Mental Health and the Brain: Working Group, June 15th

Mental Health and the Brain Working Group:

 
June 15th, Depression
 
Synopsis and forum for continuing discussion

Thoughts welcomed in the on-line forum below.

 

Background for discussion
 
Participants
Anneliese Butler, Laura Cyckowski, Adi Flesher, Paul Grobstein, Julia Lewis, Brie Stark
 

Summary

 

 


Comments

Clive Sherlock's picture

Adaptation - understanding and dealing with emotional problems

Adaptation Practice introduces an ancient way of understanding and dealing with emotional problems.
Our conventional ways of understanding and so of dealing with emotional problems (such as depression, anxiety, anger, stress, etc.) are often based on the assumption that there is something fundamentally wrong with us: weak or bad personality, traumatic past, faulty chemicals in the brain or erroneous thoughts. This way of thinking is deeply embedded in our culture, which is based on the concept of original sin and a misunderstanding of cause and effect in human psychology.
Far eastern psychology, and in particular Buddhist psychology, is different because it is not based on these concepts and misunderstandings. In this view we are all born without such faults but because of our mistaken views we have come to behave in ways that produce our own emotional problems and suffering. Although we are born weak, dependent and sensitive these are not considered to be faults even when they persist into adult life. An inner strength can be developed through suitable training and with this we can learn to become independent: to stand on our own two feet. We can learn to cope with being sensitive and to live with our emotions (all of which are natural and normal - although often unpleasant, painful, overwhelming and frightening). Adaptation Practice brings in us a clearer understanding of emotional problems and a more effective way of dealing with them without resorting to drugs, analysis of thoughts and memories or adjusting our thoughts but by changing how we react to what we dislike in life, which, inevitably, includes upsetting and disturbing emotions.
The assumption that there is something wrong with us is regarded as an example of how our judgments and opinions are so often based on misunderstandings and misinterpretations - that is, they arise from our theories without awareness or understanding of the underling conditions of cause and effect.
Recently there has been a growing number of scientific studies in the West showing the benefits of Buddhist-style meditation. They all show that it is better to be quiet inside - that is, not to pay attention to thoughts and not to engage in thinking.
Adaptation Practice is the preliminary practical preparation for Zen Buddhist training. However, in this context it is entirely secular. We could say that it is nothing to do with Buddhism or any other religion or belief system but in practice it is the basic training for all of these and for simply living a better life. Adaptation Practice offers a structured program for daily life practice, which, traditionally, meditation is based on.
The latest movement in clinical psychology (called mindfulness-based cognitive therapy) is based on this and yet, even though without the foundation of daily life practice, it has, nevertheless, been shown to be more effective than antidepressant drugs for recurrent depression.
More about this can be found at http://www.adaptatiopractice.org

Paul Grobstein's picture

depression, another discussion

anneliese's picture

significant symptoms, signifying bodies

"Perhaps diminished activity and a more general inclination to hide is part of what might, in some circumstances, be an adaptive response to being abandoned and unprotected in a world of unknown threats?"

 

...in other words, the symptoms of depression make sense, signify, embody an individual's lived narrative or story-in-the-making. The body communicates the internal experience, signals to the self and to others that something is amiss.Hence, symptoms can be thought of as useful, something to attend (i.e., pay attention) to rather than to treat. Messengers from the unconscious? "Screaming" to be heard? Or perhaps messengers from the collective unconscious, insofar as one's experience is embedded in and shaped by one's sociopolitical context?

 

I bring this up because I enjoy the idea of accepting and inquiring into rather than fighting against symptoms. It also nicely challenges the notion that depression is a 'mental illness.' Was prompted to dig up an article I read back in college by Nancy Scheper-Hughes and Margaret Lock, critical medical anthropologists both, who in 1987 published an article entitled "The Mindful Body: A Prolegomenon to Future Work in Medical Anthropology" [Medical Anthropology Quarterly, New Series, Vol. 1, No. 1 (Mar., 1987), pp. 6-41]. I remember being struck me at the time I first read it, and I find it continues to make my brain glow. They propose a model of "three bodies," "three perspectives from which the body may be viewed: (I) as a phenomenally experienced individual body-self; (2) as a social body, a natural symbol for thinking about relationships among nature, society, and culture; and (3) as a body politic, an artifact of social and political control" (6). They further suggest that emotion may be the common link between these bodies, "[i]nsofar as emotions entail both feelings and cognitive orientations, public morality,and cultural ideology" (28). To better explain, let me offer a few direct quotes rather than attempt to paraphrase:
 

"We would tend to join with Geertz (1980) in questioning whether any expression of human emotion and feeling-whether public or private, individual or collective, whether repressed or explosively expressed-is ever free of cultural shaping and cultural meaning. The most extreme statement of Geertz's position...would be that without culture we would simply not know how to feel." (28)
 
They go on to argue that "Sickness is not just an isolated event, nor an unfortunate brush with nature. It is a form of communication-the language of the organs-through which nature, society, and culture speak simultaneously. The individual body should be seen as the most immediate, the proximate terrain where social truths and social contradictions are played out, as well as a locus of personal and social resistance, creativity, and struggle." (31)


By drawing on what is known about non-Western medical systems, the article casts a critical eye on Western biomedicine, including psychiatry, and offers alternative ways of making sense of body, mind, and (mental) health. I offer here a few choice morsels that seem particularly germane to our discussions, and I would be happy to forward a pdf of the article to anyone who's interested.

"Geertz has argued that the Western conception of the person 'as a bounded, unique . . . integrated motivational and
cognitive universe, a dynamic centerof awareness,emotion, judgement, and action . . . is a rather peculiar idea within the context of the world's cultures' (1984:126)."
(p. 14)
 
"...many ethnomedical systems do not logically distinguish body, mind, and self, and therefore illness cannot be situated in mind or body alone. Social relations are also understood as a key contributor to individual health and illness. In short, the body is seen as a unitary, integrated aspect of self and social relations. It is dependent on, and vulnerable to, the feelings, wishes, and actions of others, including spirits and dead ancestors. The body is not understood as a vast and complex machine, but rather as a microcosm of the universe." (p. 21)
 
"The proliferation of disease categories and labels in medicine and psychiatry, resulting in ever more restricted definitions of the normal,has created a sick and deviant majority, .....Negative and hostile feelings can be shaped and transformed by doctors and psychiatrists into symptomsof new diseases such as PMS...or AttentionDeficit Disorder...In this way such negative social sentiments as female rage and schoolchildren's boredom or school phobias (Lock 1986b) can be recast as individual pathologies and 'symptoms' rather than as socially significant 'signs.' This funnelling of diffuse but real complaints into the idiom of sickness has led to the problemof 'medicalization' and to the overproduction illness in contemporary advanced industrial societies... The medical gaze is, then, a controlling gaze, through which active (although furtive) forms of protest are transformed into passive acts of "breakdown." (26-27)
 

 

Paul Grobstein's picture

more on symptoms and signification

I'll take a .pdf please.  Sounds like an article I should be aware of, and perhaps others too given the contemporary interest in "embodied knowledge".

"a model of "three bodies""

Or perhaps of one brain, which is the convergence point of all influences on oneself, including one's "self," the "social body," and the "body politic"?

"symptoms can be thought of as useful, something to attend (i.e., pay attention) to rather than to treat."

There's a lot in here, needing I think to be unpacked a bit.  Yes, the idea of "sickness" as a "form of communication" is very much along the lines of "an adaptive response," an ensemble of things of which "symptoms" are only a part, something which in totality may have "meaning" that is lacking in any single part.  Calling attention to this was part of what Laura and I were trying to do by going beyond the "medical model" in Models of Mental Health. 

A problem that arises, one that has come up repeatedly in our discussions, is how does one distinguish between situations where symptoms are part of a larger meaningful "story," and situations where symptoms are ... just symptoms?  And, further, how does one handle symptoms in situations where they may indeed be part of a larger yet-top-be-understood story but are also troublesome in their own right?  My point is not at all to deny the significance of "illness as metaphor" nor the related idea of "culture as disability"; both importantly broaden our reportoire of ways to make sense of aspects of human suffering. They are though  additions to the "medical model" perspective rather than complete replacements for it.  And so we need a way to think about the relative usefulness of the different perspectives in relation to particular cases.  In the example of depression, does one handle it as something to live with/learn from, or try to treat it pharmacologically, by talk therapy, by social action, and in what relation to one another?  

anneliese's picture

Agreed. Got a bit carried

Agreed. Got a bit carried away...do not mean to suggest that the cultural model should replace the medical. Indeed, it would be unethical and inhumane to not offer some form of treatment. Am more interested in how social/cultural/political context gives rise to very real symptoms. Treating symptoms (e.g., with medicine) does not have to mean ignoring the fact that (in some cases, at least) they are social in origin.

I like the "three bodies" model because it attempts to integrate multiple perspectives on the body and suffering into "a larger meaningful 'story'." .pdf is on its way.

anneliese's picture

how to arrive at an inclusive definition of depression?

The more I think about it, I think I misinterpreted the idea, or understood it only partially.

Am reading "The Illness Narratives" by Arthur Kleinman (MD and anthropologist), who talks (amongst many other things) about how culture shapes/teaches one how to express distress. The particular illness idiom that we identified for depression during our discussion is not, apparently, universal; in China, depression tends to be expressed in more somatic terms, offering a whole other set of symptoms that cluster together. I wonder whether people there do not experience the same symptoms we do here, or whether they are simply not emphasized? Or sanctioned? Warrants further investigation, certainly...

Brie Stark's picture

I think it's especially

I think it's especially interesting that all of these characteristics constitute the broad definition of depression that we hold today.  While we discussed that not every person feels all of these emotional or motor consequences, a large number of people will, at some point, feel almost all of them.  I think this particularly interesting because, as Paul said, there seems to be several causes for this -- but perhaps a 'causal' relationship is not actually how we should approach the situation.  It is probable that, for instance, the emotional 'hopelessness' could cause (see picture) lack of meaning, nothing to draw on to create a story, and so on.  However, I also think it could be an emergent-type feedback system: lots of emotional/motor responses in the brain culminating to form this specific collection of 'consequences.'  However, I've no idea what those intangible feelings/neurons/emotions are that come together to form such a situation.

I do find it interesting that seasonal affective disorder, a subcategory of depression, emits these 'symptoms' listed in the picture only at certain points in time.  Could there be an environmental impact far greater than we have taken into account before?  I think evidence points in this direction for seasonal affective disorder in particular, but perhaps could also hold links to the broader category of depression.

Paul Grobstein's picture

depression, continuing the conversation


click on image for enlargement

Rich conversation, thanks all.  It further strengthened my feeling that depression is not well understood either as "sadness" or as "chemical imbalance."  And that substantial future progress, both conceptual and therapeutic, depends on taking a broader view of what's going on, one that includes greater attention to internal experiences

Perhaps the most striking feature of depression is that it is a mix of several different characteristics, of which sadness may not be even the most typical one.  There are clearly both sensory features (grayness, relative loss of perceptual range in several modalities) and motor ones (slowing and reduction of movement, flatness of tone in speech), as well changes in sleep and eating patterns and cognitive abilities.   There are also several features of self-experience: senses of being trapped, of being located in an inescapable present with no meaningful future or past, of helplessness, of hopelessness, of loss of ability to motivate or control oneself. and of alienation, distance from both others and onself.

Cataloguing the mix is important from several perspectives.  One is that it makes it likely that depression is not a particular single thing but rather the expression of a more or less orderly interaction among a diverse array of things.  A second is that it makes explicit the question of what the causal relationships are among the diverse array of things.  And a third is that the diverse array of things includes what one is consciously experiencing:  "stories" of one's sense of onself and one's relation to one's surroundings.

Could the diverse array of characteristics of depression all be secondary consequences of one of them, or of some other underlying cause?  In principle, yes of course.  But thinking about depression in terms of a number of interacting parts, as an emergent property of a complex system, opens up a whole array of alternate conceptions that may in fact better fit existing observations, and perhaps a set of new productive questions as well.  The death of someone one can trigger depression but so too stressful situations (eg marital or job difficulties) in which sadness is less obviously a significant factor.   And depression can also be triggered by seasonal changes, in the absence of an obvious connection to either sadness or stress.  Moreover, depression often has a certain independent coherence to it, waxing and waning over periods of time relatively independently of external manpulations.  Both the property of their being different ways to get into a particular state and of some independent coherence of that state are perhaps more consistent with the notion of multiple interacting entities, with reciprocal causal relations ("loops") among them, than they are with a single cause/multiple effects notion.        

From this perspective, "chemical imbalance" should perhaps be thought of as being potentially as much an effect as a cause of depression.  And the same holds for "self-experience," the stories one has about one's self and one's relation to the world.  Of course one's stories can be affected by one's neurotransmitters, but conversely one's neurotransmitters can be effected by one's stories.  Depression can be helped, in some cases, by pharmacotherapy.  It can also be helped, in some cases, by talk therapy.  There is no mystery in this, if one adopts an emergent systems perspective of depression, and an associated understanding that internal experiences, stories, are not simply consequences but also have themselves causal efficacy in the web of interacting components. 

The emergent perspective on depression also suggests that internal experience may be as significant an indicator of what is going on in the brain as are measurements of neurotransmitter metabolism.  A feeling of helplessness and hopelessness, of being trapped in an eternal present, of having been abandoned  all seem to me significant in this regard.  External circumstances giving rise to those feelings can trigger depression; perhaps so too can such internal experiences generated by the brain without any associated external experiences?  The internal experiences can perhaps be a cause as well as an effect?  This might also make sense of some of the other non-arbitrary mix of characteristics in depression.  Perhaps diminished activity and a more general inclination to hide is part of what might, in some circumstances, be an adaptive response to being abandoned and unprotected in a world of unknown threats?  

What might lead to an experience of abandonment and helplessness in lieu of some dramatic change in external circumstances?  Here too it may be helpful to think in terms of multiple interacting elements.  One's conscious experience is built on and in turn influences a diverse host of elements of the cognitive unconscious, a continuing dialogue from which a coherent conscious story of oneself and one's place in the world emerges.  Should that dialogue be for some reason interrupted, one might well have a conscious experience of a a dissociation, a split between the self one is aware of and other aspects of oneself.  Such a split could in turn result in a sense of having been abandoned (by another part of oneself), a feeling of loss of control/will, and the other elements of a sometimes adaptive response to abandoment in a hostile unknown world. 

Might a prolonged conflict between conscious and unconscious understandings be at least sometimes a significant element in human depression?  Such a possibility is of course consistent with the presumptions of psychodynamic psychotherapy.  And might make sense in other terms as well.  Depression associated with seasonal affective disorder might well be thought of as the result of a conflict between unconscious expectations of the amount of light that should be present at any given time and one's conscious awareness of the actual amount of light.  And so might perhaps be relieved either by phototherapy or, at least in principle, by something that makes one less conscious of the experience of light.  Virtually all organisms are subjected to changing lighting conditions.  Is it possible that humans are subject to depression because of consciousness, and that organisms lacking consciousness don't experience a conflict under such circumstances and hence don't exhibit depression in the human sense of the word? 

Might something similar be going on in the case depression caused by the death of someone one is close to?  There is perhaps an unconscious expectation of continuing contact coupled with a conflicting conscious awareness of the person's absence.  The mismatch between unconscious expectation and the lack of anticipated contact may be initially disturbing but responded to by unconscious changes.  Could depression result when conscious expectations fail to become adjusted in the way unconscious one's are? 

More to mull, but perhaps a direction for some new thinking about depression in broader conceptual terms, one that might also have useful therapeutic implications as well?  And perhaps one that can both contribute to and draw from discussions of education and other things as well?

 

Paul Grobstein's picture

depression continuing, addendum

Two recent conversations suggest ways to both expand the list of facets of depression as an emergent complex system and to better understand the interactions of the components.

  1. Sociophobia, in the sense of a wish to avoid contact with other human beings, should be explicitly added to the list.  But it is itself complex, involving both a reluctance to be with other people and a wish not to be alone.  The key here, I suspect, is a distinction between various forms of interpersonal interactions, some of which are distressing while others are important but are felt to be unlikely to be achieved.
  2. Depression involves a "break down," in the sense that one feels unable to accomplish tasks that one would normally be quite able to do.  And perhaps in a deeper sense as well, that the unconscious givens that one uses as a basic structure for living no longer work well and need to be rebuilt.  Periods of depression may in fact be quite productive in this regard, and this is another way that depression may be an "adaptive" responsive: a period of relative disengagement from "normal" things so as to allow a needed rebuilding. 

Might depression involve less suffering for the individual, less sociophobia, perhaps fewer troubling "symptoms" in general,  if it were seen culturally as a period of altered productivity rather than as an absence of productivity, a partial retreat from some things in the service of others things rather than a complete retreat lacking any justification? 

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