our natural inclinations when stressed (e.g., do we tighten up, become over-controlling, too professional?), (b) our standard of practice when confronted with despairing or suicidal clients, and (c) our assessment procedures with all clients. While there is no way to prevent the suicides of highly motivated people, we can increase our capacity to respond well to those the Lord sends our way.

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Filed under christian counseling, christian psychology, counseling, counseling science, counseling skills, Depression, Despair, ethics, Psychology, Uncategorized

Helpful read on the warning signs of suicide


Sunday’s lead story in the Philadelphia Inquirer unfolds the tragic story of two high school girls who committed suicide by stepping in front of a speeding train last winter. The death of a child is always a tragedy. But death by suicide exponentially multiplies the pain. Could anyone see it coming? Could they have prevented it?

The story in the paper details the texts and social networking trail of tears leading up to their final actions. If this event happened when I was a child, the parents might have been left with a note or a journal to pour over looking for clues. But, in this case, there are texts and posts over a long span of time. Even worse, the girls made a number of final texts just before their deaths. It appears that loved ones searched frantically for them while “watching” cyberspace during their final act. I can only imagine that this “real time” aspect multiplies the trauma for the family.

Can we learn anything from this? Yes, I think so.

  1. Pay attention to your child’s (or friend’s) social networking and texts. Clues to their state of mind may well be evident.
  2. Act on concerns; take stock of their actions and attitudes. Per this case, it appears there were efforts to help them. Probably not enough. But let us not judge the family here. It is far too easy to become complacent. A child has strong feelings that they express over a period of time, thus making suicidal expressions normal. After the fact the signs seem so obvious. During the stress, it is hard to discern how bad it really is.
  3. Compounding suffering requires additional interventions, whether the child wants it or not. One girl’s father committed suicide, parents’ divorced requiring a move and change of school, a boyfriend was killed by a car. The more these kinds of experiences happen, the more attention the child needs by mentor or mental health workers.
  4. Even good schools won’t likely pick up on problems. Don’t assume school counselors have enough time to respond. It is not that they are incapable but the sheer number of students to follow makes their capacities limited.

Know that some people commit suicide and no one could have predicted it. Be wary of judging family members. They will live with enough guilt on their own. And yet, look for this recipe of pain and perceptions (summary of Jeff Black’s booklet):

  1. Strong powerful experiences of pain
  2. Perception that the they cannot tolerate the pain
  3. Hopelessness and inability to see alternatives other than relief via suicide
  4. Isolation

Other risk factors to consider: previous attempt? Suicidal ideation/plan? Hospitalization (even for non-psychiatric reasons)? Access to lethal means? Depressive anger coupled with impulsive history. These factors aren’t that helpful by themselves but looking over the total may provide *some* clues.

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Filed under counseling, counseling science, counseling skills, Depression, Psychology, Relationships, Uncategorized

Book Note: Linkages between stress, inflammation, and mental illness


I am in the process of clearing my desk of semester debris. Well, truth be told, I am in the process of clearing a portion of my desk from said debris. The rest will have to wait. In the process, I came across a book I’ve been meaning to read since the dept. purchased it for me: The Psychoneuroimmunology of Chronic Disease: Exploring the Links Between Inflammation, Stress, and Illness (APA, 2010).

Before you all stop reading, it really is an important work! You should care if you are someone experiencing high levels of stress or if you counsel those who do. AND, there IS an answer (you won’t like it!) that can help given at the end of this post.

Yes, it is very technical. You can’t skim this book easily unless you read only the chapter summaries (not a bad idea!). However, I find it very interesting to read about how well-connected (too well!) our minds are with our bodies. Here are a couple of book highlights

1. Chapter one: Stress activates primary and secondary responses that may actually increase our vulnerability to disease. Secondary? Examples given include alcohol abuse, poor diet, non-compliance with treatments. Primary? Your body does a couple of things in reaction to stress. First, your sympathetic system starts looking for inflammation. Immune cells look for an injury. You have more glucose available to burn and cortisol increases which also works to activate anti-inflammatory responses. Inflammation is the problem (a “rapid and nonspecific response to danger”). Too much inflammation? damaged tissue. Too much anti-inflammatory response? Damaged tissue. Those with depression may have become less sensitive to cortisol and so end up with lots of non-specific inflammation. Maybe this is why depression hurts so much!

2. Chapter 3: Poor sleep has serious health consequences, especially concerning chronic diseases. One study indicates that disordered sleep has a direct link to type 2 diabetes, independent of age and body size. Individuals with sleep apneas have a greater production of inflammatory bio-markers. Women may be at greater risk for cardiovascular diseases due to sleep problems than men. One problem (sleep problems) begets the other (inflammation) which creates a vicious cycle.

3. Chapter 4: “Western diets typically contain an abundance of proinflammatory omega-6 fatty acids and are low in anti-inflammatory omega-3s.” (p. 96). In other words, dietary fish oil helps promote healing and may lower symptoms due to inflammatory diseases. More fish oil, less vegetable oil.

4. Chapter 5: Links between stress, depression, PTSD, hostility and inflammation. Each of these things increases inflammation, increases sleep disorders which in turn…(you get the picture).

Okay, does anything help l0wer stress and increase healthy immune system functioning? This is the answer I promised at the top of this post. Are you ready? It is so simple you will hate it!* (that will be something to explore at a later date–why do we resist the things we CAN do to help our situation?)

1. Diet. Having a better (lower) ratio of Omega-6s to Omega-3s (more cold water fatty fish) seem to lower rates of depression. Higher Omega-3 consumption predicts lower suicidality, lower depression, and bipolar disease. It appears these amino acids help stop the overactive inflammatory response caused by repeated stress.

2. Exercise. It will initially raise inflammation markers (hence why many with RA feel that any exercise creates more pain), but later lower it if continued on a regular basis.

3. Counseling. Cognitive-Behavioral social support interventions have shown to reduce the inflammation effect by lowering stress. be effective in doing just that.

So, encourage your stressed clients or friends (even better, do it with them) to eat well, exercise (just walk!) and seek social support. In doing so, they will find relief from inflammation and the effects on the mind and body. I guess it is time for me to get up from this desk, skip the doughnut, and walk up to the library for a bit of exercise. On the way, I should stop by a colleague’s desk and get him to come with.

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*Simple? Yes. Quick fix? No. Sure bet to solve all our problems? Absolutely no.

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Filed under counseling, counseling science, counseling skills, Depression, Psychology

Belief in a loving God and Depression?


Thanks to a friend’s sharp eyes, I learned of this news release from Rush University Medical Center:

Research suggests that religious belief can help protect against symptoms of depression, but a study at Rush University Medical Center goes one step further.

In patients diagnosed with clinical depression, belief in a concerned God can improve response to medical treatment, according to a paper in the Journal of Clinical Psychology.

The release goes on to say that the positive benefit did not stem from hope but in belief in a caring God. What it doesn’t say is whether or not those NOT taking medications get positive benefit from a belief in a caring God.

What do you make of this? Should we get excited when research confirms our established beliefs? Should we look for alternative explanations? I would be curious how they separated hope and belief. Hope and belief that God is active and looking out for you probably encourages you to look for and remember evidence! The more you look for the evidence the more you practice being mindful of something bigger than your despair.

What is your reaction?

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Filed under Depression, Despair, Psychiatric Medications

Physiology Phriday: Depressed? Check your thyroid


One of the most common mistakes made by counselors is to forget to encourage their clients to get specific medical work-ups. There are three key reasons for this problem.

1. Most clients describe their struggles with causes already in place. “I’m depressed because I have a bad marriage, because life isn’t going the way I had hoped.” We counselors accept their initial diagnosis and fail to dig further.

2. We know that counseling works. And so we help them work on their thinking, feeling, and behaviors. We do what we do best

3. When we do send someone to the doctor, we rarely get a clear answer.

Nonetheless, it is essential that your clients have had recent blood work. Case in point. Low thyroid levels often leads to experiences of confusion, mental dullness, and depression. (FYI, overactive thyroid may lead to irritability and anxiety). While there may be real counseling work to be done (everybody needs some help), it would be a tragedy to miss real mercy care (i.e., a better functioning thyroid).  

Check here for some info on hypothyroidism: http://www.endocrineweb.com/hypo1.html

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Filed under christian counseling, christian psychology, counseling skills, Depression

Physiology Phriday: Will I be on meds for the rest of my life?


During the course of discussing a person’s anxiety or depression, the conversation turns to the possibility of using antidepressants. Inevitably, I am asked, will I have to take them forever? Clearly, the questioner does not want to and sees the possibility of taking medication for the rest of their life to be unacceptable. So much so that many resist starting or even going to see a psychiatrist in order to consider whether they might take a medication. Rarely do they ever ask if the medications will help.

Consider for a minute why a person might ask this question. Here’s some of the reasons I think I’m asked this question:

1. Everybody is on them and they never get off (from the viewpoint that too many people take them for every little hangnail and then allow themselves to stay on the crutch forever, never solving their problem)

2. Medicines are for weak people, I’m not weak. (Not sure if the person would have the same response if their medical doctor said their thyroid wasn’t working and so they would need synthroid for the rest of their life)

3. It is only a spiritual problem. Taking the medication will solve the problem but not the spiritual problem. I’ll be avoiding the real issues.

4. I hate medicines of all kind. I hate remembering to take them and I hate their side effects.

5. I don’t think they will really work.

Can you think of other reasons? Now, antidepressants do work from a research vantage point. They are not the silver bullet. They will not make a bitter, angry, depressed person, less bitter. They may help them sleep better, improve their mood, and thus more clearly come to terms with their bitterness. Medications never block the heart from spiritual matters. Only the person who does not want to deal with spiritual matters will use them to avoid looking more deeply inside. God can be found in both suffering and comfort. Whether we will look for him is a bigger question.

So, what if you need them for the rest of your life? What if they really do make it possible to function well? Is our distaste for medicines due to their side effects or due to the fact that we have to accept that we are weak and broken people?

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Filed under Anxiety, biblical counseling, christian counseling, christian psychology, Depression, Psychiatric Medications

Physiology Phriday: Repetitive thoughts?


Have you ever been tortured by a repetitive word, sound, phrase, song, or the like run through your head? Does it happen only during the day? At night when you wake up?

In psychological studies, there are a number of ways people talk about these experiences. Sometimes folks talk about intrusive thoughts/imagery, but this is usually in the context of PTSD or OCD studies. Others talk about rumination or repetitive thoughts, usually in the context of worry, depression, or anger. Finally, another batch talk about hallucinations in regards to psychotic disorders.

But what is going on in the more mundane repetitive thoughts? Diagnostically, they probably fit a bit more in the OCD genre than anything else (like counting, ordering, etc.).

1. Stress is usually a factor. They happen more frequently the more distressed a person is. It means the person is on higher alert than normal. The repetitions may be directly related to the stressor or may not. What is not know is whether the repetitions are a consequence of stress or a mediator of stress. What is known is that when a person, under stress, experiences repetitive thoughts salient to the stress, feels responsible to fix the problem, and attempts to suppress repetitive thoughts, their ruminations are MORE likely to increase.

2. Neuroticism is probably a factor as well. Sorry folks: those with anxious and depressive tendencies have more repetitive thoughts than others.

3. Emotional intensity as a native trait of the person may also be a factor. There is some evidence that individuals with strong emotions have a greater predisposition to PTSD (and therefore intrusive thoughts) if exposed to traumatic events.

But what to do about repetitive thoughts? Have you found anything helpful? There are certain things that are NOT helpful

1. Ruminating over the thoughts (Ugh, I can’t believe I’m still having that thought)

2. Trying to solve the problem they may be attached to

3. Trying not to think about pink elephants

Okay, so maybe those things don’t work. What does? Sad answer? We don’t know. Distractions do for a short time. Some actually give in to them and repeat them outloud to try to quell them. The more it is possible to pay them little notice, the easier it is to let them slide on out of the mind.

Maybe try to consider them an interesting mental quirk–like the lovable Monk (TV detective) 🙂

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Filed under Anxiety, counseling science, Depression, personality, Post-Traumatic Stress Disorder, Psychology

Physiology Phridays: Deep Brain Stimulation


Next fall I will teach “Counseling & Physiology” for the first time so I am beginning now to plan through such a course. It’s my intention to use Fridays to blog on counseling stuff related to the brain and biology. Here’s my first post:

The March issue of the APA Monitor on Psychology magazine has an article on the use of deep brain stimulation for chronic and untreatable depression (after failures with medicine and ECT). DBS is a surgical procedure, first pioneered to stop Parkinsonian tremors, where electrodes are placed in the subgenual cingulate region and a “pacemaker” produces electrical current to the electrodes on a continuous basis. You can read about DBS here on wikipedia. The studies are small as of yet but the FDA has already approved this procedure for OCD patients.

This surgical procedure seems to produce positive feelings and relief from the depression. So, does this mean that depression is merely a biological problem? No. This is why medicines are quite helpful but it is counseling that maintains the relief from depressive symptoms.

Bottom line: Depression is a multi-faceted disorder–both from an etiological standpoint and from a treatment standpoint. One must consider biology, spirituality, cognition, and behavior. These areas are not mutually exclusive as work in one area has impact on the others. Efficacious treatment not only seeks to resolve the depression but also to consider how to live well–whether in a depressive state or not.

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Filed under biblical counseling, christian counseling, christian psychology, counseling science, Depression, Psychology

A window into the world of bipolar disorder


As a teacher I am on the constant prowl for books, movies, pictures, etc. that give a realistic and personal view of the experience of mental illness. I picked up a great book regarding the world of the Bipolar I person: Madness: A Bipolar Life, by Marya Hornbacher (Houghton-Mifflin, 2008).

Marya tells of her life in short chapters beginning with her memories of life as a 6 or 7 year old. It is less biography and more of a sampling of her thought and emotional life. She has severe highs that last for a couple years, severe lows, and many rapid cycling from high to low in a matter of minutes. You can help but get a sense of her inner world from times in the hospital (many times at that) to impact of her medications and the ineffective care by several psychiatrists.

She is also author of “Wasted”, a book about her anorexia and successful treatment. Ironically, while on her book tour for that book she was drunk most days (trying to control her mania), impulsive in every way, and completely out of control.  

If you check out her book on Amazon, you can search inside. See if you can read pages 11-13 (search for the word “goatman”) and get a rich and painful flavor of her inner world in 1978.

If anyone here as read “Wasted” feel free to let us know what you thought of it.

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Filed under book reviews, Depression, Psychiatric Medications, Psychology, teaching counseling

Manhattan


Off to NYC to talk to a group of pastors regarding their spiritual and relational health. My basic point: unique stressors of ministry plus unmet personal/professional expectations equals stress responses that either destroy or strengthen a pastor. No rocket science here but I hope to get them thinking about some practical steps they might take to ensure their own renewal. Some Shepherds tend, I’m sorry to say, to focus on the care of the sheep but neglect their own care–thus forgetting they themselves are sheep.

Interested in a summary of research on the unique situation of pastors? Check out the “slides” page for a brief paper written by me last year for a group of us meeting to dream about starting a center for multi-level care for christian leader families.

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Filed under Anxiety, Christianity, Christianity: Leaders and Leadership, Depression, Evangelicals, pastoral renewal, pastors and pastoring