[Tonight, I sat on a panel of three respondents at the (ongoing) Sarnia Justice Film Festival. The film being discussed was Beyond the Blues: Child and Youth Depression. The other two speakers were psychiatrists, pretty firmly rooted in the medical model of care, and so I was a bit of the odd-person-out. This is an extended version of what I said.]
Within his history of madness, Michel Foucault argues that madness, or mental illness, is not a natural and constant phenomenon throughout human history but is, instead, a construct that arises within a given society based upon various cultural, socioeconomic, political, and intellectual structures. Countering political, scientific and psychiatric narrative that posit an ongoing history of discovery and progress – a narrative which assert that we have simply gotten better and better at diagnosing and treating an unchanging historical constant – Foucault argues that societies construct their own unique experiences of madness.
I was thinking about Foucault’s analysis while watching this documentary.
In particular, I was wondering what it says about us, and our particular cultural moment, that we wish to construct depression within youth as a “biologically-based mental illness” which, although perhaps incurable, may receive ongoing beneficial treatment by a mixture of Cognitive Behavioral Therapy (CBT) and prescription pharmaceuticals. Is Foucault wrong? Have we simply gotten better and better at resolving psychiatric matters or is Foucault on to something, and is more going on in or own present moment than we are led to believe by the narrative related in this documentary?
I believe that Foucault is on to something. Note, for example, the way in which this documentary goes out of its way to lead the viewer to conclude that the environment or the context of the four young people mentioned was not the primary or central determining factor in relation to the depression. Despite some reference to situational factors in the cases of the first two youth, the implication of this presentation is that the environment is not that significant – rather, the internal biology of the youth is said to be the determining cause.
I would like to challenge this assumption – and it mostly is assumed in this documentary as the research about environmental causes of depression is not explored here. What the film does not mention, but what studies have shown, is that a young person’s context is a very large factor in whether or not that person exhibits symptoms of mental illness and, just as importantly, that context is a very large factor in the formation of the biology and neurological workings of a young person’s brain. In this regard, I would refer others to studies explored by the folks at the Alberta Family Wellness Initiative. What they rather conclusively demonstrate is that a young person’s environment – and especially the nature of the relationship that person has with caregivers – will determine how that person develops cognitively.
Furthermore, as Dr. Gabor Maté notes, depression and bi-polar disorder can develop in young people, not only because of negative childhood experiences (as conclusively demonstrated in the Adverse Childhood Experiences” [ACE] Study) but also when significantly positive childhood experiences are lacking. Parents may be full of love, may protect their children from any trauma or loss, and may never abuse their children – but if they are carrying undue amounts of stress, if they are overly busy, if they do not develop a significant enough attachment or attunement with their children, and others from the extended family are absent (the former “attachment village”) then youth are far more likely to exhibit various mental illnesses (cf. “The Biology of Loss: What happens when attachments are impaired and how to foster resilience”). This is why things like depression and BPD manifest more frequently in poor populations – poor parents are not worse or less loving than other parents, but they often are more stressed (cf. “Why Can’t Johnny Adapt?” Globe and Mail, Nov 28, 2008; see also Hold On To Your Kids: Why Parents Need to Matter More, which he co-authored with Dr. Gordon Neufeld).
Now, given all of this, it is worth asking why this documentary – along with a contingent of psychiatrists being supported by pharmaceutical companies and the government – are insisting that we remove the environment from the discussion and focus, instead, upon depression as a “biologically-based mental illness.” Not insignificant, in this regard, is the observation that mental health diagnoses have rapidly increased in children and youth over the last ten years. For example, the diagnoses of juvenile BPD jumped forty-fold between 1993 and 2004 and over 500,000 kids in America take antipsychotics, which, by the way, are the same drugs used as antidepressants (cf. The stats provided and discussion prompted by Marcia Angell’s articles in the New York Review of Books this past summer). As diagnoses increase, there is also an increasing push to view biology as the cause of the problem.
What is it about our particular context that may bring this about? I would suggest a combination of factors.
First, of all, beginning with the families of depressed teens, it should be noted that the narrative offered to us is the one that we want to believe. If our children are depressed because of strictly biological reasons, then we are all of the hook, we are in no way personally responsible, and we can sleep at night. Given that this narrative is what people want to believe, it is no surprise that they choose to believe it, when some folks come along and start presenting it in language that sounds medical and scientific (more on that in a moment). So, a psychiatrist is expected to produce a pharmacological solution. If she dares to suggest that parents are doing something wrong, and that medication isn’t the answer, she can expect a parent or lawyer to bring her to court (something “The Last Psychiatrist” explores on his/her/their blog).
Second, pharmaceutical companies support this narrative because biological problems can have concrete medical solutions, which can be manufactured and sold. Just as diabetics need assistance in maintain the proper level of insulin, so it is argued that folks who are depressed or bi-polar need assistance regulating their brain chemistry – say with selective serotonin re-uptake inhibitors (SSRIs). Of course, there is a lot of money to be made from selling such medications and, like any area of business, pharmaceutical companies have an interest in growing the population of people who purchase their products, so it is not surprising that they have become heavily invested with the American Psychiatric Association (APA) and especially with those who are responsible for writing updates to the DSM – the Bible of Psychiatry. In this way, the pharmaceutical companies have become increasingly involved in defining what a mental illness is and how it should be diagnosed and treated. So, of the contributers to the DSM-IV-TR, more than half had financial ties to drug companies (cf. this series of articles prompted by Marcia Angell in the NYRB). This has only continued to develop over the years. So, in 2009, Allen Frances, the former chairperson of the DSM-IV task force, stated that the DSM-V would be a “bonanza for the pharmaceutical industry but at a huge cost to the new false positive patients caught in the excessively wide DSM-V net.” (Of course, there is an incentive for the psychiatrist to also buy in to this narrative as they can almost double their hourly rate following this model, as opposed to more traditional talk therapy methods.)
Third, the final major partner in this push is government. Thus, for example, they provide grants in order to fund documentaries like this one. Why is government invested in this narrative? Because if one favours an approach to depression that highlights the importance of one’s environment or context, then people might start exploring how to change their environment. If more people are becoming poor, if more people are working harder and harder for less and less, if more people are living paycheque to paycheque, and if all of this is tied to the observation that more kids are being diagnosed with depression, then some folks might start banding together in order to shake things up and challenge the way things are in order to try and structure life together in a way that is less stressful and more life-giving. Therefore, and here I quote from the blog of “The Last Psychiatrist: “the point of the government’s policy on psychiatry is to treat all patients as having exclusively organic diseases and not socially generated problems; and medications, regardless of cost, are absolutely necessary to maintain this narrative” [emphasis in original]. Sometimes, we truly do live in depressing circumstances. Perhaps the thing to do, then, is to change those depressing circumstances instead of simply taking a pill that makes you feel happier and helps you to sleep better at night. This is what people did one hundred years ago, when they did not have the option of taking pills, when they fought and died so that we could have things like a five day work week, an eight hour work day, job benefits, access to education and health care, and so on. Fighting back at this level is not what government wants people to do today, as we slowly lose all those things. Hence, government supports the medical model of care.
So, these three elements – a family culture wherein everybody wants to feel like a good person and not take responsibility for anything, a business culture that wants to prioritize profit over people, and a political culture that wants to maintain the current trajectory of our status quo instead of facing seriously damning criticisms – all lead to the production of a narrative that asserts that depression is a strictly biologically-based mental illness that can be treated with a medical and scientific approach – or, as this documentary asserts, through antidepressants and CBT.
However, just as we have seen that this diagnosis of the cause of depression is problematical, so also the proposed solution faces a number of challenges.
On the medical side, three things should be taken into consideration. First of all, one must reckon with the observation that a multitude of rigourous scientific tests have been done on the use of antiphsycotics (i.e. antidepressants) in teens, and they all lead to the same conclusion: the medication does not ever fare better than placebos in any way that is clinically significant (cf. Angell again). This ineffectiveness is as true of Prozac as it is of the “atypical” or “second generation” antipsychotics that were all the rage recently (cf. this editorial by Dr. Kendall in the Oct 2011 issue of British Journal of Psychiatry). Secondly, there is also the fact that medications are being used on young people that were not developed to be used on minds that are still being developed. Thus, there is no way of actually knowing with any certainty what exactly these medications are doing to the neurological development of young people. Third, there is also the increasing awareness that these drugs actually have a negative impact upon the neurological development of young people (cf. Angell again; and Maté’s article in The Globe and Mail, Aug 21, 2004). Indeed, just as those who self-medicate with other drugs like alcohol or heroin, some of these side effects, especially those experienced with the use of the medication is discontinued, may lead to life long dependencies. Perhaps a new class of socially acceptable addiction is being created.
On the side of scientific treatment methods, and the documentary’s praise for CBT, the point that must be emphasized is that there is absolutely no evidence that CBT or any of the other ideologically named “empirically supported treatments” (ESTs) actually produce any better results than any other psychiatric methodology. Talk therapy, narrative therapy, existential analysis, cognitive behavioral therapy, all work equally well. This as been demonstrated by studies done by folks like Smith and Glass (1977), Frank and Frank (1991) and, especially, Bruce E. Wampold (2001; also David N. Elkins 2007, here, for a helpful summary) . Rather, what makes therapy effective are variables related to the interpersonal process — variables are common to all methods. So, for example, the attachment of the doctor to the patient is particularly important in treating something like depression and there is no one method – “scientific” or “humanistic” – that has more success in creating a positive attachment. Therefore, we need to be especially wary of those who wish to use the language of “science” and suggest that techniques can replace interpersonal relationship skills.
In conclusion, I wish to comment upon my own experiences both as a former homeless youth and as a person who has journeyed alongside of homeless youth, both in personal and professional capacities, for the last twelve years. While I am glad that this documentary encourages people to stop blaming depressed young people for their depression, I do not think we should fail to factor in other considerations as to contextual causes of depression. In part, we must reexamine our social structures – those that contribute to the stress and violence of some parents – and we must also examine the role the family plays. In terms of youth who are homeless (many of whom are depressed), about 75% identify violence within their home as a primary cause of their homelessness (of course, just as depressed kids aren’t “bad” kids, so also homeless kids aren’t “bad” kids). The solution to this is to establish loving, caring and encouraging attachments with these youth, attachments that are safe and affirm them as beloved and delightful. I have seen this approach do much more good (for myself and for others) than those who simply want give medication to every depressed homeless kid, thereby introducing them to yet another possible source for lifelong addiction, while doing little or nothing to change the context that produces depression.
Thank you very much.