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
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
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
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
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 the Catechism 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
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 bookone
a psychiatrist and the other a priestprecisely 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).