Last month in Massage Today, we started exploring the Western diagnosis of depression through the Five Elements. The five-element paradigm is particularly useful in looking beyond the physical manifestation, at our client's emotional and spiritual climate.

Even though we always focus on treating the whole person on all levels - not just the symptoms - sometimes it is helpful to give clients "homework" for symptomatic relief. It may not deal with the underlying cause of their problem as effective treatments would, but it could help them cope between sessions.

One type of homework you can give your clients to help ease their depression is self-moxa, if moxa use was included in your training. First, make sure the client doesn't have any obvious symptoms of heat invasion or empty heat, e.g., a red tongue and face, feeling of being too warm, or a rapid pulse. In those instances, moxa is contraindicated. Demonstrate on the client how to use moxa on bafeng/eight winds, located between the webbing of each toe, proximal to the margins of the webs (see illustration below). You can use a moxa pole, but a tiger warmer is better. It should take only about 5-10 minutes. Tell the client to use the moxa every morning, warming each point until just before it is too hot, then moving onto the next point, repeating two-to-three times. By the way, I have been advised by people knowledgeable in legal matters not to give my clients moxa because if they burn themselves, they can sue. It's best to have them purchase their own sticks at an Asian medical supply store.

Another caution that I need to repeat is that shiatsu or any other form of bodywork should not be used in lieu of professional medical treatment or psychotherapy. It works very well in conjunction with other therapies, but be very clear on what you can and cannot treat within your scope of practice.

In my last column, I gave a detailed case study of a client with a typical wood element depression. She was angry, frustrated and suffered with temporal headaches. I can't spend a whole article on each kind of depression but I can give you a basic idea of what to look for in each type so you know where to start working. Keep in mind that usually people will manifest as a combination of a few elements.

The meridians associated with the fire element are primarily the heart and small intestine. A person who has a fire element depression usually attributes "funks" to a broken heart or to relationship problems. This person invests a lot into relationships, losing the importance of the sense of self. When two hearts beat as one, usually it means one of the two people is dead! The "dead one" usually ends up being a woman. I have seen all of the other four types of depression in my male clients, but never a fire element depression. There must be a certain amount of acculturation that supports a woman who "sacrifices" -- whether she is involved with a man or in a same-sex relationship.

The season of the fire element is Summer, and the climate of this person is hot, passionate and joyful - when she is up! This person is optimistic and bubbly when she is in love. She has a lot of energy and focuses much of it on her partner. Every thought and dream is about being with the one she loves. She lives in her heart, finding pleasure in sublimating her own desires to make the one she loves "happy."

Unfortunately, the cost of this temporary bliss is dear. When she wakes up from the dream and finds herself alone, she is devastated, and often falls into a deep depression, until the next relationship that lifts her up again. She needs to eventually find herself worthy of the love that she lavishes on others.

The climate of an earth element depression is characterized by a sticky, cloying dampness. You can feel it in the muscles, which are weak and sometimes puffy filled with a soggy, muddy quality. When earth is weak, the water element backs up along the ko cycle, causing a debilitating swamp in the spleen and stomach meridians. This person obviously is going to have trouble moving through this kind of environment! Such a person may complain of being often tired with a heavy feeling in the limbs.

An earth element person will also have issues involving food, including binging and purging. This person will sometimes have uncontrollable sweet cravings, which are easily controlled by working spleen points. I had a client who would eat candy bars before her sessions because she knew she wouldn't feel like eating them afterward!

This illustrates the challenge of treating an earth element-type of person. Earth-element types are often stuck and are uncomfortable with transition and change. They sometimes have many excuses why they are depressed, and feel little gratitude for the blessings in their lives.

The metal element meridians are lung and large intestine. These meridians not only help us to let go of waste that we don't need anymore on a physical level; they also assist in that process on an emotional level. The climate that you see in a metal element depression is one of long-term grief and sadness. There is a deep and desperate inability to let go, causing disabling depression.

The physical symptoms that may accompany a metal element depression are asthma and allergies. You may notice, many children develop asthma after their parents divorce.

The last and most dangerous form of depression relates to the water element: the bladder and kidney meridians. Not only does the water element house our deep-seated fears -- it is also responsible for our genetic makeup. Therefore, often these are the types of depressions that run in the family.

This is the deepest and darkest of all depressions, and the one for which medication is most helpful (and often essential). People suffering with this type of depression are sometimes suicidal. One client of mine describes shiatsu as helping her "keep her head above water" through difficult times, juggling suicide attempts, ECT (shock) treatments, and ineffective medications with many side effects. Any off-the-cuff mention of "checking out" must be noted in your client's chart and reported to her/his therapist.

So you can see, depression is not something you want to work with without experienced professional support and a considerable amount of training yourself. Although it may be difficult at times, there is nothing more satisfying than helping people make significant and lasting changes in their lives!

For a list of schools that offers programs in ABT, go to www.aobta.org.