Are you depressed or just feeling sad? A rejoinder

I thank Jacob Smit, Michael Bennett and Alissa McCulloch for their comments in response to my article on depression (other, better, version here). This is a very important issue for university students, and a broad ranging debate is fitting. But I feel I have been misrepresented and would like to clarify some points.

Postmodernism - Jeremy Barme

First, for the record, I have experienced several depressive episodes in my life, and took counselling. I was never prescribed drugs. My motivation for writing is partially that my exit from ‘depression’ came after extensive self-reflection.

However, I entirely agree that medication has a big role to play in many instances of mental ill-health. I emphasise this in the closing paragraphs of my article. My father is manic depressive, and his condition improved remarkably after medication.

I do not undermine the possibility of ‘humane medicine’, in fact, I specifically emphasise humane medicine. Perhaps the reference to medicating cases of suicide, self-harm, anxiety disorders, manic depression and schizophrenia were insufficient to make my position clear on this count. Alas, such are the limitations of 500 word articles.

My intention was not to undermine the role of medication in treatment, merely to re-affirm the importance of reflection and counselling in cases of mental distress. I concede I did not go about this in an appropriately sensitive manner. My excuse is a poor one: in journalism it is suitable to say things in a slightly inflammatory way.

My concern is with lay understandings of depression, not those of psychiatric professionals. I underscore this in the very first sentence of the article: “it is increasingly common for laypeople to understand…” It is thus fitting that my use of the term is colloquial and not drawn directly from the DSM-IV. But I concede this was foolish, because I have muddied the waters when my intention was the opposite.

I understand the difference between depression and ‘feeling sad’; my concern is that laypeople do not.  The impetus for my article was a conversation. I mentioned that I was surprised by the length of a friend’s melancholia (I used the word ‘depression’) because of how obvious I thought the existential cause was. Another friend replied: ‘it’s a chemical imbalance, so it’s not like she can do anything about it.’

Depression has a use in common parlance that is distinct from the clinical definition. There is a consequent confusion in the general discursive space between melancholia and ‘bona fide’ depression. This leads to a situation in the discursive space where some in society at large understand the melancholic as powerless, pre-determined machines in need of repair.

They are ‘ill’; we are ‘healthy’. The possibility of society being flawed or unaccommodating rather than the individual is precluded. This is precisely the ‘othering’ that Smit and Bennett accuse me of. Yet what I’m doing by emphasising agency is giving back the human element and resisting othering. 

This is part of the reason why I find distressing the claim that my ‘prose harks back to the dark ages where hetero-normative, white, male power centres made you believe that depression was a moral/existential problem, involving weakness of character—best cured by simply “sucking it up”.’ 

I was attempting the very opposite. I emphasise that we should allow people a period of dysfunction rather than expect them to ‘suck it up’ by taking medication so they can ‘get on with things’. The overriding emphasis on functionality in Australian values obstructs any (existential) investigation of whether something is worth remaining functional at when it is causing you distress. 

Humans, contra beasts, are conscious. We can take a stand towards things. To understand mental illness as ‘nothing but’ a chemical imbalance ignores this element. It is dehumanising. It obfuscates the possibility of a human emotional reason for mental distress alongside a chemical cause.

What is the difference? When you chop an onion, you cry. Your tears are caused by a chemical reaction. They are different to the tears you shed when a friend dies; those tears have a reason.

If you are occupied in a stressful manner, perhaps you are doing a job you find morally repulsive (the reason), your body may cope chemically by increasing your heart rate, blood pressure etc (the cause). You may experience anxiety (the illness).

In this case, medicating the chemical factors may be the humane thing to do. It may eliminate the cause of the anxiety. It may very well be the correct prescription. But surely it is obvious that a course of reflection on your job and values might also help with your illness.

Values are not yet empirically accessible, and Australia’s cultural and philosophical understanding of them is in its infancy. So we turn to our extensive empirical knowledge of brain chemistry instead. This is sensible. But it should not result in us comprehensively removing the existential element in psychic distress from the lay discourse. This is why it worries me when laypeople understand depression as entirely a matter for doctors.

Drugs are the realm of doctors, and drugs have an important role to play in improving mental health. But surely sometimes an existential treatment is also needed, or even principally needed. Sometimes the patient cannot manage because they have no idea how to reflect on their life and identity. They cannot understand why their high status job might actually be killing them, for example.

A doctor, no matter how expansive their neurobiology knowledge, cannot give you an existential treatment. That is not their skill set. I am here paraphrasing Victor Frankl, a doctor and neurologist working throughout the 20^th century, whose work is the main reference point for my thoughts. He emphasised the noetic (loosely ‘spiritual’) element in many neurosis, and empirically validated his theories.

I would like to take a moment to respond directly to the charge that I do not provide empirical validation for my arguments, as I thought it was a cheap shot. I have 500 words and I am not allowed references. Moreover, it is an opinion piece, not an article for a scientific journal or even for a philosophical one.

Furthermore, I tried to address the fact that the early psychoanalytic schools did not conform to strict scientific methods, such as randomised controlled testing, but that their findings are ‘backed up by mountains of case data and thousands of cured patients’.

While case data is certainly not of the same knowledge status as modern empirical studies, they do have a degree of validity as evidence. This is especially the case given that the early psychoanalytic schools were operating at a time prior to the codification of scientific method (notably by Karl Popper in 1934 with ‘The Logic of Scientific Discovery’) and are thus precluded from conforming to it. These schools were populated by doctors, not philosophers. They were all committed to rigorous validation of their theories. To dismiss their work as irrelevant because it does not conform to a standard that did not exist at the time is unfair and counter-productive.

Doing so would seem to undermine the validity of qualitative methodologies and of rational inquiry. Yet scientific method leaves plenty of room for these approaches to contribute to knowledge. As Popper emphasised (and lived), it is the task of philosophy and the more speculative disciplines to run ahead of strictly scientific knowledge.  Their findings will never be as convincing as those of the empirical disciplines, but they still form an important component of our knowledge base.

Returning to my main argument, I’m sure psychiatrists, with both medical and existential training, do good work. You should take drugs if such a professional recommends it. But on a discursive level, we should not be in a hurry to reduce the complexity of the human condition to merely a matter of chemicals. 

Australia is an existentially impoverished nation. We have very little art, culture, literature or philosophy to speak of. In this context, I feel there is a risk that colloquial understandings of depression as chemical imbalance will prevent people from seeking existential education in cases where it would be appropriate, and undermine attempts to bring such existential matters into the spotlight in Australia. 

We are, thankfully, a nation of happy-go-lucky larrikins. But this simplistic approach we have to life, while generally effective, leaves us lost when we do suffer an existential crisis. When ‘shit gets real’ in the case of someone with mental illness, we have few ways of culturally dealing with it other than to say ‘woah; that person is messed up, something must be wrong with them.’ This is precisely othering, and precisely what Foucault was on about in ‘The Birth of the Clinic’. I am more than happy to re-read Hegel, Lacan and Levinas if Smit and Bennett will do me the turn of reading Foucault and Frankl.

If you are struggling with feelings of depression or anxiety, contact lifeline (13 11 14), ANU counselling (6125 2442) or your GP.