Counselling Dilemma: A Client Who Feels Depressed
Melody has come for counselling to deal with the death of her husband. You have been counselling her for four weeks and in that time Melody has reported that she feels “depressed”. In addition, she complains of being constantly tired and lacking motivation to do simple tasks such as showering and cooking for herself.
As you have no formal qualifications or training to diagnose or treat psychological disorders such as depression, you encourage Melody to visit a GP to have her symptoms assessed. In the next session, Melody reported that her GP had not given her a diagnosis; however he had prescribed an eight week course of anti-depressant medication.
Given this outcome, would you continue to counsel Melody?
Given that Melody?s GP did not give her any diagnosis, but prescribed an anti-depressant, I would ring the GP with Melody?s consent to discover his thoughts on her symptoms and also to check the expected/possible effects of the particular medication prescribed.
I would also ask Melody to describe what she had told the GP as he may not have been made aware of the complete scenario.
If Melody wished to continue with counselling we would need to consider whether her feelings of ?depression? were in fact related to the early stage of the grief process. The shock stage, which can last for weeks or even months, can lead to feelings of tiredness and lack of motivation.
I would explain that grief is a process which would help Melody to understand the various stages through which a bereaved person needs to pass in order to deal with their grief.
People experiencing grief often get a lot of well-meaning, if sometimes inappropriate, advice from friends and relations. Therefore the chance to work with an empathic grief counsellor could be extremely beneficial for Melody. An explanation of what the counselling process might entail would help her decide whether or not to continue.
It would also be important for Melody to understand any emotional or physical effects that the anti-depressant medication may have. I would refer her back to her GP for this type of information, if she had not been informed on her previous visit.
I would have an initial session with Melody after her visit to the G.P. to ascertain what she wanted to do.
If she decided to go through with an eight week course of medication only, then I would accept her decision. However, if she wanted to continue Counselling, I would explain to her about the stages of grief and loss and their effects, and see if she was interested in exploring these various stages, because I feel grief and loss is a major factor for Melody.
However, my concern is that because she is on anti-depressants these may prevent her from fully experiencing her feelings as she moves through the various stages of grief & loss in order to heal.
Nevertheless, the decision must rest with Melody, and if she wishes to explore her grief and loss issues, then it could be appropriate to start the process while still on medication and see how she copes. If progress is being made, then we could continue for as long as Melody feels she is being helped.
rather than using antidepressive drugs,we can continue counselling with melody.we can ask her to remember all those happy moments which she enjoyed with her husband.we can ask her to realise her responsibilities in case if she has children,ask her to be happy for her children.ask her to continue meeting her old friends and work for her livelihood.afterall,time is the best remedy for such happenings.to take care of his parents if they were dependent on her husband.
An 8 week course of anti-depressants is insufficient to successfully alleviate symptoms of depression. In the initial phase the dose must be raised slowly in order to avoid the unpleasant side-effects and weaning the client off medication takes another 1 to 2 weeks. That doesn’t leave much time left over for the client to have adapted to the treatment. An anti-depressant treatment should at least continue for 6 months, as there are many metabolical changes that should be taken into consideration. The body must adapt to the changes due to the reuptake-blockers (modifying the activity of neurotransmitters) and give the body time to get accustomed to the changes. It is also possible that the client has to change the medication to another one more suitable. There are many different types of anti-depressants and when a client is willing to try a treatment then it shoud be explained to her in advance that it is very possible that the particular medi that she is prescribed could be changed to another after a month or two if the desired reaction isn’t achieved, until the right medi for her, her situation, her body is found. The counsellor should know the different types of medications used to treat depression (even if some consider this out of our domain) and be able to inform the client of the side-effects that can come with them. If the counsellor is not aware of the different medications then the client should be advised to press her Dr for details (some Dr’s are hesitant in spending more than a few seconds with their clients! Alas!). The effects of the anti-depressants, if not discussed fully in advance with the client, could in the short term make her feel worse and in some cases lead to suicide.
I would never contact the client’s doctor without the client being present. Presumedly the Dr didn’t find it necessary to explore a possible physical cause of the client’s depression (hormonal imbalance, thyroid problems, blood sugar levels… etc), presuming that it is reactive due to the loss of her partner (therefore it is “adapting to the loss” that is causing the depresion & not a psychological disorder), therefore the counsellor should spend time exploring whether the client has ever previously suffered from depressive epsiodes (more than 2 weeks), whether it could be also a genetic factor involved (other family members suffered from depression?), whether she is taking other medication (many medis can cause feelings of depression!), history of drugs or alcohol abuse etc etc. A thorough exploration of the situation will inevitabely lead to a solution in helping the client best get through these hard times. If possible physical factors could be causing the depression it is primordial that these be discussed together with Melody & her GP.
In therapy it is rarely a choice of “either medication or counselling”. Counselling should never be considered inferior to medication! It is proven that anti-depressants are in no way more effective in treating reactive or “exogenic” depression than counselling, therefore I would absolutely encourage Melody to continue with her visits, whether this be in a group therapy (which I find to be very successful) or 1-on-1 sessions if she still needs to keep her situation private.
It is the changes in her life, the tragic loss of her partner, that has probably (but not necessarily!) triggered the depression. The counsellor can help her deal with and adjust to these changes.
There are different forms of therapy suited to help clients through these types of situations, which the counsellor can discuss with the client. If the counsellor cannot offer the form of therapy which the client wishes, then the councellor can give her a list of qualified therapist offering the chosen therapy.
In any case, all forms of depression, whether exogenic or endogenic, should be taken very seriously and treated in cooperation with the client’s doctor.
Indeed i would continue to counsel Melody. It is my belief that clinical depression cannot be cured by an 8 week course of anti depressants. I feel that she would need more intensive therapy possibly refer to a pyschiatrist.
Seeing as the statement above specified “As you have no formal qualifications or training to diagnose or treat psychological disorders such as depression”, I would encourage Melody to be referred to a psychologist who specialises in Grief & Loss therapy. I see this issue as being a case of “Client Referral”. If Melody wished to continue therapy with me I would inform her that I may need to confer with my supervisor/mentor.
In this case supervisors advice is a must. In saying so, this individual has more than just the mental health issue as depression to deal with. While as a counsellor I cannot diagnose nor treat her mental health, I can counsel her with the loss of her loved one and help her through the different phases of grief and loss. I would also be consulting with her to seek further medical assistance for the depression and finding a suitable support group to help her.
If I had no formal qualifications or training …. to treat depression, I would ensure that I familiarise myself with this very common complaint as much as possible, and as soon as possible, by reading professional literature and attending relevant seminars.
Having already established a relationship with Melody, I would certainly continue seeing her as a client if she so wished. However, I would also, as has been suggested before, consider discussing with Melody returning to her GP and ask the GP for a referral to a psychiatrist who can properly assess, diagnose and prescribe appropriate medication.
Melody has been a client for 4 weeks. She has returned from her gp appointment and sounds like she has little understanding of the consultation with her gp including diagnosis or treatment. This would be a concern for me as it would be unlikely for a gp to prescribe anti depressants for 8 weeks. So there is some confusion here and would be important to clarify with the gp first.
Given Melodys persistent tiredness , grief and lack of motivation i would want to concur with her gp (with her permission) before i would continue.
Melody is grieving and it would be expected for her to experience intense emotion and grief. However, in some instances antidepressants are needed.
It is not ethical for a counsellor to advise the client about whether they should or shouldnt be taking them. It is wise to have an understanding about the pharmacology and side effects but most importantly dont presume that they will fix everything or that the client is ok just because they are taking them.
This case definately needs communication between gp, counsellor and possible referral to speciaist/grief counselling or psycologist.
Most importantly does Melody have other support networks/phone contacts in place in the interim?? Is she at risk of harming herself.?
This case requires prompt and professional attention. The gp would be more than happy in most cases to work in conjuction with the counsellor.
We are professionals and equally play an important part in the welfare of the client/patient.
Registered nurse and counselling student
Having developed a theraputic relationship with the client I would question the wisdom of “abandoning” Melody at this vulnerable stage of her lifes’ journey. I would certainly continue on with some form of counselling (if that is still Melody’s desire) as the possible feelings of abandonment Melody may feel at the termination of the theraputic relationship are likely to compound her problems. I would look at actively including Melody’s G.P. in the ongoing therapeutic process and perhaps also (with Melody’s permission) take on the role of advocate to help ensure Melody receives appropriate and timely treatment and service delivery that includes her as an informed decision maker, which (from the information provided) she currently does not seem to be.
With regards to her G.P. prescribing an 8 week course of anti-depressants. I would consider that to be unusual and would suggest a round table conference with the G.P. and Melody to sort that out. It may be that in Melody’s current mental state she simply misheard what her G.P. said, or simply “tuned out”. Perhaps her G.P. actually asked to see her in another 8 weeks for blood work and to check the efficacy of her treatment plan. In any case, Melody’s statement about her medication is so far from what would be considered to be standard practises that its veracity needs to be tested.
I would with Melody’s permission talk to family, friends and Gp about her thinking, emotional state and her overall behaviour. And determine whether or not she has a sufficient support network to assist her at this time. I would increase the counselling to twice a week and work through the stages of grief with her. What Melody needs is a counsellor who knows how to meet her needs with the right therapeutic intervention, care, compassion, and listening from the heart. She is in shock and has gone into the natural self protective state and needs ‘time to heal’ . How easily society accepts that a pill can take away the pain of losing a partner. It’s ok to feel exhausted by the grief of losing someone we love deeply, feel the pain of his loss , feel the magic and sparkle go from our life. It takes time to create loving relationships and equally time to grieve them if they are taken from us. After four short weeks of counselling I would expect Melody to be adressing some of these feelings. It is what good counsellors do ‘assist clients to feel the pain’ and work through it together.
Permit me to respond anecdotally. Interestingly, when I lost my husband I would have described myself as depressed, yet with hindsight I was certainly not so. I was simply grieving. I was sad beyond belief, and everything in my world had changed. I find with my widowed friends that the deep vacuum of sorrow that is left is so foreign that sometimes the only word that can describe the great height from which you have fallen is ‘depression’. Grieving is tiring work, and I had five young children. Life had developed an unutterable pointlessness without my husband, and I had to work hard to restructure my original motivations and find reasons to even sweep the floor again. I think it is important to ascertain whether Melody feels she is gaining anything positive from the counselling. If she is, keep going. I know with my counsellor, I painted an emotionally authentic picture to her as she was one of the few safe zones in which I could say anything. I could try on the language of desperation and she wasn’t going to tell me ‘not to be like that’. I could let down with her, solve my own problems and draw from her prescencing. Most of the other people involved in my circumstance needed me to coach them through the loss (children), and that took effort and energy. As an aside, my current work is in a medical practice, and I would think that an eight-week course of anti-depressant medication is a strange clinical response to Melody’s situation.
You said what I was thinking. I experienced a suicide death of my former partner and although we had not been together for many years it was hard to accept. I fell apart at work and was sent to the doctor and counseling. I dont know why but my doctor prescribed me valium which seemed to settle me down for a few days and then I didn’t take anymore as I dont like taking them. It only made things worse when I returned to work my bad side came out from no-where. I like your statement that you think it was strange about the depressents being prescribed because at the end of it all Melody still has to learn coping skills and to adjust to the fact that her husband is no longer with her. I would still be there for Melody and help her gain those coping skills.
I couldn’t agree with you more Sue! My sentiments exactly. What she is describing are the “normal” grieving! I have many clients referred to me by GPs to do grief work and the majority of these clients have not been prescribed anti-depressants!
Yes I would continue counselling if Melody wished.
I would need to know more about the ant-depressant as some are extremely mild.
As I would have provided her with a “referal” when suggesting the doc I would expect some more feedback than what I am hearing.
Each situation is different so depending on her responses I would decide what she requires from me to best help her.
I completely agree with Wendy and Lola. That that would be the appropriate way to go.However after reading everyones articles no one has made the point to help this grieving women focus on the positive areas of life that she enjoys and can work towards. In turn this would help this women and to help her realise that she would not have to use anti depressents at all. All this women has to do is look inside of herself with our help of redirection into making slow but positive choices to get her through the grieving process. I have personally been grieving myself and i know thats what my counsellor would do with me.Hence everyone is different but its up to you to know when and how to make that choice of redirection with the grieving lady. I enjoyed reading everyones response.
Of course i would offer to continue counselling while Melody is on anti-depressants.
Many people stop taking them after the first few tablets because they simply make them feel worse (suicidal thoughts, depresseion are listed as possible side effects on many anti-depressants). If indeed they do help then she is in a good position to learn about her grief and strategies to help when she finishes her course.
Personally i feel this is a social problem too. What is wrong with walking around thin and unshowered for a few months when your spouse dies?
I would want to feel my grief and show it to the world, this is my pain, SEE it…. not pretend everything is jolly and rosey and that my husband meant so little to me that i just ‘got over’ it and ‘moved on’ .
Melody needs to be listened to and guided and depression and sadness are quite different however continue to be lumped into the same category.
She needs to have skills to cope with her loss when her anti depressant course finishes (if it ever does…. ).
just a note, people do not move through nice neat stages of grief even kubler ross admitted that in the end, its just a model Read about ugly grief see george Bannanos work. Depends on the individual, if its too raw, leave the open door, very very open at any time, emphasise, things can change very quickly and vividly. It is normal, and I would be concerned if you didnt return if you need me. Some people dont like to admit they dont click with you for working through grief, so invent an excuse, let them go with dignity. Its their grief and they know the kind of person who works best for them.
For a start Melody’s constant tiredness and lack of motivation may be caused by a number of health issues other than “depression”. The doctor would be wise to rule these out. The state of being depressed can also create health issues, such as malnutrition, as the person may not take adequate care of themselves when they are preoccupied with grief. Prescribing anti-depressants is in order if seen to be necessary, as is continued counselling. Losing a partner or significant other changes the way a person views the world and it takes time to re-adjust…a LOT of time. It is important to receive all the support that is available.