Health and Hope
Accentuating the positive: Allan V. Horwitz and Jerome C. Wakefield continue the fight against the over-diagnosis of depression-as-disease in their Op-Ed, â€œSadness is not a disorder.â€ They contend:
Whatâ€™s wrong is this: Depressive disorder and normal sadness are different conditions with different prognoses and implications. In responding to intense sadness, psychiatry does a disservice by confusing it with depressive disorder and thus narrowing the range of options.
Indeed, psychiatry today almost seems to deny that any sort of intense sadness can be a normal and, ultimately, even a beneficial experience.
So letâ€™s not overlook the healthy benefits of a good cry.
And this story of the health care cost crisis for small business should bring tears to your eyes. Hereâ€™s how it starts:
Frank Manzo keeps doing the math, trying to figure out how he can still offer health insurance to his employees. His 28-employee tech-staffing company, Computer Methods Corp., charges clients $35 an hour for help desk workers. He pays them $25 an hour. Health insurance premiums proposed for 2008 for a family run nearly $12 an hour – up 30 percent from last year.
Forget about profit. Forget about rent on the companyâ€™s Marlton offices, the electric bill, or even paper for the copy machine.
The middle-class, college-educated people at Manzoâ€™s company were on the edge of joining Americaâ€™s 47 million uninsured.
â€œWhere do I find the money?â€ Manzo asked, his voice rising in frustration. â€œWhat am I supposed to pay them – $10 an hour? At this point, they may as well go work for McDonaldâ€™s.â€
Health insurance makes everyone miserable. But among the most miserable are small-business owners.
Well, we canâ€™t lose hope. â€œZealously wishy-washyâ€ Mark Bowden finds a good word to say about religion: in a messed up world, it can give us hope:
Life can be seen as a brief sojourn between nothingness and nothingness, a chance to blink open your eyes and look around with wonder. Since we cannot know why, it is just as easy to believe the trip has a purpose as to believe it does not. To my mind, it is easier to believe the former, which, of course, doesnâ€™t make it right. The religious man chooses to believe life has meaning. The best Iâ€™ve ever been able to manage is hope.
The fact that these three articles appeared in yesterdayâ€™s Philadelphia Inquirer is not the only thread holding them together. Let me try to grab ahold of it.
We use the term â€œhealthâ€ as if we know what it means and how we should â€œcareâ€ for it. But I wonder if we know what weâ€™re talking about. Recently, there have been a number of nay-sayer articles appearing (Iâ€™ve alerted you to a couple) that take issue with whether â€œdepressionâ€ is really a â€œhealthâ€ issue at all. If depression means sadness, and sadness is an emotion, we might ask how an emotion becomes a syndrome or a disease. If emotions are not diseases and therefore not a matter of concern for health care providers, perhaps we can drastically reduce health care costs by ruling out mental â€œillnessâ€ all together (after all, itâ€™s really not illness).
The pieces Iâ€™ve referenced on the topic donâ€™t make this rather stark argument. Instead, theyâ€™re concerned about the negative effects of thinking of emotions as potential illnesses and what might be called the â€œmedicalizationâ€ of the soul or the person. Itâ€™s the idea that we might be cheating ourselves of something (like a good cry) by medicating away the capacity for shedding tears.
Of course, when you are feeling miserableâ€“say, about health care costsâ€“you tend to want to not feel miserable. Miserable is bad, less miserable is better, not miserable at all is good. Now suppose that you come to the conclusion that the cause of your miseryâ€“say, the unaffordability of health careâ€“is never going to go away, that neither the â€œleftâ€ or the â€œrightâ€ are going to find a solution, that it is a part of your life and always will be until you die. Further suppose that I can offer you some relief from the misery that wonâ€™t otherwise go away. Would you take it? Or would it be enough to hope for the (impossible) solution to become possible?
Let me try another tack. I agree with Horwitz and Wakefield that â€œsadness is not a disorder,â€ if by â€œdisorderâ€ they mean a purely medical condition. If they are opposed to mean old Big Pharmaâ€™s medicalizing normal emotions for the sake of profits, then I am with them. It may well be argued that some of the latest â€œsyndromesâ€ we hear about in commercials during the nightly news are â€œmanufactured.â€
So what about all those people with â€œthe bluesâ€ who say they have benefited from SROâ€™s and other depression medications? These commentators believe that it is no more than the placebo effect. There seems to be an unusually high rate of placebo effect with psycho-therapeutic drugs. (see this review of John Horganâ€™s book, The Undiscovered Mind for some thoughts on this)
I am not so sure this is easy to unpack. Is depression the same thing as sadness? Or is it that there is a frequent conjunction of the two, but that they are not identical? It may be the latter. Some principles we should bear in mind:  Humans are biological beings, made of flesh, blood, bones, sinews, guts, and nerves;  Humans are meaning-bestowing beings. We donâ€™t just exist; we act and are acted upon. And we donâ€™t just act and be acted upon; we bestow meaning on our actions, the actions of others, and the goings-on in the worldâ€“even if at times these have no meaning of their own. If  and  are true (and they are), then if oneâ€™s body feels a certain way, one will bestow meaning on that feeling. If the feel (Iâ€™ll use â€œfeelâ€ and not â€œfeeling,â€ which may be confused with emotion) in the body is the same or similar to how it feels when one is saddened by some event, then that feel will likely come to mean â€œsadnessâ€ to the person. If this view of things is correct, then it becomes more difficult to unpack what is going on with depression and its treatment. It may be that serotonin levels do affect the feel of the body. But serotonin levels cannot really treat â€œsadness.â€ The problem with clinically depressed people is not that they are â€œsad,â€ itâ€™s that they feel sad without sufficient reason. I realize immediately that â€œsufficient reasonâ€ is irreparably vague. What I mean is that there is something like a compound problem. Life creates misery (say, the unaffordable costs of health care), which in people of a certain body chemistry becomes compounded.
So what will fix the problem these people experience? Removal of the misery-producing irritant. Adjustment of serotonin levels. Administering a placebo (the very fact of doing something, anything is therapeutic). Talking therapy (professional or amateur), which might include being â€œtalked out ofâ€ the idea that the problem is a real problem.
You cannot often in this life do the first. The second and the third might turn out to have the same effect. The last is almost never a bad idea. In fact, itâ€™s probably the worldâ€™s oldest solution (if there is a solution); itâ€™s just that now it seems you have to pay for it. Used to be people just talked to their parents, their spouse, their friends, or their ministers. Somehowâ€“you know the storyâ€“talking got professionalized.
Anyway, the question of what constitutes health in the first place needs to be addressed, and that means we need to think about what it means to be human person, as well as what it means to be in community, and even about the very notion of the good. In other words, the public discussion that is going on regarding health care needs to become more philosophical than it has been. Otherwise, there is no hope in contending with our problems.
Which brings me back around to the question of hope. Suppose for a second Prozac â€œworksâ€ (either as a chemical or as a placebo). I feel a certain, undesirable, way; I take Prozac; I feel a different, more desirable, way. What happened? Did Prozac make me into something I â€œamâ€ not? Or did Prozac remove an obstacle to my being who I â€œamâ€? Which is the real meâ€“pre-Prozac me or post-Prozac me? In a similar vein, we can ask with Mark Bowden whether a believing me is â€œbetter thanâ€ an unbelieving me, and then ask which one of those is the â€œrealâ€ me.
Marx said, more or less, that religion was the opiate of the people, implying that religion drugs people into a docile and degraded state. But what if religion is the Prozac of the people (at least some people)? Is it like Horwitz and Wakefield might say, that weâ€™d be â€œbetter offâ€ just accepting and (not) dealing with the â€œnothingnessâ€ or â€œmeaninglessnessâ€? Or would religionâ€“so long as we donâ€™t O.D. on it!â€“just make us â€œfeelâ€ and then perhaps even act better (whether â€œtrueâ€ or not)? We should not forget that placebos work.
Iâ€™ll let Bowden have the last words. Heâ€™s been reading Pope Benedict XVIâ€™s new encyclical, Spe Salvi. Bowden writes:
I recommend it. The pope is dealing with first questions here. He covers a lot of ground but zeros in on the kinship between hope and faith. If life has meaning, if the soul lives on after death in some way, if the Christian message is true, then the idea of an â€œafterlifeâ€ need not be any of the cheesy human attempts to imagine Heaven, Benedict wrote, but â€œsomething more like the supreme moment of satisfaction, in which totality embraces us and we embrace totality. . . . It would be like plunging into the ocean of infinite love, a moment in which time – the before and after – no longer exists. We can only attempt to grasp the idea that such a moment is life in the full sense, a plunging ever anew into the vastness of being, in which we are simply overwhelmed with joy.â€
It may not be the bevy of virgins promised in one of Muhammadâ€™s hadiths, but it sounds good to me. It sure beats simply fading to black. Religion can go bad, but it wrestles seriously with what matters most. Unlike the zealots training to blow up thousands in the name of their God, I might never achieve faith, but hope?
Hope I can live with.