"Sad is How I Am!" Treating Dysthymia in Children and Adults

Introduction
Pamela, a young woman, looks much older than her years. She is pale with dulled eyes and dark circles beneath them and she looks as though she has not slept in many days. Her rounded shoulders give her the appearance of being burdened. Her chest appears hollow and collapsed. She holds her muscles rigidly. Her breathing is so shallow that it is barely visible. She sits on the couch in my office in heavy stillness with the exception of the restless movements of her hands and feet. Little energy is available for eye contact, for facial expression, for relationship. Pamela is depressed. We have all seen people such as Pamela in our clinical work.

Depression and the Body
From a movement perspective, depression equals suppression; suppression of the life force, suppression of self-awareness, suppression of emotion. This bodily defense whether situational or chronic is very limiting in terms of total functioning. Yet, it serves to protect the depressed person from feared aspects of inner experience. Suppression is accomplished automatically and unconsciously in the body by decreasing respiration, by holding the muscles tensely, and by limiting movement. Hence, movement is the enemy of depression.

In combination with other therapies, such as verbal psychotherapy and medication, movement is a critical, but often overlooked, aspect of the treatment of depression. The usefulness and effectiveness of working with the physical/physiological suppression in the body cannot be underestimated. Because the mind and body function as an integrated whole, bodily activation positively affects total functioning- physiologically/physically, emotionally, cognitively, and relationally. Yet, how do we get our patients moving when certainly our patients are hesitant to go beyond suppression? And, how do we begin to use movement as intervention, especially when we may be working in non-movement-oriented clinical practice or when we may not accustomed to considering movement as part of the treatment protocol for depression?

Beginning: Including Movement in Your Assessment
As I inquire of patients what depression-related symptoms they might be experiencing bodily, such as disturbances in eating, sleeping, sexual functioning, etc., I also inquire about any changes in their movement habits. Of course, it is not unusual to hear that there has either been a decrease in their usual movement activities or amount of movement generally. It is also not uncommon to hear that movement has never been of particular interest to them.

If the person has or has had preferred movement activities, such as walking, playing a sport, dancing, etc., I note that information to use in considering and shaping movement interventions. If there doesn’t seem to be interest in movement-oriented activity, I will inquire about movement activities the person did or liked to do as a child. Children are developmentally more movement-oriented, so I can usually gather some information by asking this question. As in any client-centered treatment, the goal is to start where the person is, no matter how disinterested in movement he or she seems to be and build from any available starting point. The way a client responds to the movement-related questions also gives me a gauge regarding how receptive he or she may be to movement interventions.
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Getting Started: Using Movement as Intervention in Your Sessions
First, there are questions for the clinician. How comfortable are you with body movement? Would you be comfortable to use simple movement in your sessions with depressed patients? If you have answered that you are reasonably comfortable with movement and the idea of using it as intervention in your sessions, this section applies to you. If not, the good news is that the sections below entitled Supplements and Alternatives to Movement in Your Sessions and Help! My Patient Won’t Budge will support your efforts to add movement into the treatment process.

The following are suggested interventions for working with depressed patients. All can be done while seated. Use the information gathered in your assessment combined with your clinical intuition to gauge how receptive your patient might be to movement, and to choose which technique(s) to use. The techniques are generally ordered from least to most challenging in terms of the extent of movement involved. It is recommended that you teach clients these techniques during sessions and suggest their subsequent practice at home. After completing an exercise, remember to engage the patient in exploring his or her reactions to it. What thoughts and affect emerged? Use this material as a springboard for further psychotherapeutic interaction.

1. Visualization/Ideokinetic Facilitation. Ask your client to close his or her eyes and visualize a scene involving others moving and have him or her describe it to you. Next, ask your client to include himself or herself in the scene and describe it to you. Visualization/Ideokinetic facilitation can enhance motivation to move.

2. Progressive Relaxation. Ask your client to close his or her eyes. Guide him or her to tense body parts as fully as possible, holding the tension in that part for 10 seconds and then releasing. Start with the feet and guide him or her to work toward the head part by part, in a sequential fashion.

3. Body Awareness. With your client’s eyes closed, guide him or her focus on different body parts sequentially, beginning with the feet. Ask him or her to notice the sensations experienced while attending to each part.

4. Breathing. With eyes closed, ask your client to notice his or her breathing. Encourage him or her toward slightly deeper breathing. Or, ask your client to take a breath and hold it until he or she reflexively exhales. Repeat.

5. Stretching. Beginning from the feet, guide your client to slowly stretch each body part or body area, proceeding sequentially.

6. Rhythmic Movement. Ask your client to bring in some favorite music to play. While seated or standing, guide him or her to move to the music by moving different body areas- hands and arms, feet and legs, head and shoulders, hips, and finally the whole body.

Supplements or Alternatives to Movement in Your Sessions
Using the interview information regarding receptivity to movement and movement interests and experiences, refer your clients to suitable movement experiences and classes. Possibilities include stretch class, dance class, yoga, t’ai chi, playing a sport, walking, running, etc. Remember to think incrementally, as the defense to movement in depression is powerful. For example, putting on music at home, visualizing dance, watching a dance performance, moving to music at home, signing up for the dance class, observing a class may all be precursors to actually attending a class as a participant. Again, your patient’s reactions regarding the possibilities for movement, as well as his or her experiences of participating in it provide you with opportunities for therapeutic exploration.

Help! What to Do When Your Client Won’t Budge
As is often the case, the nature of the depression/resistance to overcoming depression is such that self-generated movement does not seem feasible. If this is the case, I suggest less active ways to get started, for example massage, other forms of body work, or acupuncture. These methods allow a person to remain still, to receive passively and to feel relationship with and nurtured by the practitioner. At the same time, these forms of treatment are very powerful and, because they address symptoms of depression physically/physiologically, from a holistic perspective, they also can have positive psychological effects. As with any referral, it is essential that the body work professional be suitable for the particular patient in mind, and that the professional is interested in working together with the clinician in support of the patient. If you do not have personal experience with these methods of treatment, it is very likely that therapists you know can provide informed referrals. One caution is that body work may not be suitable for patients who have experienced body-related traumas, at least until their psychotherapy has progressed sufficiently.

If your patients won’t go to body work, and are not self-motivated, I suggest that, if they like music, that they listen to music. If they like dance, that they watch dance. If they like sports, that they watch sports. The vicarious experience of movement can enhance the motivation to begin to move.

Additional Considerations
Throughout the course of treatment, it is also very important to consider “the basics,” for example, sleep disturbances, poor nutrition, and the use of substances, such as alcohol, caffeine, nicotine, and other drugs can seriously affect mood. Resistance to making changes in these areas must be addressed and explored over and over again in the therapy, as a stable physiological baseline is a crucial support for ameliorating depression.

Final Thoughts
Working with depressed patients can be frustrating and challenging. Additionally, projected states by the patient into the therapist can leave the therapist feeling helpless, hopeless, angry, sad, isolated, etc. Hence, the therapist should be aware of the effects of working with the depressed state on his or her state of being. Support and a combined team approach can make the work more bearable. Many of the practices suggested above can also be of value for the practitioner!

Anne C. Fisher, PhD ADTR is a licensed clinical psychologist and a registered dance/movement therapist in private practice in Washington, DC. For the past 20 years, she has had a general psychotherapy private pCEU Continuing Education for
Social Worker CEUs, Psychology CEUs, Counselor CEUs, MFT CEUsractice involving the long-term treatment of adults individually and in couples in psychodynamically-based treatment using verbal and nonverbal techniques. She has also provided supervision to many student and professional psychotherapists.

For many years, Dr. Fisher was Assistant Professor in the Dance/Movement Therapy Graduate Program at Goucher College in which she taught courses related to dance/movement therapy theory, practice and research. She also served as Thesis Coordinator for the Program and was responsible for overseeing research for and writing of the master’s thesis. Most recently (2000-2003), Dr. Fisher was Co-Editor of The American Journal of Dance Therapy, the official publication of The American Dance Therapy Association.

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Personal Reflection Exercise Explanation
The Goal of this Home Study Course is to create a learning experience that enhances your clinical skills. We encourage you to discuss the Personal Reflection Journaling Activities, found at the end of each Section, with your colleagues. Thus, you are provided with an opportunity for a Group Discussion experience. Case Study examples might include: family background, socio-economic status, education, occupation, social/emotional issues, legal/financial issues, death/dying/health, home management, parenting, etc. as you deem appropriate. A Case Study is to be approximately 300 words in length. However, since the content of these “Personal Reflection” Journaling Exercises is intended for your future reference, they may contain confidential information and are to be applied as a “work in progress.” You will not be required to provide us with these Journaling Activities.

Personal Reflection Exercise #1
The preceding section was about Movement as Intervention in the Treatment of Depression. Write three case study examples regarding how you might use the content of this section of the Manual or the “Positive Reinforcement” section of the audio tape in your practice.

Online Continuing Education QUESTION 20:
What is the enemy of depression?