Thursday, 6 November 2014

Sadder but Wiser? Interview with Jennifer Radden

Jennifer Radden
This week we feature an interview with Jennifer Radden. Jennifer is a Professor of Philosophy at the University of Massachusetts Boston. Her teaching and research interests include philosophy of mental health and the ethics of psychiatry. She is the author of ‘Divided Minds and Successive Selves: Ethical Issues in Disorders of Identity and Personality’, and ‘The Nature of Melancholy’.

MA: In our project we investigate the idea that mental imperfections may carry some important epistemic benefits. Do you find it plausible to say that depression may carry some benefits of this kind, even if it is a harmful experience?

JR: Answer: Harmful? Or painful? If it’s harmful also, then we’d need to do some weighing of relative harms and goods, I’d guess, for an overall assessment of the right kind, and my answer is: I don’t know… If you meant something more like painful, then yes, this is certainly the way people sometimes speak about these episodes, even using ‘no pain, no gain’ language. But I’m not sure we can judge in any general way. People’s sense of the meaning of pain and, indeed, of depression, are so varied, that it seems to be a sort of empirical question for social psychology, and one to which helpfully uniform answers may be hard to come by.

More generally, there’s an issue here about what’s covered by the term depression. Some people think there’s a kind of psycho-creep that wrongly includes normal sadness under the category of depression. (Horwitz and Wakefield 2007 are one source for this position.) There’s also a new view that what’s called depression actually divides into two rather different disorders: true melancholia, and a kind of mild neurasthenia. True melancholia, on this view, is less responsive to placebo, or antidepressants, and may possess a biological marker (Carroll 1982, Taylor and Fink 2006.) Finally, the issue of bipolar disorder requires a comment; because it seems to have a genetic component, it is usually (but not by all) separated from unipolar depression. So it may be difficult to generalize before we’ve straightened out what we’re talking about by ‘depression.’

Another point worth noting here is that although severe depression is sometimes accompanied by delusional thinking, unlike the so-called motivated delusions found in some other disorders, the delusional ideas associated with depression have no evident emotional benefit. Rather than making the person feel better, they are typically on themes of guilt, inadequacy and deserved punishment that seem to only play into and reinforce the distress and hopelessness of the prevailing mood.

MA: What is your view on whether depression may enhance one’s ability to make more accurate (realistic) predictions about the future or increase one’s empathy and sensitivity towards the suffering of others?

JR: I have found the ‘sadder but wiser’ (Alloy and Abramson 1988) studies rather compelling. They focus on assessments of past action rather than predictions about the future though, for the most part; and the sadder and wiser correlation didn’t hold up as well with future predictions (that’s Dunning and Story 1991). But also, predictions about the future would I expect be confounded by self-fulfilling prophesy tendencies - the more so as depression seems to be deeply affected by expectation, as proven by the effectiveness of placebo treatment for at least mild versions of the disorder.

As to improved empathy and sensitivity: my impression is that it’s going to be a mixed bag. Some people are so self-centred when depressed, they really can’t be very good at empathy. Maybe afterwards, episodes of depression could work that way. Even afterwards, though, it may not be the depression as such, but having had a temporarily life-stopping, episodic illness - type indifferent - that explains any enhanced fellow feeling, or sensitivity.

Sensitivity perhaps also covers a different trait. The gains from the experience of depression (and other severe mental disorders) portrayed in first hand accounts are sometimes put in terms of a deepened understanding, not necessarily of other people, but of the meaning of existence - what it’s all about, what’s really important, etc. There’s also sometimes a sense of freedom that seems to be seen as the result of the sheer social exposure that severe mental disorder brings: almost the idea that you’ve transcended the petty, which includes social norms and others’ narrow opinions and choices. I don’t know how you’d measure these self-reported changes, but we can suppose they might be freeing, and have some positive effects on a person’s beliefs and epistemic practices (making them more open-minded, less concerned with trivial matters, less conformist, and so on).

MA: Studies regarding so-called positive illusions indicate that predictions made by people in the non-clinical population seem to be more optimistic than is objectively warranted by the evidence. It is believed that one benefit of such cognitive bias is to enhance wellbeing. What costs, if any, may be associated with positive illusions?

JR: Well, depending on what the illusory belief is, there’ll be a jolt (occasional or frequent) when/if reality intrudes, I suppose, and the resulting dissonance might lead to some nasty self-protective habits, like lying, obfuscation, active self deception. But yes, many fairly benign positive illusions are likely soothing. E.g., believing one is a better than average driver, as an above average number of the driving population apparently does, might augment confidence, enhance self-esteem – as might the illusion that we are more in control of our fate than we actually are. But of course if these illusions diverge just a little away from the social norms, you’ll have fantasists, chronic exaggerators, narcissists, the grandiose, control freaks etc., who seem likely to get into trouble in social settings. Their positive illusions will be damaging. And some subset of the non-clinical population may be prone to shift towards these traits with harmful outcomes, even if they begin with seemingly innocuous illusions.

MA: You studied the history of depression in some detail. Have the way in which we view depression and the way we tackle it changed substantially through the years? What would you say are the challenges we need to meet now to improve the prospects of those who suffer depression and to fight the stigma associated with it?

JR: I do think there are interesting parallels between melancholia of old and present-day depression, but few that can be generalized about unqualifiedly. These are cultural as much as medical categories, they don’t translate without remainder. Moreover, even within the last century depression as a state of unusual sadness and distress has been construed in a range of ways, both by its sufferers and by those treating them. And these differences will reflect a similarly illimitable range of factors. To name just three, there are varying assumptions introduced to explain depression (psychodynamic, biomedical, CBT etc.), each carrying its own particular ontological baggage; there are cultural attitudes towards it (the associations with sensitivity, wisdom, the feminine, passivity, self-centeredness, and so on); there are trends in treatment (e.g., single ‘magic bullet’ remedies in contrast to more holistic ones, psychopharmacology and forms of talk therapy) and these in turn affect how the sufferer selects and presents the symptoms.

Social questions about stigma are complicated by these very significant differences in how depression is understood. Medical psychiatry has supposed that casting its sufferers as the hapless victims of a disease is the best remedy against stigma. But the challenges to the disease model and to that causal hypothesis have been persistent - and from many directions. Thus, for example: if a great deal of normal sadness has been inappropriately pathologized, then the first step towards reducing stigma may be sorting these things out, and encouraging people with mild depressive states to take affect regulation into their own hands – as in the new trend today of apps for self-administered cognitive therapy, for example.

Today, a plethora of theories, assumptions, remedies, and ideas about depression all jostle together and there’s little agreement over them – particularly when it comes to milder forms of disorder. Two that could count as overall and fairly recent trends would be the movement towards CT/CBT approaches; and a self help orientation, allied to a more organized and active population of consumers of mental health services, the focus of which is often more holistic and ‘alternative.’ In fact, even though we equate depression with melancholia at some risk, each of these trends can be seen to echo earlier efforts at affect regulation. Cognitive approaches hark back to ancient Stoic prescriptions and their medieval and Early Modern interpretations. And adhering to the six non-naturals to prevent melancholy (a self-help regimen) was a form of Galenic humoral medicine that prevailed in some form or another from ancient times all the way through to Burton’s Anatomy, and on into the modern era. So, with some bumps and digressions along way (psychoanalysis, early biological psychiatry), and many qualifications, it might be said that we are seeing a return to past remedies.

As a final note: psychiatry ignores all but its most recent history. With the exception of a revival of nineteenth century Kraepelinian thinking that was heavily, and we would now say implausibly, biological, there is rarely reference in the research literature to anything before the 1980s. But because depression is still not fully understood, I think this omission is a mistake. We can reject humoral medicine as a causal model without also ignoring some of the treatment recommendations associated with it, for example. And unless human nature has changed more than seems likely, the rich phenomenological record of mood disorders from past times can aid our understanding of depression and anxiety today.

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