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Depression Narratives: How the Self Became a Problem1

Jette Westerbeek Karen Mutsaers


Literature and Medicine, Volume 27, Number 1, Spring 2008, pp. 25-55 (Article)
Published by The Johns Hopkins University Press DOI: 10.1353/lm.0.0017

For additional information about this article


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Depression Narratives: How the Self Became a Problem1


Jette Westerbeek and Karen Mutsaers

A scholar of Melancholy am I Chastised By Sorrow Forced to ceaseless learning Till the end of my life

Charles dOrleans (13941465)2

Many people afflicted with a serious disease ask themselves why they in particular have been afflicted, and this nagging question soon generates a negative picture of their identity.3 In her famous essay, Illness as Metaphor, and in its sequel, AIDS and Its Metaphors, Sontag argues that diseases with unknown causes give rise to personality-focused interpretations and to a variety of damaging metaphors, and illustrates her thesis with myths about tuberculosis and cancer. For a long time, there was no clear medical-biological explanation for these diseases, which made them puzzling and mysterious; this in turn gave rise to interpretations that sought causes within patients personalities and behaviors. However, the moment an organic origin was discovered for a disease, such interpretations came to a halt. At that point, physicians and patients regarded the disease as curable and thus not representative of the sufferers character. These shifts in understanding tuberculosis and cancer led Sontag to oppose all metaphorical interpretations of diseases: My point is that illness is not a metaphor, and that the most truthful way of regarding illnessand the healthiest way of being illis one most purified of, most resistant to, metaphoric thinking.4 Depression is a disease surrounded by the unknown. Despite extensive research, there is still no theory to explain conclusively the origin of depression on exclusively somatic grounds, since both internal and external causes can disturb serotonin metabolism. Although modern antidepressants (selective serotonin reuptake inhibitors, SSRIs) can reduce major symptoms in about two-thirds of the cases, full recovery
Literature and Medicine 27, no. 1 (Spring 2008) 2555 2009 by The Johns Hopkins University Press

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still remains impossible. It is possible that this has helped alter the negative image of depression in the general publics understanding of the disease: if it could be cured with a pill, then it is a disease and not a sign of personal shortcomings. One-third of patients, however, are resistant to antidepressants.5 Hence, there is ample room for personal blame. In this article, we will present a picture of how, in the age of Prozac,6 people suffering from depression think about their illness and their selves. Popular narratives and Depression: Stigma We approach depression from patients perspectives as written down in published illness narratives. By reading these stories, we get a glimpse of how the authors wider social circles perceive people in low spirits. We look at the relationship between illness and identity as a matter of labeling, prejudice, internalization, and particularly, stigma. Stigma is not an easy concept to define because it is a constantly changing reflection of cultural and social contexts. However, Goffmans definition is still regarded as the most adequate one: stigma is a deeply discrediting attribute, and the stigmatized are viewed as less than fully human because of it. He states that every human quality (physical and mental, as well as social) is potentially stigmatizable.7 Stigma can be understood as the social rejection of a person or a group of people for being different in a negative way, for deviating from the norm, which, in Western culture, is generally to be an optimistic and a vigorously ambitious striver for success. The concept of stigma is loaded with moral overtones. In the eyes of the non-stigmatized (normal people), the principal question is that of responsibility: More often than not, the blame for the stigmas existence is attributed, at least in part, to the personality of the stigmatized person himself or herself. It is assumed that the person has committed some immoral act and that the stigma is punishment for this moral transgression.8 As Wolpert says, the discrediting stigma of mental disturbances, such as depression, is so compelling because it is not localized in the external world or in any other specifiable organ, such as the lungs or heart, but rather in the core of someones self.9 Since the nineteenth century, two views on depression prevail in the general population: a romantic version of depression as a dramatic cultural phenomenon among a western intellectual elite, even to the

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point of signifying what it means to be a thinker, a scholar, or poet. This sublime version, called Melancholia, is historically reserved for men. By contrast, women who fall into the depths of sorrow are all too easily dismissed with the banal and unprestigious term depression.10 This banal image of depression stigmatizes because it devalues the sufferer by designating her as a weak-willed, oversensitive boor. Despite progress in diagnosis and treatment, there is, as far as we can see, hardly any evidence of a diminishing stigma on depression. Schreiber and Hartrick conducted a small-scale qualitative study of female patients suffering from depression; the study suggests that, due to the advent of modern antidepressants, some patients tend to accept the biomedical explanation and attribute less importance to psychosocial factors, treating their depression as a simple biochemical imbalance. Paradoxically, even though these female patients experienced relief from their feelings of guilt and shame, their social surroundings kept defining them as weak mental types.11 Despite the introduction of modern antidepressants, depression continues to carry a considerable stigma. Wolpert thus argues, in a personal reflection in the British Medical Bulletin, that depression is still considered typical of housewives (and certainly not something that elite soccer players would suffer from) and is attributed to people lacking willpower, that is, to those who would do much better if they only tried harder.12 Self: Cause or effect? next to the popular understanding of depression, patients themselves also try to give meaning to their illnesses. Since about 1990, a growing scholarly literature (psychotherapy, sociology, womens studies, literary studies) has examined the relationship between identity and mental disturbance from the perspective of illness narratives by patients themselves or by their psychotherapists.13 These publications focus on illness stories in moderate opposition to the currently dominant biomedical argument. As for the relationship between depression and self, this literature demonstrates two distinct positions: person-oriented and problem-oriented14 In the person-oriented position, depression is perceived as an integral part of the self. From this essentialist position, depression is seen as deforming an already existent, and partly recoverable, identity. More essentialist psychodynamic psychologists locate the cause of depres-

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sion in interactions with important (former) binding figures and in the manner in which these interactions are subsequently preserved in the self.15 Understanding and processing generated emotions enables patients to at least partly recover their impaired identity. Alternative person-oriented, holistic therapies are also directed explicitly toward the person as a whole and not toward the affliction alone.16 By contrast, in the problem-oriented position,17 depression is regarded as independent of the self. Grounded in the oeuvre of Michel Foucault, this postmodernist approach regards psychic problems not as something derived from a personality structure, but as the manner in which surrounding culture affects it, in the so-called constitutive effects of power. The self is not seen as a cause, but as an effect of depression, a new identity generated through narration. The current, dominant medical-biological way of thinking in psychiatry, with the DSM as a diagnostic instrument, also represents the problem-oriented position, although quite different in its theoretical orientation. In this view, everything is directed toward making the right symptom-related diagnosis and prescribing the right symptom treatment. The self does not appear; . . . the diagnosis, not the patient, often gets treated.18 Outside the disciplines of medicine and psychotherapy, sociologists Karp and Frank (2000), literary scholar Stern, and womens studies researcher and psychiatrist Metzl present a postmodernist view of the relationship between depression and the self, although not all of them are indebted to the theory of Foucault. These scholars conclude from their research into the experiences of depressed patients that the self is a constant recursive process in which the harrowing experience of the disease prompts the patient toward reviewing his or her own self-image. They attribute an important role to modern antidepressants in this process, as these medications seem to foster a problem-oriented self-view. However, as time goes by, the central role of anti-depressants does not last, and a more person-oriented self-construction finally emerges. Karp explicitly elaborates the person-oriented problem in his concept depression career,19 which describes the successive phases people go through during their illness. Based on fifty in-depth interviews with depressed men and women, he distinguishes four phases: 1) a phase of indefinite negative feelings which precede depression, 2) a phase in which a person realizes that the perceived problems cannot be attributed exclusively to unfortunate circumstances and have to do with himself or herself, 3) a crisis phase in which the person enters the world of professional experts/therapists who deliver the diagnosis of depression, and 4) the last phase in which the patient comes to grips

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with an illness identity. As Karp shows in his study of the subjective experience of depression, each of these career moments assumes and requires redefinition of self.20 Since most sufferers of depression are confronted with recurrent depression episodes, they are forced time and again to go through this whole cycle. The process is paralleled by a pharmacological career in which patients learn at first to accept a biomedical view of their problems but eventually become disappointed in and critical of their antidepressants. . . . [T]he experience of taking antidepressant medications involves a complex and emotionally charged interpretive process in which nothing less than ones view of self is at stake.21 Metzl analyzed four literary Prozac narratives, all short stories written by women, and distinguished three phases: euphoria (wild enthusiasm, overvaluation of Prozac, a self experienced as hyperthymic and liberated from restrictive gender norms), followed by disenchantment (Prozac does nothing, many side effects, the problems return), and finally, rationalization (they all stay on Prozac, but claim the discovery of a genuine self beyond Prozac that is less productive, more sensitive, emotional, and more corporal).22 Metzls course starts at a later point than Karps depression career and results in a wishful kind of thinking, which he terms a Prozac selfhood, a selfhood depicted as removed from the constraints of early life experiences and gender expectations and transformed into a chemically engineerable (by Prozac) self. Metzl interprets this self-image as drug-induced and typical for the optimistic first phase. In time, however, a hidden side of the former self re-emerges: fears, disgust, passivity, gloom, but also tenderness and sensitivity to natures beauty. Patients claim this self as genuine, an awareness beyond medication. Metzl sees it as wisdom from the third phase: . . . marked, not by disillusionment and discontinuation, but by a lasting, if wounded, resolution. 23 Although Frank did not analyze depression stories (he studied cancer narratives), he describes a related development in the way patients come to see themselves over the course of their illnesses and treatments. When a person is first confronted with a life-threatening disease, there is only chaos, total desperation, and disintegration. In this phase, a story is hardly possible: one is in the midst of narrative wreckage, and everything seems to happen in one stretched present. As soon as one can tell something about the experience, some measure of control is attained. A story thus helps to restore coherence but presupposes a far-reaching redefinition of ones past, present, and future. This redefinition results in a new story, the quest narrative,

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in which the illness is accepted, and the storyteller gives testimony of self-change due to the suffering. Frank notes that self-change due to suffering seems remarkably unrelated to gender; women, as well as men, go far in their self-reflection and create new moral versions of their selves, in which memory is revised, interruption assimilated, and purpose grasped.24 Translated into the concepts of Karp, chaos stories belong to the crisis phase, and quest stories can be seen as attempts to reach an illness identity. Cancer and depression call for rather different therapies, but when cancer is in remission and depression is in abeyance, the resulting situation for the patients is quite comparable: they are unable to carry out all former tasks and responsibilities and experience a continuous uncertainty about their health, which forces both types of patients to find their own answers to existential questions about their lives, their selves, and the meaning of illness. Where person-oriented (essentialist) scholars underline sameness and continuity of a persons identity, problem-oriented (narrative) researchers point to the changes, or the watershed moments,25 a serious clinical depression can bring about in a persons self-image. Both persistence and change must have a place in each personal concept of identity, but perhaps too much emphasis on sameness could be less favorable in the struggle with stigma. The question we want to answer, based on ten autobiographical texts written by people with depression,26 is to what extent and in what way do people who openly admit that they have suffered from depression intentionally relate their identity to the disease? In what way, if any, does stigma enter their stories? And does gender affect the way people write about depression? If so, how? Selection and Analysis of Autobiographical Texts We selected our materials using purposive sampling.27 Our point of departure for Dutch sources was the Bibliography of Ego-documents of Mental Health,28 published by the Pandora Foundation, an advocacy group established for the social improvement of people with histories of psychiatric problems. In internet files and referenced articles, we sought publications in english, selecting only ego-documents on unipolar depression. Unipolar depression has both milder and more severe forms, but our documents concern mostly clinical cases, known in DSM terminology as Major Depression or Depressive episode. ego-documents on bipolar, postnatal, and psychotic depression fall

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outside our analytical framework. Manic depression has a clinical diagnosis that differs from unipolar depression, a different etiology, calls for a different treatment, and is less gender-specific. We also eliminated cases of postnatal depression because one of our objectives was to find out possible differences in the way men and women write about depression. Because of delusions and its assumed biological origins, psychotic depression is too severe to be compared with milder, chronic, or clinical depression. We decided to use only diaries and autobiographies, bypassing genres such as autobiographical novels and poems. Although constructed from lived realities, autobiographical histories have a more homogenous structure and are consistently told from first-person perspectives, which contributes to their comparability. In our research, we limited ourselves to published autobiographies because of the open accessibility of this material. Our time restriction (i.e. only publications from 1990 and later) covers the period since modern antidepressants (SSRIs) have become standard medication, and we expected ego-documents to tell something about the effects of these prescriptions. For the sake of clarity, we limited ourselves to texts in Dutch and english. In our sample there are more women than men who write about their depression. That confirms robust statistical data that in Western culture twice as many women are diagnosed with depression as men.29 Only five documents by male authors and nine by female authors met our criteria; we have included the five men in our study and selected five of the nine female authors whose demographics best matched those of the male authors (see Table 1 below). The authors are Dutch, American, and British and are between twenty and sixty years of age at the time of writing. not surprisingly, the authors of published autobiographical texts are experienced writers and often have careers in journalism, fiction, or science. The authors are distinctive due to their verbal talents. Several authors underline that depression as an experience can hardly be expressed verbally; it is played out in a parallel infernal universe in which time stands still and where language is inadequate. It is no coincidence that professional writers are the ones who manage to give us a glimpse of this hell. These writers should, therefore, be considered spokespeople for others who suffer from depression; otherwise, the stories they tell lose much of their cultural impact. Some of the authors are university-educated (Manning, OBrien, and Wolpert are even professors), some are wellknown writers (Styron, Wurtzel, and in the netherlands, Brunt and Udink) and near-professional medical personnel themselves, some have

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Table 1: Demographic characteristics of selected ego-document authors


# pages 125 50 Severe clinical depression 1317 + 49 Cultural anthropologist, columnist; divorced, 2 children Student of medicine; single Professor of psychology, psychotherapist; married, 1 child Professor of english and American Culture; Single 32 Case manager, psychiatry; married, no children 31 Severe clinical depression 60 Writer; single Writer; married, children Diary/ columns Age when writing Self-description of depression Age at depression Social position Form

Author

Gender

Nationality

Publ. year*

Brunt

Dutch

1994

Bakker 201 37 Severe chronic therapy-resistant depression Chronic anxiety and depression Student years + midlife 37 and earlier

Dutch

1995

108

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Severe depression

20

Autobiography Diary

Manning

American

1994

OBrien

American

2004

329

52

Autobiographical family history Autobiography Autobiography Autobiography

Smith

American

1999

292

37

Chronic therapyresistant depression Severe depression, 3 episodes

Solomon 94 65

American 2002 (2001)

569

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Styron

American 2003 (1990)

Udink 240 68 Severe clinical depression Chronic, atypical depression 1126 Student of comparative literature; single Autobiography 65 Professor of medical biology; widower, children Autobiography

Dutch

2001

104

50

Moderate depression

50

Writer, journalist; married, 3 children

Diary / columns

Wolpert

British

1999

Wurtzel

American

1995 (1994)

368

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* first publication year in parentheses

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interspersed their work with scientific accounts of depression (Solomon, Wolpert, and Smith), and one is a professional psychotherapist (Manning). Because they have substantial cultural and social resources at their disposal, the authors are in a position to stand up to stigma and to be heard. Although our selection of ego-documents does not justify broad generalizations about how people experience depression, it provides an opportunity to look for and analyze patterns of and connections between self-reflection and depression. In order to extract patterns of meaning in life stories, we used qualitative-interpretive content analysis. We developed a code list of categories and subcategories based on sensitizing concepts30 derived from the scholarly literature (coping, stigma, identity) and inductively produced items (the various ways the depressive experience is described, explained, or otherwise made sense of) while analyzing the autobiographies. Depression appeared to be a changing condition, so in addition to these categories and topics, we also coded for the process, or the development each patient experiences. Most of our categories (identity, description, explanations, coping) have been structured along Karps consecutive phases. We filed relevant passages from each text in a literal or paraphrased form, into our code list. In this way, the ten autobiographies became comparable. This process of analysis and constant comparison occurred in two phases. After the first round of coding and analyzing, we restructured and selected our categories and topics; the final result is shown in Table 2. While the procedure yielded a very broad picture, our analysis revealed a core issue in the depression texts: the connection between identity and depression. All the authors wonder about the cause of their depression and why it happened to them in particular. Their answers to these compelling questions are the subject of the rest of this article. Phase One: Initial Meanings of Depression in ego-Documents Karp describes the first phase in the depression career as unnamed, inchoate, or negative feelings, almost unnoticed while occurring and often only seen in retrospect.31 The authors we studied point out that the experience of depression begins in rather banal ways: joy of life diminishes; anxiety sneaks into their lives; bodily symptoms, such as insomnia and dwindling appetite, appear; and previously self-evident mental balances gradually break down:

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Table 2: Final code list


Social context - Reasons for writing an autobiography (to complain, to support or warn fellow patients, raise consciousness, give hope, search for meaning, counter stigma) - For whom is it written? - In which country? - From what perspective (e.g. critique or support of medical-biological framework)? - Socioeconomic status of the author - Personal data (sex, age, nationality, occupation, marital status) - Self-description and self-evaluation (character, including hypochondria, etc.) - Identity transformation, identity disruption, and uncertainty - Appearance Onset of depression (recognition and acknowledgement) Feeling of depression (consecutive phases) Metaphors (consecutive) Loneliness What kind of depression (in their words)

Identity, self and self-image

Description of a depressive experience

Explanations and justifications

- Interpersonal relations (as a child, at present; loss) - Work problems - Body and brain (e.g. disturbed serotonin exchange, other illnesses) - Personality, character, self, identity - Related to culture, society, or time - Traumas - No explanation found, although searched for - Seeking distraction (sports; alcohol, medicine, or drug addiction) - Brooding, ruminating - Ignoring - Hiding/pretending to be fine (coping with stigma) - Wanting to know everything about it - Accepting it as part of ones life and self - Trying to live with it while waiting for the right medicine - Reaction to diagnosis - Therapy (biological, psychological, supporting/ structuring interventions) - Reaction to/evaluation of therapy - Feeling of being excluded, misunderstood, underappreciated, reproached for complaining, lacking willpower, being passive, oversensitive, victim; shame or guilt - Fear of being devalued, etc. - Lack of understanding by others - Stigma on therapy and/or medication - Stigma on suicide

Ways of coping (consecutive phases)

Therapy and medication

Stigma

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Table 2, cont. Meaning of depression - Message to fellow sufferers and their relatives (e.g. depression will pass; you will learn to live with it; dont be ashamed) - Gain, lesson, new insight - no lesson, only burden - Defining subgenre (complaint, defense, confession, example, informative, quest) - Size of document (number of pages) - Type of document (published autobiography, published diary) - Publisher, own property - narrative structure: problem > crisis > suffering continues but hope it will be cured problem > crisis > being able to cope with it problem > crisis > growth, incorporation problem > crisis > recovery

Form

As June moved into July, my vague feelings of purposelessness deepened. I found myself unable to take pleasure in things I used to enjoy, unable to make use of the long summer days and glowing evenings to garden, read, or be with friends.32 Most authors realize in hindsight that depression does not come out of nothing. Almost every one of them mentions a period of vague malaise. Only later do these feelings get a proper name: But after I had returned to health and was able to reflect on the past in the light of my ordeal, I began to see clearly how depression had clung close to the outer edges of my life for many years. Suicide has been a persistent theme in my booksthree of my major characters killed themselves. . . . Thus depression, when it finally came to me, was in fact no stranger, not even a visitor totally unannounced; it had been tapping at my door for decades.33 When the authors experience these unmistakably serious feelings of depression for the first time, they have no idea what it is that has overcome them so suddenly. In order to describe these sensations, they resort to images and metaphors. In all the books we studied, depression is characterized as an enemy, which, as it were, sneaks through a back door. Over the course of time, the authors had heard doors creaking and some background noises, too, but never thought about

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them extensively. Suddenly, the intruder depression is there, standing right in front of them and crippling them. Some authors describe the intruder as a tumorous growth that multiplies itself in the body and can be as fatal as cancer. The authors use metaphors derived from horror films such as evil spirits or monsters that have lain in wait for years, ready to attack and crush the self bit by bit, suck the self out, or strangle the self with deadly tentacles or claws. Phase Two: Depression Settles In According to Karp, in the second phase, the suffering is no longer vague, but very obvious, concrete, and persistent.34 The depressed person comes to realize that there is something wrong with him- or herself. For the authors of the texts we examined, the monster turns out to be merciless and devastating. It shatters the old self to bits and pieces and robs it of its former qualities, which authors once took as obvious parts of their personalities. What remains are zombies, vacant bodies, empty shells. Then the monster creates total strangers, terrorizing them with overwhelming anxiety, guilt, and feelings of self-hate and worthlessness, making them unable to do anything except stand around destitute, paralyzed, and desperate. The monster can assume the form of a parasitic creeper. As Andrew Solomon describes it: My depression had grown on me as that vine had conquered the oak; it had been a sucking thing that had wrapped itself around me, ugly and more alive than I. . . . I have said that depression is both a birth and a death. The vine is what is born. The death is ones own decay, the cracking of the branches that support this misery. . . . eventually, you are simply absent from yourself.35 Other authors, William Styron and elizabeth Wurtzel especially, describe depression as a dark, poisonous wave that threatens to swallow them: . . . my thought processes were being engulfed by a toxic and unnameable tide that obliterated any enjoyable response to the living world.36 Finally, the enemy, in whatever metaphorical form, drags the former self all the way down a dark stairway, across the border to a des-

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perately hopeless no-mans land between life and death, to a shadow zone where time stands still and agony and the darkest thoughts never give way. Some nebulous force has moved you into this chambered and unearthly landscape, its origins obscure, its meridians unmapped. It is a state unto itself. . . . You are resident now in some parallel universe, a place inclined to resist the concrete nouns, verbs, and adjectives we use to describe other landscapes.37 The invisibility of this landscape to others, the paralyzing and unceasing hopelessness, deadly anxiety, shame, guilt, and feelings of failure all make depression become intolerable. Phase Three: Crisis In this phase, those with depression are no longer able to cope and seek professional help.38 The authors in our sample write about how they finally reach the limits of their endurance. Depression has slowly but surely changed them into invalids, into people who can hardly breathe or move anymore and who only long for liberation from this interminable pain. As they see it, there are just two alternatives: suicide or seeking help. . . . [s]uicide is an end to the pain, the agony of despair, the slow slide into disaster, so private, but as devastating as any other act of God.39 Although some of the authors tried to commit suicide, all of them decided to seek help. I drew upon some last gleam of sanity to perceive the terrifying dimensions of the mortal predicament I had fallen into. I woke up my wife and soon telephone calls were made. The next day I was admitted to the hospital.40 Most often, help consists of antidepressants. The effect of antidepressants can be initially miraculous: in a single stroke, they take away all unhappiness. The authors are overjoyedthey feel as though they have been born again.

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It was miraculous to me that I returned to normal: at the time I felt like Lazarus risen from the dead and given a second chance.41 The positive effects of medication provide counterarguments to the idea that depression is the result of a weak personality. These effects liberate the authors from stigma because most of them accept disturbed serotonin metabolism in the brain as a biochemical cause of their disease. In other words, they become convinced that depression is a disease to which anyone can fall prey. The fact that there is chemical medication (Prozac and related stuff) that can cause a change in the general feeling suggests that we indeed have to deal with a disease, as otherwise it would be inexplicable why psychopharmacology should have any impact.42 The initial hallelujah feeling experienced by so many authors in this phase, the feeling that depression has totally vanished, is most often short-lived. Slowly but surely, they discover that antidepressants do not guarantee recovery. Despite the medications, many authors still face and fight milder forms of depression. They still experience guilt, anxiety, and obsessionssome of these feelings are milder, others more acute, sometimes leading to heavy relapse. I stopped taking Desyrel once I started on lithium, but all my attempts to lower my Prozac dose have resulted in an onset of the same old symptoms. I have occasionally tried to go off of lithium altogether, because it is a draining, tiring drug to take, but those attempts to cut it out inevitably lead to scenes like the one that found me spilled across my bathroom and wrecked out in tears and black chiffon after wed had that huge party at our house. At times, even on both lithium and Prozac, I have had severe depressive episodes, ones that kept my friends in a petrified all-night vigil while I refused to get up off the kitchen floor, refused to stop crying, refused to relinquish the grapefruit knife I gripped in my hand and pointed at my wrist.43 For other authors, in time, antidepressants seem to lose their power or have too many side effects, triggering a long process of experimentation with other medications. Since that first visit to the first psychopharmacologist, seven years ago, I have been playing the medicine game. For the sake of my

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mental health, I have been on, in various combinations and at various doses, Zoloft, Paxil, navane, effexor, Wellbutrin, Serzone, BuSpar, Zyprexa, Dexedrine, Xanax, valium, Ambien and viagra . . . . Trying out different medications makes you feel like a dartboard.44 Even if the right medication is finally found, patients frequently have to keep fighting cyclic relapses and milder complaints. There are also authors who, in the long term, develop resistance to medication. Their depression persists and even intensifies despite the use of antidepressants. . . . in that time I had been tried on six different antidepressants. Some of them had not worked at all; others had worked fast and bright, yanking me up almost immediately, and then a week or a month later each one stopped working altogether, and no increased dosages would restore their magic. It was exactly as if I had gone immune to them.45 These authors lose faith in medication and take radical steps. They seek admission to hospitals or undergo electroconvulsive therapy (eCT). Although hospitalization and eCT often provide relief from the heaviest symptoms, authors emphasize that a milder form of depression remains, and there is a constant danger of relapse into a more acute depression. The conclusion that antidepressants and other forms of therapy cannot help them makes most of the authors question the biochemical explanation as the only possible explanation. Thus, elizabeth Wurtzel writes: Mental health is so much more complicated than any pill that any mortal could invent. . . . And after a while, a strong, hardy, deepseated depression will outsmart any chemical.46 Phase Four: In Search of Another Story After the crisis has been overcome, and an identity transformation from person to patient has taken place (at least partially), they enter a new phase in which they try to develop their personal narratives of what depression has done to their identities.47 Once medication (or another form of therapy) has finally annihilated the most serious symptoms of depression, the authors we studied tend to ask why, of

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all people, they are afflicted by this disastrous disease. Emma Brunt, for example, feels the need to scrutinize her identity: Since Ive been on Prozac I came to think that I need to reconstruct an entire record of my life, including all small bits and pieces of the tape that I threw away into a waste basket, in order to see it all again and put it together in a totally new way. The logic in my script is lost and chronology does not agree anymore either: everything clatters as a pocket full of coinsIll have to rewrite the whole story.48 Through psychotherapy, the authors start searching for deeper, mostly psychic, causes that can explain why they always feel more or less depressed. They often arrive at past experiences of loss (especially of a parent) or inheirited depressive character traits. This seems to offer new possibilities. Insight into deeper causes leads some authors to a conviction that depression is not only of a purely biochemical nature but also something individual. What we often see in the narratives we studied is the creation of an intermediate narrative form: depression as a disease and as identity. The authors see acute manifestations of depression as biological, as extreme symptoms which call for forceful measures, whereas they consider lighter forms of depression that persist despite medication as inherent parts of the self. Whatever this was, it had no interest in cooperating with my selfimprovement schemes. It seemed time to square up with it.49 In the midst of these stories, we also see a recasting of the role of depression. Depression as an external enemy and threat to identity changes into something that is no longer menacing and that becomes a part of identity itself. After a long struggle, Martha Manning discovered that she can only disarm her depression by accepting it and not by fighting it. Writing about it, she refers to her biblical namesake: Unlike so many of the heroes of the day who subdued monsters and dragons by beating the crap out of them, [St.] Martha took a different approach. She sprinkled the dragons tail with holy water, tied her silken belt around it, and led it peacefully from the town. There is something in that legend that moves me deeply. . . . St. Martha saved the town from its terror, not by charging ahead with that kind of force and will, but by allying herself with the thing

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that she most feared. She gave the object of her fear something that it needed and wanted. And in that way, she saved them both.50 In most, but not all, the authors writings, we found a pattern of acceptance of depression as part of ones own identity. Some of the authors come to terms with their depression, considering causes as temporarily unknown and investing hope in pharmaceutical science. Two male authors (Jaap Berend Bakker and Lewis Wolpert) remain convinced that their conditions are of purely biological origins and that depression will become curable one day by means of medication. In other words, they stick to the biochemical interpretive framework. Both authors work in the medical profession: Wolpert as a medical biologist specializing in embryology and Bakker as a student of medicine. Wolpert sees his depression predominantly as a side effect of medication for his heart condition, whereas Bakker argues: I emphasize again that I got into this state not because I experienced something shocking but only because of a biochemical deregulation in my brain.51 For most of the authors who, despite antidepressants and other therapies, regularly relapse into depression, this biochemical interpretive framework is insufficient. They have a need for an understanding of their disease that does not demand a perpetual fight against it. They want an answer to the question of why they are always depressed and need to be shown ways to lead a sensible and tolerable life. Strange as it may seem, sometimes thats just what you want to hear, someone else saying that things are not ever, really, going to be all right. Because as long as you feel theres a happy ending up ahead youre not reaching, you cannot be content with your life. . . . Im working on finding a new story for my life, a story that gives me hope but doesnt require the happy ending of recovery.52 Like OBrien, other authors often accept that depression will always constitute part of their lives and their selves, and this resignation has unexpected results: the possibility of a sensible existence and the ability to regain control over their lives. Authors stories can literally take up the form of well-known metamorphosis fairytales in which the courage to recognize the monster in oneself deprives the monster of its devastating power.

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How should we be able to forget those ancient myths that are at the beginning of all peoples, the myths about dragons that at the last moment turn into princesses; perhaps all the dragons of our lives are princesses who are only waiting to see us once beautiful and brave. Perhaps everything terrible is in its deepest being something helpless that wants help from us.53 The reconciliation with the fact that depression will remain part of them allows these authors to discover the value of depression. They give up their hope for a stereotypically long and happy life, and instead, discover that life with depression has more to offer than they expected. They no longer feel lonely, but instead, they feel more generous, empathetic, and able to enjoy unnoticed, everyday things. Andrew Solomon describes this experience as follows: I have a million faults, but I am a better person than I was before I went through this all. . . . Depression is lonely above all else, but it can breed the opposite of loneliness. I love more and am loved more because of my depression. . . . depression can indeed justify and support a life . . . . To regret my depression now would be to regret the most fundamental part of myself. I take umbrage too easily and too frequently, and I impose my vulnerabilities on others far too readily, but I think I am also more generous to other people than I used to be.54 And so, the role of depression as a devastating monster can change into that of a mentor: Accepting melancholia as a kind of spiritual mentor offers a creative way to respond to it. . . . Approaching it in this way, we have no choice but to engage with it.55 This seems a livable construction, one that enables acting, alleviates suffering, helps individuals to carry an intolerable burden, and makes it possible, after all, to live a more or less happy life. Jeffery Smith thus concludes: Maybe I wasnt happy but it sure didnt seem like I was missing anything. For now, this was enough. This life felt to me like healthin the literal sense of the wordit felt like wholeness.56

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Stigma Although not all the authors have personally faced an equally burdensome stigma of depression, they all know it well: as a renowned scholar, Lewis Wolpert considers it a serious disease, which you can simply admit having, but he also recognizes that his preference for biological explanations liberates him from a sense of guilt for having depression. On the contrary, others like Betsy Udink, emma Brunt, and Martha Manning reflect on the anxiety and specific experience of being castigated, dismissed as born losers, defective non-performers, chronic invalid poseurs, or impostors: When you run into an acquaintance and in passing he asks how your weekend was, youre not going to answer honestly and say you lay in bed for two days. If you did, wouldnt you be seen as a sort of . . . complete failure?57 Several authors published their experiences in hopes of countering the stigma attached to depression. This motive is also present in more recent autobiographies (Lewis Wolpert, Andrew Solomon) and in some earlier published ones (William Styron, Jaap Berend Bakker). Most of the authors are people with a certain celebrity statusLewis Wolpert, William Styron, Andrew Solomon, emma Brunt, and Betsy Udink who, by virtue of their positions, can try to clear the moral ground for their less-known fellow sufferers. The authors employ images evoked by stigma, which are representative of two themes: first, those with depression are weak-willed and lack perseverance, and secondly, depression is a kind of bad cold of the soul or an imaginary luxury problem of pampered consumers. Although antidepressants enable some authors to cope better with the effects of stigma, the use of antidepressants seems to be charged with moral reservationssilly medication for crybabies or a happy pill for the happy few.58 Some authors notice the existence of such a stigma because of the publics grateful reactions to lectures they give or to articles they publish about their own depression. Stigma against depression is so powerful that some authors have been warned by their psychiatrists not to come out about it in their columns (Brunt) or have been advised not to admit themselves into a hospital (Styron): Sometimes I feel like a clandestine dope dealer who started his business at home and shamelessly advertises in newspapers. Are

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you sure youre better now?, my old trusted friend the psychiatrist asked me the other day, rather admonishingly. Or is it just a manic episode? Do I sound like that?, with great display of control and composure, trying by all means to assuage his suspicion. Well, you are talking a bit fast . . . he said, not very convinced. Listen, I am in a hurry, I have to finish typing my column before this evening! What is it about, this week? About Prozac, the medicine. Oh, he said, and remained suspiciously silent for a while. And then: Do you think it wise to profile yourself in the media as a case of depression and regular Prozac user? Dont you fear the stigma?59 The autobiographies can be read in at least two ways: first as a rebuttal to the accusation of being weak-willed and lacking persistence. In this reading, most authors use a variety of metaphors which demonstrate that even with the best will in the world, nothing could be done to prevent the onset of their depression. These metaphors compare depression to natural disasters: black wave, poisonous banks of fog, plague of locusts, strangling vine, howling blizzard, treacherous quicksand; (fear of) death: suffocating, drowning, or burning down; becoming deaf, blind and paralyzed, falling into an abyss, a sawn-down tree on its way to the sawmill; mechanical faults: feeling like a damaged car, driving with the handbrake on, emergency landing of an airplane, gradual flooding of a telephone exchange, unnoticed rusting away of some iron construction and then its sudden collapse; and the violence of intruders or demons who come, seemingly, all of a sudden to harass, preferably in a small, overheated room with no way out. Second, these metaphors can also be read as conceptual, evocative descriptions of the experience of a serious clinical depression. This in fact is the way the authors present their experience, but as readers we can clearly conclude that neither weakness of will nor luxury problems are at issue here. every author expresses relief that the initial positive working of antidepressants leads them back to the realm of people with a real disease for which there is medication available. However, the antidepressants (partially or fully) lose their power, and the authors feel again the weight of the stigmatizing image of a violated self. edward Shorters optimistic conclusion that Prozac has helped to make psychiatric conditions seem acceptable in the eyes of the public60 appears to be premature: Prozac is not a success story for everyone, and the stigma, although it may have changed a bit, has not disappeared yet. Whereas William Styron, in 1986, needed to be on the verge of

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committing a carefully planned suicide before he could surpass his psychiatrists advice not to seek admission to a hospital, elizabeth Wurtzel, in 1994, complained of a certain trivialization of depression because so many people use Prozac. This chronology, of course, marks an important difference: the fear of stigma, the shame of depression has diminished.61 But in the trivialization of depression, a new, albeit related, stigma lurks: when serious depression is downplayed to a sort of mental common cold, the sufferers become happy pill-poppers with their low-level sorrow.62 Discussion When studying the ten autobiographical reports of writers depression, we recognized the importance of the question Why me? All the authors ask themselves whether depression tells something about their identity, and eight give positive answers. Those who suffer from more or less therapy-resistant forms of depression bear witness to a developmental process in which they have finally learned to accept their depression as an inevitable or even positive part of their future existence and self. For these authors, depression does not signify a disease or personality defect, weak will or hypochondria, nor do they attribute the heroic philosophical-poetic status to it that melancholy types of the Romantic period would have, nor do they consider it a praiseworthy ailment,63 as Solomon terms it. All the authors describe their depression initially as an incomprehensible, hardly expressible, deregulating, or destructive experience, which robs them of everything fundamental to human existence. Most of them close their stories with a much more positive image of depression, sometimes that of a mentor and often part of the self. This acceptance of depression offers unexpectedly new possibilities: sufferers become more modest, wise and empathetic; they improve their relationships with others; they are less lonely; and they are better able to enjoy small things they hardly noticed before. While reinterpreting their identities, these authors grow equipped to give shape to their own lives, maintain meaningful relationships, and give their readers hope for similar possibilities. In describing the dynamics of coming to terms with depression, Karps concept of depression career was very helpful to us. The more restricted views of Metzl and Frank fit well with Karps view, each emphasizing some relevant aspects: the great influence of Prozac on a temporary, problem-oriented vision of depression (Metzl)

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and a corresponding hypomanic sense of self, followed by the final testimonial phase where the problem becomes incorporated into the self and the self-image more modest, if not wounded (Frank). Thus, we conclude that the earlier mentioned sharp distinction between a problem-oriented and a person-oriented view on the relation between illness and identity cannot be confirmed by our results. The more modest postmodern positions of Karp, Frank, and Metzl seem more appropriate than those of the strictly problem- or person-oriented therapists. even in our postmodern culture, where the authors we studied evocatively reclaim the right to speak for themselves, they see their identity not solely as an effect but ultimately as partial cause of their depression. The authors processes of redefining, rebuilding, and reconstructing their self-images show change as well as continuity. The postmodern self is perhaps not a completely new figure on the stage of Western culture, and it still shows some affinity with a modern or even premodern self, as Charles dOrleans poem, with which we began this essay, may suggest. Our findings enable us to conclude that despite the relative success of antidepressants, the stigma of depression is still a menace that can embarrass depressive patients and deter them from coming out with their condition. The patients who dare to be open about their illness display an overwhelming use of metaphor to describe yielding to circumstances far beyond their control. Such language use is rational in the context of a still-existent stigma of personal blame. Stigma is a moral accusation, unjust as it may be. According to Frank, the postmodern way to counter this imputation is to go beyond the victim position and take responsibility for ones own life by telling others about it and claiming the right to speak ones own truth in ones own words.64 And this is exactly what the authors of the depression narratives we studied tried to do. Their stories tell us about their capacity to persevere and survive, and often also about the courage to give up former favorable self-images. These are veritable counter-stories, against stigma and against the popular theory of pure chemical imbalance. The authors describe their identities as cause as well as effect, so we cannot confirm our former suggestion that a more person-oriented vision of the self is an obstacle to the overcoming of stigma. On the contrary, claiming that depression is a part of ones self turned out to be a kind of empowerment, at least for some people suffering recurrent depressive episodes. The metaphorical writing style our authors resorted to seems functional in two ways: it made visual what could hardly be put into words and, by doing so, opened the depression

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experience up to communication with others, fellow sufferers as well as other involved persons. The stigma related to depression persists, but the recent publishing of these depression stories can be seen as a sign of and a contribution to its diminishing perniciousness. Although we purposively selected an equal number of autobiographies written by men and women, we could not find meaningful gender differences in the way they wrote about their depression. Perhaps men prefer a scientific approach, but that did not keep them from exploring their own lives and selves. Men may slightly prefer the biomedical story, as we see in the subdominant pattern of the two men who keep waiting for the pill that helps, but these very men are in the medical field themselves. Our conclusion is that gender differences do not play a role here, and this is in agreement with Franks finding on cancer narratives.65 One way to explain this conclusion is that the writers we studied do not live traditional lives. Their narrative storylines are rich, complex and self-reflective. Neither male nor female writers show an over-identification with particular social roles. People have an inherent need to understand themselves, especially when their life perspectives have fundamentally changed. The depression stories we studied make clear that the popular as well as the medical story of a chemical imbalance is not enough: it is the personal narrative that can create such an understanding. By way of reply to Sontag, we note that, even in this age of Prozac, a special kind of metaphorical thinking can help reach a more agentic way of life. Following Hawkins and Frank,66 we should not banish all metaphors but rather search for the most empowering ones. For some people with an obstinate depression, this implies a less flattering self-image: sadder but wiser. APPenDIX A: Summaries of Autobiographies Studied Bakker, Jaap Berend (1995), Krachtmeting : chronologie van een depressie. Ambo, Baarn. [Trial of strength: chronology of a depression] The author describes how, in 1989, as a second-year medical student, he came to experience an endogenous depression. He talks about his feelings of depersonalization, obsessive thoughts, shame, and anxiety. Thanks to a combination of antidepressants and deprivation of sleep, in 1994, he felt that his recovery was beginning.

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Brunt, emma (1994), De Breinstorm: over depressie en Prozac. Arbeiderspers, Amsterdam. [The brainstorm: on depression and Prozac] Columnist emma Brunt describes how she, middle-aged and with a years-long history of mild depression, confronts a clinical depression that deprives her of her true identity. She describes positive effects of the antidepressant Prozac and argues against the contemporary culture which tends to see depression as a form of weakness and Prozac as a happy pill for softies. Manning, Martha (1994), Undercurrents: A Life Beneath the Surface. Harper, San Francisco. (Dutch edition 1994) Through diary entries, psychotherapist and university professor Martha Manning tells her story of numbing depression. She describes her devastating sleeplessness, thick mist in her head, and alienation from everything that previously used to make her happy. Finally, she agrees on electroshock therapy, which alleviates her depression. OBrien, Sharon (2004), The Family Silver: A Memoir of Depression and Inheritance. University of Chicago Press, Chicago. More radically than in other autobiographies, writer and university professor Sharon OBrien searches for the roots of her depression in her family history and her familys historical-cultural context. She uncovers the darker side of the American preoccupation with upward mobility, and she describes how among immigrant (Irish) families, not only hope but depression, too, is transmitted from generation to generation and how it is kept secret. She compares depression to family silver: a form of inheritance, which has not only genetic but first of all relational and emotional aspects. Smith, Jeffery (1999), Where the Roots Reach for Water: A Personal and Natural History of Melancholia. north Point Press, new York. Jeffrey Smith is 32 and works as a psychiatric case manager when he himself confronts a clinical depression. He describes his depression as a malicious voice in his head. Because antidepressants cannot save him from this evil spirit, he learns to accept it. In this way, he discovers the spiritual value of depression. Smiths personal story is interwoven with a more general reflection on depression.

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Solomon, Andrew (2001), The Noonday Demon: An Atlas of Depression. Scribner, new York. (Dutch edition 2002) novelist Solomon confronts clinical depression at the height of his career. He regards it as a malicious growth that deprives him of his self. Despite finally discovering the right combination of antidepressants, he keeps fighting relapse. Acceptance of his condition gives him more insight into positive aspects of depression. This personal chronicle is accompanied by extensive general reflection about depression. Styron, William (1990), Darkness Visible: A Memoir of Madness. Random House, new York. (Dutch edition 2003) At about 60 and just about at a high point in his career, author William Styron faces clinical depression. His book is an attempt to verbally express the darkness of depression. He describes his feelings of suffocating despair and paralyzing panic. Ultimately, hospitalization is his salvation. Udink, Betsy (2001), Klein leed. Meulenhoff, Amsterdam. [A lesser kind of grief] Author and journalist Betsy Udink describes her sudden breakdown around the age of 50 caused by devastating sleeplessness and feelings of self-hate, shame, jealousy, anger, and failure. She portrays an everyday lonely reality of depression. A Prozac-related medicine in combination with cognitive therapy help her keep her depression under control. Wolpert, Lewis (1999), Malignant Sadness: The Anatomy of Depression. Free Press, new York. At about 65, medical biologist Lewis Wolpert finds himself in heavy depression. He describes his experiences with total paralysis of feelings, loss of hope, and inability to make decisions. Hospitalization, combined with antidepressants and cognitive therapy, finally help him. His personal narrative is interspersed with general reflection on two major theories of depression: a biological and a psychological one.

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Wurtzel, elizabeth (1995), Prozac Nation: Young and Depressed in America. Riverhead, new York. 26-year-old Harvard student elizabeth Wurtzel portrays her chronic (atypical) depression, which has haunted her since childhood. She describes extensively her feelings of despair, nihilism, and anxiety and her many admissions to the hospital. Thanks to Prozac, she manages to keep her depression under control to some degree. Therapy helps her subsequently to cope with recurrent bouts of depression. nOTeS
Many thanks for the constructive criticism of our colleagues Ruud Abma, Catelijne Akkermans, Jaap Bos, Willibrord de Graaf, Martine Noordegraaf and especially Ludwien Meeuwesen at the Department of Interdisciplinary Social Science of Utrecht University on an earlier draft of this article. We also wish to thank our anonymous reviewers of Literature and Medicine for their very useful suggestions. 1. Here we refer to Baumeister, How the Self Became a Problem. 2. Translation by the authors. See also Starobinsky, Die Tinte der Melancholie, 31. In Charles dOrleans own words: Escollier de Merencolye / des verges de Soussy batu / je suis a lstude tenu / es derreniers jours de ma vye (Champion, Charles dOrleans). 3. In this article, identity and self are considered synonyms and are used alternatively. In the framework of our article, they refer to a layered consciousness of an individuals own place in a given social context. An important condition is autobiographical memory and an ability to situate ones own experiences on the past-present-future axis. Continuity and uniqueness are important characteristics of this identity perception, which presupposes an interpersonal context as well as an ability to communicate it in language, image and/or interaction with others (cf. also Damasio, The Feeling of What Happens). 4. Sontag, Illness as Metaphor, 3. 5. See Bos, Berichten uit het laboratorium; Pieters, te Hennepe, and de Lange, Pillen & psyche. It is difficult to find grounded and accurate data on the effectiveness of these modern antidepressants. On the basis of meta-analysis, van den Burg, De effectiviteit van SSRIs, states that the difference with placebo effects is rather minor. Also Moncrieff, The antidepressant debate, The antidepressant debate continues, and The antidepressant debate should move on, in a debate with two pairs of opponents, maintains that the evidence of effectiveness of antidepressants is complex even in cases of serious clinical depression. 6. See Shorter, A History of Psychiatry. 7. See Goffman, Stigma, 219. 8. Gibbons, Stigma and Interpersonal Relationships, 125. 9. See Wolpert, Stigma of depression. 10. Schiesari, The Gendering of Melancholia, 34. 11. See Schreiber and Hartrick, Keeping it together. 12. See Wolpert, Stigma of depression. 13. Cf. e.g. Baart, Ziekte en zingeving; Carr, Michael Whites narrative Therapy; Frank, Illness and Autobiographical Work; Hutschemaekers and Festen, Vragen naar zin; Jack, Silencing the Self; Karp, Speaking of Sadness; Lock, epston, and Maisel, Countering That Which Is Called Anorexia; McClean, The illness is part of the

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person; McLeod, Resisting Invitations to Depression; Metzl, Prozac on the Couch; nijhoff, Levensverhalen; Romme and escher, Accepting Voices; Schreiber and Hartrick, Keeping it together; Stern, Border narratives. 14. See Hutschemaekers and Festen, Vragen naar zin. 15. See Hutschemaekers and Festen, Vragen naar zin; Jack, Silencing the Self. 16. See McClean, The illness is part of the person. 17. Most explicitly expressed by narrative psychologists Lock, epstein, and Maisel, Countering That Which Is Called Anorexia; Carr, Michael Whites narrative Therapy; McLeod, Resisting Invitations to Depression. 18. Tucker, Editorial, 160; cf. also Wakefield, Meaning and Melancholia. 19. Karp, Speaking of Sadness, 55. 20. Ibid., 557. 21. Ibid., 102. 22. See Metzl, Prozac on the Couch, 16789. 23. Ibid., 188. 24. Frank, The Wounded Storyteller, chapters 5 and 6; the gender remark is on 1301. 25. See Chandler, et al., Personal Persistence. 26. For a short description of the content of these texts, see Appendix A. 27. ego-documents such as autobiographies lend themselves perfectly to research into subjective experience because they came into being unsolicited by the researcher. The authors make their own selections of what they want to write and how they structure their narratives (see Wester, Smaling, and Mulder, Praktijkgericht). To be sure, all of the autobiographical texts we studied were life stories structured with publication in mind, not unelaborated or uninfluenced reflections of lived reality. This factor does not detract from their value as texts for analysis. Despite the question of whether the latter (unelaborated reflection) is possible at all, subjective reflection on ones own world of experience, the narrated reality, is exactly the story we want to analyze (see Bjorklund, Interpreting the Self). 28. Dutch: Bibliografie van egodocumenten over geestelijke gezondheid (Aernoudts, Het eigen verhaal). 29. See nolen-Hoeksema, Sex Differences in Depression, 18; Westerbeek, Mannen, vrouwen en depressie. 30. Glaser and Strauss, The Discovery of Grounded Theory, 2401. 31. Karp, 579. 32. OBrien, The Family Silver, 207. 33. Styron, Darkness Visible, 789. 34. Karp, 57, 603. 35. Solomon, The Noonday Demon, 18, 19. 36. Styron, Darkness visible, 16. 37. Smith, Where the Roots Reach for Water, 21 and 61. 38. Karp, 57, 6371. 39. Manning, Undercurrents, 99. 40. Styron, Darkness Visible, 67. 41. Wolpert, Malignant Sadness, 158. 42. Brunt, De Breinstorm, 53. 43. Wurtzel, Prozac Nation, 3445. 44. Solomon, The Noonday Demon, 119. 45. Smith, Where the Roots Reach for Water, 6. 46. Wurtzel, Prozac Nation, 3045. 47. Karp, 57, 715. 48. Brunt, De Breinstorm, 99. 49. Smith, Where the Roots Reach for Water, 23. 50. Manning, Undercurrents, 1956.

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51. 52. 53. 54. 55. 56. 57. 58. 59. 60. 61. 62. 63. 64. 65. 66.

Bakker, Krachtmeting, 456. OBrien, The Family Silver, 257. Quoted in Manning, Undercurrents, 196. Solomon, The Noonday Demon, 43640. Smith, Where the Roots Reach for Water, 220. Ibid., 260. Brunt, De Breinstorm, 32. Brunt, 701. Ibid., 501. Shorter, A History of Psychiatry, 324. See Jones, Mental illness made public. Wurtzel, Prozac Nation, 342. Solomon, The Noonday Demon, 301. See Frank, The Wounded Storyteller. Ibid. See Frank, Review.

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