On a comment left at Storied Mind, a great blog and depression resource created by John Folk-Williams, I mused about whether or not depression is an illness. (A recent post on this site covered the same question from a different angle.) What follows connects my reply to John’s essay with Acceptance and Commitment Therapy (ACT), which WillSpirit readers have heard me discuss many times before.
John focuses on ACT in his essay and only mentions the illness question in passing. The issue comes up because the ACT view of mental symptoms contradicts the biological disease paradigm of conventional psychiatry.
ACT is based on behaviorism, a philosophy that dominated psychological study in America for much of the early and mid-twentieth century. By the 1980′s behaviorism had been supplanted by cognitive science, a movement that was driven by neurobiology’s computational model of the brain. Behaviorism suffered intense criticism after falling from grace.
The backlash was so thorough and effective that when I first learned that ACT is a behaviorist approach, I assumed it succeeded despite that heritage and not because of it. Behaviorism has a reputation for being overly mechanistic and dehumanizing. The common caricature is that it rejects the importance of mental life and views people as automatons who don’t choose their actions but only react to environmental contingencies.
In his 1974 book, About Behaviorism, B.F. Skinner (the most prominent leader of the movement) defended his views. The text more often assumes than establishes the basic foundations of its philosophy; it insists that inner life is a consequence rather than a cause of a person’s interaction with his or her environment but doesn’t provide much supportive evidence (although subsequent research has bolstered such assertion). So the book isn’t terribly effective as a counterattack. But it does demonstrate that Skinner looked at human behavior with an admirably practical eye.
In managing depression and other psychiatric symptoms, it is this practicality that makes a behaviorist approach effective. CBT (Cognitive Behavioral Therapy) has trained many of us to challenge negativity. But thoughts arise rapidly and seldom cooperate with attempts at control. Positive thinking is a great concept, but every uplifting thought is dogged by its counterargument. The affirmation, “I’m a good person” seldom can escape whispering rebuttals like, “but remember the time you…”
I don’t deny the helpfulness of monitoring thoughts to weed out inaccuracies and unfair self-criticism. But CBT assumes that feeling is a result of thinking, and that we can feel better if we think better; both these premises are questionable. Thinking and feeling are internal processes that mutually interact and respond to environmental input; thinking isn’t the sole determinant of how we feel. And we all know from experience that positive thinking by itself never resolves a deeply entrenched depression.
But the real problem with CBT, and most other therapies, is precisely that they teach us to focus on thoughts and feelings as we battle mental difficulty. If we are stuck in a deep funk and spending our days in bed, we are taught that if we adjust how we view our childhood, or how we think about our current situation, we will soon feel better. Having established a sunnier inner landscape, we’ll want to get up and live our lives again. Sadly, most of the time the sun simply refuses to shine no matter how much we rethink our past or challenge our negativity.
Skinner would reply that our staying in bed results from learning, not from thinking or feeling. Something in our environment has taught us that lying down pays off. Maybe we get sympathy. Maybe we avoid facing stress. There is a reward that sustains the behavior despite the fact that it undermines our progress in life.
The answer to depression isn’t to wait for our inner state to improve while we do little to alter externals. Rather, we should act on the outer world, which will provide new consequences and teach us better behavior. If I attend a community picnic when depressed, two benefits accrue: I interact with others and so increase my social connections, and I spend some time outdoors. These positive outcomes, especially if repeated a few times, will teach me to adopt similar outgoing behavior in the future. Waiting for the depression to lift before attending such an event would win me neither more friends nor contact with nature. My future behavior would be unlikely to change.
Which finally brings me to the substance of my comment on Storied Mind and the question of whether depression is an illness. Here is an excerpt:
…whether depression is an illness or not [is] a semantic question, and it can have different answers depending on one’s stage in dealing with the problem. If ‘illness’ means a condition that feels unpleasant and limits life, then yes, depression can be (and usually starts out as) an illness. But if it means a definable brain disease that can be treated with specific medications, one can only say that at this point there is little evidence to support that view. I’ve followed this research for years and have yet to see any findings that solidly (or even plausibly) demonstrate organic pathology. For every suggestive piece of evidence one can find powerful refuting arguments.
Although the disease concept helps relieve us of shame and so can be helpful early on, eventually we want more than escape from blame. We want better living. ACT offers an approach to achieving that… what works is living life with purpose without so much emphasis on how [we] feel or what [we] think…
I no longer react reflexively out of fear, anxiety, insecurity, or negative self-talk. As I’ve begun to live a richer life despite my frequent feelings of sadness, regret, and fear, I’ve started to see that the ‘illness’ concept no longer serves me as it did earlier…
I would add, in light of the behaviorist perspective, that if the answer to depression lies in interacting differently with the environment, then it seems unlikely that the problem resides in the brain. Instead the difficulty is, and has always been, a consequence of the world around us and how it’s taught us to respond to circumstances. This is a radical concept when compared with the traditional view on mental distress. It takes the problem out of the realm of thoughts and feelings and places it in the real world. And isn’t that where we want to live our lives?
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