I was interested to read an article published today by a journalist called Mary Kenny on the BBC News website that refers to a longstanding argument about modern-day conceptualisations of sadness and depression. In it, she argues that as the stigma surrounding depression has decreased and it is more ‘acceptable’ as a condition than it was, say, 50 years ago, the idea that periods of sadness, bereavement and loss are part and parcel of normal fluctuations of human experience has been lost.
Increasing openness about personal distress and suffering marks a departure from a time when such things were kept behind closed doors, leaving the individual to suffer alone and in silence. The marked shift in attitudes towards mental health is no doubt a good thing (though there’s still a long way to go), but Kenny fears that the vocabulary now used to describe human experiences of loss and sadness is reductive and the use of medical terms implies that the experiences are indicative of disorder, of something having gone wrong, and therefore not a normal part of human life. She cites increasing use of the technical-sounding term ‘trauma’ in place of grief or mourning: when someone suffers a loss or experiences a particularly emotionally turbulent time they are described as going through a ‘traumatic experience’ for example. Yet bereavement, loss and mourning clearly are part of normal human experience, and thus her argument runs that we are losing touch with old rituals and rich, varied ways of describing such sadness as these experiences are increasingly brought out of the dark recesses of human nature and into the light.
I see Kenny’s point and agree fully that the rich varieties and subtleties of human experience cannot and ought not to be reduced in the way she describes. But I feel that actually, her argument has nothing whatsoever to do with the stigma of depression and mental illness.
Firstly, she has identified the wrong target. Her suggestion is that reductions in stigma, accompanied by increasing frankness and openness about the prevalence and nature of depression have led to the loss of the “dark poetry of the human condition”. Yet I see no reason why in and of itself, wider knowledge of depressive mental illness should have this effect: if anything, it might enrich our understanding of such experiences.
The problem as I see it is that she is not actually talking about depression. Kenny appears to have conflated ordinary, normal kinds of experience such as bereavement, nostalgia and loss – which she views through a somewhat romantic lens – with the far more debilitating condition we have come to call ‘depression’. The very reason depression is considered an illness is that it marks a significant, distressing and impairing, departure from the vagaries of normal life (though the DSM-IV somewhat clumsily differentiates depression and bereavement through a seemingly arbitrary distinction regarding the duration of symptoms). It can disrupt or destroy a person’s life, relationships and ability to function in the world- it is not a nostalgic yearning for past loves, wistful sorrow or romantic melancholy as Kenny seems to think.
Here we come to the crux of the issue. Whilst it is still an open question as to quite how depression (as a mental illness) ought to be classified and diagnosed, it is certainly true that today certain kinds of normal human experience are overmedicalised and pathologised. Any period of sadness or social withdrawal may be instantly viewed through a medical lens, either by the person or by others around them. We are quick to judge that any deviation from our normal routines and moods is inherently pathological. Such feelings may of course signal the onset of something sinister but at the same time they may simply be, as Kenny is keen to emphasise, normal variations that we should accept as part of the human condition. It is the ‘illness’ label that is problematic here- the domain of ‘symptoms’ has perhaps spread too far and encroached on “normal” fluctuations in experience, but this is an issue to do with how we label and understand those troublesome and distressing periods of life that we all experience, not an issue about the stigma of what can be a devastating mental illness.
Humanities and Health 
A very interesting post Natalie – I wonder whether the relative de-stigmatisation of mental illness in recent years leads to overmedicalisation; that it is precisely the idea that these are normal and very treatable manifestations (or symptoms) which normalise them in the eyes of society (as, for example, the word “cancer” seems to have lost some of its fearfulness now that treatments are far more advanced than, say, when my parents were young). That is, in bringing an unknown or mysterious quantity forward (such as a manifestation of depression) and categorising it as a symptom, it loses its potency. Perhaps there is something of loss of poetry, as poetry draws its power from the unsaid; the sophistication of modern psychiatry allows symptoms to be named and categorised, making treatment possible but also diminishing the aura surrounding concepts of depression and mental health.
Whether this leads to overdiagnosis I am unsure – perhaps an analogy could be drawn with the overprescription of antibiotics, for easily treatable bacterial infections. For example, antibiotics for tonsillitis have been shown to reduce recovery by one day; it is not a cure but a shortening of recuperation. In this way, can bacterial infections be seen to be a “normal kind of human experience” – and should they be treated? Can benefits be derived from treating sadness – and if so should we treat it? Isn’t all activity which makes us feel good “treatment” – the endorphin-producing effects of chocolate, for example? A hundred years ago, death in childbirth was a relatively normal experience. My mind harks back to the amazingly prophetic “Brave New World” – all the more powerful because it is so credible as a vision of the future.
Interesting point- I certainly don’t think the destigmatization of mental illness is entirely dissociated from the increasingly medical language we use to talk about all manners of suffering and distress. Such language has a powerful role to play in reducing blame and responsibility for one’s predicament: being ill means that one ‘cannot help it’, rather than being an indication of, say, laziness or lack of moral fibre. This itself is destigmatizing, but needn’t necessarily reduce the totality of a person’s experience to the dry, impersonal medical concepts under which it is being subsumed.
Why is medical language used to describe such experiences as sadness, bereavement, stress? What concerns me as a clinician in the conflation between distress and pathology is that I experience a demand for medication as a solution to distress caused by often modifiable environmental conditions. Also a demand for access to ‘the Sick Role’ with its attendant secondary benefits. Medicalisation in the sense used by Illich has secondary gains. It is ‘easier’ to be off work whilst sick than unhappy and it is easier to prescribe than to listen. Since Daniel McNaughton’s failed assassination of the Prime Minister, English law is sympathetic where criminal activities are the result of madness rather than badness. Conversely I also see people who are profoundly debilitated by florid mood disorders being told to ‘buck up’ by workmates and family members. Illich’s 40-year old tirade about the lucrative market in psychopharmacology is part of a general tirade against medicalisation and institution-driven dependency in general not helped by a widespread belief that attainable happiness should resemble the WHO definition of Health: a state of total physical, mental and social wellbeing. Moreover this is coupled with a notion that such a state should be available on the NHS.
For an update on what Andrew Papanikitas calls above the ’40-year old tirade’ against psychopharma, and a cynical angle on the ‘conceptual gerrymandering’ that sometimes goes along with affect and its disorders, I was interested to read Mikkel Borch-Jacobsen’s review of David Healy’s 2008 book on mania, in this week’s London Review of Books:
http://www.lrb.co.uk/v32/n19/mikkel-borch-jacobsen/which-came-first-the-condition-or-the-drug
Meanwhile, like Natalie, I wonder if medicalizing language is really reductive; or at least, there seem to me to be several questionable assumptions in this. Does an experience imagined as a medical symptom or condition, as well as a ‘normal’ part of life, really cancel out or subsume that supposedly pre-existing ‘normality’ (is it always ‘instead of’?). There can be augmentation as well as diminution of meanings in the language of the clinic: as Andre Breton and Paul Eluard once proposed (admittedly, tongue in cheek) the terminology of mental illness ‘could advantageously replace the ballad, the sonnet, the epic and other such decrepit literary forms’.