How do we Balance Individual Agency and Social Factors in Depression?

Emphasizing individual accountability in depression exacerbates blame but a sole focus on social factors diminishes agency.

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In a new chapter in the book Depression Conceptualization and Treatment, psychologists Maria Orphanidou and Irini Kadianaki discuss the longstanding controversies surrounding the conceptualization of depression. They explore the place of the individual in understanding the causes behind depression and illustrate how the “individual accountability versus sociological factors” debate might be a dead-end.

Using their research on the lived experience of depression with Greek-Cypriot patients, the authors propose a socially conscious understanding of empowerment that preserves individual agency while also considering the importance of sociological factors as essential to understanding depression.

Research around depression has seen some drastic changes in the past decade. Experts are increasingly distancing themselves from the “chemical imbalance” theory. Resultantly, the role of antidepressants has also been problematized by recent findings.

More recently, researchers have suggested that depression could be a response to the stress of trauma, loneliness in teens and even connected to a sense of purposelessness and meaninglessness. Economic stressors such as unemployment have been connected to the increasing diagnosis of depression across the globe.

Another important concern has been the overdiagnosis of depression because of overreliance on the Pfizer questionnaire for screening, to the benefit of pharmaceutical companies.

Orphanidou and Kadianaki point to a central controversy in the way depression is understood. The bio-medical and psychological models suggest that the causes of depressive symptoms lie within the individual—from serotonin imbalance to dysfunctional thoughts—and target the individual for treatment. The sociological model insists that life circumstances that lie outside individual control, such as racism, poverty, unemployment, etc., are the core causes of depression. Thus, focusing on the individual puts unnecessary pressure on them and is part of a larger neoliberal culture that solely focuses on individual responsibility and self-improvement, and not problems in the system.

At the same time, other researchers maintain that individual accountability can give people a sense of empowerment and agency. Resultantly, there is an impasse, with one side being severely critical of individualization and another insisting that if we remove individual accountability, we also remove a sense of power and agency. The authors write that what we need is an understanding of empowerment that is social and does not burden the individual but maintains agency.

They begin by noting that despite the biopsychosocial model of mental health, individualization is predominant in research and practice. Even when structural factors such as poverty and homelessness are discussed, the pressure to fix them is still on the individual—asking them to take control of their treatment, make lifestyle changes, etc.

At the same time, personal empowerment has been linked to lower-self-stigmatization and depressive symptoms and better outcomes. Given that feeling a loss of control or power and hopelessness are key in depression, individual empowerment is likely to be beneficial. Originally, empowerment was supposed to be applied at all levels of society, the individual, community, and organizational/structural, but the focus has only been on individual empowerment.

Several criticisms of the individual/patient empowerment narrative have been put forth. First, it is related to Western values such as self-control and self-management. Resultantly, instead of being objective and universal, it is steeped in societal values of what it means to be a responsible self-enhancing good citizen. It falls short in other cultures with different value systems.

While this narrative of self-empowerment sounds good, it can lead to self-blame, victim-blaming, self-responsibilization, and the marginalization of socio-cultural factors. People can be judged and blamed for not managing their depression even when the causes are largely social. As a result, people may not question systemic injustices (exploitation of labor, poor living conditions) and how they might be connected to what they are feeling.

The researchers show how this self-blame and excessive self-responsibility is reflected in the participants of their research. They conducted eight semi-structured interviews with Greek Cypriots about their experience of depression.

They found rampant self-blame in patient discourses. The effect of the individualization narrative was evident. This held true even when patients were aware of the role of sociological factors, such as bullying, drug abuse in the family, financial troubles, etc. However, they still internalized both the cause and treatment of their depression. Some excerpts from their narratives highlight this point:

“[Depression] was due to my stupid [reactions] of [overthinking] and anxiety, (…) and my personality traits. (…) Many times, I create problems for myself on my own to be honest. It is no one else’s fault. (…)”
“You put yourself in a prison, in a box, so I believe [depression] is a torture. Um, you imprison yourself on your own, no one else is putting you there, and you create things with your thoughts, and the only one responsible for this situation is you. (…) No one can help you if you don’t want to help yourself.”
“The weak ones, the sensitive ones [are affected more by depression]. (…) I was a weak character. (…) You need strength. Maybe you acquire this strength because you are suffering? And you say [to yourself] that you need to do something, you can’t stay like this. (…) I told myself that I will fight [depression] on my own. (…) If [the pills] help me and I help myself, I will make it.”

At the same time, for most patients, self-responsibility and accountability were also a source of strength and empowerment. One patient said:

“Psychotherapy. [It’s] when you discover your strengths and that it’s okay for others not to like you. [You] learn things, [you] change, [you] begin to love yourself. [You] work on yourself and to get to know yourself. (…) Little by little, you discover your strengths.”

Even when some patients knew that social factors had been at least partly responsible for their depression, these factors were not discussed in treatment.

The researchers suggest including more social aspects in understanding and treating depression while also acknowledging how personal accountability is important for empowerment and agency. Individual empowerment is embedded in socio-cultural contexts—growing up in a community that looks out for each other instead of punishing those in poverty, a loving and encouraging family, a state that takes measures to reduce poverty and unemployment, etc.

The authors write that they think a big reason social systems are avoided in favor of individual responsibility is that social change requires long-term effort, resources, and time. What is needed is research that studies practical difficulties hindering these changes. They write:

So, it is possible that in an attempt to compensate for these barriers and offer a more immediate solution in the treatment of depression, mental health professionals focus on individual factors, which are more easily amenable.”

Their solution involves practitioners explicitly acknowledging the place of the social determinants of depression, reminding patients about these factors and their role in their own condition, and moving beyond focusing simply on patient empowerment. They insist these measures are essential if we are to change patient understandings around self-blame and treatment responsibility.

 

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Orphanidou, M. & Kadianaki, I. (2021). Addressing individualization in depression: Towards a socially informed empowerment. In Christos C. & Georgia P. (eds.) Depression Conceptualization and Treatment. Springer (Link)

4 COMMENTS

  1. What a delightfully simplistic dichotomy. It’s totally divorced from any kind of nuanced take that would include the possibility of actual illness. It sets up opposing positions that depression is either due to social factors or lack of individual agency, while ignoring myriad other factors such as actual physical health status, drugs a person is already taking, intellect, educational attainment, available time to research alternative approaches, individual values, maturity level, desire vs ability to obtain helpful supports, generational values, etc.

    Addressing social determinants of health and changing individual attitudes about agency are just two of many factors that influence psychosocial functioning in individuals and in communities. These are living dynamic processes all interacting and influencing each other. It’s not an either/or but more like an and.

  2. I was misdiagnosed with “depression caused by self,” despite telling a psychologist I was not depressed. But I did explain to her that I was dealing with bullying by a pastor, whose pension fund had been managed by my father for years, who denied my innocent child a baptism three times, on the morning of 9/11/2001. She then changed her misdiagnosis to “bipolar.”

    Both 9/11/2001 and the bullying, and my entire identity, were then dismissed as “irrelevant to reality,” (according to medical records) in regards to a potential cause of my legitimate concern. Let’s be real, 9/11/2001 was a distressing event for the entire world. And most certainly it wasn’t caused by a “chemical imbalance” in my brain alone, as that lunatic psychologist tried to tell me years later, when I was picking up her medical records.

    So I’m quite certain it is that some psychologists are outright blaming and lying to their patients, and their families, that is the problem. Especially, since psychologists are not medically trained. And none of the psychologists – or other doctors – I encountered were intelligent enough to even know that the ‘brain zaps’ and a spiritual dream I went in questioning in late 2001, are common symptoms of antidepressant discontinuation syndrome, until 2005.

    https://www.cambridge.org/core/journals/psychiatric-bulletin/article/brain-shivers-from-chat-room-to-clinic/642FBBAE131EAB792E474F02A4B2CCC0

    Symptoms that should NOT have been misdiagnosed as “bipolar,” even according to their DSM-IV-TR “bible.”

    “Note: Manic-like episodes that are clearly caused by somatic antidepressant treatment (e.g., medication, electroconvulsive therapy, light therapy) should not count toward a diagnosis of Bipolar I Disorder.”

    And what a sign of total corruption, that psychiatrists took that disclaimer OUT of their DSM5 “bible,” due to Robert Whitaker pointing out their ADHD drug and antidepressant induced iatrogenic “bipolar epidemic.” Since this will only result in more and more massive societal “mental health” industry malpractice.

    https://www.alternet.org/2010/04/are_prozac_and_other_psychiatric_drugs_causing_the_astonishing_rise_of_mental_illness_in_america/

    I’m quite certain a big problem with the psychiatric industry is that they have a bunch of non-medically trained, and DSM misinformed, people – psychologists, therapists, social workers, et al – misdiagnosing the common adverse effects of the psych drugs, then shipping people to the psychiatrists.

    Non-medically trained people should not be “diagnosing” anyone, with anything. Especially since the psychiatric DSM “bible” was debunked as “invalid” in 2013.

    https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2013/transforming-diagnosis

    I was eventually handed over the medical evidence of why that pastor was bullying me. His “soul mate,” and possibly also that pastor, had sexually assaulted my other child. I was able to scare the school, that had a pedophile on their school board, and where some of the abuse likely happened, into closing forever – on, of all days, 6.6.06.

    But I’ve since learned, through extensive research, that covering up child abuse and rape – historically and today – is the number one actual societal function of the “mental health” industries, and this is all by DSM design.

    https://www.indybay.org/newsitems/2019/01/23/18820633.php?fbclid=IwAR2-cgZPcEvbz7yFqMuUwneIuaqGleGiOzackY4N2sPeVXolwmEga5iKxdo
    https://www.madinamerica.com/2016/04/heal-for-life/
    https://www.psychologytoday.com/us/blog/your-child-does-not-have-bipolar-disorder/201402/dsm-5-and-child-neglect-and-abuse-1

    And the systemic pedophile aiding, abetting, and empowering “mental health” system has turned – via a faustian medical/religious “partnership” – the pastors, bishops, and other employees of my childhood religion, into systemic, unrepentant, child abuse covering up criminals, too.

    https://books.google.com/books?id=xI01AlxH1uAC&printsec=frontcover&source=gbs_ge_summary_r&cad=0#v=onepage&q&f=false

    And we all now live in a “pedophile empire,” many thanks to this systemic “dirty little secret of the two original educated professions.”

    https://www.amazon.com/Pedophilia-Empire-Chapter-Introduction-Disorder-ebook/dp/B0773QHGPT

    I do so hope to see an end to this pedophile empowering “dirty little secret” soon, since it’s destroying our entire country, psychologists, psychiatrists, pastors, and bishops.

    But I do know that there are some “delusions of grandeur”-filled psychologists and pastors, who want to “maintain the status quo.” That are handing out conservatorship contracts, under the guise of “art manager” contracts. In the hopes of stealing from people, rather than repenting, changing from their criminal ways, and utilizing their insurance for what it is intended.

    The criminality and lies of the “mental health professions” really seem to have no bounds. But I’m quite certain it is not in our society’s best interest to have systemic child abuse covering up, pedophile empowering, scientific fraud based “mental health” industries anyway. Especially since they are murdering “8 million” innocent people EVERY year, with their “invalid” DSM disorders, and neurotoxic psychiatric drugs.

    https://www.nimh.nih.gov/about/directors/thomas-insel/blog/2015/mortality-and-mental-disorders

    By the way, child abuse survivors can heal and thrive. If one can keep one’s child away from systemic child abuse covering up, “mental health” and social workers. Many of whom bizarrely believe the best way to help an already healing child abuse survivor is to neurotoxic poison him.

    Oh, and the “mental health” system does also need to garner insight into the fact that both the antidepressants and antipsychotics can create “psychosis,” via anticholinergic toxidrome. A medically known way to poison a person, that is missing from your “invalid” DSM “bible.” Neuroleptic induced deficit disorder, which looks like the negative symptoms of “schizophrenia” to the “mental health” workers, is also missing from your DSM.

    How long until we may say “goodbye” to both the iatrogenic – not “genetic” – “bipolar” and “schizophrenia” stigmatizations?

    • And, make no mistake, I have had to recommend Whitaker’s “Anatomy” to Catholic parents, of a child abuse survivor who was misdiagnosed as “depressed.” Then that child abuse survivor was turned into a “bipolar” stigmatized person as well. So this is a systemic “dirty little secret” of many, if not all, of the mainstream religions, and their so called “mental health” and “social” workers.

  3. First, I want to commend anyone who claims they discover their strengths in psychotherapy. I never discovered any such thing about myself. Of course, during much of my psychotherapy, I was too “drugged” to learn anything about myself. I am not even sure if psychotherapy is truly set up to discover anything about oneself, much less strengths or weaknesses.
    Second, when we will we ever learn the truth—that depression or being depressed is just a natural part of life and living as is being happy or happiness? Wouldn’t be odd if a person did not get depressed over losing a job or the loss of a loved one or a million other life’s happenings? I know there are those who achieve something they thought they wanted to achieve and instead of joy and happiness, they are depressed and can not understand why. But, this is usually something that is similar, in many cases, to what emotions we feel at Christmas time.
    Third, I realize that many times a fear that the person will resort to suicide in the throes of depression could be a main reason for what we call; “therapeutic intervention.” This is a valid fear, however, we know that many therapeutic interventions, such as psychiatric drugs can be a main cause of suicide.
    Fourth, many people, no matter depressed or not do need some assistance in discovering the direction or purpose for their lives. Therapy and other psychiatric and psychological interventions are the least successful ways to accomplish this. We have very few ways for someone their situation that can help people with this main issue in their lives. This can make a person very vulnerable and gullible to the evils of all this therapy.
    Fifth, whether it is societal cause or individual causes is actually a moot question. And, it is silly to discuss it. It only adds to the misery of psychotherapy and other interventions.
    Psychotherapy, etc. could be considered “strawman” approaches. The person puts all their faith in their next appointment or the perfect drug. It is all lies and the only result is terror and damage.
    Is there an answer? Yes, but few want to hear it. It is only when we admit that we are helpless without God that we can literally be “saved.” Thank you.

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