Holistic Care for Depression-Anxiety

This is a lengthy article. It is best read as a pdf, which you may find here.

There is a great scene at the end of The Lord of the Rings: The Return of the King that really captures what true friendship looks like. Sam and Frodo are nearing the end of their journey to destroy the One Ring. Frodo – even more so than Sam – is completely exhausted not only physically but also from the internal burden of carrying the Ring all this way. As they’re both collapsed on the side of Mount Doom, Sam asks Frodo, “Do you remember the Shire, Mr. Frodo?…Do you remember the taste of strawberries?”

Tragically, Frodo replies, “No, Sam. I can’t recall the taste of food…nor the sound of water…nor the touch of grass. I’m naked in the dark, with nothing, no veil between me and the wheel of fire! I can see him with my waking eyes!”

Sam, responding perhaps as the greatest friend in cinema history says, “Then let us be rid of it, once and for all! Come on, Mr. Frodo. I can’t carry it [the Ring] for you, but I can carry you!” He proceeds to pick up his dear friend, and although he can’t carry his friend’s deepest burdens, he can help get him to the place he needs to go. Recognizing his friend’s exhaustion, Sam helps him by meeting Frodo’s immediate physical need.

What do you say to your friend who comes to you and tells you they’re struggling with depression and/or anxiety (depression-anxiety)? Unfortunately, we in the Church today tend not to respond very well to our hurting brothers and sisters. Most of our advice amounts to nothing more than, “Take a dose of Romans 8:28 with this glass of John 3:16 and call me in the morning.” We brush our friends off with passive comments like, “It sounds like you just need to believe this truth, know that I’ll be praying for you.” By quickly passing off our friend’s deepest pains, we essentially provide them with an over-spiritualized version of “God helps those who help themselves.” This type of care is not only unhelpful, but it is not Christian and it is potentially destructive.

Think of it this way: what if Sam had looked in Frodo’s face and said, “It sounds to me like you just need to believe Gandalf wants you to make it to the top of the volcano. Remember that you’re loved and everyone is counting on you! I’ll pray for you when I’m back at home eating those strawberries.” Sam would have been an incredibly bad friend! He would have been passing over Frodo’s immediate needs without providing him any real help at all.

How can we as Christians, who have been called to care for and love one another, better respond to our friends who are struggling with depression-anxiety? We can do so by better understanding how the Bible presents the person as both a material (physical) and immaterial (spiritual) being. In other words, by understanding the person holistically, we will know how to respond and care for our hurting friends in a loving and Christian way.

A Biblical Foundation

There tends to be two extremes our society (and by extension, the church) takes in regards to our anthropology (our understanding of the person) today. On the one hand, secularists tend to view the person as a primarily physical being. When you follow this extreme, every issue within a person has a physical cause. Depression-anxiety becomes a disease that is a result of something gone wrong in the brain, but if you can fix the brain, you can fix the issue. Meeting one’s physical desires and comforts – such as the desire for sex – becomes a physical need that must be met, regardless of the relational, emotional, or spiritual consequences.

The other extreme is to view the person as a primarily spiritual being. This is happening both inside and outside the Christian Church now that spirituality is back in vogue today. With this extreme, the solution to one’s problem must be found in some sort of belief system, usually directed within the self. The gospel of self-love presents a world where believing in yourself and your own internal strength is the answer to your problems. In Christian circles, this over-spiritualization results in chasing spiritual “experiences” and “encounters” with God that give us a spiritual high. When the spiritual high runs out, we are told there is something wrong with us and that the answer is found in creating and experiencing another encounter like ones we have had previously. Like any addiction, the more we go down this path, the more we find that we need increasingly robust experiences in order to create the same feeling we had before.

Contrary to either of these two extremes is a biblical anthropology. The Bible presents a unique answer to the human dilemma by telling us that we are both material and immaterial, physical and spiritual. We are a mysterious blend of the two, what some might call an “embodied soul.” Counselors call this the “dichotomist” view of the person.  C.S. Lewis describes us as “composite beings – a natural organism tenanted by, or in a state of symbiosis with, a supernatural spirit.”[2] There are numerous passages that explain this view to us in Scripture, but I’ll just mention a handful of them:

1. We are spiritual beings clothed in an earthly tent (2 Corinthians 5:1).
2. God made man out of two substances, dust and spirit (Genesis 2:7).
3. As Christians, when we die our bodies return to the ground but our spirits return to God (Ecclesiastes 12:7).
4. Christ summarizes the person as both body and soul (Matthew 10:28).
5. Paul, in his defense of the resurrection, cannot comprehend of a person without a corporeal nature (1 Corinthians 15:35-49).

If this is true, how do we differentiate between what is spiritual and what is physical? The Bible uses numerous words to describe the spiritual side of the person: spirit (pneuma), heart (kardia), mind (dianoia, phrenes, nous), soul (Greek: psuche, Hebrew: nephesh), conscience (suneidesis), inner self or inner man.[3] These various terms have slightly different emphases, but ultimately can be summarized by the term “heart.” Herman Ridderbos describes the human heart as, “the concept that preeminently denotes the human ego in its thinking, affections, aspirations, decisions, both in man’s relationship to God and to the world surrounding him.”[4] In other words, the heart is our “motivational center” that is at the root of all of our moral responsibility and behavior before the face of God.

But what about the material side of the person? With our description of the spiritual side of the person out of the way, we can conclude that the material consists of…everything else. The best way to comprehend this might be to look at a list of differences in symptoms between physical or spiritual issues.

What are we to make of this? When we properly understand Biblical anthropology, we are better equipped to understand how depression-anxiety is impacting our brothers and sisters, and how we can best care for them. What we have seen is that the person is a mysterious blend of both body and soul. This means that we should have the expectation that what is happening in one part of the person is going to be reflected in the other. The Bible predicts that an issue rooted in our hearts will manifest itself with physical symptoms (including changes in our brain). Similarly, an issue with a physical origination might have an impact on what comes out of our heart.

The Dichotomist View of Depression-Anxiety

Let’s start to direct this foundation toward the issue of depression-anxiety more specifically. What should you do when your friend or loved one comes to you to communicate their pain and struggles with depression-anxiety? The first task we have is to recognize what is happening as some form of depression-anxiety. While we all have some general idea of what depression-anxiety is, don’t assume that you understand what the experience is like for your friend. Ask good questions and listen more than you talk. Try to understand the experience your friend is going through. Allow their experience to drive you to compassion (Matthew 9:36, 14:14).

The next thing we must do is distinguish between physical and spiritual symptoms. This is important for two reasons: 1) because we do not want to hold people morally responsible for a physical symptom or cause, and 2) we do not want to excuse spiritual problems or lose hope for spiritual growth, even if there has been a psychiatric diagnosis. Here are some examples of what it might look like to distinguish between physical and spiritual symptoms for someone who is going through depression-anxiety.

It may be difficult to begin to separate physical from spiritual symptoms. This is where most Christians begin to struggle in caring for their loved ones. What do we say? What questions should we ask? It is at this point our foundation of a biblical anthropology becomes exceedingly practical. With our understanding of the material and immaterial person, we can begin to care for and meet people’s physical symptoms while intentionally observing, listening to, and addressing any underlying heart and spiritual issues/symptoms. I believe this approach works best for a number of reasons.

1. Focusing on the physical symptoms first builds trust with your friend. It is likely that you are not the first person your depressed or anxious friend has spoken to. In all likelihood, they have already spoken to multiple people who have brushed off their struggles with depression-anxiety as a small problem that needs a quick fix. By affirming the person’s struggles and then committing to helping meet their practical, physical needs, you will establish a deep relationship of trust with your friend. Depression-anxiety naturally creates a filter of skepticism in the individual; your commitment to their physical needs can go a long way in beginning to overcome this skepticism. As author John Lockley once said,

The presence, the availability, just the existence of a friend like this provides a tremendous degree of comfort to the depressed person, as it demonstrates in physical terms how much he is cared for, accepted, loved, as he is, warts and all. It is not difficult for the depressed person to go on to realize that if individual Christians can love him that much, how much more will God do the same.[7]

2. Caring for physical symptoms often draws out the deeper heart issues. If you offer care to someone and they reject it, you’re seeing their pride at work. If you tell someone they need more sleep but they respond that they can’t because of work commitments, you might have exposed an idol of control. If depression-anxiety always sets in during the evening, there might be a pattern of fear of man or circumstances that arises throughout the day. This is a pattern we see in Christ’s earthly ministry, where his physical miracles are often the catalyst to address a deeper spiritual need (John 6:1-59, Luke 13:10-17).

3. If an individual has been struggling with depression-anxiety long enough, their physical, emotional and mental exhaustion might prevent fruitful counseling. If your friend hasn’t slept for weeks and is plagued by constant panic attacks, then they’re probably not in a good place to begin thinking hard about what is causing the panic attacks. One of the best things you can do is help provide the rest and nourishment they need to search their heart and mind for what is really going on. 

4. Caring for physical symptoms is a vehicle for evangelism. Our service to one another does not occur in a vacuum. There is a broken, hurting world looking at us to see if our actions line up with our words. Jesus himself said the world will know we are Christians if our love for one another mirrors the love he has for us (John 13:34-35). In this way, committing to and caring for physical needs will be peculiar to our broken and sinful world.

In addition, developing wisdom and sensitivity in meeting and caring for physical symptoms and needs equips you to care for not only Christians, but non-Christians as well. As we ask good questions, apply wisdom, and care for the physical symptoms of our depressed or anxious non-Christian friends, they will naturally want to know how we have the wisdom, insight, and care that we do. This is the perfect opportunity to point our hurting friends to our Savior, Shepherd, and true Caretaker who meets our deepest need: forgiveness and reconciliation with God.

Application: Practical Questions for Everyday Ministry and Friendship

So what should you say when your friend comes to you with their struggles of depression-anxiety? What questions should you ask? This is a wisdom issue for all of us. However, there are some questions we can have in the back of our heads at all times that can become good launching points for conversation, as well as finding and addressing physical symptoms and needs. My hope is that these questions, although not exhaustive, will serve you well as you seek to minister to your friends and loved ones both in and and outside of the church.

0. Affirm their decision to open up about their struggle with depression-anxiety. This isn’t a question (hence the number 0!), but it should always be the first thing we do. We have already said that depression-anxiety creates a skeptical filter toward individuals and the world. By affirming your friend’s decision to share what is going on in their life, you are removing the stigma our society carries and disarming their fear and skepticism.

1. How does depression/anxiety make you feel? What words would you use to describe your experience? This goes back to the idea of trying to empathize with your friend or loved one. Depression-anxiety tends to force the individual into one of two extremes: either a heightened sense of physical or spiritual pain, or a numbness to any kind of pain

2. Is there any way you have identified I might be able to help you? Your friend might already know they are struggling to get enough rest, eat well, or maintain a regular pattern. If that is the case, allow them to share that need with you before you ask any more specific questions.

3. Have you had a physical recently? Even if your friend had a physical at some point during the same year, if they have not received a physical during their depression-anxiety then they probably should. The reason for this is two-fold. One, because they can alert their physician to their struggles and begin a conversation about medication. Secondly, because there are numerous diseases an individual can have that might manifest itself with depressive symptoms. These include:

4. How are you resting? Depression-anxiety often causes a person to get either more or less sleep than normal. We should know how it is impacting our friend or loved one specifically. Related questions might be, “How much caffeine are you consuming?” or “How much media are you consuming on an average day?”

5. Are you exercising? Physical exercise often helps our body get rid of unhelpful chemicals and instead produces helpful chemicals in our body. Encourage your friend to begin a modest exercise routine – perhaps even offer to go on a walk with them once or twice a week outside.

6. How are you eating? Similar to our sleep patterns, depression-anxiety almost always has an impact on our eating habits in one of two extremes: either we eat way too much, or we eat way too little. Help your friend identify their pattern, and offer assistance in providing healthy, routine meals.

7. How has this impacted your routine? While your friend may have once been the cleanest and hardworking person you know, depression-anxiety might be completely decimating their daily routines and habits. Good hygiene might seem like an impossible task, and showing up to work on time or being productive at all might be equally so. Try to identify small steps your friend can take to return to a normal routine. Help them create a schedule for the next week or two to accomplish some of their errands and chores, and hold them accountable to it.

8. Is there a particular time of the day or season of the year during which this has a greater impact on you? Seasonal depression-anxiety is not uncommon. If you can identify a time of the day or season of the year where depression-anxiety becomes particularly severe, then you can help your friend or loved one develop a “battle plan” to get the jump on depression-anxiety before it gets out of hand.

9. What are your priorities? An individual’s depression-anxiety might be the result of burnout from out-of-order priorities. These priorities might include family, work, church, neighbors or travel. Help your friend reprioritize their life and attend to what is necessary now while putting secondary commitments on hold. Once the individual has returned to a sense of normalcy they may be able to pick up some of the activities or commitments again

10. Have you thought about hurting yourself? Don’t avoid the hard question just because it is difficult. If your friend has thought of specific ways to hurt themselves, this is an indication that it is time to pursue immediate counsel and suicide watch.

11. Are you taking a Sabbath and participating in the Lord’s Day? The Sabbath was created as a means of rest for us (Mark 2:27). What a novel idea that the Lord knew we needed regular rest! Encourage your friend to obey the biblical mandate for rest and participation in worship with the saints on the Lord’s Day.

12. May I read a Psalm with you? Many Christians struggling with depression-anxiety are under the impression that the Bible does not allow for a Christian to struggle in the way that they are. However, the Bible is absolutely full of examples of God’s people crying out in pain, despair and lament in ways that mirror what we call depression-anxiety today. Great examples of this are the Psalms of Lament. Within these Psalms are beautiful demonstrations and prayers for God’s people to cry out in pain while simultaneously striving to put their trust and hope in the Lord. Reading through a Psalm of Lament with your friend may provide hopeful reassurance that God knows, hears, and is not ashamed of the things they are going through. It may also show your non-Christian friend that God’s Word has something to say to them in the midst of their brokenness or despair. The Psalm can be a perfect springboard into how your friend relates to the pain of the psalmist. Great examples of Psalms of lament include Psalm 22, 51 or 73.

The careful reader will take note of my indebtedness to the work of Edward T. Welch for much of my views in this article. In particular, his book Blame it on the Brain?, as well as the articles “Medical Treatments for Depressive Symptoms” and  “Who Are We? Needs, Longings and the Image of God in Man” have been instrumental to me. My hope is that I am entirely faithful to the work that has come before me and the shoulders on which I stand.

[2] C.S. Lewis, Miracles, 126.

[3] Edward T. Welch, Blame it on the Brain?, 35.

[4] Herman Ridderbos, Paul: An Outline of His Theology, 119.

[5] Edward T. Welch, Blame it on the Brain?, 45

[6] Ibid., 120.

[7] John Lockley, A Practical Workbook for the Depressed Christian, 338.

^[8] Edward Welch, “Medical Treatments for Depressive Symptoms,” ed. David A. Powlison, The Journal of Biblical Counseling, Number 3, Spring 2000 18 (2000): 46.