If Despair Is the Disease, What Is the Treatment?
If Despair Is the Disease, What Is the Treatment?

If Despair Is the Disease, What Is the Treatment?

How discarded images can forge a path to life.

June 21 st 2018

Recent reports of the state of health in the United States are both surprising and disturbing. After consistently rising for most of the past one hundred years, life expectancy has fallen for the second year in a row. Mortality rates for big diseases like HIV, cardiovascular disease, and cancer continue their decline, but deaths by suicide, fatal drug overdoses, and liver disease caused by alcohol abuse have increased significantly. Between 1999 and 2015 these “deaths of despair,” as some have called them, were particularly pronounced among individuals between twenty-five and fifty-nine years of age living in rural counties. Then in 2015–2016 some of these sad statistics shifted, with the largest increases in drug and suicide death rates among ethnic minorities in more urban settings. We already know the rich and famous are not immune, as current news stories have sadly documented. Though not contagious in any usual terms, like most infections this epidemic of despair has propagated without any respect for social or economic boundaries.

In 1849 Søren Kierkegaard explored the relationship between despair and death in his intriguing little book The Sickness Unto Death. He was referring to the passage in John 11, where Jesus is informed that his close friend Lazarus is sick. “This sickness is not unto death,” Jesus declares. Yet Lazarus dies—only to be raised from the grave by Jesus four days after he was buried. It is a pretty simple story as long as you believe in miracles.

But if we stop reading the map and start walking the terrain, the experience of knowing the person and the world they live in changes our perspective.

But Kierkegaard will not let us rest with the straightforward outcome. “Ah! But even if Christ had not awoken Lazarus, is it still not true that this sickness, death itself, is not unto death?” In human terms death is the last thing of all, but because Jesus is the resurrection and the life, he says, not even death itself is the “sickness unto death” in the eyes of the Christian.

If it isn’t death itself, what is it? The answer is in his title to part 1 of his two-part book: “The Sickness unto Death Is Despair.” He then invites us on the challenging journey of discovering what he means. And what is his conclusion? At the risk of oversimplifying, his conclusion is that the only way out is to be who you were meant to be. And the only way that will be possible is to recognize that you have not established yourself; you have been established by something else, rather someone else. Despair ends when “the self is grounded transparently in the power that established it.”

Now how can we ever talk about things like that in a world like ours, where questions of how we are here and why we are here are far too personal for public discussion—even if we are living in an age of despair?

In Search of Other Images

In the homeless clinic where I work, despair is a common reality, and routine risk assessments for suicide are often frighteningly high. Depending on our model of early identification and treatment, a high-risk patient is quickly surrounded by a multidisciplinary team offering a variety of resources. It could be one-on-one counselling or medications to alter imbalanced neurotransmitters. Perhaps a group is needed where others are struggling with the same stresses. We even have the equivalent of radical surgery, offering to transplant the person from a toxic environment to a new location far away where they can live in a community with others focused on recovery.

But whatever we offer, the biggest obstacle is always the same: Will they accept the help? For those who do, they find a way to transform their despair of life into a desperate desire for life. In what we offer, or maybe the way we offer it, they see a chance for a new beginning. But for that to happen they have to believe, at some deep and unseen level, that they, and their lives, are worth it.

In the opening lines of his 1942 essay The Myth of Sisyphus, Albert Camus makes the stark claim that “whether life is or is not worth living amounts to answering the fundamental question of philosophy.” He uses the story of Sisyphus the Greek king of Corinth to show that, yes, it is worth living, but only if you are willing to face the absurd reality that life is painful and your efforts useless. Sisyphus is a heroic figure because he faces his meaningless suffering “with lucidity” and yet refuses to give up. At the end of the story we are there with Sisyphus at the foot of the mountain. He has been ceaselessly rolling his rock to the top of the mountain whence it constantly falls back of its own weight, and once more he prepares to roll it back up. And in that moment Camus asks us to believe that Sisyphus is happy.

I may lack Camus’s imagination or Sisyphus’s nobility, but I do not find these circumstances either happy or hopeful. Nor do I believe that we can change the shifting trajectory of our life expectancy if that is all there is. For the patients in my clinic or in our communities ravaged by diseases of despair, are there no other images?

The Discarded Image

In one of C.S. Lewis’s last books, The Discarded Image, he relates a story from Cicero’s Republic, written around 50 BC. In the sixth and final section Scipio Africanus Minor, one of the speakers in the dialogue, relates a remarkable dream. He is carried up to heaven by his grandfather and namesake, Scipio Africanus Major, from where they look down on Carthage. The elder Scipio foretells his grandson’s political future and tells him that those who serve well in their public roles will have their appointed place in heaven. Why wait, the younger abruptly asks as he contemplates the joyous band about them. Why not join this heavenly company at once? “No,” replies his grandfather, “unless that God who has for his temple the whole universe which you behold, has set you free from the fetters of the body, the way hither is not open to you. . . . All good men must retain the soul in the body’s fetters and not depart from human life without the orders of him who gave you a soul; otherwise, you may be held to have deserted the duty allotted by God to man.”

So we have Cicero in the first century BC and Kierkegaard in the nineteenth century AD offering similar ideas: we need to recognize the source of our life and stay the course to complete the life we have been given. For life to be worth it, wouldn’t it make a big difference to know you have a purpose bigger than yourself and a sense of duty to accomplish it? But who is willing to engage with such ancient ideas in our advanced culture? For most professionally trained helpers like me, these ideas don’t belong in the public world of the clinical encounter. As C.S. Lewis said, they are discarded images, consigned to the scrap heap long ago. But desperate people will dig through dumpsters if it means finding food.

I met a patient a few months ago who unnerved me with the revelation that he had attempted suicide more than six times in his life. Too stunned to speak, I was grateful he had more to say. He said that each time some surprising circumstance had intervened to thwart his efforts. And then he resurrected an old image. “I don’t think there’s much use in trying again. God must have a reason I’m still here.”

Though I could not have anticipated his response, I quickly saw what was happening: with a fresh image in his mind he had created a small opening in his despairing heart. He was beginning to wonder if his journey in this world may be part of bigger plan and under Another’s authority. But who was going to help him on the path to deeper engagement with his newfound hope?

Out of their powerlessness and despair may come new images, even ancient ones, that can teach all of us how to face despair and restore hope.

Who Has the Courage to Face Powerlessness and Despair?

In the professional world where I live, the community of medicine and health care, the centre is sickness. Whether we are treating it or trying to prevent it, the enemy is always sickness and death. The fortunate thing is that we have many tools at our disposal, more than any prior generation could have imagined, and in the course of our training we learn how to use them with great effect. But what we don’t do well is learn how to face powerlessness and despair. It is part and parcel of the divide in our culture. On one side are the problems we have and the tools we can use to solve them. On the other are the personal issues that make problem-solving difficult and abstract solutions inadequate.

Randy (not his real name), a first-year medical student in my group, in a course in the medical school curriculum aptly titled “Problem-Based Learning,” was particularly stressed by the amount of information he was expected to know. His solution to this conundrum was common, but he followed it to the extreme. Everything must fit a linear paradigm. Like an apple picked and easily held in the hand, he needed to press the untidy mountains of information into neatly rounded truths that would make him a good doctor. The only problem was it made him the most rigid thinker in the group. Whenever we discussed other factors that might be affecting our patients’ health, be it the socioeconomic reality that they were uninsured or the painful truth that a spouse had been unfaithful, he was least able to integrate these factors into his plan of care. He just simply avoided them; it was far more convenient to act as if they were not there.

Lesslie Newbigin, in Foolishness to the Greeks: The Gospel and Western Culture, decries the fragmentation that arises when we passively accept the divide between science and faith, knowledge and experience, theory and practice, or the secular and the sacred.

We have come again, from another angle, to the cleavage running through our culture between the private and the public worlds, a public world interpreted in terms of efficient causes and a private world in which purpose and therefore value judgments still have a place. I have affirmed that we cannot accept a situation in which Christian faith is admitted as no more than a possible option for the private sector. We cannot settle for a peaceful coexistence between science and religion on the basis of an allocation of spheres of influence to the public and private spheres respectively. We cannot forever postpone this question: What is the real truth about the world?

One of the ways Newbigin suggests we begin the process of breaking down the divide in the search for “real truth” is to change our speech. Professionally trained to understand the problems of our patient, abstract knowledge of the facts about a person leave us talking about “them.” But if we stop reading the map and start walking the terrain, the experience of knowing the person and the world they live in changes our perspective. Our speech in the third person, Newbigin says, is replaced by speech in the first and second. And when I start listening to the other person speaking, that can mean change not just for “you” but for “me.”

Crossing the Bridge

It turns out Randy, the medical student, had more courage and insight than I realized. He asked if he could come to the homeless shelter to meet some of the patients. He knew his thinking was too small and he wanted to make it bigger. I guess he knew he had a lot to learn, because he came back again. And what he did is a hopeful action available to all of us who are learning how to help people. It means wanting to use “you” and “me” instead of “us” and “them.” It does not diminish our desire to learn all the things we can do to change a person’s problems with efficient tools, but it includes a willingness to sit with suffering, share in powerlessness, and become open to new images.

Whether we see the need and take our own initiative, as Randy did, or institutions of higher learning take the lead and foster these experiences within the curriculum, if we really want to help despairing people we will have to cross the divide. Unfortunately our culture has big gaps, in the way we think, how we are trained, and who we consider our neighbour.

Do you ever wonder why Jesus said in Matthew 26:11, “You always have the poor with you”? Too often we have used this most famous biblical passage about the poor as an excuse for passivity in the face of poverty. But what if it is more a statement of hope that it is good that the poor and needy are with us, and if they are a part of us and not apart from us, we will both be better because of it. Out of their powerlessness and despair may come new images, even ancient ones, that can teach all of us how to face despair and restore hope.

Kierkegaard, in one of his parables, tells of a student taking an exam who has four hours to finish. It matters not, he says, whether he finishes early or at the end of the time, because the task is one thing and the time another. But when time itself is the task, it becomes a failure to finish too soon. “To be finished with life before life has finished with one, is precisely not to have finished the task.”

So let us continue to study the problems and build the models that will support our communities through prevention, early identification, and treatment. But let us also not neglect the real truth. People will always need a vision that gives them hope: that they are here on purpose, that they have a task to do, and that we care enough to want to see them finish both their time and their task. But they will only know we care if we get close.


Bob Cutillo
 
Bob Cutillo

Bob Cutillo (M.D., Columbia University) is an Associate Faculty at Denver Seminary where he teaches on health and justice, a physician at Colorado Coalition for the Homeless, and an assistant clinical professor at the University of Colorado School of Medicine. He has worked for many years in faith-based health care for the uninsured and under-served, including several years in Kinshasa, Democratic Republic of Congo (formerly Zaire) as a medical missionary in urban primary health care. He is the author of Pursuing Health in an Anxious Age (Crossway, 2016).

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