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UNIVERSITEIT VAN AMSTERDAM
Medical Anthropology and Sociology
Master of Science Thesis
The Cohabitation of Depression and Capitalism: A critical
analysis of the illness experience of depression and lived
experience of taking antidepressants
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Supervisor: Stuart Blume
Author: Kate Hedley
Student Number: 11185112
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Abstract
This thesis explores the subjective illness experience of eight individuals suffering with depression, and their lived experience of taking antidepressants in the capitalist context of the United Kingdom. The in-depth, qualitative interviews and ethnographies of depression self-help groups are analysed to gain an understanding of how a capitalist context can contribute to human discontent. This analysis is done from a predominantly phenomenological, critical hermeneutic perspective. An exploration of capitalism’s contribution to the choice, or lack of choice, in the use of antidepressants as the predominant treatment for depression ensues. The effectiveness of this treatment is explored by analysing individual’s subjective experiences of taking antidepressants. Results indicate the necessity of exploring sufferer’s perceptions of alternative causations of their discontent to the dominant biomedical model. It also indicates various ways the capitalist system may create discontent in individuals, to then be medicalised and treated by antidepressants. Participants experiences of antidepressant consumption show that, even from a capitalist perspective, medication could not be considered a ‘cure’; revealing the potential ineffectiveness of treatment and the need to consider alternatives. This thesis advocates the need for future research focusing on the structural factors that cause human discontent, and a move away from the biomedical model and biological reductionism of depression. The illness experience, and lived experiences of individuals must be prioritised to address the multiple causes of depression and to find effective preventions and treatments.
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Acknowledgments
I would like to thank my supervisor, Stuart Blume, for his unwavering support, expert knowledge, and advice throughout this process. I feel extremely lucky to have learnt and been guided by such a knowledgeable, humble, and supportive supervisor. Also, the exposure to the talented researchers and teachers of the Medical Anthropology and Sociology department; without their hard work, prior and during the thesis period, I would not have been prepared for this challenge.
Without the courage participants displayed by disclosing their experiences of suffering, this study would not have been possible and I am sincerely grateful for not only their cooperation, but the friendships gained through our interactions.
I would also like to thank my father, Andrew, for prioritising my questions, proofreading, and offering continuous support throughout both fieldwork and the write-up period.
Molly and Oshi, thank you for keeping me positive and always helping me in whatever way I need.
Finally, I would like to thank the University of Amsterdam for allowing my enrolment in this enlightening programme; I have learnt and grown in ways I never anticipated. My determination to use research as a dynamic tool to relieve suffering has never been so strong.
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Contents Page
1. Chapter 1: Introduction
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1.1 Depression
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1.2 The Capitalist Context and Life Events
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1.2.1 A Disposable/Replaceable Workforce
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1.2.2 Emotion Work
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1.2.3 A Culture of Comparison and High Expectations
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1.2.4 Prioritisation of Consumption
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1.3 Antidepressants as a ‘Coping Strategy’
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1.3.1 Help-seeking Behaviour
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1.3.2 Pharmaceuticalisation/Medicalisation
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1.4 Illness Narrative of Depression
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1.5 The Present Study
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2. Chapter 2: Research Methodology, Theoretical Frameworks, and
Data Analysis
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2.1 Study Sample and Location
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2.2 Approach; Difficulties and Benefits
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2.3 Interview as Therapy
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2.4 Ethical Considerations
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2.5 Theoretical Approach and Conceptual Tools
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2.5.1 Interpretative Phenomenology
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2.5.2 Critical Hermeneutics
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2.5.3 Embodiment
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2.5.4 Illness Narrative
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2.5.5 Explanatory Maps
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2.5.6 Attribution Categories and the Meaningful Encounter
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2.6 Data Collection and Analysis
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2.7.1 Sampling Limitations
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2.7.2 Time and Length Limitations
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3. Chapter 3: The Illness Experience of Depression
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3.1 Making Sense of the Onset of Depression
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3.1.1 Erin, William, and Matthew
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3.2 Attribution Categories for the Persistence of Depression
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3.2.1 Insecurity and Hostility
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3.2.2 Inauthenticity
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3.2.3 Pressure
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3.2.4 Social Networks and Isolation
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3.2.5 The Self
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4. Chapter 4: The Lived Experience of taking Antidepressants
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4.1 The Meaningful Encounter
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4.1.1 Succumbing to Life’s Pressures
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4.1.2 The Alternative/A Reaction to Suicide
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4.2 The Lived Experience of Taking Antidepressants
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4.2.1 Bodily Effects
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4.2.1.1 Improvements, or Lack of…
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4.2.1.2 Side-effects
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4.2.1.3 Me or the Medication
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4.2.2 Reliance on Medication; Prop or a Cure?
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4.2.3 Exerting Control
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5. Chapter 5: Discussion
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5.1 The Experience of Depression and Antidepressants in a Capitalist
Context
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5.2 Making Sense of the Onset of Depression
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5.3 Capitalism’s Contribution
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6. Chapter 6: Recommendations for the Future – ‘Misery Needs
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Chapter 1: Introduction
1.1 Depression
There has been an exponential increase in the consumption of antidepressants in postmodern Western society preceding the era in the late 1980s (Metzl, 2003). Notably, the United Kingdom (UK) has witnessed a staggering increase in the consumption of antidepressants among young people, reflecting a twelve percent increase between April 2015 and June 2016, wherein 166,510 under eighteen year olds depend upon regular consumption of antidepressants (Marsh, 2017). This innately concerning figure embodies the necessity in critically analysing this ‘hot topic’ proliferating the UK. However, the scale of interest has not led to a consensus on its origins or appropriate treatment. An enduring debate has questioned whether the causation of depression lies with genetic selection, social contexts, or a combination (Dohrenwend, Dohrenwend, 1969; Dooley, 2000). Whilst not denying a genetic component to the aetiology of depression, it has been argued that episodes are often triggered by adverse life events (Brown, Harris, 1978; Hirschfeld, Cross, 1982; Turner, Noh, 1988; Ensel, Lin, 1991; Aneshensel, Frerichs, 1982). And whilst studies have evidenced unemployment to be potentially consequential of depression (Hammarstroem, Janlert, 1997; Mastekaasa, 1996), others have identified low socioeconomic background and work experiences as precipitating factors (Catalano et al., 1994).
Suffering; the way it is experienced, recognised, perceived, understood, and treated are all shaped by the culture in which a sufferer is imbedded (Ohnuki-Tierney, 1984). Forms of suffering that are labelled, ‘depression’ are culturally and socially constructed (Karp, 1996). The focus of this thesis is on phenomena specific to a capitalist context which could contribute to mental suffering. The West’s dominant biomedical response to depression (antidepressants) will then be examined through a consideration of patients’ help-seeking behaviour and the concepts of medicalisation and pharmaceuticalisation. Finally, the possibilities of understanding the subjective illness experience of depression through the analysis of illness narratives in research will be explored.
1.2 The Capitalist Context and Life Events
Firstly, it is necessary to place the UK in the context of the wider, global, capitalist market. The widespread adoption of a capitalist agenda encouraging ‘free trade’, ‘free markets’, and the
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increased ‘flexibility’ of labour has benefitted transnational corporations (alongside their owners and senior managers) tremendously (Magdoff, Magdoff, 2004). A constant struggle to maintain labour wages in wealthy countries due to harsh working conditions and low wages in countries on the periphery of capitalism, combined with diminishing welfare support with governments advocating privatisation has left workers in a tenuous position (Magdoff, Magdoff, 2004).
1.2.1 A Disposable/Replaceable Workforce
A drive towards globalisation began succeeding World War II in search for “new profitable investments abroad” (Magdoff, Magdoff, 2004: 19). This drive aimed to enhance profitability through increased flexibility; “to hire and fire workers, obtain low-cost labour, decrease worker and citizen benefits, invest and market abroad, repatriate profits, and gain access to needed raw materials” (Magdoff, Magdoff, 2004: 20). A further drive to increase profitability was the production of a pool of workers able to enter and leave the workforce dependent on the needs of capital; during growth, an increase in labour is necessary for a business to reach its full capital potential, and as this diminishes the excess workers are dismissed (Magdoff, Magdoff, 2004). Capitalism’s success has created an insecure environment for most workers. From a Marxist perspective, to have workers living a dubious existence was in itself an intended outcome. This ‘reserve army of labour’ minimises costs therefore increasing profitability, whilst the insecurity it breeds is used as a weapon against workers (Marx cited in; Magdoff, Magdoff, 2004).
The work environment which many individuals experience daily can cause stress and discontent resulting in both emotional and physical illness (Colligan, 2006). Advancements in technologies add to the underlying feelings of insecurity and vulnerability with some individuals lacking the capacity and resources to improve their skills to meet these advancements. For these individuals, both the environment and more able colleagues are then perceived as a threat (Lazarus, Folkman, 1984). A toxic workplace revolving around extreme pressure, unrealistic demands, and ruthlessness (Macklem, 2005) where employees operate and are driven by anxiety, paranoia and unease ensues (Colligan, 2006). Studies have shown that fearful, harassing environments combined with a high, pressurised work load can induce severe stress (Karasek, Theorell, 1990; Mausner-Dorch, Eaton, 2000). As a result, interpersonal
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relations are put in jeopardy as individuals experience anger and frustration (Israel et al., 1989). Murphy (1995) identified problematic1 workplace relationships and group dynamics as the primary factor contributing to workplace stress. Individuals working in close proximity facilitates comparison with others who appear to be more successful. If, for example, a colleague in the same role earns a higher salary this can potentially lead to negative self-perception and feelings of jealousy.
1.2.2 Emotion Work
Hochschild’s emotion-management perspective uses an interactive account of emotion to consider how individuals work daily on “inducing or inhibiting feelings so as to render them ‘appropriate’ to a situation” (1979: 551). The implicit rules inherent in ideology on how to manage feelings, or even how to feel in itself, is rarely commented on in literature. Durkheim (1961), Geertz (1964) and in some ways Goffman (1974) however, present ideology as an interpretative framework which ‘frames rules’, affecting how feelings are felt, interpreted and narrated (Hochschild, 1979). ‘Framing rules’ refers to rules of how we ascribe meanings to a given situation, for instance depending on how you frame getting fired from employment will result in either the worker feeling anger at a capitalists unfair treatment, or, sadness at one's own failure (Hochschild, 1979: 566).
Modern capitalism leaves little room for emotions, sentiments, and reactions, instead appropriating and commodifying them: a process that has been termed the ‘commercialisation’ of intimate life (Hochschild, 2003) and which is said to have created an ‘emotional capitalism’2 (Illouz, 2007: 5). Today’s capitalist economy
requires emotion work as an essential skill with a growth in interactive service work, the reimagining of a sovereign customer and public/private sector hospitality services meaning workers must have an increased awareness of social skills and an adaptability in the appropriateness of how they are deployed (Thompson, 2003). Meaningful, abiding human connection is replaced by brief isolated moments (Fleming, Murtola, 2001). In consumer capitalism, emotion work becomes increasingly difficult and
1Here, ‘problematic’ refers to the presence of stressors including “harassment, discrimination, threats of violence, and
managerial bullying” (Colligan, 2006: 96).
2 This is where “emotional and economic discourses and practices mutually shape each other, thus producing [a] sweeping
movement in which affect is made an essential aspect of economic behaviour and in which emotional life follows the logic of economic relations and exchange” (Illouz, 2007: 5)
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demanding as the regulation of feelings and as the presentation of the self becomes an intrinsic part of working life (Bolton, 2004). This vital and exhausting aspect of labour however, is rarely recognised or acknowledged due to its intangible and immediately perishable nature rendering it an ‘invisible skill’ (Bolton, 2004).
1.2.3 A Culture of Comparison and High Expectations
“There exists in the human organism, a drive to evaluate his opinion and abilities” (Festinger, 1954: 117). In making sense of ourselves and the social world we inhabit, social comparison is of central concern (Duunk, Gibbons, 2006: 15). Festinger hypothesised that individuals are motivated to make positive self-evaluations through social comparison, arguing that the ‘unidirectional drive upward’ (Festinger, 1954) or the desire to “do better or at least appear better than others” (Suls, 1977: 7) occurs through comparing oneself to another on a similar, or lesser, level of ability (Kuiper, Swallow, 1988). This positive outlook Festinger presents on social comparison could be outdated with the boom of social media. Individuals no longer compare themselves to their equal or less able neighbour and instead have the means of comparison with the elite in society. The abundance of media now available (television, magazines, movies, social media) means that avoiding (potentially negative) social comparison entails complete withdrawal from society (Kuiper, Swallow, 1988). This becomes increasingly worrying given that a key symptom of depression is to hold a negatively distorted view of the self (Kuiper, Swallow, 1988; Beck et al., 1979; Jaroly, Ruehlman, 1983; Kuiper, Olinger, 1986) in the light of unattainable expectations arising from comparison potentially amplifying this.
The fetishism of the commodity is “the domination of society by intangible as well as tangible things” (Debord, 2012: 36). Relating again to social media, the real world is replaced by abstract images which individuals aspire to achieve, believing them to be the apotheosis of reality (Debord, 2012: 36). The ‘spectacle’ complements the domination of society by money as representing universal equivalence; representing a commodity world of what “the entire society can be and can do” (Debord, 2012: 49). Individuals can only look and aspire to this ‘spectacle’ money as it has already been exchanged and now only embodies abstract representations, deeming the spectacle in itself a pseudo-use of life (Debord, 2012: 49). The inability to actually attain it is potentially damaging to individual’s self-esteem and mental well-being.
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A consideration of how social comparison, unattainably high expectations and an emphasis on consumption could negatively affect the mental well-being of individuals must occur, especially in the presence of studies evidencing that difference in income (as long as basic needs are met) between individuals in developed economies has little effect on their subjective well-being (SWB); implying that increased consumption does not equate to increased SWB (Ahuvia, 2002: 23). Correlations between income and SWB generally explain a 5% discrepancy in SWB between individuals (Ackerman, Paolucci, 1983; Douthitt et al., 1992; Macdonald, Douthitt, 1992; Mullis, 1992), leaving a remaining 95% explainable by something other than affluence. Kasser and Ryan argues that the key to SWB is to be motivated by one’s subjective intrinsic goals and needs (1996), similarly to Csikszentmihalyi’s (1999) view that intrinsically motivated ‘flow experiences’ produces happiness. Ahuvia (2002) would argue that the individualism accompanying economic development enables individuals to construct lifestyles aligning to their ideals (Veenhoven, 1999), and consequently their intrinsic needs. However, it is possible to deduce from the above literature that whilst capitalist ideology portrays individualism to enable the construction of a lifestyle which meets individual’s subjective needs, the reality is that many cannot due to low wages, excessive working hours and inhospitable work environments.
When considering depression specifically, many studies have alluded to the importance of social relations for mental well-being (Ali, Avison, 1997, Hope et al., 1999; Wu, Hart, 2002; Croux, 2007); a prioritisation on consumption is therefore doubly damaging due to its negative effects on social relations (Colligan, 2006). Furthermore, the capitalist transformation of human interaction into a market exchange threatens social reproduction (Ciscel, Heath, 2000) and arguably contributes to the onset and persistence of depression. The social fiber positively influencing human experience is eroded alongside resilience to adversity (Ciscel, Heath, 2000), increasing individual's vulnerability to depression even more so.
13 1.3 Antidepressants as a ‘Coping Strategy’
1.3.1 Help-seeking Behaviour
The complex and ambiguous symptomatology and origin of depression means various coping strategies are often made use of. Contradicting Parson’s conception of a seemingly passive patient in their performance of the ‘sick role’3 (1951), a patient’s reaction to biomedicine can be active, as suggested by the notion of therapeutic citizenship (Rose, Novas, 2005; Nguyen, 2005). An ‘expert patient’ discourse (initiated partially by the pharmaceutical industry with profit interests) has developed (Abraham, 2010). This contributed to the development of online self-diagnostic tools “transforming the patient into a consumer” (Ebling, 2011: 825) facilitating patient’s self-diagnosis enabling the request of specific pharmaceutical medication, therefore increasing the pressure and prescription habits of medical professionals (Mintzes et al., 2003). Whilst Karp argued that this is less common than doctors/psychiatrists instigating considerations to begin medication, this may have changed in more recent years with both psychiatry and pharmaceutical companies ‘educating’ the public regarding the nature of depression and antidepressant drugs being advertised in America4 as a “revolutionary cure for depression” (1996: 87).
Conflicting with this argument is the concept of ‘somatisation’5, evidencing resistance from individuals to discuss their mental suffering with healthcare professionals (Pill et al., 2001). Strengthening this are studies demonstrating individuals intentional concealment of psychiatric problems from General Practitioners (GPs) due to the belief that ‘doctors have insufficient time’ and ‘that there is nothing the doctor can do’ (Meltzer et al., 1996; Pill et al., 2001).
1.3.2 Pharmaceuticalisation / Medicalisation
So why, if individuals are so reluctant to disclose emotional distress to GPs (Pill et al., 2001) is the biomedical models approach of antidepressants the primary treatment for
3It must be noted however, that in Parsons (1975) reconsideration of the ‘sick role’ he exclaims that the patient is not
completely passive in this relationship.
4 Whilst direct to consumer advertising is still prohibited in the UK, education of patients regarding the nature of depressions
and antidepressant drugs can be seen though pamphlets found in doctor’s surgeries, and through health professionals themselves (Grime, Pollock, 2004).
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depression in the West? In an attempt to understand this, the crucial role of medical professionals and the pharmaceutical industry in defining, legitimating and treating illness must be considered (Gerhardt, 1989).
The concept of medicalisation entered medical sociology in the late 1970s as the need to critically consider “the involvement of medicine in the management of society” (Zola, 1972: 488; Pitts, 1968) became undeniable. Medicalisation is generally understood as a reaction to processes in the late 17th and early 18th century which catalysed modernisation in western society; namely industrialisation (Foucault, 1963; Lock, 2004). With this, a concerted attempt was made to increase control over the natural world through science (Lock, 2004), which arguably transformed medical institutions into forms of social control (Bell, Figert, 2012; Foucault, 1963). ‘Medicalisation’ is seen as “a process by which non-medical problems become defined and treated as medical problems, usually in terms of illness or disorders” (Conrad, 1992: 209). The gradual medicalisation of daily life went remarkably unnoticed (Zola, 1972), and historically it was health professionals who were subjected to the analytical lens of medicalisation theorists. However, more recently attention has been directed at the pharmaceutical industry in the ‘Prozac era’ of the late 1980s (Metzl, 2003) as a key enforcer of medicalisation (Abraham, 2010: 604).
Conflicting arguments amongst theorists concerning the usefulness of medicalisation as a concept to analyse the postmodern world, occasioned the coining of ‘Pharmaceuticalisation’ (Bell, Figert, 2012): “the transformation of human conditions, capacities or capabilities into pharmaceutical matters of treatment or enhancement”6
(William et al., 2011: 37) and the causes and effects of this (Abraham, 2010; Padwel, Majumber, 2007; Throsby, 2009). ‘Biomedicalisation’ was also conceived; a shift to the biomedical perspective (Clarke, 2010). It is argued that both processes are key drivers of medicalisation, for example, through the pharmaceutical industry's influence on medical experts who formulate “diagnostic boundary changes and disease-awareness campaigns” (Abraham, 2010: 606; see also; Conrad, 2005; Davies, 2013). With this in mind, I argue postmodern societies hybridity would benefit from the use of Abraham’s concept of the “medicalisation-pharmaceuticalisation complex”, which captures the two-way causality(2010: 608).
6 This is not however, uncontested. There are many definitions (see Abraham 2010, Davies, 2013: 100; Abraham, 2010a:
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Although depression is generally accepted as a psychiatric condition, general allopathic practitioners are often responsible for treatment in the West, with 746/1000 individuals [2011 statistic] on antidepressants having been prescribed them by GPs in the UK (Davies, 2013: 196). This overlap of psychiatry and general medical practice enables the concealment of medicalisations’ and pharmaceuticalisations’ responsibility in increased prescriptions of antidepressants, using GPs as a scapegoat. GPs lack of psychiatric training renders them unarmed when approached by generous drug representatives of pharmaceutical companies and distressed patients. When GPs feel unable or unequipped to help “the temptation is to medicalise” (Davies, 2013: 262). Biomedical advocates argue that pharmaceuticalisation echoes a heightened discovery of individuals requiring drugs expedited by continuously ameliorating clinical diagnostics; ‘therapeutic diffusion’ (Abraham, 2010: 608). However, with the number of new pharmaceuticals on the market offering therapeutic improvements declining, this is discredited (Abraham, 2010; Gabe et al., 2011). Further reducing the legitimacy of this argument is that pharmaceuticalisation could reflect either improved clinical diagnostic, or just as easily, an expanding diagnostic criteria with roots in medicalisation (Abraham, 2010: 608). Creating even more confusion and ambiguity are the small but significant changes made to the diagnostic criteria of depression from DSM7-IV to DSM-5; dividing ‘mood disorders’ by separating ‘depression disorders’ and ‘bipolar disorders’ has “expanded the core mood criterion to include hopelessness” (Pavlova et al., 2014: 459). Also, rather than bereavement being excluded, the DSM-5 now exclaims a clinical judgement must be made to distinguish a disorder from normal grief. This increases the subjectivity of a diagnosis and problematises the relationship between depression and adversity (Pavlova, 2014).
In light of this, Abraham’s (2010) claim that the pharmaceutical industry has prioritised commercial aspirations over biomedical, with changes in diagnosis potentially encouraging this, as well as medication being deceptively portrayed as disease specific ‘cures’ in the pharmaceutical industry’s pursuit for profit (Moncrieff, 2008: 135) and psychiatry’s for professional status8 (Davies, 2013) must be considered. ‘Disease
mongering’ (Goldacre, 2008; Heath et al., 2002; Payer, 1992) strengthens this argument.
7 The ‘Diagnostic and Statistical Manual’ of mental disorders.
8 The need for Psychiatry to prove itself professionally was partially due to Rosenhans (1973) revelation of the fragility of
psychiatry’s diagnostic system in the study ‘On being sane in insane places’. Whilst considered unethical today, the study entailed ‘sane’ individuals being detained in mental institutions; the difficulty they found in being discharged revealed the illegitimacy of psychiatric diagnostic criteria.
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Defining and promoting diseases to patients and doctors is given much attention and money by pharmaceutical companies; “the social construction of illness is being replaced by the corporate construction of disease” (Heath et al., 2002: 886).
Regarding the effects of antidepressant medication being offered as a main ‘coping strategy’ in the West, it is of note that this biological ‘reduction’ of depression, brackets off and ignores the structural sources of human pain. Antidepressant medication locates illness as an individual, biological pathology, rather than a normal human reaction to adverse social, structural conditions (Karp,1996; Kleinman, 1988).
1.4 Illness Narratives of Depression
Whilst sociologists and anthropologists alike have given ‘depression’ much attention (Bart, 1974; Brown, Harris, 1978; Brown, Harris, 2012; Latkin, Curry, 2003; Miech, Shanahan, 2000), illness narratives of depression have been neglected (Kangas, 2001; Karp, 1996; Kleinman, 1988). There are still some examples however; Karp’s (1996) analysis of individuals illness narratives of depression recognised their journey’s in terms of a depression and medication ‘career’; “the moving perspective in which the person sees his life as a whole and interprets the meanings of his various attitudes, actions, and the things which happen to him” (Hughes, 1958: 73). The limited literature on this topic is unfortunate as accounts could reveal “individual and social circumstances that create discomfort, depression accounts act as powerful describers of society” (Kangas, 2001: 76). Illness narratives provide a space for reflection as sufferers attempt to make sense of their illness and answer the existential question of bafflement, ‘why me?’ (Kangas, 2001: 77; Karp, 1996; Kleinman, 1988); this is both a reflection of the individual experience and the social constructions and consequences surrounding their depression (Kangas, 2001; Billig, Radley, 1996). The word ‘perceived’ is crucial when considering the potential stressors of living in a capitalist socio-political-economy on an individual’s mental health. The individual must perceive a situation to be threatening. The individual's “emotional, cognitive, behavioural, and physiological response to stress has a direct relationship to the characteristics of the stressor, the resources [they have] to buffer the stressor, and [the individual's] personal characteristics” (Colligan, 2006: 92). An investigation of all of these is therefore necessary through exploring individual’s illness narratives.
Whatever the analytic value of the many theories on the aetiology of depression, human variability renders it difficult to pinpoint a firm causation (Dooley, 2000). Similarly, there are
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many possible explanations of how and why antidepressants have developed into the predominant form of treatment, for example the marketing of antidepressants to doctors in Buenos Aires during the Argentine financial crisis (2001). The relations between the pharmaceutical industry and doctor’s being based on a ‘gift economy’ requires the questioning of whether increased antidepressant sales were based on social situation or due to promotional (and therefore prescription) practices (Lakoff, 2004). Of great value in understanding both phenomena are individuals’ subjective perceptions: of the aetiology of their suffering and their experiences of taking antidepressants. By exploring these we can locate social causes of discontent as well as the benefit and harm using antidepressant as treatment can bring. This will enable a reconsideration of how we treat depression to include psychosocial, as well as biological, causes.
1.5 The Present Study
Central Question(s) guiding the research:
In this study, I investigate the subjective illness experience of depression, and the lived experience of taking antidepressant medication within a (UK) Capitalist context.
What, if any, aspects of living within a capitalist context do participants perceive as contributing to their depression?
- What other aspects of life to participants perceive to contribute to their depression? - What, if any, value do participants place on antidepressant medication as a coping
strategy?
- What are the consequences on individuals daily lived experiences of taking antidepressants?
- What other coping strategies did participants employ to enable their coping in this environment?
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Chapter 2: Research Methodology, Theoretical Framework, and Data
Analysis
Using qualitative in-depth interviews and ethnography of depression self-help groups will enable an insight to be gained on the highly individualised, contested, and ambiguous illness experience as well as the experience of the Western ‘coping strategy’ of taking antidepressant medication. Discourse analysis of email exchange also informed the research. I will explore the ‘explanatory maps’ participants used when considering the aetiology of their depression, the meanings participants assigned to their first encounter with medication and the ‘attribution categories’ assigned to the persistence of their depression. Using a variety of theoretical frameworks and concepts these will be considered in the broader capitalist socio-political-economical context.
2.1 Study Sample and Location
London being the UK’s hub of capitalism made it a desirable location when considering the social-cultural contributors to human suffering. I was however, aware that my location, to a certain extent, had to be led by the location of participants due to the sensitivity of the topic potentially problematising access (Kleinman, 1985). Although much work to reduce stigma surrounding depression and mental illness in the UK has been done, undoubtedly, prejudice still exists whether this be actual or perceived (Dietrich et al., 2014).
For this reason, depression self-help groups were used as gatekeepers to participants. The independently organised groups avoided the issue of entering into a clinical settings, which can prove difficult when working with vulnerable individuals (Miller, Moore, 1999; Moyle, 2002). Furthermore, I hoped the attendees of such groups would be more willing to speak of their experiences, due to their membership implying an already apparent openness (Karp, 1996). After emailing facilitators of various groups in London, four agreed to disseminate information about myself and the research to attendees, leaving it up to them to make contact if they wished to be involved. From this, eleven individuals showed interest. We remained in contact via email and agreed to meet once I arrived in London. A facilitator of a self-help group (who also became a participant) empathised with my background and research and, following a few conversations, agreed to approach the group with the idea of myself sitting in and observing the sessions. Much
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to my surprise, all attendees agreed and allowed my participation in two sessions.
The self-help groups attended were held in a Church in South London. Once access was gained I met few difficulties. A point worth mentioning however was the minimal opportunity to build relationships in the very short time I had to meet the attendees before the session. I had intended to do so in an attempt to minimise the effect of my presence on individual’s contributions. I did however, speak to the group regarding myself and the research in hope that this would suffice in justifying my presence and making participants feel comfortable.
Entering the Field
Self-help group: 07/03/2017
I sit in a café across the road of the church as I got there a little early, the waiter smiles and shows me to a table whilst exchanging friendly small talk. The café is empty. I order a coffee and sit down. I notice a man walk in and order a drink to go, and wonder whether he’d be attending the group. After finished my coffee, I pack up my stuff and begin the cold, dark walk towards the church. Following the man from the cafe, I soon realise we are heading in the same direction.
It is the group's 1st birthday, so attendees met 15 minutes earlier to have a little celebration; cake, crisps, cheese, crackers, and orange juice. The church is grand with beautiful stain glass windows and a comforting ambience. I soon find out that the man I saw in the café is Fergus; a representative from Mind9. I take a moment to observe the other attendees; Ben, a warm, cheery man – the facilitator, I interviewed him last week. He gives me a big hug and we briefly catch up. A blonde bubbly woman, very forthcoming and chatty. She comes over and introduces herself; Sarah. I briefly explain why I’m here but try to keep it vague as I’m aware Ben intends to give me the opportunity to explain the study properly. Gurn10 seems timid, quiet and a little nervous. I wonder if it’s her first time attending. I try to get her attention and smile, but her eyes are fixed on the ground. Matthew11 is sitting on a pew in the corner, he seems shy and reserved.
I go over as he is helping himself to food and introduce myself. After contact is made, I instantly experience his warmth, engagement and calmness. Alex12 appears confident, like he’d been
here before, he knows what he’s doing; interacting with joviality and ease. Jack, an older man, walks towards me with a welcoming smile. As he introduces himself I realise that we have
9 A mental health charity involved in the organisation of the group. 10 At this point I was unaware that was her name.
11 At this point I was unaware that was his name. 12 At this point I was unaware that was his name.
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already been communicating with via email regarding the possibility of me interviewing him. And finally, Akeel – smiley, young man. Forthcoming and kind, he approaches me. Another man enters, I don’t catch his name, he then makes a u-turn and walks out, swiftly followed by Ben. Returning, Ben explains the mystery man is having a bad day and won’t be attending the meeting this week.
Once everyone has eaten, we begin moving upstairs to start the session. I’m led through an old oak door and up a winding staircase; red carpet, bare sand stone brick walls, high ceilings, and traditional church like interior. We enter a small room starkly contrasting with my experience of the church so far; still cosy and comforting, but not grand. Cluttered with gowns, children’s toys, books, and various other tit-tat. A beautiful, stone carved, stained glass window dominates the back wall but is mostly hidden behind a fuchsia pink sofa. Ben and Fergus take the sofa whilst the rest of us make ourselves comfortable on wooden chairs. The church bells ring a slow, familiar sound in the background.
Feeling a little awkward and intrusive I hope Ben will allow me to explain my presence soon. Right on cue, he asks for quiet and gestures to me. I start speaking. I explain that I will not be recording or taking notes, I simply wanted to be here. And if my presence made anyone uncomfortable, I could leave at any moment. I ask whether they would like me to participate in the discussion and tell a little about myself, or whether they would prefer me to be a fly on the wall. All attendees express their desire for me to participate. The session now commences; each attendee is given a five minutes slot to talk about how they have felt since the last meeting. There is no obligation to speak, but if you chose to, you cannot exceed five minutes. Five minutes seems short, I reflect silently, but I begin to understand the need for this regulation as the flood-gates open and the number of topics being addressed grows: suicidal thoughts, suicide attempts, both discontent and praise of medication, coping mechanisms; exercise, diet, sleep, structure, self-help groups, relationships with doctors (positive and negative), relationships in general (friends, family, partners), therapists, what they gain from these group sessions, employment, adverse events, addictions … to name a few. Suddenly, it is my turn to participate, I struggle with what to say, stumbling over my words. I don’t want to compare my own menial struggles with their pain, however equally, I want to be open and reveal my own vulnerability, if nothing else to thank them for showing me theirs. “I should have planned what to say previously…” my inner voice curses. I then say exactly that. I also explain that I feel a little unsettled being in London as I haven’t lived here. I feel very emotional as the research I’m conducting is bringing up many memories of my past, and experiences at present, as my mother
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and sister both suffer from depression as well as many friends. I feel thankful and touched that people are so willing to be open with me about their experiences.
After everyone has spoken, Ben facilitates a more general conversation touching upon anything individual’s desire to discuss. A massive topic at this point is a feeling of discontent with GPs. Not as a whole, but some attendees specifically have had bad experiences. Matthew expresses frustration with the limited treatment of medication or Cognitive Behavioural Therapy13 (CBT) offered. The other attendees passionately agree; “when you’re really bad you can’t begin to process thoughts so how is CBT going to work?” A further topic is individuals internal conflict between wanting to take control over their illness, whilst simultaneously wishing somebody else would control their recovery and just give them a pill – especially in their darker moments when they are incapable of processing thoughts.
The pure, sincere openness of the group surprises me – even with my presence, which inevitably must change the dynamic, if only slightly – the individuals who were previously timid, quiet, and reserved, speak openly, making eye contact with other members, displaying passion about their experiences confidently. Those who were very withdrawn, and the more initially forward individuals, are equally open about difficult, personal topics. The strength and support in the room is amazing, exhilarating. All the members express the benefit they find in attending the group; the space to be honest with no facade of being fine. No one has to pretend. Even with friends and family who know they are suffering from depression, attendees express the pressure they feel to act okay when they are not, and find it liberating to not have to do so in this space. I find the session difficult, hearing the ‘honest’ experiences of people suffering from depression. Previously, I had only heard these from friends and family, my research previously focusing on the relationship between patients and doctors rather than experiences. I question and reflect on whether people who I’m close to who are suffering feel that same pressure, even with me. I instantly feel confronted.
My hope was to interview each participant at least twice, in order to allow sufficient time to discuss perceptions and experiences in depth (Horrocks, King, 2010). Also, as previously mentioned, the stigma surrounding depression I feared would limit what participants were prepared to divulge (Kleinman, 1985). To combat this, I intended to build rapport and trusting
13A form of psychotherapy combatting negative patterns of thought about the self and the world in order to change negative
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relationships in which participants felt comfortable confiding (Marshall, Rossman, 2014). On the other hand, I realised that to request numerous interviews, to potentially not be completed could create the perception that their experiences were of little value. To avoid disappointment (Estroff, 1995) I discussed second interviews with especially reflective participants following first interviews. This resulted in one participant being interviewed three times, two participants twice, and five once. In total conducting twelve interviews with eight participants14, lasting between forty-five minutes and five hours, as well as conducting two ethnographic studies on two self-help sessions, each lasting ninety minutes.
The interviews were conducted in a variety of locations dependent on the individual requirements of participants. These included; a participant's’ flat, cafe’s situated in different areas of London and a public park. A few difficulties arose with location generally oriented around being in public spaces and participants consciousness of others in close proximity and therefore earshot. Although no participant exclaimed this overtly, I was mindful that a trail of thought may be lost or eyes wandered if, for example, the cafe suddenly became quiet. All participants surprised me with their openness, hopefully therefore, this did not affect the data significantly15.
2.2 Approach; Difficulties and Benefits
The interviews in this study were led in an attempt to establish a more participant-focussed mode of reflexivity (Riach, 2009). By asking for the biography of participants depression and experiences of taking antidepressants, allowing them to include or exclude information they saw relevant with limited input from myself, I hoped to gather a reasonably accurate representation of their subjective perceptions (Karp, 1996). Participants narratives were frequently very detailed, resulting in large quantities of data being gathered. Locating focal points in analysing long, complex descriptions took a lot of time.
As mentioned previously, considering how depression is often a shunned or silenced topic (Karp, 1996; Kleinman, 1985) all participants surprised me with their openness. This commonality likely being explained by all being attendees of self-help groups therefore presumably having reached a point in their ‘depression career’ of willingness, even eagerness, to talk (Karp, 1996). My aim of exploring individual illness and lived experiences benefited
14Three of the original eleven individuals who came forward retracted their offer due to feeling too emotionally vulnerable to
take part.
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hugely through speaking to those who had reached this point in their depression career. Saying this, the study sample did not avoid all difficulties.
For example, the biography of an individual’s depression often manifests into a life story and therefore inevitably many events and experiences are alluded to with the impossibility to cover everything (Karp, 1996). However, what they choose to disclose displays what participants perceive as important when making sense of their depression, arguably then, this is not necessarily a limitation. Furthermore, participants narratives were never a simple chronological time line; the mind wanders onto different tangents, into different time periods, explaining complex stories (sometimes interrelated and other times completely polarised); following this process was a challenge. Exacerbating this challenge further in some cases, was the unorganised, scattered, and forgetful mind of some participants (Karp, 1996; Moyle, 2002).
2.3 Interview as Therapy
The emotional strain involved in relaying illness experiences of depression and lived experiences of taking antidepressants was ethically compromising at points. Participants using interviews as therapy combatting these ethical issues in ways, however, generated its own specific concerns (Moyle, 2002).
Participants using interviews as therapy is not something I anticipated, though perhaps I should have done considering the nature of in-depth qualitative interviews (Rossetto, 2014) and the implications of researching depressed individuals (Moyle, 2002). The effect on data production and ethical consideration must be considered.
All eight participants commented on the therapeutic value in delineating their illness experience, aligning with previous research (Kleinman, 1988; Karp, 1996; Moyle, 2002). Whilst this put me at peace ethically in some ways it also compromised my ability to direct interviews as I was conscious not to devalue narratives by interrupting or changing topics. In reality, this affected the data minimally as interest lay in personal perceptions and experience, meaning everything said held analytical value. Furthermore, their use of the interview as therapy focussed the topic on their depression experience making my role as interview guider redundant in some cases. However, the presence of emotional participants sometimes made it difficult to end an interview. When witnessing raw pain and anguish I found keeping my professional distance a challenge. Setting boundaries when comforting participants was fundamental however, in order to prevent presenting myself as a support which could harm
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participants when our relationship ceased to exist post fieldwork (Moyle, 2002). To avoid this, I made sure to confirm, on various occasions, the nature of our interactions was for research, not therapy, whilst simultaneously acknowledging my relief that therapeutic value was gained (Moyle, 2002).
A further unexpected consequence of participants using interviews as therapy manifested through some interviews being ‘taken over’ and controlled by the interviewee with their own needs, rather than those of the research, in mind. The implications of this are not wholly clear, though these interviews too have analytic value.
2.4 Ethical Considerations
Participants gaining therapeutic value from interviews could be seen as fulfilling the ethical obligation ‘give something back’ (Rossetto, 2014). Nevertheless, an acute awareness of maintaining boundaries was necessary to avoid role confusion (Dickson-Swift et al., 2006; Weiss, 1994) by participants using the interview as therapy, and therefore myself as therapist (Rossetto, 2014). Equally, whilst all participants expressed the value they found in speaking of their experiences, my obligation as researcher to do no harm (Birch, Miller, 2000; Dickson-Swift et al., 2006; Haynes, 2006) was potentially hindered when participants became emotional within the interview process. To combat this, prior to each interview I asked if the participant wished to avoid any topics in an attempt to steer clear of distress. When conducting the interview I was hyper conscious of recognising distress signals (Kavanaugh, Ayres, 1998) and giving the option to draw back if participants did become distressed (Haynes, 2006), whilst concurrently allowing space to be emotional if they wished to be. Also, it is necessary to recognise that whilst sadness and despair were key characteristics of interviews, I was equally awed by the strength and determination participants showed in the face of adversity.
I identify myself as an empathetic person, however, this does not equate to being a trained therapist, meaning I found the experience emotionally demanding (Dickson-Swift et al., 2006), and felt conflicted by my natural instinct to console the participant and my obligation as a researcher to maintain some distance (Birch, Miller, 2000). Once I had built relationships with participants however, I expressed my discomfort with wanting to show support conflicting with my professional obligation, and was assured that they recognised my role as “listener, learner, and observer, not counselor or therapist” (Rossetto, 2014: 487).
25 2.5 Theoretical Approach and Conceptual tools
2.5.1 Interpretative Phenomenology
Interpretative phenomenology focuses on individual meanings within their context, and how these meanings may affect the choices made by individuals. Each individual will give different meanings to a particular experience or event. Close attention is given to the social, historical, and political influences of the culture which shape individual experience (Smith, 2004).
Phenomenology, as an approach, aligns well with healthcare research. This is due to its prioritisation in attempting to understand subjective meanings individuals give to interactions and experiences in their specific environment (Lopez, Willis, 2004: 726) which is necessary when generating culturally relevant interpretations of individual’s social realities (Meleis, 1996). ‘Situated freedom’ (Leonard, 1999) argues that the individual and the social are inseparable and therefore subjective individual experience is affected by social, cultural, and political context (Heidegger, 1962). Individual’s freedom to make choices is not absolute; their freedom is confined to the conditions of their context (Lopez, Willis, 2004: 729). I use interpretative phenomenology to focus on the individual’s relationship with their lifeworld and how a lifeworld influences similarities and differences between individual participant’s subjective experiences (Lopez, Willis, 2004). Using phenomenology guided questions considering lived experience of depression in the context of socialisation and daily practices (Smith et al., 1987).
2.5.2 Critical Hermeneutics
Critical hermeneutic theory argues that the socially accepted/constructed reality undeniably influences all interpretation and acts (Thompson, 1990). Socially accepted worldviews reflect the values of interest groups (in this instance, the pharmaceutical industry, biomedicine, and the capitalist ethos in general). I utilise critical hermeneutics theoretical framework to highlight the neglected voices of those absent from interest groups (Lopez, Willis, 2004). I review “dominant ideologies and analyse in detail how these ideologies shape and organise the daily lives of study participants” (Lopez, Willis, 2004: 730) examining how ideologies potentially ignore subjective realities of participants. Critical hermeneutics also assisted the analysis of narratives, revealing power relations embedded within them (Thomson, 1990).
26 2.5.3 Embodiment
Embodiment conceptualises the conflict between the subject body; the body which is pre-reflectively lived, and the object body; the physical body which is perceived by oneself and others (Fuchs, Schlimme, 2009). Embodiment also explores to what extent an individual is bound to their environment and therefore their subjectivities is only understood as an embodied relation to the world (Fuchs, 2009). Analysis of embodied existence in depression enabled an understanding of the subjective illness experience of participants. Looking at their illness in relation to their lifeworld and others was gained (Fuchs, 2007; Fuchs, Schlimme, 2009).
In the case of depression, embodiment disruption occurs primarily in the subject body and sense of self (Fuchs, Schlimme, 2009). The body becomes an obstruction to the world an individual inhabits as the sense of self is no longer implicit and transparent, instead becoming conspicuous; the phenomenal space is no longer embodied (Fuchs, Schlimme, 2009). Previously taken-for-granted feelings are lost, bringing one’s sense of self, and the way they interact with their environment, into question. The object body is then disembodied as it is completely identified with itself (or loss of self), rather than transcending itself (Fuchs, Schlimee, 2009). ‘Embodiment’ assisted analysis, through its consideration of how the capitalist context effects an individual’s subjective experience, is vital in the exploration of mental illness as a disturbance in individual’s embodiment of their environment.
2.5.4 Illness Narrative
“Illness narratives edify us about how life problems are created, controlled, made meaningful. They also tell us about the way cultural values and social relations shape how we perceive and monitor our bodies, label and categorise bodily symptoms [and] interpret complaints in the particular context of our life situation…” (Kleinman, 1988: xiii). Narratives are never objective, instead presenting specific version of a reality as interviewees make conscious decisions of what to disclose (Reissman, 1990). The analysis of narratives generated fruitful interpretations of participant’s illness experience in relationship to their wider cultural context.
2.5.5 Explanatory Maps
Innumerable ‘explanatory models’ were located within individual narratives. I found the interchangeability of beliefs could not be portrayed through the fixed, singular term
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‘explanatory model’ and instead, opted to use ‘explanatory map’ as I believe it more appropriately encompasses the fluidity or thoughts and beliefs of individuals (Healy, Williams, 2001).
2.5.6 Attribution Categories and Meaningful Encounter
‘Attribution categories’ (Girodo, 1981) common in all (or most) of the illness narratives for the persistence of depression were located. It must be clarified that these categories are not bounded in reality. They are complexly interwoven and ever changing (Karp, 1996). For analytical purposes however, it was necessary to categorise in such a way. Unless you have walked every step in someone’s shoes, you will never understand their depression experience (Kleinman, 1988); I have however, attempted to do so to the best of my ability. A consideration of the first contact with medication as a ‘meaningful encounter’ for participants ensued. This embodied a pivotal point in all participants ‘illness career’ (Karp, 1996).
2.6 Data Collection and Analysis
All twelve interviews were recorded and transcribed in preparation for analysis. My decision to not record or take notes during the self-help sessions was motivated by a commitment to minimise the effect of my presence and respect the confidentiality of meetings; believing the absence of overtly recording data would assist in this. By giving my absolute attention and involvement within the session I felt confident that I would not compromise the professionalism of my research and people would feel comfortable contributing as normal.
Each participant employed an utterly different explanatory map when making sense of the onset of their depression. Condensing these into a readable, comprehensible, and analytical piece without losing the subjective, raw experiences participants presented was a challenge (Kleinman, 1988). The relaying of these in Chapter 3 should be viewed as a brief reflection not nearly encompassing the multitude of perceived factors contributing to the onset of participants depression; instead intending to give an insight into the complexity of such explanatory maps. I chose to explore Erin (54), William (58), and Matthew (26) narratives in more detail due to the diversity in their demographic, backgrounds, and explanatory maps. By showing this diversity a deeper understanding of the breadth of individuals vulnerable to depression, and their experiences could be uncovered.
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of participants depression are as follows; ‘insecurity and hostility’, ‘inauthenticity’, ‘pressure’, ‘social networks and isolation’, and, ‘the Self’.
Finally, the meanings assigned to the ‘meaningful encounters’ of participants first interaction with medication were ‘succumbing to life’s pressures’ and ‘the alternative/a reaction to suicide’. A consideration of the ‘bodily effects’ of medication, ‘reliance on medication’ and individuals attempt at ‘exerting control’ over their lives and depression through a desire to discontinue consumption of antidepressants also ensued.
2.7 Limitations of Study and Coping Strategies 2.7.1 Sampling Limitations
I initially intended to locate a diverse demographic enabling the analysis of depression amongst a variety of genders, nationalities, ages, classes etc. Utilising depression self-help groups to gain access to individuals was ethically reassuring as individuals approached me with interest of involvement, however, difficulty arose with gaining the diversity of individuals I desired. Once entering the field the diversification of illness experiences of depression was realised, even among participants of similar gender, ethnicity, age, and class. I was reassured that the lack of varied demographic would not hinder my efforts to uncover the variety in subjective experiences (rather than trying to link experiences of depression with status characteristics of groups).
Interviewing vulnerable groups comes with difficulties; and those with depression bring their specific ones (Moyer, 2002). Many suffering from depression don’t have the luxury of day-to-day mood consistency which was evidenced when three participants felt unable to participate at the last minute making the sample male dominated (five males, three females).
One limitation of using self-help groups as gatekeepers is that arguably, a specific personality type would attend such a group. Another is that attendees will have reached a particular point in their depression career, and so not represent the experiences of depression who are not willing, or physically cannot, speak. However, again, as the aim here is to explore subjective experiences of individuals rather than groups this is less of a problem. Also by interviewing individuals who were not only willing, but actively wanted to talk, proved useful when uncovering difficult and sensitive topics.
29 2.7.2 Time and Length Limitations
Although I hope to have provided an insight into individuals’ lived experiences, I am fully aware that the time and length limitations of this study limit my ability to do justice to the complexity and depth of the stories I witnessed. Emotions, thoughts, perceptions and experience are not solid entities; their fluidity transcends over time (Kleinman, 1988) and cannot be caught in the temporal trap of a thesis. With this in mind, this study should be viewed as highlighting the experiences of individuals at a given moment and undoubtedly these experiences are subject to change and should never be taken as absolute ‘truth’ (Karp, 1996).
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Chapter 3: The Illness Experience of Depression
This chapter aims to explore the ‘explanatory maps’ (Healy, Williams, 2001) participants employed to understand their illness experience of depression. I will begin by exploring the explanatory maps of three participants. Following this, I will look at participants’ first interaction with medication as well as the ways in which they make sense of the persistence of their depression.
3.1 Making Sense of the Onset of Depression
Individuals experience adversities daily, in many shapes and sizes. When asking for an individual's biography and perceptions of the aetiology of their depression, this often entailed a life story and a reflection of the existential question of bafflement ‘Why me?’ (Kleinman, 1988). No narrative followed a solid, linear line. Instead, involving many conflicting, contradictory statements alongside numerous interrelated and interchangeable perceptions of what may have influenced and contributed to the onset of depression, exemplifying the diversity and complexity even of a single individual's depression illness experience.
The lack of a clear-cut ‘eureka’ moment of realisation (Karp, 1996) problematises discussing the onset of depression. Rather, this realisation often consists of periods of sadness with well-being, sometimes being conceptualised, other times not, often only realised through retrospective reflection (Karp, 1996). The onset of depression often includes a clinical diagnosis; the significance an individual assigns to this, must be considered; has the individual self-diagnosed depression prior to the interaction? Are they opposed to such a fixed diagnostic category or do they desire the acknowledgement of their suffering?
3.1.1 Erin, William, and Matthew Erin:
Erin explained how the depression began ‘officially’ in January 2015 after being prescribed medication by her GP. Unofficially however, she had been suffering for some time, explaining before “succumbing” to medication she had managed on sheer strength and survival instinct. Growing up in Ireland, as a middle child of twelve siblings, with an alcoholic, abusive father her childhood was turbulent. Erin was not personally beaten, but witnessed the abuse of her mother and siblings in a household ran on fear. The confiscation and banishment of all mirrors as “indulgence in vanity was a sin”
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contributed to Erin’s fractured self-esteem. I could sense an utmost respect for her mother’s strength to withstand such abuse and still ensure “dinner was on the table every night”; this did not equate to emotional support however, which Erin explained “was not met with the same vigilance.”
She moved from her hometown, Templemore in 1996, after her mother was diagnosed with stomach cancer and later died aged 48. Her father died twenty-three years later. After fleeing his violence their relationship ceased to exist and she expressed feeling nothing when he died, believing his fate to be self-inflicted through alcoholism and the development and mismanagement of diabetes type 2. Whilst caring minimally about her father’s death, Erin expressed guilt for abandoning her younger siblings. The opportunity to change her dire situation however, outweighed her perceived obligation to stay. Erin later found out her mother’s stomach cancer was hereditary when her brother died of the same disease aged 44 within 6 months of diagnosis in 2004. Her nephew committed suicide in the same year.
Once migrating to Cork (Ireland) Erin quickly became engaged; John’s family epitomised everything her own did not. She spoke warmly of the love and support they offered, blatantly contributing to her love for him and their relationship. Unexpectedly John cancelled the wedding at the last minute, breaking her heart and already fragile self-confidence. In complete despair, Erin fled to London, aged 23, in a desperate attempt to escape her pain. Erin reflected regrettably on how major decisions in her life had been driven, almost dictated, by others’ actions or circumstances she was fleeing rather than her intrinsic desires motivating her.
In London, Erin established what she perceived to be a good life, building a long career with British Telecom. Erin applied for voluntary redundancy in 1999 after experiencing unbearable stress. She then joined the Metropolitan Police. She formed two extremely close friendships. Carl and Erin began a relationship in 1987, later to break up but remain very close platonically; Carl died in 2009. In 1988, Erin assisted an elderly woman who fell on the London underground. Her name was Bridie and they remained friends ever since. With no husband and few social networks, Bridie found as much comfort and companionship in Erin, as she did Bridie. Bridie died in 2015.
Amongst many adversities life threw at her, Erin fell pregnant to a man unexpectedly, resulting in a termination. This decision I could see persisted to distress her. Whilst not
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acknowledging it at the time, retrospectively, she realised she had entered a harrowing, dark period and was absolutely, utterly, disastrously depressed. After taking some time off work however, using resilience and the aid and support of her friends she “pulled through” without seeking professional help.
Throughout her trials, Erin never conceptualised herself as depressed, seeing these as painful but manageable parts of life. However, with the deaths of Carl and Bridie combined with difficulties surrounding her housing and employment Erin felt isolated, unsupported and unable to cope. Bewildered, not understanding how or why her two closest companions had be taken away from her, after all she had been through, Erin began questioning herself as a person; did she deserve this? Not knowing where else to turn, she visited her GP and was diagnosed with depression, prescribed antidepressants and put on the waiting list for CBT.
William:
From the moment I spoke with William, he explained he was experiencing a period of exaltation so his narrative would not embody the raw pain and anguish he felt when consumed with depression, but assured me with a shudder, that he could remember it well and feared returning to that place daily.
William saw his depression developing, or more accurately being apparent, from the age of 8, catalysed by his first memorable experience of rejection by his school friends, to then persist throughout his life sporadically. The self-perception of being a “little shit”; someone deserving rejection and isolation had been internalised. This self-perception was amplified through continued mistreatment during his school years. William considered suicide for the first time when he was bullied by a group of girls and no one came to his aid.
He persevered through his school years with a tempestuous academic and emotional career - the former due to lack of effort rather than lack of intelligence. During William’s time at the University of York studying Philosophy, his infatuation with a girl was not reciprocated; the distraction of this emotional pain led him to believe he would fail his degree. Perceiving himself as a failure; relationship-wise and academically, William attempted suicide a month before his final exams. After being seen by a psychiatrist who prescribed him antidepressant’s (and did little else), he proceeded to take all of them with alcohol in a 2nd attempt of suicide. William recalled these attempts having a
