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:
- The experience we call depression is a form of distress.
- Even when we fall in love things change in our brain.
- We also know that depression is linked to feeling out of control, helpless, trapped or defeated in certain life….
- 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.