The stated goal of The Myth of Depression as Disease
is to explain the nature of depression and the existing array of treatments in
order to disabuse potential consumers of mental health services of the
currently dominant view that depression is a biological disease/disorder that
is best treated by medication, and to persuade them to make use of behavioral
therapies instead.  It is to be "a primer on depression–an objective
evaluation of what has been said about it and the truth about treatments
available for it." (p. xiii) After reading the book, depressed persons
presumably should be able to make better-informed, scientifically based and
validated choices about treatment. The work is principally aimed at that body
of potential consumers but is also "directed at professional caregivers
who either make referrals for the treatment of depression or are providing such
treatment….[and at] readers who are concerned about health care in the United
States and how the health field has come to be dominated by the pharmaceutical
industry and managed care." (ibid.) The intended audience covers a wide
spectrum indeed.

Myth‘s major thesis is that the widely sanctioned and
implemented pharmacological approaches lack credible scientific theoretical and
experimental support, but that such support is available for a variety
of behaviorally-oriented approaches that are putatively based on scientifically
validated  learning theories and confirming outcome studies. "Good science"
is the one and only benchmark–a credo often called "scientism". To
make their case the authors: 1) present a critique of
biological/pharmacological frameworks and approaches, drawing on key
publications (e.g., Valenstein’s Blaming the brain [1998]; Kirk and Kutchins’
The Selling of DSM [1992]); 2) explain psychology as science, especially
its learning theory (principally: conditioning and its contextual aspects); 3)
describe the several major variants of therapy based on this theoretical
framework and cite supporting scientific evidence of their efficacy ("claims
[of efficacy are] supported by data… behavioral treatments [are] derived from
many years of good research" [p. xiv]); and 4) offer critical and highly
negative comments that support their rejection of the remaining major
alternative treatment framework, psychodynamically-grounded thought and its
allied practices (pp. 13, 93-95, 136-137), largely on the basis that it is
unscientific.

The
authors consider why the pharmacological treatments of depression and the
neurobiological theories on which these are based so clearly have won the day.
They point out, quite correctly in my view, that research results that run
counter to these beliefs simply make no impact on the true believers, on those
scientists who are convinced ab initio of the inviolable truth of their
neurobiological-clinical theories, findings, and philosophical presuppositions
(typically, unstated and unrecognized), and, furthermore, that powerful
interests (primarily the pharmaceutical and insurance industries) back
biological belief systems for financial reasons. I would also add that many if
not most mental health consumers (and their families) like simple, quick and
passive fixes that hold all blameless thus turning a blind eye to individual,
family and societal pathological dynamics, and so do other important players:
physicians, politicians, law enforcement agencies, school systems, just to name
a few. Now, one of the ironies in what I see as a mediocre, simplistic, limited
book is that in their own way, Myth‘s proposed behavioral alternatives
can be seen as suffering from many of the same kinds of major drawbacks. Its
authors are true believers too. They, too, elide the voluminous, compelling
literature critical of their belief system (see, for example, the later works
of Sigmund Koch, or Raymond Tallis’s critical analyses) which has accumulated
over more than half a century; those critiques remain invisible in their book.
And they, too, advocate mechanical, mechanizing, relatively simple, quick,
externally administered and passively received treatments that claim to be
effective on the basis of published "scientific research", findings
that adverse critiques reveal to be suspect, to say the least. 

The
extensive literature supporting psychodynamic alternatives and criticizing
behavioral approaches is considered superficially and then disdainfully
dismissed. Old, familiar charges are revisited: psychoanalytic theory lacks
scientific credibility, no experimental evidence is offered in support of its
treatment methods, the framework relies on anecdotal evidence, the therapy is
long, expensive, inefficient, often unsuccessful, and so on. Psychodynamic
thought is disparaged, sometimes by the use of scare quotes that imply that a
concept or term is at best suspect–e.g.: "some treatments are aimed at
changing ‘intrapsychic processes’ … [or at] ‘uncovering’ hidden psychological
processes" (p. 94). In these ways any and all potential consumers are
encouraged to indiscriminately steer clear of psychodynamically-oriented
treatment approaches. Are these hoary criticisms really valid? It takes a good
deal of intellectual work and clinical experience to see their limitations (not
that psychodynamic thought and practices are without their own severe problems–for
decades, my own published work certainly has been severely critical of both).
At any rate, the knowledge and understanding of psychodynamic thought and
practice exhibited by the coauthors is marginal. For example, they seem unaware
of what I see as perhaps the most important contemporary critique and
alternative approach coming from within psychoanalysis itself, namely, Paul
Gray’s and his followers’ work on Close Process Listening.

Myth has other clinical and philosophical significant
shortcomings. Examples of important clinical shortcomings of the
promulgated approach are: 1) It is a one-size-fits-all approach that ignores
the issue of what I long ago called the matter of "targeted referrals".
Myth strongly implies that all depressed persons seeking therapy should
opt for a behaviorally-based treatment, but I have argued that ideally,
patients should be matched to treatment modality on the basis of sophisticated
clinical thought (although, sadly, it must be granted that for many reasons,
for far too many would-be patients the authors’ advocated approaches may be the
best of a bad lot). 2) It misleads its readers by falling in with the defensive
view that "depression" or dysthymic mood is something like a foreign
object, an alien, unwanted element or symptom rather than an important,
meaningful aspect and manifestation of one’s makeup. 3) It is an instrumental,
dehumanizing technique that treats the person/patient as one functional
component in a depersonalizing behavioral learning "system", as a
mechanism that mediates between input and output "variables". Within
this setting it counts on self-mastery, self-manipulation (those deceptively
simple sounding but highly paradoxical terms) to remove or suppress the
supposedly alien aspect: behavioral approaches show "what you can do to
overcome these [depressive] negative feelings" (p. xiv). The person
becomes fundamentally split and fragmented into the "good" part that
does the controlling, and into the "bad" part that needs to be
squelched, or eliminated altogether. 4) It assumes without further ado that "getting
rid of the symptom" is equivalent to regaining mental health–a
questionable, simplistic assumption. Is being "happy" or at least "not
depressed" really a healthy way of responding to living in a highly
pathological, self-destructive society (see, for example, Joel Kovel’s, James
Hillman’s, or Morris Berman’s critical writings)? 5) By its total reliance on
normal scientific logic and methodology, behavior theory and therapy ignores
the infantile aspects which are invariably present in persons, aspects that not
only have their own peculiar logic and in that sense are "irrational"
but that also resist basic change via therapies based on ordinary rationality
(e.g., behavioral therapies).

Need
I add that these and similar objections are likely to be dismissed out of hand
by behaviorism’s true believers? Again: typically, neither they nor their neurobiologically
oriented cousins can take any fundamental criticisms of their frameworks
seriously.

As
to philosophy, especially philosophy of science: the book exhibits a
truly appalling lack of awareness of the profound philosophical difficulties
that issue from its basically logico-positivist philosophical stance,
difficulties that have been identified and analyzed in a huge corpus of
philosophical critiques. The difficulties to which I allude include those that
derive from the book’s implicit Cartesian substance dualism; from its
unexamined operationalizing of psychological phenomena; from the partitioning
of psychology into a disjunct theory/practice dichotomy; or, from its reliance
on "objective observation" and concomitant linguistic descriptions of
psychological phenomena. Furthermore, the authors do not seem to realize that
not only have their kind of logico-positivist positions been severely called
into question for a long time now, but also that they have been largely
abandoned within contemporary natural science itself. Psychologists are lagging
behind; they still tend to operate in a philosophically Newtonian world. One
therefore ought to ask not only whether applying such a rigorously and rigidly
positivist framework to psychopathologies (or to psychology in general) is defensible,
but whether it really is the only legitimate, defensible option? I do not think
so; elsewhere I have suggested a radical alternative: a praxis–based
framework.

Now,
admittedly, objections may be made to these claims and criticisms; let me anticipate
two obvious ones. First, one can legitimately complain that I have made a lot
of unsupported criticisms and claims. To adequately support these, however,
would take volumes as I have shown over decades in my own publications. I would
be pleased to furnish a short list of key references to any interested reader.
Second: One might well ask, Is it fair to expect authors of this kind of a book
to be able to avoid the assorted shortcomings which I have pointed out? For
example, should and can such authors be expected to be familiar with the
relevant works and critiques of Continental philosophers, or of radical critics
of our society who call the goals and means of the entire mental health
movement into question? (The book does reference a work of one such critic, the
strident Thomas Szasz’s The Myth of Mental Illness, in Appendix D, "Suggestions
for further reading" [p. 149].) I think that they should be, but of course
I also realize that according to that expectation most mainstream clinical
works would fall short, or even should remain unpublished. So, does that mean the
we shouldn’t expect these kinds of clinical books to be sufficiently deep and
knowledgeable? To be adequate? (which raises an important and puzzling
pragmatic question: sufficiently deep, sufficiently adequate for What?)
Do we not need to offer potential consumers of the mental health field, to the
mental health professionals themselves, and to concerned others a richer,
sounder, less provincial, superficial view of "mental health", of psychopathology,
and of psychotherapy? a more deeply human, meaningful vision? I suppose the
answer depends on one’s value system, and I leave it to the reader to decide.

© 2006 Louis S. Berger

Louis
S. Berger‘s career has straddled clinical psychology, engineering and
applied physics, and music. His major interest is in clinical psychoanalysis
and related philosophical issues. Dr. Berger has published 6 books, including Introductory
Statistics, 1981; Psychoanalytic
Theory and Clinical Relevance, 1985; Substance
Abuse as Symptom, 1991, and most recently, The Unboundaried
Self, as
well as several dozen journal articles and book reviews.  His book Psychotherapy
As Praxis was reviewed in Metapsychology in January 2003.  He lives in rural
Georgia.

Categories: Depression, Psychology