When Did Sadness Become a Disease? How We've Pathologized Everyday Life
One Nation Under Stress: The Trouble with Stress as an Idea
By Dana Becker
Oxford University Press. 245 pp.
How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown
By Edward Shorter
Oxford University Press. 256 pp.
Here’s the bad news: you’re stressed out and depressed. The good news? According to two recent books, you’ve got a lot of company. But, given the ubiquity of stress and depression these days, what do those terms actually mean anymore, and what effects do they have on our lives and our society as a whole?
While Becker’s book focuses on stress and Shorter’s solely on depression, they tell a larger, and largely similar, story: how these concepts have eroded through the decades into catchall conditions so pervasive that they’ve become virtually meaningless as terms for diagnosis or treatment. More troubling, according to these authors, is that each of these “conditions” has become so prevalent that the distinction between normal and abnormal pressures or moods has become completely blurred. And once stress and depression are considered to be as ordinary as the common cold, we all become targets for Big Pharma’s marketing campaigns of medications that may not actually help us. Also, there’s one more danger, the authors charge: in focusing inward on our own stressors or personal capacities to bounce back or rebalance, we risk losing sight of the impact of larger societal and economic pressures and policies—areas where readjustment could make a real difference in beginning to slow the treadmill quality of contemporary life for the benefit of all, perhaps especially for women.
That’s the discomforting bigger picture that reading these books one after the other yields. Yet, with their distinct subjects and emphases, each author comes to somewhat different conclusions about who’s to blame and how to move forward.
In the more compelling of these books, One Nation Under Stress: The Trouble with Stress as an Idea, Dana Becker, a professor of social work at Bryn Mawr College, uses a potent mixture of social-science research, critical thinking, and sarcasm to get her points across. She blames general anxieties about social change, economic uncertainty, and possible terrorist threats—combined with countless misleading articles and ads about what produces stress and how it operates—for creating a public consciousness saturated with the dangers of stress and the benefits of soothing lotions, yoga classes, and calming medications. According to Becker, this nonstop hype has helped elevate the uncertainties, fears, and pressures of modern life to the status of a seeming disease so widespread and damaging that it’s no wonder a British newspaper dubbed stress the “Black Death of the 21st Century.”
Yet focusing on stress as if it were synonymous with anxieties that originate from within, rather than a reaction to external pressures or forces from without, turns the word’s original historical meaning inside out, Becker says. She traces the start of this turnaround back to the 19th-century concept of neurasthenia, or “nerve weakness,” popularized by American neurologist George M. Beard, who asserted that the pressures of modern life were pushing people beyond the limited energy they possessed. Hungarian-Canadian endocrinologist Hans Selye solidified the public’s perception of stress and its impact on our mental and physical well-being. In The Stress of Life, published in 1956, he defined stress as “the rate of wear and tear caused by life.” Stress was problematic, he said, because it disrupted our natural state of homeostasis, and the road back to healthy homeostasis, he argued, involved successful adaptation to life’s stresses.
But whose job was it—and is it—to do the adapting required to reach healthy homeostasis? Is it society’s responsibility to legislate public policy and fund safety-net programs, such as Social Security and Medicare, that help lessen the economic and social stressors wearing people down? Or is it each individual’s responsibility to figure out a solution to everything from bad hair to life’s larger and more pressing issues, like not being able to find, or afford, the appropriate therapy or educational program for a disabled child?
This question is central to Becker’s analysis. She coins the term stressism to describe “the current belief that the tensions of contemporary life are primarily individual lifestyle problems to be solved through managing stress, as opposed to the belief that these tensions are linked to social forces and need to be resolved primarily through social and political means.” Here’s just one example of stressism: the idea that working mothers must learn to juggle their multiple roles and the stress that results from dealing with the responsibilities of work life, childcare, and family life. This stereotype is so widely accepted that it’s easy to forget the assumption that lies behind it: juggling is a woman’s problem, not that of a man, a family, or society. It’s an assumption that favors the status quo. Yes, stressed out working moms who take up yoga and follow a Mediterranean diet may indeed feel calmer, more “balanced,” and in the moment. But unless their companies institute family-friendly policies, the stress inherent in the pressure to juggle so many activities will remain constant.
This isn’t the only way that the idea of stress becomes a dodge from facing up to and acting on its underlying or systemic causes. Becker applies this reasoning to other social ills that remain invisible when stress becomes the focus, especially when discussing the impact of poverty. It’s too easy for social and political scientists to gloss over poverty as merely one of many “stressors” affecting the mental health of people stuck in dire economic circumstances, she says, rather than addressing poverty directly and looking at issues of inequality, affordable housing, and better wages.
She further argues—less persuasively—that diagnosing post-traumatic stress disorder in soldiers returning from combat medicalizes responses to horror, neutralizes the reality of the contact horror experienced by those who didn’t serve in combat, and distances lawmakers and civilians from the political responsibility of going to war. But this perspective misses the ways in which this diagnosis has contributed to much greater public and professional understanding of the aftermath of trauma. Nor does Becker propose a better way of approaching and treating the severe psychological distress, discomfort, and pain resulting from combat trauma.
Becker’s book is densely detailed and filled with footnotes, which can make for slow going, but she’s outspoken, proactive, and provocative—which keeps you reading. Depending on your political views and the particular issue under discussion, you may find yourself agreeing with her, becoming impatient with her, or alternating between the two, as I did. Ultimately, her book is as much a call for social action as it is for psychological clarity.
In How Everyone Became Depressed: The Rise and Fall of the Nervous Breakdown, the noted historian of psychiatry Edward Shorter similarly demonstrates how we’ve come to misunderstand and misuse the concept of depression. Shorter focuses on the ascent of antidepressants and, especially, the American Psychiatric Association’s Diagnostic and Statistical Manual (DSM) as the main culprits. His book thus serves as a scholarly, history-focused companion to two other recent polemics criticizing the newly published DSM-5:psychotherapist Gary Greenberg’s The Book of Woe: The DSM and the Unmaking of Psychiatry and Saving Normal: An Insider’s Revolt Against Out-of-Control Psychiatric Diagnosis, DSM-5, Big Pharma, and the Medicalization of Ordinary Life by psychiatrist Allen Frances.
From Shorter’s viewpoint, the constant rewriting and reinterpreting of depression from one edition of the DSM to the next has mangled its meaning. He chronicles how the political infighting and compromises among different factions writing theDSM over the decades have transformed a real illness of body and mind into an amorphous compilation of mood disorders that wrongly lumps together potentially suicidal depression with passing bouts of sadness. In his view, this mislabeling in the ongoing DSM editions has had disastrous consequences, leading to misdiagnosis and ineffective treatment.
In his scathing critique, he argues that we’d be better off dividing depression into two separate disorders and using an older terminology to distinguish them. He advocates using melancholia to define the severe depression that affects body and mind. While the malady of melancholia may include symptomatic mood disturbances, it goes beyond fluctuating moods and “may lead to despair, hopelessness, a complete lack of pleasure in one’s life and suicide.” He adds, “Melancholia means a dejection that appears to observers as sadness but that the patients themselves often interpret as pain,” numbness, and the inability to experience joy. Readers of Shakespeare will recognize in this the melancholia that Hamlet describes.
Further, Shorter advocates using the term nonmelancholia in reference to the low mood and sadness commonly referred to as depression. Using melancholia andnonmelancholia would contrast and distinguish between what he sees as “two different kinds of depression, as different as tuberculosis and mumps.” Rethinking the nature of depression in this way, he believes, would help clinicians refine their treatments. Rather than resorting to one-size-fits-all solutions—which all too often means prescribing an antidepressant—psychiatrists and therapists would look to a wider array of therapeutic tools.
Shorter’s perspective has much to recommend it. He can be fascinating as he traces the origins of the uses and meaning of depression and melancholia. And though his detailed chronicle of the endless squabbling that’s gone into the writing of different editions of the DSM is disheartening, it goes a long way toward explaining the manual’s weaknesses. Even so, as one fact follows another, his larger arguments can be hard to follow. His research is thorough, but it becomes trying to navigate.
In the end, the message both books provide is clear: as cloudy as the concepts of stress and depression have become, they can still be useful—but only if we can see through the layers of misuse and misunderstanding that too often veil their true meanings.
Contributing editor Diane Cole is the author of the memoir After Great Pain: A New Life Emerges and writes for The Wall Street Journal and many other publications. Contact: email@example.com.