The Idea of Depression, Part Three

Bob Fancher, PhD
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Last winter, a particular client of mine complained, “I think I’m depressed. I think I need meds.”

No doubt he was miserable. He’d graduated law school the previous Spring, passed the bar on his first try—and gotten no job offers. An acquaintance was letting him work out of the supply closet in his office, trying to generate income by taking on nuisance suits—personal injury suits from opportunistic people trying to turn a buck. He was rather ashamed of the suits he was pursuing, and since few of them had merit, he was making very little money.

His long-time girlfriend had dumped him because she’d discovered that, yet again, he’d cheated on her.  He lived in his parents’ house, apparently an emotionally barren place where the main activities were watching Fox News and reality TV and cursing Barack Obama. He tended to stay up too late, distracting himself with video games, porn, and alcohol. He couldn’t get himself into his “office” before late morning. He tended to go in wearing jeans and casual shirts, often rather lackadaisically groomed.

He certainly would not have been considered “clinically depressed” before DSM-III. His misery would have been seen as indicative, a sign of his difficulties. In fact, he was disappointed with the state of his life, ashamed of himself at many levels, bereft of love, discouraged, and emotionally starved. Positing some underlying illness, Depression, to account for his negative affect, seems to me un-illuminating.

Another friend from law school contacted him, to ask whether he’d like to work out of the offices of the small law firm the friend’s dad ran. My client was skeptical, and he wasn’t inclined to muster the energy. But we decided he should give it a try. Immediately, he had an office befitting a professional person, and within weeks, he was doing work he didn’t mind. He enjoyed being around his friend and his friend’s dad—and the office staff. He got up on time, dressed well, began going to lawyers’ professional events. Etc.

He was surely no longer “depressed.” He still had pragmatic changes to make—getting out of his parents’ house, for instance—and a lot of issues to work out—like his compulsive, self-defeating and other-harming sexual behavior. But his affect was infinitely better.

In my last two postings, I argued that our current concept of Depression is an artifact, conflating what once was called melancholia—which is an horrific, dangerous state of mind in which we’ve lost agency and control over the pain that assails us—with a great variety of painful negative affects that, in common language, we would call “depression.”

Scientifically, this makes little sense, since the concept of “major depression” does not meet standard conditions for positing an unseen entity, process, or force. Clinically, this new concept leads to ham-handed, often misdirected care.

In ordinary language, as I’ve pointed out before, ‘depression’ as a word sits within a complex semantic web. We can say someone is depressed when he or she is discouraged, despondent, dismayed, disconsolate, demoralized, despairing, disappointed, disheartened, dispirited, defeated, downtrodden, heartsick, unhinged, bereft, enervated—and so on. The ways these various states of mind resemble each other allow us usefully to see them as having something in common.

But each has its unique qualities, too—and those often matter, if we’re paying enough attention to notice. Finer-grain distinctions between affects help us toward more detailed knowledge of what’s going on in our lives and the lives of our patients. The DSM concept of Depression takes us in exactly the wrong direction—teaching us to make cruder, rather than more precise, analyses.

Treating all “down” states as manifestations of an underlying Depressive disorder mistakes family resemblance for identity, which can be highly problematic.  Kissing one sibling has some things in common with kissing another, but they’re not at all the same thing. Two sisters may look a lot alike, but you’d better know which one you’re dating before you pucker up.

And each affect may have different causes, and different solutions. A loss of courage is different from a loss of meaning, and each is different from the effects of being overwhelmed by dire circumstance. Enervation is different from loss of faith in the dependability of important others. Absence of resources, social or financial or personal, is different from absence of opportunity. And so on. Each of these may be brought about by different events, different circumstances. And each patient will have different proclivities and capacities to institute particular changes in response.

Besides encouraging cruder analysis, the DSM concept of Depression often misdirects our attention in another way: in reality, the negative affect may be the least important aspect of a person’s situation, or even an important dimension to preserve—as an indicator and motivator—for as long as the status quo remains in place. We evolved our affective systems for reasons. We need to pay attention to affects—they serve important purposes.

One of the most distressing aspects of the rising emphasis on “affective disorders” is that care becomes preoccupied with mood manipulation.  We cannot learn anything from affects, or use them as guides in changing our lives, if we manipulate them away.

Under the influence of the idea of Depression, therapists become very good at mood manipulation, and at teaching mood manipulation skills, but less and less informed about, and less helpful with, understanding life. Teaching patients to manipulate their moods replaces understanding and sorting out people’s lives.

We return, then, to the contention that conflating melancholia and the many ways we can be depressed (in the ordinary sense of the word) is just wrong. With melancholia, which rightly deserves to be seen as a disorder, one’s affects bear little or no relation to reality, and their intensity is dangerous enough that relief is critical. Suicide is likely in melancholia not so much because one thinks one doesn’t deserve to live, or because one cannot see a good future, but because the pain is too great to bear. Pain relief must be the first order of business. Furthermore, precisely because one’s moods have become unhinged, one’s beliefs about what has caused them are unlikely to be accurate. Melancholia needs to be relieved, not analyzed—and extreme caution about making changes in one’s life should be exercised in a state of melancholia.

Treating all negative affects as if they were part and parcel of melancholia—or dangerous and undesirable precursors that need to nipped in the bud—precludes our making proper use of them to change what needs changing in our lives.  And that, to me, seems like bad care.

24 COMMENTS

  1. Why can’t we just get back to the simple explanation in life ~~~ the simple explanation in life for several things ~~~ “LIFE HAS ITS UPS AND DOWNS.” I still cannot believe (even tho I have lived thru it) that other people feel the need to take over someone else’s life AND that an entire system actually allows that take-over to occur AND tops it off with more causes for pain. It will never make sense to me except that we all have learned what $$$ hungry $$$ fiends are involved with drug companies. The Celts matched emotions of people back in history with variation in music and the different modes, etc. THAT was honoring ! We, in this day and age, need to get back to honoring people, their personal goals and their own processes. THAT would be right in line spiritually as well and the spiritual approach/insight is far superior to psychiatry any day.// MCW

  2. There is also the mistaken notion that we can do nothing about all these feelings (including depression) ourselves (there are a lot of things we can do to help ourselves recover – I didn’t start getting better until I got off the pills, facing my problems and dealing differently with them and choosing to think differently).
    There’s also the mistaken notion there’s something “abnormal” about all these feelings (including depression). In order for there to be an “abnormal” there needs to be a description of “normal” – and I have yet to see one.
    I have seen some apparently real “mental illness” – I’ve known several psychiatrists that suffered from psychosis and God complexes. They thought they could read their patient’s mind and tell their patient their reality was a figment of their imagination when it was very real – and the psychiatrist had evidence it did. One example would be a doctor telling a rape patient “It didn’t happen” even with overwhelming evidence to the contrary. Sadly, it happens a lot of the time with psychiatrists. There is absolutely no way for them to “diagnose” a person’s “mental illness” – nor to tell if what a person is going through is a result of trauma or psychosis – and it is devastating when the assumption of psychosis is made.

  3. Melancholia is just another quack label and false medicalization of despair. Dredging it up from the dustbin of psychiatric label history doesn’t legitimize it. The medicalization of despair never had any legitimacy.

    Labeling people ‘melancholic’ and alleging they have no human agency, is just another leap of faith. A person labeled melancholic still runs from the room to outside during an earthquake.

    They still go to the toilet when nature calls rather than soil themselves where they stand. Even killing yourself is an act of agency.

    There is human agency there. To claim otherwise is a claim I reject.

  4. I have what I call “the evolution of a diagnosis”. It got to a point where the list was so long, it became almost laughable. I wondered how it was possible to have SO many “disorders”. How on earth could I even be alive?! I must have the DNA of a cockroach.

    Depression
    Major Depression
    Post Traumatic Stress Disorder
    Circadian Rhythm Disorder
    Delayed Sleep Phase Syndrome
    Borderline Personality Disorder
    Bi-Polar Disorder
    “Cluster B Personality Disorder”
    Psychotic
    Psychosis
    Paranoid
    Schizowhat?

    Oh and I’m mental; a nut-job, whacko, freak, weirdo, mental case, invalid, schizo, crazy, coo-koo, bitch, nuts, odd-ball, “blonde”, stupid, witch, loser, whore, idiot, reject, cunt, moron, retard, piece of something.

    Something MUST be wrong with me, because I always thought all of that was straight out A B U S E. But religion taught me that all of the above is HUMILIATION which is meant to bring about humility and is god-approved.!

    FAIL.

    The level of violence I’ve known has altered my gender role: I now associate MORE as a man than as a woman. My femininity is nearly annihilated and I’m *dying* to know the diagnosis for a GIRL who grows up to be a MAN instead of a woman.

    Let me lay down my cross here – cuz this burden is a CONDEMNATION.

    • It would be laughable if it didn’t happen to a lovely and sensitive human being such as yourself. I hope you are able to see all of these efforts as directed to keeping the labeller feeling safe, and have really nothing whatsoever to do with who you are. I felt very sad reading your post. I hope you are on a different path now where you can ignore others’ labelling efforts and be the great person you were meant to be.

      —- Steve

      • Thank you Steve for your kind words. I’m truly sorry that I made you feel sad. I felt bad writing it – but it just flew off my finger tips and I swear there’s a magnet in that black “Post Comment” icon on the screen.

        “Sticks and stones may break my bones, but words can never hurt me”. I found out that words can hurt the worst of all. We are FORMED by words. The words we use make a world of difference.

        “The truth is hidden in plain sight” – the truth is our language; words. Words are the ultimate tool of creation.

        A single word can throw me into a violent fit, lasting hours or even days. I’ve yet to find the right word that can send me into a state of Bliss or Joy. Well, if it ever happens – I have a personal need for it to be world-wide. I hope somebody somewhere, some day soon – speaks a good word of Peace (understanding) and truly brings Humanity into UNIFIED RELIEF. *I* need that.

        Hey Obama – Kenya do it? Can you speak to Humanity and bring planetary Relief? KENYA do it, Obama? I HOPE. (word play, but it’s also a hint).

        Enough of my rambling. Thanks again Steve – for your kind response. I appreciate.

  5. Thanks for emphasizing the complexity, variety and nuance of human mind and life.

    On “mood manipulation”, the extreme example is that Breivik got to commit his crimes partly with the help of effective mood control practice:

    http://www.guardian.co.uk/commentisfree/belief/2012/may/22/anders-behring-breivik-meditation

    This very extreme example might be another illustration of your point, that mood and emotions are often meaningful signals. If the perspective of killing people creates an uncomfortable paralyzing mood, it is probably better to examine the morality of your plans rather than treating your mood as a burden that should be numbed.

    On a different aspect, I wonder how far your disagreement with the DSM goes. For instance, you recognize that something like melancholia can be defined meaningfully. You disagree with the naming, the criteria, and the severity of syndromes in the current DSM (and with the etiology and assumptions that doctors associate with the DSM, even if the DSM itself tried to be agnostic on etiology). But do you think that there is a theoretical possibility of doing a useful DSM (for instance starting with trying to find a correct definition for melancholia)?

  6. This may well be my favorite Fancher post! Good stuff. The emphasis on “finer” distinctions implies a need for more individualized care and I think we are all for that. “We’re not making widgets!” my old counseling professor would say. The complexity of human beings should make us awestruck not arrogant. Approaching people with this sense of awe and consideration can go a long way in forming a relationship.

    PS Check out Melancholia the movie! Beautiful in it’s production value…perhaps a bit lacking in writing.

  7. Depression:
    “For myself, the pain is closely connected to drowning or suffocation-but even these images are of the mark. The pain persisted during my museum tour and reached a crescendo in the next few hours when, back at the hotel, I feel onto the bed and lay gazing at the ceiling, nearly immobilized and in a trance of supreme discomfort. Rational thought was usually absent from my mind at such times, hence trance.” _W Syrton, “Darkness Visible.”

    I search through the dozens of PDF docs on this laptop, looking for a good example of the latest science research on human development, which seems to hint at a natural reason for our experience of depression;
    “Humans have three principal defense strategies—fight, flight, and freeze. The Polyvagal Theory describes three developmental stages of a mammal’s autonomic nervous system: Immobilization, mobilization, and social communication or social engagement. Faulty neuroception might lie at the root of several psychiatric disorders, including autism, schizophrenia, anxiety disorders, depression, and Reactive Attachment Disorder. We are familiar with fight and flight behaviors, but know less about the defense strategy of immobilization, or freezing. This strategy, shared with early vertebrates, is often expressed in mammals as “death feigning.” (Porges, 2004).

    “In humans, we observe a behavioral shutdown, frequently accompanied by very weak muscle tone. We also observe physiological changes: Heart rate and breathing slow, and blood pressure drops. Immobilization, or freezing, is one of our species’ most ancient mechanisms of defense. Inhibiting movement slows our metabolism (reducing our need for food) and raises our pain threshold. But in addition to freezing defensively, mammals immobilize themselves for essential prosocial activities, including conception, childbirth, nursing, and the establishment of social bonds. However, immobilization with fear elicits profound, potentially lethal, physiological changes.” (Porges, 2004).

    Consider Styron’s description of depression again;
    “I feel onto the bed and lay gazing at the ceiling, nearly immobilized and in a trance of supreme discomfort.” (Styron, 1990). When viewed along side Steven Porges recent discoveries concerning our unconscious autonomic nervous system, the stimulus for depression’s fearful immobilization seems to be yielding to our conscious awareness, yet such knowledge is still so new it finds little awareness even amongst the profession most charged with depression’s alleviation. Perhaps only our common system of rank and status is preventing the nervous system’s role in mental illness being fully acknowledged by the medical profession. Healing disciplines that have traditionally focused on the body, have certainly embraced this new awareness though, and it seems a paradigm shift in the understanding of mental anguish is underway.

    The price we pay for our “I think therefore I am,” experience awareness?

    Consider a further description by Styron;
    “Rational thought was usually absent from my mind at such times, hence trance.” (Styron, 1990). Perhaps these words of personal experience are beginning to be understood by some therapists as this example shows;
    “Excessive parasympathetic branch activity leads to increased energy-conserving processes, manifested as decreases in heart rate and respiration and as a sense of ‘numbness’ and ‘shutting down’ within the mind (Siegel, 1999, p.254). Such hypo-arousal can manifest as numbing, a dulling of inner body sensation, slowing of muscular/skeletal response and diminished muscular tone, especially in the face. Here “cognitive and emotional” processing are also disrupted.” (Hartman and Zimberoff, 2006).

    ATTACHMENT ISSUES:

    “A person whose social engagement system is suppressed has trouble reading positive emotions from other people’s faces and postures, and also has little capacity to feel his or her own positive affects.

    According to the polyvagal theory, being in shutdown (immobility/freezing/or collapse) or in sympathetic hyper-activation (fight/flight) greatly diminishes a person’s capacity to receive and incorporate empathy and support. To the degree that traumatized people are dominated by shutdown (the immobility system), they are physiologically unavailable for face to face contact and the calming sharing of feelings and attachment.

    And while immobilization is rarely complete (as it is in catatonic schizophrenia), its ability to suppress life and one’s capacity for social engagement is extreme. Traumatized clients are stuck in the primitive root of immobility with its greatly reduced capability for reading faces, bodies and emotions, they become cut-off from the human race. As highly dissociated and shut-down clients “involuntarily” retreat, they experience additional self-recrimination and shame.

    “I feel all alone in the universe, dissociated from the human race …. I am not sure that I even exist …. Everyone is part of the flower; I am still part of the root” Indeed the brain stem’s immobilization system is the “root” of a default hierarchy” (p, 111)”

    References:
    Styron, W, 1990, “Darkness Visible a memoir of Madness,” Vintage Books, USA.

    Porges, S, W, 2004, “NEUROCEPTION: A Subconscious System for Detecting Threats and Safety,” University of Illinois at Chicago.

    Hartman, D and Zimberoff, D, 2006, “Healing the Body-Mind in Heart-Centered Therapies,” Journal of Heart-Centered Therapies, 2006, Vol. 9

    Levine, P, 2010, “In an Unspoken Voice,” North Atlantic Books, USA.

  8. In discussing the nature of depression, we can stay within the “forest” of words, that constitutes our modern “I think therefore I am.” Or we can return to origins within the body, as so much of the latest neuroscience research is starting to do.

    People in our Western culture are flocking to Eastern meditative techniques including yoga practice, in a much needed effort to restore organic balance, to our mechanical “cause & effect” mindset.

    From my own writing;

    “Long Night of the Soul, an Invitation to Depression:

    May 8th 2012:
    A no thrills hotel room in Laos, 2am and the mechanical hum of an old pedestal fan accompanies a grinding ache in my stomach, thoughts of defeat and a fraudulent sense of self won‘t stop buzzing around my head.

    Almost two and a half years into my self discovery sojourn here in South East Asia, I fear I’m running out of time with dwindling finances and visa restrictions, becoming pressing concerns.

    “I’m just kidding myself that I understand anything about the processes involved in mental illness. The fantasy of writing a book just rationalizes a life’s unconscious default pattern of withdrawal and isolation. Follow my heart notions are a mania fueled romantic joke, leading me to ruination not salvation.” After five years with no return to a cyclic pattern of depression and no need for medications of any kind, I’m feeling the old familiar sensations of defeat and collapse here. There‘s a pressured sense of doom inside my head, as a continual loop of disaster thoughts hold my mind in a vice like grip of driven compulsion. “It’s a physiological state and my mind is amplifying it,” I tell myself. “Then face it and stop running away from it, the negative thoughts are stimulated by a core feeling, its innate fear-terror.”

    I turn onto my stomach and adopt my mind-less meditation routine, a practice that has worked really well for dissolving the racing thoughts and energies of bipolar disorder’s mania. If the mind is dependent on physiological state as the polyvagal theory indicates, then changing this physiological state should work just as well for this dreadfully negative state of mind. I focus on the felt sense of my flesh on the mattress sheet, feeling the sensation of my internal organs and the knot of painful tension just below my rib cage. I follow Peter Levine’s advice and try to feel into this pain sensation, staying with it and noticing any subtle shifts. Yet I can’t seem to get into my body now, stuck fast in my head as each attempt to experience the felt sensation is blocked by an instant rush of thoughts. Curiously, thoughts and image memories of the same painful gut spring to mind, a forty year old memory of fear and avoidance, the same knotted tension in the same place, just below my rib cage.

    “A body memory, the place I’m always running away from, always avoiding,” I tell myself. A whole slew of thoughts about trauma and how we normally think in terms of external, causal events, runs through my mind. “Yet its an internal process, my brain stem and my nervous system with their electro-chemical stimulation are the actuality of post traumatic experience.” A familiar shudder runs straight down my spine now, as if making a comment on this thoughtful interpretation, “a conversation with my unconscious self, perhaps?” I try again to just feel into the knotted tension in my stomach, and let all awareness reside there, and again there is an instantaneous surge of thinking. This time self recriminations about wasting time, letting months drift away instead of writing. “Self revelation is an organic process, there is no clockwork timetable involved,” some part of me kindly advises.”

    http://www.bipolarbatesy.blogspot.com/2012/06/long-night-of-soul-invitation-to.html

    Readers may ask themselves, whether I’m trying to sell them a book, or “my soul?”

    • The conscience lives in the stomach. I lived with stomach torture for years. I did the only thing I could: I “spilled my guts” – which all my life I put a LOT of effort into holding. There’s even some pictures of me holding my stomach. But I was “driven” to it – forced, by nature. I felt total relief, but then the pain came back because it wasn’t done. I ended up going through starvation (for many reasons) and became skeletal. Some social workers / others thought I was hiding a drug problem. I insisted that I didn’t have one; they took the denial as a sure sign that I did. Their ignorance made my problems severely worse.

      I used to have to force feed myself (which is very painful). I discovered that baby formula was a miracle.

      Yeah – the conscience will torture the stomach. The mind and the stomach are replicas – we intake, digest and output. I laugh when I see people talk about “there’s no such thing as information overload”. YES, THERE IS. Maybe not for that person, but there sure is for some others!

      “I try again to just feel into the knotted tension in my stomach, and let all awareness reside there, and again there is an instantaneous surge of thinking.” – exactly. You put your awareness on your stomach and then your mind acknowledges *every painstaking detail* – am I right? Are you Aquarius, David? Have Aquarius as a rising sign? Aquarians are known to flood and dump their knowledge – in other words, “spill their guts” (minds). The Water Barer is an AIR sign (air = mind). Aquarian Keyword is: I KNOW.

      There’s a certain burden from carrying knowledge.

      • In my current state mjk, I knowledge all understanding in the attempt to unfold our deepest nature.

        Unfortunately I’m a cranky Capricorn, December 27th, although I’ve never pursued astro-theology as Peter Joseph calls it in ZEITGEIST: THE MOVIE.

        My healing has come from self-education & learning how to NOT think to much, in that classic attempt at spontaneous release of the trauma trap, we call mania.

        Do you noticed how the educated priesthood, declines to comment on “stuff,” we poor souls contribute? There are so few letters awarded after one’s name, for doing a double degree in LIFE.

        • I’m not familiar with zeitgeist, but Capricorns are good sign. Well, I like to think they all are. 🙂

          Maybe healing is our deepest nature.

          Yes, I do notice sometimes but I’m very used to being invisible and non-existent, haha.

  9. 1boringoldman.com recently had a series of posts, the most recent here http://1boringoldman.com/index.php/2012/06/17/a-minority-report-ii/ , where he pondered the conflation of melancholia with “depression” and any number of “down” conditions.

    He traces the history of the “depression” diagnosis in various DSM editions.

    It’s led to an enormous amount of diagnosis creep, begging the question: Why hasn’t all this confusion been clarified in the proposed DSM-5? (In fact, the DSM-5 “depression” diagnosis failed in field trials.)

    It seems to me, psychiatry allows this nonsense to stand because it doesn’t matter what the diagnosis is, the treatment is going to be an arbitrary succession of drugs anyway.

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