A while back, I went to a wedding in Texas. I distinctly remember flying into Dallas, as there was a terrific thunderstorm and from above the clouds I could see the lightning strikes as dazzling patches exploding in the darkness, like some science fiction artillery was bombarding the ground. Yet that is not what I remember most vividly about that trip. The night before the ceremony, I was staying in a motel with various guests for the wedding who had come over from the UK. One of the them must have been in a confessional mood, as he told me all about how he had recently been debilitated for several months with crippling depression. He suggested to me that there needed to be a change in the way people see depression; that it should be taken to be more like a cold, something anyone can get that passes.
I could see he needed support at that time, so I bit my tongue. But what I wanted to say was: “How dare you, who have just had one short bout of depression, come to me who have spent my whole life wrestling with it and suggest that we should be downplaying depression and making it out to be something small and trivial like a cold? You’re just a damn tourist in my homeland and have no respect for what it’s like to live with something like this. Your whole reason for making it out to be ‘like a cold’ is because you recognize there’s a stigma attached to ‘mental illness’ and you want permission to have briefly experienced what those of us who live with it must endure without you having to bear that stigmata.” I let it slide. But I never forgot that conversation.
What presumably motivated him to make his argument was an attempt to push back against the prevalent but never-voiced default rhetoric of depression, indeed, of any kind of variation from the perceived norms of mental function: ‘they’re not right.’ This is the rhetoric that makes depressives, schizophrenics, manic depressives and so forth outsiders, because they aren’t normal, they’re not ‘like us’ (whoever ‘us’ might be). This is the rhetoric that makes admitting to depressive tendencies a career-ending event for some people, that leads others to end their lives, and that can never really be eliminated because it is never really espoused. It is a fear of shadows and the unknown, thriving on ignorance and the erroneous perception that normality is both possible and desirable.
Against this default rhetoric, the wedding guest’s view (which he also connected with some remarks by Prince Charles) was to downplay depression as something less serious. But this ‘like catching a cold’ rhetoric is not really an improvement. Because depression is only anything like a cold for those people whose brush with it is a passing affair. I don’t want to belittle those experiences – depression, as anyone who has gone through it knows, is a serious business. But it’s precisely because it is a serious business that a rhetoric that downplays its seriousness can’t really be an improvement on the mob mentality of the ‘not right’ rhetoric. What deeply offended me about this perspective is that at its heart it is trying to make it okay to suffer depression by splitting off incidents of depression from ‘mental illness’ in general. But this means that it is equally a rhetoric of exclusion: it allows some to escape the claim of ‘not right’, but it still condemns the rest of us to banishment.
There is a third rhetoric of depression that is in common circulation, that of the medical establishment. According to this, depression (or major depressive disorder, or clinical depression) is a mental disorder caused by irregular behaviours of the neurotransmitters serotonin, norepinephrine, and dopamine, sometimes described informally as a ‘chemical imbalance’. It is treated through the application of anti-depressant drugs of various kinds, perhaps with additional counselling or cognitive behavioural therapy. In effect, this ‘mental illness’ rhetoric of depression views those suffering from it as faulty and in need of fixing. What I find striking about this perspective is that it insists in seeing depressive people as broken, just as the other two rhetorics do. Whether it’s because they’re ‘not right’, it’s just ‘like a cold’, or it’s ‘mental illness’, the three rhetorics of depression are united in ensuring that depression, and ‘mental illness’ in general, are set up as something that is not normal. Depressive people are broken people.
But these rhetorics are all misleading. Because depression, despite its unpleasantness, despite its severity, despite its radical effects on people’s lives is normal. It’s completely normal. As normal as falling in love with your high school sweetheart and marrying them, and actually less rare (eight times more common in the United States), whatever the movies may suggest! The problem is, we are still operating with the Eighteenth century mythos of Nature, one that tends to equate ‘natural’ with normalcy, and presupposes that there are natural norms against which everything else is measured. Deviations from the natural are thus judged as wrong in some way. This is the origin of the hermeneutics of ‘sickness’, which we are not obliged to accept for all that we have saturated ourselves with this mythology.
A hermeneutic is a principle of interpretation, and applying this term to medicine is heresy. But I have always fancied myself a heretic, especially in situations where resistance is rare. I am not, however, entirely alone in this matter, and first heard it suggested by the philosopher Charles Taylor, who was drawing on radical ideas by the renegade Catholic priest, Ivan Illich. Illich saw clearly the transformation in our mythology of health and dying in the last few centuries, and set out serious problems with our contemporary perspectives in Medical Nemesis, a book that became required reading for many studying to become medical practitioners. Alas, it does not appear to have in any way halted the trends that it argued against.
The general criticism I am advancing here has nothing to do with the efficacy of contemporary medical techniques, because it is not about treatment at all: it is about diagnosis. The medical establishment’s mission is to find a box to place everyone into. If you go to your doctor with any kind of complaint whatsoever, you will either be assigned an appropriate box for your sickness, or you will be referred to a specialist who can find an even more exacting box for you. But you will be found a box, or you will be condemned to infinite tests to attempt to establish that box. And the number of boxes available has steadily increased, without any question about the merits of categorising people in this way. As a simple empirical observation, our ever-improving medical knowledge has utterly failed to halt depression: it has increased in incidence throughout the last century, and is ten times more prevalent than it was seventy years ago.
There are good reasons to question medicalisation in general, particularly when the commercial practices of pharmaceutical companies are taken into account, but in the case of ‘mental illness’, it should be even clearer that something has gone horribly wrong. People in the autism spectrum or those with Down’s syndrome have unique ways of being in the world, but we are in no way obligated to view these phenomena as sickness, which is always a negative judgement. Recall that as recently as 1974, homosexuality was classified as a ‘mental illness’, and is still claimed as such in some places according to the mythos of Nature that perceives ‘normal’ as some idealised state of being that it is therefore wrong to deviate from. Declassifying homosexuality was a first step, but it cannot end there.
What truly bears a claim to ‘normal’ for life is diversity, variation, and change – the concept of ‘species’ that suggests that every kind of organism can be perfectly standardized is no longer plausible, and has not been for quite a while. We are at the fringes of completely overturning the old mythos of Nature and normalcy, but it cannot be done without substantial revisions to the hermeneutics of ‘sickness’. But here, our deference to doctors and medical science is a barrier in part because, as Mary Midgley observed, they have inherited the powers that used to be ascribed to priests. There is a non-religion of medical power that generates the psychological effects of blasphemy far more reliably than traditional religions these days. Woe betide anyone who challenges the authority of doctors to classify us into categories of sickness!
Yet there is resistance. It comes with the term ‘neurodiversity’ that grew out of adopting the phrase ‘neurotypical’ as a contrast case by autistic people. Similarly, it comes under the banner of ‘mental diversity’, a term I broadly prefer since the prefix ‘neuro-’ is clearly intended to draw against the authority of the sciences and this issue is not a matter of measurement or experiment, but one of ethics and understanding. These alternative rhetorics (and the movements behind them) make it easier for me to talk about depression, although even now I do so with feints and allusions and without much in the way of detail. This is still uncomfortable territory for me, and for reasons that have much more to do with the third rhetoric than the first: those who argue against medical orthodoxy are seldom welcome. Yet the standard explanation of depression that treats it as akin to a mechanical fault cannot suffice as a general explanation since it utterly fails to account for our depression epidemic. We urgently need fresh perspectives.
In my life, experiences of so-called ‘mental illness’ have made me stronger, nourished my creativity, and led me to life-long friendships. It helped that I vowed to reject suicide as an option at an early age because I could see all too clearly how devastating it would be to others. It may also have helped that I rejected pharmaceutical interventions in favour of methods that mostly built my virtues rather than my dependencies. I flatter myself that I have taken control of depression, for all that I still occasionally stumble. But I recognize that what has worked for me will not necessarily work for others. For some, pharmaceuticals have helped them establish a life worth living. For others, drugs have simply incapacitated them for a while. There is no adequate pattern here that is beyond questioning, and no-one – not even depressives themselves, and least of all doctors! – can claim ownership of depression and force everyone into just one box.
This is perhaps the greatest problem with depression: although the experiences we mark with this term have common traits, they do not share common circumstances. They reflect different biologies, different psychologies, different environments, different ways of living and thinking and being. The statistical methods of the sciences are not suited to understanding such variety; they thrive on picking out the common patterns. But boxes built to one size cannot fit all situations, any more than averaging our measurements will produce a garment everyone can wear. The essence of mental diversity is that we are all different, and we cannot be subsumed into generic models of sickness and treatment. Medicine provides us valuable options, but so too does religion, non-religion, and every other source of practices and community. We each have to find our own path. And this is true, regardless of how ‘normal’ we might think ourselves.
The opening image is And I Can Feel Your Pain, by Ruth Batke, which I found here, where it had been on sale. As ever, no copyright infringement is intended and I will take the image down if asked.