Sitting with Depression

Depressed people think they know themselves, but maybe they only know depression.

By Mark Epstein

A woman named Sally called me not long ago seeking advice. I had seen her for a single session in consultation months before, and we had talked about a variety of therapeutic and spiritual issues. Like many people with an interest in spirituality, she was suspicious of the role of psychiatric medications in today's culture. It seemed like the mark of some kind of Brave New World to have mood-altering drugs so readily available. But like many others, Sally wondered if there might be a medicine that could help her. She had been plagued with chronic feelings of anxiety and depression for much of her adult life, and despite a healthy investment in psychotherapy, she still felt that there was something the matter with her. When I spoke with Sally the second time, she had been taking a small dose of an antidepressant for several weeks, 25 milligrams of Zoloft, and she was finding that she felt calmer, less irritable, and, dare she say, happier. She was going on a two-week meditation retreat later that month. Something about taking her medication while on retreat made Sally uncomfortable, and that was the reason for her call. "Perhaps I should go more deeply into my problems while I'm away," she said. She worried that the antidepressant would impede that process by making her problems less accessible to her. "What do you think?" she asked.

Let me be clear right from the start that there is no universal answer in a situation like this. Some people notice when they take drugs like Prozac, Paxil, or Zoloft, antidepressants of the SSRI (selective serotonin re-uptake inhibitor) variety, that they feel cut-off from themselves as a result. They don't feel their feelings quite so acutely and sometimes report feeling numb. Some, both men and women, find that the drugs interfere with their ability to reach orgasm. Many others find that the damping down of their feelings is more subtle. One of my patients notices she no longer cries in movies, for example, but she is willing to accept this because she also no longer worries to the point of exhaustion about things she can do nothing about.

I was relieved to hear that Sally was feeling better. People who respond well to these antidepressants often have none of the side effects mentioned above. Instead they feel restored, healed of the depressive symptoms that they were expending so much of their energy trying to fend off. Less preoccupied with their internal states, they are freer to participate in their own lives, yet they often wonder if they are cheating. "This isn't the real me," they protest. "I'm the tired, cranky, no-good one you remember from a couple of weeks ago." As a psychiatrist, I am often in the position to encourage people to question those identifications. Depressed people think they know themselves, but maybe they only know depression.

Sally's question was interesting not only because of the drug issue but because of her assumptions about the nature of spiritual work. The notion that we need to go more deeply into our problems in order to be healed is a prevalent one, and one that, as a therapist, I am sympathetic toward.

Certainly, ignoring the shadow side of our personalities can only lead to what Freud once called the "return of the repressed." Yet it struck me that there was a remnant of American Puritanism implicit in Sally's perspective, or at least a Judeo-Christian tendency to divide the Self into lower and higher, or better and worse.

When people believe that they are their problems, there is often a desire to pick away at the Self. People think that if they could just admit the awful truth about themselves they would start to feel better. But going more deeply into our problems can be just another variant on trying to get rid of our problems altogether to return to a state of original purity like the Garden of Eden. While most therapists would probably deny a religious influence on their thinking, many collude unconsciously with this mode of thought. Going more deeply into one's problems is the standard approach of most therapies, and it can lead to a kind of sober honesty and humility that gives people a quiet strength of character.

But to go more deeply into our problems is sometimes to go only into what we already know. I was sure that Sally did not have to go looking for problems on her retreat. Retreats are difficult enough even for people who are not depressed.

Sally's unresolved issues would come rushing in to fill every space whether she took her antidepressant or not, but she might have more success in not being sucked in by them with the medicine inside of her.

I told her that at this point I felt she needed to come out of her problems, not go into them more deeply, and that the antidepressant should not get in her way in that regard. To be overwhelmed while on retreat would not be useful. As a therapist influenced by the wisdom of the East, I am confident that there is another direction in which to move in such situations: away from the problems and into the unknown. If we stay with the fear this often induces, we have a special opportunity to see our own egos at work, defending against the unknown while hiding out in the very problems we claim to want freedom from. Buddhism is very clear about how important it is to move in such a direction.

The Buddhist writer and translator Stephen Batchelor, in his austere new book on the teachings of a third-century Indian philosopher-monk named Nagarjuna, Verses from the Center: A Buddhist Vision of the Sublime (Riverhead Books), eloquently describes how the mind can be set free of all constraints in meditation. He tells of how the eighth-century Indian monk Shantideva, author of A Guide to the Bodhisattva's Way of Life, was liberated upon uttering the following words: "When neither something nor nothing/Remains to be known,/There is no alternative left/But complete non-referential ease."

Rather than going more deeply into his problems, Shantideva learned how to disentangle his mind from them. This is an approach that Western therapy has little experience with, but it is the foundation of Eastern wisdom. The contents of the mental stream are not as important as the consciousness that knows them. The mind softens in meditation through the assumption of a particular mental posture called "bare attention," in which impartial, nonjudgmental awareness is trained on whatever there is to observe. Problems are not distinguished from solutions; the mind learns how to be with ambiguity.

The imagery that describes this transformation in classical Asian cultures is revealing. When nourished with meditative awareness, the mind unfolds like a lotus, symbol of the primordial Buddha-nature that is obscured by our identifications with our problems. Buddhas themselves sit upon a lotus throne, symbol of a mind that contains everything but holds nothing. The lotus is another way of evoking the womblike nature of emptiness or sunyata, whose translation is literally "pregnant void." In Batchelor's book he describes how the understanding of emptiness "eases fixations," another way of talking about freeing the mind from an obsession with "problems." A translation of the Sanskrit prapanaca, "fixations" take root when we turn fleeting and ephemeral pleasures or displeasures into objects that we then try to hold on to.

They are evidence of a kind of psychological materialism that holds us as much as we would like to hold it. Sally felt that she should go more deeply into her problems, not to understand their empty nature, but to admit the awful truth about herself. But this sort of truth-seeking masked a continuing attachment to the kind of person she thought she should be: a person without problems.

We are freed from our problems, I have learned, not by going into them more deeply, but by knowing the empty and womblike nature of our minds. Sally did not need to make Zoloft into another problem. She could use it, rather, to help unfold her lotus mind in meditation.

Mark Epstein, M.D., is a psychiatrist in New York and author of Thoughts without a Thinker: Psychotherapy from a Buddhist Perspective (Basic Books, 1996) and Going to Pieces without Falling Apart (Broadway Books, 1999). He's been a student of Buddhist meditation for 25 years.