Manufacturing depression

by Gary Greenberg

  Those hardships were substantial, the discontents widespread. Leaving America after an eight-month lecture tour in 1927, Sandor Ferenczi, a Hungarian analyst and close colleague of Freud, told a New York Times reporter that “life in America is so strenuous that the people are naturally driven into neurotic conditions.” Criminality and insanity and “incorrigible children” demanded our attention, Ferenczi added, but “another issue…is the psychological readjustment that thousands upon thousands need in their relation to family, profession and society in general.” Which meant that the whole world could be put on the couch.

  But that didn’t mean that the whole world was insane—or, for that matter, that it needed doctoring at all. Ferenczi may have sounded like George Beard in flagging the dislocations of modernity as a widespread pathogen, but the Freudian diagnosis was at once more universal and less medical than Beard’s—not neurasthenia but neurosis, not the rest cure but restless exploration of the incurable human condition. This difference helps to explain something remarkable about Civilization and Its Discontents: that in this sometimes bitter, often mournful, and always melancholy lament about who we are, what kind of world we have created, and where we are headed, Freud never once mentions melancholia.

  My doctors at Mass General would no doubt have interpreted the absence of melancholia from Freud’s book as yet more historical evidence that depression is not unhappiness itself but an illness that has unhappiness among its symptoms, and that Freud himself was trying to make that distinction. They would claim that now that they have returned to a Kraepelinian diagnostic scheme, they are able to sort out the diseased from the merely discontented. Far from indicating a flaw in that logic, or at least that their diagnostic net was cast too wide, my presence in their study meant that their science worked. It told them something about me that I didn’t know: that if I thought I was only suffering from das Unbehagen, that was my depression talking.

  But Freud would have had a different explanation. Civilization and Its Discontents may not have been an account of a medical condition—his own or anyone else’s. (“I believe that I have not given expression to any of my constitutional temperament or acquired dispositions,” he wrote, perhaps forgetting how this denial would sound to a Freudian.) But that didn’t mean it wasn’t scientific. The book’s gloomy conclusions were the only ending that the evidence allowed: “My pessimism appears to me as a result,” he wrote, “the optimism of my adversaries as a presupposition.” Science, after all, sometimes tells us what we would prefer not to hear.

  But what kind of science was psychoanalysis? Ferenczi’s interview with the Times ended with a coded message that answered this question. All that psychological readjustment, he said, “opens a tremendous field for the analytically trained social worker.” The general reader might have heard the good news that help was on the way for the discontent he evidently was bound to suffer; young people looking for career opportunities may have heard a different encouraging message. But to doctors, especially those with a professional interest in psychoanalysis, Ferenczi’s words had another meaning: social workers, not doctors, were going to reap this bounty. Medical science was one thing, psychoanalytic science another.

  Ferenczi was in fact firing a salvo in a battle that had already been raging in his profession for a few years and that had just recently surfaced in a Times article that had run just a couple of weeks before the interview. An American doctor by the name of Newton Murphy, the story went, had gone to Vienna for analysis with Freud. The master was too busy to see him and referred him to a student analyst, Theodor Reik. After several weeks of treatment, Murphy, according to the Times, “declared that his health was worse rather than better.” He complained to Freud but evidently received no satisfaction, because he then approached the Austrian authorities, claiming that because Reik was not a physician, he was guilty of quackery.

  The trial was attended by the elite of medicine and psychoanalysis in Vienna, among them Julius Wagner-Jauregg, a Nobel Prize–winning psychiatrist. Testifying on behalf of thirty-one of his colleagues, Wagner-Jauregg warned that psychoanalysis was “dangerous when practiced by a man not educated in medical science.” Freud countered that medical science was not only irrelevant to his treatment, it might actually get in the way. “A medical man cannot practice psychoanalysis because he always has medicine in his mind,” he told the court. The judge decided that Freud knew what he was talking about when it came to psychoanalysis and dismissed the case against Reik.

  But a court in Vienna couldn’t stop what had already happened in America. In 1926, the New York Psychoanalytic Society declared that only physicians could practice analysis. Freud’s response came in The Question of Lay Analysis, in which he spelled out why doctors were ill-suited to psychoanalysis: their education was exactly the wrong preparation for the job. “It burdens [a doctor] with too much…of which he can never make use, and there is a danger of its diverting his interest and his whole mode of thought from the understanding of psychical phenomena.” Doctors are subject to the “temptation to flirt with endocrinology and the autonomic nervous system,” as if psychic suffering was just another illness whose cause and cure were organic.

  Some mental suffering may indeed be organic in origin. A few cases of melancholia, Freud wrote in “Mourning and Melancholia,” “suggest somatic rather than psychogenetic diseases,” but his own interest lay in the “cases whose psychogenetic nature was beyond a doubt.” These maladies—the neuroses—were the proper object of his therapy, and because the mind was shaped by history and culture, the education of analysts must “include elements from the mental sciences, from psychology, the history of civilization and sociology, as well as from anatomy, biology, and the study of evolution.” There was no time to teach medical students these subjects in addition to all they had to learn about medicine. But without this breadth of knowledge, doctors would make poor analysts. Perhaps even more important to Freud—whose “self knowledge,” he wrote, “tells me that I have never been a doctor in the proper sense”—their ignorance would lead them to turn psychoanalysis into a “specialized branch of medicine, like radiology.”

  That was the last thing Freud wanted. “As long as I live,” he declared, “I shall balk at having psychoanalysis swallowed by medicine.” But even Sigmund Freud could not control the fate of psychoanalysis. The New York Psychoanalytic Society continued the policy that Freud, his already rabid anti-Americanism inflamed by his quarrel with American doctors, called “an attempt at repression.” Mental suffering may have been democratized, but it was still an illness, its understanding and treatment still firmly in the hands of the medical elite. The social workers would have to find some other way to save the world.

  Staking the territory of das Unbehagen for medicine, the renegade analysts opened the way for the depression doctors eventually to corner the vast unhappiness market—a debt of which my doctors at Mass General were most likely unaware. But the New York psychoanalysts left their future colleagues with a problem that would only deepen as more and more of the mysteries of the human organism fell to the microscope and the scalpel: the diseases the psychiatrists were claiming as their own were problems of the mind, their origins in culture and history, their treatment in the refashioning of biography. But the authority behind the doctors’ claim derived from treating diseases that were biochemical in origin for people who, as Freud grumbled, “expect nervous disorders…to be removed.” It was only a matter of time before the obvious contradiction between form and content became an embarrassment.

  The solution to this problem is obvious in retrospect: to swallow psychoanalysis and all the psychotherapies it spawned, to turn them into a specialized branch of medicine, the depression doctors had to turn away from biography and back to biology. They eventually had to declare that the mind does not exist except as a property of the brain. Which meant that doctors could have it both ways: dominion over our discontents and a claim to scientific knowledge about them. Only then would das Unbehagen
be folded into major depressive disorder, the disease at which my doctors, funded by the federal government and employed by the most prestigious university in the country, could aim their magic bullets.

  CHAPTER 7

  THE SHOCK DOCTORS

  The most fun part of my clinical trial came on my fifth visit. By then I’d been dutifully taking my pills—five glistening amber gelcaps a day—for six weeks. I’d been asked the same questions, filled out the same forms, gotten my parking ticket stamped by the same receptionist four times. I knew the combination to the lock on the men’s room door by heart.

  I’d also been told that I was improving. And maybe I was feeling a little better, a circumstance that I would normally have attributed to some minor successes or to the relative ease of life in the summer or to the random nature of emotional life or to increasing maturity and wisdom or to the fact that I was finally getting my book off the ground or indeed to nearly anything other than a daily dose of three grams of omega-3 fatty acids.

  Or maybe I wouldn’t have ventured any explanation at all. After a while, you just start to think that depression and its remission just can’t be explained, not fully anyway. You look at your immediate circumstances and see if there is one you can change, some trouble to manage or irritant to eliminate, some loss to mourn. You take the steps, make the change, spill the tears or voice the rage, and if that doesn’t make you feel better, if you still wake up nauseated and afraid and spend your day that way, you contemplate other measures, therapy maybe or some distraction or maybe even psychiatric drugs, but all the time you are doing this you are also just waiting for it to pass like bad weather. Maybe you regret that you are built this way, the same way that you regret that your musical talent is limited, that you are losing your hair, that you drive away some people and attract others, and maybe you stand in alternating awe and resentment at just how narrowly the margins are drawn around what you can change, and you take all this as a reason to develop your humility before the indignities really catch up with you. But mostly you can’t really know what made life turn ugly any more than Job could.

  Because you can’t live an experimental life and a control life at the same time. You just take your best guess at what causes what and try to live accordingly. And by the time you’re fifty, you like to think that the few things of which you are certain—beyond, of course, the increasing impossibility of being certain about anything—are also true, that you haven’t just snared yourself in some unjustified faith, some ideology, held against science and, increasingly, common sense, that posits that consciousness has to be more than the sum of its parts, that history is important, that self-examination is, if not a cure, then surely more than a mere consolation. So when the doctors start not only to tell you that they know what is wrong with you better than you do, but also to show you the proof that you are actually getting better in exactly the way they predicted, when they add up their numbers and the survey says you have improved, when their certainty about where your depression resides and what ought to be done about it has the ring of scientific truth, you really have to wonder about the conclusions you’ve arrived at. Maybe you have to face the possibility that you are like Schopenhauer, in William James’s version, barking at the moon. Maybe you have to choose between being right about the ways of the world and being happier.

  But I couldn’t decide. I kept taking my pills, but I never totally got on board with the doctors, no matter what the numbers said. This was partly my native orneriness, a pigheaded clinging to my worldview over theirs. But it seemed to me there was a big problem even within their world. It was those tests, the ones they were using to measure my depression and to tell me that I was improving.

  In addition to the HAM-D and a questionnaire filled out by the doctor about constipation and fevers and other possible side effects, I was completing a battery of forms on every visit—the Q-LES-Q, which rated my life enjoyment and satisfaction, the Quick Inventory of Depressive Symptomatology (QIDS), which asked me to circle a number on an item like this one:

  View of Myself

  0. I see myself as equally worthwhile and deserving as other people

  1. I am more self-blaming than usual

  2. I largely believe that I cause problems for others

  3. I think almost constantly about major and minor defects in myself

  And the Ryff Well-Being Scale, which measured my emotional state by asking me to rate on a scale of one to six how much I agreed with statements like “For me, life has been a continuous process of learning, changing, and growth” or “My daily activities often seem trivial and unimportant.”

  What was bothering me about the tests wasn’t only that they seemed inane and puny compared to what they were trying to measure. It was also their logic—or their lack of it. It’s the burden the depression doctors took on when they revived Kraepelin: you have to assume that the patient is depressed in order for his feelings to be considered symptoms, but the symptoms are the only evidence of the depression. Wondering if “life is empty” or “if it’s worth living,” may be, as the QIDS insists it is, a thought of suicide or death—but only if you’re depressed. Otherwise, it’s just a common, if disturbing, thought. To logicians, this is known as assuming your conclusion as your premise, or begging the question.

  The depression doctors know about this problem. Even the best doctors are skeptical of the ability of these tests to parse inner life. On an early visit, I complained to Papakostas about having to choose from one of four options, or worse, a yes or no, to describe what I thought were complex, sometimes even incomprehensible experiences. “I’m sorry to seem dense about this,” I said, “but it’s just not how I usually think about things.”

  Papakostas was reassuring. “You know, this question condenses a lot of areas of life into just a number. It doesn’t work well,” he said. “Some questions we just don’t like.”

  Since condensing life into a number seemed to be more or less exactly what we were supposed to be doing here, and since the results were the basis of my diagnosis and the claim that the drugs were treating it (not to mention of the whole antidepressant industry) this seemed like a startling admission—sort of like a priest telling me from his side of the confessional that he’s not so crazy about this venial sins business. And later, when we got to the question about my naps (I had snoozed four times for thirty minutes or more that particular week) and Papakostas said, “See, some of the questions are really nice in terms of being objective,” it seemed like the right time to speak up, to remind him that when doctors and drug companies tell people that drugs cure the disease of depression, they don’t add, “But by the way, the tests that allow us to say so are really bullshit.”

  But I didn’t protest. Quite the opposite, I sympathized. “I suppose it would be easier if there were biochemical markers,” I said. “Otherwise, you’re just stuck with language.”

  And even when Papakostas said, “Hey, we’re psychiatrists. Language is good,” as if this entire enterprise weren’t an attempt to avoid the uncertainties of language, I still didn’t speak up.

  Maybe it was the abrupt change from Papakostas to Dording, or just the fact that I didn’t like her so well, but by the time of my fifth visit, I was over my attack of Stockholm syndrome and ready to stop giving the depression doctors a free ride.

  My chance came when Dording, administering the HAM-D, asked (as Papakostas had already asked four times), “In the past two weeks, have you been feeling excessively self-critical?” There’s no doubt that I am a very self-critical person. If there’s a problem somewhere in my vicinity, if someone I care about is unhappy, I assume that it’s at least partly my fault. I don’t particularly enjoy this about myself. But is it excessive? Or is it what makes me caring, responsible for myself, a conscientious citizen, an effective therapist, a decent writer? And to what or whom am I supposed to compare my self-criticism to determine its excessiveness? To another depressed patient? To the way I wish I were or think I ought to be? So I a
sked.

  “If there’s a comparator implied, it’s always to when you’re not depressed,” she answered crisply, as if no one had ever asked such a silly question, as if it was as plain as the nose on my depressed face. She seemed so sure of herself that I began to wonder if her answer really was as circular as it sounded, if it meant more than saying self-criticism is a problem when it’s a problem and not when it’s not, and if it wasn’t a call, if ever there was one, for some self-criticism on the psychiatrists’ part. It seemed like a denial of the basic assumption of this whole clinical trial—that they were the experts about my mental health, that depression isn’t something I’m equipped to detect in myself, because if I was, I’d have been in the other study, the one for the minor depression I thought I had in the first place. I began to wonder if this was really the old Kraepelinian problem or if all this wondering and my resulting inability to blurt out a yes or a no was just another example of my excessive self-criticism.

  But I was staying on my side that day, on the side of language and meaning. So I asked her if she really thought self-criticism is pathological.

  “Pathological?” she asked, as if she’d never heard the word. “I don’t know if I’d call it pathological.”