Depression And Christian Counseling
by Rev. Harry A. Smith, D.D., Ph.D., D.Min.
Presented by Saint Luke Evangelical School Of Biblical Studies
Biological Model of Depression
The basic cells of the nervous system are called neurons. They communicate with each other by one neuron releasing chemicals called neurotransmitters which act on the second neuron leading to activation or inhibition of that neuron. This entire process is called synaptic transmission. What follows is a brief summary of this process. When an electrical signal travelling down the cell body of a neuron reaches its terminus, a series of ionic events are initiated which result in the release of the neurotransmitter into the gap (called a synapse) between the two nerve cells. The neurotransmitter then binds to a special protein called a receptor on the second nerve cell. The interaction between transmitter and receptor results in ionic events in the second neuron which either activates it or inhibits it based on the specific transmitter and receptor involved. Following this action, the transmitter may be taken back up into the first cell and reused. This involves a transmitter reuptake system. In some cases the transmitter may be broken down and not reused. This process uses an enzyme on the second cell whose primary function is to breakdown the transmitter.
One particular example of a transmitter system involved in depression is the serotonin system. Serotonin is a neurotransmitter which appears to be involved in generating mood elevation and general feelings of wellness. After release, serotonin is normally taken back up into the cell which released it by a serotonin reuptake system, although it may sometimes be broken down by an enzyme called Monoamine Oxidase (MAO) and not reused. There is ample evidence in the biological literature that many cases of depression are linked to depressed levels of serotonin. As such, a number of chemical therapeutic strategies have been developed to relieve states of depression by raising the levels of serotonin in the synaptic gap. One approach is to block the serotonin reuptake system. This results in an accumulation of serotonin in the gap until it reaches normal levels and presumably restores normal function in the pathways that use serotonin. A classic drug acting in this manner is Prozac. In most cases Prozac has been shown to have dramatic effects in reversing depressive states. The main problem with the drug is that it may have variable and serious side effects in individuals which cannot be predicted prior to use. Efforts have been made to find other drugs to replace Prozac. Zoloft is one such replacement which has fewer side effects. Another strategy is to block the MAO's. This will slow down the breakdown of serotonin and again results in its levels in the synaptic gap being raised to normal levels. Interestingly, an herbal remedy long known to relieve depressed states, St. John's Wort, is now known to have an MAO inhibitor.
What is clear from the above discussion is that if someone suffers from depression and has no reasons for not seeking medical treatment, there is a good chance that medical treatment may be effective in relieving the major symptoms. However, there are many cases where the underlying causes of depression are not demonstrably related to these medical conditions and in which classic chemical therapy does not work. In such cases counseling techniques to relieve depression may be the only method of therapy possible. Moreover a counselee presenting signs of depression needs to be recognized as such even to a non-medical counselor so appropriate initial counseling may be effective as well as appropriate referrals. Finally, even if medical treatment is effective there may be many other coping mechanisms that need counseling support to enable the counselee to return to normal psycho-social and spiritual effectiveness
2. Other Factors Causing Depression
Many studies focusing on causes of depression have indicated that along with (or more accurately in association with) the biological causes indicated above, a number of Psychological-Cognitive factors have been positively correlated with the appearance of depression. Such factors include developmental, psychological, interpersonal, and spiritual influences. While it is not all clear that these influences, of themselves, lead to depression, it is now fairly certain that they may lead to changes which result in biological depression.
For example, it has been suggested that childhood experiences may lead to depression in later life. Lack of appropriate caring influences in early childhood has been correlated with depressed states later in life. Stress due to a loss has also been positively correlated with depression whether the loss involves a job, opportunity, loved one, possessions, status, health, etc. Loss of control and an accompanying "Learned Helplessness" is another factor where the individual feels that nothing they do is any longer effective in reaching a goal or bringing about change. Negative thinking has also been associated with depression. Depressed people not only have a negative view of themselves, but also of the world in general. Often expressing such views as "Oh, I'm no good", is merely an attempt to control the reaction of others. Repressed anger has been suggested as another factor leading to depression. When anger is repressed, the individual often resorts to a "revenge mode" which may lead to destructive actions, or if this is also repressed, to depression. Sin and guilt over sin is a powerful force for depression. Guilt arising from sin leads to feelings of self-condemnation, frustration, hopelessness and other signs of depression.
It is clear then that depression, having an underlying biological cause, is often manifested by a plethora of internal and external factors which need to be discovered in order to inform the counselor of the root of the depression and appropriate strategies for handling it.
3. Depression and Counseling
From a counseling point of view, it is important to be able to recognize signs that a counselee may be experiencing the condition. Gary Collins' Christian Counseling - A Comprehensive Approach, revised edition is an excellent source of this material and I have followed the outline present in Collins' discussion fairly closely. There are a number of common indicators that point to depression. Some of these are:
Unhappiness and inefficiency. Feelings of hopelessness, self-criticality, "down in the dumps", fatigue, loss of enthusiasm, etc. are often accompaniments of depression. The person experiencing these emotions tend to be non-motivated and lack even the energy to perform simple tasks. The person's life then becomes quite inefficient resulting in a marked lack of achievement and an increased dependency on others.
Physical Illness. The state of depression is often accompanied by a depression of immune functin. The exact mechanism behind this effect is not known, although there has been some evidence that immune cells have receptors for certain "stress hormones" (mainly the glucocorticoids) and the stress accompanying depression may be an important factor. In any case, the individual is more susceptible to certain other physical illnesses.
Low Self-Esteem. Low self -esteem due to the depressed state often leads to social withdrawal. The person does not feel like communicating with others and may withdraw into realms of escapism such as television, reading, etc. Fantasies of leaving the current condition and finding a "new life" are common. In particular the person is often reticent at speaking about the condition itself.
Suicide. In more extreme cases, this is a mechanism of escape some depressed persons fantasize about or actually carry out. It is most common among teenagers, people living alone, unmarried persons and divorced persons.
In some cases the depression may be masked in such a way that it is not apparent to the depressed individual. Instead, it is manifested in a number of ways including hypochondriasis, aggressiveness, anger, violence, drinking, drug abuse and other forms of self-destructiveness. The emotional hurts seen here may only be hiding the underlying depression to the extent that close family members and even trained counselors may not recognize the underlying cause.
Counseling someone who is depressed requires some different approaches than are used in other counseling situations. For example the counselee is often passive and nonverbal. Hence the counslor's listening skills must be augmented with a willingness to reach out verbally and take a more active role than would otherwise be the case. Here are some tips:
Listen attentively and be particularly careful to look for signs of hurt, negative thinking, loss of control, guilt, etc.
Be careful not to encourage dependence.
Be aware of the need for medical and psychiatric treatment when needed.
Look for the underlying psychological and spiritual causes such as background, stress, learned helplessness, negative thinking, anger, and guilt.
Deal with modes of thinking. For Christians sometimes unrealistic expectations of "perfect" behavior cause feelings of helplessness and guilt over minor issues. Of particular importance is the need to constantly reinforce the fact of God's control in our lives and that we need not always be in personal control.
Deal with the environment. In some cases, changes in the environment can be extremely beneficial in overcoming depressed states. Sometimes any change no matter how minor can have an enormous effect by itself as well as being a first step in leading to self-directive changes!
Use Spiritual Resources. Holy Scripture can be a great comfort to the depressed. The Psalms are of particular usefulness since many themes of comfort and support are found therein. In addition, faith in God is a powerful force for allowing the counselee to gain a more balanced view of their situation and their proper relation to it. In prison, Paul learned how to be content in all of his circumstances, knowing that God strengthens all of His children ad supplies all of our needs, especially in times of crisis. Such a conviction that God is in control can give great encouragement even in times that seem without hope. Unfortunately, some forms of Christian counseling have been shown (by Christian not secular psychiatrists) to be counterproductive in relieving and preventing depression. Being told to "trust in God and the depression will go away" may lead to an even deeper depression when symptoms are not relieved at once! It may even lead to a crisis of faith where unrealistic expectations of God's immediate intervention do not match with His Will for the person. What seems to be of more help is a community that offers prayer and sympathy for the depressed person with as little judgement as possible. Focusing on sin as a cause of depression often leads to more feelings of guilt and a further deepening of the depression. It should be pointed out, however, that there is a wide disagreement over these last few points with anti-psychiatrical Christian counselors advocating a noethic confrontational-based approach. Such techniques have been claimed to be effective in some cases, though no academic study has been done which fully supports this claim.
Look for ways to prevent the depression.
Be alert to depression-prone situations.
Help the counselee to handle anger and guilt.
Challenge negative thinking.
Help the counselee find support, familial or otherwise.
Encourage the counselee to take positive action.
Encourage physical fitness.
Depression is a serious mental disorder confronting an ever increasing number of persons in our contemporary society. In counseling persons with depression, there are a number of factors which may need to be evaluated including the nature of the illness and how rhe counselee relates to the illness. The Christian counselor is particularly faced with the effort to place the counseling process upon sound spiritual principles while avoiding the possibility of misusing the spiritual approach and actually enhancing the depressed state. Perhaps the strongest tool in the Christian counselor's repertoire is the notion that God is in control of our lives and will support us if we but ask. Such a personal notion of faith and grace can then be coupled with psychological techniques (avoiding negative thinking, taking some decisive actions) and communal outreach of support. Within a religious context, depression can often be helped by these methods as a support to medical treatment or in minor cases as a supportive mode of spiritual help which may obviate the need for more drastic treatment. In any case, it should never be suggested as a replacement for proper medical care when such care is clearly needed.