Women’s Mental Health and Spirituality During Perimenopause

Dissemination of Research and Scholarship in Counseling, Liberty University Papers / Tuesday, June 11th, 2019

The following is a paper I originally wrote in Spring 2019 for COUC 810: Dissemination of Research and Scholarship in Counseling class at Liberty University.

Disclaimer: The case study presented toward the end of this paper is completely fictional and not meant to represent anyone in particular. Any resemblance to a real person is completely coincidental.

Abstract

There is little research on the treatment of women’s mental health during perimenopause concerning Christian approaches to cognitive behavioral therapy. This article will discuss common mental health symptoms women experience during perimenopause, practical applications of these spiritual interventions, and implications for counselors.

            Keywords: perimenopause, depression, anxiety, Christianity, cognitive behavioral therapy

Women’s Mental Health and Spirituality During Perimenopause

            Menopause is a natural biological process and significant life event experienced by millions of women around the world indicating the end of fertility (Grochans et al., 2018; Muslić & Jokić-Begić, 2015; Onder & Batigun, 2016; Sharma & Mahajan, 2015; Steffen, 2011). There is inconsistent information regarding the stages of menopause (i.e., pre-, peri-, post-menopause). In some research, the term “menopause” is used to describe the entire process; whereas, in other research “menopause” is a separate stage. Menopause is a worldwide health issue that brings about physical, psychological, and social changes requiring further investigation into effective treatments (Muharam, Setiawan, Ikhsan, Rizkinya, & Sumapraja, 2018; Onder & Batigun, 2016; Sandilyan & Dening, 2011; Sharma & Mahajan, 2015).  For this article, perimenopause will be the main focus.

Perimenopause, which can begin as early as a woman’s 30s, lasting anywhere from a few years to 10 years or more, is categorized by reduced and/or varying fluctuations of hormonal (i.e., estrogen, progesterone, and testosterone) levels signaling the transition of the non-reproductive phase of a woman’s life (Delamater & Santoro, 2018; Elavsky, & McAuley, 2007; Gordon-Elliott et al., 2017; Mauas, Kopala-Sibley, & Zuroff, 2014; Sandilyan & Dening, 2011). Additionally, mental (i.e., emotional instability, irregular mood, depression, anxiety, cognitive deficits, forgetfulness) and physical (i.e., insomnia, inconsistent menstrual cycles, night sweats, hot flushes, sexual dysfunction, metabolic irregularities, headaches, weight gain) health issues are common symptoms related to perimenopause (Delamater & Santoro, 2018; Elavsky, & McAuley, 2007; Gibbs, Lee, & Kulkarni, 2013; Mauas, Kopala-Sibley, & Zuroff, 2014; Pagán, 2018; Sandilyan & Dening, 2011; Terauchi et al., 2013). Clinicians are urged to have a clear understanding of the symptoms which will guide management of treatment (Delamater & Santoro, 2018).

Treatments for perimenopausal symptoms typically surround some form of medication regimen (e.g., hormone replacement therapy [HRT], selective serotonin reuptake inhibitors [SSRIs], and serotonin-norepinephrine reuptake inhibitors [SNRIs]); however, other treatments in the form of counseling, meditation, relaxation techniques, exercise, dietary changes, improved sleep, nutritional supplements, among others have been investigated, and have shown to be of benefit to those suffering the symptoms of perimenopause (Bromberger &  Epperson, 2018; Gordon-Elliott et al., 2017; Muharam et al., 2018; Pagán, 2018; Pearson, 2010). Spiritual interventions such as prayer, devotionals, spiritual study groups, and pastoral counseling, used as a means to seek comfort, strength, purpose and peace, have been found to be beneficial during times of physical, psychological, and social stress such as perimenopause (Briggs & Dixon, 2013; Galloway & Henry, 2014; Pimenta, Maroco, Ramos, & Leal, 2014; Steffen, 2011). However, a search of a major university library database using the terms “perimenopause, mental health, spiritual interventions” yielded no results. Other similar search terms were utilized with comparable results requiring the need to separate search terms (i.e., “perimenopause and mental health,” “perimenopause and depression,” “mental health and spiritual interventions”). Unfortunately, there is little to no research on how spiritual interventions affect women’s mental health during perimenopause, requiring the need for further inquiry. The purpose of this article is to bring awareness to women’s mental health (i.e., depression and anxiety) during perimenopause and how Christian accommodative approaches to CBT may alleviate negative mental health symptoms, in addition to identifying and describing practical applications for these spiritual interventions, as well as implications for counselors.

Mental Health and Perimenopause

Depressed mood and anxiety are two very common mental health symptoms that accompany perimenopause, with depression being a more prominent complaint (Becker, Orr, Weizman, Kotler, & Pines, 2007; Bromberger & Epperson, 2018; Bromberger et al., 2011; Flores-Ramos, Tomassoni, Guerrero-López, & Salinas, 2018; Jagtap, Prasad, & Chaudhury, 2016; Karkhanis & Mathur, 2016). Without proper identification of symptoms and treatment, quality of life, relationships, and occupational life suffer (Delamater & Santoro, 2018; Elavsky, & McAuley, 2007; Sandilyan & Dening, 2011; Terauchi et al., 2013; Woods & Mitchell, 2011; Worsley, Bell, Kulkarni, & Davis, 2014).  In the following sections, symptoms of depression and anxiety will be identified and discussed as to how they relate to perimenopause

Depression

According to the World Health Organization (WHO, 2018), mental health disorders are a common global concern which can significantly impact one’s physical health, motor functioning, social support system, human rights, and finances. Depression, described as the main cause of mental illness, currently affects 300 million people worldwide (WHO, 2017). Depression is more than having the “blues,” a bad day, or going through a rough patch in life; if left untreated, depression can have devastating side effects for those who suffer from depression and those who support them (National Alliance on Mental Illness [NAMI], 2017a). Anybody can experience depression in their lifetime no matter their sex, gender, age, financial status, race, ethnicity, etc.; however, some groups of people are affected by depression more than others (e.g., women are affected by depression more than men; Gordon-Elliott et al., 2017; Muharam et al., 2018; NAMI, 2017a; WHO, 2017). Some people may only experience one major depressive episode in their lifetime; however, for many more people, depression is recurring (NAMI, 2017a).

According the Diagnostic and Statistical Manual of Mental Disorders (DSM-5, American Psychiatric Association [APA], 2013) symptoms of depressed mood include feelings of sadness, emptiness, hopelessness, worthlessness, meaninglessness, tearful, lack of interest or pleasure in all, or nearly all, activities, unexplained changes in weight, increased/decreased appetite, sleep problems, observed changes in psychomotor function, loss of energy, tiredness, guilty feelings, difficulties making decisions, concentration problems, thoughts of death or suicidal ideation, plans to complete suicide, and previous attempts of suicide. Depression presents differently in each person as there are different types of depression (i.e., persistent depressive disorder [formerly known as dysthymia], postpartum depression, psychotic depression, seasonal affective disorder, bipolar disorder; DSM-5; National Institute of Mental Health [NIMH], 2018a). No two people experience depression in the same manner, and there is no single cause for depression (NAMI, 2017a). Depressed mood can result from a number of different factors to include genetics (i.e., biological family history), trauma (e.g., sexual assault, domestic violence, car accident, combat related), life circumstances, other medical conditions (e.g., sleep disturbances, hypothyroidism, perimenopause, chronic pain, side effects from some medications), and drug and alcohol abuse (i.e., particularly alcohol and depressants such as marijuana and heroin; NAMI, 2017a). Proper screening and treatment are essential to alleviate symptoms. Treatment options are available in the form of mental health counseling, medication management, exercise, brain stimulation therapies (e.g., electroconvulsive therapy [ECT], repetitive transcranial magnetic stimulation [rTMS]), light therapy, acupuncture, meditation, incorporating, spirituality, and proper nutrition (NAMI, 2017a). Several studies have found, during peri- or post-menopause, women are at greater risk for depression and anxiety, with depression being a primary complaint (Becker et al., 2007; Bromberger &  Epperson, 2018; Bromberger et al., 2011; Flores-Ramos et al., 2018; Jagtap, Prasad, & Chaudhury, 2016; Karkhanis & Mathur, 2016).

Anxiety

Anxiety disorders, described as the sixth cause of mental illness, currently affect 264 million people worldwide (WHO, 2017). In the United States, 40 million people suffer from an anxiety disorder, making this the most common mental disorder in the United States (NAMI, 2017b). As with depression being more than “just having the blues,” anxiety is more than worry one may have before taking a test, anticipating an unpleasant conversation with the boss, or whether or not to make a major purchase (NIMH, 2018b). For those who suffer from anxiety, the occasional worry or fear is not occasional; it is a constant and persistent worry or fears that do not go away and can sometimes get worse over time (NIMH, 2018b). With anxiety being the number one mental illness in the United States, anyone is susceptible to developing anxiety in their lifetime; however, women, children, and teenagers under 18 affected more than men (NAMI, 2017b; WHO, 2017)

Anxiety presents differently in each person as there are different types of anxiety. The most common forms of anxiety are generalized anxiety disorder (GAD), social anxiety disorder, panic disorder, phobias, obsessive-compulsive disorder (OCD), post-traumatic stress disorder (PTSD), and separation anxiety (NIMH, 2018b; WHO, 2017). According the DSM-5 (APA, 2013) symptoms of anxiety include excessive worry (apprehension), restlessness, easily fatigued, difficulty concentrating, irritability, muscle tension, sleep disturbance, social avoidance (social anxiety), compulsive behaviors (OCD), fear of being separated from someone significant (separation anxiety), and flashbacks (PTSD). Causes and risk factors for anxiety are typically genetic (i.e., biological family history) or environmental (e.g., experience of a stressful or traumatic event such as abuse, death of a loved one, violence, prolonged illness); however, causes and risk factors of each type of anxiety disorder may differ (NAMI, 2017b; NIMH, 2018b). Proper screening and treatment are critical to relieving symptoms. Treatment options are available in the form of mental health counseling (e.g., cognitive behavioral therapy), medication management, support groups, deep breathing, and exercises (NAMI, 2017b; NIMH, 2018b). Depressed mood and anxiety have been found to affect women during peri- and post-menopause greatly, with depression being the predominant complaint (Becker et al., 2007; Bromberger &  Epperson, 2018; Bromberger et al., 2011; Flores-Ramos et al., 2018; Jagtap, Prasad, & Chaudhury, 2016; Karkhanis & Mathur, 2016).

Perimenopause

            Also known as the “menopausal transition,” perimenopause, has been identified as a time of vulnerability for women to develop mental health issues such as depression and anxiety due to a number of factors to include fluctuations in hormone levels; dysfunctional familial, friend, or intimate partner relationships; employment status; lower level of education; perceived health condition; previous history depression and/or anxiety; and adverse life events (Bromberger &  Epperson, 2018; de Kruif, Spijker, & Molendijk, 2016; Gibbs, Lee, & Kulkarni, 2013; Grochans et al., 2018; Jagtap, Prasad, & Chaudhury, 2016; Muslić & Jokić-Begić, 2015). Mental health (i.e., emotional instability, irregular mood, irritability, depression, anxiety, forgetfulness, hostility, confusion) and physical issues (i.e., insomnia, inconsistent menstrual cycles, night sweats, hot flushes, sexual dysfunction, metabolic irregularities, headaches, decreased energy, random aches and pains) are common symptoms related to perimenopause that negatively impact a woman’s quality of life, relationships and occupational life (Delamater & Santoro, 2018; Elavsky, & McAuley, 2007; Gibbs, Lee, & Kulkarni, 2013; Mauas, Kopala-Sibley, & Zuroff, 2014; Pagán, 2018; Sandilyan & Dening, 2011; Terauchi et al., 2013; Woods & Mitchell, 2011; Worsley et al., 2014). Several studies have found that women are at greater risk for depression and anxiety during the perimenopausal and post-menopausal stages than at other times during their lives, with depression being a more prominent complaint (Becker et al., 2007; Bromberger &  Epperson, 2018; Bromberger et al., 2011; Flores-Ramos et al., 2018; Jagtap, Prasad, & Chaudhury, 2016; Karkhanis & Mathur, 2016).

            The typical treatment regimen for perimenopause is a combination of psychotropic medications (e.g., SSRIs or SNRIs) and hormone therapy (e.g., HRT, estrogen, progesterone, testosterone); however, there are several alternative treatments to medication or to supplement a medication regimen (e.g., counseling, meditation, relaxation, exercise, nutrition, supplements) that are efficacious in treating the symptoms of perimenopause (Bromberger &  Epperson, 2018; Gordon-Elliott et al., 2017; Muharam et al., 2018; Pearson, 2010). Little attention has been paid to spiritual interventions with this population; however, spiritual interventions such as prayer, devotionals, and pastoral counseling, are beneficial during times of physical, psychological, and social stress (Briggs & Dixon, 2013; Galloway & Henry, 2014; Steffen, 2011) and may prove to be beneficial for perimenopausal women as well.

Christian Approaches to Cognitive Behavioral Therapy

            There are several different theoretical orientations counselors can espouse in treating clients with depression and anxiety; however, the most common form of treatment for depression and anxiety is cognitive behavioral therapy (CBT; Jennings, Davis, Hook, & Worthington, 2013). CBT is derived from the work of Aaron Beck (i.e., cognitive therapy; 1976) and Albert Ellis (i.e., rational emotive behavioral therapy [REBT]; 1962), and is a goal-oriented form of therapy with the purpose of identifying, challenging, and replacing problematic thoughts that adversely affect one’s emotions and behaviors with positive, healthy behaviors (Jennings et al., 2013; McMinn & Campbell, 2007; Pearce & Koenig, 2013). CBT is an easily adaptable form of treatment as there have been many alterations of CBT over the years (e.g., mindfulness-based CBT, acceptance and commitment therapy [ACT], dialectical behavior therapy [DBT]).

For clients seeking religious or spiritual integration into their counseling experience, Christian accommodative cognitive therapy has many similarities to secular forms of CBT (Hook et al., 2010; Jennings et al., 2013; Pecheur, 1978; Worthington, Hook, Davis, & McDaniel, 2011). Clients are still made aware of their problematic thought processes, in relation to Biblical untruths, and how those thoughts influence negative behaviors; and then clients learn ways to identify and change future maladaptive thoughts to affect more appropriate emotions and behaviors (Jennings et al., 2013; Worthington et al., 2011). Pecheur (1978) goes into further detail in describing the parallels between Christian accommodative cognitive therapy and secular CBT in that the believer (i.e., the client) first becomes aware of thoughts of the flesh (i.e., negative thought processes are acknowledged); then the believer is presented with or reacquainted with the Word of God (i.e., psychoeducation on healthy and unhealthy thought processes); through the presence of the Holy Spirit, the believer is empowered to reject thoughts of the flesh, taking captive of every thought (2 Corinthians 10:5), and focus on Christ-like thoughts and behaviors (i.e., negative thoughts are reframed, and healthy thought processes and behaviors are developed); finally, spiritual growth through prayer, meditation, and worship is continued by the believer (i.e., healthy rational thoughts automatically erase irrational thoughts and behaviors).

Jennings, Davis, Hook, and Worthington (2013) point out the purpose of Christian accommodative cognitive therapy is to help clients become aware of how their flawed thinking goes against biblical views of people, the life and works of Christ, and the Word of God. Prayer, scripture, Christian imagery and/or mystical practices (e.g., contemplative or centering prayer), meditation, devotional readings, church service attendance, and Bible study are all tools used within Christian accommodative cognitive therapy to help clients deepen their spiritual growth and to alleviate symptoms of depression and anxiety (Hook et al., 2010; Jennings et al., 2013; Knabb, 2012; Mohr, 2011; Steffen, Masters, & Baldwin, 2017; Worthington et al., 2011). Over the years numerous studies have been conducted to determine the effectiveness of Christian approaches to CBT over traditional CBT. As a result, many of those studies have found Christian approaches to CBT to be as beneficial as traditional CBT (Hook et al., 2010; Jennings et al., 2013; Pearce & Koenig, 2013). A more detailed review of the literature is not possible for this article; however, a brief review of relevant literature will follow.

Propst, Ostrom, Watkins, Dean, and Mashburn (1992) found subjects treated in the religious and pastoral counseling groups reported decreased symptoms of depression than those in either the nonreligious or wait-list treatment groups. The purpose of this study was to ascertain the efficacy of religious or nonreligious CBT for the treatment of depression. Additionally, Propst et al. (1992) compared religious and nonreligious CBT treatment to pastoral counseling and looked at how these therapies met the needs and values of the subjects by nonreligious counselors.

Maltby et al. (2010) found, through the employment of a cognitive-behavioral theoretical framework, subjects reported improved physical and mental health. The focus of the study was to explore the relationship between religion and health within a CBT framework for religion. Religious orientation, religious coping, and prayer activity were assessed and examined in relation to physical and mental health.

Stanley et al. (2011) found subjects reported better coping mechanisms, problem-solving abilities, and heightened faith through the inclusion of religion and spirituality in their treatment for anxiety and depression. The motivation for conducting this study was to integrate religion and spirituality with traditional forms of treatment for anxiety and depression for the development of new treatment approaches. Emphasis was placed on the appreciation of client preference, coping skills, and belief system in relation to implementing spiritually integrated approaches to counseling.

            Worthington, Hook, Davis, and McDaniel (2011) found subjects showed greater improvements in psychological and spiritual outcomes with Christian accommodative cognitive therapy than traditional CBT. The study intended to survey the outcomes of religious accommodative and nonreligious therapies. Counselors are encouraged to inquire about their clients’ religious and spiritual backgrounds and desire to incorporate religiosity and spirituality into the counseling experience.

            Koenig et al. (2014) found no relationship between religiosity and depressive symptoms; however, they did find participation in religious activities improved mood which in turn could positively impact depressive symptoms. The goal of this study was to determine the efficacy of religious forms of CBT over traditional CBT for the treatment of depression with a sample of religious individuals with physical illnesses. The focus of this study concerned religious involvement relating to decreased depressive symptoms, despite physical health, and how commitment to religious activities amplified meaning, purpose, hopefulness, generosity, and gratitude in their lives.

            Tulbure, Andersson, Sălăgean, Pearce, and Koenig (2018) found no difference between subjects treated with religious CBT (R-CBT) from those treated with conventional CBT (C-CBT); however, it was found that R-CBT was perceived as a more trustworthy form of treatment for religious or spiritual clients. The objective of the study was to determine the efficacy of two Internet-based interventions for the treatment of depression (i.e., R-CBT and C-CBT). Through the use of spiritual or religious interventions, it is suggested that there is greater treatment accessibility for those individuals who may not normally seek out treatment.

Other forms of contemporary CBT counseling that can be religiously or spiritually-integrated include mindfulness-based CBT (MBCBT), acceptance and commitment therapy (ACT), and dialectical behavior therapy (DBT). Although, secular in nature, MBCT has roots in Buddhist meditation and can be easily adapted for secular or other spiritual use (i.e., Christian meditation; Knabb, 2012; Tan, 2011). The purpose of MBCT is to help clients be in the moment with their experiences, rather than avoiding them, through awareness of one’s bodily sensations at that moment to disengage from thoughts that provoke sad or depressive thinking (Hathaway & Tan, 2009). While not inherently spiritual, ACT draws upon spiritual traditions such as mind and experience to understand and improve human suffering through acceptance (i.e., depression and anxiety; Hayes, Strosahl, & Wilson, 2012). Lastly, DBT, an approach used to assist clients in recognizing triggers that lead to reactive states and to achieve emotional and cognitive regulation, can be adapted for religious/ spiritual use (Dimeff & Linehan, 2001; Liu, Fang, & Gau, 2011).

            The previous section served to describe and highlight the efficacy of Christian approaches to CBT in treating clients with depression and anxiety as well as briefly highlighting spiritually-integrated forms of MBCT, ACT, and DBT. Little is known about the effectiveness of Christian approaches to CBT in treating anxiety and depression with a population of perimenopausal women. Therefore, research is needed in this area. The following section discusses practical applications of spiritual interventions to address women during the perimenopausal stage suffering from depressed mood and anxiety.

Practical Application of Spiritual Interventions to Treat Depression and Anxiety during Perimenopause

As it has been shown that symptoms of depression and anxiety are more prevalent in perimenopausal women, it is essential for clinicians to be mindful of their clients’ needs, inquire about any recent changes in symptoms or decrease in quality of life, and refer their clients to appropriate medical providers when necessary to augment treatment (Jagtap, Prasad, & Chaudhury, 2016; Kanadys, Wiktor, Bucholc, Robak-Chołubek, & Wiktor, 2017; Wariso et al., 2017). Clients’ religious and spiritual beliefs are an essential part of the assessment and treatment process as these beliefs influence the client’s worldview and should be addressed (Paterson & Francis, 2017). There is little research on practical applications of spiritual interventions for the treatment of depression and anxiety during perimenopause; however, a small subset of studies have found spirituality to be a protective factor in symptom development and severity (Pimenta et al., 2014; Steffen, 2011). Furthermore, there is research indicating the benefits of spiritual interventions when applied to secular theories such as CBT for treating depression and anxiety (Hook et al., 2010; Jennings et al., 2013; Pearce & Koenig, 2013).

Culturally sensitive spiritual interventions such as prayer, scripture, prayer journals, spiritual-religious imagery and/or mystical practices, meditation, devotional readings, religious service attendance, and spiritual/religious study are incorporated within spiritually augmented forms of traditional counseling therapies such as CBT to reduce clients’ depressive and anxiety symptoms and to help clients develop spiritually and grow closer to their higher power (Hook et al., 2010; Jennings et al., 2013; Knabb, 2012; Mohr, 2011; Steffen, Masters, & Baldwin, 2017; Worthington et al., 2011). Other spiritual interventions include a technique for replacing depressive or anxious thoughts with religious or spiritual imagery where the client uses visualization during a stressful situation to help relieve stress (Propst, 1988), and inner healing prayer has also been shown to be helpful with clients who have unresolved trauma (Tan, 2007).

Examples of spiritually accommodative approaches are found in the literature (here you would cite whatever you can find). For example, Pecheur (1978) details the parallels between Christian accommodative cognitive therapy and secular CBT in working with a perimenopausal client with complaint of depression and anxiety who wanted to integrate her faith into the treatment. The counselor first helped the client become aware of their negative thought processes or thoughts of the flesh (i.e., focus on the self rather than God)… These negative thought processes could be in relation to the physical symptoms of perimenopause such as the end of the menstrual cycle and the inability to no longer bear children; the effects of hormonal changes that bring about hot flashes, sleep issues, memory problems; and/or depression and anxiety symptoms as a result of the increased fluctuation of hormones. Once the client is made aware of their maladaptive thought process, discussions can then take place concerning healthy and unhealthy thought processes in addition to the presentation of God’s word through scripture (Pecheur, 1978). Through the exploration and recognition of how unhealthy thought processes lead to inappropriate behaviors, the client has a better understanding of how to reject negative thoughts of the flesh. The Holy Spirit enables the client to reframe those unhealthy thoughts and for healthier thoughts and behaviors to be developed. Lastly, spiritual interventions such as prayer, meditation, and worship benefit the client in their path to spiritual growth and mental stability (Pecheur, 1978). The use of spiritual interventions in the counseling setting help bring about meaning, peace, better ways of coping, and a greater sense of the quality of life for women during perimenopause (Peres, Kamei, Tobo, & Lucchetti, 2018; Pimenta et al., 2014; Steffen, 2011).

Implications for Counselors

Utilization of religious or spiritually based materials in therapy must be done with caution and as a natural part of the therapeutic process to elicit beneficial changes (Vasegh, 2011). Special attention must be paid to clients’ religious and spiritual belief systems as maladaptive thought processes are known to arise from religious and spiritual belief systems, further aggravating psychological symptoms (e.g., excessive guilt; Mohr, 2011; Vasegh, 2011). Treatment is counterproductive and unsuccessful without extensive knowledge and understanding of religious and spiritually based materials and a clear appreciation of the client’s religious and spiritual belief system (Vasegh, 2011). In an effort to provide ethical and effective counseling, the client and counselor must agree upon the specific type of treatment being used, particularly the use of religious and spiritually based materials, to decrease the chance of the counselor imposing their beliefs on the client (American Counseling Association [ACA], 2014; Association for Spiritual, Ethical, and Religious Values in Counseling [ASERVIC], 2019).

            Studies have been conducted to determine the effectiveness of religious and non-religious CBT in the treatment of depression and anxiety concerning a variety of subjects of varying ages, religious or non-religious backgrounds, with or without medical conditions. The results of these studies revealed that many subjects preferred the inclusion of religious and spiritual interventions in counseling and found a reduction of symptoms of depression and/or anxiety (Hook et al., 2010; Jennings et al., 2013; Koenig et al., 2014; Pearce & Koenig, 2013; Propst, Ostrom, Watkins, Dean, & Mashburn, 1992; Stanley et al., 2011; Tulbure, Andersson, Sălăgean, Pearce, & Koenig, 2018). Unfortunately, there is little to no research on how Christian accommodative approaches to CBT affect women’s mental health during perimenopause. Research and advocacy for this population are desperately needed. Dependence on one’s Christian faith has been found to be a protective factor in symptom development and severity of physical illness (Pimenta et al., 2014; Steffen, 2011). Religious and spiritual beliefs are an essential part of the client’s worldview and should be addressed in the assessment and treatment process (Paterson & Francis, 2017). As perimenopause is a physical health issue, counselors should highly recommend their clients seek out medical attention for lab work and any necessary medication management.

Case Study

Ashley Black is a 44-year-old, Caucasian female, presenting for counseling with complaint of depressed mood and increased symptoms of anxiety to include concentration problems, difficulties making decisions, eating too much, feeling inferior, forgetfulness, impulsivity, irritability, lack of interest, low energy, memory problems, mood swings, poor motivation, relationship difficulties, religious concerns, sexual problems, sleep problems, social withdrawal, and worry. Ashley was referred for counseling by her gynecologist following a diagnosis of perimenopause several months before. Upon completion of a comprehensive assessment process to include bio-psycho-social-spiritual-chemical assessment, mental status exam, and diagnostic assessments (i.e., PHQ-9, GAD-7) Ashley met criteria for major depressive disorder according to the DSM-5. Ashley and her counselor discussed what she would like to accomplish through the counseling process and determined that Ashley would like to improve how she is currently coping with stressors in her life, self-confidence, and motivation to complete important tasks in her life.

            Through the assessment process, Ashley reported many stressors she is juggling at this time such as owning and operating her own business, going to school, managing her household, financial issues, and physical health issues believed to be related to perimenopause. Ashley expressed frustration in not being able to obtain acceptable answers to her questions from the medical establishment about what she has been experiencing physically. She revealed she was on antidepressant medication (prescribed by her general practitioner) for several years and had been on anti-anxiety medication for a short time last year, but felt it was not working and decided to stop all her psychotropic medications last year. She stated, “Why should I continue with the medication if it is not working?” She reported the anti-anxiety medication gave her intense headaches and made her so tired she could not function the next day after taking the medication. She reported she spoke with her doctor but felt she was not getting anywhere with her doctor. Ashley reported she is planning to see a new physician that comes highly recommended and is hopeful about the experience.

            Ashley indicated she has been exploring her faith and finds comfort and strength through prayer, devotional readings, Bible study, Christian music, and church attendance. Despite the comfort and strength, she feels in her spiritual walk; she admitted that she continues to struggle with depression and anxiety thus leading to concerns about her spirituality. The counselor indicated that Ashley’s depression and anxiety stemmed from both her current physical condition and current ways of coping with her stressors (i.e., overeating when feeling overwhelmed, going back to old unhealthy habits, social withdrawal, avoidance of important projects).

Ashley consented to use Christian accommodative approaches in her counseling. Christian accommodative approaches to CBT were utilized to treat Ashley’s depressive and anxiety symptoms and to help her achieve her goals for treatment. The counselor explained to Ashley the Christian CBT approach to help her have a better understanding of how these approaches will help her achieve her goals for counseling. Christian accommodative approaches to CBT are very similar to traditional CBT in that Ashley will be made aware of challenging thought processes that influence her emotions and behaviors; however, this will occur in relation to biblical untruths, and then Ashley will learn more appropriate ways of coping (Hook et al., 2010; Jennings et al., 2013; Pecheur, 1978; Worthington et al., 2011).

During therapy, Ashley explored how she has been coping with stressors in her life which have led to low self-confidence and lack of motivation to complete important tasks in her life thus leading to depression and anxiety. The counselor explored with Ashley her belief system and how she viewed God’s love for her through daily journaling and devotional exercises focused on God’s love for His people. The counselor also suggested that Ashley seek out a women’s Bible study for increased social interaction. Lastly, the counselor recommended Ashley get a full blood workup of her current hormone levels and inquire with her new physician what she can do physically to help offset the physical symptoms of perimenopause (e.g., diet, exercise, medication). 

Ashley’s mood was regularly assessed through personal report and completion of PHQ-9 (i.e., depression) and GAD-7 (i.e., anxiety) measures. Ashley admitted through counseling and a structured routine of diet and exercise she has seen improvements in her mood, coping, self-confidence, and motivation. Ashley expressed she felt more motivated to treat her body better as she started to see herself as God saw her and realized her importance. She also expressed she felt she no longer need to avoid important projects in her life and felt confident in her abilities. Ashley stated she was grateful for the experience of incorporating spirituality into her counseling experience.

Conclusions

This article sought to bring awareness of a global health issue known as menopause. Menopause is a natural biological process signaling the end of a woman’s menstrual cycle and the beginning of the non-reproductive phase of a woman’s life (Delamater & Santoro, 2018; Elavsky, & McAuley, 2007; Gordon-Elliott et al., 2017; Mauas, Kopala-Sibley, & Zuroff, 2014; Sandilyan & Dening, 2011). The process of menopause is described as a global health issue requiring further study into effective treatments for the physical, mental, and social changes that occur during menopause (Muharam et al., 2018; Onder & Batigun, 2016; Sandilyan & Dening, 2011; Sharma & Mahajan, 2015). The primary focus of this article was on one stage of menopause called perimenopause, and its effects on a woman’s physical and mental well-being, and quality of life, due to fluctuations in the female hormones (Delamater & Santoro, 2018; Elavsky, & McAuley, 2007; Gordon-Elliott et al., 2017; Mauas, Kopala-Sibley, & Zuroff, 2014; Sandilyan & Dening, 2011; Terauchi et al., 2013; Woods & Mitchell, 2011; Worsley et al., 2014). The purpose of this article was to shine a light on the negative effects of women’s mental health during perimenopause and how Christian accommodative approaches to CBT may help relieve negative symptoms for Christian clients. Practical applications for these spiritual interventions and implications for counselors were highlighted and discussed. Further research and advocacy is greatly needed.

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