(Visual China/Photo)
How does a person become a "depressed person"? You may be experiencing a workplace or academic crisis, facing stress due to life changes, falling into a bad relationship, or experiencing long-term distress after trauma. You often feel tired, depressed, unable to lift your spirits during the day, and unable to sleep at night. This state lasts for several weeks and affects your normal life. Eventually you decide to turn to a doctor.
After walking into the hospital's clinical psychology department, you will be asked to do a scale with dozens of questions. In the test results, your mental state is quantified into a complex set of indicators: depression, anxiety, hostility, somatization symptoms... If your doctor determines that you need treatment, you may be given a prescription with the name of a complex medication written on it and advised to start counseling. By chance, you need to wait a while because there are too many patients who book counseling.
Even so, you may still be in the lucky few. The Lancet-World Psychiatric Association's Major Report on Depression, published in February 2022, estimates that 5% of adults worldwide suffer from depression each year. About half of people with depression in high-income countries go undiagnosed or untreated, while in low- and middle-income countries the proportion is as high as 80% to 90%.
But depression is never just about individuals. In his book "Sociological Analysis of the Emergence of Depression in China", sociologist Xiao Yixin argues that depression is related to the development of neoliberal globalization. After the reform and opening up, China's drastic changes in time and space have led to greater life pressure and instability for individuals and families. Under the shroud culture of competition, the life course of the individual is disciplined by the "symbolic other" shaped by social norms, and only the winner of the competition can live a "good life". Consumerism and technological advances have exacerbated the atomization of the individual, making it easier for people to get caught up in their emotions.
An individual's mental health is a mirror of the health of society. For example, David M. Lee, author of Telling Sadness: A Sociological Analysis of Depression. A. Karp said: "If we do not fulfill our personal responsibility to society to nourish society, we will pay the price of personal illness." "Reinventing social connections is one of the antidotes to depression.
Xiao Yixin is also one of the translators of "Telling Sorrow". Born in Taiwan, he received his Ph.D. in sociology from the University of Essex in 2012 and then did postdoctoral research at East China University of Science and Technology, where he has since taught social work. After coming to Shanghai, he found that the friends he met during his study abroad had more or less been depressed, but in the sociology community of Chinese mainland, there were few monographs on depression. In 2014-2015, he conducted fieldwork, interviewing depressed patients, family members, counselors, and psychiatrists to try to illustrate how individuals' experiences of depression relate to social structures and social constructs.
Southern People Weekly discusses the social factors that make depression more prevalent, how society structures the disease, and how we should respond to depression on a sociological level. Medication and psychotherapy are the mainstream treatment for depression today. But beyond medical initiatives, we also need to build support systems that support individuals, and we need to destigmatize mental disorders. "Sociology also needs to deal with macro-level issues, such as the friendliness of social policies, the construction of the medical system, and what should be done at the school and community levels to make there less discrimination against depression." Xiao Yixin said, "In short, it is necessary to cultivate people's psychological resilience and create a friendly environment, so that people's depression can be alleviated." ”
The following is a conversation between Southern People Weekly and Xiao Yixin:
Depression may be a breathing space for the patient
Southern People Weekly: What perspective can sociology, especially qualitative research, provide for understanding depression?
Xiao Yixin: Sociology believes that human beings are a social existence and attach importance to social context. We are born dependent on our parents, and many direct or indirect people, such as manufacturers of daily necessities, medical staff in hospitals, school staff, etc., as the basis to support our existence. For depression, sociology is more concerned with the problem of social structure and how society constructs the disease. At the therapeutic level, we also focus on establishing better social connections and thinking about how the relationship between individuals and the external environment can become more friendly, rather than just looking at the problem from the biochemical reaction, thinking that the brain serotonin and dopamine are not enough, resulting in insufficient mediators of brain nerve transmission, resulting in depression.
Southern People Weekly: There seems to be a lot of debate about whether depression is a physical and mental illness or a social construct. How do you define depression?
Xiao Yixin: Of course, medicine has its contribution to the treatment of depression. The mental state can be indexed by medical means. Neuroscience can explain why some people with major depression look weird, perhaps because their brain nerve state is already bad. But there are different perspectives to understand depression. For example, from a sociological point of view, from the perspective of social interaction, I will interpret depression as an emotional disorder caused by the person's incongruous interaction with the environment.
One factor that causes the disorder is the self-attack of the "superego." You are very demanding of yourself, which may also be the pressure that the culture puts on you. When the "superego" is too strong to self-actualize, the individual tends to attack himself. Another factor is frustration. If you are in a state of frustration for a long time, not getting positive feedback in the interaction with the external environment can lead to depression. In addition, a constant sense of uncertainty can also cause emotional disorders.
Depression may also be a psychological defense mechanism for avoidance. Freud studied a woman who was subjected to domestic violence, who did not have the courage to divorce and could only hide in illness all day. She thinks it's the best she's been so far. Freud's explanation was that the disease was her protest. To some extent, every person with mental illness is hiding in the disease, and they need a breathing space.
The development of depression involves both the inner self and the external environment. Looking at depression from the perspective of self-perception and brain nerves is the work of psychology and neuroscience; The sociology society places more emphasis on the external environment. Social work attempts to coordinate between the inside and outside of the client. Only when both internal and external parts are healthy can we better deal with the problem of depression.
We are all gazed at by a powerful "symbolic other"
Southern People Weekly: You associate the increase in depression in China with the background of rapid economic development. How can drastic social change trigger depression in individuals?
Xiao Yixin: When I wrote the book "Sociological Analysis of Depression in China", I mentioned that depression is related to neoliberal globalization.
In terms of changes in social structure, over the past four decades, capital has been concentrated in Chinese cities and accumulated on a rolling basis, resulting in cross-regional spatial flows. A large number of migrant workers have poured into the cities to make money, and many have also migrated from small places to big cities, or even abroad. This meant that many families were disintegrated, giving rise to issues such as divorce and left-behind children. Of course, these problems are not necessarily related to depression, but these factors make individual lives more unstable than in the planned economy era. When we are faced with a society full of uncertainty, the potential for emotional problems is greater.
In addition, on the consumption side, the commodity economy amplifies human desires. In the past, everyone was generally poor, but now the gap between rich and poor is widening, and others can buy better houses and cars, and these things are right in front of you. People's desires are amplified, the overall gap in the social environment is also amplified, and individuals are prone to emotional distress.
Lembke, a professor of psychiatry at Stanford University, also explains emotional problems in consumer societies. She mentioned that pleasure and pain are processed by the same part of the brain, and the brain works to keep them in balance. After the release of the happy dopamine, the brain adapts to the number of stimulated dopamine receptors and tilts to the painful side for balance, which is why happiness is often accompanied by a low level.
The richer and more pleasure a society has, the more pain and depression. There are too many products in the consumer society that can give people short-term pleasure, such as cigarettes, alcohol, short videos, and even drugs, and people have too many opportunities to enjoy the pleasure of dopamine without effort. This is actually an early overdraft, and the brain nerves will be balanced with pain, which causes people's emotions to rise and fall.
The recent situation is different from when I published this book in 2016, and the architecture of neoliberal globalization is undergoing a major adjustment, the United States is promoting supply chain restructuring from "offshoring" to "friendly shore outsourcing", and there is also a trend of polarization in international politics and economics.
Under the premise of the existence of the WTO trade framework, if geopolitical conflicts intensify and international competition pressure increases, it may lead to a sense of urgency for domestic industries to face an overall improvement. Many professions are gradually standardized, no longer growing wildly, and many assessments have come. Everyone is clockwork up in their respective industries and is always in a fighting state.
Although the lockdown is now lifted, the economic situation this year is supposed to be better than last year, but there are still many risks, and it will not be easy to return to the pre-pandemic situation. More than 10 million college students graduated last year, making it more difficult to find a job, which may exacerbate the prevalence of depression.
Simply put, both underproduction of dopamine and overdraft can produce depression. Overwork in production, coupled with increasingly strict industry management, only blame but little motivation for the work and school environment, will make people depressed due to insufficient dopamine secretion. But on the consumption side, people can quickly get dopamine pleasure without paying a price, which will also produce the pain that comes with it. Therefore, excessive high pressure and excessive looseness have dangers, and improving personal psychological resilience and creating a friendly working and studying environment are the directions we should strive for.
On December 27, 2022, a patient waited in a fever clinic at Beijing Chaoyang Hospital, Capital Medical University (Visual China/Photo)
Southern People Weekly: You also mentioned the phenomenon that the life course of an individual has become a one-way path controlled by a series of competitions, and behind the competition is the promise of a certain "good life". This culture of competition also seems to induce depression.
Xiao Yixin: Capital concentration will also lead to time acceleration. East Asian development-oriented countries want to catch up and accumulate advantages in a short period of time, so they emphasize competitiveness. This discourse permeates from national strategies to individual requirements. In our culture, there is also a tradition of evaluating the imperial examination, which further intensifies the competitive atmosphere.
In the current education system, everyone is playing a game of "squeezing dry in advance". Our path to education is elementary school, junior high school, high school, high school university, and when we reach university, it seems to be capped. We prioritize competition and test scores and rarely prioritize building self-confidence and developing students' personality. In this atmosphere, we have been in a tense competitive relationship with our classmates for a long time, and many students also have psychological problems in the process.
This competition also continues into the rest of life, after being admitted to a good school, you must find a good job and be a good employee; After marriage, you must be a good husband, a good wife, a good father, a good mother... People who fail to fit into these good roles are not defined by society as living a good life. It is as if there is a "symbolic other" gazing at us and must meet his expectations. This other may be a social atmosphere and social norms, embodied in roles such as teachers, parents, and bosses. You will feel like he is asking for it endlessly.
Southern People Weekly: In China, "neurasthenia" and related physical pain were more common before the 1980s, but around 2000, "depression" began to gradually occupy the public eye. For example, the news of celebrities suffering from depression has increased, and the number of research on the topic of "depression" has increased. At present, the discourse of depression is widely spread. What are the psychosocial factors behind this?
Xiao Yixin: The medical and pharmaceutical industries, the authorities, academia and the media have all promoted the construction of the name of this disease. Of course, it cannot be said that all problems are issues of economic interests, but in order for pharmaceutical companies to invent drugs, they must be profitable. Some literature will emphasize the role of pharmaceutical companies in social construction, and some scholars may even think that mental illness is basically manufactured, which may be a radical statement, but it provides a constructivist perspective on how capital produces so-called "depressed patients".
Mass media have also driven psychology fever. Many psychological tests online are free, and we can play them as games to measure our depressive tendencies. Now there are also telephone counseling, online psychological counseling, and various self-help courses, which invisibly convey the words about depression. If we go to a random website that sells books and search for the word "depression", we will come up with a bunch of results. My translation of the book "Telling Sadness" actually participated in the social construction, (laughs) to let everyone understand depression from different perspectives. I think it's also a process of social development, and we don't stigmatize depression as much as we did in the 1980s.
Crisis or gift?
Southern People Weekly: Do you think the three years of the new crown epidemic have made people's mental health more vulnerable?
Xiao Yixin: Of course, the epidemic and secondary disasters will exacerbate the risks faced by people. I think there may be two trends: one is that many anxiety, depression and post-traumatic stress disorder (PTSD) will gradually emerge after the epidemic. Another possibility is that individuals experience post-traumatic stress growth (PTG), where a person is more empathetic after experiencing difficulties or traumatic events. The pandemic may also make us more mature. For example, Malala, who won the Nobel Peace Prize, was shot and later had a sense of mission to speak up for women's rights. Trauma has allowed her to grow in a positive direction. A bad thing doesn't necessarily lead to a completely negative outcome, depending on what your cognitive framework is.
Southern People Weekly: It is difficult to completely eradicate the pain of life, and many problems are difficult to solve through a single channel. So what is the purpose of psychotherapy and counseling?
Xiao Yixin: A very important point of psychological counseling is to change our cognitive framework. Psychoanalysis may not help you solve problems, but make you see the problems you once avoided. Challenge your logic, let you think in a different framework, maybe you want to open.
There are also many genres of counseling. For example, in focused short-term therapy, the counselor will give the client a little homework each time, and you will complete a little each time, accumulate these small achievements, and finally come over. The counselor usually plays an encouraging role, adjusting you from the depression circuit to "so can I." This process allows the client to rediscover themselves and discover that they are not as bad as others say they are.
When we say "this is a person with bad grades", "bad grades" is just a certain symbol that refers to this person. But a person himself is much larger than this symbol, he may only have poor grades temporarily, or he may be a very optimistic person. People have many facets. Therefore, psychological counseling will actually guide the client to reflect on the mainstream value discourse of society, and even deconstruct it. Let the symbol loosen and reconnect to another symbol to discover the advantages and adjust the cognition.
"Never waste a crisis," Churchill said. Depression can more or less lead to a smarter way of thinking, and of course it can make life worse, depending on how we choose. The disorder can be judged on "good and bad," but depression can also be seen as a gift. The experience of depression can be an important stage in life, and it may allow us to gain a deeper sense of self and be more empathetic to others.
Southern People Weekly: Depression screening was included in the content of adolescent health checkups in 2021, but in mental health prevention work, some teachers and parents only hope that students with emotional disorders will not make deviant actions after treatment, while ignoring the deep situation of individuals. Does this make people with depression more isolated?
Xiao Yixin: This is the position of comparative functionalism, in order to make the function of the collective work properly, you need to get better quickly. But if you only deal with the problem of personal behavior, when you throw the individual back to the original school, family, or workplace, his symptoms may recur. I know a counselor who says he only does family therapy, not individual therapy. Because many of the child's problems are parents' problems. Even if the child is tutored alone, and the parents' perception does not change, the problem still exists.
The individual cannot exist in isolation from the social environment system, and the person concerned must be subject to the surrounding environment. If there is a problem with the system itself, then we also need to pay attention to how the key people in the system should improve. Sociology also needs to deal with macro-level issues, such as the friendliness of social policies, the construction of the health care system, and what should be done at the school and community levels to reduce discrimination against depression. In short, it is necessary to cultivate people's psychological resilience and create a friendly environment, so that people's depression can be alleviated.
Our distance from mental disorders
Southern People Weekly: What parts should ideally be made up of a support system for people with depression?
Xiao Yixin: There is a theory in social work called "ecosystem theory", and the social system on which individuals rely is divided into micro, meso and macro levels. At the micro level, we investigate the situation of those closest to us and analyze what resources those around them can give him. For example, if a teenager who has dropped out of school living in a single-parent family lacks tutoring, the social worker will help him contact volunteers who are willing to help him guide his homework; When he lacks money, he has to help him apply to the foundation or find donors for him. If he encounters domestic violence, we must put him in a safer place and accompany him through the difficulties.
The meso level is in the community, such as helping people with depression integrate into society. At a broader level, in social policy, for example, some professionals can make some suggestions in the decision-making group to make policies more friendly to people with mental disabilities, so as to promote social change.
Southern People Weekly: What problems do Chinese mainland have in dealing with depression and other mental health issues?
Xiao Yixin: First, the practitioners of the psychological counseling industry are uneven. In 2017, the Ministry of Human Resources and Social Security cancelled the national professional qualification examination for psychological counselors, and after that, the qualification certification of psychological counselors has become a phenomenon in which different training institutions occupy their own hills, and there is no national unified certification. For example, the Chinese Psychological Society has launched a course certification for the professional ability of psychological counselors, and the Institute of Psychology of the Chinese Academy of Sciences also has a certificate of qualification for basic training in psychological counseling. There are also many uneven psychological counseling and certification websites, and the threshold for examination is relatively low.
To obtain a psychological counselor license in Taiwan, you must have at least a master's degree and an internship in a psychology-related department for at least one year. Internships in the mainland are not a requirement, and college students can apply. In this case, it is easy to lead to the inflow of people with no internship experience and unsolid training into the market, and it is undeniable that some people think that psychological counselors are like quacks and warlocks, and they do not have enough trust in them.
Second, the number of psychiatrists and the number of beds are insufficient. The number of psychiatrists in Taiwan in 2018 was 8 per 100,000 people, while the mainland had only 3.55 per 100,000 people in 2020. In 2020, there were 5.65 psychiatric beds per 10,000 people in mainland China and 13.9 per 10,000 people in Taiwan. This somewhat affects patient care. (Data source: Ma Ning, Chen Runzi et al. "Analysis of China's Mental Health Resources in 2020", Taiwan's "Executive Yuan Comptroller General's Office" statistical data.) ）
Southern People Weekly: What experiences can Taiwan learn from?
Xiao Yixin: There is a Cifang Care Center in New Taipei City, Taiwan, which serves people with mental disorders who are not severe enough to need to be hospitalized. They put a lot of emphasis on social connection. For example, every day, social workers accompany patients to grocery shopping, encourage them to cook together, and remind them what to do so as not to pose a danger to themselves and others. The care centre does not consider a mental disorder to be a disease, but only a temporary disorder in the life stage. When they have enough social connection and companionship, their condition will slow down and they can live a normal life.
In addition, they also co-create and curate with some artists in Taiwan, so that the rest of the community can understand the inner world of patients. In the pavilion of the care center, people with mental disabilities become guides. They express their life stories through songs, photography, painting, etc. These are social education to destigmatize mental disorders, and they are things that sociology or social work can do.
In 2019, there is a Taiwan drama called "Our Distance from Evil", which also discusses the problem of crimes committed by mentally ill people, and how to return mentally disabled people to society and protect their rights and interests. It seems that we rarely touch on such topics, but only when mental disorders can be discussed by public opinion can it lead to social reflection. In Taiwan, some psychiatrists often share cases in the media, of course, they obfuscate cases based on ethical norms. We can analyze many problems through these stories, such as why domestic violence occurs, what parents think when children have psychological problems, what children think, and what we should do. I think this kind of extensive education is necessary.
Intern reporter of Southern People Weekly Ni Yuyao Southern People Weekly reporter Ouyang Shilei