Depression: A Clinical and Pastoral Guide
According to the World Health Organization (2005) depression effects over 121 million people world wide and is the leading cause of disability measured by Years Suffered with Disability [YLD]. The effects of depression are varied with insidious consequences both to the suffering patient, their families and society in general.
Attenuated mood, loss of interest or pleasure, low self esteem, self worth and guilt, sleep disturbances, appetite irregularities, energy loss, lowered concentration and significant cognitive impairment are characteristic of the disorder. Such characteristics often become chronic and result in significant diminishment in social and occupational functioning. Even an individual's ability to care for themselves in ordinary daily health and hygienic activities are effected.
At the worst end of the spectrum, depression results in suicide, with the loss of about 850,000 thousand lives every year. Depression was known to the Old Testament Patriarch Job who tells us: “My eye has grown dim from grief [depression], it grows weak because of all my foes.” (Job 17:7). The prophet Jeremiah tells us: “My grief [depression] is beyond healing, my heart is sick within me.”(Jer 8:18).
The Apostles and Church Fathers equally knew the deleterious effects of depression. “…worldly grief produces death,” states St. Paul. (Rm 7:10). This ‘death’ is in the world of personal, family social and occupational functioning, and more importantly “spiritual death” of the soul blocking out the light of God’s love and leaving the depressed individual in the darkness of despair. St John Cassian tells us: "But first we must struggle with the demon of dejection who casts the soul into despair. We must drive him from our heart. It was this demon that did not allow Cain to repent after he had killed his brother, or Judas after he had betrayed his Master.” (Philokalia I).
Because we are made in God’s image and likeness, we can use our intelligence to help understand and treat mental disorders such as depression. The best use of our “intelligence” today is scientific research. One of the fruits of this research is the Cognitive-Behavioral Model of Emotional Dysfunction (Beck, Rush, Shaw & Emery, 1979,; Ellis, 1962; Morelli, 2001, 2004; Morelli, 2006 January 01; 2005 September 17).
According to this model, emotions such as depression are produced by distorted or irrational beliefs, attitudes and cognitions. Situations, (some event that has happened or something that someone has said or done) do not produce or cause emotional upset, rather we upset ourselves by our irrational “interpretations” of events around us.
Recent research by Izard (1993) has revealed additional sensory-motor and affective neural pathways of emotional activation. Morelli (1996) has pointed out however, that because of the reciprocal interaction of these events, cognitive behavioral intervention is usually effective with patients suffering from emotional disorders activated by any of the three (cognitive, sensory-motor, affective) pathways. Thus understanding and restructuring the cognitive distortions that produce dysfunctional emotions, and more specifically depression, can still be effective both clinically and pastorally.
-Selective Abstraction is ‘focusing on one event while excluding others.’ In one of my recent cases, “Jack” an engineer, selectively focused on a reprimand, he just received from his supervisor, while ignoring the praise he received the previous week from the Senior Project Manager. This irrational perception led to his depression.
-Arbitrary Inference is ‘drawing a conclusion unwarranted by the facts in an ambiguous situation.’ The same patient mentioned above, the engineer, concluded his next evaluation (given by his supervisor) would be unsatisfactory. This led to further depression.
- Personalization is attributing an event that occurs is being done to you ’personally.’ Another patient “Linda” became depressed when during a business meeting (attended by her section comprising about 25 people), her supervisor made a said some in the section are not “team players”. She immediately “personalized” the statement, of course with no evidence that the boss was directing it at her.
-Polarization is perceiving or interpreting events in ‘all or nothing’ terms. “Cynthia”, another patient of mine, became depressed after receiving a ‘B’ in a college course. She “polarized” events into two categories, good student-bad student. A ‘B’ fell into the bad-student pole. She failed to seen that all events can be graded on a continuum between two poles. On such a scale a ‘B’ is closer to an ‘A’ that to an ‘F’ for example.
-Generalization is the tendency to see things in ‘always or never’ categories. Another patient, “Mary” became depressed during marital therapy, when she irrationally concluded that her husband will “never” change and will “always” be the same. Her dysphoria led to a self defeating pattern of behavior which further distanced her and her husband an set herself up for the very thing she did not want: a poorer marriage.
-Demanding Expectations are beliefs that there are laws or rules that ‘have’ to be obeyed. “Kim” came into treatment because she was depressed over her son’s talking back to her. She irrationally believed that there is a “law in the universe” that says that children should do what mothers ask and if not she has the right to get upset. God “asks” us to obey Him. He gave us free will. Christ Himself, respected the free will of the creatures he created as shown by the gentleness of His admonitions Like Christ, parents should prefer and constructively work toward reasonable obedience from their children. A program of rewards for appropriate behavior and punishment for inappropriate behavior administered without anger, anxiety or depression would be constructive.
-Catastrophizing is the perception that something is more than 100% bad, terrible or awful. “Kim” erroneously reacts to her son’s talking back as the “end of the world.”
-Emotional Reasoning is the judgment that one’s ‘feelings are facts.’ Sandy has a “feeling” that her new boss does not like her. When asked how she knows this she responds that her “feelings are always right”. She fails to distinguish a feeling as real which it is versus a feeling ‘proving something’, which is impossible. For example, I tell patients: “No matter how strongly some people ‘felt’ during the time of Christopher Columbus the world was flat, it did not make it so”.
Beck, (1976) points out that besides the cognitive distortions, depression involves the cognitive theme of “loss”, and in addition, what he calls the cognitive triad: a negative view of self, world and future. In other words if a clinician were to analyze the “self-talk” of depressed patients, these themes as well as the cognitive distortions would be present. One example from above will illustrate this. “Jack” the engineer who received the reprimand from his boss, thinks of losing his bosses respect and esteem and further perceives he is less of a person, thinks others will see him as incompetent, and he may loose his job and never find another one. This cognitive feedback loop of distortions, loss, and triad, produces a cascade of deepening depression.
Effective clinical intervention involves helping the patient to first recognize and label the cognitive distortions and themes. This is followed by helping the patient restructure the distortions.
1) Where is the evidence?
2) Is there any other way of looking at it?
3) Is it as bad as it seems? This can be illustrated with “Jack” the reprimanded engineer mentioned above.
Answering these questions “Jack” might come up with an alternate more rational perception, “True my boss criticized my project, but in fact, he has praised other work I have done and even last week the Senior Project Manager was real pleased with something else I was working on; just because I was reprimanded for one error doesn’t mean all my work is bad and unappreciated and it surely doesn’t mean I will loose my job and be out in the street.”
Following this cognitive restructuring process “Jack” begins to feel less depressed. The next step is to help “Jack” become more behaviorally ‘pro-active.’ “Jack” was helped to “debrief” the error. Debriefing involves understanding what brought the error about, and to developing a plan to change these circumstances to bring about more effective current and future functioning. This behavior change process interacts with the ongoing cognitive restructuring to produce even less depression. The person’s mood begins to elevate.
Special cognitive intervention procedures however, must be done with Demanding Expectations, Catastrophizing and Emotional Reasoning. As alluded to above, patients with Demanding Expectations frequently try to forcibly impose a personal set of rules on others or the world around them.
Because of the way God made the universe: the ‘Physical Laws of Nature’ (e.g. gravity) are inviolate. God made all objects in the universe to function by these laws out of necessity.
God’s moral commandments to us, society, governmental family and personal rules, are of a different category. They function by virtue of God’s gift of “free will.” Individuals are free to chose to obey or disobey these moral precepts. We cannot violate the laws of gravity, but we can disobey His commandments
God out of His love for us does not want us to choose to disobey his statutes. Of course to disobey these voluntary laws or rules have differing degrees of consequences for violators. The most severe being choosing “hell”: the absence of God.
This is not to trivialize God’s commandments, society’s laws, parental values or family rules. God ‘wants us’ to obey Him. So too, for example, parents ‘should want,’ that is prefer, (not demand) their children respect and obey them. (Morelli, 2006, January 01; Morelli, 2005, September 17; Patterson, 1976). When ‘demands’ are made and not obeyed anger follows. This is in and of itself sinful and sabotages the obedience to the rules God out of His love, wants us to obey. Our interactions with one another whether in parental, family, social or occupational settings should also be on this level of ‘requested love’ and not ‘sinful demands.’ If not two demons appear: the demon of dejection and the beast of anger (Morelli, 2005, October 14).
A special cognitive technique has been shown to be effective with Catastrophizing (Burns 1980, Morelli, 2005, October 14). The “Mental Ruler Technique” involves evaluating a situation on a 0 to 100 scale, with 0 being the most pleasant thing you could picture happening to you. Patients infrequently have trouble imaging a very pleasant event (0). Sitting on a sun drenched tropical beach is a typical image. Patients frequently need help however, imaging a “graphic” worst event (100).
Use of the example of the particularly horrifying death of a medical missionary in South East Asia several years ago has been helpful. After starvation failed to kill him quickly, his captors placed chopsticks in his ears and hammered them in a little each day, until they penetrated his brain with his resulting death. Patients or parishioners will frequently speak with me about the death of loved one especially a child as “the” most awful thing on earth. This is frequently said in a sanitized abstract way. ‘Pounding chopsticks’ is much more powerful than ‘death.’ This a much more effective “100.”
While the clinician and/or parish priest surely must help the individual with the grieving process allowing for the expression of feelings, care should be taken not to endorse a “catastrophe” mental ruler appraisal. Thus for example, while the loss of a child is a bad thing and for which one has appropriate sorrow and grief, unless it reaches the dimensions of “100” it is surely less than the “most” terrible thing on earth.
Catastrophic evaluations also frequently broadcast a lack of commitment to God. The follower of Christ has the experience of God Who freely gives life and calls this life back to Him. God does all out of love for us even though on a human level it may it is out of our understanding and seemingly meaningless. The Christian knows God has a greater, higher, beyond human understanding.
For us presently on earth this is all dimly revealed. As St. Paul told the Corinthians: “For now we see in a mirror dimly, but then face to face. Now I know in part; then I shall understand fully, even as I have been fully understood.” (1 Cor. 13:12).
Emotional Reasoning also requires special cognitive intervention, because depressed patients tenaciously hold onto the irrational erroneous belief that feelings are proofs of the truth or falsity of events. How many times has a parishioner or patient said something like: “I just feel I will never [get better…find a job…get over this…make friends …etc.]. As mentioned above, such individuals frequently mistake a feeling or emotion as real or felt (which it is) versus proving the truth or falsity of the event one has the feeling about.
Giving the depressed individual extensive practice with ‘feelings and events’ is an effective starting point. For example, the clinician or priest may ask the individual to recall an event that he/she felt “really sure about”, that turned out to be untrue.
One of my patients recalled an instance in which they “felt certain” they had failed an exam. [Another common example is a ‘strong feeling’ someone does not like or approve of them.] In all cases the depressed individual explores what happened when they discovered they had ‘felt’ incorrectly. What lesson is there in this discovery? The individual above found out they had done well in the test, when they had previously “felt” they failed: What does this say about feelings as facts? This helps to break down the feeling-fact [emotional reasoning] connection.
Behavioral practice accompanies the cognitive restructuring procedures. This includes the filling out restructuring charts (see Burns, 1980) as well as to in vivo exposure to challenging social and environmental events related to the depression. For example “Jack” our erstwhile patient, may be encouraged to go to his supervisor and ask for feedback regarding other projects he has worked on.
Behavioral assignments decrease depression by providing realistic information that then may be processed through veridical cognitions. Increased behavioral activity itself has been shown to ameliorate depression (Beck, et. al. 1979). It may be hypothesized this dysthemic attenuation takes place due to the mediation of yet unspecified CNS neurotransmitters.
It behooves the Orthodox Christian counselor or pastor to use spiritual as well as psychological means to help depressed persons. With the Orthodox Christian patient, spiritual intervention can be initiated concomitant with the cognitive-behavioral intervention. Prayer, selected spiritual reading, and the sacraments provides spiritual healing for mind body and spirit.
Care that the patient does not misinterpret scriptural passages and spiritual reading and thereby increasing the depression. The patient may well make his/her own the words of Job: “For the arrows of the Almighty are in me; my spirit drinks their poison; the terrors of God are arrayed against me…. Can that which is tasteless be eaten without salt, … My appetite refuses to touch them; they are as food that is loathsome to me.” (Job:6: 4-7). If reading were to stop here, surely the depressed individual might consider God has abandoned as Job thought initially that God abandoned him.
Of course, Job was faithful to God despite his adversity and in the end God rewarded him. Rather a prayer of hope can be made: “But thou, O LORD, be not far off! O thou my help, hasten to my aid! Deliver my soul from the sword, my life from the power of the dog. Save me from the mouth of the lion, my afflicted soul from the horns of the wild oxen! I will tell of thy name to my brethren; in the midst of the congregation I will praise thee:” (Ps. 21:19-22).
Orthodox Christians may also be given spiritual reading that includes the Church Fathers on despondency. St. Symeon the New Theologian tells us:
“Contrition of heart, then excessive and untimely, troubles and darkens the mind, destroying the soul’s humility and pure prayer and paining the heart. This induces a hardening to the point of total insensibility; and by means of this the demons reduce spiritual people to despair.”…when this happens you should sit down in a solitary place by yourself, collect yourself, concentrate your thoughts and give a could counsel to your soul saying: ’Why, my soul, are you dejected and why do you trouble me?....my salvation lies not in my actions but in God… Put your hope in God…Yet by virtue of my faith in God I hope that in His ineffable mercy He will give me salvation….resolutely enter your normal place of prayer and falling down before the God of love, ask with a compunctive and aching hear, full of tears, to be freed from the weight of listlessness and from your pernicious thoughts.” (Philokalia, IV)
The Prayer Against Despondency of Fr. Arseny can be so powerful for those depressed:
PRAYER OF FR ARSENY TO THE MOTHER OF GOD
“O my beloved Queen, my hope, O Mother of God, protector of orphans and protector of those who are hurt, the savior of those who perish and the consolation of all those who are in distress, you see my misery, you see my sorrow and my loneliness. Help me, I am powerless, give me strength. You know what I suffer, you know my grief—lend me your hand because who else can be my hope but you, my protector and my intercessor before God? I have sinned before you and before all people. Be my Mother, my consoler, my helper. Protect me and save me, chase grief away from me, chase my lowness of heart and my despondency. Help me, O Mother of my God!”
One factor that deserves special consideration in the treatment of depression is suicide. Suicide should be immediately addressed by the clinician chaplain or clergy with severely depressed individual. An unlicensed or certified clergy or chaplain should immediately seek a mental health licensed specialist.
This is a clinical emergency and more than one concurrent session may be needed. One effective cognitive-behavioral clinical technique is a paradoxical approach to first explore with the individual all the ‘favorable’ reasons to commit suicide. This helps the clinician understand the potentially suicidal depressed individual from their viewpoint.
Feeling understood the suicidal person may then may feel empowered to explore the reasons ‘not’ to commit suicide. Of course the latter exploration coupled with cognitive restructuring, and spiritual intervention is the psycho-spiritual healing factor.
Such individuals may also require psycho-pharmacological treatment. In no case should a suicidal patient be released without attenuation of suicidal ideation.
In situations in which Orthodox Christians have successfully taken their lives, merciful and major pastoral consideration should be given to the scientific research findings that suicide-depressed patients have a significant impairment of cognitive function.
In as much as ‘deliberateness’ is a major factor in evaluation of the culpability of “sinful” thoughts and actions, most suicides are most probably ‘involuntary.’ Severely depressed individuals have sharply attenuated cognition. Most depressed patients are not capable of sufficient reflection and willfully rejecting God and his gift of life.
A person who commits suicide under such conditions would not be blameworthy in terms of voluntary sin and thus consideration of the usual Orthodox Funeral and Memorial should be given. Depression is so insidious, not only because it takes away life’s pleasures hopes and aspirations, but because it also robs us of the sight of God.
In the depths of despair we do not pray to Whom we do not see. We see ourselves cut off from Him who is the source of all life. However using our intelligence, we may use scientific clinical approaches, which as outlined above, have been shown to be effective in the treatment of depression, enlivened with the Holy Mysteries, the channels of Grace given to us by Christ a genuine healing can be commenced.
The Church is the healing Body of Christ. All the parts of His Body work toward healing of the sick member. Christ is the vine the source of strength for the branches.
He who dwells in the shelter of the Most High, who abides in the shadow of the Almighty, will say to the Lord, "My refuge and my fortress; my God, in whom I trust." his faithfulness is a shield and buckler. You will not fear the terror of the night, nor the arrow that flies by day, … nor the pestilence that stalks in darkness, nor the destruction that wastes at noonday. (Ps 90: 1-2, 5-6)…
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