Session on Church's care for depressed patients

XXVII International Christmas Readings' session on "Church care for depressed patients" was held In Moscow

On January 26, 2019, a session of the XXVII International Educational Christmas Readings was held in Moscow on "Church's care for depressed patients". The meeting was organized jointly by the Synodal Department for Church Charity and Social Service of the Russian Orthodox Church, the Department for External Church Relations of the Moscow Patriarchate and the Commission for Church Formation and Diaconia of the Inter-Council Presence, which has a working group on pastoral care for mentally ill people.

The meeting was moderated by Metropolitan Sergiy of Voronezh and Liski, the chairman of the above working group. The section coordinators were M.B. Nelyubova, secretary of the Commission for Church Formation and Diaconia, DECR staff member and V.V. Leontieva, member of the working group on pastoral care for mentally ill people, the area coordinator for assistance to people with disabilities, Synodal Department for Church Charity.

More than 50 people from 14 dioceses participated in the session: clergy and laity of the Russian Orthodox Church, academic psychiatrists, staff of the Scientific Center for Mental Health (SCMH) of the Russian Academy of Sciences, doctors, church social workers.

Metropolitan Sergiy of Voronezh and Liski noted in his introductory report, that the session aimed to encourage local clergy to respond to the problem that the meeting was about, so that they would not be afraid of mentally ill people and provide assistance to both sick and medical specialists, who also need support and understanding. In helping people with mental disorders, balanced approaches have to be found, all manifestations of such disorders shall not be reduced exclusively to mental illness, or only to possession.

Metropolitan Sergiy noted that depression is one of the manifestations of "the general damage of the human nature by sin; it develops as a result of a complex interaction of social, psychological and biological factors." The most significant reasons for the spread of depression in modern society are the loss of traditional religious values and crisis of the family. "Depression is a mental illness of a person who is tired of passions. This reveals the spiritual roots of the depressions. Sadness and despondency overwhelm a person when he cannot achieve the desired to which he is bound by passion. Melancholy and grief always accompany the loss of what the person couldn't withhold. The spiritual goodness of a person free from passions is the most radical remedy for depression". "Depression, whatever the reason for it, is not only a subject of clinical practice of psychiatrists and psychologists, but also the target of pastoral care and theological assessment of the Church. Patients with depressions are especially sensitive to pastoral attention, and therefore the combination of pastoral and psychiatric care, with proper differentiation of the fields of competence of a doctor and a priest, turns out to be very fruitful in the treatment of mental illness," said Metropolitan Sergiy.

In conclusion of his report, Metropolitan Sergiy stressed: "Depression is one of the most frequent diseases that are encountered by both psychiatrists and clergy. I hope that today we will be able to fruitfully continue the dialogue of the clergy with the medical community in order to give mentally ill people with depressive disorders an opportunity to get rid of suffering with the help of God's grace. "

V.G. Kaleda, doctor of medical sciences, deputy director of the SCMH for Development and Innovation, professor of the Department of Practical Theology of the Orthodox St. Tikhon Humanitarian University made a report on "Depression and the notion of sadness and despondency in patristic literature". He noted that 250 million people suffer from depression worldwide, and about 9 million in Russia. Scientists call it the number 1 killer, as it often becomes the cause of suicide. The speaker spoke about the types of depression, its forms and causes. Listing criteria for depression, he noted that one can talk about mental disorder when a low mood lasts for at least two weeks, and the person feels it for most of the day. Sleep disturbance, low self-esteem, lack of energy, fatigue, lack of appetite, unreasonable feelings of self-condemnation and excessive guilt feelings, unwillingness to live - these are some criteria that indicate the development of depression. He noted that women are more likely to be depressed than men. Due to a number of endocrine changes, more than 20% of women are prone to post-natal depression.

The physical component of depression is manifested in the feeling of sadness, sorrow, grief; disordered motor activity, when a person becomes inhibited, as well as in mental changes, when a person's thoughts flow slowly and sluggishly. Spiritual manifestations of depression include the feeling of "hardened insensitivity" when a person turns to God with prayer and does not feel any answer; proceeds to the Sacraments and does not feel that he communicated; unable to read spiritual literature; feels "cold in the heart" and therefore cannot pray. These are consequences of depression.

Speaking of what the holy fathers wrote about sadness, despondency - manifestations of depression, - Professor Kaleda noted that the holy fathers describe in detail the symptoms and spiritual causes of depression. "And the most surprising thing for us, as psychiatrists of the XXI century, for example, is that John Cassian the Roman described that sadness can be inexplicable. Now we would say that this is an endogenous depression, when the cause is biological, when depression occurs without any provocative factor. " According to the speaker, in many cases spiritual causes lead to depression, and therefore the disease requires not only medicinal, but also spiritual treatment.

G.I. Kopeiko, Ph.D., deputy director for scientific research of the SCMH, in his report "Age Aspects of Depression" showed that at present depression as a disease is becoming more common in young people, the problem of suicides among youth is particularly relevant. Many cases of suicide attempts have been recorded even in 10-12 y.o. children. 91% of those attempting suicide suffer from mental illness, and the greatest risk is associated with depression.

Statistical peaks with a high suicidal risk occur in adolescence and after 40 years, about a quarter of older people are prone to depression. Understanding the age characteristics of depression allows to choose the right approach to both treatment and care for patients.

Archpriest Ilya Odyakov, cleric of the Church of the Mother of God Icon "Healer" at SCMH noted in his presentation on "Assistance provided by a priest in depression" that many clergy believe that depression does not exist as a disease, but "it is only a manifestation of passion, sadness, despondency, laziness, weakness; they say that a true believer cannot have depression." This is fundamentally wrong, and in the case of depression, a person should certainly turn to doctors. The priest "can and should, if necessary, convince his parishioner to consult a doctor." It often happens that hearing word "psychiatrist" a sick person turns inwards; he can stop trusting the priest and even go to church. Therefore, according to the father of Ilya, the priest in this case should be particularly cautious and try to involve the patient's relatives to solve such situations. The speaker named the complaints, some kind of markers in speech or behavior, which should alert the priest and let him know that his parishioner really needs medical help. A patient can talk about a "feeling of godforsakenness," "lack of a sense of grace," there may be "complaints of hardened insensitivity," "emptiness in the soul," "loss of the meaning of life," "loss of faith in God." A person feels indifferent to everybody and everything, feels a "heart yearning." "Sometimes they talk about heavy thoughts. In conversations it turns out that these are thoughts about suicide. The person has a feeling of a "special guilt", "extreme sinfulness", "worthlessness", a feeling of immense "shame for his past life", reaching despair. At the threat of suicide, "it is categorically unacceptable to use or maintain the attitude towards the disease as a punishment for sinful life or hereditary vices ... It is advisable not to make any reproaches to a sick person concerning church life. We must remember that a sick person is very vulnerable and easily sees in any words the idea that he is considered worthless and incapable of anything. The priest should not give the patient trivial advices, such as: "You should pull yourself together" or "you could easily cope if you wanted", etc. Flat consolations should be avoided. "Pay attention to any complaints of a sick person and in no case ignore them as a trifle, but listen carefully to everything he says," said Father Ilya.

One must constantly convince the patient that the depression is to blame for the fact that his life seems so painful, empty, distressing. It is necessary to support and strengthen the patient in the pursuit of the gracious help of God through church Sacraments.

O.A. Borisova, Ph.D., leading researcher at SCMH made a presentation on "Religious coping strategies in depressions." She explored manifestations of the endogenous depression and presented the results of scientific research of the SCMH regarding psychocorrectional work based on the religious values of the patient.

The speaker identified and analyzed in detail four ways of coping with depressive conditions (the so-called coping strategy): the religious method of "preserving traditional values and meanings"; social support from a religious community or religious relatives; religious rethinking of the situation and self; the so-called unifying religious method, i.e. gaining an emotionally comfortable condition, which is based on religious faith: comfort, peace, forgiveness, reconciliation. Spiritually oriented communication is very important, which leads to the harmonization of the patient's personality and changes in his behavior and lifestyle. Unlike other mental illnesses, depression has a beginning and an end. To help depressed patients, a multidisciplinary approach is needed, which, along with therapy, also requires pastoral care by clergy, support by a religious community, organization of special conditions for therapeutic communication, participation of relatives in the patient's program, a deep personal value-reorientation through actualization of the spiritual component, improvement of interpersonal relationships in the family in the process of group psychotherapy and their transition to a new quality level.

Presentation of A.A. Matienko, master's student of the Theological Seminary of the Presentation of our Lord, was dedicated to the theme "Pastoral Counseling for Depressed Patients (according to the patristic literature)". The writings of the holy fathers describe conditions of sadness and despondency, which are not depression itself. For example, St. John Chrysostom in Letters to Olympia writes about the despondency that the saint woman was able to overcome, and about the need to continue "to watch carefully that you would find full peace ...". Abba Dorotheus, addressing the young man who was tormented by a fornication passion and who was afraid of falling into despair, examines in detail his condition and builds up a "strategy" of spiritual struggle. First of all, he relieves the young man from a feeling of guilt for this condition: "The culprit of your battle is the devil"; he instructs him to avoid situations that provoke fornication thoughts; he sets out for him ways for further improvement, he also teaches to pray for this situation, he promises to pray for the young man and shares his own experience of spiritual struggles, he promises to pray for the young man and shares his own experiences of spiritual struggles.

The speaker noted that the holy fathers did not talk about death and the Last Judgment with people who were in a difficult psychological state and who had suicidal thoughts. They often shared their own experiences in overcoming difficult mental conditions. "If a priest shares his experience, this increases trust and has a great psychotherapeutic effect," the speaker said.

Holy Fathers - especially in pateriki, letters and reminiscences of saints - have a description of cases with a specific set of symptoms that are similar to depression. The speaker drew a parallel between the signs and symptoms of depression described by the Holy Fathers and the International Classification of Diseases: "ideational inhibition" - despair, a feeling of being abandoned, suicidal thoughts and attempts; "anxiety disorder" - a desperate soul that rushes everywhere and terrifies everybody, etc.

The speaker described the following ways of spiritual care that holy fathers provided for the suffering people: prayer of the priest for the afflicted person, encouraging to pray and teaching how to pray; compassion, emotional support; call for patience and hope in God; proper attitude to suffering and work therapy. According to the speaker, some approaches of the holy fathers are comparable to the methods used by modern psychologists, for example, active listening, stimulation to reflection, self-disclosure, etc.

E.A. Kazmina, Cand. Sc., clinical psychologist, leading researcher at SCMH, made a presentation on the "Specifics of the psychotherapeutic management of patients with depression. Psychometric methods for the analysis of depressive conditions ". The speaker focused on three main areas for research in depression: cognitive-behavioral, psychodynamic and existential psychotherapy, and presented psychometric techniques for diagnosing the severity level of depressive disorders. She described in detail the psychotherapeutic methods used in the model approaches mentioned. E.A. Kazmina noted that when working with religious patients, an important healing factor is common religious values, which give meaning to illness and suffering. In the treatment of depressed patients, a "team" approach is important - the cooperation of a psychiatrist, psychotherapist and a priest.

A.A. Shevchenko, Cand. Sc., general physician of superior expert category, officer of the medical department of Voronezh Diocese in his report "Causes of depressive disorders from a theological perspective" noted the problems of dialogue between psychiatry and theology in understanding the experience of mental disorders. "The experience of science can be described from the point of view of theology, but the language of science cannot adequately describe the religious experience of communion with God," said the speaker. He spoke about some foreign research results in the field of psychiatry, which tried to find in the human genes and the brain not only the cause of depression, but also the source of religious experience, and tried to describe the religious experience of a person with objective methods. The speaker stressed that he highly appreciates the fact of the dialogue between the Church and science in the field of helping the mentally ill, but believes that modern psychiatry still lacks theological loyalty.

E.V. Gedevani, Ph.D., researcher at SCMH presented a report on "Depressive disorders and religiosity", where she offered a review of the international scientific literature on the effect of religiosity on depressive conditions. Foreign researchers have accumulated significant data on the protective effects of religion and spirituality on depressive disorders and the level of suicide. There are numerous studies showing an improvement in overall mental well-being and health associated with a religious worldview.

In studies, scientists divide patients into people with "internal religiosity", who consider religion as the basis of their existence and follow it in their lifetime, and people with "external religiosity" for whom religious beliefs are not so significant and can be "adjusted" to other life goals, for example, to social relations or to personal comfort.

Studies show that external religiosity is associated with an increased risk of depressive disorder and a higher degree of depressive symptoms. Contrary to that, internal religiosity tends to oppose depressive symptoms.

The protector effect of religiosity is more pronounced in persons who have endured a traumatic situation: a trauma often gave a push for a deeper spiritual development of a person.

According to research results of American scientist Harold K?nig, who observed 87 elderly patients with depression within 47 weeks, internal religious motivation leads to early remission. After eliminating a number of depression factors (emotional state, social influence, endogenous factors, etc.), each increase in internal religiosity by 10 points (according to the scale adopted in the study) is comparable to an increase in the rate of onset of remission by 70%.

The speaker presented the results of American, Australian, Latin American and European studies showing the positive impact of religious life motivation on the recovery of depressed patients.

Foreign and Russian authors point to the important role of the religion that gives patients a sense of purpose and so helps in their recovery: "Participation in the life of religious institutions is associated with a higher religious and social identity and, consequently, with a higher level of subjective psychological well-being." This is evidenced by a 2007 study by Professor Greenfield, in which 3032 people of 25-74 y.o. participated.

Studies by another author (G. Kirov, 1998) testify to the great significance of the religion that gives a sense of purpose to patients with mental disorders: "Mental illness, is as a rule, accompanied by fear, feelings of chaos and helplessness and violates the inner order of a person. With the help of faith in God, the balance and integrity of a person split by illness can be restored, which is experienced by the person as a revival, finding a source of happiness, peace and confidence ... Many patients consciously use prayer in times of great suffering and despair, others see their illness as an ordeal (positive revision), or rely on their church activities (increasing socialization). " "The most obvious protective factor hindering the realization of suicide is, in the opinion of many researchers, its religious ethical ban, because most religious teachings recognize the unconditional value of human life. This idea gives a sense of purpose and reflects on the general attitude towards life and the self-esteem of a sick person. An important protective factor is the belief in an afterlife and a loving God. In all religions there are role models for believers, demonstrating how to cope with crisis and stress, thoughts of suicide, and contributing to the development of resources that help to cope with life difficulties. Personal participation of the patient in religious ceremonies is important - this contributes to the reduction of depressogenic effects in stressful life situations. "

At the conclusion of the meeting, Metropolitan Sergiy of Voronezh and Liski noted that all the issues raised in reports and discussions will be included in the agenda of future scientific and practical seminars and conferences on the issue "Church care for mentally ill people."

Below are contributions made at the conference

Opening speech Metropolitan of Voronezh and Liski SERGY

Dear fathers, brothers and sisters, dear participants of our meeting!

The paradoxical and, at the same time, magnificent task of psychiatry is the investigation of madness by the mind. Holy Scripture repeatedly speaks of wisdom God has given to man. Thus, according to King Solomon, "A wise man is full of strength, and a man of knowledge enhances his might" (Prov. 24:5). However, we should be aware that the sciences about spiritual manifestations of human life are created by the mind of mankind, whose cognitive abilities are distorted after the fall. Man's mind cannot comprehend the abyss of himself. Therefore, any science about the soul is limited in its ability to give an exhaustive understanding of the mystery of its existence: "a man is unable to comprehend the work that is done under the sun. Despite his efforts to search it out, he cannot find its meaning" (Eccles. 8:17). Unfortunately, modern psychologists and psychiatrists pay little attention to the source of divine revelation - the Holy Scripture. However, the subject of revelation is not only God himself, but also the man.

The sacred history testifies that the mind without God usually performs unreasonable transformations of life, which lead to destruction in the world and society, to the loss of a sense of the integrity of life, unity with other people and the world at large. Such state makes a person vulnerable, contributes to the development of mental illnesses. Among them depression is one of the most common pathologies. According to the World Health Organization, more than 300 million people are currently suffering from depression [1].

Depression, as one of the manifestations of the general depravity of human nature, develops as a result of a complex interaction of social, psychological and biological factors. However, one of the most significant causes of the spread of depression in modern society is the loss of traditional religious values. After all, a person who does not have religious guiding principles in his life, loses the opportunity to treat his adversity as the trials that God sends him, and to confront it having God on his side.

Another significant cause of depression is a family crisis. The crisis is manifested primarily in the fact that the family is performing its main purpose - raising children - progressively worse. A society in which Christian faith is either not at all taken into account, or occupies a secondary place as a keeper of some useful moral values, is incapable of reconciling the will of people with each other, because it does not know the will of God. In the family, this leads to conflicts and violence, to problems that threaten not only the well-being and mental health of family members, but also their very life. It is well known that children growing up in a lack of love, observing enmity between parents, are prone to various forms of self-destructive behavior. They tend to join social groups with fanatical behavior, to chemical addictions, self-harm and suicide. Every year around 800,000 people die worldwide from suicide - the second leading death cause among 15-29 y.o. youth [1]. Such behavior is the response of young people not to suffering, but to the absence of the meaning of life, which they could not find in the family. The efforts of people to create family relationships in love, but without God, are vain and contradictory: "But when I hoped for good, evil came, and when I waited for light, darkness came." (Job. 30:26).

Depression is a mental illness of a person who is tired of passions. It reveals the spiritual roots of depressions. Sadness and despondency overwhelm a person when he cannot attain the desired to which he is bound by passion. Melancholy and grief always accompany the loss of what the person was unable to keep. The most radical remedy for depression is the spiritual perfection of a person free from passions. According to John Climacus, "If someone has hated the world, he has run away from its misery; but if he has an attachment to visible things, then he is not yet cleansed from grief. For how can he avoid grief when he is deprived of something he loves?" [2]. A man without God is a selfish being who makes himself the center of the universe. But other people stubbornly do not recognize this, which undermines the egoist's self-efficacy, his belief that he can achieve something in the future, makes him seek to externalize the causes of his failures. As a rule, a depressed person has a low opinion about himself and his environment, does not see his future, lives his past.

Reflections on sadness and despondency in patristic literature lead us to the very nature of man: lack of self-sufficiency in the man, limited possibilities, finiteness of his existence, death. Therefore, depression, whatever the reason for it, is not only a subject of the clinical practice for psychiatrists and psychologists, but also the subject of pastoral care and theological discourse of the Church. Depressed patients are especially sensitive to pastoral attention, and therefore the combination of pastoral and psychiatric care, with proper distinction between the competences of a doctor and a priest, is very fruitful in the treatment of mental illness. Those who do not take into account the ecclesiastical experience of counteracting melancholy and despondency, according to prophet Jeremiah, "They have dressed the wound of My people with very little care, saying, 'Peace, peace,'when there is no peace at all." (Jeremiah 6:14).

The Orthodox theology has a tradition that does not allow considering the image of God as a combination of the ideal qualities of human nature. This is due to the danger of diminishing the extra-natural, personal origin in man, which has not a biological, but a religious origin. Our spiritual life, which has its source in communion with God, is manifested both in the soul and in the body and is interconnected with them in such a way that it is difficult to distinguish the spiritual from the mental and physical. Therefore, sin (personal and original), as a distortion in the sphere of spiritual life, is displayed in human nature as a disease: physical or mental. Unfortunately, ignoring the interconnectedness of the spiritual life of a person and mental disorder, the disassociated from the Church society wants to abandon the notion of "sin" and replace it with the notion of "illness". This also applies to depression. Of course, no disease can be attributed simply to sinfulness, one's own or one's relatives. Sometimes God allows a person to have illness as a way to salvation (John. 9:1-38). But this does lift up the causal connection between sin and sickness. This connection is often not seen by depressed patients, who want to recover very quickly and completely; they do not understand that the basis of mental or physical illness is moral and ascetic imperfection; and its healing can last a lifetime.

The stumbling block for modern psychiatry is diabolic obsession, which is often found in psychiatric patients. Obsession exacerbates mental illness, and the illness enhances the influence of demons. There is only one prerequisite for distinguishing between mental disorder and obsession - belief in the existence of angels and demons. A person who abides in God is able to feel the demonic darkness. God's action is experienced as peace, joy, humility, and oblivion of oneself. The influence of demons is experienced as anxiety, joylessness, stupefaction, self-centeredness, contempt and arrogance towards others. The existence of demons, like the existence of God cannot be proved by reason. If you do one doesn't believe in the existence of the devil, obsession will always be perceived only as a manifestation of mental illness. A differential diagnosis is not always possible on the basis of symptoms assessment or patient's behavior analysis in the presence of sacred object. After all, demons are individuals who are capable to deviously deceive those who test them.

The crisis of medicine it is much talked of today. But what is meant is not a state of a certain social institution, but a crisis of humanity, love and mercy in the medical profession. In healing the sick and casting out demons, the Savior did not think about reward, health economics, and medical law. God calls from eternity any doctor to compassion, mercy and love; his call is especially addressed to psychiatrists who cure mental illnesses. Although there is no discipline that would teach medical students love, mercy and compassion, prestige and money should not become the main motives of medical practice. Calling to follow the principle of the least restriction of the patient's freedom, the Church does not interfere in the specific forms of medical intervention necessary for a mentally ill patient. A careful study should be made of the experience of the psychiatric community in a number of countries that have changed the system of psychiatric care by transforming specialized psychiatric clinics into psychiatric hospital wards. Such changes make mental care more humane, not only in relation to patients, but also to medical personnel. Humanization of mental care must begin with the humanization of the psychiatrist's work. After all, a daily encounter with insanity, an intense working rhythm and truly devilish haste are destructive and can only be stopped by inner spiritual work and love for the sick. I am convinced that it is especially difficult for physicians working in psychiatry to preserve their mental health without prayer, without Church and Church sacraments.

A year ago, during the Christmas Readings we talked about new problems of pastoral work with mentally ill people, which require serious thought. We continued this discussion at the international conference "Church Care for Mentally Ill People", which was held on November 13-14 2018 at the initiative of the Commission on Church Education and Diaconia of the Inter-Council Presence of the Russian Orthodox Church and the Department for External Church Relations (DECR) with the support of the International Foundation "Kirche in Not". The conference was attended by priests, psychiatrists, experts from Greece, the Netherlands, Spain, Great Britain, Italy, and specialists from the Scientific Center for Mental Health of the Russian Academy of Sciences. A fruitful dialogue took place between the representatives of the Church and medical community on various problems of psychiatry. In addition, last year our working group submitted a draft document on "Pastoral care of the Russian Orthodox Church for mentally ill people" to the Commission on Church Education and Diaconia of the Inter-Council Presence of the Russian Orthodox Church. We are concerned that the moral crisis is increasingly affecting the state of mental health of the population, which indicates an extremely strong deviation of society from moral standards. Depression is one of the most frequent illnesses encountered by both psychiatrists and clergy. I hope that today we will be able to fruitfully continue the dialogue of the clergy with the medical community in order to give mentally ill people with depressive disorders the opportunity to get rid of suffering with the help of God's grace - according to the words of the Psalmist David: "Why, my soul, are you downcast? Why so disturbed within me? Put your hope in God, for I will yet praise him, my Savior and my God" (Ps. 43:5).

References

1. https://www.who.int/ru/news-room/fact-sheets/detail/depression
2. St. John Climacus, The Ladder of Divine Ascent. Part 7. Word 2.7.

Pastoral help to people with depression

Archpriest Ilia Odyakov, Cleric of the church of Our Lady the Healer, Scientific Center for Mental Health, Russian Academy of Sciences

The theme of my paper a priori assumes that a priest is aware of such a mental disorder as depression. However sad it may be to state that many clergy of various level are convinced that depression as such does not exist, but there is only a manifestation of the passions of grief and despondency, laziness and weak will, whims and satiety and that a truly believing person cannot be depressed. One should endure with courage attacks of the evil power, which, according to Holy Scriptures, can be driven away only by fasting and prayer, whereas pills are altogether harmful for one's health.

Thank God, the Church carries out continuous educational work for the rational attitude to medicine in general and psychiatry in particular. We remember that the Gospel says nothing about clinical depression. We recognize that refusing to be treated for appendicitis by a surgeon or for a dental abscess by a dentist is not an act of martyrdom. Just as pain and pus in one's soul are manifestations of mental pathology and these conditions should not be 'endured on one's feet' but should be treated.

Therefore, I should begin with a statement that very often a priest could be the first to realize that a person, who confides his spiritual problems to him one way or another, has a mental illness.

At the same time, undoubtedly it is not the business of a spiritual father to diagnose a particular illness. However, he can and must distinguish normal affects from morbid ones. In this connection, it is necessary to learn to understand what a mental illness is, to learn 'to recognize its face', so to say. It is a very important stage in training a pastor and to prepare him for his further service.

Very often parishioners with mental problems who talk with a priest do not understand the gravity of their condition. Therefore, another important aspect of priesthood lies in helping a person to become aware of the unhealthiness of his particular emotional experiences and to assist him in turning to a medical specialist.

These efforts often give rise to considerable difficulties due to the danger that a sick person may altogether withdraw into himself and leave the Church. In this connection, the need arises to involve relatives so that they could explain to him softly but insistently the need for medical help. This problem at parishes causes great complications since normally people give a hostile reception to an attempt to lead them by the hand to a psychiatrist. A psychologist can give come help if there is such at the parish. Together with a priest, a psychologist can explain (now in the language of psychology) to the person what mental disorders he has and recommend him to turn to a doctor.

Those who come to the church in the Mental Health Research Center, unlike others, have a clearer and more critical attitude to their condition since they are already in an in-patient department and, as a rule, accept having an illness. In the language of ascetics, this vision of oneself can be described as sober, which undoubtedly represents a great possibility for a priest to give the necessary advice and recommendations.

SOS signal of distress

Those who suffer from depression, during their confession or a 'hairdown', pronounce, so to say, 'special' or some certain words from which a priest can surmise that what is at stake is a grave depressive condition that needs serious medical help. I will try to cite some commonly occurring utterances:

1. The feeling of being abandoned by God, a loss of the sense of grace.
2. Complaints of 'petrified insensitivity', powerlessness, inability to pray, to read Holy Scriptures and didactic literature.
3. One can speak about 'an emptiness in the soul', a loss of the meaning of life, a loss of faith in God.
4. Lamentations over a 'weakened' or 'lost' feelings both physiological (everything seems to be colourless or tasteless) and spiritual (love, gentleness, affection), indifference to all and everything, a full 'petrification of the soul', a feeling of emptiness, inability to rejoice or to cry.
5. Occasional complaints of 'anguish of the heart', 'pericardia', the feeling 'as if there were a poker in the chest', 'cats scratching my soul', 'a slab on the heart'.
6. Sometimes one speaks just of the so-called 'gloomy thoughts'. Closer questioning helps to clarify that the point are thoughts of suicide.
7. Painful feeling of one's own guilt, sinfulness, worthlessness and a feeling of boundless shame for one's life, and despair.
8. A wish, as they say, 'to croak', or at least 'to perish quietly'. In the same vein: 'everybody would feel better without me', or 'I would feel better without you'.
9. A sudden indulgence in, as it were' 'philosophical reflections' about the meaning of life and inevitability of death. A feeling of non-acceptance and misunderstanding on the part of those around.
10. Complaints of a lapse in intellectual abilities, 'dull stupor'.
11. Absence of the wish to carry any physical loads, the feeling of fatigue, weakness, powerlessness.
12. Statements about the development of gloominess, grumbling, complaints about everything around, accompanied with outbursts of exasperation, anger, fury. It seems that everything around is done from bitchiness.
13. Problems with sleep: it is difficult to fall asleep, frequent wakes-up during the night, early awakening without feeling restful.
14. Reluctance and rejection of marital relations;
15. Anxious expectation of a forthcoming misfortune, disaster, imminent end of the world.
16. In some cases, a depressive condition can be manifested as non-stop listening to rock music with specific melodies and texts, just as sitting on the Internet sites for suicidal individuals (for instance' 'Blue Whales').
17. Utterances about a negative perception of one's own past, present and future: 'the whole life is a chain of mistakes', 'everything in my life went wrong - it is gloomy now and there will be nothing good in the future'.
18. Finally, a priest often encounters talks about one's reluctance to study, attempts to give up one's job and family; in saying so, patients state that 'it is distressing to study and 'it is sickening to work'. It may also speak of the existence of depression.

It is necessary to realize that if at least a part almost certainly an illness.

Therefore, a person should be helped to realize that he or she is ill. A priest should explain extremely carefully and delicately to the person the need for treatment that will bear no delay as it can linger on.

How can a pastor help treat depression?

From the point of view of the Church, there is One Doctor who is Christ the Saviour, who heals people's every infirmity, illness and suffering. It is only at the Saviour's feet that one can find real healing from sins, illnesses and suffering. Nevertheless, if we turn to the patristic legacy we will find valuable advice and recommendations that holy fathers gave on appropriate occasions.

In the Old Patericon, there is a saying of Great Abba Ischirion: "Some monks in an Egyptian hermitage talked about the last times: 'What have we done?' they asked. Abba Ischirion answered: 'We have fulfilled God's commandments. And what will do those who come be after us?' 'They', abba said, 'will do half of what we have done.' They asked again, 'And what will those do who will be after them?' Abba answered, 'They will not do what we have done but will be allowed to grieve and suffer, and those of them who will hold out will be above us and will be our fathers."

Abba Pimen the Great used to say: 'If three persons live in one place and one of them prays properly and keeps silent while the other is ill and thanks God and still other serves them with in a good mood, then the three of them do an equal work'.

St. Seraphim of Sarov, one of the greatest ascetics of our time, said that 'he who bears his illness with patience and thanksgiving is imputed with heroism or even more than that'.

St. Ambrose of Optina, who himself was seriously ill for fifty years, taught that 'God does not require much from an ill person - only that he may endure his illness with trust in God and, if he can, with gratitude'.

In such cases, it is important for a priest to emphasize that among the spiritual recipes of the struggle with depression are patience, acceptance of God's will and appeal to a doctor. In doing so, he can refer to scriptural texts, namely, The Wisdom of Sirach, Chapter 38, Verses 1-14: "Give doctors the honor they deserve, for the Lord gave them their work to do. Their skill came from the Most High…

The Lord created medicines from the earth, and a sensible person will not hesitate to use them. Didn't a tree once make a bitter water fit to drink, so that the Lord's power might be known? He gave medical knowledge to human beings, so that we would praise him for the miracles he performs, with them He treats man and destroyed his illness.The druggist mixes these medicines… and uses them to give health to the people of the world. My child, when you are sick, do not ignore it. Pray to the Lord, and He will make you well… Then call the doctor-for the Lord has created him-and keep him at your side; you need him. There are times when you have to depend on his skill. The doctor's prayer is that the Lord will make him able to ease his patients' pain and make them well again".

Therefore, an ill person should be helped to understand that his illness is not a manifestation of being abandoned by God. God continues to love him and take care of him. It is important to help him understand that his illness does not tear him away from God, from himself and from the surrounding world (because it is sin that tears you away). Illness is a way of the Cross that is given us for salvation and that brings us up to God. Illness is a way of the divine providence, a way of change and growth.

It is necessary to strengthen a patient's confidence that a depression, given the doctor's instructions are observed, often has a favorable clinical course. A priest can and must convince a patient of the need to have trust in the doctor and the effectiveness of the medicine. If possible, a patient should be helped to overcome the fear of medication by stressing that there is no risk of being addicted to antidepressants.

It is necessary to remind a patient regularly that the life of a Christian is the continuous co-work of man and God. In this connection, the duty of a patient is to pray zealously not only for himself but also for his doctor (whatever the latter's ethnic background and religion may be) so that the Lord, 'through the mind and hands of the healer, may give the right treatment, grant him wisdom, help him choose a proper medicine and to ask God that the doctor's prescriptions may help him cope with the illness.

It is necessary to support and strengthen a patient in seeking the grace-giving help of God through church sacraments (Anointing, Repentance and Communion).

It is essential to underscore our calling to be, first of all, 'warriors of Christ', to wage an active struggle with evil and illness, to mobilize all our resources. The body and soul needs to be forced to work (it often seems to a patient that the only salvation lies in lying on the sofa with his face turned to the wall. Meanwhile, salvation from an illness lies in work. The soul aches while the body needs to be compelled to work; otherwise it is death).

Some methods of modern behaviour psychotherapy (I will mention two such techniques -activity treatment and skills and joy treatment) are rooted in patristic recommendations. Thus, the activity treatment presupposes that the more rest one gives oneself the deeper one's depression will be. In this connection, the monastic slogan 'Pray and work' expressed by St. Benedictus of Nursia comes just at the right moment. The pastoral advice to be always busy will be very important as soon as the illness becomes less acute.

Also appropriate is the advice to compile a list of tasks that earlier (before the illness) used to bring a real joy and to fulfil them methodically, like a penance (for instance, drawing, music, walks in a park, fitness exercises, etc.).

Thus, St. Innocent of Chersonese writes, 'Physical work dismisses depression. Let one begin working, even reluctantly; let one continue working even without success; for movement will first revive the body and then the spirit, too, and one will feel vivacity; a thought amidst work will subtly turn away from wearisome things, and this already means a lot in a state of despondency'.

I will also cite a story from the Old Patericon: 'St. Abba Anthony, being once in a desert, became depressed and very gloomy. And he said to God, 'O Lord, I want to be saved but my gloomy thoughts do not allow of it. What shall I do in my sadness? How can I be saved?' And soon Anthony got up and went out, and now he saw somebody resembling himself, who was sitting and working. Then he got up and prayed and after that he sat down again and twisted a rope and stood up again to pray. It was an angel of the Lord, who was sent to admonish and strengthen Anthony. And the angel said to Anthony, "You do the same and you will be saved! Having heard this, Anthony conceived a great joy and daring and, doing so, was saved".

The next question that should be considered is as follows: what is not to be done by a priest when he sees a patient with depression? What pastoral mistakes happen in these cases?

As is known, the most frequent types of thoughts that attack the consciousness of a depressed person are as follows:

1. Thoughts about one's own inferiority, blemish, ineptness;
2. Thoughts about one's own guilt and sinfulness, which often become a delusion.
3. Suicidal thoughts and intentions.

In these cases, a priest should avoid not only blaming the patient but also supporting his conviction that he is a sinner to be punished by God for his sins. A priest should try to present the Lord not as a severe Judge Who punishes one for one's every mistake, transgression and fall but to show that Christ is love, light, goodness, mercy, all-forgiveness and that He knocks at the soul of a sick one.

It is absolutely forbidden to make use of one's illness or support one's attitude to it as a punishment for one's sinful life or inherited vices.

It is desirable not to cast any reproaches on a patient, especially if they concern church life. It is necessary to remember that a sick person is very sensitive to everything and vulnerable and easily sees in any words a confirmation that he is believed to be useless and dull. It should be stressed and made clear to a patient that he is not guilty of his present sickliness. It is necessary to bring home to him continually that it is the depression that is to blame for making his life appear so empty and distressing.

A priest should not give banal advices to a depressed person, such as, 'you should pull yourself together; you could cope if you felt like coping'. Any primitive, consoling utterances or trivial encouragements should be excluded. Any complaint and feeling of a depressed person should be taken with attention and by no means should be ignored as a trifle but heard carefully and patiently.

A priest must not support a patient's wish to present the morbid vision of his life as a reality. The task of a pastor is to show that God, for a certain reason, has given us precisely this country and family, school and work, friend and foes, joys and sorrows, health and illnesses. Precisely in this situation, there is something important, sometimes hidden, but 'divine'. It is important that a patient should be persuaded that our salvation is accomplished (according to St. Paul) 'here and now'.

It is extremely important that a pastor should strongly advise to a patient in this condition not to make radical decisions with regard to his or her study, work, family, and the choice of a spiritual father. This advice is dictated by the fact that in the period of depression, one's adequate perception of the world is distorted and one cannot make a right decision in such a state. It is only after recovery from the unhealthy condition that it is possible to return to dealing with these social problems (what is called 'sitting in a cell' in the language of asceticism).

During a period of depression, a patient often cannot pray or read the Prayer Book or Holy Scriptures. Sometimes even the participation in divine service and sacraments do not bring relief. A priest should find words of consolation and, ideally, try to pray together with the patient, seeking to help him see the mystery of God's mercy, to explain him that God seeks love in us, not self-reproach.

It is also wrong to advise 'to be distracted from sadness' through joining a company of cheerful people, to go to a holiday home, to make a pilgrimage, to become a worker in a monastery, etc. This can drive one into an even more depressed mood.

In case of thought and intentions about suicide that a person can share with a priest, it is very important for the priest not to show horror and express criticism over what he heard. He should not either argue, or dissuade, or persuade the person that 'there is something to live for'. He should calmly and attentively listen to the person and express his compassion. Ideally, they should pray together. Depending of the situation, he can give a moral assessment of these impulses, point to their external, unhealthy nature ('When ill, do not wish death to yourself - it is sinful', St. Pimen the Ill).

At the same time, it is impossible to agree with the wish of a person to run inward, to remain 'insensitive'. It is necessary to inculcate in him the idea of the importance of such virtues as generosity, charity and various external manifestations of love. All this helps one not to be caught in the loop of one's weakness and uselessness and to learn to see and gratefully accept the reciprocal help from the other.

It should be noted that people in depressive conditions often try to find answers to their questions by asking for advice at forums, using self-medication, visiting fortune-tellers, homoeopathists, prayer exorcists, etc. A priest should point to the lack of prospects in such actions and the harmfulness of such approaches used in place of a timely appeal to a specialist.

There is another extreme - a desperate attempt to find an 'Orthodox psychiatrist', 'an Orthodox psychotherapist', 'an Orthodox psychologist' or 'a priest with education in psychiatry'. It is necessary to persuade a patient, just as his or her relatives, of the need for prayerful search not for an 'Orthodox' but a good and careful doctor.

Of the same kind is a search for either 'the magic pill' or 'the wonderworking icon healing from depression'. A priest should point to the false and magical character of this path and advise to embark on the path of personal prayerful feat in the task of healing.

Finally and most importantly, it is desirable that a priest should remember the experience of the holy ascetics who themselves endured a depressive condition and use their spiritual advice.

As an example, I will cite extracts from the letters of St. Ignatius Brenchaninov, who suffered much in his life, and having spent his whole life in suffering, came to consider compassion for those who suffer to be his sacred duty. Below are extracts from his letters to his spiritual children.

'You are still ill! What are you doing! An ill one cannot be fully ranked among the living because he lives a half-life, some shadow of a life. His greatest spiritual abilities become numb and stop doing what they should do. Today, Christians do not suffer from shackles and swords; we are tormented by illnesses and other troubles. Each time is given the suffering of a sort: our time is given petty suffering. Let us endure them. Scales and recompense belong to God' [1].

'Those who are in an unhealthy condition are like those who are put in irons from within and without' [2]. '…The state of one who is treated for a chronic decease is harder than the state of one who is ill: it takes all the time; the operation of a medicine puts the body in an unnatural condition; it deprives one of the physical and mental abilities,… holds one in a state of continuous tiredness, some numbness and falling to sleep' [3].

'The hair on our heads is given by God; no dumb bird falls down without the will of its Creator: could a temptation come close to you without this will? - No! It comes close to you by God's permission. The Vigilant Eye of the Providence continuously keeps watch on you; the all-powerful hand guards you ruling your destiny. It is by God's permission or nod that troubles have come to you as tormenters to the tormented… Do not give way to sorrow, cowardice and hopelessness! Say… to your desperate thoughts, say to your heart imbued with sorrow: The cup which my Father hath given me, shall I not drink it? (Jn. 18:11)… Let us put people aside: surely, they are outsiders! Let us fasten our eyes on God and cast down at His feet our whirling and confused thoughts and say with awesome obedience, 'May Thy will be done!" [4].

The cup of sorrows, 'the Cup of Christ, opens the entrance to the country of spiritual reason and spiritual condition. He who comes to it… begins to accomplish his earthly journey as if flying in the air above everything, on the wings of faith… Faith raises you from the earth, liberates you from shackles, takes you out of the midst of torments, elevates you to the sky, brings you into the tranquillity of the spirit' [5].

'Rejoice! And I say again: rejoice! You are on the cost of the sea of sorrows in order to swim over to the country of joys… Those who reach this blissful cost forget all the sorrows, which they had endured in the sea, in their ecstasy of pleasure. Step with your undaunted foot into the light boat of faith… Sooner than you expect, than you may imagine, you will be carried over the sea to the paradise. But between the spiritual paradise and corporal life, mental, ordinary such as all people live, there is a demarcation… - the cross and the crucifix' [5].

'Here are arms given to a servant of Christ by the holy rage of the preaching of Christ for struggle against… gloomy thoughts and feelings of sadness appearing in the soul in the image of fearful giants who are ready to erase and devour it:

1st - words: 'Glory be to God for everything'

2nd - words: 'O Lord! I give myself up to Your Holy Will! Be with me, Your Will'

3d - words: 'O Lord! Thank you for everything that You are pleased to send to me'

4th- words: 'O Lord! For what I am worth according to my deeds, remember me, O Lord, in your Kingdom' [5].

'If a sad thought or melancholy appear in your heart, begin pronouncing one of the above sentences from your heart, from all your power, doing it calmly, slowly, without excitement so that only you could hear them. Pronounce them till… your heart is alerted to the coming to God's beneficial help… these arms… will do more than all the grave judgements and fancies of theoretical theologians, tellers of letters - German, Spanish, English, American!' [5].

References

1. Святитель Игнатий (Брянчанинов). Полное собрание сочинений. Том 7. Избранные письма. Письмо 113. К некоторому священноиноку, духовному сыну. О болезнях и душевном ожесточении, URL: http://брянчанинов.рф/tom7/113.shtml
2. Святитель Игнатий (Брянчанинов). Полное собрание сочинений. Том 7. Избранные письма. Письмо 279. О претерпении болезни телесной. URL: http://брянчанинов.рф/tom7/279.shtml
3. Святитель Игнатий (Брянчанинов). Полное собрание сочинений. Том 7. Избранные письма. Письмо 266. О своем телесном и душевном состоянии. URL: http://брянчанинов.рф /tom7/266.shtml
4. Святитель Игнатий (Брянчанинов). Полное собрание сочинений. Том 7. Избранные письма. Письмо 75. К некоторому священноиноку, находящемуся в скорбных обстоятельствах. URL: http:// брянчанинов.рф/tom7/75.shtml
5. Святитель Игнатий (Брянчанинов). Полное собрание сочинений. Том 7. Избранные письма. Письмо 114. К отцу, постигнутому скорбными обстоятельствами. О борьбе с помыслами. URL: http://брянчанинов.рф/tom7/114.shtml