“Patriarchy did her in” or Politics, Pathology and Dangerous Thinking
Gloria Steinem’s curiously sexist remark that “only women become more radical with age” can be left, like a helium balloon, to float harmlessly away until, drained of gas, it subsides silently towards the ground. But on tour in the UK to promote – and why not? – her memoir, she spoke of her mother, Ruth’s, “nervous breakdown” and partiality for “Doc Howard’s medicine”, namely liquid chloral hydrate.
Ruth, the eponymous subject of her essay “Ruth’s Song”, was in it described as an “energetic, fun-loving, book-loving woman” who turned into “someone who was afraid to be alone, who could not hang onto reality long enough to hold a job and who could rarely concentrate long enough to read a book”. Asked by her London interviewer if she was worried she would inherit her mother’s depression, she replied: “Only if patriarchy is hereditary. To me she was not crazy, she just had her spirit broken. I don’t think mental illness was part of her life. I think patriarchy did her in”.
This is myth with potentially fatal consequences rather than droll and disposable aphorism of the kind that we expect or demand from engaging polemicists such as Gloria. Although at 80+ she is happy to be free of what she has called “the demands of gender”, she no doubt has to make up for the lack of a cushioning pension and free health care by maxing her income from writing. We want and expect the sparkle of flaky subjectivity from her, the neutral dullness of empirical or objective evidence being the currency of other occupations.
However, the idea that most depression, a dangerous disorder implicated in a high percentage of suicides, is mostly bound up with events and circumstances is now dominant among clinical policy-makers and practitioners as well. So-called “NHS Choices” begins its piece on “clinical depression” by citing its causes as “an upsetting or stressful life-event such as bereavement, divorce, illness, redundancy, job or money worries” and endorsing the contention that it is “more common if you’re in difficult social or economic circumstances”. The National Inquiry into Suicide and Homicide by People with Mental Illness (2015) also invites readers to posit a causal, linear link between unemployment, unstable housing and serious financial problems and an increase in depression and suicide among men between 45 and 54. Again, the Nursing Times lists among the possible causes of depression feeling low after an illness, bereavement, stressful life-events, relationships ending, too much alcohol, overwork and so on. Advice to reflect on and make changes to “your lifestyle” when the “early warning signs” appear follows naturally from this approach to the condition.
This understanding of the disorder, which is self-evidently a package of disparate and qualitatively different phenomena, was given impetus back in the late 1970s by an influential though methodologically dodgy treatise by George Brown and Tirril Harris on the “Social Origins of Depression”. This zeitgeist-driven work concluded, from its observation of women in Camberwell, that having a number of young children, no close confiding relationship and no work outside the home were important aetiological factors in the development of the illness. The same zeitgeist, as it happens, generated the Laingian thesis promoted a decade before that mental illness, schizophrenia in this case, could be understood as a response to familial communication.
Cumulatively, these ideas – and they are ideas rather than science or the product of unaligned in vivo observation – have all but seen off the traditional division of depression into two primary types, reactive and endogenous, a dualism which is essentially a reworking of the ancient Greek notion that the roots of mental affliction were either found in internal, bodily humours (for example, µέλαινα χολή or black bile) or the external actions of the gods or Fate. In physical medicine there is a general acceptance, maybe held with differing degrees of intensity, that some illnesses are largely inherent or intrinsic while others, which may look similar, are largely the product of cultural, economic, material or political factors. The two main types of diabetes are a reasonable example of this: while you are 12 times more likely to develop type 1 diabetes if you have a close relative with it – and it is a condition which can’t, as the science of it currently stands, be prevented – type 2 diabetes is much more bound up with extrinsic factors such as lifestyle and over-eating promoted by supermarkets which can only find a margin if people eat more rather than different.
This is not to say that type 1 diabetes and, if you like, type 1 depression are exclusively organic or hereditary in the way that, say, Huntingdon’s disease is. We know from epigenetics that the emergence of disorders may be a function of environmental factors triggering the expression of certain genes: for example, viral infection, some vaccines and low levels of vitamin D may be implicated in the development of type 1 diabetes. But a synthesis of politics and vested interest is what generally determines how depression is understood at the point of intervention. Generally, those who are left-inclined instinctively see troubling mental states as a product of power-relationships, inequality, deprivation and so on with echoes of the Marxian concept of alienation as a function of exclusion from ownership of the means of production.
Thus, Tad Tietze, an Australian psychiatrist, argues for the apparent increase in the prevalence of depression to be located in the “dynamic, contested space at the intersection of powerful corporate and state interests, the reductive biological horizons of capitalist medicine, and the growing distress produced by three decades of neoliberalism”. In another piece, he connects the “premature death” in a Yorkshire canal in 1983 of Peter Sedgwick, socialist activist author of PsychoPolitics, a brilliant treatise and staple of social work courses at the time, with his “overwhelming depression….as the impact of Thatcherism became obvious”. Mistaking the causes of despair for the causes of depression is a logical error or bias which can also misdirect and diffuse clinical focus in a way which may amplify risk.
At the other end of this particular spectrum, such mental states tend to be attributed to biology operating independently of whatever may be going on extrinsically. Where social change – for example, eliminating patriarchy – is seen by the former group as a primary or authentic way of relieving subjective suffering, pharmacological intervention is the logical choice of the second group. In turn, psychological, non-biological therapy is the preference of a middle-of-the-road, perhaps liberal, caucus who want to hedge their bets and see medication as a tainted or even toxic product of the market. Therapy, however, is essentially another service industry and bound up in the market just as physical treatments such as medication unavoidably are; and, as Sedgwick himself argued rather convincingly, as much a product of positivism in its separation of facts from values as the medical model. In other words, different professions may have different names for what they do or apply to disorders but underneath the wrappings of nomenclature the package remains the same.
Providing therapy, of course, is a political act whether it’s promoted, funded, controlled and closely prescribed by a state which links it explicitly with saving money elsewhere and moving people off sickness benefits and into some kind of work – as in the case of IAPT (Improving Access to Psychological Therapies) operating out of GPs’ surgeries under the banner of its top brand, CBT; or is a more local micro-activity regulated by a range of self-interested psychotherapy guilds.
Inevitably, where politics and the market are confluent, depression is traded as a quasi-commodity. So, a pharmaceutical rep, when asked if his company was promoting anti-depressants on the Indian sub-continent, replied: “well not yet – first we have to export depression to them”. Inevitably, also, depression is inflated most in the US where, in DSM-5 (their classification of mental disorders), what the majority of outsiders would call the phenomena of normal grief meet the criteria for a major depressive disorder. Opponents argued that this would pathologise the normal response of millions of Americans to a normal, unavoidable event but vested insider interests trumped outsider wisdom, arguing that “bereavement is often debilitating and people experiencing it deserve recognition and treatment”. The so-called “bereavement exclusion” was removed from the final version, a decision which, if logically extended, should lead to those who are disabled by having their normal reactions pathologised by the medico-psychiatric establishment also being given deserved “recognition and treatment”.
Therapists, whether employed by the public or private sectors, psychiatrists – and polemicists, for that matter, are salesmen just as much the drug rep. There are no necessary dangers in this where their interests and the dynamic are made explicit and understood, and patients or consumers (they are not the same thing) can make informed decisions about which route they take. But there are players, such as the “Anxiety Centre”, who don’t declare their interests, at least visibly and explicitly. Their blurb asserts that “marketing was the primary driver behind the acceptance of the chemical imbalance theory” without sharing with the reader whether “marketing was the primary driver” behind its acceptance of the learned behaviour theory. Inconvenient facts such as the movement of forms of mental disorder down through generations are quickly dealt with: “[this] is because of handed-down behaviour not because of genes…..some family members have learned healthy coping skills while others haven’t”. This is true, of course, but only partly true: there may well be better ways of coping with negative or distressing mental states but this does not necessarily or logically mean that those states are not biologically or chemically produced.
Assertion is the favoured medium for discussion about mental disorder, a statement which, of course, is an assertion itself. Thus, an “expert by experience” recently asserted to an All Party Parliamentary Group on Social Work as follows: “out of personal experience and general observation it is my firm belief that the bio-medical model which dominates our mental health system is dangerous, damaging, oppressive and reductive”. She goes on to say: “the social model of distress is the one that makes sense to me. Life stories and life events are what have preceded or are the current backdrop to a presentation of mental distress”. Putting to one side the suspicion that this looks very like the fallacy that because B follows A, B must be caused by A, it has unarguable value as belief or even hypothesis with, maybe, the same status as Laing’s contention that “psychosis is a hyper-sane state of healing from psychic injury”, but not as fact.
A counter-hypothesis of equal status is that attaching primacy to social, contextual or cognitive manipulation as a way of treating or healing mental ill-health may, in some cases, may be dangerous or damaging. It is now extremely common to find in the histories of depressed patients who go on to commit suicide long stints of therapy, most often CBT, and attempts to improve their material circumstances (e.g their income through benefits, where they live and so on). This is frequently accompanied by a failure to find out whether anti-depressants are being taken a prescribed, an omission which you would rarely find in the management of people suffering from schizophrenia.
While this may say more about the depth or intractability of the depression than the efficacy of non-pharmacological approaches, a meta-analysis published in the British Psychological Society Research Digest in 2015 clearly suggests that CBT is now less effective in treating depression than it was when it was first developed 30 years ago or more. The authors stress that this isn’t because therapists are now less competent or more sloppy, or that they are now treating people with a mixture of disorders – in fact, the opposite is true. They suggest instead that the placebo effect of the treatment may have worn off over time with its discussion and promotion via the internet and social media.
Another explanation for the waning effect of CBT is that, being the treatment of choice, it is now being applied to forms of depression which would once have been treated much more rigorously and consistently with medication than they now are and, on occasions, electroconvulsive therapy (ECT) which in a few particular cases can be demonstrably effective, at least in the short-term. With the caveat that the analogy isn’t a perfect one, this is comparable to giving CBT to patients with type 1 diabetes: it may help them manage their illness better but if they don’t also take insulin they will die.
Myths are stories which fill the wide gap between fact and fantasy or between the coldness of reality and the warmth of wishing – religion without God, if you like. Depression, a capricious and elusive phenomenon which is subjectively an unvoiceable terror for some and objectively a condition which seems to ravage appearance and personality, is ideal territory for myth-making. Gloria Steinem’s position is perhaps an egregious, lay example of this but there are many other subtler myths closer to the clinic. For example:
Happy people don’t get depressed
Depressed people are unhappy
Depressed people will always have low self-esteem
Depression will always have a trigger
Exercise and a healthy way of life are an effective treatment for depression
People with what appears to be lifelong or long-term depression actually have a personality disorder
Depression is a response to adverse events
If you are depressed it is best not to work
It helps people to talk more openly about their depression
CBT is the most effective treatment where there is anxiety or agitation
Solving people’s practical or social problems goes a long way towards curing their depression
Anti-depressants are not addictive
Some possible correctives, from the bottom up, are as follows:
Anti-depressants may have a “pro-depressant” effect, in time causing processes which are the opposite of those which they produced at first. As a result, the brain permanently loses its ability to “re-normalise”. This means, not that they shouldn’t be taken, but that for some people with some brain chemistries they shouldn’t be stopped
Social, emotional or relationship problems may often be present when someone is depressed. This may increase the risk of suicide because they are likely to increase despair but it doesn’t necessarily follow that they are causative or that their removal will reduce depressive symptoms. Paradoxically (perhaps), seeming improvements may intensify depression and increase risk. Thus, a well-educated, able man, on taking up a good job after months of unemployment as a result of depression, shortly afterwards went on to commit suicide because he discovered or believed that he wasn’t up to it and would never manage to cope with that kind of work
Positive symptoms of depression, that is features which by their nature encourage action (such as anxiety, agitation and sleeplessness) are the most risky. Negative symptoms such as catatonia, flatness of affect, withdrawal and excessive sleeping lead to inaction. Where positive symptoms are biological in origin, talking may help the accompanying cognitions to physical facts but not the facts themselves
It is not possible to talk about the benefits of not talking about something. Culture, when teamed up with the market, promotes disclosure and self-revelation because there is no margin to be made out of managed self-sufficiency and privacy. Many sufferers from mental disorder choose carefully who they disclose it to, not out of stigma or shame, but because they want to circumscribe its effects on the rest of their lives and don’t want to become identified with it
Illness may obscure the individual. This happens most often with psychotic disorders where patients move through the tariff, starting as someone who “may be displaying features of schizophrenia” etc and reaching the endgame of disqualification as “a schizophrenic”. But clinical staff often compound the burden and abnormality of depression by encouraging resignation from work or early retirement, and even facilitating a move to supported housing or living. The side-effects of work – distraction, company, routine, feelings of self-worth, capacity and independence, the shoring up of identity and so on – are, if anything, more important in depression where the foundations of agency and self-belief feel under mortal threat
Depression may be a response to adverse events but often it comes from a clear blue sky, a tendency which feeds the dark, lurking sense of being unable to control or dispel the fear of catastrophe or of endless purgatory which lies at its heart
Depression is a highly capricious condition. Often it will seem to remit, with sunnier seeming days which lead sufferers who are inexperienced in its ways or not-yet-hardened by them to believe that they are on the mend. But they may instantaneously find their mood and cognitions profoundly tainted with dread and with no reassuring understanding of the causal steps which took them to this state. An inability to ride out or tolerate this sudden switching often leads sufferers to behave in a way which is characterised by mental health professionals as unstable, demanding, manipulative and even disruptive. As a result, the primary focus switches from illness-treating to setting boundaries and referring out to personality disorder services.
The failure of professionals to understand that there is a wide spectrum of cognitions and feelings that depressed people have to contend with (it is a rare professional who can fully understand the cognitions and feelings themselves) may actually increase risk. Prescribing, say, exercise as a treatment for depressive symptoms, as opposed to seeing it as one among many things which will help shore up morale and resilience, may demonstrate to the sufferer that the professional is unable to appreciate the seriousness of his or her state of mind – and generate feelings of despair and isolation.
Similarly, reassuring the sufferer that he or she will “get better” will be received as evidence that the defining belief that there will no respite or relief for the rest of time which pulses at the heart of depression has not been understood, full and intuitive understanding being a first-line palliative for depression.
The erroneous belief that depression will always have an external trigger leads professionals to favour a diagnosis of personality disorder (this person is manipulative, has poor impulse control, is looking for secondary gain, needs appropriate boundaries, is medication-seeking, is inadequate……..) when no obvious trigger can be identified.
While low self-esteem may often be a feature of depression, depression is much less often a function of low self-esteem. The theory that depression follows in the wake of either distant or recent narcissistic injury (i.e. when inflated feelings of self-worth are not grounded in reality) may not have much or any evidential traction but it at least casts doubt on the clinical notion that increasing self-esteem will lessen the depression. In other words, low self-esteem may well be a by-product of the disorder but it shouldn’t be viewed as integral to the disorder.
Happy people are not immune from depression nor will all depressed people be intrinsically unhappy. They are likely to be unhappy because they are depressed, not vice versa. Again, this also has important clinical consequences. Picking out or homing in on the negative aspects of the life of someone suffering from depression may well convey to him or her that the professional does not understand, which is the first and indispensable base for the treatment of depression: if someone truly understands, there may be a route back through the quicksand of catastrophe to the self and safety.
Professionals may be dangerous just as ideas may be dangerous. Or rather, a mental health professional will always be dangerous and the career-long task is to move along the spectrum towards safer practice. In parallel, dangerous practice is institutionalised in such a way that illogical or irrational thinking becomes the norm. For example, it is widely and justifiably accepted that with most cancers external factors have a determining influence, and that even those factors which are predominantly physical (for example, smoking, pollution, particular chemicals or substances such as asbestos, or alcohol) can be tracked back to power relationships, class, deprivation, inequality and so on. While oncologists will immediately focus on analysing and treating the end state, groupthink among mental health clinicians is such that, when referred or presented with a case of depression, discussion will invariably be about triggers, stressors or contributory factors (usually use of alcohol or drugs, personality traits or cognitive shortcomings). Energy is then inevitably and seemingly logically directed towards manipulation of environment or thinking (most often, CBT) instead of active, physical treatment of a potentially life-threatening condition. And the myth of the myth of mental illness continues to clock up its casualties.