During her annual physical examination, a nurse friend of mine mentioned that she had been depressed. Her hurried physician tried his best to say something empathic: “So, who’s not depressed? If you work in health care, you’re depressed.”
Americans live in the age of industrialized medicine, and everyone—inside and outside of health care—is now in the same boat. Doctors are financially pressured to be speedy mechanics, and patients often receive assembly-line treatment, which can be a painful reminder of their assembly-line lives. While most Americans manage to go to work and pay their bills, more than a few struggle just to get out of bed, and growing numbers feel fragile, hollow, hopeless, and defeated.
In 1998, Martin Seligman, then president of the American Psychological Association, spoke to the National Press Club about an American depression epidemic: “[W]e discovered two astonishing things about the rate of depression across the century. The first was there is now between ten and twenty times as much of it as there was fifty years ago. And the second is that it has become a young person’s problem. When I first started working in depression thirty years ago . . . the average age of which the first onset of depression occurred was 29.5. Essentially middle-aged housewives’ disorder. Now the average age is between fourteen and fifteen.”
Despite the unparalleled material wealth of the United States, we Americans—especially our young—are increasingly unhappy. What is happening in our society and culture? How is it that the more we have come to rely on mental health professionals, the higher the rates of depression? And are we in need of a different approach to overcoming despair?
During the course of our lives, it is the unusual person who does not have at least one period of deep despair. The majority of depressed people do not choose professional treatment but many do, and my intent is not to create discontent among patients satisfied with their mental health treatments. This book is for people who believe that any approach to depression that does not confront societal and cultural sources for despair becomes part of the problem rather than a sustainable solution. Standard mental health treatments routinely ignore the depressing effects of an extreme consumer culture, and for people who feel alienated from such a culture, it is my experience that conventional treatments can actually increase their sense of alienation and contribute to their despair. This book is also about providing hope and a practical path for people who have lost faith in psychiatric orthodoxy, often because it has failed them or their loved ones.
I am in my third decade of working with people who have not been helped by standard psychiatric treatments. I have found that while the majority of such “treatment resisters” do not identify with any political party, most share these political views: they are deeply pained by a society that focuses on increasing consumption rather than celebrating life; they believe that powerful corporations rather than individuals and communities dictate public policy; they suspect that many of those authorities and institutions—including those in mental health—that inform Americans have been corrupted and hijacked by corporations whose singular goal is increased profit; and they consider it common sense that an alternative approach that threatens the societal status quo will be ignored or derided by those who financially profit from the status quo.
I recall one such treatment resister, a middle-aged man who was dragged into family counseling by his wife because of their daughter’s self-destructive behaviors. On his own, he had valiantly struggled to overcome rage and despair that he attributed to job stress caused, he said, “by a new CEO whose only loyalty is to stock share value.” He made clear that he disliked manipulative managers and know-nothing mental health professionals as well as the term depression. He said, “I know what helplessness and hopelessness are, and I know what shutting down my pain is, but the diagnosis of depression is some damn shrink psychobabble.” He explained that the word depression didn’t do justice to his experience and only irritated him. In contrast, when I used the word hurting, it touched him deeply.
I have found that the words people use to describe their conditions lead them down certain paths. The term depression so pervades our culture that I cannot escape its use. However, when I am in emotional pain and without the energy to act constructively, I consider myself demoralized rather than depressed. Depression reminds me that I am depressing my pain and my being—this I need no reminder of. Demoralized reminds me that I am lacking morale, and morale is exactly the word I need to be reminded of when I am down in the dumps. It heightens my awareness to that which is energizing and inspiring. Morale is the emotional experience of cheerfulness, confidence, and zeal in the face of hardship. Without morale, difficult tasks seem impossible to accomplish; with morale, those same tasks can feel challenging and fun. When I think about morale, I am reminded that an individual can inspire a community, a community can energize an individual, and we can all remoralize one another.
Much of what I will spell out is increasingly neglected in the education of mental health professionals. Today I would give most professional training programs failing grades in the following areas necessary for revitalization:
• Regaining morale. The demoralized need people skilled at the craft of transforming immobilization to energy, and they need to learn the craft of self-energizing.
• Understanding depression. Depression is a “strategy” for shutting down pain, a strategy that can result in the depressing of one’s being and a vicious cycle of more pain and repeated depression. • Healing the source of depression. The unhealed need helpers skilled at the craft of healing emotional wounds, and they need to learn the craft of self-healing.
• Distinguishing self-acceptance from self-absorption. While the self-absorption associated with extreme consumerist society is one source of depression, self-acceptance provides the security necessary for connecting with the whole of life, which is an antidote to depression.
• Teaching the essentials of relationships. Beyond simplistic communication skills, depressed people often need a deeper wisdom about friendship, intimacy, family, and community.
• Reforming society. Whether people are successful or not in shaping a less depressing world, they are often rewarded with community and vitality when they go beyond their private sphere. Many people I have known who are diagnosed with depression are more gentle than the world around them. It saddens me when unhappy people who have become so despondent that they consider suicide view themselves as weak or sick. If death feels more attractive than life, it means nothing more than the fact that one’s present pain feels unbearable. There is no more scary topic for mental health professionals than suicide. The book Suicide: The Forever Decision (1992) by psychologist Paul G. Quinnett is not only compassionate but candid about mental health professionals’ anxiety: “[M]ost of us do the conservative thing when we have an actively suicidal person on our hands; we lock him or her up. Whether this is always for ‘their own good’ or ‘our own good,’ I can’t say—maybe it is a bit of both.” In many nonconsumer cultures, a person seriously considering suicide would be watched by loved ones until the self-destructive impulses had passed; but in societies where moneymaking is prioritized over all else, hospital or prison staffs are employed to guard against a suicide attempt. Books about depression often start off with a disclaimer such as this: “If you are considering suicide, immediately seek help from a mental health professional.” From my experience, it would be only with great sarcasm that suicidal people would respond: “Gee, what a valuable suggestion! Why didn’t I think of that?” I suppose instructing suicidal people to seek professional help makes the author appear responsible to those people not considering suicide. However, if suicidal, you usually know what you are supposed to do but are overwhelmed by pain. The last thing you need is another’s anxiety, and if you’re paying for it, it’s enough to make you even more hopeless and angry. When your pain feels unbearable, it is likely that you desire someone who can bear your pain. In the United States, if you are considering suicide, you are not alone. In 2000 it was estimated that every year, 750,000 people make a suicide attempt. That’s over two thousand every day who give suicide a try. The U.S. Surgeon General, focusing on mental health in 1999, reported that suicide was the eighth leading cause of death and the third leading cause of death for teenagers and that the rate of teen male suicide had tripled since the 1960s. While many Americans are reluctant to criticize our way of life, it is clear that Happy Meals are not quite doing the trick. I have talked to many extremely demoralized adults and teenagers who have been diagnosed with depression. When we humans are seriously depressed, no matter what our age, we routinely become selfabsorbed. While depressed adults can pretend to care about another’s presence, depressed adolescents are usually more genuine, and their self-absorption is often straightforward. Adolescents’ blank faces and one-word replies make clear the futility of my probing. When I stop torturing them with questions, they usually stop torturing me with nothingness. One day, instead of firing questions at a sixteen-year-old boy, I started to rant and rave about my views on society. He appeared relieved, as my pontifications meant less pressure on him to perform. He could remain silently self-absorbed in his own pain. I told him that I was ready to give a commencement speech at his high school. This got his attention. “Bruce, I don’t think the principal will allow it. You’d probably start off your speech with that Mark Twain quote you like. The one that goes ‘Never let your schooling get in the way of your education.’” I was pleased to discover that he had been listening to me. He agreed to hear my proposed commencement speech, and I began, “Parents, faculty, and students, there are two types of adults, and one day you students will become one type or the other. Type one, the vast majority of adults, spend all day thinking about two things: how to get other people’s money, and how to keep other people from getting their money. Type two, the other kind, are . . . homeless.” He laughed, and guessed that while most parents and teachers wouldn’t appreciate this speech, most of the kids would like it—they wouldn’t feel quite so badly about themselves for being scared of the world. Before I met this young man, he had been treated by two other doctors with different antidepressants and his condition had worsened, the severity of his diagnosis deteriorating from “mild depressive disorder and doing poorly in school” to “major depression and suicidal ideations.” It was heartbreaking for his mother to listen to her intelligent son say that he felt like a failure. The first time we met, he told me, “I must be unfixable, one of those incurable cases. I mean I’ve talked to other doctors and have had all different kinds of medicine.” I told him that his conclusion of being incurable was only one possibility, but a more likely possibility was that none of those doctors took the time to get to know him, which could have made him even more depressed. He considered that for a few seconds, and agreed. He and his mother were convinced that medication had been a failure, and he wanted to stop taking his current antidepressant. I explained to them the dangers of abrupt withdrawal from antidepressants. Pharmaceutical companies once denied this withdrawal problem but today accept it and term it antidepressant discontinuation syndrome. To prevent potentially debilitating withdrawal symptoms, he cut back gradually. Two months off his antidepressant, he was no longer demoralized, suicidal, or feeling like a failure. This is not to say he was walking around with a chronic grin. The opposite of depression is not so much happiness as vitality. He continued to dislike school and was distressed by his parents’ ugly divorce, but he came to believe that his pain made sense, and he was no longer immobilized by it. He got a good parttime job, passed his classes, and made mature career plans. I took the time to get to know him, and I’d like to believe that I helped him with what I will talk about in the following pages, but it would be hubris to say this for certain. Science cannot unravel whether I helped him, or whether he would have gotten his act together without me. In reflecting on the empirical research on depression, on my work with depressed people, on the memoirs and essays of people who have experienced depression, and on my own personal experience with demoralization, immobilization, and despair, it is difficult to deny the power of faith and belief—what scientists term “expectations” and the “placebo effect.” In a 2004 study on the influence of patient expectations on the effectiveness of an experimental antidepressant, it was found that among depressed patients who expected that medication would be very effective, 90 percent had a positive response; while among those expecting medication to be somewhat effective, only 33 percent had a positive response. No depressed people were included in this study who expected the experimental drug to be ineffective, but such nonbelievers rarely tell me about having a positive response with antidepressants. It has been my experience that to the extent that one has faith in the efficacy of any treatment or approach, one’s likelihood—at least temporarily—of overcoming depression increases. By contrast, an absence of faith in anything is associated with chronic depression. People can choose to have faith in religion, philosophy, art, dietary supplements, or exercise. I have seen many different belief systems work to reduce despair. However, I do not advocate that you believe in anything for the sake of belief. What we believe in matters a great deal. The beliefs we choose determine in no small way what kind of people we are, what kind of friends we have, and what kind of effect we have on society. The faith encouraged by consumer culture is a faith in money, technology, and consumer products, and it is a faith that often has significant adverse side effects, including addiction and withdrawal. Americans who don’t share the faith of such a culture will likely feel alienated from society, and alienation—from either one’s humanity or one’s surroundings— is painful and can be a source of depression. I believe that many people feel alienated in consumer culture, and it is my hope that this book will help energize them to find others who share their beliefs and then together create community. In the United States, mental health treatment is increasingly shaped by two powerful industries: giant pharmaceutical companies, often collectively referred to as Big Pharma (the industry’s trade association is Pharmaceutical Research and Manufacturers of America or PhRMA), and insurance companies (and their managed-care bureaucracies). It is in the best interest of Big Pharma if people are prescribed drugs, and it is in the best interest of insurance companies if treatment is extremely brief. In addition to encouraging doctors to prescribe drugs, insurance companies also pressure psychotherapists to focus narrowly on what is easiest to do in a few sessions. Commonly, this means teaching “rational thinking” and “social skills.” Ironically, these simplistic techniques require little in the way of a therapeutic relationship and can be learned through a book. Prior to the current era, psychotherapists were free to choose among many options. For example, one therapy—now threatened with extinction in the time-pressured world of managed care— consists of helping depressed people find meaning in their lives. Once, it was routinely accepted that meaninglessness was an important source of depression, but today, managed-care time restraints have resulted in denying and ignoring this reality. Historically, the mental health profession has been a joke of sorts when it comes to morale boosting. Specifically, I recall the old joke: “How many psychiatrists does it take to change a light bulb? Only one, but the light bulb must want to change.” Even before the time pressures of the managed-care era, many mental health professionals were quick to abdicate responsibility for patient immobilization. Today, most of them spend little time being frustrated. They simply write a prescription or refer to a drug prescriber. The new joke—not quite as funny—is, “How many psychiatrists does it take to change a light bulb? Only one, but the light bulb must be medication compliant.” If you are immobilized and behaving self-destructively, I don’t assume that you are irresponsible or in need of medication. One strong possibility is that you are not around anyone—even if you are seeing a mental health professional—who has the capacity to energize you. What about the craft of healing? Mental health professionals increasingly view themselves more as technicians who provide medications and skills rather than healers who care about wholeness. Despite that, relationships still do occur in psychotherapy, and occasionally, sometimes even accidentally, so does healing. However, in our timepressured era, even more prevalent than simplistic therapy is a procedure called medication management. A typical “med management” session consists of checking symptoms and updating prescriptions, and recipients tell me that they are usually in and out with a new prescription in ten or fifteen minutes. They also tell me that it’s common for med managements to be scheduled every two or three months, and that during these appointments, the doctor often needs to peek at their files to remember their names. In such assembly-line treatment, there is virtually no chance of a relationship forming, and gone is even the accidental possibility of healing through another’s humanity. In the training of mental health professionals, the revitalizing component of reviving community is all too often neglected. There is no greater antidepressant than focusing beyond one’s private sphere to a societal concern. Whatever the scale, mental health professionals need to encourage community building of some kind. People who engage in life-affirming change have a greater chance to connect with likeminded others, and they are rewarded with greater vitality. A major reason for writing this book is my conclusion that standard psychiatric treatments for depression are, for many people, unsustainable. The latest research shows that antidepressants often work no better than placebos or no treatment at all, can cause short-term and long-term adverse effects that may be as or more problematic than the original problem, can result in drug tolerance (an increasing need for higher dosage), and can promote dependency on pharmaceutical and insurance corporations. Moreover, antidepressants and other mental health industry treatments divert all of us from examining the unsustainable aspects of society that create the social conditions for depression. In this book, I am speaking to those who feel alienated from an increasingly extremist consumer culture and who are seeking genuine community. And I am speaking to those who have already rejected standard psychiatric theories and treatments of depression and are seeking alternative explanations and solutions. The U.S. Surgeon General reported in 1999: “Nearly two-thirds of all people with a diagnosable mental disorder do not seek treatment.” The reason for this, Americans often hear, is “the stigma of mental illness.” This is certainly the explanation provided by the American Psychiatric Association, the National Alliance for the Mentally Ill, and other mental health institutions that are financially linked to pharmaceutical companies—collectively referred to in this book as “the mental health establishment.” However, a recent poll suggests that the reason for this disinclination toward psychiatric treatment, at least for some Americans, is simply a lack of confidence in psychiatrists. A December 2006 Gallup poll asked Americans about the “honesty and ethical standards” of different professions. The percentage of Americans reported to have a positive opinion of nurses was 84 percent, and for clergy it was 58 percent; but for psychiatrists it was only 38 percent—much lower than the 69 percent positive rating for other medical doctors. While some of what I will say is not controversial, much will be cultural and professional heresy—but I believe it is necessary. How else can this epidemic of depression be turned around without letting go of cultural arrogance and professional pretensions? Surviving America’s Depression Epidemic by Bruce Levine is available now.