SADNESS, DEPRESSION, AND THE DARK NIGHT OF THE SOUL: transcending the medicalisation of sadness

As a trainee psychiatrist in South Australia, forty years ago, I was sent to work in one of the 'back wards' for women in a large state mental hospital. On arrival, the nurses asked me to see an elderly Irish Catholic woman; as a favour, it seemed, because her mental health was stable. The two of us sat together in a small, darkened interview room for twenty minutes or so. I found the experience peaceful. All I had to do really was listen, and occasionally to encourage flow in the ensuing, essentially one-sided, conversation. The river of words – of which, regrettably, I now remember not one – eventually slowed to a trickle and then dried altogether, at which point we rose simultaneously and left the room. The final heartfelt words I heard as we parted were these, 'Thank you, Father'. This child of God had very likely used me to make her final confession, for she died a little while after.

The nurses indulged the Irishwoman's religiosity as harmless, but I could see how a routine of prayer and worship, however low key, might offer an effective antidote to the encroaching melancholy of old age after a barren, restricted and potentially meaningless life. This poignant episode was one of a number of encounters with patients – both medical and psychiatric (for I had earlier been a GP for two years) – persuading me of the importance for clinicians of taking full account of the spiritual dimension of people's lives. Thinking and later writing about this, discussing it with colleagues (doctors, psychologists, nurses, social workers, hospital chaplains and other clergy of my acquaintance), also with a Buddhist monk I encountered at the time, served only to convince me further.

In the late 1990s, groups of similarly minded professionals, meeting each other at SMN conferences, joined to initiate the 'Spirituality and Psychiatry' Special Interest Group (SIG) of the Royal College of Psychiatrists, and the 'Transpersonal Section' of the British Association of Psychologists. These developments led eventually to publications and policy statements, but still attempts to publish articles on spirituality as relevant to psychology and psychiatry were being rejected by journal editors, who frequently asked the impatient rhetorical killer question, 'Where is your evidence for these assertions?' It would have been wonderful to have Glòria Durà-Vilà's excellent book to hand then.

'Sadness, Depression, and the Dark Night of the Soul: transcending the medicalisation of sadness' is an account of a detailed, extensive and informative piece of qualitative research conducted by the author, a bi-lingual Spaniard, living and working as a practising psychiatrist in London. It reports a study designed to explore the conceptualisation of 'deep sadness and consequent help-seeking behaviour', through analysis of data gathered from interviews with 57 practising Catholics in different parts of Spain.

Four groups of people on different religious pathways were involved: contemplative monks, contemplative nuns, lay theological students, and Roman Catholic priests. 'Carrying out this research was a wonderful and exciting experience for me', the author writes impressively. Her enthusiasm for the task, and for even-handedly discussing her findings, shines through on every page. This book was a genuine pleasure to read, the bonus being that many of my own thoughts and experiences over long years seemed substantially verified within its pages.

At the heart of Durà-Vilà's thesis is the idea of two types of 'deep sadness' – one pathological, one salutary – that sometimes overlap. One is a mental illness, not a reaction to identifiable challenges or loss. It is characterised by hopelessness, risk of self-harm, and requiring psychiatric intervention and physical treatment. The other reflects the notion of a spiritual aspect to human suffering, and the understanding that times of intense sadness often represent a normal and valuable aspect of spiritual growth, a condition (usually temporary) sometimes referred to as 'The Dark Night of the Soul', during which the subject remains 'hopeful in the middle of hopelessness' and is not at risk of self-harm.

A corollary of this dichotomy, also sensitively explored here, is a divergence of views and allegiances. On one side, there is an essentially worldly and commercial, science-based, pharmaco-medical community, ignorant and intolerant of the ways and wisdom of religious people. On the other is a more spiritually orientated, faith-based congregation, wary of secular formulations and pharmaceutical remedies for 'meaningful sorrow', the leaders of which admit lack of training on matters pertaining to psychiatry and mental illness. Those in each camp, the author concludes, would do well to examine their own weaknesses, with the aim of improving the service they offer people in distress, rather than entrench themselves in fixed positions and blame the others.

The fixed position of psychiatry, Durà-Vilà tells us, depends on a diagnostic classification system, 'deeply embedded in all aspects of psychiatric research and practice', that fails to tease out normal from pathological forms of sadness. This system is unlikely to change, she regretfully predicts, but adds more hopefully that conscientious doctors and other professionals who give sufficient consideration during assessments to the personal, social, cultural and spiritual dimension of patients' lives, rather than applying an inflexible, 'tick-box' medical model for diagnosis and treatment, overcoming constraints of time and resources where necessary, will contribute to progress and general enlightenment by setting examples of 'good practice' for others to follow.

The book is divided into three parts: 'Setting the literary and historical contexts' (chapters 1-3); 'Unfolding the narratives of sadness and spiritual growth' (chapters 4-7); 'Stepping beyond the monasteries' and the parishes' walls' (chapters 8-11). Chapter 10, 'The clergy's role in assisting those suffering from sadness and depression', offers a warning that, as well as ignorance about psychiatric matters, 'Neglect of their own spiritual development' often prevented clergy from providing optimum spiritual support for those in need of it'. The final chapter, 'A framework to differentiate normal sadness from depression', intelligently encapsulates and develops the author's research and its constituent themes, offering relatively simple, useful, and indeed meaningful, guidance to clinicians seeking to help those who are deeply sad, clinically depressed, or experiencing something of both conditions.

I found the book is worth reading particularly for Durà-Vilà's evocative description of her subjects and their ways of life, and for the revealing testimonies concerning their own 'Dark Nights' of the religious people interviewed, especially the contemplatives. It is worth noting her point that, 'In the Dark Night, the suffering is not over the loss of God but rather the loss of prior notions of God' (p45).

To be divested of false or incomplete notions (whether of God or anything else), obviously serves to promote personal, intellectual and perhaps spiritual maturity, however painful the process. Durà-Vilà has done her readers a great service in exploring and lucidly explaining the subtleties of the debate, showing clearly the opportunities for growth and new wisdom involved in looking at problem areas like this 'from both sides'. I have no hesitation in recommending this thought-provoking and encouraging book to as wide a readership as possible: mental health professionals adrift of religion and spirituality; religious people adrift of psychiatry and mental health issues; plus anyone concerned with human suffering, with how to manage one's own emotional pain, and how to help others in similar distress. Such essential questions are at stake.