My first exposure (that I can remember) to mental health issues was back in 1988, I was 12.
We got the news that my uncle had taken his own life.
Flash forward several years and it happened to my best friend’s dad, then one of my mentors from the firehall, then last year it was my brother.
In each case something happened with these otherwise healthy people, where the pain they were experiencing was just too much. They couldn’t take it anymore.
Every time things like this happen, it comes as a shock to the people around them.
Over the years on the fire department we have responded to several scenes where mental health has been an issue and possibly the cause of someone’s death.
We decided we should learn more about mental health to understand how to respond more appropriately. We set up a mental health first aid course.
It was like the words leaped off the page and slapped me in the face.
Symptoms of Major Depressive Disorder:
- unusually sad mood most of the day and nearly everyday
- loss of enjoyment and interest in activities that used to be enjoyable
- significant weight gain or loss, even when not dieting
- sleeping too much or too little everyday
- moving more slowly or becoming agitated and unable to settle
- lack of energy, chronic tiredness
- inappropriate feelings of guilt and worthlessness everyday
- difficulty concentrating, making decisions nearly everyday
- recurring thoughts of death.
But we don’t talk about that stuff.
I’m supposed to be tough and I’d be a total wimp to bring it up.
So many of those thoughts and feelings had been running through my head for years.
I wasn’t excited about the things that used to get me worked up. Playing hockey, exercising and even volunteering with the fire dept wasn’t as fun as it used to be.
Classifying Mood Disorders
There are times when we’ve all felt a little down.
I’m sure we can even notice it in our patients, especially when it’s a patient who we’ve been seeing for a considerable amount of time.
Perhaps something has happened at work, in life or they have suffered a loss and just aren’t themselves.
However this doesn’t classify as a mood disorder, it’s just part of life.
The above feelings become a mood disorder when people feel that their emotions and feelings are no longer under their control, they begin to feel adversity in their social and work life functions.
There are a couple types of mood disorders – depressive and bipolar which can then be broken down further in to subcategories:
1. Depressive disorder
- Clinical depression
- Major depressive disorder.
- Has a depressed mood or loss of interest with enjoyable activities for more than two weeks.
- Post Pardum Depression
- Starts within four weeks of having baby.
- Symptoms are more severe and last longer than typical depression.
- SAD (seasonal affective disorder)
- Symptoms of depression occur typically in darker times of the year (fall, winter).
2. Bipolar disorder
- People experience extreme mood swings with depression and mania, but can have extended periods of a normal mood in between.
In addition, sometimes mood disorders can be related to medical conditions and/or substance abuse.
How many times have you seen a patient dealing with chronic pain, a motor vehicle accident or a chronic medical illnesses come in to your clinic that have feelings like they are never going to get better and can’t deal with other issues in life i.e.: work, family, finances?
As research develops and we understand more with the biopsychosocial pain model, there is a direct correlation between these mood disorders and the other pain our patients are dealing with.
It is imperative that we can understand and recognize when these symptoms are developing in our patients.
Massage Therapy Scope Of Practice
There is debate about wether treating depression is within our scope of practice.
Studies have shown that massage can have some positive benefits in helping with depression, but what about recognizing depression as a healthcare practitioner?
There are things we can do to help those with depression, but we are not treating depression. The specific treatment of depression needs to be referred to a medical doctor or appropriate mental health professional.
However, it IS our responsibility and within our scope to recognize patients with symptoms of depression.
Locally our legislation and bylaws state:
- Massage Therapists must act in the best interest of the patient.
- Massage Therapists must provide complete and accurate information to enable the patient to make an informed decision regarding the need for, and nature of, therapeutic services. This includes answering any questions that the patient may have, in an understandable manner.
- Massage Therapists are responsible for recognizing their personal and practice limitations.
- Massage Therapists must request consultation or refer a patient to colleagues or other healthcare professionals when such actions are in the best interest of the patient.
I’m sure we have all had patients on our table who like to talk. In fact I’ll bet it’s most of our patients.
But what about when that talk takes a negative angle or starts to take on a self-depreciating or self-harm mindset?
You may hear someone who is depressed say negative things about themselves like:
- I’ve let everyone down
- I’m a failure
- It’s all my fault
- It’s not possible to love me
- Things will always be bad
- Life is not worth living
- I’m so alone
There is a tool that can be used called the Goldberg Depression Scale.
It contains questions that can help recognize if one of your patients or friends could be having symptoms of depression. However it is just a screening tool, not an assessment.
If a person is asked the following questions and ranks high, then they should be referred to their doctor for help.
Arguments can still be made as to wether this is within our scope of practice. When communicating with a patient we are required to discuss their healthcare. If you’re using the Goldberg scale, the questions are all related to the persons healthcare and are well within our scope to ask.
- Have you had low energy?
- Have you had loss of interests?
- Have you lost confidence in yourself?
- Have you felt hopeless?
If a person answers yes to any of the above questions, then ask them the next five questions:
- Have you had difficulty concentrating?
- Have you lost weight (due to poor appetite)
- Have you been waking up early?
- Have you felt slowed up?
- Have you tended to feel worse in the morning?
The scale recommends that you give a value of one point for each “yes” answer if those feelings have occurred a majority of the time over a 2-4 week span. Someone who scores 2 has a 50% chance of a mental health problem and with any scores higher than that, their chances continue to increase.
Their outward appearance can also be altered in both physical appearance and with attitude accompanied by the description of being emotionally blunted or numb.
If any of this is present, we now have a responsibility to our patient.
Mental Health First Aid
Okay, so now we have established there is a risk of depression with someone.
We need to assess if there is a risk of suicide or personal harm. The Mental Health Commission of Canada gives us a great mnemonic to use for a situation like this called A-L-G-E-E
- Assess the risk of suicide or harm
- Listen non-judgementally
- Give reassurance and information
- Encourage the person to get appropriate professional help
- Encourage other supports
Engaging the person in a serious conversation about their feelings can help you to determine what’s going on with them (and let’s be honest, most of your patients are already having conversations with you and there is a level of comfort there).
If you are trying to assess for risk of suicide or harm, it can be a scary thing to start asking about.
However we learned on the course that it is okay to ask directly wether a person is having these kind of thoughts. It is often believed that asking about that is taboo and could lead a person to having those thoughts.
In reality, asking about it shows you care and the fact that you show a wiliness to talk about it can bring great relief.
If the person confirms they are having these thoughts, you need to determine if they have the means to do it, or a plan in place to make it happen.
Do they have the necessary equipment to be able to do it (firearms, pills etc) and is their plan imminent?
There is a big difference between someone who’s planning this today and someone who says they’re thinking about doing it in a month.
If you think there is a risk that this could happen soon, they need professional help and you should call 9-1-1 and make sure they are not left alone.
The most important thing in all of this is your personal safety. While the person should not be left alone, if your safety is in question, this takes precedence and you should try to observe the person from a distance (but still call 9-1-1).
If you figure there is no risk of harm, you can move on to the next step.
This is a skill we as Massage Therapists should be skilled at.
Imagine your intake interview whenever someone comes in for their first treatment. Give the person time to vent their frustrations and realize they are trying to cope with this issue.
As with any other time when they come in, don’t offer advice, leave that to the professionals.
Listening non-judgementally can be tough with mental illness, especially if you’ve never had to deal with it, so remember not be critical or say things like “suck it up” or “cheer up”, this will only make matters worse.
Give Reassurance And Information
Remember, in this case that you are a medical professional and your patients look to you as such.
They are probably more comfortable talking to you than their family doctor. They will probably be looking for some sort of advice from you.
The thing you can do is remind them there are treatments for depression and they should see their family doctor for more guidance on what to do.
It is okay to give them reassurance about depression being a medical condition, common in today’s society.
In fact it is so much more recognized now than it was years ago and the available assistance is at their fingertips.
Encourage The Person To Get Appropriate Professional Help
No, this doesn’t mean another massage.
There is so much help nowadays for depression. Beyond the family doctor, there are counsellors, mental health therapists, clinical psychologists, psychiatrists, volunteer organizations and telephone helplines.
Just make sure you get them to some sort of appropriate help.
It might even be a good idea to start a referral relationship with a counsellor in your area, just for this type of situation.
Encourage Other Supports
Have them reach out to family, friends or co-workers for some solid emotional support.
People who get this support from family can recover a lot quicker.
In addition, exercise and massage therapy are a couple of other therapies that are recommended as treatments that help with depression.
We are at the forefront of being able to help people with this kind of illness. When our patients get on the table they talk, they talk because we have a different relationship with them than other healthcare professionals do. If a person is unsure of wether they are dealing with a mood disorder, there is a greater chance of us picking up on it than the family doctor because they typically see us a lot more. This gives us a large responsibility that must be included as a part of our scope of practice, not to treat but to recognize and refer. While this blog post is just a little bit of advice on the topic, I venture to say it’s something we all need to learn more about. As the biopsychosocial model of care becomes more prevalent and we understand the relationship between pain and psychological issues we stand to see a greater degree of this happening in our clinical setting. As I mentioned earlier, how often do you have someone come in to see you who has been in a car accident or experienced some other injury who has lost a degree of hope and is in despair? I know I’ve certainly seen it. I hope I never have to deal with a patient who tells me they are considering harming themselves but the reality is, we will all probably have to deal with this at some point. Take some time and do some research for your area to gain some knowledge about available resources someone may need. If you handle it appropriately, not only will your patients thank you, their family will too.
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