Excerpt from “Diaries of My Older Sister”
When it comes to accurately defining the causes of major depression, many questions still remain unanswered today. While researching this topic, I had the chance to interview Dr. Chad Ebesutani, a leading clinical psychologist with a Ph.D. from UCLA and founder and director of the Seoul Counseling Center in South Korea. Following are excerpts from our conversation.
Dr. Ebesutani: “If I were to grade the current level of mental health treatment for depression in the world, I would give it a C. We have figured some things out, but definitely in need of improvement. I’m not satisfied with the current state of things at all. There’s so much we can do and I know we can do more. I don’t want to blame psychologists—as I understand the challenge of treating complex things—but we have yet to really understand what works [for depression] and how to communicate what works to others.
At the end of the day, I believe that effectively treating depression involves starting with looking at what the individual can do first. In this way, everyone can be part of the solution. Otherwise, it really is a downward spiral—you start feeling down, you don’t do anything, you feel even more down so you don’t meet anybody. It’s hard to pick yourself up after that [spiral].”
Dr. Ebesutani states that depression is a multifaceted problem that often cannot be addressed by medication alone, but needs more of an integrated, comprehensive approach. He also sees the need to integrate “cognitive behavior psychotherapy” (which is more of a science and technique-oriented) with the warmer and more emotionally-oriented “client-centered” approaches.
Dr. Ebesutani’s opinions rang true to my own experiences as well. Most people did not challenge the over-simplistic explanation from Katie’s psychiatrist that he wasn’t exactly sure what had led to Katie’s suicidal depression. After all, Katie had been going through weekly therapy sessions and prescribed antidepressant medication by the clinic. When I started experiencing depression myself in college and showed up at the university health clinic in desperation, I also got a sense of what Katie might have experienced. I felt like a nameless object in a factory queue that just needed another quick-and-easy fix so that I could make room for the next person in line. I waited my turn in a quiet lobby with other grim-looking students and then received a 45-minute conversational evaluation in a private room where I was told to talk about my biggest problems to a complete stranger who told me she was a social worker. After I was done trying to poorly articulate my internal struggles and rumination to this person in 45 minutes, she simply told me that I should be prescribed SSRI medication and come back next week if things don’t improve by then. To be honest, it was an incredibly discouraging and disappointing experience.
Fast-forward to today, we still have yet to see any noticeable paradigm shifts for diagnosing or curing depression. One of the reasons I wrote this book is to bring more awareness to the fact that things are clearly not working very well with the status quo. If the current system of psychiatry and psychotherapy were enough to handle this global, multifacted problem, we wouldn’t be seeing the continuing rise of depression and suicide rates today. I am not saying that we should discontinue trusting in psychiatrists altogether; we can all benefit immensely from their expertise and experience. To be honest, they all have an incredibly tough job. When you compare psychology to “observable” sciences like chemistry, biology or physics, we must remember that we still have no reliable way to see into the “black box” of the brain and deduce which thought patterns are exactly leading to which neural activity. No objective tests or measurable metrics are currently available for doctors to deterministically “test” for depression, like we can test blood samples, urine samples or heart rate for detecting various diseases. This may be one of the biggest reasons psychology continues to rely on subjective patient feedback and conversational evaluations. Psychologists ask questions to their patients and check to see if they fit the criteria for depression outlined in a book called the DSM, Diagnostic and Statistical Manual of Mental Disorders, published by the American Psychiatric Association.
However, there’s so much more we can do right now as individuals and a collective community to improve our understanding of depression and the general level of treatment at large, instead of chalking everything up to an unexplainable “chemical imbalance in the brain” that only doctors and prescription medicine can solve. In fact, many professional psychiatrists, psychologists and pharmaceutical companies today may be just as confused as the rest of us about the underlying causes of clinical depression. Dr. Daniel Carlat, a renowned clinical professor of psychiatry at Tufts University School of Medicine, covered this very topic in his 2010 book, Unhinged: The Trouble with Psychiatry – A Doctor’s Revelations about a Profession in Crisis. Dr. Carlat emphasizes that the current psychiatric community places undue emphasis on psychopharmacology (the study of the use of medications in treating mental disorders) while convincing ourselves that we now have cures for mental illnesses “when in fact we know so little about the underlying neurobiology of their causes that our treatments are often a series of trials and errors. ”
It’s not all bad news, however. Cognitive Behavioral Therapy or CBT has proven to be very effective and promising for treating depression in the psychotherapy community. CBT is intriguing because it focuses on how your thoughts and feelings lead to behavioral patterns, and teaches you to notice and change your negative habitual patterns by challenging your own thoughts, similar to what we discussed in the first section. As disappointed as I was in Katie’s campus psychiatrist, I do still have a lot of hope and respect for doctors and therapists out there who genuinely care about their patients, continue to create groundbreaking research and are skilled in different forms of therapy such as CBT. Based on my experiences, I can definitely say with confidence that not all psychiatrists, psychologists and psychotherapists are “created equal.” Some are better than others, by a mile. Some are absolutely terrible and care more about money than their patients.
Furthermore, researchers and academics are constantly improving their understanding of clinical depression all over the world. For example, in 2015, the PNAS scientific journal published that meditating, exercising and spending time in nature are highly effective in preventing rumination and overactivity in the brain. According to the study, participants who went on a 90-min walk through nature reported lower levels of rumination and showed reduced neural activity in an area of the brain linked to risk of mental illness compared with those who walked through an urban environment. Studies also show that maintaining a nutrient-rich diet, journaling about emotions, engaging in art/music therapy, exposing yourself daily to sunlight and spending time to bond with others all help in fighting depression by helping you regain a balanced level of neurotransmitters such as dopamine, serotonin and oxytocin. As much as I want to expand on every single one of those important findings, there’s already plenty of great literature out there on each of those topics so I encourage you to read them (some of them are below). If I were to highlight three topics in particular, it would be nutrition, physical exercise and social support. Speaking as someone who’s experienced and recovered from major depression before, understanding and improving those three aspects were major game changers for my own recovery.
Here’s a short list of great books that I most recommend on the topic of defeating depression, handling rumination and understanding our brain:
- Change Your Brain, Change Your Life: The Breakthrough Program for Conquering Anxiety, Depression, Obsessiveness, Lack of Focus, Anger, and Memory Problems by Daniel G. Amen
- Feeling Good: The New Mood Therapy by David D. Burns.
- The Depression Cure: The 6-Step Program to Beat Depression without Drugs by Stephen S. Ilardi
- How God Changes Your Brain: Breakthrough Findings from a Leading Neuroscientist by Andrew Newberg and Mark Robert Waldman
- Stress-Proof: The Scientific Solution to Protect Your Brain and Body–and Be More Resilient Every Day by Mithu Storoni
- Brain Rules: 12 Principles for Surviving and Thriving at Work, Home, and School by John Medina
- How to Stop Worrying and Start Living by Dale Carnegie
Although we are still currently unable to pinpoint the exact causes of depression today, if we were to integrate the efforts of experienced healthcare professionals and researchers with our own individual efforts, depression may be more effectively understood and treated all over the world. As it stands now, there’s no denying that there’s so much more we need to discover about how depression works.
The following is the rest of my interview with Dr. Ebesutani. We talked about the impact of culture, history and economics on the depression and suicide epidemic in South Korea.
Terry: “Dr. Ebesutani, what do you think about South Korea’s unique relationship with depression today?”
Dr. Ebesutani: “There seems to be two worlds trying to integrate. New Korea & Old Korea. Parents & Children. East & West. Modern & Traditional. They are trying to integrate and they don’t know how. And I believe this is causing a lot of pain in Korea, as there is a lack of understanding of each other leading to social conflict.
Another factor affecting depression in Korea, I think, is that society is still built upon rigid structures, hierarchies and order. While these things do have their merit and can help societies, such as helping to stabilize systems, I believe they are hard on individuals. In rigid systems, you often need to give up choice and your desire to pursue what is individually meaningful to you. There’s pros and cons with that. But I do believe that overly rigid hierarchies, order, and structures can harm individuals.
The third factor that I see affecting depression in Korea are, ironically, the close-knit relationships here. Koreans value connecting with each other and Korea is a very close-knit society. Koreans worry a lot about each other. And they genuinely care about each other. The general Korean mindset seems to be: “I genuinely care about you. We are connected and I need to take care of you.” For example, there’s frequent mixing of money, helping each other financially through family, relatives and friends. People also make comments to each other on personal matters, mostly out of concern. While this can be positive, I do see the negative side effects of being too closely intertwined in relationships. Things get messy, and people get hurt. There’s a lot of unwanted intrusion into peoples’ lives.”
Terry: “What do you think about the impact of South Korean parent-child relationships on their mental health?”
Dr. Ebesutani: “This is a complicated and difficult question to answer. My opinion is this. When Koreans recovered from the IMF crisis, they sacrificed their individual desires and pooled money and efforts together to keep the country alive. It’s definitely related to the Korean culture—if you want to do something great, you need others and sacrifice yourself to do something as a group. Korea has proven that. Koreans are willing to sacrifice themselves for their family and their country like they did for IMF, and parents do the same for their children. Some influences include Confucianism, and the ideas of group harmony over individual desires.
I work with lots of international Korean students who studied abroad and have become westernized. They definitely do not see the same world as their parents. Korean parents tend to have high standards and also want their children to try hard to live a better life than their own because they had to make many hard sacrifices in the past. So they force their children to live a “better” life that they think they should live.
Children are thus often criticized and rarely praised, disciplining them often in order to keep their children achieving more and more, which leads to long-term stress, anger and frustration in their relationships. Korean children become angry at their parents and the world. The parents’ perspective is that they are sacrificing so much for their children and their family so their children should sacrifice to meet their demands as well to be able to live a better life. But that generational integration is not happening very well. We need to find ways to better support that.”
I sincerely thank Dr. Ebesutani again for his gracious support. I was deeply moved by his willingness to accept my request for an interview out of his busy schedule and his words of encouragement for me to continue writing this book.