From the Editor: the following was originally published at The Catholic World Report and is used with kind permission.
Dr. Aaron Kheriaty, MD, is the author, with Msgr. John Cihak, STD, of the book, The Catholic Guide to Depression: How the Saints, the Sacraments, and Psychiatry Can Help You Break Its Grip and Find Happiness Again (Sophia Institute Press, 2012). Dr. Kheriaty is the Director of Residency Training and Medical Education in the Department of Psychiatry at the University of California, Irvine. He co-directs the Program in Medical Ethics in the School of Medicine, and serves as chairman of the clinical ethics committee at UCI Medical Center. Dr. Kheriaty graduated from the University of Notre Dame in philosophy and pre-medical sciences, and earned his MD degree from Georgetown University. Msgr. Cihak is a priest of the Archdiocese of Portland in Oregon who currently works in the Vatican. He helped to start Quo Vadis Days camps promoting discernment and the priesthood at the high school level that now operate in several U.S. dioceses. He has been a pastor and served in seminary formation.
Their book “reviews the effective ways that have recently been devised to deal with this grave and sometimes deadly affliction — ways that are not only consistent with the teachings of the Church, but even rooted in many of those teachings.” The authors were recently interviewed by Carl E. Olson, editor of Catholic World Report, about the serious challenges posed by depression and how those challenges can be best addressed through faith, clinical science, and other means.
CWR: The topic of depression is fairly commonplace, but you note that there is no simple definition of “depression”. What are some of the major features of depression? Is it just an emotional state, or more?
Dr. Kheriaty: Depression is more than just an emotional state, though of course it typically involves profound changes in a person’s emotions. Sadness and anxiety are the most common emotional states associated with depression, though anger and irritability are also commonly found in depressed individuals. Depression affects other areas of our mental and physical life beyond our emotions. Depressed individuals typically experience changes in their thinking, with difficulty concentrating or focusing, and a lack of cognitive flexibility. Depressed individuals develop a kind of “tunnel vision” where their thoughts are rigidly and pervasively negative. In many cases, suicidal thinking is present, driven by thoughts or feelings of hopelessness and despair. A person with depression often feels physically drained, with low levels of energy, little or no motivation, and slowed movements.
Another feature of depression is what psychiatrists called “anhedonia”, which is the inability to experience pleasure or joy in activities that the person would typically enjoy. Sleep is often disturbed, and the normal sleep-wake cycle is disrupted. Changes in appetite are common, often with consequent weight loss or occasionally weight gain (in so-called “atypical depression”). So we see that depression involves many mental and physical changes, and affects not just a person’s emotions, but also their physical health and their ability to think clearly and act in the world.
CWR: Christians sometime think, or are tempted to think, that depression is a sign of spiritual failure or evidence of a lack of faith. What are the problems with, and dangers of, such perspectives?
Dr. Kheriaty: The problem with this perspective is that it does not recognize that depression is a complex illness with many contributing factors. While we acknowledge in The Catholic Guide to Depression that spiritual or moral factors can be among the causes, we also argue that there are many other factors that play a role in the development of depression, many of which are outside of the patient’s direct control – biological factors, genetic predispositions, familial and early attachment problems, interpersonal loss, traumatic experiences, early abuse, neglect, and so on. If we attend only to the spiritual or moral factors, then we do the person a disservice by ignoring other important contributing elements that often play a significant role in depression. With that said, the spiritual factors, and other behavioral factors within a patient’s control, should not be ignored either. We wrote this book, in part, as a way to bring the medical, social, and biological sciences into dialogue with philosophy, theology, and Catholic spirituality, in order to gain a fuller and more comprehensive understanding of this complex affliction. We hope that this multifaceted approach will help people more adequately address depression from all of these complementary perspectives.
Msgr. Cihak: I would completely agree. I think perhaps sometimes in our desire to get to the bottom of things, we can tend to oversimplify the situation. As Dr. Kheriaty said, there can be many contributing factors. The book reflects an intentionally Catholic approach by integrating the truths of medicine, philosophy and faith. We should keep the whole in mind as well as the deep connection between the body and the soul. In our respective vocations, we have both encountered people suffering from depression who actually manifest a strong faith, which they themselves might not be able to see, but which has been helping them to keep going in the tough times. That being said, we attempt to demonstrate in the book that our Faith has profound things to say about depression, its deepest theological origins, its redemption by Jesus Christ and its transformation in His Church.
CWR: Are psychiatry and Christian faith in opposition to one another? If not, how can Christians discern between the benefits of psychiatry and problematic theories, for example, Freudian or Jungian accounts of religious belief and human relationships?
Msgr. Cihak: Put simply, no. Since all truth has its ultimate origin in God, the Church has always taught that the truths of faith and the truths of reason can never contradict each other. On this point, we can appeal to giants such as St. Thomas Aquinas and St. Bonaventure as well as the various pronouncements of the Magisterium such as Bl. John Paul II’s Fides et Ratio. Because of this common divine origin, we can say that all truths have an intrinsic unity; truth is symphonic. Put one truth next to another and they resonate with each other. Sound medical or psychological science, and Christian faith rightly understood and interpreted, are not and never have been in opposition. We see our task as Catholic thinkers to build bridges between these sciences, always maintaining their proper competencies and autonomy, and to search out these harmonies, confident that they are already there to be discovered.
Dr. Kheriaty: We should add, however, that at various points in the history of psychiatry, some psychiatrists have ventured beyond what medical science can legitimately claim, and have made anti-religious claims in the name of psychiatry, or masquerading under the banner of “science”. For example, the founder of psychoanalysis, Sigmund Freud, famously claimed that religious belief was psychologically unhealthy – indeed, he called religion the “universal obsessive neurosis of mankind”. But this claim had nothing to do with actual empirical research; it instead reflected Freud’s own personal bias against religion. The elements of his theory upon which this claim supposedly relied were never scientific; that is, they could not be subjected to scientific measurement or empirical proof. The fact is that more recent evidence from a large body of medical and scientific research has shown that for most people, religious and spiritual practices (like meditative prayer, attending church regularly, and participating in communal worship) actually have positive benefits on a person’s mental and physical health, including reducing the risk of depression and helping patients to recover more quickly from depressive episodes.
Our book is one attempt to help readers thoughtfully discern between the legitimate benefits of psychiatry and problematic theories that have sometimes been put forward in the name of psychiatry or psychology. There are other Catholic writers, Paul Vitz for example, who have addressed these issues in some of their writings as well. Certainly there is more work that needs to be done in this area by people that have expertise in both the medical and psychological sciences and in philosophical anthropology and spiritual theology. We need ongoing academic research and dialogue here, as well as people who can “translate” this intellectual work into writing that is accessible to a lay audience. We hope that our book can make a contribution to this dialogue. We also hope that it will serve as a user-friendly and practical guide for people suffering from depression, as well as for therapists, clergy, spiritual directors, and family members or friends who are trying to help a loved one with depression.
CWR: Bl. John Paul II said (as you quote), “Depression is always a spiritual trial.” What should Christians know about the relationship between depression and the spiritual life? How is the “dark night of soul” different from various forms of depression?
Dr. Kheriaty: Depression certainly affects our spiritual life, and our spiritual life is central to helping us prevent or recover from depression. Depression is indeed a spiritual trial because it wounds us so deeply – you could say that it is an affliction not just of the body but also of the soul. Depression can make prayer feel impossibly hard (though prayer is always possible, even when affective consolations are absent, even when we are assailed by dryness or distraction). We can know, with certainty and confidence, that God is our loving Father, that he is close to us and that he sustains us, even through painful trials and periods of suffering in this life. We know also, in faith, that our suffering is not pointless, but can be redemptive when united to the sacrifice of Christ on the Cross.
Msgr. Cihak: Although depression can sometimes resemble on the surface other spiritual or moral states, like spiritual lukewarmness or acedia on one hand, or the dark nights of the senses and of the spirit described by St. John of the Cross on the other, we argue in the book that it is very important to distinguish carefully between depression and these states because these states mean different things. In the case of lukewarmness or acedia, it is a negative, bad trend in the spiritual life involving moral fault which results in weakening one’s movement toward the Lord. The dark nights are actually positive, good, grace-filled movements in the spiritual life bringing one into deeper intimacy with the Lord.
Dr. Kheriaty: Yes, exactly. With careful and prudent discernment, these states of mind and soul can be distinguished. For example, the dark night is typically not accompanied by the physical or bodily symptoms of depression, like sleep disturbances, appetite changes, or changes in one’s level of physical energy. These distinctions can be made by consultation with a prudent spiritual director, ideally in conjunction with and communication with a sensitive psychiatric or medical assessment when symptoms of depression are present. We describe these various states and distinguish them in some detail in The Catholic Guide to Depression; however, it’s also important to recognize that sometimes these states can appear together, so clean distinctions are often difficult in practice. Depression can go hand-in-hand with acedia or spiritual lukewarmness; it may be sustained by behaviors that, wittingly or unwittingly, the afflicted person is engaging in, and which call for repentance and reform.
CWR: What are some reasons for people committing suicide? What are some of the challenges faced in dealing with those struggling with suicidal tendencies and impulses?
Msgr. Cihak: I think the first thing we must say is that suicide is awful. I think one of the more powerful parts of the book is Dr. Kheriaty’s discussion of one such tragedy. God is the sovereign Master of life. We are the stewards, not owners, of the life entrusted to us by Him. Suicide contradicts the natural human inclination to live, which is placed in us by the good God. So suicide is gravely contrary to the just love of self, love of neighbor and love of God. However, though it is always wrong, the Church teaches that conditions such as grave psychological disturbances, anguish, grave fear of hardship, or suffering can diminish one’s responsibility in committing suicide (Catechism of the Catholic Church, 2280-2283).
Dr. Kheriaty: The reasons for a person’s suicide often remain a mystery, to a large extent. Research on suicide suggests that it is typically an ambivalent and impulsive act. The person’s rationality may be impaired by a serious mental illness, like depression or psychosis. Often drug or alcohol abuse catalyze a suicide attempt, by making a vulnerable individual more impulsive and impairing his judgment. Depression plays a central role in a majority of suicides, which is one of the chief reasons why we should recognize and treat depression early on in the course of the episode. A central psychological theme of most suicidal individuals is a profound sense of hopelessness. This is one of the reasons, as research has demonstrated, that Christian faith can significantly lower the risk of suicide: our faith raises our sites to a glorious future, beyond the vicissitudes of this life; in faith, we have hope for eternal life with God. Faith, hope, and love can therefore help us endure situations in this life that might otherwise feel intolerable.
Suicide is, tragically, all too common. It is now the second leading cause of death among college students, and the third leading cause of death among young people age 15 – 24. Many family members and friends struggle for the rest of their lives with a sense of guilt and self-blame after the death of a loved one by suicide, wondering what they might have done to prevent it. In my professional experience, some suicides can be prevented, and we should always do whatever we can to lower a person’s risk of suicide. That being said, there are some suicidal individuals who are very difficult to assist. In these instances, we place these individuals prayerfully in the hands of God, as theCatechism states with pastoral sensitivity: “We should not despair of the eternal salvation of persons who have taken their own lives. By ways known to him alone, God can provide the opportunity for salutary repentance. The Church prays for persons who have taken their own lives” (2283). And so should we.
CWR: What are some of the myths or misnomers regarding psychotherapy? And what basis exists for a Christian approach to psychotherapy?
Dr. Kheriaty: It seems in recent decades that the psychotherapist’s office has replaced the confessional in the Western world. While it is true that the confession lines are all too short, and most of us, including those suffering from depression, would benefit from receiving the Sacrament of Reconciliation more frequently, it is also true that the confessional is not meant to cure psychological disorders like depression. Blessed John Paul II said as much in an address to psychiatrists when he said that the confessional is not and cannot be an alternative to the psychoanalyst or psychotherapist’s office, nor can one expect the Sacrament of Penance to heal truly pathological conditions. He went on to say that the confessor, though he is a healer of souls, is not a physician or a healer in the technical sense of the term. In fact, if the condition of the penitent seems to require medical care, the confessor should not deal with the matter himself, but should send the penitent to competent and honest professionals.
The relationship between psychotherapy and the Sacrament of Confession once again points to the need for constructive dialogue between religion and psychiatry, between priests who are instruments of Christ’s healing in the confessional, and psychiatrists and other therapists who are instruments of Christ’s healing in psychotherapy. Neither one can or should try to replace the work of the other. Psychotherapy has its limitations, and therapy alone cannot cure our deepest wounds, but it can play an important role in the lives of many people in need of psychological healing.
Msgr. Cihak: Another way of stating this truth is that no amount of psychotherapy can take away sin or the guilt that comes from sin. For this, we need conversion and Sacramental Confession. On the other hand, while we never presume to limit the way in which God works, the grace of the Sacrament and the counsel given in the confessional (which by necessity is usually very brief), isn’t designed to work directly on the deep and habitual patterns of thinking and feeling that are the focus of treatment in psychotherapy. In fact, by respecting the competence and autonomy of each of these two ways of healing, they can come together to work powerfully in a person’s life. We made the deliberate choice to work together on this book—one a psychiatrist and the other a priest—precisely to show how this Catholic approach can be so effective.
Dr. Kheriaty: I’ll add a few remarks regarding your question about a Christian basis for psychotherapy. A Christian approach to psychotherapy does not just mean that the therapist quotes Bible verses when offering counsel (though of course, this may be helpful in some circumstances). Rather, it informs the entire approach to the patient in therapy, which seeks to know and heal the person in a way consonant with the person’s nature as a human being. All therapists can recognize some foundational truths about the human person, by the light of reason and sound science: that the human person is a substantial unity of body and soul; that he is rational (able to grasp truth), relational (made for relationships of love and self-giving), and free to pursue the good. A Christian therapist, moreover, by the light of revelation, can also perceive that the human person is created good, though fallen and therefore wounded, but also redeemed and capable of being sanctified by God. This is the philosophical and theological framework within which a Catholic therapist approaches his or her work. These characteristics, unfortunately, are often denied or contradicted by many modern and overly narrow psychological theories that do not take into account the full truth about the human person, but instead attempt to reduce the person to one or another aspect only. This may allow for partial truths and insights to emerge, but such a reductionistic approach ultimately prevents one from seeing the full and marvelous truth about the human person as created and redeemed by God.
Msgr. Cihak: As people can see from what Dr. Kheriaty said, psychotherapy has everything to do with the big questions of human life, and therefore has everything to do with philosophy and theology. Psychotherapy is basically applying philosophical and theological insights to the way we think, feel and approach life. It is fundamentally a human science. Psychotherapy can benefit from the full truth of the human person that comes from the philosophical and theological tradition of the Church; and this same tradition can benefit from way these ideas actually come to bear on a person’s life in psychotherapy.
CWR: What are some of the spiritual disorders that lead to depression?
Msgr. Cihak: I think we could begin by observing that sin creates misery. Moral evil is not simply a bad idea; it harms and ruins peoples’ lives. The fundamental spiritual disorder is the choice of sin, which if left unchecked becomes habitual and begins to corrupt and even destroy that vital relationship with the Lord of life who desires our fulfillment and happiness. So being immersed in serious sin can certainly lead one to or hold one in a depressive state.
Dr. Kheriaty: Precisely. I will mention as well the sin of despair, which is contrary to the virtue of hope, and commonly leads to depressive states. Also envy, which is a form of sadness at another person’s good, can also incline one toward depression. Spiritual lukewarmness or coldness in relation to the things of God, and what George Weigel has called “metaphysical boredom”, a sort of spiritual ennui, can put a person at risk for depressive or anxious states. Atheism, especially in the face of death, can lead ultimately to despair or a denial of reality. A person faces his own mortality, yet lacks a transcendental hope or a spiritual reference point, will often resort to desperate attempts to control the timing and circumstances of his death, or to avoid suffering at all costs. We see this in the push for physician-assisted suicide, for example. The world is chock full of dead end paths that lead a person away from ultimate and lasting happiness. Not all spiritual disorders lead to clinical depression, but all spiritual disorders ultimately lead toward unhappiness of one form or another.
CWR: How can the saints and the sacraments bring freedom from anxiety and depression?
Msgr. Cihak: The saints show the life of Christ to be real, concrete and possible.
Dr. Kheriaty: Well said. When we look to the saints for help with depression, it’s important to remember that every one of the saints was a person of flesh and blood, just like us. Each of them had defects that they had to struggle to overcome. Too many overly pious biographies of saints gloss over the messy aspects of their life and omit their defects or vulnerabilities, as though these people were sanctified from birth – as though they were made from fundamentally different “stuff” than the rest of us. These well-intentioned books ought to be tossed in the trash bin. The saints were real people. They fought and won; they fought and lost. But the thing that made them saints is that when they were defeated by their own weaknesses, they got up again, brushed themselves off, and with God’s grace, they went back into the fray to fight again. Many of them suffered from depression or other severe mental illnesses at various points in their journey of life. With God’s grace they finished the race, they kept the faith. The saints can, through their friendship and their intercession, help us also to fight the battles against our own defects and weaknesses, to struggle and persevere on those days that feel messy, where nothing seems to be going right. They know; they’ve been there too. And from Heaven they are cheering us on to victory.
Msgr. Cihak: If the saints make the divine life a real possibility and a concrete invitation to imitate, then the Sacraments are the primary way that the divine life is communicated to us. Jesus does nothing superfluous, and so the Sacraments that He instituted should be of paramount importance to the Christian. Immersing ourselves in the sacramental life, as well as cultivating a life of prayer and virtue, is what we call “the ordinary means of sanctification”. These means can be of great help in resisting and recovering from mental illness, including depression. It is important to remember that the primary aim of the graces of the Sacraments is to accomplish the work of salvation in us, but we ought not to overly compartmentalize the effects of grace given the unity of the human person. Grace can also accomplish physical and mental healing when it is part of God’s plan for us. In any case, the Lord’s grace is always good for us.
CWR: Therapy, you note, cannot uncover the most important truths about the human person. What is the foundational truth that must be appropriated in order that we might be whole and healed?
Msgr. Cihak: God desires our happiness. We were made in His very image and called to become like Him. We were created to live with the Blessed Trinity forever and to have our humanity become fully illuminated and enlivened by the divine life. This happens through Jesus Christ, the one and only Savior of the world. Because of sin, the path to that destiny is marked by the Cross. So every follower of Christ will have difficulties and struggles in this earthly life. Sometimes struggling against depression is part of one’s conformity to the Cross of Christ, which always leads to everlasting life. By union with Christ, in the end, He will form us by the power of His grace to be like Him, truly Godlike.
Dr. Kheriaty: Here is another way of saying the same thing: the most important truth about us is truth of our divine filiation – the marvelous truth that God is my loving Father. In Christ the Son, my Savior, I am an adopted son or daughter of God. Each day we should try to go deeper into the meaning of this truth for our lives. The fact that God is my loving Father is not just one more fact among many; it is, so to speak, the lens through which I should view everything else in my life and in the world. God loves me more intensely and more affectionately than all the fathers and mothers of this world love their children. He is close to me, so very close, “more inward to me than I am to myself,” in St. Augustine’s mysterious formulation. Not only did he create me, in love he sent his own Son to redeem me from sin, from death, and from despair. Jesus Christ, who is our brother, our friend, our Savior and our God, says to us now what he said to his apostles the night before he died: “Truly, truly, I say to you, you will weep and lament but the world will rejoice; you will be sorrowful, but your sorrow will turn into joy” (Jn 16:20), and he assures us, “In the world you will have tribulation, but take courage, for I have overcome the world” (Jn 16:33).