If you ask me, the dominant discussion around mental ill health is a guarantee of more mental ill health. Of course, you didn’t, but I have been wont in any case to provide an answer: popular journalism, political speech and public campaigns on mental health are faulty. Both conversation and policy are led by a faith that “awareness” is a primary defence against illness — nowhere has this placebo been more adamantly served than in the ABC’s “Mental As” programming, which delivers us the message that “stigma” is the cruellest cut of all.
Stigma is a problem, but to declare this with such centrality is to imply that stigma’s absence is a cure. Yes, it is unhelpful when the common disorder of depression is perceived by some as indolent self-pity. No, if we remove the “stigma” from the social body and swap it with “awareness”, the best medicine has not been prescribed.
What we will get, at best, is a load of destigmatised, aware sad people who can neither afford the psychiatric assistance TV personalities trial and recommend nor access it in their outer-suburb or region.
The view of mental illness is made possible by the faith that our misery is “chemical”. This is the idea Johann Hari seeks to challenge in the new blockbuster Lost Connections.
Good. A popular book to take the scientific advocacy for the non-chemical case from eminent psychiatrists including Allen Frances or Horwitz and Wakefield — their 2007 plain-language book The Loss of Sadness is recommended — is what the West needs. A book whose first-person, non-academic form permits it to go beyond mere medicine? Great. While Frances and others are bound to review only nosology (the classification of diseases) Hari can not only make the case that depression is not, in all cases, chemical, but that it can be a response to social conditions.
Clear links between poverty and depression notwithstanding, the idea that It Can Happen To Anyone remains common. Organisations like beyondblue are reluctant to acknowledge poverty as a forecast of depression. They retain the view that the disorder comes from within. The view that the disorder may also derive from without is only permitted in campaigning when advocacy groups make that relentless demand. That we have seen advertisements and read accounts of depression’s disproportionate prevalence among Aboriginal and LGBTIQ people is entirely down to the activism of those groups. These are the two exceptions to the It Can Happen To Anyone rule.
It can happen to anyone, but it happens disproportionately to those of social and/or cultural categories whose everyday survival is endangered.
That Hari has sought to elaborate on the bleeding obvious is marvellous. The “depression always comes from inside us” view is an unscientific rationale that refuses to see depression itself as a symptom of societies that are ailing. So, I took to this book with gratitude, its jacket endorsement from Hillary Clinton and author’s history of plagiarism notwithstanding.
Hari does challenge the powerful, policymaking view of depression as a thing arising in the individual. This is commendable, as are his efforts to tie the thing back to the social. Yes, neoliberal techniques of economic organisation have produced conditions in which misery prospers. Yes, this misery has been codified by the same conditions that produced its “solution”: antidepressant medication. Hari is not keen at all on drugs. I am not so keen on his anti-drug fervour.
Nor are many psychiatrists. While Hari says that he does not wish to deny those with depression their diagnosis or their drugs, he does make a passionate case against both. Which would be permissible if this book was offered only as bold plea for reason — like this one — and not as reason itself.
Hari is so keen to see depression as the product of an alienated and unequal age, he has little to say about the distinction that scientists like Frances, and even Hippocrates, make clear. It was, right up until the neoliberal era, both medical view and practice that depression fell into two kinds: one from the inside and one from the outside. Hari has so much interest in the latter, the former is occluded in this ardent account.
The book demonstrates that the practice of science is very often compromised by profit. It reasonably challenges some of the unreason that feeds us so very many antidepressant drugs. But, not all of Hari’s book is pure reason. If you’re going to use your own journey through psychiatry as a means to perceive psychiatry, you need a load of disclaimers. Sure, Hari finds studies and esteemed experts who support his mostly reasonable view. He will also find, I feel certain, readers who’ll just want to go off their meds after chapter one.
Plenty of others with plenty of distinctions have made this case against Hari. Goodness, I wish that they were not compelled by the author to do so. What might have been a theoretical book that urged us to think of the classification of depression in a better way masquerades as a “scientific” work. Moreover, one that makes most shrinks seem like stupid people who completely ignore the social. Not, in many cases, doctors who work to the biopsychosocial model of illness.
My reading and conversation with psychiatric scholars these past ten years has persuaded me that biopsychosocial must again become as foundational in diagnostic practice and research as it was in the past. You elevate one part of that, and the others are eclipsed. Sure, depression has been for far too long attributed to the “bio” alone. Then again, anorexia, a disorder known to have biological markers and believed by many scholars to have a biological basis, has been understood as almost entirely social (skinny models are to blame etc) and research, and patients, have suffered.
I wish he’d toned it down. I wish there was a little less Hari here. However much one supports a very sensible opposition to “destigmatising” or to “awareness” of depression as a chemical thing that can Happen To Anyone, one cannot fully support a book about a self that purports to be about everyone.