Of all mental disorders, depression is the third most prevalent with about 8% of the population suffering from it (Robins & Regier, 1991). It is also currently the leading cause of disability world-wide (Murray and Lopez, 1997). The effects of depression are varied affecting not only the patient, but family and society as well.
The Book of Job offers an early record of depression: My eye has grown dim from grief (depression), it grows weak because of all my foes," (Job 17:7, emphasis added). The prophet Jeremiah wrote: "My grief (depression) is beyond healing, my heart is sick within me" (Jeremiah 8:18, emphasis added).
The Apostles and Church Fathers also knew the deleterious effects of depression: "Worldly grief produces death," wrote St. Paul (2 Corinthians 7:10). The death to which St. Paul refers is both a social and occupational death, that is, the diminishment of function in interpersonal relationships as well as the blocking of God's love and light in the soul that leads to existential despair.
The Church Fathers described depression as dejection. About 1400 years ago St John Cassian wrote: "But first we must struggle with the demon of dejection who casts the soul into despair. We must drive him from our heart. It was this demon that did not allow Cain to repent after he had killed his brother, or Judas after he had betrayed his Master" (Philokalia I).
St. John Cassian offered a remarkably accurate and lucid description of depression in terms that are corroborated by the modern clinical definitions. In "On the Eight Vices", he described dejection as: obscuring the soul, keeping it from good works, preventing it from praying and reading, the inability to be gentle and compassionate toward our brethren, instilling hatred of work, undermining resolutions and persistence, and captivity to despairing thoughts. The contemporary scientific criteria that describe depression include: feeling sad or empty, diminished interest or pleasure, agitation, energy loss, and inability to think (American Psychiatric Association, 2000).
Modern psychological research adds a quantitative dimension to St. John's insights, especially the "Cognitive-Behavioral Model of Emotional Dysfunction" (Beck, Rush, Shaw & Emery, 1979; Ellis, 1962; Morelli, 1987, 1988. 1996, 2006c). According to this model, emotions such as depression are produced by distorted or irrational beliefs, attitudes, and cognitions. Situations (some event that has happened or something that someone has said or done) do not produce or cause emotional upset. Instead, we upset ourselves by our irrational interpretations of the situation.
Recent research by Izard (1993) revealed additional pathways of emotional activation which include sensorimotor and affective neural events in the Central Nervous System (CNS). Morelli (1996) pointed out however, that because of the reciprocal interaction of these events, cognitive behavioral treatment is usually effective with patients suffering from emotional disorders activated by any of the three (cognitive, sensorimotor, affective) pathways. Thus, an understanding of the cognitive distortions that produce dysfunctional emotions, including depression, is necessary for effective clinical intervention.
There are eight cognitive distortions related to depression:
- Selective Abstraction: The focusing on one event while excluding others. In one of my recent cases Jack (all names are changed), an engineer, selectively focused on a reprimand he recently received from his supervisor while ignoring the praise he received the previous week from the senior project manager. This irrational perception led to his depression.
- Arbitrary Inference: Drawing a conclusion unwarranted by the facts in an ambiguous situation. For example, Jack concluded that the next evaluation given by his supervisor would be unsatisfactory. This led to further depression.
- Personalization: Interpreting a general event in exclusively personal terms. Linda became depressed after a business meeting (attended by about 25 people) when her supervisor mentioned that some participants were not team players. Linda immediately personalized the statement by assuming the supervisor directed the comment at her even though no evidence supported the conclusion.
- Polarization: Perceiving or interpreting events in all or nothing terms. Cynthia became depressed after receiving a B in a college course. She polarized events into two categories: good student versus bad student. Her B grade fell into the bad-student category. She failed to see that all events can be graded on a continuum between two poles. On such a scale a B is closer to an A than to an F for example.
- Generalization: The tendency to see things in always or never categories. Mary became depressed during marital therapy when she irrationally concluded that her husband "will never change" and "will always be the same". Her dysphoria (an emotional state characterized by anxiety, depression, and restlessness) led to a self defeating pattern of behavior by further distancing her from her husband thereby weakening the marriage even more.
- Demanding Expectations: Beliefs that there are laws or rules that must be always obeyed. Kim came into treatment because she was depressed over her son's back talk. She irrationally believed that there is a universal law that children should always do what their mothers ask. If they don't obey, she has the right to get upset. She failed to apply the Christian principle that God asks and never coerces obedience. A program of rewards for appropriate behavior and punishment for inappropriate behavior administered without anger, anxiety, or depression would be the constructive response to apply here (Morelli, 2006a).
- Catastrophizing: The perception that something is worse than it actually is. Kim erroneously reacted to her son's talking back as if it represented a grave and catastrophic event and thus reacted with even more dejection.
- Emotional Reasoning: The judgment that one's feelings are facts. Sandy had a feeling that her new boss did not like her. When asked how she knows this she responds that her "feelings are always right". She failed to distinguish between the fact that although feelings are real, feelings cannot prove whether something is true or false. I tell my patients that no matter how strongly some people "felt" the world was flat when Christopher Columbus set sail, Columbus proved the world was round. Feelings are not facts.
Beck (1976) pointed out that alongside these cognitive distortions, depression also involves the cognitive theme of loss and what he termed the cognitive triad: a negative view of self, world and future. In other words, if a clinician were to analyze the self-talk of depressed patients, the cognitive distortions mentioned above would be present in some manner as well as the cognitive theme of loss.
For example, Jack, the engineer mentioned above who received the reprimand from his boss, also believed that the reprimand included a loss of his boss' respect thereby diminishing his self-respect and appearing incompetent to his co-workers, thereby at risk of losing his job, and so forth. This cognitive feedback loop of distortions, loss, and triad produces a cascade of deepening depression.
Effective clinical intervention first involves helping the patient recognize and label the cognitive distortions and themes, followed by helping the patient restructure the distortions. Three questions are helpful in challenging the patient's thinking so that restructuring can occur:
- Where is the evidence?
- Is there any other way of looking at the situation?
- Is the situation as bad as it seems?
For example, if Jack were to answer these questions he might come up with a more rational perception: "True my boss criticized my project but in the past he praised my other work. Just last week the senior project manager was very pleased with another project I worked on. Just because I was reprimanded for one error doesn't mean all my work is bad or that I will lose my job." Following this cognitive restructuring process Jack begins to feel less depressed.
The questions helped Jack debrief his error by helping him understand what brought the error about. The next step is to help Jack become behaviorally proactive by developing a plan to respond more effectively in the future. The deliberate change in behavior interacts with the cognitive restructuring to diminish the strength of the depression, that is, elevate his mood.
This cognitive restructuring technique works with all the cognitive distortions listed above. The cognitive distortions of demanding expectations, catastrophizing, and emotional reasoning however, require more specialized intervention techniques beyond the scope of this article.
Misconstruing Christian teaching
As indicated above, patients with demanding expectations frequently try to impose a personal set of rules on others around them, often coercively. They assume the inviolability of physical laws (gravity for example) applies to moral laws and social norms as well.
Sometimes this distortion is rooted in a faulty understanding of human nature and God. God gave man free will. Obedience, while a requirement, always remains a choice and cannot be coerced. A person cannot violate the law of gravity for example, but remains free to disobey God's commandments (as well as social rules and norms). Disobedience to the moral law of God certainly causes different degrees of consequences, some major like the loss of eternal life, and others more minor. Nevertheless, God does not force obedience. Obedience is offered only in freedom. So too should parents in particular cultivate obedience in their children rather than coerce them through emotional over-reactivity. The most effective approach is through consequence management (Patterson & Guillon, 1971).
When demands are not met, our capacity to achieve the desired results usually diminishes. One example where this may occur is parenting. Parents who struggle with depression, anxiety, and anger are therefore often poor at parenting. Their ineffective dealing with their own cognitive distortions precludes any development of a behavioral management program that brings about the desired behaviors in their children.
A motto for more effective parenting might be Teddy Roosevelt's dictum "Speak softly but carry a big stick." The stick here is not a literal stick of course, but consequences lovingly and consistently applied in a behavior-reward model. Continuing with the parenting example, if a child has difficulty finishing homework, the rule could be all homework must be done before playtime starts. No exceptions. Without worry, anger, or even depression, the parent lets the consequence do the work of motivating the child to finish his homework.
A technique effective with catastrophizing is the "Mental Ruler Technique". It involves evaluating a situation on a zero to 100 scale, with zero being the most pleasant thing you could picture happening to you (Burns 1980, Morelli, 1987).. Patients infrequently have trouble imaging a very pleasant event (zero). Sitting on a sun drenched tropical beach is a typical image. Patients rarely need help however, imaging a worst event (100). I offer the example of a medical missionary in South East Asia several years back who suffered a horrifying death. His captors placed chopsticks in his ears and hammered them in a little each day until they penetrated his brain and killed him.
Patients or parishioners I counsel frequently characterize the death of loved one, especially a child, as the "most awful thing on earth" -- often in sanitized and abstract terms. While a counselor certainly must help a person with the grieving process allowing in particular the expression of feelings, he must take care not to endorse a catastrophic mental ruler appraisal. For example, while the loss of a child is tragic and the cause of great sorrow and grief, unless it reaches the scale of "100" it is not the "most awful thing on earth."
Moreover, catastrophic evaluations frequently broadcast a lack of faith. Surely the faith of the Christian is in a God Who freely gives life and calls us back to Him. God does all for love and even though some events are beyond our understanding, we can nevertheless know that some events have a greater, higher, and divine purpose even when we don't see what they might be. The Christian clinician in particular must use spiritual as well as psychological tools to treat the depression of his patients.
Emotional Reasoning Management
Emotional reasoning requires special cognitive intervention because depressed patients tenaciously cling to the irrational belief that their feelings prove the truth or falsity of an event. How many times has a parishioner or patient said something like: "I just feel I will never (get better ... find a job ... get over this ... make friends, etc.)"? As mentioned above, these patients make the mistake of concluding that the way they feel about a situation functions as the proof that situation really is that way. The standard of proof is not an objective appraisal of the facts, but the feeling one has about the event regardless of the facts. Feelings replace the facts in this scenario.
An effective starting point in the therapy involves having the patient reflect on events in the past (and not related to the current event) that he had strong feelings about. For example, I might ask the patient to recall an event that he "felt really sure about" but that turned out to be untrue. One of my patients recalled an instance in which he felt certain that he had failed an exam. Another common example is that they feel that someone does not like them. Then I help the patient explore what happened when they discovered that their feelings did not match reality.
What lesson is there in this process of self-discovery? The main one is that feelings and facts are two different things. For example, I asked the person who found out they had done well on the test: "What does this say about feelings as facts? Are there other ways of interpreting or understanding feelings?" Only after these types of cognitive exercises are accomplished can the patient's current emotional reasoning distortion (the feeling he has about the current event) be addressed.
Behavioral practice accompanies the cognitive restructuring procedures. This includes filling out restructuring charts (see Burns, 1980) as well as to in vivo (real life) exposure to challenging social and environmental events related to the depression. For example, Jack, our erstwhile patient introduced above, may be encouraged to consult his supervisor for feedback regarding other projects he has worked on. Behavioral assignments decrease depression by providing realistic information that can be processed through veridical (truthful, non-illusory) cognitions. Further, increased behavioral activity has been shown to ameliorate depression (Beck, et. al. 1979). It is hypothesized this activity may affect the biochemistry of the brain in ways that alleviate depression.
Proneness to suicide
Suicide deserves special consideration in the treatment of depression. If a loved one or friend knows of someone suspected to be suicidal, immediate professional help should be sought. Expressions of the desire to kill one's self and thoughts and feelings of hopelessness are special risk factors.
Suicide should be immediately addressed by the clinician and patient. This is a clinical emergency and more than one session may be needed. One effective cognitive-behavioral clinical technique is to first explore with the patient all the favorable reasons to commit suicide. This helps the clinician understand the patient's problem from the patient's viewpoint. Once the patient feels that his despair is understood, he may feel empowered to explore the reasons not to commit suicide. Of course, the latter exploration coupled with cognitive restructuring and spiritual intervention is the therapeutic factor. Such patients may also require psychopharmacological treatment. In no case should a suicidal patient be released without attenuation of suicidal ideation (without treatment of the suicidal thoughts).
With the Orthodox Christian patient, spiritual intervention can also be initiated alongside with the cognitive-behavioral treatment. Evagrios the Solitary, reminded us: "Prayer is the remedy for gloom and despondency" (Philokalia, I). Prayer, selected spiritual reading, and the sacraments provides spiritual healing for mind body and spirit.
The clinician must be careful that the patient does not misinterpret scriptural passages and spiritual reading and thereby increase the depression. For example, the patient may easily make Job's despair his own: "For the arrows of the Almighty are in me; my spirit drinks their poison; the terrors of God are arrayed against me ... Can that which is tasteless be eaten without salt ... My appetite refuses to touch them; they are as food that is loathsome to me" (Job 6: 4-7).
If the patient stopped reading at this passage, he might conclude that God abandoned him just as Job thought he was abandoned. Of course, Job is faithful to God despite his adversity and in the end God rewards him. Instead a prayer of hope can be made: "But thou, O LORD, be not far off! O thou my help, hasten to my aid! Deliver my soul from the sword, my life from the power of the dog. Save me from the mouth of the lion, my afflicted soul from the horns of the wild oxen! I will tell of thy name to my brethren; in the midst of the congregation I will praise thee" (Psalm 21:19-22). Evagrios the Solitary said:
Of the demons opposing us in the practice of the ascetic life, there are three groups who fight in the front line: those entrusted with the appetite of gluttony, those who suggest avaricious thoughts, and those who incite us to seek the esteem of men ... But Our Lord, having shown Himself superior to these temptations, commanded the devil to "get behind Him". In this way He teaches us that it is not possible to drive away the devil, unless we scornfully reject these three thoughts (cf. Matthew 4:1-10; Philokalia I).
Notice that St. Evagrios taught that appetite, avaricious thoughts, and the yearning for the acclaim and the esteem of men have a demanding imperative -- a "should" quality -- to them. This is similar to the demanding expectations cognitive distortion that accompanies the dysfunctional emotions discovered by modern research science discussed above.
Other Fathers touched on the same theme. In his commentary on Acts, St. Maximus the Confessor wrote: "For the state of spiritual knowledge heals the mental dejection produced by the storm of trials and temptations" (cf. Acts 28:1-4; Philokalia II). St. Peter of Damaskos revealed what spiritual knowledge is:
He begins to give thanks with a humble soul ... and because of the thankfulness, patient endurance and humility which have been bestowed on him as a result of his knowledge, he begins to have hope that by God's grace he will obtain mercy. In the light of his experience of the blessings he has received he watches ... at once he receives a still further increase in knowledge, and he contemplates not just the blessings he personally has been granted, but also those what are universal (Philokalia IV).
St. Peter continued that what follows next are tears of grief that arises when a person realizes that God cannot be adequately thanked for His mercy. Paradoxically, out of this grief arises spiritual knowledge:
His intellect begins to attain purity and return to its pristine state, that is to the state of natural spiritual knowledge which it lost through its amity with the passions ... it is called spiritual insight, since he who possesses it knows something at least of the hidden mysteries, that is, of God's purpose in the Holy Scriptures and in every created thing ... and perceive the inner principles of things ... (Philokalia IV).
In modern terms we can sum up St. Peter's counsel this way: A Christian who orders his life in the world in ways that relate to God's purposes for him, has embarked on the path that leads to the spiritual and psychological healing of depression.
St. Peter's words about the "hidden mysteries" reference the Scripture, particularly St. Paul's words: "But we impart a secret and hidden wisdom of God, which God decreed before the ages for our glorification" (1Corinthians 2:7). The wisdom is not the hidden knowledge of the Gnostics (an ancient heresy) or the secret rituals of fraternal societies. Rather, it refers to the knowledge of God attainable through the virtue of humility; seeing the world as God sees it. It consists of clarity of mind, a penetration into the true nature of things and events that comes with the purification of the heart. "Blessed are the pure in heart for they shall see God," wrote St. Matthew (Matthew 5:8).
The ways of God are hard to fathom at times. This is especially true when a patient is depressed. A bad turn of events can make it seem like the favor of God has been lifted. Painful events can make it seem like God is nowhere to be found. Sometimes a patient will ask after an unfortunate event: "Why has God done this to me?"
In both my pastoral and clinical practice I employ an old parable to illustrate that God's ways are not always our ways. The story goes like this:
An unemployed and impoverished young new father leaves his wife and child early one morning to go to a town miles away to interview for a job. It's still dark and exceptionally foggy. Creeping up a hill a tire blows out. He barely makes it onto the shoulder. Then he discovers the spare is flat. Nowhere to turn, he knows he will miss the interview and lose out on the job.
His family is on the brink of eviction. He has no money to buy food. He cries out in despair: "God how could you let this happen?" Unknown to him, a driver, also blinded by the fog and totally drunk from a night of partying was crossing over the crest of the hill from the other direction and in the wrong lane. A few seconds later a terrible collision would have occurred disabling, perhaps even killing, the father.
By the light of human logic, the blowout was a catastrophe. Spiritual knowledge however, can discern a good in all events, even the bad ones. Spiritual wisdom affirms a trust in God who promises to "make all things new" (Revelation 21:21). The father, despite the tragedy could say: "Lord, somehow you will provide. I will go on. Show me Your will."
If the parable above sounds dubious, consider this real life example. Fr. Arseny was an Orthodox priest in a Soviet Gulag where he suffered alongside the other prisoners banished to this living hell. The level of depression and suicide in the camp was overwhelming. He saw in spiritual visions the humanity of his fellow prisoners and said: "I remembered their faces, exhausted, lost, sad, full of sorrow...". His biographer continued:
Fr Arseny saw each person carried within himself a soul ... souls of some were afire with faith which kindled the people around them; the souls of others burned with a smaller but ever growing flame; others had only small sparks of faith and only needed the arrival of a shepherd to fan these sparks into a real flame. There were also people whose souls were dark and sad, without even the least spark of Light. "Lord! How can I leave them? How will I be without them? Do not leave all those who live here without your mercy help them!" And kneeling in the snow he prayed. "But suddenly the words of prayer drained out of me," recalls Fr. Arseny, "and I found myself in this field lost, crushed by memories, doubts and an unfathomable emptiness ... I felt compressed, my nerves stretched to their limit; I was utterly filled with painful sorrow. It had become dark and oppressive outside. I felt broken, smashed."
From the depths of his sorrowful heart, Fr. Arseny, with the grace of spiritual wisdom cried out: "O Lord, my Lord, show me Thy mercy" Fr. Arseny made the sign of the cross, "And suddenly the wind that had been hiding in the forest and the grass was free again; it gave life to the grasses, shook the trees and blew insistently into my face; suddenly everything changed, came awake, came alive ... The feeling of confusion, of oppressive sickness of heart and despair left me. I stood up straight, shook off all fear ... the wind brought me coolness, the smell of grass ... of exceptional joy."
One day Fr. Arseny encountered a woman in the deepest clutches of despair. She had gone to see him after suffering a "terrible breakdown." "I wanted to throw myself onto the floor and pound it with my head, crying, sobbing for all I had lost, lost forever. Life seemed pointless and useless," she cried. She came across Fr. Arseny, as he was standing before the icon of the Mother of God and reciting this prayer:
O my beloved Queen, my hope, O Mother of God, protector of orphans and protector of those who are hurt, the savior of those who perish and the consolation of all those who are in distress, you see my misery, you see my sorrow and my loneliness. Help me, I am powerless, give me strength. You know what I suffer, you know my grief -- lend me your hand because who else can be my hope but you, my protector and my intercessor before God? I have sinned before you and before all people. Be my Mother, my consoler, my helper. Protect me and save me, chase grief away from me, chase my lowness of heart and my despondency. Help me, O Mother of my God!
I call this prayer the "Prayer of Fr. Arseny to the Mother of God to Overcome Despondency". It began the distraught woman's conversion, and healing. It belongs in the prayer book of every Christian. May it rest in the heart of anyone who suffers from depression.
Alexander, Servant of God. (1998). Father Arseny, 1893-1973: Priest, Prisoner, Spiritual Father. Crestwood, NY: St. Vladimir's Seminary Press.
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