Is positive psychology all it’s cracked up to be?
Just over 20 years old, this field has captivated the world with its hopeful promises — and drawn critics for its moralizing, mysticism, and serious commercialization.
By Joseph Smith
The story of positive psychology starts, its founder often says, in 1997 in his rose garden.
Martin Seligman had just been elected head of the American Psychological Association and was in search of a transformational theme for his presidency. While weeding in his garden one day with his young daughter, Seligman found himself distracted and frustrated as Nikki, then 5, threw flowers into the air and giggled. Seligman yelled at her to stop, at which point Nikki took the professor aside. She reminded him how, from ages 3 to 5, she had been a whiner, but on her fifth birthday, had made a conscious decision to stop. If she could change herself with an act of will, couldn’t Daddy stop being such a grouch?
Seligman had an epiphany. What if every person was encouraged to nurture his or her character strengths, as Nikki so precociously had, rather than scolded into fixing their shortcomings?
He convened teams of the nation’s best psychologists to formulate a plan to reorient the entire discipline of psychology away from mostly treating mental illness and toward human flourishing. Then, he used his bully pulpit as the psychology association’s president to promote it. With Seligman’s 1998 inaugural APA presidential address, positive psychology was born.
Seligman told the crowd that psychology had lost its way. It had “moved too far away from its original roots, which were to make the lives of all people more fulfilling and productive,” he said, “and too much toward the important, but not all-important, area of curing mental illness.”
Seligman’s own experience made this deficit very clear. He had become famous, as he would later write in his autobiography, for his work on what he called “the really bad stuff — helplessness, depression, panic,” and that this had made him perfectly placed to “see and name the missing piece — the positive.”
The APA leader called on his colleagues to join him to effect a sea change in psychology and to create a science that investigates and nurtures the best human qualities: a science of strengths, virtues, and happiness. What Seligman named “positive psychology,” using a term coined in 1954 by humanistic psychologist Abraham Maslow, promises personal transformation through the redemptive power of devotional practices: counting blessings, gratitude, forgiveness, and meditation. And it is expressly designed to build moral character by cultivating the six cardinal virtues of wisdom, courage, justice, humanity, temperance, and transcendence.
Today, Seligman is the foremost advocate of the science of well-being. He had made his name in academia in the 1970s and ’80s for discovering the phenomenon of “learned helplessness,” in which individuals become conditioned to believe that negative events are inescapable, even when those events are within their control. In 1991, he came to the public’s attention with his book about combating these kinds of processes, Learned Optimism, which he claimed was the world’s first “evidence-based” self-help book.
But it was when Seligman shifted toward the psychology of happiness with the 2002 publication of Authentic Happiness, followed in 2011 with Flourish, that Seligman started to become a household name. The theory and practice of positive psychology caught fire in the public’s imagination, thanks in part to Seligman’s informal prose and optimistic message. Now, Seligman’s TED talk has been viewed more than 5 million times online; he has met heads of government and religious leaders, including the UK’s former prime minister David Cameron and the Dalai Lama, and has appeared on shows such as Larry King Now.
Despite his association with the science of happiness, Seligman is by his own admission brusque, dismissive, and a grouch. He casts himself as a maverick, butting heads with the academic establishment, and yet he’s the ultimate insider — probably the best-known, best-funded, and most influential psychologist alive. As a scientist, he insists on the value-neutral purity of the research he directs, yet presides over a movement that even its fans say seems to have some of the characteristics of a religion.
To many of its followers, the movement is a godsend, answering a need to belong to something larger than themselves and holding out the chance of better, fuller lives through truly effective techniques backed by science. To its critics, that science is undercut by positive psychology’s moralizing, its mysticism, and its money-spinning commercialization. But how valid are these concerns, and do they matter if positive psychology makes people happy?
Positive psychology has grown at an explosive rate since Seligman ushered it into the public conscious, surprising even Seligman himself. The field has attracted hundreds of millions of dollars in research grants. Its 2019 World Congress was attended by 1,600 delegates from 70 countries. It inspires tens of thousands of research papers, endless reams of popular books, and supports armies of therapists, coaches, and mentors.
Its institutional uptake has been no less impressive. More than a million US soldiers have been trained in positive psychology’s techniques of resilience just two years after the “Battlemind” program was launched in 2007. Scores of K-12 schools have adopted its principles. In 2018, Yale University announced that an astonishing one-quarter of its undergraduates had enrolled in its course on happiness.
Since that inaugural presidential address in 1998, Seligman has distanced positive psychology from its original focus. At its inception, the field sought to map the paths that end in authentic fulfillment. But with Flourish, Seligman changed course. Happiness, he declared, is not the only goal of human existence, as he’d previously thought.
The purpose of life, he said, is well-being, or flourishing, which includes objective, external components such as relationships and achievements. The road to flourishing, moreover, is through moral action: It is achieved by practicing six virtues that Seligman’s research says are enshrined in all the world’s great intellectual traditions.
“Positive psychology gives the impression you can be well and happy just by thinking the right thoughts.”This shift toward moral action hasn’t helped the critical response towards positive psychology’s lofty aims and pragmatic methods. Philosophers such as Chapman University’s Mike W. Martin say it has left the field of science and entered the realm of ethics — that it is no longer a purely factual enterprise, but is now concerned with promoting particular values.
But that’s not the only critique. Others decry positive psychology’s commodification and commercial cheapening by the thousands of coaches, consultants, and therapists who have jumped on the bandwagon with wild claims for their lucrative products.
In several high-profile cases, serious flaws have been found in positive psychology’s science, not just at the hysterical fringe, but in the work of big stars including Seligman himself. There are worries about its replicability, its dependence on unreliable self-reports, and the sense that it can be used to prescribe one thing and also its opposite — for example, that well-being consists in living in the moment, but also in being future-oriented.
And for a science, positive psychology can often sound a lot like religion. Consider its trappings: It has a charismatic leader and legions of rapturous followers. It has a year zero and a creation myth that begins with an epiphany.
“I have no less mystical way to put it,” Seligman wrote in Flourish. “Positive psychology called to me just as the burning bush called to Moses.”
Seligman’s inclusion of material achievement in the components of happiness has also raised eyebrows. He has theorized that people who have not achieved some degree of mastery and success in the world can’t be said to be flourishing. He once described a “thirty-two-year-old Harvard University summa in mathematics who is fluent in Russian and Japanese and runs her own hedge fund” as a “poster child for positive psychology.” But this can make well-being seem exclusive and out of reach, since accomplishment of this kind is not possible to all, or even most.
Professors Edgar Cabanas and Eva Illouz, authors of the 2019 book Manufacturing Happy Citizens, have accused positive psychology of advancing a Western, ethnocentric creed of individualism. At its core is the idea that we can achieve well-being by our own efforts, by showing determination and grit. But what about social and systemic factors that, for example, keep people in poverty? What about physical illness and underserved tragedy — are people who are miserable in these circumstances just not trying hard enough?
“Positive psychology gives the impression you can be well and happy just by thinking the right thoughts. It encourages a culture of blaming the victim,” said professor Jim Coyne, a former colleague and fierce critic of Seligman.
Then there are positive psychology’s financial ties to religion. The Templeton Foundation, originally established to promote evangelical Christianity and still pursuing goals related to religious understanding, is Seligman’s biggest private sponsor and has granted him tens of millions of dollars. It partly funded his research into universal values, helped establish the Positive Psychology Center at Seligman’s University of Pennsylvania, and endows psychology’s richest prize, the $100,000 Templeton Prize for Positive Psychology. The foundation has, cultural critic Ruth Whippman wrote in her book America the Anxious, “played a huge role in shaping the philosophical role positive psychology has taken.”
We should find this scandalous, Coyne says. “It’s outrageous that a religious organization — or any vested interest — can determine the course of scientific ‘progress,’ that it can dictate what science gets done.”
Despite the criticism, positive psychology remains incredibly popular. Books with “happiness” in the title fly off the shelves, and people sign up for seminars and courses and lectures in droves. We all seem to want what positive psychology is selling. What is it that makes this movement so compelling?
Sonja Lyubomirsky, professor of psychology at the University of California Riverside and an early star of the movement, told me that positive psychology was born at a time of peace and plenty. Many today “have the luxury to reflect and work on their own well-being,” she says. “When people are struggling to get their basic needs met they don’t have the time or resources or energy or motivation to consider whether they are happy.”
The 2008 financial crisis, though, seems to challenge this hypothesis. Suddenly, the luxury to reflect evaporated for vast numbers of people. But analysis by social scientists shows that the number of academic papers published on positive psychology and happiness continued to rise.
That’s led skeptics such as Coyne, Cabanas, and Illouz to suggest that positive psychology’s popularity today is less a question of demand than supply. There’s so much money in the movement now that it is propelled by the energy and entrepreneurial vim of the coaches, consultants, writers, and academics who make livings from it.
It’s also possible, however, that positive psychology’s entanglement with religion may contribute to its popularity. As Vox recently reported, secularism is on the rise in the US. But the propensity to believe in the divine runs very deep in the human psyche. We are, psychologists such as Bruce Hood say, hard-wired for religion. Positive psychology’s spiritual orientation makes it the perfect receptacle for our displaced religious impulses. Critics such as Coyne claim this is by design. The missionary tone, being called like Moses — these are all part of Seligman’s vision for positive psychology.
“Seligman frequently makes claims of mystical intervention that many of us dismiss as marketing,” Coyne told me.
But does the marketing matter if positive psychology helps people lead better lives? Skeptics, once again, question whether the benefits of positive psychology are really as great as claimed. Cabanas said that there “is no major conclusion in positive psychology that has not been challenged, modified or even rejected.” Yet the fact of positive psychology’s meteoric rise cannot be ignored; Seligman and his colleagues are very clearly doing something right, something that gives hope, optimism, and perhaps even happiness to millions of its consumers.
When I asked Seligman about the field’s connection to religion, he said most practitioners “would dissent from my strange beliefs,” and that those beliefs were his own. He referred me to the final chapter of his autobiography, in which he describes the death of his friend and mentor Jack Templeton, whose father’s foundation has funded Seligman’s research.
Seligman was bedridden at the time, but after reading a tract on positive Christianity, he had a “command hallucination” to rise and attend the evangelical memorial service.
The tract read: “Religion and science are opposed, but only in the same sense in which my thumb and forefinger are opposed — and between the two, one can grasp everything.”
Americans are the unhappiest they've been in 50 years, poll finds
Just 14% of U.S. adults say they're very happy.
June 16, 2020, 8:34 AM CDT / Source: Associated Press
By Associated Press
ST. PETERSBURG, Fla. — Spoiler alert: 2020 has been rough on the American psyche. Folks in the U.S. are more unhappy today than they've been in nearly 50 years.
This bold — yet unsurprising — conclusion comes from the COVID Response Tracking Study, conducted by NORC at the University of Chicago. It finds that just 14% of American adults say they're very happy, down from 31% who said the same in 2018. That year, 23% said they'd often or sometimes felt isolated in recent weeks. Now, 50% say that.
The survey, conducted in late May, draws on nearly a half-century of research from the General Social Survey, which has collected data on American attitudes and behaviors at least every other year since 1972. No less than 29% of Americans have ever called themselves very happy in that survey.
Science-backed ways to achieve happiness
Most of the new survey’s interviews were completed before the death of George Floyd touched off nationwide protests and a global conversation about race and police brutality, adding to the feelings of stress and loneliness Americans were already facing from the coronavirus outbreak — especially for black Americans.
Lexi Walker, a 47-year-old professional fiduciary who lives near Greenville, South Carolina, has felt anxious and depressed for long stretches of this year. She moved back to South Carolina late in 2019, then her cat died. Her father passed away in February. Just when she thought she’d get out and socialize in an attempt to heal from her grief, the pandemic hit.
“It’s been one thing after another,” Walker said. “This is very hard. The worst thing about this for me, after so much, I don’t know what’s going to happen.”
Among other finding from the new poll about life in the pandemic:
“It isn’t as high as it could be," she said. “People have figured out a way to connect with others. It’s not satisfactory, but people are managing to some extent.”
The new poll found that there haven't been significant changes in Americans’ assessment of their families' finances since 2018 and that Americans' satisfaction with their families’ ability to get along financially was as high as it's been over nearly five decades.
Jonathan Berney, of Austin, Texas, said that the pandemic — and his resulting layoff as a digital marketing manager for a law firm — caused him to reevaluate everything in his life. While he admits that he’s not exactly happy now, that’s led to another uncomfortable question: Was he truly happy before the pandemic?
“2020 just fast forwarded a spiritual decay. When things are good, you don’t tend to look inwards,” he said, adding that he was living and working in the Miami area before the pandemic hit. As Florida dealt with the virus, his girlfriend left him and he decided to leave for Austin. “I probably just wasn’t a nice guy to be around from all the stress and anxiety. But this forced an existential crisis.”
Berney, who is looking for work, said things have improved from those early, dark days of the pandemic. He’s still job hunting but has a little savings to live on. He said he's trying to kayak more and center himself so he’s better prepared to deal with any future downturn in events.
Reimagining happiness is almost hard-wired into Americans’ DNA, said Sonja Lyubomirsky, a psychology professor at the University of California, Riverside.
“Human beings are remarkably resilient. There’s lots and lots of evidence that we adapt to everything. We move forward,” she said, adding that she’s done happiness studies since the pandemic started and found that some people are slightly happier than last year.
Melinda Hartline, of Tampa, who was laid off from her job in public relations in March, said she was in a depressed daze those first few weeks of unemployment. Then she started to bike and play tennis and enrolled in a college course on post-crisis leadership.
Today, she’s worried about the state of the world and the economy, and she wonders when she can see her kids and grandkids who live on the West Coast — but she also realizes that things could be a lot worse.
“Anything can happen. And you have to be prepared,” she said. “Whether it’s your health, your finances, whether it’s the world. You have to be prepared. And always maintain that positive mental attitude. It’s going to get you through it.”
The survey of 2,279 adults was conducted May 21-29 with funding from the National Science Foundation. It uses a sample drawn from NORC’s probability-based AmeriSpeak Panel, which is designed to be representative of the U.S. population. The margin of sampling error for all respondents is plus or minus 2.9 percentage points.
Published June 7th, 2020
What we can learn from 'untranslatable' illnesses
By Zaria Gorvett
From an enigmatic rage disorder to a sickness of overthinking, there are some mental illnesses you only get in certain cultures. Why? And what can they teach us?
“DO NOT FEAR KORO,” screamed the headline in the Straits Times newspaper on November 7, 1967. In the preceding days, a peculiar phenomenon had swept across Singapore. Thousands of men had spontaneously become convinced that their penises were shrinking away – and that the loss would eventually kill them.
Mass hysteria had quickly taken hold. Men desperately tried to hold onto their genitals, using whatever they had to hand – rubber bands, clothes pegs, string. Unscrupulous local doctors cashed in, recommending various injections and traditional remedies.
The word on the street was that the sudden penis withering was caused by something the men had eaten. Specifically, the locals were suspicious of meat from pigs that had been vaccinated in a programme the government had imposed on Singaporean farms. Pork sales quickly plummeted.
Though public health officials scrambled to contain the hysteria outbreak, explaining that it was caused by “psychological fear” alone, it didn’t work. In the end, over 500 people sought treatment at public hospitals.
As it happens, the fear of losing one’s penis is more mainstream than you might think. It pops up fairly regularly in certain cultures across the globe. In South-east Asia and China, it’s common enough that it even has a name: “koro”, possibly – and rather graphically – after the Javanese word for tortoise, referring to how it looks when they retract their heads into their shells.
Koro has a history stretching back thousands of years, but the most recent outbreak occurred in 2015, in eastern India. It affected 57 people, including eight women, for whom it tends to manifest as a fear that their nipples are retreating into the body.
Koro is considered a culture-bound syndrome – a mental illness that only exists in certain societies. For decades, “untranslatable” disorders like these were studied as mere scientific curiosities, which existed in parts of the world where people apparently didn’t know any better.
Western mental illnesses, on the other hand, were viewed as universal – and you could guarantee that every “bona fide” problem would be found in the hallowed pages of the American psychiatric bible, the Diagnostic and Statistical Manual of Mental Disorders (more commonly known as the DSM). But today scientists are increasingly realising that this is not the case.
In the Islamic world, mental illnesses are often attributed to evil spirits, or “jinns”
In the central plateau region of Haiti, people regularly fall sick with “reflechi twòp”, or “thinking too much”, which involves ruminating on your troubles until you can barely leave the house. In South Korea, meanwhile, there’s “Hwa-byung” – loosely translated as “rage virus” – which is caused by bottling up your feelings about things you see as unfair, until you succumb to some alarming physical symptoms, like a burning sensation in the body. Dealing with exasperating family members is a major risk factor – it’s common during divorces and conflicts with in-laws.
Though to the uninitiated, these mental illnesses might sound eccentric or even made-up, in fact they are serious and legitimate mental health concerns, affecting vast numbers of people.
It’s estimated that Hwa-byung affects around 10,000 people in South Korea every year – mostly older married women – and research has shown that it has a measurable footprint in the brain. In 2009, brain scans revealed that sufferers had lower activity in an area known to be involved in tasks such as emotion and impulse control. This makes sense, given that Hwa-byung is an anger disorder.
The consequences of culture-bound syndromes can be devastating. Koro attacks can be so convincing that men cause serious damage to their genitals, as they try to stop them receding. Those who suffer from reflechi twòp are eight times more likely to have suicidal thoughts, while Hwa-byung has been linked to emotional distress, social isolation, demoralisation and depression, physical pain, low self-esteem, and unhappiness.
Intriguingly, some untranslatable illnesses have recently been disappearing, while others are spreading to new parts of the globe. Where do these sicknesses come from, and what determines where they’re found? The quest for answers has been gripping anthropologists and psychiatrists for decades – and now their findings are shaping our understanding of the very origins of mental illness itself.
The award for the culture-bound illness with the most surprising history surely has to go to “neurasthenia” (also known as “shenjing shuairuo”). Though it mostly occurs in China and South-east Asia today, it’s actually a colonial malady from the 19th Century.
Neurasthenia was popularised by the American neurologist George Miller Beard, who described it as an “exhaustion of the nervous system”. At the time, the Industrial Revolution was leading a massive upheaval of everyday life, and he believed that neurasthenia – a syndrome of headaches, fatigue and anxiety, among other things – was the result.
Sometimes culture-bound illnesses only occur in a certain social class or era of time (Credit: Science Museum/ Wellcome Collection)
“Once famous novelists like Marcel Proust were diagnosed, it became this super popular condition,” says Kevin Aho, a philosopher from Florida Gulf Coast University, who has studied the history of the illness. “It was almost fashionable and indicated sensitivity, intellectual creativity – it was kind of an indicator of one's own cultivated refinement.”
Eventually neurasthenia spread to European colonies around the world, where it was enthusiastically picked up by moustachioed officers and their wives, as a way to add a label to their general feelings of homesickness. According to a survey taken in 1913, neurasthenia was the most prevalent diagnosis among white colonisers in India, Sri Lanka (then Ceylon), China and Japan.
As the years passed, neurasthenia gradually lost its appeal in the West, as it became associated with more serious psychiatric problems. Now it’s been forgotten about altogether. But elsewhere, the opposite happened: it was adopted as a diagnosis that didn’t come with stigma of mental illness and remains in use to this day.
In some parts of Asia, people are more likely to say they have neurasthenia than depression. A 2018 study of a random sample of adults from Guangzhou, China, found that 15.4% identified as having the former versus 5.3% who said they had the latter.
The final twist is that now neurasthenia is vanishing from Asia too. “When I first interviewed patients at a psychiatric hospital in Ho Chi Minh, Vietnam, in 2008, almost all of them said that they had neurasthenia,” says Allen Tran, a psychological anthropologist from Bucknell University, Pennsylvania. “Then when I did some follow-up research 10 years later, I think only one person in my sample said they had it.”
So what’s going on?
There are two possible scenarios playing out here. First, there’s the idea that the entirety of humankind is susceptible to the same limited range of mental sicknesses – we all feel anxious and depressed, for example, but the way we talk about these things varies depending on when and were you live.
The fact that culture-bound illnesses can be gained and lost within a single community, and with such rapidity, is an important clue. This suggests that they’re not driven by, say, genetic factors, as this kind of change usually takes hundreds or thousands, rather than tens of years. Instead, the swift extinction of neurasthenia in Vietnam could be down to the growing popularity of the concept of anxiety, which has been imported from overseas. It’s possible that the actual incidence of mental illness has been the same all this time – but conceptually, one has been replaced with the other, says Tran.
In some cultures, distress and grief can manifest with physical symptoms (Credit: Alamy)
Along these lines, the author and medical historian Edward Shorter has suggested that each society has its own “symptom repertoire”, which is the array of symptoms from which we unconsciously draw when we start to feel mentally unwell.
For example, a grieving Victorian woman might say she felt faint, where her modern counterpart in the UK might suggest she felt anxious or depressed, and someone in the same position in China might explain they had a stomach-ache. In this scenario, they would all have had identical experiences – perhaps they all felt faint, on edge, or suffered physical pains – but the symptoms they paid the most attention to were different, depending on what was considered normal in their society.
In Britain, the out-dated illness “hysteria” – which was thought to mostly affect women, and caused fainting, emotional outbursts and nervousness – disappeared from the public consciousness in the early 20th Century. But Shorter suggests that it didn’t actually die out. Instead, the array of symptoms we look out for evolved. Today the same mental phenomenon hides behind other diagnoses, such as depression.
I would say that there are definitely instances where the meaning that is attributed to experiences actually changes biologically what that experience is – Bonnie KaiserThis fits with another concept that has been gaining in popularity, “idioms of distress”, which suggests that each culture has certain acceptable, established ways of expressing emotional anguish at any given time. In one society, you might drink excessively, while in others you might say you’re a victim of witchcraft, or diagnose yourself with illnesses like koro or depression.
For example, in the Islamic world, it’s widely believed that it’s possible to become possessed by “jinns”, or evil spirits. They can be good, bad, or neutral, but they’re generally blamed for erratic behaviour. The concept is so mainstream, it’s even in the Muslim holy book, the Koran. “A lot of my patients do hold these beliefs quite strongly,” says Shahzada Nawaz, a consultant psychiatrist at North Manchester General Hospital in the UK.
Nawaz explains that the ability to invoke jinns is particularly useful in Islamic cultures, because of the stigma that tends to accompany Western mental illnesses. One study of 30 Bangladeshi patients attending a mental health service in an east London borough found that, though they had been diagnosed with a variety of problems between them, such as schizophrenia and bipolar disorder, their family members often felt that jinn possession was responsible.
"Neurasthenia" is a colonial malady from the 19th century, which mostly occurs in China and Southeast Asia today (Credit: Getty Images)
But are culture-bound illnesses really just the result of differences in labelling? Another tantalising possibility is that the society we live in can actually shape the way we get sick.
Physical vs psychological pain
It turns out there is an invisible global divide in the way people experience distress. In the US, the UK, and Europe – at least in the 21st Century – it tends to occur in the mind, with symptoms like sadness, anger or anxiety prevailing. But this is actually pretty weird. In many parts of the world, in countries as diverse as China, Ethiopia and Chile it manifests physically instead.
For example, the most up-to-date edition of the DSM describes a panic attack as “an abrupt surge of intense fear or intense discomfort”. However, in Cambodian refugees, the symptoms tend to centre around their necks instead. Many non-Western mental illnesses, such as koro and Hwa-byung, fit this pattern of perceiving physical symptoms. The divide even extends to the way people in certain societies respond to exercise or surgery; where it’s more usual to experience physical pain, it’s more likely.
In contrast, mental illnesses that involve the perception of pain are rare in the Western world, and hotly debated. Some scientists think chronic fatigue syndrome and fibromyalgia fit into this category, though this is controversial.
In fact, it’s been known for years that our beliefs can have a powerful effect on the way we feel – even on our biology. One example is “Voodoo death”, in which a sudden demise is brought on by fear. In a famous case documented by an early explorer in New Zealand, a Maori woman accidentally ate some fruit from a place that was considered taboo. After announcing that the chief’s spirit would kill her for the sacrilegious act, she died the very next day.
Whether someone could bring about their own death though fear alone is not clear. (Read more about the contagious thought that could kill you.) But there is strong evidence that our thoughts and feelings can have a tangible physical impact, such as when a patient expects a medication to have side-effects, and therefore it does – known as the nocebo effect.
“I would say that there are definitely instances where the meaning that is attributed to experiences actually changes biologically what that experience is,” says Bonnie Kaiser, an expert in psychological anthropology at the University of California, San Diego. She gives the example of the illness kyol goeu, literally “wind overload”, an enigmatic fainting sickness which is prevalent among Khmer refugees in the US.
In their native Cambodia, it’s commonly believed that the body is riddled with channels that contain a wind-like substance – and if these become blocked, the resulting wind overdose will cause the sufferer to permanently lose the use of a limb or die. Out of 100 Khmer patients at one psychiatric clinic in the US, one study found that 36% had experienced an episode of the illness at some point.
Bouts usually proceed slowly, starting with a general feeling of malaise. Then, one day, the victim will stand up and notice that they feel dizzy – and this is how they know that the attack is starting. Eventually they’ll fall to the ground, unable to move or speak until their relatives have administered the appropriate first aid, which usually consists of massaging their limbs or biting their ankles.
While medications are helpful for a lot of people, those with certain cultural beliefs might be more comfortable with treatments like psychotherapy (Credit: Science Photo Library)
Kaiser points out that when most people experience light-headedness, they just shake it off. But if someone interprets that feeling as signalling the start of a kyol goeu attack, they think: “Oh my gosh, something terrible is happening.”
“They really attend to it and they panic,” she says.
The meaning that’s attributed to the feeling of dizziness changes everything. “Fundamentally the actual experience in the body becomes very different,” says Kaiser. “So, to me, this isn't something that has a different name in different places – this illness just doesn't exist in some places. The very biology of that experience is affected by the culture.”
According to Kaiser, in reality, it’s likely that for many mental illnesses, there is both a difference in the way people interpret the same physical experiences, and a positive feedback loop which allows their cultural ideas to shape how they manifest.
Revising Western illnesses
As our understanding of culture-bound illnesses has improved, some psychologists have begun to question whether certain Western mental health conditions fit into this category too. Though certain disorders appear to be universal – schizophrenia occurs in every country on the planet, at a relatively constant rate – this is not true for others. Bulimia is half as common in Eastern cultures, while pre-menstrual syndrome (PMS) is virtually non-existent in China, Hong Kong and India. It’s even been argued, somewhat controversially, that depression is an invention of the English-speaking world, stemming from the misguided notion that it’s normal to be happy all the time.
In the modern era, it would be naive to think that the mental illnesses we suffer from are independent of our way of life. “I think there's a tremendous arrogance in the way that we universalise these mental illnesses and don't see them as socially and historically specific,” says Aho, pointing out that attention deficit disorder (ADD) was only added to the DSM in 1980. “It's clear that children have a more difficult time paying attention now, because they're bombarded with sensory stimulations and their existence is largely mediated by screens. And so it's not as if we’ve only just discovered some discrete medical entity – you can see the way in which technology is shaping the mental and emotional and behavioural lives and children.”
Regardless of their cause, in an increasingly mobile world, some experts are concerned that culturally specific illnesses aren’t being recognised by mental health professionals. “In East Asian cultures, the vocabulary and language that people use to express their distress and symptoms is quite different,” says Sumin Na, a psychologist at McGill University. This means that when East Asian people migrate to places like North America, it’s often not clear when they need help.
Khmer refugees in the US often suffer from the fainting sickness kyol goeu, or "wind overload" (Credit: Getty Images)
“For instance in a lot of Western society, I think we see depression and anxiety as a chemical imbalance. And that leads us to seek help through our doctor and getting medication,” she says. “But in East Asia it’s seen as more of a social or spiritual or a family concern – so people might seek spiritual help or, you know, find ways to resolve family conflict.”
In order to get people the help they need, Na says it’s important to understand a patient’s backstory – the cultural norms where they come from and the loss of power and privilege they might have experienced when they moved, which can often lead to mental health problems down the line. “I think we also have to try to let go of what we think is 'correct' knowledge of mental health and mental illness and not to get really stuck on [them] or the DSM-5 as the only way of understanding and labelling mental illness,” she says.
Equally, it’s unreasonable to expect the same treatments to work for everyone. Na suggests that, while medications are helpful for a lot of people, those with certain cultural beliefs might be more comfortable with things like psychotherapy.
In an era that’s seeing drastic losses in diversity of virtually every other kind – from species to languages, it’s been suggested that we’re standing on a precipice, potentially about to lose our range of mental illnesses too. In the book “Crazy Like Us”, the author Ethan Watters describes how we’ve spent the last few decades slowly, insidiously Americanising mental illness – shoehorning the colourful array of emotional and psychological experiences that exist into a few approved boxes, such as anxiety and depression – and “homogenising the way the world goes mad”.
In the process, not only do we risk missing out on diagnoses and foregoing the most appropriate treatments, but the opportunity to understand how mental illnesses develop in the first place.
Is Everyone Depressed?
Suddenly, many people meet the criteria for clinical depression. Doctors are scrambling to determine who needs urgent intervention, and who is simply the new normal.
by James Hamblin
May 22, 2020
The word I keep hearing is numbness. Not necessarily a sickness, but feeling ill at ease. A sort of detachment or removal from reality. Deb Hawkins, a tech analyst in Michigan, describes the feeling of being stuck at home during the coronavirus pandemic as “sleep-walking through my life” or “wading through a physical and mental quicksand.” Even though she has been living in what she calls an “introvert heaven” for the past two months—at home with her family, grateful they are in good health—her brain has dissented. “I feel like I have two modes,” Hawkins says: “barely functioning and boiling angry.”
Many people are even more deeply unmoored. Michael Falcone has run an acupuncture clinic for the past decade in Memphis, Tennessee. When he temporarily shut it down, the toll on his mental health was immediate. “I went into a pretty instant depression when I realized that my actual purpose was disintegrating,” he says. He began spending his days staring at his bookshelves. Falcone and I have exchanged emails for weeks now, and while his notes have been full of whimsical musings about adjusting to home life, one included a jarring line: “I’ve lost faith in myself. I don’t know if I can actually justify taking up space and resources.”
After I confirmed with Falcone that he had no intent to harm himself, I recommended that he seek medical help. But given the unprecedented circumstances we’re all in, I’m not sure whether I under- or overreacted—or even what “help” should look like, exactly. The pandemic is a moment of historic loss: unemployment, isolation, stasis, financial devastation, medical suffering, and hundreds of thousands of deaths globally. Suddenly droves of people are being thrown into a state like Falcone’s, feeling lost, hopeless—in his words, “depressed.”
Over the past month, Jennifer Leiferman, a researcher at the Colorado School of Public Health, has documented a tidal wave of depressive symptoms in the U.S. “The rates we’re seeing are just so much higher than normal,” she says. Leiferman’s team recently found that people in Colorado have, during the pandemic, been nine times more likely to report poor mental health than usual. About 23 percent of Coloradans have symptoms of clinical depression.
As a rough average, during pre-pandemic life, 5 to 7 percent of people met the criteria for a diagnosis of depression. Now, depending how you define the condition, orders of magnitude more people do. Robert Klitzman, a professor of psychiatry at Columbia University, extrapolates from a recent Lancet study in China to estimate that about 50 percent of the U.S. population is experiencing depressive symptoms. “We are witnessing the mental-health implications of massive disease and death,” he says. This has the effect of altering the social norm by which depression and other conditions are defined. Essentially, this throws off the whole definitional rubric.
Feelings of numbness, powerlessness, and hopelessness are now so common as to verge on being considered normal. But what we are seeing is far less likely an actual increase in a disease of the brain than a series of circumstances that is drawing out a similar neurochemical mix. This poses a diagnostic conundrum. Millions of people exhibiting signs of depression now have to discern ennui from temporary grieving from a medical condition. Those at home Googling symptoms need to know when to seek medical care, and when it’s safe to simply try baking more bread. Clinicians, meanwhile, need to decide how best to treat people with new or worsening symptoms: to diagnose millions of people with depression, or to more aggressively treat the social circumstances at the core of so much suffering.
Clearly articulating the meaning of medical depression is an existential challenge for the mental-health profession, and for a country that does not ensure its people health care. If we fail, the second wave of death from this pandemic will not be directly caused by the virus. It will take the people who suffered mentally from its reverberations.
Like COVID-19, depression takes erratic courses. Some predictable patterns exist, but no two cases are exactly alike. Depression can percolate for long periods then quickly become severe. Some people will barely notice it, and others will be tested in the extreme.
Andrew Solomon, the author of The Noonday Demon: An Atlas of Depression, groups people based on four basic ways they’re responding to the current crisis. Two are straightforward. In the first are people who are drawing on huge stockpiles of resilience and truly doing okay. When you ask how they feel and they say “eh, fine,” they actually mean it. In the second, at the opposite end of things, are people who already have a clinical diagnosis of major depressive disorder or a persistent version known as dysthymia. Right now, their symptoms are at high risk of escalating. “They develop what some clinicians call ‘double depression,’ in which the underlying disorder coexists with a new layer of fear and sorrow,” Solomon says. Such people may need higher levels of medical care than usual, and may even need to be hospitalized.
The remaining two groups constitute more of a gray area. One group consists of the millions of people now experiencing depressive symptoms in a real way, but who nonetheless will return to their baseline eventually, as long as their symptoms are addressed. People in this group are in urgent need of basic interventions that help create routine and structure. Those might involve regularizing sleep and food, minimizing alcohol and other substances, exercising, avoiding obsessions with the news, and cutting back on other aimless habits that might be easier to moderate in normal times.
The fourth group encompasses people who are starting to develop clinical depression. More than simply a wellness regimen or a Zoom with friends, they need some type of formal medical intervention. They may have seemed fine and had adequate resilience in normal times, to deal with normal difficulties, but they’ve always had a propensity to develop overt depression. Solomon describes this group as “hanging on the precipice of what could be considered pathologic.” It can be especially precarious because people in this state—what some researchers refer to as “subclinical depression”—have not dealt with depression before, and may not have the capacity or resources to proactively seek treatment.
The earlier specific types of depression can be identified, the better people can be directed toward proper treatment. The mental-health system has always had barriers to identifying and helping people early—issues like access to care and stigma around seeking it out. In the midst of this pandemic, not only is the current population of psychiatrists insufficient to suddenly treat several times as many people as usual, but their basic capacities of diagnosis are also hindered by distance, volume, and confounding variables. “It takes considerable wisdom to delineate who has a clinical condition and needs medication and therapy, and who is just stressed out within the bounds of good mental health,” Solomon says. Clinicians train for years to understand that line, and placing people on one side or the other typically requires long interviews in which every element of a person’s affect is noted.
Even for people who manage to connect with clinicians, subtleties are difficult to read over video calls, says Meghan Jarvis, a trauma therapist who has been seeing a spectrum of reactions to the pandemic, including depression. Normally, Jarvis sends maybe one patient a year to the hospital for a pathologic response to trauma. Since March, she has already had to hospitalize four people. Typically, she explains, symptoms of depression are considered problematic if they last six weeks after a traumatic event. The precise length is arbitrary, but is meant to generally help distinguish depression from periods of grieving, such as after the death of a loved one. That distinction is largely useless in the pandemic. “I mean, we’re all going to have that,” Jarvis says, “because we’ve been in this mode for more than six weeks.”
Now Jarvis and others have to develop new thresholds. Just as, in the time of COVID-19, not everyone with a cough can go to the hospital, clinicians are working to identify and prioritize those who truly need in-person mental-health attention. Jennifer Rapke, the head of inpatient consultation at Upstate Golisano Children’s Hospital in New York, has seen a surge in teenagers reporting suicidal ideation and instances of self-harm, so she has been carefully turning away the less severe cases to make sure that inpatient facilities aren’t overwhelmed. “We’re only seeing people who absolutely need to be here,” she says. Meanwhile, those with milder, emerging cases are sometimes left in limbo. “The places we would normally send people, the things we would put in place to address the depression or the anxiety in early phases—they don’t exist or they’re unavailable,” Rapke says.
With less preventive and maintenance care accessible, people are more likely to come to hospitals in more severe states. During crises, extreme events like self-harm and suicide lag in time. At first, being anxious about the proximity of death, or sad about the loss of loved ones is logical; any other reaction would be bizarre. Our minds and bodies can’t endure that state for too long, though. The United States was slow to test for the coronavirus, and COVID-19 cases accumulated before we knew just how widespread it was. Rapke and others are now bracing for a similarly delayed wave of severe depression—and the difficult decisions they will have to make about treatments.
The elusive definition of depression has always been a source of academic tension with serious consequences. Among the many challenges the pandemic is posing, it is exposing the borders of medicine’s ability to distill human suffering into a billable diagnostic code. Some people with symptoms of depression will be told, “Everyone feels that way,” or advised to try breathing exercises when they need urgent medical attention. Others will be diagnosed with clinical depression, changing their life and self-conception indefinitely, when the problems were truly circumstantial. The system has never been flawless, but its limitations are now brought into stark relief.
For most of human history, depression was not treated in the same medical model as were diseases of the body. People with mental illnesses were written off as morally bankrupt or simply “insane.” Only in the latter half of the 20th century did the profession of psychiatry become a medical specialty and create systematic approaches to treatment. The process for diagnosing a condition in psychiatry and clinical psychology will never be as straightforward and objective as saying whether a bone is broken or not, or whether a person has had a heart attack. But it provides a common, basic language for what a clinician means when he or she diagnoses a patient with something like depression. It also helps patients get the insurance coverage and health-care service they need.
Today, depression—the clinical condition, otherwise known as major depressive disorder—is defined by the American Psychiatric Association in its Diagnostic and Statistical Manual as a mood disorder.* To receive the diagnosis, a person must have five or more symptoms such as the following, nearly every day during a two-week period: fatigue or loss of energy, feelings of worthlessness or inappropriate guilt, reduced physical movement, indecisiveness or impaired concentration, a decreased or increased appetite, and a greatly diminished interest or pleasure in regular activities.
Experts are trained to identify exactly how much “impaired concentration” or “loss of energy” is enough to qualify for a diagnosis, and the criteria are intentionally flexible enough to factor in patients’ individual circumstances. But as the pandemic has made clear, the DSM-5 and medical model as a whole don’t provide the richness of language to account for all the nuanced ways people might look or feel depressed, even when they don’t need medical intervention. Well-meaning attempts to standardize the diagnostic process have created a false binary wherein you are a person with depression, or you are not.
Outside of medicine, depression has been most cogently defined through metaphor. As Sylvia Plath wrote: “The silence depressed me. It wasn’t the silence of silence. It was my own silence.” David Foster Wallace described depression as feeling that “every single atom in every single cell in your body is sick.” Even some clinical models reach for alternative ways of articulating despair beyond the conventional medical model. James Hollis, a psychodynamic analyst and the author of Living Between Worlds: Finding Resilience in Changing Times, says that depression is sometimes the result of “intrapsychic tension,” a conflict between two areas of our psyche, or identity. The tension is created, Hollis observes, “when we’re forced to try to make acquaintances with ourselves in new ways.”
Many Americans do seem to be experiencing something like this tension during the pandemic. People who define themselves by their work can lose a basic sense of self if that work disappears. In such moments, Hollis says, many people regress. Many also try to escape—whether by organizing an already well-organized sock drawer, baking bread they don’t even want, or endlessly scrolling through Instagram. Jarvis, the trauma therapist, is seeing similar escapist tendencies: “For someone’s response to a huge global pandemic to be like, I’m going to work out really hard, is just as pathological and sort of dissociative as if you went to bed and didn’t get up for five days.”
For people whose response to the pandemic turns from acute anxiety into general malaise, Jarvis recommends facing the numbness head-on. It’s treatable, and not necessarily with medication. First, she says, create regimens of simple tasks that give structure to the day. The approach is working for Falcone, the acupuncturist. He starts every day with 30 minutes of stretching, no matter what. Then he walks his dog, makes coffee, and sits down to teach massage via Zoom. Deb Hawkins, the tech analyst, sent me a list of things she’s doing to help others and stay busy: She donated money to a couple of worthy causes, and made an appointment to give blood. She has created a small social bubble and signed up for an online ballet class. She says her sense of self is returning.
Small steps like these will not work for everyone, but they may help many in the subclinical realm to mitigate a dangerous slide. With the medical system already stretched thin, these could buy some time to build its capacity to care for the people who will emerge from the pandemic with severe and lasting symptoms. As important as preventive behaviors can be, human resilience has limits. Those will be tested for months to come.
The individual model of depression was never meant to address a significant percentage of a population. When the diagnosis seems to apply so widely, it’s not the people or the entire medical system that’s broken, but the social context. While many people will find ways to recalibrate their expectations and individual thresholds for joy in the pandemic, ultimately basic needs still have to be met. This means eliminating sources of anxiety, such as by ensuring financial, housing, and food security. In Colorado, Leiferman’s group is among those scrambling to help stem the tide of depressive symptoms. “Our nation is under stress. It may be that more people need [medical] treatment,” she says. “It may be that we need to, as a population, do more to relieve the stress.”
Patterns of pain: what Covid-19 can teach us about how to be human
We can expect psychological difficulties to follow as we come out of lockdown. But we have an opportunity to remake our relationship with our bodies, and the social body we belong to.
By Susie Orbach
When lockdown started, I was confused by bodies on television. Why weren’t they socially distancing? Didn’t they know not to be so close? The injunction to be separate was unfamiliar and irregular, and for me, self-isolating alone, following this government directive was peculiar. It made watching dramas and programmes produced under normal filming conditions feel jarring.
Seven weeks in, the disjuncture has passed. I, like all of us, am accommodating to multiple corporeal realities: bodies alone, bodies distant, bodies in the park to be avoided, bodies of disobedient youths hanging out in groups, bodies in lines outside shops, bodies and voices flattened on screens and above all, bodies of dead health workers and carers. Black bodies, brown bodies. Working-class bodies. Bodies not normally praised, now being celebrated.
We are learning a whole new etiquette of bodies. We swerve around each other, hop into the near-empty street, calculate distances at entrances to parks, avoid body contact, even eye contact, and keep a look out for those obliviously glued to their phones, whose lack of attention threatens to breach the two-metre rule. It’s odd and disconcerting and isn’t quite second nature.
Until the pandemic arrived, many of us were finding texting, email and Whatsapp more suitable to our speeded-up lives. But now we are coming to reuse the telephone, and to enjoy the sounds in our ears and the rhythm of conversation, instead of feeling rushed and interrupted. A few of my sessions as a psychoanalyst are now conducted on the phone but, for the most part, I am spending my time looking into a screen, and seeing faces rather than whole bodies. Until I learned to turn off the view of myself, I, like others, was disconcerted by the oddness of catching sight of myself – a view I don’t think we are meant to see.
Conversations in therapy defy many of the customs of social intercourse. There are silences, repetitions, reframings, links across time, reminiscences of fragments, rushes of emotion, shards of dreams, things told and then disavowed. There can be fidgeting or absolute stillness. These form the idiosyncratic and personal ambience between each therapeutic couple. As a therapist, I am also alert to how the dilemmas that beset the person or the couple I am seeing are brought to our relationship.
The conundrums that brought the person to seek therapy in the first place can be replayed right here. For example, a person fearful of intimacy can experience the therapy relationship or the therapist as too close. Someone else who worries they are too needy may be reluctant to show their longings directly to the therapist, although well able to talk about how things go wrong for them in other relationships. The therapy relationship and the sessions are our petri dish. The field of study is the human subject (and her, his or their ways of being able to develop and change).
The therapist works to understand an individual’s personal psychological grammar – to help the person take the risk of unlearning and then learning anew, finding ways to not be in so much hurt. So too with the body. Those with troubled bodies bring them to the session. They may sit too close, for example, or seem to be concave, or dress incongruously, as though presenting a different persona in each session. In the course of therapy, such an abject body experience can be addressed, and, in unlearning and then learning anew, the person finds a more comfortable way to sit in their body.
How is the dematerialisation of bodies affecting us and going to affect us? Me, my patients, you – all of us? For some of my patients, their screen or home is a prison. Their experience is full of woe and worry. Therapy keeps them just about on the border of sane, but it’s a sanity that hurts: isolation can maraud all of us as we miss the interactions, intimate or casual, that confirm our sense of our value, our place in our community, our work and the world.
Some of my clinical preoccupations centre on how we acquire a physical, corporeal sense of self. Although psychoanalysis is a theory of mind and body, its main emphasis has drifted to the development of the mind and its structures: what we call defences, and the relationship patterns we have absorbed. Bodies have been very much the bit player to the main drama of the mind, even when mental processes or disturbance have resulted in bodily symptoms such as eczema or a non-biologically induced paralysis. As therapists, we traditionally read back into the mind the troubles visited on the body, seeing them as the result of mental conflicts. And of course, they often are, but I have long been keen to understand body troubles and body difficulties in their own terms, and to build a theory about the development of the body.
Bodies have always been bound and marked by social rules. Different societies make different sense out of similar bodily actions or gestures. The variety of body adornment and transformations around the world, from rings around the neck to the recent upsurge in labial reductions and penis enlargements, has made it ever more apparent that the body is not simply the product of DNA. The body we inhabit develops within relationships to other bodies. Usually it is within the maternal orbit where, to take an obvious example, we first apprehend gender-based forms of comportment. When I grew up, being told to sit like a girl and not to climb trees were some of the ways we were treated differently to boys. Research across many cultures show that baby girls are weaned and potty-trained earlier, fed less at each feed, and held less, than boys. There may be no biological basis to this, but rather a social, unconscious basis that then informs how we personally experience our particular embodiment.
We have very few verified reports of humans growing up outside of human culture but the feral child Victor of Aveyron, who was discovered living wild in the woods of southern France in 1800, did not have body movements that were recognisably human. The body-to-body relationship that was foundational for him was with the bodies of the wolves he apparently grew up among. He seemingly mimicked their gait and moves, their posture and their vocalisations. Of course, we know this more familiarly, and less dramatically, from when youngsters develop their group identities by adopting the mannerisms of film actors or musicians.
Through screens, billboards and photoshopped images, we reduce the wide variety of bodily expression. It’s as though we are losing body diversity just as we are losing languages. The digitised, westernised body image predominates, and in the last two decades has spawned a cosmetic surgery industry worldwide – from leg-lengthening surgery using steel rods in China (now banned), to rhinoplasty in Iran (which has the highest rate of nose surgery per capita in the world) to double-eyelid surgery and jawbone reduction in South Korea. In the west, surgeons resculpt cheekbones, breasts and calves, and offer day procedures for facial ‘thread lifts’. Cosmetic surgery tourism hubs in Hungary, South Korea and Singapore were thriving until the lockdown.
One Chinese smartphone app allows the selfie-taker to adjust their portrait to bring it closer to a very specific standard of beauty known as wang hon lian, or “internet celebrity face”. It’s very popular: billions of wang hon lian images are uploaded every month.
The richest Europeans are not in tech, but in the business of beautifying bodies – the owners of fashion, luxury and cosmetics brands such as LVMH, L’Oreal and Zara. Increasing automation has led us to move from using our bodies to make things to turning our bodies the site and the product of our labour, through diet and exercise regimes, clothing and cosmetics. The surface body is meant to be on display.
Paradoxically, the sweating, smelling, holding, stroking body of the other becomes, for those socially distancing, too distant – while for others, such as those sharing a house with teenage boys, it’s all too present. All is on show for families and housemates, while all is hidden for those living alone during lockdown.
The experience of the body on FaceTime or Zoom contrasts with the pulsing, breathing, weeping, sighing, tired, achy or indeed springy and enthusiastic bodies we inhabit. We no longer have social communion in the flesh, the handshake or the hug, the pleasure of eating in a restaurant with a friend or lover while seated near strangers. Afraid of infection, for our protection, we collapse our social space.
During the second world war, the psychiatrist René Spitz studied orphan babies in care. He discovered that those closest to the nurses’ station thrived, while those at the end of the ward did not do so well. The difference was touch: the nurses would casually touch and interact with those closest to them, and this gave those infants the essential food for physical and psychological development. They absorbed the will to live. A decade later – in research now considered controversial for the way in which he removed baby monkeys from their mothers – the American psychologist Harry Harlow discovered that baby monkeys given ersatz mothers in the form of basic cloth puppets would find some crucial security and comfort even in this simulation of maternal touch; those baby monkeys deprived of any kind of maternal touch at all became highly disturbed, and many died.
Touch, feel and proximity are central to survival. Consider the genius of premature infants’ capacity to regulate their own and, extraordinarily, their parent’s body temperature, if they are held skin-to-skin in a pouch. The gaze – the search to be seen, to recognise and to influence the other – is also crucial to human subjectivity. In a fascinating video made by the developmental psychologist Edward Tronick, he instructs a mother playing with her baby to keep a still face and refrain from interacting with her infant for a minute or two. We observe as the infant girl seeks to engage the mother. When she is unable to, the baby collapses psychologically and physically until contact is restored. What is so shocking is how fast the collapse is.Trauma Therapy (EMDR)
I’ve been thinking of how impossibly difficult and challenging our quasi-dematerialised life through the Zoom screen is, whether chatting with friends or being in a meeting. Conflict and harmony become cartoonish as subtle gestures collapse and the conversations we have with our eyes are shut down.
Reading each other well enough is a new skill in the therapy room, too, for both people. By now we are used to the screens and the telephone, and the occasional technical blips. We are seeing a physical interior – a study, bedroom, shed or kitchen, and being surprised by an occasional child that floats in. We hear the suddenly hushed voice of someone not wanting their partner to get a drift of the conversation we are having. It illuminates aspects we didn’t see before. Is it better? No. Is it worse? Marginally. I miss noticing how people enter the therapy room – the subtle difference from the session before, or the way they may hold their face and body; above all, the animate body in the room. I suspect that I am more animated to make up for the loss of that precious physicality.
Former hostages Terry Waite, John McCarthy and Brian Keenan have all written and spoken eloquently about solitary confinement and their struggles to find a way through and back – or should I say forward – to familial and social life. It was tough. And although many of us are not self-isolating alone, unless one is able to do interesting or valued work during this period, or have enough people to hang out with, we can expect considerable psychological difficulties to follow as we come out of lockdown. How will we re-establish social interaction with other bodies? What kind of rhythms will we want and be able to have going forward?
Many have been ultra-busy with home schooling, working from home, managing three generations and so on. Time has bent and contracted in perplexing ways. Busyness has increased for some, while others, for whom slowing down is a foreign concept, have had idleness forced on them. Empty time feels alien – or at least did at the beginning. For many it has been an unexpected pleasure. No need to rush to social occasions. No need to dress. No need to get everything done and more. Being wanted, being needed, being in demand have been psychological supports that have melted away. Finding new ways to nourish one’s needs in this new reality – especially in the absence of touch and gaze, which we unknowingly rely upon to recognise ourselves – can be tricky.
Today, there is a frightened, wary, social body. A body that is tense, in which avoidance is the watchword. The covered face, whether by a hoodie or a veil, which formerly some found challenging, now offers reassurance. Indeed, many public places – from Eurostar trains to the streets of New York, Prague, Dubai, Havana and many more – now demand it. Meanwhile, much of society is now paying attention to bodies that had been scandalously overlooked. The bodies of working women, the carers who go in and out of the houses and homes of the people they look after. The faces of vast numbers of black, Asian and minority-ethnic bodies, particularly in the health service, who are finally being recognised for their value, and the shockingly disproportionate number of their losses.
Before Covid-19, the ruling party were happy to slash social and health funding, to put money into management in the NHS, and not into professional carers, doctors and nurses. Now society is waking up to the value of care and medical expertise that comes from the hospital floor – that is to say, from the doctors and nurses who are reorganising what occurs there. The people keeping society going in every sector – transport workers, small shopkeepers, workers in food production and delivery – are often first-generation immigrants. More people are seeing a more nuanced social landscape. The opportunity is here for reframing how we represent the social body. It is of necessity differently hued, and that needs acknowledging, as does the shame of our previous marginalising. Covid-19 is cleaning the lens, so we can see more clearly.
From the individual to the social body, and how it is being challenged by the pandemic, we turn to the corporate body – the body of state – and what we have been learning about how it has functioned. On 17 April, Prof Anthony Costello, a former director of the Institute for Global Health at UCL, told the select committee on health and social care that he feared Britain might have the highest number of deaths in Europe, which has now been confirmed. Costello had estimated 40,000 deaths; on 5 May the official UK death toll was just over 32,000, but the Financial Times reported the same day that the true figure had likely already surpassed Costello’s estimate. London and the north-west of England are showing higher rates of death than other regions, while according to the ONS, people in the most deprived areas of England and Wales are dying at twice the rate of the most affluent areas.
Costello argued for this figure because we were slow off the mark to take precautionary moves early on. He spoke to the chair of the committee, Jeremy Hunt, who has spent this period appearing to stress about the lack of testing, ventilators and PPE equipment. This is the same Hunt who, as the longest serving health secretary in British history, also had social care in his portfolio, and the pay of doctors, nurses and social care workers. Even more damningly, he was the minister in charge during Exercise Cygnus, the UK government’s drill to test our preparedness for a pandemic, carried out in 2016.
The full review of Exercise Cygnus has never been officially published, but leaks have revealed that it showed the UK’s health system and local authorities were woefully unprepared for such an eventuality. The exercise showed hospitals and mortuaries being quickly overwhelmed, and shortages of critical care beds, ventilators and personal protective equipment for hospital staff.
Cygnus, and other such exercises, are meant to show the government what they need to do to be prepared – which was not, as Hunt was doing, cutting beds. On 28 March of this year, when the Cygnus debacle came to light, we were told that the projections were not remedied because of worries that beds, ventilators and PPE would become outmoded or obsolete and that the government had worked on securing reliable supply chains. (As we have seen, in a pandemic, reliable supply chains become very quickly overwhelmed.) A 2018 Red Cross conference report on Cygnus and infectious diseases stated: “The financial and human cost of an outbreak can be staggering and early response reduces the cost.” Our government chose not to act.
Fund for Peace, the Washington-based NGO that publishes the annual Fragile States Index, lists criteria for a failed state. I think we have come dangerously close to fulfilling two of their criteria: the inability to provide public services for the poor, and the inability to interact with other states as a full member of the international community.
As these last months’ farcical developments show – the question about the independence of the Scientific Advisory Group for Emergencies (Sage), the alleged missing communications with the EU on PPE, the political decision not to cooperate with the EU, the posting out of tests without return envelopes, and the expired dates on PPE equipment – the government is in Fawlty Towers territory.
Plans for British companies to design new ventilator machines, detailed by the Financial Times, went belly up. Our government chose to source new ideas rather build to the existing plan under licence. Why, one must ask? Could it be Brexit hubris?
I don’t want to contrast the UK’s response with that of the EU, because the latter has not always covered itself in glory during the pandemic. The ethics of cooperation in Europe and the ethics of transparency and honesty have been mightily tested in the past months. Perhaps now though we can be encouraged by the joint project of the European Investment Banks and WHO to bolster global healthcare systems. Will the UK state be contributing? I think not. So much depends on the actions of citizens now to move things forward. In this light, it is encouraging to see the formation of a new independent panel of experts – a “rival” to Sage – led by the former UK government chief scientific adviser David King, whose deliberations are on YouTube for us to watch.
I am not sure how we characterise the following failure of the state, because it is in part the expression of public good: of the 750,000 people who signed up to volunteer to help the NHS, invited by the government, fewer than 100,000 have been deployed. As citizens, we want to contribute. This squandering of people’s generosity is disturbing. Fortunately, people such as Capt Tom Moore or the many making masks and contributing 3D printers keep on going. And the programme Feed NHS, in which the restaurant chain Leon and other chefs are prepping to feed patients, doctors, nurses, hospital porters and ambulance workers, is now in train. This voluntary work, in which groups of people self-organise, is outstanding, and yet it is in contrast to the inability of our state to mobilise those who wanted to help.
The Gates Foundation’s contributions to seven different vaccine programmes, and Twitter CEO Jack Dorsey’s donation of $1bn, are impressive. Will hedge funds in the UK such as Ruffer investment, which pocketed £2.4bn in March, or Somerset Capital (the fund Jacob Rees Mogg used to run) who see Covid-19 as a “once or twice in a generation” opportunity for investment, make a contribution, too?
There are several dozen UK-based hedge funds managing assets worth £1bn or more. Could the mood of the country be such that hedge fund investors and managers might be persuaded to donate some of their obscene profits to the coronavirus response or to sponsor migrants from beyond Europe (who work here as cleaners, carers, drivers), who do not earn the £30,000 currently demandedfor a work permit?
Covid is a sad story. It is also a story of resilience. The body of state has failed us. We need to grow up and recognise that. Covid-19 has exposed unforgivable systemic failure. In the years leading up to this, we’ve seen a reduction in the status of civil servants and a downgrading of health workers. We have seen teachers, doctors and academics hidebound in a managerial economy. At least it seems that micromanagement has been temporarily overturned in hospitals, thank goodness, because right now doctors and nurses need to be running the show.
And to return to our bodies – the live ones, so many devoid of touch and gaze, facing a long period of isolation, and frightened. How can I conclude?
In a way, I can’t. We are far from the other side of this crisis. Psychological therapies are going to have a huge part to play in the remaking of body and soul. I don’t much like the word trauma, because it has become so overused, but we are a society that is in trauma. A societal trauma gives opportunities for people to go through things together, rather than suffer alone, as long as we don’t bury or make light of what we have experienced and continue to experience. We will have to find new ways to live with our fears and discomforts, to overcome Covid-minted social phobias, with what we project on to other people’s bodies and the fears we have about our own vulnerabilities. We will need all the help we can get in reshaping our relationship to our own and each other’s bodies, to find a way to build bonds of attachment and respect.
What started with the dematerialisation of the individual body has now morphed into the dematerialisation of the body of state. The economist Joseph Stiglitz reminds us that, with the stripping back of the state under Ronald Reagan and Margaret Thatcher, we lost capacity. This needs to be addressed.
There is a lively debate from a range of economists on how to get to a more equitable economy. Moneyweek editor-in-chief Merryn Somerset Webb’s call for a sovereign wealth fund, with the government owning shares in bailed-out companies, is interesting, as is political economist Will Hutton’s idea of expanding the British Business Bank and the Future Fund. UCL economics professor Mariana Mazzucato insists that the state must invest in innovation.
We began trying to make a different kind of society after the second world war. We will have to do that again. Principally, we will need to recognise the contributions and the losses of the UK’s minority and working-class people, above all. Our governments have shamed themselves through creating divisions in society, particularly since austerity was imposed under David Cameron’s government. Now we have an unexpected chance to redress the divisive fallout of Brexit.
The impact of remote working and the need to balance domestic and work life, allied with dire warnings on mass unemployment, gives us an opportunity to write a social contract in which we divide work more fairly. At both ends of the pay scale, people overwork. The evidence for a more balanced relationship between work and home is compelling.
Since the crisis began, the outpourings of artists, musicians, programmers, cultural and scientific workers at all levels has been outstanding. The talent, the will, the desire is there to remake our world. The urgency is not in question. Globalism can’t simply be a celebration of “just-in-time” deliveries. It will need to be recast as mutuality – local and global mutuality – so that we learn from each other, including those who’ve been in lockdown in war zones.
Therapy under lockdown: 'I’m just as terrified as my patients are'
Our institutions will need to be rebuilt with transparency, with heart and by learning from the people who have been staffing them, not just the managers and owners. Doctors, nurses, carers and delivery people have things to say about how their institutions could be better run. The body politic and the politics of the bodies that make up our world must be reconfigured, and we need to start thinking about that now.
I conclude with Freud: “The aim of psychoanalysis is to turn hysteria into ordinary human unhappiness.” That is an accomplishment for an individual and for a society. We cannot escape unhappiness. It is constitutive of being human, just as are creativity, courage, ambition, attachment and love. Let’s embrace the complexity of what it means to be human in this time of sorrow as we think and feel our way to come out of this, wiser, humbler and more connected.
What Meditation Does To The Brain
May 1, 2020
by Betty Vine
Anyone who has ever attempted to meditate can vouch for the fact that while it is theoretically simple, it is extremely challenging in practice. In fact, its simplicity is what makes it difficult, and it is also what makes it worthwhile.
“Mindfulness meditation” (the practice most popular in the United States) requires a steady observation of one particular object or sensation. As we find ourselves increasingly surrounded by modern distractions and the hustle and bustle of everyday life, focusing our attention on something very basic can have indelible effects on the brain. Let’s explore some of these effects.
As research published in Frontiers in Human Neuroscience found, meditation increases gyrification in the cerebral cortex — that is to say, the brain’s surface has more folds, and is therefore thicker. As UCLA’s Dr. Mark Wheeler explains, “Presumably then, the more folding that occurs, the better the brain is at processing information, making decisions, forming memories, and so forth.” Further, researchers have drawn a positive link between the number of years someone has practiced meditation and the amount of cortical folding.
Larger amounts of grey matter are found in the orbitofrontal and hippocampal regions when compared to nonmeditating controls, as a study in NeuroImage discovered. These portions of the brain are related to “emotional regulation and response control.” As such, this could help explain and contribute to the balanced, rational, and resilient demeanor of many meditation practitioners. Further, it allows one to see his- or herself in a more objective light, sans bias, as a study in Perspectives on Psychological Science proposed.
Neural connections between the ventromedial prefrontal cortex and the insula/amygdala begin to diminish, as research in Social Cognitive and Affective Neuroscience found. In layman’s terms, this means that one is less likely to associate “gut feelings” and inappropriate fear-based responses with catastrophic ideas of self; ultimately, it can explain the ostensible decrease in anxiety in those who meditate.
On the other side of the coin, neural connections between the lateral prefrontal cortex and the insula/amygdala are strengthened. Again, this allows one to have a more logical and collected response to pain or discomfort. As Dr. Rebecca Gladding clarifies in Psychology Today, “when you experience pain, rather than becoming anxious and assuming it means something is wrong with you, you can watch the pain rise and fall without becoming ensnared in a story about what it might mean.”
Researchers from Brown University suggest in a study in Frontiers in Human Neuroscience that frequent meditators have the ability to control cortical alpha rhythms. In other words, they can more easily devote their attention away from physical and emotional pain.
As the evidence above proves, a consistent meditation practice can foment beneficial alterations in brain structure and functioning — and this list doesn’t even begin to touch on all of the other health benefits for your body, your spiritual well-being, and your interpersonal relationships.
From "The guardian": 'For those of us with depression, coronavirus is a double crisis' by Andrew SolomonRead Now
For Those of Us With Depression, Coronavirus Is a Double Crisis
by Andrew Solomon
From now on, when someone who hasn’t experienced clinical depression and anxiety asks me what they feel like, I won’t have to resort to florid comparisons. I’ll say: “Remember when the Covid-19 pandemic hit town?” and they will understand. Except that for people with depression and related conditions, the present moment is one of escalated distress. For this is a double crisis, of physical and mental health, and those living the psychiatric challenges need not only acknowledgment but also treatment. I have had dozens of letters and Facebook messages from people who are anxiously upping their doses of antidepressant and anxiolytic medication.
My depression and anxiety share a lot of territory with how most other people feel now: fear of getting sick and dying, fear of losing people I love, fear of unpredictable shortages and economic disaster. Others worry whether their cough is a symptom of Covid-19 or just an allergy. I am in the sizeable part of the population who must seek to distinguish between ordinary fear and the beginnings of a breakdown. I’ve had to alert the doctors who oversee my mental health that I am Code Fragile and will count on them to help me discern whether I cross over from ordinary unhappiness into neurotic paralysis. I have had to cancel my planned withdrawal from a medication that makes me sleepy and fat; lowering my dose would leave me unsettled for a spell, and that’s more than I’m up for now.
In March, I experienced the whole panoply of Covid-19 symptoms: a racking cough that kept me up all night but was not accompanied by any congestion, a fever that soared over 103F (39.4C), aching joints and trouble breathing into lungs that felt like they couldn’t expand all the way. Despite pulling every string I could muster, I was unable to get a test. My doctor diagnosed flu at first; when I couldn’t breathe, I had a chest X-ray and he diagnosed pneumonia. I took Tamiflu, then azithromycin. I quarantined myself at home and rigidly kept distance even from my husband and our son. Now I am fine, and nobody who was in contact with me has been infected. But the unavailability of tests was terrifying and the circumstances seemed to invite in psychic decay.
Quarantine is the oldest medical technology out there: isolation of the sick dates to the ancient world. While it protects those who are not ill, it is toxic for the patients, who show elevated rates of depression, anxiety and post-traumatic stress disorder. Physical recovery is slower for those cut off from friends and family. Quarantine is often necessary for people with incurable or highly contagious infections such as MRSA, Sars or H1N1, but it comes at a terrible cost. No one wants to die alone.
Sheltering inside when you have no symptoms, however, is essentially a new phenomenon: it happened in Toronto during the Sars outbreak of 2003, and many authorities felt its costs far exceeded its benefits. Richard Schabas, formerly Ontario’s chief medical officer of health, wrote: “In the unlikely event of another Sars outbreak in Canada, public health officials should quarantine no one.” His intent was not to dismiss the physical dangers, which were real then as they are now, but to illuminate the psychiatric ones.
This is a bizarre time, and people are dying – but people are always dying, I remind myself. One acquaintance of mine died yesterday of the virus, and another has died tonight of cancer. The first death terrifies me; the second merely saddens me. Social distancing is staunching the proliferation of new cases, but some of us are overreacting and some of us are underreacting and no one knows which are which; it is unlikely that many have hit the sweet spot of appropriate caution. The need for caution must also take into account the effect of isolation on mental health, as anyone knows who has seen The Shining or Cast Away. When I lived with the Greenlandic Inuit, I found that their high rates of depression and suicide were tied not to the sunless winter, but to the intimacy it forced. Whole families gathered in small houses and were stuck with one another and no one else for months because it was too cold and dark for anyone to leave or visit. Emotional repression was the natural consequence, and it was calamitous.
I was on holiday with my extended family when the idea of social distancing was introduced into the popular vocabulary, and had to come home early when the place we were visiting sealed its borders. I have since been sheltering with my husband, my son and my father-in-law in upstate New York. Two weeks ago, I set out for New York City to pick up our family dog, get my 10-year-old son’s school books and pay some bills. I didn’t recognise the empty city where I had grown up. I perched in my office thinking grimly that I would never be able to live at home again. I lie awake with my mind running and have to remind myself that this is how my mind runs when it is in bad shape. I saw my elderly father today and we met outdoors and kept a 6ft distance. I suffered anew the collapse of that feeling of safety he had created in earlier crises, a role he cannot fill at nearly 93. Intellectually I know that my father could never have solved this crisis; that I will eventually live at home again; that I am probably safe in the house upstate. It is my project to keep up a good face for my son, and it is utterly exhausting, sometimes impossible and profoundly redemptive.
Yet, as always, at the bottom of depression’s box there is hope. The very feeling of frailty gives me a window into the suffering of friends who are waiting out this terror by themselves. The feeling of isolation awakens me to the ongoing plight of older people who are alone all the time. I feel singularly well-placed to comfort those who are taking their first deep plunge into depression. I can help them assess what is pathological and treatable.
I am in pretty good shape. I had a bad depression two years ago, and I feel much better now, which seems bizarre given how much worse things are than they were then. I am not all by myself, and I have not lost my job. I don’t feel sorry for myself and I don’t think I am suffering more than others are, but I am suffering a bit differently. The second-guessing all the time is burdensome. Am I proportionately or disproportionately having these particular feelings in this particular moment? Depressives find that our intense sadness and fear easily become intense depression and anxiety. People with pre-existing pulmonary illnesses drop dead of this thing. People with previously existing mood disorders will die of it, too, if mostly in a slower and less obvious ways.
Feeling Anxious? Here’s What You Can Do About It Now
By Lucie Zhang
April 14, 2020
As those of us in New York are coming up on one month of life “on pause,” feelings of anxiety and unease have only become more layered. We’re facing entirely new fears. We cry at unpredictable times. We crave intimacy and connection.
Keeping mounting anxiety under control is an increasingly challenging task during unprecedented times, and it is top of mind for many. Since Laurie Santos, a Professor of Psychology at Yale University and host of The Happiness Lab podcast, uploaded her popular Yale course, The Science of Well-Being, to Coursera two years ago, she’s had over 500,000 people enroll. In the last three weeks of March alone, 800,000 new learners signed up for the lecture series.
“People are worried about their physical health, but we know what we need to do [there], like wash your hands, socially distance six feet from other people. We have stuff we can do to protect our physical health, but I think people are searching for evidence-based things they can do to protect their mental health during this time,” says Santos about the recent surge in sign-ups. “This situation is unprecedentedly scary and anxiety-provoking and uncertain. It’s causing us to face our mortality in a way that I think most Western, first-world-problem people haven't had to face in a long time. And I think we’re forced to do it without the one coping skill that most of us use during a crisis, which is to be more social.”
Below, Santos gives advice on how to recognize and cope with anxiety amid the coronavirus pandemic.
Notice How Your Body Responds to Stress
Because many have had their sense of normalcy and safety upended during this pandemic, Santos says the resulting stress has activated our sympathetic nervous system, which is our “fight or flight” mode that’s basically preparing us for a tiger that’s going to jump out from a bush. Our “tiger” is doorknobs, other people, not washing our hands after getting the mail, and so on.
“It’s flooding our body with stress hormones. It’s actually causing us to tighten our muscles so they’re prepared to run away. Being in a constant state of that can lead to things like muscle problems, digestive problems, even sexual health functioning problems. The ‘fight or flight’ system is meant to be activated in tiny, short bursts when there is a real emergency, and many of us are activating it chronically right now.”
To assuage our sympathetic nervous system, Santos says we must consciously activate our parasympathetic nervous system, which is “our ‘rest and digest’ system.” She notes, “Naturally, it’s not turning itself on because we’re flooding our autonomic nervous system with cues that everything is threatening.”
But one simple (and free) thing to do is to take deep, calming, “belly” breaths whenever you begin to feel signs of anxiety, such as chest-tightening.
Give Yourself a Mental Break
“I think the thing to notice is: If you get a moment free, is it like all the anxiety pours in at that point?” Santos says. She recommends making a habit of taking breaks in order to allow feelings to emerge. "That can feel really scary, especially if you’re not the kind of person who’s mindful normally, to sit there and feel what it feels like,” she acknowledges. “But those things are going to come out naturally and if you’re not letting them out in some form, that’s when you get the neck troubles and the sleep troubles and the digestive stuff that a lot of us are facing. If you’re feeling that, it might be a sign that you need to do some paying attention and really give yourself explicitly some time to notice that you’re feeling anxious, or notice that you’re feeling sad or scared, and just kind of be with that for a little bit.”
Create a New Social Routine
Santos says everyone, including introverts, should make a point to reach out to people for virtual time together. “In fact, it’s a great time to reconnect with people you might not normally interact with. I’m realizing that if I have to Zoom with my lab, who I would normally see every day, I can also Zoom with my friend in Seattle who I haven’t seen in forever, or my college roommates who are all in different states,” she says. “In theory we could’ve done that all the time before, but it would have been weird. But now it’s not weird, because it’s our only way of connecting.”
Our bodies and minds are creatures of habit, so creating a routine can add structure to your life, Santos says; but you may have to reevaluate old habits and schedules in the process. So-called workaholics, for instance, should recognize if they are burying themselves in busyness in order to avoid feeling their emotions.
In particular, Santos notes, it’s important to schedule in informal social time–i.e. social interactions that are casual and without an agenda–into your routine, to fill in for those types of spontaneous exchanges that we are now missing.
“One thing that we don’t notice as part of our routine but core to our normal day is we also run into lots of people,” she explains. “Those can be our coworkers, our friends, but even just a barista at a coffee shop, who you don’t notice you’re having a conversation with, [but] your mind notices. There is research showing that we’re happier when we have those quick interactions with a person on our commute or someone in the coffee shop or something like that. And we’re really missing those right now.”
Be Self-Compassionate, Not Just Self-Aware
Santos cautions against defaulting to filling a social void with social media, warning: “This might be a time to wean off the social media more than you think, for a couple of reasons. That tends to be a really easy, low-cost, go-to, fix-our-boredom strategy, but the content on that is going to be different right now. Especially if you’re a person who experiences anxiety—you’re not going to see as many baby videos or cat videos or good recipes. It’s going to be doom and gloom. I think limiting that is important. I also think that those kinds of moods–when you’re bored and feel the need for social [interaction] and the easy thing to do is to click on Facebook or something–can come at an opportunity cost for putting in that little bit of extra effort to call a friend or call your mom.”
Another thing to keep in mind is that everyone is going to react very differently to this unprecedented situation. “Some are going to be like, ‘This is my time to get the perfect abs in the next three weeks and I’m just going to show off my ab videos.’ That’s a way of coping, not my way of coping, but it’s someone’s way of coping. Whereas other people are going to be like, ‘I’m going to watch Netflix and eat my entire cartons of ice cream that I bought for three weeks in one night,’ and that’s also a way of coping. That’s fine. I think we just need to chill out with ourselves,” says Santos. “...Realize that we’re all doing it in our own way–and what counts as our own way is going to change because this is going to be a long process. There is going to be ups and downs.”
This is not the first time that people have faced uncertainty, but we have never been as technologically advanced as we are now, says Santos. “As a species, we’ve faced pandemics. We made it through the 1918 flu, which was as bad as this and required as much socially distancing, and we did that without Netflix or Zoom meetings or even really good telephone technology. In some ways, we’re so grateful,” she says. “Even relative to 9/11, which wasn’t that long ago, technology-wise we couldn’t be doing this back then. So I think we’re really lucky to live in the time that we do live in, where there are these modes of communication and modes of staying connected that can allow us to get through this stuff.”
Likewise, Santos predicts what she calls a “surge” in happiness will occur once things do return to normal. “We’re going to realize all the things we took for granted,” she says, such as getting your favorite latte at your go-to cafe or giving your mom a hug.
We did that every day without an enormous burst of happiness from that, and now we’re kind of like, ‘How was I not incredibly grateful every time I did that?’ I think we’re all going to have so much more to savor when we get out of this. And recognizing that–that we are going to get out of this. Most of us are going to be fine. We’re going to get to enjoy things that make us happy in a way we’ve never experienced before."
From Science MAg.org: Brain scans could help personalize treatment for people who are depressed or suicidalRead Now
Brain scans could help personalize treatment for people who are depressed or suicidal
By Emily Underwood
Aug. 20, 2019 , 12:45 PM
By his late 20s, Moe had attained the young adult dream. A technology job paid for his studio apartment just blocks from the beach in Santa Barbara, California. Leisure time was crowded with close friends and hobbies, such as playing the guitar. He had even earned his pilot's license. "There was nothing I could have complained about," he says.
Yet Moe soon began a slide he couldn't control. Insomnia struck, along with panic attacks. As the mild depression he'd experienced since childhood deepened, Moe's life collapsed. He lost his job, abandoned his interests, and withdrew from his friends. "I lost the emotions that made me feel human," Moe says. (He asked that this story not use his full name.)
Although many people with depression respond well to treatment, Moe wasn't one of them. Now 37, he has tried antidepressant drugs and cycled through years of therapy. Moe has never attempted suicide, but he falls into a high-risk group: Though most people with depression don't die by suicide, about 30% of those who don't respond to multiple antidepressant drugs or therapy make at least one attempt. Moe was desperate for relief and fearful for his future. So when he heard about a clinical trial testing a new approach to treating depression at Stanford University in Palo Alto, California, near his home, he signed up.
People like Moe present a conundrum to doctors but an opportunity for researchers: a group whose health could be transformed by precision psychiatry. Depression is often treated as a single disease, but many researchers agree that it is actually multiple, distinct ailments. Some of those conditions may heighten suicide risk more than others. How many depression subtypes exist—and how they differ—is hotly debated. One way researchers are trying to settle the question is by peering into the brain. They're studying the neural circuits that light up during specific tasks and then correlating those patterns of activation with symptoms.
Those efforts are part of a broader campaign to explore the brain biology of mental illness, including depression, bipolar disorder, and active suicidality. The goal is not just to find biological markers of risk, but to tailor care accordingly—sometimes by reaching beyond psychiatry's usual armamentarium—and improve the prognosis of Moe and others like him.
The study Moe is part of, Research on Anxiety and Depression-Anhedonia Treatment (RAD-AT), sits on the leading edge of such efforts. It enrolls volunteers with a subtype of depression who are at higher risk of suicide than other types, and the study is among the first to offer treatments based partly on brain circuitry.
Whether such a targeted approach to depression can prevent suicide isn't clear. But researchers hope that linking symptoms to brain biology could help people who have languished despite treatment. Moe also longs for something else: insight into his own condition. "Therapists always [say], ‘Tell me the reason you feel this way,’" he says. "I want an answer."
The RAD-AT study is led by Leanne Williams, a Stanford clinical neuroscientist who has spent more than 20 years probing how depression manifests in the brain. She has orchestrated international collaborations to collect thousands of brain scans from depressed people. Like many in her field, Williams is driven to prevent depression's worst outcome: She lost a patient early in her career and, more recently, a loved one.
Thanks to her own and others' data, Williams believes at least six subtypes of depression exist. Each is generated by abnormal activity in a distinct set of brain circuits that regulate mood and cognition. One subtype affects a circuit called the default mode network, a constellation of brain regions that generates aimless mental chatter when the brain is "in idle" and can lead to unrelenting negative thoughts. Another type dampens reward networks, robbing a person of the ability to feel pleasure, a depression symptom called anhedonia. Those two subtypes, along with a third called cognitive control—which orchestrates attention, planning, and impulse control—often respond poorly to depression treatments, Williams says. She and others worry most about the anhedonia and cognitive control groups, partly because of their elevated suicide risk.
Scientists have already found several brain features that align with suicide risk. The best studied comes from neuroscientist John Mann of Columbia University. In the early 1980s, he examined the brains of people who had died by suicide, donated by their families. The organs had markedly lower levels of the neurotransmitter serotonin than those of depressed people who had died in other ways.
More recent work by him and his colleague Maria Oquendo, a psychiatrist at the University of Pennsylvania, suggests low serotonin levels may be more common in depressed people who attempt or die by suicide after struggling with persistent suicidal thoughts. That hypothesis is based on studies in which the pair used positron emission tomography (PET) imaging, which uses radioactive labels to track neurotransmitters, to capture serotonin levels in the brain. The team's data, which included a 2016 study of 100 depressed and suicidal people, suggest the low-serotonin group is biologically distinct from people who experience "spiky" bursts of suicidal thoughts during acute stress, such as a financial catastrophe or a breakup.
A June study in the Proceedings of the National Academy of Sciences, led by neuroscientist Irina Esterlis at Yale University, marked another step forward. It focused on post-traumatic stress disorder (PTSD), which can also raise the risk of suicide. Esterlis's group also used PET imaging. Among people with PTSD, those who had experienced suicidal thoughts had 30% more receptors for the signaling molecule glutamate, suggesting they were making less glutamate and the brain was struggling to compensate. The work pointed to a biomarker of suicide risk in people with PTSD. Her finding also engendered hope that ketamine, a drug that targets glutamate, might help people in that group. Recently approved as a rapid-acting antidepressant, ketamine is now being tested to see whether it can reduce suicidality.
Categorizing patients into neat buckets on the basis of neurotransmitter levels and other brain scan features is challenging. No matter what any scan measures and what struggles a patient faces, a scan is a snapshot in time. It can't reliably capture symptoms that wax and wane. "How does one pull up a brain readout of an emotional fluctuation like a surge of elation or anxiety or suicidal thoughts?" asks Helen Mayberg, a neurologist at Mount Sinai Hospital in New York City.
Depression subtypes can be parsed in many ways, and scientists don't agree on the best approach. Some researchers sort people based on how they respond to treatment, others according to symptoms. Volunteers are typically asked to engage in mental tasks, but those tasks can vary. Other researchers use biological markers as diverse as genetics, hormones, and gut bacteria to distinguish dozens of depression categories. In a 2016 study, on which Mayberg was an author, researchers analyzing 1000 functional magnetic resonance imaging (fMRI) scans of depressed people found four depression subtypes, not the six Williams has identified. Unlike PET scans, fMRIs measure brain activity by detecting changes in blood oxygen levels. But a separate group could not replicate the finding, Mayberg notes.
Because depression is so varied and complex, nailing down definitive categories could take many thousands of brain scans, says Elizabeth Ballard, a clinical psychologist at the National Institute of Mental Health in Bethesda, Maryland. But, "Everybody acknowledges that is what's needed," she says.
If the goal is to prevent suicides, some researchers also question whether probing depression is a good starting point, because most of those patients aren't at risk. Some scientists even argue that the biology of suicidal behavior is so different from that of depression—and can include symptoms of anxiety, agitation, and impulsivity—that "suicidal behavior" should be a stand-alone diagnosis. "We can't simply rely on the treatment of depression" to prevent suicide, Oquendo says, because suicidal behavior has different biological roots.
Williams agrees that suicidality and depression don't neatly align, but she rejects the notion that they must be studied separately. In some people, the two are undoubtedly intertwined, she says. Her partner, an emergency room doctor, had long struggled with depression but feared that seeking treatment could mar his professional reputation. Four years ago, he killed himself. The loss steeled her resolve to crack the biology of depression and improve its treatment. "Regardless of the labels," Williams says, "we need to look at where the crisis is."
For Williams, characterizing depression begins with the fMRI scanner, where her study volunteers lie, heads immobilized, while performing a battery of mental tasks. Each task exercises a different assembly of circuits that correspond to the six depression subtypes Williams has hypothesized are key to guiding treatment. The subtypes marked by repetitious negative thoughts and anhedonia are rooted in the default mode and reward circuits, whereas others involve circuits that respond to threat or help the brain maintain focus. When those circuits are dysfunctional, people may interpret events in a more negative light or feel trapped inside a mental "fog," Williams says.
The scan detects neuronal activity by measuring changes in blood oxygen levels, revealing how different regions of the brain fire and coordinate brainwide neuronal chatter. To account for individual variation in brain structure and activity, researchers must digitally "strip" the brain from the skull and align it to a standard model, says neuroimaging research engineer Brooke Staveland, who works with Williams at Stanford.
Sophisticated computer algorithms extract relevant patterns from the fMRI results and compare them with the healthy baseline. The result is a six-item chart that scores activity in each circuit, helping the researchers flag abnormalities.
Although Williams and her team have scanned patients with depression for years, the 8-week RAD-AT study goes a step further. It examines how 160 people with the anhedonia depression subtype, who often aren't helped by antidepressant drugs, respond to two treatments: transcranial magnetic stimulation, a noninvasive therapy that uses magnetic fields to stimulate nerve cells and is approved for treatment-resistant depression, and pramipexole, a drug for Parkinson's disease. Pramipexole mimics dopamine, the signaling molecule for the reward circuit that seems sluggish in those patients. In other studies, Williams is targeting additional subtypes, such as the tough-to-treat variants involving the default mode and cognitive control networks.
To qualify for RAD-AT, volunteers must score higher than normal on a standard questionnaire of anhedonia. Those who do are offered one of the two treatments. (Because pramipexole can increase impulsivity, actively suicidal people are excluded from the study for safety reasons.) Participants get their brains scanned beforehand to gauge activity in the reward and other depression-related circuits. After 8 weeks, they'll get scanned again to see whether treatment altered the circuits' activity and whether that change is associated with a change in symptoms.
Moe's brain scans are among those now being analyzed and considered alongside his clinical history. So far, the two appear to match up: He maxed out at an anhedonia score of 50, the highest possible, and had abnormally low activity on a task that activates the reward circuit: looking at photos of happy faces. If Moe's inability to experience pleasure is driven by too little dopamine, pramipexole could help, Williams says. In July, Moe agreed to take it.
What ultimately matters to Williams is not the number of depression or suicide subtypes, but how that knowledge helps patients. One barrier to widespread application is the time and expense of brain scanning. Williams is working to shorten the time to analyze a scan from a few hours to 5 minutes, and she and colleagues are weighing whether more easily tracked measures, such as heart rate, can serve as proxies for certain neuroimaging data. If so, the researchers hope to create wearable devices to help monitor depression, anxiety, and suicidal behaviors in real time. But first Williams needs more data, from her own lab and others, to determine whether differences in brain biology can translate to better treatment decisions.
RAD-AT is slated to end next year. Meanwhile, Williams and colleagues are running other neuroimaging studies, including one of 250 young people with depression that will explore how suicidal thoughts and prior attempts manifest in the brain. One young woman, who was actively suicidal, had refused medication because it failed her in the past. Brain scans suggested an abnormality in one of the three brain circuit types that don't respond well to antidepressants. She was then offered—and accepted—transcranial magnetic stimulation because previous studies showed its ability to correct abnormal activity in that network.
Her symptom scores and level of suicidality dropped into the healthy range. "I remember when she said to her mom, ‘I feel like myself,’" Williams says. Recasting depression as a disease of misfiring circuits can be a huge relief for people, she believes. Depression's stigma stopped her partner from seeking treatment. By lifting it, she hopes to make it easier for others to get help.
Moe is providing another, still provisional, data point. After 2 weeks on pramipexole, he felt better than he had in years. While driving to Stanford for an appointment, Moe switched on his car radio and heard the indie rock he'd loved in college. To his amazement, the music moved him. "I teared up for the first time in a long time, not because I was sad but because I was connecting with something again," he says.
Moe knows it's too early to tell whether what he describes as his reawakening will endure. If he continues to benefit, he'll keep taking pramipexole under a psychiatrist's supervision. But right now, he feels hope. "It's so weird," he says, "that you can take a medication and then wake up and say, ‘I think there's a future now.’"
My ongoing exploration into therapy related topics.