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The Medicalisation of Misery: a Critical Realist Analysis of the Concept of Depression

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The Medicalisation of Misery: a Critical Realist Analysis of the Concept of Depression Journal of Mental Health (1999) 8, 3, 261±274 The medicalisation of misery 261 The medicalisation of misery: A critical realist analysis of the concept of depression DAVID PILGRIM 1 & RICHARD BENTALL 2 1Queen’s Park Hospital, Blackburn, Lancashire & 2University of Liverpool, Liverpool, UK Abstract This paper will explore some difficulties with the concept of depression from the perspective of critical realism. We have three aims. First, we will describe the variable, and sometimes incommensurable, ways in which the diagnosis of depression has been defined and discussed in professional mental health texts. Secondly, we will examine this confusion in relation to historical and cross-cultural work on emotions and distress. Thirdly, we will provide two case studies from social science which reveal the limitations of conventional approaches to depression ± the research of George Brown and Lyn Abramson and their co-workers. Introduction Boyle, 1990). In the second position, follow- ing Foucault and Derrida, psychiatric diag- Recent debates about psychopathology are noses are studied as representations of a vari- characterised by two polarised positions. The egated and ultimately unknowable human first of these might be described as `medical condition. Mental illness, according to this naturalism’ and the second `social approach, is a by-product of the activity of constructionism’. Medical naturalism, fol- mental health professionals (Parker et al., lowing Kraepelin, assumes that psychiatric 1995). According to this view, causal argu- nosology proceeds incrementally with a con- ments about mental health or illness are seen fidence that there exists a real and invariant as inherently problematic, and the study of external world of natural disease entities psychopathology `itself’ is replaced by a (Hoff, 1995). The logic of this position is that study of the ways in which psychopathology these entities are studied by diagnosticians is represented or socially constructed. Within with increasing sophistication, leading to a medical sociology, constructionist critiques more and more accurate description of real- have also been evident about non-psychiatric ity. A variety of critics have argued that the illnesses (Bury, 1986) although, as with func- absence of hard signs in psychiatry renders tional mental illness, there has been a ten- all of its functional diagnoses (i.e. most of the dency to focus on conditions with contested work of the profession) as problematic or or unknown aetiology, such as multiple scle- mythological (e.g. Szasz, 1961; Ingleby, 1981; rosis. Address for Correspondence: Professor David Pilgrim, Department of Clinical Psychology, Queen’s Park Hospital Blackburn, Lancashire BB2 3HH, UK. Tel: 01254 687106; Fax: 01254 293417. ISSN 0963-8237print/ISSN 1360-0567online/99/030261-14 Shadowfax Publishing and Taylor & Francis Ltd 262David Pilgrim & Richard Bentall It is possible to take a third approach, which about `affective disorders’ in general and in some respects lies between these `depression’ in particular, rarely include dis- oppositional points of debate. This position, cussions about the general nature of emotions which can be called `critical’ or `sceptical (Power & Dalgleish, 1996). Even within realism’ (Bhaskar, 1990; Greenwood, 1994), psychology texts, when the emotions are shares with social constructionism the re- addressed, discussion about their nature usu- quirement that scientific and technical con- ally occurs in separate chapters from discus- cepts be examined in the context of the social sion of psychopathology. We will argue that and historical conditions which allowed them the incoherence of many psychiatric accounts to emerge. However, in contrast to the social of depression becomes understandable when constructionist approach, it does not assume this literature is examined. that the study of psychopathology itself must give way to the study of discursive practices Professional representations of alone. Rather, the study of the social and depression historical context of concepts is seen as an indispensable strategy for replacing biased or Within the psychiatric and clinical psy- misleading concepts with ones which are chology literature, there are a variety of posi- more useful scientifically and clinically. In a tions taken about what constitutes depres- critical realist account it is not reality which sion. In some texts, no working definition is is deemed to be socially constructed (the offered at all, although a range of symptoms axiomatic radical constructionist position), are explored. This approach is evident in the rather it is our theories of reality , and the writings of some biological theorists (e.g. methodological priorities we deploy to in- Golden & Janowsky, 1990) as well as some vestigate it. Our theories and methods are who are more psychologically orientated (e.g. shaped by social forces and informed by Beck et al., 1979). This failure to provide a interests. These include interests of race, clear definition implies that the concept of class and gender as well as economic invest- depression has a self-evident validity. How- ment and linguistic, cultural and professional ever, closer inspection reveals that different constraints in time and space. These forces authors assign primacy to different psycho- and interests invite forms of sceptical or logical phenomena when writing about de- critical analysis when we are asked to accept pression. For example, some texts insist that or reject empirical knowledge claims about it is primarily a disturbance of mood and that reality. Thus deconstruction has a part to play all associated phenomena are secondary to in this exercise, but human science should not this affective state (Lewis, 1934; Becker, be reduced methodologically to this position 1977). Others focus primarily on cognitive alone. We can, and should, make attempts at features. Perhaps most influential in this investigating reality in itself, but do so cau- latter respect has been Beck and his col- tiously and critically. leagues, who have argued that the depressive In this paper we illustrate this approach by experience is characterised by a negative offering an exploration of emotions and emo- view of the self, the world and the future tional distress, focusing on the way in which (Beck et al., 1979). the concept of depression has been employed In an attempt to avoid assigning primacy to in psychiatric theory. It is striking that psy- one particular feature of depression some chiatric texts, despite asserting knowledge writers have argued that depression is a `Syn- The medicalisation of misery 263 drome not a symptom and this syndrome physical dysfunction (disease) who none the requires the presence of several symptoms’ less report a range of experienced symptoms (Montgomery, 1990, p. 31). In accord with (illness). However, the diagnostic approaches this assumption, DSM-IV (American Psy- to depression outlined above differ from those chiatric Association, 1994) requires the pres- in physical medicine in at least two important ence of depressed mood and four other symp- respects. First, there appears to be no consis- toms before `major depression’ can diag- tent transcultural, transhistorical agreement nosed. Other psychiatric definitions include about minimal necessary and sufficient looser or more arbitrary inclusion criteria. pathognomic criteria for the phenomenon of For example, in one standard text it is stated interest. For this reason, depression, like that: other functional psychiatric diagnoses such In the clinical context the term depres- as schizophrenia (Bannister, 1968; Bentall et sion refers not simply to a state of de- al., 1988), is a disjunctive concept, poten- pressed mood, but to a syndrome com- tially applicable to two or more patients with prising mood disorder, psychomotor no symptoms in common. Secondly, as in the changes and a variety of somatic and case of other psychiatric diagnoses, the diag- vegetative disturbances. All of these nosis of depression is based exclusively on changes may be present but none includ- symptoms and not on signs. If it was possible ing depressed mood is essential... to redefine depression in terms of unambigu- (Willner, 1985, p. 3, emphasis added). ous biological markers it would be possible In another text it is stated that, `The word to distinguish between those who were really depression is used in many ways to describe depressed and those who just appeared to a mood, a symptom, a syndrome... as well as share some experiences in common with de- a specific group of illnesses...’ (Mendels, pressed people. Of course, in redefining 1970, p.1). Moreover, following the presen- depression in this way, there would be a tation of a list of symptoms, the text goes on danger that the clinical concept of depression to observe that: would become entirely divorced from the The extent to which these symptoms everyday concept of depression. However, are present and their combination are this danger is not imminent because biologi- infinitely variable: other symptoms are cal markers are ipso facto missing for all frequent and sometimes dominate the functional diagnoses, including that of de- clinical picture (Mendels, 1970, p. 6). pression. A similar `anything is possible’ position can be found in accounts written by psy- Drawing the line between depression chologists. For example, Davison & Neale and other phenomena (1990) provide a symptom checklist of nine points blended from the American Psychiat- One consequence of the ambiguity
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