Depression, Disconnection, and the Meanings of Illness
Based on a series of interviews with fifty depressed men and women, as well as the author's personal experience of depression for nearly twenty years, Speaking of Sadness will help the reader learn what depression really feels like.
As a sociologist, Karp brings to light the myriad ways society contributes to widespread alienation and emotional exhaustion. Karp believes that, in our fragmented, post-modern society, an increase in the number of individuals suffering from depression is to be expected and will, unfortunately, continue until we 'rediscover community as the very best medicine for the sadness of depression.'
What follows are excerpts and ideas from Speaking of Sadness:
From The Author:
In greater or lesser degree I have grappled with depression for almost 20 years. I suppose that even as a child my experience of life was as much characterized by anxiety as by joy and pleasure. And as I look back on it, there were lots of tip-offs along the way that things weren't right. I find it difficult to remember much of my early years, but throughout high school and college I felt uncertain of myself, feared that I could not accomplish what was expected of me, and had plenty of sleepless nights. During college one of my roommates nicknamed me 'weak heart,' after a character-type in Dostoyevsky novels, because I often seemed a bit of a lost soul. During all those years, though, I had no real baseline for evaluating the 'normalcy' of my feelings. At most, I had defined myself as more anxious than other people and as a 'worrier.' None of this seemed to warrant treatment of any sort. Even though I was sort of muddling along emotionally, probably like having a low-grade fever all the time, I was achieving well enough in school to presume that underneath it all I was okay. It wasn't until my early thirties that I was forced to conclude that something was 'really wrong' with me.
People who have lived with depression can often vividly remember the situations that forced them to have a new consciousness as a troubled person. One such occasion for me was a professional meeting of sociologists in Montreal in 1974. I should have been feeling pretty good by any objective standards. I had a solid academic job at Boston College, I had just signed my first book contract, and I had a great wife, a beautiful son, and a new baby daughter at home. From the outside my life looked pretty good.
During the week I was in Montreal I got virtually no sleep. It's true, I was staying in a strange city and in a borrowed apartment. I thought that maybe this was the problem. But I had done a fair amount of traveling and never had sleeping problems quite as bad as this. Then, I thought, 'Maybe I'm physically ill. It must be the flu.' But again, it was unlike any flu I'd ever had. I wasn't just tired and achy. During each sleepless night my head was filled with disturbing ruminations and during the day I felt a sense of intolerable grief as though somebody close to me had died. I was agitated and felt a melancholy that was qualitatively different from anything in the past. I couldn't concentrate because the top of my head felt as though it would blow off, and the excitement of having received the book contract was replaced by the dread and certainty that I wasn't up to the task of writing it. It truly was a miserable week and the start of what I now know was an extended episode of depression. It was also the beginning of a long pilgrimage to figure out what was wrong with me, what to name it, what to do about it, and how to live with it. It has been a bewildering, frustrating, and often deeply painful journey.
By some standards I have been fortunate. Even though depression has periodically made me feel that my life was not worth living, has created havoc in my family, and sometimes made the work of teaching and writing seem impossible, I have not lost my family, my work, or, for that matter, my life. At age 50 I have surrendered myself to depressive 'illness' in the sense that I do not believe I will ever be fully free of it. For me, depression has a chronicity that makes it like a kind of mental arthritis; something that you just have to live with. My aim is to live with depression as well as I can.
Given the pervasiveness of depression, it is not surprising that both medical and social scientists have tried to understand its causes and to suggest ways to deal with it. When I first considered writing about depression I did a computer search that turned up nearly 500 social science studies done in just the last few years. Researchers have tried to link the incidence of depression to every imaginable social factor. For example, since the rate of depression is twice as great for women than for men, studies have been conducted seeking to relate depression with gender roles, family structure, powerlessness, child rearing, and the like. Studies can also be found trying to link depression with, among other things, age (especially during adolescence and old age), unemployment, physical illness, disability, child abuse, ethnicity, race, and social class. Another focus of the literature is on the efficacy of different social programs or intervention strategies for reducing the impact of depression. Of course, the medical literature alone contains hundreds of studies on the use of different drugs for treating depression.
As valuable as these studies might be, something crucial is missing. My view is that to really understand a human experience, it must be appreciated from the subjective point of view of the person undergoing it. To use the language of social psychology, it is necessary to 'take the role' of those whose behaviors and feelings we want to fathom. Underneath the rates, correlations, and presumed causes of behavior are real human beings who are trying to make sense of their lives.
The essential problem with nearly all of the studies of depression is that we hear the voices of a battalion of mental health experts (doctors, nurses, social workers, sociologists, psychologists, therapists) and never the voices of depressed people themselves. Nowhere in the literature do depressed persons speak for themselves. We do not hear what depression feels like, what it means to receive an 'official' diagnosis, or what depressed persons think of therapeutic experts. Nor do we learn the meanings that patients attach to taking psychotropic medications, whether they accept illness metaphors in assessing their condition, how they establish coping mechanisms, how they understand depression to affect their intimate relationships, or how depression influences their occupational strategies and career aspirations.
This book is primarily directed at letting people speak about how their lives, feelings, attitudes, and perspectives have been influenced by depression. There have been some attempts by writers such as Sylvia Plath, Nancy Mairs, William Styron and Elizabeth Wurtzel to record their battles with depression. As instructive as these accounts are, they are not based on systematically collected data and are not directed at discovering underlying patterns in the depression experience. I have elected to do in-depth interviews with 50 people who have been 'officially' diagnosed as depressed and who consequently became involved in a therapeutic world of psychiatric experts. I approach in-depth interviews as a directed, artful conversation requiring a sensitivity about when to ask certain question, when to prod respondents, and when to respect people's need for privacy. Each of the these interviews both tells a unique story and reveals common themes in the lives of depressed people. Each interview caused me to marvel at the courage depressed people display in dealing with extraordinary and debilitating pain.
Media stories often claim that the cure for depression is just around the medical corner. They describe depression as clearly a biological disease that is best treated with anti-depressant medications like Prozac and virtually promise a 'brave new world' in which we will be able to choose our personalities, like choosing clothing off a department store rack. Prozac and other drugs do wonderful things for some people, but the claim that depression is wholly a matter of biology is overblown and represents a form of determinism that I find unacceptable. It is appealing to have simple recipe theories about things because they offer neat and tidy explanations. The problem is that social reality is a very messy thing and can rarely be understood with such easy prescriptions. In fact, I see this book as an antidote to overly pat biological explanations about the meaning of depressive illness. Plainly, there is a biology to bad feelings. To assume, therefore, that bad biology constitutes the explanation for depression is specious thinking. As a sociologist writing about depression, one of my messages is to be very careful about jumping on a bandwagon that locates the source of illness in any single thing.
What Depression Feels Like...
Nina was among the 30 people who read about my study in the newspaper and came to talk with me at my Boston College office. At exactly the appointed time, an attractive woman, dressed in a conservative business suit appeared at my office. If ever there was a person who could destroy the stereotype that only occupational unsuccessful individuals, or those from severely dysfunctional families, suffer from depression, it would be Nina. Nina's parents, it turned out, were successful professional people. While she described her father as 'somewhat odd and eccentric,' her mother and father were, she thought, good and loving people. Both Nina and her sister had been identified as gifted children and from the age of three Nina was placed in exclusive private schools where her talents might be nurtured. Nina's otherwise positive childhood was, unfortunately, deeply marred by an unusual illness that still often requires several operations a year. She has an auto-immune condition that causes frequent cancers, especially in her mouth and jaw area. As a result, she constantly needs attention to detect the potentially deadly cancers and then to remove them once they appear. In fact, shortly before we spoke, Nina learned that her problems would require yet another hospitalization. Because of this condition, she was frequently absent from school as a child. And because of changes in her physical appearance occasioned by the surgeries, Nina was often the brunt of the kind of venomous attacks of which children seem uniquely capable. In response she 'read voraciously, cultivated unusual interests and hobbies, and avoided large social gatherings.'
As we talked I was thinking to myself that Nina's depression was certainly understandable in light of this medical difficulty. However, as she told her story and theorized about the causes of her depression, she claimed that it had little to do with her difficult medical history. Rather, she believed, it was precipitated by a sexual attack experienced in the home of her brother and sister-in-law while visiting them in Europe. The attacker had been a family friend and when Nina reported it to her parents, as well as to her brother and his wife, she was disbelieved. She was told by everyone that the close family friend could not have done this and perhaps she was misinterpreting what actually happened. Nina and I explored the meaning of this event to her. She described in detail how the event has affected her relations with family members.
About a month after we talked I received a letter from Nina. I had given her a draft of one of this book's chapters and in the letter she shared her thoughts about it. She also indicated that, in retrospect, she felt she had not provided a clear enough answer to my interview question 'How would you describe what depression feels like to someone who has not experienced it?' With an artistry that affirms her status as a gifted person, Nina tried to convey what depression feels like.
Illness of Identity...
An essential filter for inclusion in my study was that individuals had at some point been diagnosed and treated for depression by doctors. For that reason there is a built in bias in the sample toward acceptance of a medical definition of depression's cause and the proper response to it. In contrast, there is no way to know how many people are troubled by bad feelings which never acquire a name or receive medical treatment. I suspect that, if we could somehow count them, the greatest numbers of such persons would be found at the lower levels of America's class structure. After all, the poorest and most disenfranchised members of the society have least access to the medical system and typically have real life situations that appear to explain their pain. For example, why would we expect a parent, without secure work, struggling to support a family while living in a dangerous housing project, to define his or her distressing feelings as illness? Such persons have good reasons to feel terrible, none of them apparently connected to having a disease.
There are probably millions of people who inhabit a 'parallel world' to mainstream America who never define their difficulty as something requiring medical treatment. Physicians would likely say that such persons suffer from 'masked depression,' a kind of veil of medical false consciousness that could be lifted if only they talked to the right person. Such individuals, furthermore, probably experience emotional crises every bit as powerful as those described by the respondents in this study. However, instead of going to doctors, they might instead seek solace in religion, for example. They too could be described as following a career path prompted by suffering, but it would be bounded by symbols and stages wholly different from the ones analyzed in this chapter. Like their counterparts in this study who eventually come to acquire an identity as a depressed person with a biochemical disorder, they no doubt construct explanations about the source of their misery and adopt identities consistent with their definition of the situation. They simply are not illness identities. I am suggesting, in other words, that there is nothing intrinsic to the feelings experienced by people in this book that necessarily and inevitably lead to a definition of the pain as disease.
The Meanings of Medication...
My own view -- rooted in personal experience, listening to others, a lifetime of reading social science, and what seems commonsensically true -- is that depression arises out of an enormously complicated, constantly shifting, elusive concatenation of social circumstance, individual temperament, and biochemistry. As such, I would never flatly declare that medications which revise body chemistries should be avoided. Too many people have been dramatically helped by medication to take such a position. At the same time, I strongly resist an approach that systematically minimizes the role of social experience in shaping emotions, good ones and bad ones. To resort primarily to pills because other approaches for treating depression have not worked nearly as well may make sense as a practical strategy. That pills sometimes greatly help people, however, does not warrant the prevailing medical judgment that depression has, first and foremost, an organic basis.
Connected with my professional and personal resistance to wholly biological explanations for any human behavior, I have misgivings about the current practice of psychiatry on political grounds. Whether the proposed psychiatric cure for emotional problems has been talk, as in the past, or medication, as is presently the case, the solutions have neglected the larger structural bases for emotional distress. For example, if, as studies routinely show, women suffer from depression twice as often as men, it strains credibility to believe that such a finding can be accounted for by biological differences alone. To me, there is an obvious validity to the assumption that something about the patterned social situations of women accounts for the statistical gender difference in all the studies. If this is so, a medical treatment focused exclusively on changing patients (either changing the person's self through talk or their biochemistry with pills) leaves wholly unattended the structural sources of human pain. As such, most psychiatric treatment is inherently conservative by implicitly supporting the systemic status quo. Medicine nearly always interprets illness as a reflection of individual physical pathology and rarely as a normal response to pathological social structures. Following this line of thinking, I find the current medical rhetoric which hypes medication as the cure for depression to be both scientifically arrogant and politically retrograde.
Coping and Adapting...
One of the most well-documented relationships in all of social psychology is the link between frustration and aggression. Frustration breeds aggression. Such a simple, nearly commonsensical association, makes the anger expressed toward psychiatrists understandable. Depression itself and then the treatment for it can be hugely frustrating. Belief that this treatment, this new therapist, this new form of therapy, or this drug that you haven't yet tried might be the thing to finally cure you, generates for many a frustrating cycle of high hope followed varying degrees of disillusionment. When patients realize that their doctor's can't cure them, faith in their expertise fades and may be replaced by animosity. Despite their physicians' best efforts, most of those with whom I have talked come to realize that their therapists will not clear away their confusions about depression. In a more fundamentally existential way, many conclude that their depression is likely never to be fixed once and for all. Such a consciousness, in turn, requires a shift in thinking about coping with depression. The new thinking is typically less mechanistic and more spiritual in nature.
Sickness, Self, and Society...
Sigmund Freud was once asked what people needed to be happy. The questioner no doubt expected a long, complicated answer reflecting Freud's years of deep reflection on the matter. His simple response, however, was 'arbeiten und lieben,' work and love. Happy people feel connected to others at work and through their intimate relationships. When those connections are threatened, diminished, or broken, people suffer. Today, millions of Americans are suffering from what my colleague Charles Derber calls 'double trouble.' Those in double trouble have neither meaningful work nor sustaining intimate ties. The withering of community life in both of these domains fosters a rootlessness and social disintegration that unquestionably contributes to the growth of emotional disorders.
The poor in America have always lived with occupational instability and its fallout. In contrast, middle-class workers have historically been immune from occupational insecurity. Indeed, achieving the American Dream of middle class life has until recently been synonymous with tremendous occupational stability. In decades past, middle to upper-middle class workers in large organizations could count on being taken care of from 'womb to tomb.' No more. Today, the catch-words 'downsizing' and 'reengineering' keep the fear of job loss at the forefront of middle-class workers' collective consciousness. Once again the logic of capitalist accumulation is creating a revolution. This one is qualitatively different than earlier economic restructurings because it directly touches the middle classes in hurtful ways. Instead of the strong bond of commitment and loyalty that organizations and middle class workers previously felt toward each other, the new economic rules of corporate life emphasize efficiency, whatever the human cost. Knowing that they could be here today, but gone tomorrow, middle-class workers are constantly in 'fear of falling.'
The essential problem posed by 'excessive' individualism is that it privatizes the goals and pursuits of persons and thereby erodes the social attachments that provide society's moral anchor. Individualism undermines commitment to community since membership in any community (from the family to local community to nation) implies constraints on the behaviors of persons that they perceive as inconsistent with personal fulfillment. The dilemma posed by the need both for attachment and freedom is beautifully captured in Bellah's analysis of romantic love in America. On the one side, Americans believe deeply in romantic love as a necessary requirement for self satisfaction. At the same time love and marriage, which are based on the free giving of self to another, pose the problem that in sharing too completely with another one might lose oneself. The difficulties that Americans have in maintaining intimate relationships stems in part from the uneasy balance between sharing and being separate.
It is said that when persons on their death beds review their lives they rarely say they should have worked harder in order to own even more things than they do. Presumably, most regrets center on relationships that could have been better nurtured and more fulfilling. However...to live a life that truly centers on the quality of relations with others is exceedingly difficult for many, maybe most, Americans. The cultural pull away from others is often too powerful to resist. A culture which prizes individual self-realization above all else becomes a world held together by only the barest and most tenuous social connections. More and more Americans, identifying individual achievement as the primary medium for personal fulfillment, join the 'lonely crowd' identified years ago by David Riesman. To be part of the lonely crowd means being connected to many in general and few in particular. Having opted for loose intimate conn