Women and Depression

Recovery and Resistance

Michelle N. Lafrance

• Publisher: Routledge
• Year: 2009
• ISBN:
  9781134138289
• Edition: 1
• Topic: Psychology
• Subtopic: History & Theory in Psychology
• Index: Psychology

Women and Depression: Recovery and Resistance takes a welcome look at women's experiences of living well after depression. Lafrance argues that the social construction of femininity is dangerous for women's health, and ultimately, central to their experiences of depression. Beginning with a critical examination of the ways in which women's depression is a product of the social, political, and interpersonal realities of their everyday lives, the analysis moves on to explore an often ignored aspect of women's experience – how women manage to 'recover' and be well after depression.

The book draws on extensive in-depth interviews with women who have been depressed, as well as on previous research and on analyses of representations of women's health practices in the media. In this way Lafrance critically examines how women negotiate and actively resist hegemonic discourses of femininity in their struggles to recover from depression and be well. Threaded throughout the analysis is the exploration of a variety of subjects related to women's distress and health, including:

• negotiating identity
• the medicalization of women's misery
• women's narratives of resistance
• the material and discursive context of women's self-care

In exploring the taken-for-granted aspects of women's experiences, Lafrance sheds light on the powerful but often invisible constraints on women's wellbeing, and the multiple and creative ways in which they resist these constraints in their everyday lives. These insights will be of interest to students and scholars of psychology, sociology, women's studies, social work, counseling, and nursing.

CHAPTER 1
INTRODUCTION

Studying women’s experiences of recovery from depression

This book is about women’s stories of moving out of depression and striving to become and live well. I came to this subject through my interest in women’s mental health and a discontent with the fact that the bulk of research in this area focuses on pathology and illness rather than health and well-being. I believe that while an understanding of women’s suffering is essential, attention to the ways in which women become and live well is also vitally important. Thus, with a view to better understanding women’s health more broadly, I wanted to explore the ways in which women talk about ‘recovering’ from depression and nurturing their own health and well-being in their everyday lives (I take up the term ‘recovery’ at the end of the chapter). Further, I wanted to examine women’s health narratives for their personal, social, and political meanings and implications.

Feminist scholars have firmly situated women’s depression as a consequence of patriarchal society (Jack, 1991; Stoppard, 2000; Stoppard & McMullen, 2003; Ussher, 1991, 2006). And, while very many women do become depressed, many also ‘recover’ and emerge from their despair. Thus, at the heart of this book is a concern for the ways in which women describe and experience ‘recovery’ from depression. Starting from a feminist, social constructionist perspective, I explore women’s narratives of recovery and well-being through an analysis of interviews I conducted with women in two related research projects. In the first, I interviewed women who self-identified as having ‘recovered’ from or overcome depression in some way. In describing recovery from depression, these women recurrently pointed to both the importance of beginning to attend to their own needs and pleasure, and their difficulties in doing so. In talking to these women, I began to wonder about the possibility of other ways in which women might come to attend to their own health and well-being, other than through the pathway of crisis and depression. I then conducted a second study in which I interviewed another group of women who self-identified as taking care of themselves in their everyday lives. Through an analysis of these sets of interviews, in conjunction with an examination of the literature on women’s mental health and of representations of women’s health practices in the media, I explore women’s narratives of health and healing, and the ways in which they position themselves and are positioned in discourse.

RECOVERY FROM DEPRESSION: A NEGLECTED TOPIC OF INQUIRY

Recovery from depression is the anchoring theme of this book. I chose to investigate recovery experiences from depression in particular because depression is the most common mental health problem among women (Bebbington, 1996; Weissman, Bland, Joyce, Newman et al., 1993). Not only is depression a leading cause of disability among women worldwide, but it ranks as one of the most important health problems for women overall (Murray & Lopez, 1996; World Health Organization (WHO), 2000a). Further, women outnumber men in terms of prevalence at a fairly consistent rate of about two to one (Beaudet, 1996; Bebbington, 1996; Eaton, Anthony, Gallo, Cai et al., 1997; Jenkins, Kleinman, & Good, 1991; Kessler, McGonagle, Swartz, Blazer, & Nelson, 1993; Maier, Gänsicke, Gater, Rezaki et al., 1999).¹ This gender gap appears to emerge at the time of puberty when rates of depression among girls rise precipitously (Nolen-Hoeksema & Girgus, 1994). In adulthood, the risk of depression is estimated to range from 5 per cent to 12 per cent for men, and from 10 per cent to 25 per cent for women (American Psychiatric Association, 2000). Thus, substantial numbers of women experience depression. Moreover, depressive experiences are associated with significant impairments across physical, emotional, cognitive, occupational and social functioning. Depression can therefore, be understood as a ‘woman’s problem’ (Marecek, 2006); one that is often profoundly and pervasively debilitating.

An extensive and wide-ranging body of literature has been dedicated to understanding the causes of depression. Across this literature, the models currently receiving the most attention are rooted in either biomedical or psychological frameworks, including neurochemistry, genetic inheritance, hormones, attributional style, cognitive coping style, interpersonal relationships, and negative life events (Blehar, 2006; Gotlib & Hammen, 2002; Keyes & Goodman, 2006; Mazure, Keita, & Blehar, 2002). While integrative ‘biopsychosocial’ and ‘diathesis-stress’ models have been proposed, the literature remains largely comprising efforts to establish the dominance of one or more of these domains in the explanation and treatment of depression. For instance, while some are dedicated to demonstrating the role of neurochemical dysregulation, others work on elaborating the ways in which depression depends on patterns of thinking. Meanwhile, feminist scholars have critiqued such narrow conceptualizations as decontextualized and pathologizing. Instead, they have offered new understandings of women’s distress based on the material and social conditions of women’s everyday lives (Nicholson, 1998; Stoppard, 2000; Stoppard & McMullen, 2003; Ussher, 1991).

While depression continues to be the focus of concentrated attention and debate, researchers have largely ignored the experience of recovery from depression. Those who have attended to recovery tend to focus on identifying predictors of recovery and recurrence in clinical and non-clinical samples (Eaton et al., 1997; Kendler, Walters, & Kessler, 1997; Kessler et al., 1993; Lewinsohn, Zeiss, & Duncan, 1989; Mueller, Leon, Keller, Solomon et al., 1999; Solomon, Keller, Leon, Mueller et al., 1997; Solomon, Keller, Leon, Mueller et al., 2000; Viinamäki, Tanskanen, Honkalampi, Koivumaa-Honkanen et al., 2006). When participants in these studies recover without treatment, researchers acknowledge recovery only insofar as to label it ‘spontaneous remission’ (Frank, Prien, Jarrett, Keller et al., 1991; Gardner, 2003). When recovery occurs among those who receive intervention, researchers conceptualize it in terms of ‘treatment outcome’ or ‘treatment effectiveness’. Therefore, these investigators appear to view recovery almost exclusively as an outcome that can be adequately expressed in terms of a number (for instance, ‘percentage recovered’ or ‘time to recovery’). Considering that recovery is presumably the goal of treatment interventions, it is surprising that researchers should fail to consider it as a process in its own right.

I propose that there are several reasons for this significant gap in the literature, all of which stem from the way in which researchers conceptualize depressive experiences. Intense and prolonged sadness has taken on widely different meanings across culture, time, and place (Jackson, 1986; Jenkins et al., 1991; Marecek, 2006). In the West, it is currently viewed as the hallmark of individual pathology; signs of a clinical disorder. Defined by the American Psychiatric Association in the Diagnostic and Statistical Manual of Mental Disorders (2000), depression is signified by the presence of a standard constellation of symptoms including depressed mood, diminished interest or pleasure, fatigue, feelings of worthlessness or guilt, problems concentrating, suicidal thoughts, and changes in weight, sleep, and activity level. A person who experiences a certain set of these symptoms over a period of two weeks or more can be diagnosed with ‘Major Depressive Disorder’ by a mental health professional. This diagnostic term invites a decontextualized understanding of despair whereby subjective experiences of suffering become viewed as objective signs of pathology. Displaced from view, then, is an appreciation of the ways in which depressive experiences are embedded in the landscape of people’s lives. Further, the construction of depression as a ‘disorder’ invites the assumption that it is a separate entity that invades the life of an otherwise healthy person (Davidson & Strauss, 1995). Within this formulation, health is assumed to be the natural state, one that unfolds automatically unless otherwise impeded. Consequently, ‘[i]f it is assumed that health is something that is passively given at the outset, or taken away by illness, then it follows that the process of restoring health be viewed as a similarly passive affair’ (Davidson & Strauss, 1995, p. 48). Thus, it appears to be taken-for-granted in mainstream models that recovery from depression is nothing more than the removal of the presumed cause. When depression and recovery are understood in these ways, it follows that research should be directed toward an exploration of the causes and treatments of pathology, leaving recovery a somewhat irrelevant and invisible focus of study (Davidson & Strauss, 1995).

A second and related reason why recovery has been overlooked is that sustained recovery from depression (in terms of mainstream understandings of symptom remission) is a relatively rare occurrence. Research conducted by the National Institute of Mental Health (NIMH) provides perhaps the most extensive picture to date on the course of depression (Keller, 1996; Mueller & Leon, 1996; Mueller et al., 1999; Solomon et al., 1997). Participants in this longitudinal study were individuals who sought treatment for an affective disorder at one of five US university medical centres between 1978 and 1981. Participants were evaluated on intake with the Schedule for Affective Disorders and Schizophrenia (SADS) and 495 individuals were diagnosed with major depression. Follow-up evaluations were conducted with the Longitudinal Interval Follow-up Evaluation (LIFE) every six months for the first five years and annually thereafter. Rates of recovery indicated a positive course. Most participants recovered in the first year (69 per cent), after two years, the cumulative probability of recovery was 82 per cent, after three years 85 per cent, and after five years 90 per cent (Keller et al., 1982; cited in Keller, 1996). After ten years, only 7 per cent remained ill with no recovery (Mueller & Leon, 1996).

While the statistics from this series of studies appear encouraging, further investigation of the long-term course of depression suggests that a pattern of recovery and recurrence is the rule rather than the exception. One quarter of those in the NIMH study who recovered in the first year of follow-up relapsed within 12 weeks of recovery (Keller, 1996). At 15 years’ follow-up, the researchers paid particular attention to 380 individuals who had recovered at some point from an index episode of major depressive disorder and 105 individuals who had recovered and subsequently remained well for at least five years. Although the vast majority of participants in the total sample recovered from depression, 85 per cent of the 380 experienced a recurrence, as did 58 per cent of those who remained well for at least five years. Based on these and other epidemiological findings, mainstream scholars tend to conceptualize depression as a recurrent disorder, one from which many may not ‘recover’ once and for all. Therefore, when depression is understood in this medicalized, symptom-based way, then the study of recovery may appear to be a misguided endeavour since few may qualify as ‘properly recovered’.

A third reason for the fact that recovery has been largely overlooked in research is that the term itself does not appear to resonate with those who have been depressed. From a medical perspective, recovery implies both sustained symptom remission, and a returning to one’s previous state of health. It means ‘getting back to how you were before the illness started, being restored to your former state… It involves being the same as before’ (Whitwell, 1999, p. 621). However, even among those who experience symptom remission, many report ongoing struggles with low mood or daily functioning (Boland & Keller, 1996; Coryell & Winokur, 1992). Further, people do not tend to simply return to the way they were before, but are often fundamentally altered by their experiences (Ridge & Ziebland, 2006; Whitwell, 1999). That is, even though people may feel better, they often report feeling changed in multiple ways by their profound experiences of emerging from despair (Ridge & Ziebland, 2006; Schreiber, 1996a; Steen, 1996). These findings have led some to question the utility of the very concept of recovery vis-à-vis ‘mental illnesses’ such as depression. Indeed, some have gone so far as to suggest that recovery from mental illness is, in fact, ‘a myth’ (Whitwell, 1999). However, I would argue that the problem with the concept of recovery lies not in people’s experiences, but in our preconceived notions about what recovery means, including the ways in which it is understood and studied. Instead, I would argue that new ways of understanding people’s experiences of recovery, healing, and well-being are required.

By arguing for a re-conceptualization of recovery, I am not suggesting that modifications to the symptom criteria for recovery are required (e.g., Fava, Ruini, & Belaise, 2007; Frank et al., 1991), nor do I mean to dismiss people’s experiences of ongoing pain and distress. Rather, my aim is to highlight the problems inherent in any attempt to make lived (personal) experience fit into preconceived (expert-based) notions. Perhaps what is missing from current formulations is an understanding of recovery from the perspective of those who have experienced it. If individuals do not identify with the word ‘recovery’, is this because they do not experience well-being after depression, or because a symptom-based understanding of recovery does not adequately describe their lived experiences? If individuals are not considered to have recovered, are they then by default chronically ill? Do continued struggles with stress or sadness preclude individuals from claiming to be recovered? Are experiences of distress and well-being best understood by reducing them to the dichotomy of ‘sickness’ and ‘health’? Or, are other ways of understanding depression and recovery needed?

One way to address these types of questions is to ask people to talk about their experiences of living well after depression. However, given that the dominant methodological approach in psychology is positivist, empiricist, and quantitative, psychologists have rarely explored such questions in their research. Therefore, a final reason why recovery has not been the subject of in-depth investigation is that the types of questions that would lead to a richer understanding of people’s experiences of recovery are not easily addressed with the research methods normally adopted. If we want to look ‘inside the numbers’ and explore not only rates of symptom remission and recurrence, but people’s stories of healing and the meanings they ascribe to them, then alternative approaches to research are required.

RESEARCH ON RECOVERY

Drawing on first-person narratives and qualitative methods, a small, but growing body of literature on recovery has recently emerged (Anonymous, 1989; Anthony, 1993, 2004; Corrigan, Giffort, Rashid, Leary, & Okeke, 1999; Davidson, Harding, & Spaniol, 2005; Davidson & Strauss, 1992; Deegan, 1988; Lapsley, Nikora, & Black, 2000; Pettie & Triolo, 1999; Young & Ensing, 1999). Focusing on experiences such as schizophrenia, this literature was born out of the consumer/survivor movement of the 1970s in which recipients of mental health services spoke out against the marginalization, mistreatment, and abuse they endured as patients. Mainstream understandings of ‘mental illness’ were critiqued as pathologizing and limiting for consumers of mental health services, theorists, and clinicians alike. Consumers advocated for more empowering models of intervention and a consideration of the needs of the ‘person behind the patient’ (Fisher, 1994; Frese & Davis, 1997). Within this Zeitgeist, recovery emerged as a guiding vision for research and services in mental health, one that can open our eyes to new possibilities for what it might mean to live with and beyond ‘mental illness’ (Anthony, 1993). From this perspective, recovery is not limited to symptom-based notions, but is understood as a complex and deeply personal experience that is ‘best understood as a process, not an outcome’ (Frese...

Table of contents

• WOMEN AND PSYCHOLOGY
• CONTENTS
• ACKNOWLEDGEMENTS
• CHAPTER 1 INTRODUCTION
• CHAPTER 2 NARRATIVES OF DEPRESSION
• CHAPTER 3 RECOVERY FROM DEPRESSION
• CHAPTER 4 STRUGGLING TO SELF-CARE
• CHAPTER 5 CONCLUSION: IMPLICATIONS FOR USEFULNESS
• APPENDIX A A BRIEF DISCUSSION OF EPISTEMOLOGY, SOCIAL CONSTRUCTIONISM, AND DISCOURSE
• APPENDIX B ADDITIONAL INFORMATION ABOUT THE RESEARCH PARTICIPANTS AND INTERVIEW PROCESS
• APPENDIX C TRANSCRIPT NOTATION
• REFERENCES
• INDEX