I recently had the pleasure of co-teaching a Continuing Education seminar here in Los Angeles titled "Clinical Despair" with fellow PT blogger S. Nassir Ghaemi, M.D., director of the Mood Disorders Program and assistant clinical professor of psychiatry and psychopharmacology at Tufts Medical School in Boston, Massachusetts.
We come from two very different places clinically, he being a basically biologically-oriented psychiatrist and myself a depth-psychologically oriented psychologist. But we both share a keen interest in existential psychotherapy, and, despite our differences, did manage to find some common ground in how we approach the ubiquitous phenomenon of despair in clinical practice.
Of course, one of our fundamental differences had to do with the very nature of clinical despair and depression. Whereas Dr. Ghaemi, like most psychiatrists and psychopharmacologists today, views depression, especially bipolar depression, predominantly through a scientifically based, biogenetic, disease model, medical lens, I tend to conceptualize it somewhat more psychologically, existentially, or even spiritually. I see clinical despair primarily as a psychospiritual crisis, a prolonged "dark night of the soul." And it is precisely this spiritual aspect of clinical despair I want to further elaborate here.
But first, what exactly is "clinical despair?"
Despair is a common human experience. We have all felt despair during difficult periods in our lives. We may occasionally despair about our job, marriage, love life, family, finances, world events, etc. But typically this despair dissipates in time, and life goes on. At least till the next crisis.
When despair doesn't dissipate but rather deepens, hunkers down, takes control, and becomes chronic, diminishing quality of life that impairs functioning and keeps us from moving toward our goals, dreams, and desires, it has become pathological or clinical despair.
Clinical despair can be conceptualized as a profound and existential hopelessness, helplessness, powerlessness and pessimism about life and the future. Despair is a deep discouragement and loss of faith about one's ability to find meaning, fulfillment, and happiness, to create a satisfactory future for oneself.
Existential psychiatrist Viktor Frankl, whose horrific concentration camp experience during the Holocaust made him somewhat of an expert on the subject, defined despair as meaningless suffering in the simplistic but powerful formula D=S-M: despair equals suffering minus meaning. The clinical implication here is that despair can be treated by helping the patient attribute to or discover some meaning in his or her personal suffering, misery, and symptoms.
Indeed, when a psychiatrist diagnoses the patient's despair as stemming from clinical depression or bipolar disorder, he or she has provided some meaning to their suffering, and also some hope for psychopharmacological salvation.
Unfortunately, this too often turns out to be a disappointing, false or fleeting hope, which then tends to exacerbate and reinforce the patient's already devastating clinical despair. The same may be said of psychotherapies, both brief and longer-term, that offer patients the perhaps overly optimistic hope of relieving their clinical despair and then do not deliver. (See my previous post.)
Pragmatically speaking, patients suffering from clinical despair may need psychiatric medication to either prevent them from falling deeper into despair and the very real dangers of suicidality, or to help lift them up from the depths of despair, hopelessness, and resignation at least enough to summon the energy, will and motivation to make use of psychotherapy and deal with their day-to-day problems.
Symptoms of depression such as hopelessness, suicidality, anxiety, apathy, anhedonia, insomnia or hypersomnia, irritability, emotional lability, and chronic cognitive impairment can be extremely debilitating and dangerous: Medications such as antidepressants and mood stabilizers can do much to mitigate, suppress, or control at least some of these symptoms.
But despite the considerable benefits of medication, especially at first, it is well-known that in many cases clinical despair stubbornly persists despite all pharmacological treatments, diminished perhaps, but not nearly defeated. In such situations, sooner or later, the patient may still need to face his or her spiritual crisis and, with the right psychotherapeutic support, find some solution for it. But how?
Philosopher Soren Kierkegaard, in his Sickness Unto Death (1849), suggested that despair could be understood as comprising three stages: Spiritlessness, which applies to those who outwardly seem well-adjusted and successful yet inwardly live in a state of deep and perilous despair; despair in weakness and despair about weakness, which has to do with a refusal to become authentically and fully one's self and the existential guilt (what Sartre called mauvaise foi or "bad faith") of this cowardly refusal to move forward and frustrating inability to retreat back to their former identity; and, thirdly, the despair of defiance, which pertains to the capacity of despair to turn, sometimes quite suddenly, to elation, excitement, optimism, enthusiasm, hypomania or mania and frenetic creative activity as so often seen in extremis during the manic phase of bipolar disorder.
For Kierkegaard, the cure or antidote to despair is religious faith, in his case, Christianity or what he called Christian existence. (For this brief section on Kierkegaard, I am mainly indebted to Dr. Robert L. Moore's paper titled "Theory Matters: Analytical Psychology and the Human Experience of Despair" cited below.)
The implication of Kierkegaard's conclusion for psychotherapy is profound: For if despair can be cured by religious faith, then it can be surmised that the absence of some spiritual stance or faith is what, at least partially, underlies and comprises clinical despair. But the nature of despair has little to do with any one particular religious belief system, I would argue, and everything to do with the frustrated need for existential freedom, self-transcendence, purpose, and meaning.
Clinical despair is primarily a spiritual crisis. This is not to say that despair is never a biochemical or physiological crisis, the temporary and most immediate remedy to which may be psychopharmacological intervention. Only that the possibility of a patient's clinical despair stemming from or expressing a spiritual crisis must always be carefully considered in the psychiatric treatment of depression.
This is something that C.G. Jung saw in his patients, and worked toward rectifying during treatment however he could, trying first to refer them to their place of worship whenever possible, but recognizing that, for many, this return to organized religion was no longer viable nor spiritually meaningful. They needed to find their own way through this spiritual crisis, as had Jung himself (see my prior post), sometimes with the assistance of secular psychotherapy substituting for religion.
Clinical despair can occur at any time in life, from infancy to adolescence to mid-life to old age, as famously described in psychologist Erik Erikson's eighth and final life stage known as "integrity versus despair." But what is the best way to deal with this pervasive and perilous experience we call clinical despair?
Paradoxically, it may be that suppressing, escaping (e.g., with addictive behaviors) or denying despair only makes it worse. As C.G. Jung once said, " We cannot change anything unless we accept it." This treatment philosophy can be seen in the teachings of Alcoholics Anonymous: First the addict must admit and surrender to his or her despair and powerlessness before making any real progress toward sobriety and recovery.
Commonly, clinical despair results from the chronic repression of what existential psychologist Rollo May called the daimonic: the ultimate source of our vitality, will, power and creativity. When, for example, we habitually deny or repress our anger, sexuality, passion, spirituality, sadness, anxiety, creativity—and even our existential despair—we are cutting ourselves off from the daimonic and our true selves, and drifting toward clinical despair, apathy, and depression.
Clinical despair, which often contains a kind of embitterment (see my previous posts), typically stems from chronically repressed anger or rage about how unfairly life has treated us, and how powerless and helpless we are to do anything constructive about it. This is why it can be vitally important for the patient to get in touch with this daimonic anger and harness its power and motivating energy to courageously change themselves and their lives for the better. Otherwise, clinical despair festers, sometimes expressing itself in self-destructive and even violent behavior.
Finally, there is a close connection between clinical despair, nihilism, and courage. As theologian Paul Tillich put it, clinical despair, when expressed in the form of nihilism, "the negation of life because of its negativity is an expression of cowardice." Clinical despair can be considered a failure of courage to face and embrace the existential facts of life.
"Courage," writes Tillich, "is the power of life to affirm itself in spite of its ambiguity," by which he means the reality of good and evil. The patient suffering from clinical despair is deeply discouraged about the world and their ability to create the kind of life they desire. They have all but given up.
But as Rollo May makes clear: "Courage is not the absence of despair; it is rather, the capacity to move ahead in spite of despair." Overcoming clinical despair requires encouraging the patient to continue to choose to move forward in life even while allowing themselves to fully experience the depths of their despair. As Sartre suggests, "Human life begins on the far side of despair."
Instilling some hope in the patient suffering from clinical despair seems an obvious and simple therapeutic ploy, but in practice proves much easier said than done. Counterintuitively, confronting clinical despair can be closer to taking Dante's sojourn through Hell in The Inferno, where he anxiously reads the daunting inscription on the gate: "Abandon all hope all ye who enter here."
Clinging desperately to false hope, whether in childhood, adolescence or adulthood, can paradoxically be a neurotic defense against despair, a defense which, while serving the valuable purpose of survival in some cases, ultimately prevents one from facing and moving past the despair of abandonment, abuse, neglect, loss, and other traumas. This is what Jung may have meant when he noted that "neurosis is always a substitute for legitimate suffering."
Sometimes clinical despair, it seems, must simply be endured, patiently accepted, tolerated, and suffered through with the stabilizing and supportive presence and accompaniment of the compassionate psychotherapist until it eventually turns into something else: courage, hope, joy, love, rage, passion, spirituality, faith or creativity. (This subtle shift is something fundamentally different in intensity from the radical, dramatic, transitory, destabilizing and dangerously exaggerated mood swings seen in bipolar disorder.)
Moving through this excruciating process can be likened to both a terrifying death of one's old self, and a birth of the new self, with despair being the prolonged pregnancy and painful labor. But when clinical despair is totally avoided or prematurely aborted during treatment by pharmacological and/or psychological means, there can be no true transformation. Tragically, the patient remains stuck in the destructive vicious cycle and potentially deadly snare of clinical despair.
Havens, L.L. & Ghaemi, S.N. (2005). "Existential despair and bipolar disorder: The therapeutic alliance as a mood stabilizer." American Journal of Psychotherapy (59), pp. 137-47.
Moore, Robert L. "Theory Matters: Analytical Psychology and the Human Experience of Despair." Jung: the e-Journal of the Jungian Society for Scholarly Studies 2.1 (2006): 24 pp.