When Older Women Speak

Aging, Emotional Distress, and the Self

Ester Carolina Apesoa-Varano, Charles Varano

• Publisher: Routledge
• Year: 2020
• ISBN:
  9781000043952
• Edition: 1
• Topic: Psychologie
• Subtopic: Psychopathologie

Studying the interaction of gender, class, race/ethnicity, and aging in the depression experience of older women provides a unique opportunity to understand how aging plays a significant role in shaping conceptions of self and emotional health trajectories for women. Based on author interviews with mostly working-class, depressed, elderly women, this book contributes to the theoretical understanding of femininity and aging and the practical implications for policy and effective health care treatment. Cultivating an "alternative self" can reduce older women's suffering and provide the emotional resources to change their inner worlds, even if the outer world stretches beyond their control.

Depression affects women twice as often as men. Up to 40 percent of older adults respond poorly to depression treatment, and depression is linked to higher morbidity and mortality rates and cognitive decline. Older adults with depression have 50 percent higher health care costs, yet depression is accurately recognized in less than one half of older adults in primary care. While older men are more likely to die by suicide, older women are two to three times more likely to attempt suicide, and depression is the best predictor of suicide in older adults. Latina and African American women have lower rates of depression treatment compared to non-minority women. From issues of health care access to the stigma of depression, older Latinas and African American women are at an increased risk for untreated depression. This book seeks to address some of the significant gaps in our knowledge of late-life depression in women, especially in ethnic minorities, ranging from detection and efficacy of depression treatment to informal influences (e.g., family) on formal depression care seeking.

Chapter 1

Introduction

It’s like a curse. Your body is breaking down. Your breasts are down to here, and it’s just horrible. Who wants to age? Think about it.

Rita, aged 68.

“You should write a book about me,” said my grandmother one wintery evening as we sat on her porch in a small coal mining town nestled in the hills of eastern Pennsylvania. “I could tell you stories you wouldn’t believe,” she sighed. “Life hasn’t always been that easy.” Having talked with aunts, uncles, and my parents over the years, I (Charles Varano) knew some of what grandma was referring to. She was a strong woman, stoically independent, and still cooking on her coal stove down in the basement (despite my uncle urging her to stop – “it’s hard to lug coal from the outside cellar and it’s bad for her lungs”). But though her smile could melt the winter snow draping the porch steps, her melancholy betrayed the struggles of life. From my knowledge, grandma was never diagnosed with depression, nor would she have agreed she was if asked. But I could tell from her heavy sighs that life had taken its toll, and though her spirit was not crushed, it had clearly been tested.

As our study of a diverse group of older women unfolded, I often thought about my grandmother, as did Ester Apesoa-Varano of her grandmothers in Argentina. The resilience and fortitude we observed in them was also evident among the women Apesoa-Varano interviewed for this book. As she asked them about their lives, their families, and their current struggles with aging, they spoke of physical and emotional pain along with memories that often circled from fond recollection to hideous nightmare. Many had faced poverty and discrimination growing up, only to endure violence and marital discord in their havens of hope. Some found redemption in domesticity, others in their work, and many in their God. Some of the women acknowledged suffering from severe depression, even to the point of attempting suicide (multiple times), while others rejected the term outright or as something that was “hard to pin down.” But they all shared one thing in common even if it meant or was lived somewhat differently – they were women who were negotiating their gender in their older years. And it wasn’t easy. This book shares their stories and the lessons we might learn from their words; specifically, how they forged a gendered self through their “worlds of pain.”¹

We were moved to engage in this study for many reasons. Apesoa-Varano had previously been involved in a team-based study of Latino and Caucasian older men with depressive symptoms.² The findings of this research inspired her to inquire about how an ethnically diverse group of women understood their emotional distress in older age. In particular, upon reflecting on how older men’s masculinity was at stake, especially in how they spoke about suicide,³ she became interested in how older women’s gender might be relevant in the context of their expressed emotional distress. Further, our study on caregiving in an institutional setting⁴ and Apesoa-Varano’s ongoing research on family care work of the elderly with dementia⁵ have informed our interest in the care issues facing the women in this book. These issues emerged in the context of their relations with physicians and family members to be sure, but also insofar as women sought to balance care relationships with their concerns for independence and autonomy in older age. Finally, as with so many who are reading this now, we are not strangers to people (be they friends or loved ones) with diagnosed or treated depression or who have experienced various forms of mild to severe emotional distress. The stories we heard from the women interviewed for this book provide important insights into what we thought we knew and what we hope to learn about this often puzzling and always deeply troubling dimension of the human condition.

In the chapters that follow, we argue that through their stories of domestic heartache, financial instability, physical pain, recurring emotional distress, and confronting the medical system, the women we spoke with are actors who make choices within constraints. Though they may have been victimized in their lives, they are not victims, but rather agents who interpret and reflect upon their worlds. Their narratives display the ways they have exercised their preferences and goals, whether with respect to health care or to family relations, or to their definitions of mental health, aging, and self. We understand these older women as “moral agents” acting within the parameters of race, gender, and class. Despite the social constraints they have faced, and the physical and emotional distress they endure, these older women struggle to define, if not enact, a life of dignity and purpose. In particular, we explore how they spoke of their gendered self as younger women and how a few negotiated an authentic and valued self through their emotional distress as older women.

Women, Depression and Moral Agency

Epidemiological studies find that women are at greater risk than men to develop depression and are more likely than men to be treated for depression.⁶ Mexican American and African American women show lower rates of treatment compared to Caucasian women, yet they suffer from depression at equal or higher levels than previously thought.⁷ Still, there are gaps in our knowledge of late-life depression diagnosis and treatment, especially of minority older women,⁸ and the informal influences (e.g., family) on formal depression care seeking.⁹ Without denying the role of biological and psychological factors, sociologists such as Thomas Scheff, George Brown, and Tirril Harris have offered perspectives on depression that substantially integrate its social origins and contexts.¹⁰ For example, scholars have long argued that experiencing depression can devastate the “self,” and this is precipitated by tenuous social bonds or the absence of a supportive community. Thomas Scheff proposed that receding social connections lead directly to feelings of sadness, anger, and ultimately shame. As this shame deepens, an “unworthy” self-concept develops. Scheff further argues that depression is linked to the absence of positive memories about past relationships or membership in a community.¹¹

In a complementary tone, David Karp in Speaking of Sadness (1996) explores the social and cultural contexts of depression. For Karp, who has suffered from depression most of his life, the “postmodern self” is prone to disease of the mind given the fragmentation and isolation of contemporary life. The culturally defined illness we experience as depression is different from the disease medical science defines as needing to be cured whether through psychotherapy or, most frequently, through psychotropic medications. Such illness comes from experiences of emotional distress that must be found “in a cultural chemistry that catalyzes depression.”

…one piece of the mix that foments depression [is] a culturally induced readiness to interpret emotional pain as illness.… A second factor that really gets the depression reaction going is the increasing disconnection that appears to characterize Americans’ relations with each other and with society … depression, at its root, is a disease of disconnection.¹²

Karp’s argument here predates Johann Hari’s more recent and publically well received Lost Connections (2018) by 20 years, but the parallels are evident. Hari, who like Karp also suffers from depression, argues that depression and anxiety are not adequately (if at all) addressed by using more antidepressants at higher doses for longer periods of time. Rather the sources of various forms of depression and emotional distress are to be found outside the self, largely through the ways that our political economy has undermined and injured human(e) connections with others in our social and cultural life. “The primary cause of all this rising depression and anxiety is not in our heads,” he writes. “It is, I discovered, largely in the world, and the way we are living in it.”¹³

In this book, we follow this sociological thread regarding the challenging, but woefully confusing and confused distinction between depression and other forms of emotional distress. As noted above, we do not deny that depression exists nor do we deny the role of biological and psychological factors affecting its emergence or duration. Though we are not medically trained diagnosticians, our sociological interest in the condition draws upon those who have written about their suffering, those who study and treat the afflicted, and our own research. Here, we wish to outline the interdisciplinary empirical and theoretical work that informs our approach to the narratives of the women we spoke with.

One of the most developed and informed statements that advances the work of Scheff, Karp, Brown, and Harris, was put forth by Allan V. Horwitz and Jerome C. Wakefield in The Loss of Sadness (2007). Briefly put, their thoroughly argued critique of depression studies, symptom designation and diagnosis (evident in all DSM versions, but also other measures including those used by sociologist George Brown and his colleagues with whom they express partial affinity), and institutionalized treatments (especially psychotropic medications) does not hold that depressive disorders do not exist. Rather, they state that clinicians and scholars must attend more carefully to distinguishing between normal “biologically ‘designed’ functioning (i.e., the result of natural selection) and the failure of such functioning, that is, dysfunction.”¹⁴ This distinction underlines Horwitz and Wakefield’s key argument that much of what is defined, diagnosed, and treated as depression is actually a normal and expected expression of sadness regarding conditions or events in life that elicit such an emotional response. Such a response can be shorter or longer in duration, or can be expressed more or less intensely, but it eventually dissipates, whereas depression is a “malfunctioning” of a normal state that profoundly and detrimentally affects people’s ability to live their lives. In this regard, Horwitz and Wakefield follow Scheff, Karp, Brown, and Harris in emphasizing the contextual nature of depression and specifying the precise sources of sadness versus depression that are critical to their appropriate treatment (not to mention addressing the stigma that accompanies depression diagnosis/treatment).

From a complementary perspective, psychological and medical anthropologist Janis Jenkins in Extraordinary Conditions (2015) argues that “the experience of mental illness is better characterized in terms of struggle than symptoms and that culture is integral to all aspects of mental illness.”¹⁵ For those contending with conditions ranging from severe emotional distress to clinical depression, such struggle occurs at many levels; from within as the afflicted forge through a maze of mental mirrors and blind alleys, and in relation to families, friends, and the health care establishment. But at every level, at every turn, the self is implicated and at risk. In particular, Jenkins observes, “Within the family emotional precarity is related to the cultural definition of self, and the degree to which self is understood and experienced as a bounded entity influences the manner in which fundamental self-processes take place.”¹⁶ For the women we spoke with, these self-processes were alluded to in narratives of their family of origin, the family (often multiple) they tried to form as adults, and the family they now confront as older women. Further, the struggles they wage(d) are framed in ways that reveal the importance of a dignified self that is often just beyond their grasp.

Related to Jenkins’ emphasis on the struggles waged by those with depression and emotional distress, is anthropologist Neely Laurenzo Myers’ analysis of people “in recovery” at a mental health clinic. In Recovery’s Edge (2015), Laurenzo Myers expands on this notion of struggle by placing it in the context of what she calls “moral agency” or “a person’s freedom to aspire to a ‘good life’ in a way that leads to intimate connections to others.”¹⁷ But such moral agency among the emotionally distressed must operate in an environment with others for whom the self is supported and respected, yet also held accountable.

The concept of moral agency suggests that in order for people to become the kind of people they want to be in the world, they must act in a way that helps others recognize them as the person they hope to be and holds them accountable for it. The way that they are expected to act in order to be perceived as ‘good’ must match up with the cultural expectations of the group that they are trying to join, and they will need resources that go beyond financial assistance to help replenish lost moral agency.¹⁸

To the degree that one’s family might compromise such moral agency, as we frequently found expressed by the women we spoke with, where might one turn to be emotionally replenished? Where might their emotional distress not be held against them, and where might a dignified and worthy self be reconstituted?

What all these scholars share is an emphasis on the contextual meaning of depression and returning dignity to those so aff...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Dedication
• Table of Contents
• Acknowledgements
• 1 Introduction
• 2 The Way It Was
• 3 Marriage, Motherhood, and Work
• 4 Doctors and Families in Health Care
• 5 Depression and Its Treatment
• 6 The Aging Self: Redemption and Dignity
• 7 Conclusion
• Appendix A: Research Methodology
• Appendix B: Descriptions of Women from Each Group
• Bibliography
• Index