When The Holidays Aren’t Happy; How Do We Help Our Patients?

Last week I was working with a patient when she started getting emotional about the upcoming holiday season.  She was struggling enjoying her 8 month old’s first holidays and the sadness that she was also feeling.  “Why am I not just happy and enjoying this time?” she asked me.

I perked up for a variety of reasons.

One, I knew she struggled with postpartum depression immediately after her daughter’s birth.

Two, it is not unusual for people to have feelings of sadness and stress during the holidays, and then guilt for feeling that way!

So I listened; why was she feeling this way?  She was overwhelmed by demands from family to see the baby, juggling an infant’s sleep schedule while keeping them happy, and starting traditions of her own.  I told her this was completely normal, but also reminded her that she only needs to be responsible to herself, her daughter and her husband.

“How do I do that?!?” she responded a bit exasperated at the idea of telling the in-laws that no, they were not staying for 12 hours on Thanksgiving Day.

Every year I have similar conversations with patients. 

So what do we tell them?  While we all need to stay in our scope of practice, and our own comfort zone, the following will help us navigate the conversation.

There are many reasons why people experience a range of anxiety/depression/stress during the holidays.  Symptoms can be anywhere on the spectrum from “holiday blues” to a more serious depression.  The good news is, the vast majority of people will have a mild case of the blues.  In spite of long-held beliefs and even occasional media coverage, suicide rate and depression-related hospital admissions do not go up during the holiday season.  The U.S. Center for Health Statistics shows that November, December, and January actually have the lowest daily suicide rate.  However, that does not mean that the holiday blues are not a real concern.  

No systematic reviews exist regarding mental health around the holidays. 

However, the American Psychological Association has conducted surveys with some interesting information:

  • While the majority of people report feeling happy, loved and in high spirits during the holidays, they also report feeling fatigue, stress, and irritability.
  • 38% of the people said their stress level increased during the holidays.
  • 56% of people said their stress was the worst at work, while only 29% said the stress was experienced at home.
  • 53% of people said their stress had a financial component. 

So what do we tell our patients? The American Psychological Association recommend several coping strategies:

  • Most importantly, remember the holiday season does not banish reasons for feeling sad or lonely. There is room for all feelings and anything the person is feeling should be acknowledged and validated.
  • If they have experienced a recent loss or a loss around the holidays, grieving may be strong and surprising, even years later.  Reassure them all feelings are valid and sharing them is the best way to positively grieve.  Encourage them to share with trusted friends or a counselor and prepare to celebrate their loved one’s life in a positive manner.
  • Spend time with supportive and caring people.
  • Save time to take care of themselves. No guilt. Do whatever activity they wish.
  • Be aware of excessive drinking and excessive junk food.  There isn’t consistent evidence that one particular food staves off depression, but there is some research to suggest an overall healthy diet is helpful in treating depression.
  • Go to bed! Getting plenty of sleep will help manage anxiety and stress.
  • Get some light. Exposure to light, especially in the morning is important to anybody at risk for depression.
  • Exercise.  There is a lot of research that movement, any kind, can help with general mood.
  • Identify the source of the pressure and make priority lists. Don’t feel bad if something doesn’t make the list. 
  • Don’t be afraid to say “No” if occasions are not on your priority list.  Or say “Yes, but” as in “Yes I would love to see you but right now is not a good time and I really want to be fully engaged. How about we arrange that end of January?”
  • If feeling lonely, reach out or try other activities to make friends.
  • Finances are often the source of stress.  Set a budget, communicate intentions well ahead of time with loved ones and concentrate the larger reasons for the seasons.  Do a group outing or volunteer for a charity as a family instead of focusing on gifts.

It is important we know and recognize the signs for a more serious depression.  Past posts on The Massage Therapist Development Centre have done an excellent job of describing the signs and what we can do.  Find the link here.  For most of our patients, listening, validating, and giving them permission to be a priority will help them thrive, not just survive the holidays.  Reassuring them all feelings are normal and the stress is short-lived goes a long way to have the happiest of holidays.  And remember—that goes for us caregivers as well!  Remember to not just take care of your patients, but take care of yourselves and have the happiest of holidays!




Day-Calder M  How to beat the post-holiday blues. Nurs Stand. 2016 Sep 14;31(3):37-38.

Hirthler MA  Change of shift. Holiday Blues.  Ann Emerg Med 2010 Dec, 56(6);690

10 Evidence Based Reasons Why You & Your Patients Should Exercise

Exercise is great, we know this, right?

Well, sort of.

Many people know exercise is good for us on a general level, but the question is, do they know it’s right for them on an individual level and is it the right fix for their problem?

This is an entirely different proposition, applying that general information to the person. This idea that these things are good for us can be quite vague, one of those things we may have glanced over in a newspaper or half-hearted on the news whilst eating our corn flakes.

People also build up ideas about what is the correct treatment for them. This can be from their own in-depth research on the internet (right!), what they have picked up from friends and family or from previous treatment with a therapist. This can lead to some pretty strong ideas about what should and perhaps should not be done to help them.

These beliefs don’t always align with the best available data we have about interventions. A prime example of this is the belief that exercise risks outweigh the benefits with back pain (55% of folk in New Zealand). This stat was taken from this Darlow paper in 2016 HERE. 

We know that exercise can be effective with back pain, certainly not a magic bullet, but one of the best things we have at our disposable within a comprehensive treatment plan, especially as it is low cost and low risk too.

Beliefs And Expectations

Our beliefs drive our expectations and actions. Predicted expectations are gaining weight as a prognostic factor in recovery over the past decade. They may influence my participation and behaviour in a treatment plan that will ultimately affect the outcome.  If I don’t believe in something I am much less likely to do it.

How can we combat this? Well, in my opinion, the best tool we have is good quality information we can use to combat the beliefs that may hold people back. A key to start affecting beliefs, again, in my opinion, is not to challenge too firmly, but inform people using well-evidenced information. One of my favourite one-liners is “That’s what we used to think but we are learning new things all the time, the latest research suggests…”

Here are some small tidbits of information that we can use to start informing our patients and clients about the role of exercise in pain AND health, which of course ultimately affects pain too!

Remember that giving people information is really designed to change behaviour rather than just show how smart you are so monitoring what happens is pretty important.

1. Exercise Is One Of The Best Evidence-Based Interventions We Have For MSK Pain

This paper HERE from 2017 in PLOS one shows moderate to strong effectiveness of exercise as an intervention for many MSK issues. This is in contrast to the belief that things need to be zapped, needled or popped back into place.

My therapist only gave me some exercises. Yep. Because they followed the evidence!

2. Exercise Won’t Make Your Body Worse

So many people see the body as a bit of machinery. The more it works the more the parts need replacing. Is this true? Absolutely NOT. The body is an organic organism that adapts both positively and negatively to stimulus. The more active we are (within reason) the stronger we become. The less active, well…

A classic common belief is that our intervertebral discs wear out the more we use them. This classic study from Battie HERE (2009) looked at twins to determine the major contributors to disc degeneration. They suggest that the “commonly held view that disc degeneration is primarily a result of ageing and ‘wear and tear’ from mechanical insults and injuries, was not supported by this series of studies”.

This study HERE from 2017 found that if you have a rotator cuff tear, the tear getting worse did not appear to be simply related to activity levels. In fact, they suggest pain development is actually associated with LOWER activity levels. If I had a pound for every time it has been suggested to me that running damages the knees then I would be a rich man. A study of marathon runners HERE showed that they had LESS meniscal abnormalities than non-runners.

3. Exercise Might Actually Make The Discs In Your Back Healthier!

Two recent studies have shown a POSITIVE effect of activity on intervertebral discs. Firstly this study HERE from 2017 showed that MORE vigorous activity was associated with BETTER disc health on MRI. Secondly, in this paper from 2016 HERE. Runners were shown to have intervertebral discs that had increase hypertrophy compared to the non-athletic group. The authors suggest that running actually strengthens the discs, whether we can infer a causal relationship here is unclear but this goes against activity causing wear and tear which is a common belief.

4. Activity Is A Pain Killer

This study HERE showed that older adults who were MORE active also had better endogenous pain inhibitory mechanisms when their conditioned pain modulation (CPM) was tested. Simply put, this means the more active the better their natural pain-killing mechanisms were. Which of course is super cool.

5. Exercise Is An Anti Inflammatory

This study HERE showed that regular physical activity caused an increase in interleukin -10 which is an anti-inflammatory cytokine that can reduce nociceptor sensitisation.

Now the caveat here is this study was performed in an animal population but as we know that there are associations between inactivity and both acute and chronic pain in humans it is a linked that potentially needs to be better explored.

6. Lack Of Exercise Is Associated With Chronic Pain

This large study HERE looked at the relationship between recreational exercise and chronic pain. Both older and younger folk were studied and the researchers found that for both groups exercise participation was associated with reduced chronic pain. A relationship was also present for the frequency, duration and intensity of that exercise.

7. Lack Of Exercise As A Major Cause Of Chronic Diseases

This comprehensive paper HERE makes a case for a lack of exercise being a primary prevention against 35 chronic conditions suffered by us poor humans. This goes beyond what most of us involved in the musculoskeletal field would have to deal with but also shows the importance of exercise for systemic health too.

8. It’s Involved In Mental Health As Well

We are understanding more and more that the mind and the body cannot really be separated. Physical health and mental health are interlinked in the human being and guess what…..exercise plays a role in improving mental health too. This paper HERE explores the mechanisms that may relate to mental health and exercise.

This randomised control trial looked at aerobic exercise and a variety of measures of psychological health HERE. The authors found significant group differences that favoured the exercise group.

9. You Want To Live Longer Right?

Strength training in this paper HERE was found to have a significant association with decreased mortality in adults over 65. But only a minority of this age group actually meet the current guidelines.

10. Have A Healthier Heart

This prospective study of 15 years duration HERE found that physical activity was a predictor of cardiovascular disease.

Summing Up

There are a whole bunch of others studies that relate to these topics but I just picked a few. I think it demonstrates that physical activity and exercise have an effect on us on a number of different levels, from the heart to the head to pain as well.

  • Do it
  • Do it
  • Do it
  • Do it

Exercise Saves Lives

I’m a firm believer in that statement. If that is too bold of a statement you could at least agree that exercise enhances lives.

The different forms of exercise can make you stronger, faster and more mobile. Aside from physical benefits, what about the mental benefits of exercise? Can movement also help you cope, decrease depression and anxiety, and also make you happy?

I say, yes!

This best can be shown through two real-life examples: myself and one of my long-term patients.

Helping With Postpartum Depression

In May of 2017, I gave birth to a beautiful baby girl. My husband and I are so lucky! She was and still is, an easy baby. She’s laid back, very cute and eats and sleeps like an angel. 

So it was shocking to me when at about three months postpartum, until very recently, I suffered from postpartum depression. Wasn’t I the luckiest person to have this sweet girl in my life? I didn’t know how to get out of feeling so low all the time.

I have been a gym rat since I was 13 years old. Now as a 35-year-old mother I have never appreciated exercise more! I strength trained through my entire pregnancy and once baby arrived I couldn’t wait to feel well enough to get back in the gym! As my journey through postpartum depression intensified I found strength in the gym. I didn’t care that I could deadlift only half of what I used to and I could no longer do a pull-up without assistance.

I felt so much healthier mentally by just spending 40 minutes lifting weights.

Evidence supports the anti-depressive effects of exercise in the general population and small studies have been done to determine if exercise can also decrease postpartum depression. The literature suggests this is true, though more and larger studies should be conducted. While science hasn’t concluded that exercise can decrease depression in postpartum women, if you want real life proof, I will be your case study!

Helping With PTSD

An even better example of a positive exercise story is through my patient. He came to see me for massage therapy the first month of my career as a registered massage therapist and I have treated him almost weekly for eight years. 

Talk about loyal!

This patient had a significant workplace injury, was forced to retire and now lives with constant pain. He also has post-traumatic stress disorder (PTSD) and deals with frequent episodes and nightmares. I have learned a lot from him in the past eight years.

He has had ups and downs. High levels of opioids, sleeping pills and other medications, weight loss and weight gain, good days and very low days. He has had plans and goals that have fallen through because he feels too much pain.

Recently, he came into my massage room and said, “F*#& It! I’m going to do this on my own!” He didn’t want to rely on constant pills, doctors and psychologists anymore. He decided to take his health into his own hands.

He started walking. Five kilometres almost every day.

Then he started running.

Running turned into more running. More running turned into healthy eating. Healthy eating turned into losing 60 pounds in less than a year. I joke that we both lost 60 pounds last year, him from exercise and me from giving birth (plus exercise and healthy eating)!

But the best part of the running was the things positive things he would say to me each week:

“My PTSD symptoms are less severe.”

“I’ve been sleeping a lot better.”

“I can handle intense situations now.”

He still has pain. Every day. That has not changed. But he has found something that makes him feel good and has improved his mental health:


I saw dark roads for both myself and my patient, but now we lift or run our way to health and happiness.

“Sometimes the briefest moments capture us and demand that we live the rest of our lives in reference to them.” – Lucy Grealy.

This quote hits the nail on the head for our type of situations. An injury, a traumatic experience, or a lifestyle change can hugely affect how we view and live the remainder of our lives. Encourage your patients (or yourself) to find movement that they enjoy and that makes them feel good. You might find exercise saving one of your patients one day.

Understanding Depression, Ways To Recognize And Help

A couple of weeks ago, I was on my way to the gym when my mom called.

She started the conversation by saying she was thinking about me. My response was “why?”

I hadn’t heard the news yet, but she let me know that someone I’m a huge fan of had died. As the news about his death rolled in, it was confirmed that Anthony Bourdain had taken his own life. I’d read some of his books, cooked his food from one of my favourite cookbooks, watched his shows, and basically loved everything he did. I looked up to him.

Strange that someone who you’ve never met, can have an impact on you. Some may even think, strange for a mom to think about their son because of what a famous person did. But, perhaps she was thinking of me because of the way he did it.

I’ve written a little bit about it on this blog before, but have never gotten really personal with it. I debated hard whether I would write this post because it’s so personal. Depression is something I’ve dealt with a lot in my life, (I’m not sure if depression is actually a genetic thing, but it’s something that is certainly prevalent in our family) and was faced with suicide for the first time when I was around 12 years old. My uncle had taken his own life, years later my best friends dad, then one of my mentors at the firehall,  just a few years ago my brother, and a couple of months ago, a childhood friend.

So, any time something like this happens, maybe it hits a bit close to home.

Of course, when it’s a famous person, inevitably there is a lot of media attention. People take to social media to voice their opinions, mourn, share stories, and ask questions.

Most of the time people are left bewildered how someone who has “the ultimate life,” could possibly do something like this, they have it all!?

Then, of course, a barrage of the comments centre around how suicide is a selfish act because the person isn’t thinking about what they left behind, what they’ve done to family and friends, or that they took the easy way out.

Many friends who I’ve talked with since Bourdain’s death, haven’t really dealt with depression in their lives, so they have a difficult time understanding what could lead to this. I’m sure every person who deals with depression has varied experiences and different ranges of severity, so I can’t speak for others, or their experiences, but I will speak of mine.

Now for the personal part.

What Depression Feels Like

I can’t make a blanket statement on this as it’s going to be different for everyone.

Depression isn’t just simply a case of being “down” or feeling “blue” for a little while, it goes far beyond that. We are all meant to have a range of emotions and some days not feel as good as we do others. How could we ever experience how great happiness feels if we’ve never experienced grief or sadness?

Sadness can come and go depending on the experiences we have during the day. When you’re depressed, it’s like there’s a scratch on a record being played that is constantly skipping, playing the same line of a song over and over again. Only the line of the song is negative thoughts and no matter how hard you try, you can’t turn it off.

The longer it goes, the worse the negative thoughts get, and the harder it is to turn it off.

Possibly the worst part, is that you know those thoughts are wrong, you know they’re irrational, but there’s nothing you can do about it, they just keep pounding into your head. Then, you start to believe them.

When you start believing them is when things get really tough. You start to pull away from others because those negative thoughts aren’t just a matter of a feeling of sadness, it’s a feeling of worthlessness. You start to think that no one cares, that you’re not loveable, that maybe, just maybe, you’re as worthless as the thoughts in your head.

You could be laying in bed with someone you’re totally in love with, and when they tell you they love you, you don’t really believe it because, why would they!? When you already believe the negative thoughts in your head, why would anyone else think any differently? You assume everyone else thinks the same thing.

As it persists, things continue on that downward spiral. Sometimes laying in bed just thinking “maybe the world is a better place without me,” “maybe my friends and family would find it so much easier not having me around.” And the thoughts just won’t shut off, they won’t go away.

Then some of the isolation begins. You pull away from everything social because you’re not likeable anyway right?, so why subject your loved ones to HAVING to put up with you being around. It’s such an irrational thought, your loved ones having to PUT UP with you. It makes no sense, but you just can’t help it, it makes sense to you at the moment!

One of the strange things is that it doesn’t matter how good everything else in life is going, you could literally experience the greatest highs, and still have those negative thoughts constantly spinning in your head. One of the greatest experiences of my career was travelling to Russia this year with hockey, it was a major accomplishment, but there was still a night where I had to lock myself in the bathroom to have a good cry…damn those negative thoughts!

According to Mental Health First Aid Canadasome of the outward signs of depression can have both a physical appearance and a shift in attitude. 

Some signs of a change in physical appearance can be:

  • Looking sad, dejected, or anxious.
  • Speaking slowly in monotones.
  • Have a lack of attention to their physical appearance (look unkept).
  • Slowed thinking and body movements, agitation, pacing, or unable to sit still.
  • Decreased energy, tiredness, and fatigue.

With changes in attitude, a person may say things like:

  • I’m a failure.
  • I’ve let everyone down.
  • It’s all my fault.
  • I’m worthless.
  • I’m so alone.
  • Life is not worth living.
  • No one loves me.

Take a moment and just think about what it would be like having those thoughts repeatedly playing in your head. So, yeah I can see and understand why these famous people with the “ultimate lives” can get to a point where it seems like their only option is to end it all.

Treating Depression

There has been lots of discussion about what works for treating depression, that we need to raise awareness, and we certainly need to talk about it (the main reason for me writing this post).

What I haven’t seen much on, is how does the depressed person feel about all of these things?

This article was being shared around last week about the great effects of resistance exercise in reducing depressive symptoms. While this is great (and is hopefully used as a preventative measure), when you’re going through dark bouts of depression, the last thing you want to do is exercise. Just getting out of bed can be hard enough.

Raising awareness, yes we need to do this and fortunately, mental health, in general, is becoming more recognized and talked about. However, when you’re dealing with it, the last thing you want to do is raise awareness around your mental health. There’s a lot of fear associated with it.

Again, maybe irrational thoughts, but all you can think is:

  • No one would want to date someone who deals with this.
  • I could get turned down for that job I’m applying for if they find out.
  • People are going to look at me differently.
  • I’ll get less professional opportunities if people know.
  • No one would want to read a blog post I’m writing.

Talking about it, yes let’s get this going! However, it’s important to keep in mind that whether we like it or not, there is still a lot of stigma surrounding mental health (at this point). So, the depressed person may not want to talk to anyone about it, because remember, it’s also possible they think that NO ONE cares anyway.

While exercise and massage therapy are both recommended as lifestyle and alternative treatments for mild to moderate depression, anything more severe, the person should seek medical attention. This can be both medical and psychological treatment. Some of the best scientific evidence points to antidepressants, Electroconvulsive Therapy (ECT), and Cognitive Behaviour Therapy (CBT) as the best approaches for the treatment of depression.

The best thing we can do is start building relationships with medical professionals who provide the above therapies, so we can refer our patients when they need it. 

Assessing Risk Of Harm

This is one of the reasons it drives me bananas when some of our regulatory bodies say the biopsychosocial approach is out of our scope. Not only is massage therapy recommended as a treatment for depression, it’s also our responsibility to recognize and refer out should our patient need it.

How do we handle it if our patient is dealing with a mental health crisis and it gets to be too much for them?

Mental Health First Aid Canada gives four steps as crisis first aid in these situations:

  1. Engage the person in a serious conversation
    • Connect in a personal way.
    • Ask if they are feeling hopeless, or engaging in risky behaviour.
    • Show sensitivity and let them describe their feelings.
    • Listen for anything that could be an invitation to talk about suicide.
  2. Ask about suicide
    • Are you thinking about killing yourself, or having suicidal thoughts?
    • Asking this will not encourage suicidal thoughts, but rather it shows you care and are willing to talk with them, which can be a great relief for them.
    • Creating this conversation can identify you as a safe person to talk to.
  3. Explore and assess risk
    • Ask if they have a plan in place.
      • Have they made arrangements, or have things they could use to do it?
    • Ask about prior suicidal behaviour.
      • If they do, see if they need extra support, or if there are things that helped them in the past.
    • Ask about their supports.
      • See if they have people to turn to (at this point it might be you).
  4. Engage them in a plan for safety
    • Try and make sure they don’t have access to the means of killing themselves.
    • Develop a safety plan for a manageable period of time along with emergency or crisis line information.
    • Try to ensure no access to drugs/alcohol.
    • Listen to them.
    • Refer them to appropriate professional help.
    • Connect them with their support resources (and try not to leave them alone).
    • If necessary call 9-1-1.
    • Ensure your own safety.

While I hope this is something you never have to deal with, it’s an important conversation to have, as it could quite literally save one of your patients (or loved ones) lives.

While this is just a blog post, it should not be used as a substitute for more education about mental health, or suicide. I would encourage anyone reading this (healthcare professional or not) to take a mental health first aid course to better equip you to handle these situations should you ever need it. 

Whenever a famous person succumbs to mental health issues and takes their own life, it raises lots of awareness online. Along with that is discussions and opinions about the act of suicide itself. People make statements like: “it’s a selfish act,” and “why couldn’t they think about the ones they left behind?” While those things are all valid statements, as the ones left behind are left with nothing but hurt, and questions about how they didn’t see it coming, or just disbelief that it could ever happen. It may seem like a selfish act, but as we talked about earlier in the post, the person doesn’t believe that anyone cares, loves them, or that there is any other way out. From my own experiences, I’m not concerned about whether the person was selfish, it’s more sadness that whatever was going on in life was so bad, that the only thing they thought would fix it, was to end it all. So please, if you have any concern surrounding this with one of your patients, assist them to get the help they need.