Pastor, I feel so miserable." I was still in bed when the cry on the phone awakened me. The words were heavy with sadness. The tone reflected emptiness and inner loss.
"Marie, what's wrong?" I asked.
"He's gone, pastor. My husband's gone. Not that he's run away or anything. It's just that he has this new job and he's never home! How does he expect me to keep things going by myself? I just can't do it! And my brother ... he's so sick. You know, he had back surgery, and the doctors are worried about him. And my mom, she's calling me and crying all the time. Oh pastor, I'm just so unhappy!"
Marie had struggled with her problems. Finally they had become too much. For two days prior to calling me she had shut herself in, refused to answer the telephone or doorbell, relinquished all the household chores to her two daughters, and stayed in bed weeping.
Do Marie's complaints appear some what inconsequential? The truth is, she was suffering from depression.
Depression is a common malady of our times. Every pastor encounters it in the parish. Though treatment and recovery are promising, depression can be a protracted problem, one that diminishes the overall health of the sufferer, along with the well-being of their family.
Twenty-four years of pastoral ministry has led me to the conviction that the local church can play a dynamic role in ministering to the depressed. Depressed people crave love. They feel guilty, worthless, and despairing. The church lives to care and to impart to people the sense that they matter. At the core of our proclamation is the reality of forgiveness, faith in an omnipotent God, and the true worth of every human being.
This being so, it is important that pastors learn how to offer this kind of care with competence. More than one study has shown that often the pastor is the first point of professional contact for depressed persons seeking help. There fore, the kind of help pastors offer is a matter of critical significance. Skilled care may help to diminish the scope and duration of a parishioner's pain, while inept care may prove disastrous, even life threatening.
What makes up competent pastoral care? From my experience two skill areas constitute pastoral competence when dealing with depressed persons: identification and intervention.
Common sense told me that Marie was experiencing depression. But common sense alone is hardly adequate when the need is to intervene effectively in a given situation. Thus the pastor needs to have training and proficiency in recognizing the symptoms of depression and evaluating the degree of their severity.
Recognizing symptoms
The common symptoms of depression fall under five categories.
1. Feeling. Depressed persons feel sad or dejected and may be prone to frequent bouts of weeping.
2. Cognitive process. Depressed individuals think negatively about almost everything. They ruminate a great deal over past mistakes.1 As a result, they have low self-esteem. Trivial problems seem monumental. Hope is in short sup ply. Guilt is a constant plague, not only in the light of things done or undone, but simply in the light of being.
3. Motivation. Depressed persons suffer from a paraplegia of the will. They are indecisive. Projects go untouched. Tasks undertaken frequently go unfinished.
4. Physical health. Depressed persons generally exhibit one or more symptoms of waning physical health. These may be real or imagined.
5. Behavior. Depressed persons display a general slowdown in physical activity. A few days prior to calling me, Marie had retreated to bed, refusing to get up despite the pleas of her daughters and friends.
Viewed together, all five categories of symptoms serve as a conceptual tool for recognizing depression. However, research shows that symptoms of depression are not always clearly manifested. Often they are masked by "depressive or affective equivalents," 2 that is, changes in physical health, behavior, or temperament that do not obviously attach themselves to a depressive event. When this happens, identifying depression may be difficult.
These masked symptoms may include hyperactivity, anxiousness, agitation, over-achievement, underachievement, chronic tardiness, over work or laziness, insomnia, excessive sleeping, bowel irregularities, over-politeness, inappropriate laughter, flightiness, excessive pleasure seeking, forgetfulness, overeating, undereating, neglect of appearance, excessive generosity, inability to concentrate, compulsive TV watching or radio listening, reckless driving, overindulgence in alcohol or drugs, daydreaming, obsessive-compulsive activity, apathy, supersensitivity, lack of humor, angry outbursts, mood swings, sarcasm, or cynicism.
Evaluating the severity
Recognizing the symptoms of depression represents half the identification task. Evaluating the severity rep resents the other half. Estimating the severity of a depressive condition is vitally important in that underestimation could prove fatal.
David, 21, a recent college graduate, asked to see me for a few minutes. The visit became an extended one during which David described his struggles with depression. His distress was obvious, but I underestimated its intensity. Smiling as he left, he said he looked forward to meeting me the next day. He never made it. At 5:00 the next morning his brother called to convey the news that David had jumped off a near by bridge, plummeting 300 feet to his death.
One way of weighing the degree of seriousness in a depressive situation is to find out how much the depression has upset the person's usual daily routine. Generally, the more significantly the daily routine is disrupted, the more serious the depression is.
Mild depression is usually characterized by: (1) a cause that is likely to be recent and overt; (2) a mood of sadness; (3) a slight lack of ambition; (4) occasional daydreaming (particularly about activities of pleasurable escape); (5) a low-grade pessimism; and (6) a general sense of lethargy.
Moderate depression is characterized by: (1) occasional thoughts of suicide; (2) a diminished sense of efficiency in daily responsibilities; (3) a lowered sense of self-esteem; (4) numerous aches and pains; (5) a desire to with draw; (6) a feeling of melancholy; (7) fatigue; (8) frequent fantasizing; (9) an active resistance to taking on new responsibilities; and (10) a sense of being immobilized.
Severe depression is characterized by: (1) hallucinations (in some cases); (2) strong suicidal wishes; (3) an inability to carry out the daily routine; (4) thoughts of total worthlessness; (5) radical social withdrawal; (6) despair; (7) severe physical lethargy; and (8) an almost complete loss of motivation.
Intervention
Once depression is identified and assessed, intervention follows. Ten guidelines for intervention have proved to be helpful.
1. Be caring, not just concerned. Depressed persons generally feel unloved and unlovable. When pastors express "concern" and do not follow up with "caring," their support may be viewed as coming from a sense of obligation rather than love. This reinforces an already overdeveloped self-perception of worthlessness, only exacerbating the depression.
2. Take the initiative. Depressed persons will often deny their need for help and resist it. Pastors need to find discreet ways to make contact—perhaps a telephone call, an invitation to lunch, a personal note, or a quiet conversation in the hallway after church.
3. Empathize rather than sympathize. Sympathy is not necessarily negative, but it may reinforce self-pity, which is not helpful to the recovery process. Something like the following could be said: "I have never been exactly where you are, but I have been depressed enough to know how very unpleasant it is. I also know that there are certain things that can be done to ease your pain and help you regain your peace of mind. If you'd like, I'd be glad to help you work things out."
4. Hold out hope. A depressed per son often gets such pithy counsel as "Cheer up," "Hang in there," or "It'll work out." These put-off comments are not hope-infusing; in fact, they are hope-diffusing. Of far greater benefit is a comment such as this: "I want you to know the time will come, perhaps soon, when you'll be beyond this depression. Although now it is a limiting distress and the process out of it may not be easy or painless, the depression will pass." When I look a depressed person in the eye and articulate these words with conviction, almost without exception the result is an audible sigh of relief. The person may not grasp the hope straightaway, but hope finds root, to be owned at a later date.
5. Actions speak louder than words. For a depressed person, words may seem empty, powerless, and futile. Action is more likely to communicate. In ministry the action that talks the loudest is the pastor's willingness to spend time with the depressed parishioner. Because depression hurts, avoidance is instinctive. But a pastor's willingness to share the hurt through voluntarily personal association speaks volumes about the authenticity—and thus the healing properties—of the pastor's caring.
6. Remember that recovery is a process. In dealing with pain, one is greatly tempted to seek a quick closure. Depression is no exception. Marie left my office after our first conversation, having gained an understanding of why she had become depressed. Mistakenly she thought the depression was over. She was astonished and disappointed the next morning to discover that she felt bad again. Moving from a depression to recovery always involves a process. This process takes time.
7. Beware of manipulation. Depression breeds dependence, accompanied by a demand for attention. This in turn frequently causes a depressed person to latch onto the pastor to get the kind and degree of attention desired. Flattery becomes common: "Pastor, you're the only one who understands"; or "Pastor, you're so in touch with what I feel. I'd like to continue seeing you until I feel better." At face value, there is nothing wrong with such attitudes, but they should be viewed as a red flag. It may be advisable to connect the depressed person with other support persons or groups, or to refer them to professional counseling.
8. Utilize faith resources. Pastors have an advantage over secular caregivers in that they are expected to draw upon spiritual resources. Prayer, Bible reading, preaching, and the sacraments, if appropriately presented, connect the depressed parishioner with the healing grace of God. It is at the heart of the pastor's calling to propose the "good news" themes of the Christian faith, such as God's rescuing nature, the constancy of His love even in times of doubt and despair, the promise of forgiveness in Christ, the personal avail ability of the Holy Spirit, the assurance of God's unremitting purpose at work in individual lives, and the confident hope that one day we will all be victorious over pain and death.
9. Be ready to refer. If a pastor has serious questions about the profile of a given state of depression, he or she may refer the parishioner to a specialist in counseling. It is important to be gentle in doing this, so that it is not misconstrued as rejection. Reassure the parishioner of your continued support and encouragement as a pastor.
10. Don't hesitate to take emergency action. In some cases of depression the risk of suicide is high. Stanley Lesse lists a number of signs of suicidal tendency: a sudden shift in feeling; an increase in psychomotor activity; a sudden drop from agitated behavior into lethargy; increased defiance; acting out; giving away of important possessions; an expression of hopelessness or helplessness.
If suicide seems possible, the pastor needs to intervene immediately and enlist emergency assistance from appropriate authorities or family members. It is helpful to create a select file of competent (and preferably Christian) professionals to refer to in the variety of situations a pastor is likely to face.
Eventually Marie returned to normalcy. I'm glad she came to see me.
1. Frank Minirth and Paul Meier, Happiness Is a Choice (Grand Rapids: Baker Books, 1994), p. 26.
2. Stanley Lesse, ed., Masked Depression (New York: Jason Ironstone, 1974), p. 4.
3. Lesse, pp. 130, 131.
