Feminist women's accounts of depression

Feminist Women’s Accounts of Depression Affilia: Journal of Women and Social Work 27(2) 180-189 ª 2012 SAGE Publications Reprints and permission: sagepub.com/journalsPermissions.nav DOI: 10.1177/0886109912443959 http://affilia.sagepub.com Jenna M. MacKay1 and Alexandra Rutherford2 Abstract Feminist theorists have argued that women’s experiences of depression are intimately tied to multiple systemic factors, such as oppression and violence. Although these theories challenge the dominant paradigm, they tell little about how feminist women who have been diagnosed with depression construct their own experiences. This article reports on interviews with nine feminist women who had received a diagnosis of depression that were conducted and analyzed using thematic analysis. The participants’ understandings of depression were elicited and examined. The majority of participants constructed subjective understandings of depression that emphasized social factors, but this understanding neither mitigated their material suffering nor was entirely dismissive of biological understandings. Keywords depression, feminist theory, medicalization Since the rise of second-wave feminism, a large body of psychological research has explored the relationship among feminist identity, distress, and well-being. These studies have highlighted a number of clinically relevant correlates of feminist identification. For instance, some studies have suggested that identifying with feminist values may help reduce depressive symptoms, stress, and anxiety and promote a positive body image and increased self-esteem (Fischer & Good, 2004; Hurt et al., 2007; Peterson, Tantleff-Dunn, & Bedwell, 2006; Saunders & Kashubeck-West, 2006; Snyder & Hasbrouck, 1996; Weitz, 1982; Yakushko, 2007). It has also been suggested that integrating feminist values into psychotherapy may yield positive treatment outcomes (Brown, 2006). Feminist researchers have challenged dominant medical and psychological conceptualizations of depression by demonstrating the profound effects of social conditions on women’s lives as expressed in women’s own words. This body of research has been informed by poststructural feminist and critical disability theory. According to these theories, Cartesian dualistic thinking, which artificially separates the body from the mind, has detrimental consequences on people’s lives (Baglieri & Knopf, 2004). Binaries create a ‘‘right’’ and a ‘‘wrong,’’ which limit new, innovative possibilities of care that can emerge from the flexibility and openness of not being committed to an either or 1 2 Department of Psychology, Carleton University, Ottawa, Ontario, Canada Department of Psychology, York University, Toronto, Ontario, Canada Corresponding Author: Jenna MacKay, Department of Psychology, Carleton University, 1125 Colonel By Drive, Ottawa, Ontario, Canada K1S 5B6 Email: jennamackay@gmail.com MacKay and Rutherford 181 understanding and practice of health (Fletcher, 2006; McAllister, 2003). The ramifications of dualistic thinking are particularly salient for women. It has been argued that dualistic thinking, which upholds the medical model, falsely universalizes women’s health and health care experiences; reinforces a preoccupation with the ‘‘abnormal,’’ thereby pathologizing women’s bodies and minds; and minimizes the opportunities for alternative health care (Annandale & Clark, 1996). In reimagining health, critical disability theorists have advocated for changing dominant meanings ascribed to differences and reframing difference as common, expected, and of value (Baglieri & Knopf, 2004). They have suggested a dismantling of binary thinking instead of shifting from a medical to a social model. Indeed McAllister (2003) found that learning to see the self as both objective and subjective and capable of holding conflicting emotions and thoughts simultaneously can be healing for women who use mental health services. A body of feminist literature has also explored women’s lived experiences of depression and the limitations of reductionistic, medical explanations (Jack, 1991; Lafrance & Stoppard, 2006; Stoppard, 2000; Stoppard & McMullen, 2003). These researchers have highlighted the contextual factors that imbue women’s narratives in the development of experience with, treatment of, and recovery from their depression. Gammell and Stoppard (1999) interviewed nine women who had been diagnosed with depression and treated with antidepressant medication, exploring the impact of the medical model on these narratives. They found that the women quickly adopted a biological, diseaseoriented conceptualization of their experiences after receiving a diagnosis. This conceptualization was often accompanied by life choices that decreased the likelihood of personal empowerment and reinforced traditional gender roles. But as the researchers noted, ‘‘an element missing from the accounts of the women interviewed . . . was an understanding of their lived experiences from a perspective informed by feminist analyses of depression in women’’ (Gammell & Stoppard, 1999, p. 126). Thus, one of the primary purposes of the study presented here was to elicit accounts from feminist-identified women that would illuminate whether or how feminist analyses have informed how these women conceptualized their depression. Many feminist researchers have shown how uncritical acceptance of individualistic, biomedical explanations of depression often simplifies the complexity of women’s experiences, ignores gaps in knowledge, and dismisses inconsistent findings (Stoppard, 1999, 2000; Stoppard & McMullen, 2003). However, it is important to note that although feminist theory is useful in conceptualizing and politicizing mental health, it may not capture the painful material reality of living with depression (Ussher, 1992). In an effort to address this difficulty, Ussher (2010) proposed that feminist researchers adopt a critical realist epistemological position to conceptualize women’s depression. This position acknowledges the material reality of the subject, but sees that reality as mediated by culture, language, and politics. Describing this epistemological position, Ussher (2010, p. 23) stated: ‘‘A critical-realist analysis allows us to acknowledge the ‘real’ of women’s psychological and somatic distress, whether this distress is mild or severe, yet to conceptualize it as a complex phenomenon that is only discursively constructed as ‘depression’ within a specific historical and cultural context.’’ Thus, a critical realist position acknowledges that the individual woman who adopts or is subjected to the diagnostic label of depression is situated within a specific social, historical, and cultural context that interacts with the unique distressing circumstances of her life that shape both individual and dominant conceptualizations of ‘‘depression.’’ Given that the dominant discursive construction of depression in the early 21st century in North America is a medicalized one, how do feminist women who have received a diagnosis of depression understand this diagnosis? How do they reconcile their feminist worldview with the medicalized discourse that surrounds them and has material effects on how their distress is labeled, managed, and treated? In our study, we conducted interviews with self-identified feminist women who had received a clinical diagnosis of depression to try to understand the material-discursive experience of having one’s distress professionally labeled as depression and to explore how that label is made sense of in tandem with one’s feminist values. 182 Affilia: Journal of Women and Social Work 27(2) Method Participants and Recruitment Ten women who lived in and around Toronto, Ontario, Canada, participated in the study. A poster, which was distributed online and via community boards, read ‘‘Feminist? Experience/Experienced depression?’’ and detailed the purpose of the research and eligibility criteria. Women who were aged 18 and older who self-identified as feminist and had received a diagnosis of depression from a regulated health professional (a general physician, clinical psychologist, or psychiatrist) were invited to take part in an interview. All 10 women who scheduled a time to participate in an interview completed the study. One woman’s transcript was not used for analysis because this woman developed a feminist identity after she recovered from depression. Her experience of depression and her feminism were two separate aspects of her identity, and she was not able to speak about the relationship between them. The nine women who were included in the analysis ranged in age from 24 to 54, with a mean age of 33.5. One woman was black, and eight were white. One woman was a newcomer from Eastern Europe, and the rest were Canadian-born citizens. Six women were single, three had partners, and two had children. The women were diverse in their sexual orientations: two identified as lesbian, two identified as bisexual, and five identified as heterosexual. One woman was unemployed, two were employed part time, four were employed full time, and two were students. All the women had some college or university education, although only two had completed their degrees. The socioeconomic status of the participants varied, and their yearly income was slightly skewed toward a lower income bracket: Five women earned less than 25,000 CAD (Canadian Dollars), two women earned 25,001– 50,000 CAD, one woman earned 50,000–75,000 CAD, and one woman earned more than 75,000 CAD. One woman had a visible disability and used a wheelchair. The participants varied in terms of the length of time since their diagnosis, treatment history, and whether they thought depression was an ongoing or resolved issue. The length of time since the diagnosis ranged from 2 to 16 years, with a mean of 8.22 years. Six participants thought that depression was an ongoing or cyclical issue, two were unsure, and one thought it was resolved. All the participants had taken antidepressants at some point in time, and at the time of the study, all but two women were not taking medication. Five participants provided information on the length of time they had used medication, which ranged from 6 months to 10 years with a mean of 3.2 years. In terms of the number of years they had identified with feminism, the participants reported a range from 3 to 38 years, with a mean of 13 years. All the women currently engaged with feminist media and resources. Five women felt connected to a feminist community, three felt somewhat connected, and one did not feel connected at all. How the participants defined feminism and the issues in which they were interested were diverse and rooted in their individual experiences and identities. Interview Procedure Semistructured interviews with the participants took place in a study room at a public library or an alternative private location chosen by a participant. The participants were asked to complete a set of questionnaires, including a demographics survey, a mental health and treatment history survey, and a feminist identity survey. These questionnaires were designed by us as part of a larger study on feminism and depression (MacKay, 2009). The interviews were conducted by the first author and lasted an average of 1 hr and 10 min. The interview first explored the participants’ relationship to feminism, moved toward discussing their experiences of depression, and finally explored any relationship between their feminist identity and experience of depression. In this article, we concentrate on responses to this last set of questions. Examples of questions included, ‘‘What sort of relationship, if any, do you think there is between MacKay and Rutherford 183 your feminism and depression?’’ and ‘‘How do you make sense of depression with your feminist identity?’’ A completed transcript of the interview was e-mailed to each participant to verify its accuracy, and following completion of the study, each participant was e-mailed a detailed summary of the findings. Four women responded to the summary, each expressing positive feedback regarding both participation in the study and its results. Thematic Analysis The transcripts were coded inductively, meaning that the development of the themes was driven by the raw data, not by a priori theory. This approach was used to discover themes, patterns, similarities, and differences among the participants’ narratives by staying as close as possible to the women’s own words. Although the theoretical underpinnings of the thematic analysis were driven by Boyatzis (1998), coding was completed using the techniques outlined by Braun and Clarke (2006). After each participant had verified the accuracy of her transcript, the first author read and reread the transcripts to immerse herself in the data, develop a summary of the interview, and group the text into preliminary codes. The coded text was then organized into tables and further grouped into possible themes across the participants. The text within each theme was continuously reread, and mind maps (Braun & Clarke, 2006) were developed to help organize the possible themes into subthemes and to develop overarching categories. Results and Discussion When we explored how the participants made sense of depression in relation to their feminist identity, the primary theme that emerged was that the participants described the commonplace social– medical binary conceptualization of depression. This conceptualization is described according to the following subthemes: (1) biological accounts of depression, (2) contextual accounts of depression, and (3) relating to both biological and contextual accounts of depression. Biological Accounts of Depression An important factor for the two women who identified solely with the medical model was the lived experience that ‘‘medication works.’’ By experiencing a benefit from medication, the women were able to relate to and understand the popular medical explanation of a ‘‘chemical imbalance.’’ Candace, who identified with the medical model, found that her experience supported the often-contested hormonal explanations of depression. In particular, she related her experience of depression to the flux of hormones during menopause. Rather than view this explanation as reductionistic, she was able to connect hormonal explanations of depression to her feminism and thought it was empowering: I think that it is a feminist health perspective saying, ‘‘OK, I am in a woman’s body, and how much research has really been done on women’s bodies and hormonal changes?’’ . . . I have talked to other women, and these breakdowns are prevalent in women’s mid- to late 40s. It is not just that we have been alive longer, and more things have happened to us. We are going through a physical change, and why wouldn’t one of the things pushing our brain chemistry over the edge [be] our hormones or lack or hormones? I just don’t think it is coincidental that this happened at 47, not 37. Although Candace understood her experiences from a medical framework, she was able to connect it to a feminist analysis and question the context of research and knowledge. Specifically, she drew attention to the ways in which a gender- and sex-based analysis has historically been (and continues to be) excluded from scientific, medical research. 184 Affilia: Journal of Women and Social Work 27(2) May, the other participant who primarily identified with the medical model, said that she was not interested in engaging with a feminist understanding of depression: I really believe I don’t have issues. I am not sure if I am blaming myself, but I am explaining it to myself that I have a chemical imbalance. I totally bought that product, even if it is a product of the mainstream, I don’t know. I am not even looking for the feminist look on chronic depression because this totally works for me, and when I started the medication, I didn’t have issues in my life. In her meta-awareness that she may have ‘‘bought’’ the explanation of a chemical imbalance, May drew attention to a possibly internalized sense of how a feminist ‘‘should’’ understand depression. The assumption that feminism is more compatible with a social model of health constructs a binary understanding of the ‘‘right’’ and ‘‘wrong’’ feminist perspective. In the context of the interview, this binary seemed to create distress for May because she felt judged for her ‘‘incorrect’’ understandings of depression. While May felt that the chemical imbalance explanation explained her depression, she subsequently implied that she may be open to the possibility of her beliefs evolving. For instance, later in the interview, she stated, ‘‘I am not there yet’’ when contemplating the relationship between her feminist values and depression. However, at the time of the interview, May’s lived experience of having no ‘‘issues’’ in her life at the time her distress began and the fact that the medication had worked were influential in her identification with the medical model, although she acknowledged a disjuncture between the ‘‘mainstream’’ viewpoint and a feminist one. Since some feminist women are able to understand depression from a perspective that is commonly affiliated with a medical framework, the medical model is not necessarily incompatible with feminism. Although both women understood that depression is rooted in biology, only Candace incorporated a feminist analysis. The variation within this shared understanding demonstrates that women’s experiences of health cannot be universalized. Contextual Accounts of Depression The majority of the participants thought that social understandings of depression were more congruent with their feminist worldviews. There was an explicit acknowledgment that medical discourse surrounding depression is situated within a knowledge–power nexus. As Julie noted: The understanding that feminism has given me is that knowledge is situated and comes from a certain understanding of the world. My understanding doesn’t fit with theirs, so, of course, I am not going to believe everything they say or I am not going to take that on because they are characterizing me within all these power dynamics. And Dee said: Through feminism, I have been taught to advocate for people and really question Western medicine and how it is the dominant approach over all other types of medicines and therapies. So I look at medicine as being one of those social constructs that I was raised into believing was the only possibility. In these statements, Julie and Dee demonstrated that through feminism, they recognized that there are ways of understanding depression outside the dominant, medical discourses. Like the participants who identified primarily with the medical model, those who identified most strongly with the social model also believed that a social understanding reflected their lived experiences. The participants were able to relate their depression to social factors and situations. Kelly put it this way: MacKay and Rutherford 185 I have really been trying to figure out what my depression has been about because I really don’t think it is a physiological thing. I think that is a component. I think the depression manifests itself in the body, in neurotransmitters or whatever, but I don’t think that it was caused by some inherent problem. I think it is definitely brought on by my social relationships with my family, basically my family and the way I was socialized. Carol stated: I was suffering from low self-esteem, and as a fat, black woman, that is enough! Things are a bit different now, but depression is just feeling the pressure of all those things, all those pressures; . . . it is the stress of living in a culture that sees you as other. It is draining, and it makes you depressed. Joella noted: From my experiences, [depression] is very much connected to the social, to what is going on in my personal life. I am not going to say it isn’t connected to the biological because I am not sure; I don’t know how the brain works. There needs to be something going on with the brain chemicals because otherwise my meds wouldn’t work. But I don’t understand the biological, so I don’t connect to it. In their statements, these participants resisted an individualistic, biological view of depression, demonstrating the significant impact they thought that the social environment has on their emotional health. Even when they referred to psychological (e.g., low self-esteem) and physiological (e.g., in the body) aspects of their depression, they connected these aspects to contextual, environmental factors. The participants commonly thought that depression is too prevalent not to be a structural issue. In Lucy’s words, ‘‘the fact that so many people need to take drugs to negotiate the world is symptomatic of the fact that something is wrong with the world and not our chemicals.’’ As a group, the women believed that depression is caused by experiences of trauma, oppression based on marginalized aspects of identity, self-silencing, and socialization, supporting a body of feminist research on these issues (Beauboeuf-Lafontant, 2007; Belle & Doucet, 2003; Edge & Rodgers, 2005; Jack, 1991; Jones & Ford, 2008; Lafrance & Stoppard, 2006; Mauthner, 2002; Szymanski, 2004). In using a feminist lens to understand the possible causes of their depression, the participants situated their experiences within a systemic framework, externalizing their experiences, rather than internalizing stressors as a personal deficiency. This finding corroborates the findings of previous research that feminism acts as a tool with which to name and frame distressing experiences (Klonis & Worell, 1997; Landrine & Klonoff, 1997). Indeed, although this point is beyond the scope of this article, the participants noted that feminism provides an alternative script that values aspects of the self, which are typically devalued by the dominant culture. This alternative script provides motivation and empowerment in navigating their own healing process (MacKay, 2009). Relating to Both Biological and Contextual Accounts Although the participants understood and described depression from both the biological and the contextual standpoints, the dominant binary discourse created a space of tension for all of them. The majority of participants did not neatly side with one account of depression, which seemed to create a paradox in which depression was understandable, yet simultaneously abstract and incomprehensible. This incoherence seemed to be the result of socially constructed understandings of depression conflicting with and being renegotiated in relation to material realities or ‘‘symptoms’’ that are typically owned and defined by the medical paradigm. Biological accounts of depression appeared more understandable than did socially contextualized conceptualizations in moments of distress because 186 Affilia: Journal of Women and Social Work 27(2) they were easier to define and drew on a widely accepted language and meaning system that had been established to describe these experiences. Thus, at these times, the participants said that they more easily related to biological accounts. However, doing so led to their questioning their sense of self, since contextualized accounts (which they identified with more generally) were more compatible with their worldviews. Kelly aptly described depression as a ‘‘socially constructed embodied problem’’ to capture her experience that although depression may be socially constructed, ‘‘it does not mean that you are not physically struggling.’’ For Kelly and other participants, reconciling their beliefs in depression as a social construction with the physiological aspects, both material and discursive, was often confusing. As Kelly and Julie stated: I think we need to see depression as socially constructed, but then the body is impacted by your social interactions, and that does change your physical experience of the world. I mean I don’t know, I don’t know. I really don’t know, I guess it is just that whole causation thing of what caused the physical change. (Kelly) It is helpful to see sadness or irritation or whatever as signals. Of your body or mind giving you information about your environment. But, in the end, it may not be helpful because for me, the whole point is I cannot control it. (Julie) Understanding biological accounts as only one discursive possibility for understanding depression, the use of medication held important and sometimes emotional meanings for the participants. The participants were aware of criticisms of the pharmaceutical industry and, to various degrees, identified with these critiques. However, medication was simultaneously experienced as positive for those who benefited from the use of antidepressants, and there was no consensus that medication should be rejected outright as incompatible with feminism. This tension was demonstrated by Lucy, one of the two participants who has explicitly resisted taking medication for ideological reasons: I cannot imagine what it would be like to get through a day easily, regularly. And if that is possible, it might be nice to try. And there is even this little feminist part of me that says I could be capable of really incredible things, and maybe I need drugs to do them. Like I am holding myself back from my own potential by not taking drugs. Lucy’s decision not to take drugs on principle, the suffering she experienced, and her questioning of this decision exemplify how the conundrum of relating to both biological and contextual accounts plays out materially. Although the majority of women were aware of feminist positions that reject medication altogether, none of the participants held this belief or attitude, although two women who currently used antidepressants said that they had held these beliefs in the past. The tension between binary conceptualizations of depression was difficult for the participants to sustain, especially those who chose to politicize their depression and strived to make choices in healing that best reflected their politics. The shortcomings and limitations of binary systems for understanding the participants’ experiences reflect a similar dialogue in disability activism and scholarship that seeks to destabilize the social–medical binary and theorize the space in between. Butler and Bowlby (1997) argued that while the social model has been a useful tool in creating a strong political platform in which to dismantle ableism, it has also disregarded the lived reality and diverse identities of people with visible and invisible disabilities. The daily embodiment of being differently abled may be accompanied by realities, such as pain, which are traditionally defined and owned by the medical model. How, then, can disability, including depression, be reconceptualized within a framework that simultaneously acknowledges the (positive and negative) work that certain discourses do while honoring the diverse material realities of living with distress? MacKay and Rutherford 187 Conclusion In our study, we asked self-identified feminists to reflect on the relationship between their feminist values and their diagnosis of depression. All had received a formal diagnosis from a mental health professional, and all had firsthand exposure to a medicalizing discourse. Rather than talk about their depression in passive, individualist, medicalized, terms, however, the majority of the feminist participants framed their depression in terms of a social context in a way that was congruent with their feminist values. They did not completely dismiss a biological understanding; many acknowledged it but questioned how it might connect and interact with their lived experience. For the two participants who did embrace a biological explanation for their depression, one reframed it as a feminist health issue, and the other positioned this explanation as separate from feminist theory, which she viewed as irrelevant to or unnecessary in accounting for her own experience. In most cases, an important determinant of how the participants understood their depression was the interaction between their lived experience and the discourse that best matched this experience, although this was usually not a perfect match. In the case of the participants who identified most strongly with a contextual account, their constructions did not necessarily protect against the painful, uncontrollable aspects of depression, and there was some struggle to reconcile physiological experiences with social explanations. Their struggle to reconcile their values with their experiences of depression can be construed as a complex dialectic that captures both feminist understandings and the realities of living in a society that is increasingly imbued with a medical perspective. It also suggests that a simple binary in which medicalization is disempowering and feminist analyses are empowering does not adequately capture feminists’ experience of depression. Just as Ussher (2000, 2010) called attention to the need to contextualize and legitimate the material suffering of women’s depression, the participants in this study articulated that understanding their depression as socially mediated does not ease the material reality of living with depression. The tension between the biological and contextual accounts may be partially explained by what has been described as a ‘‘language trap’’ (Spender, 1998). Spender, a feminist theorist, described language as being paradoxically inhibiting and freeing. While one is able to use language to create one’s reality, new meanings become absorbed by dominant categorizations (such as medical or social), and even if lived realities contradict these categories, creative uses of language ‘‘systematically subscribe to old beliefs, are locked into principles that already exist and there seems to be no way out even if those principles are inadequate or false’’ (Spender, 1998, p. 96). The participants’ accounts of depression did not fit into any one narrowly defined script, whether biomedical, psychological, or social. In building a discourse that is based on a critical realist position, using women’s own words and lived experiences, it may be possible to create a language that sustains the social– medical tension in feminists’ understanding of depression rather than force its resolution. Acknowledgments The research for this article was supported by a Richard Goranson Memorial Award from York University to the first author. 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