Vol 3, no 10, Oct 90 p 3-4
Reply to Carolyn Reichelt
CRR suggests that the depressive taking the
role of physical sickness
replays the part of the baby with the caretaker it is imprinted
onto, thus eliciting from the caretaker the
reassurance and loving nourishment which
made the baby feel the centre of the universe and in this way restoring
the depressive's self-esteem. I think
this may be true, although we know little about the effect of loving
nurturance in relieving depression or
raising self-esteem. Let us imagine an experiment in which we follow three groups of sick
people who have just been put off work by their physicians. The first group
suffers from some physical illness. The second group suffers from depression but is told by
the physician that they have a physical
illness. The third group suffers from depression and is given the correct
diagnosis. If we then measure the amount of loving nurturance received by these patients from their
families, I would predict that the
physically ill would receive the most and those diangosed as depression
the least, and those depressives
diagnosed as physically ill would come in
between, probably nearer to the physically ill than the diagnosed depressives. In other words, what the family
believes about the illness is
probably more important than the actual behaviour of the ill
person.
In
primitive tribes and in ancestral times it was probably the usual thing for depression to be treated as
physical illness. It is only the sophistication of western medicine
that has enabled us to distinguish it
from physical illness and so reframe the depressive as
psychologically rather than physically
ill and thus deprive him of the loving nurturance which is accorded to the physically ill.
I
doubt whether patients perceived as psychologically ill are really given much support by their families.
Depression is often treated
by families as badness rather than illness. The lack of energy of
depression is
treated as laziness, the social withdrawal as rudeness, the unhappiness as sulking. Rather than boosting the
depressive's self-esteem, the family often lowers it with criticism of the
depressive symptoms, as CRR pointed out
in an earlier ASCAP. Suggestions such as "pull yourself together" or "snap out of
it" imply that the depressive is malingering, and could already have pulled himself together if he
had wanted to. The work on
Expressed Emotion in depression has shown that criticism by the
family impedes recovery.
Families
probably vary very much in how they deal with depressed members, and within families there is
probably variation with time, especially
depending on whether they are in the agonic or hedonic mode. In an excellent book (1), two family
therapists write (pp. 145-6):
"Watzlawick et al......pointed out that
when people attempt to cheer up someone who is sad they may turn a
temporary state of sadness into a
prolonged state of depression. They suggested, for example, that families may develop
a rule forbidding sadness. In the event that an individual in the family becomes depressed, she is
told to cheer up and thus may in fact be
punished for an appropriate emootional response. The sad and depressed individual may internalize other
people's responses and try to cheer
herself up. The person believes it is "bad" to be depressed
and fights to change
a normal reaction, increasing the state of depression."
Reflecting on CRR's comments, it occurs to me that the depressive sick role may have
one important effect on the family, in that it may reduce the family's expectations of the depressed person
in the realm of agonistic behaviour. It
is the fundamental thesis of the yielding hypothesis of depression that the
function of depression is to keep the individual out of the competitive social arena, from
places (in Goffman's words) “Where the
Action is”. Beck's cognitive triad of negative thoughts ensures that the depressed person
does not enter the arena of his own volition, but that does not prevent him being pushed into the
arena by his family. It may be that the sick role message convinces
the family that he is "out of action"
and encourages them to postone the depressed person's engagements for
a period. A message of physical illness
is likely to be more effective in this regard than the message "I am
depressed".
In
summary, following this chain of reasoning, it may well be that in reassuring the
depressive that he is depressed rather than physically ill, we are depriving him of the basic message he
is trying to convey to his family. If we
could randomly allocate depressives into psychological and physical labelling,
we could discover the effect of the label on the family's responses.
1. Weeks, G.R. & L'Abate, L. (1982)
Paradoxical Psychotherapy.