The Pastoral Care of Depression

A Guidebook

Harold G Koenig, Binford W Gilbert

• Publisher: Routledge
• Year: 2014
• Print ISBN: 9780789002655
• eBook ISBN: 9781317790877
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

What is depression, and what are its many and varied types? Who becomes depressed, and how can it be recognized? How can depression be measured, and what are its suicidal potentialities? What are the therapeutic interventions the pastor can use in helping people who are undergoing the pain of depression? The Pastoral Care of Depression: A Guidebook answers these questions and many more. With a focus on the pastor as an instrument of healing in cooperation with families, physicians, and other mental health professionals, this book will help you understand some of the current research and procedures used in helping people suffering from depression. As the frontline mental health workers in many communities, pastors need confidence, competence, and skill in handling people with emotional problems. As Author Binford W. Gilbert explains, "Depression is among the most treatable of major illnesses. It enters the realm of the spiritual and demands the best of the pastoral leader to guide, assist, and enhance the struggle for peace and soundness of mind and body." The Pastoral Care of Depression helps caregivers by overcoming the simplistic myths about depressive disorders and probing the real issues. This book covers:

• a thorough description of clinical depression
• predisposing factors that may lead to depression
• the need for a multidisciplinary approach, and the role of the pastor on the treatment team
• the importance of church and family involvement
• diagnosis--the ability to distinguish between normal grief, ordinary blues, situational depression, and clinical depression
• ministers'own emotional, physical, mental, and relational health
• the pastor's privileged role that gives him/her unique abilities and opportunitiesA valuable resource for pastors, chaplains, counselors, psychiatrists, psychologists, physicians, family members, and teachers of pastoral care, The Pastoral Care of Depression is meant to inspire action-oriented counseling; to establish cooperative relationships between ministers, families, and the medical community; to carry out responsible and innovative creative therapeutic interventions; and to treat the whole human being.

Chapter 1

Depression: How It Feels

 

A distinguished community leader walked into his local church one Sunday morning. He spoke pleasantly with two men and put his hat on the shelf. Instead of turning to his left and going down the hall to the men's breakfast meeting, he walked calmly and quietly into the sanctuary where he stayed alone for two or three minutes. He then left and walked away from the church down the side street, where he took a small gun from his pocket. He pulled the trigger and his life was over.

Was he depressed? If so, who knew about it? What were the outward signs, and could they have been interpreted by family, close friends, pastor, or physician?

A younger man, angry because his wife left that morning due to his drinking and debts, killed himself after having consumed a large amount of alcohol.

A twenty-three-year-old girl, responding to an unfortunate love affair, overdosed on barbiturates after leaving a note for help from her personal hell.

There is a common misconception that suicides are mainly caused by depression. While depressed people may and do commit suicide, there are other clinical diagnoses more accurate for these unfortunate victims. Many depressed people do not take their own lives. Only about 15 percent of depressed persons commit suicide; 85 percent do not. Besides depression, anxiety, neuroses, schizophrenias, business problems, manipulation of others, extreme anger, hormonal changes, or chemical imbalances can all lead to suicide.

Many depressed people lack the emotional and intellectual strength and energy to carry out plans to take their own lives. It is when strength and energy begin to return that suicide becomes a severe threat. Therefore, suicide is more likely to occur in the early stages of depression or in later stages when personal energy becomes more mobilized. Other illnesses and problems, in addition to depression, contribute to the suicide rate.

Depressed persons are usually physically sluggish. They may walk slowly as if weighted down (depressed) with a great burden on their shoulders. Their speech is labored and slow, as though they are searching for words. Mental processes become sluggish and intellectual acuity is, or may be, greatly reduced. Even simple problems, which they may have previously handled with alacrity, become tedious. Adding a column of figures can become a painful chore.

These symptoms, which fall under the diagnosis of psychomotor retardation, are some of the first and most visible outward signs of incipient classical and clinical depression. The mind and body are slowed down to the point that family and friends begin to notice a difference in behavior. For the depressed person, concentration is difficult, if not impossible.

The depressed person begins to lose interest in events that were previously pleasant or appealing. Life loses its joy, and there is little or no desire to respond to invitations or participate in social events. People can suffer from anhedonia (lack of pleasure) without being depressed, but most depressed people exhibit the loss of involvement and responsiveness. This particular stage of depression creates a cyclical response. The more the individual withdraws from society, the more depressed he or she becomes. The more depressed they become, the more uninvolved and withdrawn they are. If this cycle can be interrupted and reversed, we can then move in the direction of healing. This will be discussed in more detail in Chapter 6.

As the depressed person participates less in life's activities and even routine requirements, his or her bodily functions slow down. Less food is desired or required. Food loses its taste and there is little appetite. However, the loss of appetite seems to be disproportionate to the lowered activity rate. The depressed person begins to lose weight, sometimes slowly but surely, and for no apparent reason. Friends may comment that the depressed person looks thinner than usual, or that he or she must be dieting, when actually the person is not even aware of, nor interested in, the continuing weight loss. Weight loss is unintentional and usually of little concern to the individual.

Most depressed persons develop sleep disorders. They previously may have been sound sleepers, but now experience difficulties in getting a good night's sleep. This compounds the onslaught of an encroaching depression by adding tiredness and fatigue to the other problems.

Sleep disorders (insomnia) of the depressed are usually one of three major kinds. The first is difficulty in falling asleep. This initial insomnia occurs repeatedly when the person goes to bed tired but is unable to doze off for several hours. Many times he or she may remain awake and restless all night, sleeping only rarely and fitfully, if at all. The second form of sleep disorder is called intermittent insomnia. The person falls asleep, but awakens one or more times during the night, and may remain awake from thirty minutes to two or three hours each time. The third form is terminal insomnia. This is manifest through early morning waking and the inability to return to sleep, remaining awake until it is time to get up and prepare for work or school.

In many depressions, anxiety is a component and may be involved in the waking episodes. The individual may rehearse frightening scenes or replay and imagine woeful consequences that are envisioned for the future. Doom may seem imminent. Small setbacks and reversals may be magnified to overwhelming proportions. Severe anxiety components in depression are often overlooked by therapists and pastors.

The reverse of insomnia (which is also known as hyposomnia) is hypersomnia, the tendency to sleep more than usual. Instead of sleeping too little, the individual may escape from his or her problems and pain by sleeping too much.

One talented young wife came for help complaining that she was sleeping all the time. After a few hours of work in the morning, she would find excuses and ways to take one or two naps in the afternoon and perhaps again in the evening. Then she slept soundly through the night. Once she was able to discuss her internal conflicts and face her ambivalence, she spontaneously discarded her extensive sleep pattern as an unnecessary escape. Her hypersomnia was no longer needed.

Any professional who is sensitive to signs presented by his or her client or parishioner will be aware of sleep patterns as an indicator of disturbance. Hyposomnia and hypersomnia are both to be noted, although hyposomnia or insomnia is statistically more prevalent in depressive disorders. The type or pattern of sleep disorder may be a clue to accurate diagnosis of the form of depression involved.

Perhaps the most outstanding and obvious symptom of depressive behavior is dysphoria. When depressed, a person usually feels so bad that he or she hurts all over. The person will complain of feeling down, sad, alone, alienated, hopeless, and grieving. The depressed individual hurts so much emotionally that the pain carries over into the physical sphere. Depressed people's physical activity is not only slowed down, but their bodies also ache with an unidentifiable and nonspecific malady.

All of us have experienced days in which we did not feel exuberant or happy. These days may flavor our lives and make the good moments seem that much better. The depressed person, however, in her dysphoric state, often does not remember ever having felt well in the past. All she can remember is having been depressed, and she expects to remain depressed in the future. She does not recover spontaneously after twenty-four or forty-eight hours of rest.

Often parishioners or patients will develop a compound depression; that is, they become depressed about their depression and tend to make it worse by ruminating about their painful emotional state.

One woman came to her pastor in such a down mood that she said, “Life is not worth living. I am of no value to anyone else and no one else cares about me or whether I live or die. It is all so hopeless that if I could, I would like to die right here on this spot.”

There are certain forms of depression in which the dysphoria is extensively masked. Masked depression has many forms and shapes. Usually, however, dysphoria of the kind indicated above is the overwhelming outward sign of classical depression.

Four other factors are often involved in depression: decreased competency and concentration, lowering of sexual interest, diminution of feelings of self-worth, and vague or sometimes blatant psychosomatic complaints.

A usually skilled and competent professional began to forget his appointments. He would go into his office and tell his secretary that he didn't want to be disturbed. He would sit for several hours trying to concentrate on the work in which he had previously excelled. Slowly but inextricably, he moved into a failure cycle until family and colleagues were able to get him professional help. His loss of competence was an outward sign of an inward depression. He could not concentrate, nor could he produce in ways that had previously been part of his lifestyle.

If all roads lead to Rome, it must also be true that most, if not all, psychic roads lead to feelings of self-worth. Depressed persons may consider themselves too fat or too skinny, stupid, slow, repulsive, unlovable, or unlikable. At some points, their egos have not been strong enough to endure narcissistic injuries or trauma. The rejections of life send them spiralling downward into the depths of self-rejection. The feelings of loss of self-worth are usually very severe and pronounced. The therapist must be able to walk with her patient and outwardly maintain her valuing of the depressed person while he is unable to value himself.

A movie critic at a newspaper reviewed Arthur Miller's play, Last Yankee. In her review, she stated that “women's woes seem relatively minor in the scheme of real problems…. You want to shake them out of their self-indulgent depressions….”

A reader responded:

There is nothing “self-indulgent” about depression. It is an extremely painful and debilitating condition, seldom understood by the unafflicted. While I was never institutionalized, my depression was severe enough to prevent my pursuing my career for several months while I was under the care of a psychiatrist. As a lifelong liberal, I have always been concerned and involved with the “real problems” she cites, even during my illness.¹

Those suffering from clinical depression remain aware of their surroundings and react to them in their usual way, knowing what is expected of them. Nevertheless, possessions, a good job, caring family members and friends, or a social conscience, although desirable and appreciated, cannot pierce the encircling blanket of gloom that is the crux of depression and is nearly always impossible for outsiders to comprehend.

Women seem to be more sensitive to the loss of personal relationships than men. The death of a husband or a family member, or the rupture of a close and sincere friendship will cause many women to become depressed.

Men seem to identify very strongly with their occupations or vocations. Therefore, the loss of a job in which they had invested a great deal of their sense of self-worth can be extremely damaging to the male ego and lead to depression.

A decrease in sexual activity is a sign that the clinician may discover either from the depressed person or his or her spouse. Previous sexual patterns are broken and sexual energy (libido) decreases. In some cases, the person loses all interest or desire for sexual relationships, when they had previously been very active and functioned normally in this area.

The last symptom, but certainly not the least important, is the presence of psychosomatic illness. The term “psychophysiological” would be more accurate since the organ (e.g., colon) is not functioning properly, although the tissue itself is not at this point damaged. However, after many years of being nonfunctional or malfunctional, an organ system may actually become tissue damaged.

For example, an irritation of the stomach, which results in indigestion, can become chronic and result in the development of tissue destruction in the form of ulcers. These ulcers become a protest of the system against the psychological conflicts and disturbances that are going on.

Psychosomatic or psychophysiological disturbances take so many different forms that they are the nucleus of extensive research and study. They can range all the way from high blood pressure, gastric ulcers, ulcerative colitis, migraine headaches, and allergies, to a less specific form of ailment such as chronic fatigue.

Physiological complaints should neither be taken lightly nor overlooked by the pastor or general physician. They should be checked thoroughly to eliminate any root causes or actual bodily illness.

For this reason, the pastor needs to develop close working relationships with physicians whom he trusts and whom he feels are not only medically competent, but humanly sensitive. Pastors must exert every effort to develop and nurture interprofessional relationships for the sake of their parishioners. Many pastors, and indeed many physicians, psychiatrists, and psychologists, are at first uncomfortable in collegial relationships. Pastors at times feel they are in an over-under relationship until they understand the medical profession and some of its needs, fears, and sensitivities. Regardless of this initial discomfort, mutual respect and cooperation is worth seeking, asking for, and cultivating. Ministers should not be surprised (but often are) to learn that medical doctors whom they have placed on a pedestal, have needs and fears just like everyone else.

People who are depressed need the strength and understanding of their pastors in order to move in the direction of healing and wholeness. Clinical depressions hurt and indeed may kill. They need not be as destructive as inaction and incompetence have let them be in the past. Consider the words of one of America's greatest statesmen, Abraham Lincoln:

I am now the most miserable man living. If what I feel were equally distributed to the whole human family, there would not be one cheerful face on the earth. Whether I shall ever be better, I cannot tell; I awfully forebode I shall not. To remain as I am is impossible; I must die or be better, it appears to me.²

Thank God, this continuing suffering is no longer unavoidable. With compassionate and sensitive guidance, there is more hope than ever before that this illness can be managed. Depression can also produce insight and wisdom that can be had in no other way. Nothing is as tragic as a grief (depression) wasted. Let us vow to learn from it, rather than be bound by it. Thank God there is hope-always hope.

Chapter 2

The Roots of Depression

The term “clinical depression” is used to describe an entity separate and identifiable from the blues, feeling down, or simple, ordinary feelings of depression. A clinical depression has specific and rather clear diagnostic symptoms that set it aside from other forms of grief or “just being down.”

Three factors are always present in psychologically induced clinical depression. First, there is obviously a hereditary predisposition that makes the psyche vulnerable to responses of a dysthymic or dysphoric nature.

Second, there is a history or indication of a childhood background that involves affectional and emotional deprivation. Unreasonably high expectations, along with manipulation by guilt and humiliation, often contribute to the emotional loading that in turn adds to the depress...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• About the Author
• Introduction
• Chapter 1. Depression. How It Feels
• Chapter 2. The Roots of Depression
• Chapter 3. The Subconscious and Depression
• Chapter 4. Making the Diagnosis
• Chapter 5. Cognitive Therapy
• Chapter 6. Behavioral Treatment
• Chapter 7. The Pastor. Unique Caregiver
• Chapter 8. A Theology of Pastoral Care
• Chapter 9. The Minister's Own Mental Health
• Chapter 10. Taking Charge of Your Life
• Chapter 11. Summary
• Notes
• Index