Whilst we all have days when we would rather stay in bed, depression is an insidious and hope-draining affliction in which the sufferer truly sees life itself as the enemy. Whilst the word ‘depressed’ is now commonly used colloquially to express the sense of feeling a bit down, depression is a recognised illness in the Diagnostic and Statistical Manual (DSM) with a clear set of symptoms and a range of treatment options. Any ethical therapist, whether a yoga therapist or otherwise should, therefore, be aware of the symptoms and strive to become adept at recognising clients suffering from depression. Therapists need to be aware that there are two types of depression; endogenous (resulting from an internal, biological source) and exogenous (which can be traced back to an external trigger). Alarm bells for endogenous depression might ring for the therapist who hears their client complain of physical ailments whilst also bemoaning a low mood, inability to sleep, changes in motivational levels and appetite etc. It is to be remembered, however, that endogenous depression may not have any related physical complaints and that these two types of depression can be, and often are, inextricably linked.
Exogenous depression may be more easily identifiable in the context of yoga therapy, since pointers will mostly come from what the client directly says. At such recognition, it may be useful to ascertain how often such episodes of low mood occur, enquiring as to their severity and finding out their common duration. If the episodes of low mood and associated difficulties are frequent, severe and of extended duration then the likelihood that the client is suffering from depression is quite high. There are also particular symptoms related to specific types of depression. A person with unipolar depression, for example, may complain of a feeling of constantly low mood, a person with bipolar may describe (or, indeed, present with) extreme highs and extreme lows, a person with major depression may complain about feeling apathetic and seem completely disinterested in life and so on. It is useful to use what the client says, the way in which they present (are they staring at the floor? Are they of unkempt appearance? Have they lost/gained weight for no apparent reason?), and knowledge of the life events of the client. A client who has recently given birth and struggling with chronically low mood, for example, may be suffering from postnatal depression.
When planning a yoga therapy program for a depressed client, all of these elements will need to be taken into account; the type and severity of the depression, the life events and family situation surrounding the depression, previous incidences and treatments of such depression and so on. An ethical therapist would also carefully consider whether or not, indeed, they would be able to treat the client; clients with psychotic depression, for example, may also need to be referred to a specialist. Harm to self or others could also be indicators that a higher level of care is needed.
Recent bereavements should also be taken into account when dealing with a client with depression. Currently, the Diagnostic and Statistical Manual of Mental Disorders assigns special status to bereavement-related depression, claiming that it is distinct from all other depressive episodes. However, some recent findings refute this special status as Sidney Zisook, MD, from the University of California, San Diego, explains to Medscape Psychiatry; “depression that occurs in the context of the loss of a loved one is essentially identical to depression that occurs in the context of any other negative event or loss,” Dr. Zisook from the Journal of Psychiatry agrees; “if a bereaved person’s depression otherwise meets criteria for major depression, it should be taken seriously, diagnosed as major depression, and treated accordingly, rather than continuing to use the bereavement-exclusion rule and treating this as ‘normal grief’”. Below are some guidelines for grief, which may be useful when working with clients with depression who have suffered a recent loss in their lives
Guidelines for Grief
- Face your feelings. You can try to suppress your grief, but you can’t avoid it forever. In order to heal, you have to acknowledge the pain. Trying to avoid feelings of sadness and loss only prolongs the grieving process. Unresolved grief can also lead to complications such as depression, anxiety, substance abuse, and health problems.
- Express your feelings in a tangible or creative way. Write about your loss in a journal. If you’ve lost a loved one, write a letter saying the things you never got to say; make a scrapbook or photo album celebrating the person’s life; or get involved in a cause or organisation that was important to him or her.
- Look after your physical health. The mind and body are deeply connected. When you feel good physically, you’ll also feel better emotionally. Combat stress and fatigue by getting enough sleep, eating right, and exercising. Don’t use alcohol or drugs to numb the pain of grief or lift your mood artificially.
- Don’t let anyone tell you how to feel, and don’t tell yourself how to feel either. Your grief is your own, and no one else can tell you when it’s time to “move on” or “get over it.” Let yourself feel whatever you feel without embarrassment or judgment. It’s okay to be angry, to yell at the heavens, to cry or not to cry. It’s also okay to laugh, to find moments of joy, and to let go when you’re ready.
- Plan ahead for grief “triggers.” Anniversaries, holidays, and milestones can reawaken memories and feelings. Be prepared for an emotional change, and know that it’s completely normal. If you’re sharing a holiday or lifecycle event with other relatives, talk to them ahead of time about their expectations and agree on strategies to honour the person you loved.
(Guidelines dapted from the Help Guide for Mental Grief and Loss, Smith &, Seagal, 2012).