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)