In my work as a psychologist for people dealing with the aftermath of significant injuries, I am often presented with the question of whether low mood in my patients is best understood as a normal reaction to a serious health event — it’s reasonable, for instance, to respond to news that you may never walk again with questions about how life might be different and more challenging — or as clinical depression that should be treated. This is an extremely difficult determination to make.
Part of the reason it is so hard is that there are serious disagreements about where to draw the line between the two and even whether it can be drawn at all. Psychiatry’s guiding paradigm is that some extremes of mood are sufficiently severe that they constitute illness. But a longstanding criticism of psychiatry claims that the issues it professes to treat are just ordinary aspects of the human condition (or “problems in living,” as the psychiatrist Thomas Szasz, a staunch critic of his own profession, would have it) that are being unnecessarily pathologized. This argument isn’t restricted to questions about diagnoses; a version of it plays out across multiple mental-health-related debates. At first glance, these can look like separate discussions, but they tend to boil down to the same central questions: Is happiness always the goal of mental health treatment? How can we know when we’re happy enough? How miserable are we supposed to be?
This debate is perhaps at its fiercest when it involves discussions around psychiatric medication. The generation of antidepressants that were introduced in the 1980s were initially hailed as miracle drugs that could help patients feel, as one psychiatrist put it, “better than well,” improving their personalities and resolving depression. In time, however, concerns developed that such medications blunted people’s moods or numbed them. Today clinicians and researchers argue interminably about the minutiae of whether antidepressants really address a brain chemistry issue or they work by dampening emotions. Are we treating people who need help or sedating them through the highs and lows of life?
Emotions run particularly high around medication, and the same questions arise in the field of psychotherapy. The intervention being debated in this case is slower moving, but clinicians still disagree about the fundamental purpose of the talking cure.
For those operating in the tradition of cognitive behavioral therapy, the goal is something like symptom reduction. Moods can be measured and, with the right approach — by adjusting distorted patterns of thinking, for instance — improved.
Existential and psychodynamic approaches to psychotherapy frame things differently, placing understanding and meaning making at the center. Freud provided a sense of the mission early on with his comment that the goal of psychoanalysis is to transform symptoms into “ordinary human misery.” The psychologist George Prigatano, in his book about the psychological treatment of neuropsychological disorders, baldly states (quoting Charlie Chaplin) that “the theme of life is conflict and pain.”
The basic fault line that runs through various mental health controversies has to do with the role of misery in our lives. Misery is inevitable, but we also have a sense that there can sometimes be too much of it. We don’t want to eliminate misery; that seems somehow morally dubious and practically impossible. But nonetheless, it sometimes strikes us that we could be happier than we are. One way of dealing with this problem is to think in terms of illness — and, certainly, misery can become so profound that it starts to resemble an illness.
Pinning down the broader tensions in these disputes can help explain what we’re really arguing about. Because these discussions often happen among clinicians and scientists and because they often take place in peer-reviewed journals, they have the appearance of technical debates. The hope appears to be that, with enough care, we could land on a successful definition of mental disorder, the correct psychotherapeutic protocol or set of guidelines for prescribing. This hope is misguided. When we argue about definitions, therapy and medicines, we are often arguing about something more significant and overarching.
How miserable are we supposed to be? It is extremely difficult to know when low mood trips over into depression or when people’s thoughts about their lives are distortions. When does emotional dysregulation become mania? When do idiosyncrasy and magical thinking become psychosis? This difficulty is what leads us to outsource such determinations to clinicians and other assorted experts. Those experts are then imbued with significant power. They assess and diagnose us and reflect for us a view of how maladjusted we are. Concerns about this power have made mental health such a fraught topic. We want clinicians to have some power, but we worry about it.
But the power to make determinations about when we are ill and what constitutes too much distress is actually a power that still resides, to a great extent, with the general public rather than specialists. Psychiatrists have tried in various ways to develop a definition of mental disorder. These can be based on statistical notions of normality or on theories of mental dysfunction that are grounded in what is considered natural. Such definitions fall down, though, as pointed out by the philosopher Derek Bolton, because statistical rarity by itself does not entail aberration. And determining mental dysfunction is impossible, given that it’s apparently hard to agree on how our minds ought to function: Are we supposed to go through periods of intense, crippling sadness, or are we not?
Dr. Bolton resolved this by deciding it was impossible to ground our notion of disorder in any set of biological or statistical facts. Mental disorder, he concluded, is more or less whatever a community decides it is. If you start behaving in ways that are uninterpretable by your community, you might find yourself in front of a psychiatrist. The extent to which we are mentally unhealthy is a function of what starts to seem unhealthy in the context of people who know us well and are trying to get along with us. As the psychoanalyst John Rickman succinctly put it, “Madness is when you can’t find anyone who can stand you.”
To navigate the question of who should be referred to treatment for their misery, I need to be guided by medical definitions of depression. These definitions are what we’ve used to test the efficacy of treatments, and they translate our idiosyncratic preferences as clinicians into the professional standards of our peers. If patients seem sad but still basically engaged with life, I might aim to support them in navigating their experience of loss and change through therapy. If their low moods are persistent across several weeks and they are consistently hopeless, with disrupted sleep, guilt and negative thoughts, I might refer them to a psychiatrist to consider medication.
My thinking about this process has changed. Earlier in my career, I was concerned about missing “true” cases of depression. Now I take a more pragmatic attitude. If I refer patients to a psychiatrist, it is not that I think the underlying fact of the matter is that they are depressed. Rather, I am aware that some people are able to benefit from antidepressants — that their lives can plausibly be made better — and that my patients, because they resemble other such individuals, may be such people.
When I ask myself some version of “Are these people more miserable than they’re supposed to be?” my clinical judgment comes to resemble something more commonplace than a medical diagnosis. Not detached from the standards set by my professional peers but now more grounded in practical considerations about the intelligibility of a person’s feelings, rather than abstract technical notions of pathology and treatability.
The value of this reframing is that it has a sort of democratizing power. It gives more weight to people’s priorities and their life contexts alongside the definitions created to guide expert diagnosis. I am not deciding that they are depressed; we are deciding together, alongside the community at large, that the misery has become too much to bear.
