Podcast: A Christian Perspective on Depression (Kathryn Butler, MD)

May 20, 2024 by: Crossway

This article is part of the The Crossway Podcast series.

Clinical Depression and Christianity

In this episode, Kathryn Butler shares encouraging insights that offer hope for those who struggle with depression and help for those seeking to care for someone who does.

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Topics Addressed in This Interview:

01:16 - Is a Struggle with Depression a Result of a Lack of Faith?

Matt Tully
Katie, thanks so much for joining me today to talk about a really important and really challenging topic.

Kathryn Butler
Thanks so much for having me, Matt. It’s a privilege as always.

Matt Tully
Perhaps more than ever today, it seems like the topic of depression is one that we hear discussed a ton. There’s probably never been a time that we’ve had more access to more support and conversation about this difficult topic than we maybe do now. And yet my sense is that, for many Christians, the topic—and even just more broadly, mental health topics in general—can still feel very confusing, sometimes controversial, and embarrassing to talk about with other people. Have you seen that in your own experience with other Christians?

Kathryn Butler
Oh, absolutely. I actually knew medicine before I knew the Lord. We’ve talked before about how the Lord worked through my work and the suffering I saw there to bring me to Jesus. So I learned about depression first and experienced it firsthand, initially, before I even came to the church or interacted with others who follow Christ. And I was really struck and saddened by the narratives and the questions and the struggles I would hear. People were confused and worried that, Well, since I have the gospel and I should be joyful, if I have depression it means that my faith is weak. Or saying, I shouldn’t be taking antidepressants when this is a spiritual issue. I was seeing this conflict, and it was almost as if having periods of deep sorrow and walking through deep darkness are somehow incompatible with Christianity and the knowledge of the gospel and the knowledge that we’re saved in Christ. And it’s something I think that, unfortunately, is probably pretty common. They’ve done very few studies, but those that have been conducted, looking at support of mental health concerns within the church, there often is this stigma that is voiced, where people say they don’t feel comfortable talking about it among church family because they’ll think it shows that their faith is weak or they should just be able to get over it because they know the gospel. And so I do think it’s tremendously confusing. As the church, we really can come alongside and love others well in ways that no other resources can because we have the truth and the hope of the gospel and how life giving that is. But I find that sometimes we miss the mark when it comes to this topic.

03:45 - How Common Is Depression?

Matt Tully
I want to get into some of the reasons why we think this way sometimes and some of the misconceptions that maybe do exist. Before we get there, help us understand just the lay of the land right now. How common is depression in the US today?

Kathryn Butler
It’s incredibly common, and it’s becoming more so. The lifetime prevalence in the United States for depression is 21 percent, meaning that one in five people in the US will have suffered an episode of depression at some point. And we often think about it as a disorder of the affluent and the privileged, but actually worldwide the prevalence is also high. It’s about 12 percent. And the World Health Organization actually cites depression as the number one cause of disability worldwide. And in the US, that disability is actually commensurate with struggles and dysfunction that’s associated with cardiovascular disease and stroke and arthritis. It has a tremendous impact. Those statistics hint that when we go to church every Sunday, we’re likely walking among people for whom just getting up and coming to church that morning has been a struggle. And so it’s something I think we need to have an awareness of and a sensitivity to because it is so incredibly common.

Matt Tully
Are there studies or numbers about how common it is among believers in particular? Or do we just have general numbers for the population at large?

Kathryn Butler
As far as I am aware, there are just general numbers for the population and nothing that’s been explicitly studied for the church. But I could be wrong on that. I’m just not aware of any.

Matt Tully
My sense is that, from reading various books and articles and listening to podcasts, that the struggle with depression seems to be getting worse for our culture and for our society in particular. I don’t know about around the world. Is that true? And what do we know about the change in the rates of depression today?

Kathryn Butler
We know that it is becoming increasingly frequent in young people, especially since COVID and especially for young women. We’ve seen an increase in the numbers over the last decade or so.

05:46 - What Is Depression?

Matt Tully
Take us back to that word depression. It’s a big word. It’s a word that we throw out a lot, and it carries with it a lot of meaning for a lot of people. But what do you actually mean by that? How do you define a term like depression?

Kathryn Butler
It’s an important question because we all go through seasons of grief and of sadness. And honestly, tears are an appropriate response to the fallenness of our world. And we see that throughout the Bible. Job has everything taken away from him, and he falls to the ground and tears his robes and he cries. And Christ himself, anticipating the cross in Gethsemane, falls to the ground and is overcome with sorrow. In Isaiah we read he was “a man of sorrows acquainted with grief.” There is a place for sorrow, especially when it’s in response to the brokenness of our world. When I’m talking about depression—and the word can be bandied around frequently—I’m specifically talking about clinical depression, which is a constellation of symptoms that go beyond this typical sadness. It’s sadness that lingers for too long. There’s no healing that’s associated with it. And it has far reaching effects on every avenue of life. The technical clinical criteria that we see in the DSM-5, which is the manual for psychiatric disorders, is depression, meaning depressed mood, a sad mood, and/or anhedonia, which means that you no longer can glean joy from the things in your life that you used to love. In addition to several other potential symptoms, they usually have to do with functions of daily life like struggle with sleep or sleeping too much, having no appetite or eating too much, restlessness and not feeling like you can sit still versus having trouble getting up and moving. Difficulty concentrating is a big one. Fatigue is a big one. And actually, feelings of worthlessness and guilt that are out of proportion and inappropriate. And those symptoms need to persist for two weeks consistently every day for it to be considered clinical depression. And what we see is that the reasons behind this constellation of symptoms are often multiple different pathways. Clinical depression is probably best thought of as an umbrella term, where there are many possible ideologies and they all result in this similar constellation of symptoms. What’s common for all is that the outcome is very debilitating, and it’s not something that you can usually pull yourself out of by simply just positive thinking. Usually you need some kind of help to overcome it. And the reasons for that are multifactorial, but depression often does have some kind of neurobiological underpinning. It’s not responsible for everything, and I need to make that clear, but we do see brain changes on multiple levels among those who are struggling with depression and those who don’t. And so we see changes in the hypothalamic pituitary adrenal system, which is responsible for emotional regulation. We see it on the cellular level with differences in neurotransmitters that signal communications between nerve cells. And we don’t know exactly why it occurs. We don’t know if this is a result of depression or if depression arises from these. We don’t know. But we do know that there are some changes, which I think sets it apart from what we typically deal with in terms of the sadness that we deal with in life. And I think it hints at why it’s so hard to overcome just with the typical positive mindset and other measures that we would do to overcome grief, for example. And so the effects are far-reaching, and very often people find themselves dealing with episodes recurrently over a lifetime. There’s usually a family predisposition to it. And we find that certain people are just more susceptible. So if you overcome one episode, and you’re sighing with relief that you can finally see the light again, another episode may be around the corner a few months or years later. So it’s a lifelong affliction for many, and one that comes with a deep sense of isolation. It’s very common for people to feel that nobody understands what they’re going through.

Matt Tully
As you mentioned earlier in our conversation, and you hit on this a little bit in this book that you’ve written but also some of the other books that you’ve written with Crossway, that you yourself have struggled with depression in the past. You write in the book that you are “a sufferer intimate with its subtleties.” What do you mean by that? What are you trying to communicate when you talk about the subtleties of depression?

Kathryn Butler
I learned about depression first and foremost when I was in medical school and cared for patients who were receiving significant treatment for it—severe treatment. That means those who are hospitalized and needed to have electroconvulsive therapy, for example. So I witnessed the impact on an external level of seeing that this was not something that was typical for what we deal with in life when we’re dealing with ordinary sadness. It was very debilitating. People really needed help. But then I also struggled with it personally myself. I want to emphasize with depression that everyone’s experience is unique and even every episode is unique. My first episode had a spiritual trigger. Afterwards they did not. Afterwards they would be isolated and it would almost be like a light would switch in my mind and suddenly I was seeing the world through gray. But in my first experience with it, even though I knew all of the ins and outs and the criteria and I had seen patients struggling with it, I hadn’t grasped until I went through it myself just the ashenness of every day. There was this deep-seated exhaustion. And what was most upsetting to me was I found the anhedonia really debilitating. The fact that I would look out and I would see evidence of God’s work, in terms of a beautiful clear day or trees that were flowering and in bloom, things that were just such an obvious manifestation of his love, and I would look at those things and feel nothing. And I think that for me was the hardest part. And I had not ever really comprehended how profound that was. And for Christians and for those who follow Christ, that’s part of the experience too is that they might know and hold dear the Bible, and first of all, they’ll try to read, and they can’t concentrate. So reading, oftentimes—I’ve already heard others describe this and I’ll talk about it myself too because I’ve experienced it—you’ll read one of the Psalms—I’ll read Psalm 23, which normally is just such a fount of peace and encouragement—and you’ll read the words but you’ll just feel nothing. You’ll know them. You could recite them. But they lose their imprint on your heart. Or you’ll go to church and you find you can’t sing along with the hymns because suddenly you can’t connect with their import anymore. And so I find that that’s something that’s hard to comprehend unless you’ve actually walked down that shadowy road. The degree to which depression actually changes your perception, and it changes your appreciation of the truths so that you know them still, but you can no longer experience and feel their impact on your life. And so often you’re just holding on for dear life, praying that the fog lifts because every day is a struggle.

Matt Tully
What’s the relationship between depression and anxiety? Those are two things that seem like they’re often discussed together.

Kathryn Butler
Yeah, that’s because they often occur together. About half of people who struggle with depression also have generalized anxiety disorder as well. They often do occur together.

Matt Tully
Why is that?

Kathryn Butler
I think because, as I said, they’re multifactorial. Very often the worries and the concerns that we’re dealing with in life can be triggers. And so if we are exceptionally prone to worry, it becomes all encompassing and it becomes crushing. That can then be a trigger to lead you into despair. And so I think that there’s this wedding of the two, of worry and concern, that’s out of the proportion to daily life then leading to a sense of despondency that can then develop and slide into depression. But yes, you’re absolutely right. They are often aligned.

Matt Tully
And they can kind of feed on each other. There’s a bit of a cyclical nature to those.

Kathryn Butler
Absolutely.

14:14 - Shouldn’t Christians Struggle Less with Depression than Non-Christians?

Matt Tully
So I wonder if we can talk a little bit more about some of the causes of depression. And you’ve already alluded to maybe the assumptions that Christians have often made about depression, some of the ways that we default to thinking about this, at least as we have historically. I wonder if I can play devil’s advocate a little bit and hear how you would respond to somebody who might have this view. So they would think that, on average, it makes sense that Christians should struggle less with depression because we’re Christians. We know that we are God’s creatures and we’re loved by him. We know that our sins have been forgiven. We know that we have the hope of eternal life, even if our life in this world is difficult in different ways. We even have the Holy Spirit indwelling us, empowering us for life and godliness and joy. So shouldn’t that mean that, on average, we should be more joyful, more happy, more stable in our emotions than those who don’t have Christ? Is there any truth in that way of thinking? What does that miss that you would want to encourage Christians to really think more carefully about?

Kathryn Butler
Sure. The two things that I think it misses biblically are I think it misses the reality that Jesus himself said we would have persecution and tribulation. He did not promise that every day would be joyful and we’d be skipping down the garden path. He told us instead that when those times come, and they will come, to take heart because he’s overcome the world. And so he gives us an assurance to buoy us through these tempests. They will still come. And I think the idea that we’re to perpetually be happy, number one, undercuts the reality of suffering, which is not what God intended, and reflects something that’s backward and broken and abhorrent. And I think the right response to that is to cry and to look and to be sorrowful. And number two, the truth that this is why Jesus came was to free us from the wages of sin and from the sorrow and from the suffering. But right now we still labor in the now and the not yet. We are not yet at the time of Jesus’s return when all things will be made new. We have the gospel and we have sanctification and we are growing in our faith and our towards our glorification every day, but that’s not come yet. And so we’re still laboring in a sinful world, and the right response to that sinful world I think is to be sad and grieved in the face of it. And so biblically, I don’t think that that line of thinking actually reflects what we see. The second thing I would say is I know that there is controversy, especially in certain counseling circles, regarding depression as having a physiologic basis and saying, No, it’s just on a spectrum of emotional difficulties. I understand that and I respect those opinions, but it’s harder for me to ignore that there’s possibly something physiological at play because, number one, looking at the studies; number two, because we see in medicine people who are struggling with disorders that are entirely physiologic—for example, hypothyroidism or lupus—who’s presenting symptoms are depression. I’ve met people who have hypothyroidism, and they are depressed and they think that they’re being treated for depression. That’s why when people come in and if you see a physician for symptoms of depression, they’ll talk about antidepressants and counseling, but they’ll also check your labs. And that’s because just treating hypothyroidism can reverse it without anything else, because the cause is hypothyroidism. We see a lot of depression concurrent with Alzheimer’s disease because it actually involves changes in the brain. So it is not solely a physiologic disorder, but I do think that there is a physiologic component. And I think that actually is partly why it is so hard to overcome just with, I’m going to try to pull myself up by my bootstraps. I really think the architecture of our neurobiology can kind of lock us in the darkness. Now, that’s not to say that the only cause is physiologic. It’s not strictly a matter of, I’ve got a vitamin deficiency, and I’m just going to replete it. It’s very complicated. So we know that there are family predispositions to it; it tends to run in families. We know that a life event that is traumatic can often trigger that first episode. We know that the more social support you have, that’s protective against depression. We know that involvement in church actually—and I’m sorry. I misspoke earlier when I said I don’t know about the prevalence among church members. I do know that involvement in a church community is protective against suicide. If you are struggling with depression but you are attending church and involved with the church community, that actually tends to have a protective effect in terms of you being able to combat that despondency. There are a lot of factors that go into an episode happening and it persisting, but I think it’s really an oversimplification to say it’s just an issue of outlook exclusively, and that as Christians we shouldn’t be depressed because we should always have a good outlook because we have the gospel.

Matt Tully
Do you think Christians are ever guilty of, in this dualist way, separating mind and body, our souls from our bodies, thinking our emotions and our feelings are a function of our souls, and the body shouldn’t really have anything to say to that?

Kathryn Butler
I think that’s a great question. It’s possible. I think that we maybe make a dividing line between the two. But the truth is that it’s far more complex than that. The two are very closely interrelated. Our spiritual disciplines and unrepentant sin can absolutely inform whether or not we’re struggling with depression. I can attest to that personally. My first big episode with depression was a spiritual crisis, and I didn’t know the Lord. He used it and worked through that to bring me to himself, but it need not be. So there may be unrepented sin, but not necessarily. And I think we tend to err, like Job’s miserable comforters, when we try to claim that, The reason that you’re feeling this way is necessarily because you’ve done something wrong that you’ve not repented of. That’s possible. It’s absolutely possible, but it need not be in all cases. And in my more recent episodes of depression, for me it really is like a light switch. One time I was at the playground with my kids. It was a beautiful fall day. And all of a sudden it was like a curtain going over my eyes. Another time I was sitting at the breakfast table with my family. There was nothing preceding it. It was like a switch. In my mind I said, “Oh Lord, please, not this again!” And I just went into weeks of prayer and trying to hold on. So I think we do a disservice when we try to claim that it’s solely an issue of spirituality or motivation. I think there’s something more at work that’s more complicated.

Matt Tully
That seems to be one of the main themes I’m hearing from you is that, as we think about the multiple possible causes or contributing factors to depression, it’s probably a mistake to focus on any one of those causes as the exclusive thing that’s going on. It’s probably some combination. That’s perhaps harder because we have to think a little bit more broadly about how to actually go about treating it and dealing with it, but maybe it’s more true to who we are as body/soul, complex creatures.

Kathryn Butler
You mention that, and I think the fact that the treatment that we have that is imperfect, I should say, but the best treatment we have—reflecting that body and soul coming together and being integrated—is actually for moderate to severe depression; it’s antidepressant medication and counseling. So the combination of the two is more effective than either one in isolation. We found that for people with very mild depression, we actually will just recommend counseling because it avoids the side effects of the medications. But for those who have more moderate to severe, combining the two is more efficacious and brings about remission more effectively than either alone. And I think it’s because the antidepressants do help with a physiological component. They are not a miracle cure by any means. But they do ameliorate symptoms in many cases, not often bringing about full remission, but at least bringing the severity down so people can at least function. And then counseling is critical to help dig into what are those patterns of thought or behavior that led to this? How can we develop some better coping skills so we can prevent this? So I think you hit the nail on the head by saying that it’s both together. And I think we see that even in the treatment that our studies have shown are most effective.

23:20 - Is Taking Medication Unbiblical?

Matt Tully
I think among Christian circles, but probably even more broadly than just Christian circles, in the past we’ve heard criticisms of the over medication that is so prevalent, where doctors or psychologists are just jumping right to medication. Is that a fair critique today? Or is that maybe something that was true in the past but isn’t as prevalent today?

Kathryn Butler
I think it is a fair critique, but we also don’t want to swing the other way and demonize people who really need these medications. Usually your first stop when you have clinical depression is to go to a primary doctor. And I think sometimes too often they will just prescribe a medication without adequately discussing its side effects, its expected efficacy, and also maybe just give you a list of possible counselors to see without really walking you through it. And I think that’s a disservice. And I would emphasize that we should never be giving antidepressants for just normal, refining grief. But I would also say we don’t want to downplay the effect these medications can have for those who are really struggling in the dark. And someone who has moderate to severe depression, and there’s a whole scale about this in the DSM-5, but who has moderate to severe depression where they’re really struggling just to get out of bed every day, if those medications can help—they’re not miracle cures; they bring about remission I think in only 40 percent of cases, so it’s pretty low—but they do help decrease the severity of some of these symptoms. That can be life giving. That can be enough of a handhold for people to be able to say, Okay, now let me do the hard work of counseling. Let me do the hard work of diving into prayer to do what I need so I can start working towards the light again. And so while we shouldn’t be quick to dive into medications, if it’s recommended because our symptoms are really severe, and a physician should be able to say yes or no to that, then we should not be saying to people that you shouldn’t be taking them. Because they do help. They’re not a miracle cure. They do not help well in isolation. We need to continue with counseling, psychotherapy, or whatever that other support is so we can analyze how we can better develop our coping strategies for the future. But they do critically help in some cases. I think I just want to emphasize too that we tend to think of Christian help versus secular. It’s true that there’s that distinction, but I think it’s important for believers to recognize that God gives us medicine as an ordinary means of his kindness. And just as we’re talking and saying that there are all of these social and behavioral components that can influence developing depression, there appears to also be a physiologic component as well. And God’s given us medications that have the potential to help in those cases. So it’s not unbiblical to pursue treatment when God has given it to us as a means of his own grace. And I think in depression, it’s just important to keep that in mind, that we have the means to help and it’s not unbiblical to pursue them.

26:21 - What Role Do Spiritual Disciplines Play in the Battle with Depression?

Matt Tully
You’ve just been talking about the two main answers or responses to depression that the secular world offers that you’re saying Christians can also avail themselves of—medication and therapy or counseling. But you also write in the book, “While both medication and counseling play vital roles in recovery, neither diminishes the importance of spiritual disciplines for sufferers striving to reclaim their joy.” So I wonder if you can unpack that. What role should spiritual disciplines play in our battle with depression?

Kathryn Butler
I think for the believer, they are vital because when you’re struggling to see the meaning in life and the meaning and continuing on, your prayers are reduced to single words sometimes or single phrases. But that’s what keeps you going. When I was at my worst, I would just say, “Lord, have mercy on me!” And that’s all I could say, but I would say it a hundred times a day, and it helped me through. And to have someone send you a verse that’s meaningful for you to look back to in your text messages or to have in your pocket, to have people come alongside you and pray with you and for you when you don’t have the words to pray, I think is vital. There was a wonderful survey that was done by Ed Welch from CCEF, and he was asking Christian sufferers of depression what was helpful to them and what wasn’t. And a hundred percent would say staying connected with people who were compassionate and listened. And the other thing was prayer. And oftentimes their prayers were not complicated, but they said, “I have to force myself to pray every day because it’s a lifeline.” And it’s because we’re wallowing in the valley of the shadow of death. It really is walking through despair and walking through deep darkness, and we need the light of the world more than ever. And so as hard as it is to pray during depression—and it’s hard because you feel foggy headed and you cannot even put two words together. You read, and your eyes just dance over the page. But trying to stay in the routine of, It’s going to be difficult, but I’m going to come back and I’m going to try to read something. Or to work out with someone that you trust, Can you please text me every day? Check in with me. Send me a prayer that you’ve been praying. I think it’s life giving and I think it is an anchor to hold you when everything else is just nothing but gloom.

28:52 - How Do I Tell Someone I’m Struggling with Depression?

Matt Tully
That’s such a beautiful, again, nuanced picture of how we as Christians have common resources that other people would have, but also the unique gospel-centered resources that we actually do have at our disposal as God’s people. Maybe just a few other questions that may get a little bit rapid fire here. What would you say to the person who says, I think I’m struggling in this way, and I would love to loop in people in my church, especially my pastor but maybe even others in my congregation. And yet I’m afraid. I don’t know how to do that, and I’ve even had some bad experiences with Christians in the past who have maybe responded just like you’ve described here in this conversation. What would you say to that person?

Kathryn Butler
Oh goodness. First of all, I would say it is incredibly common to feel that way. I want to emphasize that feelings of worthlessness and guilt are part of the disorder. So we all, by nature, feel really ashamed of what we’re going through and scared to talk about it, not even including the misconceptions that we might have in the church. And yet it is so critical not to isolate ourselves because we’ll just fall and sink deeper and deeper into that mire. So what I would strongly encourage is to find someone that you trust within the church. Maybe it’s your pastor, maybe it’s a small group leader, or maybe it’s just a dear friend who’s been a prayer partner. Start with one person. Have a conversation and just be open about what you’ve been experiencing. I might preface, and this is a burden that I feel like we need to switch the tables and instead, as the church, approach people this way rather than the depressed having to tell them to do this, is for a sufferer to, as they’re having this conversation, maybe say like, I’m not asking for advice right now. I think too often because we’re so used to going out into the mission field and we want to help and we want to fix things, we’ll sometimes give unsolicited advice that actually oversimplifies people’s problems, and they’ll shut down. They’ll not want to divulge further because it’s like they’re not really understanding. They’re offering me quick fixes right now. Oftentimes, what sufferers want instead is just someone that they can talk to and have them listen and be an empathetic presence. Say, I’m not looking for advice, but can I please just talk with you and can you pray with me about this? Start there. And the more you wind up talking about it to people, the easier it actually gets. But start initially just with someone that you trust who can help to guide you through and offer you the guiding light of God’s word when you can’t put heads or tails together.

31:32 - When Will I Get Better?

Matt Tully
How about the person who’s saying, I’m doing everything you’re suggesting. I’m seeing a Christian counselor and they’re helping me think through these things and talk through this. Maybe they’re even taking some kind of medication, but it just doesn’t seem like things are getting better. They’re wondering, Why is this taking so long? I thought this was supposed to help.

Kathryn Butler
First of all, I want to know how long they’re dealing with it, and the reason is because this does take a long time. Medications usually will not kick in to deal with the depressive symptoms until after eight to twelve weeks. And in addition, there’s a very high dropout rate for antidepressants. And I should have said this earlier when you were asking me about them. We worry sometimes, Am I going to become addicted to these medications? That risk is zero with antidepressants because they’re not pleasant to be on. They have a lot of side effects of weight gain, stomach upset, drowsiness, and they worsen your concentration. And those side effects happen before the benefits of the antidepressants kick in. So people are still struggling with symptoms of depression while they’ve got all these side effects in play. So the dropout rate from these medications is very high. But as a result, they worked up the courage to tell someone, they’ve been referred to a counselor, they start on these meds, and then it takes weeks and weeks and weeks, and they don’t feel any better. So number one, I would say that that’s a common experience. It doesn’t mean that the fog won’t lift. As hard as it is, just hold on, keep talking, keep praying, and they will start to see some improvement, hopefully, after that twelve-week mark or so. If not, if things are still getting worse after a trial of therapy like that, we do have people who are treatment resistant, who really have very, very severe depression where they need more than our usual methods. And so if that’s the case, it really requires circling back with your physician and saying, Do I need an additional antidepressant? Do I need to do some of the bigger, more involved measures? Transcranial stimulation is one of them. There’s electroconvulsive therapy. Those are for real severe cases that are treatment resistant. And so those are the two things I would say is number one, just hold on and know that it does take time. And number two, if you, however, feel like you’re getting worse and worse and by now the medication should have kicked in and things should be improving, circle back with somebody who’s involved in your treatment and ask, Do I need something further?

Matt Tully
Can depression ever be cured? Is there hope for a total cure for most people?

Kathryn Butler
When the Lord returns. Not to be glib, but I would say the rate of recurrence is very high. It usually is a lifelong episodic disorder. Not always.

Matt Tully
By episodic, you mean it’s not going to be constant all the time. You can make progress.

Kathryn Butler
Right. It’s very rare that you are depressed your entire life. They come in episodes. They come in episodes of weeks, usually months. It could be a year or two, but it’s usually episodic. For those who have an episode, the recurrence rate is usually about 40 percent within the next five years. So if you have an episode of depression and you recover, about 40 percent of people will have another episode within five years. If you have had two episodes, your risk that you’re going to have another one within five years goes up to 75 percent. It’s not always, but often is something where it does come back, which is all the more reason I think that it’s important to ensure that you go and seek counseling for an episode. What counseling does is it helps you to develop an awareness of the symptoms and gives you strategies to help cope the next time it comes around. And if you don’t pursue that kind of counseling because you’re think, When it comes around it’s going to be just as hard, I've learned to earmark certain psalms in my Bible for when I have another episode. When I’m in the midst of it, I am too cloudy headed to figure out where to even look in Scripture for help. But if I earmark the ones that have spoken to my soul and point to God’s love and point to the reality of this broken world and the darkness that can happen and point to the light of Christ in the midst of it, that’s life giving. But I can’t remember where to look. And so I’ll earmark certain psalms when that happens. I’ll make sure I tell my husband when it’s clear I’m struggling. And he’ll say to me, “What can I do to help?” And I just say to him, “Just be patient, please, and pray. It’ll be okay. God’s brought me out of this before. I know he will again. Just please be patient with me as I’m not responding in my usual way when you tell a joke. It’s not you. It’s what’s going on inside.” I think it’s critical that we do seek out help, even though we don’t want to and even though we’re ashamed, because it can help you through that first episode, but it can also help you if it ever comes back to have an idea, a strategy, and also the awareness to say, The Lord brought me through this once. He’ll do it again.

36:48 - Do I Have to See a Christian Counselor?

Matt Tully
Another question that I think sometimes we can wrestle with as Christians is when we decide, Okay, I’m going to go see somebody. I’m going to try to get some help from a professional, but then their question is, Well, do I need to see a Christian counselor? Or is it okay for me to go talk to a secular psychotherapist who’s got a lot of experience, who I’ve heard good things about? How do you think about that? What counsel would you offer to the Christian who really wants to do as you suggested—hold all of these factors together and come at this from a distinctly Christian way?

Kathryn Butler
I would say, first and foremost, if you are so severe that you need medication that has to be through a doctor, it can be your primary doctor. So it need not be that the same person who’s giving you counseling has to give you medications. If he wants the same person to do both, it needs to be a psychiatrist. I would say that I personally would recommend seeing a Christian counselor or a christian psychotherapist. And the reason is because a lot of the things we might be struggling with are caught up in our worldview, are caught up in questions of, Why won’t God answer my prayers? I’ve been praying and praying for relief and he hasn’t. The big question, which we’ve touched upon, of, Does this mean I’m not a Christian?—the walk through depression stirs up questions of faith. And I think the suffering and the struggle we’re going through is best addressed as we’re wrestling through the lens of the gospel and through God’s healing word. And so I would make sure that you’re going to a Christian counselor who is not judgmental in their approach to depression, who accepts it as one avenue of suffering—and we all endure suffering in this fallen world—and with whom you feel trust and a connection. If it’s someone who has those qualifications, where they’re empathetic, they’re patient, you trust them, then absolutely I would seek out a Christian counselor.

38:50 - Advice for Pastors on Providing Support

Matt Tully
Maybe just a couple last questions. I would imagine that few people are on the front lines of human suffering and the trials that we face as humans as pastors are. Pastors are probably often some of the first people to perhaps hear about someone’s struggles and even their depression. So what advice would you offer to pastors as they think about their role in all of this? Maybe this is someone who’s been to seminary, had some counseling classes in seminary, but certainly isn’t a medical doctor or a psychologist but wants to be a good support to the people in their church. What would you say to them?

Kathryn Butler
I would say from the pulpit it can be hugely comforting for your congregants to hear you address depression as a means of suffering in our world, rather than as something that’s an anomaly. I don’t want to say normalize it, but basically to take away some of that stigma. I think that in itself is tremendously comforting for people who are suffering with this. And then as you walk alongside those who have confessed what they’re dealing with and been open about it, to withhold judgmental comments. That was actually one of the other items in Ed Welch’s survey was what kind of people did you feel comfortable divulging your struggles with, and what made them safe. And the number one thing was the ministry of presence. People who just said, “I love you and I’m here for you, and I just want to hear what you’re going through.” Number two was not unsolicited advice that oversimplified things. The third thing, which is important, was that they withheld judgment when they discussed things. It’s a pastor’s role to also point out unrepentant sin, of course, but I would say do that gently, and do that after there’s been some dialogue where you’ve gone beyond coming alongside someone and offering support and you’re offering some kind of counsel of, Okay, how can we help? So I would just say to be very discerning and not to be condemning in your interactions, and really just seek to love them, knowing that depression is very deep suffering. That’s fundamentally what it is. And I just hope that all within the church can see that those who are depressed are struggling through very deep suffering because their very capacity to feel and experience joy has gone. That often feels very out of their control in terms of getting it back.

41:23 - Advice for Supporting a Loved One with Depression

Matt Tully
And maybe this is going to be overlapping with that answer, but maybe speak to the friend or even the spouse who’s listening right now. They would suspect, and maybe they don’t know for sure because they’ve not been told that there’s a diagnosis of depression, but they suspect that somebody they love and care about is struggling in this way. What would be the next practical thing that this person could do to help to support them in the best way?

Kathryn Butler
Yeah, absolutely. Two things. I would say ahead of time, do a little bit of research. Make sure you know what you’re seeing. And also what I would do is I would research potential avenues for support ahead of time. What happens too often when people admit that they’re struggling with depression is someone will say, Well, you should go to a counselor or You should exercise more. What is I think more effective across the board is to come alongside someone and say, Listen, I looked up this counselor who’s really well reputed or that our pastor recommended. Why don’t I make an appointment? I can even go with you that first time if you want. Do a little bit of research ahead of time to make sure you know what you’re seeing. Sit down with your loved one, talk to them, come from a place of love rather than accusation. Say, Listen, I really love you. I’ve noticed you seem to be having a lot of struggles right now. You don’t even need to put a label on it. But if you say, I think it might help if you tell me what you’re going through, and I think we need to actually go and get some help for you. And then offer to go with them. But the way to help is never just to tell someone what they should do. We know that exercise actually helps with depression and going out and being in the fresh air. Instead of saying, You need to exercise more, invite them out for a walk. Sit down and instead of saying, You need to pray more, pray with them. Come alongside them, and whenever possible, offer to go to appointments with them. Help them to look up potential counselors they could contact. Make the phone calls with them. Try to alleviate some of their burden, knowing that just the actions of getting up out of bed and doing what they need to do every day can feel excruciating and is hard. So when you load more on, that’s actually not helpful, rather than coming alongside and actually trying to bear the burden with them.

Matt Tully
Katie, thank you so much for taking the time today to answer these questions about, like we said, a very sensitive and a very important topic that, as Christians, we want to think very carefully, very biblically and wisely about as we navigate our lives. We appreciate it.

Kathryn Butler
Oh, thank you so much, Matt.

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