Causes of Depression

One set of questions arises around why someone has become depressed. The prevailing popular view sees depression simply as misfortune, and not the fault of the depressed person. However, both religion and psychology are willing to consider that it might be more complicated than that, and that people might, to some degree, be responsible for their own depression.

The recent psychological literature has widely embraced a “diathesis–stress” model, which sees depression as arising from an interaction between preexisting vulnerability factors and their current circumstances (Alloy and Abramson ). There seems to be some scope for those who are vulnerable to depression to take action to reduce that vulnerability. Indeed, it seems to be one of the advantages of tackling depression with psychological methods rather than medication that it is more likely to make someone less vulnerable to depression.

Religion is also sometimes inclined to regard depression as arising from sinfulness or lack of faith (Bringle ; Webb ), though the relevant religious literature partly predates the use of the modern category of “depression” and uses other terminology. It can be unhelpful, in pastoral terms, to say to someone who is depressed that they are to blame for how they feel. However, it would be possible to reframe the widely accepted diathesis–stress model in a way that incorporates a spiritual perspective. It seems entirely plausible to suggest that vulnerability to depression includes personality characteristics that can be framed in religious or spiritual terms.

This raises interesting issues about guilt. Being excessively guilty is psychologically harmful, as twentieth‐century psychology has made us very aware. “Neurotic” or irrational guilt, in which people become excessively guilty about a wide range of things, can be very debilitating. But Christians would not want to conclude that guilt is always bad. There is a proper and helpful place for the recognition that a person has done wrong and needs to improve, a place for what Christians call “repentance.” Realistic guilt can help people to become better adjusted, and to behave in ways that are in everyone's best interests (Ivimey ; Watts ). It is quite difficult to find a middle way between being excessively guilt‐ridden or excessively complacent about ourselves. Guilt itself is multifaceted and has both cognitive and emotional aspects. It is the cognitive aspect, a recognition that one has done wrong, that is perhaps most valuable, and the emotional aspect of guilt that is most likely to run to excess.

The Constructive Role of Depression

However, the point where the religious perspective differs most sharply from the prevailing view that depression is a severe misfortune is over the promise and possibility that depression brings. This is encapsulated in the book title Depression as a Spiritual Journey (Sorrell ). The idea that depression indicates that the person concerned has important needs that are not being met would be quite widely accepted by psychologists. However, a religious perspective probably places unusual emphasis on the opportunities for personal and spiritual growth that depression creates.

Depression is characterized by negative thinking, about the world, the self, and the future (Beck et al. ). That is not at all the outlook to which faith leads, but neither does faith necessarily lead to the antithesis of negative thinking. Faith doesn't lead to the kind of excessively negative thinking that saps motivation, but neither does it lead to the kind of rosy optimism that doesn't recognize the reality of problems and difficulties. I suggest that faith leads to a commitment to balance and objectivity, rather than to an unremittingly positive outlook.

There is an intriguing phenomenon known as “depressive realism” (Alloy and Abramson ). The judgments of depressed people (for example, about how they are regarded by others) can be more accurate than those of people who are not depressed. The formal evidence for this is somewhat inconclusive, but it is supported by the claim of some people with a depressive outlook that they are seeing things more accurately than others, without a distorting rosy glow. That can lead them to see their depressive outlook as a kind of virtue.

There can be a path between the negative thinking that is characteristic of depression and the overpositive thinking that is often an alternative to it, what psychoanalysts might call a “manic defense” (Klein ). Something similar emerges from research about coping styles. Negativity doesn't help people to cope, but neither does it help to pretend there are no problems and challenges (Meichenbaum ). The most helpful stance is to recognize that there really are problems, but still to think you will be able to handle them.

Similarly, faith does not lead either to optimism or pessimism; it eschews both. However, faith does lead to hope; but hope is very different from optimism, as Terry Eagleton has argued in his recent book on Hope Without Optimism (Eagleton ). Hope is much more flexible and versatile than optimism. It does not depend on circumstances being favorable; indeed, it can come into its own when circumstances are very unfavorable. That is evident in how Victor Frankl found ways to maintain hope in a Nazi concentration camp (Frankl ). Hope seems to be more a general attitude or disposition than a prediction about what is going to happen. It also carries a commitment to work for a better future. Optimism is rather passive; it just takes stock, and predicts what is going to happen. Hope, in contrast, transforms the future.

Depressed people are negative about many things, and Beck et al.'s () triad of being negative about the world, oneself, and the future is well known. But there may be another kind of negativity that is especially pernicious, when you get depressed about being depressed (Segal et al. ). There are indications that it is when people get into that kind of second‐order negativity that depression gets a grip, and becomes difficult to escape from. It seems to make depression self‐perpetuating and less sensitive to changing circumstances.

How easily people become depressed may depend on their attitude to depression. I suspect that there have been cultural changes in the West over the last century, and that people now expect at least to be content, if not happy. So, it becomes a real problem for someone if they are not content; they start to feel that it is unacceptable and get upset about the fact that they are unhappy. I suspect that there is a vicious circle going on here. The more you expect to be content, the more easily you can get locked into depression. Expecting to be happy may actually make you more vulnerable to depression.

If that analysis is anything like correct, the solution lies in a measure of detachment. If you accept the Ignatian approach, that what matters is how close to God you are, not how happy you are, then you may actually be less vulnerable to depression. Mindfulness explicitly fosters this kind of detachment, which is probably why it enhances the effectiveness of psychological treatment of depression (Segal et al. ). It trains people to avoid the kind of second‐order judgmental thinking, of which being depressed about being depressed is a particularly pernicious example.

Other Problems

I suggest that it is not only depression that can be the starting point for a spiritual journey. In fact that is probably true of all mental health problems. I will illustrate that with two brief examples. The first is worry or, in more technical language, “generalized anxiety disorder.” In an interesting chapter on worry, Christopher Cook (Cook in press) has pointed out that the situations that trigger worry are similar to those that trigger prayer. They are both responses to challenging circumstances and to uncertainty. That leads to the interesting idea that they might function as alternatives; if people prayed more they might worry less. Both are ways of thinking through difficult circumstances, but prayer is more constructive than worry and can contribute to adjustment (Watts ).

Addiction also raises interesting issues, and again Cook () has done helpful work. He rejects the moralistic approach to alcoholism and instead develops an alternative theological account around the divided self. Those who are addicted to alcohol are often divided about it, partly wanting to be free of their addiction but partly still in thrall to it. There is a compulsiveness about addiction, as there is too much sin (McFadyen ) that coexists alongside good intentions, something on which Saint Paul reflects in Romans 7. A constructive resolution of this kind of divided personality often seems to be a spiritual process, either implicitly or explicitly; there is a close analogy between the “twelve steps” process of Alcoholics Anonymous and the religious life. In this sense, addiction is also often the starting point for a spiritual journey and involves embracing virtues such as discernment, honesty, dignity, community, responsibility, simplicity, and “loving our longing” (May ).

The Broader Debate

I do not think a spiritual approach to psychosis needs to be an alternative to the medical approach. Emphasizing the importance of spiritual aspects of psychosis can equally well be seen as a broadening of the medical approach, just as emphasizing social aspects represents a similar broadening. I suspect that Clarke is motivated by a fear of reductionism, that if you accept the illness model of psychosis it will imply that the spiritual experiences entailed are “nothing but” symptoms of illness. However, I believe that we can accept the illness model of psychosis without drawing those reductionist conclusions, so I am less worried about the implications of adopting the illness model.

The most persuasive exposition of the antimedical, psychosocial approach comes from Richard Bentall (). It is beyond the scope of this article to attempt a detailed examination of the complex arguments involved, but I do need to indicate in broad terms where I stand on some key issues. I think Bentall makes a persuasive case, but one that is not wholly convincing.

I agree with him that the attempt to carve up the psychotic territory into a number of discrete illnesses has not really worked. The strongest distinction is that between schizophrenia and manic‐depressive psychosis, but even that often gets blurred. People with “schizophrenia” also often differ markedly from one another, but there is no agreed subclassification. We perhaps need to conceptualize psychosis in multidimensional terms rather than in discrete illness categories. However, I don't think that discredits the idea that something has gone seriously wrong with people who become psychotic in multiple ways.

I would also agree that many psychotic features can be found quite extensively in people who would never be diagnosed as having a psychotic illness. That is more true of some features than others. For example, hearing voices is found in many people who would not be considered to be psychotic. We now know much more about hearing voices, partly as a result of an extensive research program at the University of Durham (Fernyhough ). Hearing the voice of God is a common feature of the religious life (Dein and Cook ).

I think that the “symptoms” of schizophrenia tend to cluster together in a syndrome. Some can be found in other contexts such as hearing voices, but others (the so‐called “front‐rank” symptoms) are rarely found elsewhere. I am also impressed by the biological aspects of schizophrenia; it has biological markers, and responds to major tranquilizers, though that is not to say that it is exclusively caused by biological factors. Medication can play an important role in helping such people to function in a relatively normal way.

However, despite the fact that particular psychotic features are quite widely distributed in the general population, I still think it is true that there is a narrower group of people in whom multiple psychotic features can be found over a long period, and that such people often have serious problems in coping with life. They develop prominent negative symptoms and incapacities that are at least as disabling as their psychotic characteristics. I don't want to dismiss the idea that something has gone seriously wrong for such people, which is what the idea that they have an “illness” is trying to reflect.

The fact that phenomena like hearing voices can be found in many people who would not be classified as psychotic has led some to propose a continuous dimension, such as the “schizotypy” proposed by Gordon Claridge (). This seems to be a helpful move. However, for Claridge, one of the implications of someone having a high schizotypy score is that they are more likely to develop a psychotic illness. Claridge sees a causal link between the two, rather than seeing the concept of schizotypy as replacing that of psychotic illness.

Transliminal Experience

Clarke uses the word “transliminal,” a term first proposed by Michael Thalbourne (), for an alternative mode of consciousness, of which psychosis and spirituality can both be manifestations. It has connotations of crossing the border. Sometimes people suggest that spiritual and psychotic people are exploring different worlds or different realities. However, I prefer to talk about two different “modes” of consciousness (one psychotic/spiritual, the other ordinary and rational). I don't want to lapse into a new kind of dualism that postulates two different worlds, and to say that in one mode of consciousness we access one world, and in the other mode we access a different world.

I assume there is one world, but that we experience different aspects of it in different modes of consciousness, and there is a good deal that is accessible in the transliminal mode that is filtered out in the rational mode. We can potentially explore different aspects of it in different modes of consciousness. I see no reason to say that the world we know in our rational mode is real, but that the world we know in our transliminal mode is not. However, the transliminal mode is accident‐prone. It is venturing into domains where it is hard to be sure‐footed, and easy to get things wrong. In the rational mode, we are playing safer, exploring more limited territory, but being less error‐prone.

The idea of filters is helpful in understanding this different mode of consciousness. We never consciously experience everything that goes on in our information processing. It is widely accepted that there are two different modes of processing, one fast and with high capacity, but nonconscious; and another that is slower, conscious, and with much more limited capacity. Obviously, there is filtering that determines what gets into the conscious system; human functioning depends on cognitive “filtering,” or cognitive “inhibition” as it is sometimes called. There is widespread agreement that this filtering process is one of the things that goes wrong in psychosis. As Christopher Frith put it, psychotic people have difficulty limiting the contents of consciousness (Frith ). It seems reasonable to suggest that there is similarly reduced filtering in people with spiritual or visionary experiences.

There are both individual and cultural variations in how much people use the transliminal mode. Some people are more open to transliminal experience than others, and there may be a genetic basis for that (Watts ). There are also variations between cultures. For example, Africa seems more transliminal than the West. There are things people can do such as trans dancing that make them more transliminal. I suspect that when people are in transliminal mode they are more open to certain kinds of experience, and that spiritual healing works better when people are in that mode.

Though I have suggested that there is similarly reduced filtering in psychotic and religious experiences, they may arise for quite different reasons. There are very significant differences between psychosis and visionary religious states, despite the similarities. I am impressed by the incapacities associated with schizophrenia, the so‐called “negative” symptoms, which do not seem to be found in other forms of transliminality. Those incapacities require explanation, and it is not enough to present psychosis as merely a form of transliminality.

The impact of unusual experiences is also very different in psychosis and in religious forms of transliminality. Religious experiences are generally felt to be positive, to be a blessing. But psychotic experiences generally cause distress, and can be incapacitating. There is a similar issue with regard to the similarity to religious experiences of the experiences of people with temporal lobe epilepsy. There are indeed similarities, but the strange experiences of people with temporal lobe epilepsy are distressing in a way that religious experiences are not. That seems a very important difference.

With benign spiritual experiences, people are choosing to follow a path that leads to a weakening of the normal processes of cognitive inhibition and opens them up to a range of experiences that would not otherwise reach consciousness. In psychotic states, something similar happens, but it seems to arise from a pathological process that people have not chosen, and over which they have little control.

Iain McGilchrist () has suggested that in schizophrenia there is a disordered relationship between the two hemispheres, with intrusions from one hemisphere into the other. Clarke () similarly highlights the different logic of the transliminal from our ordinary rational consciousness; the latter operates an “either‐or” logic, whereas the transliminal operates a “both‐and” logic. One mode splits; the other joins up. It is not straightforward to bring these two modes of consciousness into conversation.

It seems to me plausible that careful conversation about psychotic ideas could help to integrate different modes of consciousness and normalize a disordered mind. It is often thought that psychotic delusions cannot be challenged, but a series of research reports (the first being that of Watts et al. ) have shown that this is not the case. It is, however, important in such work to approach things gently, avoiding psychological reactance, and opening up alternative interpretations rather than challenging ideas head on.

It might be thought that people who have taken a psychotic route into the transliminal would emerge from it more at home with transliminal experiences, but it may go the other way round. Once people have extricated themselves from the mires of psychosis, they may be wary of all forms of transliminality. People who have been deeply psychotic may stay clear of religion because it brings them too close to the times when they have lost their footing. Religious people can be seen as having very managed, very controlled transliminal experiences. That may make them less liable to slip into psychosis or, if they do, they may have resources that will help them to navigate the strange world in which they find themselves. That is all a matter for empirical research.

Nevertheless, it seems likely to be helpful to engage with the spiritual experiences of psychotic people, and to take their experiences seriously. It might be feared that taking psychotic ideas seriously and entering into conversation about them would represent an unhelpful collusion with mad ideas. However, it seems potentially to be helpful in rebuilding connections between the transliminal or psychotic experiences and the ordinary rational modes of consciousness, so that people can navigate between the two, and have more control over which they are in.

Two Factors: Neurological and Spiritual

On the basis of these scientific findings, it was tempting to say to Rob that he was simply wrong in his assumptions that he was being troubled by an evil spiritual presence, and that what he was experiencing was just a neurological symptom. However, there seemed good reasons for not saying that, both intellectual and practical. I am not comfortable philosophically with the kind of reductionism that says that spiritual descriptions of experience should be discarded once we have a neurological explanation.

There was also the problem that Rob was strongly opposed to the idea that there might be a medical explanation for what he was experiencing. He would probably not have accepted it if I had said that the explanation was neurological not spiritual, and I don't think I would have been able to get him to see a doctor about it. He thought that he would risk being labeled as crazy, and he did not want to take that risk. It is also not clear how it would have helped him to see a neurologist, or what treatment it might have led to. So, I looked for some kind of integration of the neurological and spiritual perspectives, and one that Rob might be able to accept.

The one chink in Rob's objections to a medical explanation concerned a traffic accident that he sustained on his motorbike. It turned out that the feeling of presence roughly dated from that accident. Moreover, the accident resulted in injuries that were particularly on his left side, and he admitted that the presence was usually on his left. As we discussed that together, he came to accept that the injury may have left some “vulnerability” to the presence on that side. However, that didn't persuade him that the presence was nothing but a neurological symptom, and I agreed with him that it didn't prove that.

It seemed that the idea of neurological vulnerability was more likely to be acceptable to Rob if it was part of a broad approach that included spiritual aspects as well. I remained agnostic about his belief in an evil spiritual presence, though I saw no conclusive reason to reject it, and thought I could help him more if I worked within his framework. I felt it was reasonable to accept his view that there was a dark spiritual force at work, and to try again to help him on that basis.

Whether or not Rob was right about an evil presence it seemed that he might benefit from cultivating his spiritual life. After discussion he began to read a few verses of one of the gospels each day, and to use prayers for protection, including a version of Saint Patrick's Breastplate. When I saw him we said it together, and it evidently gave him a powerful sense of protection. On one occasion, his parents joined us and we moved round the house saying these prayers in each room. We also went together to a healing service that was held in his local church. The healing service seems to have been a turning point. He said that while he was in the church he was completely free of the troubling presence, for the first time in ages. Rob had a strong sense of having placed himself under God's protection, and had a strong belief in the power of that protection. As he put it, “The thing knows it can't get at me now, because it knows that He [i.e., God] is protecting me.”

After this, he was left with a sense in the background of some kind of presence (which I assume to be a neurological symptom dating from his accident). However, the sense of being a victim of a malign power went almost entirely after the evening of the healing service, leaving him feeling much better. So, the spiritual aspect of the problem seems to have been dealt with quite quickly and effectively.

The integration of neurological and spiritual factors that we arrived at was essentially a two‐factor theory. The first hypothesis was that his traffic accident had led to neurological damage that left him vulnerable to a sense of presence. The second was that this vulnerability had been exploited by a malign spiritual force, which had caused him considerable distress. This account took proper account of relevant medical research, though without drawing reductionist conclusions from it, and took proper account of case history evidence about the onset of the problem, where it was particularly experienced in relation to the body (i.e., over the left shoulder). It also took account of spiritual activities and circumstances that affected the problem, and used that perspective to alleviate his distress. It was an account that made sense to Rob, and which he was able to accept; and it led to a marked improvement in his sense of well‐being.