Called to Self-care, or to Efface Self?

Abstract

Pignarre's How Depression Became an Epidemic and Ehrenberg's The Exhaustion of Being Oneself: Depression and Society are two recent titles exploring the latest manifestation of a historically resonant phenomenon -- depression, nervous exhaustion, melancholia. Over the millennia, treatments and explanations have bounded. This mysterious ailment has been viewed as the call of the soul seeking self-purification; the inner wail of the child, mourning forever the loss of its own mother (primary sense of self); the sob of the woman who cannot cope with the realities of childbearing; and the nightmarish groan of the adult reliving trauma. It has been classed as the inability to grieve and the inability to stop. Yet for all the disciplinary disputes about its origins, one thing remains clear, to us, as to the Greeks, depression is as universal as society, and as specific as the human being living next door. For all the academic chatter about post-modernity and social constructions of disease, there is an eternality and specificity about the depressive condition which defies attempts at de-selving, that is to say, depersonalizing the illness. Depression, in other words, is as universal and specific as subjectivity. It is perhaps one of the primary diseases (conditions?) of self. As with depression, so with its treatments. Whatever the form of treatment, the basis remains the same: an encouragement of the sufferer towards self-care and self-medication and away from the suicidal impulse towards self-harm. The Greeks recognized the condition as a serious illness, and variously prescribed exercise, fresh air, and thoughtful conversation. In The Anatomy of Melancholy, dating from the sixteenth century, sufferer-writer Robert Burton recommended that sufferers be treated kindly, encouraged to get better and not ostracised or simply ignored. Nonetheless, the Catholic churches fought for years against relatives' protest that the will to suicide could be considered a kind of disease rather than a sin. Is this an illness from which the patient suffers, or a state of mind which is the patient's duty to try to control? This understanding is potenitially the difference between treatment and punishment, social ostracisation or community support. Should the suffering self be left alone, encouraged metaphorically or metaphysically to pull its socks up, or should it be re-integrated into social normality by gentler means, in particular through social and medical care? More specifically, is the suffering self right to seek help? These are the questions which have always faced depressives, as well as those who know and care for them, and there has in most instances been a delicate balance drawn between the need to care effectively for those in emotional pain, and the need to be seen to observe less tolerant social norms. Hence Greece has one of the lowest contemporary official records of suicide, since suicide is not tolerated by the Greek Orthodox church and to confess to a relative's suicide is to refuse them the right to be buried in sacred ground. The same can be said for the surviving taboos in UK culture against admitting to mental instability of any form, but particularly to affective disorders (the legacy of the 'stiff upper lip'). Such cultural biases suggest that depression is at some level the 'fault' of the sufferer, that they are not doing enough to self-heal, and that depression therefore demands a punitive-repressive social response. Obviously, it is excellent news that Western society has moved on from this. However, there are hidden costs. At the other end of the extreme of social acceptability, Elizabeth Wurtzel, sufferer-author of Prozac Nation makes a strong post-scriptive protest against those who are coming to represent the depressive self as socially normal, acceptable, useful even: I wanted this book to dare to be self-indulgent….[but] I can't get away from some sense that after years of trying to get people to take depression seriously -- of saying, I have a disease, I need help -- now it has gone beyond the point of recognition as a real problem to become something that appears totally trivial. (316, 302) This cultural tendency to see depression as a trivial, socially manageable adjunct to the human condition of being is, as Wurtzel puts it, a form of 'low-grade terminal anomie' (302). The facts would seem to bear out her argument. In 1994 six million Americans were on Prozac. The statistic was then shocking, but now seems strangely low. Peter Kramer's Listening to Prozac (1993) articulated a process whereby the 'Prozac culture' was and is systematically re-socialising the Westernised sense of the depressive self. As Wurtzel rightly foresaw, taking Prozac is becoming so usual it is in danger of no longer being an illness, no longer a genuine cry for help: the danger of Prozac Nation or world today is not that the problem has been ignored, but that it is too mainstream. We are in danger of no longer seeing depression (at least in its milder forms) as a serious illness needing treatment. Rather, it is just part of life, an occasional disability we encounter, rather like catching a cold. The very availability of Prozac is starting to affect sufferers' ability and willingness to face up to the fact of their illness, but also to the genuine problems facing Western society: we do not take Prozac to heal ourselves, but as a way of avoiding the difficulties of life. Wurtzel is not alone in her concern. Taking Prozac is coming to be seen as one of the latest manifestation of self-interested postmodernism, a social paradigm celebrated by medical technologists, despised by biomedical essentialists, and looked on with bemusement by almost everyone else. Faced with the vast numbers turning to Prozac, should we ignore the nay-sayers, treat them as Luddites? Certainly the suffering caused by depressive disorders is considerable, and certainly Prozac is making people happier and 'saner' than they were before. Yet the questions the nay-sayers are asking are profound ones. What is our sense of self? Is it something that can be materially altered by a drug? Can we consume a sense of ourselves, make ourselves truly happier? Should we even try? And with these questions come a sense of moral obligation. A history of Protestant Puritanism is brought to bear on the reading, as the sufferer and the doctor argue establish the existence of either a serious depression needing treatment, or the meandering complaints of a normally diseased or discomforted self. In the phenomenological diagnostic context that is the contemporary clinical encounter, it is not just questions of health but questions of self-hood, of the right to a sound sense of personal being, that are being discussed. The presenting sufferer says, I am not myself, give me something to make me better, that is more myself, and the general practitioner is left to decide whether or not to prescribe. The decision to prescribe is also a decision to accept the self-diagnosis of not-self, that is to say, not the usual self, and to enable the patient to imaginatively separate 'self' from 'pain'. And this is a difficult decision. And since it is often made on the run, as it were, that is to say in the short time averagely available for consultation (10 minutes in the British NHS), it is unsurprising that issues of self-hood, being and the personalised response to clinical depression get overlooked: and that in particular the concerns associated with the post-war phenomenon of pharmaceutical consumerism tend to get ignored. And this occurs not just in the doctor's surgery, but in the wider cultural context in which such difficult issues as 'Prozac' and 'clinical depression' are emotively and often thoughtlessly discussed. Prozac is part of cultural studies, but also the subject of media debates, scientific conferences and family arguments. In this cacophony of technologically sophisticated voices, ill-informed prejudice from outsiders and difficult professional decision-making, some of the fictions of the self which accompany our 'modern' and 'post-modern' concepts of depression are overlooked. These include the fact that contained within the fictions of pharmaceutical consumerism there is the ideal that an ideal drug exists which can be effectively targeted at a consumer, that this consumer can engage with or consume the drug in order to overcome a disease, and that although this drug affects the physiology of being it does nothing materially to alter the reality of 'self.' This should rightly lead the academic enquirer to question the inherent assumptions of a stable self, the assumption of the interpersonal right to clinical care, the assumption that in the condition of mental illness there exists the possibility of restoring the sense of self, of returning the sufferer to some semblance of a mental 'status quo': the difficulties of interpersonal subjectivity, the difficulties of knowing what is a subjective complaint and what is not -- the difficulties in fact, of self-defining oneself as a medical (mental health) patient in a consumerist era of pharmaceutical postmodernism. That is to say, the patient is called to self-diagnose, to separate the sense of a continuing self (an 'I' which is not materially altered by pharmaceutical treatment) from the temporary and contingent phenomenon of depressive pain. Issues such as self-esteem, self-love, self-care and self-motivation are therefore moved from the ontological to the physiological sphere of being, becoming a chemical-physiological condition rather than a complaint of personal identity. Issues of self become issues of body. The concerns of 'I' (Who am I? What am I doing? What am I worth? What do I need?) are transposed into a fictive third-party -- this body-brain, this being of which 'I' is made but which has its own serotonin-deficient identity, and which is of its own volition creating a sensation of I-worthlessness which needs to be dealt with without reference to first-person concerns. To self-diagnose as a depressive, concerns of body and self have to be ruthlessly separated. And this has to be done within a diagnostic and treatment context in which the contemporary problems of self -- career, family life, personal fulfillment, generalized well-being -- are inevitably the central topics of conversation, in which physical health concerns are secondary to discussion of emotive-behavioural patterns, and in which (in the British context) there is a 50% chance of being sent away undiagnosed. This means that, in ontological terms, the central decision for the would-be self-diagnoser is not, as many cultural commentators have suggested, whether to take Prozac or not. Rather, the decision is whether to accept blindly the terms of self-body separation which have characterized pharmaceutical-orientated depressive rhetoric, and therefore to accept the view that the continuing stable 'I' of 'healthy' selfhood is somehow separate from one's identity as a depressive. This enables depression to be seen unproblematically as a sickness, and therefore enables the would-be self-diagnoser to imagistically escape from the complaints of self-indulgence, lack of self-esteem, lack of self-respect, etc. As such it may be seen as a positive stage in the move towards wholeness and healing. And yet there is in this stance a sense of de-selving, of unhealthy depersonalization: a sense in which the sufferer is forced to step back from the self's experience of its own reality as a depressive sufferer. The 'self' is no longer stigmatized, but the depressive self certainly is. And this may be one of the problems with Prozac-orientated thinking. It is not that it is not good to treat depression pharmaceutically, but that in treating it so unproblematically as a biomedical entity the pharmaceutical companies and the medical establishments have failed to point out the more personal-universalist aspects of the depressive condition. It needs to be pointed out that the suffering self is not necessarily separable from the 'normal' self of pre-depressive illness. Nor is the prescription of an SSRI necessarily going to propel the sufferer backwards into a more 'normal' and 'usual' sense of self. The integration of the depressive experience into the sense of self-hood, the acceptance of the depressive identity as an aspect, albeit a problematic one, of one's personal sense of being: that may appear challenging, difficult, unsympathetic to the sufferer even but it does allow one to begin to see the self as an entity which is in some sense called to care for itself. A late Foucaltian remedy of selfhood, perhaps. References Borch-Jacobsen, Mikkel. "Psychotropicana" London Review of Books. 11 July 2002: 18-19. Burton, Robert. An Anatomy of Melancholy. Chicago: Michigan State University Press, 1965. Ehrenberg, Alain. La Fatigue D'Etre Soi: Depression et Societe. Paris: Odile Jacob, 2000. Kramer, Peter. Listening to Prozac. New York: Fourth Estate, 1993. Pignarre, Philippe. Comment La Depression est devenue une Epidemie. Paris: Decouverte, 2001. Solomon, Andrew. The Noonday Demon: An Anatomy of Depression. New York: Chatto and Windus, 2001. Wurtzel, Elizabeth. Prozac Nation: Young And Depressed in America, a Memoir. London: Quartet, 1994. Citation reference for this article Substitute your date of access for Dn Month Year etc... MLA Style Kidd, Kerry. "Called to Self-care, or to Efface Self? " M/C: A Journal of Media and Culture 5.5 (2002). [your date of access] < http://www.media-culture.org.au/mc/0210/Kidd.html &gt. Chicago Style Kidd, Kerry, "Called to Self-care, or to Efface Self? " M/C: A Journal of Media and Culture 5, no. 5 (2002), < http://www.media-culture.org.au/mc/0210/Kidd.html &gt ([your date of access]). APA Style Kidd, Kerry. (2002) Called to Self-care, or to Efface Self? . 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