The role of spirituality in depression treatment

Spirituality and Depression

What is Spirituality?

The absence of an adequate definition of spirituality is perhaps one reason why researchers have difficulty identifying the role of spirituality in the treatment of depression. What is spirituality? Every culture, every school of thought, even every individual can differ on this point. For the purposes of this paper, we will work with a variety of perspectives concerning "spirituality" -- but at the same time we may assert a kind of working definition that will help guide our review of the literature which follows. According to Bernard Fellay (2011), a bishop of the Roman Catholic Church, spirituality may be defined as "a sense of God."

However, as the modern age is distinctly more secular with regard to science than the medieval age in which Church and science were united in the effort to reconcile faith and reason known now as scholasticism, spirituality outside the Church often refers to a kind of humanistic endeavor: as Jan Fawcett (2006) states, spirituality is seeing the 'big picture'…it is looking for a spark of divinity within myself, but also in every person I meet…it is about empathy, fairness to others, loving kindness, feeling a part of the great connectedness of human life -- of all life everywhere, of all the amazing and beautiful joys that the 'Force' or whatever has endowed us with consciousness and the capacity of appreciation of this continuing miracle (p. 137).

Fawcett's definition is encouraging, for it illuminates to some extent the definition provided by Fellay. If Fawcett's sounds like an expansion of the Golden Rule, we may be inclined to believe that "spirituality" as it is understood today, in a humanistic sense, is a philosophical holdover from the religion of the age of faith. While the Christian Triune God of Western civilization has been replaced by a vague, disoriented deism, there remains the sense that mankind may benefit from an evaluation of his spiritual aspect.

The impact that spirituality may have on the treatment of depression is, therefore, not to be ignored. Fawcett argues: "Being able to convey an appreciation for the miracle of consciousness, implicitly or explicitly, to patients who find conscious life meaningless or a source of continuing pain, is the core of giving a sense of hope that life is worth the struggle" (p. 137). Fulton Sheen (1954) likewise asserts that "life is worth living" when he asks the question: "Is life worth living, or is it dull and monotonous? Life is monotonous if it is meaningless; it is not monotonous if it has a purpose" (p. 15). However, the purpose of life, Sheen implies, is spiritual in essence.

What is depression/Major depression disorder?

Many patients, however, suffer from a disorder now termed as depression. Depression may take a variety of forms -- but it is most frequently characterized by a state in which the mind and body suffer from a loss of drive and initiative. The DSM-IV classification of depression is that of an Axis I disorder (categorized, therefore, as clinical). According to I. Sarason (2005), who gives a more clinical explanation, a major depressive episode is marked by either depressed mood or a loss of interest or pleasure in almost all activities, as well as at least four additional symptoms from the following group: marked weight loss or gain when not dieting; constant sleeping problems; agitated or greatly slowed-down behavior; fatigue; inability to think clearly; feelings of worthlessness; and frequent thoughts about death or suicide. These symptoms must last at least 2 weeks and represent a change from the person's usual functioning (p. 339-40).

Yet, one problem with DSM-IV classifications is that many researchers find them restrictive: according to Johns Hopkins Medicine (n.d.), DSM-IV categorizations "have not shown to be helpful in predicting outcomes of the disorder," and researchers hope to better pinpoint causes of schizophrenia by classifying "types based on the preponderance of 'positive' vs. 'negative' symptoms, progression in terms of severity, and the co-occurrence of other mental disorders."

Depression, therefore, may fall under any one of the five axes in the DSM-IV multi-axial system. Axis IV, for example, which is concerned with psychosocial disorders, could very easily serve as a category in which depression might be analyzed: "Psychoanalytic theorists have suggested that clinical episodes of depression happen because the events that set off the depression revive dimly conscious, threatening views of the self and others that are based on childhood experience" (Sarason, p. 349). What is more likely the case is that depression is not limited to any one classification -- but extends through many of them.

Conventional Treatment for Depression/Medication and Therapy

According to George Papakostas et al. (2007), "Recent studies suggest that the treatment of major depressive disorder (MDD) with newer antidepressant drugs that simultaneously enhance norepinephrine and serotonin neurotransmission might result in higher response and remission rates than the selective serotonin reuptake inhibitors (SSRIs)" -- a fact which indicates what the modern conventional method of treatment for depression is: the application of antidepressants. Mood stabilizers, support groups, day programs, and alternative medication are also options available in the treatment of depression, but conventional medication and therapy relies upon prescription drugs.

The Mayo Clinic (2010) lists a variety of antidepressants in the treatment of depression: selective serotonin reuptake inhibitors, serotonin and norepinephrine reuptake inhibitors, norepinephrine and dopamine reuptake inhibitors, atypical antidepressants, tricyclic antidepressants, and monoamine oxidase inhibitors. Psychotherapy and electroconvulsive therapy are also available: in the former, "cognitive behavioral therapy is one of the most commonly used therapies…[which] helps you identify negative beliefs and behaviors and replace them with healthy, positive ones. It is based on the idea that your own thoughts -- not other people or situations -- determine how you feel or behave" (Treatments and drugs, 2010).

Here is where the role of spirituality in the treatment of depression can be said to find a foothold: as Richard Weaver (1984) suggests, ideas have consequences and it is the loss of transcendentals (aka "spirituality") that may account for the plethora of mental disorders seen today: "It is inevitable that the decay of sentiment should be accompanied by a deterioration of human relationships" (p. 30). Weaver, likewise, has nothing but suspicion for the sociological research of the 20th century by men like John B. Watson, whose tendency to view disorder as a mechanical kink produced a program of scientific inquiry that continues to this day. As Weaver says, "To one brought up in a society spiritually fused -- what I shall call the metaphysical community…the art of manipulating personalities obviously presumes a disrespect for personality. Only in a splintered community, where the spirit is starved to the point of atrophy, could such an imposture flourish" (p. 31). The role of spirituality, therefore, may be of primary importance. Let us look at the history and evidence of other cultures that have used spirituality in the treatment of depression and other mental disorders.

Cultural Differences/Considerations

Jennifer Farrah and Mary Ann McColl (2008) state that "prayer is a 'spiritual practice which establishes communication with a higher being' and is 'the simple act of turning our mind and our heart to the sacred.' It is an act central to the practice of most major world religions, including Christianity, Judaism, Islam, Buddhism, Sikhism, and Hinduism" (p. 6). They also observe that "praying for the sick is one of the oldest religious practices in the world" (p. 6). Because all of the major civilizations of the past have found some form of relief in the exercise of spirituality, we look at the ways in which those civilizations did so and the reasons that backed these exercises.

Theocharis Kyziridis (2005) notes that the symptoms associated with mental disorders, as they are now classified, "can be traced in written documents to the old Pharaonic Egypt, as far back as the second millennium before Christ" (p. 42). Symptoms associated with schizophrenia, for example, "are described in detail in the Book of Hearts, which is part of the Eber papyrus. Heart and mind seem to have been synonymous in ancient Egypt" (Kyziridis, p. 42), and ancient Egyptians associated mental disturbance with the physic.

In Asia, the Hindus, whose literature dates back to over a millennium before Christ, imply that poor mental health "resulted from a balance between 5 elements (Buthas) and 3 humors (Dosas) and that an imbalance between these various elements might result in madness" (Kyziridis, p. 42). The Chinese, likewise, ascribed the symptoms to a disturbance of spiritual elements: "Demonic or supernatural possession was often implicated as the cause of psychotic behaviors" (Kyziridis, p. 42).

Chinese medicinal treatments for depression were varied and ranged from massage to acupuncture to herbal ingestion: Tui Na was a massage technique used for the those who suffered from mental and physical problems; acupuncture -- a technique that is as old as written history itself -- is the application of needles inserted into the skin at precise points of the body to desensitize the patient; natural foods and herbs were also viewed as necessary in the proper balance of mind and body (Ting, 2009).

Similarly the Ayurvedic tradition of India emphasized rest and relaxation and nutritional well-being, along with various mentally stimulating exercises. Ayurvedic resorts are still popular in the East. Buddhism is also viewed as an avenue out of depression -- a mode to enlightenment. Nonetheless, as James C.-Y. Chou (2005) states, "The concept of psychological depression in Eastern cultures is not as well accepted as it is in Western cultures. In fact, the whole idea of illness in Eastern cultures is based on physical illness…if they have a psychological illness, then they are perceived as being a persistently mentally ill patient as you would see in a state hospital…it's stigmatized."

Perhaps more than any ancient civilization, the Greeks "took a great interest in the human psyche and especially in madness. Plato who lived in the 5th and 4th centuries BC speaks about two kinds of madness, one with a divine origin and another with a physical origin" (Kyzirids, p. 43). Kyziridis gives a detailed analysis of the Platonic view of mental disorders:

In the Dialogues Plato wrote that '…to think about curing the head alone, and not the rest of the body also, is the height of folly…. And therefore if the head and body are to be well, you must begin by curing the soul.' He advanced the idea of unconscious and illogical mental processes, suggesting that all people had a capacity for irrational thinking. He also speculated that '…when the rest of the soul -- which is rational, mild and its governing -- is asleep, and when that part which is savage and rude, being satisfied with food and drink, frisks about, drives away sleep, and seeks to go and accomplish its practice…that in every one resides a certain species of desires that are terrible, savage, and irregular, even in some that we deem ever so moderate…' (p. 43).

The Greek worldview was a rational interpretation of what Christian mythology would later describe as humankind's fallen nature -- a result of an original offense against God -- a note of discordance written into the melody of the world.

Christian mythology, of course, was based to an extent on that of Israel, and as Kyziridis observes, "the platonic ideas of a connection between madness and prophecy recur in the ancient Israel" (p. 43). This madness is often observed in the Jewish prophets -- odd characters whose behavior often went against the grain. Likewise, "the same conceptions later appear in the Koran in the Islamic countries, [but] even if the Muslim nursing ward sometimes used brutal procedures the Orthodox Islam did not give as much support to exorcism as Christianity did" (p. 43). The Muslim world did, however, believe that it was possible for a supernatural entity to be the root cause of mental disturbance. The Indian practice of yoga likewise intimated a connection between the spiritual and the physical: "aspects of yoga -- including mindfulness promotion and exercise…[were] plausible biological, psychological, and behavioral mechanisms by which yoga (impacted) depression" (Uebelacker, 2010). But yoga was also derived from a belief in serpent power, the foundation of Hatha yoga -- and the alignment of mind, body, and soul with the serpent.

But as the ancient Greeks were the first to establish a rational and philosophical inquiry into the nature of man, we look first to them, as the founders of Western civilization, for clues as to the manner in which the ancients treated disorders of the mind.

While Hippocrates, a partial contemporary of Plato, believed mental disorder to be caused by the brain alone (or by various humors of the blood) -- not by the gods -- "there were a lot of other persons, for instance priests, who tried to cure the ill with an arsenal of different therapies, such as medical herbs, gymnastics, magic and exorcism. In the holy temples academic treatments were mixed with religious rites" (Kyziridis, p. 43). Yet, from Hippocrates came a tradition of medical analysis that led physicians to be concerned primarily with the physical rather than the spiritual. Not until the age of Christianity, did "the belief that demons lie behind mental diseases (become) more influential" (Kyziridis, p. 44).

Matthew, Mark and Luke depict a scene in Scripture in which Jesus cures a madman set outside the city by its populace. By casting out his demons and driving them into a herd of swine, Jesus delivers the madman from his condition. Such an example served as a guide for priests of the medieval ages, who practiced exorcism as a means of curing those whose symptoms are sometimes now described as schizophrenic. Even still today, exorcism is practiced, though at a much lower rate. The scholarly view of exorcism is divided, although Malachi Martin (1992) makes an excellent case for the reality of supernatural possession, even as he asserts that "the most important reminder to our churchmen is also the simplest and the most direct. A reminder of the admonition of Christ himself to his Apostles as they were beset in their little boat by the fury of a storm on Lake Gennesaret: 'How is it that you have no faith?'" (p. xxiv-v).

The middle ages, in fact, were defined by the Church -- and in the age of faith there was no lack of those holy fools, as they would be termed by the Russians, nor of the possessed, as they would be termed by the Church. All the same, mental disturbances were not necessarily indicative of possession. The Church did adopt a rational view of human nature and illness that was far from superstitious as is popularly believed. Daniel Smith (2007), for example, cites the story of Teresa of Avila, a nun and mystic of the sixteenth century. Known for "her spiritual purity," she endeavored to clear spiritual obstructions between God and man. However, "sensory visitations from God" gave her cause for concern, "for she had to be certain that they were in fact divine and not the result of, for example, melancholy or a hyperactive imagination. For in these latter instances a person could not be considered a visionary at all. Instead, she had to be considered 'como enferma': 'as if sick'" (p. 64).

As Smith attempts to show, some symptoms classified as signs of mental disorder today, may, in a Christian worldview, have actually been part of a mystical relationship with God -- but, as Teresa, a popular mystic, points out, it was a case by case basis that needed to be judged individually and rationally: in other words, not everyone who claimed to be a visionary was in fact one. Nonetheless, "in the medieval era many mentally ill persons were congregated near churches where they found shelter and protection by monks and priests" (Kyziridis, p. 44). By the 16th century, Church tactics were being abandoned -- one consequence of the humanism of the European Renaissance and the Protestant Reformation. The age of Enlightenment that followed attempted to rationalize this divorce from the custom of centuries. This rationalization saw the beginning of psychiatric hospitals in Europe. With these hospitals came attendants and medical supervisors and the birth of psychiatry. But…it was widely believed in the asylums that the way to cure someone was to shock them. Early shock methods included pinning patients down and pouring cold water on their faces until they were nearly drowned, or strapping patients to chairs so that they lost sensation and became calm (Kyziridis, p. 44).

As awful as this sounds, it was hardly much different from the electroshock therapy of the 20th century. Three centuries of Enlightenment ideology had produced no better solution to mental disorder: now more and more researchers are regrouping to turn back the clock and take another look at the wisdom of the ancients.

What was this wisdom? Dan Blazer (2007) attempts to provide the answer with a cross-cultural study of depression and spirituality:

No discussion of depression and spirituality can be complete without a discussion of depression and culture, for culture and religion/spirituality are so intertwined. The negotiation between religion and culture ranges from ongoing discussions by mainline Christian theologians This is a list of notable Christian theologians. They are listed by century. If a particular theologian crosses over two centuries, they may be listed in the latter century or in the century with which they are best identified.

.Click the link for more information. about the proper stance of religion within culture (1) to commentaries on the dramatic revolts against culture by fundamentalist groups in virtually every religion around the globe. (2) Perhaps of greatest importance for any discussion of depression and spirituality is a discussion of those cultural forces that augment, shape, and perpetuate depression. In many cases, a culturally shaped depression may be manifested as a spiritual crisis or as a challenge.

Ghana, for example, was a place where Margaret Field's ethnographic survey yielded evidence of a cultural link between the depression that accompanied women who "had completed their childbearing years" and belief in spiritual relief: "The depression arose out of the fear of sorcery and evil spirits that made them barren…[they] visited a shrine to gain relief from that depression" (Blazer).

Eaton and Weil similarly studied the Hutterites of North America, "a small group of people who isolated themselves for cultural and religious reasons…They prized the simple life and had a reputation for mental health…Yet the Hutterites' protective social structure was associated with…a high frequency of symptoms of depression" (Blazer). What Blazer points out is that a shared ideology (as was found among the Hutterites) was no guarantee of mental health, despite appearances.

The wisdom for which we look, in fact, is only partially revealed in these two examples of cultural treatment: invocation of the gods and separation from elements of degradation. Yet, what both studies tell us is that nature presents a problem. How effective then is the role of spirituality in effecting a mind-body balance? Again, we look to Kyziridis:

The origins of many enlightened treatments may be found in the Greek and Roman period. Asclepiades advocated the use of music and invented a swinging bed designed to relax the agitated patient. He regarded mental disorders as stemming from emotional disturbances (passions of sensation). Cicero rejected the Hippocratic bile theory stating that emotional factors could cause physical illness. He believed that man could help with his own cure through philosophy. Soranus, in the 2nd century, suggested that patients should be housed in light and airy facilities. He believed that corporal punishment should not be used, and emphasized the importance of the physician's relationship with the patient and believed that it was important to understand the social environment to gain a full understand of the patient. Therapuetuic interventions by the Romans tended to be humane and emphasis was placed on warm baths, massage, and diet (p. 43-4).

However, shock and inhumanity were also prevalent: electric eels were used as shock devices, and "Cornelius Celsus suggested that starvation, fetters, and flogging would help to stir up the spirit. He justified these means on the belief that the anger of the gods caused these maladies" (Kyziridis, p. 44). Such a viewpoint had more in line with the sacrifice of Agamemnon's daughter to pay for the king's indiscretions than with the rationalistic inquiries of Greek physicians. Despite the cruelty in Celsus' method, his premise was not without historical precedent.

Then there is Aristotle, whose works (and those alleged to be by him) constitute a wealth of information concerning the betterment of man's condition. Aristotle's definition of catharsis -- a purifying of the emotions -- gives some clue to the link between formation, morality, and spirituality. Achievement of the cathartic effect was of the highest importance in Greek drama, which provided the world the first golden age of theater: the works of Aeschylus, Sophocles, Aristophanes, and Euripides are the classic texts left from antiquity, through which the medieval world learned the wisdom of the Greeks.

The Greek drama festivals, in fact, were intimately united with the rites of religion, as David Allen White (2000) shows. Just as the medieval mystery plays would be performed in conjunction with Church services, often providing a religious story in dramatic form prior to the celebration of Mass, the Greek dramas were performed in conjunction with the formalized rites of the cult of Dionysus: "An essential part of the rites of Dionysus was the dithyramb. The word means 'choric hymn'…It began as a part of a purely religious ceremony, like a hymn in the middle of a mass describing the adventures of Dionysus…For more than a generation after its introduction the dithyramb attracted the most famous poets of the day" (Guide to Ancient Greek Theater, 2004).

As James Rachels (1997) states, "Aristotle thought that such universal elements of human experience provided the basis for an ethic that was not simply local to one culture" (p. 25). Thus Aristotelian Ethics are based upon the concept of universals -- which is another way of saying natural law. Virtue is defined as "excellence in fulfillment of a particular function," or as a good habit. Through virtue one may attain a state of happiness. Nonetheless, because mankind is inclined to follow feeling over reason, he is easily swayed by his passions rather than by his intellect, and allows himself to form bad habits in hopes of attaining happiness, which however remains elusive as long as his habits remain bad. As Aristotle notes: "The soul of the student needs to have been prepared by habits for enjoying and hating finely, like ground that is to nourish seed" (Cahn, ed., 2002, p. 291, Nicomachean Ethics).

Plato's Republic also offers a glimpse of virtue ethics. The four cardinal virtues of wisdom, justice, fortitude and temperance are detailed by Plato -- followed later and adopted by Christianity and accentuated by the theological virtues of faith, hope, and charity.

The modern tendency to subjectivity, however, confuses the question of what is good and what is bad -- and Richard Weaver laments the loss of universals at the hands of the philosophy of William of Occam -- which he calls the beginning of the end of Western civilization (p. 7). Nonetheless, that same civilization criticizes the objectivity with which Aristotle and Christianity could claim to know what was right and what was wrong. Like Hamlet, the first modern man, we are all doubters and skeptics now, and our philosophy is Kantian and crude: we can only know our perception of things, not necessarily the things themselves. We rely upon empirical data to prove what our intellect should already be able to conclude. The problem of studying the role of spirituality in the treatment of depression stems from this point: empiricism cannot effectively gage such a role (Cohen, 2000, p. 42, cited by Farah, McColl) -- and according to the Kantian principle, it is impossible for universals to exist. Therefore, a return to the practicalities of medieval scholasticism is recommended.

The medieval European focus on mental disorder took into account the spiritual more fully and more rationally than any other civilization of any other era. What is often referred to as a Dark Age, was not so because of any Christian superstition -- rather it was because the foundations of the Roman Empire had given way to the attacks of barbarism. It was the uncivilized influence of invading barbarian tribes that rendered the times dark, not the philosophically and theologically sound doctrines of the early Church.

Christianity, in one sense, owes a debt to Aristotelian ethics -- after all, it was St. Thomas Aquinas who used the pagan philosopher to reconcile faith and reason in his medieval opus Summa Theologica. All the same, Christianity is founded not upon Greek philosophy, but upon Christ Himself -- both his teachings and his works. Still, as the medieval scholastics showed, the Christian worldview is one in which, as St. Basil said, we may "trace out a kind of rough sketch, as it were, of what virtue is according to the teaching of the pagans. For by those who make it their business to gather the benefit to be derived from each source many accretions from many sides are won't to be received, as happens to mighty rivers." Here we present an analysis of the Christian worldview as well as an explanation of Aristotle's virtue ethics.

According to Church doctrine, the universe is both material and immaterial. The prime example of this is man, made of both body and soul. However, because of Original Sin, nature is not what it should be:

By his sin Adam, as the first man, lost the original holiness and justice he had received from God, not only for himself but for all humans. Adam and Eve transmitted to their descendants human nature wounded by their own first sin and hence deprived of original holiness and justice…As a result of original sin, human nature is weakened in its powers, subject to ignorance, suffering and the domination of death, and inclined to sin. (Catechism of the Catholic Church, p. 416-18).

Mankind, however, is not doomed to suffering: an abundance of grace has been guaranteed through the person of Jesus Christ. In fact, Christ, the Second Person of the Holy Trinity, directs the events of the universe for a good end: God, also known as Providence, allows evil to happen for the reason that some good may come of it: "For though he wounds, he also bandages. He strikes, but his hands also heal" (Job 5:18).

Human beings, according to the tenets of Christianity, are created by God, as narrated in the Book of Genesis. Adam, the first man, was made from dust, and his soul was breathed into him by God. Eve, the first female, was made from Adam's rib, and was created to serve as his companion. Christian mythology states that Adam and Eve were created to be happy in a garden of earthly delight -- but that misery and suffering befell them and all their progeny as a direct result of disobedience: they failed to obey the one command of God -- namely, that they should not eat the fruit of the tree of the knowledge of good and evil. Their sin of disobedience violated the harmony in the earthly garden, and Adam and Eve and all their children now had to grow old, suffer concupiscence, and die -- whereas prior to their sin they were to be assumed into Heaven. Heaven was closed to mankind, and mankind awaited the coming of the Redeemer, by whose virtue Heaven would be restored to them (Baltimore Catechism No. 1, 1885, 39. Q-91. Q).

Thus, the age of faith directly related suffering to sin: and death was viewed as the separation of the soul from the body. Because the soul is immaterial and not composed of parts (as Aristotle tells us), it cannot die (Smith, trans., 2006, p. 28). But the body, which is composed of parts that break down -- does decompose and return into dust. However, according to Christian theology, the soul comes before God to be judged. If the soul departs from the body while still in the state of grace, it goes to Heaven (by virtue of the passion and death of Jesus Christ, who opened the gates of Heaven and redeemed the fallen human race). If there is no life of grace in the soul -- if, in other words, the soul has rejected God, it is damned to eternal suffering. The tenets of Christianity, grounded in the concept of the Resurrection, affirm that the body will rise again (just as the body of Christ rose from the dead) to be rejoined with the soul wherever it is at the end of the world -- whether in heaven or in hell. This, as Fellay tells us, serves as the basis for the medieval sense of God.

God, therefore, is the prime reality -- and to be united to God is the purpose of man's life. Here, we return to the theme established by Fulton Sheen: if man is depressed, it is because he has forgotten his purpose in life; his purpose is to be united to God: God is essence itself. If life is worth living, it is only because it is to be lived for God -- God who is: omnipresent, omnipotent, all-knowing, all-seeing. Anselm states in the Proslogium that God is "that than which nothing greater can be conceived" (Deane trans., 1903, p. 6). Because God created the world, it is ordered to a natural law -- but through sin, nature is corrupted.

The age of faith, therefore, acknowledged the relation of mankind to God -- an acknowledgement that would have had profound effects on the treatment of depression: human beings are made in the image and likeness of God, as recorded in Genesis. And after death, we come before the seat of God to be judged accordingly. We know through faith and reason: as Aquinas tells us, faith rests upon reason (McInerny, 2004, p. 58). Thus, we are not doomed to skepticism: rather, man is endowed with an intellect so that he may know God. Accordingly, we may know right from wrong by virtue of the natural and the supernatural law, given to us by God through tradition (Moses and Christ and the Church) and through the literature of the Gentiles, whom Basil, a father of the Church, recommends. The purpose of life is not to make a paradise on earth but store up your treasure in heaven -- or, as the Baltimore Catechism No. 1 (1885) puts it succinctly, to know, love, and serve God so that we may be happy with Him in the next life (Lesson First: On the End of Man, 6. Q.). Here, essentially, are the tools for introducing the role of spirituality (as it predominantly served to bolster the formation of Western civilization) into the treatment of depression.