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, following 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 h ealth p rofessionals (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 w orld of natural d isease 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 àffective disorders’ in general an d 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, wh en the emotions are shares w ith social co nstructionism 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 p sy- misleading concepts w ith ones w hich 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 d eemed 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 fo rms 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 affect ive state (Lewis, 1 934; B ecker, be reduced methodologically to this position 1977). Others focus primarily on cognitive alone. We can, and should, make attempts at features. Perhaps most in fluential in this investigating reality in itself, but do so cau- latter respect h as b een Beck and his co l- tiously and critically. leagues, who have argued that the depressive In this paper we illustrate this approach by experience is ch aracterised 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 featu re 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 sy ndrome 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 `m ajor 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 the se 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 w ay, there w ould 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 p resent and their co mbination are this danger is not imminent because biologi- infinitely variable: other symptoms are cal markers are ipso facto missing for all frequent and sometimes d ominate the functional diagnoses, including that of de- clinical picture (Mendels, 1970, p. 6). pression. A similar ànything 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 about ric Association sources but then go on to note what co nstitutes d epression is a series o f that a `...single individual seldom shows all important disagreements about the dividing the aspects of depression; the diagnosis is line between depression and other kinds of made if at least a few signs ( sic) are present...’ psychological states. For example, some au- (p. 207). thors regard depression as a categorical con- Of course, it is common in physical medi- cept, whereas others regard it as existing on a cine to find groups of patients with the same continuum with normal functioning. Taking 264David Pilgrim & Richard Bentall the first of these approaches, Murphy (1982) occurrence of this mixed condition notes that true `clinical depression’ in the (Montgomery, 1990). Some authors have elderly may be difficult to distinguish from therefore argued that the `neurotic’ forms of more common dysphoria. In contrast, some depression cannot be distinguished from other cross-cultural psychiatrists have argued that neurotic d isorders (Tyrer, 1990) or that it each culture has varying criteria for describ- may be most useful to speak of a general ing everyday misery and distinguishing this neurotic syndrome that can be manifest with from abnormal unhappiness (e.g. Klienman, varying degrees of d epression or anxiety 1988). It appears that psychologists are more (Goldberg & Huxley, 1992). Researchers prone to assume the continuous distribution using factor analysis h ave sometimes at- of personality features and psychological tempted to resolve these disputes by classify- functioning, including the depressive experi- ing pathological emotional states in ways ence (e.g. Eysenck, 1977), whereas psychia- which d iffer markedly from ordinary lan- trists are more likely to argue that illness is a guage usage. For example, Clark & Watson category or discontinuous state (e.g. Kendell, (1991) have proposed a model which divides 1975). These b iases p robably reflect the negative emotions into three factors: non- professional socialisation of each group ± specific negative affect, manifestations of psychologists operate statistical assumptions somatic tension and arousal and anhedonia about experience an d behaviour, w hereas and the absence of positive mood. medical p ractitioners are tau ght to distin- There are also disputes about the dividing guish normality from abnormality by empha- line between depression and madness. It is sising diagnostic criter ia. A fundamental usually assumed that affective states can be- basis of the social status of medical practi- come psychotic if sufficiently severe, in which tioners is their unique claim to diagnostic case they are accompanied by `lack of in- rights. Accordingly, it is rare for doctors to sight’ or other psychotic phenomena such as abandon or problematise the latter. Simi- delusions and hallucinations. Kraepelin held larly, psychologists accrue social status by that these psychotic forms of depression were their applied scientist role and so require a distinct from dementia praecox (later renamed scientific rhetoric (about statistical reason- schizophrenia) and proposed the term manic ing) to maintain their professional mandate depression to describe both psychotic unipo- (Pilgrim & Treacher, 1992). lar depression and depression accompanied The relationship between depression and by episodes of mania, now known as bipolar anxiety is just as contentious as the relation- disorder (Goodwin & Jamison, 1990). How- ship between depression and normal func- ever, this distinction was soon challenged by tioning. In some texts, depression and anxi- some authors who argued that mixed condi- ety are regarded as having such a common tions are common and who suggested that the co-presence that a mixed group of symptoms term `schizoaffective’ might be used to de- from each `condition’ come to constitute a scribe such mixed states (K asanin, 1933). single pathological condition. For example, DSM-IV (APA, 1994) distinguishes between the tenth edition of the International Classifi- schizophrenia, schizoaffective disorder, cation of Diseases (ICD-10) describes a mixed major affective disorder and bipolar affective anxiety depression syndrome (World Health disorder, each of which is divided into further Organisation, 1992). Psychiatric texts about subtypes. Although the term `bipolar affec- primary care work also point to the common tive disorder’ implies that mania lies at the The medicalisation of misery 265 opposite end to depression on a spectrum of how both the professional and lay concepts of affect, phenomenological studies indicate that depression have emerged from their cultural manic patients report negative mood as much contexts. as positive mood (Goodwin & Jamison, 1990). Finally, there have been disputes about the Historical, cross-cultural and relationship between depression and physi- intra-cultural aspects of affect cal disease. Textbooks of psychiatry often point to the somatic features of depression The psychiatric concept of depression has (e.g. loss of weight, fatigue, loss of appetite), its roots in three separate diagnoses which thus allowing the possibility of attributing have now faded from the professional dis- these symptoms to depression in the absence course. The first was melancholia (a form of of overtly negative mood or cognitive fea- lunacy) and another was neurasthenia (ner- tures. This ambiguity about the central role vous exhaustion). During the nineteenth of somatic symptoms in depression is most century, a third notion, `mopishness’, was evident in the debates which have surrounded also found in common parlance along with the nature o f `chronic fatig ue syndrome’ melancholia, but was primarily attributed to (CFS) ± formerly known as `post-viral syn- the lower classes (MacDonald, 1981). drome’ or `myalgic encephalomyelitis’. Some The rise of depression as a single term for authors have entirely rejected the view that negative emotional disturbance followed the CFS is even, in part, a psychological phe- demise of its three predecessors. Until the nomenon (Ramsay, 1986). Others have seen Napoleonic wars melancholia w as: `b ut a it as a form of hysteria or masked depression rag-bag of insanity states whose only com- (McEvedy & Beard, 1970), whereas others mon denominator was the presence of few (as have argued that it is caused by physiological opposed to many) delusions’ (Berrios, 1995) dysregulation which, none the less, is af- but, by the mid-nineteenth century, it had fected by some of the processes thought to been transformed into a disorder of the emo- affect depression. (For a review of the di- tions characterized by inhibition and a de- verse competing theories about shared, sepa- cline in function. The concept of `mental rate and direction of etiology, in CFS and depression’ was introduced at this time as an depression, see the Joint Royal Colleges Re- analogy with `physical depression’, a term port (1996).) used to describe a decline in cardiovascular Given these confusions about its nature and function. Its dominance was assured by the boundaries, it is perhaps not surprising that later dissolution of `neurasthenia’ following Seligman (1973) has described depression the theoretical challenges created by shell- as, `The common cold of psychopathology, shock during the Great War (Stone, 1985). at once familiar and mysterious’. This de- This precursor of the currently preferred `post- scription, while reflecting the fact that de- traumatic stress disorder’ subsumed a variety pression is the most common diagnosis as- of symptoms including `hysteria’, ànxiety signed in psychiatric practice, acknowledges states’, `neurasthenia’, `disordered action of that the term belongs both to the technical the heart’ and `shell-shock’ itself (putatively vocabulary of the mental health professions caused by the neurological trauma of explod- and also, like the common cold, to ordinary ing missiles). language. In order to understand the existing Although modern Anglo-American psy- confusions, therefore, it is essential to know chiatrists consider neurasthenia to lack con- 266David Pilgrim & Richard Bentall ceptual validity, the concept is still used in studies of emotions, found that some states China, reflecting cultural differences of opin- which are d escribed regularly by English ion about the relationship between somatic speakers have no analogue in other cultures. illness and depression (Kleinman, 1988). To For example, in some African languages, the take another example of these differences, in same word covers what would be described some parts of the Indian sub-continent mis- separately as ànger’ and `sadness’ in English ery is often expressed through reports of a (Leff, 1973), whereas the Gidjingali aborigi- fallen or painful heart. This observation has nes of Australia do not discriminate `fear’ led western psychiatrists to claim that these and `shame’. patients are `really’ suffering from depres- Prototypical emotions which play a central sion and that they are mistakenly siting their role in western descriptions of psychopathol- grief behind their sternum. By contrast, medi- ogy may be entirely absent in other cultures. cal so ciologists stu dying distressed Asian Thus Marsella (1981) found no word for patients point out that depression is a recent `depression’ in many non-western cultures Western medical representation, which has and Leff (1973) found no words equivalent to no inherent conceptual superiority to that of ànxiety’ among Eskimos or Yorubas. Even alternative descriptions of unhappiness from when equivalent words do exist in two sepa- other cultures (Fenton & Sadiq, 1991). Apart rate cultures, which might point to similar from the cognitive preferences and interests meanings (e.g. Japanese words for ànxiety’ of Western medicine reifying concepts such and `depression’), studies using word asso- as `depression’, its diagnostic concepts are ciation or semantic differentials suggest that shaped and reinforced by drug company these experienced meanings are not always marketing and research strategies. This point equivalent (Chan, 1990). In his rev iew, is made with specific reference to `depres- Russell (1 991) concluded that w e cannot sion’ by Healy (1997) and highlights one of even take for granted the pancultural mean- our introductory points that economic forces ing of facial expressions. Japanese and Ameri- at times may shape concept formation and can subjects agree on `surprise’ or `sadness’ retention. but not on ànger’ or `fear’. Sometimes poor The problem of psychiatric diagnosis in agreement is even found about which internal different cultures can be understood by look- states are emotional. For example, the Japa- ing to more general cross-cultural studies of nese word `jodo’ has been translated as the affect. Different societies using different equivalent of the English word èmotion’ languages use a wide but variable range of (Matsuyama et al., 1978) but the range of words to describe emotional states. Wallace states it describes in Japanese includes Eng- & Carson (1973) found over 2000 words lish equivalents of `lucky’, `motivated’ and describing emotions in English, although less `calculating’. than 200 are found in the vocabulary of most Russell’s review of a range of ethnographic people. By contrast, Lutz (1980) found only studies suggests that in a minority of cultures 58 words used by the Ifalukians of Micro- there is no collective word for èmotion’ and nesia to refer to transient internal state s. that most cultures have idiosyncratic emo- Howell (1981) found that the Chewong of tional descriptions. For example, the English Malaysia have only seven words which trans- speaker has no immediate empathy for, and, late into English as emotional states. Russell no precise translation of, the German notions (1991), in a large review of ethnographic of angst or schadenfreude (hence our neces- The medicalisation of misery 267 sity to retain the words untranslated) . Simi- versus sleepiness’ (Russell, 1980; see Figure larly an Arab speaker may not understand the 1). This two- dimensional model also seems notion of frustration. Some cultures have to produce consistent judgements about emo- many variants o f one emotion (they are tional states reported in photographs of facial `hypercognized’ (Levy (1984)) compared to expressions from varying cultures, including other cultural lexicons. By contrast a culture North America, Greece, S pain, Vietnam, may have only one word for an emotion (it is Hong Kong and Haiti (Russell, 1991). `hypocognized’ ). From these o bservations it can be con- These studies beg the question of whether cluded that social constructionism is correct there are any grounds for making a claim for to emphasize the cultural and historical rela- universal emotional states. It could be argued tivism of first-person accounts of emotional that cross-cultural differences are so great states, but is incorrect when problematising that this task is doomed. However, some all empirical claims about invariance in the methodologies, su ch as m ulti-dimensional reality and causality of mental distress. scaling, point in a limited way to the exis- Equally, medical naturalism is correct to place tence of universal affective states. In this an emphasis on empirical investigations of method, in formants are a sked to rate th e distress but incorrect in na—vely confusing similarity of a range of emotion words. Rat- culturally and historically specific profes- ings are then analysed using a statistical pro- sional concepts (in this case `depression’) cedure which tries to account for them in with invariant templates of reality. The map terms of a minimum number of dimensions. is never the territory and, in the particular This method has been used to identify a broad case of `depression’, the map is extremely two-dimensional model of universal emo- unclear. tions, `pleasure versus dysphoria’ and àrousal

A la d r e m s d u e A e o h d r is f n r A a to A id s nn A d o ite ye c D d Arousal Ex ist d res ighte sed Del Happy

Pleased Unpleasant Pleasant Miserable Glad Sad Co d nte sse R nt pre Sleepiness e De la ed C x r ed o y al B p S m o l o e r d e e p D r i y T

Figure 1:The emotional circumplex 268David Pilgrim & Richard Bentall

Differences between professional and within the context of their unique bio- lay accounts of depression graphical frame of reference and might be construed with reference to various as- These cultural findings, together with the pects of their current, past or future life inconsistencies in the way that the term `de- situation. pression’ has b een used by professionals, 4.Professional accounts cannot be gener- suggest that professional and lay uses of the ated without reference to lay accounts term `depression’ differ in a variety of ways about emotional distress. Lay people take (Pilgrim & Rogers, 1993, Ch. 1; Rogers & up a range of views about professional Pilgrim, 1997). Thus we have a second major expertise from trusting dependency to criti- problem about the search for a universal cal o pposition. In between, some lay lexicon of emotions ± we cannot even assume people may understand, accept and par- consistency of meaning within a culture, tially internalise the professional discourse particularly when a restricted professional (a phenomenon de Swaan (1990) describes code is used about abnormal emotional life as `protoprofessionalisation’). Because by mental health experts. Similarities and terms such as `de pression’ co-exist in differences between the two groups can be both professional descriptions and in the suggested as follows: vernacular, culturally specific representa- 1.Professionals often assume that trans-his- tions of distress are sustained by the inter- torical an d trans-cultural consistencies action between the discourses of lay peo- exist ab out mental illn ess w hereas la y ple and professional healers. Analogously, people express themselves about ordinary as Kleinman (1988) observed, Chinese feelings and distress in a way which varies psychiatrists eschewed the diagnosis of both across and within cultures. depression in favour of neurasthenia just 2.Professionals claim a general p re-emi- as much as their patients. nent and superior epistemological status Thus, confusion about the concept of de- for their descriptions. Lay people do not pression within the psychiatric literature re- aspire to this p re-eminent position al- flects a tension between lay experiences of though they may expect that their idiosyn- emotions (which have both trans-culturally cratic experience is taken seriously. The recurring and biographically unique features) status of professionals is therefore bound and professional accounts. Whereas lay ac- up with their competence at generating counts of distress have specific parochial and expert accounts which are meaningful and temporal value for ordinary people, they do transparent enough to be persuasive, but not aspire to universalise their particular at- not so transparent th at lay people can tributed meanings. In contrast, professional readily capture professional authority. accounts assume the universal (i.e. 3.The social setting of professional diag- transcultural and transhistorical) validity of noses is not typical of the social settings in their representations of misery (such which emotions are experienced and emo- as`depression’), an assumption that, on re- tional distress generated. A point diagno- flection, may seem unwise. sis is a snapshot taken at one moment in a This conflict between professional and lay clinical setting using a type of lens owned accounts is likely to be particularly problem- by the diagnostician. By contrast a lay atic in the context of research into emotional person’s experience of distress occurs problems. When potential patients state that The medicalisation of misery 269 they are `depressed’, they are presumably more sophisticated understanding of the lim- evoking the lay representation of depression bic sy stem because they have accepted a because it best fits their subjective apprehen- na—ve naturalist account of emotional states. sion of their position on the emotional It seems likely that research in psychopa- circumplex. For example, th ey may feel thology will have been affected by similar dysphoric and to some extent either aroused difficulties. In the remaining sections of this (agitated) or sleepy (lethargic). Their self- paper we discuss tw o influential line s of report will also be influenced by the extent to research in which we believe these difficul- which their cultural representation of depres- ties are evident. sion is concordant with other aspects of their current experience ± for example, feelings of The work of George Brown and low self-esteem or a lack of interest in events colleagues on the social origins of which would otherwise be pleasurable. To the researcher, this report of `being depressed’ depression is translated into the professional representa- The work of George Brown and his col- tion of a discrete and universal em otional leagues has produced a highly sophisticated condition ± a diagnosis of `depression’. social m odel o f `depression’, which sub- Brothers (1997), a neuroscientist who has sumes a multi-factorial picture of past and been sensitive to these kinds of difficulties, has recently shown how the assumption of present determinants within specifiable in- transculturally and transhistorically valid dis- ter-personal, as w ell a s, so cial situ ations. crete emotional states has led to confusion in However, Brown has quite self-consciously her field. She has argued that researchers evaded any pre-empirical consideration of have differed in their attempts to implicate the legitimacy of the diagnostic category of particular structures in the limbic system in depression (see Brown & Harris, 1978, p. 20) particular emotions, according to the differ- and has made it clear that he believes that ent behaviours (elicited by brain stimulation there is a biological substrate to an identifi- or eliminated by ablation) which they have able and diagnosable psychiatric condition singled out as representative of those emo- which is different from everyday misery ± tions. She has also pointed out that th e `depression’. changes in emotional behaviour observed in Brown’s work can be situated within a animals following brain stimulation or abla- Durkheimian tradition of sociological position depend on the social context in which the tivism which is highly compatible with medi- animal is placed. Finally, she has argued that cal n aturalism. Ingleby (1981) describes many of the assumptions apparently support- Brown’s work as a version of `weak positiv- ing the more general hypothesis that the lim- ism’ because of its uncritical retention of a bic system is the neurophysiological locus of dubious diagnostic category, despite its ex- emotion (that there are clear anatomical cri- ploration of the meanings-in-context of dis- teria for assigning structures to the limbic tressed people. As a consequence of this, it system; that these structures are exclusively fails to engage with the conceptual problems involved in visceral regulation; that visceral we have highlighted earlier, or with the points changes are th e basis o f emotion) do not about cultural and historical relativism legiti- survive scrutiny. In her account, physiologi- mately raised by social constructionists. cal researchers have been unable to achieve a (Brown and his colleagues are still working 270David Pilgrim & Richard Bentall on cross-national comparisons in which they ticular Seligman’s (1975) learned helpless- export assumptions about the universal ap- ness theory, which argued that depression plicability of western psychiatric nosology.) occurs when individuals have no control over Paradoxically, the very determinants t he their environment. Like much of the neuro- Brown model en umerates, which provide physiological research discussed by Brothers empirical evidence for the social causes of (1997), Seligman’s model therefore depended misery, may be obscured by emphasising on identifying a particular class of animal depression as a `real’ medical condition. In- behaviours as equivalent to an apparently deed, the medical diag nostic ap proach to discrete emotional state in humans. Faced by depression individualises the very social proc- the observation that depressed patients often esses and antecedents the model quite per- claim excessive responsibility for the misfor- suasively explores. tunes in life, the theory was then modified to Brown’s work is most illuminating if the include an attributional component. Accord- focus of attention is shifted from his chosen ing to the revised learned helplessness theory end-point (the diagnosis of depression) to the of Abramson et al. (1978), depression there- antecedent and situational factors which at- fore occurs when the individual experiences tend human misery. These have both political negative events as uncontrollable but also and psychological dimensions. For example, attributes them to causes which are internal to the inadequacies of male partners as sources the self, stable over time, and global in their of nurturance for women, and the tendency impact of areas of the individual’s life. Sub- of the former to entrap and humiliate the sequent research indicated that d epressed latter, may create what Brown calls patients, on the whole, did make the expected `depressogenic’ effects (Brown et al., 1995). attributions for negative events, but much However, this could be reframed by simply less clearly indicated that attributions (espe- stating that miserable women live with op- cially of internality) were trait vulnerability pressive men. Similarly, sexually abused markers for depression as the theory sup- children are likely candidates for the later posed. psychiatric diagnosis o f depression (and In the wake of these inconsistent findings, others) (Browne & Finkelhor, 1986), with Abramson et al. (1989) further revised the these victims constituting up to half of the theory, and argued that attributions were distal psychiatric population. Given this linkage, causes of hopelessness, which was now con- while it is possible to talk about `the diagno- sidered the proximal mediator of depressed sis of childhood sexual abuse’ and `the diag- mood. They suggested further that the model nosis of depression’ in its survivors, it is less was only valid for a subtype of depression, mystifying to think about the enduring mis- which was labelled `negative cognition’ de- ery created by the sexual oppression of chil- pression. In order to avoid the otherwise dren by adults. inevitable circularity of this position, Rose et al. (1994) compared depressed patients with The work of Lyn Abramson and a pessimistic cognitive style with those who colleagues on attributions and appeared to lack this style, finding that the depression former group were more lik ely to have a diagnosis of personality disorder, and were Attributional theories of depression have more likely to have experienced difficult or evolved from earlier animal models, in par- abusive relationships with their parents. These The medicalisation of misery 271 findings imply clearly that attributions play Implications for mental health an important role in psychopathology, but do research and practice not provide a particularly compelling case for allocating them a specific causal role in a We have argued that the contemporary subtype of depression. To complicate mat- western medical n otion of `depression’ is ters further, other researchers have shown confused, woolly and inadequate as a basis that the so-called `depressogenic’ attributional for formulating mental health problems. We style is also observed in people diagnosed as have also argued that two major epistemo- suffering from anxiety disorders (Mineka et logical p ositions about p sychological d is- al., 1995). tress (medical naturalism and social These disputes can be resolved by aban- constructionism) do not provide adequate doning the idea that attributions are linked to practical solutions to the problems created by a discrete and readily identifiable condition this conceptual incoherence. We have sug- of depression. For example, T ennen & gested that a third or middle p osition of Herzenberger (1987) showed that attributional critical realism is a more helpful approach to style was predictive of self-esteem, and that mental health problems, as it ensures a proper the apparent relationship b etween attribu- caution about historical and cultural relati- tions and depression disappeared when self- vism, without degenerating into the unend- esteem was included as a covariate. This ing relativism and nihilism attending social observation raises the possibility that other constructionism (Bhaskar, 1990, Greenwood, behaviours and experiences which are some- 1994; Pilgrim & Rogers, 19 94; Busfield, times subsumed under the label of depression 1996). This position respects empirical find- may be accounted for by other mechanisms. ings about the reality of misery and its multi- For example, some authors have argued that ple determinants but does not collapse into disruption of circadian rhythms is the core the na—ve realism of medical naturalism. It feature of depression (Healy, 1987), but this accepts causal arguments but remains sensi- would seem to be a better explanation of tive to the relationship between empirical those symptoms which are so metimes de- methods and pre-empirical (e.g. professional) scribed as `biological’ (early wakening, interests and social forces. fatigue and loss of appetite) rather than prob- One implication of our analysis concerns lems of self-esteem that appear to be associ- research. Given that the concept of depres- ated with abnormal attributions. The tangles sion is in sufficiently narrow to allow the which cognitivists have got themselves into, specification of cognitive and biological shown in this short section, have been a mediators of distress, it may be necessary to function of them accepting the concept of focus research on more narrowly defined depression uncritically. Like other fu nc- behaviours and experience, for example low tional psychiatric diagnoses it is a profes- self-esteem, fatigue and anhedonia, experi- sional reification about human misery, not a enced in specific social contexts. However, fact. If the concept is n ot w orking as a we have also argued that th e concept of coherent pre-empirical notion perhaps we depression is insufficiently broad to allow a should review its utility instead of generating full exploration of the social and political more and more empirical studies producing conditions which contribute to human mis- more and more ambiguous findings about ery, and that the current focus on a psychiatric `depression’. diagnosis m ay mystify and obscure these 272David Pilgrim & Richard Bentall conditions. For these purposes, therefore, a Instead of focusing on the end-point diag- much broader concept of human misery may nosis of `depression’, therapists might seek be required as well, allowing sociological or idiosyncratic formulations of the antecedent social-psychological studies which focus on and current conditions (including the pa- the supra-individual phenomena associated tients’s individual attributed meanings) which with family, social and work life. have shaped the patient’s expression of this A second implication of a critical realist misery. Signs of this approach are already view of misery concerns problem formula- evident within therapeutically orientated tion and intervention. The current outcome froms of community psychology (e.g. Hol- literature on the treatment of `depression’ land, 1979) and in feminist th erapy (e.g. suggests that many therapeutic approaches Eichenbaum & Orbach, 1982). However, are helpful, but that a combination of antide- because of the latter’s psychodynamic roots, pressant medication and cognitive±beh av- it has been criticised for still being prone to iour therapy is the most efficient treatment psychological reductionism (Busfield, 1996; option (e.g. Klerman et al., 1 994). This Pilgrim, 1997). A more holistic understand- conclusion, if valid (and Fisher & Greenberg ing would attend to the social determinants of (1997) dispute the findings about the efficacy misery and would involve exploring the pa- of anti-depressants), m ay be explicable in tient’s individually attributed meanings. This terms of a `blunderbuss’ approach. Antide- would be similar to the current practice of pressants have a fairly non-specific effect on cognitive±behaviour therapy (CBT), but negative mood as well has having anxiolytic would also involve applying the lessons effects (Goldberg & Huxley, 1992). At the learned from the work of Brown and his same time, the positive connotations about colleagues, together with other evidence about reality encouraged by cognitive±beh aviour antecedent stressors explored in other socio- therapy serve to reverse demoralisation and logical research on health and quality of life. demotivation. While it is n ot surprising, In its traditional form CBT is also prone to then, that a biological and cognitive pincer psychological reductionism, as it singularly approach seems to be effective, compared to focuses on the patient’ cognitive processes, no treatment, when helping miserable peo- implying that reality is not a problem, only ple, th e danger of these reductionist a p- the way we construe it. (Logically these are proaches to treatment is that they may mys- not mutually exclusive ± we do not have to tify the oppressive social conditions which only problemetise one or the other, both/and generate the distress experienced by the pa- are possible.) tient ± the technical fix of treatment may In order to avoid the pitfall of victim blam- obscure our pathways into misery. For exam- ing in the psychodynamic and cognitive treat- ple, in secure w ork and poor task control ments of `depression’, attributed meanings increase the risk of psychological distress in and external reality need to be attended to in workers (Marmot et al., 1991) and unem- equal part. This would require a therapeutic ployment raises the probability of both de- flexibility which responds to the experienced moralisation and suicide (Fryer, 1995). The distress of different individuals from differ- point diagnosis (or `identification’) of `de- ent circumstances. 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