Forthcoming 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.

Keywords: depression, shame, anger, recursion, social bonds, unacknowledged emotions, community.

My 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.

Instant Remissions

The 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.

Those 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. 

The 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 lost interest.

But 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 mood.

Self-concept and Community

The 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 outcasts (303).

One’s 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 social psychology.

Because 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 autobiographical essays:

…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).

Woolf 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 community.

One 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.

On 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.

My earlier 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. 

The 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.

A Novel Approach to Shame

Lewis’s 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.

Lewis 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 shame."

Hiding Shame

Lewis 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).

OU 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.

Even 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.

The 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.

The 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.

However, 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 processes).

Cultural Assumptions about Emotions

The 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.

In 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.

But in 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.

Another 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).

In 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.

Another 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 both emotions.

In 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 considered below.

Finally, 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 puzzling.

There 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.

These 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 exaggerating anger.

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.

I call 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. 

Even 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.

Numbing 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.

In 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.

Emotion Spirals

Lewis’ 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.”

Lewis 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.

Lewis’s 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.

Lewis 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?

Some 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.

Recursive 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.

Judging 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) mentioned above.  

In the 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.

Whether 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.

In an 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 agitated depression.

Four Steps toward a Social/Emotional Treatment of Depression

The steps listed here follow from my discussion of Lewis’s work above, and from my explanation of my earlier study.

1.      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 the therapist.
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 Rosen 2004).

3. 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.

One 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.

Uncovering Hidden Shame

A 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.

For 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).

The 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.

4. 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 Leary 1995).

Anti-depressants?

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 zero.

There 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, merely placebo.

In my 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.

There 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.

I have 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.

The 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.

It 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 (1993):

My father 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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