HIDDEN ACCESS: UNDERSTANDING AND COPING WITH DEPRESSION

"My breath is low and slow.  My heart feels so heavy I am not sure I can keep going My throat clutches. the tears lurk right behind my lids.  How can people care about all this stuff?  I am so tired.  I just don’t feel like talking to anyone anymore.  What’s the point?"    (45 year old woman)

"I don’t feel like myself anymore.  I used to have energy and care about things.  There is nothing to look forward to.  Everything irritates me.  There is just so much pressure." (36 year old man)

 "I don’t know, Mom,  I mean,  what’s the point ?  I get the new set of cards or a new game and it’s  fun for like 10 minutes and then who cares?  Nobody seems to like me. Everybody is criticizing me.  I just don’t care anymore." ( 10 year old boy)

"Nothing seems to be working.  Nothing is ever right with him I just can’t get things done quickly enough.  I try but nothing seems to be good enough for him any more."

(Wife of 72 year old man )

"I never thought it would be like this.  I thought I would be able to have a family when I was ready.  We have been trying for 4 years now and I am tired".  (38 year old woman)

'I don’t know what has happened to me.  I thought when the baby arrived everything would be ok.  I don’t even want to get out of bed.  I hate the crying.  Isn’t that awful? How can I say that about a baby my baby? "( 31 yr old woman)

INTRODUCTION

An individual who walks through the door suffering with depression may present a variety of issues, but they often share a deep sense of heaviness and fragility: a sense of hopelessness, deep despair, silence that wants to scream, heaviness.  Conversely, there may be an agitation present. A frustration at nothing seeming to work right anymore, impatience and intolerance and sometimes a scream that is not so silent.  Initial attempts to engage the client in a conversation about their discomfort and suffering will often end in statements of futility, silence or one word answers.  The gate appears locked: the walls too high, the access to the person and their world hidden and impenetrable .

 The estimates of depression are high and vary greatly from19 to 50 million American. Frequently, 5% of the US population are estimated to suffer from depression.  It is likely to be one of the most frequently encountered clinical issue. Although depression can be effectively treated in 80-90% of all cases, it is estimated that only one third of all people may seek treatment.  What causes such disparity?  What might prevent people from seeking treatment?   It often seems that emotions and moods carry a negative value or stigma in our present world.  We are encouraged to not let ourselves get "too carried away" or be "too sensitive".  Emotions are supposed to be conquered, ignored, let go, dismissed.    We must acknowledge  that in America we reward and admire mastery, achievement and success.  Perseverance and achievement can rightly be admired and rewarded.  It is the degree and cost to which they are pursued and valued to the exclusion of the other ways of perceiving, interacting and living which may need examination.  If an individual does not fit into the ideals of a society there is likely to be an experience of isolation and feelings of sadness, confusion or frustration and perhaps, anger.  These feelings may be natural and expected in relation to the person's circumstances.  It is the degree to which they are experienced and their impact on the individual's functioning in life, love and work that need to be considered when assessing for depression.

Emotional responses of sadness, anger, frustration and despair are part of the human experience.  Our emotional experience is complex and rich.  The experience of emotions is natural and healing to ourselves and our souls.  Repression of the emotions can be costly on all levels: physical, emotional, and spiritual.  Feeling all of these emotions in relation to loss, hardship and struggle is the essence of the human experience. On the other hand,  depression requiring treatment through medicine and psychotherapy is distinguished by its severity, duration and resistance to all efforts made by the person to overcome the symptoms.  The self defeating  dilemma of depression is the tendency for people to think that they can “tough it out” and it would only be a sign of weakness to seek help.  Negative thinking and self condemnation are often hallmarks of the depressed person's state of mind. (John Preston, Depression and Anxiety Management, 1999)

When evaluating depression, we must first look for the possible causes of depression: physical, life stress, and psychological.  There are several physical sources which may cause depression and a medical exam with an evaluation for medication is often indicated for clients struggling with these issues.  Thyroid dysfunction, Seasonal Affective Disorder, chronic illness and certain medicines have been known to cause depression.  Conversely, when there does not appear to be any physical cause for symptoms of  anxiety, frustration, sadness, sleep disturbance, appetite changes a referral may be made to a therapist to examine issues of life circumstances past and present.

The  emotional core of the depression seems to be emptiness and loss: the loss of a loved one, sudden trauma, abuse, the loss of a dream or a sense of meaning in life. The loss may result through, death, divorce, break up, disability, a job, dream or value.  In instances where the loss leads to a  depression, there is a tendency for the person to take on the responsibility of the loss and treat themselves with judgment, harshness and condemnation.  They may question the fairness of the entire world or life they have lived, earned or deserved.  The harshest critics of the depressed person may be themselves.  This can be tricky in the clinical setting as interventions suggesting self help or other methods may first be interpreted as further evidence that they have not done enough themselves and have somehow failed.  As justice in life and the world may be questioned, current events can add to this struggle.  With the events of September 11,  there appears to be a  traumatic cultural loss of safety, security and innocence.  In spite of the great freedoms and abundance enjoyed currently in American culture, there are also ongoing issues for many in western society and its focus on achievement and acquisition.  Many disillusioned young people and adults question the striving and what the satisfaction is for them in these endeavors. 

There are often gender differences in the diagnosis and presentation of symptoms of depression. The socialization of boys ,in particular, often does not encourage the full spectrum of emotion.  In Raising Cain, the authors do an excellent exploration of the impact of our practices on our young boys.  Boys and men are likely to appear more agitated and angry in their mood as they struggle against these feelings of powerlessness.  Women, who represent the largest demographic of people diagnosed with depression, often exhibit a more classic picture of sadness  and may have issues related to self, pregnancy, hormonal changes, infertility, fertility, parenting/not parenting, balancing self, work and family, menopause and aging.  In no way is it implied that these issues are inherently depressing.  They just represent many of the issues confronting women and men in our society as we struggle towards individuation, balance and wholeness.  Not only are the emotions associated with depression natural and healing, but depression itself may also deserve consideration as a part of a process of developing wholeness and authenticity in our lives. I have often found in my own personal and professional experience that the journey towards wholeness involves a passage through the “dark night of the soul”: a place where all hope does indeed  feel lost.  It is in this time of uncertainty and suffering that we often touch the divine or a different level of understanding about life. What brings us in direct contact with this suffering is often an experience of loss.  While medical treatment can help alleviate symptoms, You may need to seek counsel from clergy or a mental health professional to touch the core of your sadness.  The sadness will lift: it is important to seek help.

Regardless of the causes and results,  it is important to realize that depression reaches across, culture, economics, gender, and age.  It is a serious problem that blocks access to the health of  body mind and spirit. When a family has a depressed member it affects every member of that family with a sense of futility and frustration and often misplaced responsibility.  For those not suffering directly from depression, compassion can give way to disappointment, impatience and frustration with the ongoing struggles of  the depressed individual.   It is often very important to treat the family of the client with depression, as well as the client themselves.  This can be done in session or through education and support groups.

There are many ways to approach depression.  In this course we will look a depression as an issue of body, mind and spirit.  We will start with the  warning signs, the possible physical causes to the life events and to the spirit.

From the National Institute of Mental Health these four steps to better understand depression are crucial for clinician and client.

  • Four steps to understand and get help for depression:

    Look for signs of depression.

    Understand that depression is a real illness.

    See your doctor. Get a checkup and talk about how you are feeling.

    Get treatment for your depression. You can feel better.

SIGNS OF DEPRESSION FROM NIMH

Posted: January 24, 2002

Read the following list.

Put a check mark by each sign that sounds like you:

 I am really sad most of the time.
 I don’t enjoy doing the things I’ve always enjoyed doing.
 I don’t sleep well at night and am very restless.
 I am always tired. I find it hard to get out of bed.
 I don’t feel like eating much.
 I feel like eating all the time.
 I have lots of aches and pains that don’t go away.
 I have little to no sexual energy.
 I find it hard to focus and am very forgetful.
 I am mad at everybody and everything.
 I feel upset and fearful, but can’t figure out why.
 I don’t feel like talking to people.
 I feel like there isn’t much point to living, nothing good is going to happen to me.
 I don’t like myself very much. I feel bad most of the time.
 I think about death a lot. I even think about how I might kill myself.

If you checked several boxes, call your doctor. GET HELP. your life is valuable and there is support available. Take the list to show the doctor. You may need to get a checkup and find out if you have depression.

 


 

Depression in Children and Adolescents 
  
  
 

This fact sheet, prepared by the National Institute of Mental Health (NIMH), the lead Federal agency for research on mental disorders, summarizes some of the latest scientific findings on child and adolescent depression and lists resources where physicians can obtain more information.

 Scope of the Problem

 Clinical Characteristics

The diagnostic criteria and key defining features of major depressive disorder in children and adolescents are the same as they are for adults. However, recognition and diagnosis of the disorder may be more difficult in youth for several reasons. The way symptoms are expressed varies with the developmental stage of the youngster. In addition, children and young adolescents with depression may have difficulty in properly identifying and describing their internal emotional or mood states. For example, instead of communicating how bad they feel, they may act out and be irritable toward others, which may be interpreted simply as misbehavior or disobedience. Research has found that parents are even less likely to identify major depression in their adolescents than are the adolescents themselves.

 Symptoms of Major Depressive Disorder 
 Common to Adults, Children, and Adolescents 

      Persistent sad or irritable mood 
      Loss of interest in activities once enjoyed 
      Significant change in appetite or body weight 
      Difficulty sleeping or oversleeping 
      Psychomotor agitation or retardation 
      Loss of energy 
      Feelings of worthlessness or inappropriate guilt 
      Difficulty concentrating 
      Recurrent thoughts of death or suicide

 Five or more of these symptoms must persist for 2 or more weeks before a diagnosis of major depression is indicated.

 Signs That May Be Associated with Depression in Children and Adolescents

      Frequent vague, non-specific physical complaints such as headaches, 
      muscle aches, stomachaches or tiredness 
      Frequent absences from school or poor performance in school 
      Talk of or efforts to run away from home 
      Outbursts of shouting, complaining, unexplained irritability, or crying 
      Being bored 
      Lack of interest in playing with friends 
      Alcohol or substance abuse 
      Social isolation, poor communication 
      Fear of death 
      Extreme sensitivity to rejection or failure 
      Increased irritability, anger, or hostility 
      Reckless behavior 
      Difficulty with relationships 
 

 While the recovery rate from a single episode of major depression in children and adolescents is quite high, episodes are likely to recur. In addition, youth with dysthymic disorder are at risk for developing major depression. Prompt identification and treatment of depression can reduce its duration and severity and associated functional impairment.

 Screening

There are several tools that are useful for screening children and adolescents for possible depression. They include the Children's Depression Inventory (CDI) for ages 7 to 17; and, for adolescents, the Beck Depression Inventory (BDI)  and the Center for Epidemiologic Studies Depression (CES-D) Scale 20. When a youngster screens positive on any of these instruments, a 
comprehensive diagnostic evaluation by a mental health professional is warranted. The evaluation should include interviews with the youth, parents, and when possible, other informants such as teachers and social services personnel.

 Risk Factors

 In childhood, boys and girls appear to be at equal risk for depressive disorders; but during adolescence, girls are twice as likely as boys 
 to develop depression. Children who develop major depression are more likely to have a family history of the disorder, often a parent who experienced depression at an early age, than patients with adolescent- or adult-onset depression. Adolescents with depression are also likely to have a family history of depression, though the correlation is not as high as it is for children.

 Other risk factors include:

      Stress  
      Cigarette smoking  
      A loss of a parent or loved one  
      Break-up of a romantic relationship  
      Attentional, conduct or learning disorders  
      Chronic illnesses, such as diabetes  
      Abuse or neglect  
      Other trauma, including natural disasters  
National Institute of Mental Health 
  
 

I have listened to many stories through the expressive therapies of play therapy, art and sandplay.  These modalities give voice to regions where there are no words.  Children take little to no encouragement to engage in these interventions.   Making art materials available, setting things up as a play to be enacted or being invited to play with the shelves full of toys used with Sandplay are motivation enough for the child to engage in the process.  Adults may need a little more encouragement.  Saying that you have seen many people be able to express things more clearly when words


Timing is everything in this work.  You have experienced something traumatic and unexpected against their will.  It is imperative that you lead the timing of the healing.  Regaining a sense of control and purpose to your life is essential. I have often related this process to clients as having a scar from battle. You have survived and although not unscathed the scar just adds another dimension to your soul, your heart and what you have to offer.  Be aware there is a timing for this type of intervention.  I can personally attest to being distanced by a well meaning but premature remark that trauma and pain were somehow good for me. 

Emotional healing from violence and trauma or loss is not a straight line. These are the issues wherein words are hard to find. There is often a need express through play, art or another non verbal medium.  Many times a scene might be repeated or a play reenacted as the client struggles to grasp a sense of control and completion of the incident.   As stated education and normalization, are primary interventions.  The feeling of not being alone is critical.    Healing modalities incorporate boundaries, consistency and safety.

KEEP THE FAITH
Young or old, the most important part in helping yourself or another with depression is commitment to their safety and patience with the process of healing.  Learn as much as you can about depression and healing from trauma. Visit sites like Gift From Within  to read stories of healing and inspiration. Access doctors, therapist, clergy and friends to make it through the rough times.  If you are struggling with recovery issues, make use of the twelve step groups. Do not give up, there is help available and time will bring new perspective and healing.

 

 I gratefully acknowledge the following authors and sources for permission to link and download.

The National Center for Post traumatic StressPrins, A., Kimerling, R., Cameron, R., Oumiette, P.C., Shaw, J., Thrailkill, A., Sheikh, J. & Gusman, F. 
                       (1999). The Primary Care PTSD Screen (PC-PTSD). Paper presented at the 15th annual meeting of the 
                       International Society for Traumatic Stress Studies, Miami, FL.

National Clearinghouse for Child Abuse and Neglect at http://calib.com/nccanch

 Richard Leslie, The California Therapist January/February 1990 issue of The California Therapist, the publication of the California Association of Marriage and Family Therapists, San Diego, California.) 
A National Center for PTSD Fact Sheet 
  References:

                       DeWolfe, D. (2001). Mental Health Response to Mass Violence and 
                       Terrorism: A Training Manual for Mental Health Workers and Human 
                       Service Workers.

                       Monahan, C. (1993). Children and Trauma: A Parent's Guide to Helping 
                       Children Heal. Lexington Books, New York, NY.

                       Pfefferbaum , B., Nixon, S., Tucker, P., Tivis, R., Moore, V., Gurwitch, 
                       R., Pynoos, R., & Geis, H. (1999). Posttraumatic stress response in 
                       bereaved children after Oklahoma City bombing. Journal of the American 
                       Academy of Child and Adolescent Psychiatry, 38, 1372-1379.

                       Pfefferbaum, B., Seale, T., McDonald, N., Brandt, E., Rainwater, S., 
                       Maynard, B., Meierhoefer, B. & Miller, P. (2000). Posttraumatic stress 
                       two years after the Oklahoma City bombing in youths geographically 
                       distant from the explosion. Psychiatry, 63, 358-370.

                       Pynoos, R. & Nader, K. (1993). Issues in the treatment of posttraumatic 
                       stress in children and adolescents. In J.P. Wilson and B. Rapheal (Eds.), 
                       International Handbook of Traumatic Stress Syndromes (pp. 535-549). 
                       New York: Plenum. 
http://playtherapycentral.com/ideas.html

Moving in The Rhythm of the Child video, Gift From Within

National Institute of Mental Health

 Counseling Abused Children. Highlights: An 
                     ERIC/CAPS Digest.