Wednesday, July 30, 2014

The Weariness of the Self

The Weariness of the Self: Diagnosing the History of Depression in the Contemporary Age
Alain Ehrenberg
(McGill-Queens University Press, 2009)

It appears that we live in the midst of an epidemic of an illness that we call Depression. Looking back to my training as a psychiatrist in the early 1970s, the diagnosis of Depression was usually limited to states that were so disabling that a person could not work, was at risk of suicide, often needed hospitalization and was usually treated with tricyclic antidepressants or ECT. There was a diagnosis of Neurotic Depression that was milder and was always treated with psychotherapy. Our current epidemic is usually explained by two factors: first, the Diagnostic and Statistical Manual of 1980 which eliminated Neurotic Depression and created a vaguely defined category called Major Depression and second, the advent of Prozac, an easy to take medication that was effective for a broad range of symptoms. 
Ehrenberg takes a different tack. He traces the history of depression focusing on two models. The conflict model, initiated by Freud, sees people as whole, but divided by conflict. Transgression and guilt are the forces that drive it, especially in France where Lacan's version of psychoanalysis is dominant and about which Ehrenberg is writing. The key term in the second model is deficiency. Following the social and cultural changes of the 1960s, he argues, transgression and guilt were no longer dominant concerns. She, and Ehrenberg is religious about using that pronoun, can do anything she wants. Now what matters is feeling inadequate, that is to say deficient. Depression is no longer about conflict and guilt, but about feeling inadequate and deficient. Medications like Prozac help with this by allowing people to feel more capable. Ehrenberg seems nostalgic for the old days when conflict reigned and psychoanalysis was popular. He seems to hold the view that feeling better because of a chemical effect is not authentic. Nonetheless, because he sees the changes as cultural, and social he does not make case for going back to the old days. 

What to make of a book like this. It was certainly confusing at times, especially because most of his references are to twentieth century French psychiatry about which I am not very familiar. The broad idealistic/Foucauldian perspective where cultures change without clearly marked material causes is hard to follow. Nonetheless, posing a contrast between a view of human nature centered on the idea of conflict and one centered on a notion of deficiency is quite refreshing. It isn't a matter of a biological/psychological dichotomy. Ehrenberg is clear psychotherapies, going back to Janet, can be based on a deficiency model. Indeed as I think about discussions of psychotherapy in recent years it seems to me that these were often based on the premise that the patient was somehow injured and in need of repair, not that 'she' was in conflict about how to live. The medications and the psychotherapies that we use are consistent with one another in how they view human nature. In this regard it seems to me that Ehrenberg is onto something and that this book was worth reading.