Experiences of Depression Connected to Declining Sense of Purpose

In-depth interviews find that those who screened positive for depression did not explain their experience in terms of diagnostic symptoms.

Zenobia Morrill
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Research has suggested that there is a divergence between scientific understandings of depression and the way that depression is experienced by those diagnosed. A new study, conducted by a team of researchers led by Miraj Desai at the Yale University School of Medicine, explored these discrepancies further. In-depth interviews with individuals who had screened positive for depression indicated that their experiences were connected intimately to a declining sense of purpose.

People who screened positive for depression were “dealing with profound ruptures to what they were living for—their dreams for work, relationships, and a meaningful life,” Desai and his co-researchers write. Rather than describing their experience in terms of a “depressive illness,” participants in this study traced their declining sense of purpose to the ways their goals and values in life had been threatened. In turn, they experienced accompanying constrictions in their energy, action, and body.

“The present study found that the experiences underlying a positive depression screen were best characterized as a context-dependent, life-historical phenomenon,” Desai and team write, adding:

“The problem for participants was a world in which they now faced a declining sense of purpose and incapacity to reach goals. During moments when various individuals did reflect on their situation, the experiences in question were viewed more in terms of their biographical import (e.g., a “noble struggle” for social justice), rather than as a biomedical illness or disorder.”

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Incongruencies that exist between patient perspectives and scientific conceptualizations raise various problems. Patients’ viewpoints affect how they go about seeking help, their preferences for treatment, treatment engagement, the patient-provider collaboration process, and finally, the outcomes of treatment. In other words, how individuals understand their experiences of depression matters, and if this perspective is overlooked, it can impinge healing and resolution.

Notably, wider discrepancies between biomedical explanations of depression (e.g., depression is a medical illness) and beliefs about depression that exist in communities of color have been observed. African Americans and Hispanic Americans are more likely to view depressive experiences as related to social difficulties, including financial problems, caretaking burdens, and inadequate housing. One study found that Chinese Americans who had screened positive for depression often did not perceive themselves as having a psychiatric condition.

Desai and colleagues conducted their study “to narrow the gap between community perspectives and scientific knowledge.” Using a qualitative approach designed to explore the meanings participants initially make of their experiences, phenomenological inquiry, the researchers endeavored to remain as close as possible to participants’ understandings of depression and abstain from applying external interpretations.

Participants included patients who were seeking help for medical conditions at a primary care clinic in New York City. While waiting for their regular physician’s appointment, participants were recruited who were not currently utilizing behavioral health services, had screened positive for depression, as measured by the Patient Health Questionnaire-9 (PHQ-9) instrument. To focus on the study’s aim to explore possible divergent perspectives, patients who were currently receiving mental health treatment were not included.

Overall findings of this study revealed that those who screened positive for “depression” characterized the experience as the destruction of what they were living for, of “what they centrally valued in their lives,” write Desai and team. They did not describe it as a clear, distinct depressive illness or disorder. In this way, the nature of their suffering as rooted in threatened life goals and values was only partially captured by screenings that focused on individuals’ thoughts and bodily experiences.

Rather than being central to their experience, constrictions of participants’ bodies, actions, and energy were described as paralleling and accompanying the overarching decomposition of their life’s purpose. Desai and team write:

“The ensuing experiential process, in the face of decaying life purpose, involved enjoyment of their situations turning to sadness about them, their active body becoming passive, time becoming stuck in a hollow present as the future collapsed, and space contracting.”

Participants expressed this experience in different ways. Many discussed a moment in their lives when they were grappling with an unclear future—the sense that they were heading in an unsteady or uncontrollable direction. Desai and colleagues write that he participants “understood important, even cherished life goals and pursuits—in the course of their quest for love, work, and meaningful participation in the world—as under threat, facing the possibility of destruction, or having been actually destroyed.”

Moreover, individuals focused primarily on the challenges they faced regarding important life commitments as a core feature of the experience. They did not understand their situation as a formal health condition. Unlike how depression has been framed in the scientific community, participants did not describe a clear constellation of symptoms. Desai and team write:

“Many did not use the word ‘depression,’ and for those who did. . . the word typically carried life historical meanings, often implying great sadness at losing the good or frustration in relation to thwarted life pursuits, rather than a medical condition.”

One participant described different types of depression that she experienced. Each type was related to a loss. She shared: “Sometimes I feel depression coming when I think back to times. When I think back to better times.” She later added, “That’s another depression, when you can’t do what you want.”

Sadness, passivity, and stuckness characterized participants’ experiences. “In the midst of failing efforts toward goals,” write Desai and team, “individuals’ lives and bodies, now without a central unifying purpose, started to erode.” Furthermore, participants experienced a sense of being devalued, experiencing low social worth, and a sense of failure.

They felt blameworthy, incapable, and worthless. This demonstrated a complex, interdependent relationship between self and other. For instance, feeling a greater sense of self-worth is connected to experiences of being valued and chosen by others (e.g., obtaining a job, maintaining a relationship).

Desai and colleagues describe this experience by those diagnosed and demonstrating a teleological structure. Individuals’ sense of direction and purpose was at the heart of participants’ wellbeing. The collapse of these life goals and values “underpinned a positive depression screen.” Is the loss of this direction and purpose then, that in turn manifests as problems in “body, behavior, emotion, and thought.”

They summarize the meaning of this finding:

“We contend that this structure has not been adequately accounted for in the mental health literature, nor given an equal footing in the wider world of theory and research design, which remain mostly focused on illness, intrapsychic, cognitive, and context-independent conceptualizations and explanations.”

Implications offered for how treatment approaches can change based upon this data are plentiful, including the need for providers to respond directly to patients’ goals and commitments. Adherence must be reframed such that it is not only referring to patients adhered to decontextualized treatment requirements. Desai and colleagues discuss this further in a concurrent paper.

In addition, these data may be used to draw connections and bridge the gap between science and community life. Desai and team conclude:

“We are essentially seeing a type of experience that is understood in relation to its purpose or future-directedness, from which it receives its organization and meaningfulness. Thwarted goals at work, in relationships, and in fostering social change signified the loss of direction in life; without direction, one’s energy, body, actions, and even self lost value and purpose.”

They continue:

“This directedness to something beyond themselves, or transcendent quality of experience—for which everything including so-called ‘symptoms’ carried meaning—has typically not entered the frameworks of mental health causality, which tend to remain on the level of physical cause (e.g., biological substrate, physical disease, or even mental disorder) or internal-mental cause (e.g., intrapsychic factors, a cognitive model of illness, etc.).”

More careful consideration of the “sufferer’s perspective” and multiple sources of discontent in the world are needed to better inform how we understand and approach such distress.

 

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Desai, M. U., Wertz, F. J., Davidson, L., & Karasz, A. (2019). An investigation of experiences diagnosed as depression in primary care—From the perspective of the diagnosed. Qualitative Psychology. (Link)

29 COMMENTS

  1. thank you Zenobia.
    It is obvious that if this has to be talked about or explained to psychiatry, then they are not equipped to deal with the complexity of themselves or anyone else.
    Scary indeed.
    The psychiatrist is there to hand out a label of depression and most likely a few more.
    He does not realize that the client is aware. If someone understands the feeling of depression, that is the only way to make connection.
    It is probably time for all psychiatrists to be replaced by computers.
    Seriously.

    • I have to rather agree, sam. How embarrassing that seemingly all “mental health” workers went off believing the insane belief that “all distress is caused by chemical imbalances in people’s brains,” rather than real life distressing events.

      How insane can our “mental health” workers collectively be?

      And what’s particularly sad is I have medical and legal proof our “mental health” workers want to defame, neurotoxic poison, and/or steal from those of us who don’t lack a goal or sense of purpose in our lives.

      As an artist, it’s my job to visually document what’s going on in my society, hopefully for the art history books. But the systemic, primarily child abuse and rape covering psychologists and psychiatrists, are now terrified by my artwork.

      https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo

      https://www.madinamerica.com/2016/04/heal-for-life/

      When they thought their lies would be attached to my artwork, my work was “insightful,” and “work of smart female.” When the truth is attached to my artwork, it’s “too truthful” and “prophetic,” for the insane, systemic child abuse covering up, psychologists and psychiatrists.

      • Well Someone Else,
        We know there are chemicals, but we wonder how “imbalance” is measured.
        And the pills one takes also cause an imbalance lol.
        How does anyone buy the childish theory of imbalance.

        Now we have to be impressed by little colors on spect scans. The ‘scientist’ does not inform the gullible public that it is like looking at a star and pretending to know the universe. It always amazes me that educated people believe.

        • Precisely.

          There’s way more to our neurochemical makeup than dopamine and serotonin despite what NAMI would have us believe. Most of the chemicals in the human brain remain unclassified by science.

          If they don’t even know what they’re trying to fix how can they fix it?

          • They can’t even cure migraines lol.
            Guess the easiest part of the body to sell labels and drugs for?
            “emotions and thoughts”.
            I do feel that more people are questioning, not just those that went through the cleansing.

    • Yep. Replace all psychiatrists with kiosks containing computers. You can take the test for “mental illness” with in the multiple choice quiz already used by shrinks.

      Print up the new diagnostic label/s on a receipt. Then run your Medicaid/Medicare/insurance cared through various vending machines that will dispense 7-30 days worth of pills.

      The machines won’t make you wait 2 hours extra for a 10 minute office visit. They don’t play golf.

      • Exactly Rachel and Steve. Perhaps one of our great computer giants can cash in on this. Every person knows the Q’s a shrink throws at you, but they’re getting smart,so no matter what one says, it’s a disorder.

        Steve, I bet there would be an invalidation slip along with the meds. Wonder if you can kick the machine for that.

        • Maybe you can select options: “If you’d just like a prescription, press 1. If you’d like a spurious but scientific-sounding ‘diagnosis,’ press 2. If you’d like to have the context of your ‘symptoms’ specifically invalidated, press 3. If you’d like a psychobabble explanation of why you need to keep taking your drugs forever, press 4. If you’d like someone to actually listen and understand your struggles, hang up and call somewhere else!”

  2. The radical psychiatrist has options.
    The one option he can choose is not
    to see a person’s discontent or confusion about
    life and themselves as an illness.
    The “illness” paradigm and it’s following theories and fixes is nothing but a belief and based
    on “dysfunction” or “non function”, and those are
    measured by what the client or society/shrinks
    believe functions should look and feel like.
    It is based on a very limiting view, which is widespread
    because of it’s simplicity. It reduces massive interactions
    across spectrums to be residing in one person.

    The simplistic answers in our society are a refection of how far we
    have not come along.
    Perhaps if we tried the reverse? Reverse psychology has merit they say.

  3. Thank you for this very helpful summary. At a recent Zen retreat there was discussion of the fundamental human fear of losing group attachment…community, tribe. Really an existential threat to one’s being, as we are so fundamentally social. Someone who has taught in many parts of the world said that one of the biggest and most troubling surprises for her has been realizing how much greater this fear is among Americans, just terribly, terribly afraid of and/or suffering from a sense of expulsion from community, or simply not having it at all. And so: lots of depression.

  4. Interesting what they are learning at Yale. About 15 years ago, after having ECT treatments for what was then diagnosed as “treatment resistant major depression”, in my late 40s, at Yale Psychiatric Hospital, the psychiatrist told me, “You have borderline personality disorder. That’s why the ECT didn’t work.”. Talk about a declining sense of purpose – with those words I went from seeing myself as a basically good person with problems to a profoundly disturbed, dangerous person (the Dr didn’t explain to me what BPD was. I went home and looked it up online). Within 2 years of this event, I went from fully employed to “permanently disabled” according to the Social Security Administration. Though I no longer believe in the borderline diagnosis, I’ve never recovered from what felt like a gut-punch from a doctor I’d put my trust in. The fallout from getting the diagnosis was huge – it impacted all of my relationships, most of all the relationship I had with myself. I never returned to the work force and, at this point, it looks like I won’t.

    • I wish I knew 15 years ago how little they know at Yale about, like, life. I put myself in the hands of these doctors, I put my trust in people who, come to find out, need a study to tell them that bad things happening to a person can make them depressed.
      What a waste. I’d still be able to work, still be able to function, if not for the “help” these people provided.

    • It is normal to have a response to being told one is not right in the head.
      It’s weird that psychiatry can’t come up with anything better than naming and shaming.
      Only cults leave people demoralized. (I do believe some shrinks are embarrassed)
      One practice that would make a lot of money is a practice that tries to undo psych/cult damage.

      • Krakatau,
        I’m not sure if you were writing in response to my comment…if so, I’m sorry that you had a similar experience. Now I realize, there are so many who psychiatry did a number on.
        While I was still in treatment, I had only a dim awareness of the antipsychiatry movement. It’s only within the past couple of years that I’ve become aware of the extent of the rebellion against psychiatry and it’s myriad abuses of power. When I was still a patient, they had me believing I was an outlier, one of the few who didn’t “respond to treatment.”. At least now I know the truth, but still, as you said, it’s painful.

  5. Sense of….? What’s the difference between a man with a job and a man without a job? Reasonably, one might say, a sense of purpose. Chronic unemployment is not a disease. It’s a systemic, or, administrative dysfunction.

    Economic depression is related to lack of finances. Ditto, in my view, psychological depression.

    • Why many find “mental health”=depression. You get your entire identity out of popping pills and attending “groups” to reinforce how sick/crazy/helpless you are.

      Normal things that give most a sense of life purpose–career and family–are strongly discouraged.

  6. “Research has suggested that there is a divergence between scientific understandings of depression and the way that depression is experienced by those diagnosed.”

    Where is this scientific understanding of depression? I have never met a person who talked to me about a scientific understanding of depression. That’s one of the problems regarding the over prescribing of antidepressants and other medications. No scientific assessments are made. It’s a lot easier to write a prescription than it is to practice medecine.

    If I have an accident and fall into a coma – is there a nut that will say “oh, she is depressed, obviously”. Sometimes, it seems to boil down to that. If I’m experiencing kidney failure and the doctor simply concludes to depression – you’ll reply – I exagerate.

    Well, I’ve lived more than half a decade and I find every professional is able to guess “depression”. Only a few have the intellectual curiosity to look further and assess scientifically the ailment.

    How did this happen? A pill for every problem. A scientific assessment of depression. Don’t make me gag. How ’bout a little bait and switch. Or in this field, gait and twitch, all for the price of one. I’ll stop here before I get too upset.

    • Well redcat,
      they say we asked for it.
      Shrinks talk to each other about how useless the treatments are, how bored they are with dealing with a bunch
      of whiners and that we are spoiled, discontent, and that it is a societal problem.
      Yet it keeps them in business, yet they blame their clients. Funny how that works out.
      If we could convince people of the idea of the sick treating the sick, perhaps there would be less people looking in all the wrong places.
      A few therapists are trying it, and it works for some.

      • Is that so?

        I keep hearing shrinks tell everyone–not just us–how their treatments are 100% safe and effective. They prevent murder, adultery, homelessness, drunkenness, theft, suicide, etc. And they’re “safer than aspirin.” “Just like insulin for diabetes.”

        So they admit to each other that all their medical help is worthless? A pack of lying scoundrels.

        Shrinks whining about how the geese laying their golden eggs squawk too much.They’re the ungrateful ones IMHO.

    • Yeah, they should say, “…divergence between commonly accepted pseudoscientic and self-serving ‘explanations’ for depression and the actual experience of those having those labels slapped upon them without any attempt to understand the context of the ‘symptoms.'”

  7. It doesn’t seem to have occurred to the article’s “thought leaders” that this ennui about aspirations and goals might come from an individual’s energy levels that might be fading for some reason or other, making the aspirations and goals harder to pursue. Apparently, trying to find out why doesn’t have much of a following in psychiatry.

  8. Almost. funny, if it wasn’t so sad.
    I believe the. solution is social workers, not shrinks. It’s no surprise loosing purpose in life makes life purposeless… why do something that has no purpose?

    But what’s to be achieved with a chemical straight jacket?

    The treatment needs to shift from the hands of shrinks and into the hands of social workers. They need someone who will listen and see them as humans. The notion that this loss of purpose in life and narrative being deluded obstacles for treatment is ridiculous! What’s ridiculous is disregarding them. Whatever road blocks that. are. central to this loss. of one’s purpose should be considered and they only will benefit by being validated, lended a hand and coaching them on things they can do to improve, and what they can’t fix helped to realize acceptance and alternatives. So they have a purpose to live, ya know. Medication. and “treatment” isn’t the reason to live when you’ve lost purpose to.. (live?) You should be damned about your life loosing purpose, especially after becoming helpless and loosing and sight of that purpose- the best advice you receive is “sorry” which just confirms that helplessness.

    Reading my reply is probably painful from the common sense

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