RatcliffeTheworldofdepression-1.pdf

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The World of Depression

Matthew Ratcliffe

In this short paper, I will offer a brief sketch of how I think we should go about trying

to understanding experiences of depression. First of all, it is important to be clear

about what the problem consists of. If we don’t know what depression is like, why

can’t we just ask someone who’s depressed? And, if we want others to know what our

own experience of depression is like, why can’t we just tell them?

In fact, many autobiographical accounts of depression include the claim that the

experience or some aspect of it is indescribable. As one author remarks, “I have no

words to describe this thing that was totally alien to my life experience” (quoted by

Whybrow, 1997, p.23). Shenk (2001, p.244) observes how most accounts will “have

this sort of disclaimer” and that others “disclaim implicitly through dependence on

metaphor and allusion”. It is not clear what exactly the problem is or whether it is the

same in all cases. Some state that they struggle to articulate the experience, others that

it is simply ineffable, and others that only certain media, such as poetry, are adequate

to the task. In addition, sufferers often state that other people are unable to understand

the experience or just don’t care. Now, although it is often not true that others don’t

care, I do think there is a problem with understanding and articulating the experience

of depression, which applies to both first- and third-person perspectives. If we consult

diagnostic manuals and the like, we don’t get much help. The fifth edition of the

Diagnostic and Statistical Manual of Mental Dis s was published in May 2013.

When we turn to the category ‘major depressive dis ’, we find an appeal to five or

more of nine symptoms, which is much the same as that in the previous edition:

Major Depressive Dis (DSM-5)

Five or more of the following, including (1) and/or (2):

1. Depressed mood

2. Diminished interest or pleasure in activity

3. Weight loss or weight gain

4. Insomnia or hypersomnia

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5. Psychomotor retardation or agitation

6. Fatigue or loss of energy

7. Feelings of guilt or worthlessness

8. Inability to think or concentrate

9. Frequent thoughts of death or suicide

What does this tell us? Well, it is not clear what a depressed mood actually is or how

it differs from diminished interest and pleasure. And the requirement that any four of

the other symptoms be present allows for enormous variety. As we read on, we find a

brief discussion of how depression is to be distinguished from grief, which raises far

more problems than it manages to solve, the admission that depression and anxiety are

frequently inextricable, that many episodes of depression involve “mixed features”

(thus blurring the boundary between mania and depression), and a host of other

complications that make ‘depression’ even harder to pin down. In short, it’s a mess.

Now, from a clinical perspective, one might argue that this is not a concern. The goal

is to reliably identify depression, not describe it in detail. However, the task of

identifying depression unavoidably involves appeal to kinds of experience, given that

almost all of the diagnostic criteria are implicitly or explicitly experiential. So, if we

don’t understand the experience, there is the concern that (a) psychiatric categories,

based as they are on a cursory appreciation of experience, will be inaccurate or

otherwise uninformative or (b) even if our categories are in some way informative, we

will be unable to use them reliably. There are also repercussions for treatment. If the

term ‘major depressive dis ’ lumps together a range of importantly different

predicaments, it seems likely that they will respond to treatments in different ways. In

summary, better understanding of experience facilitates better psychiatric categories

and more reliable identification of conditions, something that is likely to have an

effect upon treatment outcomes.

However, there are other compelling reasons for seeking an improved understanding

of depression experiences. Central to depression is a sense of painful isolation from

other people, which can be exacerbated by an inability to convey what one is going

through to others. Hence an ability to appreciate and communicate what depression

experiences involve could help sufferers relate to other people, as well as help others

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to empathize and offer appropriate support. By implication, improved understanding

of the experience also has considerable potential to enhance so-called ‘talking

therapies’.

But, we might ask, why is depression so hard to understand? The first thing to

appreciate is that it is not simply a matter of the intensification of certain familiar

aspects of experience and the diminution of others, such as feeling more sad and less

happy, or more tired and less energetic. What we find in almost all detailed first-

person accounts is the claim that depression involves something quite alien to what –

for most people – is mundane, everyday experience. One finds oneself in a ‘different

world’, an isolated, alien realm, adrift from social reality. Let us consider some first-

person reports:

“Most of all I was terribly alone, lost, in a harsh and far-away place, a horrible terrain

reserved for me alone. There was nowhere to go, nothing to see, no panorama. Though

this landscape surrounded me, vast and amorphous, I couldn’t escape the awful

confines of my leaden body and downcast eye.” (Shaw, 1997, p.40)

“You know that you have lost life itself. You’ve lost a habitable earth, You’ve lost the

invitation to live that the universe extends to us at every moment. You’ve lost

something that people don’t even know is. That’s why it’s so hard to explain.” (quoted

by Hornstein, 2009, p.213)

“It is the glass wall the separates us from life, from ourselves, that is so truly

frightening in depression. It is a terrible sense of our own overwhelming reality, a

reality that we know has nothing to do with the reality that we once knew. And from

which we think we will never escape. It is like living in a parallel universe but a

universe so devoid of familiar signs of life that we are adrift, lost.” (Brampton, 2008,

p.171)

Such reports give us a good sense of the nature of the problem: depression involves a

radical departure from ‘everyday experience’. And it is not a localized experience that

one has within a pre-given world; it encompasses every aspect of one’s experience

and thought – it is the shape of one’s ‘world’. Nevertheless, passages like the above

do not wear their interpretations on their sleeves, and do not give us a much of a

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positive appreciation of what is going on. This is the point where my own work

begins. Amongst other things, I’ve been extracting insights from the

phenomenological tradition of philosophy and applying them to the task of

understanding and articulating depression experiences. That tradition includes

philosophers such as Edmund Husserl, Edith Stein, Martin Heidegger, Maurice

Merleau-Ponty and Jean-Paul Sartre, all of whom engage in ‘phenomenological’

reflection – that is, reflection upon the structure of human experience. Why should

this be of any help to us? Well, in short, what all of these philosophers claim is that

human experience incorporates something that is overlooked by most of those who

have tried to describe it – what we might call a sense of ‘belonging to’ or ‘finding

oneself in’ a world. This is something so deep-rooted, so fundamental to our

experience, that it is generally overlooked. Whenever I reflect upon my experience of

a chair, a table, a sound, an itch or a taste, and whenever I contrast my experience

with yours, I continue to presuppose a world in which we are both situated, a shared

realm in which it is possible to encounter things like chairs and to experience things

like itches. As Husserl puts it, in his typically obscure way:

“Waking life is always a directedness toward this or that, being directed toward it as

means, as relevant or irrelevant, toward the interesting or the indifferent, toward the

private or public, toward what is daily required or intrusively new. All this lies within

the world-horizon; but special motives are required when one who is gripped in this

world-life reorients himself and somehow comes to make the world itself thematic, to

take up a lasting interest in it.” (1970, p.281)

What he is trying to get at, essentially, is that whenever we perceive, remember or

imagine something, we already experience ourselves as ‘there’. This sense of being

rooted in an interpersonal world does not involve perceiving a (very big) object or

believing that some object exists. It’s something that is already in place when we do

that, and therefore something that we seldom reflect upon. We can get some insight

into this by reflecting on ways in which this aspect of experience ‘wobbles’ or ‘shifts’

from time to time. In several publications, I have referred to such changes as

‘existential feelings’, by which I mean feelings that involve alteration of our overall

sense of belonging to a world, rather than something more localized:

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“People sometimes talk of feeling alive, dead, distant, detached, dislodged, estranged,

isolated, otherworldly, indifferent to everything, overwhelmed, suffocated, cut off, lost,

disconnected, out of sorts, not oneself, out of touch with things, out of it, not quite with

it, separate, in harmony with things, at peace with things or part of things. There are

references to feelings of unreality, heightened existence, surreality, familiarity,

unfamiliarity, strangeness, isolation, emptiness, belonging, being at home in the world,

being at one with things, significance, insignificance, and the list goes on. People also

sometimes report that ‘things just don’t feel right’, ‘I’m not with it today’, ‘I just feel a

bit removed from it all at the moment’, ‘I feel out of it’ or ‘it feels strange’.” (Ratcliffe,

2008, p.68)

And something like this seems to be going on in depression, a shift in the sense of

belonging to a shared world. However, this still does not add up to much of an

understanding. What, exactly, is it to undergo a shift in the structure of world

experience, and what kind of shift is involved in depression? We can gain a better

appreciation once we acknowledge the role that possibilities play in our experience.

When I get up in the morning, feel very tired, stop at a café on the way to work and

then look at a cup of coffee sitting in front of me, what do I ‘experience’? On one

account, what I ‘see’ is just what is ‘present’, an object of a certain type. But I think

it’s important to recognize that experience of the cup is permeated by possibilities of

various kinds. I see it ‘as’ something that I could drink from, as something that is

practically accessible and practically significant. Indeed, it appears more than just

significant – it is immediately enticing. Rather than, ‘you could drink me’, it says

‘drink me now’. Many aspects of our situation appear significant to us in some way or

other, meaning that they harbor the potentiality for change of a kind that matters. And

certain things draw us in, calling for some kind of action. We can, I propose, better

appreciate what experiences of depression consist of once we construe them in terms

of shifts in the kinds of possibility that we have access to. Whereas the non-depressed

person might find one thing practically significant and another thing not significant,

the depressed person might be unable to find anything practically significant. It is not

that she doesn’t find anything significant, but that she cannot. And the absence is very

much there, part of the experience – something is missing, painfully lacking, and

nothing appears quite as it should do. Many first-person accounts explicitly refer to a

loss of possibility. Here are some representative responses to a questionnaire study

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that I conducted with colleagues two years ago, in collaboration with the mental

health charity SANE

“I remember a time when I was very young – 6 or less years old. The world seemed so

large and full of possibilities. It seemed brighter and prettier. Now I feel that the world

is small. That I could go anywhere and do anything and nothing for me would change.”

“It is impossible to feel that things will ever be different (even though I know I have

been depressed before and come out of it). This feeling means I don’t care about

anything. I feel like nothing is worth anything.”

“The world holds no possibilities for me when I’m depressed. Every avenue I consider

exploring seems shut off.”

“When I’m not depressed, other possibilities exist. Maybe I won’t fail, maybe life isn’t

completely pointless, maybe they do care about me, maybe I do have some good

qualities. When depressed, these possibilities simply do not exist.”

We can understand a great deal, I suggest, by taking this one simple step. Suppose the

depressed person inhabits an experiential world from which the possibility of

anything ever changing for the better is absent. In other words, nothing offers the

potential for positive change and, with this, nothing draws the person in, solicits

action. This lack permeates every aspect of her experience. Her situation seems

strangely timeless, as no future could differ from the present in any consequential

way. Action seems difficult, impossible or futile, because there is no sense of any

possibility for positive change. Her body feels somehow heavy and inert, as it is no

longer drawn in by situations, solicited to act. She is cut off from other people, who

no longer offer the possibility of significant kinds of interpersonal connection. Others

might seem somehow elsewhere, far away, given that they are immersed in shared

goal-directed activities that no longer appear as intelligible possibilities for the

depressed person. Something else that this helps us to understand is why so many

people who are depressed maintain that recovery is utterly impossible or simply

inconceivable. Here are some quotations from published accounts:

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“There was and could be no other life than the bleak shadowland I now inhabited.”

(Shaw, 1997, p.25)

“My father would assure me, smilingly, that I would be able to do it all again, soon. He

could as well have told me that I would soon be able to build myself a helicopter out of

cookie dough and fly it to Neptune, so clear did it seem to me that my real life, the one

I had lived before, was now definitively over.” (Solomon, 2001, p.54)

“In the middle of a depressive episode, it is impossible to believe it will pass. It is,

oddly, a problem of believing that one is seeing the world ‘as it really is’ and unable or

unwilling to put a gloss on that perception.” (Burnard, p.244).

The experience can be further exacerbated by the fact that, although certain kinds of

possibility are gone from experience, other kinds can remain and become more

prominent. To be more specific, the anxiety that is a salient feature of many

depression experiences can involve a sense of everything as somehow threatening –

other people and the world more generally offer only threat. Furthermore, as nothing

matters in any other way, there can be nothing of significance between one’s present

situation and the realisation of this inchoate, all-enveloping threat, which thus

crystallises into the sense that one is about to die.

“I awoke into a different world. It was as though all had changed while I slept: that I

awoke not into normal consciousness but into a nightmare. [….] At that time ordinary

objects – chairs, tables and the like – possessed a frightening, menacing quality which

is very hard to describe vividly in the way that I was then affected. It was as though I

lived in some kind of hell, containing nothing from which I could obtain relief or

comfort.” (Testimony quoted by Rowe, 1978, pp.269-70)

“There is something in the future which is coming…. I am afraid it will suck out my

core and I will be completely empty and anguished.” (Thompson, 1995, p.47)

“….what is happening to you in depression is horrible, but it seems to be very much

wrapped up in what is about to happen to you. Amongst other things, you feel you are

about to die” (Solomon, 2001, p.27).

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All of helps us at least start to appreciate why the kind of ‘hopelessness’ or ‘despair’

that is central to so many experiences of depression differs in important respects from

more mundane feelings that might be described in similar ways. I could lose hope in a

certain project, but I retain the capacity for hope – I can still hope for other things.

However, some depression experiences involve erosion of the capacity for hope.

There is no sense that anything of worth could be achieved or that anything good

could ever happen. Hence the attitude of hope is no longer intelligible; the person

cannot hope:

“I have absolutely no faith, in fact, in anything. In a muddy way, I see that depression

manifests itself as a crisis of faith. Not religious faith, but the almost born instinct that

things are fluid, that they unfold and change, that new kinds of moment are eventually

possible, that the future will arrive. I am in a time-locked place, where the moment I

am in will stretch on, agonizingly, for ever. There is no possibility of redemption or

hope. It is a final giving up on everything. It is death.” (Lott, 1996, pp.246-7)

However, it is important to stress that depression experiences are extremely variable

in this and many other respects. So it is possible to discern many different kinds of

hopelessness experience. A basic distinction, which I think needs to be recognised, is

between the collapse of a system of projects that are central to one’s life, the loss of a

system of hopes, and a loss of a capacity to hope. Current diagnostic criteria are not

sensitive to that distinction and so the category ‘major depressive dis ’ no doubt

accommodates both. But a range of other, more subtle, distinctions need to be made

too, reflecting the various different ways and extents to which a capacity for hope can

be eroded. Compare the following first-person accounts:

“When depressed I feel I have no future and lose any hope in things improving in my

life. I feel generally hopeless.”

“I feel hopeless, as though there is nothing I can do that will ever truly improve my life.

I often feel like I’m in a rut, like I’m stuck.”

“Whilst depressed, I feel an impending sense of doom. I feel hopeless and useless, and

my self-confidence drops so low that sometimes I cannot even leave the house to

food as I don’t feel worthy to be taking up any space and time.”

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“The world looks very different when depressed as I find my life becomes valueless.

The world seems very bleak and there seems to be no point in anything. All actions and

tasks become pointless and irritating. Daily tasks become a chore and social contact

becomes a real hassle. The problem with depression is you lose hope and then you get

very self-destructive. I also find that the world becomes a dark and dangerous place and

I become unable to find any joy or happiness in it.”

We cannot draw confident distinctions on the basis of cursory remarks. But, if these

descriptions are taken at face value, they are suggestive of different kinds of

‘hopelessness’. Feeling that “I have no future” differs from the conviction that no

human being has a meaningful future, and “I’m in a rut” suggests something perhaps

less severe, where there remains an appreciation that one’s own life could improve.

The “impending sense of doom” in the third response is not necessarily incompatible

with a meaningful life but surely interferes with it. Here, it is associated with lack of

confidence in the efficacy of one’s actions, but ‘I am likely to fail at this’ is different

from ‘this is of no worth’. And the fourth response does not apply to a specific

project, a wider system of projects, parts of one’s life or even the whole of one’s life.

Instead, there is a dread-imbued sense that all human life is bereft of value. In extreme

cases, it is not just that one takes all human life to be without value; one cannot even

contemplate the possibility of its being otherwise; the experience has a feeling of

irrevocable certainty to it.

In my view, sensitivity to such differences is crucial when it comes to engaging with

the kinds of experience that are associated with the label ‘depression’. And

philosophical research into the structure of experience, of the kind that I have briefly

outlined here, can help us to do so (see e.g. Ratcliffe, 2009; 2010; 2012; in press). Of

course, there’s much, much more to be said about depression experiences. I hope I

have conveyed at least some idea of the role that phenomenological research can play,

but I should also stress that depression is a heterogeneous, complicated, multi-faceted

phenomenon; no single approach or perspective will yield a comprehensive

understanding. What I’m working on is just part of the puzzle, which can feed into a

broader understanding of depression and inform our response to it.

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References

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Burnard, P. 2006. Sisyphus Happy: the Experience of Depression. Journal of Psychiatric and

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Hornstein, G. A. 2009. Agnes’s Jacket: A Psychologist’s Search for the Meanings of

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Husserl, E. 1970. The Vienna Lecture. In his The Crisis of European Sciences and

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269-299.

Lott, T. 1996. The Scent of Dried Roses. London: Viking.

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