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
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
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.
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 ([email protected]) if you would like a copy of the original essay.