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The Myth of Depression as DiseaseReview - The Myth of Depression as Disease
Limitations and Alternatives to Drug Treatment
by Allan M. Leventhal and Christopher R. Martell
Praeger, 2005
Review by Louis S. Berger, Ph.D.
May 9th 2006 (Volume 10, Issue 19)

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.


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