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.
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.
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?
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.
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 doesnt 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.
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 Wont Budge will support
your efforts to add movement into the treatment process.
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
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
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.
Body Awareness. With your clients eyes closed, guide his 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.
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.
Stretching. Beginning from the feet, guide your client to slowly stretch each
body part or body area, proceeding sequentially.
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.
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, tai 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 patients reactions regarding the possibilities for movement,
as well as his or her experiences of participating in it, provide you with opportunities
for therapeutic exploration.
What to Do When Your Client Wont 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.
your patients wont 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.
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.
Working with depressed patients can be frustrating and
challenging. Additionally, projected states by the patient onto 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 practice 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 masters 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.
Management of Major Depressive Disorder (MDD) in Adults
Primary Care Skilled Assessment and Diagnosis
- VA/DoD Depression Practice Guideline Provider Care Card. (2009). Management of Major Depressive Disorder (MDD) in Adults Primary Care Skilled Assessment and Diagnosis.
The article above contains foundational information. Articles below contain optional updates.
Reflection Journaling Activity #1
The preceding section contained
information on 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 in your practice.
Online Continuing Education QUESTION
What is the enemy of depression? To select and enter your answer
go to CEU Test.