Thoughts on Manufacturing Depression by Gary Greenberg

Image: Simon & Schuster (US)

The book: Manufacturing Depression: The Secret History of a Modern Disease by Gary Greenberg (2010). Simon & Schuster (US)/Bloomsbury (UK)

By Geoffrey Hugh Miller

If we claim to see massage as a component of a holistic therapy, and feeling depressed is so common, there is much in this book for massage therapists.

I wrote ‘feeling depressed‘ rather than ‘suffering from depression‘, because that is one of Greenberg’s main points – that depression should not (in most cases) be considered as a disease and that the medicalisation of depression has created many problems for patients as well as a raft of opportunities for therapists and, of course, pharmaceutical companies. These have all happily contributed to a lot of misinformation about depression, not least by the argument that if (pill/proprietary methodology) fixes the problem, then the problem must be real; the problem is thus defined by its cure.

Massage therapists who advocate particular beliefs about the causes of the problems they are trying to address may want to consider this point carefully – the fact that a therapy based upon a particular model of what is happening in the tissues or nervous system appears to achieve its desired ends does not, in itself, confirm that the model is correct.

The broader value of the book for massage therapists is that the history of the medicalisation of depression provides a case study of the attempt to convert an art into a science. What I mean by an art is a skill, based on intensive study and experience, which addresses complex problems and is practised in a way that at its highest levels often goes beyond rational analysis, at least without the benefit of hindsight. In any activity involving living systems, the complexity and scale of issues to be addressed almost guarantees that a “by the numbers” approach will, if not fail, only achieve a limited success. Consider the gardener with “green fingers”, or the horse trainer who achieves an almost magical rapport with a horse – they have gone beyond simply following a recipe, they are practising an art.

Another aspect of an art is that artists will not all find identical solutions; consider the variety of techniques in massage or in psychotherapy, and then allow that each therapist will find his or her own approach to using these techniques. Each encounter between therapist and client/patient involves two unique individuals, so why should we expect a standardised, script-driven approach to achieve the best results?

But if psychotherapy is an art, why was it felt necessary or desirable to try to convert it into a science, or something that could be presented as a science, with theoretical justifications and standardised processes?

This is where the massage profession may be able to learn a lesson. In part the change occurred because psychotherapists wanted to increase their own status within the medical professions, to be seen as real professionals, and that meant adopting the formal definitions and standardised methods of treatment appropriate to a ‘scientific’ discipline. However, there were also financial pressures on therapists and their patients:

‘In 1975, a Blue Cross representative told Psychiatric News that his industry was reducing mental health treatment benefits because “compared to other types of services, there is less clarity and uniformity of terminology concerning mental diagnoses,” and added that because “only the therapist and the patient have direct knowledge of what services were provided and why,” the insurers couldn’t be sure they were even paying for the treatment of an illness.’

(Greenberg 2010, p. 238)

Does that sound familiar to anyone who has dealt with health funds (or the NDIS)? Are we seeing, in some quarters at least, a similar attempt to biomedicalise massage therapy, and for similar reasons? The more benefits our clients can claim, the more they will use our services, and therefore the more we get paid. Perhaps true as far as it goes, but if the cost is a restriction on our ability as professionals to exercise our skills in the way that we feel will best benefit our client, is that a price we are prepared to pay?

Greenberg also introduced me to the ‘Dodo Bird Effect’. This is probably familiar to psychotherapists, but it also has relevance to massage. The reference is to Alice in Wonderland, but in psychotherapy it goes back to a study by Saul Rosenzweig in 1936, in which he concluded that all forms of therapy, competently practiced, were equally effective. This might have been filed as a minor embarrassment, except that Luborsky, Luborsky and Singer (1976) re-investigated this effect using more recent data and modern statistical analysis techniques and reached the same conclusion. Luborsky et al even suggested an explanation: that the common elements, including a helping relationship with a therapist and other related, non-specific effects, may, in large part, account for a therapy’s success. As Greenberg puts it (2010, pp. 300-301):

‘The conclusion is inescapable: to the extent that therapy succeeds, it’s due not to the particular help that’s offered, but rather to the fact that something is offered in the first place, and by a person whom the patient expects, and believes, will help. Therapy, no less than drugs, works by the placebo effect.’

This was written about psychotherapy, but I suggest it is equally applicable to physical therapy, or at least with the partial qualification of ‘works in large part by the placebo effect’. And of course that’s not a bad thing – another way of looking at the placebo effect is that it provides the mind with a structure that allows it to engage the body’s own healing mechanisms and participate in the therapeutic process. The client’s belief that the therapist cares, and that they are being helped, is vital to success.

Obviously, the Dodo Bird Effect has supporters and detractors, and Wikipedia provides an interesting summary of the arguments for and against – and why neither side has convincingly proved its case. However, it is also something that massage therapists should consider as we weigh up the pros and cons of trigger points, myofascial release, dry needling and whatever other entries turn up in the therapeutic alphabet soup; the fact that one particular approach works for us does not invalidate other approaches used by other people.

I found this a very interesting and stimulating book. If massage is a component of a holistic therapy, then we need to be willing to look beyond just what we do and learn from the experiences – good and bad – of therapists in other professions.

Other Reading

Book review by Nicholas Pimlott, MD (Canada)


About the Author

Geoffrey Hugh Miller is based in Canberra. Geoff began studying TCM Remedial Massage in 2007 to complement an interest in Tai Chi before undertaking further studies in Remedial Massage and, more broadly, in the health sciences. Geoff is interested particularly in the application of massage and Tai Chi in disability care and aged care.


All other images courtesy of Pixabay.

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