in Journal of Ethical and Human Psychiatry
A Social Theory and Treatment of Depression
Thomas J. Scheff
Abstract: This paper outlines a
theory of depression and the rudiments of a treatment plan. It builds upon my
earlier study of interviews in a mental hospital and the work of the
psychologist Helen Block Lewis. Theory: recursive shame-based spirals may be
the basic mechanism of both clinical depression and extreme violence.
Shame/fear, shame/shame, and shame/anger spirals are described. Hypotheses:
depression may result from a shame/shame spiral or when the anger in
shame/anger spirals is directed in, recursively, without limit. Similarly,
violence can result if the anger in the shame/anger spiral is directed out.
These ideas lead to a proposal for treatment of depression focused on social
bonds and hidden emotions. In this connection, possible effects of
anti-depressants on emotion are also discussed.
depression, shame, anger, recursion, social bonds, unacknowledged emotions,
earlier (2001) article described a series of brief recoveries from depression.
As a visiting researcher at Shenley Hospital (UK) in 1965, I observed all
intake interviews of male patients for 6 months: 83 patients in all. Of this
number 70 patients were sixty or older. The comments that follow concern the
older men. The 13 younger men were mostly not diagnosed; the older men were
diagnosed as depresssed. Contrary to my
expectations, every one of the men presented as deeply depressed in their speech
and manner. However, even more surprising, there were moments in some of the
interviews that seemed to me like miracles of recovery.
psychiatrists asked 41 of the seventy older patients about their activity
during WWII. For 20 of those asked this question, their responses shocked and
surprised me. As they begin to describe their activities during the war, their
behavior and appearance in varying degrees underwent a transformation.
who changed in the greatest degree sat up, raised their voice to a normal level
instead of whispering, held their head up and looked directly at the
psychiatrist, usually for the first time in the interview. The speed of their
speech picked up, often to a normal rate, and became clear and coherent, virtually
free of long
pauses and speech static. Their facial expression became lively and showed more
color. Each of them seemed like a different, younger, person. The self-blame
that was frequent in their earlier speech disappeared.
majority changed to a lesser extent, but in the same direction. I witnessed 20
awakenings, some very pronounced, however temporary. The psychiatrists told me
that they had seen it happen many times.
After witnessing the phenomenon many times, like the psychiatrists, I also
some 35 years later, because of my work on shame, I proposed an explanation
(2001): depression involves the complete repression of painful emotions, such
as shame, grief, fear, and anger, but with shame the major component, and lack
of a single secure bond. The memory of
the patients’ earlier acceptance as valued members of a group during wartime
relived the feeling of a secure bond and generated pride that counteracted the
shame part of their depression.
Telling the psychiatrist about belonging
to a community during WWII had been enough to temporarily remove the shame of
being outcasts. Conveying to the psychiatrist that “once we
were kings,” had briefly relieved their shame and therefore their depressive
historian Lucy Dawidowitcz (1989) reported a parallel response to severed bonds
by survivors of the Holocaust:
…the survivors liked best of all
to talk about their former lives, the houses they lived in, the family
businesses, their place in the community. By defining
themselves in their previous existence, they were confirming their identity as
individuals entitled to a place in an ordered society. They had not always been
identity as a worthy person depends both on the level of respect one is
currently commanding, and also on memories of being treated respectfully.
Social psychological theories of the self touch on this issue in the
distinction that is made between the self-image, which is heavily
dependent on the immediate situation, and the more enduring self-concept.
But the way in which the self endures current situations is little discussed in
Virginia Woolf’s writing, even her novels, was largely based on her own
memories, she devoted some attention to the role of memory in sustaining the
self. This passage, by her editor, occurs in the preface of Woolf’s volume of
…memory is the means by which the
individual builds up patterns of personal significance to which to anchor his
or her life and secure it against the “lash of random unheeding flail.” (Shulkind, in Woolf, 1985, p. 21).
herself made the point forcefully: “…the present when backed by the past is a
thousand times deeper than the present when it [the present] presses so close
that you can feel nothing else.” (Woolf 1985, p. 98).
If Woolf is right, then profound depression arises not only out of being an
outcast, but also from not having had, or being cut off from, memories of
possible source of depression therefore, is having no experience, as an adult,
of being accepted by a community. Of course every one who lives to be adult,
depressed and not depressed, has had the experience as
an infant of being emotionally connected to at least one caretaker, a little
community of two or three. But for virtually everyone, this experience is
beyond recall, and cannot serve as a source of comfort and sustenance of the
self. The task for the therapist in the case of those with no adult experience
of community would be to develop a bond for the first time in the adult life of
the patient, which might take considerable time, patience, and skill.
the other hand, the therapist’s task with those patients who have had the
experience of community as adults, but are cut off from it, would seem to be
much simpler. These patients, like the old men described in the earlier study,
need only be asked the right questions, and listened to respectfully. It would
appear that the deficit in these cases is not in the patient, but in his social
environment. The men in the earlier study lived in a milieu in which they were
not likely to be asked about their experiences of any kind, much less those
twenty years earlier. If, in the unlikely event that such
memories were retold, given the quality of their relationships, their
hearers would likely have reacted with exasperation rather than respect.
article outlined a emotional/relational explanation
based on the link between the pride/shame dynamics, on the one hand, and the
degree of empathic emotional union (secure/insecure bond), on the other. This
earlier explanation implied a treatment plan, which will be outlined. First it
will be necessary to review some of the features of the work of Helen Lewis.
treatment proposals below are based primarily on the published work of Lewis,
especially her 1971 book, and contact with her by myself and Suzanne Retzinger
beginning in 1981 and ending with her death in 1987. My own work on shame and
Retzinger’s has been based largely on Lewis’s.
Novel Approach to Shame
conception of shame and other closely related emotions (such as guilt) was and
is still radically different than that of most other shame experts. At its core
is her unique definition of the social/psychological origin of shame: threat to
the social bond. This definition puts her work in opposition to both technical
and popular approaches to shame. Another important contribution was a step
toward explaining the origin of long-lasting emotions. If, as she explained in
her definition, normal shame is merely a brief signal of threat to the bond,
how could shame last for days, much less years? First I will recount Lewis’s
theory of the origin of shame.
Her working conception of shame grew out the
results of her study (1971) of the transcripts of psychotherapy sessions. Using
a systematic method based on long lists of indicators words for the major
emotions (Gottschalk and Gleser 1969) she located many emotion episodes in the
transcripts. She found that shame/embarrassment was by far the most frequent,
with more occurrences than all the other emotions combined.
noted that shame occurrences were very rarely verbalized by patient or
therapist. When other emotions occurred,
such as sadness, fear, or anger, they were sometimes referred to by patient and/or
therapist. But in the many instances of shame/embarrassment/humiliation,
emotion names were virtually never used, not even indirectly (see the
discussion of indirection below). Lewis called these instances "unacknowledged
found that shame goes unacknowledged in two different ways. The
first way she called “overt, undifferentiated shame” (OU shame).
The patient is in pain, but it is referred to indirectly. There are hundreds of
words and phrases in American English that can be used to refer to shame
without naming it. For example, one can
say “I fear rejection,” or “This is an awkward moment for me,” I lost my
dignity” and so on. Many of these cognates have been recorded by Retzinger
(1991; 1995). Her entire list of anger and shame cognates can be found in the
Appendix of Scheff (1994).
shame is usually marked not only by pain, but often by confusion and bodily
reactions: blushing, sweating, and/or rapid heartbeat. One may be at a loss for
words, with fluster or disorganization of thought or behavior, as in states of
embarrassment. Many of the common terms for painful feelings appear to refer to
this type of shame, or combinations with anger: feeling peculiar, shy, bashful,
awkward, funny, bothered, or miserable; in adolescent vernacular, being
freaked, bummed, or weirded out. The phrases “I feel like a fool,” or “a
perfect idiot” are prototypic.
indirect reference may be avoided when shame is labeled erroneously. One error
is to misname the feeling as a physical symptom: “I must be tired” (or hungry
or sleepy, or pregnant, etc). Although Lewis found this kind of shame occurring
with both women and men, it was predominantly used by women.
usual style of men, she called “bypassed.” Bypassed shame is mostly manifested
as a brief painful feeling, just a flicker, followed by obsessive and rapid
thought or speech. A common example: one feels insulted or criticized. At that
moment (or later in recalling it), one might experience a jab of painful
feeling (even producing a groan or wince, although not necessarily), followed
immediately by imagined, compulsive, repetitive replays of the offending scene.
replays are variations on a theme: how one might have behaved differently, avoiding
the incident, or responding with better effect. The scene may be replayed
involuntarily through meals and keep one awake at night. One is obsessed.
there is also a form of bypassed shame in which the indications are weaker.
Apparently it is possible to further hide bypassed shame to the point where it
is almost invisible. One may feel blank or empty in a context of embarrassment
or shame. This mode will be discussed further below under the rubric of
recursive shame/shame spirals: being ashamed of being ashamed, etc. (For a
general discussion of the importance of internal recursion, see Corballis 2007.
He proposes that recursion is unique to humans, but he considers only cognitive
Assumptions about Emotions
discussion of Lewis’s social/psychological definition of the origins of shame
brings up a delicate issue, because it implies an utterly different conception
of emotion than the one held in modern societies, especially English-speaking
ones. Most people in modern societies believe that emotions are feelings. That is, like fatigue or affection, emotions
are always felt. Lewis’s work on unacknowledged shame suggests, however, that
the emotion of shame is not mainly a feeling, but a bodily state, one
that might not be felt.
Lewis’s description of OU shame, it is clear that there is a feeling, but it is
misinterpreted. In the case of bypassed shame, there seems to be little or no
feeling of any kind. When Lewis first discovered this form of shame, she was
very cautious about naming it. She called it unacknowledged because she
couldn’t tell from the transcriptions if the emotion was being felt, but not
referred to, or it wasn’t referred to because it wasn’t felt.
her clinical practice, she questioned patients whose responses suggested
bypassed shame. She invariably found that they were not feeling shame or any
other emotion. After many such trials, it became clear to her that bypassed
shame states were not felt. This finding, since it runs against a central
cultural assumption, is a hard sell. Although widely praised, this aspect of
Lewis’s study has been little cited. Indeed, she once complained to me that her
1971 book was frequently praised but seldom read.
implication of Lewis’s approach is that it widens the definition of shame to
include a host of siblings and cousins (Sedgwick and Frank 1995 also point to
shame siblings and cousins, even though their approach is based on the work of
another shame pioneer, Sylvan Tomkins).
English-speaking cultures, the conception of shame is extremely narrow: a
crisis emotion involving disgrace. But in all other languages, there is also an
everyday shame that is more or less present in ordinary social occasions,
especially as an anticipation of the risk of shame. In French, for example,
there is the idea of pudeur. In English, this kind of emotion would be
called modesty or shyness, and not considered as a type of shame.
example is embarrassment, which in English seems to be a separate emotion
because it is seen as inflicted by others and is brief and weaker than shame.
But in other languages, embarrassment is considered to be a member of the shame
family. For example, in Spanish, the same word, verguenza, is used for
Lewis’s conception, guilt is also a member of the family, if only a cousin.
That is, guilt is a shame-anger sequence, with the anger directed at self. By
the same token, resentment is also a cousin, being a shame-anger sequence, but
with the anger directed at other. The idea of emotion sequences will be further
Lewis’s definition of the origin of shame as threat to the bond casts a new
light on the meaning of genuine pride. Her approach implies that the origin of
pride is always social: pride arises from empathic emotional union, i.e., no
threat to the bond. In the English language, particularly, in which emotions
are seen as highly individualistic, social ideas of pride and shame may seem
is another problem with the meaning of pride that causes trouble, especially in
the English language. Without inflection (genuine, justified, authentic, etc),
pride is usually taken as negative: arrogant, self-centered, “pride goeth
before the fall” and so on. I call this kind of “pride” false pride, because I
think of it as a defense against shame.
difficulties with emotion arise in all modern languages because they have
evolved in societies that are individualistic and oriented toward the visible
outer world of material things and behavior, and only cognition in the interior
world. Since English was the language of the nation that modernized first,
through industrialization and urbanization, the emotional/relational world in
English speaking cultures has become the most hidden.
Bypassing and gender.
Boys, more than girls, learn
early that vulnerable feelings (love, grief, fear and shame) are seen as signs
of weakness. First at home, then at school they find that acting out anger,
even if faked, is seen as strength. Expressing anger merely by verbal means,
rather than storming, may be seen as weakness. For self-protection, boys begin
suppressing feelings that may be interpreted as signs of weakness and
In Western cultures most boys
learn, as first option, to hide their vulnerable feelings in emotionless talk,
withdrawal, or silence. I call these three responses (emotional) SILENCE. In
situations where this option seems unavailable, one may cover vulnerable
feelings behind a display of hostility. Young boys, especially, learn in their
families, and later, from their peers, to suppress emotions they actually feel
by acting out anger whether they feel it or not.
this pattern “silence/violence.” Vulnerable feelings are first hidden from
others, and after many repetitions, even from self. In this latter stage,
behavior becomes compulsive. When men face what they construe to be threatening
situations, they may be compelled to SILENCE or to rage and aggression.
without threat, men seem to be more likely to SILENCE or violence than women.
With their partners, most men are less likely to talk freely about feelings of
resentment, humiliation, embarrassment, rejection, loss and anxiety, or for
that matter, joy, genuine pride and love. This may be the reason they are more
likely to show anger: they seem to be backed up on a wide variety of intense
feelings, but have the sense that only anger is allowed them. Two studies of
alexthymia (emotionlessness; Krystal 1988, Taylor et al, 1997) do not mention
any difference between men and women, but most of the cases discussed are men.
out fear, particularly, makes men dangerous to themselves and others. Fear is
an innate signal of danger that has survival value. When we see a car heading
toward us on a collision course, genetic endowment has given us an immediate,
automatic fear response: WAKE UP SLEEPY-HEAD, YOUR LIFE IS IN DANGER! Much
faster than thought, this reaction increases our chance of survival, and
repressing it is dangerous to self and others. If the sense of fear has been
repressed, it is necessary to find ways of uncovering it.
order to avoid pain inflicted by others, we learn to repress our emotions.
After thousands of curtailments, repression becomes habitual and out of
consciousness. But as we become more backed up with avoided emotions, we have
the sense that experienced them would be unbearably painful. In this way, avoidance leads to avoidance in
a self-perpetuating feedback loop.
study points in this direction, but only as a first step. She noted that when
shame occurs but is not acknowledged, it can lead to an intense response, a
"feeling trap:" one becomes ashamed of one’s feelings in such a way
that leads to further emotion. Since normal emotions have extremely short duration,
a few seconds, Lewis’s idea of a feeling trap opens up a whole new area of
exploration. Emotions that persist over time have long been a puzzle for
researchers, since normal emotions function only as brief signals.
The particular trap that Lewis described in detail involved
shame/anger sequences. One becomes
instantly angry when insulted, and ashamed that one is angry. One trap, when
the anger is directed out, she called "humiliated fury.” The other path she noted, when the anger is
directed in, results in depression. This idea is hinted at in current
psychoanalytic approaches to depression. Busch, Rudden, and Shapiro (2004), for
example, devote their chapter 7 to “Addressing Angry Reactions to Narcissistic
Vulnerability.” As is usually the case in modern societies, they avoid using
the s-word, shame, by encoding it: “narcissistic vulnerability.”
shows many word-by-word instances of episodes in which unacknowledged shame is
followed by either hostility toward the therapist or withdrawal. In her examples
of the latter, withdrawal takes the form of depression. She refers to the
shame/anger/withdrawal sequence as shame and anger “short circuited into
depression” (1971, p. 458-59 and passim):
[The patient] opened the hour by reproaching herself for being "too
detached during intercourse.” She had
had a satisfactory orgasm, as had her husband, but she noticed that she was not
totally absorbed in the experience and then reproached herself for having been
detached enough to make this observation. A. now herself observed that she was
scolding herself and immediately located a source of humiliated anger at her
husband. He had criticized her that same day for having been so
"drained" by caring for the children that she had no energy left for
him when he came home, and she had at the time thoroughly agreed with him. She
had also agreed with his criticism over irritable behavior with the children.
(It should be noted that her husband was accustomed to projecting onto his wife
his own guilt for disliking chores and feeling "drained" by work, and
that she was normally in agreement with him about her faults.)
A careful analysis of her experience at the time her husband reproached
her unearthed the fact that she had had a fleeting feeling something like
resentment accompanied by thoughts which ran approximately: "I wonder how
he can be so 'detached' that he has no feeling for me. You'd think he was
lecturing in class." (Her husband is a teacher.) That night she readily
agreed to intercourse, partly to placate her husband. A short time afterward
she was scolding herself for being "too detached,'” and too observant.
idea of humiliated fury as a feeling trap might be a first step toward a theory
of the emotional origins of both depression and violence. Since none of the
therapy sessions she studied involved depression to the point of complete
silence, nor even a hint of physical hostility, she didn’t consider the kind of
feeling traps that could result in lengthy silence or violent aggression. The aftermath of unacknowledged shame that she noted involved
slight hostility toward the therapist or the kind of momentary withdrawal
and/or self/blame that might be indicative of depression.
described feeling traps as emotion sequences. The sequences she refers
to involve at most three steps, as in the case of the shame/anger sequence
short-circuited into depression. A model
of feeling traps that can go far beyond a few steps may be necessary. How could
such a process lead to a doomsday machine of interpersonal and inter-group
withdrawal or violence?
emotion sequences may be recursive to the point that there is no natural
limit to their length and intensity. People who blush easily become embarrassed
when they know they are blushing, leading to more intense blushing, and so on.
The actor Ian Holm reported that at one point during a live performance, he
became embarrassed about forgetting his lines, then
realized he was blushing, which embarrassed him further, ending up paralyzed in
the fetal position. This feeling trap would not be a shame/anger sequence, but
rather shame/shame: being ashamed that you are ashamed, etc.
shame-based sequences, whether shame about anger, shame about fear, or shame
about shame, need not stop after a few steps. They can spiral out of control.
Perhaps collective panics such as those that take place under the threat of
fire or other emergencies are caused by shame/fear spirals, one’s own fear is
not acknowledged, the obvious fear of others cause still more fear in a
recursive loop. Although Lewis didn’t consider the possibility, depression
might be a result not only of a shame/anger spiral, but also shame/shame.
from her own transcriptions, withdrawal after unacknowledged shame seems to be
much more frequent than hostility toward the therapist. A shame/shame spiral of
unlimited duration would be a blockbuster of repression, covering over not only
all shame and other emotions but also all of the evidence of its existence.
This level might correspond to the blankness, emptiness and hollowness of
complete depression or the alexthymia (Krystal 1988, Taylor et al, 1997)
causation of violence, it is possible that the shame/anger spiral, humiliated
fury, might be a basic cause of violence to the extent that it loops back upon
itself without limit. A person or group caught up in such a spiral might be so
out of control as to become oblivious to all else, whether moral imperatives,
danger to self or to one’s group.
recursive shame-based loops lead to depression/withdrawal or to violent
aggression seems to depend on whether the anger in the shame/anger sequences
point inward (guilt) or outward (resentment). In intergroup process, a scapegoat group seems to provide a target that
directs the anger outward into violence. Scape-goating can occur at the
interpersonal level also, in the case of rage directed toward a woman by a man
or toward a black person by a white. If, as suggested here, the direction of
anger in or out determines depressive or violent outcomes, it would be fair to
say that violence serves as a defense against depression.
article based on the research literature (The Role of Shame in Depression over
the Lifespan, 1987, pp. 29-49), Lewis reviewed studies by other authors using a
variety of measures that showed strong correlations betweens shame and
depression. My own study of depression in working class men (2001), referred to
above, focused on the voluminous shame indicators shown by depressed patients
during intake interviews in a mental hospital.
Reporting on 25 years of quantitative research, Shohar (2001) found
strong links between shame and depression. Wilkinson (1996; 1999) has published
survey evidence of a connection between shame and depression. Future research
might determine that shame/shame spirals are the basis of the withdrawn type of
depression, and that shame/anger spirals might lead to other types, such as
Steps toward a Social/Emotional Treatment of Depression
steps listed here follow from my discussion of Lewis’s work above, and from my
explanation of my earlier study.
Elicit memories of
times where there was a secure bond with at least one other person, or better
yet, a sense of community with a group. Explore each memory at length, to the
point that patient feels genuine pride. Depression should lift at this time, if
only temporarily. This step, when it works, provides a powerful incentive for
patient involvement in treatment, and for the next step, empathic union with
2. As therapist, from the first moment of contact, try to form an empathic
emotional union with the depressed patient, by hook or crook, no matter the
content. Some find this goal fairly easy, but others might need coaching and
practice. Get off of TOPICS, into RELATIONSHIP talk. Discussion of anything
than that is not happening in the moment is topic talk. An example of
relationship talk is “I didn’t understand what you just said. Could you repeat
it?” or “You seem sad,” “I am proud of
you,” “You seem distracted,” and so on.
Relationship talk is about what is happening in the moment, either to the
patient or therapist, or between them. For most people, it is very difficult to
stay on track, avoiding topic talk. (The psychiatrist Melvin Lansky refers to
topic talk as “Mother-in-law stories.”) Empathic union in psychotherapy is the
central idea in a recent volume on relational-cultural therapy (Walker and
When therapist and client are connected, encourage patient to discuss their
shame episodes to the point of ACKNOWLEDGEMENT (Lewis 1971). Lewis indicated that a core goal of most
psychotherapy is the acknowledgment of shame. The sub-title of one of her
essays on psychotherapy (Chapter 7, 1980) was The Problem of Abreacting Shame
and Guilt. However, she didn’t make
clear what she meant by acknowledgement or abreaction (catharsis). Chapter 13
of her earlier book (1971) is entirely about treatment, but the cases are
presented concretely, for the most part. The concepts that are used are mostly
conventional psychoanalytic ones. They don’t help to explain acknowledgment.
way to explain the meaning of acknowledgment is that it is a verbal recognition
of a shame state that is accompanied by the actual experience of shame. Most of
the confessions of shame in AA meetings wouldn't qualify, since they seem to be
were merely verbal, without being backed by the requisite feelings. In seeking
to explain a parallel situation, Goffman, Ian Miller and I have suggested that
the expression of shame is the key to a sincere apology. A verbal apology,
unless accompanied by the expression of shame or embarrassment, usually doesn’t
satisfy the recipient.
problem that needs to be faced concerns repressed shame. The reason most shame
states are not acknowledged is that they are covered over by layers of
defenses, often many layers. Children learn to repress emotions very early,
first by the example of their caretakers, later to avoid punishment, such as
ridicule. Males, particularly, are taught to hide shame and other vulnerable
emotions behind a façade of swagger, anger and/or aggression. After many repressions, one might have the
sense that to feel repressed emotions would be unbearably painful. How does one
overcome such barriers to feeling?
Earlier, I used the concept of distancing,
from drama, to explain a path into repressed emotions (1979; 2007). According
to drama theory, audiences may experience a performance as over-distanced
(detached from feelings), under-distanced (so close to feelings to be a
repetition of the original unresolved situation) and aesthetic distance. The
goal of classical drama was to allow audiences to experience emotions at
aesthetic (optimal) distance.
drama, optimal distance means that audience members are able to experience
unresolved emotions safely. The events in the drama are not their own, as they
can reassure themselves. In this setting, what seems to happen is that viewers
of drama can move in and out of painful emotions in a way that lessens the pain.
Indeed, a formerly painful emotion, such as fear, may be experienced as
pleasurable, as is the case with young people in horror movies and roller
coaster rides. Using different language,
a recent approach, “somatic therapy,” seems to be based to on the same idea:
“pendulating” in and out of painful emotions (Levine 1997).
application of this idea to psychotherapy suggests a way of finding the
distance that is optimal for each patient. Patients who are too removed from
their feelings can be asked to retell an incident more slowly and in more
detail. Those who are too close can be encouraged to touch on
the incident more quickly and it less detail, or to leave it entirely, at least
for the nonce. Maneuvers of this kind could lead to the kind of
catharsis and acknowledgment that Lewis seemed to have had in mind.
Help find and/or rebuild at least one secure bond in the patient's social life,
in addition to the one with the therapist. Using many case
studies of persons who recovered or at least improved from serious mental
illness, Neugeboren (1999) shows that in every case there was at least one
person who stuck with the patient through thick and thin. The biography A
Beautiful Mind (1998) makes the same point about a famous case (Nobel
Laureate John Nash) not included in the 1999 book. Contrary to the film
version, the author of the biography states that Nash took none of the “newer
psychiatric drugs” as claimed in the film. She gives credit for Nash’s recovery
to the unfailing support of his wife and mother. Even with only a single secure
bond, one is no longer alone in the universe (Masserman 1953; Baumeister and
Since the treatment of choice for
depression is currently anti-depressants, some discussion is warranted. On the
one hand, it has been frequently claimed that a combination of anti-depressants
with psychotherapy is the most effective treatment available (e.g. Coyne 2004).
As far as I can tell, in this study and all the others that recommend
anti-depressants and therapy, the follow-up was only 4 to 6 weeks.
The brief follow-ups seem to be one
way that RCLs (Random Clinical Trials) are organized so as to give misleadingly
positive results. For 13 other ways, see Jackson (2005). Glasser’s brief review (2005, pp. 115-116) of
the research literature on psychiatric drugs, including anti-depressants,
suggests that the reliable evidence supporting their effectiveness is close to
are a few studies that follow-up the effects of anti-depressants for a full
year (e.g. Kirsch, et al 2002). These studies invariably report no significant
difference between treatment and control groups. It seems likely that the
positive effects of anti-depressants are at best short lived, or at worst,
1965 study almost half of the men who were asked about WWII did not show any
change. It is therefore possible that they were suffering from endogenous
depression, which opens up the possibility, at least, that anti-depressants
might be indicated. On the other hand, the psychotherapy offered to these men
was only one intake question. It is possible that they would have
required more psychotherapy than the few minutes inadvertently offered.
is also a substantial amount of evidence that psychiatric drugs, and anti-depressants
specifically, interfere with one’s emotional life, and with sensitivity to the
emotions of others. For example, many studies have made it clear that the
SSRI’s suppress crying. Some of the causes and ramifications are explored by
Healy (2004). Karp (1996) and Horwitz and Wakefield (2007) analyze the
medicalization of sadness.
been unable to find a broad treatment of the effect of drugs on the full
spectrum of emotions. Virtually all the studies are extremely narrow, focusing
on single drugs or classes of drugs, and one or two emotions or emotional
expressions at most.
second point is that in virtually all the studies, emotions are the enemies.
This orientation is understandable with respect to rage, but laughing and
crying also are usually treated as pathological. There are many studies of a
new pathology called Emotional Lability (EL), and a more extreme label,
“Emotional Incontinence.” The very phrase is highly prejudicial and shaming.
seems to have occurred to only a few drug researchers that the absence of
emotional expression might be a far wider problem, and possibly a much more
damaging one. I found one conventional drug research article that touches
indirectly on this issue. Scoppetta et al (2005) showed that SSRIs suppress crying even in normal persons. They
admit a doubt about the wisdom of the widespread use of these drugs:
SSRIs are among the most used drugs in the
world, every day they are consumed by millions of people including politicians,
businessmen, soldiers, army commanders, policemen and criminals. The idea is…
worrying that the control of the emotions and behavior of these millions of
people can be quickly modified by one SSRI for a few days….
The management of grief provides one example
of over-, rather than under-control of emotions. It may be that the inability
to mourn/unresolved grief (Mitscherlich 1975; Parkes 1988) particularly among
men, is a social institution in modern societies. To the extent that the theory
outlined here is true, then the use of drugs that further inhibit crying and
other forms of emotional expression would be damaging rather than helpful
(Cummings 2005, p. 102 makes this point also.)
I recently heard a comment in passing that provides food for
thought: a woman reported that she stays on anti-depressants because she gets
“weepy” when she goes off them. There is a detailed description of a situation
like hers in Iris Dement’s song, No Time to Cry
died a year ago today,
the rooster started crowing when they carried Dad away
There beside my mother, in the living room, I stood
with my brothers and my sisters knowing Dad was gone for good
Well, I stayed at home just long enough to lay him in the ground
and then I caught a plane to do a show up north in Detroit town
because I'm older now and I've got no time to cry
I've got no time to look back, I've got no time to see
the pieces of my heart that have been ripped away from me
and if the feeling starts to coming, I've learned to stop 'em fast
`cause I don't know, if I let them go, they might not wanna pass
And there's just so many people trying to get me on the phone
and there's bills to pay, and songs to play, and a house to make a home
I guess I'm older now and I've got no time to cry…
When I questioned my colleague, the
psychiatrist Melvin Lansky, about this matter, he said he would never prescribe
anti-depressants for grief. But hospice workers tell me that they are
continually facing bereavement clients who have been put on anti-depressants.
Dr. Lansky went on to say that in his experience, anti-depressants not only
don’t suppress emotions, but help to uncover them. However, he knew of no
published references to this effect, nor have I been able to find any. On the
other hand, Healy (1994) reviews several studies that suggest that
anti-depressants blunt emotion (pp. 174-75 and 182-184).
Under the circumstances, it may be
best to avoid drugs in the treatment of depression, or at least use them no
more than three months. In any case, a social/emotional therapy directed toward
increasing genuine pride by working through unresolved shame and building
secure bonds might add a new technique to the treatment of depression.
A recent film, Lars and the Real Girl, provides a detailed
spelling out of the social model, the idea that “it takes a village.” Lars, a
young unmarried man in a small town, is obviously delusional. After considerable
hesitation, the whole community responds to his delusion by treating it as real,
rather than rejecting it. Seen in this way, the film represents a moment by
moment spelling out of the resolution of mental illness in a social, rather
than a medical model. Perhaps the makers of this film have never heard of
anti-psychiatry and the social model of mental illness, but it fits anyway.
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