…And that distortion is one of the hardest things to face as a depressive Christian.
But before we get into that, about my guest.
Kathryn Butler, MD is a trauma and critical care surgeon who trained at Massachusetts General Hospital and Harvard Medical School, where she then joined the faculty.
She left clinical practice in 2016 to homeschool her children, and now writes regularly for Desiring God, Christianity Today, and the Gospel Coalition, as well as her own blog Oceans Rise, on topics intersecting faith and medicine.
She is the author of Between Life and Death: A Gospel-Centered Guide to End-of-Life Medical Care (Crossway).
I’m a big fan of her work, particularly the wonderful pieces she’s written on depression, including her own battle with it (click here and here for two of her pieces with Desiring God and The Gospel Coalition).
She’s lived it, and with her medical background, she also has great insight on the medical component of the disease.
WC: Can you tell me about your battle with depression?
DR. BUTLER: I’m from a family with a history of depression. My mother has struggled with it, my maternal grandmother, several aunts.
And looking back, I think I did have some issues with mental illness growing up. I struggled with anorexia and bulimia in my teen and twenties.
I did not grow up as a believer. We were nominal Christians. We never went to church, never studied the Bible. I thought that being a Christian was synonymous with being a good person, which totally does not encapsulate the Gospel and the sense that we all need a Savior and we’re saved by grace.
I had no concept of it.
I grew up with this hollowness inside me, like I needed to prove my right to exist through actions, through earning my worth with merit.
I struggled on and off with depressed mood, and had my first major depressive mood when I was training to become a surgeon, specifically focusing on time in the ICU.
I had this one harrowing night that acted as a trigger.
I was working in the ER, and it was my job to triage and take care of everything that came into the ER that could potentially require surgery. I loved the chance to be able to help people, and found it tremendously gratifying.
But I had one harrowing night, where in quick succession, there were three young people whom I couldn’t save.
The first was a gentleman in his twenties who was assaulted with a baseball bat in his bed. His wife died next to him. The EMT’s reported to us that his 4-year-old son saw the whole thing happen.
He’d been bludgeoned so severely that he was bleeding into his brain and he was at risk of dying there in the ER.
My job was to try to prepare him to go into the operating room with the neurosurgeons, and while I was scrambling to do this, all I could think of was that 4-year-old kid. And thinking that if his father dies – even if he survives – that child is going remember it the rest of his life. How is that going to affect him? What is that going to mean for his life?
Right after that patient left the ER, there was a 15-year-old who’d been stabbed in the chest. He arrived with no pulse.
In that scenario, you have to open the patient’s chest right then and there. There’s not even enough time to go to the operating room. So I did that and found this huge hole in the artery, leaving his heart to go to his lungs. And it was unfixable. He basically bled out.
I was covered in this poor child’s blood, and I changed my scrubs to go talk to his family, and then found out the cruel irony that he was from Guatemala and was living with his aunt and uncle who’d brought him here for a better life. And he’d gotten assaulted on the streets of Dorchester.
And then the last one.
He was another 15-year-old who’d been shot in the head. When he came in, it was clear he was brain dead and that he wouldn’t survive. But I said, “What can I do in this scenario to try to soften the blow for the family?”
So I started to clean the wound up, and someone brought his mother in the room while I was still working, and my hands were covered in his blood and his brain matter and she just howled and sank to the floor.
And I just felt like I’d been gutted.
And with those three examples in such quick succession, it was so clear that whoever had assaulted these people, had looked at them and saw nothing. How else could you take someone’s life?
My concept of God was still flimsy to begin with and I thought, “How could God allow this? How could God allow such suffering?”
And I finished the rest of my shift and felt just completely hollow.
Even though I’d been up 24 hours, I got into my car the next morning and drove two hours because I was feeling just desperate to feel something. I was so numb.
It was October, and I drove out along the Mohawk Trail in Western Massachusetts through the Berkshire Mountains, and it was one of those gorgeous October mornings. Everything was just lit up, and the sky was clear blue, and the foliage looked like it was on fire.
And I stopped at this bridge over the Connecticut River and stood at the railing and tried to pray, and I couldn’t.
At that point, I was officially agnostic and then began to sink into a very deep depression. That’s why I say it was the trigger.
I already had this predisposition to it. I’d already struggled with a low-grade mood disorder in my younger years and now not having God? I lost meaning.
It was an existential trigger, and I sank into a very deep depression that lasted at least a year, and became so severe that I was suicidal and would think constantly about returning to that bridge and just throwing myself over it because what was the point?
The only reason I didn’t was because I didn’t want to hurt my husband. I knew he’d be crushed if I took my own life. So that was my first major depressive episode. It was tied to spirituality.
Since then, it’s something I’ve continued to deal with, although not to that severe degree.
A year into it, I was still struggling feeling like life was worthless. It was hard to get out of bed in the morning. I was working to get through the day but unable to focus. The typical despondency you have, where there’s just no joy.
Then one day, I was working in the ICU, taking care of a gentleman who had a severe brain injury with a cardiac arrest after the surgery. He didn’t have enough blood flow to the brain, and the neurologist thought he was going to be in a persistently vegetative state or at least minimally conscious state for the rest of his life.
His family would ask all the time if we’d seen any improvement, and we’d say we didn’t think he’d improve.
But then one day, his wife is belting Tiffany’s “I think We’re Alone Now” at the top of her lungs in the ICU and she’s wearing a crucifix the size of an avocado and she says to me, “Dr. Butler, I was praying and praying last night, and I woke up this morning, and God told me everything was going to be okay.”
My heart broke for her, and I was sitting here thinking, “No, it’s not going to be okay.” I didn’t think, at the time, there was a God.
But then later that day, the family said, “Dr. Butler, come here, come here! He moved his toe when we asked him.”
I felt badly for them because I thought it was probably just a reflex, and I yelled his name and he didn’t do anything. And then they yelled his name, and he did move his foot.
And I was thinking, again, that it was probably just a reflex.
But the following day, he started to look at them when they talked with him. And the day after that, he started moving his upper limbs. And then he started to talk, and he had a full recovery that we could not explain. In response to prayer!
The moment gave me chills and made it so clear that however I couldn’t understand suffering, there was something at work that was beyond what we could comprehend.
My husband had started going to church around that time, because he was having a crisis in his own life and had been encouraging me to go.
None of it penetrated me, but at his urging I read the Gospels and the Book of Romans. And when I was already so low with the depression, like Jonah, I had nowhere else to go except to turn to God. And his sovereignty and grace opened my heart to the Word.
Reading the Gospels and Romans, we realize that even if we can’t comprehend suffering in the moment, we have a Savior who knows suffering and who earned our salvation through that suffering.
So if we’re enduring deep darkness, it’s not because God doesn’t love us.
And in fact, he can engage with suffering in a way that takes away all that grief when we look at what’s to come. And that healed me. He brought me to himself, and that grace was something I could cling to.
I still had to do the hard work of the recovery from the depression. It wasn’t as if the scales fell away and I was cured. There was still the hard work of the waiting and therapy.
But since then, it’s given me an anchor.
So when I’ve had subsequent episodes, I turn to the Psalms because they offer a language for the laments I often experience – David struggling and feeling disconnected from God – while also realizing that David was a man after God’s own heart.
We can go through these struggles, and it doesn’t mean we’re less Christian. The Psalms don’t solve things, but they can help you through.
WC: You have a unique perspective because you’ve been depressed as an unbeliever and as a believer. Your experience illustrates two different ways people can go. In your first episode, you left whatever faith you had – if you even had faith. And in subsequent depressive episodes, your faith has been a means of strength.
But I’ve had Christians friends who go through depression and drift away for a long period. Instead of saying, “I don’t have anything to lean on, so I’ll lean on Christ,” they say, “God wasn’t there when I tried leaning on him, so I’m going to go do whatever I want for fulfillment.”
What do you say to Christians who say they’ve been leaning on him, following him, and he never seems to answer?
How do you fight with depression that seems to linger forever?
DR. BUTLER: Part of the issue with depression is that God can seem remote. That’s part of the disease.
You literally lose your capacity for joy. You know the passages, you know the Gospels, but the darkness just persists and he feels so remote.
I know there’s an ongoing debate in the church about whether or not depression is a medical condition, but we have tremendous data showing there are neurological underpinnings.
It’s a complicated process, but there are definitely mechanisms at work in the brain that ensnare you. It distorts your perception.
By its very nature, you will feel guilt where there’s no guilt.
You’ve done nothing wrong, but you feel terribly guilty and unworthy. You will perceive things as hopeless when that’s not the case. But you can’t pull yourself out of it just by trying to reprimand yourself.
Our faith walk is affected by that same process. We can be told God loves us, but we sure don’t feel it. And that’s not because of a lack of faith, but because depression, by nature, changes your perception.
When I’m in a full-blown depressive episode, I struggle to read. I have to force myself to read and when I do, I have trouble focusing on the Lord. When I feel well, I have to earmark the Psalms I need, knowing that when depression hits, I need to go to these passages, because I’m not going to have the focus or clarity to sift through and decide what I should read.
People need to be clear that these kinds of distorted perceptions are part of the disorder. Our brains are disallowing us to feel his presence.
And when we witness someone struggling with depression, we need to come alongside them and remind them that their disordered perception is trapping them in the dark.
We need to say, “It’s not your fault you can’t see him right now. It’s part of your depression. But he’s still loving you, and working in you, even when you can’t discern him.”
Those struggling with depression should not be judged as having a deficit of faith, as if we need to pray more, or do more.
This is why we need to deal with depression in a multidisciplinary way. Medication can help. It can give you an extra boost to give you the clarity of thought to perceive things accurately.
But then we have to do the hard work of recovery, through counseling or therapy or whatever that might be. And we need others in the church to come alongside us and pray with and for us.
WC: When I’m super depressed and read the Bible, maybe 10% of the time it actually helps. But that extra 90% can get me even angrier because Christianity seems full of false promises and so distant from my experience. So I think, “Maybe I shouldn’t have read at all if it’s making me doubt Christianity’s promises more.”
I think a lot of us feel this way.
In that case, what do we do?
DR. BUTLER: Can I ask what you’ve found helpful in those situations?
WC: Nothing.
DR. BUTLER: I’m not sure except to say that my own prayers become very truncated and sometimes just single words. Maybe my prayer will be a single word or a single verse.
Have you found it helpful for people to pray with you?
WC: In those situations, I’m usually too cynical to go to fellow Christians because I know exactly what I’ll hear. “Brother, we’re here for you.”
Then they’ll pray over you, and you have to pretend it’s helped. Your face has to glow just a little more once the prayer is done and you have to say, “Guys, I think that might have helped a little.”
You have to put on a façade that can actually make your depression worse, at least in my case.
DR. BUTLER: I can understand that. I’m just thinking about my own experience. I’ll often just ask people to pray for me, because at that point, I don’t know what to do.
You get to the point where you realize you’re just holding on until the course passes. This thing is just going to play out and run its course and until then, “Please, I just need prayers.” I don’t necessarily talk with anyone about it, I’ll just ask my husband to please be patient and kind to me.
And I’ve found the Psalms – especially 22, 23, and 77 – helpful because they assure me that even when I’m despondent and God feels distant, I can cling to the truth of who he is and what he’s done. That he’s there even when I can’t discern him.
WC: I’ve become slightly disillusioned about getting better, but that’s actually helped, a bit. To me, depression is a little bit like an autoimmune disease where you’re going to have horrible flare ups and remissions.
I’m a pessimist by nature, but I’m leery about telling people they can “get better” because I think it might set them up with a false hope because, for a lot of us, it’s going to be coming and going for the rest of our lives.
DR. BUTLER: Has going through it and coming through those reoccurrences been a help to you when it happens again?
WC: Sometimes. If it’s a severe enough episode, I despair and think, “I can’t handle another one of these” rather than thinking, “I’ve been through this and I’ll get through this again.”
If it’s not as severe a flare, I have a better perspective. Sometimes, I think that when the Bible talks about maturity, it means, “Wisdom is knowing your depressive spells will end.”
But circling back, we were talking about the medical component of depression. The church doesn’t involve itself much in cancer other than to say, “Get medical help, and we’ll pray God supports you during this time.”
But they largely divorce the prescriptive part of cancer from spirituality.
I wonder if the more spiritualism we apply to depression, the more people will put God on the hook for recovery when it’s more of a medical thing.
Should we divorce spirituality from the process of treating this thing?
DR. BUTLER: I wouldn’t call for divorce. I think a balanced approach is most appropriate. What’s fair to say is that it’s a condition with medical underpinnings but the ramifications can be spiritual. And I think we need to be cognizant that people can go through one of these episodes and walk away from their faith.
What is the culture of the church that pushes them to that?
The experience is a very spiritual one, where you need support. And I’ve benefited from turning to my Bible when I’m struggling, even if it’s a verse or a song, something to cling to, because you do feel God is remote.
The problem in the church is there’s a dichotomous view of it. When the church becomes involved, it sometimes views depression as simply a spiritual issue, and that’s a mistake. That oversimplifies what’s a very complicated issue by design.
The reason antidepressants only bring about remission in half the cases is because it’s a very multifactorial disorder, and when we talk about major depression, it’s probably an umbrella term for multiple different subtypes and we’ve started to tease these out by MRI scanning but the research is pretty rudimentary.
If it was a simple issue of just a chemical imbalance, you should be able to give that chemical back and the illness goes away. That’s what we expected when we first saw that serotonin signaling was involved in depression, but we haven’t seen widespread cure because it’s very complicated with multiple neural networks involved.
There are even differences in the size of the hippocampus in those who are depressed and those who aren’t. There are structural changes and connections in the brain involved in depression. It’s more than just lacking one chemical.
There are multiple different subtypes, and it’s often triggered by something environmental or social. It’s a very complicated disorder that yields spiritual effects and has spiritual significance.
Rather than divorcing it, we just need a good awareness in the church of the fact that there are spiritual effects, but it doesn’t mean that anyone suffering from depression has a deficit of faith.
Part of the problem is there’s a long history of the church being very distrustful of psychiatry because of Freud being an atheist.
But there are many types of psychotherapy, and frankly few professionals practice classic Freudian psychodynamics.
But there’s a lot of misunderstanding and people are distrustful and think you’re trying to take a secular approach and medicate people for what’s a spiritual problem.
As Christians, God gives us medicine as a common means of grace. God, through his mercy, has given us means to help deal with it. And some of it is medication, and therapy. Therapy is probably even more important than antidepressants. The best, probably, is to combine them both.
WC: What do you think the peace of God is? Not peace with God, because we know that’s a status. We’re no longer at war with him. But the peace of God.
I know a lot of non-Christians who seem to have a lot more peace than I have. What is this peace of God that Paul continually talks about?
DR. BUTLER: When Paul and Silas were imprisoned, they were singing and praising God. In the face of adversity, in the face of suffering, they had peace such that they could still praise God. Is that something that’s transient or permanent? I think the Spirit gives it to us. But sanctification is ongoing.
Because depression affects perception, I wouldn’t point to people and say they don’t have the peace of God because they don’t “feel” peaceful and are not singing praises every moment. I think there’s a danger in saying that. But I think the peace of God refers to how we find our hope in the Gospel, even in the face of tragedy and suffering.
WC: Do you think the peace of God is a feeling?
DR. BUTLER: I think it’s more of an assurance. Having the assurance that despite what sufferings you’re going through, God will work all things for your good and God has overcome, in Christ.
There are these trials, but God is sovereign even over this, and he will work all things for our good.
In Christ, he loves us so deeply, and everything will be made new. To embrace that, though, you have to have a sense of what’s real, and to be cogent and clear-minded, which is what depression steals from you. And so when we’re struggling with depression, it’s so crucial to have reminders of the truth of God’s love for us.
WC: So it sounds like you think the peace of God is more of a belief?
DR. BUTLER: A conviction.
WC: Yeah, so I wonder if “peace,” as we think of it today, is the right word for it. In the scientific literature, peace is defined as “a feeling of well-being and emotional calm.”
I think a lot of Christians guilt themselves, because isn’t peace a fruit of the spirit? Well, what does that mean? Does that mean peace with others? Paul talks a lot about having peace and unity with others and that’s something we can do whether we’re depressed or not.
But the problem arises when you look at your life and, as you grow, you see yourself being more loving and humble (hopefully), but depressed people often don’t see more peace in their life, no matter how much they grow.
DR. BUTLER: That’s why I find the Psalms so helpful. And when you look at people throughout the Bible that God loves – even Christ himself – you realize that suffering is part of the Christian walk. Jesus didn’t have peace in the sense that he was placid in the Garden. He’s crying to the point where his tears turn to blood. But what he says next is, “Not my will be done, but yours.”
I think it’s the hope and assurance that persists, even through the suffering. I think that’s closer to what Paul talks about.
WC: So maybe peace is an acceptance of God’s plan. In order to accept his plan, you have to have some measure of peace with it. Maybe Christians need to talk more about what the peace of God actually means, instead of relying on the popular definition.
Final question that is totally off topic. I want to ask you, because you have medical chops AND Christian chops, combined. It’s perfect for this kind of question.
What’s your view on medical marijuana for anxiety?
DR. BUTLER: My hesitation on marijuana. The truth of the matter is that any medication should undergo a rigorous process by which we’re sure it actually helps and doesn’t actually cause harm.
And we have some data showing that, in some cases, cannabis products can help.
We already have prescriptions for those indications. I think about Marinol for cancer patients who have poor appetite to try to prevent weight loss. That’s a marijuana component that’s now in pill form.
My concern with the widespread use of marijuana, without requiring studies to prove efficacy, is that we’re trying to bypass the process where we can make these things available and ensure they’re safe and effective. Let’s make sure they’re actually going to help and not make things worse. Marijuana can sometimes cause paranoia, so is that necessarily a good thing to give someone who has anxiety?
Let’s make sure it’s a formulation where it’s targeting the specific component that’s going to help and in the right dosage. So that would be my one caution.
The studies we have, so far, show that that in some specific scenarios it can help with pain, and we know that it can help as an appetite stimulant.But the effects in other areas are far less robust and I would be cautious about pursuing it until we have more data.
And when we have more data, things will be more clear, and there will be prescriptions available. We don’t need to get in a shop and smoke it and have all the effects of the carcinogens in your lungs. I think it’s better to be cautious and wait for more evidence.
WC: One of the objections I hear form Christians is that the THC in marijuana puts you in an altered state of mind or somehow deadens your mind. And I think people with anxiety who read that think, “Um. I could use my mind being deadened a little. If I could just take it down a notch, it’d make things a lot better.”
I think the Christian church, at some point, needs to have a conversation about what it means to have a deadened mind. The key question, I think is: does a deadened mind make you more likely to sin or not? Or, does it just make you less anxious?
DR. BUTLER: It’s important to clearly define terms. The idea of “deadening your mind” could be concerning, because you could pursue self-medication of some pretty harmful substances and become dependent. That’s what happens when you’re suffering from depression and turning to alcohol. It’s not therapy, it’s escapism.
But people then extrapolate that thinking to antidepressants. And the point with them isn’t to cloud thinking or distort but to try to normalize and bring you back to normal function.
It’s important to ask: What is the point of this, and what is it targeting?
Is it used as method to escape only? That’s dangerous. But if it’s something you take that targets something very specific in the brain that’s been identified, and it helps you to function normally, that’s different.
It’s important to define terms.
WC: Thank you so, so much for your time and talking with me.
