Theology or Therapy?: In What Sense Does Depression Exist?

I am grateful to Anastasia Scrutton for opening up a very important area for thought, reflection, and practice. Her paper presents a fascinating argument for an understanding of depression that is framed as a potentially spiritually transformative experience with positive therapeutic implications. In doing so, she offers a way for theologians, philosophers, and practitioners to effectively perceive, understand, and engage with the spiritual dimensions of the experience of depression. As such, she has made an important contribution to the ongoing and often fraught conversations around the role of spirituality in understanding mental health issues. The models she outlines neatly encapsulates a broad range of experience and her development of and preference toward the potentially transformative (PT) model of spiritual experience is compassionate and helpful. Although I do not necessarily agree with everything that she has said, I do respect, value, and appreciate her work on this vital area for theory and practice. There are, however, some significant issues that require clarification, critique, and further conversation.

The Problem of the “Natural”: In What Sense Does Depression Actually “Exist”?

One of the basic presumptions that underpins the study and its conclusions is that depression is a natural entity which can clearly be identified and responded to. Throughout there is a general assumption that depression is a definable entity or ‘thing’ that we can look at and examine with regard to its implications for our understanding of spirituality, spiritual experience, and therapeutic intervention. Throughout, it is named as a pathological entity that requires professional identification, authentication, and intervention. Such reification of depression as a pathological entity is problematic. As Dan G. Blazer notes in his reflections on the nature of major depression, when a diagnosis is reified:

[t]he assumption seems to be that there is a “real disease” called major depression and, by attaching the label, the psychiatrist pronounces that the patient has this disease. (This process of making an idea real has been labelled “reification.”) Reification numbs us to the possibility that depression can be more a signal of the emotionally toxic society in which we live than a thing in and of itself. And if the effects of this toxicity are initially expressed through depression, then depression should signal a need to better understand and improve society.

(Blazer 2005, 6)

Pilgrim and Bentall cast further doubt on whether there is a single, easily identifiable entity called ‘depression’ that can be recognized cross-culturally or even intraculturally:

there appears to be no consistent transcultural, transhistorical agreement about minimal necessary and sufficient pathognomic criteria for the phenomenon of interest. For this reason, depression, like other functional psychiatric diagnoses such as schizophrenia ... is a disjunctive concept, potentially applicable to two or more patients with no symptoms in common.

(Pilgrim and Bentall 1999, 263)

If Blazer and Pilgrim and Bentall are correct, then we have a problem. In what sense can depression be described as ‘natural’ or even inevitably ‘pathological’ if it is a disputed and disjunctive concept?

Pilgrim and Bentall also point out that the description of depression and the symptomatic definitional criteria offered by people experiencing deep sadness often differs significantly from that offered by professionals and mental health ‘experts.’ So the question then is: Whose reality counts? To make claims about the naturalness of depression and to declare knowledge of depression using the language of pathology (which is clearly a medical/professional discourse), one needs to take sides. The language of depression as pathology is fundamental to Scrutton’s argument. Yet the validity of such a claim is deeply controversial.

This point becomes important, for example, when she criticizes Dein and Durà-Vilà’s idea of there being two forms of depression. She pushes back on their position by suggesting that “distinguishing between two forms of depression risks limiting the potential of depression diagnosed as ‘pathological’ to become transformative and therefore ‘salutary’” (Scrutton 2015, 284). It is interesting that Blazer talks about the numbing effect of reification. He notes the way in which it distracts our gaze away from society...