If you have ever experienced anything remotely close to depression, chances are that you have been assailed by well meaning friends, family members and the world at large to enhance positive thinking. Everyone from Deepak Chopra, and Oprah Winfrey to the friendly next-door neighbour have been telling the world repeatedly that we hold the key to solving all our mental health problems in our own hands. Apparently, by perpetuating positivity, we can wave our magic wands and make depression go away. A slew of motivational and self-help resources, relying more often than not on questionable research, anecdotal evidence and gross extrapolation from and over generalisation of scientific findings offer techniques and strategies to combat depression. Most recently, the Ministry of Health and Family Welfare, Government of India has joined the bandwagon, tweeting a poster advocating “Think Positive”, a strategy along with some others that to help combat depression.
However, there are multiple problems with this approach.
The first and most obvious flaw lies in the assumption that one can combat depression alone. It is a surprisingly glaring error that amidst the multiple strategies advocated in the poster, seeking help from a trained mental health practitioner is conspicuously absent. India harbours seemingly insurmountable taboos against the mentally ill already when by all accounts mental health problems are on a steep rise. The poster sends out a dangerous message: Depression can be coped with without resorting to medication or therapeutic interventions. An analogy would be asking a diabetic individual to exercise and control diet for disease management with no allusions to medical care. The simple idea that the mind is just as organic as a heart or a liver or a lung, something that needs care, gets diseased if neglected or exposed to specific hazards, and therefore, requires treatment is something that Indians are overwhelmingly refractory to. While no one can rationally deny the lifestyle changes recommended are well intentioned, and have overall health benefits, they can augment, not replace targeted treatment to clinical depression.
Further, depression is a generic word that is often used to cluster various conditions sharing some symptoms such as negative affect, lowered mood, a sense of hopelessness and emptiness, but with considerable different etiologies. While some individuals lapse into depression following a sudden traumatic life event, some others may suffer from it following years of unpredictable stress, or after being diagnosed with a terminal disease. Each person’s depression is unique and therapies, both medical and psychological, need to be tailored for depressive symptoms to go in remission and preventing relapse. Factored into this already complicated scenario is each individuals’ resilience, which in turn is a complex interaction between biology and the environment. There can be no one universal therapy or coping strategy that works for everyone, and most importantly, therapies have to be administered by trained and experienced clinicians.
Since positive psychology is such a buzzword in the popular science lingo of today, let us take a closer and critical look at the primary literature in the field. In one of the earliest articles on this subject, Seligman and Csikszentmihalyi (2000) posited that while mental health professionals were overwhelmingly focused on healing and treating the damaged mind, the potential of positive attributes such as hope, wisdom, creativity, perseverance were being systematically ignored. At the onset of 21st century, the field of positive psychology gradually took off and within a very short time acquired considerable critical mass of research to be introduced in to clinical practice. In 2008, Seligman proposed positive mental health as something more quantitatively measurable than simple absence of mental illness and predictive of outcomes such as achievements, depression severity and physical health. The term positive psychology has since been broken down into subjective constructs pertaining to the past (well-being, contentment, satisfaction), present (flow and happiness) and the future (Hope and optimism). Each one of these constructs have since been operationalized into different variables, using psychometric questionnaires and instruments. The validity and reliability of these instruments are very often debated among psychologists. The research literature on positive psychology on depression, stress, anxiety resulting from multiple etiologies is therefore widely fractionated in terms of methodologies employed (clinician administered vs self-report), Constructs and questionnaires used (well-being vs optimism) and subject population (age, gender, physical health status). It is humanly impossible to synthesize generalized conclusions from this colossal amount of data, which is sometimes self-contradictory. It is not very surprising therefore, that positivity cannot uniformly predict better mental health outcomes across conditions and age groups. Just within the field of stress research, constructs such as optimism has been shown to have protective against stress when the stressor is brief. However, when the stressor is unpredictable and prolonged, higher optimism is linked to greater stress related damage. Examples such as these show that positivity can be a dual edged sword, and its benefits are extremely context dependent.
Keywords related to positive psychology, positivity and positive thinking bring up an embarrassing riches of studies from research databases, yet a single comprehensive, case controlled, blinded randomized control trial specifically demonstrating clinically significant benefits in depression in a statistically respectable sample has not yet been conducted. Most of the benefits that have been reported are in samples drawn from people suffering from grave illnesses, most notably, terminal cancer and cardiovascular disease. And to reiterate, the depression that is secondary to a physical illness is biologically, and psychosocially very different from unipolar depression, dysthymic disorder or major depressive disorder, which constitute the bulk of patients given a diagnosis of depression.
In the populist narrative of positivity, there is almost no room for accommodating negative thoughts such as anger, frustration or grief- which is very harmful. These negative emotions have evolved through millennia with important adaptive functions. Casually brushing them under the carpet to foster a sense of positivity is likely to create complications and mental health concerns much harder to treat in the long run. With positive psychology blossoming into a fierce industry, sociologist and writer Barbara Ehrenreich warns of “a corporate culture which, by the middle of this decade, were completely in a bubble of mandatory optimism and positive thinking”. According to Ehrenreich, unbridled, shortsighted and reckless push towards optimism and buying into the perception of a future where nothing could ever go wrong partly catalyzed the US financial meltdown of 2008. The Harvard psychologist Susan David has also spoken at length about the dangers of positive thinking without emotional agility, or reckoning with the negative feelings first, in face of a challenge.
The literature in support of positive psychology can be more or less synthesized to an application which can augment and bolster traditional therapies in patients suffering from depression secondary to serious illnesses. However, to promote it as an easy fix to cope with depression is irresponsible and dangerous.
A characteristic presentation of depression is anhedonia, the inability to feel pleasure. This has been well validated in animal models of depression, as well as human patients who report their inability to feel any pleasure from one or more activities they had enjoyed before. Simply asking a depressed individual to “think positive” without giving the person a cognitive restructuring framework and providing requisite skill sets is completely ineffective. It can actually worsen a depressed persons’ sense of social isolation and over time, the additive pressure of positive thinking thrusted upon by peers, friends and family is extremely damaging. Invalidating someone’s struggle by summarily dismissing negative emotions only will lead to the individual further withdrawing from social contact and increase their distrust on mechanisms originally designed them to protect them. Popular discourse in depression and mental health needs to acknowledge this clearly – that the anhedonia in depression has robust biological basis. Each of the seven or eight biochemical theories on depression, each dealing with one neurotransmitter (molecules used by neurons for chemical transmission of signals) as well as structural and functional neuroimaging studies have shown this pretty conclusively over the years. While definitive concrete therapeutic strategies and medical intervention have reported better outcomes in behavior as well as biological correlates of depression, a generalized benefit of positive thinking alone has never been demonstrated. Simply put, a primarily blind person cannot process certain visual cues and details no matter how much the resolution of an image is increased. It is just as laughable to hold him responsible for not trying hard enough to see, as to expect a depressed individual to benefit from positivity when the hardware in the brain needed for processing positivity is compromised on multiple fronts.
Also, there is a widespread idea that positivity somehow improves immune function across gender, age and clinical condition. However, the research evidence backing such claims is at best, nebulous. While it is very clear that depression lowers white blood cell counts in a subset of patients, exposing them to opportunistic infections, rescuing the immune deficiencies and behavioral outcomes with positive thinking has never been clearly shown in a depressed sample, with clear biological and psychological correlates.
In summary, this is not an effort to advocate negativity but caution against the trap of buying into the myth of the unicorn of mental health – positive thinking. Especially, a government should steer clear of such sweeping generalizations in a country where the National Mental Health Survey suggests that out of 150 million people who are mentally ill, only 30 million are seeking care. The effort of the ministry is probably needed in areas of developing infrastructure for quality accessible mental health care and spreading awareness about mental health, rather than promoting visual aids that can be widely interpreted as a do-it-yourself treatment plan for the mentally ill.