Body-Subject or Neo-Liberal Subject? Phenomenology, Depression, and CBT

Abstract

Depression is notable for high rates of disability. The medical model typically characterizes depression as a physiological dysfunction or psychological disorder. However, both views fail to appreciate the phenomenology of depressed experience. Drawing on the existential phenomenology of Merleau-Ponty, this article contends that the lived experience of chronic depression is marked by a disturbance between the body-subject and the world. More specifically, the experience of depression is characterized by alienation from the world, self and others. While anti-depressants have long been the first line of treatment of depression, many governments subsidize cognitive behavioral therapy (CBT) as an adjunct treatment. CBT is said to be the gold standard psychotherapeutic treatment given that it is evidence-based, cost-effective, and short in duration. However, not only are these justifications questionable, but the theoretical underpinnings of CBT have ideological significance. Rather than approaching depressed persons as body-subjects, CBT casts service users as neo-liberal subjects, insofar as depression is characterized as disordered thinking that is independent of a person’s situated life. The emphasis on quickly returning people to work to reduce strain on welfare systems, while a valid economic concern, is not a valid therapeutic concern. The limited choice of subsidized psychotherapeutic options fails to recognize that depression is a heterogenous phenomenon, meaning that the CBT model of disordered thinking is not necessarily representative of the way in which depression manifests.

1. Introduction

When comparing the experience of acute illness to that of chronic illness, a crucial distinction is that, in the former, there is a sense of trust that the functional impairment in everyday life will return to “normal.” By contrast, with respect to chronic illness, impairment becomes the new “normal.” For example, in instances of the common cold or influenza, there is an arc of illness that typically begins with infection and resolves in restored health that occurs within a relatively short period of time. While acute forms of illness can certainly result in more serious complications, they are generally representative of a relatively brief divergence from, and return to, health. In the context of chronic illness, the return to health is either uncertain or unforeseeable. For this reason, chronic illness reflects a phenomenologically distinct experience that transforms one’s sense of being-in-the-world [1].

This paper will consider specific phenomenological modifications associated with the experience of depression. While many chronic illnesses share experiential features, they are nevertheless unique phenomena. While we can speak broadly about similarities that cut across debilitating illnesses, it would be unjustified to assume that specific illnesses engender the same overarching social and political consequences. While depression is a common condition, the prevalence of depression varies. According to the World Health Organization, 350 million people suffer from depression, and it is notable for its long duration, making it the ninth largest marker of disability and death [2]. Since the number of people who experience depression is considerable, and many patients are not relieved of suffering despite medical intervention, I believe it is a phenomenon that warrants closer analysis, from both an experiential perspective and a critical social perspective.

This article begins with a brief definition of depression. I then sketch out a phenomenological account of depression. This is then further supported by articulating the way in which depression is characterized by three experiential forms of alienation: from world, other, and self. This analysis predominantly draws from the existential-phenomenological philosophy developed by Merleau-Ponty, who insisted that not only is subjectivity embodied, but the embodied subject cannot be understood independently of its relationship to the world. The phenomenological approach, as Ratcliffe contends, engenders a form of empathy that enables the ability to understand psychiatric illness, noting that phenomenology might not necessarily “amount to empathy, but that a phenomenological stance can be integrated into our attempts to engage with the experiences of others” [3] (p. 486). The phenomenological approach, in other words, attempts to grasp the way we experience a shared world by suspending common sense (or explanatory) attitudes about certain phenomena. The final portion of the paper addresses how the cognitive behavioral therapy (CBT), as the overwhelmingly predominant therapeutic intervention for depression, eschews insights drawn from phenomenological accounts of subjectivity. Rather than viewing the sufferer as a body-subject, CBT promotes the ideal of recovery vis-à-vis a neo-liberal subject. This ideal not only assumes a potentially self-sufficient subject, but it likewise views existence through a lens of rationalism, whereby depression is attributed to (incorrect) ways of thinking.

2. Clinical Depression

From a clinical perspective, the American Psychiatric Association defines several types of depression under a broad category of Depressive Disorders. The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Text Revision (DSM-5-TR) uses a criteria-based approach to diagnosing mental disorders, meaning that a person must exhibit a specific number of symptoms to qualify for a diagnosis. When speaking of depression, the two common categories are Major Depressive Disorder (MDD) and Persistent Depressive Disorder (PDD). The two disorders are similar, though a distinction is the duration of illness. A cursory overview of the diagnostic criteria will offer a point of departure for the forthcoming analysis.

A diagnosis of MDD is broadly defined by loss of mood or loss of interest or pleasure in activities for at least two weeks. This is accompanied by changes in one’s appetite or weight, sleep, and psychomotor activity; decreased feeling of energy; sense of worthlessness or guilt; problems with thinking, concentrating, or decision-making; or thoughts of dying, suicidal ideation, making a suicide attempt, or plans for suicidal behavior [4] (p. 187). The diagnosis of PDD is made when the person experiences depressed mood for most days. However, unlike MDD, this must be experienced for a period of two years. Additionally, two of the following symptoms must be present: changes to appetite or overeating; problems with sleeping; fatigue; poor self-esteem; problems with concentration or difficulty making decisions; and a sense of hopelessness [4].1 Importantly, though a depression diagnosis must meet certain criteria, some of which I have outlined here, the DSM-5-TR notes that simply meeting the criteria is not sufficient without proper clinical. In other words, the clinician must assess the symptoms in the context of potentially mitigating factors, such as other potential illnesses that may elicit similar symptoms.

The above definition has generated considerable discussion about the extent to which it accurately reflects depression, or whether a criteria-based approach is a sound method for capturing depressed experience. Though my intention is not to scrutinize the content of the criteria as such, in the following section, I will employ a phenomenological analysis to offer an alternative account of how depression is experienced.

3. Phenomenological Overview

The aim of a phenomenological analysis of depression is to make the structures of conscious experience explicit. Moreover, it attempts to draw forth experiential aspects of depression that are otherwise overlooked by the medical model, which is primarily concerned with depression as a dysfunction of the brain or mind. From a phenomenological perspective, this approach is limited in scope insofar as it is grounded in two key assumptions: that mind and body are distinct from one another, and that subjective experience may be understood independent of its relationship to the world. Merleau-Ponty contends that consciousness is not predicated on the Cartesian “‘I think that’ but rather an ‘I can’” [5] (p. 139). Accordingly, consciousness is embodied and therefore practical, whereby the subject—more specifically the body-subject—is situated in the world, which offers practical possibilities. Because we are situated, our relationship to the world is perspectival, meaning that perceptual experience is established by the body’s perceptual opening onto otherness. We encounter things in the world as possibilities for practical engagement: “my body as a system of possible actions, a virtual body whose ‘phenomenal’ place is defined by its task and by its situation. My body is wherever it has something to do” [5] (p. 260). For example, the act of grasping for a glass is not cognitively or reflectively calculated, but rather the glass is experienced as graspable, within reach, out of reach, and so on. The overarching point espoused by Merleau-Ponty is that the body-subject comports itself towards the world non-conceptually. This sentiment is reflected by Gallagher when he notes that “my knowledge of what I can do with my hands is in my body, not in a reflective or intellectual attitude that I might take toward my hand” [6] (p. 74, emphasis original). Since consciousness cannot be isolated from the body, our understanding of illnesses like depression cannot be restricted to physiology or psychology alone.

In normal circumstances we unreflectively engage with, and cope with, situations in which we find ourselves. The ability to unreflectively cope with situations is derived from our capacity to develop and establish bodily habits. For Merleau-Ponty, bodily habits are derived from the primacy of unreflective experience. In general, habits represent basic skills that are learned from infancy, such as walking, grasping, and crucially, perceiving. Perceptual experience is not a passive reception of stimuli. Rather, it is something done by the body-subject, which in turn becomes incorporated into the body schema as habit. The body schema, according to Merleau-Ponty, is characterized by a non-conscious (unreflective) establishment of motor-intentional capacities: “The acquisition of the habit is surely the grasping of a signification, but it is specifically the motor grasping of a motor signification” [5] (p. 144). Put another way, learning a habit is learning the meaning of an action through the body itself. The body does not just execute movement, but instead it understands movement. Over time, the body-subject “sediments” bodily habits, which in turn make it possible to comport oneself unreflectively with respect to practical goals.

Phenomenological accounts of depression generally agree that depressed experience is predominantly characterized by a change in how things in the world stand out as being meaningful for us [7,8,9,10]. Phenomenologically speaking, world significance (or salience) refers to the variety of ways that the body-subject may be affected by virtue of how he or she contacts the world. This position broadly contends that the relationship between subject and world is modified. One of the key aspects of embodied subjectivity and habit is that self-experience establishes a foreground–background structure. This structure characterizes the body as both Leib (lived body) and Korper (physical body) [11]. This formulation expresses the way one’s body can both be an object of experience or the background of experience. In everyday life, the body is not explicitly experienced as an object but is instead “absent,” insofar as our intentional experience is directed away from ourselves. As Leder notes, health and illness reflect how the body is experientially ambiguous. In health, the body is absent or “silent” [11] (p. 91). By contrast, the experience of illness reflects how the body often becomes the foreground of experience, which Leder characterizes as “no longer alien as forgotten but precisely as-remembered” [11] (p. 91). For instance, when one experiences a headache, it can prove difficult to be “absorbed” in the task at hand since the pain becomes the intentional point of focus. The “as-remembered” reminds one that the body is concretely experienced, though, more often than not, it remains a silent aspect of everyday life. By contrast, when out walking in the park with a friend, the body, so to speak, blends in with the background of experience, such that one is absorbed in conversation while the bodily is absent from reflective experience.

3.1. Depression and Alienation from the World

The phenomenological sketch provided above allows us to better comprehend the suffering associated with depression. Illness presents itself in multifarious ways. In general, some illnesses are more “visible” than others. In the context of depression, despite attempts to identify biomarkers that would causally explain depression, there is no consensus that would attribute a specific physical dysfunction to depression. As a result, while the suffering associated with depression is acknowledged as real, in the absence of an identifiable dysfunction, it can prove challenging for many to understand how (or even why) people suffer from depression. Much like somatic illnesses, the experience of depression is characterized by the reduced ability to unreflectively engage with the world.

Just as the pain associated with certain somatic illnesses becomes the foreground of self-experience, the discomfort experienced in depression likewise becomes thematized. However, with depression, the suffering is neither localized to a specific place nor is it specifically physical pain. It is instead diffuse: it is everywhere, yet nowhere, in the sense that the “pain” of depression is all-encompassing. If we consider the pain associated with a muscle sprain, though one cannot make it disappear, it is possible to compensate in such a way that when walking, one can try to place less stress on the bothersome appendage. This is not possible in depression since it is a pervasive affective experience.2 Consequently, the pervasive feelings of depression have an isolating quality. Rather than feeling “caught up” with the world, there is a sense of estrangement from the world.

When healthy, the perceptual significance of the world is experienced unreflectively, meaning that what is, and is not, practically possible is grasped by the body-subject non-conceptually. In depression, however, the world no longer solicits one in the same way. Svenaeus contends that “[t]he lived body (Leib) is not only the central vehicle of our going outside ourselves to the world of others but it is so by its capability of being affected by the world” [10] (p. 10, emphasis original). In depression, what stands out to the body-subject as significant has been transformed. For instance, the otherwise simple act of getting out of bed may become challenging since the horizon of possibilities no longer “speak” to the person who is depressed. Similarly, Ratcliffe notes that “[a] world bereft of any practically significant or enticing activities is one from which certain kinds of noetic feelings, those associated with effortless immersion in activity, are absent” [9] (p. 85). Hence, one’s ability to be affected, to move or be moved, which is normally experienced implicitly, becomes explicit in depression. Not only are the body-subject’s practical motivations disrupted or reduced, but it is also the case that self-experience is turned toward oneself rather than toward the world.

A notable feature of depression is that the body-subject struggles with motivation. For Merleau-Ponty, motivation cannot manifest without the experience of depth. This means that our relationship to the world is grounded by our experience of existential space. Distance is not simply an empirical measurement between two points. The relationship between depth and motivation structures situations in such a way that our concerns, or what counts as significant for us, need not be close to hand: “a lived distance links me to things that count for me and exist for me, and links them to each other. At each moment, this distance measures the ‘scope’ of my life” [5] (p. 299). In depressed experience, one’s situatedness contracts. Hence, normal self-experience is centrifugal (expansive) while depressed self-experience is centripetal (constrictive). It is not just a loss of “possibilities” [9], of what one can or cannot do, but is a transformation of how the situated body-subject experiences perceptual thickness or existential depth, which expresses the inviting quality of the world as such. While levels of motivation in depression admit of degrees, changes to motivation nevertheless express an indelible feature of depressed experience. This characterization draws attention to the way the self-experience in depression is one of alienation from the world.

3.2. Alienation from Self and Others

Another crucial aspect of depression is the experience of alienation from others. The ability to interact with others changes in ways that are not dissimilar to the ability to be affected by the significance of the world. This compounds the sense of isolation that characterizes depression. What stands out as significant in the shared world with others may fail to affect the person with depression. Accordingly, “marked by profound inability to interactively connect to other people, depressed patients come to feel removed, detached, and alienated from others” [12] (p. 27). This same sentiment is found in Karp’s study of depression, which highlights how “depression inevitably speaks to questions of isolation, withdrawal, and lack of connection. The pain of depression arises in part because of separation from others; from an inability to connect, even as one desperately yearns for just such a connection” [13] (pp. 26–27). Just as the body-subject’s ability to be motivated by world significance is changed, the intersubjective dimension of existence also reflects profound changes. The connection between self and other is challenged by two aspects: the body-subject’s tendency to eschew others but also the other’s inability to comprehend the experience of depression.

First, depression in general reflects a tendency to withdraw from practical and consequently personal engagements. The implicit sense of belonging to a shared world that underscores intersubjective relationships is eroded for people with depression. One clear reason is that the suffering experienced in depression is notoriously difficult to make explicit to others: “There is a feeling that they do not understand, which could equally be described as a feeling that they are unable to ‘relate to’ or ‘connect’ with the depressed person” [9] (p. 202, emphasis original). Some illnesses are more visible than others, and though depression may manifest some visible symptoms, the symptoms do not convey the extent to which the depressed person suffers. This is a profound source of alienation, insofar as others can “know” that someone is depressed yet fail to “understand” what it is like.

Depression that is disabling is especially difficult to understand since it is an illness that endures over time, such that the abnormal state becomes normal. This is complicated by the fact that there is a continuum of disability in depression. While some people may be able to work and others may not, depression is associated with high unemployment and high costs to employers and governments [14]; the ability to maintain basic levels of self-care will also vary.

Hence, the outward perception of someone who is chronically depressed may belie the extent to which he or she is suffering. Empathy is a crucial phenomenological component for intersubjective experience [15] (p. 60). Yet, depression poses challenges for empathetic understanding. According to Ratcliffe, “[b]eing ‘empathetic’ is not a matter of being able to perform a singular cognitive feat: first-person replication of someone else’s experience. Instead, it is a way of approaching and interacting with another person” [9] (p. 243, emphasis original). This “way” of interacting with chronically depressed persons is arguably eroded over time, since

Most healthy people have only sketchy ideas about what it would be like to live with an illness or impairment. Without first or second hand acquaintance with the details, their view would probably be based on popular representations of illness and may be limited and anecdotal.

[1] (p. 136)

While empathy does not imply that one shares the direct experience of the sufferer, depression is unique in that it is challenging to grasp the depth of suffering, particularly if the depressed person is unwilling or unable to express to others that they are ill.

With respect to depression (and chronic illness), the ability to relate to the sufferer is compounded by its duration. In a poignant (and satirical) short story by David Foster Wallace, he sketches an account of how a depressed young woman’s self-deprecation alienates her from others. The depressed woman’s therapist encouraged her to rely on a select few friends who would constitute a “support system,” a group she felt comfortable contacting when in need:

It felt demeaning; the depressed person felt demeaned. She said it felt demeaning to call childhood friends long-distance late at night when they clearly had other things to do and lives to lead and vibrant, healthy, nurturing, intimate, caring partner-relationships to be in; it felt demeaning and pathetic to constantly apologize for boring someone or to feel that you had to thank them effusively just for being your friend.

[16] (p. 45)

Her apologies for burdening these friends during daylight hours at their workplaces were elaborate, involved, vociferous, baroque, mercilessly self-critical, and very nearly constant, as were her expressions of gratitude to the Support System for Being there for her, just allowing her to begin again to be able to trust and take the risk of reaching out, even just a little.

[16] (p. 59)

[w]hen whatever long-distance friend the depressed person had reached out to finally confessed that she (i.e., the “friend”) was dreadfully sorry but there was no helping it she absolutely had to get off the telephone and back to the demands of her own full, vibrant, undepressed life, a primal instinct for what felt like nothing more than basic emotional survival drove the depressed person to swallow every last pulverized remnant of pride and to beg shamelessly for two or even just one more minute of the friend’s time and attention.

[16] (p. 62)

The intersubjective dynamic between depressed people and others is complicated by the former’s sense of being burdensome to those around them. It is particularly challenging given that the depressed person is often unable to effectively uphold social expectations that underlie intersubjective interactions, which, in ideal situations, is one of mutual reciprocity. While the reality of depression for the sufferer is concrete, it remains obscured from others unless raised to the level of linguistic expression. Hence, intersubjective relations are strained by the depressed person’s desire to articulate his or her suffering while simultaneously risking alienation from others by virtue of “empathetic fatigue”.

The experience of self-alienation cannot be understood independently of the estrangement from others. While illness in general has the capacity to alienate the body-subject from oneself, depression (and chronic illness in general) is unique in the way it alienates. Experiences of influenza, for instance, affect the sense of self insofar as otherwise normal practical possibilities are no longer open to us in the same way. The difference, however, is that influenza is experienced with an implicit trust that self-experience will return to normal. By contrast, the experience of depression often renders one unable to imagine the possibility of recovery.

It is commonly noted that depressed people retrospectively report that they have always been depressed. A similar feature of depressed experience is the inconceivability that depression will ever end:

From the outside in, her life might strike others as good, if not enviable. She knows this on some level but the knowledge dries up as the wind howls through her, reminding her that she feels barren and lost and quite without hope […] The condition that envelops her respects no calendar; it arrives precisely when it feels like it. To the woman, it seems as if she has felt this way, in one form or another, for what feels like forever.

[17] (pp. 9–10)

As much as I wind my mind back in time, I’m unable to locate the start of a downward spiral.

[18] (p. 37)

Doubtless depression had hovered near me for years, waiting to swoop down.

[19] (p. 3)

Depression is no different from other chronic illnesses in that one finds it near impossible to remember what it is like to feel “well.” As I noted earlier, chronic illness becomes normal. Then again, the new normal does not obscure the fact that the sufferer is estranged from oneself, or at least, that self-experience is qualitatively different. That a depressed person believes he or she has always been depressed speaks to the fact that the pervasiveness of depression effaces a normal sense of self. This also validates the phenomenological insight espoused earlier, that the experience of depression is one in which the world—not just the self—is transformed.

In states of health, the body-subject’s experience is one of ekstasis, meaning that he or she is oriented away from oneself toward the world, which solicits an array of practical possibilities. In depression, self-experience is characterized by turning back towards oneself. The world no longer affectively “resonates” [20] with the body-subject. To illustrate, in Karps’s study of depression, a respondent notes how “if you’re in your bedroom and someone said there’s a million dollars on the other side of the room and all you have to do is swing your feet over the edge of the bed, and walk over and get the million, you couldn’t get the million. I mean you literally couldn’t” [13] (p. 30). What makes the experience of alienation in depression all the more painful is its ambiguity; I remain myself yet not myself. If, as Merleau-Ponty [5] contends, life taken up as an existential project, the previous sense of what was significant or meaningful for the sufferer is eroded.

More specifically, a sense of self-alienation is dependent upon the relationship to both world and others. It’s not that depression severs connection between self and otherness, but rather,

Someone with depression feels that their experience of the world is so alien to their friends, partner, or family, seeing the other no longer awakens the habitual sense of connectedness; they feel their own experience as in contrast to the other, as inaccessible and not shareable between them.

[21] (p. 11)

Hence, the experience of self-alienation is a consequence of feeling isolated, which in turn reflects the inward turn towards oneself. Rather than an expansive or ekstatic experience of otherness, depression is experientially directed inward. This is what Fuchs calls “corporealization,” whereby “the patient’s imagination, the sense of the possible, fails to generate future goals and plans, leaving the self confined to the present state of pure bodily restriction” [22] (p. 99). Again, the inward directedness is not simply a decision to turn toward oneself. Instead, “[t]he own self, then, becomes apparent in virtue of how it is encountered by others” [23] (p. 209). Thus, the experience of self-alienation in depression is not merely a matter of not “being oneself.” Though this may be true at face value, self-ambiguity in depression manifests through the estrangement from both world and others.

4. CBT Gold Standard and the Neo-Liberal Subject

The first line of depression treatment is dominated by psychopharmacological and psychotherapeutic interventions. Less common interventions include electro-convulsive shock treatment, transcranial magnetic stimulation, and, more recently, ketamine infusion treatment, the emergence of which is tied to novel research concerning the therapeutic application of psychedelic drugs. It is beyond the scope of this article to explore the efficacy of all these interventions; however, I want to address how and why psychotherapy in the form of CBT remains the gold standard for the treatment of depression.

One of the overarching reasons CBT is widely accepted as the most fruitful psychotherapeutic approach for treating depression is that it is putatively evidence-based. In the same way that psychiatric practice moved away from the theoretical underpinnings of psychoanalytic theory in order to establish itself as a legitimate medical science [24], psychology likewise established itself as a discipline driven by empirical data. The dominance of CBT is partly explained by standardization. In principle, CBT treatment may be applied by various clinicians across disparate patient populations and achieve similar outcomes. More importantly, not only is therapeutic efficacy supported by evidence, the positive effects of CBT are achieved quickly. Unsurprisingly, the fact that CBT is data-driven and reliably reproduced has made it popular with bureaucrats as a cost-effective approach to reducing disability. The problem, however, is not that CBT is evidence-based per se, but rather the way evidence is established, along with underlying assumptions about what it means to be ill in modern life.

The focus of CBT is considerably at odds with the phenomenological summary of depression outlined above. Consider the following:

Unlike psychodynamic and other insight approaches to psychotherapy, CBT focuses on changing what and how people think, behave, and feel in order to reduce psychopathology and promote human growth. CBT does not focus on identifying unconscious drives or past memories but instead is based on the premise that people’ s thoughts and language influence their emotions and actions. CBT posits that certain types of cognitions lead to functional emotions and adaptive behaviors, whereas other types of cognitions generate dysfunctional emotions and maladaptive behavior, leading to psychological disorders.

[25] (p. 15)

The most obvious assumption here is that our experience of both oneself and the world is primarily cognitive. The second assumption is that disorders such as depression are causally attributable to how a person thinks. Because the etiological nature of depression remains unknown, it is possible that in some instances disordered thinking is implicated in depression. For instance, the theoretical underpinnings of CBT draw a link between beliefs and behavior. A person who believes that people do not like her might actively avoid social situations (behavior). Drawing from the definition above, the aim of CBT is pragmatic, such that the belief is interrogated with the intention of modifying the behavior. Hence, if the belief that the person is unlikable is unjustified by evidence, then a more accurate belief ought to in turn elicit behavioral change (placing oneself in social situations). This characterization reflects how CBT views the relationship between cognition and behavior, namely that the former is the catalyst for the latter.

However, this top-down view, that behavior is derived from cognition, is at odds with the phenomenological position that behavior is a derivative of embodied situatedness. In other words, behavior, though it may be amenable to modification via cognition, is pre-reflectively established through motor-intentional habits that develop over time as habitual ways of dealing with situations. With CBT, behavioral modifications follow from cognitive modifications, whereas from a phenomenological perspective, “because the behavioral patterns that trouble us are habitual and not merely occasional, the relevant behavioral changes will also have to be at the level of habit” [26] (p. 133). Additionally, it seems entirely plausible that a behavior may not be altered even with a new belief. If avoidance has reduced anxiety for years, it can persist even after the belief that “avoidance is necessary” weakens. The behavior has its own momentum. Nevertheless, even though CBT seeks to modify cognition and behavior, the dimension prioritized is cognition.

Another problem for proponents of CBT is that the supporting evidence that shapes the practice wrongly assumes that depression is a homogenous phenomenon [9]. Moreover, because CBT has been the subject of countless randomized control trials (RCT), it is often taken for granted that inclusion/exclusion criteria generally go unreported. Accordingly, it is plausible that difficult to treat clients represent a proportion of those excluded from such studies. Exclusions from RCTs often include co-morbidities such as anxiety and substance abuse [27], the purpose of which is to establish as pure a sample group as possible. Treatment-resistant depression (TRD), for instance, by definition represents a population that is difficult to treat, which raises two questions: (a) are people with chronic depression regularly excluded from RCTs, and (b) does TRD directly challenge the claims of CBT efficacy itself?3

A final point on methodological limitations of CBT is that, as a practice, it is not monolithic. It has been widely noted that CBT has developed in waves [25,28,29], which over time have expanded the scope of what constitutes CBT:

What characteristics do the ‘waves’ share that allow them both to be called forms of CBT? It seems to me that their shared characteristics have little to do with actual content (as the values and forms of the ‘waves’ are so divergent), and more to do with the ways in which the ‘treatment’ is legitimated and promulgated.

[29] (p. 37)

CBT retains privileged treatment status within policy development and public medicine despite the fact that the evidence used to justify its superiority over other interventions is not without methodological limitations. Why does CBT continue to be the “gold standard” for treatment of depression?

The public funding for CBT is arguably motivated by two factors: limited duration and cost-effectiveness. While it may be a valid concern to quickly return people to work, it is not a valid therapeutic concern: “It would be naïve to believe that economists, governments, insurance companies, and so on—primary shapers of the therapeutic landscape—are more invested in the population’s happiness than in its productivity and its maintenance of societal institutions” [30] (p. 203). Since many researchers and institutions problematize the economic burden of mental illness, they thus “frame the accessibility and affordability of mental health care services as a solution to an economic and governmental problem, rather than as something to benefit the welfare of those experiencing emotional distress” [31] (p. 13).

While the provision of CBT for mental illnesses such as depression is ostensibly intended to facilitate recovery, the justification is driven by economic productivity rather than therapeutic alignment with what is most appropriate to the person’s needs.

In contrast to the phenomenological notion of a body-subject, government funded CBT programs cast the individual as a neo-liberal subject. Though the concept of neoliberalism is rather elusive, Wendy Brown offers a lucid characterization:

Neoliberalism is most commonly understood as enacting an ensemble of economic policies in accord with its root principle of affirming free markets. These include deregulation of industries and capital flows; radical reduction in welfare state provisions and protections for the vulnerable…and, most recently, the financialization of everything and the increasing dominance of finance capital over productive capital in the dynamics of the economy and everyday life.

[32] (p. 28)

Broadly, neoliberal rationality reflects an impetus for institutions to maximize profit. For individuals, it emphasizes an “entrepreneurial” spirit, which implies individual responsibility for personal success (or failure). A neoliberal subject, then, is less dependent on state support, and his or her life is defined by self-determination. By contrast, the body-subject is inseparable from the world and is embedded in social, cultural, and state practices. A neoliberal subject stands in isolation from his or her practical world. Rather than addressing the social, political, and economic, vicissitudes that inform one’s horizons of possibilities, the impetus is to establish and “enterprising self”, which is “a self that calculates about itself and acts upon itself in order to better itself” [33] (p. 154), emphasis original). Although there is certainly a need for people with illnesses to assume some responsibility for remedying their circumstances, and while self-advocacy is crucial to establishing a care plan that suits the sufferer, the emphasis on self-responsibility ignores the lived experience of depression. The loss of motivation and the inability of others to fully grasp the sufferer’s experience are obstacles to self-responsibility.

Moreover, an essential aspect of instituting a care plan with one’s health provider ought to include choices about therapeutic interventions. By contrast, “[c]onstructed as freely choosing, it turns out that such individuals—and their family members and practitioners as well—are to be guided toward choices regarding their personal mental health that are both ‘evidence-based’ and cost-efficient” [34] (p. 33). The subsidization of CBT is a narrow slice of psychotherapeutic options. Psychodynamic therapies, which are largely relational in their approach—and therefore quite suitable for addressing the intersubjective aspects of depression—are only viable options for those with the financial means. Because many people with depression are often unable to work, non-CBT psychotherapies are not viable in the long term.

The final consideration with respect to the contrast between the body-subject and the neo-liberal subject is that the latter abstracts the former from the world. Depression, phenomenologically characterized by alienation from others and from the world, is at odds with the atomistic treatment approach of CBT. As Merleau-Ponty notes, “[t]hought is a relationship with oneself and with the world as well as a relationship with the other; hence it is established in the three dimensions at the same time” [35] (p.145). From a phenomenological perspective, the body-subject is not constituted by thoughts, but instead expresses a situated nebula of meaning that is established through embodied experience within the world. The focus on correcting thoughts in CBT takes for granted that thoughts are acts taken up by the body-subject. In other words, thinking does not derive meaning in isolation. Instead, it is predicated on pre-reflective practical significance that can only be established by virtue of the indelible relationship between body-subject and the world. This does not mean that the pre-reflective experience that makes reflective experience is inscrutable. The appropriate therapy for individuals cannot necessarily be determined a priori, but given the phenomenological insights explored in this article, a therapeutic approach that appreciates the condition of being a body-subject ought to

involve learning to describe the way in which one experiences objects, the way in which one finds situations calling upon one, how one’s compulsions are experienced…the nature of human contact is always intersubjective. This means first that we are always in search of confirmation of our sense of ourselves and of our world. It also means, second, that the projects upon which we embark are limited in their ability to come to fruition by the level of support provided by our societies.

[26] (p. 137)

The principles of CBT neglect the fundamental intersubjective nature of existence. The experience of alienation from otherness in depression cannot be remedied solely by interrogating the veracity of one’s thoughts. Merleau-Ponty rightly posits that thoughts and ideas always exist between people: “there is no ‘inner’ life that is not a first attempt to relate to another person” [36] (p. 67). A notable limitation of CBT is the neo-liberal assumption that individuals are not subject to external influences that shape their horizons of possibility.

Even though psychodynamic therapies are typically relational in their orientation, they too are by no means perfect. Likewise, it does not mean that relational approaches necessarily incorporate phenomenological considerations. Still, if the impetus of psychiatric and psychological care is to empower people with depression to take responsibility for their well-being, limiting the therapeutic landscape to a single option is prohibitive. It must also be acknowledged that depression may not be ameliorated by any intervention at all. Chronic illnesses, in general, reflect the limits of curative medicine, and while this does not imply “cures” are impossible, a compassionate approach to chronic illnesses should recognize that economic self-sufficiency and self-sufficiency, in general, are ideals at odds with the vicissitudes of lived-experience of depression.

5. Conclusions

The incidence rate of depression is significant. While it is medically characterized by a standard set of symptoms, these symptoms fail to reflect the phenomenological reality of depression. Merleau-Ponty’s notion of the body-subject contends that existence is embodied and, therefore, situated. Our primary experience of the world is not cognitive but rather practically engaged via perceptual significance. Our body responds to the practical demands of our situations without adopting a reflective attitude. In states of health, the body is not experienced as an object but is instead “transparent” in the sense that it belongs to the background of experience. The lived experience of depression is characterized by alienation from self, others, and the world. What was previously possible no longer appears possible, and things in the world no longer “speak” to us. Relationships are complicated by an inability to connect with others since the backdrop of a shared world is eroded. Also, the invisible nature of depression prevents other from fully understanding the person’s suffering.

The most subsidized form of treatment for depression (and mental illness in general) is CBT. This therapeutic paradigm operates on the assumption that depression is the result of disordered thinking. The aim of CBT is to challenge and reframe incorrect or irrational thoughts that elicit depression. The prevalence of CBT is attributed to the fact that it is evidence-based, cost-effective, and short-term. However, the justifications of the CBT model reflect the needs of a neo-liberal subject rather than a body-subject. The evidence supporting CBT’s efficacy is not inscrutable. In addition to considerable methodological limitations that undermine the supposed superiority of CBT, the theoretical assumptions about the nature of subjective experience are at odds with those of phenomenology. Not only is the CBT user taken in isolation from his or her world, but there is also an implicit assignment of responsibility to the user, insofar as one is responsible for correcting one’s thinking.

While CBT may prove effective for some people, depression is very often difficult to remedy. Moreover, that people with depression are limited to one form of therapeutic intervention is somewhat at odds with empowering people to take responsibility for their care plan. Since depression is heterogenous, it is reasonable to question whether CBT is always the most suitable form of therapy, and understanding which therapy is most appropriate for a particular individual remains an open question. Furthermore, it must be acknowledged that, like other chronic illnesses, depression may be irremediable, and this raises larger questions about how government institutions ought to support flourishing in the face of disability, specifically by re-conceptualizing the economic, medical, and social needs of those who are ill.