For most of us, a case of the midwinter blues — fairly epidemic
during the bleak months of January and February — can be conquered
with a little post-holiday bargain shopping or, for those more
fortunate, a quick trip to warmer climes. Unfortunately, there are
a growing number of Americans — studies estimate between ten and
fifteen million — for whom such a cure is neither quick nor easy
to define. For these individuals, depression is far more than a
temporary case of the blues: it is a devastating illness that can
lead to family breakups, loss of employment, even suicide. Although
the subject of depression has been explored at length via self-help
books and the talk-show circuit, and despite the prevalence in our
society of this debilitating condition, few of us really
know what depression is like. David Karp aims to tell the story of
what it’s like to live with depression from the point of view of
the sufferer.
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.
Introduction:
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
