Behaviorism and Mental Health

Shahnawaz: There is a strong temptation, when we are confronted with opinions which differ from our own, to conclude that the other party doesn’t understand the issues. This theme – that I have simply missed the point – is very evident in your comment.

Please let me assure you, I am very familiar with the illness model currently being promoted by psychiatrists and pharmaceutical companies. I have studied this model extensively for the past forty years, and have watched it burgeon at the expense of society generally and individuals in particular. I am very familiar with DSM and the criteria for the various so-called diagnoses. I have worked in prisons, mental health centers, addiction units, and private practice. I have worked compassionately, and, I believe, very helpfully, with people from all walks of life and presenting all manner of problems.

The essential point of the illness model is that problems that people encounter in their lives are caused by mental disorders. In DSM the APA defines a mental disorder as “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress (e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom.” Now if you analyze this definition, what it actually amounts to is: “any behavioral or psychological problem.” In other words, when the APA say that people’s troubles are caused by mental disorders, the substance of this statement is that people’s troubles are caused by their troubles. It is not a valid explanation. A true understanding of people’s problems requires more than a label.

Over the years I have watched the American Psychiatric Association’s mental disorders “morph” into brain illnesses. The APA has never officially endorsed this development, but their members in the field promote this notion whole-heartedly. Incidentally, one of the APA’s criteria for a Major Depressive Episode is that “the symptoms are not due to the direct physiological effects of a substance (e.g. a drug of abuse, a medication) or a general medical condition (e.g., hypothyroidism).” In other words, if the depression is caused by a brain illness, it is not, according to the APA, a major depression. This contradiction is seldom discussed or even acknowledged.

Anyway, it is clear you are a thinking person. It is also clear that you are comfortable taking antidepressants and that you have a good working relationship with your practitioner. We each must find our own way in this world, and if your methods work for you, who am I to argue.

Thank you for your very detailed and thought-provoking comments.

CP: Thanks for your comment and your interesting question. It’s a particularly thorny question because “conventional wisdom” in mental health circles dictates that this should be done, especially if there has been any talk of suicide. It’s a brave practitioner who will go against the “conventional wisdom,” or standards of care as they are sometimes called. Economics makes cowards of us all.

That being said, it is my experience that “stop-gap” has a way of becoming permanent or semi-permanent. Additionally, if the antidepressants are successful in inducing “happy” feelings (sometimes they do, sometimes they don’t) then the incentive to change is often dulled, and motivation wanes. Conventional wisdom, of course, maintains the opposite, i.e. that the antidepressants give the individual the power to make lasting life-style changes.

I think the best way to conceptualize this whole thing is that many people like the effect of mood-altering drugs and will go to considerable lengths to obtain them. Some clients come to mental health centers to obtain a mood-altering prescription – and that’s what they get. Others come for counseling – often just someone who will listen to them and validate their concerns. I don’t think it’s for me to say, “you shouldn’t be taking antidepressants” any more than I would tell another person not to eat lettuce. Ultimately each person must choose what he or she eats. In this context, however, I think the comments by Louise on this post are pertinent.

The drugging (“medicating”) of children is a particularly thorny issue, but here again, the ultimate decision rests with the parents. (See my earlier blog on ADHD.)

Back to your question. I feel that this issue is particularly pertinent in cases of bereavement. The best (perhaps only) way to cope with bereavement is to put one foot in front of the other (in other words, stick to your routines) and talk frequently and at length to friends and family about the loss and its effects, etc.. So often today, however, there is a great rush to “medicate” (i.e. drug) the bereaved person. This is all done with the best of intentions – but the result is often that the bereavement process just doesn’t take place.

With regards to the suicide question, there are some who contend that antidepressants can make people more suicidal. I really don’t know. I would love to see a graph of suicide incidence (as a percentage of population) each year for the past 50 years. And plotted on the same page a graph of antidepressant usage (again as a percentage of population) year by year for the same period. I know that the second curve will show a steady rise, but will the first curve show a steady fall? Possible research project for someone?

Once again, thanks for the question.

Gee: Thanks for your interesting and thoughtful comment. You mention our “place in the web and cycle of life,” and I agree that this is an important notion. In a relatively short space of time (a few thousand years) we have gone from being hunter-gatherers in small groups to wielders of technology living in enormous cities. Even the farmers (the producers of food) spend most of their working day sitting in the cabs of tractors and combine harvesters. We call all of this progress, and of course in many ways it is. Nobody wants to go back to washing clothes in a cold river or watching their children die of diseases that are seldom even heard of today. There is a cost, however, to all of this. In my post on the so-called anxiety disorders I discussed some of these costs, and I think you care correct in identifying the severance from our biological roots as a fundamental issue.

You also make the point that there is often a wide discrepancy between what people actually eat and what they say they eat. This is certainly true. People whose diet is less than ideal often feel very guilty about these matters, and will present a picture of their dietary intake that is rosier than the reality. In many cases this is as much self-deception as a desire to deceive others. Many years ago I was talking to a client and he mentioned that he always ate a good breakfast before going out in the morning. I asked him what he actually ate, and he replied “two pop tarts and two cups of coffee.”

The central theme of my depression post was that depression is not an illness, but is rather a warning signal from our bodies, to the effect that something is wrong – something needs to be changed. Tragically the bio-psychiatric school has persuaded large numbers of people that depression is an illness (“just like diabetes”) and needs to be “treated” by taking drugs.

Once again, thanks for your comment.

Nostalgic: Thanks for your detailed comment. You make the point that suicide is as much “…a failure of the society as it is of the individual.” This is certainly an interesting perspective. In Western culture we tend to emphasize independence in our child-rearing practices. “Standing on one’s own two feet” is considered a great virtue, and there’s a measure of validity in this notion. However, we sometimes neglect the need for companionship and mutual support. Asking for help of any sort is, in various subtle ways, considered a weakness. Tragically many young people reach adulthood without any truly supportive relationships. They have no one with whom they can be truly honest; no one to whom they feel they can turn in times of emotional need. They are so driven to appear “cool” that they tell no one that they are hurting, even when the hurt is extreme. Your point seems to be that as a community we should be reaching out to these individuals in an active, solicitous way, and encouraging them to talk about their hurts and concerns. Perhaps you are right, though there is a danger of guilt-tripping the families and friends of people who have killed themselves, on the grounds that they didn’t do enough to reach the individual. The problem with this approach is that in my experience families and friends have usually made great efforts in this regard, but without success. So, like everything else in this field, this is complicated.

You express the view that mild depression is not an illness, but severe depression is. You also state that: “Many types of depression are quite clearly a biological malfunction.” My position is that there is insufficient evidence for either position. Of course depressive feelings are always accompanied by neural events. If I punch someone in the jaw, my action can be described from various perspectives. From a psychological point of view, it could be pointed out that the individual had insulted my favorite baseball team (say) and I retaliated physically. A sociologist might note that there were on average five physical altercations in the particular establishment each month, and that the combatants always came from different ethnic groups. An anatomist might describe how the human arm was uniquely suited to the purpose of striking blows to other objects. A physiologist might study the movement and interplay of muscles, tendons, etc. And a neurophysiologist might focus on specific mechanisms that link neural and hormonal correlates of anger with large muscle neurons, etc.. Now all of these perspectives are valid ways of examining the event in question. But no one would suggest that the act of throwing a punch should be regarded as an illness just because it has some neural correlates. Similarly, feeling good or feeling down can only occur if certain neural events happen in the brain. This does not establish the principle that depression is an illness. At the risk of stating the obvious, it is clear that a brain malfunction could cause depression. But the biopsychiatric adherents, despite their claims, have never established that this actually occurs. For a very detailed examination of the evidence in this matter, I recommend Elliot Valenstein’s book Blaming the Brain (1998).

Even if brain malfunctions were identified and were shown to cause depression, it seems unlikely that it would account for more than a tiny proportion of the depression we see in our society. The notion that human brains are “breaking” with such frequency is difficult to accept, especially when more parsimonious behavioral explanations are available.

You ask that I not categorize all depressed people into the same group. And in this, we are in full agreement. One of my major criticisms of DSM is that it does just that. It purports to collapse the enormous complexity of human life into the so-called diagnostic categories. My position is firstly, that every case of depression is different, and secondly, every depressed person is understandable if we are willing to take the time and trouble to listen and encourage communication. Within the DSM context, this almost never happens. The “diagnosis” is assigned and the pills are administered, and the “just like insulin” fiction is perpetrated.

With regards to pills, I don’t encourage people not to take them. In my experience some people take pills, others don’t. If you find them helpful, who am I to argue? My only position is that depression is not an illness, and anti-depressant drugs are not medication.

Anyway, despite our disagreements, I’m extremely grateful for your comments. I believe that dialog is the only way to move forward, and your thoughtful and detailed comment is greatly appreciated.

Salvora: Thanks for your comment/question.

When people’s lives are lacking one or more of the six factors you mention, they become despondent. If corrective measures are not taken promptly, the despondency deepens, which in turn leads to a reduction in overall activity – including the very activities that would in fact mitigate the depression. It is clear from your comment that you recognize this dynamic very clearly.

The question you raise is: which causes which?

Well, my fundamental position is that the normal state of the organism is one of pleasure /happiness/joy/contentment. When things are going well for us, we feel good. This is not an accident – it is nature’s way of telling us to keep doing what we’re doing. This “message” from our bodies is not infallible. It apparently tells smokers, for instance, to keep smoking! But for the most part, the feelings of joy and depression are essentially “messages” from our bodies that nudge and coax us in directions compatible with the welfare of the organism, in the same way that hunger drives us to eat and the feeling of satiation encourages us to stop eating.

This perspective on the joy-depression mechanism is internally consistent and can be conceptualized as an adaptive mechanism that has evolved in a great many species besides man.

Now if we consider the alternative – that the inactivity was caused by the depression, the first question that arises is how did the depression arise in the first place. The bio-psychiatric position, of course, is that depression is an illness – that for unknown reasons, a “chemical imbalance” arose in the brain and this pathological condition can only be corrected by taking drugs.

The first thing that needs to be noted is that the bio-psychiatric position is making an extreme assertion, i.e. that a very large proportion of our population has incurred some kind of brain damage or brain illness. (My position, in contrast, asserts that what’s going on is in fact the normal life activity of evolutionarily advanced organisms). In science, the onus of proof lies with the individual or group making the assertion and the bio-psychiatric lobby has never made its case.

Here’s what Joanne Moncrieff – herself a psychiatrist – has to say:

“Overall there is little evidence to suggest that there is a characteristic abnormality in either of these systems [serotonin and noradrenalin levels] that is associated with depression.” (The Myth of the Chemical Cure, 2009, p.156)

Here’s what Elliot Valenstein – Professor Emeritus of Psychology and Neuroscience – has to say:

“Although it is often stated with great confidence that depressed people have a serotonin or norepinephrine deficiency, the actual evidence contradicts these claims.” (Blaming the Brain, p. 100)

and in the same book:

“The evidence is clear that none of the proposed biogenic amine theories of depression can possibly be correct.” (p. 102)

and

“…it has not been possible to demonstrate that any biochemical abnormality is associated with any of the subgroups of depression.” (p. 102)

So who do you believe? Now the APA and the pharmaceutical companies have a huge vested interest. Writers such as Moncrieff, Valenstein, and others do not. In the end of the day, each individual must choose for him/herself. What sort of an organism do you think you are? Are you “broken” and in need of pills? Or are you – as I believe to be the case – nature’s supreme moment: the apex of about 3 billion years of evolution. In my view, the bio-psychiatric position is not only false, but is a tawdry and venal insult to the human race, and is promoted by psychiatrists and pharmaceutical companies for financial reasons.

And so to the question of pills. Some people like to take drugs – others don’t. I never suggest that people take pills – nor do I ever suggest that people stop taking pills. In the end of the day this is a personal preference similar to eating meat or being a vegetarian. Some drug users get their product on the street – others from physicians and pharmacists. Do what seems right for you – but know the risks.

My primary objection in this area is to the practice of telling people that they have a brain illness which is corrected by the drugs in the same way that insulin corrects the blood chemistry of a diabetic. This is not only false, it is insulting, but it is a fiction that has to be maintained to preserve the bio-psychiatric sand castle. I strongly suggest that you read Mad in America (2002) by Robert Whitaker.

Anyway, there it is – complex issues arising, as always, from apparently simple straightforward questions.

You did mention in your comment that there are “difficulties” that preclude you from having good relationships. And I assume that this is a reference to something in your history. The key to traumatic history is to talk about it – over and over – until the bad memories become desensitized and lose the grip they hold on us. Psychotherapy in my view can be extremely helpful if it provides a context in which this kind of desensitization can occur. But it is also important to practice interpersonal skills in the “real world.” If this is difficult – and your letter suggests so – then start with “baby steps” and work up. Also try to figure out what it is that is making you sad. This is a question that almost never gets asked, but is often quite helpful and revealing when pursued with self-honesty and determination. Are you feeling sad because of some problem/deficiency in your life? Or because the days are passing and you feel you’re getting old? Do you feel overwhelmed? Do you wish for something you don’t have? Etc… Life is so busy for most of us nowadays that often we don’t take the time for this kind of introspection. But it is important, and can provide clues to why we are feeling down. I hope you are pursuing these kinds of questions in your therapy sessions.

Anyway, thanks for a very insightful and pertinent question. If you’re doing well with your therapist, then stay with that person and use the sessions to the full. I hope things continue to improve for you. Don’t hesitate to get back if there’s something you don’t agree with or would like clarified.

Tereza: Thank you for such kind words! I apologize for the delay in responding. Nancy, my wife of forty years, fell and broke her thigh bone Monday of last week. She was in hospital for about a week. She is home now but very incapacitated, so I haven’t had a chance to blog.
Your comments concerning dogmatism are extremely relevant and compelling. Dogmatism confronts us in almost all areas of life and can be very destructive. You suggest that it might be an adaptive mechanism. I could agree with that up to a point. I think that dogmatism provides a measure of comfort in a world that can be fraught with uncertainty. In that sense I believe it could be described as adaptive. But it would be more adaptive (in the sense of useful) to accept that there is always a degree of uncertainty and unpredictability to life, and to develop coping strategies and networks of mutually supportive relationships to enable us to deal with life’s vicissitudes (like broken legs!) as they arise.
In my view the notion of mental illness is spurious for reasons discussed elsewhere in the blog. But once this spurious step had been accepted, the APA was free to invent “mental illnesses” pretty much at will. And, of course, the drug companies were able to develop the “treatments.” I suppose this bio-psychiatric system provides a measure of comfort to some individuals, but comfort bought at the expense of truth is illusory and usually short-lived.
I can find within me a measure of sympathy for psychiatrists. After all, their livelihoods are at stake, and economics makes cowards of us all. Most of them avidly support the official dogma. Occasionally – very occasionally – one encounters a psychiatrist with a conscience. I recall many years ago talking to one such individual. He said: “Someday this whole sand-castle is going to crumble, and we’ll have to find honest work.” Well, of course, that day hasn’t arrived! But the sand-castle is under serious attack. Robert Whitaker’s book Mad in America is selling well and creating a stir, and other writers are raising serious questions about the validity of the DSM system.
Anyway, thanks for your nice words, which were greatly appreciated, and for your very interesting thoughts and observations.

Tony: Thanks for your comment which raises several interesting issues. Yes, there is no scientific evidence to support the so-called chemical imbalance theory of depression. Valenstein’s credentials preclude the possibility of dismissing him as a crank. What the bio-psychiatric sector does with writers like Valenstein is simply ignore them. The pharmaceutical companies have hijacked medical research so that it supports their agenda, and they spend enormous sums of money in promoting their philosophy and practices. Valenstein becomes a voice in the wilderness. But lately there are other voices.

Joanna Moncrieff, herself a psychiatrist at University College London, has written a truly wonderful book: The Myth of the Chemical Cure (2009). She has this to say:

“My thesis in this book is that the disease-centred model of drug action has been adopted, and recently widely publicised, not because evidence for it is compelling, but because it helped promote the interests of certain powerful social groups, namely the psychiatric profession, the pharmaceutical industry, and the modern state. Therefore, I offer the following study as an example of the way in which vested interests and the political environment can distort knowledge, in this case successfully deluding most of society for over half a century.” (p 13)

And later in the same volume:

“The data surveyed in this book suggest that psychiatric drug treatment is currently administered on the basis of a huge collective myth; the myth that psychiatric drugs act by correcting the biological basis of psychiatric symptoms or diseases. We have seen that for the three main classes of drugs used in psychiatry there is no evidence to substantiate this view. Instead, the evidence suggests that these drugs induce characteristic abnormal states that can account for their so-called therapeutic effects. This book has been about how and why this myth of psychiatric drugs as ‘chemical cures’ was constructed and sustained.” (p. 237)

Robert Whitaker has two books in print on these topics: Mad in America (2002) and Anatomy of an Epidemic (2010).

You mention the question of suicide, and of course this is the bio-psychiatric contingent’s trump card. Nobody wants to have a suicide on their conscience, and the bio-psychiatric lobby has established the myth that anti-depressant drugs are the best way to prevent this – indeed the only way. Robert Whitaker devotes a good deal of attention to this question in Anatomy of an Epidemic, and it is clear that the efficacy of anti-depressant drugs in this regard is not as straight-forward as the pharmaceutical companies would have us believe. In fact, there are indications that some anti-depressant drugs increase the risk of suicide.

As a general principle, I refer to pharmaceutical products that are designed to alter mood and behavior as drugs. Medicines, in contrast, are for treating illness. Encouraging the use of the term “medication” to refer to their psychotropic products is just one of the ways that the bio-psychiatric lobby has developed and promoted their spurious philosophy.

You refer to the myth that “there has been no progress in psychiatry apart from the development of useful drugs.” This is indeed widely believed and actively promoted. In reality there had been some great developments by psychiatrists prior to the drug era. Eric Berne’s Games People Play (1964) was, and is, a classic analysis of human interaction. Harry Stack Sullivan, a psychiatrist who wrote extensively and with insight on human relations, is dismissed by modern psychiatrists as irrelevant. And so on.

The problem for psychiatrists is that the problems they purport to treat are not illnesses. But for turf protection reasons they have to pretend that they are illnesses. The inevitable shoe-horning of ordinary human problems into a medical mold creates an untenable level of tension. I once heard a psychiatrist remark that some day the bio-psychiatric edifice will come tumbling down and “we’ll all have to find honest work.” Well, of course, vast resources are being expended to shore it up. So we’ll see. The fundamental question is: what does one mean by the term “illness.” My definition is: something going wrong with the organism either from internal malfunction or from external attack. But the bio-psychiatric lobby will argue for a much more inclusive definition. In a reply (#2) in the comment section under another post I have discussed the problem with the APA’s definition of a mental disorder. Their definition can be paraphrased as: any problem of living. So, of course, they can expand their turf endlessly.

You are correct in drawing attention to the guidelines of the professional psychiatric bodies, or standards of care. And at present the standards of care in this area enshrine the spurious bio-psychiatric position.

And so it goes. Life’s problems are complex and will never succumb to simplistic explanations or solutions. Once again, thanks for your comment. I believe you are correct in not encouraging or discouraging individuals with regards to anti-depressants. In my experience, some people like to use drugs (street or pharmaceutical); others don’t. Some feel they derive benefit from these products. But there are always costs!

Derek: Thanks for an extremely insightful comment.

What you say about the need for sleep is true and very important. In future, when I talk about the natural anti-depressants, I will add “adequate and regular sleep.” I can remember from my clinical days working with young mothers, many of whom worked full-time jobs then came home and performed all the duties of traditional homemakers. These individuals often recounted how they would be doing laundry at 2a.m. and getting by on 4-5 hours of sleep a night. And of course, they would be depressed.

There are other factors in our culture that militate against adequate sleep, including: the Internet; multi-channel 24-hour TV; economic pressures requiring people to work two jobs; etc..

We need sleep because during the day the brain takes in far more data than it can properly store in long-to-medium term memory. In sleep the brain “closes down” various areas and severely limits incoming data so that it can review the data of the previous day and decide what needs to be retained and what can be safely discarded. When deprived of sleep – for whatever reason – the brain is working on permanent overload. This results in feelings of depression – which is nature’s way of telling us that something is wrong. There are various steps we can take to promote good sleep patterns – but perhaps that’s a subject for another post.

You mention that your doctor had led you to believe that depression is an illness, and of course in this you are not alone. Literally millions of Americans (and people elsewhere) have been told this same falsehood.

Your insight that depression is no more an illness than happiness is correct and noteworthy. They are both normal aspects of the human condition. Obviously we strive for more of the latter than the former, but bad things happen to all of us, and we need to deal with our feelings of loss and despondency rather than drugging them into oblivion.

Your description of anti-depressants as “slow-fuse narcotics” is accurate, and psychiatrists – and the mental health system generally – have degenerated into drug-pushers. There are two ways to get drugs in the US: the street corner or the doctor’s office.

But you can’t solve life’s problems by ingesting chemicals, whether it’s alcohol, cocaine, Valium, or Zoloft. You can numb yourself to the point where you don’t feel the pain so much – but the problem is still there when you “wake up.”

Once again, thanks for your insights and best wishes in your endeavors. A drug-free life can be more challenging – but infinitely more rewarding.

Samuel: Thanks for your comment and for the reference. The article in question, written by Richard Bentall, is tongue-in-cheek satire – along the lines of Jonathan Swift’s “A Modest Proposal.” Dr. Bentall is a vocal critic of the DSM system, and his book Madness Explained is a classic. His message in the article is essentially the same as Derek’s: if depression is an illness, why not happiness also?

The answer to this question, of course, is: The APA would make happiness an illness and the pharmaceutical companies would design an anti-happiness drug except for the fact that they probably couldn’t get away with it!

See also Dr. Bonkers’ diagnostic innovation: Asymptomatic Depression: Hidden Epidemic and Huge Untapped Market

Martin: Your secret is safe with me!

Poo,

Thanks for a very insightful comment.

The brain is a pattern-seeking organ. It looks for explanations. When we experience periods of depression, we look for reasons for this. We want (and indeed need) a frame of reference – a name by which we can call it. I call it an adaptive mechanism which encourages me to make changes. You call it: “a loss of focus…a pause for breath.”

I am struck by how similar these formulations are. The phrase “a pause for breath” suggests a period of reflectiveness – some critical self-appraisal – some re-grouping and perhaps some alteration in life-strategy or tactics. This strikes me as a very functional and effective way of conceptualizing bouts of despondency.

You mention that the idea of depression as an illness “sounded so ridiculous.” And of course it is. Our ancestors would have laughed out loud at the notion. But large sums of money can develop and promote even ridiculous ideas to the point where they are widely accepted. The bio-pharma-psychiatric bloc has become very adept in this area, not only with depression, but also with the behaviors labeled schizophrenia. (Please refer to my posts on schizophrenia.)

So, there it is. A brave new world. Your concept of depression – though out of step with the spurious bio-pharma-psychiatric model – strikes me as eminently sensible, and I encourage you to develop and promote it in your various activities.

Best wishes.

Ricky,

Thanks for your enquiry. Sorry for the delay in getting back to you. My Internet was down for a few days, and I had to have some medical work done, which slowed me down a little. Meanwhile, I think the comment from Susan makes a great deal of sense.

Because I don’t know you, it would not be proper for me to give you any direct advice or counseling. What I can do is offer some general thoughts and comments and let you draw your own conclusions.

There are three things that strike me immediately.

1. The fact that you wrote your enquiry in the first place suggests that you are genuinely trying to find a way through these difficulties. That in itself is positive.

2. The fact that you don’t appear to want to take psychotropic drugs. Again, this suggests an awareness of the downside of these products.

3. Thirdly, your recognition of the fact that your thoughts had become “crazy” indicates a good measure of critical self-scrutiny. Again, a positive.

Back in the days when I was a practicing psychologist, if someone had come to my office and described the problems you outline in your letter, I would initially have spent a good deal of time (probably about two hours) just trying to get a good picture of the problem. I would ask lots of questions. My initial area of interest would be the context in which the panic attacks occurred. What was going on generally in your life at the time as well as what was going on at the precise time of the attacks?

A panic attack is essentially an extreme anxiety reaction. Please read my post on anxiety.

A person experiencing anxiety attacks has three broad options:

1. Stay away from the anxiety-arousing situations.
2. Desensitize him/herself from the anxiety-arousing situation
3. Take anxiety-reducing drugs. These include alcohol and various pharmaceutical products. Also, most users of nicotine find it has an anxiety-reducing effect even though it is a stimulant.

Each option has its pros and cons. Number 1 is useful when the feared object/situation is relatively uncommon. For instance, if speaking in public stimulates an anxiety attack, then one could arrange one’s life so one never had to speak in public. Number 2 works well for some specific situations, but is difficult to implement when the anxiety is more general. For instance, if one experiences anxiety/panic attacks when confronted with snakes, it is relatively easy to arrange a program whereby one is gradually acclimated to the presence of the snake. For instance, start with a picture of a snake at the far side of the room – bring it closer gradually over a period of days. Eventually, as tolerated – a live snake in a cage at the far side of the room etc., etc.. The presence of a “trainer” who is not anxious about snakes is helpful. Number 2 is more difficult to implement if the anxiety-arousing stimulus is more general, e.g. crowded streets, riding in cars, the presence of members of the opposite sex, etc.. The principles, however, are the same.

Number 3 (chemical) works well enough but has obvious downsides. If one routinely uses alcohol to cope with anxiety, for instance, there is a very real likelihood that one will become alcoholic. All anxiety-reducing chemicals have adverse side effects.

So, Ricky, there it is. Think it over and take your pick. Also, it always helps to take a look at one’s life in general. Are you getting enough sleep? Is your diet adequate and varied? Do you have at least one good relationship – someone with whom you can be completely honest? Fresh air? Sunshine? Exercise? And are you routinely finding some sense of satisfaction and success in your activities?

Perhaps the most important single thing is to talk to someone that one trusts – someone reliable – who will listen and provide support. In the end of the day you must do as we all must do: harness your strengths and the help of others to overcome the problems you encounter in life. And you do have strengths!

Jocko,

Thank you for your rather forthright comment. It’s difficult to know how to respond. I think it’s safe to assume that you disagree with something I have written. Perhaps if you could come back, outlining the areas of disagreement, then I will respond to the best of my ability.

But I do ask that you drop the invective. There are a great many people within the mental health system who believe as I do – but they are effectively silenced by bullying and vituperative comments like yours. So come back by all means – but please keep it civil.

Lee,

Thanks for your comment. We can agree to differ concerning the medical status of severe depression and mania. But I’m delighted to hear that you plan to embrace the seven natural anti-depressants. I hope that this goes well for you. Please come back later to let us know how it’s going.

Best wishes.

Martin,

Thanks for your comment. I agree with what you say. Unfortunately the behaviorist model is extremely threatening to the industry, and to the individuals who take these drugs. The great tragedy in all of this is that the victims (i.e. the individuals who take the pills) always rally to the defense of the drug pushers, which of course is understandable.

So once again, thanks for your kind comments. I don’t enjoy being beaten up (even for a good cause), and your words of support are very welcome.

Best wishes.

Cathryn,

Thanks for such an open and honest comment. I’m glad you came back.

Because I don’t know you personally, it would not be proper for me to give you direct advice. But I can discuss some general topics in the areas you mention, and you can choose for yourself what actions you would like to take.

The seven natural anti-depressants don’t specifically mention avoiding alcohol abuse. But the concept is contained under Adequate Nutrition. You mention that you were drunk when you wrote the first comment. Now my purpose here is not to pass judgment on your drinking, but simply to point out that getting drunk is a poor nutritional practice. It constitutes a huge assault on the body’s systems and (because alcohol is a depressant drug) it leads directly to depression.

Now I don’t know how often you get drunk. Perhaps that was the only time or perhaps it’s a regular occurrence. The problem with alcohol is that it is very seductive and very destructive. You lashed out pretty aggressively at me while drunk. Do you do this to those who are close to you? Do you have anyone you feel close to?

You say: “I go from school to school from major to major from city to city, from haircut to hair dye constantly trying to change and fix my life so that depression and mood swings go away.” The tone of this statement is frantic – almost desperate. So let’s look at these issues.

A good many young people in college today will tell you that they don’t know what major to take or what career path to pursue. So if you ask these individuals what career specialism they want to pursue, they say “I don’t know,” and from a linguistic point of view, it appears that they have answered the question. Language has traps, however, and if you examine things closely, you will see that “I don’t know” is not an answer, but merely a deflection of the question. Contrast this with the question “What’s the mass of the planet Mercury?” To which a person might answer “I don’t know.” And this is a perfectly valid answer. It means: that particular piece of information is not within my repertoire. Questions about one’s career ambitions, however, although they look like ordinary questions, are nothing of the kind. The mass of Mercury is an objective established fact which a person either knows or doesn’t know. There is a reality out there called the mass of Mercury. But with career questions, there is no reality. Deciding what career to pursue is NOT a matter of figuring something out. There is no reality here that one tries to discover. Rather it is a decision – a decision which like all important decisions has to be made with incomplete information.

Now of course you can postpone that decision all you want, but there is a cost to this: tuition, board, books, fees, and, of course, time, which slips away relentlessly. So choosing a career is not a matter of figuring out the perfect option that’s going to be just right for me. Rather we make the best decision we can given the data to hand, and then we work at making it be the right decision.

Changing your hairstyle or color won’t drive depression away. These things may give you a temporary lift, but it’s not the answer.

“How is it I walk around loathing every minute of my day?”

This is a very compelling question. But Cathryn, you already know the answer. During my career I worked with perhaps hundreds of people who were depressed. And I always asked them: what are you so unhappy about? Almost invariably the response was: I don’t know. So I would point out that that wasn’t a valid answer (along the lines mentioned above). And we would talk around the issue until the specific sources of unhappiness were identified. The possibilities are endless: discord with parents; jealousy of a sibling; feeling devalued at work; marital discord; remorse over deeds done; remorse of deeds not done; etc., etc.. Now I don’t know what it is that has you so turned off by life. But the answer to this question is within you, and you can remediate it – but first you have to articulate it.

Competitive swimming. I have a couple of concerns in this area. Firstly, I believe that many competitive athletes are actually addicted to the activity. It ceases to be fun or healthy exercise or anything like that, and instead becomes a kind of desperate obsession to win. Secondly, in every race there are more losers than winners. The only way a person can succeed is by defeating others. There are other activities (e.g. a community mural project) where everybody wins. Here in America our school system has promoted the competitive ethos, and when it’s kept within reasonable bounds, it’s ok. But in so many cases today I see it becoming very ugly and very destructive. The drive to win becomes insatiable – one is constantly chasing a bigger prize – an Olympic gold – two Olympic golds, etc., etc..

Also, if you’re spending a lot of time in swimming pools, I would wonder about the effects of chlorine. It is a toxin. That’s why they use it – to kill germs. Here again, in moderation it probably does no harm, – but a lot of exposure might be having some harmful effects.

“Because I am hoping depression can be an illness.”

This seems very honest to me. If I want to believe that all Muslims are bad people or that all black people are criminals, then I can sift and sort evidence in support of these positions. But they are still not true. Wanting something to be true doesn’t make it so. The pharmaceutical companies have been trying to prove that depression is an illness for the past forty years – but without success. In my view, the most logical and consistent position is that depression is an adaptive mechanism which alerts us to the need for change.

So there it is – that’s the best I can tell you. If there’s anything further that you would like to discuss, please come back, and I’ll do what I can. Meanwhile, best wishes in all your endeavors.

Martin,

This is a very helpful suggestion.

Best wishes.

Tony,

Thanks for the comment. I’ve been a bit under the weather – hence the delay in responding.

Back in the late ‘80s, the US government passed some legislation called, I think, PASARR (an acronym, of course). Anyway, the idea was that people going into nursing homes had to be screened for “mental health” problems, and if problems were found, the home had to provide services. Well, of course, the vast majority of people going into nursing homes are going to manifest some measure of despondency. So it gets translated into “mental illness,” and off we go. Business boomed for psychiatrists and, of course, their pharmaceutical allies.

Then about ’95 or thereabouts, I became aware of the pressure to legitimize drugs for very young children. And that’s what this 0-3 is about. It masquerades as legitimate concern for this “underserved” population languishing pitiably from medical neglect. And before you know it, we have these very young children as drugged as their parents. The markets will expand until every niche is filled.

I did notice that 37% of the ad pages in that issue of Time magazine (7 of 19 pages) were from drug companies. Economics makes cowards of us all, including journalists and publishers.

Peace and good wishes.

tneveca,

Thanks for an interesting and thoughtful comment. Of course I disagree with most of what you say, but this makes it all the more interesting. I hope Cathryn has read your comment and is actively considering a variety of viewpoints.

The notion that borderline personality disorder isn’t just a label but rather a theory seems quite a reach. The term “descriptive paradigm” strikes me as self-contradictory, in that descriptions of phenomena are usually regarded as different from an explanatory theory. “Paradigm” is one of those words that has some flexibility in its meaning, in that it can mean an example or archetype but can also mean a theoretical framework. Now borderline personality disorder as specified in DSM could be considered a paradigm in the first sense, but certainly not in the second. What I think you are doing is introducing the word paradigm in the archetypal sense, but then drawing the unwarranted conclusion that it also applies in the explanatory theory sense (which it certainly does not).

The acid test for a valid explanation is that it advances our understanding. Regular readers of this blog will be familiar with my argument:

Client: Why am I so upset when people break up with me? Why can I not have a lasting relationship? Why do I mutilate myself?

Therapist: Because you have borderline personality disorder.

Client: How do you know I have borderline personality disorder?

Therapist: Because you get so upset when people break up with you; because you can not have lasting relationships; because you mutilate yourself.

The point of all this is that borderline personality disorder, like most of the so-called diagnoses in DSM, has no explanatory value. It is just a label. The only evidence for the “diagnosis” is the very behavior that it purports to explain.

Clearly you believe otherwise – but simple assertions don’t cut much ice if they are not backed by some kind of logical argument and evidence.

With regards to looking into the DSM’s checklist for borderline personality disorder and discovering oneself, let me present this brief quote from Ullman and Krasner (A Psychological Approach to Abnormal Behavior, Second Edition, 1975), p 218:

“There are statements that have no semantic validity, that is, that may be true of everybody or true of nobody and thus cannot be checked as differentiating. Such statements may seem penetrating and true… This occurs when a class is handed back individual personality analyses after taking a personality test. After each student has said how good the interpretation is, one student reads his or her evaluation aloud, and all find that they have been given the same write-up.”

The same thing occurs when a fortune-teller “reads” your palm and tells you that you have a rather unique sense of humor, that you have always tried to be strong in the face of adversity, and that you are sometimes misunderstood. These kinds of pronouncements are known as Barnum statements. Barnum statements are statements that elicit agreement either because they are overly flattering or, more usually, because they are so vague as to be almost devoid of content.

Let me tell you an anecdote. Many years ago I was associated with a mental health center which had a satellite office in a small town (population 2000). The satellite office hired a new therapist, and it became known that he had an interest in the so-called multiple personality disorder (now known as dissociative identity disorder). Within two months of being there, this therapist had “found” 18 cases of “multiple personality disorder” and had started two therapy groups for these people. Prior to his arrival, nobody had noticed this phenomenon!

The point is that if you look at individual people through the lens of a DSM checklist and “see” that the individual fits, this says more about your perception than it does about the individual. The richness and complexity of human existence is simply not reducible to the APA’s cookbook. The APA’s “diagnoses” were invented by its committees to legitimize the prescription of mood and behavior-altering drugs.

Now you say that the theory of depression is useful “regardless of its ontological status.” It sounds like you’re saying that the notion of depression is “useful” – even though it doesn’t exist. Like Santa Claus? I don’t understand this. I think depression is a useful concept if we mean a natural adaptive mechanism which alerts us to the fact that something is going wrong in our lives and encourages us to make changes. But if you mean the notion that depression is an illness, then I certainly don’t agree that it is useful, unless, of course, you’re selling anti-depressant drugs or writing prescriptions for these products, which, incidentally, have been shown time and again to be only very slightly better than placebos in altering people’s mood.

With regards to brain chemistry, it is obvious that there is a link between brain activity and depression. There is a link (literally) between brain activity and every action of the organism. This doesn’t establish the notion that depression is an illness, which is the essential issue in this blog.

You say that a psychiatrist is primarily concerned with the “health of the mind.” I would ask you to define the term mind. In my view “mind” is an archaic pre-scientific explanatory concept which has been superseded by advances in various life sciences. There are no minds; rather there are organisms that engage in various activities including higher level activities such as thinking, remembering, hoping, etc..

“Phil’s mistake is to argue that these factors constitute the true ontological context of depression, whereas the science of depression is merely ideological.” I have read this sentence several times, but I can’t discern what it is you are trying to say. Certainly, I emphasize the importance of environmental factors in studying and understanding behaviors. Are you seriously suggesting some alternative? Are you suggesting that environment doesn’t influence behavior? That seems extreme to me.

Finally you exhort Cathryn to trust her doctor. This strikes me as an extraordinary recommendation. (I’m assuming that you are not acquainted with the individual in question.) He may indeed be an extremely competent, helpful person, in which case your recommendation would have some merit. But for all you know, he may be incompetent. He may be a scoundrel. He may even be an incompetent scoundrel! Your advice rings more like a propaganda mantra than a recommendation based on sound judgment.

Anyway, there it is. I realize that this reply is lengthy, but the issues you raised are, I think, fundamental, and warrant a good measure of consideration. I hope you will come back and continue the debate.

Susan,

Thanks for a very engaging comment. It’s clear that you are giving these matters a great deal of thought. I don’t claim to have all the answers, but I’ll try to unravel some of these issues.

For me the notion that depression is an adaptive mechanism which prompts us to make some changes is self-evident. The example I like to give is that of sitting around idle on a rainy day, overeating and watching TV. Most people in this situation sooner or later become “bored.” What “bored” actually means in this context is depressed. Language is full of traps. Because the words “bored” and “depressed” are different, we assume that they should have different meanings. And indeed there are some slight differences in connotation. But if I were to ask you to write down a list of descriptors that you would associate with a bored person and a list that you would associate with a depressed person, my guess is that there would be a good deal of overlap. I would expect to see words like “inactive,” “listless,” “glum-faced,” “slumped posture,” “disinterested,” etc. in both lists.

The point here is that everybody knows the remedy for the condition we call boredom. The remedy is to get up off the couch and start doing something; get the raingear on and go for a walk, or go down to the basement and play table tennis, or get out to the garage and build something, or wash the dishes, etc., etc.. Well similar considerations apply to the condition we call depression – the seven natural anti-depressants. The feeling we call depression is a message from our own bodies prompting us to make some changes. It’s as if our bodies are saying to us: “This sitting around moping and inactive is no good; get up and get going!”

Now some people routinely respond to this message and do get up and get going. Other people don’t. The latter group tend to slip deeper and deeper into depression, and they begin to think of depression as their normal emotional state.

For most people the feeling that we call “boredom” first arises to a significant degree in adolescence. The fun and games of childhood are no longer interesting, but we haven’t yet entered the world of adult activities. So we get “bored.” The critical need here is for parents and other significant adults to coach the teenager to “get up and get going.” Now don’t misunderstand me – this is not easy. As is well known, teenagers aren’t always receptive to parental input.

But the point is this: the adolescent who gets up and gets going as a response to boredom learns one of the most important lessons of life – namely that getting up and getting going WORKS. If I do something and it has a positive outcome, then I am more likely to repeat the action next time I’m in the same situation. So a young person experiencing boredom who pulls himself together and gets up and gets going, not only dispels the depression he is feeling at the time, he also has begun to establish a habit – a habit that will stand him well in the future when feelings of boredom/depression arise. As they will!

The person who doesn’t get up and get going, on the other hand, often overeats in a futile attempt to beat the blues. And so the habit of overeating in the face of adversity is established.

Now the habit of getting up and getting going is better than the habit of not getting up and getting going. There’s no question about that. The question you are posing is: should the latter be considered an illness? Or perhaps: does there come a point where the latter becomes so severe as to warrant being called an illness? Or to put it differently, still: has the message aspect of depression been blunted or even extinguished through lack of use? And this is an excellent question. The answer hinges on one’s definition of illness. I take the position that illness means something going wrong with the organism. And I know of no convincing evidence that the individuals described above have an illness in this sense. Rather, in my view it’s a case of: nothing succeeds like success and nothing fails like failure. So the person who gets up and gets going gets better and better at beating the blues, while the person who doesn’t get up and get going gets worse. This leads to a situation where the depression gets deeper with the passage of time.

Another thing that needs to be kept in mind is that the organism is always doing something. So the person who doesn’t get up and get going instead does something else. The something else might be overeating (as in the example given earlier), but it might be sitting in the chair wearing a doleful expression. There’s a tendency to think of this latter as “doing nothing.” But this isn’t quite accurate. It is “sitting-in-the-chair-wearing-a-doleful-face.” If we conceptualize this as an activity and then ask some critical questions, then we begin to understand some of the dynamics of depression. The primary question of course is: what happened next. If significant others began to express concern, offer their help, bring tea/soup/meals, etc., then clearly the activity of sitting-in-the-chair-wearing-a-doleful-face is being reinforced. So the next time the individual feels a bout of the blues, the likelihood of him dealing with it in this way is increased.

People who for whatever reason feel somewhat unloved/neglected are particularly vulnerable in this regard. But what’s noteworthy is that the activities that we label depression are learned/acquired in accordance with the same principles underlying the acquisition of more functional behavior.

Also bear in mind that we live in a society in which multiple forces combine to keep us anxious and depressed.

The words mood, emotion, feeling, sentiment, etc., all mean essentially the same thing. When I was in college I learned that feeling meant the very general emotional states of pleasure versus displeasure, and that emotion referred to the more specific states such as anger, joy, depression, etc.. The DSM conceptualizes mood as a pervasive and sustained emotion while affect is behavior which expresses an emotion or feeling state. And so on. I think it’s important not to get bogged down in the semantics. The critical point is that the human organism has the ability to feel certain emotions. Or you could say: experience a range of moods. Or whatever.

And the ability to feel in this way is an adaptive mechanism, i.e. it is something that serves the organism’s interest as set out above.

You are correct of course in saying that there is no difference between sadness and depression. When someone says: “It’s more than sadness,” what they are doing is defending their status quo. The behavioral translation is: “You don’t understand. Your efforts to help me will be to no avail. Go away!”

Your final sentence is on the money. If emotion is an adaptive mechanism, then like all mechanisms in the organism it could, conceivably, malfunction. I have very little knowledge of physiology, neuropsychology, etc., so I don’t know how often this might happen. I suspect it would be very rare, and that the vast majority of depressive behavior is learned/acquired as outlined earlier.

Once again, thanks for your comment – great questions that took us right to the heart of the issues! Feel free to come back.

Cathryn,

Thanks for your comment/query. I’m glad that you responded to tneveca. I think this kind of dialogue is always helpful – even though I personally disagree with most of what he/she says.

With regards to what this website is saying, it’s this:

• At the end of the day, every “diagnosis” in DSM is essentially a checklist of counter-productive behaviors.

• A great deal of genuine knowledge and insight has been gained concerning how various behaviors become habitual.

• Both productive and counter-productive habits are acquired in the same way – i.e. in accordance with the same fundamental principles of learning.

• If you want to understand something, you must study it, and if you’re lucky enough or smart enough or industrious enough, you may discover patterns/regularities. Finding these patterns/explanations is the stuff of science. Fortunately for the rest of us, some very clever people have made incredible discoveries in almost all sciences over the past 150 years – including the science of behavior. If you want to explain/understand behavior, then behavior is what you must study. The APA’s cookbook, which they put forward as an explanation of counter-productive behavior, is not an explanation at all. It is simply an assortment of labels, with no explanatory value.

• What I have tried to do in the various posts in this blog is to take the DSM’s behavioral checklist items one by one and show that it makes much more sense to think of these as problems of living (counter-productive habits) rather than illnesses.

• In my view the reason the APA has invented these so-called diagnoses is to legitimize the sale of mood and behavior-altering drugs.

• Almost all mood and behavior-altering drugs have significant adverse side effects, especially if they are ingested over long periods and/or in large quantities.

• I never tell people not to take drugs or to stop taking drugs. If people ask my advice on this matter, I simply go through the pros and cons and tell them they have to make their own decision. I pass no judgment either way.

• Morality is a highly individualized issue. In my view the only immoral acts are those that involve hurting other people or hurting animals. Whether or not to take drugs is not, in my view, a moral issue.

With regards to pharmaceutical products not working any better than placebos, this, to the best of my knowledge, applies only to anti-depressants. The major tranquilizers are extremely effective at suppressing behavior.

The pharmaceutical companies and the psychiatrists no longer call major tranquilizers by this name, because the widespread tranquilizing of clients, especially in the mental hospitals, attracted a good deal of negative attention. For a while they called them neuroleptics, implying that they somehow grabbed the nervous system. Then that name faded. And now they’re called anti-psychotics – implying that they somehow target only crazy behavior, which is simply false. They impact a wide range of behaviors.

Anyway, I gather you’ve been taking Saphris (asenapine) for four months and that your life is going better. What else is there to say? My only suggestion is to go to PubMed and download the pharmaceutical sheet on asenapine, and become an informed consumer. In particular go to the section on serious side effects. The sixth one down is:

“uncontrollable movements of the arms, legs, face, tongue or lips.”

Now the way the document is presented makes it seem like this side effect is just a possibility. In fact, the incidence of this condition, which is known as tardive dyskinesia, is quite high and increases with dose and duration. (Look this up – be an informed consumer!)

When the “new” major tranquilizers started to appear (in the late ‘80’s, I think), it was widely claimed that they didn’t cause tardive dyskinesia. But the pharmaceutical companies retreated from this position as the evidence accumulated.

Psychiatrists sometimes tell their clients not to worry, that they will stop the major tranquilizer at the first sign of tardive dyskinesia. But by then a good deal of brain damage has already been done, coupled with the fact that when a person has been using a drug to help him/her cope for an extended period, stopping isn’t always trouble-free.

No one can tell you how long you would have to be taking asenapine before you would have tardive dyskinesia, for which, incidentally, there is no cure. The damage, which is extraordinarily disfiguring, is permanent. The critical factors are dose and duration.

I imagine that all this feels like I’m pushing you to stop taking the drug. But this is not the case. Every human activity involves risk. I’m simply encouraging you to know the risks. I’m sure your psychiatrist has been through all this with you already.

Cathryn, with regards to the “trust your doctor matter,” I wasn’t saying that your doctor is an incompetent scoundrel. What I was doing was taking tneveca to task for saying “trust your doctor” even though he/she, presumably, knew nothing about him. This just sounded to me more like propaganda than thoughtful advice. Anyway, it sounds like your doctor is very helpful to you, and what more needs to be said?

My general concern about psychiatrists is that they frequently tell their clients that human problems such as depression, anxiety, “craziness,” etc. are illnesses (which they aren’t) and that the drugs which they prescribe are medications “just like insulin” (which they aren’t). Other than that, I can readily accept that most of them are fine fellows.

One final point. When a psychiatrist sees a new client, his first session is devoted to putting the client in the correct pigeonhole (“diagnosis”) and prescribing a drug. There is very little concern with precise problem definition. (I realize that your psychiatrist did this very differently.)

For a behaviorist, on the other hand, precise problem definition is essential, and typically at least a week will be spent in data-gathering and problem definition.

As an example of what I’m talking about, consider the statement in your first paragraph: “…I do go crazy sometimes…” If you said that to a psychiatrist in session one, he would start thinking about one of the psychotic “diagnoses,” and would ask a few more questions in that area.

If you said this to a behaviorist, he would want to know precisely what you had done and with what frequency and over what length of time. He would work with you to define “crazy,” and would give you a notebook in which to record and describe every incident of this sort over a one, two, three week period. Next session he would review the notebook with you, constantly asking for more detail. Essentially he wants to know

• what you did (exactly)

• when you did it

• what was the context

• what happened after each episode

• etc., etc., etc..

Now the behaviorist position is that if you are doing “crazy” things, it’s because there’s some kind of payoff. But usually it’s quite difficult to tease out exactly what this is.

There has been, and continues to be, a great deal of debate as to which approach is better. And these debates will continue, though the bio-psychiatric-pharma propaganda has, for now, virtually eclipsed all opposition. In the end of the day, however, it is for each person to choose how to live his/her life, and to identify what kind of help they might or might not need.

I hope things continue to go well for you. Feel free to come back if there are other questions/concerns.

mdkw tod,

Thank you for your interesting and contentious comment and questions.

Yes, I think you have missed something! Your comment came in under the depression post, and perhaps you have not read any of the other posts. It appears from your comment that you have an interest in, and are knowledgeable about, this area, and I think it would probably be helpful if you browsed around some of the other posts to get a sense of the issues that are being raised. There is a great deal of muddled thinking in this field, and it is easy to get into arguments over matters that are purely semantic.

The central theme of this blog is that there are no mental illnesses. Mind and mental illness are pre-scientific explanatory concepts. What I mean is this. For most of what is called civilized history, people have wondered and speculated on a wide range of topics. Over centuries they began to accumulate some genuine knowledge and understanding of phenomena, but other matters they found completely baffling. The activity of thinking and knowing, in particular, had them puzzled, and they invented the word “mind.” So if asked: “how is it that man can think?” the reply was: “because he has a mind.” Now if the matter were pressed by asking: “how do you know he has a mind?” the only possible answer was: “because he is able to think.” In other words, man can think because he has a mind. But the only evidence for this mind is the fact that he can think. The concept of mind adds nothing to our understanding. Nevertheless the notion persisted for thousands of years.

Language is full of traps, and because the notion of mind looked – from a linguistic point of view – like an explanation, it was accepted widely as such, even by individuals who otherwise were very brilliant.

In recent times there have been two developments that have helped debunk the concept of mind. Firstly, the rise of behaviorism in the early twentieth century. The methodology here was to study behavior directly and to seek genuine explanatory (i.e. cause and effect) patterns. This endeavor was remarkably successful, and by mid-century a great deal of insightful and useful information had been accumulated.

The second major development was in the area of computers. It is difficult for modern humans to appreciate just how baffled our ancestors were about the entire business of knowing/thinking. If you visit a house, for instance, it can be said that you know the house. You could draw a rough sketch of it. You could certainly sketch from memory a house you know well. The ancients couldn’t understand how the house could – somehow, some way – be inside you. Today, of course, every school boy and girl is familiar with uploading and downloading information, and with the notion that pictures and even sounds can be put into a computer and retrieved later. There is also a good understanding that the brain (which to the ancients had simply seemed like a mass of grey matter) is in fact an extraordinarily sophisticated computer.

So to get back to the question why is it that man can think, we know that it’s because he has a brain – a computer. A computer of bewildering complexity. So the concept of mind should have been consigned to the rubbish dump by now. And indeed it has in genuinely scientific circles. It remains, however, in two contexts. It remains in general speech in such phrases as: “I’ve changed my mind; what’s on your mind,” etc.. But it also remains in the APA’s DSM, where it is wrapped up in the notion of mental disorder/illness.

The central contention of this blog is that the checklist items of the APA’s “diagnoses” are counter-productive behaviors and that these counter-productive behaviors are acquired in accordance with the same general principles as productive behaviors. And that these counter-productive behaviors can be unlearned in accordance with the same principles. This is not, I hasten to add, original thinking on my part. The theme was developed extensively by several authorities, notably Ullmann and Krasner (A Psychological Approach to Abnormal Behavior, Second Edition, 1975).

Some more history. About 200 years ago there began to be some concern in official circles about people who were considered crazy or mad. Thinking was very muddled, and the group in question almost certainly contained individuals we would today call retarded. The notion that these individuals were somehow possessed (which had been popular in the middle ages) began to give way to the notion that they were sick – mentally sick. Just as the body could get sick, it was argued, so could the mind. And as the 1800’s progressed, various attempts were made to provide “treatment” for these “mentally ill” people. Unfortunately the treatment almost always consisted of involuntary confinement, sometimes in poor conditions.

A great deal more could be written on this area, but the point I wish to make is this: that the notion of mental illness (although spurious and invalid) gained enormous ground with the building of the asylums, and continues to bedevil our efforts to understand and help ameliorate counter-productive behavior.

Fast forward to the present day APA and their so-called diagnostic manual. The APA defines a mental disorder (illness) as, essentially, any significant problem of human existence. So is depression a mental illness? Of course it is, but the assertion is contained in their definition and therefore is devoid of content. Similarly is childhood misbehavior a mental illness? Of course. And so on through the entire manual. What I try to do in my posts is examine the “diagnostic” checklists and show that the items can be better conceptualized as ordinary day-to-day behavioral problems that people have acquired (in accordance with the scientifically validated principles of behavior mentioned earlier) than as symptoms of an illness.

Now you ask for proof. And this is always a good idea. But in science the burden of proof lies with the individual who is making the more extreme claim. My position is that unusual, disturbing, or counter-productive behavior is learned in accordance with the same general principles as so-called ordinary behavior – not an extreme claim, and one for which there is an abundance of compelling evidence. The APA’s position, on the other hand, is that these (counter-productive) behaviors are symptoms of an illness! An extreme claim indeed. They dodge the issue conceptually through the all-inclusive definition of mental illness discussed earlier.

As an example, consider item 2(b) in ADHD: “often leaves seat in classroom…” For the APA this is a symptom of a mental illness simply because it is a problem! There’s no question of proving this proposition; it is simply contained within their definition for which no proof is possible. Fifty years ago the notion that this misbehavior should be considered a symptom of an illness would have been considered ludicrous. Today it is widely accepted. But the linguistic sleight of hand that the APA has used to achieve this is seldom articulated or noticed. One of my purposes in writing this blog is to draw attention to this.

In more recent decades the notion that the so-called mental illnesses were really brain illnesses began to gain ground and is today widely accepted. Essentially all of these theories assert that some form of brain malfunction (“chemical imbalance” is the currently popular term) underlies and causes these counter-productive/disturbing behaviors. I must acknowledge that I have little expertise in the area of neurophysiology. So I look to others. Unfortunately a great deal (perhaps most) of what’s written in this field today is tainted by pharmaceutical dollars, but it is possible to find unbiased voices. For instance, Elliot Valenstein, Professor Emeritus of Psychology and Neuroscience at the University of Michigan, reviews in detail the various neurological theories of mental illness and concludes:

“Through critical examination of the facts, it will be seen that …. the evidence does not support any of the biochemical theories of mental illness.” (Blaming the Brain, 1998, p 96)

I thoroughly recommend Valensteins’s book to anyone who has an interest in these matters. There are multiple references in this book where various aspects of the matter can be pursued in great detail.

So why is it that very few people have heard of Valenstein, but almost everybody “knows” that depression is caused by aberrant brain chemistry? I don’t think the man in the street is reading the neurology journals. Rather, I believe that this false belief is the result of a truly enormous propaganda campaign on the part of the pharmaceutical companies, aided by the psychiatrists.

Which brings us to the notion of conspiracy which you mention. The word “conspiracy” has been endowed with connotations of ridiculousness in recent decades. This process was fuelled by a number of conspiracy theories that did indeed seem outlandish. But the fact still remains that people do conspire. With regards to the present issues, I think it would be accurate to say that between the 1950’s and the present, the APA has conspired to expand the notion of mental illness (spurious though it is) with the view to increasing their business. This is not a far-fetched “conspiracy theory,” but simply an honest statement of fact. Similarly I believe there is no doubt that the pharmaceutical companies have conspired to distort medical research and medical practice in ways favorable to their own interests. I have touched on these matters in more detail elsewhere.

With specific regard to depression, I believe that this feeling not only is not an illness, but is actually an adaptive mechanism which prompts us to make some changes in our lives: prompts us in helpful, positive ways. So just as hunger prompts us to seek food, the emotion we call depression/sadness/the blues etc., prompts us to do something different. This is a notion I developed myself, and I would be happy to expand on it if you would like more information.

So there it is. I sincerely hope that you will browse around and come back. I believe very much in the importance of dialogue and discussion. It was difficult not to detect a measure of anger in your comment, which causes me to wonder if you have a particular interest in these matters. If so, I encourage you to declare this when (if) you come back. An appreciation of context, in my view, helps us understand one another’s points of view. I encourage openness on this blog – but also civility and dignity. If you come back, as I hope you will, perhaps you could go easy on the angst.

Best wishes.

tneveca,

Thanks for your two recent comments. I’m sorry if I missed the points you were making. I thought that I was addressing the issues you raised, but these are complex issues and I sometimes ramble.

I think we differ in a number of areas, but perhaps the “illness” aspect of depression is the main point of contention. You say that depression is a “real illness” with “a biological basis.” I say that depression is a normal part of human existence; that it is an adaptive mechanism that prompts us to pursue activities and interests favorable to the organism’s well-being, and that it is not an illness in any conventional sense of the term.

In my experience arguments in support of the illness position fall into two categories. Firstly, it is argued, people who are depressed can be shown to differ from the general population in certain physio-biochemical ways. And this proves that depression is an illness. The precise nature of the physio-biochemical marker has varied over the past few decades. There was the biogenic amine theory in the 50’s. This gave way to the catecholamine theory in the 60’s. Levels of serotonin, norepinephrine, monoamine oxidase, and other chemicals have at different times been proposed as having a direct causal link to depression.

My response to this set of arguments is as follows. Firstly, depression is an imprecise term. We use the term in ordinary speech, and I certainly use it in my writings, but for truly scientific work it is hopelessly imprecise. If you examine the APA’s criteria for a depressive episode you will find the following:

“…decrease or increase in appetite…”

“….insomnia or hypersomnia…”

“… psychomotor agitation or retardation…”

This is why, when I write of depression, I often use an expression like: “depression, the blues, feeling down, etc,” in an attempt to convey the fact that the individuals we are describing are not a homogeneous group.

But setting this issue aside, I think the illness argument could be summarized as follows: people who are depressed can be shown to have some abnormal bio-chemical feature. (Abnormal in this context meaning significantly higher or lower than the population mean). Therefore depression is an illness.

Now I challenge the premise and the conclusion. I know of no study that demonstrates that all depressed people (however you define this group) meet some biochemical abnormality criterion. Interestingly in this regard, I have never heard of anyone trying to “diagnose” depression with a biochemical test, which you would expect if the above premise were true.

But more importantly, even if depression were a single phenomenon, and even if this phenomenon were 100% associated with a biochemical marker, this would not establish the finding that depression is an illness. Let’s take an analogy. Consider the activity of bike racing. If you were to conduct a range of biochemical tests on bike racers just after a race, I am certain that you would find that they differ from the norm in a range of areas and that in some areas these differences will be truly enormous. Should we consider bike racing an illness? Of course not. Similarly, I would guess that individuals hiking serenely through flower-speckled mountain valleys might differ in predictable biochemical ways from the population average. But we wouldn’t say they were sick.

So the presence of a biochemical marker to a greater or lesser degree than the general population has no bearing on the claim that depression is an illness. It is just as conceivable – and in my view more plausible – that depressive activity generates within the body certain physical or biochemical conditions, as does bike racing, sleeping, eating food, watching movies, running away from bulls, etc.. What the illness theory lacks is clear evidence that a certain biochemical marker is also pathological.

The second set of arguments in support of the “illness theory” goes something like this: antidepressants are effective in alleviating depression; therefore depression must be an illness. Once again, I reject the premise. Anti-depressants don’t work anywhere near as well as claimed. They are very marginally better than placebos, and the difference is so slight as to be unnoticeable in most cases. I also reject the conclusion. Another analogy: bashfulness is often alleviated by a couple of alcoholic drinks. Would we therefore conclude that bashfulness is an illness and alcohol a “medication?” Tiredness is alleviated by caffeine. Should tiredness be considered an illness? Of course not.

Now you introduce the term “clinical depression,” and I think this is interesting. The term is not used in DSM, and it is difficult to find a clear definition. In fact, it embodies a linguistic trap – it contains within itself the notion that depression is a medial condition (i.e. an illness) without ever having to prove that this is so. During the Korean War it was popular in the western press to use the term “hordes” when referring to Chinese soldiers. The word has connotations of wildness and savagery without actually saying so. Of course propaganda is common in times of war, but has no place in these kinds of discussions. The use of the term “clinical” in my view is akin to propaganda, i.e. promoting an unproven or false idea in a subtle or subterfuge way.

In my view there are many forms of depression, triggered by a wide array of causes, and manifested in an almost infinite variety of ways. These range in severity from a mild case of “the blues” to devastating despondency. But there is no such thing as “clinical depression.” The “clinical” modifier has no content and has merely propaganda connotations, i.e. it promotes the notion that depression is an illness without ever saying so directly.

You mention the common cold. But I don’t think your analogy holds up. When we contract a cold, a virus invades the organism through the airways, finds a temperature-appropriate niche in the throat, and starts to colonize. We experience this as soreness and the body’s immune system attacks the virus colony. We experience the immune system’s response as a fever, runny nose, etc.. This is a real illness; i.e. something going wrong with the organism. The organism is under attack by an invading parasite, is incurring damage, and has mobilized its defenses. The fact that the cold might have been avoided with more sleep and better nutrition is immaterial. The cold is a real illness. The virus colony at the back of the throat is real. I know of no counterpart for the condition(s) that we call depression.

Similar considerations apply to your example of heart disease.

With regards to the question of whether or not people should take the mood/behavior altering pills, I make no judgment. These are individual decisions, and the only input I offer is: be an informed consumer; check the side effects. What I object to is the promotion of the false notion that these products are medications “just like insulin,” and that they treat illnesses “just like diabetes.” I think this is an untenable position, widely promoted to serve the financial interests of the psychiatrists and the pharmaceutical companies. I think that the medical profession has prostituted itself in promoting these products and that psychiatry has degenerated to the point where it does little more than sell prescription slips. I discuss the matter of pharmaceutical products and drugs generally in other posts, and you might be interested in taking a look.

Your final point about suicide is important and is often mentioned in these contexts.

My position on suicide is that it embraces a wide range of circumstances. Because it is a single word, the impression is given that it is a single phenomenon and that it is always the result of depression. In fact, in most circles it is considered the extreme end of the depression scale.

In my experience suicidal activity is a more diverse phenomenon. Some people who engage in suicidal activity are not depressed at all. Rather it is a dysfunctional method of communication: “Now will you listen to me!” Often the suicidal behavior is reinforced by the solicitous concern of loved ones and is repeated frequently – sometimes with fatal results. A slightly different form of suicidal activity can be conceptualized as: “I’m lonely, will somebody please talk to me, comfort me, console me.” The outcome is often the same as the above.

Some people take their own lives from a sense of shame/disgrace. Perhaps some misdeeds have come to light, and they jump from the window without any real sense of depression involved – unless you expand the notion of depression to include shame – a legitimate expansion perhaps, but adding to the heterogeneity of the concept.

And then there are individuals who have suffered a major loss and conclude that life is no longer worth living.

Now I would certainly concede that there are elements of negative feelings in all of these presentations, but I think it’s misleading to assume that depression is the dominant issue in every case.

On the question of whether or not these individuals should take pills – I have no position. Taking or not taking pharmaceutical products is an individual decision. I don’t promote these products and I don’t try to dissuade people. I’m quite sure they are not as helpful as is touted, but you could say the same about many products that we all buy and use in our daily lives. It is sometimes suggested that anti-depressants should be used as a temporary measure pending appropriate psycho-social interventions. In my experience it seldom works that way. The pills become long-term, even permanent, and the life-style issues are not addressed.

Once again, thanks for coming back. I hope that this time I have addressed your issues. If not, please come back. Debate and discussion are critical in these matters.

Martin,

Thanks for your reply to tneveca. I particularly appreciate the point about experimenting on human subjects without informed consent!

tneveca,

Thanks for coming back and for your interesting question. The condition known as bipolar disorder is widely believed to be a physical illness. Even individuals who are skeptical with regards to the ontological status of the other so-called diagnoses will sometimes accept the notion that bipolar disorder is indeed a physical illness.

But I disagree. The individuals identified and embraced by the APA’s bipolar criteria are not a homogeneous group, i.e. the various criterion behaviors do not cluster or cohere to the degree that the term “bipolar” would suggest. In my view it makes more sense to examine each item on the manic and hypomanic episode checklists individually, and when I do that I conclude that each checklist item is better conceptualized as a counterproductive habit than as a symptom of an illness. Excessive talkativeness, irresponsible spending, grandiosity, etc., can all be considered habits, and are more explicable and understandable from a behaviorist perspective than as symptoms of an illness.

I discuss these matters in more detail in my post on bipolar disorder.

Once again, thanks for your interest and best wishes.

Sam,

Thanks for your responses to tneveca. I have also posted a reply to his April 27 comment (above). I agree that these are complicated issues. There are many reasons why people resist behaviorism, one of which is that it represents a radically different way of conceptualizing our lives and our relationships. Keep up the good work.

tneveca,

There was no subterfuge. A cold is caused by a germ, but – and this is the critical point – the germ starts to inflict damage on the tissues at the back of the throat. If you have a cold and look down your throat, you see the damage. If you die because of heart disease and an autopsy is required, the pathologist will examine your heart and will see the damage. But if a person dies while carrying a “diagnosis” of depression and an autopsy is done, no pathology corresponding to depression will be found in the brain.

You stress the point that dysfunctional behavior (smoking and drinking) can cause real illness (heart disease). Then you argue that dysfunctional behavior can bring on depression. Therefore, you seem to be saying depression is a real illness. But I suggest your logic is flawed.

A causes B
A also causes C
Therefore B and C must be essentially the same thing.

Take an example. The sun causes skin cancer, which is an illness. The sun also causes the pupils to contract. Therefore papillary contraction must also be an illness.

With regards to PTSD, I am familiar with the argument that exposure to highly stressful events causes changes in the brain, and that therefore this should be considered a real illness. But every experience causes changes in the brain. If you watch a movie, something is changed in your brain, but we wouldn’t consider the change pathological. But you are ready to jump to the conclusion that brain changes that result from exposure to stressful events are pathological. If this is so, then convince me. Show me clear evidence that the changes in the brain following stressful events are pathological changes, i.e. changes that clearly involve damage or malfunction. My position on this matter is simply that painful memories are painful and very painful memories are very painful. That’s how memory works. And it is because the memory is working properly that very painful memories are indeed very painful. If the memories were not particularly painful, then that would cause me to wonder if indeed something had been damaged! I discuss the so-called diagnosis of PTSD in more detail elsewhere.

With regards to depression, I agree with you entirely that if a person ignores or doesn’t act on the early prompts to get up and get going, then the depression deepens, and a point can be reached where a person needs some outside assistance to get out of the black hole (as you put it). My point is that this doesn’t make it an illness.

To clarify one point. I’m not saying that depression is not a mental illness. I’m saying that there are no mental illnesses. My point is that the whole concept of mental illness is spurious, and as a way of conceptualizing human problems it is unhelpful and even harmful. The concept of mental illness is promoted by people with a vested interest for their own gain (to sell prescription slips and drugs). The APA defines mental illness, essentially, as any significant human problem, and then they play fast and loose with the idea that those problems are also physical illnesses. So which is it? If you accept the APA’s definition, then virtually any dysfunctional behavior will attract a diagnosis. Habitual criminality and deception, for instance, are grounds for diagnoses of conduct disorder and possibly anti-social personality disorder. Should they also be considered brain illnesses? There is as much evidence for this as there is for considering depression a brain illness.

You make a good point when you say that as depression deepens it no longer seems to prompt people to make changes – or at any rate they don’t seem to respond to these prompts to any significant degree. And this is a real issue. I discussed this matter at some length in a reply to Susan dated April 18, 2011 in my post on depression (comment # 22). Perhaps you would have a look at this and come back if you would like to discuss. Also please take a look at Cathryn’s comment of April 18, 2011 on the depression post (comment #23) which in my view provides an excellent description of how depressive behavior can become habitual.

I have never to my knowledge trivialized depression or any human problem. You seem to allow only two alternatives – either depression is an illness, or it is being trivialized. There are other options. You seem to be saying that severe depression is a fundamentally different phenomenon from “ordinary” depression. I’m certainly not aware of any evidence to support this position. But even if this were true, the APA’s own criteria do not require that the depression be particularly profound. For major depression the wording is “…depressed mood most of the day, nearly every day…” and for dysthymic disorder “…depressed mood for most of the day, for more days than not…”

I notice that in his reply to you dated April 29, 2011, Martin stresses the role of poverty in precipitating and aggravating human problems. I certainly support this position, and would add that exploitation of any kind can be distressing and depressing. In this context, one of my major objections to the DSM is that it promotes the notion that the problem lies within the person, rather than resulting from interplay between the person and his/her environment. In fact, the phrase “…occurs in an individual…” is included in the APA’s definition of a mental disorder. And this is no accident of phraseology. In the first DSM the word “reaction” was included in each diagnosis. Depressive reaction, psychotic reaction, etc.. The idea was to acknowledge that the counter-productive behavior being addressed was a response to adverse circumstances. But this simple, far-reaching word was systematically expunged from DSM II and from subsequent revisions. In my view this was an extremely stigmatizing move that diverted the mental health system away from the real issues and into the lucrative business of selling behavior and mood-altering drugs.

Finally, let’s stay on the issues and avoid personal attacks. Grief and loss depression and despondency touch us all at some point or another. It is unwarranted of you to challenge my viewpoints by assuming that I have no personal knowledge of the topics at hand.

Once again, thanks for coming back (times 4). I genuinely appreciate your challenges, as it is in these kinds of discussions that our ideas are developed and improved.

tneveca,

I will respond to the points you make in your comment of April 30 in the order of presentation.

“What difference does it really make whether you call depression an illness?”

1. It’s an inaccurate statement.
2. It leads to a diversion of healthcare dollars away from real illnesses.
3. It promotes a system in which people who are depressed do not receive the help they need, but instead are sold pills.

“ ‘The concept of mental illness is promoted by people with a vested interest in their own gain,’ therefore there are no mental illnesses.”

I am astonished that you attribute the above assertion to me. My position is simple and I think easy to grasp.

1. There are no mental illnesses because there is no such thing as a mind to be sick or well or anything else. “Mind” is an archaic, pre-scientific concept which has no place in modern scientific disciplines. The behaviors generally embraced under the heading mental illnesses are better understood within the scientifically validated framework of behaviorism.
2. The concept of mental illness is indeed promoted by people with a vested interest in their own gain. But this has no bearing on the ontological validity of the concept nor have I ever stated or even implied otherwise. As much clarificatory material as I have written in response to your comments, I am at a loss to understand how you could have missed my point so completely.

“The real difference in our points of view is that I’m for and you’re against the use of prescription medication [for] psychological problems.”

I have no position on whether people take or don’t take drugs. What people ingest is a matter for them to decide for themselves. In my view, everything I wrote about street drugs in Drugs and Alcohol Parts 1, 2, and 3 applies equally to most, if not all, mood-altering pharmaceuticals. In other words, I believe that these products should be sold without the need for a medical prescription, but with the same safeguards in place that I suggest for street drugs. Mood-altering pharmaceuticals are not medicine and should not be treated as such.

“I would simply counter that maladaptive conditioning can cause pathological brain changes…”

1. Your use of the word “can” dilutes this statement of much of its content. Flying in airplanes can lead to sudden death. This is a true statement, even if it occurs only once in every ten million flights. But it doesn’t detract from the assertion that air travel is extremely safe. Similarly, the term “maladaptive” is vague. So that although I cannot readily think of a situation in which your assertion might apply, it (your assertion) is too open-ended for me to refute. Even if one were to concede this point, it raises a huge question which I have never seen addressed. Why are these problems not being treated by neurologists? After all, they are the specialty that treats illness/damage to the brain. Are we to believe that neurologists have simply ceded this territory to psychiatrists without a murmur? Or could it be that the neurologists realize that these conditions are not real illnesses?
2. It is indeed true that brain damage and brain illness can cause disturbing behavior, but this does not establish the contention that the same kind of disturbing behavior is necessarily the result of brain damage.
3. With specific regard to the behaviors referred to as PTSD, I believe it is more reasonable to conceptualize this as a normal fear response which has resisted extinction through lack of exposure – the fearful stimulus in this case being the memory of the distressing event. The fear response associated with painful memories usually extinguishes over time because the memories are not paired with actual danger as was the case with the initial exposure. This is why talking about these experiences helps. During the discussion, the memory is “awakened” and enters consciousness, and nothing fear-arousing actually happens (in reality). With repeated presentation of the fear-arousing stimulus (i.e. the painful memory) without the simultaneous occurrence of an adverse fear-arousing stimulus from the outside world, the fear response to the painful memory extinguishes in the normal way. Similar desensitization can be accomplished for a wide range of fear-arousing stimuli including snakes, spiders, heights, etc… Or to put the matter in ordinary language: exposing the painful memory to the “light of day” causes it to lose its ability to generate fear/terror.
4. But in the present context the critical point here is that the fear response was learned in accordance with the normal principles of learning, and subsequently the fear response was unlearned in accordance with the same general principles. There is no pathology – no illness. In particular I believe it is unsafe to assume neural pathology solely from the presence of fear-arousing memories.
5. Of course if the individual doesn’t talk about the painful experience, then opportunities for extinction are greatly reduced and the memory retains its ability to arouse fear. In the same way, people who fear snakes and who for that reason adamantly refuse to even look at snakes tend to retain the fear response indefinitely.

“May I venture (committing the genetic fallacy myself) that you are against psychiatric medicine because as a psychologist you can’t prescribe.”

1. Your attribution to me of this kind of self-serving factionism is ungrounded. I argue consistently against the medicalization of behavior problems primarily because they are not medical in nature, and secondarily because medical interventions are not especially helpful in these contexts. I have no vested interests in these matters. In fact, I argue against medical insurance dollars (including Medicare dollars) being used to pay for any kind of psycho-social intervention in purely behavioral problems.
2. If I were to come out of retirement such a position would not be in my own financial interests.
3. For the record, psychologists are authorized to prescribe mood-altering drugs in at least two states and in some departments of the military. I have consistently argued against psychologists entering this field.

Martin,

Excellent questions. The process by which the so-called mental illnesses morphed (I can think of no better word) into brain illnesses is truly remarkable. Pharmaceutical dollars of course was the driving force, but the history of this phenomenon cries out for further study, especially since the DSM specifically excludes a general medical condition as a criterion for a great many of the so-called diagnoses.

Best wishes

Follow-up.

Before he signed off, tneveca had sent us four links in response to my request for evidence that depression is caused by neural pathology. I had promised to come back with some comments on these. That was over a week ago. I’ve been a little under the weather, but I’m ok now, so here we are.

1. “A study of neurotransmitter activity using brain imaging.”

The link is to a magazine article in Science Daily. The article describes a brain imaging study conducted by Johnstone et al. The full article can be seen here.

I have two comments. Firstly, the study was funded by a pharmaceutical company (Wyeth-Ayerst). Given the revelations that have come to light in recent years, I am skeptical of any piece of research that was conducted under the auspices of a pharmaceutical company. Secondly, and more importantly, is that the study shows that depression is associated with activity in certain areas of the brain versus other areas for people who are not depressed. But nobody is disputing that depression is associated with specific kinds of brain activity. The difference between a person experiencing joy and a person experiencing depression is specific brain activity. But this does not establish the much more fundamental position that depression stems from neural pathology any more than it provides that joy stems from neural pathology.

2. “A call for a more radical neuroethics: The case of Pediatric Bipolar Disorder.”

This paper was written by scarestories on June 7, 2010 and can be viewed here. I can only assume that tneveca sent this link in error, because the paper is actually very critical of the use of fMRI technology, and does not address the question of neural pathology being the cause of depression.

Scarestories writes: “Children and parents now both become victim to the faith in medical technologies such as the fMRI and psychotropic drugs prescribed by physicians.”

Enough said.

3 and 4. These links revealed pictures of brain scans with enhanced color. There was no text.

With regards to the material at the beginning of tneveca’s comment (re: magnesium, zinc, potassium, etc.), I think Susan said about everything that needs to be said in her comment (#117) above.

Derek,

Welcome back. Yes, we’ve been busy. We had multiple comments from tneveca. He was very committed to the illness notion and he marshaled many good arguments, but between Cathryn, Susan, both Martins, Sam, and myself, I think we held our own.

Your point about the placebo effect is very cogent. I don’t think placebos would have much effect on diabetes or kidney failure. I hadn’t heard of the money study, but it sounds interesting. Of course, at the present time the Social Security Disability Administration pays people substantial sums of money for being depressed. What’s the likely outcome?

Best wishes.

Vichy,

Thanks for an interesting and far-reaching comment.

In so many ways we are better off then our ancestors of even 100 or 200 years ago. Technology and machinery have relieved us of back-breaking toil; labor protection laws have eliminated the worst aspects of exploitation; government pensions and medical services have eased the plight of the elderly; the Internet enables us to “socialize” endlessly without having to leave home; and pharmaceutical products promise an end to negative feelings. So this should be a utopia. Right?

But somehow there’s an almost Faustian aspect to all of this. The great gains that have been made have been bought at a price. And the price is what you describe as pressure. I’m certainly not advocating a return to the bad old days, but you are, in my view, absolutely correct in identifying this lack of pressure as playing a key role in the ennui/boredom/depression phenomenon.

Recently Susan, a regular contributor to this blog, mentioned a book by Stephen Ilardi – The Depression Cure. This is a very interesting work. Ilardi makes points similar to yours. He also mentions that the Kaluli tribe of Papua New Guinea experiences virtually no depression. And whilst I know very little about these people, one can readily imagine that they have fewer of the advantages we enjoy, and a great deal more pressure in the sense of things that need to be done.

About thirty years ago I lived in West Virginia and knew an elderly man named Mark. He always grew a large vegetable garden until he reached the age of 80. Then he gave it up. When I knew him he was about 85, and it was clear that he missed the gardening. He recounted to me one time that when he was a boy it was hard to get to the town to buy food, and it was pretty much true that if you didn’t grow your own food, then you didn’t get to eat very well.

And that sense of urgency didn’t just apply to food. People made their own clothes, shoes, vehicles, houses, sheds, etc… There was always something to do and serious consequences if things were not done.

Of course one can’t put the clock back. And I for one am grateful for the advances of modern society. I survive on dialysis – a process unknown before the 50’s. My wife, Nancy, had cataract surgery recently as an outpatient procedure!

The great challenge, however, is to live in the modern world, but still find and develop activities that bring a sense of meaning and purpose to our lives.

Your final point about people “languishing on the borderline and feeling terrible, but not required to do anything about it” has enormous implications for the so-called mental health system. The message that mental health practitioners give to depressed people is not “get up and get going,” but rather “you’re sick, take this pill – for the rest of your life.”

Thanks again for a very helpful and insightful comment. I encourage you to develop the idea further. How do we keep that sense of urgency alive in our daily lives? How do we find a sense of purpose after the children have moved on, after retirement? etc..

Best wishes.

Mary,

Thanks for your comment.

The anti-psychotics have a number of negative side effects. Perhaps the most obvious is tardive dyskinesia (TD). This involves involuntary sucking movements of the lips and jaws accompanied by more or less permanent tongue protrusion. This condition – which is caused by brain damage – is irreversible and was noted as early as 1954. In 1973, George Crane, a NIMH physician, concluded that TD appeared in 5% of patients taking anti-psychotics for one year, with the percentage increasing by a further 5% with each additional year of exposure. I’m not aware of any subsequent studies that substantially contradict these earlier findings.

Another side effect of anti-psychotics is neuroleptic malignant syndrome. This is a toxic reaction which usually develops within a few weeks of taking the drug. Incidence is around 1%. The condition is often fatal unless the symptoms are treated promptly and aggressively

When the second generation anti-psychotics began to appear (late 80’s, I think) it was claimed that they had fewer and less severe negative side effects than the older drugs, and there may be some truth to this. But the potential danger even with the newer drugs is still profound.

The best general reference for drug side effects is the Physician’s Desk Reference (PDR). It’s a daunting volume and expensive, but hospitals and doctors offices generally replace their copies each year, and if you know someone in the medical business, they might give you a discarded copy. Be aware, however, that if you have been prescribed anti-psychotic drugs and then ask for a copy of the PDR, this request may well be seen as evidence of paranoia!

There is a smaller (nurses’) version of the PDR which is available in paperback and lists the negative side effects of almost all drugs on the market.

Finally a note about terminology. When these drugs first appeared in the 50’s, they were called major tranquilizers because they reduced all bodily activity, and in high enough doses produced an almost zombie-like state. In the late 50’s the term neuroleptics began to be used. This word implies that the drug grabs hold of the nervous system and so acts as a restraint on the individual’s activity. Finally the term anti-psychotic came into use (I’m not sure when), implying that the drugs somehow targeted only crazy, out-of-control behavior, which simply isn’t true. The use of the term anti-psychotic is essentially a marketing ploy – an attempt by the pharmaceutical companies to shift attention away from the chemical straitjacket aspect of these products. My personal preference is to call these drugs what they are: major tranquilizers.

An excellent book to read in this area is Robert Whitaker’s Mad in America.

Once again, thanks for your comment, and best wishes.

Cathryn,

Thanks for coming back. I’m never sure what people mean by “genetic engineering.” It seems almost like asking: would I be a better person if I had been born of different parents? But of course then I wouldn’t be me – but somebody different. So the question becomes: would the world be a better place if somebody else – instead of me – had been born? And these sorts of questions are too imponderable.

The medicalization of problems of living is fraught with perils. In this blog I tend to focus on the psychological and social consequences of this spurious thinking, but it is also important to recognize that the eugenics movement sprang directly from this kind of nonsense, and vestiges of eugenics are still encountered occasionally even today.

Thanks again for your comment.

Susan,

Thanks for a very interesting comment. We neglect history at our peril.

In general I agree with what you say about nutritional deficits and illness. As societies become more affluent, nutritional standards paradoxically seem to deteriorate for many individuals. This often leads to obesity, diabetes (type 2) and other illnesses.

I think that psychology (the science of behavior) should be more involved in this field. The question is: what can be done to encourage people to eat more wholesome foods and less of the so-called junk foods? I don’t know the answer. Does anybody have any ideas?

Once again, thanks for a very thoughtful comment.

Vichy,

Thanks for coming back.

The nature versus nurture debate has been going on for a long time and will likely continue into the future. On the nurture front, the extreme position, I guess, would be that the organism at birth has two basic drives – pursue pleasure and avoid pain – and all other behaviors are built into this basis through classical and operant conditioning. On the nature side I suppose the extreme would be that certain behaviors or behavioral traits are “wired in,” as an integral part of one’s genetic endowment. I would describe myself as fairly extreme on the nurture side, but I’m open to research findings that suggest otherwise. In my view “either/or” thinking is dangerous in that most of the activity (animate or otherwise) in the universe is caused by multiple determinants. If a meteorite strikes the Earth, the causes of the impact are many: the sequence of events that generated the meteorite in the first place; the gravitational influence of the Sun and other planets on its trajectory; the Earth’s gravitational attraction; the effects of the Earth’s atmosphere, etc.. To point to any one cause as definitive is misleading. And even more so in trying to determine the causes of behavior. Behavior is multi-determined. I tend to think of anatomy and physiology as setting limits to our behavioral repertoire. For instance, I can jump over an object two feet high. With lots of practice and coaching perhaps I could jump over an object four feet high. But I could never jump over a house – no matter how much I train and practice.

Often the issue of timing is neglected in the nature versus nurture debate. What I mean is this. When people say that certain behaviors are “wired in,” I think they need to specify when –at conception? birth? one year? two years? etc..

I must say that I’m not too impressed by the argument from Chinese/American similarity. As a behaviorist I could just as easily argue that despite some superficial differences, the basic parameters of human existence are the same the world over, and because of this, we learn to respond to the world in very similar ways. But I acknowledge that my position is no more defensible than yours. In my view the way forward is not through these broad brush position statements, but rather testable hypotheses. What initially attracted me to behaviorism (back in the sixties) was that it was the only school of thought in this field that defined its terms unambiguously and routinely tested its hypotheses.

Your comment reminds me of Cyril Burt – an English educational psychologist who did research work for the city of London back in the 50’s and 60’s. He was very widely respected and was considered a world-authority on intelligence. Throughout his career his findings were consistent: intelligence is almost entirely inherited. According to his years of painstaking research, it didn’t matter what you did for a child, if he wasn’t born with the right equipment, he would never excel intellectually or academically.

Well this kind of thinking became dogma, not only in England, but also in North America, and, I believe, in other countries.

Then after his death (in 1971) it emerged that his research had been faked. I forget the details, but I recall that he invented subjects and gave them IQ scores to bolster his position. He also invented a field assistant who was “travelling” around England testing these non-existent children. His work is now discredited, though some of his notions linger as undercurrents in these kinds of issues.

Apparently Burt was deeply committed to the notion that upper class children are inherently more intelligent than their working class counterparts, and he faked research to support this position. What’s particularly noteworthy is that his findings went largely unchallenged for years.

We also see this kind of thinking in the world of fiction. The Tarzan novels are a good example. Written by Edgar Rice Burroughs, the books portray Tarzan, the biological son of an English earl, raised by apes in the jungle, but still developing his intelligence and other skills to become “Lord of the Jungle.” Genes will tell!

Anyway, the debate goes on . You do seem a little down on the human race generally? Personally I would describe myself as more optimistic. Certainly we humans acquire counterproductive habits, but I believe this is usually through the vagaries and vicissitudes of upbringing, rather than genetic aberrations.

Finally, with regards to genetic engineering, I want to repeat my earlier question. Who decides? At present breeding and the choice of partners is left to individuals, and all sorts of interesting factors influence these choices. Maybe we don’t do a good job, but I’m not convinced that government or wealthy, powerful individuals would do any better.

Once again, thanks for coming back.

Louise,

Thank you for “chiming in.” You make good points.

I’ve posted a more detailed response to Type (above) which you might find interesting.

Best wishes.

Opie,

Thanks for the comment.

You are raising a very valid and very real issue. Here’s how I think it works.

Depression is a feeling. It has something in common with hunger, in that it drives the organism towards a certain kind of activity. Hunger drives us towards food-seeking. Depression drives us towards novel stimulation – movement – something different. From an evolutionary point of view I can imagine a group of humanoid hunter-gatherers, having worked a certain location for a period of time, becoming bored (i.e. depressed) and being driven by this feeling to move on. This would be advantageous, in that it induces them to abandon a feeding site before they have permanently damaged the vegetation, so plants will still be there to provide food next year. It also ensures that they leave a site before their own feces become hazardous to their health.

So I think that depression as an adaptive drive is very deep-rooted and in this sense “natural.”

But as we know, basic drives are significantly modified by experience and learning. Small babies – as every parent knows – become bored. They want to see new things; they crave novelty. This craving is depression – though we don’t call it that in small babies. But it is the same emotion – the same sense of dissatisfaction with the status quo.

The picture then becomes complicated because what the growing child does about this feeling of dissatisfaction is primarily a function of his experience. If he grows up in a family where the accepted response to these feelings is to get up and go, then he will probably do the same throughout his life. If, on the other hand, he grows up in a family where the response to these feelings is to sit on the couch, watch TV, whine and mope, then – well, you get the picture.

Note that I’m grossly over-simplifying the socialization process. Parental influence is a strong factor in child-rearing outcomes, but it is by no means the only one.

But to get back to your question. In my view, for most people feelings of depression continue to be the adaptive process that evolved in conscious organisms: i.e. an incentive to get up and go, to seek out novel stimuli, to do something different. At the other extreme are individuals in whom this adaptive response has been virtually extinguished through less than optimal training/modeling. So for them depression becomes a sort of morass of self-pity from which it is difficult to extricate oneself. The answer for these individuals, of course, is still the same – get up and go – but they may need the help of a friend to accomplish this. In a very literal sense, that’s what friends are for. And this is how people conceptualized social life for most of human existence.

The first major assault on this supportive social network was television, whereby stimulation was provided through a small window to each individual to the detriment of social supports generally.

The second major assault was, of course, the bio-psychiatric/pharmaceutical assault which created the destructive fiction that depression is an illness.

So to get back to your question. In the situation which you describe, the “natural” response to depression has been extinguished in the same way that the natural response to sexual stimulation is extinguished in the case of a celibate monk; or the natural response to overwhelming danger is extinguished in the case of a soldier; or the natural response to hunger is extinguished in the case of an ascetic who routinely fasts and performs other acts of self-denial.

With regards to the lack of craving to go out in the sunshine and socialize – I think the critical point here is how do you identify craving in another person? The answer, of course, is by his behavior. You will see that he/she is actively pursuing the object in question. But behavior, as we know, is subject to extinction if it is not reinforced and if counter behaviors are reinforced. The extinction of this kind of get up and go behavior doesn’t usually occur overnight, but is rather something that happens gradually over time.

I hope I’ve answered your questions. If not, do come back. Once again, thanks for your interest, and best wishes.

Amanda,

Thanks for coming in. Sorry for the delay in getting back to you – I’ve been a little under the weather.

As I stated in the post, in my view depression is not an illness. Rather it is a message from our bodies to make some changes. If you attempt to walk into a burning building, the heat will almost literally push you back. Similarly if your life is plodding along in a certain direction and you feel really rotten about everything – well that’s your body telling you to change direction – do something different!

Now, as I’m sure you realize, I’m very much in a minority in this view. The disease notion is widely accepted, and billions of dollars are spent each year on its promotion. Most physicians accept the disease notion and prescribe drugs accordingly. In my view this is one of the great tragedies of the modern world.

But I’m not in your shoes. You have to do what’s best for you. And if you find the disease concept comforting and if the drugs seems to help you get by – then who am I to argue? I would, however, suggest that you keep an open mind. Look out for areas where you might be able to effect positive changes. Ask yourself what would you prefer to be doing, etc., etc..

You have gotten yourself stuck in the “either it’s an illness or I’m just no good” mindset. There’s another option: You are a normal person who operates in ways that have yielded payoffs in the past. Depressive behavior is frequently rewarded in our culture and we are all capable of succumbing to this kind of enticement, particularly if alternative modes of operating are not high in our repertoires.

Depression is normal. It is a message from the body to “get up and go.”

Once again, thanks for coming in, and please come back if you have other thoughts or concerns.