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Laura, the Layers of Depression, and the Therapeutic Relationship
Alyssa Bird
MACP Program, Faculty of Behavioural Sciences, Yorkville University
PYSC 6104 W22 1AK A Biopsychosocial Approach to Counselling
Dr. Angela McCoy-Speight
March 12, 2022
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Laura, the Layers of Depression, and the Therapeutic Relationship
In this paper I will examine the case of Laura, a third year university student whose presenting
concerns are stress and overwhelm with the use of depressive language. To examine Laura’s case
I will use the Culturally Responsive and Social Just metatheoretical lens and the biopsychosocial
framework. Background on causes, symptoms, and pervasiveness of depression will also be
given. The paper will conclude with the role of counsellor in the therapeutic relationship, ethical
considerations, and a case conceptualization for Laura that will serve as a living document for
the duration of the therapeutic relationship.
Overview of the Metatheoretical Lens
The Culturally Responsive and Socially Just (CRSJ) framework in counselling is a
metatheoretical lens that takes a ubiquitous approach to understanding a client, the counsellor,
and the client-counsellor relationship with regards to their current worldview, culture, social
location, and intersectionality (Collins, 2018). The CRSJ framework demands that we consider
the interconnectedness of who we are, what we are, and where we are are in the world that
contributes to overlapping and interdependent systems that contribute to an individuals’
experience of discrimination, oppression, or privilege. We consider these systems and their
impact on the experience of the client and the counsellor by examining several factors such as
culture, sex, gender, religion, race, geography, sexual identity, politics, spirituality, genetics,
economic status, social location, social support, and life experience (Collins, 2018). The
examination of these factors as a counsellor leads to greater self-awareness which is critical to
being a culturally competent counsellor because our actions, although well intentioned, can be
interpreted and experienced differently by different clients (Shebib, 2020). In the practice of
counselling, examination of these factors considers that the client’s presenting concerns are
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influenced by variables outside of their control (Shebib, 2020). Through critical examination of
these factors, the CRSJ framework enables counsellors to collaboratively explore the contextual
experience of the client’s concerns and to co-construct their preferred future based on the
emerging knowledge built within and because of the therapeutic relationship that works to
dismantle and confront systems of oppression (Jay & Brown, 2021). In addition to working
directly with the client, the CRSJ framework also calls for counsellors’ engagement in social
justice action at the mesolevel and macrolevel on behalf of clients to deconstruct systems that
marginalize and oppress (Collins, 2018).
Overview of the Biopsychosocial Framework
The Biopsychosocial (BPS) model of counselling is a framework that acknowledges the
multicausation of a client’s concerns rather than a single cause (Sperry & Sperry, 2020). This
model asserts that a client’s vulnerabilities and resources can be understood through three sets of
vulnerabilities and resources: the biological, the psychological, and the sociocultural domains
(Sperry & Sperry, 2020). Applying the BPS model requires that counsellors identify factors,
within the three domains, relevant to the client’s behavior, symptoms, and/or impaired
functioning (Sperry & Sperry, 2020). Sperry and Sperry (2020) outline what constitutes factors
in each domain:
The description of biological factors emphasizes the client’s health status and
familial health and includes health history, medication and medical treatment,
exposure to environmental toxins, and substance use: alcohol, illicit drugs, nicotine,
and caffeine. The description of psychological factors emphasizes personality style
and coping capacities and includes adaptive and maladaptive beliefs, emotions and
emotional regulation, behavioral excesses and deficits, skill deficits, as well as
resilience and coping capacity. The description of social factors emphasizes family
dynamics and social support and includes the influence of friends and peers, school
or work demands, environmental and community risks (p.91)
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Human beings are complex systems made of subsystems. We are built of cells that create organs
and tissues and those systems are part of larger social systems through relationships and
societies. The BPS model recognizes that the whole cannot be fully understood by separating it
into its parts because relationships and interplay among each of the different elements is
fundamental to how the whole functions (Tramonti et al., 2020). In other words, the BPS model
rejects a nature vs nurture dichotomy and accepts that who we are as human beings is more
complex. Who we are is the product of our genetics, experiences, and the perception of our
current circumstances all interacting with one another and building on each other over time
(Pinel and Barnes, 2021).
Overview of Depression
Depression is a common complex mood disorder. There are more than 300 million people in the
world suffering from depression (World Health Organisation, 2017) and one in five people are
estimated to be affected by major depressive disorder which is the most prevalent (Dudek, et al.
2021). Major depression disorder, also known as clinical depression, occurs in approximately 11
percent of men and 16 percent of women in Canada over the course of their lives (Health
Canada, 2009). Although women are more commonly diagnosed with depression, the differences
in gender diagnosis diminishes with age (Depression, n.d., "Gender Differences" section).
Clinical depression has physical, psychological and social symptoms. Physical symptoms of
depression include always feeling tired or having no energy, crying for no apparent reason,
changes in appetite or weight, change in sleep patterns or excessive fatigue, headaches or
stomach upsets that occur frequently (Depression, n.d., "Signs & Symptoms" section; Health
Canada, 2009, "Symptoms of Depression" section). Psychological symptoms of depression
include feelings of despair and hopelessness, pervasive sadness lasting all day and for days, not
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being able to concentrate or make decisions, feeling useless, hopeless, excessively guilty,
pessimistic or having low self-esteem, thoughts of suicide, agitation or feeling slowed down, and
feeling irritable (Depression, n.d., "Signs & Symptoms" section; Health Canada, 2009,
"Symptoms of Depression" section). Social symptoms of depression include loss of interest in
work, hobbies, people or sex, withdrawal from family members and friends, and overall
detachment from life and close friends (Depression, n.d., "Signs & Symptoms" section; Health
Canada, 2009, "Symptoms of Depression" section).
With regards to what causes depression there isn’t a single factor but rather many possible
conditions that can contribute to depression or trigger a depressive episode. Genetic
predisposition or biological imbalances can increase the chances of a person becoming depressed
or their risk can be increased by external life experiences such as death or illness of a spouse,
friend or family member, challenges in their work or interpersonal relationships, low self-esteem,
financial strain, climate that they live in, or addiction (Health Canada, 2009, "Causes of
Depression" section). Depression can also be related to other illnesses in that it can be a reaction
to another illness, a cancer diagnosis for example, or caused by neurological changes from
another illness such as a stroke or be a result of another aliment that has the same symptoms like
hypothyroidism (Depression, n.d., "Causes & Risk Factors" section).
Case Description
Laura is a 22 year old cis-gendered single white woman who grew up in a suburb of Toronto.
Laura is the oldest sibling in her family. She has two younger brothers and a sister who is the
closest in age to her. Laura describes both of her parents, who are still married, as hard working
people who are both first-generation italian canadians. She shares in the counselling session that
her father was emotionally distant and worked long hours as a child but Laura believes that her
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father’s efforts gave her and her siblings a good home and the necessities to grow up well
although modestly. On the other hand, Laura’s mother, during her childhood, would return each
day from her high-pressure office job and share her anxieties with Laura about decisions that
were made and the relationships she had with people in the office. As a family they would go to
catholic mass together every Sunday until Laura moved out of the house and downtown to attend
university.
Lately, Laura has noticed that her mother is forgetting things from her past and sometimes
struggles to find the words she needs to express her thoughts. Laura has raised her concern about
her mother to her father but he believes that there’s nothing wrong with her mother. He believes
her mother is just under a lot of pressure. Laura shares that the last time she went home to visit
her mother couldn’t recall where certain kitchen items were stored. While making dinner Laura’s
mother asked Laura who she was.
Laura is currently a third year university student studying science and she is struggling with her
assignments and is concerned about her grades. In the session Laura discloses some challenges
she’s having fitting in with her friends at school. Laura admits that she has been hanging out with
friends but she doesn’t feel comfortable gathering against public health orders although she is
torn because she fears being rejected by these friends. Laura wants to belong but has struggled
with trying to fit in with this group. Laura remembers feeling a similar way when she was
younger as she was teased and bullied in grade school. This same group of friends has introduced
Laura to alcohol and drugs. Laura discloses that she has increased her alcohol and marijuana
consumption to levels that she hasn’t experienced before and she doesn’t feel comfortable with
this level either.
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Laura confesses that she has been struggling lately. She describes experiencing significant mood
swings. One day she will feel great and happy but then her mood will shift and she will avoid
people and not want to go out for days. Laura is also feeling a great amount of anxiety as the
pressure of assignments begins to build, exams are coming, and Laura does not feel prepared.
Laura shares that she is very concerned about her mother and asked her family to get her mom an
assessment but her siblings are not willing to do one right now. Laura says that she is physically
healthy but at the same time she has been feeling quite low in mood. Laura is concerned about
how she will be able to move forward because she has never faced this quantity and diversity of
stress all at the same time ever before in her life.
Application of the BPS and CRSJ Approaches
Biological Approaches to Counselling. There are several biological factors that could be
contributing to Laura’s current concerns including her gender, age, family history, and
consumption of mind-altering substances. It has been found in epidemiological studies that
women have consistently reported a higher prevalence of major depressive disorder, it’s been
suggested that increased incidence of depression is related to the onset of puberty and continues
throughout a women’s reproductive years while hormones are fluctuating (Dudek, et al. 2021).
Given that Laura is 22 years old and her depressive symptoms are relatively new, her age and
gender may be contributing factors to her current concerns. In addition, Kendall et al (2021)
claim that depression can be heritable. Heritability of depression ranges from 30 percent to 50
percent and early-onset, recurring, and postpartum may be the more heritable subtypes (Kendall
et al., 2021). The challenges that Laura recalls her mother having when returning from work
everyday might suggest that she found engaging with others challenging. Finding it difficult to
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connect and relate with others is a symptom of depression with others as is retreat from life and
social situations - a trait that Laura used to describe her father (Depression, n.d., "Signs &
Symptoms" section; Health Canada, 2009, "Symptoms of Depression" section). Lastly, Laura has
shared that she is participating in the use of drugs and alcohol. Substance use is positively
correlated with the onset and existence of depression given the impact that the substances have
on the mind and body (Davis & Nahar, 2020).
Psychological Approaches to Counselling. There are several psychological factors that could
be contributing to Laura’s current concerns including low self-esteem, her perception of her drug
and alcohol consumption, and anticipatory grief. Overuse or addiction to mind-altering
substances like drugs and alcohol can create internalized stigma in its users. Given that most
individuals are aware of the social stigma of mind-altering substances, when the individual
agrees with the stigma they can project that stigma onto themselves which causes psychological
distress such as depression (Davis & Nahar, 2020). In an academic study of drug-using college
students, Davis and Nahar (2020) found positive associations between self-stigmatizing beliefs
and depression. Many studies have suggested that self-esteem is related to mental health and
when it is low it is associated with the presence of depression in young adults (Pereira da Silva,
et al., 2022). This is significant to Laura’s case given that she has reported low self-esteem.
Lastly, given the description that Laura has given about her mother’s current condition and
Laura’s concern about it, it is possible that Laura is experiencing anticipatory grief. Anticipatory
grief is the act of grieving someone or something that is not yet over or lost (Rogalla, 2020). A
study by Frumkin et al. (2021) found that depression was common among people who were
experiencing complicated grief - grief with persistent substantial distress and impairment.
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Interpersonal Social Factors in Counselling. There are several social factors that might be
contributing to Laura’s current concerns including the relationships with her peers at university,
the stress of school assignments and exams, and the growth experience of transitioning from
child to emergent adult. In an article by Marcotte and Villatte (2021) the authors describe the
transition to adulthood as one distinguished by instability. Within this life transition, individuals
explore and experiment in many different contexts such as identity, sexuality, interests, etc and
this exploration may be associated with high amounts of stress and depressive symptoms for
some emerging adults (Marcotte and Villatte, 2021). This stage of life is exactly where Laura
currently is situated. She is experimenting with drugs and alcohol and trying to find her place in
a community at school. In addition, Laura’s stress with assignments and exams, on top of the
concerns she has about her mother’s health, might be contributing to her depressive state if she
does not have effective tools to manage her stress. If Laura has made it to her third year of
university without effective stress management techniques she might be suffering from lasting
impacts on her quality of life and academic abilities (Ribeiro, Freire & de Araújo, 2020). Lastly,
Laura has mentioned a fear of rejection. If Laura is masking her own thoughts and feelings,
given the drugs, drinking, and gathering during COVID-19 examples, she may be masking to fit
in socially with her peers. Masking, particularly among women and neurodivergent individuals,
is positively correlated with depressive symptoms (Hull, et al., 2017).
CRSJ Approach to Counselling. At a cultural level there are several factors that could be
contributing to Laura’s depressive symptoms including the pressures that are put on first
generation university students, partying culture among youth today, as well as cultural
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differences in how first-born children are parented differently than later-born children. A study
by Davis and Nahar (2020) found that college age students who use drugs were at an increased
risk of depression in comparison to individuals their age who were not students. The added
pressure of stress and using controlled substances contributed to self-stigmatizing and depressive
symptoms (Davis & Nahar, 2020). Laura has disclosed that she is consuming more drugs and
alcohol than she is comfortable with currently. This increased consumption is culturally accepted
among youth today and although not everyone participates there is certainly pressure on youth
people to do so to fit in (Peterson, 2019). There’s also added pressure on students who are the
first in their families to attend university given that they do not have immediate family members
who understand their experience but who want them to succeed, typically because their family
wants them to have more opportunities than they did as young people. These students are at a
greater risk of dropping out or falling behind than their multigenerational peers (Bond, 2019).
Lastly, given that Laura is the oldest child in her family she might be feeling different pressures
to succeed and take care of others, like her mother. Birth order has been found to be a
mechanism that can create differences early in life that have long reaching consequences
(Custódio & Siegel, 2020) including differences in expectations and cognitive support for the
first-born child (Lehmann, 2018).
Counsellor Role in Therapeutic Relationship
Counsellor’s Professional Role
The role of the counsellor in the therapeutic relationship is to respect the client as a whole and
individual person who has the right to self-determination; to welcome and accept humanity’s
unique difference through cultural competency; to recognize that we are all a product of complex
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interacting systems, identities, and cultures; to help the client restore self-respect through the
therapeutic relationship; and to help the client make meaning of their current concerns and define
how they would like their future to be different.
The therapeutic relationship is underpinned and formed through respect of individuals to be
themselves (Slay-Westbrooke, 2017). The primary goal within the therapeutic relationship
should be helping the client restore their own self-respect from where it was taken away in other
relationships (Slay-Westbrooke, 2017). When respect for the client as a unique human being is at
the heart of the therapeutic relationship, we as therapists can respect and accept a client’s right
and freedom to make their own decisions and choices (Shebib, 2020).
To be able to accept and respect the client, the counsellor must remain culturally competent,
aware of their own bias, thoughts and feelings, and take good care to manage their own reactions
to any client’s lived experience, values and beliefs (Shebib, 2020). Counsellors must also be
aware of their own intersectionality and how it compares to the experience of the client so they
are not tempted to assume they understand the client’s lived experience and how it relates to their
presenting concerns (Jay & Brown, 2021). With respect, intersectionality and self-determination
forming the foundation of the therapeutic relationship, the counsellor’s role is to support the
client in to consider “what specific goals and processes support the client to attain their preferred
outcomes” (Collins, 2018, p. 581).
Ethical Considerations
The ethical considerations that must be considered for any therapeutic relationship to protect
clients from impermissible behaviour that may harm them. The Code of Ethics from the
Canadian Counselling and Psychotherapy Association (CCPA) (2020) states that the following
are the fundamental principles for ethical conduct: beneficence, fidelity, nonmaleficence,
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autonomy, justice, and societal interest (p.2). In Laura’s case, the ethical concern that could arise
is the possibility of a dual relationship given that we have similar life experiences and I think we
would get along well as friends if we’d met outside of the therapeutic relationship. To avoid the
possibility for unethical behaviour on my part, I will diligently refer to the CCPA Code of Ethics
(2020).
Case Conceptualization
Laura’s current stress and feelings of overwhelm appear to be a response to unprecedented
school and peer pressures as well as family stress. These feelings are perpetuated by low selfesteem, fear of rejection, and being the oldest child in the family which comes with feelings of
greater responsibilities than her siblings. Laura’s family history and gender suggest that she may
be predisposed to depression or depressive symptoms. The pressure she puts on herself to
succeed and the pressure of being a first-generation university student in her family may be
having psychological implications. Laura has successfully made it through two years of
university which can be considered a strength. She also appears to have strong bonds with her
family and catholic faith which can be considered protective factors.
Conclusion
In this paper I have given an overview of the Culturally Competent and Socially Just
metatheoretical lens and the Biopsychosocial framework to examine the case of Laura and the
different factors that might be contributing to her present concerns of stress and overwhelm. Her
gender and genetics suggest she might be predisposed to depression but her interpersonal
relationships, low self-esteem, and cultural pressures to succeed as a first-generation university
student are possible perpetuants of her concern. Laura’s case was fully described as was the role
of the counsellor in the therapeutic relationship and the necessary ethical considerations. This
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paper concluded with a case conceptualization for Laura that will continue to be a living
document as I continue to work with her as a client.
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