A new study reveals reveals the limitations of current diagnostic methods and research approaches for depression.
Researchers Oskar Otto Frohn and Kristian Moltke Martiny from The Enactlab in Copenhagen argue that current methods often overlook the nuanced experiential aspects of depression, which are crucial for understanding and treating this complex experience. They propose that a phenomenological approach, which focuses on the individualss subjective experiences, offers a more comprehensive understanding of depression, thereby enhancing both diagnostic accuracy and therapeutic efficacy.
Fundamental to phenomenological psychopathology is the critique of the dominating biomedical model of psychopathology and its conformity to the method of operationalism, Frohn and Martiny write.
The longing for objectivity and reliability seen within operationalism has led to the notion that psychopathological symptoms are explainable in biological terms, and that the field of psychopathology is therefore reducible to the field of biomedicine Criticism of the reductionistic and objectivistic tendencies seen in operationalism indicates that a reformation in the field of psychopathology should include more nuanced understanding of psychopathological symptoms by including the subjective experience of mental disorders.
Frohn and Martiny believe that by using qualitative and phenomenological methods to understand a phenomenon like depression, a richer and fuller understanding of depression can be found. However, Frohn and Martiny are not attempting to eliminate or negate operationalist, quantitative findings. Instead, their overall aim is to bridge the gap between the subjective and objective approaches to psychopathology and understand mental disorders through lived experience avoiding the risk of reductionism and oversimplification.
By applying these methods in their study, they were able to expand on the current mainstream paradigm that many in the psychological and psychiatric fields have been working from, raising questions about research, theory, and practice.
Recently published qualitative and phenomenological research from Oskar Otto Frohn and Kristian Moltke Martiny exposes areas of lack in the current mainstream diagnostic and treatment models around the phenomenon of depression. Critics, including Frohn and Martiny, believe the current paradigm is too reductive, using qualitative science approaches, or operationalism, as Frohn and Martiny call it, to try and understand mental suffering. These approaches include experimental models, surveying and quantitative methods, and neuroscientific technology to understand the mental phenomenon, including what is often referred to as mental illness.
Frohn and Martiny believe this reliance on operationalistic approaches creates a belief that all mental illnesses can be understood and treated within the biological dimension alone. Their critique comes from the school of phenomenological psychology and philosophy, which tries to understand human beings through a more holistic lens, including understanding subjective experiences that are usually unable to be demarcated and measured by quantitative approaches.
The Phenomenological Model of Depression
The team first gathered existing research on phenomenological models of depression collected by researchers using similar methods. They organized this data into four dimensions: existential, biological, social, and psychological. As for the biological dimension, it was not simply the measurements of bodily functioning, as may be found in an fMRI examination of the brain, but focused more on the bodily experiences and sensations (or lack thereof) in depression. [A] persons embodied, somatic, and corporeal relation to the world.
The existential dimension of depression, they found, included the feeling that the world loses its sense and feeling, and the existing experiences can be described as deprived of meaning, estranged, detached, and alienating, which leads to a paradox that participants in past studies described as a feeling of not feeling.
The biological-embodied dimension of depression includes a lack of motivation, initiation, and overwhelming sensorimotor inhibition.
Usually, we live through our body, focused on the world, where objects and situations are experienced both as ready-to-hand, affording a range of action possibilities and having emotional value and relevance The term affective affordances means that we experience the world through an emotional pull, which is part of our motivation for action. However, in depression, there is a lack or loss of affective affordances. The body is experienced in a hyper-objectified or quasi-mechanical way, where the body is felt as if it has lost its affectivity, fluidity, mobility, and flexibility.
The social dimension of depression includes a loss of connectivity to the world and diminished social interactions (often arising from meaninglessness and difficulty participating in social activities). The social dimension often interacts with the psychological dimension, creating feelings of guilt for missing social interactions, and the despair over themselves and their social inabilities becomes a negative spiral that keeps people in their depression. The result is that the person feels like an isolated object in a world without relationships.
The psychological dimension includes two specified personality types. The first, Typus melancholicus, is defined as through rigidity, conscientiousness, orderliness, over-adaptation, over-identification with social norms and roles, as well as being overly dependent and even symbiotic in relations. The other is the narcissistic personality type, defined by a persons constant need for affirmation by her environment and others. This is done to maintain an idealized prevailing self-image that captivates the individual, potentially leading to impotence and paralyzation.
The Methodological Concerns and the Phenomenological Interviewing Process
The longing for objectivity seen with operationalism is partly fueled by the worry of how we deal with subjectivity within research. Such worry has been discussed extensively in conversations about for example cognitive bias It is challenging to include peoples reports and descriptions of their own experiences, because how do we know if their description reflects their lived experiences?
Some issues that Frohn and Martiny point to are linguistic and cultural assumptions around disability. For example, people with cerebral palsy will have a narrative built around the medical explanation of the condition, grounding the language in bio-medical assumptions. This takes hold in mental health questions when mental health concerns are also grounded in medical language. This means that the participants in a qualitative study may be using language and ideas already presented to them as fact without the reflective understanding of where those ideas came from and if they encompass the experience the person is having.
This means that simply relying on the words, narratives, and descriptions coming from people with depression is methodologically problematic. The descriptions they will provide of their experiences might be over-generalized and pessimistic, telling the same negative stories they see as permanent, pervasive, and universal. As a result, the descriptions might conceal experiential nuances fundamental to understanding depression.
The duo took this into account when building their phenomenological interview process. The structure of this process was taken from existing work by other researchers, such as Shaun Gallagher and Dan Zahavi, and focuses on second-person questions and specific phenomenological analysis strategies. For Frohn and Martiny, the aim of the phenomenological [interview] is not just to understand what a particular person with depression is experiencing here and how The aim of the phenomenological interview is rather to capture the invariant structures of the experiences. This means that the phenomenological framing of the interview ensures that the data generation and analysis of the lived experiences go beyond the idiosyncratic and, for example, the coping strategies, or the specific explanatory and descriptive style seen in depression.
To do this, they structured their interview around their four different themes: (1) the existential dimension, their emotions, and feelings; (2) the biological (embodied) dimension, their agency, and bodily activities; (3) the psychological dimension, their understanding and narratives about themselves and their identity, (4) the social dimension, their social life and being together with other people.
They asked how questions to gather this rich data. Their interviews were performed with 12 Danish participants (7 female-identifying and five male-identifying) ranging in age from 29 to 57 years old and had all been diagnosed with moderate to severe depression. They also ensured that the participants were not currently in a depressive episode and were stable enough to participate.
Regarding the existential dimension, participants described feelings of immobility, including petrification, having concrete in the veins, a black hole, and a zombie mode. This immobility was experienced as a lack of meaning and agency within their own lives. This meaninglessness was described as grim, dark, empty, sad, hopeless, thoughtless, and nothingness: the experience there in the deepest depression, there is nothing. Its empty. And there is darkness. They also identified the morning time as the worst time for these experiences. However, some idiosyncrasies were found, such as fluctuations in feelings of immobility, including feelings of instability and turbulence, some of which could be bad or good but always have a profound impact.
As for the biological-embodied findings, participants often described their actions, even minor tasks as insurmountable. This was exemplified by the severe difficulty in getting out of bed in the morning. This meaningless petrification was somaticized into the daily experience of the participants bodies. Yet, participants often described times of great agency when describing their processes of researching suicide, writing suicide notes, and taking great care to ensure their loved ones would not suffer or blame themselves. Interestingly, one participant stated that this agency around suicide created a glimmer of hope that [the depression] will pass, and it would not come back.
The psychological dimension was focused on self-experiences and narratives built around those experiences. Even as they felt immobile and petrified, they also described feelings of extremely high self-expectations, and what they see as an extremely idealized self-image. Feelings of obligation and expectations were often identified as motivators to move beyond the petrification. Interestingly, some participants would describe themselves as being better than others, at least in terms of what they expected out of themselves. Yet, these feelings were often mirrored by thoughts that they were the worst person in the world, and it would be better if [they were] not here. An extremity in terms of self-expectations was consistent in the participants, as well as the mirroring feeling of being unable to live up to the standards they felt they set for themselves.
Regarding sociality, most participants described how they isolated themselves, either voluntarily or due to the feeling of immobilization. Yet, they often told how, during these sessions of isolation, their thoughts were usually focused on others, showing that their concerns were not narcissistic in the colloquial sense but often outwardly focused. [One] participant was on the brink of suicide, and he took the time to tell his dearest how it was not their fault at all. Another example [shows a participant] fantasizing about her funeral and in planning her suicide [yet she] is very aware of the social aspects, making sure that no one is traumatized by her suicide, making sure the right people get suicide notes, and that her body can be used for organ-donations, so her death is not a social burden. People in depression then are often constantly thinking of others and spending time comparing themselves to others, once again falling short of expectations. However, one participant noted that her grandchildren were her three happy pills, and to do something with them can distract my attention and let me be in something that is filled with happiness and joy.
Challenges, Nuances, and Revising the Model
[W]hile the participants do retell and reproduce the same general, negative stories about depression, which corroborate the current phenomenological model of depression, they also provide new descriptions that differentiate from – and seem to conflict with – some of these general, negative stories. Often, such as the grandmother and her three happy pills, participants were describing other emotions, such as happiness, anger, and joy. This deviates from the mainstream depression model, as in DSM-5 the nuance of the emotional variation is underplayed, and the narrative primarily focuses on the negative aspects of the depressive mood.
Many people in the pre-reflective (descriptions of in the moment; I-descriptions) state of response to questions would offer up these idiosyncrasies, showing how these other emotions that are omitted from the mainstream model exist in depression. Yet, in the reflective mode of response (reflecting back; One-descriptions, as in one usually feels/thinks), they offered a more traditional telling of the experience, using the language and ideas often found in the mainstream, bio-medical model. These reflective responses always focused on the negative, normative experiences and language around depression.
This phenomenological research helps show how nuanced the actual experience can be. Instead of focusing on affect, the rich descriptions helped Frohn and Martiny see a pattern around an individuals field of affordances, or the accessibility of choices, actions, obligations, etc., open to a person at any given time.
[I]n contrast to schizophrenia, there does not seem to be a disturbance of the ability to access the global landscape in depression, but a disturbance of how to access.
These affordances all become obligatory, things to overcome, and lack meaningfulness and joy, which leads a person to feel as though they dont know how to access the world of possibilities that is afforded to them at any given time.
As such, their daily actions are related to self-experiences of inability, shortcomings, blame, and shame when they are not able to do the actions. This means that almost every action becomes a stage where the individual must perform and show their self-worth, which is, undoubtedly, exhausting and takes a huge toll on them, the authors write.
Hyper-social experiences are, in many cases, described by the participants as what fuels their feelings of immense guilt and shame. They ruminate extensively about social interactions they have experienced or future social interactions since they desire to be perceived in a certain social light. Their experiences of sociality not only show how social life puts certain expectations unto people with depression, but also show the compassion they have toward others.
Clinical and Other Implications of this Research
Through identifying these nuances within the experience of depression, Frohn and Martiny point out that there is a double-pronged possibility that has arisen from mainstream models of identifying depression (surveys such as the PHQ-9, for example). By putting too much emphasis on certain negative characteristics of depression, as listed in the manuals and scales, it could imply that we are currently over-diagnosing. Equally, since certain experiential nuances are missing from the manuals and scales, it seems to call attention to the possibility of under-diagnosis. And yet, both may be true. Some people may have been diagnosed as depressed yet not truly be experiencing what Frohn and Martiny found, and some people, because of these nuances, may be experiencing depression that was not identified through traditional means.
Adding more nuance to questions and including open-ended questions may create a better tool for identifying depression in people that moves beyond this existing paradigm. Additionally, some talk therapies may lack depth and richness in terms of assisting people attempting to break away from the suffering they are feeling. For example, CBT works at the reflective level (one should/should not) and would possibly both reify a persons existing beliefs about themselves while also reifying the current paradigm around the negativity and non-nuance of depression. Suicidality was found as a possible avenue of therapy rather than a topic to be avoided.
Contrary to what a number of phenomenologically informed scholars previously have claimed, in our findings, the participants described at the pre-reflective level the idea, planning, and researching of suicide as a way for them to mobilize agency, energy, and social connection. For example, the same participant (quote 2F) that was unable to get a glass of water is able to spend a large amount of time writing suicidal notes be active on online forums and the internet in order to research and plan her suicide. One way to interpret this is that the actions revolving around their suicide are not experienced as a task and performance they ought to or should be able to do and are not experienced with the same psycho- and sensorimotor inhibition as other daily actions. It is rather experienced as a way to break free from normative, societal, and self-expectations. As such, the act of writing suicide letters or planning their funeral becomes a way for them to socially reconnect with others, where they do not risk the possibility of being rejected and disproven. Here, they are able to re-synchronize, resonate, and feel the possibility of being reciprocated in their current situation, although it is with imagined others.
The researchers point to therapies that focus on the pre-reflective, such as Body-Oriented Therapy, which will help people identify their idiosyncrasies and possible avenues of success, rather than the more strict and rationalist-focused CBT. Frohn and Martiny describe these alternatives as bottom-up therapies, as opposed to CBT, which is top-down where the therapist is more of an expert on the patients suffering than the actual patient.
In depression, we have illustrated that, to protect the I in relation to itself, different manifestations of an existential defense mechanism will take effect. For example, people with depression clean up their self-narrative and describe their experiences in a general, simplified, and negative way that overshadows their diverse and varied emotional life. A sense of agency is still present in depression, but experiences of corporealization will kick in, making it impossible for them to act and disprove their own identity, value, and image. They will also isolate themselves socially, not because they do not value social interactions, but contrary, because they hyper-value social relations and sociality to the extent that it undermines their self-image and self-worth.
The description of depression above, pulled from Frohn and Martiny, offers an alternative view of depression, which adds depth, richness, and more possibilities for moving past the depression than the existing static model. It highlights nuance, difference, and in those nuances and differences, possible options for people to find the how in order for them to access the field of affordances that may be overwhelming and feel inaccessible.
This research shines new light on the phenomenon of depression, yet many people who have suffered from or are suffering through depression may not be all that surprised by the findings. This begs the question, why is more research like this not being done?
Frohn, O. O., & Martiny, K. M. (2023). The phenomenological model of depression: from methodological challenges to clinical advancements. Frontiers in Psychology, 14. https://doi.org/10.3389/fpsyg.2023.1215388 (Link)
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