The Empire of Depression: A Conversation with Jonathan Sadowsky

Kylie Smith

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Professor Jonathan Sadowsky, Theodore J. Castele Professor at Case Western Reserve University, is the author of two important works on the history of psychiatry: Imperial Bedlam: Institutions of Madness in Colonial Southwest Nigeria and Electroconvulsive Therapy in America: The Anatomy of a Medical Controversy. Sadowsky is well known in the field for his nuanced and ethical approach to complex questions in the history of psychiatry. His new work is no exception, and in it he takes a deep dive into the multifaceted relationship between depression and the modern world. I talked to Professor Sadowsky about his latest book, The Empire of Depression: A New History, and the complexities of doing ethical work in the history of psychiatry.

Kylie: I am really interested in how you made the move from your last work (on ECT) to this one. Why the focus on depression?

Jonathan: I had resolved to spend the summer of 2017 working on several different projects that I had thought might be my next book, but I hadn’t really settled on one. And then I got an out of the blue email from Polity. The editor said that the series on health and illness that they were doing was “attractively priced,” which really appealed to me because I want people to actually read it. The other thing they said was that they were trying to create books that would have scholarly merit, but which could be read outside, by not simply an academic audience. And that was something that I had wanted to do anyway. Partly, it was career-stage, that I felt a certain freedom, although in some ways I wish I had started thinking that way sooner than I did.

Kylie: Why do you think that that’s important for us, especially as historians in psychiatry, to think about public-facing work?

Jonathan: In the book I wrote on ECT, I did try to be clear. I tried to be as plain as possible in my style. But I did a lot of historiographical addressing and a lot of talking to my peers in the field, which is fine, that’s part of how knowledge gets advanced. But it’s not something that the broader public is really interested in. They’re not really interested in our squabbles, except to the extent that those squabbles affect the issues that they do care about. And in the history of psychiatry, for example, I think people really do care quite a lot about what is the proper model of care.

Kylie: On that note, I’m also interested in to what extent you have to grapple with the idea of psychiatry as a form of social control versus psychiatry as a mode of treatment that provides real benefits.

Jonathan: I think this is another area in which we sometimes get false choices posed for us. For example, I’ve been very much influenced by Joel Braslow’s work, because he was one of the people who helped to pioneer the insight that not only can psychiatry both be a mode of social control and provide clinical benefit, but actually sometimes it’s happening at the same time. That doesn’t mean you can’t identify moments of extreme coercion or abuse in psychiatry. It also doesn’t mean you can’t identify moments of relatively humane, therapeutic intervention. What I took from Joel’s work was the understanding that these things exist on a spectrum, and they are not a dyadic opposite.

This isn’t simply a matter of balance for balance’s sake. Balance isn’t the supreme goal in scholarship. And there are certain things that I have no hesitation to either outright condemn or outright praise. But I do think that the history of psychiatry presents us empirically with a lot of ambiguity. And I think that we need to represent that. So in my view, documenting the harms of psychiatry is worthwhile and should continue. But we also have patients who value their treatments, and they need a voice in our historiography, too.

Kylie: This leads me to the next question related to the idea of empire, which you reference in the title. To what extent do you think that we see that particular tension (between care and control) as less ambiguous in certain places, in certain times?

Jonathan: For the most part, colonial psychiatry was coercive. It was neglectful. Much of it was dehumanizing. This has been really well-documented, not just by me, but by the many people who have also done work in this field. It was already being critiqued during the period of decolonization, by people like Fanon and Lambo. There’s another point that I really want to emphasize here, though, about colonialism as it relates to the title. One is a kind of metaphorical linguistic colonization, where depression has become a label of distress, displacing other terms, like “nerves” or “nervous breakdown.” But in a somewhat less metaphorical sense, depression as a clinical term comes from Western biomedical culture. And it has spread to become a global idiom. I do think that there are both gains and losses in that.

Then there is the idea that Black people do not suffer much from depression, which has deep roots in slavery, colonialism, and the racist ideologies of those systems. As I put it in the book, the image of Africans as immune to depression remains sturdy because it allowed a denial of slavery’s inhumanity, by diminishing the full humanity of the enslaved. But we see evidence in Sowande’ Mustakeem’s work, for example, that slave traders and owners actually did in fact perceive melancholic illness in enslaved people and yet still held on to this ideology that it wasn’t something that Black people were prone to. This raises an important point that, while it’s true that the use of a Western diagnostic term can be a colonialist gesture, so, in a way, can be the withholding of a diagnosis. So it is really my belief that depressive illness is a human universal.

Kylie: This idea that it’s only ever a negative, I think, is really a problem if we see communities of color themselves wanting help, wanting access to treatment.

Jonathan: This is important on a global scale, too, because there is a vein of thought that looks at psychiatry as a kind of global empire now and looks at that in purely oppressive terms. But there are people who would dearly like access to many of the treatments. One of the unfortunate things about the “antidepressant era” is that it did, at least for a time, have a tendency to minimize the importance and significance of nonbiological interventions like psychotherapy. And I think that a lot of people can be helped by that. But in Empire of Depression, I look at the evidence for efficacy of antidepressants as closely as I can. And I concede to their critics that there’s a lot of problems with the data. On balance, I’m convinced that while they may not help everyone, they are a legitimate and important part of the psychiatric repertoire. Now, just to round out this point here, I’ve been talking a lot about how I think about what I’ve called this relentless negativity in the historiography. And often, that takes a kind of form of absence. That is, the abuses and the social control get documented, and the therapeutic successes are not explicitly denied. They’re just not mentioned.

Kylie: That is actually a question about sources, about the struggle that we have to get the perspective of the patient into these histories that we’re trying to write. How do you deal with that in your own work?

Jonathan: I realized from the outset, as I began the work, that it was going to be dominated by the representations of various elites. The people who were able to leave records were going to have advantages of class. Even when I have access to patient voices, they might be argued to be privileged patient voices, not simply by matter of their class or their race, which might be part of it, but even by the fact that they were well enough to produce something. This poses a special problem when you’re dealing with depression because a lot of depression treatment has taken place in private office practices. And they don’t produce documents in the way asylums and mental hospitals do.

Ethically, one of our most important obligations is to be clear about the limits of our sources. But I’d also add that doing history of the psychiatric patient from below poses its own ethical problems. Unless the person has deliberately published, you’re exposing aspects of their lives that in all likelihood they wanted kept secret.

I want to say one last thing about this issue, which is about this “from below” question. So far, anecdotal reactions to my book suggest that the book does resonate with people who do suffer from depression. I’ve gotten correspondence about this. I’ve gotten emails. People say, “I saw a lot of myself in your book.” One person wrote publicly on Twitter that it was the one book on depression that he would recommend to his parents in order to help them understand the illness. This matters a lot to me.

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Featured image caption: ECG significant inferolateral ST depression. (Courtesy Wellcome Collection)