A Physician’s Personal Experience-The Gift of Depression

Depression is an insidious, ugly beast, creeping into the mind over time until one is engulfed and powerless, feeling only a sense of futility and heaviness. In my case it came some months after I had had to retire from a fruitful and enjoyable academic neurodevelopmental pediatrics practice, because of onset of a degenerative neuromuscular disease. My depression was manifested mainly by weight loss, poor affect, anger and irritability, fitful sleep, and thoughts of suicide. Luckily, my primary physician recognized the signs immediately and recommended both pharmacotherapy and psychotherapy. For both therapies and for this physician, I am extremely grateful. However, in this essay, I will speak of the ways I experienced psychodynamic psychotherapy and its ramifications into many parts of my life.

I am certain that with pharmacotherapy alone I would feel far less depressed today than I did 3 years ago. However, psychotherapy has provided me with new knowledge and an understanding of the underlying roots of and predispositions to my depression. In addition, I now understand more of the immature patterns of my behavior that remain parts of all of us and can lead to unwelcome consequences. More than this, I now know more clearly how the intimate sharing of thoughts between 2 people in a secure environment can heal. I appreciate even more that I can both give and receive love in my life despite being disabled physically.

Pharmacotherapy alone would not have given me these gifts. These understandings have provided me with a sense of strength and ease as I deal with aging and loss. I am better able to face further incapacitation and death, as well as to enjoy what time I have. In addition, the therapeutic relationship that I developed with my psychiatrist is sacred and confidential-a caring relationship that gives me time for discovery; critique; questioning; and emotional, spiritual, and intellectual freedom. I wish the process to continue until I have shaved off the top layers of consciousness and have reached more of the core below, so that unlike finding the treachery and danger of the lower four-fifths of an iceberg, I continue to understand more and more of my underlying motivations and unconscious will with awe and gratitude.

The work of 2 people

Everyone knows what a material gift is, but why should I call a process, and especially one that involves such personal vulnerability and hard work, a gift? What is the ultimate purpose of working to overcome depression, rather than only changing the serotonin, dopamine, or norepinephrine levels in the brain?

I believe that the process of 2 people working to overcome depression becomes a gift when the patient comes to find (1) success in the process; (2) previously undiscovered insights into the causes of depression; and (3) that one always has meaning in life and gifts to give to others, including one’s therapist. There is no serious therapist alive who has not learned from his or her patients. Part of this, of course, depends on there being a good intellectual and emotional fit between therapist and patient, and the desire of both parties to work toward understanding and healing.

Because of the challenge of this process and the feeling of hard-won reward when breakthroughs are made, as well as the positive effects on my life and my feelings about myself, I consider my work with my psychotherapist a supreme gift. Because my depression brought me to this, it was a gift. And because I am a conscientious student of the process, I believe I am a gift to my therapist, to others, and to myself.

Doing things well

I have learned that being a gift to anyone has always been a difficult thing for me to acknowledge. I have always felt that I have not given enough. The fact is, I have done things well, although imperfectly. And doing things well enough makes it possible to give many gifts-to love one’s husband and children well; to do one’s chosen profession well; to share one’s life with others well through understanding one’s own feelings well.

Doing things well does not mean being perfect, nor does it presuppose having a perfectly orchestrated life. Doing things well does not mean having perfect relationships. Likewise, doing things “perfectly”does not make life perfect. Perfection, after all, is an expensive illusion. Unfortunately, expecting perfection, of ourselves and of others (whatever our concept of it), contributes to feelings of being let down or of letting others down. These feelings can accelerate over time, leading to guilt and depression. Once the concept that doing things well enough can be good enough for a meaningful life is part of our inner being, we become better at accepting ourselves and being good to others.

A life of meaning-love and sacredness in relationships

Love has nothing to do with knowledge, education, or power; it is beyond behavior. It is also the only gift in life that is not lost. Ultimately it is the only thing we can really give. In a world of illusions, a world of dreams and emptiness, love is the source of truth.¹
-Elisabeth Kubler-Ross 

While I have always made it a point to share the most important parts of my psychotherapy with my husband, to make him aware both of my current thoughts and of my progress, there have also been other people in my life with whom I share meaningful aspects of my feelings and thinking.

People with whom I relate in this way give great meaning to my life and are gifts themselves. The sharing in these relationships is basically intimate and bilateral, full of meaning and involving trust and commonality of interests. These relationships are unguarded, truthful, safe, intellectually and emotionally intimate, and confidential when necessary. They are sacred relationships. What do such friendships offer? Why can having sacred friendships help prevent depression?

First, these close relationships are sacred because they are accepting. Second, the communications in these relationships frequently simulate some of the aspects of psychotherapy by virtue of their intimacy, openness, and allowance of emotional expression.They differ from communications with a spouse by eliminating the caring spouse’s frequent need to “solve the problem.”

Often my sacred friends are available only to listen; but, in addition, my really observant friends notice changes in my mood and help to alleviate pain and suffering. My friends would most likely notice signs of suicidal intent. My good friends offer understanding, suggestions, and reassurance. These friends also enhance fun, recreation, laughter, and relief. Thus, the person without truly sacred friends is indeed bereft, and such loneliness inhibits recovery from depression.

Finding new joys

It might seem that a neuromuscular degenerative disease does not provide many avenues for laughter. I rarely laughed when I was depressed, but now I find that laughter is one of the best responses to otherwise annoying situations-long waits at doctors’ appointments, difficulties in managing basic physical needs, and requiring mechanical devices to do what I used to do effortlessly. I use a power wheelchair now, and some of my very best friends have given me a decorated bicycle helmet that is hilarious to look at, preposterous to wear, and always good for a laugh when shown off to family and visitors.

We have to remind ourselves that even in seemingly senseless and painful situations, there are ways to find fun as long as we are sentient and communicative. Art Buchwald, who died in 2007 at the age of 81, spent most of his life finding ways to make us all laugh. Interestingly, he and a number of his well-known colleagues suffered at various times from severe depression. He always managed to write and speak with wit and great feeling. In explaining why he was not invited to the wedding of Grace Kelly and Prince Ranier, Mr Buchwald responded that “the Buchwalds and the Grimaldis have not spoken since January 9th, 1297.”² Furthermore, Mr Buchwald used his illness as a source of humor by managing to live longer than was predicted and to spend considerable time in a hospice without dying there. He is quoted as having said, “The National Hospice Association made me man of the year. I never realized dying was so much fun.”²

Depresssion with disability-learning acceptance, compromise, and dignity

It would not surprise most of us to think that people with severe, life-changing diseases and disabilities might become depressed. In essence, living with chronic disease means, as Blair Justice³ notes in A Different Kind of Health, a “shifting of identity.”He states, however, that “studies show that people can be both fully aware of the severity of their physical condition and retain a sense of well-being.”

For some of us, attaining this sense of well-being takes a long time and considerable effort. It is natural to define ourselves by our illness, especially when the illness involves many hospital visits, painful treatments, uncertain diagnoses, doctors who have differing opinions, and decreases in energy that make days short and opportunities for relief limited.

I have found that I can decrease illness as my identity and reduce my depressive feelings by making new friends in many venues and by inviting people with special talents in art, photography, music, and writing to join us in our home and at some of my longer visits for medication infusions. Examining new ideas gives me a sense of well-being and the ability to maintain my dignity while still accepting compromises in my daily life.

As one of my favorite teachers showed me, a major means of coping was eloquently stated by T. H. White⁴ in The Once and Future King:

“The best thing for being sad,”replied Merlyn, “is to learn something. That is the only thing that never fails. You may grow old and trembling in your anatomies, you may lie awake at night listening to the disorder of your veins…There is only one thing for it then-to learn. Learn why the world wags and what wags it. That is the only thing which the mind can never exhaust, never alienate, never be tortured by, never fear or distrust, and never dream of regretting…"

Continuing creative projects

I have been a photographer for many years, exhibiting my black-and-white photos, and sharing ideas with other photographers. Therapy has had a remarkable influence on my concepts for my photography. I express my feelings and my insights metaphorically through my photos. Photography is challenging and a way to look toward the future during a time that is full of uncertainty and pain. Although my mobility is limited, I can make photos of objects of beauty and symbolism, such as this surreal window that, for me, suggests looking onward and forward, although the path to insight may have many layers.

I also write poetry, and even in my darkest moments when I write my poems, I find out more about myself and my “less conscious”person. This poem is an example of this process.

I Dream
I dream I am walking
walking and running
I dream I am running
until I am breathless
and I stop running.
I dream I am swimming
swimming and diving
First from the low boards,
then from the high.
I dream I am dancing
dancing and sweating,
dancing in time to the
music of fast dancers;
I dream I am sleeping
sleeping exhausted,
sleeping unaware
sleeping deeply,
sleeping until
I dream again,
dreaming I am floating
dreaming I am dreaming
knowing I am not dreaming. (2006)

Accepting help when needed

One of my largest losses has been foregoing driving because of the effects the disease has had on my eye muscles. My therapy has helped me accept both my limitations and having to have a caregiver take me where I need to go, as well as help me with daily needs. This care has made it possible for me to have the energy to continue to show my photographic work in different places and to experiment with new photographic processes.

Dealing with the past and unhelpful family relationships

We are all products of our past relationships and happenings, our reactions to them, our ways of coping, the degree to which we have held on to “immature reaction patterns,”and the amounts of affection or dysfunction we experienced in our growing years. It is certainly possible to find out, even as we age, that parents, siblings, or spouses have problems that prevent them from sharing love easily. This can be especially true for one’s elderly parents who suffer strokes or have dementia.

Having a loved family member reject us when we reach out to him or her, especially as we climb the ladder from depression to hope, is tremendously painful. Whether the causes involve old hurts or jealousies, lack of communication for long periods, or fear and guilt regarding the disease process, the result can be an even greater difficulty in communication and an increase in sadness for both people.

When this involves the relationship with an aged parent, both psychopharmacological and geriatric psychotherapy can be very helpful.

Anger and resolution

Regardless of our wish for equanimity, anger is also a natural part of life, a normal reaction to the bad things that happen to us, to things we cannot control, to the death of a loved one, to one’s own or another’s disease, and to other significant losses.

Anger is a normal response, but if allowed to become overwhelming, can be destructive, can be “turned inward”along with guilt and can contribute to depression.

In Harold S. Kushner’s⁵ book, Overcoming Life’s Disappointments, he writes of an interpretation of Moses’ striking of the rock to get water in the desert for his tired and hungry brethren. This interpretation is that Moses is not frustrated and angry at his people for being so demanding of him, but rather, that he is angry at God for having imposed an “impossible burden”on him. The result is that Moses does not live to see the promised land to which he has been leading his flock for 40 years.

We, like Moses, have reasons to be angry at our “impossible burdens”-our diseases, our losses, those who have slighted us. But as Harold Kushner⁵ points out, we can prevent our anger from becoming a major and self-defining issue. Psychotherapy can help us learn harmless ways to vent anger, other than subjecting our spouses and family members to our temper, our sarcasm, or our withdrawal.

Gaining empowerment

Forgiveness is a necessary part of coping and of becoming empowered. Forgiveness and letting go of old hurts and disagreements can help tremendously in relieving tension and decreasing depression. As I have learned in my therapy, this does not mean that earlier hurtful behavior is excused, or forgotten, but it can be looked on with perspective, and sorrow, rather than with revenge or guilt. The more loving I can be, the more empowered I then become. The more I let go of old sorrows and disappointments, the easier it is for me to look forward, without denying the realities I am facing.

Other ways I become empowered include (1) continuing to learn; (2) keeping in touch with friends and family to avoid isolation and to gain the perspectives of others; (3) learning new ways to communicate-both physically and emotionally (I have a voice enhancer to enable me to speak when my vocal cords and surrounding muscles weaken, as well as a voice-directed and eye-directed computer system); (4) continuing to find ways to both give and receive love and realizing that the possibilities for both are endless.

It is empowering, although sometimes difficult, to tell others how much we appreciate or love them, or how much they have influenced our lives. I am finding it extremely helpful to take the opportunity-to make the opportunity-to do this. I felt much better after I told a dear teacher and loving friend how much her mentoring influenced my career and my success, something she had not truly realized.

Dealing with the inevitability of losses and our own mortality

Acknowledging the people we care about while they are still alive helps alleviate the feelings of “I should have told her” that often occur after a beloved friend or relative has died. This leads to one of the most difficult parts of living, whether with disability, depression, or not-the deaths of colleagues, friends, and relatives. Realizing that death is a natural part of the life cycle is easy to say, but, in reality, we are all overwhelmed by its finality. This is true even though throughout my life death has been an accepted family event, not only in older members of the family, but in 5 boys affected by the genetic disease that I share. The finality and often the rapidity of death of a beloved friend or loved one causes grief, retrospection, and introspection for me. I remember the past life we shared and my feelings of what we still could have given each other. Of course, I find myself thinking of my own disease process and the probable lessening of the length of my own life.

It is said that we have to “move on,”after the death of a loved one has been integrated into our sense of reality . . . and we do move on. But do we move on completely? Or should we endeavor to recover and keep the love of lost relationships?⁶ Does the essence of a person that lingers with us and made possible such a relationship end at death? The death of a loved one remains a loss with us forever. Contemplating the permanence of death thoughtfully helps me become at ease with the truly indefinable concept of infinity, and makes this life, however limited, more valuable.

If death is a state of “nothingness,”then we should consider that we were in a state of nothingness before we were conceived. Likewise, in the deepest stage of sleep we are totally unaware of our own being and, as during anesthesia, we are not conscious, but we are not in an unpleasant state. This state is probably much like death. However, there is a basic difference between our deaths and our previous nothingness: we WILL HAVE BEEN alive, and we WILL HAVE left part of ourselves hereafter. Whether this part of us is a soul, our thoughts, or a memory in the mind of a child, it is real and increases the sacredness of the life we are permitted to have. It makes our life on earth precious and our deeds on earth meaningful.

It seems imperative to me to enjoy my impermanence and to make the most of it. This is why it is important for me to relieve my depression and continue my processes of mental and emotional discovery. I am learning to gratefully accept help from others when I need it, and I am coming to grips with my feelings and ideas about mortality so I can achieve a death that is welcome, kind, and dignified. Accepting the certainty of physical decline seems to enhance the possibility of finding my soul while I am still alive, and sharing it, finding those parts of me that are most meaningful, and making my life more sacred to others. Even in my darkest moments, I am uplifted, and I feel fewer burdens from my losses when I read Pablo Neruda. Here is a portion from his poem, “Oblivion”⁷:

I shall go on marching, opening broad roads against the shadow, making the earth smooth, spreading the stars for those who come. Stay on the road. Night has fallen for you. Perhaps at dawn we shall see each other again.

References:

References

1.

Kubler-Ross E, Kessler D.

Life Lessons.

New York: Scribner; 2000:31.

2.

Severo R. Art Buchwald, whose humor hit the powerful, is dead at 81.

New York Times.

January 10, 2007.

3.

Justice B.

A Different Kind of Health.

New York: Peak Press; 1998:31.

4.

White TH.

The Once and Future King.

>New York: GP Putnam and Sons; 1958:185-186.

5.

Kushner HS.

Overcoming Life’s Disappointments.

New York: Alfred A. Knopf; 2006:157-158; 1-3.

6.

Vaillant GE. Love. In:

Spiritual Evolution: A Scientific Defense of Faith.

2008:82-101.

http://www.adm.monash.edu.au/community-services/counselling/positive-psychology/posemotionvaillant.pdf.

Accessed May 14, 2009.

7.

Neruda P. Oblivion. In:

The Captain’s Verses.

Walsh DD, trans. New York: New Directions; 1972:83.

Dedications

This essay is dedicated to my always loving husband, Milton; to the memory of the gentle questions of the late Dr Chris E. Sermas; to the joy of reality, wit, common sense, and knowledge of pharmacology of Dr Herbert I. Dorfan; and especially, to the caring thoughts, teaching, wisdom, and spirit of Dr James W. Lomax. I am grateful for the careful editing and reviews by Dr Earle Silber and Rabbi Roy Walter.

This essay has been shortened to fit the requirements of the Psychiatric Times.Please contact the author by e-mail (jgfinegold@aol.com) if you would like a copy of the original essay.