I often read Mark Fabian’s articles in Woroni and acknowledge his recurring exhortations about the importance of self-reflection. However, I wonder if the emphasis upon self-reflection is perhaps too indulgent; in fact, is it exclusionary of the Other, who is different through race, sex, sexuality and mentality? Does Fabian’s call to self-reflection deny the fact that we live in a community of different individual subjects who may not resonate with his belief in the omnipotence of existentialist enlightenment? I wish to critically examine Fabian’s most recent piece on the monoamine theory and the use (or abuse) of antidepressant medication. I do not claim to be a specialist in mental healthcare, but I feel Fabian’s article requires a critical response.[i]
Fabian uses the term “depression” in his article. I believe he misuses the term. Fabian writes that a student suffering feelings of depression should actually reflect upon their life and perhaps realise the cause of their depression is actually the unfair pressure that is being placed upon them by their parents. This is not depression. These are normal life stresses; depression is a medical illness.
Depression is not simply a state of escapable melancholia; it has a precise definition in the DSM-IV text revision. I will not go into the definition here, but suffice to say, it involves several physical and temporal criteria. University/parental pressure (among other factors), however, may trigger depression. But we need to remember that individuals are different. While one person may deal quite well with parental/university induced stressors, a person predisposed to depression may be unable to deal with those same stressors.
Fabian suggests that the problem with using medication, and conceiving depression as a “chemical issue”, dis-empowers the subject person. However, key symptoms of depression are a dreadful lack of motivation, loss of interest and any ability to be proactive. The example of a subject person that experiences depressive symptoms that are secondary to the inability to meet parental expectations, I would argue, would not be likely be diagnosed with major depressive disorder, requiring medication. Medication is not indicated in these reactive circumstances or, in cases of mild depression. Therefore, Fabian’s use of such an example is quite misleading.
There is a dark undercurrent in Fabian’s article which implies that a decision to take anti-depressive medication is something that one would take lightly.The implication is that people who have chosen to take medication that addresses their diagnosed depression have taken the “easy way out”; or have acted capriciously. Whatever the intention, it is violently exclusionary and actually serves to stigmatise mental illness; in turn, Fabian perpetuates the fear of the mentally ill Other.
There should be no doubt in our minds that anti-depressants are not a simple item that can be purchased over the counter; they are not analogous to performance enhancing drugs; they do not make otherwise well patients happier or perform better. They certainly do not obfuscate reality or real feelings.
Fabian writes that there is essentially no logical basis for classifying psychiatric disease with, what he describes as “chemical imbalance theory”. While monoamine theory is broad and could be criticised for being simplistic, there is numerous alternative evidence that concludes psychiatric conditions represent distinct physiological abnormalities within the central nervous system of the brain itself. This alternative evidence, is ironically, neglected by Fabian. Fabian must acknowledge the wealth of scientific research, which concludes that depression, whether or not it is triggered by parents or University related stress, has a biological cause. The evidence for that is: demonstrated genetic contribution, evidence of abnormal neurophysiological functioning, minimal placebo response, and a relatively specific response to physical treatments such as anti-depressants and ECT; and finally the presence of certain physical features.
Fabian suggests that instead of “turning to drugs”, a sort of quasi-existential, third generation Viennese “self-reflection” therapy is needed. Indeed, Fabian refers to Jung and especially Frankl to support this thesis. However, Fabian provides no empirical evidence to suggest that these therapies are effective – not only does science like empirical evidence, but most people with any understanding of evidence based research/medicine like it too. It means that consumers can rely on the efficacy of what they spend their money on and can be protected from being exploited by quacks, charlatans and general fraudsters.
To put the lack of evidence aside, there are further problems with Fabian’s suggestion. Given the fact that most depression is characterised with an inability to be proactive, I find it difficult to believe that a self-reflective exercise is going to work. Even so, what is one supposed to do in the meantime? Cease study and work? Where does that person live? How does this person afford the expensive psychoanalytical treatment that can take months or years to get off the ground?
At a time when we are speaking more openly about mental illness, and the seriousness of depression affecting university students, the last thing we need is pseudo-intellectual rhetoric espousing a return to “treatments” and indications of the early 20th century. The advent of anti-depressive medication, especially SSRIs, has, contrary to what Fabian may believe, de-stigmatised depression as a mental illness, and has given people the ability to address the “existential crisis” in their lives in their own way.
Fabian’s article would suggest that the past 100 years of medical advancement did not occur. His prose harks back to the dark ages where hetero-normative, white, male power centres made you believe that depression (or mental illness) was a moral/existential problem, involving a weakness of character – best cured by simply “sucking it up”; or divulging all your secrets to a bearded and silent shrink.
Fabian’s thesis would deny the practice of humane medicine. If people are suffering, then the community has a duty to alleviate that suffering. If someone was in physical pain, they are given pain relief in the form of analgesics. Well, if someone is so depressed they are not functional, then we have a duty to provide them with medicine that alleviates that suffering, like SSRIs for instance. Mental illness is rarely cured, like chronic pain. However, medicines can alleviate suffering and in fact, create a favourable climate for self-reflection and seeking counsel for a pathway to recovery. That is much more than simple existential therapy (or logotherapy) is going to accomplish.
Perhaps what Fabian needs to do is to recognise is that while psychoanalysts and existentialists weave seductive prose for a young philosophy grad, their methods have not been tried and tested (ethically) upon real people. Instead of helping/healing, Fabian’s sermon which outlines his knowledge of continental philosophers mixed in with his own opinion, creates violent and strict categories in which gendered/sexed/raced/and mental differences that do not slot into his categories are sublated; in this sublation, these differences are Otherised – subjects with these differences become objects, dehumanized and excluded.
In his over-zealous belief in the superiority of the psychoanalytical method, he uses what Butler describes as “the violence of exclusion” to narrow the categories by which subjects “qualify” for human status. Instead of Fabian’s admonishment of the depressed student, what is instead needed, is a realisation that the mentally ill Other exists as a real person. Each Other needs to be asked “who are You” rather than simply re-hashing tired old theories. Addressing (or interpellating) the Other opens up patient listening and in turn, allows for self-reflective dialogue to include the Other, which, as Butler (see also Lacan, Hegel and Levinas) points out, is central and at the core of the Self and existential enlightenment. Fabian could find more answers to his existential dilemmas and identity by looking beyond the Self and searching outward into the community.
If you are struggling with feelings of depression or anxiety, there are people who will listen and help: contact Lifeline – 13 11 14, ANU Counselling 02 – 6125 2442 or your GP.
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