Silence in Mood Disorders

We tend to assume that silence in and around mental illness is harmful and socially imposed. It is an assumption drilled into us by countless mental health campaigns and reams of scholarship warning that people are “suffering in silence” and urging us to “break the silence.”

There are of course good reasons for this. Stigma does pressure many people with mental health problems into silence, for fear that others will find out about their struggles and mistreat them as a result. Relatedly, the scholarship on epistemic injustice in healthcare has drawn attention to how an unfair lack of the conceptual resources people need to talk about their mental health—a kind of hermeneutical injustice—can impose silence on them. These sorts of imposed silences can, in turn, be entrenched by other people’s failure to talk about, or be open to, conversations about, mental health.

But our narrowly negative assumptions about silence can also harm because they obscure the fact that silence in mental illness, just as in our lives generally, is a diverse experience that can perform a variety of functions, both beneficial and harmful. This limits our understanding of the predicament of people with mental health problems and how we can best support them. So, I want to try to unsettle these assumptions by exploring some silences that shape the lives of people with mood disorders such as depression and bipolar disorders.

Now, silence can mean many different things, so it is worth being clear from the start about what I mean. I am concerned with first-person experiences of being literally silent—that is, of not speaking either outwardly, with our mouths, or inwardly, in our minds—in the context of major depressive and bipolar disorders. In mental health discourse and philosophy, the concept is often used much more loosely to include both literal and metaphorical silence—that is, when people are still speaking but they are, perhaps intentionally, not speaking about something.

I want to explore two types of literal silence here: empty silence and elusive silence. Both are significant sources of distress and functional difficulty in mood disorders. And in both cases, I will suggest, the injunction to break silence tends to compound that distress rather than relieve it. I also contend that they illustrate why the capacity to be silent deserves to be studied in its own right.

Empty Silence in Depression

The first silence is a kind in which it seems as though no one else, no circumstance, and no social norm is preventing you from saying something that you want to say. In fact, you might be keenly aware that your contribution is welcome, perhaps even encouraged or demanded. Rather, what seems to keep you silent is that you have nothing to say.

Many first-person accounts of depression contain descriptions of this sort of experience. In his now-classic The Noonday Demon, for example, Andrew Solomon recalls being unable to converse even with supportive family members during his depressive episodes:

I could not manage to say much; words, with which I have always been intimate, seemed suddenly very elaborate, difficult metaphors the use of which entailed much more energy than I could possibly muster.

I call this type of experience empty silence because, phenomenologically speaking, it is characterized by a kind of linguistic lack. Crucially, this is not the kind of lack associated with hermeneutical injustice, in which an individual has some experience they want to express but lacks the resources to do so because of unjust social arrangements. As Solomon’s account suggests, he has the words, but he is unable to draw on them in a way that allows him to respond to his loved ones’ invitation to speak.

Nor does empty silence involve the kind of lack of concrete opportunities to speak that we often have in mind when we talk about the need to break the silence of mental illness. Jae Ryeong Sul argues convincingly that empty silence is a distressing experience precisely because it involves a solicitation to speak—and, more specifically, a solicitation that the individual would ordinarily have been able to respond to with ease.

The lack that characterizes empty silence appears to be more akin to what the psychiatrist and phenomenologist Karl Jaspers described—using a term that will strike discordant notes today—as a form of classical retardation: “No associations appear; nothing enters consciousness. There is a tendency toward a complete blank.”

Contemporary psychiatry still recognizes a related phenomenon, poverty of speech, as a symptom of depression—which, resonating with Jaspers’ terminology, is considered a type of psychomotor retardation. Indeed, research suggests that it is one of the most reliable symptoms by which to diagnose the illness. This makes it all the more surprising that the phenomenon of empty silence remains virtually unacknowledged in both mental health campaigns and the philosophy of psychiatry.

This has real consequences for people with mood disorders: It means that something that is a potentially significant source of distress goes unrecognized, and that well-meaning people may respond in ways that compound that distress. One person with bipolar disorder we interviewed described exactly this pressure. People around them would ask what was wrong, whether they were okay, and whether they needed anything. Even when they had no words to respond, they still felt the pressure to do so and to make others feel better about their silence.

Elusive Silence in Mania

Empty silence is the first of the silence experiences that tend to get lost in our focus on breaking silence. The other is a broader type of experience that we might call elusive silence. By this, I mean silences that people struggle or fail to maintain. Examples are particularly salient in the context of hypomania and mania, though they can be found in first-person accounts of depression as well.

One of the most common symptoms of hypomanic and manic episodes is that individuals speak more and faster than they usually do, a symptom sometimes termed pressure of speech. The Diagnostic and Statistical Manual of Mental Disorders (DSM)—the handbook that U.S. psychiatrists use to diagnose mental illness—emphasizes that it is often difficult for others to interrupt someone with this symptom. What it fails to note is that many of those people themselves find it difficult to stop talking, and, indeed, to regulate whether they talk at all—that is, to be silent—and that this can be a source of great distress and difficulty.

Consider the following passage from Manic: A Memoir, Terri Cheney’s account of living with bipolar disorder. She is recounting her arrival at a prestigious writing retreat, which she saw as a milestone in her developing career:

I wanted to talk, I needed to talk, words pressed up so hard against the roof of my mouth I felt like I had to spit to breathe. One doesn’t spit in Paradise; and it doesn’t make a very good impression on the first day of a workshop. I managed, by clamping my jaw shut and sucking on my tongue, to get through most of the introductory small talk with responsive nods and a tight-lipped smile.

She paints a painfully vivid picture not just of the sheer effort that being silent demanded but also of the awkward bodily techniques she was forced to rely on in order to maintain a precarious grip on her silence.

Not everyone manages this reliably or at all. And this can have serious consequences beyond whatever distress comes with having to fight oneself to stay silent. For example, individuals also testify to being unable to keep their own secrets, listen to other people, or allow others to speak—actions that seem integral to our moral, epistemic, and social agency.

Here again, our habitual ways of speaking about silence in the context of mental illness may be harmful. That is because they are liable to obscure the distress and difficulties that people with mood disorders face and to hide how we could better support them. They might also make things harder for those who manage to keep a precarious hold on silence, by exposing them to pressures to break that silence.

The Capacity to be Silent

The phenomenology of silence in mood disorders illustrates why it is important to move beyond myopic assumptions about silence as a socially imposed harm—and not just for healthcare practitioners and mental health campaigners, but for all of us who have an interest in making the lives of people with mental illness better. Appreciating the diversity of silence in mental illness and beyond is a crucial start in effecting this move.

However, the first-person accounts, particularly of elusive silence, also point to something that warrants much further research: the importance, conditions, and fragility of the capacity to be silent.

This is a capacity that has received very little attention, even from those in the emerging field of silence studies who emphasise the positive functions of silence in human life. I think this is because it is a capacity that most of us can and do take for granted, because, unlike Cheney, we very rarely have to reflect on the need to be silent and deliberately respond to it. When a conversation or some other situation calls for us to be silent, it tends to happen automatically, and we do not even notice the moral, epistemic, social and other functions that it serves, such as withholding an unfair and nasty comment that comes to mind during an argument with a friend. And, even on the odd occasion that we do have to think about it, we do not have to, again unlike Cheney, awkwardly contort our bodies to prevent the nastiness from coming out.

What this points to is that being silent isn’t just something that happens to us. It is something that we do, that we can become unable to do, and, indeed, that others can wrongly prevent us from doing. Recognizing this opens an entirely new area of research that I think could and should occupy philosophers and other researchers for years to come.

Three questions strike me as especially pressing. First, a conceptual one: If being silent is something we do, what kind of capacity is it? One possibility is that it is a kind of skill that we can exercise well or badly and perhaps even measure. Second, an empirical one: What other conditions and circumstances might this capacity be disrupted in? Plausibly, candidates include anxiety, Tourette’s syndrome, and ADHD. And third, an ethical one: What kinds of ethical issues does this capacity raise? Perhaps its possessors can be wronged, say, by emotion-reading AI, or workplace doctrines that prize relentless disclosure.

Wherever these questions lead, the stakes are clear for people with mood disorders, because for them, both being able to speak and being able to stay silent can be equally hard-won. Understanding silence as a capacity and not just a socially imposed harm is a small but important step toward taking their predicament seriously.