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Depression Narratives: How the Self Became a Problem1Jette Westerbeek Karen MutsaersLiterature and Medicine, Volume 27, Number 1, Spring 2008, pp. 25-55 (Article)Published by The Johns Hopkins University Press DOI: 10.1353/lm.0.0017

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Jette Westerbeek and Karen Mutsaers


Depression Narratives: How the Self Became a Problem1Jette Westerbeek and Karen Mutsaers

A scholar of Melancholy am I Chastised By Sorrow Forced to ceaseless learning Till the end of my life

Charles dOrleans (13941465)2

Many people afflicted with a serious disease ask themselves why they in particular have been afflicted, and this nagging question soon generates a negative picture of their identity.3 In her famous essay, Illness as Metaphor, and in its sequel, AIDS and Its Metaphors, Sontag argues that diseases with unknown causes give rise to personality-focused interpretations and to a variety of damaging metaphors, and illustrates her thesis with myths about tuberculosis and cancer. For a long time, there was no clear medical-biological explanation for these diseases, which made them puzzling and mysterious; this in turn gave rise to interpretations that sought causes within patients personalities and behaviors. However, the moment an organic origin was discovered for a disease, such interpretations came to a halt. At that point, physicians and patients regarded the disease as curable and thus not representative of the sufferers character. These shifts in understanding tuberculosis and cancer led Sontag to oppose all metaphorical interpretations of diseases: My point is that illness is not a metaphor, and that the most truthful way of regarding illnessand the healthiest way of being illis one most purified of, most resistant to, metaphoric thinking.4 Depression is a disease surrounded by the unknown. Despite extensive research, there is still no theory to explain conclusively the origin of depression on exclusively somatic grounds, since both internal and external causes can disturb serotonin metabolism. Although modern antidepressants (selective serotonin reuptake inhibitors, SSRIs) can reduce major symptoms in about two-thirds of the cases, full recoveryLiterature and Medicine 27, no. 1 (Spring 2008) 2555 2009 by The Johns Hopkins University Press



still remains impossible. It is possible that this has helped alter the negative image of depression in the general publics understanding of the disease: if it could be cured with a pill, then it is a disease and not a sign of personal shortcomings. One-third of patients, however, are resistant to antidepressants.5 Hence, there is ample room for personal blame. In this article, we will present a picture of how, in the age of Prozac,6 people suffering from depression think about their illness and their selves. Popular narratives and Depression: Stigma We approach depression from patients perspectives as written down in published illness narratives. By reading these stories, we get a glimpse of how the authors wider social circles perceive people in low spirits. We look at the relationship between illness and identity as a matter of labeling, prejudice, internalization, and particularly, stigma. Stigma is not an easy concept to define because it is a constantly changing reflection of cultural and social contexts. However, Goffmans definition is still regarded as the most adequate one: stigma is a deeply discrediting attribute, and the stigmatized are viewed as less than fully human because of it. He states that every human quality (physical and mental, as well as social) is potentially stigmatizable.7 Stigma can be understood as the social rejection of a person or a group of people for being different in a negative way, for deviating from the norm, which, in Western culture, is generally to be an optimistic and a vigorously ambitious striver for success. The concept of stigma is loaded with moral overtones. In the eyes of the non-stigmatized (normal people), the principal question is that of responsibility: More often than not, the blame for the stigmas existence is attributed, at least in part, to the personality of the stigmatized person himself or herself. It is assumed that the person has committed some immoral act and that the stigma is punishment for this moral transgression.8 As Wolpert says, the discrediting stigma of mental disturbances, such as depression, is so compelling because it is not localized in the external world or in any other specifiable organ, such as the lungs or heart, but rather in the core of someones self.9 Since the nineteenth century, two views on depression prevail in the general population: a romantic version of depression as a dramatic cultural phenomenon among a western intellectual elite, even to the

Jette Westerbeek and Karen Mutsaers


point of signifying what it means to be a thinker, a scholar, or poet. This sublime version, called Melancholia, is historically reserved for men. By contrast, women who fall into the depths of sorrow are all too easily dismissed with the banal and unprestigious term depression.10 This banal image of depression stigmatizes because it devalues the sufferer by designating her as a weak-willed, oversensitive boor. Despite progress in diagnosis and treatment, there is, as far as we can see, hardly any evidence of a diminishing stigma on depression. Schreiber and Hartrick conducted a small-scale qualitative study of female patients suffering from depression; the study suggests that, due to the advent of modern antidepressants, some patients tend to accept the biomedical explanation and attribute less importance to psychosocial factors, treating their depression as a simple biochemical imbalance. Paradoxically, even though these female patients experienced relief from their feelings of guilt and shame, their social surroundings kept defining them as weak mental types.11 Despite the introduction of modern antidepressants, depression continues to carry a considerable stigma. Wolpert thus argues, in a personal reflection in the British Medical Bulletin, that depression is still considered typical of housewives (and certainly not something that elite soccer players would suffer from) and is attributed to people lacking willpower, that is, to those who would do much better if they only tried harder.12 Self: Cause or effect? next to the popular understanding of depression, patients themselves also try to give meaning to their illnesses. Since about 1990, a growing scholarly literature (psychotherapy, sociology, womens studies, literary studies) has examined the relationship between identity and mental disturbance from the perspective of illness narratives by patients themselves or by their psychotherapists.13 These publications focus on illness stories in moderate opposition to the currently dominant biomedical argument. As for the relationship between depression and self, this literature demonstrates two distinct positions: person-oriented and problem-oriented14 In the person-oriented position, depression is perceived as an integral part of the self. From this essentialist position, depression is seen as deforming an already existent, and partly recoverable, identity. More essentialist psychodynamic psychologists locate the cause of depres-



sion in interactions with important (former) binding figures and in the manner in which these interactions are subsequently preserved in the self.15 Understanding and processing generated emotions enables patients to at least partly recover their impaired identity. Alternative person-oriented, holistic therapies are also directed explicitly toward the person as a whole and not toward the affliction alone.16 By contrast, in the problem-oriented position,17 depression is regarded as independent of the self. Grounded in the oeuvre of Michel Foucault, this postmodernist approach regards psychic problems not as something derived from a personality structure, but as the manner in which surrounding culture affects it, in the so-called constitutive effects of power. The self is not seen as a cause, but as an effect of depression, a new identity generated through narration. The current, dominant medical-biological way of thinking in psychiatry, with the DSM as a diagnostic instrument, also represents the problem-oriented position, although quite different in its theoretical orientation. In this view, everything is directed toward making the right symptom-related diagnosis and prescribing the right symptom treatment. The self does not appear; . . . the diagnosis, not the patient, often gets treated.18 Outside the disciplines of medicine and psychotherapy, sociologists Karp and Frank (2000), literary scholar Stern, and womens studies researcher and psychiatrist Metzl present a postmodernist view of the relationship between depression and the self, although not all of them are indebted to the theory of Foucault. These scholars conclude from their research into the experiences of depressed patients that the self is a constant recursive process in which the harrowing experience of the disease prompts the patient toward reviewing his or her own self-image. They attribute an important role to modern antidepressants in this process, as these medications seem to foster a problem-oriented self-view. However, as time goes by, the central role of anti-depressants does not last, and a more person-oriented self-construction finally emerges. Karp explicitly elaborates the person-oriented problem in his concept depression career,19 which describes the successive phases people go through during their illness. Based on fifty in-depth interviews with depres