Talking About Depression

Sometimes great benefit follows great tragedy . . . Robin Williams’ unfortunate death by suicide has drawn some much-needed attention to the disease of depression.

Addiction is often a gateway to depression, and vice versa. Williams may have had a genetic predisposition toward developing both. The major surgery he underwent in 2009 to replace his aortic valve may also have been a factor. As I recently learned firsthand, major surgery can lead to major depression.

Last photo of Robin Williams via Instagram, July 21, his 63rd birthday
Last photo of Robin Williams via Instagram, July 21, his 63rd birthday

During an appearance on the Ellen Degeneres show, Williams dismissed any suggestion that he may have suffered from depression after the surgery. I suspect he was either in denial or uncomfortable talking about depression.  He did have this to say: “they literally open you up, they crack the box, and you get really vulnerable . . . and you get very, very emotional about everything.”

That was my experience in the hospital following my liver transplant. I was extremely emotional, crying at the drop of a hat. Not sad, I was happy, appreciative. I came home, was fine for a few weeks, and then . . .

Depression following major surgery is caused by a complex mix of physical, emotional, and behavioral changes a patient goes through, and in my case, there was also the medication to suppress my immune system so my body will not reject the new liver and the medicine I take to offset side effects of the anti-rejection meds. Quite a combo.

Like most people, I get depressed from time to time. It usually doesn’t last long. This was something else entirely, and it came to a climax over the 4th of July weekend. I felt alone, hopeless, helpless. I couldn’t eat, read, do any of things I would normally do when I feel blue. All I wanted to do was sleep . . . and I was thinking about the Big Sleep and how to induce it.

For the first time in my life I was afforded a glimpse into the desperation someone in the grip of severe depression must feel, when the agony of trying to get through another day seems so overwhelming that you think, what’s the point? Why try? Who cares?  You sort of just want it over.

That Sunday, I heard from my cousin. She was sick. She was afraid her cancer was back and that it was spreading through her body. I only felt worse after that. The next day I went on a clinic visit and had a meltdown in front of my doctor and the social worker. They were very patient, spent lots of time with me that morning. My doctor wrote a prescription for anti-depression medication. He said it would take 6 weeks for the drug to take effect. Listen, when I take pills, I want ones that are fast acting. I still haven’t filled the prescription.

On the way home, I began to fell lighter. Maybe it was just getting everything off my chest – and I was brutally honest about what I was going through, I didn’t hold back. I began to think about my cousin. What she was facing was much worse than what I was going through. When I got home I had some unexpected interaction with another USC transplant patient, a guy who has been on the waiting list for a transplant six years. I was on the list only a year and a half, cancer put me on a fast track. I reflected on all the people I had met during the that time, some who were very sick and weren’t going to make it, some that I saw just that morning, who had transplants also and were not doing nearly as good physically as I was.

What was I grousing about? I was so fortunate. My recovery was coming along phenomenally.  So many people had gone to bat for me, invested time and energy. What was wrong with me?  Look at all the others who are having a much rougher battle, my dear cousin was probably dying . . . Empathy began to kick in.

One of the books I relied on during my journey through liver disease and cancer was Ultimate Healing The Power of Compassion by Lama Zopa Rinpoche. It is about inner healing, based on the traditional Tibetan Buddhist healing philosophy where to cure any disease, you must first cure the mind.

I went back to the book, found a passage that had always stuck in my mind:

A compassionate person is the most powerful healer, not only of their own disease and other problems, but of those of others. A person with loving kindness and compassion heals others simply by existing.”

When you are suffering from depression, you question the value of your existence, and in your twisted thinking, you wonder if life is worth holding on to, but, here it says that just by existing your life has meaning.  A very powerful thought. Very easy to forget. Analyzing my own situation from a Buddhist perspective, I would say the root cause of my depression was self-centeredness. I was indulging in self-pity, feeling sorry for myself.

Compassion gets you out of yourself.  You can take the Noble Eightfold Path, the Bodhisattva Path, and all the 80,000 Buddhist teachings, and distill them all down to this: the enemy is your self, the battle is to win over yourself.  Compassion is the art of this war.

Lama Zopa Rinpoche has a section on dealing with depression.  I glossed over it before.  I wasn’t depressed then.  He writes,

What made you experience this depression? Your ego, your self-cherishing thought. There is an immediate connection between depression and the strong cherishing of I. You become depressed basically because the ego doesn’t get what it wants or expects.”

A former child star is taking some flak for tweeting that Williams was selfish by committing suicide. But he’s right. A person in a fog of depression has limited vision, and is capable of little wisdom. So wrapped up in their own pain, the pain that they will cause others with their act does not enter into the mind, or if it does, it is dismissed, or overshadowed by the darkness.

Lama Zopa Rinpoche offers three powerful techniques for fighting depression: remember impermanence and death, experience your depression on behalf of others, and give your depression to your ego. I like the last one. Why not? Since your ego is not you, and not real, but just a manifestation of self-cherishing thoughts, let the ego take care of the depression. Lighten your load.

orson-welles_trialI don’t know how serious was my bout with depression. It seems to be over and done with, although some residue lingers. When my thoughts were at their darkest, there was still the faint light of others that shined through – I could never intentionally do something that would inflict that kind of pain on my father and my other relatives or friends. Obviously, the darkness that surrounded Robin Williams was deeper.

I wrote above that Williams might have been in denial about post-surgery depression. It’s also been suggested that his periodic rehab check-ins to “maintain his sobriety” over the years, were covers for depression treatment. Strange commentary on our society where treatment for substance abuse has less of a stigma than treatment for psychological issues.

A few days after my cousin died, a tenant in my building left a few books in the laundry room for others to take, a romance novel, a science fiction adventure, and Against Depression by Peter D. Kramer. I grabbed the latter. I haven’t read it cover to cover but rather have jumped around. Kramer sees depression as a disease (some say it is a disorder), and he advocates an all-out, take-no-prisoners approach similar to the one that allowed us to eradicate smallpox. He says, “Not fearing depression, we might love more generously.”

Only 16 or 17 percent of Americans ever experience major depression, yet Kramer also says,

For a group that extends far beyond the minority who go on to suffer the syndrome, depression is the disease that stands in the wings. Many of us, and here I include myself, spend much our lives fending off depression, in those we care about, but also in ourselves.”

His message is clear. Anyone can have depression. Anyone can feel so alone and hopeless that almost on a whim, even though the thought has been thought many times before, they can try to cut themselves with a knife, hang themselves with a belt . . . unless someone is there to stop them.

Robin Williams has left us. He’s left us laughing, but he’s also left us talking about depression and that is a good thing. I think he would want us not to fear depression, and I think he would be pleased if by talking openly about depression we were able to love more generously.

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Time Is

Yesterday, June 12th, was the one month anniversary of my transplant. My recovery is progressing well, and in fact my doctors, nurses and coordinators all tell me that my progress is nothing short of spectacular, something I am not ashamed to admit that I love to hear.

And yet, it is not quite as fast as I would like.  I wish I were back to normal already, or better than normal, as I was told would be the case. I’m tired of being tired, sick of being cold (I feel cold all the time), and everything else that has come with this recovery. Even though they say what I am experiencing is typical and to be expected . . . I’m impatient for the healing process to be over and done with.

I know it’s the wrong attitude. I should just let go and let time heal.

Recently I read where a Buddhist teacher or blogger said time does not heal. Unfortunately, I don’t remember who it was, nor did I bother to read the article and discover the context in which that statement was offered. Now, some reason it’s stuck in my mind, and taking the statement as it is, literally, I couldn’t disagree more.

It is important to pay careful attention to the timeless reality of now, but it is equally as important to understand the passage of time, the cycles of time. As always, the first and best Buddhist solution is to find the chu-do, the middle way.

To deny time or simply remain in the mindfulness of now is as bad as living in the past, or living only for the future. Time brings change, and since the Buddha taught everything is transient, we should have faith that change can be our friend, our ally, if we choose to let go and flow with it.

We should also try to understand the cycles of time and just where certain situations stand and where they intersect with other situations, forces, and qualities, in the complex pattern of life.

In my situation, allowing time to heal forces me to work on my practice of patience, which I’ve noted more than once is not my particular forte in life. Being patient with healing, being patient with my medical team, with myself . . . for me, it’s a struggle, but I am armed in this fight with confidence, for as Shantideva wrote, “Even while I remain in this world of suffering, through the practice of patience, I shall have beauty and good health and long life, and even the extensive joy of a universal king!”

Allowing time to heal our wounds is about having confidence about acceptance, something we probably don’t think about too often, so I’ll say it again . . . have confidence about, with, and in acceptance.  It is good to accept things, to trust in the virtue of letting go, being patient . . . after all, it’s really just that old wu-wei, the natural way of things . . . it’s understanding that time does heal . . . that all things change with time and acceptance is not rushing change or being unduly concerned about time . . . you see, for some people . . . for those who love . . . who really love . . . time is . . .

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Preparing for The New Normal

It is early in the morning of my 11th day at the hospital. I was scheduled for release today but I had arranged to have some work done at home during my absence and it involved glazing the bathtub and kitchen sink, a process that produces toxic fumes, so my place will not be fit for human consumption until Saturday morning. The chief surgeon here feels that I am doing so well, and they have invested so much in my surgery and recovery, that it would be a shame to jeopardize it in any way, so rather than risk I might go into the apartment too early, they are keeping me a couple days longer.

Prioritizing allocation of liver transplants is based on The Model for End-Stage Liver Disease, or MELD, a complicated system that even the doctors involved in liver transplantation do not completely understand. By late April, my Meld score was high enough that I started receiving offers for livers. Several times, I got phone calls that a liver was available but the primary candidate might be too sick for the surgery, so I should stand by as a backup. The week before my actual transplant, the situation looked favorable enough that they brought me in, gave me a room, and I waited all day while the transplant surgeon went to New Mexico to inspect the liver. None of these worked out.

Finally, Sunday the 11th, another call. Stand by, no eating or drinking, and this time, I was the primary.  There was little question that I was well enough for the surgery. Well, I hoped I was well enough, there was a small bit of doubt on my part. In any case, around 8am Monday morning, a final call. This is it. The liver is good. It’s yours. Get here as quick as you can.

My second cousin, a young filmmaker, picked me up and stayed by my side during the several hours’ long prep for surgery. It is all a blur to me now. I remember it was around 1:30PM when the anesthesiologist, said, “I’m going to get you drunk, now.” The next thing I knew it was sometime Tuesday and I had a new liver.

One reason why I am doing so well is that, as I indicated, I was relatively healthy prior to surgery. Most recipients are very sick by the time they get a liver. They been through interferon treatments, or perhaps have battled ascites, the distended abdomen swollen with fluids. Liver cancer put me on the fast track. I got extra MELD points for cancer. Now as I write this, I realize that I have crossed over another threshold: I am a cancer survivor. I no longer have cancer.

There isn’t much to do here. Read, wait for breakfast lunch dinner, wait for someone to come in and interact with you and relieve a few minutes of your boredom, even if in doing so they prod or poke or otherwise inflict some pain upon you.  And watch TV. In my case, it’s more a vain search to find something worth watching. Unfortunately, the channel selection is limited and what most Americans find interesting on television, I have no use for whatsoever.

But here I am. Alive. And although it is such a cliché, with a new life. Biding a few more days, rejuvenating, growing stronger, preparing to embark on the new normal, one centered around taking medicine designed to suppress my immune system. It’s exciting in many ways, for now that the heavy lifting is over, I am much more confident to face what lies ahead. That confidence was always there, I just wasn’t always able to touch it. I know it will be hard. I know there will be setbacks, possible rejections, and possible future hospitalizations. And with that knowledge, I see it is really just a another phase of the old normal, the same old life, the ceaseless struggle against suffering, the path that goes on forever to the endless further.

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Meditation, Mantra, and Minis

The Benson-Henry Institute (BHI) at Massachusetts General Hospital is a leader in the clinical practice of mind-body medicine.  It’s Director Emeritus is Dr. Herbert Benson, whose primary focus has been on stress reduction. In the 1970’s, he developed a technique based on Transcendental Meditation (TM) that he calls “The Relaxation Response.”

Transcendental Meditation and Mindfulness meditation are the two forms of meditation used most often in clinical settings.  Both TM and contemporary Mindfulness are often criticized for being “meditation lite,” watered-down versions of traditional meditation.  While it is important to note that 85% of all diseases is stress related, from a Buddhist perspective relaxation and stress reduction are only the short-range goals of meditation.  The long-range goal is transcendence over suffering, moving from unwholesome states of mind to wholesome ones, and the development of penetrating wisdom.  The Buddhist focus is on the complete transformation of the individual.

At the BHI, patients are encouraged to do “minis.”  These are mini-meditations, short periods of meditation usually 5 minutes or less, a quick fix to reduce stress in a short amount of time.

“Minis” can also be reciting mantras.  Ellen Slawsby, Ph.D., the director of pain services at BHI, says that mantras use “something inborn, an internal mechanisms to elicit your own endorphins or endogenous morphine.”  Indeed, studies have shown that reciting a mantra does release endorphins.  Mantras provide other benefits as well, all similar to those associated with mindfulness meditation:  they relieve stress; move energy throughout the body, regulate heart rate and chemicals in our brains; enhance positive brainwaves; increase immune functions; and help lower blood pressure.

Slawsby claims that “As little as 30 seconds of using a mantra can dampen unpleasant sensations.”  Sure, for maybe 30 seconds. The mantras used at places like BHI are often short phrases, maybe two to four words.  Aggie Casey, director of BHI’s Cardiac Wellness Program, says “They may quietly to themselves repeat the words ‘I am’ as they breathe in and then ‘at peace’ as they breathe out.”  Such phrases are hardly mantras, though.  They are more like short affirmations.

Healing Buddha Mantra: “Thus: Om Healer, Healer, Great Master of Healing Supreme, Joyfully Going Beyond, So Be It!”
Healing Buddha Mantra: “Thus: Om Healer, Healer, Great Master of Healing Supreme, Joyfully Going Beyond, So Be It!”

It is difficult to come up with a precise definition for mantra, but traditionally, a mantra contains one or more ‘bija’ (seed) syllables that may or may not have some literal meaning.  Roger Corless in The Vision of Buddhism explains that, “A mantra may contain words, or sounds that has a specific meaning; but meaning is not its essential feature.”

Originally, mantras were considered “sacred words” possessing magic power.  However, Ryuichi Abe* says, “[It] is possible to understand mantra as a linguistic device for deepening one’s thought, and, more specifically, an instrument for enlightenment.”  If approached in the right way, mantra is a meditative discipline.

There are certainly positive short-term benefits to the relaxation and stress reduction focus of contemporary meditation.  Yet these methods are much more effective, and transformative, when practiced from a deeper level, with a real commitment of time and perseverance.  Now there were always be those who will never be interested in committing to the full path.  For them, short periods of “mindfulness” are enough.  Yet, I can’t help but wonder if the contemporary approach to meditation and mantra doesn’t have the effect of detouring those who might decide to go further.  As well, I question how repeating a short affirmation for a small period of time can cut through the delusions of self and fundamental ignorance, which Buddhism teaches is the root cause of all disease and all suffering.

Today on a number of ABC programs, Nightline commentator Dan Harris promoted his new book about meditation 10 Percent Happier. On World News Tonight, he said it only takes five minutes. “Everyone’s got five minutes.” Only 10 percent happier? “That’s pretty good.” Well, it’s better than nothing. But I am afraid that these sort of presentations mislead people into thinking that is it easy, and when they find out it isn’t then they will give up, as many do, or form a negative association with meditation. The other extreme are those who oversell the benefits of meditation, giving people the impression that it will solve all their problems. That is equally as dangerous and irresponsible.

Meditation is hard. When we engage in meditation or mantra practice, difficulties will come up. That is a good thing, for without difficulties there can be no real progress. When we talk about overcoming or transcending suffering, we don’t mean that sufferings ever go away. But rather, we view suffering differently, and that change of perspective facilitates our transformation.  Thich Nhat Hanh writes in the Miracle of Mindfulness, “Feeling, whether of compassion or irritation, should be welcomed, recognized, and treated on an absolutely equal basis; because both are ourselves.”  The same holds true for suffering, and so the transformation we speak of involves establishing a state of inner well-being that the suffering part of ourselves cannot overwhelm.

Just as meditation is hard, life is hard. People have always looked for quick and easy solutions to life’s problems, but the plain fact is that the solutions can be as complex as the problems themselves.  Five-minute mini-mantras or even twenty minutes of mindfulness does not compare to the hours of practice these methods truly demand, and I feel, depreciates their full potential.

Suffering and illness are directly related to the unstable nature of the mind. Chaotic and stressful thought patterns disturb the flow of life force in the channels and nerves, resulting in physiological disequilibrium.”

David Crow, In Search of the Medicine Buddha

Steady periods of prolonged meditation or chanting, or both, are especially powerful tools for restoring balance and leading the mind back to a state of equilibrium.  Rome was not built in a day.  Inner transformation and durable wellness cannot be achieved in five minutes.

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* Ryuichi Abe, The Weaving of Mantra: Kukai and the Construction of Esoteric Buddhist Discourse, Columbia University Press, 2000

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Healing and the Emptiness of Karma

In any discussion about the Buddhist perspective on healing, one of the first things we have to contend with is the doctrine of karma. This is a troubling notion for some modern Buddhists who are inclined to doubt karma (and rebirth) because there is insufficient evidence of their validity. I have doubts myself about these two concepts, yet I have never been willing to dismiss them outright. One thing I’ve learned over the years is that there is little in Buddhism that is not useful on some level.

Sickness is one of the four sufferings taught by the Buddha (along with birth, old age and death). Raoul Birnbaum, in Healing and Restoring, explains the traditional view of how karma relates to sickness:

Most fundamentally, disease relates to either a direct or indirect result of karma, either retribution for specific acts or the ultimate effect of longstanding patterns of thoughts, words and deeds. Since the mind drives the speech and actions that generate karma, it is the mind especially that is seen as root of disease.”

Karma has long been seen as a form of metaphysical payback. If you’re not “good,” then something really “bad” is going to happen. Your karma will get you. Karma became a tool to coerce people to adopt socially acceptable behavior. There is a flip side. Good deeds will reap future positive situations. The amount of merit (punya) a person accrues can result in good karma: a good rebirth, or in this life, good health and freedom from disease. Basically we have been presented with a scenario where a sword of Damocles is hanging over our head and a carrot dangles from a stick in front of our face.

Now, our old friend Nagarjuna had some problems with this. He understood that karma referred to “action” and not to a law of causality, and that all action is volition and volitional. Karma is not the result or effect of action. For karma to be “a law of cause and effect,” it would have to be of the nature of permanence (nityata):

If karma were a fixed thing [i.e. enduring] because of its self-nature, then its ripening would always remain.

Nagarjuna, Fundamental Verses on the Middle Way 17:25

The questions Nagarjuna dealt with in Verses, included whether or not the ripening or effects of karma were imperishable and inevitable, and if perhaps the effects existed prior to the full ripening.  As I understand it, Nagarjuna felt these questions suggested that karma exists from its own side, that it has self-nature. However, that cannot be the case, for all phenomena whether material or immaterial are devoid of any inherent self-nature or essence, and are impermanent.  Things are not “fixed.”  They are sunya – empty.

David J. Kalupahana (who passed away Jan. 15) writes in Nagarjuna The Philosophy of the Middle Way,

Even though there is no continuity of karma (and in this case, borrowing), that is, it does not continue in any subtle or substantial way, the responsibility for that karma cannot be denied once that karma is performed . . .

The simple notion of human responsibility is what is upheld here, not the metaphysical notion of the fruit or result that lies hidden and gradually attains maturity . . .”

I am simplifying Nagarjuna’s explanation a bit, and yet it is simple. He did not reject cause and effect, for actions do have consequences.  However, he does reject the notion that karma is some self-existing force, a Law of the Universe.  It seems to me that a sense of responsibility is the all-important take-away from the doctrine of karma.

Few people in this modern age have any use for the notion of responsibility. As soon as it is suggested that individuals should assume responsibility for what happens to them, one is accused of blaming the victim, etc. That’s missing the point. It is foolish not to take responsibility for one’s own actions, just as it is equally unwise to say that every consequence in life is a result of karma.

We can’t say the cause for every suffering exists within the life of the individual, or that effects are always the result of some past action. But, without a doubt, suffering exists within, and taking responsibility for the suffering can influence the future.

The first step in healing, then, is to “own” the suffering.  We take full responsibility not only for the suffering but also for the healing process. This requires a willingness to break free from past negative patterns in thought, word and deed that can impede healing. It also involves compassion or love for oneself and for others.

The English word ‘heal’ is connected the word ‘hale’, which is related to ‘whole.’ To heal is to be whole. ‘Whole’ also means, “that which has also survived” and “keeping the original sense” and “to heal.”

In Buddhism, wholeness ultimately means to be awakened.  Awakening implies wisdom, but also surviving or transcending suffering, and discovering one’s original nature.  In this way, the path to awakening is also the path to healing.

Listening to and understanding our inner sufferings will resolve most of the problems we encounter. In order to heal others, we first need to heal ourselves. And to heal ourselves, we need to know how to deal with ourselves. If we know how to go back to ourselves, listen and heal, we can change. But most of us don’t know how to listen to ourselves and understand the sufferings.”

Thich Nhat Hanh, “Stop and Heal,” Jamsil Indoor Stadium, Seoul Korea, May 2013

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