Embracing the Reality of Organic Complexity
Finally, we return to thermostats and the moodostat. Attempts to understand mood disorders illustrate the human tendency to blame problems on a single cause. Blaming depression mainly on genetics or personality or life events makes it seem tractable. However, mood disorders result not just from multiple causes but from complex interactions among multiple causes that lead to symptoms via different routes in different individuals and even in the same individual at different times.
This complex reality is increasingly acknowledged. In a thoughtful article about the “dappled” causes of depression, the psychiatrist Kenneth Kendler lists eleven categories of causes ranging from genes to culture. He argues that “mutually re-enforcing dichotomies” such as mind/brain “have had a pernicious influence on our field” and do not explain research findings. “Instead, the causes of psychiatric illness are dappled, distributed widely across multiple categories. We should abandon Cartesian and computer-functionalism-based dichotomies as scientifically inadequate and an impediment to our ability to integrate the diverse information about psychiatric illness.”79
Instead of asking what causes symptoms in some people, we can return to the question about why we all have somewhat unreliable mood regulation systems. I have emphasized the utility of high and low moods in propitious and unpropitious situations and how persisting in the pursuit of unreachable goals escalates low mood to clinical depression. However, this is just part of the picture. Sometimes there is no striving, just something missing in life.80 Sometimes depression results from desire without hope. Our desires were shaped by natural selection. We can no more set them aside than we can decide to stop eating. A real solution to depression would require either changing society and providing opportunities for all or manipulating brains and minds to control desire. However, natural selection is way ahead of us. It has already created ways to control desire and dissatisfaction; repression and unconscious defenses are addressed in chapter 10.
How Does This Help?
Low mood is psychic pain. Depression is chronic psychic pain. This should guide how we evaluate and treat it. The first step is to try to figure out if something specific is arousing the pain. Investigation often reveals the inability to give up an unreachable goal. Many such problems are caused by “social traps,” the title of an interesting book by my former colleagues John Cross and Melvin Guyer.81 A student in her last year of graduate studies was $200,000 in debt, could not pay tuition or rent, and could not get more loans. A politician was being blackmailed by a former lover who demanded ever escalating sums to keep explicit photos private. An artist wanted to divorce her philandering husband, but that would have meant getting a job and giving up her studio. Social life often creates traps whose escape requires great sacrifices.
Have you ever walked through a bog, placing your feet carefully on tufts of grass that grow between the swampy parts, always looking for that next little tuft to make your way forward? There often comes a point where a slightly elevated bit begins to sink and your feet begin to get wet with stinking mud, but as you look around there is no route to high ground without going knee-deep into muck. Life has times like that. Patients with depression feel like they are sinking on a small tuft, fearful, often for good reason, of taking that first step into the muck. Leaving a job or marriage with no place else to go can make things worse. Much of the work of therapy is to help people get up the courage to make changes and to help them see other little tufts of grass on the way to higher ground.
Understanding low mood as a useful response and depression as excessive low mood suggests different approaches to treatment. Depression is caused by the situation, the view of the situation, and the brain. Treatment can change the situation, the view of the situation, and the brain. However, all three interact in tangled webs of causes, so addressing only one of them will miss many treatment possibilities.
This view has implications for understanding how antidepressants work. The idea that they normalize a “chemical imbalance” is appealing and helps to justify drug treatment, but there is no evidence for any specific chemical abnormality specific to depression. It seems more likely that antidepressants do for psychic pain what analgesics do for physical pain: they disrupt a normal response system. People have wondered how antidepressants with effects on different brain chemicals all can be effective. There is no mystery here. Aspirin, acetaminophen, ibuprofen, and morphine all act on somewhat different links in the pain regulation mechanism. Different antidepressants act on different links in the mood regulation system. The analogy goes further. Our strategies for relieving psychic pain are about as effective as our strategies for relieving physical pain—modestly to moderately effective, usually with side effects, often with risks on withdrawal, but still an enormous boon to humankind.
There may be a connection between the pursuit of unreachable goals and how antidepressants influence motivation. They often seem to disrupt the motivation system in ways that make everything seem less important. They calm grand ambitions and make pleasing others not quite so important. More than half of patients taking serotonin-influencing antidepressants experience decreased libido and/or delayed or absent orgasm.82,83 It would be very interesting to learn if patients who experience a greater decline of sexual desire also experience more mood benefits.
I recall one professor who started an antidepressant in the spring and experienced an excellent remission from moderately severe depression. She returned in the fall to report that the stress of teaching was no longer a problem. In December, she returned to report that her mood was still fine but she was in danger of losing her job. She had become so free from concern that she had not graded any student papers or exams all term. She decided to stop her medication.
There are also implications for cognitive and behavioral therapy. Reframing the meaning of a situation is often the most powerful intervention. Being abandoned by a spouse who departs without a word can be a source of weeping and hopelessness or a blessed opportunity to escape from an untrustworthy, cruel partner. New approaches to cognitive therapy “go meta” by trying to correct not just inaccurate thoughts about specific situations but inaccurate thoughts about the whole system of mood regulation and what is worth pursuing in life.84 Some, such as the British psychologist Paul Gilbert, have written about ways to use evolutionarily sophisticated ideas to make such therapies more effective.85,86,87
What About the Person?
I have emphasized the Situation to counter the tendency of both psychological and neurological approaches to blame mental disorders on characteristics of the Person. However, people vary dramatically in their tendency to experience emotional disorders. Whether these differences are accounted for by innate factors or by experience has been the focus of interminable debates about “nature versus nurture.” The nature side is fundamental to the neuroscience schema that dominates modern psychiatry and therefore has already received great emphasis. However, a huge body of literature describes how poor early rearing, especially neglect and abuse, can scar people for life.88,89,90,91,92,93
Thousands of therapists devote their careers to helping such people transcend such experiences, or at least cope with their effects. Such treatment can be remarkably effective. Early in my career I spent hours trying to discover what past experiences had shaped each patient’s personality and vulnerability to problems. Sometimes transformative insights emerged. A patient who viewed her mother as superbly good came to recognize that her mother had steadily subtly undermined her. A patient who had blamed himself for his parents’ divorce recognized that he had nothing to do with it. Another realized that guilt for sexual experiences with her father should belong to him, not her.
This book emphasizes the impact of current situations. The powerful influences of early experiences on vulnerability to mental problems are equally important, and much work is needed to discover the extent to which such influences are products of usefu
l systems and the extent to which they are by-products. It will also be essential to learn the extent to which such effects are transmitted by neuroendocrine mechanisms, versus the beliefs they induce about others and the self. And, of course, early experiences interact with innate aspects of persons to make certain situations likely. Reviewing what we know and what we need to know about how early experiences influence mental problems is an important project whose scope is far beyond that of this book.
PART THREE
The Pleasures and Perils of Social Life
CHAPTER 8
HOW TO UNDERSTAND AN INDIVIDUAL HUMAN BEING
Perhaps the greatest problem faced by the academic social sciences is that what is measurable is often irrelevant, and what is truly relevant often cannot be measured.1
—George Vaillant, 2012
On Tuesdays in the 1990s, I experienced two different approaches to psychiatry in a disturbing but profoundly instructive way. I spent the mornings poring over spreadsheets of numbers at the Institute for Social Research. We had detailed data about age, sex, income, depression symptoms, and dozens of other measures from thousands of people. The goal was to use the numbers to predict who was depressed.
Big findings jumped out. Rates are higher for some groups than others. For instance, early in life, depression is twice as common for women than it is for men. Dozens of other factors had smaller influences: number of children; their ages; church attendance; body weight; race; losing a parent early in life; number of severe life events in the past year. The project offered fascinating statistical challenges, because every individual belonged to many different overlapping groups. For instance, people who had health problems were more likely to be older, single, taking medications, and unable to attend church; each of those factors influenced depression and one another, making it challenging to figure out what caused what.
At noon I walked a few blocks to the psychiatric clinic, where I spent the rest of the day treating individual patients and supervising the work of resident doctors. The shift was wrenching. Instead of neat mathematical generalizations about groups, I am suddenly there with Ms. H, a fifty-five-year-old heavy individual with dirty yellow-white hair, who is crying and hopeless, telling me, through sobs, that her husband killed himself because she hadn’t taken his threats seriously, so she was planning to do the same to join him. Mr. J complains of skipped heartbeats whenever he sees his boss, who, he is convinced, wants to fire him. He says he has a heart condition, is depressed, and wants to get disability. Ms. K has been staying at home, not answering the telephone or doing much of anything ever since another woman was elected president of the gardening club after an election that was swung by a campaign of vicious gossip. And Ms. L, a thirty-five-year-old office manager in treatment for depression for ten years, is worse this month, almost certainly because she stopped taking her medication because it inhibits her orgasms and she is trying to date again. Or does her depression reflect her intuition that her new, already married lover might cause even more heartbreak than the previous one?
At the end of each clinic afternoon, the doctors, nurses, psychologists, and social workers met to discuss each case. We had the same data on our patients that I used in my morning statistical analyses. We knew each patient’s sex, age, marital status, employment, health status, and more. Did we use those data to figure out the causes of an individual’s depression? Never. Instead, we wove what each patient told us into stories that described how the individual had come to have this specific problem.
Consider the case notes on Ms. D.
Ms. D is a forty-five-year-old white married insurance agent. She is the mother of two teenagers; her husband is an engineer. She has always had a tendency to anxiety and mild negative mood, but the symptoms have become worse over the past six months, with crying episodes once or twice a week, usually in the evenings, for no specific reason she can identify. Her score on the Hamilton Depression Rating Scale is moderate, at 22. She has begun wakening at 4 a.m. several days a week; she is able to get back to sleep about half the time. Her appetite has increased, and she has gained 10 pounds. She feels fatigued most of the time. She is not suicidal, but she says she feels hopeless and lacks interest in her usual activities. She was active in a community group but has not participated for several months. Her mother also had chronic problems with anxiety, and her father was an alcoholic who may have been depressed at times. She recalls being criticized a lot by her mother, but she was never abused. Her health has been generally good, except for hypertension and episodes of chronic back pain for which no specific cause has been found. She says she drinks only occasionally. Medications include an antihypertensive, ibuprofen, and a PRN narcotic for pain. She uses Valium about three nights a week for sleep. Her husband is working two jobs to get money for the children’s education. Her daughter is doing well in school, but Ms. D is worried about her son. He was arrested for underage drinking about six months ago, but he is on track to graduate from high school in June. Her diagnoses are major depression, marital and family problems, chronic pain, and possible substance abuse.
That brief case summary contains most of the facts that you would find in her medical record. But it does not say much about what set off her depression.
In response to more questions, she said her symptoms had worsened after a fight in which her husband had criticized her for “lying around all the time and not keeping track of the kids.” When she began crying uncontrollably, he left the house, slamming the door. He called the next day to say he would be away on a business trip. She suspects that he might be seeing another woman but says she does not really want to know. Nonetheless, she ruminates all day about who her husband might be with, whether he will leave her, and what she will do if he does. She does not dare to confront him for fear that he will demand a divorce and blame her for their son’s drinking in order to get custody.
Such heart-rending stories made my fancy statistical models seem cold and empty. Even the clinical summary in the medical chart often didn’t quite get to the kernel of a person’s problem. The stories we constructed in our team meetings did, but were they correct?
Tuesday nights I often went home with my head spinning, eager to pour a stiff drink. It was all so confusing. With my scientist hat on in the morning, I was discovering how groups of people with and without depression differed. When I put on my clinician’s hat in the afternoon, all that went out the window as I joined my colleagues to weave the particularities of an individual’s life into a story that would explain that person’s depression. Neither approach was fully satisfying.
The Rector’s Solution
Browsing online, I found a very old article that relieved my confusion. In May 1894, the philosopher Wilhelm Windelband gave the rector’s welcome speech to inaugurate the 273rd year of the University of Strasbourg.2 He skipped the bragging you usually hear from American university presidents about their institutions. He didn’t even mention a sports team or thank generous donors. Instead, he gave a short talk that established and explained a profound distinction between two different kinds of explanation. One is based on general laws that are true in all times and instances; examples include the laws of gravity and economics. The other traces a history of specific events that explains how something specific came to be the way it is now; examples include the origins of our moon and the origins of the United States as a nation.
He gave those two kinds of explanations fancy names. Explanations based on general laws that are always true he called nomothetic (nomos refers to laws, thetic to a thesis). Explanations based on historical sequences that occur only once he called idiographic (idio refers to individual unique events, graphic to description). You can call them generalizations and narratives if you like, but nomothetic and idiographic are wonderful technical terms.
Tuesday mornings I had been doing nomothetic science without knowing it, trying to extract generalized laws about the causes of depression from masses of
data about groups of people. Tuesday afternoons I used an idiographic approach to try to understand how a sequence of unique events resulted in an individual having these symptoms now. My confusion resulted from failing to realize that idiographic and nomothetic explanations are different beasts.
In 1899, Hugo Münsterberg introduced the distinction to the New World by featuring it in his presidential address to the American Psychological Association.3 However, it got wide recognition only after the 1937 publication of the book Personality by his student Gordon Allport, the father of modern social psychology. Although he advocated integrating both approaches, Allport gained fame for advocating an idiographic “science of the individual.” He wrote:
Psychology has been striving to make of itself a completely nomothetic discipline. The idiographic sciences, such as history, biography and literature . . . endeavor to understand some particular event in nature or in society. A psychology of the individual would essentially be idiographic.4
Idiographic explanations are the foundation for much current work in the humanities, and they persist in psychology and sociology as “qualitative research.” But individual narratives have faded to oblivion in psychiatry. They have not just faded; they have been aggressively purged, despite their persistence wherever clinicians gather to discuss cases. Many journals don’t even allow publication of case studies. Idiographic explanations are the embarrassing wayward sibling of the far more successful nomothetic approach, with its objective definitions, quantifiable variables, repeatable experiments, statistical generalizations, and big grants.
Good Reasons for Bad Feelings Page 17