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Weiterbildung.uzh.chMed Health Care and Philos (2009) 12:169–178DOI 10.1007/s11019-009-9190-2 S C I E N T I F I C C O N T R I B U T I O N The ethics of self-change: becoming oneself by wayof antidepressants or psychotherapy? Ó Springer Science+Business Media B.V. 2009 This paper explores the differences between character of the person in question, and this is important bringing about self-change by way of antidepressants versus from an ethical point of view. In the article, the concepts of psychotherapy from an ethical point of view, taking its self-change, authenticity, temperament and character are starting point in the concept of authenticity. Given that the presented and used in order to understand and flesh out the new antidepressants (SSRIs) are able not only to cure psy- relevant ethical differences between the practice of psy- chiatric disorders but also to bring about changes in the chotherapy and the use of antidepressants. Looping, basic temperament structure of the person—changes in self- collective effects of psychopharmacological self-change in feeling—does it matter if one brings about such changes of a cultural context are also considered in this context.
the self by way of antidepressants or by way of psycho-therapy? Are antidepressants a less good alternative than psychotherapy because antidepressants are in some way less Enhancement ethics Á SSRIs Á Phenomenology Á authentic than psychotherapy? And, if so, what does this mean exactly? In this paper I try to show that the self-change brought about by way of antidepressants challengesbasic assumptions of authentic self-change that are deeply ingrained in our Western culture: that changes in self shouldbe brought about by laborious ‘self-work’ in which one In this article, I will explore the differences between explores the deep layers of the self (the unconscious) and bringing about self-change by way of antidepressants ver- comes to realise who one really is and should become. To sus psychotherapy from an ethical point of view. Given that become oneself has been held to presuppose such a journey.
the new antidepressants (SSRIs) bring about changes in the While the assumed importance of self-work appears to be basic temperament (self-feeling) structure of the person—a badly founded on closer inspection, the notions of exploring hypothesis that I will try to make credible—does it matter and knowing oneself appear to be more promising in if one brings about such changes of the self by way of fleshing out an ethical distinction between psychopharma- antidepressants or by way of psychotherapy? Are antide- cological and psychotherapeutic practice with the help of pressants a less good alternative than psychotherapy the concept of authenticity. Psychotherapy, to a much because treatment with antidepressants is in some way less greater extent than psychopharmacological interventions, authentic than psychotherapy? And, if so, what does this involves the whole profile of the self in its attempts to effect mean exactly? These are questions which I will strive to a change, not only in the temperament but also in the answer in what follows. The article is thus a contribution tothe bioethical debate on new medical technologies (thera-pies), which is the very topic of this whole thematic section of Medicine, Health Care and Philosophy. In the article, I Department of Philosophy, Centre for Studies in Practical will also address the cultural components of the success of Knowledge, So¨derto¨rn University College, 141 89 Huddinge, the new antidepressants. My point of departure is a phe- nomenological analysis of the effects of the SSRIs, which involves exactly the relevant life-world issues of the people in general) to look upon certain conditions as pathologies with a biological basis, rather than as the Presently we are facing an explosion of diagnoses of painful experiences of a normal life. Indeed, it appears depression and anxiety in the Western world. It is hard to highly probable that the development and aggressive find reliable data on prevalence, but according to studies marketing of these new drugs by pharmaceutical compa- carried out by the World Health Organization, depression nies have resulted in a more liberal interpretation of the will soon become the second most common cause of dis- diagnostic criteria for depression and anxiety disorders (in ability, trailing only ischemic heart disease (Kramer both psychiatric manuals and medical practice) (Healy p. 151ff.). Anxiety disorders—whether they occur together ). This liberalisation of criteria is not necessarily a bad with depression or on their own—are also on the rise and thing only, since, clearly, many people have been helped to are receiving increased attention. A clear sign of this is the a far better life by the new drugs. To visit the doctor ever more sophisticated taxonomies of anxiety-related seeking help for psychic complaints associated with psychiatric conditions found in the diagnostic manuals of depression or anxiety appears to have become more mental disorders published by medical associations (par- socially acceptable during the last 20 years or so. These ticularly the fourth edition of the Diagnostic and Statistical conditions have undergone, in other words, a process of Manual of Mental Disorders, or DSM-IV )). It can be ‘de-stigmatisation’. At the same time the disorders have estimated that more than 5% of the inhabitants of Western also changed in character as they have expanded their countries suffer from depression or an anxiety disorder at scope. The kernels of depression and anxiety disorders are the present time, and that at least 25% will fall ill at one essentially the same as before the advent of the new drugs, time or another in their lives.1 These numbers are but the territory of illness has clearly been expanded to remarkable, considering the fact that depression and anxi- include self-feeling-problems, which were earlier consid- ety disorders appear to have been rare conditions only ered painful, but still not medical in nature.4 30 years ago, and the rapidly increasing prevalence cer-tainly calls for investigation.2 Why have we become so depressed and anxious? What are we to do about it? antidepressants, which inhibit the reuptake of both serotonin and The most important factor underlying the increased noradrenalin in the synapse, includes venlafaxine (Efexor, Effexor)and mirtazapine (Remeron). Although originally marketed to treat prevalence of these psychiatric disorders is probably the depression, the ‘new antidepressants’ have also been shown to have emergence of a new group of antidepressants, the selective beneficial effects on anxiety. In this article, I will use the terms (new) serotonin-reuptake inhibitors (or SSRIs)—the best known antidepressants and SSRIs interchangeably. In most countries, pre- of which is fluoxetine or Prozac—which are frequently scriptions for SSRIs account for more than 75% of all prescriptionsfor antidepressants; moreover, the effects of self-change on which I used to treat patients diagnosed with depression or anxi- am focusing have been associated mainly with SSRIs. For an over- ety.3 The availability of these drugs has led doctors (and view of the development of antidepressant pharmaceuticals since thetime of the Second World War, see David Healy’s book The Anti-depressant Era ).
1 This is in fact a rather modest estimation. Some investigations show 4 In the DSM-IV, the distinguishing characteristic of depressive a considerably higher prevalence of these disorders, see Horwitz disorders is the presence of what is called ‘‘a major depressive episode’’ (DSM-IV p. 356). This condition is adjudged to be 2 See Healy (). That the disorders in question were rarely present if a depressed mood (sadness, emptiness) and a loss of interest diagnosed 30 years ago does not necessarily mean, of course, that or pleasure have been present most of the day, nearly every day, for at they were in fact rare in the population.
least two weeks, and if, in addition, at least three of the following 3 Antidepressants can be divided into several different subgroups.
seven criteria have also been fulfilled during this period: significant Two subgroups of antidepressant drugs prescribed more frequently weight change; insomnia or hypersomnia; psychomotor agitation or before the introduction of SSRIs about 20 years ago are the retardation; fatigue or loss of energy; feelings of worthlessness or monoamine oxidase inhibitors (or MAOIs), and the tricyclics (so excessive or inappropriate guilt; diminished ability to think or named for their three-ring molecular structure). These drugs are often concentrate; and recurrent thoughts of death. These symptoms must effective against depression but have more bothersome side effects also have resulted in ‘‘clinically significant distress or impairment in than the SSRIs. They are also toxic in high doses, and this fact, in social, occupational, or other important areas of functioning,’’ and combination with the risk of side effects, explains doctors’ reluctance they should not have been directly caused by medication or to prescribe them to patients who are not severely depressed. For the bereavement (the loss of a loved one).
treatment of anxiety disorders, doctors have historically had access to If we turn to how anxiety disorders are described in the DSM-IV, we other kinds of drugs than antidepressants, such as the benzodiaze- find a similar litany of deviant feelings—of problems involving pines; these drugs, however, have become increasingly unpopular, altered embodiment and estranged engagement with the world. Here, since they are quite addictive. At the end of the 1980s, the SSRIs were the common characteristic of the disorders that are treated with SSRIs introduced; they were made famous by the commercial success and is the panic attack—an excess of anxiety triggered by an alarming cultural impact of Prozac (generically, fluoxetine). In some parts of situation. A panic attack is specified as: ‘‘a discrete period of intense Europe another SSRI, citalopram (Celexa), has been more popular fear or discomfort,’’ in which symptoms like pounding heart, than fluoxetine. Other widely prescribed SSRIs are paroxetine sweating, trembling, shortness of breath, chest pain, nausea, fear of (Seroxat, Paxil) and sertraline (Zoloft). A class of similar losing control, going crazy, or dying are developed abruptly and reach The ethics of self-change: becoming oneself by way of antidepressants or psychotherapy? The question of what kind of creatures depression and and which are now instead increasingly being treated by anxiety disorders really are is a very complicated one. That way of antidepressants. In this article, I will try to show they are real things, and not somehow invented or created that the success of the new antidepressants challenges basic by diagnostic manuals, pharmaceutical companies, or assumptions about authentic self-change that are deeply doctors seems to be beyond dispute. But, nevertheless, the ingrained in our Western culture: changes in self should be differentiation and boundaries of the disorders in question brought about by laborious ‘self-work’ in which one appear to be very flexible and elastic and this is probably explores the deep layers of the self (the unconscious) and related to cultural components and the holistic character of comes to realise who one really is and should become. To the phenomena in question. Persons, and not only their become oneself has been held to presuppose such a jour- brains, become depressed and anxious, and our ways of ney, but this is now increasingly contested. What judging if they are ill or not are interpretative in nature— components of the old ethics of authenticity are worth tied to understanding of symptoms, which are culturally holding on to and which ones should better be abandoned loaded in various ways.5 I will return to this cultural when we embrace the new possibilities of pharmacological ‘embededdness’ of depression and anxiety disorders self-change? This is the basic question which this article The expansion of the diagnoses of depression and anx- iety disorders with the help of the new drugs hasconsequently changed the treatment pattern for certain kinds of human problems. Psychotherapy, which has beenthe standard solution for a long time for the kind of self- A lingering suspicion, ever since the first reports of the feeling-problems of the recently expanded categories of success of Prozac, has been that the new antidepressants, in depression and anxiety disorders, now increasingly has to addition to relieving the symptoms of psychiatric disorders, compete with antidepressants. That psychotherapy, espe- also have other effects that help explain their popularity.
cially in the form of a long time project, is a much more Do not the new antidepressants also affect our self-per- expensive alternative that antidepressants is certainly a ception (our sense of who we are), in the way Peter Kramer decisive factor in the former losing ground. However, the illustrates by way of clinical examples in his well-known development in question also seems to be related to book, Listening to Prozac (According to Kramer, changes in norms regarding preferred ways of under- some of his patients went through the experience of standing and dealing with the type of ‘neurotic’ problems ‘becoming themselves’ while on Prozac, whereas others that have been addressed for centuries by psychotherapy had the experience of ‘losing themselves,’ despite feelingbetter on the drug. Similar characterisations of the effectsof SSRIs can be found in other studies (Knudsen et al.
), but it is difficult to know how we should interpret a peak within 10 minutes (DSM-IV p. 432). The panic attacksare typically recurrent, and they are often associated with being in a them, since we lack a comprehensive understanding of special type of situation (meeting or speaking to strangers in social what the term ‘self’ means in this context. What might phobia, for instance). The sufferer not only experiences anxiety while ‘enhancing the self’ or ‘becoming oneself’ or ‘losing having the attacks, he is also in many cases constantly anxious about oneself’ possibly mean in the case of antidepressants? Has the significant change taken place in the dimension of Presumably, not all physicians strictly abide by these criteria when feelings (self-feeling) or in the dimension of thoughts (self- making their diagnoses; nonetheless, they give a clear indication ofthe types of matters physicians are expected to investigate in their understanding)? The self (or personality) is apparently a encounters with patients: painful, estranging feelings which make it concept that refers to a basic disposition to feel, act, and hard to find oneself at home with oneself and in the world. Diagnosis, think in certain ways (Goldie ). How could antide- in these cases, represents a pronouncement concerning the phenom- pressants come to have an effect on this basic disposition in enological life-world; yet, the criteria were not derived in anytheoretically reflective manner. Indeed, the very rationale for the relieving the symptoms of depression and anxiety? compilation of the DSM was to delineate psychiatric diagnoses In a recently published article—‘Do antidepressants without any reference to (psychoanalytic or biological) theory; it affect the self?’ (Svenaeus )—I tried to show, with the should thus come as no surprise that the manual does not feature an aid of phenomenologists such as Martin Heidegger ) exposition of basic concepts or theoretical discussions of the nature ofmental illness.
and Thomas Fuchs (that the effects of the new 5 A very sharp illustration of this is the case of ‘‘social anxiety antidepressants must be thought of in terms of changes in disorder,’’ a recent disorder of DSM, which is essentially a new name self-feeling, or, more precisely, self-vibration of embodi- for the older notion of social phobia better handled to expand the ment. This phenomenological concept comes close to the disorder in question into the territories of painful shyness. See ancient notion of temperament—a basic disposition of the Christopher Lane: Shyness: How Normal Behaviour Became aSickness self to develop characteristic moods—the most famous of the four classic temperaments being the melancholic per- sonality type (Radden ). In the article I present theidea of a spectrum of bodily resonances, which extends Kramer’s words from his patients on Prozac—‘‘I am losing from the normal resonance of the lived body, in which the myself’’ or ‘‘I am becoming myself’’—remind us of body is able to pick up a wide range of different moods; to another practice and technique of the psychiatrist than various kinds of sensitivities, preferences and idiosyncra- psychopharmacology—namely psychotherapy. In cases in sies, in which certain moods are favoured over others; to which the new antidepressants have good effects, the cases that we unreservedly label pathologies because the results seem to be similar in many ways to the good effects body is severely out of tune, or even devoid of tune, and of the old ‘talking cures’ of psychotherapy. Prozac appears thus useless as a tool of resonance. Different cultures and to make people less ‘neurotic,’ to use a Freudian language societies favour slightly differently attuned self-styles as which has become slightly out of fashion. If I am right in paradigmatic of the normal and of the good life, and the claiming that the new antidepressants are not only targeting popularity of the SSRIs can therefore be explained not only distinct disorders but also effect changes in self-feeling, by defects of embodiment (biology) but also by the pres- this is not strange, but rather logical. The general increase ence of certain cultural norms in our contemporary society of serotonin (and other neurotransmitters) in the synapses of the brain makes people feel less miserable and enhance It is common in the contemporary philosophy of feelings their sense of self-worth.7 This is not the same thing as to distinguish between emotions and moods. Emotions making them feel happy or euphoric—Prozac is not a have an object and are based upon beliefs (love, hate).
‘happy pill’—but it means that the spectrum of moods in Moods rather color the way in which things appear to the which the person lives becomes altered in a characteristic subject in general (joy, sadness). Moods open up a world to way by the antidepressant. The mood spectrum becomes human beings in which things matter to them in different richer as the person is no longer stuck in sad moods and ways. Although moods certainly do not contain thoughts in thus more easily able to enjoy other attunements than the the same explicit way that emotions do, they nevertheless dark ones. The world opens up in more multifaceted ways determine what kinds of thoughts the thinker will be able to and allows the self to become at home with itself and in the entertain. Moods are not something I append to my world. However, the mood spectrum also becomes poorer thoughts, to make them happy or sad, depending on how I in that the steep ups and downs of intense moods such as am attuned; on the contrary, the moods I happen to be sadness and joy are cut off. The sine curve of life is immersed in underlie and inform the very process of characteristically flattened out by antidepressants, some- thought formation. Feelings of joy or sadness will give rise thing that can be both praised and lamented by patients to very different kinds of thoughts, with a very different content. This, of course, is the reason why thoughts of Antidepressants have become an alternative to psycho- death, guilt and hopelessness typically occur in the mental therapy for many persons. In some cases this is so mainly for financial reasons; a half-year prescription for SSRIs Feelings, especially in the form of moods, are basic to costs less than 1 h of psychotherapy in most Western our being-in-the-world, in Heidegger’s phenomenology, countries today. This means that the majority of the people since they open up the world as meaningful, as having who are taking antidepressants could never have afforded significance. They are the basic strata of what Heidegger treatment by a psychotherapist, regardless of whether or refers to as facticity, our being thrown into the world prior not they have wanted it. Depending on the health care to having made any thoughts or choices about it. We find insurance systems of different countries, it is sometimes ourselves there, in the world, always already busy with possible to get psychotherapy paid for by one’s employer, different things that matter to us, together with other peo- or by the state, but the rules and regulations for this seem to ple. And this ‘mattering to’ rests on an attunement, a mood- become stricter and narrower every day. At least if we are quality which the being-in-the-world always already has.
talking about psychodynamic therapy or psychoanalysis, We do indeed not choose our moods; they come to us and which demand rather lengthy treatment periods. Cognitive- cannot easily be changed. Or, at least, this was the case based talking cures of five to ten hours over a couple of before the advent of the new antidepressants.6 months’ time are more affordable, although in many casesstill difficult for patients to get access to. Cognitive(behavioural) therapy has generally strengthened its 6 I do not want to deny, of course, that people have used drugs forthousands of years to deal with painful moods (alcohol). But the 7 That the new antidepressants have effects, not only on distinct changing-temperament effect of the SSRI’s appear to be of another disorders, but also on personality and social behaviour, has been type altogether than the drunkenness effect of alcohol and narcotics.
shown in controlled studies, e.g.: Knutson et al. The ethics of self-change: becoming oneself by way of antidepressants or psychotherapy? position in relation to psychodynamic therapy over the last think this way, but contemporary psychopharmacology 15 years, and this seems to be linked to cognitive therapy’s shows us that psychiatrists and other doctors in the future having effects similar to those of the drugs. Cognitive will be able to treat a lot of conditions which are painful therapists have also taken on the challenge to evaluate their and unwanted but do not merit the label of disease. I will treatment in the same way drugs are tested—randomised not go into detail in this article, since this would take us control trials—and the researchers have been fairly suc- into a full theory of health and disease, but my point is that cessful in proving the therapy to have an effectiveness the new antidepressants have taught us that drugs can do equal to that of the drugs in cases of mild depressions and other things for us than treating illness, even if contem- porary medicine and psychiatry do not admit that they do My aim in this article is to compare treatment with anti- depressants with psychotherapeutic treatment, and to The message that antidepressants treat disorders while explore the ethical matters which this comparison might psychotherapy treats the self, and that they thus cannot be raise.8 In the introduction to the topic I have just made, I compared since they do totally different things, is conse- have tried to make a case for a view that many people and quently false. This seems to put much of the use of the new parties might contest: namely that antidepressants and psy- antidepressants under the umbrella of medical enhance- chotherapy have similar effects—do the same thing. It will ment, rather than treatment of disease (disorder). Medical become clear in the rest of this article that I certainly do enhancement by way of new technologies (therapies) has admit to there being important differences between treat- attracted a lot of interest in bioethics recently, and the lit- ment with antidepressants and psychotherapy, and that the erature is already vast.11 Most of the literature, however, comparison might come out differently depending on which deals with genetic enhancement rather than with psycho- of the many brands of psychotherapy we throw into the pharmacology (for an exception, see Elliott and Chambers contest. However, summing up my preview of the prob- ). As we saw above, the enhancement in the case of lematic so far, I will now state explicitly two related but antidepressants takes on a peculiar form which might be separate claims, which I have tried to make credible, and relevant also to the analysis of other forms of medical which will now serve as points of departure in my compar- enhancements: the change in question is rather to be ison of treatment with antidepressants and psychotherapy.
thought about as a becoming or finding oneself, than as an First claim: The sharp distinction between curing a psychiatric disorder and changing the self does not hold up; When one asks patients who have taken or are taking psychotherapy has had effects in both domains as long as it antidepressants about their preferences when it comes to has existed, and the new antidepressants cross over this line pharmacological treatment and psychotherapeutic treat- as well. Second claim: The expansion of the domains of ment, they often answer that the latter is to be preferred if it psychiatric illness in cases of depression and anxiety dis- works.12 The problem might be that it does not work (did orders has been supported by the advent of the new not work for this particular patient) or that it has not been antidepressants. An important point in naming something a possible to get psychotherapeutic treatment. Many patients psychiatric disorder is, among other things (such as allowing sick leave or admission to other social benefits), For a good discussion of the current uses of the concept of mental that it can be treated. Treatment by way of pharmaceuticals disorder, see Ross In my view, the position stated by JeromeWakefield (is a promising one. Wakefield distinguishes demands diagnosis; that is, if we have a pill that helps a two related criteria of mental disorders—they are ‘‘harmful dysfunc- condition, we will soon have a diagnosis too, since the tions’’—which means that the individual must have a biological or system demands this. Psychotherapeutic treatment has not psychological malfunction, which is responsible for the suffering and does not demand diagnosis, whereas treatment with (s)he is presently experiencing. The suffering must not only be due toexceptional, stressful circumstances, or, indeed, personality problems.
The problem of fleshing out the exact distinction between patholog- To add my two claims together: Pharmaceutical treat- ical malfunctioning and temperament-problems is not solved ment does not equal the curing of diseases (disorders), even automatically by way of Wakefield’s theory. However, the analysis if the DSM and doctors (and perhaps most lay people too) of the concept of dysfunction by way of natural evolution, which hesuggests, would have us look for temperament-profiles which are prefer to think in this way. Indeed, we have been taught to dysfunctional in most (or every) kind of human society when drawingthe border line between mental disorder and other self-feeling- 8 The article is inspired by a qualitative interview study in which 30 problems. Regarding this question see also footnote 4 above.
patients and doctors were asked about their experiences with and views on antidepressants (Svenaeus but this material will not 12 At least this seems to be the case in Sweden (Svenaeus be presented in this article, which takes on a more philosophical other countries might display other patterns either because psycho- therapy was never established as the main practice of self-change 9 For further evidence in favour of these two claims, see Healy (Asia, Africa), or because it has already been totally outdated as such a practice by the new antidepressants (the United States).
answer that an ideal would be a combination of the two this really true? Does not ‘becoming oneself’ on Prozac forms of treatment. Why do patients prefer the talking cure also involve a kind of self-knowledge? Let us come back to even if it is more time consuming and painful than phar- the patient Tess, who Peter Kramer describes in his book, macological treatment (which has its problematic side effects too, of course, see Healy )? I think the answer Tess is about 35 years old and she has suffered a chaotic can be found in the fact that psychotherapy conforms to a and painful childhood. She grew up in a poor neighbour- generally prescribed pattern of self-change in our culture hood, the eldest of nine siblings, her father an alcoholic who and society, whereas antidepressants do not. The self abuses her and her mother. When her father dies the mother should be changed by ‘work’ carried out by the person enters a depression, something that makes Tess responsible herself in which she uncovers her true, unconscious self in practice for her younger sisters and brothers. In some beneath the surface and in which she changes according to strange way Tess faces the demands, she takes care of the the insights brought about by this cumbersome process.
house, her siblings and her mother, and she also manages to Pharmacological self-change is ‘fake’, it does not really finish school with good grades. At the age of 17 she marries make one oneself, so to speak, rather it is a cosmetic an older man and moves into his house with all her siblings, change of the surface which is not true to the deep layers of acting as their mother. In spite of her husband’s being an alcoholic, she manages to make a business career as a per- Authentic self-change by way of scrutinizing and getting sonnel administrator out of her skills in motivating, inspiring to know oneself has deeper historical roots than Freudian and nurturing others. She also takes care of her depressed psychotherapy. The examined life as the only life worth mother and engages in different social projects in her own living is Socrates’ famous credo, and the Augustinian idea neighbourhood. When her brothers and sisters have left the of finding God in your own heart, or the romantic image of house the marriage ends, and Tess moves on into new the genius expressing his true nature in poetry and art, are relationships with other men, repeating the characteristic later versions of this general Western ethics of authenticity pattern with abusive alcoholics. After a hasty break-up from (Taylor But during the twentieth century the talking one of these short, miserable relationships Tess falls into a cure of psychotherapy became the dominant practice of this depression, which finally brings her to Kramer’s office: self-search. True, far from everyone actually entered psy- She was a pleasure to be with, even depressed. I ran chotherapy (this has always to a large extent been the down the list of signs and symptoms, and she had them privilege of the educated middle class), but psychotherapy all: tears and sadness, absence and hope, inability to and its basic meta-psychological assumptions nevertheless experience pleasure, feelings of worthlessness, loss of became deeply ingrained in the Western ethics of self- sleep and appetite, guilty ruminations, poor memory change.14 Even though psychotherapy is now increasingly and concentration. Were it not for her many obliga- driven out of business by other forms of treatment and tions, she would have preferred to end her life. And yet practices (not only antidepressants, but also different I felt comfortable in her presence. Though she looked Eastern meditative practices of mindfulness), the peculiar infinitely weary, something about Tess reassured me.
pattern of authentic self-change which it has established is She maintained a hard-to-place hint of vitality—a still a part of our culture. In the following I will investigate glimmer of energy in the eyes, a sense of humor that which parts of this ethics we should hang on to and which was measured and not self-deprecating, a gracious mix parts of it could better be abandoned.
of expectation of care and concern for the comfort ofthe listener. It is said that depressed mothers’ children,since they have to spend their formative years gauging mood states, develop a special sensitivity to small cuesfor emotion. In adult life, some maintain a compulsive The key difference between psychotherapy and psycho- need to please and are thought to have a knack for pharmacological treatment, as we have seen, seems to be behaving just as friends (or therapists) prefer, at that the former, in contrast to the latter, involves self- whatever cost to themselves. Perhaps it was this knowledge and self-work as central parts of the self-change hypertrophied awareness of others that I saw in Tess.
process. This is what makes psychotherapy authentic and But I did not think so, not entirely. I thought what I was drugs inauthentic, the former better than the latter. But is seeing was a remarkable and engaging survivor, suf-fering from a particular scourge, depression. […] Had I 13 Regarding the patterns and history of images of contemporary been working with Tess in psychotherapy, we might authentic life, see Guignon (See also Kramer have begun to explore hypotheses regarding the source 14 For a good account of the development of psychiatry and of her social failure: masochism grounded in low self- psychotherapy in the 20th century, see Shorter ( The ethics of self-change: becoming oneself by way of antidepressants or psychotherapy? worth, the compulsion of those abused early in life to ‘‘better than well,’’ in contrast to the old ‘‘better but not seek out further abuse. Instead, I was relegated to the well’’ of Tofranil. She is much more outgoing and self- surface, to what psychiatrists call the phenomena. I confident, and she is no longer plagued by sadness and guilt stored away for further consideration the contrast when thinking about the past. She is not afraid of conflicts between Tess’ charm and her social unhappiness. For and separations, and her social life changes as she says the moment, my function was to treat my patient’s goodbye to some of her old friends and welcomes new ones.
depression with medication. (Kramer pp. 3–4) She is no longer absorbed by the caretaking of her mother,but she does not totally abandon the mother, and she now has Kramer tries first with Tofranil (a so-called tricyclic, the confidence to confront her about the family history. As a older form of antidepressant) and gets a rather good matter of fact, the effect Prozac has on Tess resembles what response. Tess feels better, she sleeps and eats better, and one could hope for in a successful psychotherapy. There is she feels less stressed out and apathic. She is ‘‘herself just one main difference—the pill, rather than the talking, again,’’ as she puts it. But Kramer is not entirely satisfied; remembering and understanding, does the job.
he still perceives signs of an underlying depression, which Let us return to the question that brought us to the story of is disquieting in the face of Tess’s family history (the Tess. Given the fact that pharmaceutical treatment does not chronically depressed mother). The patient is still vulner- involve the same kind of ‘work’ on the self that psycho- able and worries a lot about conflicts at work, and she is therapeutic treatment does, is it also devoid of increased sad about her shipwrecked relationship with Jim—her lat- self-knowledge? I do not think it is entirely correct to say est abuser. Tess’s psychotherapy with the referring that the drug does not affect Tess’s self-knowledge. It does, psychologist does not seem to have any significant effect, but not in a form that precedes the self-change in question; but it is hard to tell why, since Kramer is remarkably silent rather, the change itself makes Tess look back on her old on this point in the book. Why, indeed, does he not try self, comparing it to the new one. In this position, with the psychotherapy, with himself as the consulting therapist? help of the drug, Tess develops a more thorough under- We do not get any answers here from Kramer. In any case, standing of what she lacked before, and what she did wrong.
But she does not do so by facing moods of despair, grief and Then Prozac was released by the FDA. I prescribed it anxiety, going back to the unconscious marks that the past for Tess, for entirely conventional reasons—to termi- has left; Tess’s self-vibrations—to hint at my earlier phe- nate her depression more thoroughly, to return her to nomenological characteristic of the basic temperament of her ‘‘premorbid self’’. My goal was not to transform the self—changes directly by way of the chemical, not by Tess but to restore her. But medications do not always behave as we expect them to. Two weeks after starting It is true that the effect Prozac has on Tess is unusually on Prozac, Tess appeared at the office to say she was no quick and solid, and in this regard hardly typical. In my longer feeling weary. In retrospect, she said, she had own interviews with patients who have gone through SSRI been depleted of energy for as long as she could treatments I rarely find the remarkable from-darkness-to- remember, had almost not known what it was to feel light-in-a-few-days scenario of Tess (Svenaeus ). But rested and hopeful. She had been depressed, it now the basic structure of the change in question—the effects in seemed to her, her whole life. She was astonished at the feelings of self-worth, confidence and stability linked to a sensation of being free of depression. She looked dif- changed mood structure—is found in my study also, and in ferent, at once more relaxed and energetic—more other ones (Knudsen et al. ). In this regard Tess is available—than I had seen her, as if the person hinted at typical, although one should not forget that far from in her eyes had taken over. She laughed more fre- everyone living in a depressed or over-anxious mood is quently, and the quality of her laughter was different, helped by antidepressants in this swift way.
no longer measured but lively, even teasing. With this Why would such a change of temperament—if the new demeanor came a new social life, one that did not person welcomes it—be less authentic—less real, less unfold slowly, as a result of a struggle to integrate true—than a similar change brought about by psychother- disparate parts of the self [read, by way of psycho- apy? That the change in question is chemical in nature, therapy], but seemed, rather, to appear instantly and rather than psychological, is not a good answer. The full-blown. ‘‘Three dates a weekend,’’ Tess told me. ‘‘I chemistry of the brain of a patient who goes through psy- must be wearing a sign on my forehead!’’ (Kramer chotherapy also changes, and the raised serotonin levels of Tess’s brain, as well as of the psychotherapy-cured brain,are brain states, which represent feelings and thoughts for Is Tess becoming manic? No, hardly; with Prozac she has the persons who are in them. If we want to hold to a basic rather gone through a personality change that makes her feel difference between biology and psychology, this difference sense. The inner travel is something that develops one as a must be thought of in terms of different causal pathways to person, makes one wiser, a bit like what the Bildungsreise similar end conditions. But why, then, is it better to bring to Italy was supposed to do for a young nobleman in the about the same thing by way of self-work instead of taking a pill? There are a few possible answers here, some bad This brings us to a fourth answer to why psychotherapy could be better than antidepressants in the process of self-change. In a course of psychotherapy (at least in a goodone) one is offered the opportunity not only to change Ethically relevant differences between psychotherapy oneself, but also to answer the question of who one wants to be. Existential matters enter the psychotherapeutic ses-sion, whereas they do not play a significant role in Let us start with the bad ones. A standard answer from a treatment with antidepressants.16 Now, again, I think this psychotherapist—I think—would be that psychotherapy need not be entirely true. The example of Tess shows us has effects on the deep layers of the self, whereas the self- that the change effected by the antidepressant can be linked change of Tess is really cosmetic: it is taking place on the to self-reflection and life choices in a fundamental way.
surface and is not reaching through to the deep, true layers And nor is it certain that all psychotherapies offer the of Tess’s personality. I think this is obviously wrong; the opportunity for these kinds of reflections. A cognitive- temperament is a deep-seated disposition of the self, which based therapy cure often resembles more a mind-set change is not a mere surface, and in many senses is fundamental to programme than a reflective process, especially if it is set who we are. Moreover, the temperament, in contrast to the up over the Internet or is brought about by way of a self- mere views and opinions of a person, is very hard to help book. An important difference between psychophar- change; it is deeply ingrained, fundamental to our self macological treatment and psychotherapeutic treatment, formation.15 It is true that the temperament is certainly not nevertheless, is that the latter is (or should be) fundamen- all there is to our personality: habits, skills, memories, tally dialogic in its form. Meetings with a psychotherapist preferences, character and many other things are also basic offer better opportunities for life-issue reflections than the to the phenomenon of self (Goldie ). But the tem- brief encounters with the consulting psychiatrists and perament represents basic strata of personality formation, general practitioners who are prescribing SSRIs.
which many of the other traits depend on, and it is therefore Why is it important that psychotherapy offers, not only a way to change yourself in the sense of relieving painful Another possible way to defend the ethical significance symptoms related to your mood-profile, but also a reflec- of the difference might be that it is always better to bring tive process involving the question of who you want to be? about a self-change by oneself, in contrast to having it done Because the changes in temperament need the whole per- by something other. It is not clear what this means, exactly.
sonality-formation process (involving existential, ethical Taking a pill is also of course something I do, at least if I reflection) in order to be stable and complete. The self is do it of my free will. Perhaps the relevant difference is that more than its temperament, and a substantial, lasting self- psychotherapy is more demanding, more laborious, but change should take into consideration the character strata why, then, are laborious things always better? If I save of the self too, which may very well involve the personal energy by not entering psychotherapy, maybe I can use that history of how we became who we are. If the temperament energy on something that is better, not only for myself, but is a basic disposition to be ‘mooded,’ attuned in different ways in your being-in-the-world, the character is a basic The most promising way, I think, to make the difference disposition to think and give reasons for acting in certain between psychological self-work and pills ethically rele- ways that you think are the key to what a person should do vant is to point out that there is more to the process of self- in various circumstances (Goldie ). The character change than the goal. Perhaps the path is the goal in some involves explicit ethical stands and choices, whereas thetemperament is only an attuned predisposition to enter (ornot enter) into moral reflection in different ways. This is 15 At this point the psychotherapist might protest that the changes she the important difference between temperament and char- is effecting, by way of listening and talking to the client, are changes acter: the temperament will admittedly play an important in the unconscious meaning formations of the clients life. This is whythey are deep changes rather than shallow ones. Such claims are hard role in the formation of a personality, but what the to defend, however, since there appears to be no convincing empiricalevidence for the meta-psychology and changes in question. The trickything is that unconscious changes, by definition, can never be directly(but only indirectly) verified, even by the person who is assumedly 16 Regarding the existential aspects of becoming oneself within the context of new medical technologies, see Christiansen The ethics of self-change: becoming oneself by way of antidepressants or psychotherapy? personality (person) essentially becomes is rather the sum Sometimes SSRIs help in effecting temperament changes of its character (and other personality) traits.17 that are lasting in the sense that they do not go away when the That psychotherapy to a much larger extent involves the patient is taken off medication. Often this way of becoming whole profile of the self in its attempts to effect a change is oneself is a regaining of oneself; that is, the person says that an important aspect when one compares it with drug the medication has brought back her old self, and not brought treatment. Nevertheless, it must be stressed that people about a ‘new’ self in the way that Tess bears witness to who visit psychotherapists want change, often changes that (Svenaeus ). But it can be hard to terminate medication are tied to depressive or anxious symptoms, which in turn when antidepressants have a good effect. Patients relapse are tied to temperament characteristics. These changes can into their old painful feelings. Antidepressants are pre- be hard to bring about through self-work, and increased scribed for much longer periods today, in comparison with self-knowledge does not guarantee the change in question.
the mid-nineties when Kramer wrote his book, and the rec- To face one’s sorrow, boredom and anxiety in discussing ommendation to doctors is to be rather generous faced with the memories that they bring up might lead to change, but it the risk of new depressive periods. As a consequence of this, is far from certain. On the other hand, the temperament more and more people are taking antidepressants on a per- changes of pharmacological treatment may remain alien manent basis. Is this a bad thing? Well, it could be, and unstable if they are not brought up for reflection and considering the possible side effects which afflict some coupled to a more inclusive self-change mission. Patients patients, things such as decreased appetite, dry mouth, who testify that they feel better on SSRIs but nevertheless sweating, nausea, dizziness, constipation, sleeping problems feel less of themselves are a sharp illustration of this.
and decreased sex drive, and it could especially be a bad Let me come back to the story of Tess, since it raises thing considering the risk of more severe side effects in the two further fundamental issues in comparing antidepres- long run (Healy ). Such long-term effects of SSRIs have sants with psychotherapy than the ones we have already not yet been discovered, but the history of pharmaceutics dealt with. After about nine months Kramer tries to take teaches us to be careful, and the drugs have only been on the Tess off medication. At first everything seems to go fine; Tess is not quite as sharp, energetic and free of care as she One last thing deserves to be mentioned in considering was on the medication, but neither is she driven by the guilt the long-term effects of antidepressants in comparison with and obligation of the time before. But then: psychotherapy. The characteristic change in temperamentstyle brought about by antidepressants appears to be par- After about eight months off medication, Tess told ticularly well suited to the New York environment in which me she was slipping. ‘‘I’m not myself,’’ she said.
Kramer and Tess lead their lives. Shyness, modesty, and New union negations at her work place were under self-forgetting caring for others appear to have no place in way, and she felt she could use the sense of stability, this cultural milieu; they are considered pathologies rather the invulnerability to attack that Prozac gave her.
than the virtues they might be considered to be in another Here was a dilemma for me. Ought I provide medi- kind of society. If I am right in claiming that antidepres- cation to someone who was not depressed? I could sants are bringing about a significant change in the self of give myself reason enough—construe it that Tess was persons, we have to take into account the consequences of sliding into relapse, which perhaps she was. In truth, I such changes on a collective level, given the frequent assumed I would be medicating Tess’s chronic con- prescriptions of these drugs in our society today. Temper- dition, call it what you will: heightened awareness of ament change by way of medication has a looping effect the needs of others, sensitivity to conflicts, residual that makes its outcome even more dramatic.18 When cer- damage to self-esteem—all odd indications for tain aspects of our personalities are relabelled pathologies, medication. I discussed the dilemma with her, but the pressure to change these kinds of temperament styles then I did not hesitate to write the prescription. Who increases. It will be even harder to feel at home with being was I to withhold from her the bounties of science? melancholic or shy if the message is that you should fix it Tess responded again as she had hoped she would, by way of pills the way your neighbour or colleague at with renewed confidence, self-assurance, and social work has already done. Nevertheless, let us not forget that melancholy and shyness are rarely praised and self-willedby the persons who are melancholic and shy. As Kramer 17 I am using the terms of self, person and personality interchange- puts it, who are we to withhold from them the bounties of ably here. Admittedly persons (selves) have personalities rather than being them, but the theme of self-change I am investigating in thisarticle is not connected to the question about which creatures areselves and which are not, but to the question of how persons change 18 Regarding such looping effects of new medical diagnoses and In this article I have explored the ethically relevant differ- American Psychiatric Association. 2000. DSM-IV-TR: Diagnostic and ences between bringing about self-change by way of Washington DC: American Psychiatric Publishing.
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