I am a psychiatrist and have just returned today from a peer review with my professional colleagues where we attempted to get some rapprochement with the Pacific Islanders view of psychosis (spirit possession that has a very long history ) and the standard psychiatric view of the syndrome as a mental disorder or illness requiring medical treatment. Such a view has a much shorter sociological history.
Auckland is the largest Pacific Island City in the world and we as clinicians are in our day to day practice confronted with just those issues Dr. Spitzer asserts is irrelevant to our everyday practice. This is just not the case. Dr Spitzer could not be more wrong!
We simply cannot leave such issues to sociologists, psychologists, philosophers of science, and members of the legal profession. We as clinicians are dealing with such issues day to day in the citizens of our country we see in distress.

One thing I expect her book to look at, (which Horwitz referred to in your interview with him), is how the prominence of the bio/medical/genetic approach is a historical and cultural phenomenon- a result of the prestige that science gained with the rise of nationalism. I think as far as understanding why psychiatry is the way it is today, Greenfeld and Horwitz probably have more in common than I may have initially represented.

I never actually disagreed with Horwitz that many of today’s cases of “depression” might not be best dealt with in some way other than medication. I think what Greenfeld will attempt to show is that those people with less severe depression are still not experiencing the “normal sorrow” that people experienced thousands of years ago, but that their suffering, (though perhaps less severe), shares a common cause with those diagnosed with illnesses like bipolar and schizophrenia. It is the idea that even the most severe forms of mental illness, (which Horwitz seems to explain biologically), are caused by culture which makes her theory radically different. You’re right to say that she isn’t suggesting any change in treatment, but that’s mainly because she believes the first step is to understand what mental illness actually is and what causes it. If the general consensus ever shifts away from the biological perspective, than we might expect to see real changes in psychiatry.

I think what you describe as the “culture in the brain” in particular is quite clever in this post and well written, though I think you may be giving Greenfield a little too much credit for defining this stance on culture in the mind perspective (in particular I think medical anthropologists have framed the duality of culture and biology in very similar terms). Nonetheless, I read the Greenfield piece you cite in your blog tonight and it does make a persuasive argument about the dual emergence of nationalism and anomic conditions, and how these dynamics may ultimately undo our well being. She paints the crises of modernity and mental health with some rather broad strokes, but her writing is eloquent and perhaps I lack the appreciation of grand theorizing. I can see why you enjoy her writing and even thinking about it now, her logic is definitely on to something very real.

A psychiatrist you might enjoy reading that takes these similar ideas to heart in a clinical sense is Patrick Bracken. There was a nice piece that he wrote about PTSD a little while ago that I think is especially portent to your thoughts, that speaks to the crisis of identity, anomie and the break down of tradition as all underpinning the symptoms of PTSD (what he calls the postmodern condition).

If I remember correctly I think Bracken cites Allan Young (a medical Anthropologist actually) who makes a similar argument to your description about the modernity of depression, but in his case in regards to PTSD. PTSD is not simply a recently uncovered condition to what previously had been termed “shell shock,” Young argues, but rather PTSD is in of itself a new condition made possible by recent social-cultural and technological conditions in Western society. He may not be pulling at the same modernity dilemmas that you, and Bracken, are, but he would agree with your sentiment about the historic-specificity of certain conditions (his book is called ‘the harmony of illusions’ it’s a nice read though it’s a little dated, he wrote it before 2001 and I believe he concludes the book by saying that PTSD was on the way out)

But I guess I keep coming back to Horwitz. I haven’t read the entire Loss of Sadness book, so I can’t say for sure, but I don’t think Horwitz is arguing that “normal depression” is in of itself not a “real” emotion or pain. Though there are some problematics with designating certain emotions as “normal” (and as you point out, particularly in terms of the cultural and historical variations that this designation tends to blur), I think the main objective of the argument is to question the pathological labeling of much depression, particularly in terms of framing psychiatry/medicine as proper domains to deal with these issues. This is not to say that people who are depressed don’t need help or aren’t suffering, and Horwitz and Wakefield themselves don’t deny the importance of therapy in these situations, nor the fact that taking medication may be optimal. Rather, they question the utility of calling most occurrences of depression as a disease precisely because it limits the institutionalized/social ways people confront these issues.

If you and Greenfield are correct, for instance, that modern conditions engender what we understand to be neurochemical imbalances in our brains and hence we feel lost and depressed, why should we call such occurrences an epidemic or a disease and call onto psychiatry and medicine for our salvation. If any thing Greenfield is calling for a cultural reformulation of how we think about community and identity (a sort of cultural or social movement solution), rather than citing an epidemic for psychiatry and medicine to cure.

Horwitz and Wakefield on the other hand are taking issue to what should and should not fall within the domain of disease management in modern psychiatry. Sadness arising out of context, with no reason, denotes a truly “organic” etiology to them and as such are types of “diseases” better suited for the somewhat biomedical approaches of modern psychiatric practices. Other forms of depression, that have more context-based or perhaps existential reasons for their etiology, are no less real or less important, but shouldn’t be limited to the confines of psychiatry. If much of this depression comes from the anomic conditions of society as you suggest, why should we look to psychiatry as having any particular expertise or legitmacy in correcting this.

Lastly, reading Greenfield I don’t see her particularly interested in psychiatric interventions at all, or how therapeutic approaches should look like in clinical encounters Rather she seems interested in dissecting the broader conditions and cultural trends shaping much emotional distress-particularly calling attention to the psychic consequences of nationalism. I don’t think medicalizing this emotional distress necessarily makes her argument any more real, or legitimate, but even if she is citing the rise of mental illness as following these trends, she is making a cultural critique rather than calling on psychiatry to change its orientation or focus.