Nassir Ghaemi's book On Depression is an engaging critique of pharmaceutical nihilism. "Nihilism," of course, has many different meanings. For Friedrich Nietzsche, it names, in part, both the absence of determinate values in contemporary society and an objectifying or universalizing science that subsumes under universals what is inherently distinct; it involves the "transformation of nature into concepts for the purpose of mastering them" (WP 322). For others, nihilism signifies the very refusal to accept an implicit order in the world. As the theologian John Milbank states, for the nihilist, "every supposedly objective reasoning simply promotes its own difference, and disguises the power which is its sole support." Friedrich Heinrich Jacobi, in a letter to Johann G. Fichte, chides idealism for being nihilistic: it refers to totalizing systems, such as those of Baruch Spinoza and his successors, which leave no room for non-knowledge or faith. "I have paraded my not-knowing in all my writings," Jacobi writes, "in my non-knowledge I have prided myself so to be with knowledge." In a certain sense, Jacobi's account brings unity to both Nietzsche's and Milbank's definitions. Whereas Nietzsche identifies nihilism, in part, with positivist scientism according to which it is only a matter of time before we can understand the universe in terms of a single or a small group of units, Milbank identifies nihilism with the postmodern belief that power struggles motivate all truth claims. Both versions of positivism and postmodernism attempt to measure and understand everything; both leave out non-knowledge or faith—a conviction that knowledge is always going to be incomplete and revisable.
Ghaemi's definition of nihilism, it seems to me, resembles Jacobi's insofar as both are combating the systematic elimination of uncertainty and unknowing in psychiatry. With respect to this elimination of uncertainty in contemporary psychiatry, nihilism as positivism holds scientific research to be ultimately capable of understanding the entire human being. On this view, we will soon be able to exhaustively trace out all the intricacies of mental processes and experiences. We might not be able to comprehend the human being now, but we will someday. Second, nihilism as relativism or postmodernism denies the existence of any universal truths. With respect to evaluations of the pharmaceutical industry, this view results in a certain universal suspicion of therapeutic drugs: because all relations are relations of power, we are warranted in suspecting pharmaceutical companies of dishonestly generating their enormous profits through manipulation and the production of unnecessary drugs; these drugs, it is said, are invented for fictional disease-entities while psychiatrists are, allegedly, pawns of the companies that covertly fund them. Ghaemi acknowledges that there is a degree of truth in both positions, but he is unwilling to accept either the positivist or the postmodernist story tout court. In what follows, I show how Ghaemi's position with respect to depression, following the leads of Leston Havens and Karl Jaspers, highlights a certain prevailing totalizing and nihilistic thinking that structures our society's attitudes toward happiness and sadness. This totalizing tendency, in turn, resembles certain mental disorders that it tries to overcome.
In articulating what he calls "biological existentialism" (OD 65), Ghaemi refers for support to a study of what Lauren Alloy and Lyn Abramson call "depressive realism." Participants in a study were asked to rate how much control they felt they had over certain test results. When the test results were altered to appear independently of the participants' actions, the participants who were aware of their loss of control ranked higher on depression measurement scales than those who felt they retained control throughout the experiment. Judging from these results, Ghaemi concludes that depression is not always bad: those who are depressed can be more aware of their own limitations (OD 25-6). Whereas cognitive-behavioral therapy generally holds that depressed patients "see the world darkly and unjustly" (OD 25), depressive-realists claim that "depression leads to enhanced contact reality" even if this is "to the detriment of the depressed" (OD 25).
In addition to providing evidence that depression leads to, in some cases, a more realistic outlook, the experiment also shows that there seems to be a correlation between feelings of depression and a subject's awareness of her control over her environment. I suggest two possible reasons for this correlation. First, a subject can feel depressed when she cannot control her environment and manipulate it in a way that suits her interests. Such a subject, driven by perhaps a certain narcissistic or obsessive impulse, wants to alter her environment or the people in it so that they follow her own agenda. Failure to manipulate others or the environment can lead not only to the subject's awareness of her limitations, but also to depression. As Otto Kernberg and Frank Yeomans explain,
patients with NPD show rather extreme fluctuations between severe feelings of inferiority and failure, and corresponding depressive reaction.
In other words, the depressive symptoms of the narcissist can occur concurrently with an awareness of her inabilities. This is, of course, an extreme case. But the principle applies more generally: mild sadness and even more severe depression can arise when one becomes aware of one's inability to authoritatively control one's surroundings.
Second, subjects can feel depressed when they cannot control the environment and manipulate it in order to allow others or themselves to flourish and prosper. For example, a study of German firefighters found that of those who are routinely exposed to the trauma of others, over seven percent suffer from depression. Sadness and depression can arise with the feeling of helplessness in the face of the suffering or deaths of others. Unlike those who lament their inability to negatively control and manipulate others, these sufferers of depression are aware of their inability to help others prosper.
Returning to the two problematic positions Ghaemi identifies in contemporary psychiatry—positivism and postmodernism—both, in their own ways, want to overcome these limitations that can lead us to depression. For the positivists, as Ghaemi notes, major depressive disorder "is viewed as biological illness...we are taking two antidepressants tonight, and the next day, and the next day, forever" (OD 25). But, if depression is in certain cases associated with an awareness of one's own limits and finitude, then the wide-ranging desire to quickly eliminate depression can be linked with a failure to appropriately acknowledge the role and even meaning of these limitations: if narcissistic subjects, for example, are led to believe they are more powerful than they actually are, their depression might diminish. But the underlying narcissistic problem remains. Similarly, those who find themselves depressed due to their inability to help others flourish might experience fewer symptoms if they come to avoid or think less about the sufferings of others. But this does not, in fact, reduce the severity of the sufferings of others. Further, medications that lead us to think less about the sufferings of others or that let us think positively about ourselves do not solve certain underlying problems but only deal with some of the symptoms.
For postmodernists, in contrast with the positivists, mental illnesses and the pharmaceutical industry are largely symptoms of underlying power struggles. On certain versions of this view, depression is a culturally constructed condition that benefits the pharmaceutical companies that profit from the sale of anti-depressants. Ghaemi cautions:
If you say that money solely drives data, and you completely ignore the content of research, then you are reducing research to money. There is no truth to the research that is being done; it's all about making a buck. [OD 64]
If the positivist believes that we need to eliminate depression by overcoming it, the postmodernist holds that the elimination of depression as an illness can come with denying its reality: depression is a fiction or a social construction that is historically contingent.
These impulses, however, are not necessarily bad and Ghaemi is far from saying that we should avoid all symptom-relieving pharmaceuticals. A reduction in the awareness of one's limitations can often be pragmatically beneficial. When reflecting on his own book, On Depression, he writes:
If I didn't think this book was somewhat better than it really is likely to be, I wouldn't spend all this effort in writing it. [OD 26]
Similarly, if parents do not think their children to be above average, they would likely not invest as much effort in cultivating their children's talents. Certainly, debilitating depression does not help its victims, but the complete elimination of depression remains a problematic flight from an awareness of limitations.
With both positivistic and relativistic approaches, the unreflective desire to eliminate depression, whether through medication and therapy or through fictionalization, is, as I take Ghaemi to be saying, a symptom of a more troubling totalizing impulse: the aim of both positivism and relativism seems to be to convince ourselves, through medication or fictionalization, that we have control over our lives or that our feelings of sadness must be overcome; they are categorically bad. But, just as for the one who wishes to control and negatively manipulate others, an awareness of one's limitations and an awareness of one's finitude can be existentially beneficial, perhaps the positivist and postmodernist desire to understand and overcome depression risks eliminating the beneficial aspects of the condition. For the firefighter who is aware of her inability to help others prosper, prolonged sadness is a valid response. Against the positivists, we do not need to eliminate depression wherever we find it; against the relativists, depression can be an illuminating condition that must be taken seriously. In essence, both positivism and postmodernism are nihilistic as long as they desire to control, eliminate, overcome, entirely understand, or explain away depressive states unreflectively.
In the third section of On Depression, Ghaemi devotes five chapters to articulating the views of certain guides who can lead us out of the deadlock that the extreme positivist and postmodernist positions have placed us in. When writing about Leston Havens, Ghaemi explains that the Harvard psychiatrist taught the value of a knowing ignorance:
He wanted us to know that we didn't know certain things we think we know. [OD 113]
Like Jacobi, Havens was suspicious of those who believed themselves able to explain away various problems and have solutions to perplexing issues, whether they were postmodernists who denied the efficacy of psychopharmaceuticals (OD 123) or positivists who would prescribe drugs for even mild conditions (OD 125). He was known for entertaining opposing ideas: when patients clearly had bodily diseases, Havens would recommend effective drugs; when, however, patients did not have bodily diseases but "problems of living," he would try to help his patients address these problems without pharmaceuticals (OD 125). Throughout his career, he would insist that, as finite creatures, we do not know everything even if we do know or can be quite certain about some things:
Hold your theories lightly, Les always said. This doesn't mean that no theory is true....Instead, he meant we can never be fully certain that a specific theory is true. [OD 113]
In this respect, Havens was open to ambiguity or an awareness that we are very much finite beings: the limits we sometimes encounter reveal our own finitude even as they might prevent us from fulfilling our desires. The depression that follows this awareness might eventually need pharmacological treatment, but even so, it can highlight or bring awareness to our human condition.
Jaspers, another psychiatrist Ghaemi describes, calls these events that make us aware of our limitations as limit situations (Grenzsituationen). These are conditions or events that bring us to reflect on ourselves and on our own contradictory existence. As Jaspers writes,
in our Dasein we cannot see anything more beyond them. They are like a wall that we run up against, against which we fail. Through us they cannot be changed, rather we can only bring them to light without the ability to explain or to deduce them from anything else. They are with Dasein itself.
When faced with a limit situation, one can grow depressed or mentally ill as a result, particularly those who have a predisposition for developing a mental illness. Thomas Fuchs describes how certain mental illnesses can be seen as reactions to such limit situations: for example the hypochondriac, in response to an awareness of his inability to prevent his own death or illness, might take extreme measures to convince himself that he does, in fact, have control:
He insists on the goal of having complete control over his body through constant preventative measures against every assault of disturbance and disease. [PLS 305]
Similarly, the narcissist might refuse to commit to anything determinate out of the fear of coming to face limitations and
stays in a state of noncommitment regarding his relationships and decisions in order to escape in this manner the frightening basic situation of the increasing limitation of possibilities. [PLS 306]
Then there is the one who grows depressed at the feelings of guilt about the inalterable character of past decisions:
the loneliness and the guilt of decisions represent a fundamental disappointment, in that his housing that has been attentively sustained until now is revealed to be an illusion. [PLS 307]
In each case, Fuchs suggests that a Jaspersian response to the illnesses would not endorse the belief that limitations should be overcome. Rather, the Jaspersian therapist should help patients address their reactions to these limitations. Fuchs observes,
it seems to me that the task of a psychiatrist or psychotherapist should include gaining such a competency...in order to help the patient recognize the existential implications of his crisis and, thereby, understand them not only as a self-caused misfortune, but also as an expression of human existence in general, in which we all participate and through which we all suffer. [PLS 308]
Something similar can be said, I believe, about positivist and postmodernist approaches to psychiatry. Like the mentally ill patient who perpetuates her illness through avoidance or attempts to compensate for her finitude, both positivism and postmodernism try to understand and make sense of what resists final explication; they try to compensate for the uncertainty of the world with either an excessive optimism or a pervasive cynicism. Though, in many cases effective, psychopharmaceuticals do not cure all mental illnesses and though drug companies are often deceptive, it is true that psychopharmaceuticals do often work: they are not just the products of power struggles. In his chapter on Jaspers, Ghaemi explains Jaspers' critique of the belief that science alone can account for all phenomena. Against such a view and by summarizing Jaspers, Ghaemi states:
Science is limited because it is probabilistic, not absolute; because it requires statistics to measure, rather than ignore, error; because it always is a mix of truth and error. Indeed it views truth as corrected error. [OD 140]
In valuing science we need to also value the limitations of what science can tell us. This does not mean that we must, by any means, reject the conclusions science has so far reached; rather, we must take the ambiguous position in which we value both knowledge and faith, both certainty and uncertainty, both success and failure. While it is tempting to endorse one side to the exclusion of the other, Ghaemi, following Jaspers, claims that in the face of our limitations we must take a stand and maintain a position:
Philosophical man, the aware soul...stands facing this mystery—solemn, silent, serious. He or she has to take a stand. Not taking a stand is not an option for one who philosophizes. He thinks, therefore he suffers. The stand Jaspers takes is to accept such tragic realities, to know that they cannot be wished away. At the same time, such acceptance is not passive nor is it unique. [OD 144-5]
This will not mean that all mental illnesses will disappear; but there is value in trying to uncover the meanings of these illnesses.
