What’s So Wrong with Losing (Historical) Sadness?
With its overt instrumentalization of America’s history for its angrily vague purposes, the Tea Party has brought the question of history’s relationship with political advocacy into sharp national focus. Of course this question is implicitly, ok sometimes overtly, addressed or entertained at this blog — Wiz in stalwart 19th century Americanist form has brought the Tea Party to task here and here for its historical smudging. Sadly Jill Lepore has beat this blog to it and recently published a book about the Tea Party’s use of the past for political ends. In my own field, Linda Greenhouse and Reva Siegel just came out with a book of documents illustrating the abortion debates that took place in the pre-Roe v. Wade period. In a later post I’ll talk about the political significance of these documents, which suggest that the “judicial backlash” narrative placing blame for today’s extremely polarized abortion politics at the Supreme Court’s door is misguided, but for now I just want to explore the idea of politicized historicization itself– the implicit assertion that making something historical, makes it good.
To take something that is unlikely (unless this blog has an audience I’m totally unaware of) to raise too much political fervor in the comments board, a book I recently read on the psychiatric definition of depression and its policy implications seems a good place to start. With the publication of a series of memoirs in the 1990s, including Elizabeth Wurtzel’s infamous Prozac Nation, the idea that our society has been invaded by depression and its related medications became a cultural truism. The subsequent decade saw a different cultural realization: that the American healthcare system was stratified between those who had no coverage and those who were covered too much. Scholarly tracts and magazine essays highlighting the constructedness of disease and proposing to reconceptualize various medical practices in order to cut corners have since become the norm. Allan V. Horwitz and Jerome C. Wakefield’s The Loss of Sadness: How Psychiatry Transformed Normal Sorrow into Depressive Disorder seems to have risen out of this perfect storm of cultural unease and economic incentive. The authors (both academics but not trained historians it’s important to note) at the end of the day have one purpose: to suggest that the way we think about depression today is not “natural,” and to use a long history of sadness to propose a different “natural” boundary that would remove a significant number of today’s patients from the category of the “psychologically depressed.”
The odd thing is that the authors seem to think that this historicization of what sadness and depression used to be should drive contemporary policy on how to medically define them today. The authors think that if they can show that a certain phenomenon has a long history, they can prove there is something humanly essential about it, and that this is significant for how we approach it today. In reality, it derives from a philosophical viewpoint (not that far from the Tea Partiers’ frequent invocation of our founding fathers) that long continuities trump recent change. Things with history are better than things without. (Where in the world would this leave women at the end of the day?)
Wakefield and Horwitz’s charge is that, far from inevitable, and in fact composed of a very short history, the recent depression “epidemic” was only made possible in 1980 “by a changed psychiatric definition of depressive order that often allows the classification of sadness as disease, even when it is not.” The current crisis is at least in part one of classification: a group of individuals experiencing a reactive “normal” sadness due to depressing but typical life events (the loss of a job, the end of a strong romantic attachment) are being gerrymandered into the constituency of the depressed due to the rewriting of the depressive disorder entry in the 1980 volume of the American Psychiatric Association’s codification of mental disorders, the Diagnostic and Statistical Manual of Mental Disorders [DSM-III]. The revised definition elided the distinction between a sadness caused by an internal, biological dysfunction and a reactive, temporary sadness caused by the trauma of everyday life.
This is a problem since, as any good Foucauldian knows, classification leads to surveillance, surveillance to control; in this case medical and pharmaceutical control. Foucault might then talk about subject formation, but the authors here can only speculate about potential negative effects of the relatively recent elision, in part because they present no historical or sociological research into its impact on those affected. And though the tracking of changed definitions might suggest a genealogical method, the authors are more interested in “diagnosing” why the changed definition is a problem. Thus they spend two chapters delving into a long history to demonstrate that there are deep historical grounds for the divide between normal and disordered sadness; this historical evidentiary basis then spirals together with the authors’ descriptions of the evolutionary biology of sadness and notes on the anthropology of non-western populations. All of this, the authors claim, establishes the divide between normal/abnormal sadness as essential, human.
The authors draw on an array of disciplinary tools to prove that a biologically-grounded, historical divide has existed between endogenous depressive disorder and a reactive normal sadness for the last 2,500 years, jumping from literary and medical history to evolutionary biology and anthropology. The emotions of Achilles and Gilgamesh are probed to prove that both normal and disordered sadness have long been identified as separate phenomena. Of course, the authors are sure to cautiously point out that the attributes of normal versus disordered sadness are culturally conditioned, yet they insist that a structural division exists.
Once this is settled, the search begins for the culprit that erased this important divide, and in a sudden switch to a sociology of scientific knowledge analysis, Horwitz and Wakefield identify the practices, instruments, and interests of the psychiatric profession as a primary cause for a definitional shift in sadnesses. This constructivist approach to psychiatric knowledge seems paradoxical given the authors’ reliance on the claims of evolutionary biology as evidence of a naturalized normal/disordered sadness divide.
This disparity may reflect biology’s status as a “harder” science than psychiatry, but more likely it represents the authors’ willingness to sacrifice consistent method for the sake of present purpose.
From the 1920s through the 1970s, empirical psychological studies relied on new statistical methods that measured symptoms of depression present at a single moment, thus erasing the situational context of their appearance. This replaced the differential diagnoses of sadnesses “with cause” or “without cause” with diagnoses based on the (perhaps momentary) appearance of specific symptoms. At the same time, a rising outpatient population, with a far wider range of problems than inpatients, began to seek treatment; their more situational issues challenged the consistency of diagnoses and resulted in competing and overlapping diagnostic systems. In this story of standardization, the Feigner group at the Washington University in St. Louis then developed new criteria for affective disorders to combat the inconsistencies. Here the authors do convince that there was no real evidentiary or scientific basis for the inclusion of normal sadness under the umbrella of disordered sadness.
But does this mean that the shift was not useful? Horwitz and Wakefield suggest that the conflation of sadness and depression has resulted in the pathologization of sadness and costly misdiagnoses and overmedications of patients. To support their claim that “a flawed definition may be facilitating the recent surge in reported depressive disorder and may even lie at its very heart,” the authors closely read the definition of depressive disorder in DSM-IV, point by point analyzing how it has directly resulted in the increased rate of depression. The main problem, Horwitz and Wakefield conclude, is that the disorder’s criteria do not have enough “exclusions” (besides bereavement) to allow psychiatrists and other medical authorities to differentiate between endogenous depression and temporarily sad reactions to everyday life.
Because the authors presume that a statistical rise in depressive disorders is necessarily a bad thing, without exploring the positive or negative effects on patients themselves, it is hard to say how effective a policy statement this historicization of depression is. One could just as easily speculate that the broadening of a definition has been useful for patients and psychiatrists: instead of pathologizing sadness it might normalize depression; while some might be overtreated, a vaguer definition might also provide access to treatment for patients who do indeed need it and may otherwise have been denied; a vague conflation of definitions might give psychiatrists wiggle room to address specific patient needs that might have been missed under the old system. Oddly enough I am sympathetic to their claims that we need to accept sadness as part of a cultural or human experience, that many patients are likely overmedicated. However, their historization of sadness hardly proves this point. It may convincingly demonstrate that depression as we now know it did not have to be this way, but it does little to prove that it should not be this way.