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Giving depression a fair hearing contd ...


The economics of depression

The direct cost of depression accounts for only a small part of the average person's medical bills, he continues, but our frenzied opposition to depression and what it represents has a close parallel in our dominant economic fears today.

We talk about an economic depression. We worry about the energy crisis in economic terms and the inhibition of drive in our patients. We ponder the threat of pollution of the world as our depressive patients ruminate about their fantasy that their insides are turning black, that they are being poisoned. We fear unemployment and the dominant feature of depressed individuals is that they can't get up to go to work, Hillman notes.

Twice as many women as men across all racial groups are likely to suffer depression, he continues.

"The manic culture is primarily a testosterone culture. This went on in the 19th century, women were the carriers of many more symptoms which they presented to male doctors.

"Today this depression has lost the confines it had in earlier psychiatry. It's in youth, children, and the term is used very broadly. But it is so important to get back to what experience that person (depression sufferer) is in."

"In practice, for people to say I am depressed is insufficient, it won't do. I want to know what, where, how, what are the physical correlates, what do you eat, what happens when you are in that chair and when you get up out of the chair. I want to know an enormous amount about your body."

It's about knowing what that depression experience is telling you as a clinician, I think to myself, getting away from the diagnosis and getting to the heart of the experience. I drift momentarily to thinking of the manic schedule I have been keeping for as long as I can remember and recalling how it feels when I slow down for a minute. It feels good to keep the momentum, I recall, as I wander back to Hillman's list of depressive correlates.

"Dry hair, shallow breathing, frequent sighs a flat to diminished tone to everything, sleeplessness and facial pain which is different to anxiety, which has a seriousness to it. That is very important Everything seems so weighty, heavy. The Romans called it gravitas, it belongs to Saturn," he continues.

"In your training you probably heard that depression is worse in the morning. Why is depression worse in the morning? What does it say about the day you are about to enter. Is it because there is no minor key used in the music they play on morning radio, because you have to keep up with the rising of the sun We have to make some sense of the things we observe."

So, what sense do you make of it, I think, getting a little impatient at the pace at which he is moving. Again, almost intuitively, Hillman suggests a break and, on return, switches on a video to play a British documentary, entitled Kind of Blue. Hillman is one of the documentary's first interviewees.

"One of the things you don't want to be is interrupted," he says, now 6 metres tall and washed in an overly rich technicolour on the screen which looms over the conference-goers.

"You can go, go, go on coffee and stimulants. When you watch the heroes on TV they never get tired (But) slowness is basic to the notion of melancholy from the very beginning. Mania is often described in psychiatry by the absence of sadness. Loss means losing what was. We want to change but we don't want to lose Without time for loss we don't have time for soul," he drives home.

"Melancholy brings us to a place where we can see more clearly the essences of life," Jules Cashford, a writer, tells the film's interviewer.

The soul knows about the chaos of the culture we're in. Somehow, if you're not in mourning, you are out of touch with the world. So, underlying depression is an adaptation to the underlying condition of the world, Hillman explains. Every time somebody slips into depression everybody comes to resurrect them, and we find drugs and convulsive therapy to assist. In ordinary life, we just get out and moving again to avoid the depression, he continues.

The movie ends, Hillman shrinks back to his podium-borne size and he resumes the live address. "This movie was deemed too slow for US audiences, hence it was turned down by the PBS This film may be part of the evolution of psychotherapy," he quips, inviting questions from the floor.

An audience member sheepishly proffers that he struggles to reconcile the existential humanist with the scientist practitioner in himself when he is faced with a depressed client. Does one tackle the depression in a workmanlike manner or sit with the uncomfortable existential questions that the depression raises?

The question irks the impressionist Hillman: "I suggest you sit down with your existential humanist and your scientist practitioner and the three of you have it out," he retorts. The questioner shrinks back to his seat.

"This is not instrumentalism, not a technique I teach you to apply. It isn't that you hold out hope You keep the faith, and one of the ways of therapy that feels most useful is not that you do something, but that you keep contact. You are a consistent, chronic companion, rather than being a therapist who enacts something against the problem," he says.

"What happens is that you become activated by the stillness or the drop. Against that paralysis are the very active methods of treatment. ECT (electro convulsive therapy) was developed by an Italian who also developed aircraft fuses," he says cryptically. "In the history of the treatment of depression, there was the dunking stool, purging of the bowels of black bile, hoses, attempts to shock the patient. All of these represent hatred or aggression towards what depression represents in the patient."

But Hillman does not decry the treatment du jour for depression - psychopharmocology.

"There is no reason why we shouldn't take advantage of medications. The important thing is what is your attitude to it, how you keep that demon in its place so that it doesn't possess you." The trick, he reiterates, is to keep your focus on what the patient is feeling, thinking, and imagining.

"I'm not out for finding ways of getting rid of depression. Depression brings slowness, a counter-move to the manic, inwardness. It opens the door to beauty of some kind. So there seems to be something in there besides the way you, the ego, see it," he concludes, completing a rough and impressionist picture of one of the world's most valuable iconoclasts that is far more valuable than that which might have been captured on my camera.


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