Beyond the Misconceptions About Depression

Depression is a much misunderstood illness, and one Catholic psychiatrist warns that people of religious faith might have their own particular misunderstandings about it.

Dr. Aaron Kheriaty is the author, with Fr. John Cihak, of "The Catholic Guide to Depression: How the Saints, the Sacraments, and Psychiatry Can Help You Break Its Grip and Find Happiness Again" (Sophia Press). 

In light of the media attention on depression over the last several weeks, ZENIT asked Dr. Kheriaty to explain in what ways the disease is misunderstood and some falsehoods that Catholics in particular should guard against.

ZENIT: Depression has had a lot of media attention in the last several weeks, in light of Robin Williams' suicide. What would you say are the main misconceptions or misunderstandings about depression in our culture today?

Kheriaty: Depression is often misunderstood.  Many people mistakenly believe it’s nothing more than intense or prolonged sadness, when in fact it’s a complex illness that can profoundly impair a person’s mental and physical functioning.  Depression is indeed a terrible affliction, which affects not just one’s moods or emotional states, but also impairs one’s ability to think clearly, to concentrate and focus.  Depressed individuals are drained of energy and vitality, often to the point where it’s difficult to get out of bed and simple tasks like brushing one’s teeth can seem like and impossible chore.  Depression impairs the sleep/wake cycle, and can cause severe appetite changes with consequent weight loss and medical complications.  Suicidal thinking and behavior are tragically common in depression, even among individuals who would never ordinarily consider suicide and are morally opposed to it.

Those who are afflicted with this disorder often suffer in silence, unrecognized by others.  If someone is diagnosed with cancer, this person is typically flooded with sympathy from family and friends, with an outpouring of support from their local church community.  If someone suffers from depression, this person probably receives, at best, a few well meaning but ineffective attempts at sympathy from family or close friends, but often without real understanding.  There’s rarely public mention of the problem due to the stigma of mental illness. 

I recall one patient, a married Catholic woman with several children and grandchildren, who had suffered both life-threatening breast cancer and severe depression.  She once told me that, if given the choice, she would take the cancer over the depression, since the depression caused her far more intense suffering.  She tragically committed suicide a few years after she stopped seeing me for treatment.  Likewise, a radio host who was recently interviewing me about depression mentioned during the show that the episode of depression he suffered after the loss of his leg was far worse than the physical ordeal of losing the leg itself.

Those who are afflicted with depression should not bear this cross alone.  As Christians, we need to support them. 

ZENIT: More specifically, what do voices in the Church most often get wrong about depression?

Kheriaty: While it is important to understand depression in relation to the spiritual life, it is also important to distinguish depression from moral or spiritual disorders like sloth, or what the early Church Fathers called the deadly sin of acedia.  We should also distinguish it from the dark nights of the senses and spirit that John of the Cross and other Christian mystics have written about.  I think most therapists have had the experience of Christian patients who prematurely ‘spiritualized’ what were actually more psychologically or biologically rooted problems.  Perhaps this was done with the encouragement of a priest or spiritual director who was not adequately informed about the nature and causes of mental illnesses like depression.

Speaking somewhat loosely and without awareness of the more technical meanings of the term, Christians will sometimes refer to any spiritual trial – dryness in prayer, doubts or difficulties with faith, or strong temptations – as “dark nights of the soul.”  I have evaluated some devout Christian patients who interpret their depressive symptoms as a “dark night.”  An exclusively spiritual interpretation of their problem may lead them away from seeking medical or psychological help.  When they fail to find relief from their suffering from spiritual direction or prayer or Bible reading, they can be tempted to despair, or may feel as though God has abandoned them.

Perhaps a few brief remarks would be helpful regarding how to distinguish these states.  John of the Cross teaches that both dark nights (the dark night of the senses and the dark night of the spirit) are the result of God’s increasing self-communication to the person, which purifies the soul first of sensory and then of spiritual attachments.  Such a state may feel like darkness to the person, but objectively it is an intensification of divine light in the soul.

Although a sense of loss is common to both depression and the dark nights, the sense of loss is manifested differently.  Depression involves the loss of ordinary abilities to function mentally and physically, and it can also be triggered by interpersonal loss, loss of a job, etc.  The interior dryness of the dark night of the senses involves a loss of pleasure in the things of God and in some created things.  However, it does not involve disturbed mood, loss of energy (with cognitive or motor slowing), or diminished sexual appetite – all of which are seen commonly in depression.  Persons in the dark night of the senses have trouble applying their mental faculties to the practice of prayer and meditation, but do not typically have difficulty concentrating or making decisions in other areas of life.  Think of Mother Theresa, who was extraordinarily effective exteriorly even while enduring dark nights interiorly.

With the dark night of the spirit there is an acute awareness of one’s own unworthiness before God, of one’s personal defects and moral imperfections, and of the great abyss between oneself and God.  However, a person in this state does not experience morbid thoughts of excessive guilt, self-loathing, feelings of utter worthlessness, or suicidal thoughts – all of which are commonly experienced during a depressive episode.  Furthermore, neither of the two darks nights involve changes in appetite, sleep disturbances, weight changes, or other physical symptoms (like gastrointestinal problems or chronic pain) that often accompany depression.

Space does not allow here a more detailed account of these distinctions, but if you are interested I discuss these issues at length in Chapter 2 of my book, The Catholic Guide to Depression.  That chapter also contains some advice on what Ignatius of Loyola called the movements of “spiritual consolation” and “spiritual desolation”, and advice for the “discernment of spirits”.

ZENIT: In your book, you speak of depression as a chance to share in the suffering of Christ. Could you explain that further?

Kheriaty: As with any other medical illness, we do all in our power to recover and heal from depression.  But we must also be convinced that whatever we suffer in life – whether from depression or any other affliction – is something that is allowed by God.  Suffering is a mystery, and Christianity’s answer to suffering is mysterious — because the answer is Jesus Christ on the cross.  Our faith does not promise a life without suffering; quite the contrary.  We should not expect that prayer, or Scripture reading, or the sacraments, will magically cure all mental disorders or alleviate all suffering.  What Christian faith offers us is the hope and the stren gth to endure whatever crosses God allows in our life.  As psychiatrist Victor Frankl put it, those who have a why to live can bear with almost any how.  Frankl knew something about suffering, having been a prisoner in Auschwitz.

In a 2003 address on the theme of depression, John Paul II said that depression is always a spiritual trial: “This disease is often accompanied by an existential and spiritual crisis that leads to an inability to perceive the meaning of life.”  He goes on to stress how both professionals and non-professionals, motivated by Christian charity and compassion, can help those with depression:

The role of those who care for depressed persons and who do not have a specifically therapeutic task consists above all in helping them to rediscover their self-esteem, confidence in their own abilities, interest in the future, the desire to live.  It is therefore important to stretch out a hand to the sick, to make them perceive the tenderness of God, to integrate them into a community of faith and life in which they can feel accepted, understood, supported, respected; in a word, in which they can love and be loved. 

Of course, we would like whenever possible to provide healing and comfort to those individuals who suffer from depression.  In addition to the standard recommendations of medication and psychotherapy, what can be done?  There now exists a considerable body of scientific research that suggests that prayer, religious faith, participation in a religious community, and other spiritual practices like cultivating gratitude and other virtues can reduce the risk of depression and help in recovery.  This does not mean that religious faith inoculates a person against depression, nor does it mean that depression is due to a lack of faith.  But it does suggest that faith may have an important role in a person’s healing.

Healing may involve restoring the depressed person’s sense of his or her divine filiation – this most beautiful and consoling truth of our existence: the truth that God is my loving Father.  God the Father created me; God the Son redeemed me; God the Holy Spirit is present within me, to sanctify and heal me.  What issues forth from this is the indispensable virtue of hope, which is so important for the depressed person’s healing.  Christianity offers hope in the midst of difficulties and pain.  Through our faith, in hope, we can find redemptive value even in and through suffering. 

The psychiatrist Aaron Beck, famous in my field for developing cognitive therapy for depression, did a long-term prospective study of 1400 suicidal patients to determine which risk factors were most closely linked to suicide. Beck managed to follow these patients for the next ten years to see who survived and who eventually completed suicide.  In trying to find the key differences between the survivors and those who died by suicide, Beck examined the patients’ diagnosis, the number and type of mental and medical symptoms, the degree of physical pain a person was in, social and economic factors, and so on.  The results of his study surprised some behavioral scientists.  The one factor most predictive of suicide was not how sick the person was, nor how many symptoms he exhibited, nor how much pain he was in.  The most dangerous factor was a person’s sense of hopelessness.  The patients who believed their situation was utterly without hope were the most likely candidates for completing suicide. 

There is no prescription or medical procedure for instilling hope.  Hope is ultimately found in the revelation of God’s love and his promises.  We can have a natural sort of hope when things in our life clearly appear hopeful.  But when our situation appears or feels hopeless, the only hope that can sustain us is supernatural – the theological virtue of hope, which can only be infused by God’s grace.  One of my patients, who had suffered sexual and physical abuse at the hands of both of her parents, once told me, “If it were not for my relationship with Jesus, I would have killed myself a long time ago.”  I have no doubt that this statement was true.  In spite of her suffering, her life remained grounded in a sure hope.

ZENIT: How can one go about finding a good therapist? Can a bad therapist cause more harm than good? Are there enough "good therapists" out there?

Kheriaty: Indeed, a bad therapist can do more harm than good, and there are not enough good therapists out there.  Unfortunately, there are many half-baked therapists out there plying their trade – the demand creates the supply, I suppose, though the quality control is not always what it should be.  How does one go about finding a good therapist?  Start by trying to get a personal referral from a trusted friend or family member, or a trusted physician.  Often the local Diocese will have a list of Catholic mental health providers that it consults. 

Many Christians who suffer from depression naturally have a preference for finding a therapist who shares their religious convictions.  Some patients have had counterproductive or distressing experiences with therapists who contradicted or blatantly disparaged their religious beliefs, or who discounted their moral convictions.  Patients should be aware that advice proffered by the therapist will be colored by the therapist’s own worldview, and may be distorted by the therapist’s own biases.  Since the quality of the therapeutic relationship, which includes above all the element of trust and confidence, is central to success of the psychotherapy, and since a person in a vulnerable state is liable to be harmed by following bad therapeutic advice, it is important to find a therapist who is trustworthy.  The right fit is the foundation for effective psychotherapy.  If you try a few sessions, and the therapist does not feel like a good “fit,” then discontinue the sessions and try another therapist until you find the right fit.

It is worth noting that shared religious and moral convictions alone do not guarantee a trustworthy therapist. He or she must also be well trained, competent, compassionate, and skilled in the difficult and demanding craft of psychotherapy.  When therapy is warranted and a competent Christian therapist is not available, a skilled therapist who respects and honors the patient’s religious and moral convictions is, in my opinion, preferable to no therapist at all.  It is worth citing here St. Theresa of Avila’s opinion regarding spiritual direction.  If she had to choose between a holy spiritual director and a knowledgeable spiritual director, she said that she would opt for the knowledgeable one.

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On the Net:

"The Catholic Guide to Depression: How the Saints, the Sacraments, and Psychiatry Can Help You Break Its Grip and Find Happiness Again" (Sophia Press): 

http://shop.sophiainstitute.com/Catholic-Guide-to-Depression-P243.aspx