Review of "Depression Is a Choice"

I can't remember the last time I read such an exasperating book. Here is a quotation that sums up Curtiss' central attitude:

Our great-grandparents used willpower instead of Prozac and Zoloft. They valued conscience, responsibility, honest, commitment, dedication, sacrifice, hard work, and courage. And they practiced learning to bear suffering. These concepts were universally taught to children, who naturally employed them as adults. These concepts had been tested and revered for thousands of years. People trusted their lives to them. In the 1960s, we threw them all out. (287)

Curtis is highly critical of modern culture, moral relativism and the emphasis on feeling good, which she sees as going hand in hand with the psychologization of ordinary life, treating ordinary problems and moral failures as mental disorders. Her message is not just that depression is not a disease, but that mania, addiction, self-destructive behavior, compulsion and even schizophrenia are not diseases either. She several times approvingly cites well-known antipsychiatrist libertarian Thomas Szasz, and even goes so far as to voice her admiration of Dr. Laura Schlessinger, well known right wing talk radio personality. Curtis argues that we can always take control of our behavior, and that no matter how painful our life is and how much despair we feel, we always have the opportunity to turn our life around through an act of will and Directed Thinking. She has many criticisms of the current emphasis on self-esteem, yet she is a firm believer in the power of positive thinking.

Clearly her beliefs go against much mainstream thought about mental health. That, however, is not what makes her book so difficult to read. Rather the deep flaws of the book come from the low quality of her argument for her ideas, her facile dismissal of views she disagrees with, and the excessive length and repetitiousness of the book (440 pages of main text and another 28 pages of notes).

To the obvious point that it does not seem to most people that they can simply choose not to be depressed, Curtiss says that people forget that they have a choice. Their forgetting is partly because of cultural trends: the treatment of depression as a disease has a self-fulfilling effect, because it makes people think that they don't have any direct power over their moods. At some points, she suggests that there is a small window of opportunity during which people can take measures to stop being depressed. She says that she herself wakes every morning filled with despair, and she has to use Directed Thinking to stop herself from slipping into depression. She also says that she has experienced mania and that many of her family have been diagnosed with bipolar mood disorder. She has suffered for decades from depression, and she has wasted many thousands of dollars on hare-brain schemes during manic periods. She has also gone through periods of enthusiasm for various psychological theories and philosophical approaches. However, she has never tried psychotropic medication. She says that her views about depression-as-a-choice is largely based on her own experience and the fact that since she has come to her current understanding, she has been depression-free for over ten years. Her views about the power to control one's own depression are not based on scientific experiment.

It is tempting to speculate that Curtiss lacks insight into her own lack of depression, and that the reason why she is no longer depressed could be to do with a change in her own brain chemistry, perhaps associated with her age. It's also tempting to speculate that her mania has not entirely left her, and that this book is partly produced by mania. It certainly has a rambling quality and with flights of ideas that bring mania to mind. However, these speculations do not address the quality of Curtiss' arguments.

So, to the argument. Curtiss mischaracterizes the views of those she disagrees with, and she leaves essential questions unanswered. For example, she claims that Kay Redfield Jamison, as a representative of mainstream psychiatry, says that we have no control over our manic depressive moods (199). But this is a distortion; Jamison may well say that we can't completely control our moods through our efforts of will, but that's very different from saying that we can't influence our moods at all through our personal actions. Indeed, it is a bizarre claim that in contemporary society we have forgotten that we can influence our own moods through our actions. All you have to do is go to the self-help section of your local bookstore (or try the Amazon.com or the Barnes & Noble sections of their websites) to see a bewildering number of books on how to make yourself happy. It's also still a part of common wisdom that we are responsible for our own happiness, and we can always take steps to make our lives better. You will even find pharmaceutical companies in their informational literature advising that there are many ways apart from using medication to improve one's mental health (see links below). Indeed, it is hard to find anyone who suggests that we are incapable of influencing our moods. Curtiss is attacking a straw target.

At various points, Curtiss blames psychoanalysis for the supposed mistakes of contemporary psychology. It's no surprise that she is unenthusiastic about the idea of the unconscious, since she has such belief in the power of conscious efforts of will to control our happiness. But it is again a bizarre claim that psychoanalysis has much influence on contemporary psychiatry, given that there's very little attention to psychoanalysis in textbooks and research projects. Indeed, psychoanalysis has received a great deal of criticism from mainstream psychoanalysis, for the lack of clear supporting evidence, for being a pseudoscience, and for its sexism. In attacking psychoanalysis, Curtiss is way off the mark.

Curtiss tries to support her claims by appeal to modern neuroscience, but her use of neuroscience is simplistic and its support of her view is implausible. She sometimes criticizes psychiatric research and she sometimes uses it in support of her view, but she does not acknowledge the diversity of opinion within neuroscience. The fact is that while there might be some rather narrow results in neuroscience about which all researchers agree, as soon as we start talking in generalities about mind, mood, self, and mental disorder, there's inevitably a variety of opinions about how to interpret the evidence even among practicing neuroscientists. Thus it is inevitably simplistic to condemn the whole of biological psychiatry for its stance on human volition, and it is highly problematic to claim that neuroscience proves one's view.

When Curtiss cites modern neuroscientific research to make a distinction between the higher mind and the primal mind, as she does again and again, I get very uncomfortable. Of course there are distinctions to be made here; human brains have parts similar to those of other animals, and all creatures with brains have a brain stem that controls automatic functions such as heart beat and breathing. But there is also interaction between different parts of the brain, and the brain itself is flexible in its function, so to suggest that different parts are simply "higher" or "lower" is almost bound to be ignoring the subtleties of how the brain really works, and when it comes to the influence of the will on mood, it's the subtleties that must be important.

Occasionally, Curtiss refers to philosophical traditions, although more often she simply refers to "philosophers" as if all philosophers agreed on basic truths. Again, her approach ignores the fact that philosophers often disagree with each other about fundamentals. Her view seems to be that she is simply agreeing with wisdom that philosophers have long known but that our recent folly has made us lose touch with that wisdom. She does not acknowledge that philosophers have rarely grappled with the nature of mental illness, and when they have, they have not come to any consensus about how to treat it.

Taking her view simply on its own terms, leaving out other work by psychiatrists and philosophers, there are elements that are puzzling. This is especially true of what she calls the "narrow moment of choice."

There is a critical moment of true awareness, an instant of clarity that we all experience before we fall into panic and darkness of when we are struggling with some seemingly insurmountable problem. & It is in this narrow moment of choice that we are given a chance to engage the use of the higher mind instead of remaining in the subbasement of the primal mind. (148).

Even granting that there is such a narrow moment, it follows that after this moment, the ability to voluntarily control one's feelings is lost. This in itself seems to contradict her main thesis, that depression is always a choice, since the window of opportunity to avoid depression is in fact narrow, and outside that window, there is no choice. One is simply overcome by one's feelings, or one's primal mind takes over. So then, at that moment, depression is not a choice. Once Curtiss admits that depression is not always a choice, then her claim that it is sometimes a choice becomes a questionable empirical issue. Could it not be that for some people, they have no moment of choice, and that their primal mind is always in control? Curtiss presents no more than anecdotal evidence to support her claim that there is such a moment of choice, even for herself.

Having made all these criticisms of Depression Is a Choice, I'd like to add that, mixed into the often self-indulgent stream of thought, there is something of real interest. Her discussion of the power of the pharmaceutical companies is clear and well-written, and adds to the growing doubt whether it is best to let our research methodologies be so closely tied to the financial needs of multinational corporations. But those criticisms have been made before. It is her central thesis that is still her most interesting point. While Curtiss misrepresents the extent to which psychiatry denies that we have power over our mental disorders, it is true that few have done much to acknowledge the tensions between our concepts of disease and our understanding of the role that personal agency plays in mental disorder. This is clearest in the case of addiction. On the one hand, we want to classify addition as a mental disorder and give people with addictions the benefits available to anyone with a disability. On the other hand, it's clear that willpower does play a role in ending addiction. How do these two ideas fit together? A simplistic solution is to assume that they are incompatible with each other, and so to conclude either that addicts have no self-control, or else that there is no such thing as addiction. But neither of these alternatives works well. We are left with difficult questions about how to think about addiction.

The argument can be applied also to the case of depression. On the one hand depression seems to be something that happens to people, and on the other, people seem to cope with it through courage and willpower. Buried in the pages of Depression Is a Choice are suggestions of how to reconcile these two ideas. Despite herself, Curtiss sometimes talks as if depression is an affliction that people including herself suffer. Through her personal strength, she says she rises above her own despair, and this may well be true. Psychiatrists have occasionally discussed what it means to have depression, and how it affects our moral assessment of a person, but those discussions have not gone far. While I find many of Curtiss' right wing political views and her condemnation of modern relativism to be ill considered and shallow, I nevertheless admire her readiness to discuss the moral dimensions of mental disorder. If this book has any value despite its deep flaws, I think it might be in sparking more debate among philosophers, psychologists, and people who experience depression and other mental disorders about how to assess the moral dimensions of people's responsibility for their own happiness.

© 2001 Christian Perring. First Serial Rights.

Pharmaceutical company webpages on depression:

• Eli Lilly Prozac.com Treatment options.
• Pfizer Zoloft.com Treatment options
• GlaxoSmithKline Paxil.com Treatment options
• GlazoSmithKline Wellbutrin.com information
• Forest healingdepression.com information
• Organon (Remeron) Depression-net.com
  
  

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A. B. Curtiss, author of Depression Is a Choice, has sent  the following letter responding to the above review of her book.

November 16, 2001.

Dear Dr. Perring,

Thank you for your review of my book Depression is a Choice. It was very thorough and interesting. I would like to comment upon a few points you made.

YOUR POINT: Indeed, it is a bizarre claim Curtiss makes that in contemporary society we have forgotten that we can influence our own moods through our actions.
MY RESPONSE: You say that we all know that we can influence our moods. Then why would you think there was a limit to our power over our own moods which stops at the diagnosis stage of mood disorder? This particular line in the sand is drawn by indoctrination not by physical incapacity. The reason people think we have limited power over our own moods is because we have been trained to think so by an industry that makes its living on our helplessness. It is no accident that everybody says Depression is a disease just like diabetes. This is a quote from a pharmaceutical company's advertising campaign. Martin Seligman has coined the term learned helplessness to describe this line drawn in the sand by mood disorder diagnoses. It is a line that is being closer and closer drawn as drug sales proliferate and our tolerance for bearing and managing emotional discomfort erodes.

YOUR POINT: Curtiss' message is not just that depression is not a disease, but that mania, addiction, self-destructive behavior, compulsion and even schizophrenia are not diseases either.
MY REPONSE: You accuse me of saying that Schizophrenia was not a disease. I never mentioned Schizophrenia a single time in my book. However you are correct that I do not believe that self-destructive behavior is a disease and I can't believe that you do either.

YOUR POINT: It is tempting to speculate that Curtiss lacks insight into her own lack of depression, and that the reason why she is no longer depressed could be to do with a change in her own brain chemistry, perhaps associated with her age.
MY RESPONSE: As to your mischaracterization of my lack of depression. I never said that I no longer had depression. Just the opposite. I said very clearly that I wake up almost every morning of my life in a state of painful depression. I do not have a lack of depression. I have simply learned to manage my depression so that it has no power to disrupt my life for more than a short time. I simply have learned how to distract myself from it by shifting my neural activity from the subcortex to the neocortex until the chemical balance that caused the depression has changed. I do this because of the neuroscientific fact that a person can think any thought they want and that certain thoughts activate certain parts of the brain. This is doable because a person can only pay attention to one thought at a time. We have only one attention. If you want to prove this to yourself get that old face/vase picture from an old Psych 101 text and try to see both the vase and the face at the same time. You can go very quickly from one to the other but you can't think both at the same time, can't hold both thoughts at the same time. I still get the same godawful, I-can't-bear-it, hopeless and helpless feelings of depression that I did when I was diagnosed bipolar as a young woman in my thirties. However, I no longer spend days and weeks in my depression as I once thought I must do. My process of Directed Thinking skirts me around the depression, out of the agitated subcortex into the unagitated neocortex whereupon the discipline of neutral thinking and some physical activity causes my brain chemistry to shift and the depression to fade in five or ten minutes.

YOUR POINT: But it is again a bizarre claim that psychoanalysis has much influence on contemporary psychiatry.
MY RESPONSE: I said that Freud's theory of the unconscious mind, not psychoanalysis, is the basis of present-day psychiatry. Yes psychoanalysis has now been debunked by almost everyone. The scary thing here is that for many years it was the orthodox medical treatment for depression, much the same as pharmacology is now the orthodox medical treatment for depression. Further proof that being orthodox is not necessarily being correct.

YOUR POINT: Curtiss tries to support her claims by appeal to modern neuroscience, but her use of neuroscience is simplistic and its support of her view is implausible.
MY RESPONSE: As to my simplistic rendering of neuroscience to prove my ideas. There is no necessity to prove my ideas. Directed Thinking doesn't need to be proved any more than a hoe needs to be proved. Somebody made a hoe, try it and see if it works for you. I made up some mind tricks, try them and see if they work for you. I just used neuroscience to explain how they work neuroscientifically. Not to prove THAT they work. How silly to prove a tool. Tools are there to be used not to be proved. The interesting thing is that those who scorn my simplistic little mind tricks remember them for the very reason that they are so simple. Many who have scorned "green frog" out of hand have ended up using the little device themselves when they found themselves falling into the abyss and grabbed for the first available blade of grass on the way down. Life is absolutely irrepressible. Ideas are proveable. Tools are useable.

YOUR POINT: Her views about the power to control one's own depression are not based on scientific experiment.
MY RESPONSE: I did not hold the scalpel in my hand and do the neuroscientific experiments on brains myself. But I studied the results of this research. Neuroscience explains how Directed Thinking works. Neuroscience research shows us that all our feelings are produced from the subcortex and if that area of the brain is destroyed by accident a person is not capable of any emotional feelings whatsoever. We don't have to function from the subcortex. As an act of will we can function from the neocortex simply by choosing the kinds of thoughts which access the neurons in that part of our brain. We suffer in the subcortex but we can't do math in the subcortex. We can only do math from the neocortex and we can't experience emotional suffering from the neocortex.  We can decide as an act of will to do math any time we want to. By doing math, or any neocortical activity, we necessarily lessen the neuronal activity in the subcortex, in the feeling part of our brain. This is the way people have always drawn attention away from painful feelings. When feelings improve we can always feel good by paying attention to feelings again. When feelings get bad, we can direct our attention to neocortical activities. One way you can stop thinking the thought I am depressed is to think the thought green frog, or recite the 23rd Psalm, or sing row, row, row your boat. You don't have to prove this. This is not an idea. This is a tool. Use it when you have need of it.

YOUR POINT: When Curtiss cites modern neuroscientific research to make a distinction between the higher mind and the primal mind, as she does again and again, I get very uncomfortable. To suggest that different parts are simply "higher" or "lower" is almost bound to be ignoring the subtleties of how the brain really works, and when it comes to the influence of the will on mood, it's the subtleties that must be important.
MY RESPONSE: As to upper and lower brain, there are many ways to divide the brain in order to study it from different angles. Right brain, left brain is one way. Neocortex (higher, by position and newer, evolutionarily speaking) and subcortex (lower, by position, and primal, evolutionarily speaking) is another way.  If one has suffered sufficient tissue damage in the subcortex alone, one will not be capable of any emotion whatsoever although the skills for language and math will be fully functioning. This is a scientific fact and not a debatable idea.

YOUR POINT: Occasionally, Curtiss refers to philosophical traditions, although more often she simply refers to "philosophers" as if all philosophers agreed on basic truths. Again, her approach ignores the fact that philosophers often disagree with each other about fundamentals.
MY RESPONSE: As to philosophers disagreeing about fundamentals. All wise people, yourself included, recognize truth when it reveals itself to them. No wise person argues with or about truth. All wise people know that anything than can be argued about or believed cannot be truth because that would make truth an object and therefore a product of the mind. The trouble with Western philosophers wrangling is political. Plato was an enlightened man but his pupil Aristotle never rose to this level of understanding. Since Aristotle was the tutor that Philip of Macedon chose for his son, Alexander, it is Aristotle's understandings of Plato that have formed the basis of what we know as philosophy, not Plato's. Few people can view Plato without looking through the eyes of Aristotle. But ideas have nothing whatsoever to do with truth. Ideas are debatable. Truth is truth.

YOUR POINT: Even granting that there is a narrow moment of choice, it follows that after this moment, the ability to voluntarily control one's feelings is lost. This in itself seems to contradict Curtiss' main thesis, that depression is always a choice, since the window of opportunity to avoid depression is in fact narrow, and outside that window, there is no choice. One is simply overcome by one's feelings, or one's primal mind takes over. So then, at that moment, depression is not a choice
MY RESPONSE: I am afraid that you have misstated my idea of a narrow moment of choice. On page 150 I clearly state "We are never without choice at any time, but we can wait overlong to make it. On page 152, I state "we are always situated in choice." This narrow moment of "divine intelligence," once one gets used to looking for it, can be used as a signal to make the choice easy, by making it in the very beginning. But I state quite categorically here that we always have choice at any point, it's just that if we wait overlong to make it, it becomes more difficult to look for it. You can argue the always part if you want to nitpick but I mean always in the same sense that we say that people are always born one sex or another when obviously some few people are born with the anomaly of indeterminate sexual physiology.

YOUR POINT: Curtiss presents no more than anecdotal evidence to support her claim that there is such a moment of choice, even for herself.
MY RESPONSE: No one has to believe in choice. Choice is not an idea, it is a reality. No one has to believe in the moon. The moon is not an idea. It is a reality. No one argues about whether or not there is a moon, they just go look up at the night sky and see it. No one has to argue about choice. If you want to see choice simply ask yourself at any instant point in your life if you have a choice or not as to what to do or think next. You have to look up at the sky to see the moon. You have to question yourself to see choice. Choice like the moon is always there. Your decision not to look at it may deny the moon, or choice, but it cannot destroy its palpable existence.

YOUR POINT: It's clear that willpower does play a role in ending addiction. How do these two ideas fit together? A simplistic solution is to assume that they are incompatible with each other, and so to conclude either that addicts have no self-control, or else that there is no such thing as addiction. But neither of these alternatives works well. We are left with difficult questions about how to think about addiction.
MY RESPONSE: As to your line of thinking about addiction and willpower being incompatible extremes. Willpower is not the opposite of addiction. Willpower is the answer to addiction, as any former addict will be glad to tell you. Willpower is the choice of long-term over short-term gains.

YOUR POINT: While I find many of Curtiss' right wing political views and her condemnation of modern relativism to be ill considered and shallow, I nevertheless admire her readiness to discuss the moral dimensions of mental disorder.
MY RESPONSE: As concerns modern relativism. Can you give me one example, even an anecdotal one, in which modern moral relativism has a useful purpose?

Finally, I do not consider depression an affliction for all that I might consider it painful. I consider depression to be a defense mechanism which has not been properly managed.

Thank you for your review of my book.

Best Regards,

A. B. Curtiss

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Christian Perring replies:

November 26, 2001

Thanks to A. B. Curtiss for her reponse to my review.  I'll refrain from giving detailed answers toeach of  the responses above, since I basically stand by my original review.  The responses to the review do help to clarify some of the issues and points of disagreement.  Concepts such as affliction, malady, mental disorder, mental illness, and mental disease are important in psychiatry, social policy and morality, but they are also complex, and so this is not the best place to sort out the complexities.  I think that it is useful and appropriate to class depression as a mental disorder.  But I agree with Curtiss that it is sometimes possible for people to use various techniques and to learn skills that will improve their mood and will stop them from acting self-destructively.  I imagine that Curtiss may agree with the common observation that sometimes these techniques and skills fail to help.  Sometimes depression is so powerful that people experiencing it have very little ability to overcome it.    I'd agree that to call depression a disease can sometimes have the counterproductive effect of making people think that they have no way to combat it except by taking medication.  But there are also important advantages to promoting the understanding of depression as a disorder; it helps to reduce the societal stigma that people with depression experience, and it also enables people in managed care organizations and national health systems to receive clinical treatment that helps them to overcome their depression.

One issue arising in Curtiss' response to my review that deserves separate comment concerns the importance of proof.  Curtiss says that. "Choice is not an idea, it is a reality."  She seems to be saying that proof of her ideas is not necessary, because people will see that her claims about choice are true when they pay attention to them.  It may be true that many of her readers do not require scientific proof of the usefulness of "Directed Thinking," or the role of choice in lifting depression.  But when governments and managed care organizations are deciding which treatments for depression to provide, I would want them, ideally, to fund those which are proven to work. When it is difficult to prove the efficacy of treatment, as it often is in mental health, we can at least evaluate the evidence for or against different treatments and the methodological problems that exist for those trying to measure the efficacy of treatments.  Furthermore, when clinicians, researchers, and even philosophers make claims about the nature of depression, they need to argue their case if rational readers are to take them seriously.  In some cases, it may be enough to say "look for yourself, and you will see that I am right," but when it comes to depression, there's a great deal of anecdotal evidence that people have already looked for themselves, trying to end their depression through their own acts of will, and they found that choice by itself was not enough.  Of course, anecdotal evidence is not full proof, and one of the challenges for future scientific research is to find ways to determine the role willpower plays in ending or reducing the symptoms of mental illness.