Four key characteristics typify the presenting features of depressive illnesses: mood, behaviour, physiology and cognition. Depression can be said to affect the whole person; body, mind, emotions, spirit, soul, imagination and relationships. With specific reference to people of religious faith experiences characterised by feelings of spiritual despair are often followed by periods of a sense of indifference. Thoughts concerning the things of God follow general thinking into a downward place and God might cease to exist as an extant, relational being for some religious people who experience a depressive illness. Statistics indicate that the suicide rate for people experiencing depressive illnesses is thirty-six times higher than for the general population, and at least three times higher than for either people experiencing psychotic illnesses or for people misusing alcohol. Suicidal thinking occurs in approximately three in four people experiencing a depressive illness; around one in seven attempts to end their life.
Mental illnesses are primarily physiological rather than spiritual in nature and they are not generally “caused by demons”. It is likely that King Saul experienced bipolar disorder and the prophet Jonah speaks of helplessness and darkness distinct from his physical predicament inside a giant fish. The Psalmist variously describes states of anguish and depression.
The treatment of depressive disorders in history is associated with the Church’s wider ministry of “soul care” and the mediaeval church used the term accidie, a term akin to sluggishness, to describe staleness in religious practices and in one’s relationship with God, especially among ascetics. Accidie can be thought of as depression in association with The Absolute, a “dryness of spirit” that affects the whole being. As is evidenced better by the Psalmist than the disobedient Saul and Jonah, accidie is primarily a disorder of the faithful religious, not of the spiritually recalcitrant, recidivist, or indifferent. Depressive illnesses have the capacity to overcome anyone.
In addition to spiritual dryness, the awareness of personal sin is a reality in the thinking of many depressed Christians; therefore pastors must be able to work with people feeling individual guilt or blame behind their feelings of unworthiness. Glib grace helps no one and leads only to greater isolation. The key theological themes of depressive illnesses are of loneliness and hopelessness and persons who experience most forms of mental disorder are often segregated from their social networks by their emotions and feelings, their symptoms, or by the (sometimes inadvertent) isolating tendencies of these same networks. In this way appropriate pastoral care must take the form of remembering, encouragement, and spiritual direction, where comfort is offered through listening, attention and presence. A community approach to pastoral care is vital to overcoming the stigma which might accompany depression in a person of faith.
The fear of encountering those who are different can be overcome through acts of encounter, both for providers and consumers of appropriate Christian forms of pastoral care. One cannot form friendships with someone one has never met and carers and patients must meet before they can begin a relationship. One reason why pastoral care of people with depressive disorders is a neglected area is because of the significant stress such care places upon individual carers. Bearing with someone who is expressing his emotions deeply takes a heavy toll on the carer therefore appropriate pastoral responses to persons affected by depressive illnesses must incorporate the care of their carers. Those within the Church who find themselves afflicted by depressive disorders must seek to understand the depth of pain and social isolation sufferers experience, and seek to reach out to them in appropriate ways to connect them with a fellowship of people who care. The Christian community must be the initiator of a process of bridge building.
It is worthy of note that for some people the experience of depression can be turned around simply by expressing and discussing their experience with an attuned person; oftentimes the pastoral carer will fill this role through being a patient, supportive, non-judgemental listener even if they are not a mental health professional. Some people find it helpful to vent their anger and again the pastor can be the sounding board. But in many cases only being a listener is not enough and the minister must say “okay, but now let’s talk about some action to help you to move on.” This is only appropriate in the case of acute depression; to insist upon rapid change in the case of chronic and endogenous depression is extremely inappropriate.
As one who is both provider and consumer of mental health services I note that pastors must be careful not to expect their clients to provide care to them: that is the job of the pastor’s own family, friends, and carers. People who are managing their mental health conditions are eminently suitable to be leaders within this ministry, in that they lack the fear of strange behaviours or depth and intensity of negative emotions, but attuned listening should be offered only in one direction in any pastoral relationship. One reason for this is that care must be tailored to the person herself and not to her perceived needs. “I know what works for me” is useful, but expecting the recipient to return care based on the carer’s own pastoral needs or wants is not. It must also be remembered that people managing their own health are still susceptible to low points and the need to withdraw themselves from caring for others in the interests of self-care.
In responding to a person with a depressive disorder the pastoral carer can be said to enter into a tension which cannot be resolved by human effort but only by the work of the Holy Spirit. It is vital that the role of the pastoral carer does not extend into diagnoses or causes of depression as that is within the remit of the mental health profession. The primary offering of Christian pastoral carers is the ministry of support; befriending and helping persons cope with living with their mental disorder and sharing the Church’s unique way of supporting people by offering friendship in the name of Christ. In this way pastoral care focuses on meaning and understanding rather than explanation and treatment.
Depression may be an indicator that something is wrong which needs changing, thus it can be of benefit in providing an impetus to change; however any individual with more than a mild depression must be referred to a GP for a thorough check-up to rule out physical or clinical disorders. Ministers and pastoral carers should always work in collaboration with mental health professionals: any case of depression or anxiety in Christian patients should be both/and rather than either/or. Pastoral counselling based on suitable training is an appropriate course of action for people who experience depression, whether they are on medication or not, and the pastor’s checklist might include questions concerning difficulties impeding functioning, the person’s strengths, the nature of the symptoms (behavioural, physiological, cognitive, or affective), and practical first steps, such as looking for positives in life, which might be taken to help turn this depression around.
For Christians, disidentification techniques can be useful in challenging negative identities and replacing them with new ones. “I do not (or “I no longer”) see myself as scum but see myself as Christ sees me,” “I have an emotional life, but I am not my emotions,” and “sometimes I am lonely but I am not loneliness personified” are all worthy mantras. Melancholic individuals have a tendency to see themselves as ineffective therefore it is important to gently assist them in getting active. The pastoral nature of this is vital as many melancholic people don’t wish to be pushed into activity and can become quite resentful at being bullied into “just doing something”. The purpose of such activities should be for the person to be able to make sense out of her existence and to rediscover her sense of meaningfulness in life yet it is also of use in teaching specific social skills to enable her reengagement with community. This should be offered only by a trained counsellor or when explicitly asked for.
In concluding let me address how the specifically religious condition of accidie might be cared for. Stigma is a barrier to many people engaging in pastoral care and mental health support, and the expectations upon Christians that they demonstrate strength in their faith may contribute to such feelings among church attendees. Do I acknowledge an experience of hope in accidie, or only despair? Do I believe such despair to be a sin (akin to sloth) or tantamount to a lack of faith? Is this merely a spiritual dryness which might be treated with prayer and meditation, or is there a physiological undercurrent which requires professional and medical help, a condition which only a doctor can safely diagnose? The Church must care for its own in how it supports those experiencing dryness to respond to the message of faith, hope and love when they feel distant from God and others, annoyed by their closest friends, and down on themselves. If this dryness is the experience of the preacher how might the community of faith support the man within accidie to speak of, and re-experience, faith and hope? For the mystic the relationship with God is changed during the dark night of the soul when God seems absent and life seems empty and uninviting. Not all people of faith who experience depression and anxiety experience spiritual listlessness, especially when their depression and anxiety is physiological in cause, but as a pastoral issue within the local congregation accidie remains noteworthy. In all things understanding which refuses to ostracise, demonstrates compassion, and offers regular prayer for the person experiencing symptoms, her family and carers, and the pastoral support team is of the essence.
beyondblue, “Stigma and discrimination associated with depression and anxiety position statement Draft for Consultation June 2012”, beyondblue, 2012.
Patton, John. Pastoral care in Context: An Introduction to Pastoral Care. Louisville KY: Westminster John Knox Press. 1993.
Stone, H.W. and W.M. Clements. (eds.) Handbook for Basic Types of Pastoral Care and Counselling. Nashville TN: Abingdon Press. 1991.
Swinton, John. Resurrecting The Person: Friendship and the Care of People with Mental Health Problems. Nashville TN: Abingdon Press. 2000.
 H.W. Stone and W.M. Clements, Handbook for Basic Types of Pastoral Care and Counselling (Nashville TN: Abingdon, 1991), 178.
 Ibid., 181.
 Such as schizophrenia
 Stone and Clements, Handbook, 185.
 Ibid., 185.
 Jesus claimed in Mark 9:29 that manifestations of demons can be seen in people, but this cannot be understood as establishing a theology explaining the causes of all disorders in mental health.
 See Jonah 2:2-7. The hope of God’s response is seen in the verses following.
 Examples might be found in Psalm 6:6-7 and Psalm 13:1-3. The hope of God’s response is seen in the verses following.
 Stone and Clements, Handbook, 174.
 Ibid., 206.
 Including, sadly, the local church.
 John Patton, Pastoral Care in Context: an introduction to pastoral care (Louisville KY: Westminster. 1993), 15.
 Stone and Clements, Handbook, 207.
 John Swinton, Resurrecting the Person (Nashville TN: Abingdon. 2000), 146.
 Stone and Clements, Handbook, 187.
 Ibid., 188.
 Swinton, Resurrecting The Person, 150.
 Stone and Clements, Handbook, 176.
 Ibid., 178.
 In this I disagree with Stone’s rule of thumb which sees ministers able to see depressives until a cut-off at “moderate” at which point medical intervention is preferred. Ibid., 183.
 Ibid., 177.
 Ibid., 184.
 Ibid., 184.
 Ibid., 184.
 Ibid., 185.
 Ibid., 189.
 Ibid., 191.
 This is certainly true of me: negotiation is the key.
 Ibid., 196.
 beyondblue “Stigma and discrimination associated with depression and anxiety position statement Draft for Consultation June 2012”, (beyondblue, 2012) 1.
 Stone and Clements, Handbook, 175.
 Ibid., 174.