Social Origins of Depression

A study of psychiatric disorder in women

George W. Brown, Tirril Harris

• Publisher: Routledge
• Year: 2012
• ISBN:
  9781135645038
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

Tavistock Press was established as a co-operative venture between the Tavistock Institute and Routledge & Kegan Paul (RKP) in the 1950s to produce a series of major contributions across the social sciences.
This volume is part of a 2001 reissue of a selection of those important works which have since gone out of print, or are difficult to locate. Published by Routledge, 112 volumes in total are being brought together under the name The International Behavioural and Social Sciences Library: Classics from the Tavistock Press.
Reproduced here in facsimile, this volume was originally published in 1978 and is available individually. The collection is also available in a number of themed mini-sets of between 5 and 13 volumes, or as a complete collection.

Part II

The Provoking Agents

4 Measurement of Life-Events

There is a large and apparently causal link between life-events and depression. At least half the depressed women we studied had a recent life-event of aetiological importance. However before this is discussed it is essential to deal with some of the methodological issues surrounding the establishment of causality in non-experimental research. It is not just a matter of statistics and technical issues – although these can be involved. Methodological considerations start from the fact that it will usually be possible to reach alternative conclusions about the same set of results: methodology concerns anything that enables the researcher to rule out explanations that compete with the one favoured. Returning to the investigation of life-events and sore throats in children, perhaps it was not emotional upset but change in routine brought about by the crisis that led to the raised rate of illness? This is an explanation that still assumes that there is a causal link. More fundamentally the whole idea of a causal link might be rejected; it might be suggested, for instance, that the regular fortnightly questioning conveyed to parents what the study was about and some parents, in order to be helpful, made an effort to think of a crisis to ‘give’ to the investigators once they knew their child had a sore throat. And that this and not a causal link explains the association between life-events and sore throats. Investigators have to do what they can to anticipate such objections. The first, for instance, might be met by excluding from the analysis events likely to have led to changes in a child’s routine (e.g. admission of mother to hospital) and demonstrating that the association still held with the remaining events (e.g. the child witnessing a bad road accident). In response to the second, more fundamental, objection it can be pointed out that the association holds not only for overt illness but for the acquisition of strep throats without overt illness. Since parents could not have been aware of such changes in their child the main results become more plausible. These are typical methodological arguments and illustrate how the issues can usually be appreciated without special statistical or mathematical knowledge. One further point should be borne in mind. It is unnecessary to demonstrate that a methodological objection is correct, only that it is a reasonable possibility. It was only possible, not obviously true, that the parents of children with sore throats had made an effort to remember events to ‘give’ the investigator. The objection is plausible enough to deserve some response.

In this chapter we start with methodological problems surrounding the definition and measurement of life-events, using for illustration some early work with schizophrenia.

Life-Events and Distress

Lindemann’s classic paper on reaction to bereavement and David Mechanic’s well-known Students Under Stress dealing with university examinations, like most work on life-events, concern distressing circumstances. However there is no need for research to restrict itself in this way. Barbara and Bruce Dohrenwend (1974a), while seeing life-events as disrupting – or threatening to disrupt – usual activities, do not view them as necessarily involving negative experience, and a wide range of incidents can therefore be studied – finishing school, starting a job, leaving parents, marriage, birth of a child, death, divorce, promotion, and move of a house. But this at once raises the question of where we stop. Hans Selye, who published the first of his influential papers based on animal experiments in 1936, has argued that stress is a natural by-product of human activities. In similar vein Lawrence Hinkle writes:

‘The ordinary activities of daily life – the ingestion of food, or the failure to ingest food; muscular activity, or the absence of muscular activity; breathing, or not breathing; sleeping, or not sleeping – all affect the dynamic steady state. Their effects are not qualitatively different from those of the “stressors” that are used in the laboratory, It has been aptly said “to be alive is to be under stress”.’ (1973: 43)

Since the reasoning behind this kind of broad definition is the notion that stress-is-a-part-of-our-smallest-activities, one response to the question of where we stop is to reject this view of stress. Mason (1975) argues that too little attention has been given to the fact that laboratory experiments with animals using physical stressors such as exercise, heat, and cold are usually also emotionally disturbing. Responses of the pituitary-adrenal cortical system first studied by Selye may be largely due to psychological responses to the experimental situation on the animal’s part. If much of biological stress research can be seen in these terms, there is not the same case for considering change as such as stressful irrespective of its meaning for the subject.

But although this simplifies the issue it still leaves us with the dilemma of what should be included as a life-event. Even if we reject the idea that ‘to be alive is to be under stress’ there is still a need to settle where to place the threshold for disruption or disturbance. The Dohrenwends, who quote Hinkle’s passage, are clearly worried by its implications and note that although they ‘do not doubt the truth of this generalisation, it nevertheless is a highly abstract truth’ (1974:4). They deal with the question by returning to the notion of distress, concluding that life-events differ in stressfulness and it is necessary to distinguish the more from the less stressful. Fortunately our early work with schizophrenic patients provided an answer which gives a flexible solution. We first became interested in life-events in 1959 when talking to the relatives of schizophrenic patients about what had led to admission. One wife told us how her husband’s doctor had insisted that he stay at home until he could be admitted to hospital for a minor hernia operation. (In fourteen years he had never before had time off work.) A fortnight later to her amazement he took off his clothes and rushed into the nearby church, shouting about a plot to get him. As we continued we found other incidents closely antedating onset of schizophrenic symptoms. In the next interview a wife told us how her son had come home from school to say, to everyone’s surprise, that it had been settled that he was to go to sea as a trainee merchant naval officer almost at once, a year earlier than they had thought. Within two days of his leaving, her husband developed schizophrenic symptoms. In the next but one interview a couple, who had been planning for over a year to move into a new home, took a week off work, ‘planning everything like a military operation’. All went well at first; symptoms developed suddenly on the seventh day of these preparations, on the night of the move itself, when the patient woke his wife with a flood of strange talk about someone stealing their gas stove.

Our first reaction was to be puzzled by the variety of the incidents. Some were unexpected but others had been eagerly sought; some were major catastrophes but others involved no more than a change in routine; some involved nothing by way of a change or disruption of routine and others even the occurrence of something much desired. No definition in the literature appeared to fit (see Mechanic, 1968:301). Most definitions emphasize the need for a novel pattern of problem-solving or threat to an important life-goal. We could not readily square the heterogeneity of our incidents with such formulations. Although we were in no position to say what was important, it was clear that the move planned ‘like a military operation’ did not demand novel patterns of problem solving (the couple had done it before and could scarcely have been better prepared) not did it involve any threat to important life-goals (they had eagerly sought it).

While at this point we did not wish to commit ourselves to a rigid definition, our interviews did suggest that schizophrenia might be precipitated by marked emotions of any kind – by joy and excitement as well as by distress and fear. This would be enough to explain our puzzlement about the bewildering variety of events. Tomkins (1962 and 1963) has discussed eight innate affects and the wide range of stimuli that produce them – interest or excitement, enjoyment or joy, surprise or startle, distress or anguish, fear or terror, shame or humiliation, contempt or disgust, anger or rage. We therefore came to see life-events in terms of the emotions they might arouse irrespective of the quality of the emotion involved; and as some psychologists have argued, it is the appraisal of the environment that leads to emotion and to ‘stress’ (e.g. Arnold, 1961; Lazarus, 1966). We will also need to keep in mind that it is likely to be the meaning of events that is significant rather than change as such.

Measurement of Life-Events in the Schizophrenic Study

In the schizophrenic study itself we therefore started with the somewhat vague belief that marked emotion could be enough to precipitate florid symptoms. At this point we made a critical decision that has had major methodological ramifications throughout our research programme. We decided to define or measure events in terms of the likelihood of their having produced strong emotion rather than by the emotion they actually produced. The implications of this decision will only gradually emerge, but it is clear that it had the considerable advantage of allowing us to avoid the onerous task of establishing the emotional arousal consequent on previous events.

We therefore drew up a comprehensive list of events which could be dated to a particular point in time and which we believed would for most people be likely to be followed by strong negative or positive emotion. These were the basic units of study. It did not matter that a particular event was not in fact followed by emotional arousal. We largely restricted ourselves to events involving the respondent (henceforth called the subject) and his ‘close ties’; that is members of his or her household or a close relative (i.e. spouse or cohabitee, parent, sibling, child, or fiance), but at times particularly dramatic incidents involving more distant relatives or even strangers were included as long as the subject had been present (e.g. witnessing a serious road accident). In the depression study we also included confidants as close ties. A confidant was an especially close friend, defined as one to whom the subject felt able to confide any problems or worries with complete trust.

The list contained thirty-eight types of event falling into the following eight groups:

1. changes in a role for the subject such as changing a job and losing or gaining an opposite-sex friend for the unmarried;¹
2. changes in a role for close relatives or household members, such as a husband staying off work because of a strike;
3. major changes in health, including admissions to hospital and developing an illness expected to be serious; and
4. similar changes in close relatives or household members;
5. residence changes and any marked change in amount of contact with close relatives and household members;
6. forecasts of change, such as being told about being rehoused;
7. valued goal fulfillments or disappointments, such as being offered a house to rent at a reasonable price;
8. other dramatic events involving (a) the subject, e.g. witnessing a serious accident or being stopped by the police when driving, or (b) a close relative or household member, e.g. learning that a brother had been arrested.

In every instance the events can be seen as involving change in an activity, role, person, or idea.²

Two illustrations will be enough to give a general idea of our standards; a more general sense can be got from Appendix 3 which gives examples of most types of event.

(1) For major changes in health we included events occurring to those with whom the subject lived as well as close relatives. All admissions to hospital for the subject were included, but only those that were urgent or lasting one week for other persons. Illnesses not followed by admission were counted only if in our judgment they involved a possible threat to life or were alarming enough for serious implications to be suspected. Accidents were covered by similar criteria. There was one exception: we included any new contact with a psychiatric service by a close relative. Deaths of anyone at home and close relatives were included but otherwise only when the respondent had been present or involved in the immediate aftermath (such events were rare).³

(2) Marked changes in social contact included anyone leaving home after a stay of at least three months, someone coming for as long as three months, and the start of a relationship with someone of the opposite sex (if it seemed likely to continue for some time) or its ending (if it had lasted for at least eight weeks). Close relatives were included where frequency of contact had been reduced by at least two-thirds and where the usual rate of contact (including telephone calls) had been at least once a month.⁴ In order to meet these criteria a total break was usually involved – the person most often moving some distance from London.

In addition to the list of events which, with the necessary probes, was used as an interview schedule, we developed a reference book of several hundred pages which included extensive instructions along the lines of the preceding paragraphs for each of the thirty-eight classes of event. These guided the interviewer and enabled a decision to be made about what to include. It was insufficient, for example, simply to ask about accidents. It was necessary to settle before the main study began whether to include, say, an accident to a woman’s husband wh...

Table of contents

• Cover Page
• Half Title page
• Series page
• Title Page
• Copyright Page
• Original Title Page
• Original Copyright Page
• Epigraph
• Contents
• Acknowkedgements
• I Introduction
• II The provoking agents
• III Vulnerability factors
• IV Symptom-formation factors
• V Interpretation and conclusions
• VI Appendices
• Notes
• References
• Index