Politicising depression

The British Psychological Society published a report on depression, Understanding Depression. As ever, I thought I’d look at how the report has been written and I am sorry to say that what I found troubled me. In a nutshell: I do wish the authors had taken much more care with how they write. This is because the report, in my view, is skewed, it hides things, it offers things despite claiming it doesn’t. Here is an account.

Of course, it’s impossible to do a thorough analysis of the entire document, at least not for a blogpost, so I looked at the executive summary. This is because the executive summary offers the bottom line of the document. It offers insight into the authors’ priorities. And, boy, did I get priorities!

I started with definitions. What exactly is depression? We have an answer straight away:

Depression is a common human experience that can be life-threatening.

Fair enough, I hear you say. But is it? After offering this definition, the authors explain that they will only argue:

that depression is best thought of as an experience, or a set of experiences, rather than as a disease.

But it’s hardly an argument, if you have already decided, is it? If you want to argue, then argue, but don’t cheat by simply saying, in the first sentence, that depression is an experience. Moreover, the sentence is linguistically at the highest level of certainty. The initial definition simply states a truth. No argument is even possible after that.

But what really irritates me is the constructing of a false dichotomy. There is no opposition, or conflict, between treating depression as an experience (or a set of experiences) and a disease/illness. In fact, all illnesses are experiences and there is a library of literature on that. Believe you me, for example, myocardial infarction (i.e. a heart attack) is not just a ‘disease’. It’s a set of experiences too. So, what’s the problem? You could also add that there are experiences that those who partook in them, fought and continue fight to call them an illness. Chronic fatigue syndrome (yuppie flu, as it was disparagingly called) or, today, the long-covid are good examples of experiences that people want(ed) to be acknowledged as illnesses.

And so, to imply that if you call something a disease/illness (the authors happily go between the terms, even though at least since Arthur Kleinman’s writing, they tend to be understood as meaning different things) cannot be seen as an experience is nonsense and it is very unhelpful. Why do this? I don’t get it.

Interestingly, the authors explain the advantages of not calling depression an illness, but somehow miss the advantages of doing so (you know, like social/disability benefits and minor stuff like that). In fact, it always drives me round the bend when I read privileged people writing about their theoretical/ideological positions, forgetting that there is real life. I have known many people who have benefited greatly from being able, for example, to take significant time off work, because the bloody depression is understood as a disease. I do wonder what would be on offer for them if tomorrow depression is demedicalised.

The authors write:

However, calling it an illness is only one way of thinking about it, with advantages and disadvantages. For many people, depression is unlikely to be the result of an underlying biological disease process or chemical imbalance in the brain and nervous system. Even if there are changes in the brain when people are depressed these are often consequences not primary causes. After all, all mental states have physiological and biochemical elements. Even when we fall in love things change in our brain. The discovery of physical changes in depression tells us nothing about causality or even the best ways for helping. Whilst of course our brains are involved in all experiences, the reasons for depression are usually complex and include the events and circumstances of people’s lives and the ways they can respond to them.

Gosh, that’s quite a statement, isn’t it? Already in the summary, we really do see where the authors are going. There will be no arguing. This is hammering the message in. But let’s have look at the language. They start cautiously:

    • calling it an illness is only one way of thinking about it
    • depression is unlikely to be the result of an underlying biological disease process or chemical imbalance
    • changes in the brain often consequences not primary causes

with all those little words making the statements weaker. But the caution very quickly disappears:

    • The discovery of physical changes in depression tells us nothing about causality or even the best ways for helping

Only to reappear a sentence later:

    • the reasons for depression are usually complex and include the events and circumstances of people’s lives and the ways they can respond to them.

So, what happened to the “often” or “unlikely” and “usually” that a sentence on causality can be rendered as another universal truth? Are you so certain that the physical changes tell you nothing? How about a “probably”? Just in case. But more importantly, why are those who do not fall under the category of “often” and “usually” not mentioned? Are they not deserving? What happens to all those people who are not covered by the executive summary?

Well, there is at least one answer. They disappear because they are spoiling the argument. They are undermining the message and the message is not that of an argument. It’s a political (with a small ‘p’) declaration.

In addition to that, I want to show one other sentence. In the note on language, the authors say:

In this sense, we experience depression, just as we experience anxiety, anger, or even love and joy.

And I do object to this normalisation of depression. This idea that depression is something similar to what we experience when we have fun is extraordinary. No, it’s bloody not. People die because they’re depressed and I am yet to hear of anyone dying of joy. Depression takes us to the edge of experience. Depression takes us to the edge of life. And no, we don’t experience depression “just as”. I find this statement insulting.

The second aspect of the report I wanted to focus on is who speaks. In a recent post, when I looked at the Guide to understanding psychosis, I noted that the author should have been clearer about who speaks and for whom. The same happens here. The authors start impersonally. They hide behind their text as they talk about the report’s focus, a common enough strategy to suggest objectivity and the authors’ detachment. And yet, a few sentences later, the authors introduce the infamous “we”. Consider:

    1. The experience we call depression is a form of distress.
    2. Even when we fall in love things change in our brain.
    3. We also know that depression is linked to feeling out of control, helpless, trapped or defeated in certain life….
    4. We need to bear this in mind when we describe and explain these experiences, and when we support others who are depressed

What irritates me again about the use of the pronoun “we” is that it changes identity, and yet, the authors use it as if it had one and the same referent. It doesn’t. In the first sentence, it is likely to mean professional people, in the second, it’s likely to mean “all of us”, in sentence 3 we go back to psychology, while in 4 it probably means all of us again.

Does it matter, you could ask. Well, it’s not exactly the manipulation of the year, yet, it is a common political tactic of aligning oneself with the audience, as if the audience and the speaker/writer spoke with one voice. And the important question is: Do they?

In case you wonder, there are 210 uses of the pronoun “we” in the document. And I find it very disappointing.

But fear not! Help is at hand.

Overcoming depression can sometimes be a difficult and slow process. Nevertheless, there are many things which can help. Different things help different people. Often practical things are central such as basic self-care, including eating and sleeping well, as well as help to address the issues that led to the depression or that are keeping it going, physical exercise or therapies of various kinds.

Psychological therapies help many people. Depression and loneliness often go hand in hand, so finding ways to connect or reconnect with our friends, families and communities can be key.

There is more:

This is one of the reasons that help and support from services needs to be guided by a personal, collaboratively drawn up formulation. We recommend that all care and treatment within mental health services is guided by individual formulations, developed and refined over time by the professional/s and the person concerned working together

To be honest, I like formulation. The entire Polish clinical psychology is founded on what they call ‘psychological diagnosis’, which is, roughly, an equivalent of formulation. Polish psychologists don’t do nosology, that’s left for the shrinks.

But as much as I think that formulation is great, there are actually other treatments, including antidepressants. And like it or not, some people find antidepressant medication helpful and consider it life-saving. To simply say that if you’re in depression, nosology (I beg your pardon: a label) is not for you and medication is not even mentioned in the summary of what’s supposed to be a major report, is incomprehensible.

And if you still have any illusions that you will get some balance in the account, do, please, think again.

So, let me finish with expressing my disappointment. Let me start by saying that I actually agree with the authors. My views (as much as I have formed them) are to a considerable extent reflected by what the authors say. I have spoken to all too many men in depression for whom the tight boundaries of the “depressive episode” did not do much good. And their experience of depression was so much more than the “depressed mood” and the rest of the diagnostic criteria. But that doesn’t mean I, or anyone else, can now dispose of psychiatry, psychiatric medication, social benefits, and all those people who have and do benefit from them.

What I strongly object to is that the authors’ views should not be constructed as the truth. They should not be shoved down the throats of people who have enough to worry about. You cannot simply forget that there are many and many people who take SSRIs and swear they save their lives. Wouldn’t it be much better to tell those people if the meds help you, take them, just make sure that you understand what you take, what it means and how you will get off them. And that formulation is not the only way to work in mental health. There are other options.

I don’t think anyone will care, least of all the authors, but I think this report is a political declaration. And as such, its function is to persuade and not to offer an argument, let alone a balanced view of depression. The report’s function is not to help, it is to gather more followers. And I am very very disappointed to say this.

 

 

6 Comments
  1. I quite liked the report and much prefer the broader contextualising of human suffering, rather than the broken brain biological story. I would have liked to have seen a clear acknowledgement that none of the individualised ‘treatments’ really work – The marketing term ‘anti depressant’ is utterly misleading. Just because people believe they were helped sadly does not make it so – I hear daily people telling me they feel they are helped by this or that psychiatric drug or have been helped by this or that past therapy- but listening further these people are suffering just as much as they ever have done and often more so but we rarely consider the drugs and or talking to be harmful or part of the problems. Both therapy and drugs are so fully embedded within the culture at this stage many have come to believe the hype – In such reports/perspectives I would like to see people like William Epstein and others detailed analysis of the none existent evidence base for any psychotherapy – His latest book Psychotherapy and the Social Clinic in the United States Soothing fictions should be required reading. In addition to the masses of evidence ever growing that psychiatric drugs cause more harm than they can ever do good.

    1. Dariusz Galasinski

      Thank you for your comment. I agree, at least to an extent. For me, any discussion on treatment, including medication, must involve those who experienced it, including both those who curse they ever tried and those who sing its praises. While personally, I have many misgivings about many treatments (e.g. ECT, quite frankly, only scares me), my misgivings are not better or more valid than positive stories of those who were helped. I am also very wary of pillshaming.

      1. I agree more people should be involved in any discussion. This is especially so given how the medical model through the DSM, corrupt research and the collusion of a vast therapy industry has infiltrated everyones lives.

        I’ve worked in the industry for years. It seems clear to me that in addition to millions of ‘clients’ ‘patients’ ‘service users’ being prescribed psychiatric drugs, compounds referred to by people like Psychiatrist Peter Breggin as ‘neurotoxins’ so too have millions of ‘professionals’

        I was prescribed an anti depressants 20 years ago – within three weeks I went from being down and distressed that my marriage had failed and I was in debt while trying to do a hideously stressful job as a social worker to being completely cut off from my emotions. I was numb and this led me to intense suicidal thoughts and I nearly completed. These numbing, suppressing, effects seem to be the most common that people report. ‘Anti depressant’ is a deeply misleading marketing term.

        We might say this was 20 years ago and things are different now but they are just the same- people are given these drugs daily under a carefully crafted illusion of marketing and self interest. There is almost no such thing as informed consent because its largely ignorance and self interest all the way down. In addition to constant mega pressure placed on GP’s etc on a production line like care system has little else it can do except shoot drugs at people.

        I don’t use social media much so I’m not sure what is meant by pill shaming – I do not know anyone that has ‘pill shamed’ anyone – of course people call each other all sorts of names but I wonder if this is something different. Is it more like anyone critical of psychiatry being called ‘anti psychiatry’ or a ‘scientologist’? An attempt by the industry to protect its market share and swat away legitimate and needed criticism?

        As I said in my previous post, the critics of the research tell us that corruption and self interest is everywhere and that the research across the board is rubbish – whether this is regarding psychiatric drugs, the DSM, psychotherapy/ mindfulness the lot of it.

        It also seems clear at this point that that the industry is causing more harm than it can ever do good.

        Imagine if we had real informed consent about the drugs and therapy on offer? When all is said and done all the advertising and false promises and self interest seems an attempt to stimulate placebo and not much else.

        Without this perhaps people would begin to look outside of themselves and seek to change the cultural disorders that have been carefully repackaged as personal disorder.

        I wonder how can mental health/ human wellbeing not be political? And deeply embedded in the economy and massaged and manipulated by a hugely powerful and influential media?.

      2. Dariusz Galasinski

        Thank you for your comment. Can I just focus on the last part of what your said. Of course, every illness is political. Many people are involved in invoking and cancelling illnesses, all of them with their vested interests. And we tend to know that.

        The problem for me is when one’s politics is passed as the only way, the good way. When others’ politics is either blanked or disavowed, because we’re cool and they’re not. Life, and particularly illness, is never so simple that we get to say: this perspective is only good and this perspective is only bad.

        As I said in the post, I mostly agree with the authors of the report. What I disagree with is making formulation sound like the best thing since sliced bread, while psychiatry as something that is as close to evil as you can get. Psychologists, even those firmly supporting formulation and PTMF framework, do not walk on water, while psychiatrists do not eat children. I would have liked the report to be much more open about the breadth of evidence on depression and be much more sensitive to how people in depression will feel after reading the report.

        And I say this with particular disappointment because two of the authors were involved in a report on MH language and were so heavily criticised for their representation of OCD (something like: things are getting out of hand, or some such) that they had to change the report. It seems that haven’t learnt. I am very sorry to say this.

  2. you sound ridiculous.
    Getting benefits is not a valid reason for an ‘illness’ to exist – really weak argument.

    1. Dariusz Galasinski

      I might well be sounding ridiculous, thank you for pointing that out. However, perhaps it’s worth considering the following points.

      1. I suspect that we should ask those who receive such benefits whether they would like give them up, because a number of people think mental illness doesn’t exist. I somehow suspect that might have something to say against such a solution.

      2. I am really tired of the argument that some diseases ‘really’ exist (mostly physical diseases are pointed to) and some, mostly mental illnesses, don’t exist. I’m no theoretician of medicine, however, it seems to me that every illness is ‘a construct’ and is invoked by the society. If you take the time to google, there are quite a number of diseases that used to be believed and treated and now we decided they don’t exist. Societies invoke and cancel diseases all the time, regardless of whether they were believed to have or not to have some physical component.

      3. It is really a fallacious argument to postulate that something doesn’t exist. It’s worth reminding ourselves that TB ‘existed’ for thousands of years before it was described and, later, cured. So, did it exist before being described by Robert Koch, if memory serves?

      Just because we haven’t found/met/seen/discovered something, doesn’t mean it doesn’t exist. Consider the statement that alien civilisations don’t exist. Just because we haven’t met a Klingon or ROmulan doesn’t mean that don’t live happily on their homeworlds.

      4. All in all, I would be much more cautious about claiming that mental illnesses don’t exist. It’s very hard to prove this.

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