Meaning-Making in Representations of Affective Disorders in Australia After the Introduction of a Sustained National Depression Initiative

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Telling sadness: Meaning-making in representations of affective disorders in Australia after the introduction of a sustained national depression initiative.

Peta Cox

Doctorate of Philosophy

2012

PLEASE TYPE THE UNIVERSITY OF NEW SOUTH WALES Thesis/Dissertation Sheet

Surname or Family name: Cox

First name: Peta Other name/s: NA

Abbreviation for degree as given in the University calendar: PhD

School: School of Public Health and Community Medicine Faculty: Medicine

Title: Telling sadness: Meaning-making in representations of affective disorders in Australia after the introduction of a sustained national depression initiative.

Abstract 350 words maximum: (PLEASE TYPE)

Background

The medical diagnoses of depression, anxiety and bipolar have become Australia’s dominant way of explaining experiences of extreme sadness, fear or happiness. Research into how people perceive, interpret and describe their experiences of affective disorders is important because individual understandings of affective disorders affect treatment access, treatment adherence and symptom severity.

Aim

This thesis aims to identify how Australians describe and construct their experiences of having affective disorders in published accounts of these conditions. Attention is given to both the rhetorical strategies used by authors of these texts and the lived experiences that they describe.

Method

The research examines published accounts of affective disorder experience including four autobiographies, three anthologies of autobiographical writing and/or edited interviews, 102 entries on two websites with illness story pages and 169 entries on an affective disorder bulletin board. Based in social constructionism and grounded theory, the analysis includes a mixture of thematic analysis, close textual analysis and semiotic/discourse analysis in order to identify common themes across narratives and the rhetorical function of specific narrative constructions.

Findings

This thesis highlights how affective disorder narratives are highly strategic constructions of self and experience that frame an author’s suffering and can assist or hinder the reduction of distress.

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Background

The medical diagnoses of depression, anxiety and bipolar have become Australia’s dominant way of explaining experiences of extreme sadness, fear or happiness. Current Bureau of Statistics data indicates that over their lifetime, one in four people will experience an anxiety disorder and approximately one in seven people will experience a depressive disorder. The dominance of certain, typically medical, explanations of emotional suffering means that in order for individuals to have their suffering recognised, they must describe their experiences in particular ways. Research into how people perceive, interpret and describe their experiences of affective disorders is important because individual understandings of affective disorders affect treatment access, treatment adherence and symptom severity.

Much of the research into affective disorder narratives has examined the lived experiences of people with depression, with particular focus given to certain aspects of the experience (e.g., taking medication, suicide ideation) or to specific communities (e.g., women, the elderly). Some studies have engaged in discourse analysis of autobiographies and interview data, with these studies highlighting the strategic and constructed nature of these recollections. The thesis builds on this work by extending such analyses to the full range of affective disorders.

Aim

# Method

The research examines published accounts of affective disorder experience including four autobiographies, three anthologies of autobiographical writing and/or edited interviews, 102 entries on two websites with illness story pages and 169 entries on an affective disorder bulletin board. A total of 2263 pages are analysed. Based in social constructionism and grounded theory, the analysis includes a mixture of thematic analysis, close textual analysis and semiotic/discourse analysis in order to identify common themes across narratives and the rhetorical function of specific narrative constructions.

Findings

This research finds that authors’ narrate their experiences in different ways according to their life stage, illness stage, gender identity and class. Affective disorder narratives utilise the rhetorical functions of legitimacy, authority and integrity in order to present the author – and their experiences – as culturally comprehensible and socially valued. It is particularly noteworthy that an author’s legitimacy is often enhanced through the use of separations between desired and undesired entities (e.g., self vs. illness, the ‘mad’ vs. the mentally ill, and the ‘normal’ public vs. those diagnosed with an affective disorder).

Implications

Current mental health promotion campaigns represent a limited version of affective disorder experience. This limitation may affect the ability for atypically symptomatic individuals to respond to the messages of these campaigns. In addition, health professionals may be more effective if they have a greater awareness of the rhetorical and strategic nature of the illness narratives that their patients report, as well as the effect that understandings of emotional distress may have on treatment adherence and ongoing help-seeking. Finally, practitioners in the human services are likely to need to

## address an increasing trend of individuals rejecting responsibility for socially unacceptable or illegal behaviour such as domesticviolence because they identify as a person who experiences an affective disorder.

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Abstract i Table of contents iv Acknowledgements x Short forms and acronyms xi Abbreviations used for references to corpus materials xiii Illustrations and diagrams xiv

Chapter 1. Introduction 1 Affective disorders in Australia: The state of play 2 Psychologists and psychotropic drugs: Common affective 4 disorder treatments in Australia Statistics and severity 11 What is the problem? Narrative responses to emotional distress 12 Illness narrative characteristics 14 Previous research 17 Diagnosis, events and identity: Research into affective 18 disorder experience The Prozac party: Selective serotonin re-uptake inhibitors 24 and subjectivity Discursive disorders: Medicalisation, medical treatment 28 and rhetorical value Professional publications and lay interviews: Australian 31 affective disorder narrative research The thesis project 34 The research gap 34 Overview of conceptual framework and methods 37 Thesis outline 37

Chapter 2. Methodological underpinnings and the social construction of 41 affective disorders PART I. From phlegm to pathological mourning: Historical 43 variation in understandings of ‘depression’ The psychiatrist’s bible: Continuing diagnostic variation in 47 the DSM Depression by any other name? Cultural variation in 51 understandings of affective disorders Telling a sick story: The social construction of illness 53 narratives PART II. Application of social construction to thesis data and 55 method Grounded theory 56 Introducing LIAM: The Legitimacy, Integrity and 58 Authority Model Benefits of the model 63 Conclusion 64

Chapter 3. Method 65 PART I. Literature review and research methodology 65 Ad hoc searching 65 Systematic searching 68 Snowballing 68 Limitations 68 PART II. Data sources 69 Moving away from the marginal: Data sources that reflect 69 dominant discourse A whole book about it! Autobiographies 70 Not too hot, not too cold, this one is just right: 72 Autobiography selection Writing to the world: Internet story pages and bulletin 75 boards Uncertain waters: Ethics and internet sources 78 Public places: Detail of internet sources 83 PART III. From a microscope to a telescope: Analytic methods 86 Looking at the dataset: Thematic analysis 86 Looking at a case: Examples 87 Looking at a sentence: Close reading 87 Coding, re-coding and sticky notes: Coding framework and 89 process Limitations of method and data sources 93 Conclusion 95

Vignette: High tea 96 Chapter 4. Depression: An expanse of blackness 97 Too much and too little: Emotional and cognitive symptoms 98 Sadness 98 Exhaustion 100 Anger 100 Fear 101 Loneliness and lack 102 Low self-esteem 103 Thoughts 105 Disappearing body rhythms: Physical symptoms and 106 consequences Sleep and tiredness 106 Eating and weight loss 107 Loss of libido 107 Changes to sight, hearing and touch 107 Pain and general physical symptoms 108 Catatonia and severe immobility 108 Ceasing school, social isolation and suicide: Behavioural 109

0 symptoms and consequences Crying 109 Suicidality 110 Poor self-care and immobility 111 Undermining relationships with others 113 Social isolation 114 Difficulties with education and employment 115 Monsters in the black pit: Metaphors 116 Depression as non-human agent 117 Depression as place 120 Depression as (lack of) colour 124 Mania 128 Conclusion 130

Vignette: Loud music 132 Chapter 5. Anxiety: Fear of fear and other foes 133 What counts as anxiety? 134 Being scared: Emotions 135 Shaking, sweating and spewing: Physical symptoms 136 Exaggerated normality and irrationality: Things that are feared 140 Feared feelings and emotional responses 141 Feared attributes 142 Feared objects 143 Feared events 143 A note on the effect of identities and social roles on object 145 of anxiety It’s too hard: Situations that are avoided due to fear 147 Dying for it to end: Consequences of fear and behaviours used to 150 mitigate fear Depression and anxiety: Experiential and narrative differences 153 Conclusion 154

Vignette: Calling her mother 156 Chapter 6. Lived experience and its erasure: Minimising anxiety 157 experiences Anxiety as precursor to depression 158 Anxiety at the same time as depression 161 Anxiety as a symptom of depression 163 The dominance of depression 166 Conclusion 167

Vignette: Baking cookies 170 Chapter 7. Biology, blame and broken bones: Affective disorders as 171 illnesses PART I. Linking to more legitimate categories: The construction 173 of affective disorders as illnesses 0# The implications of the obvious: The rhetorical functions of 173 explicit illness claims Diabetes and cancer not dandruff and chlamydia: Strategic 177 choices in analogies Corporeal credibility: Rhetorical functions of biological 187 accounts of affective disorders PART II. Distancing from less legitimate categories: Categorical 192 distinctions ‘But this is actually serious’: Categorical separation of 192 illness and sadness Divorce, death and disaster: Affective disorders and 195 situational distress PART III: Distancing from less legitimate categories: Separation 200 of self and illness Moral responsibility for help-seeking behaviour 201 Illness is not a personal failing 203 Conclusion 206

Vignette: Flaking red paint 208 Chapter 8. Severity, specialisation and sectioning: Health professionals as 209 signifiers of illness severity PART I. Not all doctors are equal 210 Brains and bills are better: Hierarchies of professionals 210 ‘Collect them all’: Number of health professionals as a 215 severity indicator PART II. Not all medical practices are equal 217 Shockingly serious: Hierarchies of treatment 217 Private clinics and padded cells: Hierarchies of choice and 223 environment Conclusion 231

Vignette: The mad woman 234 Chapter 9. Knowing more and knowing better: Professional knowledge 235 and authority PART I. Brass plaques and prescription pads: Differentiation of 236 lay and professional knowledge PART II. Knowing better: Epistemic competence and cognitive 238 authority Working together? Professional authority and levels of 238 mutuality Undermining narrative competence: Excessive professional 241 authority Alternative narratives 244 PART III. A story within a story: Performing illness for doctors 246 Reporting illness: Layered narratives and reader response 246 modelling Acting well: Counter examples 248 PART IV. Saying and being: Diagnosis and attribution as 250 verdictive speech acts 0## Conclusion 253

Vignette: Aversion therapy 256 Chapter 10. I’m not crazy: Stigma, differentiation and safeguarding the 257 self PART I. Stigma: Simple and complex 259 …but names will never hurt me? What is said and what is 259 feared The intersection of shame and discrimination 262 PART II. Negotiating stigma 268 Different negative attributions 269 Depressed and the public: Differentiating through 272 experience and knowledge The mad vs the depressed 277 Conclusion 279

Vignette: The phone call 282 Chapter 11. Doing and being: Depression and the reinscribing of 283 normative gender Methodological notes 284 PART 1. Depression as normative femininity 285 Gender as a social construct 285 ‘But I am a man’: Resolving the threat of emasculation 288 Bodily successes and failures: Femininity, immanence and 292 depression PART II. Special men and sufficient women: Constructions of 296 familial and domestic responsibility PART III. Dangerous combinations: Depression and 301 interpersonal violence Conclusion 310

Vignette: Panic attack 312 Chapter 12. Constructing or reflecting distress? Public health campaigns 313 Selection of campaigns 314 Background 315 beyondblue 316 headspace and SANE 319 Aspects of campaigns 322 Signs of depression 322 Signs of anxiety 324 Symptoms 325 Environment 327 Metaphor 329 Illness status 331 Hierarchies of illnesses 333 Separations and distinctions 337

0### Stigma 339 Gender 341 Caring and respect 345 What sort of problem? Similarities and differences between 347 campaigns Conclusion 349

Poem: Sorry 352 Chapter 13. Conclusion 353 LIAM and social construction as a framework: Research 354 underpinnings Lived experience 357 Building a narrative: Rhetorical construction of affective disorder 359 experience Legitimacy: Of illness and as an ill subject 359 Integrity: Over-simplified and multifaceted 361 Authority: Professional and experiential 363 Rhetorical functions as co-constitutive 364 Enmeshing being and telling: LIAM in context 365 Social constructionism and the influence of author 365 demographics on narrative form Genre norms and the limits of the tell-able 369 Living narrative: LIAM applications 371 Social issues: Gendered behaviour and domestic violence 372 Social issues: Stigma and medicalisation 373 Implications of the research finds 375 Clinical interactions 375 Mental health programs and promotion 376 Reflections on approaches to emotional distress 378 Thesis limitations 380 Where to from here 381

Appendix A: Australian affective disorder autobiographies 2000-2009 383 Appendix B: Thematic trees 385 Reference list 389

#2 #$,!"#)( Juliet Richters and Kristy Muir – for supervising me from 2010 to 2012 and, in particular, reading chapters many times over, encouraging me even when I wanted to pull my hair out and enduring slightly obsessive emails about due dates and process.

Katrina Schlunke and Catherine Robinson – for patient supervision in 2009 while I worked out that I was going to disappear to a different uni.

UNSW lawyers – for fighting the good fight.

Sarah Macintosh and Kat Lamb – for force-feeding me when required and especially to Sarah for entering data when my RSI was too bad for me to do so and for spending several afternoons bonding with my bibliography.

Virginia and Graeme Cox – for ongoing support and help with tenses.

Jean Curthoys and John Williams– for appearing interested throughout the process.

Jane Corless and Bron Lee – for study dates that made me pretend to focus.

Bridget Griffin-Foley and Damien Riggs – for support and encouragement.

Simon Harder – for helping to set up the Access database to manage my data.

Lucy Tatman – for always believing in me and giraffe.

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ABS Australian Bureau of Statistics APA American Psychiatric Association Australian APA/FT Australian Public Affairs/Full Text (online database) BBV Blood Borne Virus beyondblue beyondblue: The national depression initiative is an NGO that aims to increase community awareness of depression and anxiety Blue Board Blue Board is an online bulletin board run by the Centre for Mental Health Research, Australian National University CBT Cognitive Behavioural Therapy DS-HUM Disability Studies in the Humanities (email list) DSM Diagnostic and statistical manual of mental disorders DSM-IV-TR Diagnostic and statistical manual of mental disorders, 4th edition, Revised DSM-5 Diagnostic and statistical manual of mental disorders, 5th edition (currently under development) ECT Electro-Convulsive Therapy GP General Practitioner H-Madness History of Madness (email list and blog) Headspace headspace: National Youth Mental Health Foundation runs youth mental health services across Australian LIAM Legitimacy, Integrity and Authority Model MAOI Monoamine Oxidase Inhibitor NGO Non-Government Organisation PBS Pharmaceutical Benefits Scheme PMDD Pre-Menstrual Dysphoric Disorder PTSD Post-Traumatic Stress Disorder

2# ReachOut ReachOut is an online youth mental health service run by the Inspire Foundation that includes factsheets, blogs and personal story pages. SANE SANE Australia is the national mental health charity and aims to increase awareness and support for people experiencing mental illness. SSRI Selective Serotonin Re-uptake Inhibitor STI Sexually Transmitted Infection TDDD Temper Dysregulation Disorder with Dysphoria UNSW University of New South Wales UTS University of Technology, Sydney URL Universal Resource Locator WASP White Anglo Saxon Protestant

2## '+)$#(*($'''#()$$'%*(")'!( 17V Broug, M. (2008). Seventeen voices: Life and wisdom from inside 'mental illness'. South Australia: Wakefield Press. BB Quotations taken from the Blue Board bulletin board. BO Hamilton, C. (2004). Broken Open. Sydney: Bantam. BT Rowe, P., & Rowe, J. (2005). The best of times, the worst of times: Our family's journey with bipolar. Sydney: Allen and Unwin. D Deitz, M. (2004). My life as a side effect: Living with depression. Sydney: Random House Australia. GC Cowan, G. (2007). Back from the brink: Australians tell their stories of overcoming depression. Gordon, NSW: Bird in Hand Media. HS Quotations taken from headspace ‘Real stories’ pages. JwBD Wigney, T., Eyers, K., & Parker, G. (2008). Journeys with the black dog: Inspirational stories of bringing depression to heel. Crows Nest: Allen & Unwin Academic. KH Haley, K. (2006). Emails from the edge: A journey through troubled times. Yarraville: Transit Lounge. RO Quotations taken from ReachOut story pages.

2### !!*()')$#(#'"( Diagram 1: Ad hoc Search terms Illustration 1: beyondblue poster: To numb depression and anxiety, I drink. Illustration 2: headspace poster: I told my dad I felt ignored. Illustration 3: SANE poster: Depression Illustration 5: beyondblue poster: Depression is more than stress. Illustration 6: beyondblue poster: Anxiety is paralysing. Illustration 7: beyondblue poster: Bipolar disorder. Illustration 8: SANE poster: Anxiety Illustration 9: beyondblue poster: When you’re growing up […] Illustration 10: beyondblue poster: He’s changed. Illustration 11: beyondblue poster: Postnatal depression is like living in a fog. Illustration 12: beyondblue poster: You hide your depression […] Illustration 13: headspace poster: My friend reckons the best way […] Illustration 14: headspace poster: When I cry on my boyfriend’s shoulder he […]

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Affective disorders are excesses in sadness, happiness and anxiety that are clinically identified as depressive disorders (including bipolar disorder and unipolar depressions of various severities) and anxiety disorders (including obsessive compulsive disorder, phobias, panic attacks and post traumatic stress disorder) (American Psychiatric Association, 2000; International Society for Affective Disorders, 2009).1 In order for individuals to have their emotional distress recognised by others, they must describe their distress in ways that are culturally comprehensible to their audience. At present, medical explanations of emotional distress are the most readily understood in western cultures (Blazer, 2005; Greenberg, 2010). Research into how people perceive, interpret and describe their experiences of affective disorders is important because individual understandings affect treatment access, treatment adherence and symptom severity. For researchers, the examination of affective disorder narratives provides insight into dominant affective disorder narratives and their individual and cultural function.

This thesis will examine affective disorder narratives published in autobiographies, internet bulletin boards and internet story-pages in order to determine how authors describe and construct the experience of having these conditions. It answers the research question: How are experiences and understandings of affective disorders represented and constructed in current public narratives and representations in Australia? Further focus on the rhetorical structure of these narratives is provided by a number of sub- questions: Which narratives of affective disorders are dominant in Australia? Why? What discursive and rhetorical function do these narratives serve? ‘Current’ narratives are defined as those written within the past decade (i.e., since 2000). This time period has been chosen to coincide with the launch of beyondblue (a major national depression initiative focused on reducing the burden of depression in Australia) because of this

1This thesis uses the definition given by the International Society for Affective Disorders, which includes both anxiety disorders and mood disorders (depression and bipolar disorder) under the banner of affective disorders. This clustering of illnesses (which is different from the DSM-IV-TR and the tenth revision of the International Classification of Diseases (ICD-10) nosology, where mood and anxiety disorders are separated) has been chosen because it reflects the common lived experiences of having concurrent anxious and depressive states. To insist on a strict demarcation between the two diagnoses is to lose some of the nuance and complexity of the narratives being examined (Andrews, Hunt & Jarry, 1997; Andrews & Slade, 2002). P organisation’s impact on how Australians understand affective disorders (beyondblue: the National Depression Initiative, 2010).

In order to contextualise the research project, this introduction will begin by examining the state of play in terms of Australian attitudes, treatments and community programs. The introduction will then move on to detail why an examination of affective disorder narratives is an important response to the current situation, and then discuss how this thesis fills a significant gap in current Australian affective disorder narrative research. The chapter will conclude with an outline of the thesis structure and a brief discussion of the outcomes and unique contribution of the research project.

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Affective disorders are the most commonly diagnosed mental illnesses in Australia. The 2007 Australian Bureau of Statistics (ABS) National Mental Health and Wellbeing Survey found that 6% of respondents reported having experienced symptoms consistent with severe, moderate or mild depression (as defined in the International Classification of Diseases – 10) in the previous 12 months. The self-reported lifetime prevalence of depression was approximately double, with one in seven people (15%) reporting symptoms. Anxiety disorders were more prevalent than depressive disorders, with 14% experiencing an anxiety disorder in the year prior to the survey and more than one in four (26%) experiencing symptoms in their lifetime (Australian Bureau of Statistics, 2007a). These rates are significantly higher than those of other mental illnesses such as psychotic disorders, eating disorders or personality disorders (e.g., schizophrenia has a lifetime prevalence of approximately 1%) (Chakrabarti et al., 2007). In 2007, 1.2 million Australians had two or more mental disorders; 39% of these people had both anxiety and either depression or bipolar,2 with a further 27% experiencing two or more anxiety disorders (Australian Bureau of Statistics, 2007a).

These disorders have a substantial impact on health and wellbeing. Anxiety and depression are calculated to be the third leading contributor to the burden of disease (both fatal and non-fatal) for men and the leading contributor for women (Australian 2 Consistent with corpus materials and a growing number of academic texts, in much of this thesis, ‘bipolar’ has been treated as a noun. Q Bureau of Statistics, 2009). When only the non-fatal burden of disease is considered, depression and anxiety are the leading causes of burden for both men (10% of the burden) and women (18%) (Begg et al., 2007).

Suicide ideation, attempts and completions are common experiences for individuals diagnosed with an affective disorder (Balazs et al., 2006; Lee et al., 2010; Oliffe, Ogrodniczuk, Bottorff, Johnson & Hoyak, 2010; Wilson & Deane, 2010). The 2007 ABS survey found that approximately one in six (17%) people with depression or bipolar disorder reported serious thoughts about committing suicide in the past 12 months. Of the people in the ABS survey who had a mental disorder and had serious thoughts about committing suicide, 63% had a mood disorder (depression or bipolar) and 77% had an anxiety disorder (despite these findings, most people associate suicide with depression rather than anxiety: the reasons for this association are addressed in Chapters 4 to 6). (Australian Bureau of Statistics, 2009). Other Australian research has indicated that of individuals who have attempted suicide, close to one in two (46%) were at the time experiencing clinically significant depression and slightly over one in four (27%) were experiencing anxiety and panic attacks (De Leo, Cerin, Spathonis & Burgis, 2005). Suicide rates are particularly high in young men from rural areas, possibly due to reduced access to mental health services by men in these areas (Caldwell, Jorm & Dear, 2004). Approximately 2000 deaths are officially recorded as suicide in Australia each year. However, this is likely to be a substantial underestimation as data on completed suicide is notoriously unreliable because certain methods, such as single-car accidents, are not classified as suicide, while other methods are only recorded when a suicide note or other indicator of intention is found. In 2007, (recorded) suicide was the 15th leading cause of death in Australia across all genders and ages. It was the tenth leading cause of death for males across all ages, with suicide accounting for 21% of deaths in males under 35 years. Suicide is the leading cause of death for both men and women aged 15 to 34 (Australian Bureau of Statistics, 2007b).

Research about how Australians conceptualise affective disorders is inconclusive. Some data from population surveys has indicated an increase in the number of Australians who considered depression to be a seriously debilitating condition. For instance, in late 2004 to early 2005, when asked to compare depression to diabetes, asthma, arthritis and alcohol abuse, 47% of the 3200 Australians surveyed identified depression as the most

R debilitating condition and an additional 26% placed depression as the second most debilitating condition. However, such positioning of depression as a serious illness was not reflected when participants were asked to identify the major health problems in Australia, with only 1.3% spontaneously including depression in their response (Highet, Luscombe, Davenport, Burns & Hickie, 2006, p. 57).3

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A variety of treatments for affective disorders are utilised in Australia. Individuals engage in different treatment regimes according to the severity of their symptoms and their understanding of the nature and/or cause of their condition. The most common treatments involve psychotropic medications, with psychological, lifestyle and physiological treatments being far less common.

Psychotropic medication

Psychotropic medications are a very popular form of treatment for emotional distress. In a 2001 ABS survey, one in four (24.9%) people with a mental or behavioural problem reported taking antidepressants (Australian Bureau of Statistics, 2003). In 2008 the Australian government subsidised 18.8 million prescriptions for anti-depressants through the Pharmaceutical Benefit Scheme (Department of Health and Ageing, 2009a, pp. 161-164).

Despite their popularity, antidepressants are somewhat problematic drugs. Recent media attention in the United States has increased public awareness of several clinical trials where the effect of antidepressants was found to be roughly equivalent to a placebo, with some researchers indicating that antidepressants are primarily a psychological treatment (Angell, 2011; Ankarberg & Falkenström, 2008; DeGrandpre, 2004; Kramer,

3 Australia also has substantial mental health literacy research. This research tends to test whether participants know the ‘correct’ way of thinking about affective disorders. While valuable in certain contexts, this approach is in tension with the social constructionist frame of this thesis (see Chapter 2). For examples of mental health literacy research, see Goldney, Fisher, Grande, and Taylor (2005); Griffiths, Christensen, and Jorm (2009); Parslow and Jorm (2002), Highet et al. (2006); Highet, McNair, Davenport, and Hickie (2004); Jorm et al. (2006); Jorm, Christensen, and Griffiths (2006b); Jorm et al. (1997); Jorm, Morgan, and Wright (2008). S 2011). In addition to questionable efficacy, antidepressants have a number of potential side-effects such as dry mouth, blurred vision, constipation, urinary retention, tachycardia, nausea, diarrhoea, headache, tremor, agitation, anxiety, sexual dysfunction, neutropaenia, dizziness, tinnitus and, in the case of monoamine oxidase inhibitors (MAOIs), dangerous adverse reaction to certain foods such as matured cheese, cured meats and yeast extracts (Department of Health and Ageing, 2003). In an Australian study, Fullagar interviewed women who had taken antidepressants. She found that:

One-third of participants identified anti-depressants as helpful in their recovery, while two-thirds were highly ambivalent about, or critical of, medication as a solution to depression. (Fullagar, 2009, p. 389)

In addition, of the people categorised by the ABS as having a mental or behavioural problem, 10% reported taking sleeping tablets/capsules and 18% reported taking vitamin or mineral supplements. In comparison with the one in four people who experienced a mental problem who were taking antidepressants, only slightly over one in 12 (9%) were taking medication for anxiety or nerves (Australian Bureau of Statistics, 2003).4

Health professional consultations

Medicare, Australia’s universal health insurance service, provides rebates of up to 85% of the scheduled fee for many mental health services, though some practitioners may charge more than the scheduled fee. As a result, Medicare has significant influence over the types of treatments routinely used by individuals experiencing extreme emotional distress.

For all Australian citizens and permanent residents, general practitioner (GP) consultations are subsidised by Medicare. The ABS reported that 25% of Australians with a mental health issue discussed their condition with a GP, making GPs the most popular health professionals consulted about mental health issues. In comparison, only

4 In addition to antidepressants, there are two forms of psychotropic medication typically used to treat affective disorders: mood stabilisers (Smith, Cornelius, Warnock, Bell, & Young, 2007) and anti-anxiety medications (Birkenhager, Moleman, & Nolen, 1995; Martin et al., 2007). T 13% of Australians with a mental health problem see a psychologist regarding their mental health (Australian Bureau of Statistics, 2009).

Australians can also receive Medicare subsidises for consultations with mental health specialists such as psychiatrists and psychologists. The subsidy schemes are slightly different for psychiatrists and psychologists. For both types of consultation, a person can only receive a Medicare rebate if they provide a GP referral to the specialist. However, while an individual can receive an unlimited number of rebates for appointments with a psychiatrist, a person with a GP referral can only access 12 psychologist appointments per year, with the possibility of an extension to 18 in exceptional circumstances.5 Rebates are 85% of the Australian Psychological Society scheduled fee for an appointment. Only certain forms of therapy are approved by Medicare: namely cognitive behavioural therapies,6 relaxation techniques, skills training and, for Aboriginal and Torres Strait Islander clients, narrative therapy7 (Department of Health and Ageing, 2009b). This means that other common forms of therapy such as acceptance and commitment therapy,8 mindfulness,9 and psychotherapy are excluded from Medicare rebates; if a person wishes to receive these forms of therapy, they need to pay the full fee or receive subsidy through a private health fund. For the financial year 2009–10, Medicare provided rebates for 546,904 GP Mental Health Care Plans, 828,395 GP Mental Health Care Consultations, 1,049,986 standard (50 – 60 minutes) psychological therapy consultations with a clinical psychologist, and 1,745,940 standard ‘focused psychological strategies’ consultations with a registered psychologist (Medicare Australia, 2011a). Like antidepressants, counselling has questionable efficacy, with most ‘treatment groups and placebo groups [being] more effective than no treatment groups in control trials [but] most studies show no difference or equivocal

5 As of 1 November 2011, this has been reduced to 10 sessions per year per person with no capacity for extension (Australian Government, 2011). A sunset clause has since been added, with GPs from February to December 2012 able to authorise subsidies for up to 16 sessions in ‘exceptional circumstances’ (Hickie, 2012). 6 Cognitive behavioural therapy (CBT) is based on identifying ‘errors’ in thinking and providing alternative ways of understanding distressing situations (Beck, 1979; Butler, Chapman, Forman, & Beck, 2006). 7 Narrative therapy involves re-narrating one’s life in more nuanced and less destructive ways (Morgan, 2000). 8 Acceptance and commitment therapy involves promoting the acceptance of symptoms that tend to be exacerbated by attempts to control them, and also in helping the client recover a sense of meaningful living that is consistent with his or her values (Perez-Alvarez, Sass, & Garcia-Montes, 2009, p. 222). 9 Mindfulness involves learning to ‘sit with’ one’s emotions and not become distressed by them, with a focus on the use of meditation techniques (Teasdale et al., 2000). U results when the treatment and placebo groups are compared’ (Pilgrim, Rogers & Bentall, 2009, p. 245).

Government expenditure on state and territory mental healthcare services – which include inpatient care and a variety of specialised services such as research programs, early intervention programs for youth, community care, specialist hospital units for target populations and prisoner mental health units – was at $2.7 billion in 2005–06, an increase of an average of 5.2% per year compared to the previous four years (Australian Bureau of Statistics, 2009; Council of Australian Governments, 2006). The 2011 federal budget provides an extra $1.5 billion in funding for mental health services over the next 5 years, funds which will be distributed through a range of channels including non- government organisations and state and territory governments (McGorry, 2011).

Hospitalisation

Individuals with extremely debilitating affective disorder symptoms may receive voluntary or involuntary inpatient care. In order to ensure that involuntary hospitalisation is only used in extreme cases, each state and territory has a Mental Health Act. The Act has several functions, including: setting out a process for external assessment of involuntary hospitalisation decisions; placing restrictions on the length of stay; and dictating how much time can elapse until reassessment of the treatment order (Australian Capital Territory Government, 1994; Northern Territory Government, 1998; NSW Government, 2007; Queensland Government, 2000; South Australian Government, 2009; Tasmanian Government, 1996; Victorian Government, 1986; Western Australia Government, 1996). Inpatient treatment in a public hospital has no out-of-pocket expenses, but beds are extremely limited and only individuals who are an immediate danger to themselves or others can generally be accommodated (Medicare Australia, 2011b).

In order to receive private inpatient treatment a patient must have private medical insurance or significant personal funds. Private fees are often prohibitive for those without private health insurance: for example the Northside Clinic in Sydney has a weekly fee of between $6040 and $7440 for its inpatient mood disorder program (personal conversation with clinic reception staff, 3 May 2011). The vast majority of

V private hospitals do not take involuntary patients. Inpatient care may include more intensive pharmaceutical or psychological interventions. It may also involve hospital- based medical procedures such as electro-convulsive therapy (ECT).

ECT is one of the few treatments for affective disorders that requires hospital attendance. The procedure involves running electricity through the brain and inducing a seizure.10 It is performed under general anaesthetic and often causes severe personality and cognitive side effects (Sackeim et al., 1993). It is a contentious treatment that is used with patients who are catatonic, psychotic or acutely suicidal (Birkenhager, Pluijms & Lucius, 2003; Hay, Hay & Spiro, 1989). Although health professionals who use this form of treatment do not generally perceive that it involves unacceptable risk (especially given the severity of the symptoms experienced by the patient), lay people may perceive it as a high risk and dehumanising treatment (Mental Health and Drug and Alcohol Office NSW Health, 2010). For these reasons, it is a relatively uncommon therapy that tends only to be used when other treatment options have been exhausted.

Community programs

While most mental health treatments are administered by GPs, private psychologists and psychiatrists, some services are provided through community programs. Both government funded community health services and non-government organisations (NGOs) such as the Salvation Army and the Richmond Fellowship provide a range of free or low cost outpatient services. These services include, but are not limited to, outpatient psychological and psychiatric services, supported housing and day treatment programs.

In addition, there are a variety of community programs focused on specific target groups such as people from non-English-speaking backgrounds, people who identify as gay, lesbian, bisexual or transgender, or survivors of sexual assault. Most of these programs are small-scale and are characterised by either a single hub of professionals, or single professionals in a series of locations. The exception to this is headspace, Australia’s national youth mental health program, which had over 30 sites fully

10 Magnetic cranial stimulation also requires hospitalisation. W operational nationally in 2010. These sites provide a range of services including GPs, psychologists, psychiatrists, youth workers and other allied health services in a youth- friendly environment. The program was launched in 2006 with a set-up cost of approximately $65 million. In 2009–10 headspace received $17.9 million in on-going funding for the running of established centres. The 2011–12 federal budget provided an additional $197.3 million in order to set up 30 new centres by 2014–15, bringing the total number to 90 (headspace: National Youth Mental Health Foundation, 2011a). The vast majority of this funding comes from the federal Department of Health and Ageing under the Youth Mental Health Initiative Program, with additional income through Medicare service payments.

Awareness raising

In addition to service delivery programs, some organisations are funded to increase community awareness of mental health issues. Launched in 2000, beyondblue is the ‘National Depression Initiative’ (Kennett, 2005) and is the dominant organisation in the field of affective disorders in Australia.11

The primary aim of beyondblue is to increase community awareness about depression and anxiety and it receives a large amount of funding to do so. Specifically, in the 2009- 10 financial year, beyondblue received $28.8 million dollars in funding. The majority of this came from federal ($8.8 million) and state governments (ranging from $3.3 million in Victoria to $0.048 million for the Northern Territory), with $10.5 million coming from donations (beyondblue: the National Depression Initiative, 2010). The beyondblue annual report does not detail the percentage of this funding allocated to health promotion activities, but the extent of these activities suggests that they are a significant portion of the organisation’s expenditure (beyondblue: the National Depression Initiative, 2011b).

The health promotion activities of beyondblue are extensive and include billboards, convenience advertising (advertising on the back of toilet doors), posters in bus shelters 11 It appears that, as of December 2011, beyondblue may be moving from being the ‘national depression initiative’ to being the ‘national depression and anxiety initiative’. While their website still says the former, the 2010-11 annual report says the latter (beyondblue: the National Depression Initiative, 2011a, 2011b). X and train stations, posters on buses, awareness months, fundraising months, celebrity endorsement, consumer networks, consumer forums, and advertising on radio, newspapers and television (beyondblue: the National Depression Initiative, 2009b, 2010). Given the extent of this advertising, it is unsurprising that the organisation has a significant influence on community attitudes regarding depression, bipolar and anxiety. An independent evaluation of beyondblue’s activities in 2000–2004 found that:

Repeated cross-sectional population surveys suggest that there were increases in the community’s awareness of depression, and knowledge of its symptomatology, causes and treatment, during the early period of beyondblue. (Pirkis et al., 2005, p. 6)

In addition to beyondblue, there are several smaller organisations such as SANE, the national mental health charity, that aim to increase community awareness of affective disorders (SANE Australia, 2011). Almost all health promotion programs in Australia actively encourage individuals experiencing emotional distress to seek treatment from a medical professional. Despite ongoing health promotion campaigns, the majority of Australians who experience a mental health issue do not see a doctor or other health professional (Australian Bureau of Statistics, 2009).

Alternatives to treatment and alternative treatments

While many Australians receive medical and psychological treatment, it is important to acknowledge that 65% of the people identified by the ABS as having a mental health issue did not access professional help in the 12 months prior to the survey. This relatively low rate of service use is not because of a lack of services: rather 86% of individuals said that ‘they had no need for any type of assistance’ (Australian Bureau of Statistics, 2009). ‘Assistance’, when desired, can come from a wide range of professionals, including psychologists, psychiatrists, social workers, general practitioners, psychiatric nurses, youth workers, case workers, acupuncturists, music/art therapists, psychoanalysts, counsellors and pharmacists.

In addition, some individuals engage in non-medical activities that help relieve symptoms. For example, clinical studies indicate that exercise, acupuncture, yoga and

PO massage have a positive effect on affective disorder symptoms (Klein et al., 1985; Mead et al., 2008; Morgan & Jorm, 2008; Pilkington, Kirkwood, Rampes & Richardson, 2005; Wang et al., 2008). Jorm, Griffiths, Christensen, Parslow and Rodgers (2004) compared the coping strategies of people with different severities of depression. They found that medical interventions became more popular when people experienced more severe emotional distress. Specifically, they observed a peak in the use of ‘everyday strategies’ such as exercise, doing enjoyable activities or spending time with family and friends in people with mild depression, while those with moderate depression demonstrated a peak in self-help strategies such as avoiding sugar, avoiding alcohol, using aromatherapy and practicing yoga. Health professional interventions such as taking antidepressants or receiving counselling were most popular for individuals with severe depression. Thus, while non-medical interventions are popular, they become less prominent when people experience severe symptoms. This link between severity and medical intervention is discussed at length in Chapter 7.

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There is a certain irony in beginning a thesis focused on the rhetorical function of affective disorder narratives with a set of statistics about morbidity and financial impact. Academics, health professionals and lay people routinely use these types of statistics to establish the severity of affective disorders, and their use is familiar. Philip (2009) summarises the types of evidence used to justify engagement with affective disorders:

When describing the perceived depression crisis in [Australia, the United Kingdom and the United States], mental health experts point to evidence of increasing prevalence of depression since the Second World War (Klerman, 1988; Klerman and Weissman, 1989), the higher numbers of patients in treatment for depression (Healy et al., 2001), the growing number of prescriptions for antidepressant medications (Bell, 2005), and the estimates of the high social and economic cost of depression (Murray and Lopez, 1996; World Health Organization, 2001). (Philip, 2009, p. 153)

PP Despite their predictability, the Australian statistics and costings tell an important story: affective disorders are experienced by many Australians, with their suffering resulting in significant personal, communal and government expenditure and significant reductions in productivity and community engagement.

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Up until this point, this introduction has provided evidence that affective disorders in Australia are a major health issue: they are experienced by a lot of people, they cost the government a lot of money, their treatment involves a lot of professionals, they significantly reduce productivity and they can result in death. Affective disorders tick nearly every box for what makes a problem a ‘major health issue’.

Australian affective disorder initiatives are consistently aligned with a medical understanding of these conditions. The dominance of the medical model in Australian culture means that health professionals and lay people rarely examine other reasons for, treatment options for, and ways of understanding, affective disorders. While affective disorders are ‘real’ and are significant causes of suffering that should be alleviated through appropriate treatments (of which medical interventions are the primary ones at this time), they are not solely medical problems.12 Rather, the aetiology and course of these disorders are better explained through a model which acknowledges the complex interplay of social, biological and psychological factors (Cyranowski, Frank, Young & Shear, 2000; Goldberg & Huxley, 1992; McGorry, Nelson, Goldstone & Yung, 2010; Mulvany, 2001; Patel, Flisher, Hetrick & McGorry, 2007; Piccinelli & Wilkinson, 2000; Schotte, Van Den Bossche, De Doncker, Claes & Cosyns, 2006; Steffens et al., 2005). More radical scholars in disability studies and other critical humanities suggest that this nuanced model is still insufficient. Rather, these scholars argue that seeing the ‘problem’ of disability as being an individual impairment is both inaccurate and morally suspect and that we must shift to thinking of the ‘problem’ as being the lack of

12 As will be discussed at length in Chapter 2, a medical model is not the only way to understand emotional suffering. While medical explanations are dominant in western culture, other ways of understanding affective disorders are still found in certain academic (and non-academic) forums. These include, but are not limited to, the accounts of childhood pathology of Freudian psychoanalysts, the social justice interpretations by theologians and the thought pattern models of cognitive-behavioural psychologists (see for example Hollon & Kendall, 1980; Tatman, 1998; Wilson, 1999). PQ adjustment made to allow people with disabilities to lead meaningful lives within their communities (Social Exclusion Unit, 2001). While this approach moves towards a complex and nuanced understanding of the moral issues underpinning experiences of disability (including experiences of mental illness), it tends not to acknowledge the centrality of narrative in the experiences of individuals with a disability.13

Emotional and physical suffering are a universal aspect of the human condition, although, of course, the nature of the suffering and its extent varies. Certain forms of suffering can be relieved through medical intervention, but many of the conditions western cultures traditionally treat with medicine are not solely bodily sufferings. For example, a woman with breast cancer is not only suffering a medical condition that needs to be treated (e.g., through lumpectomy and radiotherapy), she is also likely to be experiencing an emotional suffering regarding her sense of self as a gendered and desirable woman (Langellier & Sullivan, 1998). Suffering – whether physical, emotional or social – is relieved or exacerbated, in part, by the stories or narratives told about it. This approach, with its focus on the function of illness narratives, is underpinned by a social constructionist understanding of illness (see Chapter 2).

The relationship between suffering and narrative is even more acute when discussing affective disorders. To anticipate an argument made in Chapter 9, how a person understands their emotional suffering can influence the level of distress, and, in turn, the severity of their mental illness.14 Put simply, a person who believes that their depression is the result of personal weakness and therefore that they are a worthless and pathetic person may experience more emotional distress than a person who does not hold these beliefs (Corrigan & Watson, 2006; Rusch, Lieb, Bohus & Corrigan, 2006). Such distress may then result in increased severity in clinically significant symptoms such as

13 Throughout this thesis, the common academic and public health policy mental health terms ‘mental health problem’ and ‘mental health issue’ are generally avoided and the terms ‘(mental) illness’ and ‘(mental) disorder’ are used. While other academics do not use this terminology as it tends to pathologise mental distress, I use the terms ‘mental illness’ and ‘mental disorder’ because the authors whose writings are analysed in this study routinely identify themselves as having an illness and rarely use the terms ‘mental health problem’ or ‘mental health issue’. Moreover, it is a central argument throughout this thesis that it is discourses of illness and disease that authors are drawing upon when they narrate their experiences of affective disorders. 14 While the DSM-IV-TR excludes ‘[mere] self-reproach or guilt about being sick’ from the criterion for ‘feeling worthless’ under the category of a major depressive episode, such exclusions do not bear out when examining lived experience (American Psychiatric Association, 2000). PR difficulty sleeping or eating or feelings of worthlessness and thus contribute to the severity of the condition as recognised and assessed by health professionals.

For many people, the medical model – that affective disorders are illnesses that should be treated by health professionals – provides a powerful explanatory framework that fits their experience and assists them to live with their condition. Yet, while providing recognition, the dominance of this framework also silences particular narratives and ostracises particular individuals. The lack of non-medical affective disorder narratives is problematic because it makes certain experiences invisible, normalises potentially unrealistic norms of emotional coping and may increase an individual’s sense of isolation. In addition, when an individual’s lived experience of an affective disorder and the expected medical narrative do not align, increased emotional distress may result as the individual attempts to navigate the cultural invisibility of their experience.

The stories that are told about affective disorders – the illness narratives of individuals, as well as the beliefs and attitudes that infuse Australian culture – affect many aspects of the lived experience of these conditions. Put differently, illness narratives do not merely change how people talk about their illness experiences; rather, an illness narrative changes what actions make sense to an individual and thus they affect what actions that person ultimately takes. For example, understandings about causation may affect the type of treatment sought or the likelihood of seeking treatment in the first place and understandings of blame (and an individual’s sense of shame) may affect levels of disclosure to friends and family. However, it is not sufficient to suggest that a person’s behaviours are altered due to their understanding of the condition, but the nature of the condition remains unchanged. As will be discussed in Chapter 2, illness narratives affect how individuals experience particular symptoms and, more generally, how they experience themselves as ‘ill subjects’.

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Illness narratives come in a variety of forms: from 400-page autobiographies to anecdotes told to friends over dinner, from internet postings to interviews with researchers. Sometimes an illness narrative will document the full illness experience

PS from initial symptoms to the present day, while at other times an illness narrative may include short snippets about a particular event or experience. Thus it is best to think of illness narratives like One Thousand and One Arabian Nights (picaresque stories where each story is complete and yet also related to the other stories), and not like a chapter from a novel such as Harry Potter (where each chapter depends on the other chapters and makes little sense without them) or an anthology of short stories (where each story is completely unrelated to the next).

Like other genres of story, illness narratives come in certain recognisable forms. In his monograph The Wounded Storyteller Arthur Frank provided a systematic conceptualisation of the illness narrative genre.15 In a summary article published a little before The Wounded Storyteller Frank identified four major types of illness narratives (Frank, 1993). Briefly, the narrative forms were as follows: 1. ‘Who I have always been’ – In this illness narrative, illness functions as a way to discover the ‘true’ contours of the self. Through the hardship of illness, an author discovers the resources and strength that are ‘covered over’ through other, less profound, life events. Although the illness has, by necessity, changed the author’s life significantly, the narrative is focused on ‘the continuity between his former and present selves’ (p. 44). 2. ‘Who I might become’ – This illness narrative is centred on a belief that the self that emerged through the illness experience is ‘wholly new’. This new self, although in some ways linked to the pre-illness self, is experienced as one that could not have emerged at a previous time. Frank describes the author of an abortion narrative as having ‘creat[ed] a self she could never have imagined, much less imagined herself becoming, before her abortion’ (p. 45).

15 Illness narrative theory is not limited to the work of Arthur Frank. For example, other theorists have examined how illness narratives require particular cultural knowledge (Garro, 2000; Mattingly & Garro, 2000), how a person’s sense of self is complicated by, and relates to, their illness narrative (Kelly & Dickinson, 2008; Riessman, 2003; Rimmon-Kenan, 2002; van Hooft, 1997; Whyte, 2009), the experience of having an illness is inextricably linked to the narrative aspects of that experience (Murray, 1999) and how individuals produce specific narratives of health/illness when they feel a need to ‘closet’/hide their suffering (Myers, 2004). In addition, some research has focused on whether illness narratives are ‘real’ or social constructions and how this relates to understandings of subjectivity (Bury, 2001; Charmaz, 1999; van Hooft, 1997; Weingarten, 2001), what happens when dominant illness narratives cannot accommodate – or make sense of – experiences of extreme suffering (Woody, 2003) and how such narratives are often strategic and use specific rhetoric to encourage particular understandings of an individual’s illness experience (Riessman, 1990; Sakalys, 2001). PT 3. ‘Cumulative epiphanies’ – Frank describes cumulative epiphanies as ‘narratives in which authors reflect on living with an illness throughout most of their lives and conclude that whatever they have become has been formed in and through this illness’ (p. 45-46). The epiphany in these instances is the realisation that the self is constructed within the illness experience, a realisation, Frank argues, that comes with time and experience. 4. ‘Reluctant phoenixes’- This narrative is told by authors who ‘remain ambivalent about whether illness has changed them at all’ (p. 47). In these stories the cultural ideal of self-change through suffering is not utilised. Rather the story is focused on the banal aspects of ongoing suffering.

More recently, Frank has argued that the stories told by people who experience illness are a mechanism for them to represent and experience themselves as fully human. This mechanism is not equally available to everyone, with only certain stories being culturally valued. Furthermore, the telling of such stories is part of a larger modern western project where the telling of one’s ‘inner truth’ is the most valued and legitimate form of knowledge. This confessional culture enables increased monitoring and surveillance of private behaviours and beliefs (Frank, 2000). Frank’s analysis highlights that illness narratives do not only change the lives of the individuals who hear and tell such stories, but rather they are socially significant narratives which both interact with and influence key social practices in modern western cultures.

Like the narratives of physical illness examined by Frank, affective disorder narratives are an essential way for people to make sense of their experiences of suffering. Such narratives not only provide a way to tell an event, they also narrate – and more profoundly, create – a sense of self: ‘not only do we exist in a story-telling world, but our very Selves [sic] are constituted by the stories we and others tell about ourselves’ (Baldwin, 2005, p. 1023; see also Vodičar (2011). For a person diagnosed with an affective disorder, the construction of a comprehensible illness narrative is a critical way of retaining a productive sense of self. In the context of illness symptoms which often render a person feeling emotionally fragile and dislocated, the relatively coherent sense of self created through the illness narrative may be essential for recovery as it enables the individual to maintain a sense of agency and ability to act.

PU Illness narratives are important to individuals with affective disorders because they are powerful determinants of behaviour and understanding. For researchers, such narratives provide insights into how people make their experiences of affective disorders both personally and culturally meaningful. As many other researchers have noted, such meaning making requires that individuals construct illness narratives that are recognisable and supported by their communities. At a more basic level, these narratives are important because they provide unique insight into the subjective experience of these conditions. As Repper and Perkins (2003, p.5) state, ‘[n]umerous personal accounts of the experience of mental health problems are now available, and they offer insights that can never be gained from symptomatic and diagnostic descriptions’.

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Scholars in a range of disciplines including anthropology, cultural studies, gender studies, library studies, linguistics, psychology, public health and sociology have analysed lived experiences16 of affective disorders and the way that these are narrated. Such research uses various methodologies including case studies, thematic analysis, anthropological fieldwork and linguistic analysis.

This brief overview of previous Australian and international research will concentrate on investigations of lived experience, the effect of increased antidepressant use on understandings of subjectivity and the use of medicalised accounts in affective disorder narratives. These topics represent the areas where affective disorder narrative research is most prolific. In addition, this section will summarise Australian affective disorder narrative research and find gaps in current research. The literature review methodology is detailed in Chapter 3.

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There is extensive international research examining specific aspects of affective disorder experience. The breadth of current international research is demonstrated in a survey of research on particular diagnoses, life events and groups/identities.

Research on diagnosis-specific illness narratives is typically focused on common lived experience. Topics include: unipolar depression (Karp, 1992, 1994, 1996; Moran, 2006) including postnatal depression (Edhborg, Friberg, Lundh & Widström, 2005) and chronic depression (O'Connor, 1998), bipolar (Highet, McNair, Thompson, Davenport & Hickie, 2004; Levy, 2009; Licinio, 2005; MacAulay, 2006; Ward, 2009), post- traumatic stress disorder/trauma (Brison, 1999; Gray & Lombardo, 2001; Krause, DeRosa & Roth, 2002; Larrabee, Weine & Woolcott, 2003; Rubin, Feldman & Beckham, 2004), obsessive compulsive disorder (Brooks, 2011) and anxiety (Hendrix, 1967; Mahoney, 2000; Olstead, 2007; Reid, 2004; Skultans, 2003). While these studies tend not to provide nuanced analysis, they are important because a basic overview of key aspects of lived experience is a necessary empirical basis for more detailed and critical research. Of particular note is a study similar to this one, in which Dominique (2005) examined the way individuals who wrote autobiographies about depression and the readers of these texts understood the condition by examining the autobiographies themselves and responses to requests for comments on the autobiographies placed on depression internet groups.

One of the most comprehensive studies of affective disorder experience is Emily Martin’s book Bipolar Expeditions. Martin (2007) argues that mania is a unique illness symptom as it is experienced as a generally desirable state, both by the person who experiences the ‘high’ and by western culture at large, which values fast-paced living and high productivity, and yet it is simultaneously pathologised. Martin examined a wide range of sources, including personal accounts, support group transcripts, pharmaceutical advertisements, hospital observation rounds and mood charts in order to gain insight into the meanings and consequences of bipolar disorders. In addition, she problematises the distinction between pathological and ‘normal’ moods and asserts the full ‘human-ness’ of those who experience bipolar disorder. Such work is particularly noteworthy because it provides rigorous analysis that is the basis of an empirically

PW justified scepticism of current mental health practices. The anthropological work of Martin is not readily transferrable to Australia as our mental health systems/cultures are significantly different; namely, Australia does not have direct-to-consumer advertising of pharmaceuticals and Australian mental health professionals do not experience routine intervention by private health insurers into decisions about clinical practice, although Medicare does dictate what forms of treatment are eligible for rebates and the Pharmaceutical Benefits Scheme (PBS) does subsidise a limited set of medications (see below for description of Australian research). While Martin’s work provides an expansive engagement with the lived experience and cultural artefacts related to bipolar disorder, other researchers provide more focused research.

Researchers have examined specific aspects of the lived experience of those diagnosed with affective disorders. This research includes studies of: suicide ideations and attempts (Biong, Karlsson & Svensson, 2008; Grill, 2006; Lakeman & Fitzgerald, 2008; Oliffe et al., 2010; Roen, Scourfield & McDermott, 2008), living with co-morbidity between affective disorders and substance abuse (Biong et al., 2008; Cunningham, 2004), treatment experiences and strategies to cope with symptoms (Bowers, 2007; Daniels, 2004; Deitz, 2000; Elfenbein, 1995; Gask, Rogers, Oliver, May & Roland, 2003; McMullen & Herman, 2009; Sajatovic, Jenkins, Cassidy & Muzina, 2009), recovery processes (Lafrance & Stoppard, 2006; Ridge & Ziebland, 2006; Roe, Chopra, Wagner, Katz & Rudnick, 2004; Roy, 2008; Schreiber, 1996), senses of embodiment during episodes (Sherry, 2009), employment experiences of people with bipolar (Hale, 2011) and experiences of interacting with health professionals (Emslie, Ridge, Ziebland & Hunt, 2007; Paul-Bramer, 2000). A few of these studies have elements of discursive analysis (e.g., Biong, Karlsson and Svensson [2008] examine the metaphors used to describe lived experience of suicidal behaviour), but most are focused on understanding lived experience as described by study participants. The focus and purpose of such research necessitates that these publications do not concentrate on the social and cultural influences on the lived experiences of those diagnosed with or experiencing affective disorders.

Perceived and experienced stigma are particularly pertinent aspects of the lived experience of people with affective disorders. Research has been completed on the content/nature of stigmatising beliefs about depression and anxiety (Alonso et al.,

PX 2008), predictors of depression stigma (including the impact of mental health literacy on levels of stigma) (Griffiths, Christensen & Jorm, 2008; Wang & Lai, 2008), the effect of stigma on help-seeking behaviours in both depression and anxiety (Barney, Griffiths, Jorm & Christensen, 2006a; Blair & Ramones, 1996; Prior, 2011), internalised stigma in people with bipolar (Michalak et al, 2011) and stigma associated with antidepressant use (Smardon, 2008).

Research into mental illness stigma (as opposed to the narrower topic of affective disorder stigma) has covered a wide variety of topics, including analysis of personal accounts of experiences of self-stigma and discrimination (Dinos, Stevens, Serfaty, Weich & King, 2004; Rusch et al., 2006; Wahl & Calabrese, 2001), examination of the impact of stigma on people with mental illness (Corrigan, 1998; Corrigan & Matthews, 2003; Defined, 1992; Mowbray & Holter, 2002), identification of the levels of stigma in the general community (Link, Phelan, Bresnahan, Stueve & Pescosolido, 1999), identification of the determinants of self-stigmatising or self-esteem as a response to diagnosis (Corrigan & Watson, 2006; Crocker & Major, 1989), engagement with specific stigmatising events such as inpatient care (McCarthy, Prettyman & Friedman, 1995), research identifying the link between certain understandings of illness (e.g., biomedical accounts) and stigmatising beliefs (Corrigan, Watson & Ottati, 2003; Jorm & Griffiths, 2008), and assessments of the effectiveness of anti-stigma campaigns (Byrne, 2000; Estroff, Penn & Toporek, 2004; Rosen, Walter, Casey & Hocking, 2000).

Another way of gaining greater nuance or depth in affective disorder research is to focus on the experiences and understandings of a particular social or demographic group. For instance, research may be focused on particular ethnic communities: Asians (Fenton & Sadiq, 1993; Ingersoll, 2011), Latinos (Ishikawa, Cardemil & Falmagne, 2010), North Americans (Merkel-Keller, 2006), Canadian Aboriginal women (Villebrun, 2002), Latvians (Skultans, 2003), Swedish youth (Danielsson, Bengs, Samuelsson & Johansson, 2011) and people from Macau (Zeng, 2009). Other researchers have focused on groups such as lesbians (Barnard, 2004), black women (Boyd, 1999), ‘gifted’ adults (Bowers, 2007), immigrants and refugees (Donnelly et al., 2011; Maier & Straub, 2011), young people with intellectual disabilities (Stalker, Jahoda, Wilson & Cairney, 2011), people from rural areas (Nieuwsma, Pepper, Maack & Birgenheir, 2011) and college students (Nawabi, 2004; Singh, 2006). In addition,

QO researchers have examined experiences of particular age groups, including the elderly (Allan & Dixon, 2009; Burroughs et al., 2006; Campbell, 2002; de Medeiros, 2006; Switzer, Wittink, Karsch & Barg, 2006) and young people (Hickie, Luscombe, Davenport, Burns & Highet, 2007; Jorm & Butterworth, 2006; Wisdom & Green, 2004).

A particularly large corpus of research examines the effect of gender on affective disorder experiences (Danielsson, Bengs, Lehti, Hammarström & Johansson, 2009; Dean, 2003; Emslie, Ridge, Ziebland & Hunt, 2006; Gattuso, Fullagar & Young, 2005;

Heifner, 1997; Johnson, Oliffe, Kelly, Galdas & Ogrodniczuk, 2011; Lafrance, 2007, 2009; Marecek, 2006; Stoppard, 2000; Stoppard & McMullen, 2003; Wilson, 2007; Ussher, 2010, 2011), and the effect of these disorders on family dynamics and the well being of carers (Ahlström, Skärsäter & Danielson, 2011, 2010, 2009; Crowley, l'Anson, Sanders, Elford & Nankervis, 2005; Harden, 2005; Highet, McNair, Davenport & Hickie, 2004; Odorico, 2001; Thorne, 2003; Wade, 2004). Gender-based studies tend to provide more critical and political engagements with affective disorder experiences and discourse. More generally, studies focused on a particular social or demographic group are significant because they demonstrate the way that identity and its lived manifestations complicate and alter the experience of having an affective disorder. In other words, this research provides evidence that affective disorders are socially inflected conditions. While much of this research is empirical, with little critical17 theory or commentary (the exception being feminist studies of gender and depression, which are often highly analytical), such research nonetheless supports the critical social constructionist approach taken in this thesis.

Although the majority of studies of affective disorder experience are straightforward empirical studies, a minority of scholars are engaged in more critical work. A body of critical work examines the discursive aspects of affective disorder narratives. This research is qualitatively different from much of the research described above as it is less concerned with ‘what happens’ when a person has an affective disorder, and more

17 ‘Critical’ in the context of this literature review refers to work within a variety of disciplines that questions and scrutinises the epistemological and ontological presuppositions that underpin participant responses and the social structures which enable such responses. Such work can also engage with the research method itself. See International Society of Critical Health Psychology (2011) for a discussion of critical research. QP concerned with how – and why – study participants choose to represent their experiences in particular ways. This research includes studies that have examined personal and communal efforts made to understand experience through narrative (Kangas, 2001, 2004; Rector, 2009; Smorti, Risaliti, Pananti & Cipriani, 2008; Stern, 2003; (4# ?)",8 ,( :QOPP), changed perceptions of self as expressed throughout illness narratives (Ridge & Ziebland, 2006; Smith, 1999), the discursive construction of self and illness in an individual with agoraphobia and her family (Capps & Ochs, 1997), the effect of bipolar experience and associated ‘socio-medical processes’ on personal and political identity and embodied experience (Levy, 2009), and the relationship between an individual’s sense of self and how they experienced depressive symptoms (Hoffman, 2005; Roe et al., 2004). More focused work has examined how identity-commitments were used in illness narratives (Jones, 2005), self- representation in social anxiety narratives (Anderson, Goldin, Kurita & Gross, 2008), representations of helplessness in depression narratives (Vanheule & Hauser, 2008) and how individuals formulated an illness narrative to comply with dominant social norms, including gender norms (Emslie, Ridge, Ziebland & Hunt, 2007; Merkel-Keller, 2006; Moldoveanu & Nohria, 2002). Other examples of this focused research include studies that are concerned with the common narrative stages in published memoirs of obsessive-compulsive disorder, depression and schizophrenia (Young, 2009), the syntax of autobiographical texts written by people experiencing psychological distress (Zinken, Blakemore, Zinken, Butler & Skinner, 2011), the ‘geographies of madness’ in bipolar autobiographies (Chouinard, 2011), the rhetorical aspects of mental illness memoirs, online magazines and art galleries (Chrisman, 2008), the function of particular statements and replies on online bipolar forums (Vayreda & Antaki, 2009), the gendered way that Swedish newspapers represent depression (Bengs, Johansson, Danielsson, Lehti & Hammarström, 2008), the utility of mental illness narratives for increasing the understanding of emotional and psychological distress by doctors and lay people who have not experienced these conditions (A Jones, 1997) and how mainstream women’s magazines represent the experience of depression (Borman, 2003). Research has also involved critical engagement with the discursive aspects of mental health policy (Teghtsoonian, 2009).

Of particular note is Jette Westerbeek and Karen Mutsaers’ comparative study of depression autobiographies and published diaries (2008). The texts examined were in

QQ Dutch and English and had been published since 1990, when selective serotonin re- uptake inhibitors (SSRIs) became a mainstream medication. Westerbeek and Mutsaers identified a typical depression narrative arc comprised of an amorphous sense that ‘something was wrong’; persistent and concrete distress; a crisis; medical or psychological treatment; and wisdom gained through the depression experience. Westerbeek and Mutsaers’ study highlighted the consistency of depression narratives and the way in which published autobiographies adhered to recognisable narrative forms. While this article demonstrated the dominance of narrative tropes in affective disorder narratives written by American, British and Dutch authors, equivalent research is not available for Australia; this is a research gap that will be filled by this thesis. More generally, discursive analysis of affective disorder narratives is important because it provides insight into how particular ways of understanding affective disorders both frame and alter the lived experience of such conditions.

In comparison with research on depression narratives, there is little completed research on anxiety narratives. Some examples of narrative research regarding anxiety disorders include examinations of: the linguistic structure of anxiety autobiographies (Anderson, Goldin, Kurita & Gross, 2008), the idealisation of nonsymptomatic experience by individuals with anxiety (Lloyd & Moreau, 2011), the differences in representation of self in people diagnosed with depression and anxiety (Greenberg, Vazquez & Alloy, 1988), understandings of gender and space in panic narratives (Olstead, 2007), gendering in post-traumatic stress disorder narratives (Krause, DeRosa & Roth, 2002) and how the self is represented in autobiographical memories of people with social anxiety (Stopa & Jenkins, 2007). Of particular note is the book Constructing panic: The discourse of agoraphobia. This book provides an extended linguistic analysis of the illness narratives spoken by a woman with agoraphobia to both the researchers and her family. The insights provided in the text include the use of particular grammatical structures to mitigate the subject’s agency, the utility of diagnosis in justifying particular behavioural choices (e.g., deciding not to go out of the house), and the presence of paradoxes within the illness narrative (Capps & Ochs, 1997).

While there are many international studies of affective disorder experiences and narratives, this literature is limited in certain ways. Specifically, affective disorder narrative research focuses overwhelmingly on interview data and tends not to critique

QR the beliefs or presuppositions of the interviewees. It also rarely focuses on rhetoric or discursive function (see Chapter 2 for details of articles discussing rhetoric, and discursive authority and legitimacy). These gaps become particularly apparent when examining research and debate regarding how the rise of Prozac and other selective serotonin re-uptake inhibitors has altered western understandings of subjectivity.

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Contemporary philosophical and political engagements with depression are rarely divorced from discussions of the widespread use of antidepressant medications. The constancy of this link is on the one hand a historical referent (contemporary engagements with depression arose from critiques of antidepressant use), and on the other hand an inevitable consequence of the continuing dominance of biomedical accounts of the nature of depression and consequent reliance on pharmaceutical treatments (Schellenberg, 2000).

Published in 1993, the monograph Listening to Prozac spearheaded an extended academic discussion of the political and cultural impacts of widespread antidepressant use. In this text, Peter Kramer, a psychiatrist working in the United States, was concerned with the phenomenon of people feeling ‘better than well’ on Prozac and how this new self was quickly internalised by many of his patients as the new norm in social and professional functioning. Kramer used a mixture of clinical vignettes, scientific findings, historical research and philosophical rumination to examine these issues (Kramer, 1993). Listening to Prozac incited significant debate; some academics supported the account of the biological cause of depression and the social phenomena of Prozac developed in the text, while others found the book to be overly ‘pro-Prozac’ and with little critical engagement with the potential negative effects of the drug (Breggin, 1994; Hansen, 2003; Metzl, 2002; Wilson, 1999). While not the only text published on the topic of antidepressants at that time, Listening to Prozac is the text that is credited with beginning the widespread discussion of antidepressants and their effect on subjectivity.

QS Where Kramer’s research used clinical vignettes to discuss how Prozac had affected patients’ sense of self, other researchers engaged with the impact of Prozac on understandings of subjectivity. For instance, several academics discussed the impact of the capacity to alter mood on modern understandings of what it means to be human (Charlton, 2000; Coulter, 1973; Hewitt, Fraser & Berger, 2000; Stepnisky, 2006; Svenaeus, 2007), others saw the rise in antidepressant use as both a symptom and a cause of an increased dominance of a medical or biochemical model of self (Crossley, 2003; Gussin & Raskin, 2000), while a minority question whether antidepressants promote the biological determinism that is the centre of more mainstream concerns about these medications (Fraser, 2001; Wilson, 1999). These theorists highlighted how changed understandings of depression and its treatment altered fundamental presuppositions about the nature of humanity. Due to the significance of antidepressant use, research into how individuals understand affective disorders is important not just to those who suffer from such conditions, but to society as a whole.

Not only has the rise in antidepressant use altered understandings of what it means to be human, it has also exacerbated certain political and social dynamics. Specifically, there is a body of research concerned with relationships between antidepressants, contemporary understandings of subjectivity and broader social institutions such as capitalism. For example, some scholars examined the ways that antidepressant advertising promoted particular forms of selfhood, while others have critiqued the way that discussions of these drugs have affected feminist debates on biological essentialism (Kegan Gardiner, 1995; Wilson, 2004a, 2004b. In addition, academics have critiqued the link between increased antidepressant use and late-capitalist expectations of continual happiness (Clarke & Gawley, 2009; C. Elliott, 2000; Greenslit, 2005; Ryan, 2009). Related research examined the link between widespread antidepressant use and increased expectations of an ‘improved’ (or ‘improving’) self (Degrazia, 2000), the historically recent normalisation of understanding of suffering as purposeless (Davies, 2011) and how advertising of antidepressants has promoted docile feminine subjects (Blum & Stracuzzi, 2004), a point made earlier by feminist critics of the advertisement of barbiturates to, and use by, women (Boston Women's Health Book Collective, 1996). Gender studies scholars have critiqued the ‘convenient’ link between increased representation in popular magazines of normal feminine experiences (e.g., emotionality before menstruation) as pathological and the approval by the FDA of certain

QT antidepressants to be used to treat such conditions (Metzl & Angel, 2004).18 Like the philosophical texts described above, research that links antidepressants to broader social trends highlights the social impact of current mental health practices and the social norms that such practices perpetuate.

Critique of pharmaceutical advertising is another aspect of the broader criticism of western antidepressant discourse. For example, Paula Gardner (2007) examined web campaigns funded by both public institutions (e.g., National Alliance on Mental Illness, National Institute of Mental Health and the American Psychiatric Association) and pharmaceutical companies (e.g., Eli Lilly, Forest and Pfizer) in order to ascertain the gendered nature of these campaigns. She argued that these campaigns pathologised normal aspects of women’s embodiment (e.g., menstruation) and lived experience (e.g., juggling family and work responsibilities). Gardner asserted that depression was a broad-spectrum illness, meaning that the illness category has been expanded to cover behaviours and sensations not previously considered pathological. Such expansion reinscribed conservative gender norms as it narrowed what behaviours were considered acceptably ‘feminine’. Most of the research in this area occurs in the United States, where direct-to-consumer advertising is legal and widespread (Fenter, 2006; Ryan, 2009; Stepnisky, 2007). Such research, while not directly applicable to Australia, where consumer advertising of prescription pharmaceuticals is illegal, nonetheless reflects the broader social influences on understandings of affective disorders that are identified in this thesis and other Australian research.

Critical discussion has occurred around published ‘Prozac narratives’. ‘Prozac narratives’ are autobiographies written by individuals who took Prozac. They were published primarily in the 1990s in America (e.g., Blackbridge, 1997; Bosque, 2004; Carle, 2009; Slater, 1998; Wurtzel, 1995). Humanities scholars have critiqued the narrative forms, as well as the models of self, depicted in Prozac narratives (Cheever, 2000; Fee, 2000; Metzl, 2002; Schilb, 1999; Stepnisky, 2006). An example of this type of scholarship is Dwight Fee’s analysis of Elizabeth Wurtzel’s Prozac Nation. Fee uses a social-constructionist lens to examine the construction of understandable and meaningful illness narratives in Wurtzel’s memoir. Fee’s analysis leads him to argue 18 Similar arguments have been made regarding the pathologisation of women’s desire and the search for a ‘pink viagra’ (Moynihan, 2005). QU that the popularisation of knowledge about affective disorders impelled authors to align their experiences more closely with dominant accounts of these illnesses (Fee, 2000). Australia did not experience the proliferation of Prozac narratives experienced in the United States, but rather had a later publication boom of depression and bipolar memoirs. At present there is no analysis of these Australian narratives. Despite this, Fees approach is similar to that taken in the thesis.

More common than research using published accounts are interview-based studies. As will be discussed in Chapter 3, individuals are likely to narrate more ‘alternative’ understandings of antidepressant use in interviews than in published memoirs or autobiographies. As a result, interviews have been a common methodological tool for researching understandings of antidepressant use (Fullagar, 2009; Hickie et al., 2007a; Knudsen, Hansen, Traulsen & Eskildsen, 2002; Lafrance, 2007; McMullen & Herman, 2009; Paul-Bramer, 2000; Smardon, 2008). An example of this scholarship is Jacob Hess’s dissertation. Hess performed an empirical study of depression narratives as told in research interviews in Utah and Illinois, United States. Hess found variation in participant narratives, identifying a range of views on the extent to which people with depression had agency during their episodes, the role of medication in the treatment of depression and the extent that they believed depression was a biological illness. While interview studies are important because they help find patterns in individual narratives, they are of limited value to this thesis, as they do not provide access to the dominant narratives that are enacted in published accounts (see Chapters 2 and 3).

Despite the different mental health cultures of America and Australia, the limited evidence available suggests that understandings of antidepressant use are relatively similar across the two countries. Where Australian health promotion materials and published accounts tend to valorise the use of antidepressants, interview research suggests that users may be more ambivalent about their usefulness than these sources suggest (beyondblue: the national depression initiative, 2009a; Fullagar, 2008; Griffiths & Christensen, 2002). Simone Fullagar noted three understandings of antidepressant use in interviews with Australian women who took antidepressants and found them beneficial. First were biomedical accounts of depression as a ‘genetic neurochemical problem’ that should be corrected through medication (p. 396). Second were narratives focused on self-improvement where help-seeking behaviour (including taking

QV medication) was valued as an indicator of self-worth (p. 398). Finally, some participants understood that antidepressants were a way to gain control over their life but that they were also a reminder of an ‘“essential” biological deficiency and by extension a lack of control over oneself’ (p. 399). Fullagar argued that these narratives of antidepressant use employed biomedical accounts of the aetiology of depression that mitigated ‘women’s feeling of being a failed moral subject – not good enough daughters, mothers, wives, workers, friends etc.’ (p. 403). These findings are replicated in international studies of how women understand the medical treatment of depression (see below).

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Due to their widespread use and their significant political and philosophical implications, antidepressants have received greater critical interest from social scientists than other forms of medical treatment of affective disorders. This initial interest in antidepressants has sparked a more general concern with experiences and understandings of medical treatment.

Researchers have examined understandings and experiences of affective disorder treatment. Such research includes studies focused on experiences of help-seeking (Sword, Busser, Ganann, McMillan & Swinton, 2008), patient diagnosis (Hayne, 2001) and treatment experiences (Hardtke, 2008; Rapport et al., 2010), including the treatment experiences of young people (Hickie et al., 2007a; Polvere, 2011; Wisdom, Clarke & Green, 2006), individuals diagnosed with bipolar (Highet, McNair, Thompson, et al., 2004; Sajatovic et al., 2009; Ward, 2009), people who have experienced severe depression (Paul-Bramer, 2000) and individuals’ personal and institutional care during outpatient relapse prevention programs for depression (Thorne, 2003).

While some studies have examined experiences of treatment, others have analysed understandings of medical treatment. This research includes studies of health professionals’ perceptions and attitudes towards affective disorders (Burroughs et al., 2006; 0#- (8 0 (.&)1:QOPP;Morant, 2006; Oopik, Aluoja, Kalda & Maaroos, 2006; Zani, 1993), lay people’s perceptions of their treatment for affective disorders (Jorm & Griffiths, 2006; Kessing, Vibe Hansen, Demyttenaere & Bech, 2005; Sajatovic

QW et al., 2009; Wright et al., 2005; Wright, Jorm, Harris & McGorry, 2007), including the perspectives of particular groups such as south asian Muslim Americans (Chaudhury, 2011), the effect of taking on an illness identity (a sick role) on patient outcomes (Gara, Rosenberg & Woolfolk, 2008), the reasons patients decided to take antidepressants (Singh, 2006; Smardon, 2008), lay beliefs about the nature and treatment of phobias (Furnham, 1995) and what patients understood to be the cause of, and appropriate treatment for, their condition (Burroughs et al., 2006; Elliott, Maitoza & Schwinger, 2011; Fu & Parahoo, 2009). Such research has demonstrated the dominance of medicalised understandings of affective disorders in western cultures. In addition, this research has shown that how people understand their emotional distress affects what types of treatment they decide to undertake. The way that people understand affective disorders has a direct impact on health outcomes.

Medicalised understandings are important not only because of their pragmatic consequences. Rather, such understandings are also significant because they are used rhetorically to position individuals with affective disorders as particular types of subjects (Pilgrim & Bentall, 1999). There is an expanding literature on these discursive and rhetorical aspects of affective disorder narratives. For example, researchers have examined how biological accounts helped, and sometimes hindered, the mitigation of mental illness stigma (Jorm & Griffiths, 2008; Lafrance, 2007; Mehta & Farina, 1997; Schreiber & Hartrick, 2002) and have argued that the acceptance of biological accounts of mental distress by the general population has affected constructions of self (Rose, 2004). 19 Other work has examined the role of particular psychiatric institutions in individual and community understandings of mental health (Saris, 1995, 1999), how older adults combine medical accounts of depression with their lived experience of the condition (Wittink, Dahlberg, Biruk & Barg, 2008), and constructions of self when 19 While this research is specific to affective disorders, there is also a body of research that examines mental illness narratives as a whole. Certain aspects of mental illness narratives have been of particular interest to researchers, including difficulties in expressing the experience of mental illness through narrative (Stone, 2004; Torn, 2009; Vanthuyne, 2008); difficulties in producing a legitimate illness narrative when one is deemed ‘mad’ (Rector, 2009); the construction of identity within mental illness narratives (Ekeland & Bergem, 2006) and the use of folk/lay psychiatry to explain lived experiences of mental illness (Haslam, 2003, 2005; Levi & Haslam, 2005; Manis, Hunt, Brawer & Kercher, 1965; Matschinger & Angermeyer, 1996). There has also been research into the use of specific narrative actions in mental illness narratives, including understanding mental illnesses as non-human agents (Weinberg, 1997), questioning the validity of the category of ‘normal’ (Donley & Buckley, 2000; Estroff, Lachicotte, Illingworth & Johnston, 1991), using religious explanations to make sense of lived experience (especially hallucinations and delusions) (Fallot, 1998; Goodman, 2001) and the political/strategic aspects of mental illness narratives (Hubert, 2002). QX using particular diagnostic tools (Galasiński, 2008), and compared the way that lay people, the media and researchers understand depression, in particular the lack of acknowledgement by researchers of the gendered differences in the lived experience of the condition (Johansson, Bengs, Danielsson, Lehti & Hammarström, 2009). In addition, researchers have examined how individuals writing on alternative medicine websites regarding depression write in ways that enhance their credibility and epistemic authority (Oliphant, 2010), how depression is represented in self-help books (Philip, 2009), how self-concept appears to be altered by diagnosis in mental illness memoirs (Tekin, 2011) and the emergence of ‘recovery’ discourse in mental health discourse (Pilgrim, 2009), including published memoirs (Chrisman, 2008).

Of particular note is the work of Michelle Lafrance, who has published extensively on Canadian women’s experiences of depression and recovery (Lafrance, 2007, 2009; Lafrance & Stoppard, 2006). Lafrance noted that the women she interviewed used the diagnosis of depression as a mechanism for ‘defending [their] experiences and identities’. Moreover, Lafrance identified that her interviewees spoke about self and illness as separate categories, compared depression to biological conditions such as diabetes but did not compare it to other mental illnesses, and used suicide attempts as a signifier of the severity of their depression (Lafrance, 2007, pp. 130-131). LaFrance observed that although the women in her study tried to use the biomedical model to legitimise their suffering, the lived experience of being depressed did not fit a strictly biomedical account, and thus such attempts ‘ultimately result[ed] in delegitimation and stigmatization’ (Lafrance, 2007, p. 137).

While most researchers have found that medicalised understandings of depression are the dominant explanatory framework, some researchers have found that study participants resisted the medicalisation of their distress. For instance, Ilka Kangas interviewed 11 Finnish individuals who identified as having depression. She identified three distinct narratives of aetiology within her data: ‘shortcomings of childhood and adolescence development’; ‘excessive demands and role-conflicts’ – specifically in relation to ‘burn-out’ in employment; and, ‘symptom-provoking factors’ – where hardship and trauma in adulthood were ‘triggers’ for depression (Kangas, 2004, p. 76). Kangas emphasised how her respondents often drew on non-medical accounts of depression and developed nuanced accounts of their illness experience. She noted that

RO her findings were different from many previous studies where participants were locked into a medical model, which suggested that ‘lay theories, perceptions and explanations of depression are constructed and negotiated in an increasingly plural and complex environment of knowledge’ (Kangas, 2004, p. 89). Kangas highlighted the narrative function of these illness narratives when she argued that:

Accounts of depression seek acceptance not as stories of madness, but as stories of suffering. They express the social and individual pressures encountered by today’s individuals and convey depression as a legitimate form of suffering. (p. 90)

Kangas’s study demonstrated that although medical understandings of affective disorders continue to gain traction, it is still possible to resist and/or complicate the dominant biomedical model (see also Cardano, 2010, Chrisman, 2008). The small amount of Australian affective disorder narrative research suggests that Australians – much like Americans and Canadians – rarely utilise alternative illness narratives, but rather tend to tell medicalised accounts of emotional suffering, although there is evidence that some Australians resist such narratives (Paterson, 2009).

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Literature on Australian experiences of affective disorders is relatively limited in comparison with research completed overseas. Australian research has examined experiences of treatment (Highet, McNair, Thompson & Hickie, 2004), how depression is experienced by those engaged in paid employment (Munro & Edward, 2008; West, 2009), and generic studies of depression experiences (McNair, Highet, Hickie & Davenport, 2002). More focused studies have investigated the post-natal depression experiences of Middle-Eastern migrants (Nahas, Hillege & Amasheh, 1999), how gay men make sense of their experience of depression (Körner et al., 2011), how mental illnesses – including depression, bipolar and schizophrenia – affect identity (Wisdom, Bruce, Saedi, Weis & Green, 2008), how young people understand taking antidepressants (Chur-Hansen & Zion, 2006), and how mental health promotion targeted at Chinese migrants has employed the illness narratives of individuals from the

RP target community (Chan, 2009). In addition, several Australian theses have examined personal experiences of mental illness, have critiqued current medicalised models of mental illness and have advocated a more nuanced model of emotional distress that acknowledges the social and cognitive contributors to affective disorders (K. Foster, 2006; Paterson, 2009; Westall, 2008; Wigney, 2010). Of particular note is Tessa Wigney’s thesis reporting on interviews with individuals diagnosed with Bipolar I or II. Her work provides an overview of many aspects of the experience of bipolar, including psychological and physical characteristics of mania and depression, diagnosis, medication, how alcohol and drugs were used to manage symptoms, experiences of distress, changes in life goals, and feelings of shame (Wigney, 2010). Typical of Australian work on affective disorder narratives, Wigney’s research provides a detailed thematic analysis that includes substantial quotations from participants. Due to her focus on lived experience, this work does not engage substantially with cultural deconstruction or critique.

While there are few Australian studies that deconstruct personal accounts of affective disorder experience, there are several studies that critique professionally produced representations of affective disorders. Four studies are particularly noteworthy: one of newspaper representations, the others a set of articles that are concerned with representations of biological causality in various mediums. In a discursive analysis of the representations of depression in Australian newspapers, Rowe, Tilbury, Raply and O’Ferrall (2003) demonstrated that representations of depression were fundamentally different from those of other mental illnesses. Specifically, they noted that ‘in the case of depression the media stress the need for the protection of the sufferer’, whereas for other mental illnesses the focus was on the protection of the public (p. 680). They argued that Australian discourse on depression constructs ‘unhappiness as individualised pathology in need of management through biological, psychological or social structural controls’ (p. 680). Despite the acknowledgement of non-biomedical aspects of depression treatment, Rowe et al. found that Australian newspapers continued to understand depression as a ‘taken-for-granted category of illness’ (p. 681). This study is valuable because it demonstrates the extent to which a biomedical account of depression is enacted in the Australian media.

RQ Simone Fullagar’s critical analysis of the information pages on the beyondblue website observed that these pages perpetuated a biomedical account of depression. Specifically, she argued that the ‘web users [were being] urged to think about themselves primarily as somatic subjects with chemical deficits that required pharmacological or psychotherapeutic treatment’ (Fullagar, 2008, p. 323). As discussed earlier in the chapter, Fullagar has interviewed Australian women regarding their antidepressant use and found that while many women were highly ambivalent about the effectiveness of antidepressants, biochemical understandings of depression and selfhood remained very common (Fullagar, 2009). As a co-author with Gatuso and Young (2005), Fullagar has also compared the representations of affective disorders in Australian women’s magazines with Australian mental health policy. The researchers found that the magazines tended to emphasise both biological and situational causes of distress and promote self-management and professional assistance. In contrast, public policy is more exclusively focussed on biomedical and psychological treatments. This research suggests that a range of sources encourage Australians to embrace a biomedical model of depression.

There are two distinct clusters of Australian affective disorder narrative research: studies that examine lay experiences, and studies that critique professional representations. With the possible exception of Gattuso, there are currently no studies which bridge the gap between these two clusters of research. This thesis will begin to fill this gap by critiquing lay narratives as they are found in autobiographies and internet postings. Moreover, this project will expand the focus of Australian research beyond depression experiences and representations by also including texts by individuals diagnosed with bipolar and anxiety disorders in the corpus. Finally, the use of different data (published materials rather than interview transcripts) and a more nuanced methodology (a mixture of thematic analysis, case studies and discursive analysis rather than solely thematic analysis) ensures that this thesis provides insights not available through previous research.

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In addition to the major research gap between Australian research on lay experiences of affective disorders and critiques of professional representations, this thesis addresses four more piecemeal gaps in current research. First, by researching Australian autobiographies, this thesis fills a gap in English-language affective disorder autobiography research that, until now, has focused on autobiographies published in the United States and the United Kingdom. Second, while there have been population surveys of public attitudes20 since the introduction of beyondblue, no Australian narrative research has explicitly focused on the period after the introduction of this major government initiative. Third, existing discursive studies of Australian affective disorder websites have not been embedded in larger discourse analysis projects and these previous studies have focused on information websites rather than narrative sites such as bulletin boards or story pages. Finally, while research into online support groups has used the concepts of legitimacy and authority, this type of analysis has not been extended to autobiographical materials.

The overall outcome of this research is a body of pure basic research on the topic of how affective disorders have been conceptualised in Australia since 2000. This research may be helpful to organisations that wish to develop public health campaigns that are deliberate in their use – or avoidance – of dominant understandings of affective disorders. Moreover, such research may assist health professionals to be aware of the role of rhetoric in the descriptions of affective disorders provided by their clients in clinical interviews and interventions.

This research project complements other research related to mental illness narratives. Specifically, this research will add to the – still emerging – body of literature that uses a social constructionist lens to examine experiences of mental illness. It will also assist in making Australian data on affective disorder narratives more robust by providing an analysis of narratives in forums other than interviews, website information or magazine 20 See for example the following surveys and commentary on beyondblue: Gardner (2008); Griffiths and Christensen (2002); Hickie (2004a, 2004b); Hickie, Davenport, Scott and Morgan (2002); Hickie, Luscombe, Davenport, Burns and Highet (2007); Jorm et al. (2006); Jorm, Christensen and Griffiths (2005); Kennett (2005); Morgan and Jorm (2007); Parslow and Jorm (2002); Pirkis et al. (2005). RS articles. Further, it will provide a point of comparison with international studies of affective disorder discourses.

In comparison with some research which focuses on alternative understandings of affective disorders, this thesis is primarily concerned with dominant (or common) illness narratives. In other words, it engages with popular narratives used by a large number of people and not the counter-narratives or alternative views that are held by small subsets of the population (see Chapter 3).

In order to examine dominant affective disorder narratives, this thesis engages with the discursive and rhetorical function of key sentences in published autobiographies and internet postings. This requires that attention be paid to the ‘nitty-gritty’ of metaphor, word-choice and phrasing. In order to understand why this form of analysis constitutes a unique contribution of the thesis, it is important to understand the three ‘levels’ of critique typically used in affective disorder research.

Some research into affective disorder narratives occurs at the most superficial level. At this level, researchers are concerned with what has been said: in other words, they report common topics of discussion. Researchers at this level write about common themes such as diagnosis, medication use and experiences of stigma. An example of this level would be a researcher writing ‘many participants did not like taking their medication. John said, “I don’t like taking my medication, it makes my tongue feel fluffy.”’

The second level of analysis is concerned with what was meant: researchers are concerned with what a particular experience means to study participants. Topics might include emotional reactions to diagnosis, ambiguity about taking medication or beliefs about whether people with mental illness deserve to be discriminated against. An example of this level would be, ‘when John says “I just can’t bear to tell them that I have just got out of the psychiatric ward” he is indicating that he feels ashamed about his recent hospitalisation’. Much of the research into affective disorder narratives occurs at this level.

RT The third level of analysis is focused on the rhetorical function of particular statements. Little current affective disorder narrative research occurs at this level. Examinations of rhetorical function are concerned with how particular statements function to position the author as a particular type of person and their experience (in the case of illness narrative research, the experience of having an illness) as a particular type of experience. An example of this level of analysis is the research by Rowe et al (2003) on Western Australian newspapers (see previous section). Parker and Burman (1993) note that the type of analysis that is done to identify discourse (and, I would add, rhetoric) is categorically different from that of simple coding: ‘[u]nlike pressing buttons in SPSS, discourses are not just waiting to be “found” but must be interpreted by the researchers in a constructive and interactive process’ (quoted in Elliott, 1996, p. 67). As Oliphant argues, this type of analysis shifts the focus onto how language use achieves particular discursive or rhetorical effects:

Rather than assess the veracity of accounts or descriptions, researchers move from studying language use as describing some objective “truth” about reality or the individual’s internal state to analyzing how people use language to construct authoritative descriptions and accomplish specific actions. (Oliphant, 2010, p. 70)

This thesis uses all three types of analysis, with a strong focus on the second and third levels. This focus has meant that the thesis provides in-depth analysis of specific concepts rather than a summary of every theme that was present in the data. By using the three levels of analysis, this thesis is able to provide sufficient evidence to contextualise some of the more sustained analyses of rhetorical function. This approach has several precedents in research using a social constructionist frame, including McMullen and Herman (2009):

When people talk they draw on discursive resources that are available in particular historical, cultural moments to perform social actions (Burr, 1995). In keeping with these assumptions, we employed a discourse analytic approach that combines an analysis of what people say, how they say it and what they accomplish by it, with an investigation of the consequences of such actions. (p.1570)

RU As will be discussed in Chapter 3, it is precisely the triangulation of several different analytic methods that grounds the research and ensures that the data interpretation is justified.

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This thesis uses Australian autobiographies and internet postings in order to analyse dominant understandings of affective disorders since 2000. The autobiographies are written by people who identify as having had an affective disorder or having cared for someone with an affective disorder. The internet postings come from a range of sources including the Blue Board bulletin board, headspace story pages, and ReachOut story pages. In addition, in Chapter 11, national population-based public health campaigns about affective disorders are examined in order to analyse the relationship between personal accounts and public narratives. As will be discussed in detail in Chapter 3, in comparison with some other potential sources – such as blogs, fictional accounts of affective disorders or interviews – these data sources were deemed to be the most productive for identifying key or dominant rhetorical functions in affective disorder narratives.

A model of the rhetorical function of affective disorder narratives informs the social constructionist analysis performed in this thesis. This model emerged during the data analysis phase. Briefly, the model provides a mechanism for naming the rhetorical function of particular statements, with a focus on the way in which certain phrases, metaphors or word-choices position authors as specific types of people and their experiences/illness as specific types of experience. The model identifies three related yet separate functions – legitimacy, authority and integrity. The model is detailed in the next chapter.

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This thesis is divided into three distinct sections: introductory and background chapters, analysis chapters and concluding chapters.

RV The first three chapters provide background to the analysis. Chapter 2 details the social constructionist understanding of mental illness that underpins the thesis. Within this chapter, historical evidence is used to justify a social constructionist approach to mental illness, with detailed theoretical discussion of the understandings of mental illness and illness narrative that are the basis of the thesis. The chapter concludes by outlining the model of rhetorical function used in the data analysis. Chapter 3 outlines the data sources and describes the analysis method.

The body chapters of this thesis are arranged according to two contrasting but connected themes. The first organising aspect is content/themes found across the dataset: this includes lived experience of anxiety (Chapter 4) and depression (Chapter 5), the erasure of experiences of anxiety in affective disorder narratives (Chapter 6), understanding affective disorders as illnesses (Chapter 7), interactions with health professionals (Chapter 8), experiences of stigma (Chapter 9), the gendering of affective disorder accounts (Chapter 10) and the relationship between personal accounts of affective disorders and their representation in population-based public health campaigns (Chapter 11). As will be discussed at length in Chapter 3, the selection of these themes was the result of ongoing thematic analysis.

The second organising aspect relates to the model of rhetorical function developed during the analysis of the data (see Chapter 2). A different aspect of the legitimacy, integrity and authority model (LIAM) is focused on in each chapter, with later chapters utilising the model in more complex and nuanced ways.

Chapter 4 focuses on the lived experience of anxiety and engages at a rudimentary level with LIAM through a discussion of the relationship between reported symptoms and the Diagnostic and Statistical Manual, 4th edition revised (DSM-IV-TR) criteria. This chapter emphasises the severity of anxiety symptoms in order to anticipate an argument made in Chapter 6 regarding the strategic erasure of anxiety experiences in accounts of simultaneous anxiety and depression.

Chapter 5 examines the lived experience of depression and mania. This chapter begins to engage more with LIAM through an examination of the metaphors used to describe experiences of depression and how these function rhetorically. Throughout this chapter,

RW the depression narratives are compared to the anxiety narratives examined in Chapter 4 and the reasons for the vastly different narrative forms are discussed.

Chapter 6 builds on Chapters 4 and 5. This chapter is the first to be primarily focused on rhetorical function, in particular the rhetorical methods of emphasis and erasure. The chapter identifies three ways that anxiety is positioned as an aspect of the depression experience and argues that this strategic erasure of anxiety enables authors to emphasise the severity of their condition.

Chapter 7 extends the analysis of the methods used by authors to emphasise the severity of their condition. Specifically, the chapter examines how authors structure their claims that affective disorders are illnesses in order to maximise their legitimacy as ill subjects. Focus is given in this chapter to the rhetorical function of analogies with physical illness and the use of separations between self and illness.

Chapter 8 examines how authors write about their experiences of medical treatment. The chapter begins by discussing the hierarchies of health professionals and medical interventions that are enacted by authors as a way of emphasising the severity of their suffering.

Chapter 9 extends this work by engaging in a critical interpretation of the rhetorical function of authority, with an examination of how the epistemic authority of health professionals is both supported and resisted by authors.

Chapter 10 focuses on the stigma of affective disorder diagnosis and experience. It focuses on how this stigma is mitigated by authors through the strategic use of separations between desired and undesired entities.

Chapter 11 provides a case study of the implications of the centrality of legitimacy, integrity and authority in affective disorder narratives by examining how affective disorder rhetoric interacts with conservative gender norms. The chapter concludes with a critique of how the culturally supported understanding of affective disorders as legitimate illnesses is being utilised by some individuals to justify domestic violence through a claim of reduced agency.

Chapter 12 provides a different type of case study. In order to ascertain how personal narratives influence, and are influenced by, population health campaigns, this chapter compares the narratives of the corpus with current population-based affective disorder promotion campaigns by beyondblue, headspace and SANE. The chapter argues that the similarities across the campaigns and the corpus indicate the extent to which a dominant affective disorder narrative is being enacted within Australia.

The thesis concludes with an examination of the theoretical and practical implications of this research. Focus is given to recommendations for clinical interactions and public health initiatives, as well as to a discussion of how the dominant biopsychosocial model might be enhanced. It concludes with a recapitulation of the contribution to pure basic research of the thesis and suggests areas for future research.

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Mental disorder refers to the conduct and speech of people who are mad, bad, frightened or miserable, who upset others and who the latter wish to exclude or control. - Alternative definition of mental disorder, developed in response to tautologies in the British Draft Mental Health Bill (Pilgrim, 2005, p.436)

There are many ways of understanding the nature and cause of affective disorders. This chapter outlines a social constructionist understanding of mental illness and details how this understanding is used within the research project. Through an analysis of the constructed nature of mental illness experience, this chapter establishes why illness narrative research is important. In addition, a social constructionist approach provides the epistemology (theory of knowledge) and ontology (theory of being/world) that underpins both the method and findings of this thesis.

This chapter is divided into two parts. The first engages with social constructionism as an explanatory framework. Specifically, the section examines the historical and cultural evidence that supports a social constructionist understanding of mental illness, with a particular focus on historical changes in understandings of extreme sadness and the ongoing changes occurring in the American Psychiatric Association’s"#&'" ''&' "( # "' &#%%&HDSM). The second part of this chapter describes how a social constructionist ontology is embedded in the thesis method.

While the lived experience of all illnesses can be understood as socially constructed, this framework is particularly appropriate for mental illness. Specifically, although conditions such as the flu or HIV are experienced in different ways across different times and cultures, the viral causes, although potentially influenced by social aspects, remain the same. In contrast, while there is growing evidence for biological causes of certain mental illnesses, the expression and experience of distress are profoundly affected by social factors. Thus, a social constructionist approach means that mental illness is not understood as a distinct and rigidly definable category of ill health. Rather, SP it is conceptualised as a way of classifying and medicalising particular clusters of psychological and physical states. Both the psychological distress and physical symptoms are real. However, what states are deemed pathological and how such symptoms are categorised and identified are social constructions that vary over time and place. This definition is consistent with that provided by Martin in Bipolar Expeditions:

Will I be claiming that manic depression is not “real”? Not at all. I will claim that the reality of manic depression lies in more than whatever biological traits may accompany it. The “reality” of manic depression lies in the cultural contexts that give particular meanings to its oscillations and multiplicities. Will I be claiming that people living under the description of manic depression do not need treatment? Not at all. I will claim that whatever suffering attends the condition should be treated by any means possible. But I will also say that manic depression is culturally inflected: its “irrational” heights and depths are entwined in the present-day cultural imagination… (p. 29)

The social constructionist definition of mental illness is supported by sustained evidence of historical and cross-cultural differences in how mental distress is understood and treated.21 This chapter begins by demonstrating the historical variability of understandings of extreme sadness. The effect of this variability on contemporary western medical practice is demonstrated through a discussion of the proposed changes to the DSM, 5th edition (DSM-5), which is due for release in 2013 (draft criteria and discussion papers are currently available on the DSM-5 website, American Psychiatric Association, 2011). Focus is then given to the way in which definitions of affective disorder categories are culturally specific. Having used this evidence to establish the explanatory power of a social constructionist understanding of mental illness, the chapter then articulates the socially constructed aspects of illness narratives. The chapter concludes with an outline of the model of rhetorical function used in the

21 While Foucault’s work on madness may initially seem like an obvious choice as an organising frame, I have chosen not to use it for two reasons. One, mental asylums in the Enlightenment period tended to have inmates with forms of psychosis, not extreme emotional distress. Two, Foucault’s work, while theoretically insightful, has been widely criticised as historically inaccurate. Thus, while much of the work on social constructionism described in this chapter is based on Foucaultian ideas, Foucault’s historical work (as distinct from his philosophical work) is of minimal value when focused on affective disorders (Foucault, 1988; Foucault & Khalfa, 2006; Scull, 1990; Sedgwick, 1982). SQ analysis of the thesis data and a description of the grounded theory approach which embeds a social constructionist epistemology in the research method.

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While emotional, psychological and physical symptoms that are consistent with an affective disorder diagnosis are seen in a range of historical documents from the Ancient Greeks onwards, what counted as pathological and what was done about such pathology varied across time.22 By demonstrating the extent to which understandings and lived experiences of emotional distress have varied over time, historical research establishes the validity of a social constructionist approach to mental illness.

The Ancient Greeks believed that illness was caused by an imbalance in a person’s humours. The four humours (black bile, yellow bile, phlegm and blood) were closely associated with the four temperaments (melancholic, choleric phlegmatic and sanguine) and four elements (earth, fire, wind and air) (Radden, 2003). Historians disagree about what was considered the cause of depression and mania.23 Martin states that ‘some traits that would look like depression today belonged to the melancholic humor and some that would look like mania today belonged to the choleric humor’ (Martin, 2007, p. 16). Healy argues that what are typically taken by historians to be ancient equivalents of depression and mania would now be identified as infection and post-infective lethargy (Healy, 2008, p. 11). In another conflicting account, Daly provides evidence that in medieval times, it was ‘an excess or otherwise pathological form of black bile’ that was understood to be the cause of melancholia or acedia (Daly, 2007, p. 44). The extensive – and at times, conflicting – theorisation of emotional distress by the Ancient Greeks suggests that some form of emotional distress is common across time and cultures. However, that distress was explained – and thus experienced – using frameworks of illness that made sense within Ancient Greece.

Another ancient and medieval explanation of the cause of both mania and melancholia was that it was a response to overstimulation. As Martin notes: 22 While affective disorders other than depression are equally historically constructed, discussion of the historical variation of all of the conditions would be an entire thesis project in itself. 23 In order to remain clear regarding the historical variation in mental illness diagnosis, throughout this section the reader should insert ‘what we might now call’ in front of any mention of depression or mania. SR In Plato’s account in the Phaedrus, manias could be caused by inspiration – from God, from poetry, or from love. A much later text greatly influenced by classical thought, Robert Burton’s Anatomy of Melancholy (published in 1621 and still in print), listed a wide range of causes for melancholy, including faulty education, stress (he cites too much studying), childhood influences, heredity, supernatural elements, Satan, the stars, God, a bad nurse, poverty, and much else. (Martin, 2007, p. 16)

This explanation of melancholy and mania is significantly different from the humoural explanations of the Ancient Greeks. The sheer variation in explanations suggests that there was a ‘problem’ that required explanation in both periods, but that the nature of the explanations – but not necessarily the ‘problem’ itself – varied significantly across time.

Religious explanations of emotional distress were also common during medieval times. One of the more prevalent accounts was that emotional distress was the deadly sin of acedia (related to the contemporary theological concept of sloth [Tatman, 2012]). Acedia was thought to come from sadness that was a result of previous anger or despair (Daly, 2007, p. 35). Hugh of St Victor describes acedia in a way that is akin to modern descriptions of depression: ‘a sadness [tristita] [sic] born of confusion of the mind, or, weariness [taedium] and immoderate bitterness of the mind; through it spiritual joy is quenched and the mind is over-thrown in itself, as it were by the beginning of despair’ (Wenzel, 1967, 52 as quoted in Daly, 2007).

The concept of ‘the noonday demon’ that tempted the religious hermit was explicitly aligned with religious moralism. Succumbing to this spirit indicated that the hermit was ‘still too much attached to sensual pleasures’, and was characterised by ‘psychic exhaustion and listlessness caused by the monotony of life and the immediate surroundings or by the protracted struggle with other temptation’ (Daly, 2007, p. 33).

While moral and religious explanations of melancholia were present from the late medieval period to the Enlightenment, it was more common during this time to understand melancholia as an illness of the intellect. Melancholia during the Enlightenment was understood to have ‘involved loss of acuity of an intellectual sort (a

SS mixture of irrationality and impaired behaviour)’. This emphasis on irrationality as the signifier of insanity was in keeping with the philosophical and theological thought of the time (Martin, 2007, p. 17). Thus, as with the Ancient Greek melancholia and medieval acedia, explanations of emotional distress during the Enlightenment reflected the dominant beliefs of the time.

While intellectual explanations of melancholia became dominant during the Enlightenment, humoral, religious and moral accounts were still in circulation. It was not until the beginning of the twentieth century that this pluralist mix of explanations was disbanded and an oscillation between biological and psychoanalytic approaches took hold (Pilgrim, 2002).

Psychoanalysis proposed a new cause of emotional distress: rather than being the result of immorality or bodily imbalances, a person’s emotional problems were believed to be caused by unresolved issues within the psyche.24 Freudian psychoanalysis understands melancholia as a pathological form of grieving. Unlike mourning where an object has been lost (e.g., a loved one has died), in melancholia the loss is psychological (e.g., loss of a particular sense of self) (Freud, 1953). This means that the psychological reality of melancholia is fundamentally the same as mourning:

In mourning we found that the inhibition and loss of interest are fully accounted for by the work of mourning in which the ego is absorbed. In melancholia, the unknown loss will result in a similar internal work and will therefore be responsible for the melancholic inhibition. The difference is that the inhibition of the melancholic seems puzzling to us because we cannot see what it is that is absorbing him so entirely. The melancholic displays something else besides which is lacking in mourning – an extraordinary diminution in his self-regard, an impoverishment of his ego on a grand scale. In mourning it is the world which has become poor and empty; in melancholia it is the ego itself. (Freud, 1953, p. 254)

24 This is an overly simplified account because the body is also implicated in psychoanalytic ideas such as the libido. Moreover, certain branches of psychoanalysis, particularly in the mid twentieth century, were highly moralistic. (Gallop, 1982; Grosz & Rowley, 1990; Wilson, 2004a) ST Freud describes melancholia as:

[…] a profoundly painful dejection, cessation of interest in the outside world, loss of the capacity to love, inhibition of all activity, and a lowering of the self- regarding feelings to a degree that finds utterance in self-reproaches and self- revilings, and culminates in a delusional expectation of punishment. (Freud, 1953, p. 252)

While Freudian psychoanalysis was dominant in the first half of the twentieth century, alternative psychoanalytic explanations of melancholia were also in circulation, For instance, in Kleinian psychoanalysis depression was understood to be a healthy aspect of childhood development, which becomes pathological only when it does not resolve. Specifically, the depression position involves the individual acknowledging that they are distinct and separate from other people. The depressive position is characterised by ‘feelings of loss, mourning, and sadness’ (Martin, 2007, p. 19).

As with each of the previous examples, the psychoanalytic explanation of melancholia reflected the dominant cultural frameworks of its time. Psychoanalytic explanations continued to have dominance in western societies until a significant shift in explanatory frameworks was spearheaded by the publication of the third edition of the DSM in 1980 (Butler, 1999; Spitzer, Williams & Skodol, 1980).

This historical overview demonstrates that understandings (and therefore experiences) of illness always occur within a cultural context and the illness discourses of a particular culture both create and restrict what can and cannot be understood as an illness. Such an acknowledgement does not require that the biological, environmental, historical or situational factors that may be influencing the illness be discounted. It simply acknowledges that our understandings of these influencing factors will always be refracted through the available explanatory discourses.

This social constructionist approach is equally applicable to contemporary understandings of affective disorders. The dominant framework for understanding emotional distress in contemporary western societies is embedded within the descriptivist nosology of the revised 4th edition of the DSM (the DSM-IV-TR).

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The DSM is the main diagnostic guide used in Australia, and as such is a central document in many affective disorder narratives analysed in this thesis. The DSM was originally published by the American Psychiatric Association in 1952 and has since had three major revisions (1968, 1980, 1994) and two minor revisions (American Psychiatric Association, 1987, 2000). Moving away from the psychoanalytic approach of DSM I and II, the DSM-III provides a more behaviouralist frame with a focus on systematic diagnostic criteria and observable behaviour. Psychiatrists in the American Psychiatric Association (APA) supported the change because of the perceived need to make the psych-sciences more scientific and for health professionals to be more consistent in their assessment of mental suffering (Butler, 1999; Rogler, 1997; Cooper, 2008). Although the change to a descriptive nosology was supposed to increase the scientific validity of the categorisations and reduce bias, Greenberg argues:

[…] the biggest problem with the DSM III approach to mental illness is that while it hinges on the elimination of theory – which is to say on the elimination of metaphysics, of any kind of preconceived notion of where our suffering comes from or what it means to be who we are – it has silently substituted its own metaphysics. (Greenberg, 2010, p. 252)

Pilgrim also notes that the DSM symptom checklists

[…] only ensure that those trained to use them are more likely to agree with one another than those untrained. It does not guarantee that they are agreeing with one another about anything that is meaningful or valid. (Pilgrim, 2005, p. 438)

The shift from a psychoanalytic to a descriptive nosology significantly altered affective disorder diagnoses. Specifically, the change removed the psychoanalytic concept of melancholia and replaced it with descriptive criteria for major depression. Although the move was influenced by a desire for more scientific rigour, the DSM-III criteria had minimal empirical validity, with the paper it was based on referencing only one empirical study that provided substantiation for the criteria (Horwitz, 2011). While melancholic depression still exists in the DSM-IV-TR, it no longer refers to a

SV psychoanalytic category, but rather refers to a form of depression with particularly acute physical symptoms (Goldney, 2006; Kendler & Gardner, 1998; Zimmerman & Spitzer, 1989).

As a continuation of DSM-III’s descriptive orientation, the current edition of the DSM (DSM-IV-TR) provides a systematic list of symptoms for each condition: if a person has a certain number and/or combination of symptoms, that person can be diagnosed with the disorder. The DSM-5 is currently in development, with the proposed diagnostic criteria maintaining the same classification schema as the DSM III and IV (American Psychiatric Association, 2011).

The DSM-IV-TR25 defines a major depressive episode as a period of at least two weeks of depressed mood or loss of pleasure with accompanying symptoms such as changes in weight or sleeping patterns, psychomotor agitations or retardation, feelings of worthlessness, difficulty thinking, and recurrent thoughts of death or suicide. The proposed DSM-5 includes no changes to the major depressive episode criteria. However, it is proposed that the DSM-5 will include the addition of pre-menstrual dysphoric disorder (PMDD) and a diagnosis for simultaneous depression and anxiety (American Psychiatric Association, 2011).26 While the diagnostic criteria for a major depressive episode (the ‘building block’ diagnosis for other mood disorders) are likely to remain the same in the DSM-5, the addition of PMDD is likely to extend the category of illness to experiences previously categorised as a normal aspect of a menstruating woman’s life (For historical precident, see Metzl & Angel, 2004).

Despite the relative stability of the diagnostic criteria for major depression since 1987, psychiatrists continue to disagree on the characteristics of subtypes of the disorder, with several contradictory distinctions still in circulation. Some of the possible divisions include a split between depression that is subclinical or clinical; is endogenous, neurotic or occurs in the context of a personality disorder; includes symptoms of psychomotor disturbance, psychotic features or none of these symptoms; and, is experienced by

25 As a short hand, textual references to the DSM-IV-TR should be read as equivalent to an in-text reference to American Psychiatric Association (2000). This convention is continued throughout the thesis. 26 Media coverage in May 2012 indicates that there may be some last-minute changes to the DSM-5, including the removal of the diagnosis for co-occuring depression and anxiety (Carey, 2012). These changes were still under consideration when the thesis was printed. SW individuals who are psychotic, anxious, hostile or young (Goldney, 2006; Parker, 2000, 2005). The continued debate regarding the nature of depression and how it should be categorised emphasises the extent to which psychiatric diagnostic categories reflect cultural norms rather than solely ‘objective’ scientific ‘fact’ (Bayer, 1981; Bayer & Spitzer, 1982; Greenberg, 1997; Kutchins, Kirk & Kirk, 2003; Michel, 2011; Rubinstein, 1995; Silverstein, 2009; Spitzer, 1981).

Ongoing shifts in diagnostic criteria are also common for other affective disorders. For instance, the DSM-IV-TR diagnostic criteria for bipolar I requires an individual to experience mania including symptoms of inflated self-esteem, ‘decreased need for sleep’, excessive talking, flight of ideas, distractibility, ‘increased goal-directed activity’, ‘psychomotor agitation’ and engagement in pleasurable activities which have a high risk of negative consequences such as sexual indiscretions and extreme buying sprees. Where in the DSM-IV-TR a person can be diagnosed with bipolar I if they experience a single manic episode, the proposed criteria for the DSM-5 require that a person experience at least one previous episode of mania (American Psychiatric Association, 2011). Thus, once the DSM-5 is published it will be possible for a person who has had a single manic episode (with or without depressive experiencing depression) and has previously been diagnosed with bipolar I to no longer be classed as having a mental disorder. In addition, it is proposed that the DSM-5 will include a new diagnosis of temper dysregulation disorder with dysphoria (TDDD) that will provide a diagnosis for children under 10 years who display symptoms that are currently classified as bipolar disorder. These shifts – one towards a narrowing of criteria (i.e., removal of single manic episode bipolar I) and the other towards expansion (i.e., sanctioning of the extension of a bipolar-esque diagnosis to children) – emphasise that the diagnostic criteria remain in flux as medical knowledge, cultural norms of behaviour and societal understandings of the domain of psychiatry continue to alter.

Even when the change in wording between editions of the DSM is very minor, certain individuals may shift from being classed as ‘mentally ill’ to ‘healthy’ and vice versa. For instance, the DSM-IV-TR defines bipolar II as recurrent major depressive episodes with hypomanic episodes. Hypomania is diagnosed using similar criteria to a manic episode, but it does not cause ‘marked impairment in social or occupational functioning or hospitalization, and there are no psychotic features’. The proposed DSM-5 criteria

SX will maintain the DSM-IV-TR criteria with small phrasing changes that may affect who is eligible for diagnosis. Specifically, in the DSM-IV-TR the duration of an episode is phrased as ‘lasting throughout at least 4 days’ which may imply that the hypomania lasts the whole day on four separate occasions (e.g., Monday, Thursday, Saturday and Sunday). In comparison, the proposed DSM-5 criteria says that the hypomanic episode must last ‘at least 4 consecutive days’, which requires that the four days are after one another (e.g., Monday through Thursday) (American Psychiatric Association, 2011). This phrasing change is very minor and is represented on the DSM-5 website as merely clarifying the meaning of the criteria (American Psychiatric Association, 2011). However, such changes are not innocuous. These changes may result in individuals with short hypomanic episodes no longer being diagnosed with bipolar II. Thus, for a small sub-set of individuals currently diagnosed with bipolar II whose access to social security benefits, health insurance, mental healthcare services etcetera is predicated on their bipolar diagnosis, this diagnostic change may be extremely detrimental.

Changes in diagnostic criteria are sometimes explicitly political. The diagnosis for extreme responses to traumatic events has shifted significantly over the past century and is often used as a case study for the cultural and historical specificity of mental illness (see, for example, Andreasen, 2004; Dayan & Olliac, 2010; Gersons & Carlier, 1992; Lasiuk & Hegadoren, 2006; Wilson, 1994). Prior to 1987, post-traumatic stress disorder (PTSD) was defined as a response to an event ‘generally outside the range of usual human experience’ (American Psychiatric Association, 1980, p. 236). Feminists agitated for the removal of this requirement, as the wording could be used to exclude traumatic responses to sexual assault. Specifically, several lawyers successfully argued that sexual assault was too common to fulfil the PTSD criterion and some sexual assault survivors were denied health insurance and/or compensation (Brown, 1995; Root, 1992; Scott, 1990; Wilson, 1994). While feminists were successful in having this criterion removed in 1987, it is likely that the proposed DSM-5 criteria for PTSD will see a return to narrow criterion for a ‘traumatic event’. Specifically, it is proposed that the previous criterion of witnessing an event be narrowed to witnessing ‘in person’; that being ‘confronted’ by a traumatic event be limited to ‘experiencing repeated or extreme exposure’; and that ‘threat to bodily integrity’ be narrowed to ‘actual or threatened sexual violation’. These ongoing changes in the criteria for a ‘traumatic event’

TO emphasise the political nature of diagnosis criteria, given their power to determine who does, and does not, receive state sanctioned care.

In addition to changes in criteria, sometimes conditions are added to the DSM or moved from one illness category to another. For instance, the DSM-5 is likely to add hoarding disorder, olfactory reference syndrome, skin picking disorder and a variety of tics to the category of anxiety disorders. Obsessive-compulsive disorder is likely to be moved out of the category of anxiety disorders and into a new category of ‘anxiety and obsessive- compulsive spectrum disorders’ (American Psychiatric Association, 2011). Such changes may affect access to treatment, particularly in countries such as the United States where access is often determined by diagnosis codes provided to insurance companies. As with depression and bipolar, these additions and movements indicate that these illness categories continue to vary as understandings of mental illness change over time.

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As well as being temporally located, understandings of affective disorders vary across cultures (Bhugra & Mastrogianni, 2004; Kastrup, 2011). Cultural variation comes in several forms. For instance, different cultures may use the same word or concept to describe significantly different symptoms:

Back pain, dizziness, headache and other somatic symptoms are said to be indicative of depression in China and Africa; acting out, substance abuse, and antisocial behaviour supposedly reflect “masked” depression in American men […] On a descriptivist analysis, these claims stretch the sign and symptom picture of depression beyond coherence. (Radden, 2003, pp. 43-44)

In contrast, different cultures may experience different affective disorders. For instance, Migliore emphasises that ‘nerves’ was a culturally located illness experienced by certain members of the Sicilian-Canadian community when distressed by the breaking of specific social norms. Migliore argues that despite the culturally located nature of the illness, the physical and psychological experiences of ‘nerves’ were real (Migliore,

TP 2001). Interestingly, ‘nerves’ are also found in Brazil (Traverso-Yépez & De Medeiros, 2005) and Norway (Foss, 2002). Although there remain cultural differences in understandings of distress, psychiatric understandings continue to gain traction in non- western countries (Radden, 2003).

This brief outline of the historical and cultural variation in understandings and experiences of extreme happiness, sadness and fear demonstrates that mental illnesses are culturally inflected conditions. A social constructionist approach to mental illness acknowledges both the lived experience of those diagnosed with mental illness and the possibility of biological aetiology of such conditions while simultaneously emphasising the social shaping of understandings and experiences of such states. Given the extensive historical and cross-cultural evidence to support it, it is unsurprising that social constructionism is the approach taken by most scholars researching mental illness experiences and narratives. For example, Martin (2007) used such a frame in her examination of the experiences of those diagnosed with bipolar in the United States, Connor-Greene (2006) has published on the utility of social constructionism as the theoretical basis for teaching about the history of psychology, Cosgrove (2000) interpreted women’s experiences of depression as both a social construction and a ‘real’ lived experience and Cromby (2004) combined social constructionism and neuroscience to provide a culturally inflected biological account of mental illness. Other authors have used social constructionism in research regarding the social and individual meanings given to bipolar (Goldberg, 2007), emerging understandings of depression in Japan (Kitanaka, 2006), changes in individual understandings of depression in America (Kangas, 2004), gendered aspects of Prozac use (Kegan Gardiner, 1995), the construction of non-depressed identities by Canadian women (Lafrance & Stoppard, 2006) and the relationship between cultural norms of happiness and affective disorder diagnosis (Merkel-Keller, 2006). Although each scholar has a slightly different articulation of their theoretical orientation, each understands an individual’s experiences of mental illness as affected by the cultural beliefs and understandings within which that the person is located.

An area where the social construction of mental illness is particularly apparent is that of how people diagnosed with a mental illness describe their experiences.

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As discussed in Chapter 1, illness narratives are a mechanism for individuals to make meaning from their suffering and to create a coherent sense of self during, and after, periods of distress. The cultural context of the individual will affect how they understand and represent themselves and their illness experience.

The socially constructed nature of affective disorder narratives is particularly apparent when examining the specific rhetorical functions of these narratives. These include positioning the author as a particular type of subject, constructing an experience as comprehensible, or justifying an action. Throughout this thesis, the term ‘rhetoric’ is used to refer to modes of speech/writing that are convincing, often because of their use of tropes or other culturally recognisable symbols and textual constructions. The phrase ‘rhetorical function’ is used to describe the way a particular statement functions in a text. In an analysis focused on rhetorical function, the examination of a fabricated illness narrative will be as instructive as the analysis of an account based on ‘real’ events as both narratives are dependent on the same cultural norms and rhetorical strategies. In other words, while the focus of this thesis on ‘real life’ experience has impelled the exclusion of fictional illness narratives (e.g., novels) from the corpus, the emphasis on rhetoric means that it is unnecessary to ascertain the truth-value of each text. As will be discussed at length in Chapters 4 to 11, these rhetorical functions are achieved through a variety of rhetorical strategies such as categorical distinctions, including the separation of self and illness as well as the separation of the ‘mentally ill’ and ‘the mad’, and the use of particular metaphors and analogies. Authors may not be aware of these strategies or functions, and it is unlikely that many actively or deliberately invoke particular narrative constructions in order to enact particular rhetorical effects. However, rhetorical functions can be found in all illness narratives.

When a person describes their experiences of an illness they are always negotiating meaning and are not ever merely reporting events ‘as they happened’. Put differently, when a person writes about their experience of an illness they are producing a ‘narrative of best fit’. This narrative is the one that best accommodates the author’s experiences (what happened), sense of self, sense of how other people see her, dominant cultural understandings of the type of experience that the author is recounting and cultural story-

TR telling norms (Kangas, 2001). In other words, people create a narrative of their experiences, as well as a sense of self, in the context of the stories and selves mirrored and modelled to them: ‘we come to know ourselves through appreciating how we appear to others and becoming an object to ourselves’ (Foster, 2007, p. 142).

The ‘narrative of best fit’ can be imagined as the result of a vector diagram: each ‘truth’ places its influence on the potential narrative, with the resulting narrative being the one that best accommodates these different influences. For example, an author who describes being hospitalised involuntarily might minimise her discussions of diagnosis and treatment, as a discussion of these topics would suggest that she had a mental illness and this may be in conflict with her understanding of herself as a mentally healthy person. McLeod (1997, p. 94) describes the relationship between dominant and individual narratives in this way: ‘[e]ven when a teller is recounting a unique set of individual, personal events, he or she can only do so by drawing upon story structures and genres drawn from the narrative resources of a culture’. As will be discussed in detail in Chapter 3, the shaping of lived experience to a ‘narrative of best fit’ is particularly apparent in published autobiographies where the pressures of creating a commercially viable story further restrict and alter the narratives that can be told.

The narrative that ‘fits’ best for an individual is also influenced by their identities (e.g., gender, sexuality, religion, race, nationality, class, etc.) and social roles (e.g., mother, doctor, friend, confidant, lover, hostess, shopper, concert-goer, etc.). These identities and roles affect what a person can – and cannot – experience and how they understand their own experiences and the world around them. For example, an unemployed person is unlikely to experience $500-a-night hotel rooms while a religious person may understand the aetiology of their suffering differently from an atheist. In the case of this thesis, although authors routinely and spontaneously identify gender, diagnosis and relationship status, most other identities and social roles are not disclosed. These unknown demographics may influence an author’s illness narrative, but it is not possible for a reader of these materials to discern these characteristics or their influence. An awareness of the possibility of undisclosed identities and social roles affecting the illness narrative was maintained throughout the research process. Moreover, where such undisclosed influences seemed likely, this is noted and discussed.

TS An individual’s ‘narrative of best fit’ must also accommodate their beliefs and attitudes about the world and their place within it. These beliefs are both about the way that ‘things’ (e.g., government, families, nature) are, and the way that they should be. Individuals generally understand their world in line with the beliefs of their culture, with people who are exposed to different belief systems believing in different things. While a person can believe in anything, the social and psychological pressures to adhere to understandings that are supported by their communities are extremely strong (see for example Lau, Quadrel & Hartman, 1990).

Beliefs are not only restricted by cultural norms, they are also constrained by the evidence available for particular understandings. For example, it is difficult – although not impossible – to say that I ride around on an elephant when I cannot see or feel the said elephant. Beliefs, not to be conflated with a (religious) faith, are more likely to dominate if they align with available evidence (although, of course, what counts as evidence and how evidence is interpreted is primarily cultural). Thus beliefs and attitudes about illness affect the type of illness narratives that ‘make sense’ to a particular person and moreover affect what types of narratives that person believes others will find convincing or understandable.

There are two ways of understanding social constructionism: as a conclusion and as a method. The first part of this chapter has been concerned with social constructionism as a conclusion. It has provided evidence that mental illnesses are socially constructed and has demonstrated that illness narratives are a particularly powerful aspect of that construction. In the second part of the chapter, the focus turns to social constructionism as a method. This section describes how a social constructionist approach is embedded in the thesis methodology. Specifically, it details how a grounded theory approach has been used in the development of theory and the analysis of data, and how this dynamic process has resulted in the model of rhetorical function that underpins the thesis.

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The social constructionist understanding of mental illness articulated in the first section of this chapter is premised on the observation that much of what can – and cannot – be

TT counted as ‘truth’ or ‘knowledge’ is culturally specific. In other words, what counts as ‘true’ in one place or time may not be counted as ‘true’ in another place or time. This observation is not limited to understandings of illness, but rather extends to a great deal of knowledge production, including the production of knowledge for this thesis. Thus, in order for the theoretical underpinnings and the method of this thesis to be consistent, a social constructionist epistemology must be embedded in the thesis methodology.

'$*#)$'. Grounded theory embeds social constructionist epistemology in the analysis of empirical data. It does this by supporting the construction of theory throughout the analysis process. Grounded theory is located in between ‘theoretically “uninformed” empirical research and empirically “uninformed” theory’ and aims to ‘[ground] theory in data’ (Goulding, 1998, p. 51). Grounded theory is used primarily in research that codes interview and observational data and is focused on ensuring that a researcher’s understanding of their data emerges from their corpus, rather than precedes it.

The following grounded theory principles are used within this thesis (the principles are from Corbin & Strauss, 1990, with examples of how these were embedded in the research project written as sub-points under each principle): • Initial data analysis informs and alters subsequent data collection/analysis and researchers continuously revise their hypotheses so as to account for emerging data. o During the research project the analytic framework was altered to include the concept of integrity as a response to initial close textual analysis. In addition, certain sections (such as the section on domestic violence and depression diagnosis) were not anticipated and were a direct result of following certain ‘clues’ in the data. o This continual revision also required that attention be given to the impact of the researcher’s preconceived understandings of the data on the analysis (see Authority, below). • A concept is deemed worthy of analysis because it is repeatedly present. o Most interpretations in the thesis are supported by several pieces of data that are from multiple data source types. However, occasionally an

TU argument is made using data that is found only in one type of source (a phenomenon that is worthy of analysis in and of itself) and in rare cases there is only one example of a particular phenomenon (this is particularly true for counter-examples). These limited cases often provide insight into the underlying logic of more common expressions and are therefore highly valuable. • Theorisation is based on conceptual clumping of events/text and not on ‘raw data’. o Certain pieces of thesis data experienced multiple ‘identity’ changes throughout the coding and analysis process: for example, the quotation ‘depression is just like diabetes’ was coded as ‘depression as illness’, ‘metaphor – physical illness’ or ‘legitimacy – legitimate ill subject’, depending on what type/stage of analysis was being completed. • Comparisons should be made with other data and similarities and differences noted. o Throughout the research process, examples were compared with each other. Although certain examples were focused on (i.e., those that ‘fit’ the analysis), during the re-drafting phase there was a substantial review of the data that ensured counter-examples were included in the thesis where relevant. In addition, the findings of this thesis were compared to throughout the body chapters with findings from other Australian and international research projects. • Analysis should not be focused solely on the phenomenon being examined, but should also engage with broader influences such as ‘economic conditions, cultural values, political trends, social movements, and so on’ (Corbin & Strauss, 1990, p. 11). o Examples of broader influences discussed in this thesis include: community understandings of certain physical illnesses (Chapter 7), ease of access to health care (Chapter 8) and gender stereotyping (Chapter 10).

A grounded theory approach requires that the researcher be open to changing their understanding of the data throughout the research project. This process was particularly apparent when developing the overarching model of rhetorical function. As will be TV discussed below, the model continued to be developed throughout the research process. The data analysis and theorisation became a type of loop where insights from the analysis helped to further develop the model, and the further developed model then enriched the analysis. Three key rhetorical strategies emerged from this dynamic process: legitimacy, integrity and authority.

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As discussed in the thesis outline in Chapter 1, the legitimacy, integrity and authority model (herein referred to as LIAM) is used throughout this thesis and is the key theoretical frame underpinning the rhetorical analysis performed in Chapters 4 to 11. LIAM provides a coherent and consistent framework that helps to both describe and explain the rhetorical function of particular aspects of affective disorder narratives.QV The model was developed during the course of the data analysis, and in line with grounded theory principles, the model changed as the data analysis progressed.

LIAM builds on the work of Galegher, Sproull and Kiesler, who used the concepts of legitimacy and authority in their analysis of postings on various health and hobby electronic support groups (Galegher, Sproull & Kiesler, 1998). Specifically, Galegher et al. identified two key discursive/rhetorical positions that were enacted in electronic support groups: legitimacy (demonstrating that a writer’s ‘concerns are genuine and justified’ p.499) and authority (‘not only that they have a right to speak [legitimacy], but also that their answers should be believed’ p.500). Both rhetorical functions were found to function as a way of locating the poster as part of the online community. The definitions of legitimacy and authority have been expanded to include a wider variety of functions in this thesis (see below).

In contrast with Galegher et al. who understood legitimacy and authority as primarily binary attributions (i.e., one either has legitimacy or one does not), legitimacy and authority are understood in this thesis as being located on a continuum from maximum to minimum expression. This means that an author may be understood to be maximising 27 Near the end of the thesis project, a paper describing a systematic way of analysing mental illness memoirs was published. While this text is of great interest and would have assisted in the formation of LIAM, the model described was not as focused on rhetorical function as LIAM and has not been embedded in the theoretical underpinnings of the thesis method. See Donohue-Smith (2011). TW their authority or reducing their legitimacy, but they will not be read as having absolute authority or having a complete absence of legitimacy. Conceptualising legitimacy, authority and integrity as continuums is important for two reasons. First, rhetorical functions are a type of speech act. This means that they are a type of ‘doing’ with words, rather than a mere ‘saying’ or ‘being’ (Austin, 1975). Conceptualising legitimacy, authority and integrity as continuums emphasises that they are a type of action, rather than a stagnant and predetermined destination. Second, although my close reading of the text reveals particular rhetorical functions, it is possible that other readers may not interpret the text in the same way. By understanding legitimacy, authority and integrity as continuums rather than absolute states it is possible to articulate the likely rhetorical function of particular phrases without denying the possibility of alternative interpretations.

The following sections examine the three key rhetorical functions.

Social validity and recognition: Legitimacy

A person or thing that is perceived to be ‘real’ or ‘proper’ has high legitimacy. When a person’s legitimacy is maximised, they are securely located as being a socially valued subject.

Legitimacy is best understood with reference to its (hopefully archaic) meaning in relation to a child who is born to parents who are married. A legitimate child is a child who was conceived in the ‘correct’ circumstances and is therefore socially accepted and valued. In many affective disorder narratives, much rhetorical work is done to position the affective disorder as a legitimate illness or the author as a legitimately ill subject (i.e., someone who has a legitimate illness). Like a legitimate child, a legitimate illness or a legitimate ill subject is socially accepted/valued.

Kathy Charmaz’s concept of ‘moral status’ is similar to the concept of ‘legitimacy’ used in this project. Charmaz interviewed people with chronic illnesses in order to investigate the relationship between self and suffering. Charmaz argued that suffering was a moral status and that the events – and subsequent narratives – imparted differing levels of legitimacy to particular narrators. Charmaz developed her understanding of the moral

TX aspects of suffering into a systematic account of factors affecting the moral status of an ill person. Her ‘hierarchy of moral status in suffering’ had three levels: Validated moral claims were those with high moral status – they included medical emergencies, illnesses with involuntary onset and conditions where the sufferer was deemed blameless for the condition. Accepted moral claims provided a sustained moral status – they included chronic illnesses with varying levels of demands on others for assistance. Minor/temporary illnesses could also be added to this category, as these forms of illness do not fundamentally upset the moral status of the individual. Questionable moral claims produce diminished moral status – there were a variety of situations or events that may have caused varying levels of diminished moral status (from being worth less than other people to being considered a worthless person). Charmaz gave several examples of factors that reduced moral status including: longevity of illness (the longer the illness the less moral status), lack of power, lack of money, lack of desirable/specialist knowledge and old age (Charmaz, 1999, pp. 368 - 369).

Charmaz observed that this hierarchy was at work both in the evaluation of a narrative by listeners, and through shifts in emphasis by the storyteller in order to provide the most compelling story.

Legitimacy is a particularly important rhetorical function of affective disorder narratives. As will be demonstrated in the body of the thesis, being the right sort of person with the right sort of illness can enable an author to more easily access health services and to receive empathy. Within the corpus for this thesis the most common rhetorical actions used to increase legitimacy were comparing affective disorders to physical illnesses and separating self and illness (see Chapter 7).

Whole and true self: Integrity

Integrity refers to a sense of coherent selfhood that is socially and internally valued. ‘Integrity’ has two meanings in this context: to be whole (a boat has integrity if it does not leak) and to be of good quality (a person has integrity if they behave honestly). In other words, integrity is a sense of self that is perceived by both the author and others as

UO ‘true’ and ‘complete’ (Soanes & Stevenson, 2004, p. 738). As selfhood is a characteristic of a person, integrity cannot be used to describe an illness, situation or thing.

In the quotations analysed for this thesis, two forms of integrity were apparent. First, some authors established a valued and coherent sense of self by removing any dissonance in their self-concept. For example, maximised integrity would be apparent in an author who fully embraces a biological account of depression and thus has no feelings of blame, stigma or uncertainty regarding their self-worth. In these instances, increased integrity also maximised the author’s legitimacy as an ill subject. More often, however, authors do not express this level of self-coherence in their narratives. Rather, authors are likely to represent their sense of self in different ways throughout their illness narrative and thus they will oscillate between statements that increase and decrease their coherent self-representation. Integrity is thus revealed to be, most often, a tenuous and unstable achievement.

Second, integrity is sometimes enacted when authors emphasise their wholeness through presenting a multifaceted self. The content of this form is in conflict with integrity based on an over-simplified self; however, the rhetorical effect is similar, with both forms creating a sense of valued and coherent selfhood. Multifaceted selfhood is typically apparent when authors identify and value the range of roles, identities and actions within their lives. By doing so, the affective disorder experience is ‘rolled’ into the broader context of the author’s identity. Like the over-simplified expression of integrity, this form of integrity is tenuous, as multiplicity cannot easily be embedded in a narrative and tends to be expressed in certain points, before returning to a more simplified illness narrative and/or identity. Analysis in the body chapters of the thesis demonstrates that this form of integrity sometimes functions to undermine an author’s illness identity (and thus legitimacy as an ill subject) or authority.

Sanctioned knowledge and power: Authority

An author or text has authority through institutional power and/or socially recognised knowledge. Unlike the institutional power of a policewoman, which is associated with the official documentation that she carries, institutional power in texts is based on

UP written claims of institutional affiliation or association such as ‘I am a consumer representative at my local hospital’ or ‘I am a psychiatrist in private practice’. This form of authority often co-occurs with claims of epistemic (knowledge) authority. Claims of epistemic authority typically take the form of ‘what I say is correct because I have special knowledge/expertise in this area’.

As will be demonstrated in Chapters 7 and 8, authoritative knowledge is characterised by its presumed accuracy and ‘truthfulness’. As Jordon says:

Authoritative knowledge is persuasive because it seems natural, reasonable, and consensually constructed […] Generally, however, people not only accept authoritative knowledge (which is thereby validated and reinforced) but also are actively and unselfconsciously engaged in its routine production and reproduction’. (Jordan, 1997, p. 57-58)

In addition to the strategic use of authoritative knowledge, authors in the dataset use a variety of means to increase their authority as individuals. For a minority of authors, this involves identifying their professional status as psychiatrists, psychologists, consumer advocates,QW etcetera. More commonly, authors ‘borrow’ the epistemic authority of their psychiatrists, GPs and counsellors by presenting certain understanding of their experience as being sanctioned or supported by their health care professionals (see Chapter 8). In other words, an author may gain authority through positioning herself as a person who knows about affective disorders – either through personal experience, their own professional qualifications, or through association(s) with those deemed to have professional expertise.

As flagged in the previous section on grounded theory, an acknowledgement of the power of authoritative knowledge impacts on how research is carried out. Throughout any illness narrative research project, an academic will make judgments about whose illness narratives sound ‘real’ and whose theory of illness is ‘true’ (in other words, it is sloppy research to suggest that the beliefs that anxiety is caused by aliens or adrenalin 28 Australian consumer advocates have varied levels of professionalisation. Some are volunteers, while others have paid positions. In addition, some advocates have influence over policy and are involved in state or national committees while others concentrate on local services and peer support (NSW Consumer Advisory Group, 2011). UQ are equally valid explanations). While such assessments are important, it is nonetheless important that authoritative knowledge is also acknowledged to be ‘a social accomplishment’ (Millard & Kingfisher, 1998, p. 450). In order to balance these conflicting needs, throughout the research process I have deliberately moved between engagements with quotes that were based in common-sense judgments and those which were based on a skepticism of truth claims. This process allowed me to better identify authoritative statements that may initially appear to be ‘mere’ fact, and thus I gained greater understanding of the rhetorical function of authority in the affective disorder narratives being examined.

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LIAM provides a mechanism for engaging with written texts that prevents the researcher from becoming too certain or too uncertain about what a text might mean to either author or reader. In other words, by focusing on the rhetorical functions of legitimacy, integrity and authority, the researcher is able to discuss discursive constructions of self without such constructions becoming the limit of the analysis. Moreover, it limits the risk of claiming certain knowledge about the intentions of an author (claims that, obviously, cannot be verified or justified), or becoming elinguid by an epistemologically sceptical postmodernist conviction that a researcher cannot know what a text might mean to either its author or its readers. For example, if an author states ‘depression is just like diabetes’ a researcher using LIAM would not claim that the author’s intention was to draw a comparison between physical and mental illnesses (although this is the effect of the sentence), nor would they wax lyrical about the interpretive frame of the researcher and the redundancy of engagements with any supposed ‘reality’ outside the text. Instead, a researcher using LIAM would focus on the rhetorical functions of the particular sentence and discuss what these functions suggest about the intentions of the author. LIAM enables the researcher to maintain a balanced perspective that allows critical engagement and helps to mitigate the dangers of too much – or too little – attribution of author intent.

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Through an examination of historical and cross-cultural variation in understandings and experiences of affective disorders, this chapter has demonstrated that affective disorders are culturally inflected conditions. Specifically, while the symptoms of affective disorders are real, what symptoms are deemed meaningful, how they are treated and how the ‘illness experience’ is understood, vary across time and place.

This project embeds a social constructionist epistemology in the thesis method by using a grounded theory approach to empirical research. Grounded theory principles of simultaneous theory development and data analysis have enabled the development of LIAM, a model of rhetorical function that is used throughout the analysis of the corpus

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XT We meet for ‘high tea’. I’ve not had high tea before and I wonder exactly what it is that I’m getting myself into. I know there are meant to be little cakes and sandwiches, but that’s about where my knowledge ends. And what exactly will we talk about, a small group of women known to each other because we happen to have been in a psych hospital at the same time? We’ve bonded over comparing drug cocktails and creating satirical skits about some of the more ridiculous therapies currently in vogue. Will we still have anything to say to each other, now that we are – supposedly – ‘well’?

As it turns out, we talk about the same kind of things we talked about in hospital. Lucy has changed her sleeping pills again and recounts the new set of side effects. Sally has spent the last two months in a different hospital. We spend a good half hour comparing different facilities – this one has a gym, that one is nearer to the ocean, this one uses more electro- shock, that one prefers cognitive therapy and mindfulness. Take away our specific words and we sound like any other group of women comparing services – discussing different car models, holiday resorts or gynaecologists.

Lucy says she is considering ECT. We ask her what her psychiatrist says, deferring our judgement to his authority. None of us have had ECT before. It’s never mentioned, but we know that to be thinking about ECT means that Lucy is getting worse. The unstated implication is that this is a frantic effort to stop her attempting suicide again.

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PRP I’ve locked the front door. I’m not sure why mum thinks that this will help keep the noise out, but she does. Mum’s in her bed, covers drawn, pillows over her head. She gets panic attacks when she can hear our neighbours playing music. It’s kind of annoying, because they play their music quite often so Mum is in a ball lots of the time.

Today the music is even louder than usual. Normally you can only hear it outside the house, but today you can feel the bass when you’re still inside. It’s making Mum frantic. She’s trying to remember the police phone number so she can ring and complain. I’m happy she can’t remember the number, because it means I don’t need to remind her that they’re actually not doing anything illegal and the police can’t help. She hates it when I tell her that.

I’ve rung Dad and he said he’ll be home as soon as possible. At times like this, Mum can’t get out of the house without Dad. She runs to the car and then they drive to somewhere quiet. For some reason she won’t go for a walk with me, even though I reckon it does the same thing as going for a drive. C'! ..#(!), =" , #-)(&3-)'/") B* ,-)(#(&&"3* ,0 (.#&.#(!C.".3)/ (1."1#.")/.#.-.,.#(!.)1 ,&#..& ."#(= -%/'# (!)! .'3))%= *,)'#- .". C&& % ), -" ()/(..)."#,.3=" -3- = ,/(.)'3,))' (!,'3))%= - ..& %)1()(/'C- = -.,., #(!",&# (." "))&. .),3.)" ,= C0 , #. ), :/.#.C-!))-.),3-) )(C.'#( , #(!#.!#(= )(C.."#(%-" C-*3#(!'/".. (.#)(:/..".C- = C&&& (" , ." ))% . ,1,-# -" 1(.-=

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This chapter examines the commonly reported experience of co-occurring anxiety and depression. Comorbid anxiety and depression is a distinct experience, and thus these narratives provide additional insight that is not available through the analysis of either depression or anxiety narratives. Additionally, these depictions provide evidence of the strategic nature of affective disorder narratives. Specifically, the following analysis demonstrates that descriptions of physical, emotional and behavioural states are influenced by cultural preferences for particular interpretations of distress, namely a consistent preference to interpret symptoms as an aspect of depression rather than as an aspect of anxiety. Moreover, within these narratives, authors consistently emphasise (or minimise) certain aspects of their experience in order to maximise their legitimacy as ill subjects.

In keeping with the purpose of Chapters 4 to 6 (i.e., to systematically and progressively introduce the reader to LIAM), this chapter provides a sustained analysis of only one rhetorical function, namely, legitimacy. By focussing on a single function, the reader becomes familiar with the analysis process and LIAM while simultaneously engaging with important corpus content.

This chapter will detail how the strategic emphasis on depression identity and symptoms within affective disorder narratives in the corpus results in a hierarchy of illness severity between depression and anxiety. Three types of hierarchical narratives will be examined: anxiety as a precursor to depression; anxiety as a symptom of depression; and anxiety at the same time as depression. Each narrative form increases legitimacy by positioning depression as a severe illness, and, by extension, enhances the author’s legitimacy as an ill subject. As this is the first chapter to be focused on rhetoric and LIAM it is worth reiterating that, in keeping with the understanding of a social constructionist method developed in Chapters 2 and 3, each of the examples below must be simultaneously understood as strategic representations that enact particular rhetorical effects and as descriptions of real life events.

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Corpus authors routinely conceptualise anxiety as a precursor to depression. When authors describe anxiety as a precursor to depression they typically mean both that anxiety comes before depression (in the same way as a person might say ‘the soup is the precursor to the main course’) and that anxiety is a less severe complaint that is an early symptom of a condition that they already have (in the same way as ‘my sore throat was a precursor to the flu’). In the corpus, both types of precursors function to position anxiety as a less severe condition than depression.

In the first example, psychiatrist Robert Fisher supplies a short introductory letter at the beginning of Beyond the Brink. In this letter Fisher provides a simple account of the development of a depressive disorder:

The initial reaction to perceived stress is usually to become anxious, and the anxiety leads to a flight or fight reaction. If a solution to the stressful situation is not found quickly, the anxiety may be replaced by a feeling of despondency, despair and depression. For people who develop a biological depression, the illness itself serves as a stressor and can cause a crisis state to develop. (GC 26)

Later in the same letter, Fisher reinforces an understanding of anxiety as a cause of depression when he describes ‘good patient’ behaviours:

[Good patients] take great care to avoid subjecting themselves to factors or influences in their lives which they recognise as likely to trigger the anxiety or worry that leads to episodes of depression. (GC 27)

In both of these quotations, Fisher understands anxiety as a precursor to depression. Anxiety, according to this account, is a normal and expected reaction to stress, as evidenced by the use of the term ‘usually’ in the first sentence – ‘the initial reaction to perceived stress is usually to become anxious’. Depression, on the other hand, is positioned as a problematic response to ongoing anxiety. This understanding is apparent in the second quotation when Fisher refers to the ‘anxiety or worry that leads to episodes of depression’. A hierarchy of pathology is enacted in these quotations by PTW indicating the relative ‘normal-ness’ of anxiety and depression: anxiety is a common experience and thus of less concern, while depression is less frequent and therefore more concerning. Put differently, depression is positioned as a more pathological or legitimate illness because it is a less common reaction to life events than anxiety. Thus, Fisher concludes, attempts to manage stress and anxiety are important primarily because they are attempts to prevent the more serious condition of depression.

Although not positioning anxiety as ‘normal’, Jeff also understands anxiety as being a precursor to depression. Specifically, he describes an episode of anxiety that he perceives as less severe because it is not followed by an episode of depression:

I did experience some severe anxiety towards the end of my time away, but I’m not so sure it actually developed into depression. (D 117)

The statement ‘I’m not so sure it actually developed into depression’, implies that an episode of anxiety that is not followed by depression is less severe than instances where this progression does occur. This hierarchy may be based on the number of conditions experienced, so that Jeff is expressing a belief that having a single disorder is less severe than having two disorders. However, the word ‘actually’ suggests that an episode of anxiety, in and of itself, is less problematic than anxiety that leads to depression. Thus, consistent with Fisher, Jeff suggests that the depression that anxiety leads to is of most importance; Jeff implies that depression is the more concerning condition.

Understanding anxiety as a precursor to depression is common across the dataset. Rarely is this hierarchy reversed. In an example of such a reversal, Geoff Gallop indicates that depression makes a person prone to anxiety:

If you’re in a depressed state, you’re prone to [a sense of panic]. (GC 167)

In this quotation, the phrase ‘prone to’ indicates that depression causes a person to be susceptible to panic. This, in turn, implies that depression is the root cause of distress. Simultaneously, and counter to the examples above, where anxiety is understood as the precursor to depression, the word ‘prone’ positions depression as the more constant condition. Thus, despite the reversal of causation (depression causes anxiety rather than

PTX the other way around), Gallop is consistent with the earlier authors as he implies that depression is the more constant and significant illness.

The tendency to interpret anxiety as a less severe condition is justified by some other authors through the different temporalities of the two conditions. An episode of depression tends to occur over several weeks, months or years, while an episode of anxiety such as a panic attack may only last 10 minutes (although, of course, the anxiety may return regularly). Thus, when Gallop understands depression as a constant that may make one susceptible to panic, he may be reflecting these different temporal forms. While this may initially seem like a simple statement of fact, when these differences are used to position depression as a more severe condition, the statement should be understood as a strategic representation. Put simply, there is no reason to give preference to depression because it is a chronic condition: anxiety could just as easily be positioned as the more severe condition because of the severity of acute panic episodes and the disabling nature of the condition. It appears that the reason that constancy, rather than severity of symptoms over a short period, is the signifier of severity is because depression is already believed to be the more constant state. The preference to represent depression as the more severe condition is an effect of pre-existing valuing of depression as the more severe disorder (see below).

Most authors who recount anxiety that is chronologically followed by depression represent anxiety as the less severe condition. However, this is not the only way to understand this chronology. Although not present in the corpus, it is possible – and logical – to understand depression and anxiety as equally severe conditions (e.g., ‘my anxiety came before my depression’ or ‘my anxiety was followed by depression’). Moreover, it is possible for authors to understand their anxiety as more severe than their depression (e.g., ‘after my anxiety, I tend to get depressed’ or ‘as I recover from my anxiety, I can feel quite depressed’). That these alternative explanations are not used does not indicate that they are less reasonable as explanations. Rather, the preference for explanations that highlight depression reflects the wider cultural acceptance of depression as a legitimate illness. Put differently, it ‘makes sense’ to say that anxiety as the precursor to depression is a discursive pattern that points to the dominance of depression as the signifier of severe emotional distress within contemporary Australian culture.

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In a minority of instances authors understand anxiety as a discrete condition occurring at the same time as depression. Like the other two narrative forms discussed in this chapter, this narrative represents anxiety as a less severe condition than depression.

Rose describes experiencing concurrent depression and panic attacks in a way that positions depression as the more severe condition:

My depression was also accompanied by anxiety attacks which I took care of myself by taking certain pills I had which were effective immediately. (D 62)

When Rose says her depression was ‘accompanied by’ anxiety, the word ‘accompany’ enacts a hierarchy between these two conditions. Specifically, an entity that ‘accompanies’ another is less important: so that, if rice accompanies a stew, it is the less important aspect of the meal; if a pianist accompanies a soloist, she is the less acknowledged musician; and, if a man accompanies his partner to a wedding, he is the less significant invitee. Thus, in this quote, the phrase ‘my depression was also accompanied by anxiety’ positions depression as the more legitimate diagnosis with anxiety being an additional – and less important – aspect of Rose’s experience.

In another example that uses ‘accompany’ to minimise the significance of anxiety symptoms, Rowe describes her opinion of certain non-pharmaceutical treatments for affective disorders:

Meditation and relaxation are used as adjuncts to treatment for depression and certainly have their place as programmes to reduce the anxiety that accompanies the illness, but only after there has been some improvement. (BT 122)

Similar to the previous example, when Rowe states that ‘anxiety […] accompanies the illness’ she is positioning depression as a recognised disease, while anxiety is understood as an epiphenomenon of the depression. Moreover, when Rowe states that meditation and relaxation treatments for anxiety are appropriate ‘only after there has been some improvement’, she describes a treatment hierarchy where depression is

PUP treated before anxiety. Such precedence reinforces a sense that depression is the more substantial and worrisome condition.

A contributor to the Journeys with the Black Dog anthology writes about the range of anxiety conditions that occur at the same time as their depression:

All the related conditions that go hand-in-hand with depression seemed to descend upon me all at once – anxiety attacks, nausea, claustrophobia and a constant feeling of choking […] I suffered sleep deprivation caused by hyper- vigilance as my brain was on full alert 24/7 and there seemed no escape from the all-consuming fear that had become my life. (JwBD 47)

When the author states that their ‘anxiety attacks, nausea, claustrophobia and a constant feeling of choking’ are ‘related conditions’ to their depression, they are positioning depression as the primary diagnosis and their anxieties as less severe or significant conditions. This hierarchy is enacted despite the author providing significant evidence that their anxiety symptoms are arresting and debilitating (and may, in fact, have more negative effects on their emotional, physical and social wellbeing than the symptoms they attribute to their depression). This insistence on maintaining a depression- orientated interpretation despite the arresting nature of the author’s anxiety symptoms emphasises the discursive power and explanatory value of the author’s depression diagnosis.

The previous examples in this section have demonstrated how simultaneous depression and anxiety are routinely represented as distinct illnesses. In contrast to this dominant narrative, a minority of authors represent depression and anxiety as similar types of illness. In the following example, a contributor to the Blue Board writes about their depression and range of anxiety symptoms:

I have been suffering from depression, anxiety, have panic attacks and have a social phobia for three years. (BB 226)

Within this quotation the author makes a distinction between the conditions that they ‘suffer from’ and those that they ‘have’. This distinction may reflect a grammatical

PUQ difference between conditions that are events (panic attacks and social phobia) or states (being depressed and anxious). Moreover, the phrase ‘suffers from’ implies that generalised anxiety has the same characteristics and/or status as depression.

This quotation is a counter example in that it cuts across the temporal and hierarchical distinctions that are evident in the other quotations. Specifically, the text positions some forms of anxiety as being equivalent to depression, which is unlike the other quotations which represent anxiety as consistently less severe than – and thus not equivalent to – depression. Moreover, this quotation denotes varied forms of temporality for anxiety, which is unlike most other quotations that only associate anxiety with acute symptoms. Finally, the sheer greater number of anxiety-related words in the quotation suggest that anxiety is the more significant condition. The existence of this counter example highlights the possibility of alternative or non-normative representations of the relationship between anxiety and depression. The potential for such variation suggests that the cultural norms of affective disorder narratives, while strong, are not hegemonic.

#-).((."%)$"$%'(($# While some authors write about anxiety as a precursor to depression or existing at the same time as depression, it is slightly more common for authors to understand anxiety as a symptom of depression. In these instances, anxiety is no longer considered a separate condition, but rather is interpreted as further evidence of the existence of depression. This understanding is gaining clinical acceptance, with the proposed DSM-5 including a new category of depression called anxious depression (American Psychiatric Association, 2011). These proposed changes to the DSM are indicative of broader shifts in understandings of affective disorders in western culture, in particular an increasing awareness of the common co-occurrence of anxiety and depression. While reflecting medical developments, the representation by authors of anxiety as a symptom of depression is nonetheless also a rhetorical strategy.

In the corpus, understanding anxiety as a symptom of depression enables depression to be secured in its categorisation as a diagnostic entity and for anxiety to be relegated to

PUR the status of symptom. The following simple example is from Jeff in My life as a side effect:

My depression took the form of an inability to feel any happiness whatsoever, as well as severe anxiety. (D 115)

Jeff explicitly identifies anxiety as a symptom of depression when he states that ‘my depression took the form of […] severe anxiety’. Put differently, Jeff positions his anxiety symptoms as evidence that he is suffering from depression.

The second example is more complex due to an interaction between lived experience, identity and narrative emphasis. Throughout The best of times, the worst of times, Rowe describes experiencing anxiety, depression and mania, but she does not think of herself as having two conditions. Rather, she only identifies as having bipolar. In order for Rowe’s identity to be aligned with the descriptions of her lived experience, Rowe is likely to give prominence to her depressive and manic symptoms. It is therefore unsurprising that anxiety is represented as a symptom of Rowe’s depression:

But the depression did not lift […] I was unhealthily thin but could barely eat as I had no appetite and my sense of taste had gone. My stomach constantly churned with anxiety. (BT 58)

Within this quotation, Rowe positions anxiety as an aspect of her depression experience. This positioning is most clear when one examines the structuring of the quotation: ‘depression’ is given as the topic of the paragraph, thereby implying that all the symptoms described (including anxiety) are evidence of Rowe’s depression. By doing this, Rowe provides a coherent diagnostic narrative that maintains focus on her bipolar diagnosis despite her experience of anxiety. Such coherence enhances Rowe’s integrity as an ill subject as it aligns her lived experience with her diagnosis.

A more ambiguous example is from a contributor to the Blue Board website who describes how she responds to her anxiety symptoms:

PUS Over the last few months I’ve become anxious about the idea of hanging out with friends. I’ve done some research about depression and have found that I should push myself to interact with my friends anyway, but the idea brings me to tears. (BB 229)

In the first sentence of this quotation, the author identifies that she becomes anxious when thinking about spending time with friends. Given this symptom, one might expect that she would engage in research focused on the management of social anxiety. However, this is not the case. Rather, the author researches depression. In order for this type of research to make sense in the context of the author’s symptom, we can only assume the author perceives her anxiety as being a symptom or aspect of her depression.

However, this is not the only discourse enacted in this quotation. Specifically, by responding to her anxiety about spending time with friends by doing research, the author indicates that it is her anxiety that she most needs help to manage. Thus, a discursive conflict emerges. On the one hand, the author positions anxiety as a less significant condition than depression, while on the other hand she simultaneously provides evidence that anxiety is her primary concern. In this way, the author is located in a conflict between the rhetoric of depression as the most severe condition and her lived experience, where anxiety is the most arresting condition.

Contradiction is also evident in the following quotation, where a young woman on the headspace website writes about her depression:

Driven by anxiety, my depression took some time to treat. (HS 190)

By positioning anxiety as the driving force of her depression, the author implies her anxiety is a part of her depression and that the she is, in effect, suffering from a single condition. However, like every author in this section, the author is simultaneously making a distinction between the two conditions as she uses two terms (‘anxiety’ and ‘depression’) to describe them. Thus, this quotation suggests a level of ambiguity and instability in the hierarchy that is being enacted. Such ambiguity suggests that affective disorder rhetoric cannot fully explain – or erase – the complex and ‘messy’ nature of

PUT lived experience. This, in turn, supports the earlier claim that affective disorder narratives are located in the space between rhetoric and lived experience.

This exploration of the three narratives of comorbid anxiety and depression has shown the dominance of understanding depression as a more severe condition than anxiety. While this analysis has suggested some of the reasons for this rhetorical preference, below, several cultural and individual reasons are detailed.

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The analysis in Chapters 4, 5 and 6 suggests that authors consistently represent depression as a more severe or more legitimate illness than anxiety. Depression obtains its discursive legitimacy through a variety of means, not least its association with suicide (an association that is not extended to anxiety, despite the frequent reporting of suicidality in anxious individuals – see Chapter 5). As is demonstrated in the next chapter, the discursive link between suicide and depression allows authors to depict depression as a fatal illness. It seems likely that part of the reason why authors tend to focus on their experiences of depression is because being associated with this more severe and legitimate illness increases their access to medical assistance and empathy (see Chapter 7).

It is possible that this hierarchy is partially a result of how the terms ‘anxiety’ and ‘depression’ are used in day-to-day conversations. Both anecdotal evidence and the analysis summarised in Chapters 4 and 5 suggest that ‘depression’ has begun to be used in everyday talk as a reference to a clinically significant condition, while ‘anxiety’ remains a term that is typically used to refer to routine worry and stress. This means that the term ‘anxiety’ may not carry sufficient connotations of suffering to ‘fit’ the severity of symptoms experienced by individuals with anxiety disorders (see Chapter 2 regarding ‘narrative of best fit’). This lack of ‘fit’ may result in authors strategically emphasising their depression symptoms or reinterpreting anxiety symptoms as part of depression.

PUU At an individual level there are several likely reasons for the emphasis on depression experiences. Authors learn how to understand and narrate their affective disorder experience through a variety of means, including discussions with their family, friends and health professionals. For some authors, it may be that none of their personal contacts distinguish between depression and anxiety and that the cultural representations that they have accessed such as the beyondblue advertising campaigns may perpetuate this conflation (see Chapter 12). If an author were not exposed to accounts that positioned anxiety and depression as separate conditions, then they would be unlikely to discuss anxiety in this way because they would not have knowledge of this conception of their emotional distress. In addition, it is possible that certain authors concentrate on their experiences of depression because the severity of previous or current depression symptoms focuses their attention on the depression diagnosis. Such focus may act as a type of selection bias in the author’s recollections, resulting in authors paying more attention to past and present experiences of depression.

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This chapter has demonstrated how authors experiencing symptoms consistent with both anxiety and depression routinely represent depression as the dominant diagnostic category. Regardless of the reason, this consistency is indicative of the greater discursive power of depression as an explanatory category for emotional suffering.

This chapter has examined three narrative forms that produce a hierarchy between depression and anxiety. In each of these narratives, depression is positioned as the more legitimate illness, with anxiety symptoms minimised or embedded in an understanding of depression. This hierarchy between depression and anxiety is not a reflection of ‘reality’ (as argued in Chapter 5, anxiety symptoms can result in levels of distress and debility comparable with depression symptoms) but rather an indication of what types of narratives of emotional distress are culturally understandable. Due to established cultural recognition of depression, by emphasising depression, authors increase the legitimacy of their illness and, in turn, the legitimacy of the author as an ill subject. In some instances, tensions or contradictions between an author’s identity, narrative and/or

PUV lived experience are erased or minimised. In these instances, the author’s integrity is enhanced through the production of a more coherent illness narrative.

In the following chapter, the rhetorical function of understanding affective disorders as illnesses is examined, with a focus on the way in which this understanding provides legitimacy to the authors of affective disorder narratives.

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I’m reading in bed, covers drawn close against the cold. She knocks on the door. I ask her in. She says, ‘I just thought you should know that I’m not really safe at the moment’. It’s a familiar statement, a stock standard phrase several of my friends use. For some it means they want to kill themselves. For this particular friend, it means she wants to cut herself.

I knew she wasn’t doing well, that she was spending extra time in her room. But I’d chalked it up to exams. It seems that the slippery slope between stress and harm is just that little bit steeper and slipperier than I had realised.

Her wrist and bicep on her left arm are covered in scars. I wonder if she’s drawn a blade across her thighs or stomach, those other favourite cutting grounds. She’s told me before that she counts her scars, that things are OK when there is an even number of cuts. I don’t know how many scars she has, but I know that at the moment she’s at an even number. I’m grateful that this is in her favour.

I put down my book and ask what happened. Last night, she tells me, she wandered down Parramatta Road, fighting the urge to jump out in front of a semi-trailer. She was frightened by her own wish to die, disoriented by feelings she had hoped she was learning to forget. Eventually she rang a friend and they took her home. Now she feels the urge to cut, the desire to force the world back onto its axis by the sacrifice of her flesh.

I ask if she has a plan. We’re both familiar enough with this kind of talk to know I’m asking if she has a plan to keep herself safe, not whether she has a plan to kill or harm herself. She tells me about her lists of friends to call, about a friend coming to stay for a few nights, about her promise to her girlfriend. We go through the standard list of questions: Does she have a psych appointment soon? Has she had her medication? Is she eating enough and exercising regularly? Is she hoarding razor blades? Is she worried about the knives in the kitchen? I suspect we’re both kind of bored with this ritual, but it’s important to remind each other that there is a set pattern of protections and supports that we can rely on. I remind her that I’m here for her any time, that she can come and knock on my door at 3 am if she needs. We talk about our plans for tomorrow, where she’ll be and if she wants company. I suggest that in the evening we should bake cookies, that cooking and listening to silly music is simply more fun than cutting or dying. She cracks an almost smile. I say we need to buy more chocolate chips.

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To say that a particular form of suffering is a disease is always to go beyond the observation that the suffering exists. It is also to say […] that the suffering doesn’t belong in our world, that we would live better lives without it, and that we ought to do so. (Greenberg, 2010, p. 36)

Throughout the corpus, authors routinely write that depression, bipolar and anxiety are illnesses. As with the temporal distinctions discussed in Chapter 6, such claims are simultaneously an accurate reflection of current medical and scientific understandings of these conditions and a rhetorical device that functions to provide legitimacy to particular experiences. The rhetorical and discursive functions of these claims are routinely made invisible because such statements are understood to be purely ‘factual’ and thus are safe from criticism as rhetorical tactics. To paraphrase Foucault (1979), it is precisely this invisibility that results in these ‘facts’ having substantial discursive power.

The importance of illness claims in published affective disorder narratives is hard to overstate. Giles and Newbold have demonstrated the centrality of diagnosis and discussion of illness on mental health internet bulletin boards. They note that:

The discussion forums of these communities are characterized by the rigorous policing of boundaries to shut out “wannabes” and fakers; celebration, even glorification, of the condition or category; intense, often highly technical discussion of psychological, psychiatric, and behavioral characteristics of the syndrome; and identification of (quasi-clinical) subgroups and subtypes of the syndrome. (Giles & Newbold, 2011, p. 420)

This research indicates that discussions based on the ‘illness-ness’ of mental illnesses are very important to the individuals posting on mental illness bulletin boards. Moreover, the securing of mental illness as an illness is part of the identity work completed by participants on these boards. A similar centrality of illness identity to PVP

authors’ sense of self is found throughout the thesis corpus.

Chapter 7 capitalises on the reader’s familiarity with LIAM in order to provide a more far-reaching analysis. Like Chapter 6, this chapter is focused on a single type of statement: in this case, that ‘affective disorders are illnesses’. It continues the examination of the use of hierarchy in the enhancement of an author’s legitimacy. However, unlike Chapter 6, this chapter engages with a broad range of examples, including explicit illness claims, analogies with physical conditions, and the separation of self and illness. In comparison with Chapter 6, which focused on ‘severity’ as a signifier of illness legitimacy, Chapter 7 is concerned with how association with – and disassociation from – particular entities enhances author and illness legitimacy.

The chapter is divided into three sections. The first section examines instances where affective disorders are explicitly identified as illnesses. Throughout this first section it is argued that authors are conflating affective disorders with the more valued category of physical illness in order to increase the legitimacy of their experiences. The second and third sections examine instances where distinctions and exclusions are used to separate affective disorders from less esteemed categories of illnesses. The second section is focused on categorical distinctions, specifically between .#0 #-), ,- )(." )( "((-., --(-#./.#)(&#-., --)(." )." ,. The third section examines instances of separating self and illness in order to refute accusations that an affective disorder is a form of personal failing. It is argued throughout the chapter that both the conflation with more esteemed categories and the separation from less esteemed categories function to maximise an author’s legitimacy and integrity. Specifically, these rhetorical devices position the person diagnosed with an affective disorder as being a legitimate candidate for medical treatment and not to blame for their suffering.

Previous research has highlighted the tension between productive and destructive aspects of the medical model of affective disorders (Fullagar, 2008; Gardner, 2007; Gattuso, Fullagar & Young, 2005). On the one hand, understanding affective disorders as illnesses enables individuals to access particular forms of intervention and treatment by positioning the person’s condition as a recognisable and ‘real’ medical problem. On the other hand, the dominance of medicalised understandings of emotional distress PVQ results in only certain treatment options ‘making sense’. Such limitations may mean that a person feels unable to access the treatments they believe to be most beneficial. Moreover, any person who does not embrace the dominant medical model in their affective disorder narrative is likely to have their status as an epistemic agent or rational subject questioned (see Chapters 2 and 9). This tension between the productive and destructive aspects of the medical model is apparent throughout this chapter. The examination of this tension begins with an analysis of the rhetorical function of the most explicit illness claims.

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"%!)$#($)$+$*(3')$'!*#)$#($-%!)!!#((!"( Many authors across the dataset explicitly state that affective disorders are illnesses. These statements tend to occur in discussions of stigma or medical treatment. This section provides insight into the way that these ‘obvious facts’ function rhetorically within these narratives.

Although research suggests that statements that position affective disorders as ‘just like any other illness’ may increase stigma, authors routinely try to use such statements to mitigate the stigma of their condition (see Chapter 9 for a discussion of shame and discrimination). For instance, a contributor to the Journeys with the Black Dog anthology states:

I am not ashamed of depression and recognise it is an illness and is treatable. (JwBD 34)

By placing a lack of shame and recognition of depression as illness within the same sentence, these two claims are positioned as being related. It is as if the author is saying that depression is not shameful because it is an illness. This logic – that the status of depression as an illness means that it is not shameful – is extremely common across the dataset and has also been identified by several other researchers. For instance, Foster (2007, p. 58) notes that an English periodical for individuals with depression

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consistently represents depression as a physical illness and advocates that ‘to label it in any other terms is both unfair and stigmatising’.

Such claims gain epistemic authority through rhetorical mechanisms that secure their status as ‘fact’ (see Chapter 8 for detail on epistemic authority). Word choice is particularly important in the achievement of this effect. For instance, the use of the verb ‘recognise’ (rather than, for example, ‘interpret’, ‘believe’ or ‘think’) in the quotation above suggests that the author has gained access to a self-evident truth or fact. Thus the author is protected against accusations of bias or dishonesty and in turn is positioned as a rational and legitimate subject.

In addition to the use of a juxtaposition to imply that the capacity to treat a condition indicates that it is an illness, authors routinely offer evidence to support their claim that depression is an illness. The evidence provided in the above quotation is that depression ‘is treatable’. Since ‘treatment’ in western medicine is generally only appropriate for those with an illness, if treatment is provided to people with depression, it is implied that depression must be an illness. This positioning of depression as illness provides the author with a reason why they do not feel ashamed. In other words, by understanding depression as a legitimate illness, the author is able to successfully negotiate their original sense that depression is shameful.

Explicit illness claims often occur when a distinction is being made between affective disorders and other types of emotional experiences. Such claims typically emphasise the ‘illness-ness’ of affective disorders by positioning them as more severe or ‘real’ than ‘normal’ emotional distress. For instance, early in her book My life as a side effect, Deitz repeats several times, and in several different ways, a distinction between depression and non-pathological low mood (the ‘normal ups and downs’ of life). In order to do this, Deitz explicitly claims that depression is an illness:

The stresses of my everyday life may not make me feel so good, but they don’t make my illness any worse. With or without stress, I still have an illness. And with or without stress, I still get depressed. Sometimes I don’t get depressed although I’m under a lot of pressure and vice versa. (D 8)

PVS Within this quote, the term ‘illness’ is used twice; in both cases it is used to argue that depression is not caused by normal life events such as stress. This understanding requires that the author position depression and stress as separate conditions, one of which is an endogenous pathology and one of which is a exogenous normative variation in experience. By making this distinction and repeatedly using the term ‘illness’, Deitz securely positions depression as a significant medical condition (see Categorical separation of illness and sadness, below).

In this quotation, depression is positioned as an illness that is independent of Deitz’s experience of stress. The claim that depression is an illness can also be made through a common association with the body and death. For instance, Rowe in The best of times, the worst of times recounts her experiences in a variety of psychiatric wards. In one of these accounts, she describes the outward manifestations of psychotic postnatal depression in one of the other patients. In the context of describing a psychotic reaction by the patient to her husband (the patient is singing nursery rhymes while hugging and clinging to her husband), Rowe states:

This was what this potentially fatal disease could do. (BT 102)

By using the familiar phrase ‘fatal disease’, the claim that depression can cause death emphasises the severity of the condition. This emphasis on the severity of depression is found in a range of other documents and has been observed by other researchers (see Chapter 1). For instance, Rowe et al note that discussions in Western Australian newspapers of mental health policy tend to involve:

a subtle implication of panic evident in the construction of depression as an “epidemic”, “a rising tide” against which a “national assault” needs to be launched, a “major health problem” producing widespread “disability” which needs to be “tackled”. Such extreme case formulations (Pormerantz 1986, Edwards 2000) justify the focus of bureaucratic attention on the condition as requiring new initiatives, interventions and resources’ (Rowe, Tilbury, Rapley & O'Ferrall, 2003, p. 688).

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Returning to the corpus quotation, and consistent with discussions of suicide in the previous three chapters, the physicality and finality of suicide positions depression as a serious illness. At a more basic level, the statement that depression is a fatal disease explicitly locates it as a recognised physical ailment.

Explicit illness claims are also found in the internet postings. Below is an explicit example from each of the internet sources:

Sometimes it takes taking a chance on science and medicine when dealing with a medical problem like depression. (BB 327)

The problem was that I was sick with depression. (RO 65)

When I was sick, I thought that there was no cure and that I would be like this for the rest of my life but that’s not true […] Get help and see your doctor. That’s all it takes [to get better]. (HS 205)

As these examples demonstrate, internet authors routinely use explicit illness statements to position people with affective disorders as legitimate ill subjects who are genuine candidates for medical treatment. This rhetorical function is the same as that found in the autobiographical examples examined above.

When authors say ‘depression is an illness’, they are using the category ‘illness’ in a very particular way. Within affective disorder narratives, ‘illness’ is conceptualised as a serious and treatment-worthy condition that is categorically distinct from non- pathological emotional distress. While authors in this study do not question or position such attribution as a decision or choice, some researchers have found that a minority of participants are aware of their strategic use of particular illness narratives. For instance, Estroff, Penn and Toporek (2004) quote a consumer panel member in the United States who said: ‘The mental health as illness theory works for me. It works for a lot of people that I know’ (p. 495). The effects of such positioning are identified by Greenberg (2007) who argues, ‘there’s no use denying that the depression doctors have succeeded in commanding for the unhappy the resources we generally grant to the sick – money for research and treatment, time from doctors and nurses, and, perhaps most important, the

PVU kind of sympathy due a victim’ (p. 357). Within the corpus, these kinds of strategic appraoches are rare, with authors consistently understanding affective disorders as illnesses, and thereby enhancing the legitimacy of their experiences of emotional distress.

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In addition to explicitly saying that ‘affective disorders are illnesses’, it is common for authors to compare or associate affective disorders with physical illnesses. Such statements have the same basic rhetorical function as explicit illness claims as they increase author and illness legitimacy through an association with recognised illness categories and are often actively encouraged in mental health awareness campaigns in Australia, the United Kingdom and the United States (Foster, 2007; Greenberg, 2010; see also Chapter 12). How authors experience and conceptualise affective disorders is reflected in their choice of illnesses for comparison with these disorders. In this section, a detailed example will introduce the reader to the strategic use of analogies; this will be followed by an examination of which illness are – and are not – compared to affective disorders and an extended discussion of the most common comparisons.

When authors compare affective disorders to physical illnesses they are enhancing the legitimacy of the affective disorders by positioning them as equivalent to physical ailments. In the following quotation, Rowe describes how people who do not experience depression or bipolar can, at times, misunderstand these conditions and advocate for inappropriate treatment:

If I had a broken leg that was in plaster, family and friends would not urge me to make a decision that the leg was mended and to remove the cast myself. If I had a colostomy bag, I would not be told to take it off before I had a bowel resection. If I had diabetes, I would not be urged to throw away the insulin and needles and meditate instead. However, depressed people don’t look as if they have anything wrong with them that a good “talking-to” about counting their blessings won’t fix. (BT 120)

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Within this statement, the analogy with physical ailments functions to construct depression as a particular type of illness. Specifically, the three physical conditions are positioned as very similar types of experience through the repeated sentence structure: each sentence repeats the first three words ‘If I had …’ and then goes on to describe a situation, a reaction by another and a need for ongoing care. In the final sentence, the use of ‘however’ positions people with depression as equivalent to those with a physical illness in the type of illness that they experience, but different from those with a physical illness in the type of reception they receive from friends and family. In this way, Rowe is making a moral claim regarding the treatment of people with affective disorders. Specifically, she is indicating that since affective disorders are the same as other physical illnesses, family and friends should treat individuals with these disorders with the same respect and empathy as they do individuals with non-psychiatric conditions.

In addition to the general meanings of comparing depression to physical illnesses, more specific meanings can be ascertained by examining the characteristics of the conditions that are compared with depression. The physical illness examples function to justify and normalise ongoing medical treatment for affective disorders, with each physical condition positioning depression as a particular type of illness. A broken leg, in this instance, is represented as an ailment that requires time and protection in order to mend, suggesting that depression, too, requires time and (emotional) protection in order to heal. A bowel resection requires a colostomy bag to be used until the resection has been completed: by implication, depression also requires medical items (i.e., medication) and is very messy without it. Diabetes, according to Rowe, is an illness that requires ongoing care using insulin and needles and is not curable by ‘alternative’ treatments such as meditation; similarly, depression is understood as not curable through non- medical practices. This equating of depression and physical ailments is consistent with Rowe’s ongoing insistence that mainstream western medical interventions such as medication and hospitalisation are the most appropriate forms of treatment for depression (see for example, BT 12, 120-121, 127).

PVW Variety of illnesses

Rowe is one of many authors in the corpus who use comparisons between physical disorders and depression in order to position depression as a particular form of illness. Across the autobiographies and internet postings, a variety of different physical conditions are compared to affective disorders. These include:

• Cancer (JwBD 81, 138, RO 26) • Multiple sclerosis (D18); including tumour (JwBD 221); • Chronic illness (D 20); • Diabetes (D 20, 60 17V 74, RO • Life-threatening illness (BT 52); 172); • Heart complaints (17V 74); • Flu (JwBD 221, RO 26); • Asthma (D 20, 17V 75, 74); • Glandular fever (JwBD 221); • Broken bones (17V 38, JwBD • Toothache (JwBD 221); and 158, BB 223); • Twisted muscle (RO 26)

The range of illnesses that were compared to depression in the corpus is consistent with Lafrance’s study of Canadian women’s accounts of depression. Lafrance notes that:

[…] participants compared depression to diabetes, cancer, heart disease, migraine, asthma, elevated cholesterol, impaired vision and broken bones. Notably absent in participants’ accounts were comparisons between depression and mental illnesses. By equating depressive experiences with biomedical conditions, women’s distress is situated under the purview of medical science, and afforded the legitimacy granted therein. (Lafrance, 2007, p. 131)

A similar set of conditions – ‘diabetes, arthritis, high blood pressure, heart disease, or asthma’ – are also used in comparisons with depression on websites advertising antidepressants (McMullen & Herman, 2009, p. 1578). The use of references to physical conditions and the implied link to medical science in order to position authors as sufferers of ‘real medical conditions’ is also observed in this dataset. The most common comparisons in the corpus are with physical illnesses or ailments that are effectively managed by medical intervention and are serious but not fatal as long as they

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are treated. This suggests that authors wish to position affective disorders as having these characteristics. The examples above support this interpretation.

Equally significant as the conditions that are compared to affective disorders are those conditions that are not compared. Within the corpus, blood-borne viruses (BBVs) and sexually transmissible infections (STIs) are not compared to affective disorders. As is discussed at length later in this chapter, representing affective disorders as illnesses functions to reduce blame for an author’s symptoms and to refute claims that the author is lazy, weak or has a flawed personality. The avoidance of comparison with BBVs and STIs is therefore unsurprising, as these conditions are not commonly understood as blameless illnesses (Hood & Friedman, 2011). Comparisons with these conditions are likely to reduce the legitimacy of affective disorders by associating them with (other) stigmatised conditions. Put simply, given the pre-existing stigma against those with STIs or BBVs, saying ‘I have depression, it’s just like having chlamydia’ is unlikely to help an author gain sympathy or empathy about their condition.

Authors regularly claim that affective disorders are a type of mental illness. However, they do not compare affective disorders to specific mental illnesses, such as schizophrenia or anorexia nervosa. Considering the substantial similarities between affective disorders and other mental illnesses, the lack of these comparisons is likely a result of rhetorical, rather than logical or practical, considerations. Specifically, a comparison with other mental illnesses cannot function as a way to bring psychiatric conditions into the – more socially legitimate and acceptable – realm of ‘simple’ physical ailments. Rather, such comparisons would securely locate affective disorders in an illness category that is highly stigmatized, particularly as many other psychiatric conditions are even more stigmatised than affective disorders (e.g., psychotic or personality disorders). Thus, to use other mental illnesses in comparisons with affective disorders would harm, rather than enhance, the legitimacy of authors as ill subjects.

Analogies with physical conditions appeared more common in autobiographical data than in internet data, with youth pages being particularly devoid of this type of statement. It is likely that this pattern reflects the age differences between the two data sources. Specifically, analogies with physical ailments are most useful to authors who understand or position affective disorders as physical illnesses that have a biological

PWO cause. Young people rarely utilise purely biomedical accounts of their suffering. Instead, they tend to focus their narratives on descriptions of their life circumstances (see for example RO 10, 16, 32, 37, HS 121, 149, 217). Given this, it is unsurprising that young authors use fewer comparisons with physical illnesses than adult authors.

The following two sections examine the most common ailments compared to affective disorders, namely broken bones and diabetes, and discuss the possible rhetorical use of such comparisons.

Empathy: Broken bones

Across the corpus, authors compare depression to a broken leg (JwBD 158, 107, BT 120), a broken arm (JwBD 221, 17V 40, BB 223), and a broken pelvis (17V 39). Despite the routine use of these comparisons, there are relatively few similarities between broken bones and depression. For instance, broken bones are typically temporary; in comparison, affective disorders tend to be long-term conditions that do not have a clear or regular trajectory towards recovery. A medical professional can determine that a bone is broken through screening processes such as x-rays; in contrast, there are no bodily scans to diagnose an affective disorder. Finally, frequently a broken bone is treated in a way that visibly signifies the ‘problem’, for example with a cast, sling or other immobolising technology; however, there are no treatments for affective disorders that are continuously or highly visible. This lack of similarity suggests that the reliance on a comparison between broken bones and affective disorders is rhetorical rather than based in the comparability of the conditions.

The analogy with ‘broken bones’ provides a specific image of the nature of affective disorders. Specifically, it is implied that affective disorders are a recognised, nonstigmatised and simple medical problem that can be cured or medically managed to ensure that the body can heal itself. Moreover, associating affective disorders with a ‘simple’ and nonstigmatised physical condition increases the legitimacy of the psychiatric conditions. Authors tend to use this increased legitimacy to normalise certain reactions to individuals with mental illness by both health professionals and lay persons:

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When you have pneumonia or a broken arm people find it easy to empathise. When you’re suffering from a “mental illness” people are uncomfortable. They either tell you what to do, put a positive spin on everything or they move away. (17V 38)

As with the earlier quotation from Rowe, the implication of this statement is that mental illness is different from pneumonia or a broken arm, not because it is a fundamentally different form of illness, but because it is regarded differently by people who are not experiencing the illness themselves. Specifically, Eva contrasts the empathy that she believes is normal for individuals experiencing non-stigmatised physical conditions with common negative responses to people with a mental illness. By comparing responses to people with an easily identified physical condition, the quotation functions to normalise desired responses to emotional distress. Thus, consistent with Rowe, this quotation suggests a moral claim regarding how people with mental illness should be treated.

In addition to normalising empathy and respect in the community, the analogy of broken bones is used to justify access to health professionals. For instance, one of the contributors to the Journeys with the Black Dog anthology writes:

I knew there was no shame in seeing an orthopaedic surgeon if I had broken my leg; I knew it made sense for my wife to consult a gynaecologist when birth complications threatened; but to see a psychiatrist was … well, somehow, it was demeaning. (JwBD 158)

Within this quote, the author contrasts professional help-seeking behaviour for physical and psychological issues. Such a comparison suggests that these are comparable forms of malaise and that help-seeking behaviour for psychological conditions is acceptable precisely because such behaviour is appropriate for (other) physical conditions. The author’s references to shame positions his unwillingness to go to a psychiatrist as a response to the general stigma associated with mental health care (see Chapter 9). By referring to nonstigmatised physical conditions that irrefutably require intervention by a health professional, the author destigmatises both depression and going to a psychiatrist.

PWQ As with the quotations above, such destigmatisation helps to position depression as a legitimate illness by associating it with culturally recognised forms of illness.

Manageable through medication: Diabetes

Comparing depression to diabetes is common across western countries, with several academics noting the dominance of this analogy. For instance, in their study of women’s use of biomedical explanations as a mechanism for reducing the stigma of depression, Schreiber and Hartrick (2002) observe that ‘a remarkable number of women described depression as a biomedical disorder similar to diabetes’ (p.96). Other academics also report finding diabetes analogies in their data, most often when participants were justifying taking antidepressants (see for example Fullagar, 2009; Oliphant, 2010; Rowe et al., 2003).

Authors in the corpus use a comparison between depression and diabetes when they claim that the Australian community is more supportive of individuals with diabetes than of those with depression (GC 143, JwBD 94, 107) and when they indicate that the use of antidepressants should be no more stigmatised than the use of insulin (JwBD 159, BT 120, D 60). Consistent with international research findings, these statements typically function to position affective disorders as biological conditions that require regular and ongoing medication. An example of this positioning is a quotation from George, a contributor to 17 Voices, who identifies as having obsessive compulsive disorder and generalised anxiety disorder. In this quotation, the comparison functions to explain why George is still legitimately sick despite a lack of observable symptoms:

I went interstate by train last weekend for that air show. I mentioned to three ladies I was talking to that I had an ‘anxiety disorder’ and one woman said to me, ‘You don’t look sick’. And I thought, ‘Well, what is sick?’ There are so many people with diabetes, heart complaints or asthma who don’t look sick. (17V 74)

Within this quote, George is countering the claim that anxiety is an illegitimate illness because it is invisible. The statement that anxiety is a sickness because other (physical) sicknesses are also invisible functions to enhance the legitimacy of anxiety as an illness

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category. Along with being – potentially – invisible, the three illnesses have many other characteristics in common. Specifically, they are chronic, require regular and long-term medication, are spectrum disorders that have symptoms varying from mild to severe and are caused by an interaction of biological/genetic and environmental factors. George may have selected his examples in an attempt to demonstrate that a wide range of legitimate medical conditions, including anxiety, are invisible. However, by comparing anxiety to conditions with such significant similarities, he suggests that anxiety also has these characteristics.

A similar comparison between affective disorders and diabetes occurs in the Mental Illness Education Australia (MIEA) factsheet reproduced in My life as a side effect. The factsheet states that:

Mental illnesses are just like other forms of illness, such as diabetes or asthma. (D 21)

The claim that mental illnesses are ‘just like’ physical illnesses functions to protect people with psychiatric disorders against the accusations of culpability by associating psychiatric conditions with illnesses that are commonly considered ‘blameless’. Put differently, within this quotation, the legitimacy of diabetes and asthma as recognised illnesses that do not deserve stigma or blame is extended to mental illness.

In an atypical use of the diabetes analogy, Rose both uses and refuses an equivalency between depression and diabetes. Specifically, she states that her psychiatrist:

… told me that I should behave as if I had an illness like diabetes and that I needed to take my medication. I found having it described as a long-term illness liberating. I suddenly found the whole thing easier to cope with. (D 60)

Diabetes, as imagined here, is the severe form of the illness that requires the use of insulin (i.e., type I). A milder form of diabetes cannot be what is meant in this example since type II diabetes is generally managed through lifestyle and diet (not medication) (Barnard et al., 2009). Unlike many medications, if insulin is not used regularly and carefully it can produce rapid and extreme consequences such as a diabetic coma. The

PWS implication is that antidepressants are similarly volatile and life-sustaining medications. This claim functions to position depression as a serious illness that may be deadly (presumably via suicide) and to justify the use of antidepressants by representing them as a necessary or life-saving treatment for this illness. This alignment with a medical understanding of depression is somewhat undermined through Rose’s positioning of the comparison as analogy rather than ‘truth’.

Unlike the two examples above, Rose is not saying that depression is the same as diabetes. Rather, she states that she should act as if she had an illness like diabetes. This suggests that she does not truly believe that the two conditions are comparable. Moreover, at the end of this quotation, Rose shifts again into a strategic use of a comparison between physical and mental illness. By stating that she ‘found the whole thing easier to cope with’ the author implies that the benefit of a comparison between diabetes and depression is not her gaining of knowledge or ‘truth’ about her condition. Rather, the comparison is deemed beneficial because it reduces her distress at maintaining medical management of her depression. Rose conceptualises the comparison between depression and diabetes as a useful way of thinking about her current situation. This agnostic approach to medical knowledge is uncommon across the dataset (see Chapter 8). Far more common are the implied wholesale acceptance and repetition of the biomedical accounts described above.

The use of asthma, diabetes and broken bones in analogies with affective disorders is dependent on oversimplified understandings of these conditions that inaccurately portray them as uniformly without environmental or behavioural cause. Each condition is not as ‘purely’ physical as authors tend to imply: asthma is made worse by environmental factors such smoking and dust mites, broken bones can be the unavoidable result of accidents or the preventable result of actions at the skate park, and diabetes can be a genetic condition (type I) or precipitated by obesity and poor diet (type II). Such comparisons are thus oversimplifications. Despite this, these comparisons are still effective rhetorical strategies as they successfully challenge certain beliefs about affective disorders (e.g., that they are the result of laziness or personal weakness). Such comparisons are often useful for authors as they position affective disorders as biological illnesses that are just as severe as (other) chronic physical

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illnesses and require – and deserve – mainstream medical intervention. Such comparisons also have broader implications for discussions of agency and choice:

The debate on control and responsibility echoes discussions as to the parallels which can be drawn between physical and mental health: if a client “suffers from” depression in the same way that an individual might “suffer from” diabetes, how much control can that client have over that condition? Such arguments, of course, assume that those who suffer from physical ailments are not seen as responsible for their conditions, something which some theorists argue is not universally the case, especially in an increasingly secular society in which health might be said to have taken place of religion in defining goodness and morality. (Foster, 2007, p. 169)

Thus, while initially appearing as relatively banal analogies, the comparison of affective disorders with physical conditions has significant implications for how people with affective disorders conceptualise their experience and what behaviours they feel are acceptable during an episode (see Chapter 10).

Counter narratives

The vast majority of comparisons between physical illnesses and affective disorders are used to support conceptualising affective disorders as equivalent to physical illness. However, there are several authors who maintain a categorical distinction between physical and mental illness, and by doing so question the validity of understanding affective disorders as physical illnesses.

Eva, a participant in the 17 Voices project who is skeptical of the value of mainstream mental health interventions, argues for maintaining a distinction between physical and psychiatric illnesses. She states:

I just don’t think that psychiatric diagnoses are the same as diagnoses like ‘broken pelvis’ and ‘arthritis’. I’ve been given different diagnoses at different times in my life, simply because I was dealing with different issues and was

PWU distressed in different ways … just like anyone else would be. (17 V 39, ellipse in original)

In this quotation, a categorical distinction between physical conditions and emotional distress is enacted. Specifically, instead of positioning her emotional states as symptoms of mental illness, Eva represents her distress as an indication that she is processing or ‘working through’ different issues. By doing this, Eva indicates that her emotional distress is not pathological and therefore should not be compared to physical ailments. Simultaneously, and perhaps contradictorily, there is also an implicit contrast between the definitiveness of physical illness diagnosis and the inconsistency of mental illness diagnosis. Again, this positions emotional distress and physical illness as categorically different.

Unlike the majority of authors who position their experience of emotional distress as legitimate because it is an illness experience, Eva represents her emotional distress as legitimate because it is the experience of an autonomous and self-determining person. In other words, in the previous examples, the author’s legitimacy was enhanced through an association with the legitimate or esteemed category of recognisable physical illnesses. In contrast, this quotation indicates that Eva presupposes a high level of legitimacy of the author as an individual and utilises this characterisation to maintain her legitimacy despite her diagnosis with several mental illnesses. Although very uncommon, Eva’s understanding demonstrates an alternative way of understanding the nature of affective disorders.

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As described in Chapter 2, the scientific evidence regarding the biological aetiology of affective disorders is still in its infancy. Despite this, authors often fully embrace biological accounts, and represent theories of the biological aetiology of these disorders as irrefutable fact. As many researchers have already noted, biological accounts assist individuals to narrate coherent accounts of their suffering in a way which, to use the terminology of this thesis, maximises the legitimacy of participants as ill subjects

PWV

(Knudsen, Hansen, Traulsen & Eskildsen, 2002; Polvere, 2011; Ridge & Ziebland, 2006; Tekin, 2011).

The associations and meanings given to the biological basis of affective disorders is revealed by identifying the parts of the body that authors typically understand as being the cause of their condition. The following are the most common mechanisms or parts of the body that are understood as being ‘faulty’: • Brain (JwBD 118, BO 81); • Brain chemistry (JwBD 160, 246, BO 81, BB 319, 326, 342, HS 79, 97); • Neurotransmitters (D 25, BB 364); • Serotonin (BB 365); • Brain cells (BT 123); and • Genes (D 33, HS 77).

Note that almost all the authors locate the aetiology of affective disorders in the brain, a placement that makes sense given that these conditions are identified as mental illnesses. However, the dominance of the brain in these accounts demonstrates a lack of awareness of the range of parts of the body that are part of the biological expression of depression (e.g., approximately 80% of the serotonin in the body is found in the digestive tract, rather than the brain, Greenberg, 2010, p.268; Wilson, 2004a). In addition, the lack of specificity in the descriptors indicates a rudimentary understanding of theories of the biological causes of affective disorders. Specifically, although aware that the biological causes of depression are located in the brain, and often have something to do with the chemicals in the brain, the authors rarely discuss the specificities of this; seldom do they refer to serotonin, dopamine, norepinephrine, epinephrine, monoamine etcetera. This suggests that rather than using biological explanations because they have a strong understanding of these theories, authors are using a basic account of biological causes as a way of making their experiences more understandable and legitimate to themselves and to others. This point is also made by Watters (2010), who writes:

When these scientific advances are translated into popular belief and cultural stories, they are often stripped of the complexity of the science and

PWW become comically insubstantial narratives.

In popular accounts the nuance and uncertainty of biological explanations are erased. These simplified narratives are used as justification for medical interventions for emotional distress in a variety of discursive contexts including pharmaceutical advertisements, doctors’ consultations and the texts in the thesis corpus (Greenberg, 2010). In addition, although associating affective disorders with physical illness is a strategy used by corpus authors to increase their legitimacy, research indicates that the ‘physical illness’ category when applied to individuals with mental illnesses may actually increase stigma. For instance, Mehta and Farina (1997) found that, in comparison with study participants who were given psychosocial explanations, individuals who were given biochemical explanations of their partner’s distress increased at a faster rate the severity of the electrical shocks that they believed they were giving to their partner. Moreover:

It is highly debatable whether “knowing” that depression is a biochemical malfunction actually works to counter social stigma. In fact, it may actually intensify shame through a sense that one’s somatic self […] is biologically or genetically flawed. (Fullagar, 2008, p. 338).

Corpus authors, however, do not seem to understand biological accounts as rhetorically ‘risky’. Instead, the use of these simplified accounts of biological aetiology is extremely common in both internet and autobiographical data sources. Such accounts sometimes position a chemical imbalance in the brain as the diagnostic category, as evident in the following posting from a young woman on headspace:

I was diagnosed with a chemical imbalance in the brain causing my depression and anxiety and was close to being put into a psychiatric ward at the local hospital. (HS 79)

Although there is no medical procedure available to diagnose a ‘chemical imbalance in the brain’, the author nonetheless positions her depression and anxiety as a consequence of this diagnosable condition. The ‘chemical imbalance diagnosis’ implies that her depression and anxiety are purely biological conditions that are not related to her

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psychological state or life circumstances. The biological account locates the author’s illness in her body. This positioning may function to mitigate any sense of blame that may be associated with affective disorders or being threatened with hospitalisation (see discussion of blame later in this chapter and in Chapter 9).

Another example of an author conceptualising affective disorders as biological conditions is a description by Rowe of her response to a set of unwelcome letters that suggested that her bipolar disorder was a result of spiritual issues:

[The letters] seemed to demand I stop seeing my illness for what it was – a confusion of brain cells – and see it the ‘right’ way that she espoused. (BT 123)

In this quotation, the biological account is positioned as the true or factual understanding of Rowe’s condition. According to this account, her disorder is the result of a biological fault, specifically a ‘confusion’ in the cells of the brain.

Although exclusively biological accounts are common, authors also routinely combine biological and environmental or spiritual theories of the nature of their depression. For instance, a contributor to the Journeys with the Black Dog anthology writes:

You could give up, but you won’t, because as well as having a bio-chemical imbalance in your brain, you also have a remarkable resilience in your soul. (JwBD 246)

Within this text, depression is positioned as having a biological cause. In contrast, the sufferer is represented as having the spiritual characteristic of ‘resilience in your soul’. In this way, while offering a more varied account than Rowe’s, the contributor is still ultimately aligned with a biological account of the cause of depression, as it is the biological aspect that is associated with the suffering, while the spiritual is positioned as either a reaction to the depression or an epiphenomenon. It is notable that the single- factor biological accounts found in the corpus do not appear as dominant in international research populations. For instance, Ride and Ziebland (2006), and Foster (2007) found that individuals with mental illness in the United Kingdom often used a

PXO multi-factorial model. These multi-factorial models have their own specific rhetorical function:

An important element of this multi-factorial model of causation is that it allows clients to remain somewhat agnostic on the question of whether mental illness has an underlying physical or social basis, as ultimately neither an internal or external model of causation is entirely satisfactory (Lewis, 1995). A multi- factorial model […] permits maintenance of a model of mental illness that emphasises the possibility of a physical foundation for mental illness, which is reliant upon triggers […] or catalysts. (Foster, 2007, p. 75).

The movement beyond single-factorial biological accounts in the UK is likely a result of cultural norms regarding ‘tell-able’ accounts of the cause of affective disorders in that country. In contrast to the UK, Australia remains more aligned with simplified biological accounts (see Chapter 12 and 13).

Within the three examples examined in this section, affective disorders are understood as having a biological aetiology. These accounts position affective disorders as a type of physical ailment. This positioning helps to normalise medical interventions, in particular the use of psychopharmacology, that are typically understood as addressing a physical deficiency in the author’s brain chemistry.

The consistent use of legitimising illness rhetoric is no longer as apparent internationally, with most other western countries experiencing the primacy of biological accounts w in the early to mid 1990s (Foss, 2002). For instance, Estroff, Penn and Toporek (2004) noted a greater variability in the understandings of mental illness by Americans with mental illness, arguing that ‘some people with psychiatric disorders object strongly to the assertion that what they have is only a disease, finding this attribution degrading […] Others find meaning and comfort with a “no fault” medical diagnosis’ (pp. 495-496). Moreover, researchers have noted that while the medical model may enhance legitimacy, in some instances it may have negative consequences for recovery. Wisdom and Green (2004) were particularly concerned about the effect of illness identity on recovery for teenagers experiencing emotional distress, arguing that:

PXP

Although some teens do find it useful to label or name their particular symptoms, our data indicate that for many, such labelling might be harmful, transforming attributions about symptoms into an illness identity that impedes recovery. (p. 1236)

While the effect of illness identity on recovery is unclear in the dataset, throughout the thesis a range of negative consequences associated with illness identity, such as reduced personal responsibility and reduced engagement with social determinants of wellbeing, are identified.

In Part I, the focus has been on how authors routinely compare affective disorders with more esteemed and socially accepted physical ailments. These comparisons function in the text to enhance author and illness legitimacy. In the following sections, the rhetorical function of distancing from less esteemed categories is examined.

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In Part II, the focus is on the rhetorical function of distinguishing between sadness or situational distress and depression. It will be observed that by distinguishing ‘serious’ depression from ‘normal life’ emotions and events, authors typically emphasise the severity of depression and thus justify medical treatment and autobiographical attention for affective disorders.

The distinction between sadness and depression is apparent in the following quotation from Deitz:

It is perfectly normal to feel unhappy or down sometimes, and you don’t always have to have a reason. Many people declare themselves depressed after a bad working week, a relationship break-up or a long period of unemployment. While these are all valid and understandable reasons to feel depressed, the difference between this sort of depression and clinical depression is that, in the majority of

PXQ the above instances, the depressed feelings are alleviated once the problem or issue has been addressed or the grief has been worked through. I use the word “depression” and the phrase “clinical depression” interchangeably throughout this book, but would like to point out that I am always referring to a chronic illness rather than a period of unhappiness. (Deitz, note to all readers)

In this quote, Deitz makes a categorical distinction between ‘everyday’ sadness and clinical depression. ‘Everyday’ sadness is understood as being a normal or inevitable part of life, a reaction to a particular event and a mood that lifts when the stressor is resolved. In contrast, clinical depression is an illness, more extreme and pervasive than ‘everyday’ sadness, and a chronic condition that does not have a direct relation to life events or stressors. As with other authors, Deitz positions the separation of sadness and depression as part of the ‘science’ of mental illness diagnosis. However, the clear-cut distinction between clinical and ‘normal’ sadness is exaggerated in affective disorder narratives, which tend not to acknowledge the uncertainty of the DSM-IV-TR diagnostic criteria (American Psychiatric Association, 2000). Greenberg (2010) makes this point rather forcefully when he says ‘the diagnostic criteria […] can’t distinguish between grief and depression, and […] as a result the diagnosis threatens to swallow everyday sorrows’ (p. 35).

By representing depression as an illness, Deitz separates depression (an illness) from unhappiness or sadness (a mood). This hierarchical relation is emphasised through the terms used to describe non-pathological low mood. Specifically, the term ‘unhappiness’ positions non-pathological low mood as being significantly less ‘serious’ than depression (compare ‘unhappiness’ to the words such as ‘despairing’ or ‘hysterical’ – see Chapter 4). Reinforcing this categorical distinction, the phrase ‘rather than’ positions ‘a chronic illness’ and ‘a period of unhappiness’ as mutually exclusive. This separation locates depression firmly within the realm of illness and the abnormal, and thus worthy of treatment and empathy.

A more caustic example of this distinction is seen in a quotation from Emily, a woman interviewed by Deitz, who describes her feelings towards her sister, who claims to be depressed:

PXR

I couldn’t feel empathetic. If she was really clinically depressed rather than just feeling down about her life at that time, I couldn’t understand how she could write a six-page letter. It didn’t even have a typo. When I’m seriously depressed I can’t even write a cheque. (D 89)

In order to justify her lack of empathy for her sister, Emily makes a categorical distinction between ‘really clinically depressed’ and ‘just feeling down about her life’. The use of the term ‘clinical’ reinforces an understanding of depression as a medical condition or illness. In contrast, the term ‘just’ situates ‘feeling down’ as being an insignificant experience, a positioning that locates ‘feeling down’ as being an everyday experience that does not deserve empathy. This, in turn, implies that Emily’s clinical depression does deserve empathy as it is a serious medical condition.

Another example of the distinction between sadness and depression is a quote from a young person on the ReachOut website who claims that people who have not experienced depression are unable to understand the experience. The author states that:

The community at large don’t seem to know the difference between feeling sad – which of course is normal – and clinical depression, which we know isn’t. This is because sadness only lasts minutes, hours or days. Depression seems to go on forever – like a pervasive and relentless sense of despair. (RO 32)

Depression, in this account, is a more extreme version of sadness, so that sadness is temporary, while ‘depression seems to go forever’. As discussed in Chapter 4, across the dataset it is common to use emphatic adjectives (‘pervasive’ or ‘relentless’) to stress the severity of depression. Like Deitz and Emily, when authors state that sadness is ‘normal’ and that depression is not, they are reinforcing a hierarchical relationship between sadness and depression, where depression is understood as an abnormal state that is more severe than sadness.

Temporality is used in this quotation to emphasise the severity of depression. In a modification of the temporality of depression and anxiety in Chapter 6, in this quotation depression is understood as the chronic and thus more severe condition, while sadness is positioned as the more temporary and thus less severe experience. The use of

PXS temporality as a signifier of severity is more common in the internet data sources than in the autobiographies (see for example HS 85, 141), perhaps because it is a particularly quick, although not necessarily informative, way of establishing one’s legitimacy as an ill subject.

In addition to the separation of depression and sadness, a distinction is made between those who have experiential knowledge of depression and those who are ignorant about depression (see also Chapter 9). This distinction is achieved through contrasting what ‘the community at large’ believe with what ‘we know’ to be the true nature of depression. The use of ‘we’ in this context has two rhetorical functions. First, it explicitly indicates that the author identifies with the group, which functions to legitimise and secure their identity as someone who has the right to speak on this topic. Second, this in-group identification functions to position the author’s knowledge claim as based in true personal experience, thereby indicating that they have the authority to speak on this topic (see above and Galegher, Sproull and Kiesler, 1998).

The representation of situational distress in the corpus is another example of the enhancement of author legitimacy through a separation from less esteemed categories.

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Authors in the corpus often have really good reasons to be miserable. Yet, despite identifying significant situational reasons for their distress, it is common for authors to use the illness paradigm to explain their feelings. Discussions of affective disorders and situational distress are most common in the internet postings, but they are also present in the autobiographical material.

Authors describe a variety of different situational stressors that accompany their depression or anxiety: • Bullying (HS 85, 128, BB 258); • Death of a loved one (HS 127, • Childhood abuse (including BB 344, 398, RO 52); physical, emotional and sexual) • Drug addiction (including (BB 373, HS 81, 83, 85, 87); addiction to marihuana, alcohol

PXT

and analgesics) (HS 101, 119, • Loneliness (HS 143, BB 315, 125, BB 240); 337); • Exams (including Higher School • Loss of home/homelessness (BB Certificate) (BB 240, HS 85, 87); 302, 383, HS 81); • Expelled from school (HS 122); • Miscarriage (HS 125); • Experiences of domestic • Relationship difficulties/end of a violence, harassment, trauma and relationship (HS 128, BB 240, (adult) sexual assault (HS 119, 302, 320, 398, RO 51); 125, RO 51, 52); • Serious illness (BB 320); and • Family break up (HS 101, 128, • Workplace difficulties (including BB 290, 294); loss of job) (BB 258, 268, 290, • Financial difficulties (BB 383); 370, 383 • Friendship break up (HS 122, BB 337, RO 51);

This list of stressors is consistent with the situational triggers identified by other researchers in Australia, the United Kingdom and the United States (Foster, 2007; Wisdom & Green, 2004; Rogers & Pilgrim, 1997). For instance, Kokanovic, Dowrick, Butler, Herrman & Gunn found that Anglo-Australians:

[…] presented accounts of major loss of health – their own and of their loved ones; loss of employment or major changes to their professional position and career, such as loss of status related to their working position; bereavement and problems in relationships with partners, parents and friends […] They talked about traumatic experiences, feelings of isolation, profound loneliness, unhappiness, lack or complete absence of social support, and financial pressures. (2008, p. 457)

In contrast, they noted that East-African Australians were distressed by:

[…] experiences of discrimination, racism, not having qualifications recognised, unemployment, poverty, isolation from members of the dominant culture who “don’t want to share with you your cultural things” (Labaan, Somali man),

PXU prolonged emotional distress as a result of not knowing the fate of relatives left behind, the separation from family members yet to migrate, and structural constraints of Australian law and bureaucracy that participants perceived as infringing upon and destabilising the family unit – in particular immigration laws relating to family reunion. (Kokanovic et al., 2008, p. 459)

This research highlights how affective disorders are culturally inflected conditions that are experienced and conceptualised in different ways by different communities (see Chapter 2). It also affirms the centrality of emotional distress in Australian affective disorder experiences, a centrality that corpus authors simultaneously acknowledge and minimise.

Authors rarely interpret their situation as legitimizing the full extent of their distress. Rather, they maintain that while situational factors may make their distress more severe, the extent and nature of their distress means that it should be categorised as a symptom of their illness.

For authors experiencing significant situational distress, positioning their affective disorder as an illness is a difficult rhetorical task. In the previous sections, a single mechanism for increasing legitimacy has been enacted: either associating with a more legitimate category or disassociating from a less legitimate category. In comparison, accounts of substantial situation distress may enact two, often conflicting, mechanisms for gaining legitimacy. The first mechanism has already been discussed at length and involves positioning affective disorders as a recognised and legitimate form of illness. The second mechanism enhances legitimacy by narrating experiences of extraordinary or extreme circumstances. The second mechanism for gaining legitimacy occurs when a statement is designed to incite reactions such as ‘Oh wow, you are so brave to have kept your job despite your brother committing suicide, your mother dying of cancer and your wife leaving you’. This situational understanding of affective disorders as a coping mechanism is rarely used as the sole explanatory framework by corpus authors. However, ‘pure’ situational explanations have been identified in other studies, particularly of PTSD, and in these instances, appear to increase author legitimacy without the use of a medical model of distress (see for example, Adame & Knudson, 2008, p. 168).

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As shall be seen in the examples below, at times these two narrative forms are enmeshed and strengthen one another, but in other instances, the narratives are in tension or conflict. In both instances, it is typical for illness narratives to maintain dominance, despite the enactment of situational accounts.

This tension is apparent in the following example from the Blue Board bulletin board:

I have been suffering from depression, anxiety, have panic attacks and have a social phobia for three years. I got like this due to work pressures and workplace bullying. I spent 3 weeks in hospital it didn’t help except making me feel safe. (BB 226)

In this quotation, the author pairs a normalising and pathologising account of their experience. On the one hand, the author’s response is normalised by describing extreme situational factors that are likely to be highly distressing for anyone. On the other hand, the condition is positioned as an illness when the author reports significant medical intervention in the form of hospitalisation. These two narratives are in separate sentences that appear distinct and almost unrelated. In this way, these two narratives are neither in tension nor entwined, but rather the author is positioning them as simultaneous yet separate accounts of their distress.

The tension between situational and illness legitimacy is more subtle in the following example from a contributor to the Journeys with the Black Dog anthology. In this text, the author lists numerous situational factors that would make many people feel profoundly unhappy, yet simultaneously positions her distress as an illness:

I am thirty-four-and-three-quarters. Divorced. Broke. Unemployed. Single. Childless. I was only officially diagnosed with depression four years ago, but truth be known, this dog has been my faithful companion since I was around eight years of age. (JwBD p. 119)

When the author states that she was diagnosed with depression, she asserts that depression is an illness. Despite this explicit identification with a medical understanding of depression, the author implies two conflicting accounts of the cause of her

PXW depression. On the one hand, the author may understand that being broke, single, etcetera, are the cause of the depression: in other words, ‘I am very sad because I am unemployed’. On the other hand, by acknowledging her 26 years of depression (her current age, 34, minus her age when she began experiencing depression, 8), the author may understand depression as causing the undesired life events: ‘because I am so depressed for so long I have been unable to get a job’. The possibility of both interpretations suggests that this quotation enhances the author’s legitimacy through both her situation and her illness status.

When examining patterns of narration across the corpus it is apparent that discussions of situational distress tend to add nuance to the author’s story. While acknowledging situational stressors, these descriptions tend to maintain the dominance of understanding affective disorders as illnesses. Specifically, the inclusion of situational factors merely expands the purview of the illness category so that it can now encompass strong emotional responses regardless (almost) of their cause.31 This is particularly apparent in narratives from the internet data sources – in these, it is common for authors to spend an entire entry discussing their situational distress and yet to simultaneously identify as having an illness that requires medical treatment (HS 119, 121, 128, BB 239-240, 290). Such narratives indicate that the authors understand their situational distress as an aspect of their illness.

By positioning depression as more severe than stress or sadness it is implied that depression is a (more) serious condition that deserves empathy and medical intervention. These distinctions rely on, and simultaneously reinforce, an understanding of affective disorders as illness.

When authors indicate that affective disorders are illnesses – and people with affective disorders are therefore understood as being sick – a unique set of social norms and expectations are implied (Arluke, Kennedy & Kessler, 1979; Fahy & Smith, 1999; Parsons, 1951; Segall, 1988; Shilling, 2002). In particular, the categorisation of

31 Where in Australia the association with illness is commonly understood to reduce stigma, in Norway health professionals mitigate stigma by telling ‘their patients that their nerves are perfectly normal reactions to harsh circumstances, cleansing them from stigma and sickness connotations’ (Foss, 2002, p. 203). This variation in what statements reduce stigma and increase legitimacy highlights how understandings of these conditions vary according to culture (see Chapter 2). PXX

affective disorders as illnesses enables help-seeking behaviour to become the moral responsibility of the sick person. Such moral responsibility requires the separation of the person (the moral agent) from their illness (the object to be acted upon).

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The separation of self and illness is predicated on an assumption that the condition that the author is experiencing is an illness. As such, it is embedded in the same assumptions and values that the explicit biological accounts discussed earlier in the chapter are embedded in. Like those biological accounts, the separation of self and illness functions to enhance an author’s legitimacy, by positioning the author as a legitimate ill subject.

When this separation is enacted, the self typically remains a positive category, while the illness absorbs the negative associations of the affective disorder diagnosis. By doing this, the author maintains legitimacy as a person, regardless of the negative valuing of the affective disorder diagnosis or the behaviours that are attributed to the disorder. Given these benefits it is unsurprising that some researchers promote this separation and go as far as to suggest that any other understanding of self is inappropriate (Ridge & Ziebland, 2006, p. 1045). Other researchers promote the separation of self and illness (referred to as ‘externalising metaphors’) as a treatment modality (see for example, McGuinty, Armstrong, Nelson & Sheeler, 2012). In a study more focused on discursive aspects of affective disorder narratives and experience, Lafrance identifies uses of a separation of self and illness in her interview participants that are very similar to those of the corpus authors (see also Michalak et al., 2011). Lafrance argues that ‘[b]y constructing depression as an independent entity (i.e., a biological condition), speakers defend against accusations that they are responsible for their own pain (for instance, by being weak, histrionic or malingering)’ (Lafrance, 2007, p. 130). This observation is echoed by Karp:

One function, then, of adopting the “biomedical causation theory” was that it allowed people to make the distinction, as they often did, between their “true selves” and their “illness selves” […] “Do I not want to go back to it, or is it because of the illness that I don’t want to return?” These and similar comments

QOO were meant to reaffirm the view that people suffering from depression are actually intelligent, proper people whose interactional competence is sometimes compromised by a disease. (Karp, 1992, p. 155)

The strategic use of a separation of self and illness is observed when writers discuss seeking help for their condition.

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The separation of self and illness positions an affective disorder as an entity that can be managed by the sufferer. Unlike a conflation of self and illness, which may result in a sense that all of one’s capacities are erased by the illness, the separation allows authors to represent a part of themselves as still able to be responsible and functional while not denying the severity of their debility. For example, the ‘black dog’ metaphor analysed in Chapter 4 typically positioned depression as an illness that authors did not have control over. By doing so, the use of this metaphor tended to enhance author legitimacy. In the following quotation, an author describes the responsibility that a depressed person has for managing their illness:

If you feel afraid, so what? Anything that really matters is always a bit scary. When you collar it, you own the dog. You formally recognise that it is not you but it is your responsibility. It is your job to ensure that your dog is not dangerously aggressive, is fed a healthy diet and exercised. You learn to be the master, just as it learns to be trained (JwBD 121, italics in original)

This quotation positions depression (‘it’) as separate from the sufferer (‘you’). This kind of non-human agent is also identified by Foster:

Objectification of mental illness as some kind of (potentially living) external entity might also occur when mental illness is represented as both external and controlling […] mental illness is often portrayed as another person or living thing: as such it follows you, you know it, you see it, and so on’ (Foster, 2003, p. 637).

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In the corpus quotation, the statement ‘it is not you but it is your responsibility’ explicitly differentiates self and illness in order to support accountability for recovery. By using a metaphor of a non-human agent, the author can simultaneously say that depression is not the fault of the person diagnosed with depression, but it is their duty to manage the condition once they have it. However, such positioning does result in a reduction in the coherence of self of the author. Thus, while enhancing the author’s legitimacy, their integrity is somewhat undermined.

In comparison with adult autobiographers, young people have a more ‘you can do it’ orientation and tend to use moralising statements less frequently, and when these types of statements are used, they tend to be less judgemental:

So keep dreaming and don’t let your fears get in the way. (RO 20)

We all need to value ourselves and focus on what we are good at […] You deserve to feel positive so try and see if it works for you. (RO 28)

You have nothing to be ashamed of. You can manage your illness and live a beautiful and fulfilling life. (HS 93)

You’re not alone, there are others suffering with you, and if you try to find out why you feel like crap and what you can do about it the better you will be. Don’t let depression destroy you. (HS 130)

These examples demonstrate the ‘you can too’ orientation of many of the internet postings. This orientation is likely to be the result of several factors, including in-group identification of the young people (i.e., since we are the same, if I can do it, then you must be able to as well), the short text length of internet postings, which encourages simplistic and supportive statements (see Chapter 3), and the tendency for young people to have experienced only a single affective disorder episode and thus to be more optimistic about the possibility of recovery.

QOQ In a more extreme example, Deitz writes that people with depression have an obligation to seek help and support. Deitz notes that depression symptoms and the ‘bad habits’ that may develop ‘alongside’ depression make help-seeking particularly difficult. She says:

Depression in itself is certainly not a bad habit, but it can be responsible for you developing bad habits alongside it. It’s possible that people who are trying to support you actually encourage your depression by way of letting you maintain any bad habits […] You might be saying and doing irrational things, but your emotions are still very real. It’s part of the illness and you and those around you have to realise this. (D 52- 53)

Within this quotation, pathological and non-pathological behaviours are separated. Specifically, bad habits are represented as distinct from depression-qua-depression. The term ‘bad habit’ signifies two things: that the action is undesirable, inferior or naughty and that it is not a necessity or requirement, but rather a tendency that could be given up. In other words, a bad habit can be characterised as a personality defect that one has a moral responsibility to alter. In contrast, depression is understood as an illness that can result in irrational actions and statements, implying that these irrationalities are not the fault of the individual, but rather an uncontrollable symptom of the illness.

It has been argued throughout this chapter that authors write in ways that maximise their legitimacy as ill subjects. This function of affective disorder narratives is partiuclarly apparent when the legitimacy or integrity of the author is put into question, such as when they are responding to stigmatising statements or recalling discriminatory experiences.

!!#(((#$)%'($#!!# By separating self and illness, authors are able to rebut accusations of weakness/failure and maintain their legitimacy or value as human beings. For example, a contributor to the Journeys with the Black Dog anthology expresses how their diagnosis reduces self- blame when they state:

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It was a huge relief to know that my problem was depression – not failure, weakness of character, or a flawed personality. I had an illness… (JwBD 30)

The quotation lists three personal characteristics that are positioned as antithetical to a diagnosis of depression: namely, ‘failure, weakness of character, or a flawed personality’. This quotation suggests that, where the symptoms in themselves may indicate failure or weakness, once those symptoms are placed into the context of an illness diagnosis, they are no longer signifiers of personal flaws. By separating self from illness, the author is able to maintain a coherent sense of self (i.e., their integrity) while still acknowledging that ‘something’ is wrong in their life.

In a very explicit example from the Journeys with the Black Dog anthology, a contributor writes:

It was simply a diagnosis. It means I suffer from a treatable, curable illness. I am no longer the problem, rather, it is this illness that I just happen to be a sufferer of. (JwBD 103)

In this quotation, the diagnosis enables the author to position their ‘problem’ as being an illness. Such identification then allows the author to separate self from illness (‘I’ and ‘it’). Moreover, when the author states ‘I am no longer the problem, rather it is this illness that I just happen to be a sufferer of’, the implication is that the illness is an independent agent that acts upon the author without their consent (Weinberg, 1997). This separation reduces the blame that the author self-imposes (‘I am no longer the problem’).

A more conditional understanding of the blamelessness of mental illness is found in Rowe’s discussion of her experiences of talking to her children about her diagnosis:

I have always impressed upon my children that mental illness does not demonstrate weakness, lack of character or some Lombrosian defects. (BT 127)

When Rowe says that ‘mental illness does not demonstrate weakness’ (emphasis added), it is implied that while a person diagnosed with a mental illness may be weak,

QOS the ‘fact’ of having the illness does not prove this weakness. Weakness, one suspects, would be indicated by the way that a person deals with the illness and the measures that they take to overcome it. In this way, the quotation functions to alleviate blame for the illness while still maintaining social expectations of appropriate character and behaviour.

The final example demonstrates how a comparison with physical illness (discussed in Part I of this chapter) can be utilised to mitigate accusations of weakness. In the context of discussing what she considers to be inappropriate representations of depression and the use of antidepressants in the media, Deitz states:

Clinical depression is an illness – no-one reacts to a need to be treated for pneumonia as being akin to admitting a personality defect. (D 16)

This quotation is consistent with those from Rowe and the two Black Dog contributors, with each quotation justifying the removal of blame from the sufferer through the categorisation of depression as an illness.

This type of reduction of personal responsibility is less common in the internet data sources. Where this minimising of blame does occur, it is generally in the context of encouragement to a particular person, such as ‘It sounds like your trying your best […] If people can’t see that or appreciate it, then that’s their problem’ (BB 270). Unlike the autobiographical sources, the internet sources are less concerned with destigmatising affective disorders through claiming that affective disorders are illnesses. It is likely that this is because, unlike the autobiographical authors who both explicitly and implicitly address an imagined reader who is discriminatory in some way, internet authors write in a way that indicates that they presume that the reader also experiences affective disorders. Thus, the need to garner reader empathy is less common in internet sources (see also discussion of age differences above).

By categorising depression as an illness, authors are able to refute accusations that their symptoms are ‘merely’ personal flaws or failings. These accusations are a significant cause of distress and suffering for people diagnosed with affective disorders (see Chapter 10) and have negative effects for help-seeking behaviour. Specifically, Jorm et

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al (2006) note that in the Australian general population, a belief that depression is a personal weakness was correlated with a belief that it should be dealt with alone (i.e., without interpersonal or professional assistance). Thus the categorisation of depression as an illness, when enabling individuals to avoid self-blame and maintain their self- esteem and respect, is beneficial because it supports help-seeking behaviour and may reduce an author’s sense of isolation by indicating that other people also experience extreme emotional distress. This benefit is not limited to people who experience affective disorders but also extends to their caregivers. Cornwall, Scott, Garland and Pollinger (2005) found that attributing the cause of a person’s depression to interpersonal issues (rather than, say, a biological condition) significantly increased the level of distress experienced by caregivers. Presumably this finding reflects the sense of blame that caregivers may experience when interpersonal issues are understood as the cause of their loved one’s distress.

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This chapter has examined instances when authors posit that affective disorders are illnesses. It has noted that these statements typically function to position affective disorders as chronic conditions that require – and deserve – medical intervention, and which do not reflect personality flaws in the sufferer.

In the corpus, there were three key ways that the understanding of affective disorders as illnesses functioned to maximise author legitimacy. First, by conflating affective disorders with (other) physical conditions, the legitimacy afforded to physical illness and the medical discourses in which such conditions are embedded is extended to affective disorders. This conflation relied on simplified understandings of physical ailments and proved to be highly strategic with the routine use of comparisons to diabetes and broken bones and the studious avoidance of comparisons to other mental illness, STIs and BBVs. Second, by separating affective disorders from the less esteemed ‘normal life experiences’ of stress, sadness and situational distress, authors justify their access to medical services and personal empathy. This mechanism was used less by young people, who were more likely to combine biological and situational accounts of distress. Third, through maintaining an illness model of affective disorders, a separation between self and illness is enacted which functions to refute accusations

QOU that the author’s affective disorder diagnosis is indicative of personal failing. Again, young people used this mechanism less than adult authors, perhaps because of less concern about negative evaluations by others. The diverse nature of these mechanisms suggests that the establishment of legitimacy is a significant rhetorical aspect of affective disorder narratives, supporting the centrality of LIAM in the thesis analysis.

The following chapter will build on Chapter 7 by furthering the examination of how the ‘illness-ness’ of affective disorders is represented in the corpus. In Chapter 8 the focus will be on the rhetorical function of accounts of medical consultations, treatments and knowledge. In order to develop LIAM, the focus will shift from author and illness legitimacy to epistemic and professional authority. Taken together, Chapters 7 and 8 will demonstrate that while integrity is a significant rhetorical function, it tends to be obscured by the more obvious and crude rhetorical functions of legitimacy and authority.

QOV

I arrive later than I had expected. The hospital grounds are large – filled with excessively undulating fields and occasional trees with accompanying well-placed benches. I feel like I am stuck between the English fields of some Victorian romance and the torture chamber of some horror thriller. I get lost, go around in circles looking for where I am meant to go. For some reason, I thought a psych hospital would have simple grounds with clear signs. It seems that the exact opposite is true – the god of this particular part of the world has a penchant for obtuse names and fallen down buildings. I wonder if all the buildings have patients in them, how many patients are chronic or acute, how many sectioned or voluntary. I know this is a ‘bad’ hospital; my friend was unlucky that she attempted suicide in a rather busy week and has been shunted to this place. I think it should be raining, for the oppressive greyness I feel seeping into me here stays with me for days. Eventually I find the particular ward I am looking for. It is an old building with cracks in the concrete. I press the buzzer, completely unsure that this is the place that I should be going. I wait. Out bustles a nurse. I don’t know the protocol of places like this and Lisa’s mobile was taken off her before she had time to tell me. I say something overly polite about wondering if it is possible to see Lisa, that I am a friend. I’m asked if I’m expected. I lie and say that ‘yes, she knows I’m coming’. Lisa had begged for me not to come, but I wanted to see her. She had just attempted to run her car off a cliff and had some head injuries. But I knew she was scared and in a place which would encourage her particular fears to become fearsome monsters. I knew her shame was deep and wide and that there will only ever be a handful of people who would be told that she is here. For these reasons, I have turned up unannounced to the locked ward. The nurse unlocks the first of several doors. I enter the ward and am told it is dinnertime. The patients are all sitting at a long table. Lisa is, as always, attempting to look as dignified as possible. Even here, her rules of decorum are in full swing. The nurse lets her know that I am here. She comes out into the corridor. Under her makeup I can see that there is a bruise over her eye and down her face. Over the next few weeks, the bruise will wander over her face, up higher and then lower again. For now though, she is saying I should not have come. I tell her that I wanted to see her and it’s OK. We hug for a time longer than her rules of decorum would usually allow. She starts to cry. Even when she was last in hospital, I never saw her cry. Things are bad. What I learn over the next two hours, sitting in the courtyard on the bench with flaking red paint, is this: in a locked ward the kettle is turned on at certain times and is then returned to the nurse station. You can only have coffee at particular times. This upsets Lisa almost as much as being here. She feels betrayed by her psychiatric intern, angered beyond reckoning. She has attempted suicide enough times to know that once she has attempted, a profound catharsis hits and she is no longer suicidal. No matter what I say, sectioning her seems to Lisa to be the most stupid thing that someone could do. Some 12 months later she starts to understand professional obligation, but on that night, there is only rage and fear and sadness.

She wants out. Not, like one might expect, to return to her daily life. Instead, she wants to go to a private hospital she has been to before and have ECT. My friend, so systematic in thought, if often suicidally depressed, wants most of all to have her brain electrocuted. I slowly wrap my head around this level of desperation. She tries to work out how to be released, contemplates ringing barristers she knows. But her fear of disclosure is too great. She is stuck between righteous anger and shame. She starts to cry again.

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All animals are equal but some animals are more equal than others - Final commandment of Animal Farm (Orwell, 1957, p. 114)

Most published affective disorder narratives describe a range of experiences related to treatment, including going to the doctor, being referred to a psychiatrist or psychologist and adjusting to various medications. In Chapter 7, the rhetorical utility of biomedical accounts of affective disorders was identified. This chapter furthers this work by establishing that a similar pattern of legitimacy enhancement through association with biomedical and bodily understandings of affective disorders is also found in accounts of treatment. In particular, it is noted that authors use hierarchies of professional authority and treatment invasiveness as mechanisms for enhancing their legitimacy as ill subjects. This chapter regularly returns to the Australian treatment trends discussed in Chapter 1 as the hierarchies are often exacerbated by, enacted in or embedded in health system policies and procedures.

The chapter is divided into two parts, each with a focus on how certain actions or experiences signify illness severity. The first part examines hierarchies related to medical personnel: specifically, the number of doctors and the types of doctor engaged in an author’s treatment. The second part analyses how certain medical practices function in affective disorder narratives to emphasise the severity of the author’s illness. The focus on illness severity hierarchies provides further insight into how the legitimacy of authors as ill subjects is represented in these narratives. By analysing how authors differentiate themselves and enhance their legitimacy through particular narratives of treatment, this chapter continues the process of establishing the range and extent of the rhetorical and strategic aspects of affective disorder narratives.

In order to analyse the rhetorical function of discussions of treatment, it is necessary to artificially separate accounts relating to medical personnel and medical practice. In the corpus these severity indicators typically co-occur. This means that authors who have highly legitimising professionals are also likely to have highly legitimising treatment QOX

environments and treatment types and to discuss these aspects simultaneously in their written accounts of their illness: for instance, the highly legitimising treatment electro- convulsive therapy typically occurs when a person is hospitalised, while talking therapies (a less legitimising treatment) typically occur in private clinics. During analysis, these aspects have been separated so that the different facets can be understood individually and the way in which multiple signifiers magnify and complicate the rhetorical function can be examined. This artificial separation means that, at times, similar quotations are examined from different perspectives.

The first hierarchy to be examined concerns the differentiation of health professionals. This hierarchy is extremely common in the corpus and is supported by the procedures of the Australian health care system.

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General practitioner < Psychologist < Psychiatrist32

Authors in the corpus consistently position certain health professionals as having greater professional standing in regards to mental health than others. As will be demonstrated below, and consistent with the quotations in Chapter 7, a professional aligned with biomedical accounts of affective disorders, such as a psychiatrist, is given more authority by corpus authors than one more focused on cognitive or social aspects, such as a psychologist. This results in a hierarchy that places general practitioners as the least esteemed professionals, with psychiatrists being understood as the most respected professionals.

The chapter is focused on GPs, psychologists and psychiatrists because these are the most often mentioned professionals in the corpus. Less commonly, authors describe the

32 This chapter is concerned with the relative (rhetorical) legitimacy of various experiences and categories associated with professional medical treatment. As a way of quickly representing these relationships, a text box is placed at the beginning of relevant sections. The text box represents the argument developed in the section: specifically, in each case, it will be argued that the category on the left hand side of the text box has the least legitimacy while that on the far right has the most legitimacy. The text in these boxes (e.g., x < y) should be read as ‘x has less rhetorical legitimacy than y’. QPO following health professionals: caseworkers, social workers, key workers (who co- ordinate care in an outpatient setting), nurses, anaesthetists, pharmacists (especially in instances of repeated suicide attempts where a person is only allowed weekly doses of their medication) and a variety of alternative health practitioners (see 17V 302, 263). Due to their relative rarity, these health professionals are not examined in detail in this chapter.

The hierarchy of professionals both informs, and is informed by, certain aspects of government policy regarding subsidised access to specialist services. As discussed in Chapter 1, in order to receive Medicare subsidies, a person wishing to see a psychologist or psychiatrist must have a current referral from a general practitioner (GP). The necessity for referrals varies according to the specialist being seen: access to psychiatrists and other medical specialists always requires GP referral. In contrast, those willing to forgo the Medicare rebate can see psychologists without a referral. In both cases, the Medicare scheme positions GPs as gate-keepers for specialist health professionals. Gate-keeping is an important aspect of universal healthcare as it aims to ensure that all individuals receive appropriate levels of care by reducing, at least partially, the tendency for those with money to be seen before more distressed but poorer individuals. However, gate-keeping is not always effective, as evidence suggests that GPs are poor at mental health diagnoses. Specifically, Leff (2001) claims that general practitioners in Britain rarely refer patients that they diagnose with non- psychotic mental illnesses (only one in twenty) and routinely fail to identify such conditions in their patients in the first place (cited in Foster, 2007, p. 30). Moreover, the current Medicare system has been critiqued by Philip (2009) who raises concerns about how it may reduce governmental engagement with social contributors to distress such as poverty and homelessness (see also Chapter 13).

This gate keeping process implies that psychologists and psychiatrists are a scarce resource and that only legitimately ill people will be – and should be – granted access to them. Given the current format of mental health support, it is unsurprising that, within the corpus, discussion of access to specialists functions to demonstrate the severity of an author’s illness.

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In instances where authors describe the referral process, this recollection typically functions to enact a hierarchy between GP and specialist:

It took me six weeks to get it together to make an appointment to see the local GP to get a referral to see a psychiatrist. (D 103)

In this quotation, the statement ‘the local GP,’ reinforces an understanding of this professional as convenient and commonplace: like the local pub, the local GP is chosen not because it is necessarily a ‘good’ service provider, but because it is close to one’s home. In contrast, the psychiatrist is not restricted to a locality, thereby implying that Deitz is willing to go further afield for his or her expertise. The description of visiting the GP in order to gain access the psychiatrist functions to position the psychiatrist as an expert that deserves – and requires – the gate-keeping of the GP. As Deitz is ultimately successful in gaining the referral, this section of text also functions to affirm Deitz’s own legitimacy as an ill subject by indicating that she is sufficiently ill to justify access to limited specialist resources.

In another example of the hierarchy of GPs and psychiatrists, Penelope Rowe describes her regular visits to a GP:

He was a kind man, but not a psychiatrist. He arranged to see me, as often as I wanted, during his lunch hour. He was appalled at what I told him and gave me pills to help me cope. (BT 56)

The statement ‘[h]e was a kind man, but not a psychiatrist’ creates a hierarchy between the GP and an imaginary or ideal psychiatrist. There are three aspects of the quotation that enact this hierarchy. First, the phrase ‘but not a psychiatrist’ functions to minimise the significance of the GP’s kindness by positioning it as an admirable personal, rather than professional, trait, albeit an important one (for discussions of the importance of kindness in heath professionals, see 17V 106, 154, 263, JwBD 164-165, BT 123).

Second, this phrase implies that the GP’s lack of professional qualifications in the field of mental health is a limitation that affects the utility of the consultations. Although it is possible that the ‘non-psychiatrist’ characteristics of the GP are desired or admired by

QPQ Rowe, her ongoing discussions of treatment (see Chapter 7) and continuing valuing of psychiatric care throughout the The best of times, the worst of times suggests that this is highly unlikely.

Third, by describing her medications as ‘pills to help me cope’, Rowe’s treatment by her GP is positioned as a stopgap measure (as opposed to a ‘proper’ treatment that would have been designed to alter the course of her illness).

In addition to the distinction between GPs and psychiatrists, it is also routine for authors to distinguish between psychologists and psychiatrists. Consistent with the overall valuing of biomedical understandings of distress discussed in Chapter 7, psychiatrists (as providers of pharmaceutical rather than solely talk therapies) are typically positioned as more authoritative than psychologists. Only a small number of authors represent psychologists and psychiatrists as having different, but equally esteemed, roles (BB 332, HS 83). More common are authors who position psychologists as less authoritative than psychiatrists:

And what about psychologists? I’d never considered them much at all. If anything, I thought you probably became a psychologist if you weren’t dedicated or smart enough to get a medical degree and become a psychiatrist. (D 107)

In this quotation, psychologists are positioned as less intelligent and less dedicated than psychiatrists because they do not have a medical degree (see also BO 85, BT 75, 17V 110). At one level, this statement is a judgement based on the length of study required before qualification for each profession (Australian Psychological Society, 2011; Royal Australian and New Zealand College of Psychiatrists). However, at another level, this quotation reflects the almost hegemonic valuing of biomedical accounts of affective disorders in the corpus. Specifically, the valuing of a psychiatrist because of their medical degree suggests that the association with biomedical knowledge in and of itself enhances the epistemic authority of the professional (see Chapter 9). This point is mirrored in an article by Pilgrim and Rogers (2009) that discusses correspondence in the British Journal of Psychiatry. Specifically, Pilgrim and Rogers observe that the epistemic and medical authority of psychiatrists is typically premised on ‘the assumed

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unambiguous legitimacy of a traditional biomedical approach to diagnosis, aetiology, treatment and prognosis’ (p. 952). Another way of explaining the differential in the corpus quotation is to understand psychiatrists as being more aligned with scientific authority, where such authority is based on the objectiveness, and thus ‘truthfulness’, of scientific knowledge. Thus, psychologists engaged in therapies that are represented as proven interventions into established cause-and-effect (e.g., CBT) may retain greater authority than those using more complex or conceptual models (e.g., psychoanalysts) (Pilgrim, 2011, p. 122).

The hierarchy of health professionals is sometimes enmeshed with other types of signifiers. In the following quotation, both the type of professional and the treatment environment indicate the severity of the author’s distress:

My GP hospitalised me (private hospital) twice in the past 6 weeks so that a psychiatrist could find the right meds for me. (BB 351)

In this quotation, the GP is positioned as an enabler of the author’s care. The referral process suggests that the GP is no longer able to care for the author and thereby reinforces that the psychiatrist has more expertise in mental health than the GP. While reflecting the lived realities of the triage system of mental health care in Australia, this referral to a specialist, along with symbols of biomedical interventions such as hospitalisation and medication, also functions symbolically to emphasise that the author is severely ill.

The widespread use of this hierarchy is likely to reflect both the realities of the health system in which authors are located and the strategic utility of such statements. There is little difference between internet and autobiographical sources in the representations of health professionals, suggesting that this hierarchy is accepted and enacted by people of various ages and from a range of backgrounds.

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GP < GP and (Psychologist or Psychiatrist) < GP and Psychologist and Psychiatrist

The number of professionals engaged in an author’s treatment often functions in corpus narratives as a signifier of the complexity of an author’s illness and/or their ability to access scarce professional resources. Although other explanations such as inappropriate initial treatment or ‘doctor hopping’ are possible, most corpus materials imply a simple linear equation of ‘more professionals equals more severe’, so that a person who has ten professionals engaged in their care tends to be positioned as having more complex or severe mental health problems than a person with one health care professional.

The nature of the referral system in Australia means that when a patient starts to see a psychologist or psychiatrist, they are unlikely to stop contact with their GP, but rather, will ‘add in’ the specialist to their ‘health care team’. The promotion of coordinated care is a deliberate strategy by the Australian government to increase service efficiency and improve individual outcomes and is outlined in the National Plan on Mental Health 2006–2011. The plan states that:

Better coordination of all these services can help to prevent people who are experiencing acute mental illness from slipping through the care ‘net’ and reduce their chances of readmission to hospital, homelessness, incarceration or suicide. Better coordinated services will also mean that people can better manage their own recovery (Council of Australian Governments, 2006, p. 3).

This ‘add in’ process results in a net increase in the number of professionals caring for the author. Regardless of the clinical or social utility of coordinated care, when authors discuss this increase, it typically functions as an indicator of the severity of the author’s distress, as it implies their condition is too complex for a single professional – especially a generalist like a GP – to treat by themselves.

It is common for authors to demonstrate the extent of their distress by describing the number of professionals they have seen, or by implying contact with many professionals through descriptions of distinct treatments. For example, the legitimacy of

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a contributor to the Journeys with the Black Dog anthology is enhanced through a description of the range of people who are engaged in their care:

If it wasn’t for my general practitioner, psychiatrist and counsellor, and the care and support of my family and a few close friends, I might even have lost my life. (JwBD 78)

In this quotation, the listing provides evidence that the author requires assistance from many health professionals. In this way, the listing indicates that the author is experiencing a complex health issue and thereby reinscribes an understanding of the author as a severely ill subject. This understanding is further emphasised by the reference to suicide (see Chapter 10).

In another example from the Journeys with the Black Dog anthology, an author describes a range of health professionals and a range of therapies:

I’ve tried hypnosis, special diets, vitamin supplements, health retreats, psychiatrists, psychologists, shamans, scream therapy, re-birthing, crystal healing, thought-field therapy, acupuncture, sand play, exercise, paint therapy, volunteer work and antidepressants. (JwBD 123-124)

By providing this listing in the context of discussing how they ‘believed that I would suffer forever, and that things would never change’, the author emphasises the length and extent of their suffering while simultaneously asserting that they have been a ‘good patient’ and attempted many forms of healing. As such, this statement increases the author’s legitimacy as an ill subject by implying that they are both ‘really’ ill and a ‘good’ patient.

Internet sources tend to demonstrate this rhetorical function more regularly than autobiographical materials. It is likely that this is because the word length on internet postings is limited and a listing of health professionals is a quick way to simultaneously assert the severity of the author’s condition and discuss their treatment regimes. The following two examples are from internet sources:

QPU In a very short post where a young woman writes about how she ‘keeps going’ despite having ‘p.t.s.d [sic], anxiety, depression [and] borderline personality disorder’, the author further emphasises the severity of her condition by saying:

I’ve been admitted to psychiatrist hospitals for breakdowns and seen many doctors, psychologists, social workers, youth workers, nurses and tried loads of medications. (HS 83)

In a long thread between two participants regarding how they are trying ‘everything’ to stop the increasing severity of their condition and yet their health professionals remain unhelpful, an author writes:

In the past week I’ve had doctor, psychologist, counsellor and mental health unit appointments. (BB 332)

As with the previous Black Dog example, the listing of health professionals functions to emphasise the severity of the author’s condition. Moreover, the willingness of the authors to see a wide range of professionals positions the authors as compliant and ‘good’ patients.

Part I of this chapter has demonstrated how the number of professionals, as well as the type of professional who is engaged in an author’s treatment, functions in narratives to indicate the severity of an author’s condition. Such severity indicators can be reinforced or compromised when they occur in the context of descriptions of medical practice.

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Talking therapy < Antidepressants < Mood stabilisers < Antipsychotics < Electro- convulsive therapy

When authors describe their experiences of treatment, it is not only the types of professionals, but the type of treatment that these professionals offer, which position the

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author as a legitimately ill subject. In daily life the over-lap between these two aspects – type of professional and type of treatment – is strong, with more legitimising professionals typically providing more legitimising treatments. This over-lap is a key characteristic of the lived experience of treatment. However, in order to perform a rhetorical analysis of descriptions of this lived experience, it is necessary to separate out these two aspects as their meanings are determined by different sets of associations. In Part I it was demonstrated that by describing particular professionals who have high biomedical authority and expertise, an author’s illness legitimacy was enhanced. In Part II it will be shown that the rhetorical function of descriptions of medical practice are less aligned with signifiers of biomedical authority, rather the invasiveness of treatment and the severity of side effects are the major indicators of illness severity.

Within the corpus, the extent and invasiveness of a treatment regime often functions to establish the severity of an author’s affective disorder:

After eight hospitalisations, thirty treatments of ECT, trial and error games with medication, three overdoses and various encounters with psychiatrists, some helpful, some damaging, I became strong enough to begin rebuilding my life and repairing my broken soul. (JwBD 141)

The author describes undergoing many different forms of treatment. There are several reasons why this author may have received more treatments than most other authors: the author may have had more severe episodes of depression (as, potentially, evidenced by their overdoses, which may have been suicide attempts), the depression symptoms may not have been more severe but may have been more treatment resistant, the author may have had a particularly complex condition (e.g., they may have had both depression and substance use issues), the author could have had higher expectations of recovery and thus kept trying different treatments when other authors may not have, or the author might have greater financial resources and thus continued treatment beyond where others might have stopped. Although each of these interpretations is possible, the first reason seems the most likely. Specifically, the word ‘after’ at the beginning of the sentence and the phrase ‘I became strong enough’ in the middle, suggest that this listing has been used to emphasise the severity of the author’s illness. Thus, the description of

QPW many treatments functions as evidence that the author has a more complex or severe condition than authors who have experienced fewer treatment types.

The quotation also enacts a hierarchy between treatments that further enhances the legitimacy of the author’s illness. Specifically, a distinction is made between ECT treatment and medication games. This differentiation implies that ECT is riskier than medication, so that one does not play games with ECT. Within the context of mainstream medical practice that aims to minimise the risk involved in treatment, this differentiation implies that the author, as someone who has received an uncommon and risky treatment, is severely ill.

The legitimacy associated with each of the main treatment types is now examined in turn.

Talking therapies: Psychological treatments, psychoanalysis and counselling

Psychological treatments are typically utilised as the sole treatment for mild to medium depression and anxiety. They are also routinely used as a positive adjunct to medical treatments for severe depression and anxiety but may be abandoned during periods of extreme distress (see Chapter 6 and Parker, 2005). For this reason, talking therapy is not associated with severely debilitating symptoms (see Chapter 6).

Within the corpus, authors routinely discuss attending counselling or psychological therapy. While such discussion can be quite lengthy, they tend to have fewer rhetorical features than descriptions of other treatments (D 154–160, 17V 318–319), perhaps because talking therapies, while positioning an author as requiring treatment, do not position them as profoundly ill to the same extent as biomedical interventions (see BT 75, Chur-Hansen & Zion, 2006, p. 20).

Medications

The function of antidepressants in depression narratives has been discussed at length by other academics (see Chapter 1). These researchers note the link between antidepressant use and legitimising biomedical accounts of suffering. While this link to biomedical

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accounts increases legitimacy, the commonality of antidepressant use somewhat mitigates this effect. Put differently, because so many authors are on antidepressants, the use of antidepressants does not significantly differentiate or emphasise the suffering of a particular author. It is therefore unsurprising that the number of types of antidepressants that an author has tried functions as a more effective symbol of illness severity:

[…] I have been suffering from severe depression [and] have been on just about every anti-depressant medication that is available. (BB 341)

In this quotation, there are two ways that taking many different types of antidepressants is positioned as evidence of the severity of the author’s depression. First, taking many antidepressants implies that the author’s symptoms are more severe and thus the author requires ‘non-standard’ or ‘more serious’ medication. Second, taking many medications may indicate that the author’s depression is particularly difficult to treat and thus it is a more severe form of depression. In each case, more medication is associated with more severity.

While individual narratives of antidepressant consumption do not markedly enhance individual legitimacy, culturally the association of depression with medication radically enhances the legitimacy of depression as a ‘real’ illness (see discussion of medication and biomedical models of depression in Chapter 7). A more explicitly political formulation of this point is made by Greenberg, who states that ‘every approval [by the USA Food and Drug Administration] of an antidepressant also ratifies the claim that the disease it treats really exists’ (2010, p. 40).

In addition, authors on the Blue Board often discuss their medication side effects in detail. Such discussions, while likely reflecting the intensity and unpleasantness of their lived experience, function rhetorically to emphasise the severity of authors’ conditions. Specifically, authors imply that their depression is a profoundly unpleasant experience when they indicate that they are willing to endure particularly onerous side effects in order to get rid of it. It is noteworthy that these discussions are not found in corpus autobiographies or internet story pages. Perhaps this is because bulletin board participations discuss side effects in the hope of gaining information on how to manage

QQO the side effects or on potential alternative medications. For other mediums that do not have this interactive element, it seems probable that discussion of side effects is not deemed necessary or appropriate and that listing medications may have much of the same rhetorical effect.

There is a significant difference in the illness severity associated with antidepressant medications and ECT. Medications to manage mania, including mood stabilisers and anti-psychotics, appear to fill this gap (although low dose antipsychotics can be used to treat anxiety, this is not discussed in the corpus, Gao, Muzina, Gajwani & Calabrese, 2006). While there is very little discussion of these medications across the corpus, when they are mentioned, authors tend to be describing extreme emotional distress, often occurring in the context of current or imminent hospitalisation (BT 86-88 and BO 28).

Electro-convulsive therapy

Like other members of the general population, authors report significant concern about the side-effects of ECT (Hay, Hay & Spiro, 1989; Mental Health and Drug and Alcohol Office NSW Health, 2010). Rowe expresses common sentiments when she states:

[ECT] is really a treatment of last recourse when nothing else has succeeded in getting a patient out of a deep depression. (BT 108)

When Rowe states that ECT is ‘a treatment of last recourse’ and that she is experiencing a ‘deep depression’, ECT is positioned as a treatment that is only appropriate when symptoms are severe and other treatments have failed. The phrase ‘last recourse’ also implies that ECT is a last ditch effort to return to a socially and personally valued subject position (i.e., a subject with integrity) as a person who, while not necessarily ‘coping’, is nonetheless not overwhelmed and profoundly debilitated by their condition. Thus, while Rowe is ostensibly supportive of ECT, this quotation reflects an overall unease about this form of treatment. This unease emphasises the risks of the treatment and thereby secures an association between ECT and severe depression. The same rhetorical function is apparent, although rarely commented on, in other research. For example, a participant in a mental health questionnaire in the United Kingdom demonstrated the severity of their depression by indicating that their psychiatrist or

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psychologist was considering ECT (Rapport et al., 2010, p. 375). The widespread use of this rhetorical strategy emphasises the similarity in/( ,-.(#(!-) #(1 -. ,( )/(.,# -=

Where Penelope Rowe provides a reasoned justification for ECT, her daughter Jessica Rowe expresses a more immediate and emotive response. In the context of describing the severity of her mother’s condition through a description of hospital stays that lasted several months, she writes:

During these endless hospital stays, Mum would have bouts of ECT. When she first told me she was having ‘electro-convulsive therapy’, I was beside myself. I felt terrified. Was Mum so sick that she needed to have electric shocks jolting her brain? It sounded so primitive and barbaric. (BT 115 - 116)

In this quotation, the terms ‘electric shocks’, ‘jolting’, ‘primitive’ and ‘barbaric’ each position ECT as a harsh and unforgiving treatment: as another author in the corpus says, ‘…it’s a bit too much like kicking the computer to make it work’ (GC 67). The combination of these phrases and the description of Penelope as ‘so sick’ indicates that the severity of Penelope’s illness is revealed through the severity of the treatment used. In addition, it is implied that Jessica is fearful about ECT because, through its association with illness severity, it symbolises that Penelope is no longer able to function in certain socially recognised and valued ways.

In comparison with other treatments, ECT is a highly legitimising treatment because it ‘scores’ high on three key factors. First, it involves extensive medical intervention, second, treatment involves a radical change to bodily rhythms, and third, it has very significant and debilitating side effects. Thus the illness severity associated with a particular treatment type is primarily to do with the extent to which the treatment ‘invades’ the author’s body. ECT is rarely mentioned in internet postings, perhaps because of the relative rareness of the treatment or a sense that in the short space of a posting it is best not to mention a profoundly stigmatised treatment as this might cause readers to dismiss the author as ‘too sick’ or ‘mad’ (see Chapter 10).

QQQ It is typical for certain treatments to occur in certain locations. In some instances, a treatment must be performed in a particular setting. For example, ECT can only be performed in a place with an ECT machine and personnel with the capacity to put a person under general anaesthetic, such as a hospital. In comparison, other treatments such as talking therapies can occur in a wide range of environments.

A complex and interdependent relationship exists between treatment type and treatment environment. In instances where treatment type and treatment environment are both aligned with high illness severity, the rhetorical effect is magnified. However, in instances where such alignment does not occur, the legitimacy associated with a signifier tends to be reduced. In the next section, this relationship is examined in the context of discussing the hierarchy of environment apparent in the corpus.

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Private outpatient < Public outpatient < Voluntary hospitalisation < Involuntary hospitalisation

The place or places where a person receives treatment for an affective disorder (or whether they receive treatment at all) are typically determined by their financial resources, their geographical location, their personal knowledge and beliefs about available services and their perceived sense of stigma about accessing services. These factors interact with the amount of encouragement, knowledge and referral capacities of an individual’s GP and the support and knowledge of their friends and family (Bilszta, Ericksen, Buist & Milgrom, 2010; Golberstein, Eisenberg & Gollust, 2008; Henderson, Pollard, Jacobi & Merkel, 1992; Jagdeo, Cox, Stein & Sareen, 2009; Moreno et al., 2011; ten Have et al., 2010; Van Hook, 1999). Yet, rather than representing the extent of an individual’s resources, descriptions of treatment environment in the corpus typically function to indicate the severity of the author’s illness. This association is based on the severity of the author’s symptoms as indicated by various factors: their inability to find effective treatment initially, their health professionals giving ongoing referrals because the author is a particularly difficult case or their relative lack of choice

QQR

about their treatment. Four treatment environments are regularly discussed in the corpus. Each is analysed below.

Taking your business elsewhere: Private outpatient care and low scarcity

Private outpatient care occurs when an individual sees a medical professional outside of a hospital and pays for the service. In cases where individuals have a mental health plan or referral from their GP and the specialist is registered appropriately, Medicare will refund some of the fee. However, the ‘gap’ between payment and refund means that private outpatient care is often unaffordable to people on low incomes. Thus, private outpatient care, while ostensibly accessible to everyone, is often the purview of the middle and upper classes. Moreover, private outpatient care can be provided even to individuals who do not have a GP referral if they are capable of paying the full fee of the specialist. Despite these class limitations, private outpatient care is widely utilised for psychiatric consultations and therapy sessions (Medicare Australia, 2011a). Because this treatment is so common, descriptions of it in corpus materials has minimal effect on author legitimacy.

In the following example of how high levels of treatment choice minimise illness legitimacy, Deitz describes deciding to stop seeing her psychiatrist:

The Paddington psychiatrist prescribed an antidepressant called Zoloft. I didn’t like the way it made me feel […] After about six sessions I stopped seeing her and stopped taking the medication. (D 57)

Deitz’s willingness to stop her treatment and stop seeing her psychiatrist demonstrates that she has the capacity to negotiate (i.e., stop and/or start) her own treatment. This capacity implies three existing personal resources: cognitive capacity (she has sufficient cognitive functioning to ‘think through’ treatment alternatives), emotional competence (she is not so distressed or dependent on her psychiatrist that she feels unable to change professionals if she is unhappy with her treatment) and financial resources (she has the money to be a private patient and thus she can go to a different psychiatrist). Both cognitive capacity and emotional competence imply that Deitz is not experiencing severe depression symptoms. Thus, while it is ultimately her financial resources that

QQS enable Dietz to change professionals, the ability to act on this capacity positions Deitz as less severely ill than authors who are reliant on public outpatient services.

Symbolically, the independence that Deitz demonstrates by being able to choose her practitioner positions her as an autonomous subject and thus aligns her with Enlightenment ideals of ‘human-ness’ (Hall, 2004; Taylor, 2003). However, such independence also functions to reduce her legitimacy as an ill subject, given that the ability to make choices implies that she is not very ill. Thus, the very autonomy that positions her as a legitimate human subject is correlated with a reduction in her legitimacy as an ill subject. The tension between these two forms of legitimacy suggests that individuals who are considered ill or disabled may be excluded from certain normative conceptions of human subjectivity, and that such exclusions complicate the rhetorical function of illness narratives.

Being assessed as worthy: Public outpatient care and high scarcity

Public outpatient care occurs in a variety of settings, including public hospitals and community health services, and are often the only services available in areas with limited private professional resources, such as regional or rural area. This form of care is generally free or low cost and thus, in areas with both private and public services, is more likely to be utilised by people with low incomes. Potential clients will be assessed to determine if they are eligible to access the limited number of public psychiatric services. In this way, an individual’s access to these services indicates that health professionals have assessed that individual as being legitimately mentally ill and in need of treatment:

I was considered such a risk, that in a 15 week waiting system, I was seen the very next day. (RO 75)

In this quotation, the movement of the author to the top of an extensive waiting list indicates the severity of their distress. This type of evidence is only available to authors who attend services that have long waiting lists (i.e., primarily public mental health services). In this way, the material reality of the treatment environment dictates which severity indicators can be used by the author.

QQT

For most adult authors, however, the mere acceptance into the public system provides evidence of the severity of their suffering. For young authors who have accessed headspace services, the symbolism may be slightly different as the headspace initiative has both significantly increased the amount of publicly funded services available to young people and has a focus on early intervention, which means that clients may be sub-clinical in presentation and still gain access to services (Muir et al., 2009).

Access to limited public psychiatric resources often functions in affective disorder narratives to indicate illness severity. However, for a small number of low income authors, it is movement from the public system to private care that is financed by public organisations that functions to imply greater author legitimacy and esteem:

Later I was referred to a public psychiatrist and she wanted me to see a private psychiatrist so that I could have some therapy […] Her desire for me was that I didn’t slip through the system. Those were her words to my psychotherapist: ‘I don’t want to see her slip through the system, because she’s got far too much potential’. (17V 110)

In this quotation, the scarcity of financially supported private services is associated with an affirmation of the author’s value as a person. The quotation from Joan’s psychiatrist that ‘I don’t want to see her slip through the system, because she’s got far too much potential’, functions to position treatment as preferentially available to individuals that are deemed worthy. In other words, by saying that she should not slip through the system because she has ‘potential,’ Joan is implying that there are those whose lack of ‘potential’ makes it acceptable that they do not receive the same level of care. Thus, the author simultaneously enhances her legitimacy as an ill subject (she is sick enough to require scarce resources) and her integrity as a socially valued one (she is ‘good enough’ to deserve them).

These quotations indicate that, unlike privatively funded outpatient care, which is effectively available to anyone who can fund their visit and thus has a minimal legitimising function, access to limited publicly funded services functions to legitimise the authors’ illness identity and secure their personal worth.

QQU Voluntary hospitalisation

Voluntary hospitalisation occurs when a person chooses to receive inpatient care. Because involuntary patients take most of the beds in public hospitals, the majority of voluntary patients attend private hospitals. Thus it is a treatment option limited to those who can afford private health insurance. Despite the limited availability of this treatment type, across the corpus, voluntary hospitalisation is provided as evidence that a person is sufficiently ill that they are no longer able to care for themselves at home. As such, it is a strong indicator of illness severity.

Voluntary hospital admission typically requires that an individual receive a referral from their psychiatrist or GP. Within the corpus, such referrals indicate that a professional understands the author to require the intensive support of hospitalisation:

I think I scared the hell out of [my GP] because the next thing I knew I was being admitted to hospital! (BB 313)

While this author utilises the GPs cognitive authority as evidence of their illness severity, it is also common for authors to use hospitalisation in and of itself as evidence of the extent of their distress:

Things became out of control and I needed to be hospitalised, three times. (RO 41)

The word ‘needed’ functions in this quotation to link being ‘out of control’ with hospitalisation. Thus, as with the previous example, hospitalisation functions to demonstrate the severity of the author’s symptoms and emphasise the immediate necessity of intensive professional assistance.

As a relatively uncommon treatment option, hospitalisation is a key signifier of affective disorder severity. Thus, while often shameful (see Chapter 10), hospitalisation is simultaneously an indication of the ‘realness’ of the author’s suffering. Karp describes how this differentiation was enacted in a self-help group for depression and bipolar in the United States:

QQV

“Have you ever been hospitalized?” I answered “no” and felt curiously diminished by the question. I felt that the question somehow disaffirmed me. Maybe this woman meant nothing by her question, but I felt at the time that it called into question my credentials as a person legitimately being a member of this group. (Karp, 1992, p. 146)

While hospitalisation in general suggests severely disabling symptoms, illness severity is even more strongly signified when individuals describe involuntary hospitalisation.

‘A danger to yourself or others’: Involuntary hospitalisation and dehumanisation

Within the Australian mental health system, involuntary hospitalisation is (ideally) reserved for patients that are deemed to be a danger to themselves or to others. A person is involuntarily hospitalised when a court order dictates that they are compelled to receive treatment, regardless of whether they consent to it or not. Involuntary hospitalisation is premised on understanding acutely symptomatic individuals as having less autonomy and capacity than non-symptomatic individuals. In this way, the action of sectioning both presumes and enacts a reduction in the socially valued subjectivity of the patient, thereby being a lived experience of the minimisation of patient integrity.

In discussions of involuntary hospitalisation, the severity of a person’s illness is often conveyed through discussion of the dehumanising aspects of the their treatment:

I have always been an involuntary patient […] You can’t say ‘no’. And you can’t go anywhere. You have no privileges […] If you don’t take your medication you are given an injection. You’re strip-searched. Sometimes body cavities are searched. They take away all your belts, bras, shoelaces … anything you can tie up and use as a weapon against yourself. (17V 259, last ellipse in original)

Involuntary hospitalisation is positioned in this quotation as similar to other forms of detention and incarceration. By describing the extent to which her treatment is against her will, Coralie is positioned as someone who is so ill that she is no longer able to perceive whether she requires professional help, and thus requires forced treatment.

QQW Moreover, she is positioned as someone whose symptoms are sufficiently severe that they justify the removal of some of her human rights. Thus, Coralie’s description of dehumanising care functions rhetorically to position her as a profoundly mentally ill subject whose integrity (in the form of social recognition as a valued subject) has been negatively affected by her incarceration.

This rhetorical function is, however, at odds with the content of Coralie’s interview as a whole. Specifically, Coralie’s anger at the dehumanising treatment that she experienced as an involuntary patient is a major theme throughout her interview (see 17V 259-264). Ultimately, Coralie feels that her repeated committals were generally ‘over the top’ and remains ambivalent about whether they were justified – or effective – responses to her suicidality (17V 264). These statements position Coralie as a rational subject who is able to understand her needs and does not deserve or require forced hospitalisation. Thus, the overall message of Coralie’s interview and the rhetorical function of the quotation are at odds. Such tension is likely to be the result of the disjunct between normative assumptions about who is, and who should be, hospitalised, and the author’s alternative interpretation, which suggests that those who are involuntarily hospitalised are victims of a type of wrongful imprisonment.

This tension results in a conflict between author legitimacy, integrity and authority. Positioning her as severely ill and irrational enhances the author’s legitimacy as an ill subject. Consistent with this, her epistemic authority is reduced by her obvious position outside mainstream or biomedical accounts of emotional distress. However, her epistemic authority is simultaneously enhanced by her capacity to make a case for her alternative understanding. In addition, Coralie’s integrity is both enhanced and diminished. On the one hand, it is enhanced because she is structuring a systematic and coherent account of her experiences that insist on her own value. On the other hand, her integrity is diminished by the very observation that she is structuring a non-normative explanation and the evidence that she has experienced the socially de-valued state of not having autonomy over her own actions. Thus, unlike much of the corpus, which has simple enactments of author or illness legitimacy, Coralie’s interview demonstrates a complex and unresolved mix of rhetorical effects. More generally, the quotation demonstrates that the rhetorical function does not always align with the apparent intent of the author in writing specific statements. Such discrepancies emphasise that

QQX

rhetorical function is the enactment of particular cultural norms and symbols within a text and is rarely a deliberate act of the author.

In comparison with Coralie, authors who are rarely sectioned tend to have more positive interpretations of involuntary hospitalisation. For example, in a section advocating a change in the name used to describe mental health facilities, Rowe positions these facilities as places of comfort and protection:

But when you’re very ill – perhaps so ill that you are a danger to yourself or others – you need and seek comfort and protection. In another context, what could have a more comforting and protective connotation than ‘asylum’? Refugees from physical and political persecution seek it […] Why cannot refugees from mental persecution be offered the same reassuring haven? (BT 125)

Although ostensibly talking about both voluntary and involuntary hospitalisation, when Rowe uses the phrase ‘a danger to yourself or others,’ she is invoking the legal criteria used to enact involuntary hospitalisation. In doing this, she effectively limits her discussion to involuntary hospitalisation.

Unlike Coralie, Rowe represents hospitalisation as a form of protection rather than a violation of her rights. Specifically, hospitalisation is described as a desired place of safety that provides protection during profound suffering.33 In this case, the lack of choice associated with the treatment environment is acceptable because it mirrors the severity of the illness being experienced by the patient.

At a rhetorical level, Rowe’s discussions of her involuntary hospitalisation enhance her legitimacy as an (severely) ill subject. However, they do so at the expense of her integrity. Specifically, her integrity as a ‘socially valued’ subject is destabilised, as her

33 Moreover, hospitalisation is understood as a way of seeking shelter from one’s own mind. This interpretation presupposes a separation of self and illness, as Rowe can only have respite from her illness if the illness is understood as separable from her sense of self. The separation of self and illness functions rhetorically to position Rowe as a legitimate and valuable person while simultaneously acknowledging the severity of her suffering (see Chapter 7). QRO sectioning means that she no longer has the socially valued characteristic of self- determination.

Young people rarely report being hospitalised: however when they are hospitalised, they are typically extremely debilitated and often spend extended periods in inpatient care. (BB 367) It is likely that this is because contemporary youth mental health programs try to maximise early intervention and minimise the removal of young people from their communities (Betts & Thornicroft, 2001; headspace: National Youth Mental Health Foundation, 2011, 2011a; McGorry, Purcell, Hickie & Jorm, 2007).

Overall, the hierarchies of treatment type and treatment environment are consistent with the valuing of biomedical understandings of affective disorders detailed in Chapter 7, with those who receive treatment in medical institutions being positioned as more legitimately ill than those whose treatment occurs within the community. While the rhetorical function of these hierarchies remains constant across the corpus, the lived reality of access varies according to the economic status of the author. As such, their rhetorical legitimacy must be understood as a strategic representation which is located in a wider economic system, rather than a mere reflection of the severity of the symptoms experienced by the author.

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Medical treatment is a major aspect of the experience of having an affective disorder. In narratives where biomedical theories of cause and treatment are dominant, these discussions are particularly important as they provide evidence that the author is experiencing an illness. Consistent with Chapter 7, it was shown that an association with biomedicine enhances the legitimacy of the author’s illness.

Three overlapping but distinct hierarchies of health professionals and treatment were examined. Author legitimacy tended to be maximised when they represented their health professionals as being exceptionally specialised, having high professional authority and providing a scarce or rare service. The nature of the rhetorical effect was altered by the author’s life situation: for instance, authors with low-incomes used

QRP

scarcity more often than their middle-class peers, as public mental health programs are often difficult to gain access to. In addition, descriptions of more invasive treatments such as ECT were associated with enhanced illness or author legitimacy, with non- invasive treatments such as cognitive behavioural therapy typically having little effect on the rhetorical positioning of the author. Listing treatments functioned to demonstrate the ongoing and treatment-resistant nature of the author’s suffering. Finally, the amount of treatment choice an individual had was inversely associated with illness severity. At times this enhancement was not straight-forward, as was the case with discussion of involuntary hospitalisation, which, while resulting in the most noticeable increase in illness legitimacy, often did so at the expense of the author’s integrity by placing them in a socially devalued context.

When authors describe treatments that are associated with severe illness they are simultaneously describing treatment practices that are likely to be available only to individuals who are severely ill, and telling a narrative which positions them as severely ill.

By examining the function of associations with biomedicine, this chapter has furthered the discussion of illness identity in Chapter 7. In addition, the brief engagement with professional authority anticipates the discussions of epistemic authority in Chapter 9.

QRQ

QRR

There is a mad woman in my building at the university. She comes and wanders the corridors, around and around the small square of linoleum that makes up our hallways. Sometimes she is there for hours. It seems odd to have a wanderer on the 16th floor of a building. I wonder sometimes whether she likes the number 16 especially, or if she likes floors that are divisible by 4 or 8, or which are squares of whole numbers. On occasion she will speak to people in an animated voice about things uncommon for conversations with a stranger – the plight of a rare form of fish or the consequences of wearing too much nylon. Some days she has a security guard with her. I think that maybe he is meant to be escorting her out, but it doesn’t seem to work so well. I have gone for an extended coffee with a friend and returned to find them still chatting about some eclectic topic.

It seems strange that my whole research centre is so confident that this woman is mad. What do we base such a judgement upon? Her eclectic topics of conversation? Her insistence on chatting in hallways and not abiding by the ‘silence in lifts’ etiquette? That she wears the same hat every day – or maybe more pertinently - she wears the hat inside? That her walk reminds one of a penguin? That she is not ‘going’ or ‘returning’ or generally rushing somewhere?

QRS %)'F4 #$,#"$'# #$,#))'3'$(($#! #$,!#*)$'). Underlying most interactions between authors and their health care professionals is an implied request for assistance from an expert. This request positions the health professional as having greater epistemic authority than the patient, a positioning that tends to function in affective disorder narratives as an indirect method for enhancing the legitimacy of the author as an ill subject (see Anderson, 2009, for an introduction to feminist epistemology and concepts of epistemic competence and authority). In order to examine epistemic authority, this chapter builds previous research on knowledge claims and affective disorders. Researchers have noted the centrality of epistemic authority in online affective disorder support groups where ‘diagnosis must be in the hands of the psychiatric profession, the ultimate authority on the illness and its treatment; the forum offers support, information and, indeed, advice, only on that basis’ (Vayreda & Antaki, 2009, p. 941).

This chapter begins with a discussion of how authors represent a hierarchy between their own lay knowledge and the expert knowledge of their health professional. Consistent with the findings of Chapter 8, these differentiations typically function to emphasise the veracity of particular diagnoses and assert the severity of an author’s illness. However, explicit statements of health professional authority may function in the illness narrative to either enhance or reduce author legitimacy, depending on the autonomy and respect that is represented as being given to the author. More focused analysis demonstrates how descriptions of interactions with health professionals function in corpus materials as a way of modelling appropriate reader reactions. The chapter concludes by using Austin’s concept of the verdictive speech act to examine how health professional authority functions in mental illness diagnosis.

The chapter is the first to be concerned primarily with the rhetorical function of authority. Despite this focus, the chapter consistently links authority to illness legitimacy, a link that demonstrates the dominance of this rhetorical function within the corpus.

QRT

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Lay person < Health professional

Across the data set, doctors are consistently represented as having more legitimate and ‘real’ expertise than their patients (see Gill, 1998). This differentiation is based on a commonsense belief that individuals who have studied these disorders, have the capacity to prescribe treatments, and are paid for their advice on these matters, have more valid knowledge than those whose knowledge is solely experiential. This hierarchy means that corpus authors are routinely positioned as having less authoritative knowledge than their health professionals (see for example BO 65, 96, BT 88-89). Such positioning has a range of potential consequences such as authors enduring treatments that they do not find beneficial in instances where either patient or doctor believes that the ‘doctor knows best’ and patients not feeling respected by their GP, psychiatrist or psychologist when their concerns are not deemed ‘serious’. Although corpus authors consistently maintained these hierarchies, they should not be seen as culturally hegemonic as alternative accounts are active in Australia. For instance, members of survivor and mental health consumer movements often question this distinction by claiming that they, as the people who live through these conditions, are the experts on the experience (for a description of the survivor and consumer movements see Adame & Knudson, 2007, 2008; Chamberlin, 1995; Cohen, 2005; Everett, 1994; Rogers and Pilgrim, 1991). As most authors appear unaware of these movements, and only a few report being involved in consumer-led programs (e.g., GROW), such critiques are unsurprisingly rare in the dataset.

Within the corpus, discussions of health professional expertise have dual rhetorical functions. On the one hand, such discussions typically position authors as having less epistemic authority than their health professionals. On the other hand, discussions of professional accounts often enhance the legitimacy of an author’s illness by emphasising that the author’s condition is ‘real’. While initially these functions may seem in conflict, the following case study demonstrates how the two functions are entwined.

QRU In a multilayered quotation, the validity of Hamilton’s diagnosis is emphasised through three signifiers of the epistemic authority of his psychiatrist: physical ‘props’ of authority, descriptors of the status of the psychiatrist and descriptors of the actions of the psychiatrist:

[T]his was a definite, stark diagnosis by an eminent psychiatrist – a professional with half an alphabet after his name and a shiny brass plaque on his front door. (BO 96)

There are two physical ‘props’ of epistemic authority described in this quotation. The first is the phrase ‘half an alphabet after his name’, which suggests that the psychiatrist has an overwhelming number of professional qualifications and, by implication, an overwhelming amount of knowledge and expertise. The second is the description of the ‘shiny brass plaque on his front door’: a description that positions the psychiatrist as an established professional who is securely located within a practice and who has sufficient standing to have his own, dedicated, room.

Hamilton describes the psychiatrist as performing an assessment and making a diagnosis. These terms emphasise the validity of the psychiatrist’s opinion in a way that other terms such ‘belief,’ or ‘suspicion’ would not. In this way, by indicating that the psychiatrist is a competent diagnostician, Hamilton is implying that the diagnosis is correct, which therefore increases his own legitimacy as a person who is suffering from a ‘real’ illness. In addition, when Hamilton describes his psychiatrist as ‘eminent’ and ‘expert,’ he is indicating that his psychiatrist is held in higher professional esteem than other psychiatrists. This characterisation implies that the psychiatrist’s diagnosis is more reliable and more certain than those produced by other (non-eminent) psychiatrists. In this way, the description of the psychiatrist’s professional standing reinforces the validity of Hamilton’s diagnosis.

Hamilton uses more symbols of epistemic authority than is typical across the corpus. However, emphasis on health professional epistemic authority is common in the dataset, with author’s routinely signifying the epistemic authority of their psychiatrist, psychologist or GP in their narrative or utilising such authority through reports of what a doctor told the author.

QRV

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In discussions of interactions with health professionals, authors often position the professional as knowing more – or knowing ‘better’ – about an author’s experiences than they do themselves (see below). Consistent with the Hamilton quotation above, in some extracts this positioning functions to emphasise the utility of health professional intervention and thus reinscribes a sense that the author’s problem justifies professional attention. However, unlike the previous case study, this differentiation can be damaging in some contexts as it can function to position the author as severely ill in a way that implies that they are incompetent narrators of their own illness narrative (see HS 79, BB 141, RO 54). Thus, while symbols of health professional authority tend to enhance author legitimacy, discussion of epistemic authority in the context of health professional interactions may either increase or decrease author legitimacy.

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Authors report varying levels of mutuality and respect in their relationships with their health professionals. High levels of mutuality are found in professional relationships where authors feel that they are meaningfully contributing to their own care. Although it might be expected that there would be less distinction in the epistemic authority of authors and their health professionals in highly mutual relationships, the examples below reveal that while the expression of authority alters, the distinction is still enacted in the author’s narratives. Moreover, in four texts examined (one with authoritative decision-making, two with one-way knowledge dissemination and one characterised by high mutuality), the descriptions of professional epistemic authority consistently emphasise the author’s legitimacy as an ill subject.

A small number of author’s describe relationships with their health professional that are marked by authoritative decision-making and non-mutuality:

I want to take myself off [the antidepressants] but I know that the doctor won’t be pleased but I can’t see why I should keep taking something that is obviously not working […] I don’t know how much more of this I can put up with. I see my GP on Wednesday and I am hoping that she can see where I’m coming from

QRW and can offer me some other options […] I did what you suggested – I wrote down everything that I had been feeling/experiencing and gave it to my GP. I think I scared the hell out of her because the next thing I knew I was being admitted to hospital! (BB 310, 313)

In this quotation, the author indicates that their health professional will be disappointed if they do not adhere to their treatment regime. No medical reason is given for the need for this compliance; rather, it is positioned as an interpersonal issue that simultaneously implies the severity of the author’s incapacity. By indicating that the author may be going against the wishes of their health professional, it is implied that the author is no longer making ‘appropriate’ or ‘responsible’ decisions, and thus is cognitively suspect. This interpretation is further supported by the description of the GP hospitalising the author. These depictions enhance the author’s legitimacy as an ill subject; however, as with some of the quotations in Chapter 8, the author’s integrity as a socially valued individual is somewhat diminished. Although there are insufficient examples in the corpus to make comment, international research indicates that a lack of mutuality between doctor and patient may be more common with young people. For example, in a study of adolescent preferences in mental health treatment, a 15-year-old male from the United States said, ‘A lot of the time it feels like doctors aren’t really listening to me. It feels like they listen to my parents, but they’re not paying attention to me … That’s why I don’t want to see [my doctor]’ (Wisdom, Clarke & Green, 2006, p. 140). Hopefully, in Australia, programs such as headspace reduce this incidence of authoritative decision- making, and thus encourage help-seeking by young people.

For a minority of authors, interactions with their health professionals are marked by one-way knowledge production. Most of these authors are writing on the internet, perhaps because these authors tend to be younger and therefore less self-reflexive. In these instances, it is reported that the health professional provides information about the author’s lived reality that the author does not know:

My psychologist diagnosed me with Dysthymic Disorder […] I’d been suffering without even knowing for a very long time. (HS 141)

QRX

… my counsellor finally gave me the news that I was on my way to recovery (RO 54)

In these quotations, the health professional’s authority extends into the experiential: it is as if the health professional knows more about what the author is experiencing than the author does. This is particularly apparent in the first quotation, where the phrase ‘without even knowing’ suggests that the author was unaware of her suffering until it was pointed out by a professional. In these instances, it seems likely that these authors would not identify as ‘sick’ or ‘recovering’ if their health professional had not given them this diagnosis. Consistent with the authoritative health professional narrative above, this deferral reinscribes a sense that the authors are dependent on their health professionals, and thus suggests that these authors are unable to interpret effectively their own reality. Such inability locates the author as currently or previously mentally ill.

A large number of authors report productive and highly respectful relationships with their health professionals. However, even in these instances of apparent mutuality, authors imply a hierarchy of knowledge that values professional expertise and subtly position the author as a legitimately ill subject:

As a team, we managed to find a reason for my overreaction or trigger […] I had told G in our first session that there was seemingly no pattern, no rhyme or reason, to my depression, and he’d already found one. (D 131)

Deitz describes her interactions with G as providing her with new insight into her distress. Although Deitz characterises herself and G as ‘a team’, the phrase ‘he’d already found one’ suggests that while Deitz provides the content, it is G who ‘finds’ the triggers. Thus, while Deitz appears to experience the therapeutic relationship as egalitarian, this mutuality is based on a hierarchy that suggests that Deitz is dependent on G for insight. While this dependence is so subtle that it does not locate Deitz as a mentally ill subject in the same manner as the previous three examples, the utility of the sessions with G does locate Deitz in this subject position. Specifically, by indicating that G does provide useful insights that Deitz cannot access by herself, it is implied that Deitz’s problem requires input from a health professional in order to be addressed. In

QSO other words, Deitz is positioned as mentally ill precisely because she receives benefits from seeing a mental health professional. This type of account is quite common in young people, perhaps because mutuality with people in power (e.g., psychologists) is a newer and therefore more note-worthy experience for them or because the interventions through services such as headspace may tend to involve more supportive or ‘youth friendly’ interactions with professionals (headspace: National Youth Mental Health Foundation, 2011a).

This section has documented a range of relationships with health professionals as authors describe them. Although these relationships vary significantly in style and content, the rhetorical function of professional authority and co-occurring author illness legitimacy is consistent across the data examined. This constancy of rhetorical function emphasises the dominance of a normative and hierarchical medical model in Australian affective disorder narratives.

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The majority of recollections of therapeutic interactions function to affirm the legitimacy of the author as an ill subject. However, in a small number of quotations by health professionals writing directly in corpus materials, this rhetorical function is not present. Rather, the text functions to undermine the narrative authority of their patient when they describe the patient’s mental health status. Commentary by mental health professionals is quite common in affective disorder autobiographies and has been explicitly acknowledged as strategic by Foster (2007, p. 42). A similar phenomenon to what is examined below was identified in the analysis of discussions of depression in Australian newspapers:

In the case of depression, those deemed qualified to speak tend to be medical professionals, researchers and politicians. Of the 49 articles analysed, 45 referred to experts in some way – academics, researchers, politicians, bureaucrats or members of the legal or medical profession. Even those writing Letters to the Editor more often than not used their expert status to warrant their views, including their position as “President of the xxyy Association of

QSP

Psychiatrists” or “Director of xxyy Anger Management Clinic” in their signatures’ (Rowe, Tilbury, Rapley & O'Ferrall, 2003, p. 682).

An example of this phenomenon from the corpus is Hamilton’s psychiatrist, Alan Weiss, who writes about his perceptions of Hamilton’s mental state after his appearance on 60 Minutes (a weekly current affairs show on a commercial free-to-air television station):

In the case of the 60 Minutes program, the viewer or audience may not be aware of his lack of insight. However, this is what we as professionals are trained to focus on, and it is my belief that insight is what is missing in Craig right now. (BO 196)

In this statement, Weiss makes a categorical distinction between the knowledge of lay people (the viewer), the mentally ill (Hamilton) and health professionals (‘we as professionals’). This status assertion is common in mental health professionals and has been noted by several other academics. For instance, Pilgrim and Bentall (1999, p.268) note, ‘professionals claim a general pre-eminent and superior epistemological status for their descriptions [of abnormal emotional life]’, an observation that is uncannily appropriate for Weiss’ statement. Weiss indicates his own superior knowledge by positioning himself (and other health professionals) as a person who has the right and/or expertise to comment on the capacities of other people. In contrast, the phrase ‘may not be aware’ implies that a viewer of the television program is unlikely to have professional-level awareness. Finally, Hamilton, as the person diagnosed with a mental illness, is understood as being without ‘insight’ and thus the least aware or cognitively competent of all the people that Weiss describes.

This hierarchy positions Hamilton as the least competent epistemic agent, a position that the structuring of the hierarchy does not allow him to dispute. Specifically, when Weiss states that Hamilton is ‘lacking insight,’ he is indicating that Hamilton understands his condition in a way that is problematic or unacceptable to the psychiatrist. The lived consequences of this positioning are significant. As a patient, Hamilton is unable to dispute the characterisation: to respond that he is not lacking in insight provides evidence that he is unaware of his condition, and to admit that he is lacking insight

QSQ means that anything he says can be immediately discounted. Thus, although Hamilton’s psychiatrist may have been concerned about a real or pressing concern about Hamilton’s wellbeing, his statement erodes all of Hamilton’s epistemic agency and forces him to support the psychiatrist’s position. 34 Perhaps unsurprisingly, in both the international and Australian literature focused on alterative understandings of mental health, participants often appear angry and frustrated by this type of inescapable pathologisation (see Foster, 2007; Oliphant, 2010; Paterson, 2009). However, the findings in this thesis are more consistent with empirical research from the United Kingdom which notes that most individuals experiencing a mental illness do not feel frustrated by such pathologisation, but rather accepted professional representations of mental illness as matters of fact (Foster, 2007, p. 111).

While typical of the knowledge hierarchies that underpin many affective disorder narratives, this quotation is atypical in its explicitness. Specifically, it is surprising that this quotation appears in a published affective disorder narrative, as the rhetorical implications are profoundly negative for Hamilton as the patient/author. Consistent with the discussion of author competence in Chapter 3, although describing Hamilton as ‘lacking insight’ securely locates him as a person with a legitimate mental illness, it does so at the expense of Hamilton being understood as a competent narrator of his own mental illness narrative. As a person who is experiencing a lack of insight, Hamilton is positioned as an unreliable storyteller. In this way, the psychiatrist’s testimony functions to undermine the narrative competence and independent living skills that Hamilton presents in other parts of the book, a representation that is ultimately not beneficial for Hamilton.

Unlike the text written by Hamilton’s psychiatrist, most accounts written by patients do not imply that disagreements with health professionals as a symptom of their illness. Rather, communication and/or empathy difficulties are typically represented as indicative of a professional that is lacking the requisite skills to interact with the author appropriately (D 57, 17V 39, 105, 284, GC 112). Despite this skill shortage, these

34 This ‘catch-22’ is part of a larger issue with psychiatric diagnoses – namely, that they are an assertion by an expert that cannot be disproved (Greenberg, 2010). Feminist scholars have examined this issue with regard to Freudian psychoanalysis – see for example Gray (1993), Grossman (1988), Irigaray (1985) and Levine, Kamin & Levine (1974). QSR

professionals retain high epistemic authority. The implications of representing health professionals as epistemic authorities are discussed later in the chapter.

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Most affective disorder narratives in the corpus position health professionals as having high epistemic authority. However, a few exceptions to this representation are present. Unsurprisingly, most of these exceptions are found in the 17 Voices anthology as this text contains most of the consumer/survivor perspectives. For instance, several authors question the validity of the clinical assessments that they underwent and note the disrespect they experienced when consulting health professionals:

I knew someone who had suffered from postnatal depression and I tried to tell the doctor that what I was going through seemed pretty similar. She dismissed me like I was being a silly little girl. (17V 203)

Here Christie reports disagreeing with her doctor’s clinical assessment and finding her doctor’s reaction condescending. The statement that the doctor ‘dismissed me like I was being a silly little girl’ both reinscribes and resists this characterisation of Christie. On the one hand, the phrase ‘silly little girl’ positions Christie as an incompetent epistemic agent, with the phrase having implications of being small, irrational, inconsequential, child-like and weak. Yet, on the other hand, the phrase ‘like I was’ implies that Christie was not actually a silly little girl, but was rather erroneously treated as one by her doctor. In this way, the condescending reaction by a health professional functions to reassert Christie’s own legitimacy as an illness narrative narrator and epistemic agent.

A very small number of authors position the patient as the more knowledgeable epistemic agent:

I think if you feel you would benefit from some antidepressants the Dr shouldn’t say no. (BB 249)

QSS In this counter narrative, it is the patient who knows what is best for them and therefore they should gain access to medication should they desire it. Thus, both the epistemic and experiential authority is located in the author, resulting in the patient being positioned as highly authoritative. However, this assertion of authority suggests that the patient need not defer to their health professional. In this way, if this perspective were enacted for a particular individual, while enhancing their authority, it may function to diminish their status as a ‘good’ patient.

Mental health consumers in international research projects appear more willing than corpus authors to question or challenge the cognitive authority of their health professionals. This challenge typically expresses reduced esteem for the ‘book’ knowledge of health professionals and increased regard for experiential knowledge. As Foster writes:

[…] clients are holders of different, and possibly alternate form of expert knowledge: they are after all, ‘the one going through it’ […] the ‘experts by experience’ […] or even ‘the primary experts’. (Foster, 2007, p. 177)

In an example of how this alternative view is expressed, Oliphant analyses a quotation on an English-language electronic newsgroup:

In his view, experimental knowledge trumps expert knowledge and his opinions about the medical profession borders [sic] on disdain – “They just prescribe a random antidepressant and hope it works”. For this poster, other members of the newsgroup act as cognitive authorities because of their experiential knowledge of depression, “Why should I trust a doctor? You people here would be more knowledgeable”. (Oliphant p. 124)

Although it is unclear why authors in the selected Australian corpus are less likely to assert their own epistemic authority, two explanations seem likely. First, the corpus is from mainstream sources that are closely aligned with dominant medical models of mental distress (see Chapter 3). It is therefore likely that that those who do not support a medical model have self-selected out of the sample. Second, in comparison with the United States and the United Kingdom, Australia appears to have less robust consumer

QST

and psychiatric survivor movements: although this may be beginning to change as Australia does have a growing mental health consumer movement that, while often restricted to a form of consultation instigated by psychiatric facilities and state governments (see for example NSW Consumer Advisory Group, 2011) is starting to include alternative community support for those experiencing mental distress (see, for example, Our Consumer Place, 2011). This means that the valuing of consumer knowledge has yet to be mainstreamed in Australia. Regardless of the cause, the relative lack of questioning of health professional authority in the corpus suggests that the maintenance of respect for health professionals assists in the production of illness narratives that ‘make sense’ in the Australian context.

The rhetorical benefit of positioning health professionals as epistemic authorities is fairly consistent, with most descriptions of interactions with health professionals functioning to enhance the legitimacy of the author as an ill subject. This rhetorical function is even more pronounced in instances where the illness narrative provides the reader with a model of ‘appropriate response’ to the author’s distress.

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%$')#!!#((3 .'#'')+(#'''(%$#("$!!# When authors describe going to see a health professional, they tell two stories simultaneously: (1) a story to the reader about their experiences, and (2) a story about telling a story to a health professional. A simple example of this duality would be an author stating ‘I went to the doctor and told him about how I can’t sleep at night’. Analysing these narratives is particularly illuminating because it reveals how authors use particular rhetorical strategies to encourage certain responses from their health professionals. Moreover, these narratives demonstrate the relationship between responses from health professionals and anticipated responses from the reader. However, the analysis is difficult because these narratives have an additional layer of uncertainty: not only is the reader unable to know what ‘really’ happened in a consultation, they are also unable to determine the accuracy of the accounts of the events being described in the consultation. Such layering makes analysis more difficult as the understanding of affective disorder narratives as both lived experience and

QSU rhetoric (see Chapter 2) is hard to maintain when there is little, if any, lived experience referent in the text.

In a typical example of this double narrative, Deitz describes seeing G for the first time:

I told him about the state I had been in recently, when I was sleeping twelve hours a night and still needing a nap in the afternoon. I hadn’t experienced any suicidal tendencies, but rather a feeling of not wanting to “be” […] he asked if this was a severe depression. No, I explained, this was what I’d call the middle level. A bad one had the added distinctions of utter despair, an overwhelming sense of doom and praying for death. “Oh, glad I asked,” he said. (D 109)

In the illness narrative that Deitz provides to her psychologist, she focuses on typical depression symptoms: excessive tiredness and a desire to not ‘be’. By recounting these stereotypical depression symptoms, G is provided with evidence that would persuade him that Dietz’s recent distress is depression. At the time of the interview with G, it is possible that Deitz was not aware that she was presenting ‘correct’ depression symptoms and thus her description may not have been a deliberate rhetorical act. Regardless of her intent, the reporting of these stereotypical symptoms functions in the published narrative as a way of emphasising the severity of her condition. Moreover, within the context of the consultation, Deitz’s construction of her description, regardless of whether she used it deliberately or not, is likely to encourage G to respond in a way that Deitz desires.

The dual aspects of the narrative make this recollection more complex rhetorically. By reporting that G responded to this presentation by asking about the severity of her symptoms, Dietz indicates that G agrees that she is experiencing depression. For the reader, this description of how the psychologist reacted to Deitz can function as a type of template for the ‘correct’ interpretation of Deitz’s symptoms. In other words, through a ‘call on’ professional authority, the reader is encouraged to understand Deitz’s condition as ‘real’ depression. It seems likely, therefore, that when authors describe telling a doctor about their depression or anxiety, one of the rhetorical functions of such descriptions is to model for the reader a particular response and understanding of the

QSV

author’s situation. For the reader, this type of description functions to reinscribe the author’s legitimacy as an ill subject by providing evidence that an expert reacts in a manner that affirms that the author is deserving of medical attention.

Within internet data sources, authors routinely make claims about the severity or ‘realness’ of their condition by reporting statements made by their health professionals. For example:

My doc told me that depression is a real illness, not something to be scoffed at […] (BB 224)

My GP keeps reminding me, it is an illness that I have. (BB 223)

My doctor has told my husband that I am now in a deep depression. (BB 330)

While it seems highly likely that the doctors did say these things, their repetition in the illness narrative is also strategic. Specifically, by presenting legitimacy and severity enhancing statements (‘depression is a real illness’, ‘I am now in a deep depression’) as truths imparted by experts, authors make these claims more difficult to dispute and more authoritative than if they were made directly by the author (Oliphant, 2010, pp. 109, 138). While not the focus of the analysis, similar uses of professional authority are evident in many of the examples given in Chapter 7.

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In a small number of cases, corpus authors describe aiming to be perceived by their health professionals as well or healthy individuals. This type of narrative is most common for involuntary patients who wish to leave a locked ward and is reported in a variety of international studies. For instance, Sayre (2000) recounts an incident on a New York psychiatric ward:

QSW [A] man who had stopped talking about his powers of extrasensory perception reminded the staff that he had agreed to take his medication and to stop talking crazy, so now they had to keep their promise to let him go home. (p. 78)

A similar example from the corpus involves Cheryl describing being highly distressed and yet attempting to pass as calm and well adjusted for the professional who determines whether she must remain as an involuntary patient:

That night I tried to strangle myself with the hose from an oxygen bottle […] But when the professor came in the following day I made sure I was as calm as anything. (17V 141)

By placing ‘but’ between her description of her suicide attempt and her presentation to the professor, Cheryl positions the ‘real’ illness narrative as the one that reveals her suicidal feelings. In contrast, the narrative told to the health professionals is represented as a strategic presentation that she uses in the hope that it will allow her to leave the locked ward. Thus, by positioning her interactions with her health professionals as strategic performances, Cheryl acknowledges the institutional power of her health professionals while simultaneously emphasising her own emotional and cognitive autonomy and authority (see also BB 308). Moreover, by affirming her own autonomy, Cheryl implicitly emphasises that she is a socially valued subject who is not solely defined by her hospitalisation. This emphasis has the effect of enhancing her integrity as a multi-faceted subject. Unsurprisingly, authors who downplay the severity of their condition are typically involuntary patients, have had an extended history of mental health issues and treatment, and are less likely to presume that their health professionals have all the answers.

While several authors in the dataset describe attempting to downplay their distress in involuntary treatment situations, no authors admit exaggerating their distress in order to receive medical attention (although there is evidence of strategic representation of symptoms and their severity – see Deitz, above). It seems likely that this is because describing the down-playing of distress still supports an account of the author as a legitimately ill subject, while accounts of exaggerated distress do not. To say ‘I pretended to be OK’ indicates that one is not really OK, while to say ‘I pretended to be

QSX

ill’ indicates that one’s illness is not real. This may be because the down-playing of severity aligns with appropriate behaviour for a ‘proper’ patient. As Garden (2010) notes:

[W]hereas any exaggeration of illness – that is, fictionalizing – is viewed as problematically inauthentic or even malingering, people who are ill or disabled are generally rewarded for an exaggeration of health or at least good nature, the cheerful stoicism expected of the “good patient.” (p. 127)

The lack of acknowledgement of exaggeration found in the corpus is inconsistent with Wisdom, Clarke and Green (2006), who argue that patients aim to balance their representations so that they were positioned at the ‘just right’ level of severity, with participants ‘stat[ing] that they disclosed information to providers carefully to minimize the risk of not being treated or not being legitimated as needing care, while attempting to ensure they were not assessed as more severely depressed than they were’ (p. 134). Returning to the corpus, it appears that, counter-intuitively, authors who describe how they ‘passed’ as mentally healthy are reaffirming their association with a mentally ill subject position.

The link between health professional authority and illness legitimacy has implications beyond how authors represent their experiences of affective disorders. As will be discussed below, health professional authority has substantial effects on authors’ self- concept and also alters the material realities of their lives.

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When authors in the corpus describe being diagnosed with an affective disorder, they often recount strong emotional responses and a change in the way that they understand themselves. In contrast with Chapters 7 and 8 where the role of diagnosis in positioning affective disorders as legitimate illnesses was discussed, this section takes a different approach to the analysis of diagnostic events and examines how health professional authority influences the impact of diagnosis on the self-concept of corpus authors.

QTO Diagnosis is a unique form of dialogue – what J.L. Austin would call a verdictive speech act. While many academics discuss the power of mental illness diagnosis, Martin is one of the few to adopt explicitly Austin’s concept (Karp, 1994; Martin, 2007; Oliphant, 2010; Perez-Alvarez, Sass & Garcia-Montes, 2009; Roe & Lachman, 2005). A verdictive speech act is defined by Austin as a type of speech that results in particular effects or actions and is structured in such a way that the verdict is difficult to dispute. Moreover, a verdictive speech act can only be completed by a person in a recognised place of authority: in the case of mental illness diagnosis this would be a health professional such as a GP, psychiatrist or psychologist (Austin, 1975). Within the corpus, authors report that one of the key ‘real-life’ consequences of the diagnostic speech act is that it changes the self-concept of the author and positions them in a ‘sick role’ (Arluke, Kennedy & Kessler, 1979; Fahy & Smith, 1999; Segall, 1988; Shilling, 2002). Only rarely do individuals diagnosed with a mental illness report resenting or doubting the verdictive power of their health professionals (Chur-Hansen & Zion, 2006, p. 22).

The relationship between professional authority, diagnosis as verdictive speech act and patient self-concept is demonstrated in the following example of a depression diagnosis, albeit one that was ultimately superseded by a diagnosis of bipolar:

‘You have diagnosed yourself correctly,’ our GP says. ‘You are clinically depressed’. This is a big kick in the guts. I had desperately wanted him to disprove my theory. Instead, he has just told me what I had already expected; but it is still a tough message to cop. (BO 65)

Hamilton indicates that his interaction with his GP has affected his self-concept. Specifically, although Hamilton reports already believing that he has depression, it is not until the GP performs a verdictive speech act and says that he is clinically depressed that he represents this belief as a ‘reality’ and he recounts becoming distressed. Although it is typical for suffering to become more ‘real’ when it is associated with a diagnosis, in some cases the over-diagnosis of individuals reduces the epistemic authority of the people performing the diagnosis. For instance, an 18-year-old woman from Canada reported that:

QTP

The first time was weird because my mom brought me to get a diagnosis […] And I’ve had several different diagnoses, since then. I kind of feel like they don’t know what they’re talking about. Because I’ve had so many. I was diagnosed with bipolar first, and then they changed it and said it’s PTSD and they just keep changing it. (Polvere, 2011, p. 16)

In contrast with this Canadian woman whose repeated diagnosis reduced her trust in her doctors and positioned her diagnoses as temporary, and potentially unreliable, labels, Hamilton gains a sense of identity through diagnosis. Specifically, Hamilton’s identification as an ill subject is contingent on the diagnostic speech act of his GP, a speech act which, by definition, is only possible because of the epistemic authority that is culturally associated with being a medical professional (see also GC 127, JwBD 99, 103). Moreover, the distress that Hamilton reports suggests that the authority of the GP functions to underscore his failure to maintain a socially valued subjectivity (i.e., integrity). This example suggests that an author’s lived sense of integrity is particularly unstable when they perceive that individuals with epistemic authority doubt it.

For the majority of authors, the verdictive power of their health professionals is limited to diagnosis. However, individuals in involuntary hospitalisation report a greater range of statements that function as verdictives.

As described in the discussion of ‘performing wellness’ above, when authors are involuntarily hospitalised, they report extreme power differentials between themselves and their health professionals. These differentials mean that a greater variety of statements by health professionals in involuntary care settings have the perlocutionary force of verdictive speech acts. For instance, Cheryl reports non-diagnostic attributions by hospital staff that function as verdictive speech acts when the author internalises these attributions and acts in ways consistent with this new self-concept:

[The nurses] told me I was hysterical and so I became those feelings. I became hysterical. A security guard grabbed me and they strapped me to a bed. (17V 141)

QTQ In this quotation, Cheryl describes a change in her self-concept as a result of being told by nurses that she was hysterical. Cheryl’s readiness to take on an external attribution is different from what might be expected from people who are non-symptomatic who tend not to alter their behaviour and identity in such an immediate or extreme way. Thus, this malleability of self-concept may be interpreted as a symptom of Cheryl’s illness, as it suggests that she is over-influenced by her environment and is unsure of her own identity.

The implications of the verdictive power of health professionals in involuntary wards are particularly concerning. Cheryl is in a situation where she no longer has control over her body and her explicit wishes are no longer respected. It seems likely that this lack of choice of embodiment (or, put more strongly, these dynamics of incarceration) encourages Cheryl to protect herself against institutional control by having a malleable sense of self that takes on the attributions of those in authority (within social constructionist or performative analysis, this flexibility in self-concept and behaviour might also be termed a social performance or performative madness). Specifically, as Cheryl’s malleable sense of self signifies her acute mental illness, this self-protection mechanism may result in her health professionals deeming that she needs to spend more time in hospital. A catch-22 then develops where the extended hospitalisation may encourage ongoing self-protection behaviours and thus, ultimately, reinforce the signs that are then interpreted by health professionals as meaning that she requires ongoing hospitalisation (see Rosenhan, 1973). This example emphasises the potential for the authority of health professionals to have serious lived implications.

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Authors in the corpus write extensively about their interactions with health care professionals. Within these accounts, health professionals are positioned as having high epistemic authority. This authority typically functions to enhance the legitimacy of the author as an ill subject. It is likely that the dominance of legitimacy as a rhetorical function in corpus narratives reflects the persistence of authors’ fears of being deemed illegitimate. This concern is directly addressed in the next chapter in a discussion of how authors negotiate perceived and lived experiences of stigma.

QTR

While authors in the corpus routinely position health professionals as epistemic authorities, they rarely position themselves as knowledgeable about their own suffering. This differs from the findings of some international research, which reports that a sizable minority of individuals with mental illness position themselves as ‘experts by experience’ (Anglicare Tasmania, 2009; Foster, 2007, p. 177). Moreover, this chapter has demonstrated how authors both resist and embrace the epistemic authority of their health professionals and shown that the institutional support for this authority may have significant impacts on the lives of authors, particularly those who are involuntarily hospitalised.

QTS

QTT

Tofu ‘con carne’. Again. I’m starting to think that the cooks here believe that vegetarianism is a mental illness best treated by aversion therapy. At least it’s better than the faux- sausages of yesterday. Most people here seem so numbed out that I guess taste isn’t exactly the most pressing of concerns.

I walk past the eating disorders table. It is filled with young women in tracksuit pants staring at their plates. They come into the dining room in a large group, sit together and leave as a silent mass. I tried to sit at their table once but was told off by the nurse. They’re an exclusive club, the anorexics and bulimics.

I sit at a small table with Julie. She’s new here. She came through the Intensive Care Unit which means that she’s here for a suicide attempt. Over dinner she tells me how she’s really pissed off that she’s not dead. Her ex-husband found her about two weeks into her drug induced coma. Her face contorts with rage as she talks about the arrogance of him thinking that she wanted to be saved, that he should call for an ambulance. Everything would have been fine if he just hadn’t turned up.

I don’t know what to say. I look at the single orchid in the small vase on the table. I’m used to despair and fatigue. Give me hopelessness and fear any day. But rage? What the hell am I meant to do with that? I manage a few umm’s and ahhh’s. I let her talk. She doesn’t seem to notice that I’m at a complete loss for words.

When we have finished our dinner, we walk back to the ward. She is limping. I ask her why. She says her cat lay on her feet for those fourteen days. She still has bad sores on the top her feet from this feline dedication. As she limps on, I wonder whether she left out cat food when she overdosed.

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I’m not crazy, I’m just a little unwell I know, right now you can’t tell - Unwell, Matchbox 20

Corpus authors routinely describe experiences of discrimination and shame. Even more common are expressions of the belief that affective disorders are profoundly stigmatised in the Australian community. The belief that affective disorders are stigmatised appears to impel many authors to write in the first place, with some authors reporting that they write on internet boards because they have experienced negative responses from their ‘real life’ friends and family and feel only depressed people can understand their experience. In addition, many authors indicate that they write autobiographies because they hope to reduce the shame that others feel about their illness.

A small minority of authors explicitly indicate that they do not experience shame or discrimination. For example an author on Blue Board writes:

I have become more open about my condition [and] most [people] have been understanding and willing to help. Some have been real helpful and I value their friendship. (BB 266)

However, this type of account is uncommon and is therefore not the focus of this chapter.

Public health scholars and health practitioners should be particularly concerned about stigma as discrimination and shame have a significant impact on treatment access and adherence. As one corpus author writes:

I haven’t gone back to see [my GP] since then. I guess the stigma involved with seeing a psychiatrist put me off. (BB 281)

QTV

As emblematic of a larger problem, the author has stopped seeing their GP as a pre- emptive defence against the perceived stigma of seeing a psychiatrist. The effect of fear of stigma and discrimination on treatment access is not limited to affective disorders and is observed in a range of illnesses including HIV/AIDS and epilepsy (Conrad & Barker, 2010).

In this quotation, the author reports that shame has resulted in them no longer receiving any form of professional support, a situation that almost certainly will result in greater personal suffering. This suffering may have also been compounded by the trauma of the disclosure event itself as research indicates that negative disclosure experiences (whether to a doctor or a lay person) may increase an individual’s distress. For some people, even positive responses to disclosure are distressing as the experience is perceived as a loss of face (see Rogers & Pilgrim, 1997 p. 32).

Empirical research has found that that there is a correlation between the severity of a depression episode and the perceived severity of stigma, with those who are more depressed perceiving more severe social judgements (Pyne et al., 2004). This means that those who are most in need of assistance may be the very ones whose fear of stigma means that they are most concerned about accessing it. Such inverse willingness to access care is a significant public health concern that requires an understanding of how people with affective disorders experience and understand stigma before it can be properly addressed.

Shame and discrimination are different expressions of the same basic phenomenon. Throughout this chapter the term ‘shame’ is used to refer to descriptions of an author’s internal sense of humiliation in relation to their own diagnosis or symptoms and is used interchangeably with ‘self-stigma’ and ‘internalised stigma’. The term ‘discrimination’ is used to refer to actions, behaviours and beliefs that reflect prejudice towards people with affective disorders as a group. ‘Stigma’ is used to refer to both discrimination and shame, and also to refer to more general cultural norms that position those diagnosed with affective disorders as having an undesired trait.

This chapter engages with the rhetorical effects of legitimacy, authority and integrity. Reflective of the rhetorical effects found throughout the corpus, the texts predominately

QTW demonstrate positioning that enhances legitimacy, with a few utilising authority and a very small number demonstrating the enhancement of integrity. The significance of the uneven distribution of these key rhetorical effects is discussed in the thesis conclusion.

The chapter is divided into two sections. The first examines what beliefs and actions are understood as stigmatising. In particular, this section examines the types of negative attributions that are associated with an affective disorder diagnosis. The section then examines accounts of discrimination and it will be argued that shame and discrimination cannot be fully separated, as accounts of one generally reflect the other. The second section examines the function of various rhetorical effects such as in-group/out-group differentiations in refuting these negative attributions.

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Authors report a wide range of negative attributions associated with affective disorders. These attributions can be made either by the author themselves, or by their friends, family and acquaintances. The nature of these attributions matter, as a different type of stigma is likely to be enacted if the attribution is associated with, for example, a perversion, rather than weakness, failure, or social inadequacy. Thus, the analysis begins by surveying the types of negative attributions that are reported in the corpus.

Across the data set a wide range of stigmatising attributes are associated with affective disorders. These negative characteristics can be categorised into six groups: • Mentally ill (D 120, BT 140, JwBD 158, 164) which includes being crazy (BO 217), mad (GC 69, 215), a loon (BO 30), insane (JwBD 103, D 164) and a nutbag (D 18); • Abnormal (D 51) which includes being a freak (HS 182), odd (17V 73), broken (JwBD 137), sub- human (17V 38, 154) and incomprehensible (JwBD 144, D 183)); • Weak (JwBD 46, 94, 99, 17V 63, 69) which includes being pathetic (D 55, BB 316), and a coward (HS 182); • A failure (JwBD 138, 79, BT 141 BB 303, 348)

QTX

which includes being lazy (D 19, GC 127), a malingerer (JwBD 156), a loser (BB 316) and worthless (JwBD 79); • Socially unacceptable which includes being a hypochondriac (JwBD 156), a drama queen (D 19), imbalanced (D 55), out of control (JwBD 81, 138, 17V 53, 64), guilty (D 15, JwBD 107) and an attention seeker (D 19); and • Having cognitive or personality defects which includes being irresponsible, (JwBD 94), irrational (D 125), shallow (D 51) and ungrateful (D 55, BT 166).

These themes are broadly consistent with research into the portrayal of depression in self-help books. Philip observes that ‘depressed subjectivity is portrayed as irrational, unrealistic, fatigued, indecisive, unproductive and ineffective, whereas healthy subjectivity is rational, realistic, autonomous, energetic, productive and efficient ’ (Philip, 2009, p. 165). Given that self-help books are also a published account, it is interesting that where corpus authors typically position these attributes as unjustified portrayals of people struggling with an illness, self-help books represent these negative characterisations as an accurate description of the depressed individual. Despite these differences in whether the attributions are deemed ‘true’ or ‘justified’, the similarity in the types of attributions suggests a consistent dominant discourse of negative attributions associated with affective disorders.

For corpus authors, the ‘negative’ aspects of these attributions are, at least in part, not about the attributions per se, but rather a consequence of the negative context in which they are expressed (for another example of negative attribution, see the discussion of temporality in Chapter 6). Put simply, to say that someone is a drama queen in a different context (e.g., a drag show dressing room) would be a compliment, but in the context of a condition predetermined as a negative, such attributions function as insults, negative attributions and/or a way of reducing the legitimacy of the subject.

The predetermined negativity of these attributes is particularly clear in the case of the category of ‘abnormality’. This category tends to be used by both young adult and adult authors and concerns over abnormality have been noted in other youth populations, including young Swedish men and women (Danielsson, Bengs, Samuelsson & QUO Johansson, 2011). The category tends to be used by corpus authors in a way that compounds ‘abnormal’ as a moral valuing (i.e., a negative characteristic – being a ‘weirdo’) and as a statistical fact (i.e., a small percentage).35 Put differently, within discussions of ‘abnormality,’ the claim that most people do not experience affective disorders is used as evidence that having an affective disorder is a negative characteristic. Yet the claim that a characteristic is ‘bad’ because it is abnormal only works when that characteristic is already conceived of as ‘bad’. That is, there is a very different valuing of the ‘abnormality’ of affective disorders than the ‘abnormality’ of genius or extreme beauty. A circular logic is produced: ‘Depression is bad. I have depression therefore I am bad. I am bad therefore depression is bad’. Such tautological reasoning is common in affective disorder narratives and may be an expression of the pessimistic thought processes characteristic of depression.

If one considers the entire ‘set’ of negative attributions, there are very few aspects of the lives and subjectivities of people diagnosed with an affective disorder that are not positioned as in some way lacking. Specifically, the attributions position authors as defective intellectually, socially, comparatively (i.e., in comparison with other people) and inherently (i.e., in relation to what a human ‘should’ be). The wide range of negative attributions means that the refutation of one attribution may inadvertently realign an author with another negative attribution, thereby making the overall stigmatised position difficult to refute. In these instances, the social and personal valuing of the author (i.e., their integrity) is often affected. In contrast, their legitimacy as ill subjects may or may not be compromised, depending on whether the author posits a meaningful refutation to the negative attributions (see below). Such disparate rhetorical effects emphasise that integrity is a more tenuous and temporary effect than legitimacy, and moreover that the enhancement of one effect does not always result in heightened expression of the others.

While the negative attributions reported in the corpus cover a wide range of aspects of authors’ lives, they nonetheless focus on particular characteristics. As such, interesting insights can also be gleaned when examining which negative attributions are not used in 35 This type of conflation is not limited to mental illness. I have also observed this phenomenon when facilitating support groups of young same-sex-attracted women where the only ‘negative stereotype’ of lesbian and bisexual women that the group could not refute was that being same-sex attracted was abnormal. QUP

the corpus. Within the dataset, people diagnosed with affective disorders are not negatively characterised through the use of descriptions of sexual orientation, perversity, class or physical or intellectual disability. It is likely that this narrowing is consistent with the characteristics of members of the corpus, with few authors being poor, gay, or having a physical disability etcetera. (see Chapter 3). For readers who are from more varied backgrounds and communities, the lack of these negative attributions may have two divergent effects. First, they may be affirmed or relieved that they are not castigated in affective disorder materials. Second, and perhaps counter-intuitively, this lack of representation may enhance their sense of isolation and pathology, by indicating that their attributes do generally co-occur with an affective disorder diagnosis. In other words, the lack of these types of negative attributions may be inaccurately interpreted as suggesting that affective disorders only affect the middle-class, heterosexual and able- bodied members of the community. However, it seems likely that for most people, the wide range of negative attributions associated with affective disorders means that at least a few of the attributions will ‘hit home’ and be experienced as stigmatising. An alternative explanation is that corpus authors, relative to their sense of affective disorder stigma, feel less stigmatised about other marginalised identities. This would suggest that, in comparison with other identities, affective disorder diagnosis is associated with greater shame or more severe discrimination. However, such an inference must be counterbalanced by an awareness that authors of affective disorder narratives are likely to emphasise experiences and feelings associated with their condition.

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In the literature on mental illness stigma, there is typically a divide between research that engages with discrimination, and research that examines self-stigma (shame). Despite using slightly different terminology, Foster (2007) notes the same research distinction when she states that:

[R]ecent work on stigma has attempted to develop a distinction between felt and enacted stigma (Gray, 2002, Scrambler, 1998), with felt stigma being internal, self-stigmatisation on the part of the individual, and enacted stigma being the

QUQ external discrimination that the individual might experience within society. (p. 141)

While this distinction was initially identified in the corpus (certain authors talked about being ashamed, while a different group tended to discuss discrimination), when these narratives were subjected to close textual analysis the distinction was eroded. Narratives that describe instances of discrimination are frequently framed or narrated in a way that signifies the author’s own shame. Moreover, when authors discuss their shame, they often invoke their own discriminatory attitudes towards (other people diagnosed with) affective disorders.

‘Pure’ discrimination

Discussions of instances of discrimination without implied shame are rare in the corpus. This finding is unlike other research where accounts of ‘pure’ discrimination appear more common. (see for example Foster, 2007, pp. 107, 109).36

Where corpus authors do do occur, authors typically demonstrate anger at being treated in ways that they feel are unjustified and rude. In the following example from Rowe, a relative (the exact relationship is not identified) is abusive and disrespectful:

“What are you doing?” demanded the person in the next room. “I’m looking for my contraceptives,” I replied. Even as I write this, I can’t believe the reply. “Why do you think someone like you would need those again?” (BT 129)

The phrase ‘someone like you’ in this quote indicates that the family member (let us call him ‘Fred’) is making their verbal attack based on Rowe’s characteristics. Rowe’s discussion of this anecdote indicates that she interprets Fred’s reply as referring to her status as a person with a mental illness (BT 129 –130).

RUThe reasons for this are unclear; however, it may be that experiences of discrimination are more common in individuals participating in other research projects, an interview methodology may encourage certain forms of confession that published narratives do not, or that other research populations have a more societal or social pressure understanding of the cause of mental illness. QUR

In this quotation, Fred is positioned as understanding mental illness as an out-group: also known as an ‘us and them’ mentality or, in the language of psychoanalysis, critical race or gender studies, it is an ‘Othering’ (Canales, 2000; Dean, 1997; Fabian, 1990; Frosh, 2002; Kitzinger & Wilkinson, 1996; Paechter, 1998). Specifically, Rowe represents Fred as stating that those with mental illness are fundamentally different from himself: ‘the mentally ill’ are a group that he does not belong to and to which he has negative associations (Brewer, 1999; Dion, 1973; Riketta, 2005; Stephan, 1977). The phrasing and tone of this categorical distinction suggest that Rowe interprets Fred as believing himself to be superior to Rowe.

A particularly vicious aspect of this verbal attack is the implication that Rowe’s mental illness lessens her right to have sex and calls into question the likelihood that she will have sex at all. The question ‘why do you think someone like you would need those again?’ can be read as positioning Rowe as simultaneously so undesirable that no person would want to have sex with her and as an asexual being that is outside the realm of sexuality. More generally, this statement implies that Fred understands Rowe – and people with a mental illness in general – as fundamentally undesirable. Within a cultural context that associates sexual desirability with full adult subjectivity, this link may be read as infantilising individuals with mental illness. Such a statement might therefore be interpreted as an attempt to minimise Rowe’s integrity as a whole and valued human being.

Unlike many other authors, Rowe forcefully rejects the discrimination and abuse that she experiences. When Rowe writes ‘even as I write this, I can’t believe the reply’ her abuse is positioned as the responsibility of the person who perpetrated it. Thus, Rowe affirms her own integrity by indicating that she is a person who requires – and deserves – respectful treatment. While this may seem like a normal expectation, within the corpus an insistence on respect that is not simultaneously an acknowledgement of shame is surprisingly rare. Lafrance (2007) noted a similar phenomenon in her Canadian study participants:

In an interesting discursive turn, however, [several study participants] are able to negotiate legitimacy through their talk of depression as a contested experience.

QUS That is, by constructing themselves as unfairly stigmatised and misunderstood, they are able to present themselves as even more worthy of sympathy. (p. 133)

Thus, in both the corpus and Lafrance’s study, accounts of discrimination were, at least for some people, an unexpected opportunity to affirm their legitimacy as ill subjects.

Stories of discrimination as reflecting shame

When authors describe instances of discriminatory behaviour, it is common for them to indicate that, while upset about being discriminated against, they nonetheless feel ashamed about having an affective disorder. The following are two simple examples of authors writing about discrimination and shame simultaneously:

In a discussion of how his family felt about telling acquaintances of his hospitalisation, Hamilton implies his own shame about being ‘mad’ when he asks:

[…] who wants to admit that a member of their family has gone mad? (BO 124)

Jeff describes talking to adolescents about mental illness as an action that simultaneously reduced discrimination and his own embedded shame:

I’ve started speaking to high school kids through Mental Illness Education Australia, trying to reduce the stigma surrounding mental illness. Being able to tell your story – this is what happens and this is how I feel about it – takes away some of your own stigma, too. A lot of stigma can be internal. (D 120)

In both these quotations, experiences of shame are an aspect of discussions of discrimination and are, in fact, heightened by the very acknowledgement of stigma within the author’s community.

In a more complex example, Cheryl writes of feeling both unfairly treated and ashamed simultaneously:

QUT

I felt that I had to qualify my behaviour and so I told her I was ‘mentally ill’. I told her that I was really comfortable telling her this, but I actually wasn’t. She stopped calling and another person at work soon found out too. I was devastated and felt violated. (17V 140)

The sentence ‘I was devastated and felt violated’ suggests that Cheryl feels that the content of her disclosure should be recognised by others as stigmatising and thus should remain confidential. It is unclear whether she believes that having a mental illness is ‘really’ shameful, or whether she is simply protecting herself from an expected negative reaction by enacting the same kinds of protections of self that would accompany shame. Regardless of the impetus for her response, the description of Cheryl’s sense of devastation reaffirms for the reader that having a mental illness is a stigmatised condition.

The shame implied in many accounts of discrimination emphasises the influence of personal interpretive lenses on illness narratives. Specifically, the intertwining of discrimination and shame suggests that authors who are more ashamed of their condition are more likely to perceive others as being discriminatory (Crocker & Major, 1989). However, the influence does not only occur in these narratives of stigma: the reverse influence is also evident in the corpus, with descriptions of shame reflecting discrimination.

Shame as reflecting discrimination

A number of authors discuss their initial sense of shame about having an affective disorder (JwBD 89, 91 17V 284, D 7, 12, 19). Such disclosures are typically in the context of emphasising the negative consequences of the stigma associated with these conditions, and asserting the author’s improved epistemic authority by indicating that they now ‘know better’. Particularly debilitating experiences of shame are more prevalent in authors who have previously been prejudiced towards others because of their mental illness diagnosis. This phenomenon is not unique to affective disorders or mental illness, but can be seen in other stigmatised communities: for example, those who come from homophobic communities, such as conservative Christian faith communities, are often more distressed by their own homosexuality than those from

QUU more progressive communities (Igartua, Gill & Montoro, 2003; Kahn, 2006; Phillips, 2005).

The following quotation highlights the way that previous stigmatising beliefs about others can form the basis for shame:

I am not who my father was. I am too in control, too successful, too everything, to have a mental illness. Bipolar, anxiety, depression, lithium … they are not who I am. (JwBD 138)

This quotation indicates a link between the author’s value judgements about his father, and his sense of self when confronted with a possible affective disorder diagnosis. Specifically, the author indicates that he associates affective disorders with being out of control and unsuccessful. By saying ‘I am not who my father was’, he associates these characteristics with his father (who in turn is positioned as a ‘bad’ person) and disassociates them from himself. However, the very need to erect this separation implies that the author is not as removed from the tarnished identity of mental illness as he desires.

This author’s shame about his emotional distress is one of the ‘ripple effects’ of illness- related negative attributions – not only is it likely that the author’s low opinion of his father was hurtful to the father at the time, it also increased the author’s distress during diagnosis and treatment. Moreover, it seems likely that some individuals who previously discriminated against others may feel intense shame when they experience emotional distress. This shame may result in individuals not getting help either from health professionals or their friends and family.

Where the Journeys with the Black Dog author limits his negative judgement to his father, other authors express discriminatory beliefs through their use of broad negative stereotypes:

During that period of time, I didn’t know I had depression. I went to the GP and she said: “You’ve got depression”. I said: “Don’t be stupid, I can’t have. I’m not a neurotic, middle-aged female who sits around and pops Prozac”. (GC 127)

QUV

On first reading, this quotation appears solely to be an expression of Pethick’s personal prejudice and pre-existing negative stereotypes of people who have depression as neurotic, middle-aged, female and habitual consumers of anti-depressants. However, that this discriminatory belief is occurring in the context of her own diagnosis suggests that this is simultaneously an expression of shame. Moreover, the phrase ‘I can’t have [depression]’ implies that a depression diagnosis is threatening her sense of self-worth. Thus, while her reaction should be considered primarily discriminatory as it is explicitly addressed at an (imagined) other, it nonetheless indicates a sense of shame that is impelled by pre-existing discriminatory beliefs.

This section has demonstrated that it is inaccurate to understand stigma as being a one- way enterprise with individuals only ever being a ‘victim’ or a ‘perpetrator’. Rather, shame and discrimination often co-occur and complicate each other in interesting ways. Such complexity does not detract from the seriousness of the negative consequences of shame and discrimination, but rather acknowledges that simplistic cybernetic models of communication are insufficient. Given these negative consequences, it is unsurprising that authors spend significant time arguing against discriminatory beliefs. In the next section, the ways that they do this will be examined.

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Shame is a direct threat to an author’s lived sense of integrity in the form of their self- worth and self-esteem. Expressions of shame and accounts of discrimination in corpus materials threaten an author’s positioning as a legitimate ill subject and as a subject with integrity. As such, negotiation of stigma is one of the most important rhetorical aspects of corpus materials.

Within the corpus, two types of statements function to counter stigmatising actions or beliefs. The first are negotiations of negative attributions, typically in the form of ‘I have an illness, I don’t have that bad characteristic’. The second are in-group/out-group differentiations, which tend to be expressed as ‘I experience affective disorders, I’m not that type of person’.

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The most common negotiations of stigma have already been discussed at length in Chapter 7. Recall how authors would assert that affective disorders are a type of illness in a way that increases their legitimacy as ill subjects and protects them from accusations of being lazy, weak, a failure, etcetera. To reacquaint the reader with this theme, some further examples include Hamilton’s affirmation that bipolar is not a result of a weak personality because it is a genetic condition:

For anyone diagnosed with bipolar disorder it is important to understand that it is not your fault. This is not an illness of guilt or a by-product of a weak personality […] Simply, it stems from the genetic map drawn for us when we were still in the womb. (BO 158)

Rowe justifies her ongoing self-care by indicating that her bipolar is like other potentially fatal illnesses:

I have also come to accept that, after an episode, I am physically exhausted and I must be patient, convalesce and nurture myself – just as anyone who has had a life-threatening illness must do. (BT 172)

Deitz pre-emptively protects herself against shame by saying:

I remind myself that if I get depressed again, it doesn’t mean I’m not strong enough or good enough. It just means I’m not well, and the episode won’t last forever. (D 8)

Finally, a Journeys with the Black Dog author normalises potentially stigmatising treatment by affirming the physical nature of depression:

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Don’t be alarmed at the thought of taking medication. If you had a heart condition, you wouldn’t hesitate to take the medicine your doctor prescribed. You have a medical condition, just like many other people. (JwBD 226)

In each of these examples, potentially stigmatising attributions are addressed by affirming that affective disorders are illnesses and that sufferers deserve the support, recovery time and empathy provided to others who are experiencing an illness.

Despite the dominance of this approach in both the corpus and Australian public health campaigns, research indicates that mental health awareness campaigns using the ‘just like any other illness’ approach are often a ‘catastrophic failure’ (Mehta & Farina, 1997; Payton & Thoits, 2011). Research has found that these campaigns ‘often increase public fear and prejudice, confirming societal phobias that mental ill-health is a random biological event that is beyond one’s control’ (Blackman, 2007, pp. 1-2). That such campaigns result in public perceptions that mental illness is beyond one’s control is in keeping with the apparent aims of discussions of stigma and biological causation by corpus authors. Moreover, while over-simplistic and denying social and psychological causes of affective disorders, a biological account is not completely inaccurate and is, in fact, more accurate than the stereotypical beliefs that such campaigns are typically trying to address (Wilson, 2004b). What is most concerning, therefore, is not the belief itself but the way that this belief is associated with increased fear and prejudice. It seems likely that when authors rely on biological accounts, they do so with the same aims as these health campaigns: to reduce stigma by reducing personal blame. It is, however, unclear whether the more detailed enactments of biological accounts in corpus materials will have any more positive public receptions than their health campaign counterparts.

In addition, for a very small number of authors, ‘traditional’ negative attributions are not resolved by referring to affective disorders as illnesses. Specifically, this type of refutation is not effective in instances where an author understands being a person with a mental illness as equally stigmatising as the comparative identification. Put simply, one’s self-esteem is not enhanced by the statement ‘I’m not a malingerer, I have a mental illness’ if one understands having a mental illness as being more undesirable than being a malingerer. Of course, most authors resolve this by minimising the mental

QVO aspects of their illness, either by affirming that they have a physical illness (‘I have an illness just like diabetes’ – see above) or by distinguishing madness from affective disorders (‘I’m not mad, I have depression’ – see below). The dominance of these methods emphasises the overall familiarity that the corpus has with medical accounts of affective disorders and the extent to which these accounts are used in predictable ways by authors.

However, a very small number of authors are unable to refute the negative attributions that they associate with their condition. In these instances, authors write in ways that position the negative attributions as all-consuming:37

So why can’t I cope? [...] Am I [a] freak? Am I weak? Am I a coward? Maybe I don’t deserve to be happy. Maybe I don’t deserve to be alive. Maybe I was [a] mistake and I was never meant to be here. (HS 182)

In this quotation, the author appears to be trying to determine why he is suffering. The text seems representative of the hopelessness felt by some people with depression, with the quotation constructed in such a way that a refutation of one negative attribute tends to reaffirm another. This is particularly apparent in the questions ‘Am I weak? Am I a coward?’ Weakness can be defined as a lack of strength. In contrast, cowardice is – typically – having strength but being afraid to use it. Thus, in the context of the pre- established attempt to determine why he is suffering, if the author affirms his own worth by replying to his own question by saying ‘I am not weak’, then it is implied that he is a person who has the strength to cope but does not use it (a coward). In turn, if he affirms himself by replying ‘no, I am not a coward’ then it is suggested that his lack of capacity to cope is the consequence of some form of weakness. Thus the author cannot escape his own negative attributions: it is a classic catch-22 that is likely to have negative effects for both the author’s self-esteem and his sense of personal integrity.

37 Oliphant (2010) reported a very similar posting in one of the online depression newsgroups that she was analysing: ‘I have a lot of the symptoms of depression – weight gain, tendency to sleep a lot (but not much at night), inability to do anything I don’t absolutely have to … But maybe I’m not depressed. Maybe I’m just a lazy bitter pig. Maybe having a diagnosis of depression is just an excuse to not be the person I’d like to be, not to have to do anything’ (p. 88, ellipse in original). QVP

In addition to the use of familiar biomedical accounts, in-group/out-group differentiations routinely function in the corpus to mitigate the stigma of affective disorders and enhance the representations of author integrity. This finding is mirrored in a range of empirical findings: for instance, Crocker and Major note that ‘one mechanism that may protect the self-esteem of oppressed groups is attributing negative feedback or relatively poor outcomes to the prejudiced attitudes of others towards their group’ (1989, p. 612).

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Corpus authors routinely make a differentiation between people with depression and those without (see also Karp, 1994; Sword, Busser, Ganann, McMillan & Swinton, 2008). Typically, this in-group/out-group distinction also enacts a differentiation between those who are deemed knowledgeable about affective disorders and those who are ignorant. In this way, this differentiation is simultaneously an enactment of an identity boundary (between the legitimate and the illegitimate) and an assertion of epistemic competence and authority. As will be discussed in Chapter 12, a belief that stigma is based in ignorance informs many education/anti-discrimination campaigns, as it is presumes that if people are educated about a topic, then they will stop being discriminatory. This knowledge-deficit model of stigma and avoidance of professional services seems particularly common in health promotion (see for example Elwy, Yeh, Worcester & Eisen, 2011). Within the corpus, the in-group/out-group distinction comes in two main forms: a separation of ‘the depressed’ from ‘the public’ and a more context- limited separation of the author from their family and friends.

The public

For many authors, their sense of stigmatisation is directed towards the reactions of an amorphous ‘public’. When authors use imprecise statements such as ‘people don’t understand’ (17V 38, D6) or ‘the wasteland of public ignorance’ (BO 247) it is unclear whether the author has experienced many minor instances of discrimination that they ‘rollup’ into a singular entity, or whether these discussions reflect a sense of shame that the author projects onto their entire community (see also JwBD 171, 17V 106, 154, 284,

QVQ D 16, BT 137-8). Regardless of the source, it appears that authors feel an acute need to refute stigma that is attributed to ‘the public’.

As mentioned above, authors typically contest stigma from ‘the public’ by affirming that they have greater epistemic and experiential authority than the stigmatising party. For instance, an author during a discussion of the reactions of people in their town to their diagnosis writes:

They say, ‘Oh, you’re not mad’ (well, not all the time!), or ‘You can’t have manic depression’. Do they think I made it up? Do they say that to a diabetic? From some I get patronising tones. Is it to denote quite firmly that they are different/OK/even better than me because they don’t have a mental illness? Do they think I chose this? Do they see it as a weakness on my part? Do they blame me for having a mental illness? (JwBD 94)

Within this quotation, a distinction between the author and her community functions to position the community as holding false beliefs about bipolar. The combination of the author’s repeated use of the phrase ‘they think’ (in comparison with phrases such as ‘they know’ or ‘they realise’) and her sarcastic tone, positions the truth as being the opposite to the beliefs of her community. Put differently, the author’s rhetoric functions to affirm that, in reality, it is not her fault, it is not a choice or weakness and it is not appropriate to blame her for her condition. In this way, a separation between those with depression and those without is mapped onto a distinction between those who are knowledgeable and those who are ignorant. This in turn enables the author to discredit the claims of her community, rebut their stigmatising beliefs and maintain her own self- esteem and integrity. This textual analysis is in keeping with empirical studies that indicate that ‘low perceived legitimacy of discrimination may protect the self-esteem of people with mental illness and encourage them to feel more empowered’ (Rusch, Lieb, Bohus & Corrigan, 2006, p. 401).

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Friends and family

Where the anthology author uses in-group/out-group differentiation to explain and condemn discriminatory community attitudes, other authors use this distinction to justify why friends and family do not provide them with support:

I don’t know if ppl [people] just don’t care or if they just don’t understand, but the fact of the matter is sometimes, in cases of depression and bi polar etc, people don’t need a rational reason for how they feel and it may be something tiny that can set them off. (HS 131)

The figure of speech ‘the fact of the matter’ functions in this quotation as a way of legitimising the author’s understanding of depression and bipolar. Again, in-group/out- group dynamics are mapped onto epistemic competence, with the author’s understanding represented as ‘fact,’ while the view of people who ‘just don’t understand’ is positioned as a fallacy. The same finding is reflected in Oliphant’s extended study of the knowledge claims of individuals participating in a newsgroup on depression and complimentary therapies. She notes that the positioning of participants as having ‘the facts’ is a critical aspect of discussions on the board, with the consequences of being considered ‘by others as poor fact constructors and incompetent information users [being that] their accounts were often dismissed, derided, or ignored (Oliphant, 2010, p. 159). Thus, in both Oliphant’s and the thesis corpus, the positioning of adult authors as competent epistemic agents is a significant rhetorical aspect of internet interactions about affective disorders.

Complexity

While most texts enact a simple layering of comparative epistemic authority and in- group/out-group status, in a small number of cases a more complex layering occurs. In these instances, a web of associations is developed that further affirms the legitimacy and accuracy of the author’s beliefs and dismisses those that are positioned as inaccurate and/or stigmatising:

QVS The initial reports were investigative in nature but I soon noticed Prozac appearing more and more often in lifestyle feature articles about ‘how to be happy’. These articles were more likely to pathologise unhappiness rather than try to understand depression, so the inclusion of Prozac was either judgemental or flippant. (D 27)

Within the quotation, Deitz makes four distinctions, between: (1) understanding and opinion, (2) truth and belief, (3) investigative journalism and lifestyle articles and (4) depression and unhappiness. These distinctions are aligned, so that investigative reports that describe depression as an illness are positioned as truthful. In contrast, lifestyle articles that claim that antidepressants can be used as a way of increasing happiness are positioned as reporting a (false) belief. In this way, Deitz increases the legitimacy of her own claims by associating them with truth. Conversely, she discredits the claims of those with whom she does not agree by positioning their claims as merely belief. This is further emphasised when those who do not adhere to a medical understanding are positioned as incompetent epistemic agents and are deemed ‘judgemental or flippant’. By using multiple differentiations, a web of associations is produced which helps to reinforce the meanings behind the comparisons. It is likely that the relative rarity of these multi-layered comparisons is a result of their increased conceptual complexity, with most authors using simple (and still quite effective) comparisons instead.

Positive interpretations

While all authors position a lack of understanding or empathy by friends and family as a negative experience, authors do not always blame their loved ones for these reactions. In a number of instances, it appears that authors make a sustained effort to abdicate blame while still acknowledging the lack of support:

There will always be people who think like this – that those with depression should be able to rise above it, or take up a hobby, or be thankful for what they have. These people may never understand. Mostly, when it comes to depressives, it takes one to know one. (D 6)

QVT

The distinction between people with and without affective disorders in this quotation allows the author to explain discriminatory behaviour without demonising the people who act in a disrespectful manner. Put simply, this understanding enables Deitz to say ‘Oh, he hasn’t experienced depression, that’s why he does not understand’. For individuals whose loved ones are not supportive, this type of explanation allows them both to acknowledge an inappropriate response and to understand the lack of empathy.

Another version of ‘positive spin’ occurs when the layering of lived experience and empathy results in non-sympathetic friends and family being understood as ‘lucky’:

Most people won’t have a clue what you’re going through and the more you try to explain it to them, the less they will understand. Accept this and be thankful that they don’t suffer. (JwBD 144)

In this quotation, a lack of understanding is positioned as evidence of a lack of experience of depression. This seems to be a particularly effective way of interpreting a lack of understanding by a loved one as it suggests that an author’s desire for their loved ones not to suffer impels them to be grateful that their friends and relatives do not empathise with their suffering.

This affirmation is enabled by the author maintaining a strict demarcation between those with and without depression. Specifically, the phrase ‘the more you try to explain it to them, the less they will understand’ indicates that a lack of understanding gets worse with increased explanation or education, and yet changes in beliefs seem unlikely to occur without some form of external input. In this way, the author sets up a fundamental – and unbridgeable – difference between those who have experienced depression and those who have not.

In the quotations in this section, those who experience affective disorders are deemed more legitimate and knowledgeable narrators than those without these conditions. In the next section, the other end of the spectrum is examined, with individuals diagnosed with affective disorders being positioned as having greater legitimacy because they are ‘more sane’ than the ‘mad’. Despite these very different positionings, both differentiations

QVU have the same key rhetorical function: to maximise the legitimacy of the author as an epistemic and ill subject.

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When authors distinguish between ‘the mentally ill’ and ‘the mad’ – or as Leah describes it, between the ‘stressed-out crazy’ and the ‘crazy crazy’ (17 V 31) – they affirm their own value and integrity by distancing from a more stigmatised category. This differentiation is seen in the following four quotations.

In a discussion of anxiety symptoms, Meg affirms that she is not really crazy by indicating that she is afraid that others will misconstrue her as being a psycho:

I couldn’t disguise the fact that I was shaking uncontrollably. I was afraid people would think I was a drug addict or a psycho. (17V 275)

When Petria Thomas says that she ‘wasn’t crazy or anything’ she separates herself from the severely mentally ill:

It wasn’t that I was crazy or anything like that; I just needed some time away. (GC 86)

By stating that their anxiety was analogous to craziness, a young person on headspace emphasises that they are not really crazy:

I was living with all kinds of irrational fears, and had many days where life seemed very dark and I felt like I was going crazy. (HS 217)

Finally, in a statement that normalises her anxiety by separating her experience from those of freaks and crazy people, an author on ReachOut writes:

Sometimes I still do get anxiety attacks, but I know how [to] deal with them. I’m not a freak and I’m not crazy. (RO 34)

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In each of these examples, the author’s own value and self-esteem is positioned as being premised on them being (merely) mentally ill and not crazy. This separation has been observed by Foster (2007), who responds to a patient saying that those who have not been in a psychiatric ward inaccurately characterise it as filled with people in strait jackets and padded cells, by noting that this statement ‘accuses the public of failing to differentiate sufficiently within mental illness, and seeing all those with mental health problems in the same negative terms’ (Foster, 2007, p. 106).

In contrast with the separation of ‘the depressed’ from ‘the public’, which is based on the greater epistemic and experiential authority of the author, this separation immediately enhances the author’s legitimacy, integrity and authority. Specifically, by locating themselves as ‘not mad’ these authors assert that while they still have a serious condition (legitimacy) they are a (more) valued type of person (integrity) and they have (more) cognitive capacity (authority) and rationality, which indicates their full human- ness (see Chapters 8 and 9). In this way, the legitimacy and integrity of many authors is based on their ongoing stigmatising of people with other forms of mental illness.38 This type of positioning is particularly concerning as it reinforces the stigmatisation of severe mental illnesses such as schizophrenia and thus further encourages the discrimination and social isolation that are already hugely problematic for individuals with these conditions.

In addition, the distinction between ‘the mentally ill’ and ‘the crazy’ is discursively intriguing as it represents a shift from a traditional conflation of these terms. As Giles and Newbold (2011) note, this shift appears to be associated with the increased ‘real illness’ status of certain mental disorders:

38This type of in-group distinction is not only found in those diagnosed with affective disorders – anecdotally, it appears to also be present in a variety of different stigmatised groups, including the GLBTIQ community (‘I’m not one of those sluts who has sex with twenty men in a week, I just want to get married to my boyfriend’), the Aboriginal community (‘I’m not a drunk like those good-for-nothings livings off the dole’), and other health categories (‘My obesity is genetic, unlike some other people who just don’t look after themselves’). QVW So great is the sanitizing power of mental illness discourse over many decades, that it seems “crazy” is no longer compatible with the receipt of a psychiatric diagnosis. (p. 421).

Thus, in addition to being an effective rhetorical strategy for mitigating stigma for individual authors, the differentiation of the ‘mentally ill’ from ‘the mad’ is part of larger social changes that encourage the destigmatisation of particular mental conditions through the reaffirming of the ‘badness’ of irrationality and psychosis.

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In contrast with other chapters, this chapter has been focused almost exclusively on adult writers – because discussions of stigma are more common in older authors. While it is unclear why this is the case, hopefully such generational differences reflect a reduced sense (and experience) of stigma in young people. However, it is also feasible that such differences indicate that young people who are feeling stigmatised are not engaging in published narratives, while older adults who previously felt stigmatised and have ‘moved through’ this shame are now willing and able to write about it.

While the extent of stigma reported by authors is alarming, of particular concern is the potential effect of the mitigation of this stigma on other marginalised communities. Specifically, it is worrying that corpus materials routinely enact a differentiation between individuals with affective disorders and the ‘mad’. While this distinction may have utility for authors, it reinforces negative stereotypes of other types of mental illness.

In this chapter, the aspects of LIAM have been in a complex interplay. Specifically, the differentiation between the public and those with affective disorders enacted a layering of illness legitimacy (‘I have a real illness’), authority (‘I know more about this illness than you do’) and integrity (‘I am more respectable than you because I am not prejudiced’). Such layering boosted the rhetorical effect of certain statements and helped to securely locate the authors as both competent and legitimately ill subjects. At other times, however, an author’s legitimacy as an ill subject was obtained at the

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expense of their integrity. In several instances where authors discuss shame, their integrity in the form of self-complexity and self-respect is reduced. At the same time, however, an affirmation of the seriousness of the condition that is positioned as the cause of the author’s shame in the first place, functions to enhance the author’s legitimacy as an ill subject. Such disparate rhetorical effects emphasise that integrity is a more tenuous and temporary effect than legitimacy, that rhetorical effects are context dependent and that the enhancement of one effect does not always result in heightened expression of the others.

The next chapter is a move away from thematic based analysis. Instead, Chapter 11 will provide a case study of the ‘real life’ impact of some of the rhetorical devices examined in this thesis. Specifically, in the context of examining the conservative gender roles that are embedded in much of the corpus, the chapter will examine how a separation of self and illness is enacted in corpus materials during justifications of domestic violence perpetrated by men diagnosed with depression.

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I am jolted into consciousness by my phone ringing. It’s some hour of extreme darkness, what I will eventually know to be a little after 2 am. It is the time of night when phone calls can only mean death or crisis. I stumble out of bed. Head down the stairs. I miss that first call. Dial my message bank. On the other end is Anna, asking that I call as soon as possible. She sounds disorientated and frightened. I press ‘return call’.

She answers. I ask what’s wrong. She says it’s real bad, things are out of control, but she can’t tell me what has happened because she’ll get in more trouble. Trouble from whom, I wonder, but dare not ask. Some four months later I will learn that she has been regularly doing things that should rightfully get her killed, signing papers she should not have been signing, losing time, not knowing her name or where she is. But for the moment, all I have is her panic. She is experiencing her first memories of this lost time and they are petrifying. She doesn’t know what is real or not. What she is certain of is that things are bad. And she is bad. And that killing herself makes the most sense of any option she can think of.

It takes about an hour, but I get her calm enough that she agrees that she is safe enough to sleep. An hour of reassurances and breathing exercises. An hour of what may or may not be lies about how things will be OK. An hour of calm overtaken by panic, panic subsumed by calm, panic, calm, panic, calm. She is frightened. I am frightened. She has to drive home so she can sleep and I’m scared she’ll get panicked again and decide to drive into a tree. But I am over 1000 km away and I can’t make her safe. All I can do is make a promise to call in the morning. It’s a pittance, but it’s all I have. And so I return to my bed and stare at the darkness until the morning light arrives.

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… the woman who is “truly feminine” [is] the submissive woman. (de Beauvoir, 1952, p. xxvii )

This chapter is premised on a seemingly self-evident assumption: that men and women experience affective disorders in different ways. Feminist scholars have researched these differences extensively, as well as providing sustained analysis of the relationship between these different experiences and the rhetorical and discursive aspects of affective disorder narratives.

There has been substantial feminist research regarding how depression is socially constructed as a ‘feminine’ illness. This research has focused on how health promotion bodies and pharmaceutical companies have represented depression and depression treatments, as well as on how women themselves narrate their depression experiences (Boyd, 1999; Danielsson, Bengs, Lehti, Hammarström & Johansson, 2009; Edhborg, Friberg, Lundh & Widström, 2005; Emslie, Ridge, Ziebland & Hunt, 2007; Fenton & Sadiq, 1993; Fullagar, 2008, 2009; Gattuso, Fullagar & Young, 2005; Lafrance, 2007; Nahas, Hillege & Amasheh, 1999; Salokangas, 2009; Schreiber & Hartrick, 2002). Researchers have observed how – both historically and in the present moment – the feminisation of depression is achieved through locating the aetiology of depression in the (female) reproductive system, specifically through menstrual cycles and hormonal variations (Ussher, 1997, 2011). In addition, researchers have critiqued how the cultural link between femininity and (excess) emotiveness positions depression within the realm of the feminine (Blum & Stracuzzi, 2004; Metzl & Angel, 2004).While work has been completed on mental illness and masculinity, less research has been done on the relationship between depression, men and masculinity (Brooks, 2001; Fraser et al., 2005; Gorman et al., 2007; Lacoursiere, 1972). The research that has been published has focused on suicidality (Biong, Karlsson & Svensson, 2008; Cleary, 2011), generic recommendations for working with men with depression (Oliffe & Phillips, 2008), men’s experiences of help-seeking (Johnson, Oliffe, Kelly, Galdas & Ogrodniczuk, 2011) and comparisons of narratives and experiences for women and men (Bengs, QWR

Johansson, Danielsson, Lehti & Hammarström, 2008; Danielsson et al., 2009; Horsfall, 2001; Riska & Ettorre, 1999).

In order to build on this previous research, this chapter begins by defining normative gender expectations and describing in detail how men and women enact these norms in corpus materials. Analysis is then performed on descriptions of caring behaviour in the dataset. Consistent with normative gender expectations, corpus materials suggest that women are expected to be more active in their care for men and to suffer more than men. The chapter concludes by examining how these conservative gender norms combine with illness rhetoric in repeated examples of authors justifying the emotional and verbal abuse of women who care for men who experience depression.

In contrast with the previous thematically organised chapters, this chapter is a case study. The use of a case study in the latter part of the thesis allows readers to see how the rhetorical functions analysed throughout the thesis body have ‘real life’ implications. Moreover, it highlights the potentially damaging aspects of rhetorical actions that may initially appear innocuous or without consequence. This type of enquiry requires a slightly different approach to that used in the previous chapters: namely, a greater focus on cultural influences and social forces outside of the text, such as normative gender expectations.

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Gender is, of course, not the only identity or social position that may complicate an individual’s experience of depression or anxiety. Other identities (e.g., class, race, sexual orientation, etc.) may also change the nature of a person’s experience of affective disorders. However, where gender is relatively easily identified in this dataset, these other identities are not generally disclosed, making the analysis of experiences according to these categories unfeasible.

Unless noted otherwise, all authors examined in this chapter have indicated their gender in some way. At times these indicators are explicit (i.e., ‘I am a 24 year old man’), but in most cases the indicators are contextual (e.g., name, identity in relationships such as being another person’s girlfriend, husband, aunt or mother, or by gender restricted

QWS behaviours such as wearing dresses, having pre-menstrual tension or buying bras). These non-explicit indicators are imperfect. For example, it is possible that an individual may have chosen a screen name that is not consistent with their gender (see BB 305) or that the person putting on makeup and a dress may identify as male. The use of such indicators to identify gender is somewhat problematic as they rely on, and therefore reinscribe, normative gender expectations and stereotypes. For this reason, explicit signifiers have been relied on wherever possible.

While there appear to be more women than men in the corpus (exact figures are impossible due to the non-gender specific user names in some internet sources and anonymous anthology materials), there is substantial data from both genders. Women tended to discuss their intimate relationships more than men did, and thus data on the effects of affective disorders and family and intimate relationships may be somewhat biased. However, an overall consistency of the themes identified in this chapter by male and female authors suggests that this bias has not had an unacceptable effect on the analysis.

This chapter is concerned with patterns of attribution and behaviour in relation to the gendering of affective disorder experiences. Except in instances where domestic violence is detailed, this chapter does not argue that there is any issue with individual enactments of normative gender expectations, nor that there is any issue with a particular woman being the carer of a particular man. However, the chapter is critical of how particular normative, and potentially harmful, gendered relations are repeated throughout the corpus.

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Like mental illness, gender is a social construction with both corporeal and cultural aspects (see Chapter 2). Reminiscent of the category of mental illness that has a biological correlate, gender is related to, but distinct from, biological sex. Where sex refers to biological differences between men and women, gender refers to the social valuing of these differences and the related categories of masculine and feminine. Within most societies, it is expected that a person’s gender will align with their primary

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and secondary sex characteristics (e.g., a man is expected to have a penis) (Bordo, 1990, 1993; Butler, 1993, 2004; Lorber & Moore, 2002).

Just as there are ideals of mental and emotional functioning, there are ideals of gendered behaviour and embodiment. These ideals are commonly referred to as gender norms or normative gender expectations. Normative gender expectations of a particular culture are best understood by imagining the characteristics that would be considered indicative of a ‘real man’ or ‘real woman’. While no single person can enact every characteristic of a ‘real’ man or woman, these norms are culturally significant and are enacted and valued throughout communities (Helliwell, 2000). What characteristics are deemed to be desirable in a particular gender change over time and are influenced by the culture, race, ethnicity, class, sexuality, age, physical ability and religion of the particular individual (Kiss and Tell Collective, 1994; McInnes & Couch, 2004; Trinh, 1989; Walker, 2001). However, while the specific behaviours or attributes vary, it is common for normative gender expectations to emphasise differences – both biological and cultural – between men and women.

Various normative gender stereotypes are dominant in western cultures. Within the corpus, certain of these stereotypes are present. Specifically, women are represented as carers of their families, especially of their young children, and as being particularly emotionally volatile. Female corpus authors also appear concerned about being physically attractive. In contrast, men tend to be represented as breadwinners who enjoy going out with their mates. Male corpus authors appear to be concerned about their career and appear to feel that they should always want to have sex.

Gender stereotypes encourage characteristics that are deemed desirable when expressed by one gender to be valued differently when expressed by the other (Gatens, 1996). Such different valuing may involve devaluing or hyper-valuing. For instance, in the corpus the stereotypically feminine trait of caring for others is deemed exceptional when performed by men but not exceptional when performed by women. In contrast, when men express the stereotypically feminine trait of emotionality, they tend to report feeling devalued due to a belief that they are seen as having failed to perform stoic masculinity.

QWU Expected forms of embodiment are another expression of gender norms. For example, it is ‘normal’ for: women to giggle (men to laugh), women to wear dresses, high heels and makeup (men to wear suits) and men to have prominent biceps (women to have prominent breasts) (for a theoretical discussion of these embodiments, see Conboy, Medina, and Stanbury,1997; Frye, 1983; Tuana,1997). Gendered embodiment can indicate a range of characteristics not directly related to gender norms. For instance, later in the chapter it will be demonstrated that female authors signify the severity of their illness through their embodiment, with non-gender normative embodiment functioning as a signifier of greater illness severity.

Moreover, gender norms produce ideals of intimate relationships, so that the ‘proper’ relationship is typically imagined to be heterosexual, reproductive and monogamous (Allison, 1989; Butler, 1990; Rich, 1980; Rubin, 1989). These norms have implications for individuals with depression, particularly those who feel judged because their relationships (or lack of them) do not fit this ideal, or whose depression is related to feeling trapped in a relationship that is stifling or unsatisfying because of a fear of social failure (Lafrance, 2009; Schreiber, 1996).

Within western culture, femininity has historically been associated with physical, moral and intellectual weakness (see Lewis, 1996; McVittie, Cavers & Hepworth, 2005; Ortner, 1972). As discussed in Chapters 7 and 10, mental illness is also associated with weakness. In this case, the weakness is primarily moral (a belief that people with mental illness are just lazy) and emotional (people with mental illness are imagined to need to learn to control their emotions). As will be discussed below, this shared association with weakness helps to solidify a symbolic association between mental illness and femininity.

This section will examine the relationship between gender norms and depression for men and women. Particular attention will be given to how male authors report experiencing depression as emasculating and how the descriptions of embodiment by female authors function to signify the relative severity of the author’s depression.

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Throughout the corpus, men use more explicit gender rhetoric than women. The relationship between depression and gender is likely to be a concern to many men because the disorder is perceived to be antithetical to their understanding of normative masculinity (Emslie, Ridge, Ziebland & Hunt, 2006).

Male corpus authors routinely describe depression as being particularly difficult for men. These difficulties are directly linked to gendered expectations of behaviour, particularly familial responsibility. Ironically, while men describe these difficulties, the corpus suggests that it is more common for depressed women to continue to provide familial care during an episode.

Hamilton indicates that depression is worse for men because they are expected to be

‘breadwinners’ (see also Davey, Dziurawiec, and O’Brien-Malone, 2006, p. 213):

That manifesto of pressures [to win-at-all-cost] is very difficult for women; but for one reason or another, it is particularly hard on men. As boys we were groomed to be breadwinners, to have a career which defined our entire existence and place in society […] The prospect of being cast on the career scrapheap in your forties with no chance of discharging the mortgage, financing your children’s education, or maybe even saving your marriage, is all too real and the examples all too abundant. (BO 154 – 155)

In the context of discussing support in the workplace, John Konrads is also concerned about depression affecting the capacity for men to provide for their families:39

If someone is, say, the head of the family and has to make ends meet to pay the mortgage and kids’ schooling and put food on the table, whatever they do without work is only going to pay them less than work, so it brings up massive social pressures. (GC 143)

39 Although women can also be heads of households, this position is historically associated with men. Such associations remain strong in contemporary western culture (Biddlecom & Kramarow, 1998). QWW Both Geoff Gallop and John Konrads position depression as more difficult for men because men do not feel as comfortable discussing their feelings:

We’re excellent at [hiding our feelings] because we get plenty of practice, and we don’t want to worry our wives anyway. (GC 140)

Men definitely don’t talk about these things as much as women. There’s no doubt in my mind about that. But there’s improvement happening. (GC 173)

Despite ongoing and explicit concerns about societal gender normative expectations, men in the corpus tend to display a heightened level of distress regarding their own gender identity primarily in the times surrounding diagnosis (see BO 66, ix, 17V 293). As Alan Weiss, the psychiatrist who writes in Broken Open, argues:

It is very hard for an Australian male to accept he may be suffering from depression. (BO 193)

The most pronounced examples in the corpus of this gender-related distress at diagnosis are by Hamilton. It is likely that Hamilton is particularly concerned about being a ‘real man’ because he is located in hyper-masculine Australian working-class, mining and (men’s) sports cultures (Connell, 1991). Hamilton discusses how his depression threatens his sense of being a ‘real bloke’ (i.e., a legitimate male) both before and during diagnosis:

Prior to visiting his GP, Hamilton reports that in response to his wife suggesting that he might be ‘mildly depressed’:

I ignore it. After all, I’m an Australian man. We catch and kill our own demons. (BO 62)

A little while after this (non)discussion with his wife, Hamilton is diagnosed with depression. In response to his GP’s initial suggestion that he might need to take antidepressants, Hamilton writes:

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That’s not what I want to hear. ‘I don’t think so,’ I begin. ‘Um, blokes don’t take antidepressants’. (BO 66)

In both these quotations ‘being a man’ and ‘being depressed’ are positioned as conflicting states. In other words, depression, in these quotations, is positioned as a threat to normative masculinity (Link, Struening, Rahav, Phelan & Nuttbrock, 1997; Oliffe, Robertson, Kelly, Roy & Ogrodniczuk, 2010). For some men, this threat of depression to their ‘manliness’ is managed through hyper-masculine coping behaviours such as drinking and joking with mates, distancing from family and friends and damaging property (BO 56, 123, D 138, 143, GC 138, 199). These findings are consistent with Danielsson, Bengs, Samuelsson and Johansson (2011, p. 616) who note that Swedish young men describe ‘[a] lot of anger, irritation and physical violence’ as part of their depression experience.

Once men move into a medical/illness model of depression (rather than blame/weakness model) they generally are less personally concerned about their gender expression, although often they remain sensitive to perceived gendered stigma and concerned about the impact of normative gender expectations on other men (for example BO 155, 193, 205, GC 18, 173, 17V 293). Hamilton’s personal sense of shame appears to abate once he embraces an illness explanation of his suffering. His acceptance of a biological explanation coincides with talking publicly about his experiences while still advocating the view that there is a societal (but not personal) stigma surrounding being a depressed man.

In another example of how the ‘threat’ of depression to men’s sense of masculinity is often based in highly normative gender expectations, a male contributor to the Journeys with the Black Dog anthology writes:

Growing up in a Catholic family, I was taught that a man should be stoic, resilient, never show weakness, rarely show emotion, roll with the punches, work hard, marry and support a wife and kids […] I didn’t believe the doctor when he said I was depressed […] I thought I must have a virus because ‘real men don’t get depression’. Only wimps and malingerers got depression. They used it as an excuse for their weakness of character. (JwBD 95 - 96)

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In the first sentence, the author identifies eight characteristics of ‘manliness’: five of these relate to being emotionally remote (‘stoic, resilient, never show weakness, rarely show emotion, roll with the punches’), with only one related to professional life (‘work hard’) and two to family responsibility (‘marry and support a wife and kids’). Thus, in this quotation, the most important aspects of ‘being a man’ are being emotionally distant, untouchable and without (emotional) vulnerability. This form of normative masculinity is difficult to maintain during a depressive episode as the typical symptoms of depression mean that a person no longer feels stoic or resilient. According to the logic of this quotation, should any other person become aware of these emotions, the threat to the author’s legitimacy and integrity as a man becomes acute: in addition to not being stoic or resilient, one is now showing both emotion and weakness. Thus, in this account, it is not possible to be both depressed and still be ‘a man’ – the emotional detachment that is the foundation of this form of masculinity cannot withstand the shift towards emotional expressiveness (read, femininity) that depression produces.

It is therefore unsurprising that the author explicitly states that ‘real men don’t get depression’. Within this quotation, it is not that no man can get depression, it is that ‘real men’ – the type of man that, presumably, the author perceives himself to be, or wants to be – cannot be depressed. The category of ‘real men’ excludes wimps (men who are weak, cowardly or effeminate) and malingerers (men who avoid work, generally by claiming sickness benefits illegitimately). In other words, depression is positioned as a signifier of failed masculinity and the author is distancing himself in order to alleviate the threat of emasculation. Thus, within this account, depression is a failure to successfully perform normative masculinity – or, put simply, ‘I am depressed because I am no longer a (real) man’ (and conversely, and simultaneously, ‘I am no longer a (real) man because I am depressed’).

When a male author says ‘men do not get depression’ (and, throughout the dataset it was exclusively men who explicitly expressed this sentiment), they are implying that ‘women do get depression.’ Moreover, across the corpus, when the reasons why ‘real’ men do not get depressed are revealed, they are remarkably predictable and normative gendered attributes: men are not weak (women are weak), men are not emotional (women are emotional), men are stoic (women are not stoic). Interestingly, while some

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international research indicates that rationality and control are indicators of mental health most often enacted by men, in the corpus rationality as a signifier of mental wellbeing was not disproportionately used by male authors (see Rogers and Pilgrim, 1997, p. 28). Despite this slight aberration from stereotypical gendering, the corpus suggests that the gender identity of male corpus authors is frequently threatened by the prospect of being ‘like’ a woman – a threat that is based in both sexism and heterosexism (see Pharr, 1988).

Men tend to be concerned with their gender expression when they are not utilising ‘illness’ explanations of their condition. In contrast, women report a more constant and complex enmeshment of their understanding of depression, their gender identity and their gender performance.

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Within the corpus, there is a strong link between women’s depression and/or anxiety and their evaluation of their embodiment of femininity. Where men in the previous section typically had a negatively valued association between depression and femininity (i.e., they considered themselves feminised through their diagnosis of depression, and evaluated this feminisation of themselves negatively), in this section these meanings are disrupted. Specifically, this section examines how, in the case of women, a culturally valued embodiment of femininity is associated with mental health, while a socially devalued gendered presentation is understood – both by the woman herself and by those around her – as a signifier of illness (Gatens, 1996). For example, Christie writes about her evaluation of self in relation to ideals of femininity:

I compared myself to other people ‘Is that girl prettier than me? ... Is she better than me?’ I was trying hard all the time to impress people and get them to like me. If people liked me, I felt safe. I tried to be the perfect weight and get the perfect job. (17V 199)

QXQ Christie describes being pretty ‘enough,’ good ‘enough’ and liked ‘enough’ as mechanisms that make her feel emotionally safe.40 This description of the author’s symptoms implies that the reverse is also true: that when she does not feel pretty, good or liked ‘enough’ she feels unsafe and is more distressed. This suggests that where the successful performance of femininity alleviates symptoms, the ongoing threat – and ‘reality’ – of failure at this performance may intensify suffering (see also RO 34; for a more explicitly political and Foucaultian reading of similar findings, see Fullagar, 2009).

Some authors report that their family or friends encourage their negative evaluation of their embodiment. For instance, a Blue Board participate writes:

Even mum and dad don’t like me anymore, I’m not good enough for them and I’m constantly compared to my other sisters. I’m not as good as them, I’m not tall pretty and thin […] That’s not good enough and never will be good enough and it tears me up. (BB 272)

This quotation indicates that the author’s emotional distress is heightened by a perception that others do not believe her to act and be embodied in normative feminine ways. In particular, the quotation implies that her distress would reduce if she could believe that others considered her to be good ‘enough’ (i.e., tall pretty and thin). While men in the corpus display low self worth, it is significant that women appear more likely to report that their body is lacking or repulsive, while men tend to limit their assessments to deficiencies in their character. This focus on women’s embodiment is consistent with the normative positioning of women as more ‘bodily’ than men (Bordo, 1993; Conboy et al., 1997; Gallop, 1988).

It is not only female authors who experience depression themselves who associate normative presentations of femininity with mental health. Rather, family and friends also use success and failure at embodying femininity as a mechanism for gauging the

40 Put more politically: ‘The demand that she [a woman who was incarcerated in a psychiatric institution in 1945] be a good woman, and the condemnation of her failure, are identifiable in our lives. Her anxiety to be a good woman is an anxiety shared by us all’ (Matthews, 1984, p.4). QXR

emotional distress of particular women. In an example from the Journeys with the Black Dog anthology, an author writes:

We became adept at reading her moods – unmade bed (depressed); wearing socks with sandals (very depressed); donning her brown beanie (possibly suicidal). (JwBD 66)

This humorous account implies that a woman would not stop certain behaviours unless she was unwell. Specifically, the quotation suggests that the woman would not cease completing her domestic responsibilities (i.e., making her bed) unless she was depressed, would not perform a fashion faux pas (i.e., wearing socks with sandals) unless she was very depressed and would not isolate herself from others or stop basic personal hygiene (i.e., wear a beanie so it can reduce her field of vision and thus not interact as frequently with others or so she does not have to show her dirty hair) unless she was suicidal. Although each of these behaviours could be an indicator of depression in a man, the meaning is more apparent when describing a woman. A man might be a bit of a slob for not making his bed or a bit nerdish for wearing socks and sandals. In contrast, for many women, such behaviours will fall outside the realm of ‘acceptable’ behaviour as these actions are in tension with gender norms regarding feminine cleanliness, domestic responsibility, concern over appearance and daintiness. Thus, in a way not fully available to men, the severity of the subject’s illness is signified through her (gendered) behaviours and embodiment.

In another example of how the severity of a female author’s illness is implied through what she does with her body, a Journeys with the Black Dog author writes: I wouldn’t recommend any of my methods for coping. Fluorescent drugs bought from dodgy bouncers washed down with vodka. Washed down with vodka while chain-smoking cigarettes. Chain-smoking cigarettes while wearing a push-up bra. And doing all of the above while letting a man I barely know take me home. (JwBD 72)

In the first sentence of this quotation, the author indicates that she understands her behaviours as inappropriate (‘I wouldn’t recommend any of my methods’). In fact, it appears that the author is positioning her ‘coping’ methods as non-coping methods or

QXS symptoms of her illness. Specifically, the author describes engaging in what is typically understood to be ‘risky’ behaviour – she smokes, drinks, does drugs, has sex with casual partners and is physically vulnerable when she goes to the home of a person she does not know. The author’s negative assessment of these behaviours is likely to be partially impelled by her sense that these behaviours, while highly gendered and consistent with a stereotype of hyper-sexualised femininity (i.e., sluttiness), do not align with the form of normative feminine embodiment that she appears to value (i.e., a responsible, non-hedonistic femininity). This non-hedonistic femininity is reminiscent of the ‘new feminine ideal where women [are expected to exercise] a highly disciplined relation to the body’ that can be found on the beyondblue website (Fullagar, 2009, p. 337). The failure of the author to uphold her own ideals of femininity functions in the text to emphasise that the author is not, in reality, coping: it is as if she is saying ‘I am not OK, because I am a woman doing the wrong sort of womanly things’. This type of social valuing is not limited to women who experience affective disorders, but rather has been identified by a range of feminist scholars for several decades: Matthews (1984), for example, argues that ‘[e]ach woman is constantly subjected to scrutiny, by others and by herself. What is at issue is not whether she is a woman […] rather, it is a question of what sort of a woman’ (p.15). Thus, while the expression of gendered norms in affective disorder narratives has particular consequences, these norms must be considered as widespread cultural forces that are not limited to the corpus materials.

For other women, their status as ‘good patients’ is affirmed through their embodiment of normative femininity. This is particularly true for women’s coping behaviours. For instance, a Journeys with the Black Dog contributor writes about her mechanisms for temporarily managing her depression symptoms:

I put on my fluffy pink bath robe after relaxing in a warm bath scented with rose petals and lavender. Flickering candles cast shadows of freshly picked flowers on the wall. The black dog is asleep on the Persian carpet and I pick up my book to read. (JwBD 247)

The Black Dog contributor describes a set of behaviours that are highly feminine. Such (reported) behaviours position the author as a ‘proper’ woman. In the context of describing her coping behaviours, behaving like a ‘proper’ woman positions the author

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as a legitimately ill patient. The description of normative gendered coping behaviours is common in the corpus, with women reporting managing their symptoms by having bubble baths, reading quietly, cooking, being affirmed by a lover and focussing on looking after the children (see for example JwBD 247, 47, BT 38, 46).

Consistent with Gatens (1996), who notes that normative gender is only valued when it is enacted by an appropriately sexed body, in the corpus we find that the normatively feminine characteristics associated with depression are valued differently when enacted by men and women. In the previous section it was shown that for men, being depressed was deemed a negative characteristic when it was positioned as the enactment of femininity in the form of ‘weakness’ and ‘emotionality’. In contrast, for women, the ‘failure’ to enact normative gender behaviours such as completing household chores and wearing fashionable clothing were deemed indicative of illness. Thus, when women ‘fail’ at enacting normative gendered behaviour this is deemed problematic, while for men, being ‘successfully’ normatively feminine is a sign of an unacceptable personal characteristic (see also, Matthews, 1984, p.6).

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Throughout the corpus, women are more likely to report being the carers for their depressed male partners, than men are for their female partners (the absence of regular same-sex relationships in the corpus is unsurprising given that only approximately 72,000 Australians are estimated to be in regular same-sex relationships - a prevalence of less than 1% of the Australian population; Smith, Rissel, Richters, Grulich & Visser, 2003, p. 141). When men do act as carers, they are likely to be less engaged than women, but to receive more praise for their actions (see D 100, 65, 190, BT 133). Accounts of responsibility and interactions within intimate partnerships show the gendered dynamics of the carer-patient dynamic.

Discussion of intimate partnerships is particularly common in internet posts by young women with depression. Such posts routinely enact conservative gender roles where the

QXU authors are represented as dependent on men and/or obtaining their entire fulfilment through their relationships with men:

[E]very day I used to think of suicide, but since I met the man of my dreams days go past and I don’t think about it any more. (HS 153)

I call success … overcoming our past and being happy in the future. I call success … my husband and 2 boys. (HS 159, ellipses in original)

In both of these examples, the author’s sense of wellbeing is dependent on their relationship with men. In the first quotation, the author’s ‘saving’ from suicidality is represented as not due to any action by her partner, but rather merely to his existence in her life. In the second quotation, the author indicates that her sense of life fulfilment is linked to the existence of her husband and sons. Again, there is no indication of any particular quality of the interaction, but rather the reader is assumed to understand that having a nuclear family is a type of success (see also HS 192). For some women, it appears that the fulfilment of family roles such as motherhood may help to improve their long-term depression outcomes (Paterson, 2009, p. 86). That some women are more content with their lives when they are fulfilling these roles may suggest that these roles are socially and personally meaningful, but it may also imply that normative gender expectations mean that certain women do not feel content unless they are engaged in these roles (see Fullagar, 2009, p. 402).

Within corpus materials, when men do act in supportive ways, their female partners tend to praise them expansively:

He really is my angel. [My boyfriend] was the one who encouraged me, finally at 17 when he realised I had a problem, to go see a doctor and it was the best thing I ever did. (HS 205)

In this quotation, the male partner is positioned as a truly wonderful partner, as ‘my angel’. Yet, the only action that the author describes him undertaking is suggesting that she see a doctor. The author does not report that her partner cared for her in any other way. The praising of men for basic caring behaviours is common in the corpus.

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In a study of Australian men who had female partners with postnatal depression, several men described their caring responsibilities. These men expressed a level of frustration about the lack of acknowledgement or praise for their caring behaviours that one would not expect from women in caring roles. For example, one participant described ‘looking after the kids and letting her go out … to the movies or whatever’, yet the participant appeared to resent this basic support and see it as contributing to their partner’s distress (Davey et al., 2006, p. 213). Although expressed differently, the expectation of appreciation for caring behaviours suggests that these men are engaged in relationships with similar gendered expectations as those of corpus authors.

In a minority of cases, conservative gender roles result in female authors being supported by their partners:

I quit my full time job […] I couldn’t cope anymore. Lucky, I have a lovely husband who supports me (BB 233)

In this enactment of traditional gender roles, the author’s husband is the sole ‘bread- winner’. This arrangement appears to be helpful for the author as it allows her to be financially and emotionally supported by her husband after she has moved out of the workforce. While conservative gender roles are often problematic, their expression in certain instances is beneficial to authors and their families. It should be noted, however, that in this instance the author feels lucky to have a supportive husband, which underscores the fact that she perceives such husbandly support to be a rarity rather than the norm. In contrast with this example, Schreiber has demonstrated that some relationships where normative gender relations are enacted are destructive for women with depression as they are expected to continue attending to their male partners during depressive episodes (R. Schreiber, 1996). This observation is more in keeping with established feminist accounts of the destructive nature of normative gender expectations, an explanation that, while there are a few exceptions, is nonetheless supported by the analysis of the corpus.

A more indepth examination of the writings of two women contributors to the Journeys with the Black Dog anthology highlights the gendered difference in expectations of

QXW familial and domestic responsibility. One of the women cares for her husband who has depression, while the other is cared for by her male partner. Although both authors are female, these quotes describe the roles and responsibilities of both the authors and their male partners, and therefore are able to illuminate the gendered dynamics of caring.

The woman who cares for her depressed husband writes:

The bottomless depth of suffering I encountered in those green eyes wrenched at my heart. Had I missed all the signs? Guilt and frustration chased each other through my subconscious. My fault! I should have been more vigilant, more aware of his slide toward the dark side […] We need help. It’s happened again. Help this precious man … (JwBD p. 178)

Compare this to the woman who is cared for by her male partner:

I have a partner, who has lived through almost as much hell as I have, except he lives on the outside looking in. He is my strength during the worst of times, he holds me up, he makes my excuses, he looks after our children, and he carries on with all of our lives when I cannot possibly take another step […] I cannot imagine how I ever would have survived without him. (JwBD p. 196)

There are four key gendered aspects of the caring relationship that these quotes highlight. Each will be examined in turn and then the significance of these aspects will be discussed.

The first gendered difference is in the understanding of the constancy of the role of carer and appears to be underpinned by an assumption that caring is a feminine domain. The statement ‘I should have been more vigilant, more aware of his slide toward the dark side’ implies that the (female) role of carer is constant as the author is positioned as being responsible for identifying the signs that her husband may be descending into depression. This pre-emptive aspect of the carer’s role, an aspect that is not represented as shared between her and her husband but is hers alone, suggests that the author is never fully outside the carer’s role. In comparison, the second author’s male partner is represented as having limited caring responsibilities that are only enacted when the

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author is in crisis. Unlike the first author, these responsibilities are only the carer’s ‘during the worst times’ and when the carer’s wife ‘cannot take another step’.

The second gendered difference is in the obligations for care. The first author positions herself as being morally responsible for taking care of her husband – a role that she depicts herself as having failed at because her husband has become symptomatic (‘My fault!’). In contrast, the second author, while indicating that the role of her male carer as being essential to her survival (‘I cannot imagine how I ever would have survived without him’), nonetheless does not indicate that her partner is responsible for the management of her condition.

The third gendered difference is in the location of suffering. Both authors discuss the distress experienced by carers who observe and identify with the distress of their partners. However, where for the first author suffering is primarily located in her husband, the second author understands her partner’s distress at observing and being affected by her depression as being near the level of her own (‘[he] has lived through almost as much hell as I have’). In other words, both authors’ emphasise the distress of their male partners, and background their own emotional situation. Thus, despite the greater caring and familial responsibilities that the women take on, it is the men in these relationships whose emotional distress is highlighted. This is consistent with other research that indicates that women with depression are likely to ‘self-silence’ in their relationships (Jack & Dill, 1992; Johnson, 2009).

The final gendered difference is in the level of identification with the depressed person’s suffering. The first author positions herself as embedded in her husband’s suffering. This is most apparent when she uses the first person plural (‘we’) when describing the need for her husband to receive support/treatment. In contrast, the second author continuously maintains a separation of herself and her male partner. Thus, within these quotations, and consistent with the corpus as a whole, women are more likely than men to identify with – and take responsibility for – the suffering of their partners (for accounts of men looking after women, written by women, see BT 42 and D 100; for an example of an account written by a man, see JwBD 181).

ROO Throughout these quotations, regardless of the authors’ position in the caring relationship, men’s suffering is usually represented as more noteworthy than women’s, and men were deemed to be more exceptional in their personal attributes than women, even though men typically had fewer ongoing caring and/or familial responsibilities. This logic, while often not as stark as in these quotations, is a common undercurrent in many discussions in the corpus of the effect of affective disorders on interpersonal relationships.

The combination of legitimate illness rhetoric and gender roles commonly positions women with depression, as well as women who have family members who are depressed, as being the ‘natural’ carers for their families. In addition, women’s suffering is naturalised (for further examples see D 41, BO 139, 228, 17V 252). In comparison, men are not expected to be responsible for the emotional wellbeing of their families and when they suffer they are often deemed to be heroic. That the enduring of suffering by men tends to function to position them as heroic, rather than to perpetuate their emasculation, provides a mechanism for men to resolve the temporary emasculation associated with depression symptoms (GC 107, BO 253, JwBD 181). This logic enables men to enhance their legitimacy as masculine subjects while remaining symptomatic and receiving sympathy and treatment for their condition. In contrast, women’s legitimacy as feminine subjects is in no way undercut by their experience of suffering, making the provision of support and treatment to reduce suffering potentially in tension with their gender identity (see also Marecek, 2006).

Unfortunately, women who care for men with depression sometimes do not only experience the backgrounding of their distress. In a minority of cases, their suffering includes domestic violence.

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Empirical research indicates a correlation between male depression and abusive heterosexual relationships. Specifically, research has found that abusive men are more likely to be depressed than non-abusive men (Julian & McKenry, 1993; Schumacher, Feldbau-Kohn, Slep & Heyman, 2001; Stith, Smith, Penn, Ward & Tritt, 2004; Taft et

ROP

al., 2005). This correlation may be partially explained by the nature of depression symptoms. Specifically, physically violent men have been found to have higher levels of spouse-specific interpersonal dependency than non-violent men (Murphy, Meyer & O'Leary, 1994). Depression encourages such dependency by, potentially, increasing an individual’s financial, practical and emotional reliance on a partner.

In addition, women who are victims of interpersonal violence are more likely to be depressed and/or anxious before, during and after the abuse, both in comparison with their own mood at other times and when compared to non-abused women (the term ‘victim’ is used rather than ‘survivor’ throughout this section as it seems a more appropriate term when discussing interactions between people during periods of violence) (Anderson, Saunders, Yoshihama, Bybee & Sullivan, 2003; Borba et al., 2011; Calvete, Corral & Estévez, 2008; Dennis et al., 2009; Martin et al., 2006; Mechanic, Weaver & Resick, 2008; Rodríguez et al., 2010; Tuel & Russell, 1998). This effect of abuse is also evident in corpus internet sources, where authors report feeling depressed or anxious as a result of being in an abusive relationship (HS 87, 197, BB

232, 398). What is not currently acknowledged in the literature is the way that dominant depression/illness rhetoric sometimes functions to obscure the identification of abusive relationships or, in instances where relationships are identified as abusive, such rhetoric is sometimes used to excuse or justify such interactions. Despite a lack of direct acknowledgement of this phenomenon, other researchers have been aware of the rhetorical structures which allow such justifications. For instance, Karp (1992) notes that many individuals in a depression support group ‘had an investment in being seen as victims of a biological disorder because such a definition partially absolved them from responsibility for their condition and consequent behaviours’ (p. 154).

Analysis of the corpus indicates that when a man – it is predominately men who display aggression in the corpus – is abusive towards his partner, this is understood as a part of the depressive illness and is therefore condoned. Rationalisations in the form of ‘it’s the depression that made him act like that’ or ‘I couldn’t help it, I was depressed’ are utilised by a wide range of men and women across the dataset and can be found in both autobiographical materials (primarily the Journeys with the Black Dog anthology where anonymity is maintained) and internet bulletin boards. Given the shame that is associated with interpersonal violence, it is likely that many authors have not detailed

ROQ their abusive experiences, and that those that have described abuse may have downplayed the seriousness of their experiences. Although all relationships involve periods of dispute and upheaval, instances have been categorised as abusive where there has been a marked lack of respect. In addition, if an author uses terms such as ‘violent’, ‘abuse’, ‘threaten’, ‘bullying’, ‘obey’, ‘aggressive behaviour’ or ‘uncontrollable anger’ when describing interpersonal interactions, I have classified these interactions as abusive.

To be clear, all relationships involve periods of dispute and upheaval and the vast majority of these are respectful. In this section I have only categorised as abusive those instances where there has been a marked lack of respect for both parties. In addition, if an author uses terms indicative of abuse such as ‘violent,’ ‘abuse,’ ‘threaten,’ ‘bullying,’ ‘obey,’ ‘aggressive behaviour’ or ‘uncontrollable anger’ when describing interpersonal interactions, I have classified these interactions as abusive. In some instances, the term ‘disrespect’ is used when an incident appears to be ‘on the way’ to being abusive but it seems overstated to say that it is abuse.

In a small number of cases, women writers explicitly state that their male partners with depression have been violent towards them. Although the type of violence is not specified, in the following example the description of the partner’s ‘angry rejection’ suggests that it is primary verbal and emotional:

Periodically he becomes a stranger, I call this intruder the ‘Fire Breathing, Soul- Destroying Dragon’ […] I have to be careful not to make the situation worse by saying the wrong thing [...] How I hate this angry, violent Dragon. (JwBD 178)

The statement ‘I have to be careful not to make the situation worse’ suggests that the author feels that it is her responsibility to avoid further upsetting her partner during an episode. Within this context, ‘making worse’ is likely to refer to the partner being (more) aggressive towards the author. It is particularly significant that the author says that ‘I have to be careful,’ implying that this both an act of self-preservation and a moral responsibility that she is obligated to fulfil (compare, ‘I have to’ to ‘I try to,’ ‘I find it easier if’ or ‘I prefer to’). This phrase implies that should her partner verbally attack her, the attack is, at least partially, her fault. That the author takes on this blame suggests

ROR

that she is locating herself in the (feminine) role of the self-sacrificing carer (Bytheway & Johnson, 2008). Moreover, this attribution of responsibility is consistent with domestic violence literature, which indicates ‘victim-blaming’ is a common aspect of the beliefs of both perpetrators and victims in abusive relationships (Heenan, 2004; LeCouteur & Oxlad, 2011; Pavlou & Knowles, 2001). This ‘victim-blaming’ suggests dynamics consistent with a domestic violence situation, rather than a respectful relationship where the author has determined appropriate mechanisms for ‘coping with’ her partner’s moods.

This quotation suggests that the author is able to excuse her partner’s actions by understanding her partner as two separate creatures – the respectful partner and the violent dragon (see Chapters 5 and 7 for discussion of mental illness as non-human agent). Specifically, when the author’s partner is ill, he is not really himself, but is rather a different type of being (a dragon). This separation of self and illness functions to position the partner as a loving and respectful spouse, who is not responsible for the actions of the dragon during an episode. Further, according to this logic, the partner is unlikely to obtain help for his behaviour, as these are not his outbursts to control or be responsible for. In this way, the partner’s legitimacy as a partner is maintained, regardless of the ongoing violence during depression episodes. Other examples of this kind of strategic separation include an author who describes one of the aspects of her partner as ‘Mr Out-of-control’ (JwBD 179) and another who describes a partner who oscillates from being her ‘hero’ to ‘someone terrifying who I wanted to hide from’ (JwBD 184).

The separation of self and illness also acts to enable the author to maintain her own self- respect. According to the logic of the quotation, the author is not staying in a violent relationship, but is rather enduring a violent visitor that is unrelated to her partner.

In the context of discussing how his relationship has been shaken by his experience of bipolar (including psychotic symptoms), another Journeys with the Black Dog author enacts a separation of self and illness that functions to justify his aggression:

[My wife] has suffered and although she knows my illness was the culprit, it looked and sounded like me at the time. (JwBD 187)

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In this quotation, the illness is positioned as to blame for the author’s wife’s suffering. Specifically, the statement ‘my illness was the culprit’ implies that the author is completely absent during the aggressive interactions. Depression, rather than being a state experienced by the author, is an entity that inhabits the author’s body and removes his agency. Thus, consistent with the previous example, it is implied that the author does not need to apologise or work towards non-aggressive behaviour, as it was not he who was aggressive. As in the previous example, the phrase ‘she knows’ functions to imply that the author’s wife is impelled to be understanding and supportive of her husband, with this expectation not abating when it is harmful to the woman. The use of a separation of self and illness enables the author to abdicate his responsibility for his actions and expect this type of support from his wife.

Earlier in the text, the same author acknowledges the damage of his violent outbursts:

The same anger, when fed through a razor-sharp tongue, caused damage to my wife that was even greater. In time, even she could not prevent exposure to my bipolar radiation and for a few years [my children] lived in a state of constant retreat to the fall-out shelter she provided at the first sign of Armageddon […] My wife, always my strongest supporter, cried in confusion and in her own anger at being placed in that impossible gulf between her great loves: her husband and her children. (JwBD 185)

In the first sentence, the author acknowledges that his verbal attacks cause damage to his wife. Yet, in the very next sentence, a partial separation of self and illness is enacted that functions to reduce the author’s responsibility for his actions. By stating that it was ‘my bipolar radiation’ that was damaging his family, the author appears to maintain partial responsibility for his actions (‘my bipolar radiation’ has more links to the author than the more detached ‘the bipolar radiation’). However, a separation is still being enacted, as it is the bipolar rather than the author himself that is being destructive.

At no point in this quotation does the author suggest that he is responsible for preventing harm to his children. Rather, the quotation indicates that his wife is expected to be both the protector of her children and the supporter of her husband. Such roles are

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represented as often being to the detriment of the wife’s own wellbeing. This self- sacrificing role is consistent with the female carers described earlier in this chapter. Similar to the other women, the author’s wife is represented as maintaining her love of her husband, despite the ongoing abuse.

While the use of affective disorder diagnosis as a justification for disrespectful interpersonal relationships is most common when a partner has been diagnosed with depression or bipolar, it is also present in quotations from authors with obsessive compulsive disorder and post-traumatic stress disorder (GC 199):

I know it’s irrational, but that’s the way it is. And then you start to pick at [your family members]. Gnaw at them. And then in some cases you try to change them to the way you want them to be. You expect them to do things the way you want. You expect them to clean the house more often. Your meals have to be dead on time. You want them to wear certain clothes because you feel that what they’re wearing is not right. You don’t like the way their hair is. (17V 70)

Although George states that his behaviours and expectations are irrational, the quotation suggests that he nonetheless normalises them and accepts them as an ongoing aspect of his life (‘but that’s the way it is’). This quotation describes how George’s obsessions affect his family members, in particular his obsessions are enacted in such a way that his family members are unable to freely choose their own behaviour (what clothes they wear, how they wear their hair). It appears that for George, it is reasonable to expect his family members to ‘do things the way you want’. Such expectations suggest that George may bully his family in order to control his own emotions. Significantly, unlike the discussion of his family life, when George discusses the consequences of his OCD in his workplace, he acknowledges that other people may be frustrated by his behaviour and find it unacceptable. This suggests that George considers that his behaviours are more readily accepted and/or forgiven in the home.

Like many of the other quotations from men described in this section, in this quotation the responsibility for the management of the author’s distress is placed on his family members. Rather than indicating a willingness to address his own obsessions by cleaning more often or making meals on time, this quotation indicates that George

ROU places this responsibility on his family. Such a refusal is most understandable within a conservative family organisation. If George is the patriarchal head of his household, it is likely that he would exert control over activities that are traditionally feminine responsibilities – preparation of food and cleaning of the home. However, in this family organisation, it would be inappropriate for him to do these (feminine) domestic chores. Thus, while indicating that he is aware that his expectations are irrational, George nonetheless reports placing responsibility for the relief of his symptoms on his family and thereby potentially reducing his responsibility for managing his condition.

The previous examples have demonstrated how men who are experiencing an affective disorder episode have been positioned in corpus materials as not fully responsible for their words or actions. In some cases this lack of responsibility is used to argue that family and friends are obliged to forgive the perpetrator:

Often, you do not even recall what you said or did to your loved one, and, at a later time, during conversation, a comment will be made and you can see the sadness in their eyes because of something you have previously said during an episode. Unfortunately, words cannot be taken back once they have been said, but it is so important to remember that the person suffering depression is not always in complete control of their words and actions, and forgiveness has to be given. (JwBD 206)

Within this quotation, it is the moral obligation of the person who has endured ‘what you said or did to your loved one’ to forgive the ‘person suffering depression’. This is explicitly stated by the author when they say ‘forgiveness has to be given’ (emphasis added). Within this quotation, it is the moral responsibility of the victim to forgive a verbal or physical attack. This becomes even more problematic when it is coupled with the complete absence of any moral responsibility on the part of the perpetrator to stop their abusive behaviour. Thus, within this quotation, the perpetrator becomes the victim of their depression, and with this identification, they are no longer expected to be responsible for their own abuse.

Despite the gendered nature of the patterns of abuse identified in the corpus, it should be noted that, of the small number of descriptions of abuse, although the majority of

ROV

perpetrators are men, a few women are also described as being abusive. For example, a young person writes about their mother:

And, when she was down, she’d say things that I don’t think anyone should have to hear let alone from their mother. (HS 109)

The author reports similar types of abuse as the other authors in the corpus. However, unlike the other examples, the author did not detail the justifications for the abuse. It is therefore unclear whether this example fits with the general trend of ‘illness justifications’ found in the corpus. Despite this limitation, this case highlights that while domestic abuse is predominately perpetrated by men, and therefore should be considered a gendered phenomenon, it is not exclusively men who are abusive to their family members (see also Flinck & Paavilainen, 2010).

It is not only authors who rationalise disrespectful interpersonal relationships by emphasising that the perpetrator is experiencing an illness. The Journeys with the Black Dog anthology, where most of the quotations in this section were published, is edited and endorsed by the Black Dog Institute, a preeminent affective disorder research and education organisation in Australia. The editors write:

Action taken and words said during the slough of a depressed mood or in the midst of an exhilarating high often leave an enduring emotional scar. For this reason, it is important for carers, as much as possible, to separate the illness from the person they love, and keep perspective on the mood distortions of the illness. (JwBD 168)

This quotation uses the same logic as those provided by participants in the anthology. Specifically, the quotation indicates that actions taken when depressed or manic are categorically different to actions at other times, minimises the responsibility of the person with the disorder by positioning the illness – rather than the individuals – as having agency, and places responsibility on carers to accept the behaviour of the person diagnosed. Although this quote is placed in the context of acknowledging the limitations of carers’ emotional resources, the extent to which the editors are mirroring

ROW the rhetoric of the anthology participants suggests that they are unaware that this rhetoric could be understood as condoning violence.

While the Journeys with the Black Dog make no reference to the gender of either victim or perpetrator, and a small number of authors describe abusive situations that are perpetrated by women, the vast majority of examples of abuse in the corpus involve men being disrespectful to their female partners. Two of the gender norms discussed earlier in this chapter support the normalisation of violence identified in this section. Specifically, when aggression is understood as a symptom of depression, the combination of gender norms that (1) encourage women to position themselves as carers and (2) encourage men to understand depression as a threat to their masculinity and support normatively gendered coping mechanisms (including aggression and the use of violence), results in the enabling of abusive situations.

This type of justification is increasingly found in media portrayals of male depression. In both Australian and international newspapers, celebrities have used a diagnosis of depression or anxiety as defence against criminal charges (Clayton, 2011; "Shelly: untreated depression is a danger", 2011; Wood, 2011). It would be unfortunate if the efforts of feminist and anti-domestic violence workers to make socially unacceptable justifications such as ‘but I was drunk’ or ‘she made me do it’ were undercut by a new justification.

At least one anti-violence campaigner is beginning to address this issue. In late 2011, Dr Michael Flood, an ambassador for White Ribbon, (an Australian organisation focused on stopping violence against women that engages men to change their behaviour, White Ribbon Foundation, 2011) and researcher on male violence towards women, commented on an actor who identified as having a range of affective disorders including, bipolar, PTSD and OCD and who received inpatient treatment after being tried for his physical and verbal abuse of his girlfriend. Alicia Wood, a journalist with the Sydney Morning Herald reported that the actor said:

“I needed to be forced and I'm very grateful to the people who forced me to get that treatment because it probably saved my life. It did save my life, […] I lost

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my mind. I went beserk [sic], I went nuts... I'd had enough of the noise.” (Wood, 2011)

In a response that demonstrates the type of statement that addresses the issue of justifying violence by an affective disorder diagnosis, Flood was reported to say:

‘I felt he did not take responsibility for violent behaviour or the impact it had on the victims. Instead, he located the problem of mental illness. That is troubling, because research says mental illness can be a risk factor for violence - but other factors are more important. Men are more likely to reform if they take responsibility and acknowledge the hurt they have caused.’ […] Dr Flood said this did not acknowledge the fact that violence against women: ‘is not a therapeutic problem, it is a criminal one.’ […] ‘This feeds into a whole lot of ways violence against women is excused – through mental illness, drug use, or the partner herself’. (Wood, 2011)

This response positions violence as fundamentally unacceptable and understands people with mental illness as just as responsible for their actions as other members of the community. While there is some doubt that ideas of ‘reform’ and ‘responsibility’ are the best approach to altering men’s behaviour, this response is promising because it simply and forcefully addresses the use of psychiatric diagnoses as a justification for domestic violence (Howells, Day, Bubner, Jauncey, Williamson, Parker & Heseltine, 2002). Hopefully, we will see more of this type of commentary in the future.

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This chapter has demonstrated some of the more egregious lived consequences of the illness rhetoric that has been examined throughout the thesis. Specifically, it has identified how authors justify interpersonal violence, particularly the emotional and verbal abuse of intimate partners, by emphasising that the perpetrator has an illness and that their problematic behaviour is a result of this (legitimate) condition. This issue is difficult to address due to the almost hegemonic cultural investment in maximising author/sufferer legitimacy by positioning affective disorders as (largely biomedical)

RPO illnesses. Throughout the examples above, male authors did not report being compelled to obtain treatment or change their behaviour in order to prevent instances of interpersonal abuse. This tendency may reflect broader norms in mental illness discourse, where mental illness is seen as ‘both a symptom and an explanation’; thereby producing a circular logic where cause and effect are indistinguishable and thus responsibility for one’s actions is erased (Pilgrim, 2005, p. 439). In addition, it was common for female partners to be expected to remain within a relationship, regardless of its violent aspects, and for this to be justified by understanding the violence as being perpetrated by the depression. Although aggression is a common symptom of depression, its expression through violent or abusive interpersonal interactions is unacceptable, and remains unacceptable, regardless of the fact that the person enacting the violence is diagnosed with a mental illness.

The analysis in this chapter has also highlighted the idea that illness rhetoric does not work in isolation. It is extremely difficult for an author to be a legitimate ill subject if they violate normative gender expectations. Moreover, the extent that authors align with normative gender expectations appears to affect the way that they – and the people around them – experience and interpret their distress. As such, authors are never just telling a legitimate illness narrative, they are also telling a legitimately gendered, classed, raced etc. narrative. In other words, illness narratives do not occur in a vacuum but rather are influenced by the rich mix of social norms that form the author’s identity and community.

The final chapter contextualises the corpus materials by comparing them with current population-based affective disorder promotion campaigns. The chapter argues that personal narratives influence, and are influenced by, population health campaigns and that the similarities across these two forms indicate the extent to which a dominant affective disorder narrative is being enacted within Australia.

RPP

‘I can’t breathe’ come the first words as I answer the phone. I can’t say that I’m surprised. I’ve watched her for the last few days, her anxiety rising, her fears becoming more and more unruly. She has been pacing the house, unable to sit still, wanting to burn her skin to force herself to be centred again. But this is her first full-blown panic attack and she has rung me so I can talk her through it.

The banality of this type of intervention still surprises me. I sit myself on the front steps of my home and resign myself to this familiar task. I start breathing loudly into the phone, making her breathe with me. I ask her to tell me five things she sees around her, five things she can feel, five things green, five things blue and five brown. She begins to calm. I get in the car and drive.

As I drive into Callan Park, I start searching. I find her in the long grass, holding with equal tightness her dog and her knees. I walk up slowly, refusing to look freaked by this sudden change in my plans for the day.

It seems ironic that she has run into the grounds of an old asylum. There is a strange mix of large sandstone wards and falling down weatherboard huts here. What was once a place of moral therapies and rather less savoury ‘cures’ is now the home of an art institute, the NSW ambulance headquarters and many many dog walkers.

I sit behind her, wrap my legs around her, put my torso against her back. I breathe deeply and tell her to breathe with me. We stay like that for a while. She starts to relax her grip on the dog, starts to tell me what she is feeling. I listen. She talks. We watch the dog run through the long grass. Nothing much happens for a while. A dog walker passes with two small enthusiastic puppies playing their own version of tag. One of the dogs has three legs, which is both exceptional and absolutely banal. The sun starts to go down. We get cold. We get in the car and drive home.

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The launch of beyondblue (‘the national depression initiative’) in 2000 marked a significant shift in Australian affective disorder discourse.41 Prior to this time, depression was addressed in generic mental health campaigns; however, there were no sustained national campaigns focused on increasing awareness about the issue (beyondblue: the National Depression Initiative, 2007; Galbally, 1997). beyondblue aimed to position depression as the preeminent mental health issue in the country and has used significant state, federal and independent funding to increase awareness of the issue and encourage help-seeking behaviours (beyondblue: the National Depression Initiative, 2009b, 2011b).

In the last ten years, public health campaigns about affective disorders were primarily produced by beyondblue, with several minor campaigns run by other organisations. These campaigns have the same range of features as the other texts examined in this thesis, including specific rhetorical functions, textual techniques, genre norms and influencing discourses. Specifically, like the corpus, in order for these campaigns to be comprehensible to their target audience they must adhere to the rhetorical norms surrounding discussions of affective disorders, be relatively consistent with other publicly available affective disorder narratives and adhere to established norms of the medium (e.g., poster, billboard, television advertisement) in which these discussions occur. Consistent with the rhetorical analysis in the corpus, it is presumed that while advertisers use particular images and words for particular reasons, the reader cannot know these reasons, nor do the reasons fundamentally alter the rhetorical effects of the text. Thus, like the analysis of the corpus, this chapter focuses on the functions of the

41 Population-based health awareness campaigns are used in Australian for a wide range of conditions (e.g., bowel cancer, diabetes and HIV/AIDS) and risk factors (e.g., drug-use, obesity and smoking) (ACON, 2012; Australian Diabetes Council, 2010; Bowel Cancer Australia, 2010; Department of Health and Ageing, 2011a, 2011b, 2012). Population-based campaigns typically aim to increase knowledge about a particular illness or change individual behaviours. They often use mass-media distribution, such as billboards, mail outs and advertisements on buses, in order to access a large cross-section of the community. Population-based campaigns are generally officially and explicitly sanctioned by the government departments and NGOs that fund them. In a limited number of cases campaigns may be run with project or research money from bodies that support the project but do not necessarily endorse all the messages/content. RPR

text (including visual text), without making unprovable claims regarding author intention.

Up to this point, this thesis has examined first-person published affective disorder narratives in order to understand how Australians understand and represent affective disorders. Such research does not provide a complete picture of Australian perceptions of these conditions, as it is limited to narratives produced by individuals. By examining affective disorder campaigns that are produced by community organisations for consumption by the Australian public, this chapter broadens the scope of the analysis and thereby demonstrates the extent to which the rhetorical functions identified in the corpus are dominant within the Australian context.

The chapter begins by providing background on the campaigns. Semiotic and rhetorical aspects of the campaigns are then compared to the rhetoric identified in the corpus (for a description of semiotic analysis see Bell, 2001 and Hall, 2007). The chapter compares the corpus and the campaigns, finding that the two use similar rhetorical strategies and address similar topics. Points of comparison include the signs and symptoms described, representations of affective disorders as illnesses, hierarchies between illnesses, and normative gender and relational expectations. As the campaigns need to have short sharp messages that are appropriate for posters and which are understandable by the whole population, they inevitably provide less detail and depth than the corpus. Despite this, there is substantial overlap in the content and rhetoric of the campaigns and the corpus.

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The campaigns were active during the period that the internet data was collected (September to December 2009) and were identified through media-releases, internet searches and a variety of web-based sources including the Consumer Advocacy Group NSW and beyondblue list-serves. Only national campaigns were analysed, because these were likely to reflect dominant affective disorder discourse and have the greatest effect on the Australian community. In order to have a comparable sample, analysis was limited to the posters of such campaigns. A total of 16 posters were analysed.

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Three campaigns were selected for analysis: beyondblue’s national advertising campaign, headspace’s ‘Someone else to go to’ campaign, and SANE’s ‘Signs’ campaign. Each campaign had a distinct aim and target group. As the beyondblue materials were more widely distributed, included a greater number of poster types and had more detailed text, it was inevitable that these posters would become the focus of this analysis. Background information and descriptions of the campaigns are provided below.

Like the health professionals described in the corpus, the three NGOs were positioned in these campaigns as having high epistemic authority. These organisations (and beyondblue in particular) had a high profile in Australia, with a phone interview study in 2004–2005 finding that 22.2% of the national sample spontaneously identified beyondblue as a depression organisation (Highet, Luscombe, Davenport, Burns & Hickie, 2006, p. 56). The 2010–2011 Annual Report for beyondblue indicates that 87% of Australians are aware of the organisation (beyondblue: the National Depression Initiative, 2011b, p. 61). The organisations positioned themselves, and were often positioned by the community, as experts who provided reliable and factual information that should be taken seriously. Without such authority, it is likely that the effect of these posters on community perceptions and help-seeking behaviours would have been minimal.

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Illustration 1: beyondblue poster: To numb depression and anxiety, I drink.

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Recall that beyondblue is Australia’s ‘national depression initiative’ and that one of its main functions is to increase community awareness of depression and anxiety (see Chapter 1). beyondblue’s education and awareness campaigns use a range of strategies, including consumer forums, fundraising activities, community workshops, representation at community events, celebrity endorsement, billboards, advertisements in toilets, advertising in local and national newspapers, radio advertisements, a website that provides information, a bulletin board and a collection of personal stories (see Fullagar, 2008, p. 327).

Extensive research has been completed regarding Australian mental health ‘literacy’, and in particular the effect of beyondblue campaigns on public understandings of depression (Gardner, 2008, 2009; Hickie, 2002a, 2002b, 2004a, 2004b; Hickie, Luscombe, Davenport, Burns & Highet, 2007; Jorm, Christensen & Griffiths, 2006; Kennett, 2005; Parslow & Jorm, 2002; Pirkis et al., 2005). Of particular note is a survey

RPU study in 1995 and 2003–2004 where participants were asked to interpret a depression vignette. Jorm et al. (2006) found that people in states with high levels of exposure to beyondblue advertising and commercials were more likely to believe that they or a person they knew was experiencing depression than individuals from low exposure states. In addition, those in high exposure states were more likely to believe that individuals with depression would be discriminated against and were more likely to believe that help-seeking, counselling and medication were effective ways to deal with depression (Jorm et al., 2006; Jorm, Christensen & Griffiths, 2005). beyondblue has several campaigns, but the focus in this chapter is the national advertising campaign. 42 In 2009, this campaign had ten43 distinct posters, each with a different image and several lines of text which are particularly suitable for semiotic and textual analysis. During the study period, the campaign had seven related TV advertisements. The campaign materials are still used and remain widely distributed. I personally see them most often in campus, airport and nightclub toilet cubicles.

The posters in the national campaign have a set format. In the top two thirds of the poster is a picture of a depressed or anxious person accompanied by a statement about how they feel. The image itself is similar across the nine posters: it shows a man or woman from the waist up, alone, staring at the camera with a ‘depressed’ facial expression. An example of this is a poster of a man sitting at a bar with a glass of wine. Consistent with other images in the campaign, he is staring at the camera with a creased brow and the image is cut at the waist and his left shoulder. The image is accompanied by the statement ‘To numb depression and anxiety I drink. But the awful sadness never goes away’ to the left of the visual field. The bottom third of the poster provides more description of what it feels like to have depression, encourages help-seeking behaviour, 42 The other major beyondblue campaign is the ‘You are not alone’ campaign. It is a long-standing and widely distributed campaign that uses a variety of media including billboards, advertisements in and on buses and posters at train stations. The advertisements are very simple and typically consist of the tag ‘Depression: You are not alone’ on a bright blue background. In the lower right hand corner is the beyondblue logo with contact details for the organisation. This campaign appears to be addressing a sense of isolation and stigma that may affect the capacity of individuals to seek help. Although this is probably the most widely seen affective disorder campaign in Australia, its lack of text or images makes it a poor choice for analysis. 43 On the beyondblue website, one hyperlink image does not align with the poster that it downloads. The posters (the hyperlink image and the download) use a similar, although not identical, image. It is therefore possible that the campaign actually only has nine posters and that an old poster has remained on the website. I have attempted to gain confirmation from beyondblue, but no one has responded to my requests. RPV

provides contact details for beyondblue and includes the beyondblue logo. For the example above, the text reads:

Over two million Australians live with depression, anxiety and associated drug and alcohol problems. Drinking and taking drugs may numb these feelings at first, but in the long run it just makes things worse. The sooner you get the right treatment, the sooner you’ll recover. To find out more visit our website or call the infoline. (beyondblue: the National Depression Initiative, 2009c)

Each of the nine posters deals with a particular aspect of depression or a specific target audience, such as men, individuals with simultaneous alcohol abuse and depression, the elderly, and women who have recently given birth. However, the overall effect of the campaign is one of general awareness raising.

The beyondblue website indicates that the scripts for the TV commercials ‘were developed with the words people used to describe how they felt and behaved when they were unwell’; however, the collation or research method was not described (beyondblue: the National Depression Initiative, 2009b). Given the consistency between the TV advertisements and the posters, presumably the same ‘voices’ were used in the posters.

In comparison with the beyondblue poster, whose primary aim is to encourage general help-seeking, both the headspace and SANE campaigns function as advertisements for the specific services of the organisations. However, these posters also function as awareness campaigns as they encourage the identification of symptoms of mental distress and promote help-seeking behaviours. These campaigns are significantly less widely distributed than the beyondblue campaign.

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Illustration 2: headspace poster: I told my dad I felt ignored.

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The headspace ‘someone else to go to’ campaign aimed to increase the access of young people to headspace services and includes posters, internet banners and radio and television advertisements. The posters were developed in consultation with the 28 member headspace Youth national reference group in order to ensure that they were youth friendly (Muir et al., 2009, pp. 21, 28). The posters contrast inappropriate lay reactions to common mental illnesses (e.g., depression) and situational distress (e.g., feeling ignored) with the service provided by headspace. There were four posters in the campaign (a further five postcards were released in early 2011 with the related tagline ‘Someone else to talk to’: these were not included in the analysis as they were not active in the research period). The posters use free-style handwriting, line drawings and, in some instances, a background of lined or grid paper akin to a schoolbook. These visual cues imply that the poster is the doodlings (distracted scribblings) of a young person.

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An example from this campaign is a poster that depicts a line drawing of a young woman holding an excited puppy surrounded by smiling daisies. The image is accompanied by the text, ‘My friend reckons the best way to get rid of depression is to buy a pet. And to draw daisies’. Consistent with the other posters in the campaign, in a bright green box (this time in the lower right hand corner of the page) is the headspace logo, a description of the organisation (‘National Youth Mental Health Foundation’) the slogan ‘someone else to go to’ and the headspace web address (headspace: National Youth Mental Health Foundation, 2009a).

Illustration 3: SANE poster: Depression

In 1996, Schizophrenia Australia changed its name to SANE in response to a broadening of their agenda to include all forms of mental illness. SANE is a national charity focussed on ‘working for a better life for people affected by mental illness’ (SANE Australia, 2011). The organisation does not have ongoing government funding, but rather receives funding for particular programs. Funding for their ‘Signs’ campaign comes from surplus from other funding sources. The ‘signs’ campaign involves television, radio and print advertising, and is mostly enabled by community service

RQO announcement provisions by TV and radio stations (Mungall, personal communication, 3 February 2011). The advertisements are based around an adaptation of common public signs such as road signs and billboards to display a mental illness diagnosis. The tagline for the campaign is ‘The signs of mental illness aren’t always this obvious’. In the two full-page versions of the advertisements, the sign is put into a personalised context. For example, in a photograph of a car park with a dedicated car space marked ‘depression’ a woman looks with a furrowed brow out of shot as she pushes her shopping trolley. The text is within the lower third of the page and reads ‘The signs of mental illness aren’t always this obvious. If you’re worried about yourself or someone you know, call 1800 18 SANE or visit www.sane.org.’ The SANE logo is located in the far bottom right corner of the poster (SANE Australia, 2009d). A simplified banner version of the advertisement is also available.

While the images and text in the three campaigns are simple, they nonetheless provide the viewer with extensive information about the nature of affective disorders and those who experience them. Below, the campaign posters are examined in order to identify the implicit and explicit understandings that underpin these campaigns.

Illustration 5: beyondblue poster: Depression is more than stress.

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In chapters 4 and 5, the descriptions of lived experience of depression, mania and anxiety by corpus authors were analysed. The signs44 of these conditions, however, were poorly represented in the corpus, as the first person narratives provide minimal information about external assessments of the author’s wellbeing. Unlike the corpus, both the SANE and the beyondblue campaigns provide direct visual representations of the signs of affective disorders.

The signs of depression are represented in half the SANE posters and eight beyondblue posters. The beyondblue campaign has a limited representation of the signs of depression and anxiety. Within the beyondblue posters, people who are depressed are represented as being worried, sad and tired through the facial characteristics of a creased brow, vacant eyes that are staring directly at the camera, no smile and darkness under the eyes. The consistency of these facial expressions across the entire beyondblue campaign is startling. It suggests that Frontier Advertising (the company who produced the advertisements) had an ideal facial expression that they aimed for in every image. While producing a coherent campaign, the repetition of a stereotypical representation of the appearance of individuals with affective disorders implies that there is only one, very obvious, facial expression that accompanies these conditions. Moreover, the direct eye contact with the camera in the photographs suggests a sense of assertiveness and confidence that is unlikely to be present in distressed individuals. This may reflect an advertising convention where audience engagement is encouraged through direct eye context with the camera. Regardless of the reason for this representation, its consistent use in this campaign affects the accuracy of the depiction of emotional distress. Far more realistic is the timidity implied in the SANE campaigns, where individuals look away or to the side of the camera.

The photographs in these campaigns depict a limited number of signs of depression. Some of the signs of depression described by corpus authors but not included in the

44 In this context, ‘signs’ refers to aspects of a condition that can be identified by a person other than the patient. This is a less strict definition than the standard medical understanding where signs are aspects of a condition that can be objectively measured (e.g., a raised temperature). RQQ campaigns include crying and catatonia. In addition, while the text in the beyondblue campaign describes mania and masking behaviours, these presentations are not represented in any campaign images. This is surprising as both experiences could easily be represented in campaign photographs (e.g., a person engaged in a social situation with a forced smile, or a person surrounded by half finished projects and frantically cooking/cleaning/painting/writing in the middle of the night). The lack of representations beyond the staring-at-camera-with-furrowed-brow images of the beyondblue campaign (and, to some extent, the SANE campaign) means that individuals who do not fit this specific representation may feel that their condition is not real or legitimate and that they do not deserve or require professional or personal support. Moreover, such campaigns may inadvertently increase the number of people who, when disclosing an affective disorder, are told ‘oh no, you don’t look depressed’, as they do not adhere to the embodiment that these campaigns imply are a constant aspect of affective disorder experience.

Illustration 6: beyondblue poster: Anxiety is paralysing.

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Anxiety is less commonly represented in the three campaigns, with only two of the 15 posters addressing anxiety. In both the SANE and beyondblue campaigns there is minimal difference between anxious and depressed embodiment, with the same facial expressions being used for both conditions. The one consistent difference is that the individuals in the ‘anxious’ photographs display greater muscle tension than those in the ‘depressed’ images.

With the woman in the beyondblue anxiety poster, her hands, which are on top of her kitchen table, are pressed tightly into one another and her shoulders appear slightly hunched (beyondblue: the National Depression Initiative, 2009d). The lack of differentiation in facial expressions in the beyondblue campaign between individuals with anxiety and those with depression results in a lack of differentiation between the two conditions. This merging of states is consistent with the accounts given by corpus authors, who tended to describe their anxiety as an aspect of depression (see Chapter 6).

The photograph from SANE depicts a rural scene, with a white and red weathered billboard saying ‘Anxiety’ to the left of the frame and an anxious young man in the foreground on the right. The young man has his shoulders raised, his arms rigid and his hands stuffed in his pockets, as if he is rocking backwards and forwards in an attempt to self-soothe (SANE Australia, 2009b). The bodily tension in this image is indicative of high levels of generalised anxiety.

Significantly, no poster in the three campaigns depicts a person experiencing a panic attack. It is plausible that this decision was made because the signs of panic that can be represented in a photograph (wide eyes, sweating, hiding, shaking, etc.) are reminiscent of a caricature of a ‘crazed’ person, although panic attacks can be effectively and graphically depicted in a still image (see for example http://www.nhs.uk/news/2008 /12December/Pages/Panicattacksheartrisk.aspx, http://panicreliefalert.com/ panic- attacks-women-health/ and fuckyeahanxiety.tumblr.com).Thus, it is possible that the organisations felt that representing this aspect of anxiety would affirm negative stereotypes of people with a mental illness. Alternatively, such images may have been avoided because they were deemed distressing and thus inappropriate for a public

RQS campaign or because the severity of the physical symptoms of panic result in people being more likely to seek medical assistance and thus a public health campaign was thought unnecessary.

Illustration 7: beyondblue poster: Bipolar disorder.

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Descriptions of symptoms are primarily found in the beyondblue campaign, as these are the only posters with detailed text (as affective disorder symptoms are internal states that can only rarely be represented with images). Unlike the corpus, where emotional symptoms are described in particular depth, the beyondblue posters describe a similar number of emotional and physical symptoms. Specifically, these posters indicate that a person with depression is ‘sad’ (beyondblue: the National Depression Initiative, 2009c), angry (beyondblue: the National Depression Initiative, 2009e), tired (beyondblue: the National Depression Initiative, 2009f), lacks interest in life (beyondblue: the National Depression Initiative, 2009g), exhausted (beyondblue: the National Depression Initiative, 2009e; headspace: National Youth Mental Health Foundation, 2009c), has

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low self-esteem (beyondblue: the National Depression Initiative, 2009e), has reduced cognitive clarity (beyondblue: the National Depression Initiative, 2009h) and may display an inability to look after themselves (as signified through greasy hair and poor grooming such as an unevenly tied tie and a wrinkled shirt) (beyondblue: the National Depression Initiative, 2009c, 2009e, 2009f, 2009h). The constancy of negative feeling is also noted in several posters (beyondblue: the National Depression Initiative, 2009c, 2009e). All of these symptoms are noted in the DSM-IV-TR.

When the beyondblue posters are examined together, it appears that they cover a wide range of symptoms. However, it is worth noting that the imagery and tone remains constant throughout the campaign, with the discussions of different symptoms embedded in these stereotypical contexts. Some symptoms described by corpus authors and forming part of the DSM-IV-TR criteria that are not mentioned in the campaign, include psychomotor agitation, psychomotor retardation, loss of libido, weight loss and rumination. Suicidality may be implied by discussions of being unsure how to ‘go on’; however, the reference could also refer to exhaustion or being emotionally overwhelmed, so the intended association is unclear (beyondblue: the National Depression Initiative, 2009f). Moreover, references to being tired may imply sleep disturbance, though this symptom is not directly addressed in any poster (beyondblue: the National Depression Initiative, 2009e). With no discussion of situational or catatonic depression, these materials only represent depression of a ‘middling’ severity (not so severe as to be catatonic, not so transient as to be situation specific). While it makes sense that the most obvious and common symptoms are included in such materials, it is concerning that a specific form of depression is being promoted and that variety in symptoms is being minimised. Again, this may have implications for help- seeking, empathy from family and friends and individual comfort in identifying as having an affective disorder.

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Illustration 8: SANE poster: Anxiety

#+'$#"#) Unlike corpus authors who describe being symptomatic in a range of situations, each campaign poster depicts the distressed person in a specific environment. These environments imply the activities and social roles that are likely for individuals with affective disorders.

The environments are markedly different in the three campaigns. In the beyondblue campaigns, the photographs are taken in the home – the bedroom, kitchen and lounge room – a bar, a playing field or workplace. In contrast, the SANE campaigns locate their distressed individuals outside, namely in a field and in a carpark. The decontextualised drawings in the headspace campaign imply that young people can be distressed at a breakfast table, in their home and with a boyfriend. Moreover, the use of a ‘school book’ layout (lined or grid paper background), suggests that young people may be distressed at school. While this may initially appear to be a wide range of environments, there are several significant omissions, with the likely environments of severely distressed individuals not represented in these campaigns.

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It is concerning that no campaign represents people with affective disorders in hospital. This omission is consistent with the lack of representations of severely debilitated (catatonic or manic) individuals in these campaigns. This seems unfortunate because those who are likely to be most affected by their condition are unlikely to see themselves represented in these campaigns. Moreover, by not acknowledging that these conditions may result in hospitalisation, the stigma of inpatient psychiatric care is not addressed. Such stigma is a significant concern to corpus authors who have experienced hospitalisation (see Chapters 8 and 10) and is likely to affect the capacity for individuals to disclose their experiences to friends and family and to gain support from their communities.

While some people may see campaign materials addressing individuals who have already sought help as superfluous, such campaigns are important for two reasons. First, one of the aims beyondblue identifies for these campaigns is stigma reduction. It seems unfortunate if such campaigns do not address the most stigmatised treatment environments. Second, because affective disorders tend to be episodic and chronic, helpseeking is not an isolated incident but rather a repeated action. Thus, encouraging people to continue treatment and engagement is an important aspect of such campaigns.

More than just ignoring the environment of the acutely symptomatic, no poster depicts a person visiting their GP, psychologist or psychiatrist. The lack of representation of these aspects of the life of many people with an affective disorder is a marked difference between the campaigns and the corpus, as corpus authors typically described their medical interventions in detail. This difference is significant because it suggests that corpus authors and campaign producers have a different understanding of what parts of the lived experience of affective disorders are significant and deserving of depiction. Moreover, this omission means that no campaign depicts people with depression trying to deal with their emotional distress and in doing so denies the capacities that people with affective disorders require in order to deal with the difficulties and complexities of seeking treatment.

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Illustration 9: beyondblue poster: When you’re growing up […] (Poor image quality due to corrupted file on beyondblue website)

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Generally, the campaigns use similar metaphors as the corpus authors. Particularly common is text that separates self from illness by presenting affective disorders as non- human agents. The dominance of this metaphor in the campaigns is unsurprising as, consistent with its use in the corpus, it appears to be used in the campaigns as a mechanism to encourage help-seeking and reduce guilt and blame.

In a statement reminiscent of a frightened heroine in a Hitchcock thriller, anxiety is described as:

It’s always there in your mind … and you wait (beyondblue: the National Depression Initiative, 2009d)

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In this quotation, it is implied that anxiety is an unwelcome guest in the woman’s mind. The woman herself is separate from the anxiety, as she is the one who ‘waits’ for it.

Depression, on the other hand, might be considered a sullen teenager or inconsiderate acquaintance:

When you’re growing up you’re told you have to be the strong one. But depression doesn’t care. (beyondblue: the National Depression Initiative, 2009i)

Here, depression is anthropomorphised as a non-human agent that has emotions and/or cognitions. Specifically, by saying that ‘depression doesn’t care’ it is implied that depression has feelings and intentions of its own that are distinct from those of the person who experiences the condition.

Alternatively, depression might be an unwelcome puppy dog that follows you everywhere:

You can’t leave depression at home. It goes to work with you. (beyondblue: the National Depression Initiative, 2009h)

Depression is positioned in this statement as an entity that follows the sufferer around. As an entity that follows one around, depression is positioned as separate from the sufferer and an undesired addition to one’s life.

Other metaphors that are found in both the corpus and the posters include describing depression as grey (beyondblue: the National Depression Initiative, 2009g) and like living in a fog (beyondblue: the National Depression Initiative, 2009f). In addition, the posters use height as a way of indicating mood: one feels high and low (beyondblue: the National Depression Initiative, 2009e). No metaphors in the campaigns were absent from the corpus. Such consistency affirms that the campaigns and the corpus are based in the same discourse and cultural imaginary.

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Illustration 10: beyondblue poster: He’s changed.

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As discussed in Chapter 7, when authors state that affective disorders are illnesses, this claim is supported by medical and social discourse, including the implicit and explicit content of public health campaigns. In the beyondblue campaign, depression is explicitly identified as an illness in several posters (beyondblue: the National Depression Initiative, 2009i, 2009j, 2009k), while in the SANE campaign, the phrase ‘mental illness’ is used in the tagline (SANE Australia, 2009a, 2009b, 2009c, 2009d). These explicit references represent the status of affective disorders as illness as established fact. More subtly, both campaigns affirm this association through the use of words that are associated with medical issues. Examples of this wording include text that: affirms that with the ‘right treatment’ (beyondblue: the National Depression Initiative, 2009c, 2009d, 2009e), individuals can ‘recover’ (beyondblue: the National Depression Initiative, 2009c, 2009d, 2009f) from depression, encourages readers to be aware of the ‘signs’ (beyondblue: the National Depression Initiative, 2009e; SANE Australia, 2009b, 2009c, 2009d, 2009e) of depression, and indicates that bipolar is a condition that can be ‘managed’ (beyondblue: the National Depression Initiative,

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2009e). Moreover, affective disorders are positioned as illnesses in the beyondblue campaign when it is suggested that readers should seek help from their doctor or health professional (see, Hierarchies of illness below). Similar explicit and implicit positioning of affective disorders as illnesses was present in the corpus, with authors often highly invested in a medical explanation of their suffering (see Chapter 7).

In contrast, the headspace posters avoid any medicalising language. In these posters, young people are positioned as having two types of problem: the ‘issue’ or mental health problem itself, and the inappropriate reactions of their loved ones. The posters depict a single solution to this problem: going to headspace (headspace: National Youth Mental Health Foundation, 2009a, 2009b, 2009c, 2009d). In this way, the focus of advertisements is on encouraging and normalising help-seeking behaviour. These posters do not imply that depression and other mental health problems are illnesses but rather puts it in the category of ‘problems’ that one might need some help coping with. By doing so, the posters imply that ‘normal’ young people may experience emotional distress. This approach is appropriate for the headspace campaign because of the early intervention focus of headspace services (i.e., aiming to intervene when emotional distress is just a problem) (headspace: National Youth Mental Health Foundation, 2011b).

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Illustration 11: beyondblue poster: Postnatal depression is like living in a fog.

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Throughout the thesis, and in Chapter 8 in particular, we have seen how corpus authors signify the severity of their condition through describing the health services they receive and through the positioning of their condition in relation to other lived experiences. The beyondblue campaign uses similar signifiers of severity: specifically, it enacts a hierarchy of illnesses which is produced through references to different types of health professionals and the likely trajectory of the condition (neither SANE nor headspace have the textual detail for this type of distinction to be apparent). As in the corpus, bipolar is positioned as the most severe condition. However, where in the corpus anxiety was positioned as less severe than depression (see Chapter 6), in the beyondblue campaign postnatal depression is represented as the least severe condition (see below). In addition, the campaigns signify illness severity with the trajectory of the condition – whether one is likely to recover or to require chronic management – in a far more consistent manner than was apparent in the corpus.

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Part of the detailed text for bipolar reads:

With the right treatment, bipolar can be managed. If you experience these extremes, it’s important to talk to a doctor. (beyondblue: the National Depression Initiative, 2009e)

Contrast this to the text on a poster regarding postnatal depression:

The sooner you seek help, the sooner you can recover. (beyondblue: the National Depression Initiative, 2009f)

The bipolar quotation has two signifiers of illness severity. First, only the poster about bipolar tells the reader that it is important to see a doctor. Moreover, it is one of the only posters in the campaign where only medical forms of assistance are recommended (other posters, like the postnatal one above, use more amorphous terminology like ‘get help’). Like the corpus writings described in Chapter 8, this focus on medical professionals positions bipolar as a severe and legitimate illness. Second, unlike depression and anxiety, which are positioned as conditions that one can ‘recover’ from, bipolar is represented as something that can be ‘managed’. Like the use of chronic symptoms as a signifier of severity in some corpus quotations (see Chapter 6), this wording implies that it is ongoing and requiring continual medical attention.

The bipolar and postnatal posters represent the polar extremes of characterisations of affective disorders in this campaign. It is more common for posters to use a mix of signifiers, balancing some wording that emphasises severity with others that minimise it. For example, the text at the bottom of the anxiety poster reads:

You can’t stop it or make it go away, but with the right treatment, you can recover. (beyondblue: the National Depression Initiative, 2009d)

This statement is usual for these posters as it depicts anxiety as a condition that requires treatment but can be recovered from. Specifically, the description of ‘treatment’ implies that anxiety requires professional remedy and is a condition of concern. However, the mention of recovery in this text is confusing. The phrase ‘you can’t stop it or make it go

RRS away’ suggests that the poster is using ‘recovery’ in its mental health specific sense: namely, as the process of leading a meaningful and fulfilling life despite continuing symptoms. This meaning makes more sense given the quotation, yet it seems an unlikely immediate reading by the target audience. Rather, the reference to ‘recovery’ seems more likely to function as a way of ‘playing down’ the severity of the condition by positioning anxiety as a temporary illness (see Chapter 6).

The corpus and campaigns represent the severity of anxiety in different ways. Where the wording of the beyondblue posters suggests that anxiety is just as severe as depression, authors consistently represented anxiety as less severe than depression (see Chapter 6). Given that beyondblue generally enacts dominant affective disorder discourse in their campaigns, it is unclear why the posters do not repeat the hierarchies of illness severity apparent in the corpus. It may be that the wording in the anxiety poster has been used to emphasise the intensity of anxiety symptoms. However, this would be surprising, as the organisation, although officially committed to increasing awareness about both depression and anxiety, appears invested in positioning depression as the most debilitating and severe common mental illness in Australia (Jorm et al., 2006).

While most of the beyondblue posters provide consistent messages regarding the relative severity of the condition, this is not always the case:

Depression is an illness, not a weakness. One in six men will experience depression at some stage in their life. If you have noticed a change in yourself or someone else, get it checked out. (beyondblue: the National Depression Initiative, 2009h)

On the one hand, the text explicitly states that depression is an illness. As has been discussed repeatedly throughout the thesis, by saying that depression is an illness, the condition is positioned as a medical issue that justifies medical attention. On the other hand, the rather amorphous and non-directive phrases ‘a change in yourself or someone else’ and ‘get checked out’ imply that depression is not a devastating condition and does not require urgent attention. This inconsistency gives a mixed message to the reader, a

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confusion that seems likely to be the result of trying to encourage help-seeking by simultaneously affirming that depression is a serious issue, and that it is not frightening.

The beyondblue campaign depicts illness severity using similar rhetorical devices as the corpus. However, while both corpus authors and the campaign position bipolar as the most severe condition, they differ in their relative positioning of anxiety and postnatal depression, with postnatal depression represented in the campaign as less severe than in the corpus and anxiety positioned as more severe. The minimised severity of postnatal depression may reflect beyondblue’s desire to not pathologise common hormone- induced and transient ‘baby blues’. Regardless of the reason, these differences in relative illness positioning indicate that while the rhetorical device is consistently utilised across the corpus and the campaign mediums, the exact hierarchy that is being enacted varies. This in turn implies that in certain instances it is the rhetorical strategy, rather than the content per se, that is most consistent in Australian affective disorder discourse.

Illustration 12: beyondblue poster: You hide your depression […]

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Like the distinctions between stress and depression discussed in Chapter 7, in the beyondblue campaigns, strategic separation of ‘normal’ and ‘abnormal’ states functions to emphasise that affective disorders are abnormal life experiences. This positioning then helps to justify professional intervention.

In one instance depression is contrasted with normal ageing:

Depression is common, but it’s not a normal part of getting older. (beyondblue: the National Depression Initiative, 2009g)

In another example, anxiety is positioned as distinct from common worry:

While everyone feels anxious occasionally, some people feel like this all the time for no good reason. (beyondblue: the National Depression Initiative, 2009d)

In both of these examples, the distinction functions to emphasise that affective disorders are pathological moods. These statements are similar to the quotations examined in Chapter 7 where the legitimacy of affective disorders as illnesses was predicated on distinguishing them from stress, situational distress or normal sadness.

Despite the similarity in rhetorical strategy, the role of categorical distinctions in this campaign is different to their role in the corpus. Categorical distinctions in the corpus function to enhance authors’ personal legitimacy and secure their epistemic authority. These functions make sense, given that corpus authors are likely to be concerned about how they, as individuals, are perceived by the audience of their writing. In contrast, health promotion organisations (including beyondblue, headspace and SANE) tend to be concerned with aligning the public’s understanding of the condition with that of the organisation, including what constitutes appropriate help-seeking behaviour. As such, the rhetorical function is more limited and depersonalised. Despite these different impetuses and roles, the consistency between the corpus and the beyondblue campaign

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emphasises that such distinctions are an important aspect of affirming the legitimacy of affective disorders.

Where the beyondblue campaign uses categorical distinctions in a similar way to the corpus, the headspace campaign is particularly focused on normalising mental illness and mental health problems. This difference appears to be a reflection of the greater focus on social determinants of mental health in headspace programs. The posters in the headspace campaign minimise categorical distinctions in a way that emphasises the normality of emotional challenges in adolescence and thus implies that individuals who visit headspace are still normal (i.e., legitimate) teenagers. Specifically, the headspace campaign focuses on young people who are experiencing problems. While sometimes these problems relate to mental health, they can equally relate to parents being dismissive or to being dumped by a boyfriend. Thus, no categorical distinction is made between normal adolescent life and mental illness, a strategy that makes sense given the early intervention focus of the organisation.

In contrast, SANE uses a mix of categorical distinctions and amalgamations. The campaign maintains a categorical distinction through the use of the term ‘mental illness’. This term implies a diagnostic distinction between the ‘well’ and the ‘sick’. In contrast, the statement ‘If you’re worried about yourself or someone you know, call 1800 18 SANE’ collapses the distinction between ‘well’ and ‘sick’ and may be read as implying that both those with, and without, mental health problems have legitimate epistemic capabilities and support needs. By making both distinctions and amalgamations, the SANE posters address stigma in a productive way. Specifically, the posters simultaneously represent people with mental illness as the same as non- symptomatic individuals and acknowledge the fundamental difference in their lived experience. By doing this, the posters address a tension evident in the corpus: namely, the apparent desire for inclusion and simultaneous wish for acknowledgment of special circumstances (see Chapter 9).

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While all the campaigns encourage help-seeking behaviours, beyondblue is the only organisation that explicitly aims to reduce the stigma of depression and anxiety (beyondblue: the National Depression Initiative, 2009b). However, rather than directly addressing stigma, the campaign aims to provide non-stigmatising representations of affective disorders, a strategy that some international research suggests may be counterproductive, (Mehta & Farina,1997; Payton & Thoits, 2011). Like several authors quoted in Chapter 7, numerous posters affirm that affective disorders are not a sign of weakness, presumably in the hope that this will reduce the blame and guilt experienced by individuals with depression. This minimal or indirect coverage seems consistent with the other ‘middling’ representations found in these campaigns. Specifically, this indirect discussion of stigma ‘speaks to’ those who experience stigma without offending anyone who enacts discrimination. Such a strategy may hope to keep those who discriminate engaged with the campaign and thus reduce their problematic attitudes through education; however, it may also just be a way of avoiding directly addressing a difficult issue.

There is only one instance where stigma is directly referred to in the beyondblue campaign:

You don’t tell anyone because you fear what others will think – but hiding it is exhausting. (beyondblue: the National Depression Initiative, 2009h)

This quotation describes a person who is afraid of stigma and so masks their depression. This anecdote is very similar to the descriptions of masking provided by corpus authors (see Chapter 9). However, where corpus authors describe both fears about stigma and lived experiences of discrimination, no poster describes actual discrimination. It seems likely that this is because the focus of the campaign is on encouraging help-seeking behaviour in the person with the disorder. As this is the key focus of the campaign, then it is the fear of discrimination, whether justified or not, that is being targeted, as it is the fear that is likely to stop people from seeking help. In addition, such focus may be the result of an intention to engage, rather than berate, individuals who are currently discriminatory towards those with affective disorders.

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Stigma is also indirectly addressed in the headspace campaigns. Specifically, by depicting inappropriate lay responses, the posters suggest that the public does not understand depression and other common causes of distress and that this lack of knowledge may result in family and friends being condescending or making counterproductive suggestions. This understanding of stigma is consistent with corpus authors who made categorical distinctions between those with affective disorders and ‘the public’ as an aspect of their explanation of discriminatory behaviours (see Chapter 9). The consistency between corpus and campaigns is also evident in the representations of gender norms and intimate relationships in the campaign posters.

Illustration 13: headspace poster: My friend reckons the best way […]

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The poster campaigns consistently depict normative gender expressions and support normative gender expectations. Despite statistical evidence that lifetime prevalence for women is twice that of men, only five out of the 16 posters depict women (Lafrance, 2009, p. 2). The disparity is entirely the result of the gender disparity in the beyondblue campaign, where only three of the posters portray distressed women (six posters depict men and one scenario of a woman looking after a distressed man is used in two posters). The reason for this disparity is unclear, although it may reflect a deliberate focus on men due to their tendency not to go to the doctor or seek other professional help and also the higher rates of alcoholism, completed suicide and perceived stigma in this group, a consequence of approximately one third of the organisation’s funds ($10,370,000 in 2010) coming from a men’s health fundraising organisation (Movember) or a universalising of male experience (when ‘man’ stand in for ‘human’) (beyondblue: the National Depression Initiative, 2011c; Caldwell, Jorm, & Dear, 2004; De Leo, Cerin, Spathonis, & Burgis, 2005; Oliffe, Ogrodniczuk, Bottorff, Johnson, & Hoyak, 2010). The over-representation of men creates a disparity between lived experience and its representation in health promotion materials. However, it is encouraging that, at least in some posters, gender is acknowledged as a factor that affects coping mechanisms, the subjective experience of the condition and help-seeking behaviours.

Femininity

Women in the campaigns consistently display normative femininity. Across the three campaigns women are photographed or drawn with long hair, feminine facial features and feminine clothing such as tailored shirts and dresses. Mostly, they wear wedding rings. In addition, and consistent with the corpus, the women’s non-feminine traits tend to be signs or symptoms of their illness. For instance, the beyondblue poster about postnatal depression shows a woman holding her baby away from her body and having oily hair, both of which can be interpreted as symptoms of her depression (i.e., an inability to bond with her child and an inability to care for self). Apart from these symptoms, the woman is normatively gendered: she is located in the home, has plucked eyebrows and long hair, and wears a wedding ring and a fitted t-shirt. While this

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normative gendering is likely to assist in allowing a large number of women to relate to the poster, in certain instances normative gendering can be problematic. For example, consistent with corpus authors, the image (and to a lesser extent, the text) in a headspace poster associates normative expressions of femininity with mental health:

My friend reckons the best way to get rid of depression is to buy a pet. And draw daisies. (headspace: National Youth Mental Health Foundation, 2009c)

This text is accompanied by a drawn image of a of young woman who displays stereotypical signifiers for an upper-middle class, white, private-school girl (also known as a WASP – White Anglo Saxon Protestant): she smiles in the middle of field of smiling daisies while patting a puppy and wearing an A-line dress and pearls. While the image is a depiction of the friend’s inappropriate suggestion, it nonetheless implies that young women who are depressed are not going to present in hyper-feminine ways. Specifically, it is implied that a depressed woman is not going to be smiling or wearing a dress or pearls. Thus, consistent with some of the examples in Chapter 11, one of the messages that may be taken from this campaign is that young women who adhere to feminine norms are mentally healthy and, by implication, those who do not are in some ways mentally suspect.

A very different aspect of normative femininity is apparent within the beyondblue campaign. Almost all women in the beyondblue campaign are depicted as married. Within the campaign photographs, where the hands of most men are out of frame, the hands of women are generally visible. In all but one instance, the women wear a wedding band. It is unclear why beyondblue or Frontier Advertising felt that this was an important thing to signify. It is possible that that this representation may reflect research that married women are more likely to be depressed than single women while men are more likely to be depressed when single (McGrath, 1990). However, this explanation does not clarify why it was important to indicate the marital status of women but not of men (placing men’s hands out of the frame means that their marital status is not signified, suggesting that it is deemed an unimportant identification for men). Some other possible explanations for this decision relate to a perceived need to present women as normatively gendered: that it was believed to be important to indicate that women can still ‘keep’ a man even when they are depressed or that there was concern that

RSQ depression would be considered situational if the women were not clearly in a relationship (i.e., ‘you’re just unhappy because you can’t get a man’). Both interpretations are problematic, as they suggest that women are dependent on men for their self worth. The asymmetrical signification in this campaign is consistent with the corpus, where women reported a greater focus on looking after their partner and family. While is some ways, this mirroring of lived experience is useful, it is also concerning as it promotes an asymmetry that underpins problematic behaviours such as domestic violence (see Chapter 11).

While the femininity found in these campaigns is highly normative, the representations of masculinity in the beyondblue campaigns are more explicitly problematic.

Masculinity

Seven beyondblue posters show depressed men. The men display a range of signifiers of normative masculinity: they wear masculine clothing such as suits, blue shirts, singlets and rugby jerseys and they often have stubble on their faces. The example below details some of the signifiers and text in the beyondblue posters that enact normative masculinity.

The photograph on one of beyondblue’s men and depression posters depicts a middle- aged man and woman who are sitting at a kitchen table having a cup of tea. The woman is further away from the camera and is looking at the man worriedly (as signified by a raised eyebrow, cocked head and her hand on the man’s forearm). While the woman is looking at the man, the man is staring dejectedly into the distance. The man is wearing a blue shirt with a white singlet showing at the collar, suggestive of agricultural or blue- collar employment. The woman is wearing what appear to be house clothes (a patterned woollen jumper and skivvy). The caption reads:

I didn’t want people to think I was weak. I am a man and men don’t get depression. (beyondblue: the National Depression Initiative, 2009l)

The caption ‘I am a man’ implies that only certain expressions of masculinity are recognised as ‘manly.’ ‘A man,’ according to this depiction, is heterosexual, a blue-

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collar or agricultural worker, has a female partner and is emotionally remote. It is likely that the category of ‘man’ can be extended to men who, while not embodying these ideals, value or identify with them. However, the statement functions to exclude men who do not valorise this form of masculinity. In Chapter 11, quotations from corpus authors relayed how men found this exclusionary form of normative masculinity distressing, particularly when they tried to align it with their experience of depression. It seems unfortunate that this beyondblue campaign is only addressing men who identify with this form of masculinity. Such concerns are mirrored in a recent critique of the ‘Real men get raped’ SuriviorsUK male sexual assault campaign, suggesting that others are also aware of the potential consequences of ‘real men’ rhetoric (Nelson, 2012). While it is positive that the beyondblue campaign is aiming to address the distress experienced by men who fear emasculation, the lack of other representations may inadvertently promote the very type of masculinity that impels this fear.

Illustration 14: headspace poster: When I cry on my boyfriend’s shoulder he […]

RSS '##'(%) While the vast majority of posters in these campaigns depict individuals with affective disorders as isolated and outside their family or community, a small subset of posters discuss caring and intimate relationships. Similar to the text from Journeys with the Black Dog analysed at the end of Chapter 11, while such campaigns do not aim to support disrespectful relationships, these posters nonetheless demonstrate understandings of depression consistent with those used by authors in Chapter 11 to justify domestic violence.

The image on the beyondblue carers poster is almost identical to that in the masculinities poster described above. However, the text is substantially different:

Depression affects the whole family. You need to look after yourself – as well as the person with the illness. (beyondblue: the National Depression Initiative, 2009j)

This message has three positive aspects: it affirms that carers should look after themselves, it acknowledges that caring can be difficult and it recognises the interdependence between carers and their loved ones. Less positive is that this text implies that carers are obligated to look after ‘the person with the illness’. Specifically, the structure of the second sentence implies that carers ‘need to look after […] the person with the illness’ (emphasis added). As this poster does not acknowledge any reason why a family member may abdicate this responsibility, this statement may be read by people in abusive relationships as an indication that they must continue in their relationship even if they are being abused by their loved one (see Chapter 11).

More problematic is what is not represented in the beyondblue campaign. Specifically, while there are two very similar posters that represent a woman looking after a depressed man, no poster shows a man caring for a depressed woman. This lack is problematic because it reaffirms the gender stereotype that it is women who should look after men. Moreover, the campaign provides no visual representation of men looking after their families. However, in comparison with one of the headspace posters, this missing representation is a minor concern.

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A headspace poster reaffirms some of the gender and relational norms that were so concerning in the previous chapter. Specifically, the poster represents an emotional girl (although the writer could be male, it seems unlikely) and sex-crazed boy through a hand drawn picture of a young man shrugging his shoulders and raising his eyebrows, with text that reads:

When I cry on my boyfriend’s shoulder he always wants to have sex with me. (headspace: National Youth Mental Health Foundation, 2009a)

This poster continues some of the relational norms that were problematised in the previous chapter. While the headspace tagline (‘someone else to go to’) positions this response to the girl’s distress as inappropriate, it is the upset woman, rather than her pushy (and potentially abusive) boyfriend who is being encouraged to get professional help. Moreover, the shrugging of the boyfriend’s shoulders suggests that he does not feel that this behaviour was shameful or unacceptable. Rather, this image is more consistent with a sentiment of ‘oh well, what do you expect from me?’ implying that such behaviour, while problematic, is not surprising or fundamentally unacceptable. In other words, while not supporting such behaviour, the poster certainly does not position it as either potentially abusive, an issue that may justify professional intervention or even a behaviour that the boyfriend needs to change.

An alternative reading of this poster would be that the boyfriend is attempting, albeit inappropriately, to be supportive by suggesting an activity that enhances his mood and that he thinks might also enhance that of his girlfriend. While this interpretation is possible and reflects the ‘messiness’ of consent, the implications of the former reading appear much stronger.

This headspace poster depicts a young woman being pressured for sex when she is upset. It is likely that the poster designers felt that this was a good example of an inappropriate response to emotional distress and that they did not intend for the poster to be read as support for disrespectful interactions with intimate partners. However, by not indicating that the boyfriend’s behaviour was anything beyond ineffectual and an inappropriate response to distress, the campaign may be normalising the dynamics that

RSU are often experienced by people in abusive relationships. This highlights one of the broader issues with the headspace campaign: namely, that the posters require the reader to reverse the meaning of the image. Rather than promoting what is depicted on the poster (disrespectful boyfriends, uninterested parents, insensitive friends, etc.), the posters are encouraging young people to do something else – to go to headspace for respectful and sensitive help with their issues. However, it seems likely that some people who might require professional help may find it difficult to perform this ‘cross- reading’ and that some young people may interpret them as saying that such behaviours are helpful or appropriate in times of distress. This possibility is worrying, as a literal reading of the posters will actively encourage a range of counterproductive and damaging coping strategies.

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The implied cause and nature of affective disorders varies significantly between the three campaigns. The beyondblue campaign is the most medicalised, with readers encouraged to understand their emotional distress as an illness that requires medical treatment. At its most extreme, some posters represent generic symptoms such as a lack of energy as indicators of a specific illness. In these instances, the reader is encouraged to interpret potentially normal bodily sensations or psychological habits as pathological, a process that Fullagar (2008) also identified on the beyondblue website. The level of medicalisation found in the beyondblue posters is similar to that found in the corpus. This may reflect an alignment of the beyondblue materials with public sentiment; however, it seems more likely that corpus authors are a self-selecting population that, like beyondblue, are orientated towards medicalised understandings of affective disorders.

The SANE campaign is less explicitly aligned with a medical interpretation of distress, although the play on the word ‘sign’ and the description of ‘mental illness’ suggests an, at least partial, acceptance of a medical model. However, the use of medical terminology without explicit reference implies a multifactorial model, such as the biopsychosocial model. Alternatively, this ‘agnostic’ positioning may reflect that the

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organisation, at least in their campaign materials, is not invested in any particular understanding of emotional distress.

In contrast, the headspace campaign appears to make little distinction between normal situational distress and mental illness. This lack of differentiation is in keeping with young corpus authors (many of whom were writing on the headspace website) who tended to identify their distress as a nameable/medical condition requiring professional help while simultaneously positioning their distress as the result of a particular life situation (see Chapter 7). The similarity between corpus authors and campaign materials suggests that the headspace campaign reflects, and influences, the understandings of emotional distress held by those members of the target audience who publish their stories on the headspace and ReachOut websites.

While a survey of the three campaigns reveals a variety of representations of affective disorders, each individual poster tends to be simplistic and based on stereotypes. In addition, the most problematic posters (i.e., those from beyondblue) are distributed far more extensively than those of the other two campaigns. Thus, while this analysis provides hope for alternative depictions of emotional distress, it also affirms that such representations are still on the periphery of Australian affective disorder discourse.

It is likely that the affective disorder narratives in the corpus have been affected by these campaigns. It is equally likely, especially given the consultation processes of both beyondblue and headspace, that the campaigns have been affected by individual affective disorder narratives. Such co-constitution has benefits and risks. On the one hand, it may mean that the campaigns are more effective and that individuals feel that their experiences are accurately represented in the campaigns. On the other hand, the alignment of personal experience and health promotion materials perpetuates existing, primarily medical, affective disorder discourse in Australia by providing few alternative explanations of extreme emotional distress. As will be discussed in the thesis conclusion, while such medicalisation can be beneficial for certain individuals experiencing an affective disorder, focusing on individual pathology rather than larger issues of social inequality and isolation can have negative effects at a societal level.

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Australian affective disorder campaigns are primarily produced by beyondblue. These campaigns depict stereotypical experiences of depression with minimal engagement with acute or situation-specific depression and a notable lack of engagement with anxiety. The posters use repetitive visual representations of emotional distress in a way that backgrounds the variation in the lived experience of affective disorders. The beyondblue campaign is consistent with the corpus in the choice of metaphor and the use of a separation of self and illness to increase the legitimacy of people with affective disorders. In addition, consistent with the corpus, the campaign utilised hierarchies of health professionals and illnesses. A relatively minor difference between the corpus and the campaign was that the posters positioned anxiety and postnatal depression in reverse severity order. Overall, the consistency between the beyondblue campaign and the corpus suggests that these forms are drawing on dominant discourses as well as influencing each other.

The SANE campaign used more creative and metaphorical ways of representing emotional distress than the beyondblue campaign. In doing so, the SANE posters began to move away from the stereotypical representations and provide a more emotive representation of the lived experience of these conditions. Despite this movement away from dominant representation, the campaign used several of the rhetorical strategies found in the corpus, including both emphasising and minimising the differences between individuals with mental illnesses and those without.

The headspace campaign is less aligned with the corpus as a whole than either beyondblue or SANE. However, the campaign is aligned with their target group of young people. Specifically, the depiction of mental health problems as situation specific but requiring professional assistance is consistent with the depictions of many of the young corpus authors (see Chapter 7). While this is a positive aspect of the campaign, it is worrying that some headspace posters encouraged normative gender expectations and depicted pressure for sex in ways that did not outright condemn such behaviour.

The existence of the rhetorical functions of legitimacy, authority and integrity in the posters highlights the usefulness of this analytic frame for a variety of mediums. In

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particular, the posters relied on the authority of the NGOs in order for their messages to be taken seriously by their target groups. Legitimacy remained a key concern in the campaigns, with the legitimacy of affective disorders as illnesses a major aspect of the campaigns, as well as the relative severity of various conditions. Finally, integrity was a minor theme in the campaigns, but was implied in the headspace posters that appeared to emphasise that emotional distress was not incommensurate with being a ‘normal’ or ‘proper’ teenager.

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I’m sorry For all the times I wasn’t the hero I wasn’t even there Or if I was there I remained silent And complicit in your suffering Those times Again and again When I did not Sit next to you or Comfort you When forever was outstretched And you did not cut Quite deep enough But not for anything I did, Did you survive

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Affective disorders are a serious social issue in Australia with one in four Australians experiencing an affective disorder in their lifetime (Australian Bureau of Statistics, 2007a). Not only are the conditions common, they are also often debilitating, as evidenced by depression and anxiety being the leading causes of non-fatal burden of disease for both men (10% of the burden) and women (18%) (Begg et al., 2007). In addition, the high proportion of individuals with affective disorders who attempt suicide indicates both the level of debility experienced by some sufferers and the devastating consequences of failing to assist individuals who are experiencing these conditions (De Leo, Cerin, Spathonis & Burgis, 2005).

The mortality, morbidity and economic costs of emotional distress and the medical explanations of such costs are readily understood in western cultures, including Australia. Furthermore, there is significant personal and professional impetus towards maintaining biomedical understandings of affective disorders, with most stakeholders in mental health either implicitly or explicitly supporting ongoing medicalisation. For example, the medical socialisation of GPs encourages, if not enforces, understanding affective disorders as medical ‘problems’, pharmaceutical companies gain greater profits when people are given medications, psychiatrists and psychologists are paid largely on the proviso that they are treating an illness, and people diagnosed with affective disorders gain legitimacy through embracing and enacting their sick role (see Greenberg, 2010, p. 17-18; Pilgrim, 2002, p. 591; Dowrick, 2009, p. 199). In addition, over the last decade, there has been significant investment by the Australian government in government-supported treatment through Medicare and ‘awareness raising’ for affective disorders, both of which have reinforced a medicalised understanding of affective disorders.

Despite increasing governmental focus on medicalised models of distress, other Australian researchers have performed qualitative research into representations of affective disorders (Fullagar, 2008, 2009; Gattuso, Fullagar, & Young, 2005; Rowe, Tilbury, Rapley, & O’Ferrall, 2003; Wigney, 2010). This research has largely involved close textual analysis of texts written by health and media professionals and thematic RTR

analysis of interviews with people who experience depression or bipolar. While this existing research provides a range of valuable insights, it does not provide textual analysis of lay narratives. Little is known about how Australians represent and construct their experiences of affective disorders or about the the nature of these narratives. Yet, this knowledge is important because individual understandings can affect the extent of individual suffering, as well as treatment access, treatment adherence and symptom severity.

The thesis has begun to fill this gap by analysing the rhetorical aspects of published Australian affective disorder narratives. It set out to answer the research question ‘How are experiences and understandings of affective disorders represented and constructed in current public narratives and representations in Australia?’ Using thematic and close textual analysis of accounts of affective disorders published in Australia between 2000 and 2010 (including autobiographies, anthologies of autobiographical writing and/or edited interviews, websites with illness story pages and entries on an affective disorder bulletin board), the thesis has critiqued the dominant illness narratives of Australians experiencing affective disorders.

This conclusion examines the thesis findings in the context of the wider theoretical framework developed for this thesis (the Legitimacy, Integrity, Authority Model – LIAM) and the existing literature on affective disorder narratives and experience. It explores the methodological and theoretical implications of these findings, as well as identifying potential impacts for the health sector and future research.

#($!$#()'*)$#('",$' 3('*#'%###( LIAM was developed as the theoretical framework for this research project (Chapter 2). It is both a consequence of the analysis process and the framework in which the analysis took place. LIAM is formed from a range of humanities and social science theories that were combined to provide an enriched basis for the central social constructionist underpinnings of the research. An explicit identification of some of these influences on the epistemology and ontology of the research project is useful when reflecting on the theoretical basis of the model.

RTS Like much of the thesis, the epistemology included aspects of a variety of disciplines and bodies of thought. A simplified standpoint epistemology informed the engagement with texts, with each author understood as the best person to write about their experiences (Code, 1995; Haraway, 1991). A structuralist framework was also utilised as the analysis of patterns of narrative was considered a meaningful mechanism for understanding a phenomenon. Finally, the presuppositions of certain feminist psychoanalytic work were also employed: while an individual was understood as being unable to access any other person’s experience directly, there is a common cultural imaginary and symbolic order that enables each person to comprehend the deeper resonances and referents found within another’s words (Irigaray, 1993, 1996).

The ontology was equally complex. Consistent with a social constructionist frame, mental illness diagnoses were understood as a way of classifying certain psychological and physical states. This claim was supported by significant existing evidence that what states were deemed pathological and how such symptoms were categorised and identified vary over time and place. The social constructionist frame also meant that the real life experiences of emotional suffering were understood as inseparable from the rhetorical construction and meaning-making that informed and accompanied these experiences (Chapter 2). In addition, a biopsychosocial model of distress was utilised, with affective disorders conceived as the consequence of biological, psychological and social determinants (Pilgrim, 2002; Merkel-Keller, 2006). In contrast with some adherents to this model however, I understand these factors as inherently inseparable – a view that aligned the thesis more closely with feminist criticisms of mind-body dualisms (Atherton, 2000). Finally, emotional suffering was interpreted in such a way that it did not negate a person’s value as an epistemic agent, although it was acknowledged that treatment or illness related difficulties in communication may mean that such agency could not be readily expressed. This moral claim was based in disability studies scholarship, although such scholarship often focuses on physical disability at the expense of theorisations of mental distress (Linton, 1998; Price, 2011; Shakespeare, 1996). The interdisciplinary web of understandings that formed the ontology and epistemology provided the basis for the theoretical model (LIAM) that enabled the analysis.

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LIAM was used in conjunction with a grounded theory approach and close textual analysis to examine how Australians represent and construct their experiences of affective disorders in published accounts. This combination of methods provided the tools to enact an analysis that balanced the examination of lived experience and the critique of rhetorical function.

LIAM provided a way of analysing the three key rhetorical functions identified in the corpus materials: • Legitimacy – statements that positioned the author as experiencing a legitimate illness; • Integrity – statements that asserted the authors integrity and value as a whole subject; and • Authority – statements that affirmed the author’s epistemic or experiential authority.

Initial coding demonstrated the dominance of these three functions, and further analysis allowed for the development of a more nuanced account of the strategies used to achieve them. Galegher, Sproull and Kiesler (1998) and Oliphant (2010) had previously identified different combinations of these functions; however, the identification of the three together and their interdependence is unique to this research.

The corpus was selected using criteria that ensured that dominant or normative affective disorder narratives were analysed. In total, 2263 pages from published accounts were examined: four autobiographies, three anthologies of autobiographical writing and/or edited interviews, 102 entries on two websites with illness story pages and 169 entries on an affective disorder bulletin board. The use of the three sources provided a unique and varied sample that supported comparisons across different sources and the triangulation of data. Published accounts were chosen, rather than interviews, because they allowed authors to deliberately enact certain rhetorical strategies. Therefore, published accounts were deemed to be particularly valuable for the purpose of understanding how an experience comes to be comprehended and made intelligible by both the subject who experienced it and their interlocutors.

RTU By applying this new theoretical and methodological approach to published narratives, this thesis contributed new knowledge on how Australians have perceived, understood and created the narratives and experience of living with affective disorders.

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At the centre of each affective disorder narrative is the lived experience of an individual who identifies as having depression, anxiety or bipolar. This core is culturally inflected with what ‘counts’ as narrate-able or narrative-worthy being dependent on the cultural and temporal location of the author. However, descriptors are not baseless cultural mirroring, as what an author chooses to recount is indicative of the sensations, emotions and symptoms they find most arresting. Thus while lived experience and rhetorical function cannot be fully separated, it is beneficial to base one’s analysis on an understanding of the ‘building blocks’ of affective disorder experience.

The most common characteristics of depression reported by authors were extreme sadness, lethargy and a sense of disconnection from ‘real world’ events and family and friends (Chapter 5). Depression was often described as an unremitting state that lasted for months or years, which affected body rhythms and encompassed a range of emotions including anger, fear, despair and self-loathing. These key characteristics are frequently reported in literature about white western experiences of depression, with almost all researchers noting similar emotional and physical changes during depressive episodes (Karp, 1996; Lafrance, 2007; Moran, 2006; O’Connor, 1998).

Corpus authors routinely understood anxiety as a condition of intense fear that occurred for short periods (often repeated many times), involving intense body sensations and hyper-arousal (Chapter 4). These key characteristics are identified in the clinical literature and reflected in the DSM criteria (American Psychiatric Association, 2000; Andrews & Slade, 2002; Kroenke, Spitzer, Williams, Monahan, & Lowe, 2007; Norman et al., 2011; Stopa & Jenkins, 2007). However, in comparison with depression, there are few straightforward academic accounts of the lived experience of anxiety, meaning that the descriptions of the subjective experience of these disorders within the

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thesis are particularly valuable (Hendrix, 1967; Mahoney, 2000; Olstead, 2007; Reid, 2004; Skultans, 2003).

Authors reported two distinct forms of mania. Milder or hypomanic episodes tended to involve extreme happiness and a disregard for consequences of behaviours such as excessive spending. More severe episodes, probably aligned with the clinical designation of a full manic episode, often included elements of psychosis (Chapter 5). As with depression, these descriptions align fairly well with both clinical and qualitative literature (Chouinard, 2011; Goldberg, 2007; Licinio, 2005; Martin, 2007; Wigney, 2010).

Accounts of anxiety, depression and mania all included descriptions of high impairment, suicide ideation and attempts, and significant social and behavioural consequences such as poor education outcomes, drug and alcohol use and social isolation. Suicide attempts in the context of anxiety are a particularly noteworthy finding as these are not well recognised in the clinical or analytic literature. This is a lived experience that, regardless of the rhetorical value of its representations in anxiety narratives, requires greater clinical attention.

Medical treatment was commonly described by authors as part of the lived experience of being diagnosed with an affective disorder (Chapter 7). While linked to the lived experience of medical interventions, the extent that authors represented their condition as having a biological aetiology was also a rhetorical strategy that was a reflection of broader affective disorder discourse. Consistent with scientific research, bipolar tended to be represented as having a stronger biological aetiology than depression or anxiety (Healy, 2008). In addition, depression appeared to be more consistently represented as a biological abnormality than anxiety. Many authors who experienced concurrent depression and anxiety understood anxiety as an aspect of depression (Chapter 6). Given the severity of both anxiety and depression symptoms, this emphasis appears to be a narrative preference that is not based in the lived experience of these conditions, but rather reflects that the concept of depression is more culturally active, and deemed more legitimising, than anxiety.

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LIAM understands legitimacy, authority and integrity as the three key rhetorical functions in affective disorder narratives. These rhetorical strategies are used by authors to position themselves as particular types of people experiencing particular types of events. However, the construction of individual narratives cannot be separated from the broader social construction of affective disorders. This means that the enactment of a particular rhetorical function is dependent on the appropriate application of existing signifiers and/or understandings. To complicate this, however, the repeated use of particular signifiers by authors is likely to enhance the power of those very signifiers – that is, the more a particular claim is used, the more logical or self-evident it becomes (see Chapter 12). In other words, rhetorical functions both influence, and are influenced by, existing cultural influences.

By a similar logic, rhetorical functions shape, and are shaped by, lived experience. In this process, certain experiences are minimised and others are emphasised. At the same time, certain rhetorical and narrative strategies are used, while others remain largely irrelevant. Put differently, lived experience is richer and more complicated than the stories we tell about it. At the same time, however, narratives must be understood as culturally rich stories that draw on a body of communal and symbolic meanings that are more complex than lived experience.

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Legitimacy was the most commonly identified rhetorical function in the corpus: it was used consistently and repeatedly across all source material types and author demographics.

The vast majority of legitimising statements identified in the corpus pre-assumed and reaffirmed medicalised understanding of emotional distress. Medicalised legitimacy enabled authors to represent affective disorders as illnesses that: (1) were not imagined, (2) had a biological aetiology, (3) were not the fault of the sufferer and (4) required treatment by medical professionals. Similar justifications are seen in other research, including Harden (2005), Sayre (2000) and Wisdom and Green (2004).

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Related to the positioning of affective disorders as legitimate illnesses is the representation of authors as people with legitimate illnesses. While closely related to claims that affective disorders are legitimate illnesses, this form of subjectivity is distinct. Specifically, when authors turn a claim about a condition into a statement about their own subjectivity, they embed it into their sense of self, an identity formation not necessary when authors are articulating the legitimacy of their illness. Numerous scholars in both the UK and the US have noted the dominance of this form of subjectivity in people who identify as having an affective disorder: all note the link between this form of subjectivity and broader medicalised discourse (Lafrance, 2007; Oliphant, 2010; Hess, 2001: Pilgrim, 2011).

While theoretically legitimacy can be enhanced by means other than medicalisation, this was exceedingly rare in the corpus, and was essentially limited to authors maintaining their legitimacy as rational subjects. Moreover, while authors typically reported psychosocial aspects of their experience, their significance was often down-played, with authors relying on biological accounts for their legitimacy as ill subjects.

The analysis of the corpus demonstrated that legitimacy was enhanced most effectively when claims were constructed in certain ways. Specifically, legitimacy was routinely enhanced through the strengthening of associations between affective disorders and legitimising categories (e.g., physical illness) and/or the reduction in associations with less legitimising categories (e.g., madness). Associations and comparisons allowed for certain legitimacy enhancing strategies to be enacted: the enactment of hierarchies (between different treatments, diagnoses or health professionals), categorical distinctions (between ‘mad’ and depressed), strategic analogies (depression is like diabetes or cancer but is not like chlamydia or anorexia) and separations between self and illness (metaphors of affective disorders as non-human agents, soul vs. biology, me vs. my illness). Each of these strategies has been reported in other research, suggesting that these are well-established and widely used mechanisms for enhancing legitimacy in both verbal and written accounts of affective disorders (Oliphant, 2010; Jones 2005; Johnson 2009; Emslie, Ridge et al; Lafrance 2007; Weinberg, 1997). Despite their wide usage, the specific formulations of these strategies are highly culturally dependent as they only have rhetorical power in communities where medical ‘problems’ are seen as

RUO more legitimate than non-medical problems, and where it is possible (although not necessarily probable) that affective disorders can be understood as a medical issue. In addition, these strategies require that certain concepts – such as ‘soul’, ‘diagnosis’ and ‘madness’ – are culturally comprehensible.

Legitimacy as an ill subject is not always a straightforward acquisition, with some authors struggling to narrate their experiences in a way that affirms the severity of their condition without disqualifying themselves as a truthful or reliable narrator. When some authors attempted to enhance their legitimacy as an ill subject by describing invasive treatments, they accidentally reduced their overall social valuing, as their legitimacy as a rational subject was positioned as precarious (see also Rector, 2009). There was a tension between narratives or statements that increase the author’s legitimacy by positioning them as having a mental illness, and those that decrease legitimacy by positioning them as having a mental illness. Thus, the legitimacy of an author is theoretically maximised when the mid-point between being represented as ‘not really sick’ (not enough mental illness) and mad (too much mental illness) is achieved. In relation to LIAM, this observation is important because it highlights the complexity of rhetorical strategies, particularly when enacted by authors who lack certain signifiers of rationality. On a practical level, this balance is important as it provides authors with a meaningful sense of self that may simultaneously support them in accessing help and provide a discursive location that assists them in managing stigma (see below).

Overall, legitimacy was the most commonly used rhetorical strategy in the corpus: it was used by a wide range of authors in all mediums and was achieved primarily through medicalised understandings of affective disorders.

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Integrity – a sense of coherent selfhood that is socially and internally valued – was consistently important in the narratives. As the forms of selfhood which are considered valuable varies according to the values and social positioning of the author, integrity should be understood as a culturally inflected rhetorical strategy.

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Some authors enhanced their integrity by removing any dissonance in their self-concept (e.g., presenting as a person with an illness and minimising any references to other social roles such as being a parent, worker or friend). This form of integrity is symptomatic of extreme medicalisation, as the author’s sense of self is represented as determined by their illness (Rose, 2004).

Seemingly contradictorily, other authors positioned themselves as having high levels of integrity by emphasising their wholeness and presenting a multifaceted self, typically through references to a range of roles, identities and actions within their lives. In some cases, this multifaceted self was enacted as a type of resistance to medicalised discourse, as it positions the affective disorder diagnosis/symptoms as only one of many aspects of the individual. This strategy was also identified by Hubert (2002) in her analysis of women’s autobiographical writings about involuntary psychiatric treatment and by Lafrance (2009) in her examination of Canadian women’s accounts of recovering from depression.

Integrity is more tenuous and fleeting than the other rhetorical functions, as it requires either a complexity or oversimplification of narrative that is difficult to maintain. In addition to being a rhetorical effect, integrity refers to an author’s sense of being a coherent and valued self. This capacity for integrity to be a lived experience as well as a rhetorical effect is another indication of the enmeshment of ‘real life’ and ‘story’.

The concept of enacting a coherent sense of self both to oneself and in interactions with others is active – and, quite frequently, critiqued – in gender studies, theology, philosophy and critical theory (see for example Butler, 1990; Foucault, 1979; Tatman, 1998). However, this concept is not routinely used in the discursive analysis of affective disorder narratives. The lack of an equivalent concept in other affective disorder research does not seem to be a result of a lack of examples of this phenomenon, but rather seems to be a reflection of the lack of cross-pollination with other disciplines that more readily question the ontologies that underpin subjectivity.

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Authors gain authority through assertions of their institutional power or socially recognised knowledge. The most common enhancement of authority involved authors ‘borrowing’ the epistemic authority of their psychiatrists, general practitioners and counsellors. Authors did this by presenting certain understandings of their experiences as coming from, or being sanctioned or supported by, their health care professionals. Thus, these enhancements of epistemic authority tended to valorise medical interventions and professionals.

Although the reliance on medical authority is notable due to its pervasiveness in the corpus, it is also unremarkable. Specifically, this level of dependence on medical authority is common in narratives for a wide range of conditions and thus should not be seen as a unique feature of affective disorder narratives (Conrad, 1992; Garden, 2010). Moreover, the reliance on medical authority in the corpus materials seems almost inevitable given the normalisation of medical authority in Australian culture.

For authors who identified as health professionals, their institutional affiliation or association typically functioned as an assertion of epistemic authority. Given the valorising of medical knowledge common throughout the corpus, such statements had significant discursive power and should therefore be considered exercitive speech acts akin to other assertions of power such as appointing, voting, ordering, advising or warning (Austin, 1975, pp. 151-152).

Authors also enhanced their authority through reference to their experience. Particularly on the bulletin board, experiential authority was used to assert the validity of particular treatments. In contrast, a small but significant number of authors used experiential authority to validate non-medicalised accounts of suffering. While most writings in the corpus are based on this type of authority – ‘I am writing because I know something worth sharing’ – such claims tended not to be made explicitly in the body of the narrative.

Researchers examining online forums have also identified experiential authority, although it appears to be more exclusionary in these forums than in the corpus.

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Specifically, researchers observe that participants regularly used experiential authority to exclude others who did not describe experiences, attitudes or beliefs that other forum members deemed appropriate (Giles & Newbold, 2011; Lamberg, 2003; Oliphant, 2010; Vayreda & Antaki, 2009). This type of practice, while not identified in the corpus, demonstrates the capacity for assertions of authority to be hurtful to others, and thus reaffirms the importance of understanding rhetoric as having significant ‘real-world’ consequences. Moreover, the lack of identification of this exclusionary use of authority in the corpus is likely to be a result of the moderating of corpus bulletin boards rather than a lack of author’s exclusionary intent.

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Throughout the thesis, legitimacy, authority and integrity were analysed as both separate and co-constituting functions. Within this context, it became clear that what happened with one type of function (e.g., legitimacy) would amplify and reflect what happened with another (e.g., authority). This meant that an increase in one function tended to result in an increase in the others (although such increases were often not immediately apparent, the sense of increased authority, legitimacy or integrity was often drawn on later in the text). The reverse was also true; so that when one rhetorical function was significantly undermined, the others were also typically affected. This finding demonstrates that while it is important to analyse the texts closely in order to identify rhetorical functions in the first place, it is also critical to place the texts within the wider textual, discursive and cultural frame.

In addition to being co-constituting, rhetorical functions are enmeshed in cultural norms regarding what stories are tellable and how those stories should be told. For many authors, medicalisation appeared to be the grounding of their narrative construction: it was the starting point, the content and the consequence of their writing. While medicalisation is central to the majority of the corpus narratives, it is equally true that it is a means to a rhetorical end: after all, people talk about affective disorders as illnesses because this helps them make sense of their experience, not the other way around. (It seems highly improbable that people make sense of their experience because it helps them to medicalise it.) Unlike other research that often examines medicalisation as the

RUS core cultural component of affective disorder narratives and experience, LIAM provides a tool for analysing these narratives that highlights their rhetorical function rather than solely their content. This focus enables affective disorder narratives to be more readily placed within the context of the personal and cultural circumstances of the author, as multiple discursive and material influences can be analysed using the same theoretical framework.

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A key finding of this thesis is that lived experience cannot be fully separated from the narratives used to comprehend or describe it. This enmeshing of ‘life’ and ‘story’ is particularly apparent when one examines how corpus authors recount their experiences in different ways, depending on their age, gender, symptom severity, level of professional expertise and writing medium. As discussed below, these variations demonstrate the cultural and demographic specificity of affective disorder narratives, as well as the effect of lived experience on conceptions of suffering. Simultaneously, each type of variation highlights a specific aspect of the relationship between lived experience and illness narrative.

Many researchers, including Bhugra & Mastrogianni (2004), Kastrup (2011) and Stoppard and McMullen (2003), have noted variations in affective disorder narratives according to the author’s or speaker’s gender, age and ethnicity. As one would expect given the culturally inflected nature of these conditions, the nature of the differences between groups (e.g., men and women, youth and adults) varies according to the temporal and cultural location of the study participants.

The age of an author appears to influence their understanding of affective disorders. Younger authors tended to represent their distress as a one-off event that was related to both biological and social factors (sometimes in surprising ways, such as when a social issue such as bullying was treated with medication). Danielsson, Bengs, Samuelsson & RUT

Johansson (2011) noted that Swedish young people also linked distress to concrete situations. In contrast, adult authors appeared more likely to utilise biomedical models of distress and to represent affective disorders as chronic conditions. The reliance of adults on biomedical models has been noted by many other scholars (e.g., Ishikawa, Cardemil & Falmagne, 2010; Lafrance, 2007), although there is evidence that adults over 65 years old are less likely to utilise a biomedical model (Switzer, Wittink, Karsch & Barg, 2006; Wittink, Dahlberg, Biruk & Barg, 2008).

It is not possible to identify whether these narrative differences are the result of different experiences (older people experience different things) or different interpretive frames (older people interpret the same experience in different ways). LIAM accommodates this analytical limit easily, as lived experience and rhetorical function are understood as inseparable and thus the question of whether an account is the result of ‘real life’ or ‘discourse’ is deemed both largely unanswerable and irrelevant.

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Male corpus authors tended to fear emasculation and to engage in coping mechanisms such as drinking and dangerous driving, while women tended to feel more guilt about not performing their family and relational obligations and coped in more private ways, such as taking bubble baths and receiving affirmation from friends and family. Although the exact nature of gendered behaviours varies with time and place, the finding that men and women experience depression differently is supported by an extensive body of international research, which highlights both clinical and social differences (Danielsson, Bengs, Lehti, Hammarström & Johansson, 2009; Dean, 2003; Emslie, Ridge, Ziebland & Hunt, 2006; Gattuso, Fullagar & Young, 2005; Heifner, 1997; Johnson, Oliffe, Kelly, Galdas & Ogrodniczuk, 2011; Lafrance, 2007, 2009; Marecek, 2006; Stoppard, 2000; Stoppard & McMullen, 2003; Wilson, 2007; Ussher, 2010, 2011).

Gender is discussed further below in the context of justifications for domestic violence.

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Most corpus authors described life circumstances consistent with middle-class status. Despite the dominance of one socio-economic group, variation was still observed, albeit more rarely than would be necessary for an extended classed analysis. One notable classed feature was how financial limitations affected service access with authors with less money being more reliant on public mental health services. This provided the material conditions for working-class authors to use success in accessing scarce resources as a severity indicator (see also, Foster, 2007). This observation demonstrates a basic but central observation: what an author narrates is (largely) dependent on what they have done. Thus, differences in rhetorical strategy between groups reflect both communal narrative preferences and the base material restrictions on the lives of members of each group.

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There is also evidence that the course and/or severity of the affective disorder affected how authors represented it. Authors who experienced an isolated episode routinely saw their distress as a situational response, a construction that Gattuso, Fullagar & Young (2005) observed in Australian women’s magazines. In contrast, those with repeated or chronic episodes appeared to be the most likely to use a biomedical model. This model was consistent with a substantial proportion of Western Australian newspaper articles and correspondence identified by Rowe, Tilbury, Rapley and O’Ferrall (2003), and the biomedical frameworks identified by Fullagar (2009) in her analysis of Australian women’s discussions of their experiences and understandings of antidepressants. Finally, authors who experienced particularly severe episodes, and were therefore likely to have experienced repeated hospitalisations, were disproportionately likely to use alternative understandings, including critiques of the power structures of mental health institutions. This resistance to psychiatric power is characteristic of certain ‘post- psychiatry’ aspects of the Australian consumer/survivor movements as outlined by Holland, Blood, Pirkis, and Dare (2008). These findings suggest that different types of experience encourage different narratives. Such differences are not limited to alterations in content, but rather reflect different fundamental assumptions about the nature of affective disorders.

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Lay and health professional authors typically characterised affective disorders in different ways. Most corpus writings by mental health researchers described a biopsychosocial model of the cause, nature and treatment of affective disorders. In contrast, GPs and practising psychiatrists were reported to routinely emphasise the biological, a finding supported by both writings from these professionals and accounts from patients. Lay people, on the other hand, often focused on understanding their experience as a physical illness. Thus, the more expertise an author had, the more likely they were to use a more nuanced account of the cause and nature of affective disorders. Interestingly, it was the authors least likely to have extensive scientific knowledge of biology who were most reliant on biological accounts of emotional distress. It is possible that this difference is a function of the intended utility of the account – experts were trying to understand the phenomena, GPs were trying to treat patients and lay people were trying to understand their condition in line with models of suffering they were already familiar with. In other words, it is not necessarily differences in what these groups know (or even what knowledge they are capable of locating) which determines these narrative differences; such differences may also be partially determined by what is useful for a particular lived or narrative context.

The variation in narratives by authors of different ages, classes, illness severities, and knowledge bases is evidence of how authors understood and represented their affective disorder experience in different ways depending on their social and cultural location. It also suggests that, despite the dominance of medicalised understandings within the corpus, Australian discourse is not constrained by a hegemonic conception of affective disorders. The variation between illness narratives, although at times subtle, supports the rejection of the more virulent political accounts of affective disorder culture – specifically, it requires the refusal of those over-simplistic accounts, particularly common in the immediate backlash to Listening to Prozac, that conceived of current understandings of affective disorders as hegemonic impositions from advertisers and multinational pharmaceutical companies (Breggin, 1994; Kegan Gardiner, 1995).

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Social constructionist illness narrative research routinely discusses how perceptions and experiences of illness alter depending on the social location of the study participants (as argued in the previous section). While this information is valuable and supports a certain conception of social constructionism, it does not acknowledge a range of other, non-person-centred, factors that may affect how individuals experience or interpret their condition. One of these factors is the genre in which the person is communicating. Most researchers examining illness narratives use an interview methodology. This use of a single genre means that researchers cannot compare narratives across genres and thus the identification of genre influences is very difficult. One of the strengths, therefore, of the thesis is that the use of multiple genres of writing allows for genre influences to be identified and thus a more rounded social constructionist approach to be developed.

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As noted by Westerbeek and Mutsaers (2008), depression autobiographies are a biased sample, as the skills required to write these extended narratives limit access to this genre to a small subset of the population. Autobiographies in the corpus tended to provide greater detail and nuance in their accounts and had more detailed descriptions of lived experience. Due to the tendency for autobiography authors to represent a range of aspects of their identity, most representations of multifaceted selfhood occurred in this medium. These characteristics appear to reflect the nature of the medium, as it is difficult to maintain a highly simplistic narrative for several hundred pages.

Of the three data sources in the corpus, autobiographies were the most carefully considered and extensively edited narratives. Autobiographical monographs were also the only narratives that routinely achieved a full narrative arc – a beginning typically focused on long-term suffering, a middle which included a crisis point of some sort, and an end that allowed the author to reflect on the wisdom they had gained through their experiences. Commercial and genre limitations meant that narratives that were far removed from this kind of arc were unlikely to be published. Thus, the genre norms affected the construction of appropriate narratives and thereby helped the ongoing process of normalising particular accounts of emotional suffering.

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In comparison with autobiographies, internet sources were less polished and provided more immediate recollection of lived experience. Both story pages and bulletin board postings had fewer institutional barriers than professionally published texts, resulting in different narrative construction and textual timbre.

The story pages tended to provide shortened and simplified versions of the autobiographical narratives, with a greater relative focus on reporting what the author had learnt through their experience. This resulted in a propensity for claims of experiential authority in this medium. Such authority was typically asserted in brief severity indictors at the beginning of the text (‘I’ve had depression for 15 years and have been hospitalised 23 times’) and an ending that demonstrated that the author was, if not asymptomatic, then at least recovering from their condition. This latter narrative aspect was particularly important for the assertion of experiential authority, as an author’s capacity to encourage others to heed their advice is largely dependent on them reporting that such advice was useful to them and did not result in a worsening of their condition.

While affective disorder story pages have received little academic attention, similar textual characteristics have been observed in other mediums. In her study of relevant women’s magazine articles from 1980 to 2000, Borman (2003) noted a shift towards representing depression as a stigmatised but treatable illness (see also Gattuso, Fullagar & Young, 2005). The brevity, optimism and ‘inspirational’ nature of these magazine accounts suggests that they function in a similar way as the internet story pages examined in the thesis, a finding that is perhaps unsurprising, given that both mediums are edited/moderated to ensure ‘appropriate’ texts are published.

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Bulletin board postings were likely to be focused on a particular issue and only provided basic information necessary for the contextualising of the author’s specific concern. Unlike the story pages whose genre effectively required ‘good news’ stories,

RVO bulletin board posts rarely included narratives of recovery (although responses to initial postings were more likely to do so). In addition, authors appeared to solicit responses from other community members through severity indicators – ‘I really need help’, ‘I don’t know what to do’ etcetera. However, these signals of distress were mediated by the need to ensure that the group moderators approved the post. This meant that certain experiences (e.g., suicide attempts) were not detailed in the medium.

Data from the bulletin board displayed responses by individuals with affective disorders to other people’s narratives of distress. These responses appeared to provide an opportunity for authors to assert their understanding of the cause and nature of affective disorders. Vayreda and Antaki (2009) noted a similar phenomenon in the replies to first posts on a bipolar online forum and argued that these statements were a type of induction into the online community. In addition to the communal function of such statements, LIAM provided a framework for identifying the more personal rhetorical functions: the assertion of experiential and epistemic authority and the reinforcement of illness legitimacy.

An analysis of genre as an aspect of the social construction of affective disorders emphasises how certain things can be said more easily – and sometimes, cannot be said at all – within certain types of communication. These limits are a reflection of cultural norms of communication. They are also, however, quite prosaic: perhaps one of the most powerful influences on the construction of narrative is the length of text. It is simply inevitable that a 200-page text will cover different content from one with 200 words. It is therefore unsurprising that while the rhetorical functions of legitimacy, authority and integrity occur across the corpus, their enactment is affected by the genre in which they are expressed.

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Rhetoric is a surprisingly powerful phenomenon. Not only does it affect how people express themselves, but also how they understand and experience their world. Rhetoric’s power is stronger in particular domains where understanding is central to experience, or where models of reality determine behaviour. Due to the enmeshment of

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belief, rhetoric and lived experience, LIAM provides a useful framework for the analysis of ‘real world’ problems with high rhetorical influence such as domestic violence and stigma.

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As with other demographic differences, there are gendered trends in the content and style of the corpus materials. There are two key reasons for this: the lived experiences of men and women were different (see above) and the signifiers and narratives of distress available to them were also gendered.

Researchers from Europe and Canada have highlighted how conservative gender roles are often particularly noticeable in individuals with depression (Danielsson, Bengs, Samuelsson & Johansson, 2011; Emslie, Ridge, Ziebland & Hunt, 2007; Lafrance & Stoppard, 2006; O’Connor, 1998; Schreiber, 1996). Within this context, scholars have been critical of the role of patriarchy in women’s suffering, in particular through isolating women in the home, telling women their social value comes from their family, and positioning women’s emotions as illogical and their anger as a sign of madness (Metzl & Angel, 2004; Lafrance 2009; Matthews, 1984). Given that much of the work on gender and depression is explicitly feminist, it is unsurprising that this research has tended to link individual meaning and behaviour (the personal) to wider social issues (the political). What is sometimes lacking in these critiques, however, is an acknowledgement of the complex nature of the relationship between emotional distress and gender norms. Specifically, the analysis presented in Chapter 11 demonstrates that while gender norms were often a source of distress, they were also the basis for certain coping mechanisms, and at least in a few cases, they provided solace. Thus, the gendered nature of depression and anxiety should be understood in a more expansive way in order to accommodate both the destructiveness and the utility of gendered behaviours and beliefs.

Although aggression in men who experience depression is well documented, the use of illness rhetoric as a mechanism for justifying domestic violence has not been identified by other scholars. It is unclear why this is the case, as much of the feminist research on

RVQ depression is highly critical of gender roles and is also attuned to subtle rhetorical aspects of illness narratives. It is also clearly not the case that these justifications were absent from other studies, as I have noted numerous quotes in published papers that demonstrate the same violence-justifying logic. Thus, the overlooking of this important theme seems to be a consequence of the analytic method used in previous research: I suspect that the focus on rhetorical function that is central to LIAM, rather than on the content of the statement (as is common in some other research using textual data), may have assisted in the identification of this theme.

The identification of the use of medicalised discourse to justify domestic violence by men diagnosed with depression required that gendered, affective disorder and domestic violence discourses were examined simultaneously. The use of LIAM enabled the acknowledgement of the complex intersection of multiple discourses, and therefore supported analysis of both the helpful and harmful aspects of gendered understandings and behaviours.

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Stigma is a ‘real world’ occurrence that is predominately rhetorical. Specifically, sigma is based on the assertion of particular values – to say, in a vacuum, ‘you have a mental illness’ is not stigmatising. This statement is only stigmatising when a value is given to the characteristic – ‘you have a mental illness and that is bad’. Thus, while stigma has a range of lived consequences, its enactment, as well as an understanding of its enactment, relies almost entirely on rhetorical analysis that acknowledges the social and narrative construction of moral or value claims.

For many authors, experiences of stigma and discrimination were a particularly distressing aspect of living with an affective disorder (Chapter 10). Authors described using biological explanations of their distress as a way of reducing the number of negative judgements directed towards them. In addition, authors appeared to use medicalised explanations as a way of safeguarding against negative responses from readers of the text (see also Schreiber and Hartrick, 2002). The centrality of concerns regarding negative judgements suggests that stigma, and more significantly, a fear of

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stigma, is a central determinant of representations and narrative structure for authors in the corpus.

Not only did authors use medical explanations to shield against stigmatising judgements, they also actively disputed discrimination through assertions of their legitimacy as ill subjects. It was common for authors to indicate either implicitly or explicitly that it was wrong to think of depression as anything but an illness. This claim used two forms of evidence against a non-medicalised interpretation of distress: that non-medical accounts were scientifically inaccurate (wrong in the sense of inaccurate) and that they were discriminatory (wrong as morally unacceptable). As has been argued by Dowrick (2009), both justifications are erroneous. Specifically, while there are biological contributors to affective disorders, it is inaccurate to highlight only these factors and erase psychological or social contributors to distress. Moreover, it is illogical to suggest that an alternative explanation of causation is, by definition, discriminatory, without reference to the value judgements that it is embedded within. (There is a difference between saying ‘depression is partially caused by social factors and this means that people with depression are to blame for their condition’ and ‘depression is partially caused by social factors and this means that we need to change society’.) Despite the evidence to the contrary, the claim that it is wrong to use non- medical explanations of distress is rhetorically compelling. This is because it enacts a dichotomy between correct and incorrect interpretations that is difficult to dispute as it is placed within an absolutist moral and epistemological frame. While this issue is not the focus of her analysis, Foster (2007) notes similar conflations in interviews and printed materials from the United Kingdom, suggesting that this is a common feature of medicalised discourse, particularly as used by consumer mental health advocates.

Medicalisation also assisted authors to deflect accusations of madness. Concerns about madness are common in people with affective disorder (Okello & Neema, 2007; Sword, Busser, Ganann, McMillan & Swinton, 2008). The sentiment ‘I am not mad, I have an illness’ was common in the corpus (Chapter 9), and its acceptance as a logical construction emphasises the contemporary cultural separation between madness and certain forms of mental illness (Giles & Newbold, 2010, p. 421). Such separations were often dependent on ‘madness’ being positioned as an abnormal cognitive or moral state that may or may not be related to a corporeal pathology, while affective disorders were

RVS represented as solely biological abnormalities. LIAM, with its focus on rhetorical function rather than textual content, allowed us to see the irony of using exclusion and discrimination to combat stigma.

The insights gained regarding stigma and domestic violence demonstrate how LIAM supports the analysis of a range of lived experiences associated with affective disorders. This is different to some other studies, where events not explicitly or exclusively related to the affective disorder were not analysed. These examples also highlight how the analysis can inform practical, as well as theoretical, implications.

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Within this thesis, LIAM was used as a mechanism for analysing texts that had already been printed. Although this was its original function, the model could also be helpful in determining effective ways of representing affective disorders and their treatments. These practical recommendations require empirical testing and further consideration by a range of stakeholders; nonetheless, the implications of the research are important for future policies, practices and approaches.

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Corpus authors routinely reiterated the explanations of their distress given to them by their GP, psychologist or psychiatrist. In addition to affirming the centrality of medicalised legitimacy in affective disorder narratives, this suggests that the epistemic authority of health professionals encourages patients to accept and internalise their doctor’s explanations and constructions of emotional distress (see also Gill, 1998; Oopik, 2006; Tasman, 2002). In a clinical setting, health professionals may deliberately use this tendency as a way of encouraging patients to try new treatments or take on new beliefs. Moreover, this research project suggests that health professionals should be sensitive to the contextual constraints on which narratives of distress are ‘tellable’ in a clinical consultation, and take this into consideration when discussing symptoms and possible treatments with a patient. A more radical approach to the same findings might result in doctors working within the confines of the ‘tellable’ story, while

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simultaneously thinking of diagnoses as a short hand for a set of experiences of emotional suffering, rather than as distinct clinical entities (Dowrick, 2009).

Another area where narrative research may impact on clinical practice is treatment adherence. Treatment adherence may be enhanced if health professionals use an explanatory framework that explains and contextualises the treatment. Moreover, the cultural dominance of biological explanations of affective disorders may mean that doctors need to over-emphasise the importance of psychosocial contributors in order for these to be given equal significance by the patient (see Pilgrim & Bentall, 1999, p. 270). Health professionals may also find that, along with helping the patient to feel a little better about their situation, treatment adherence is enhanced if they simultaneously acknowledge the legitimacy of their patients suffering and the authority of their own expertise (and thus, both the validity of their treatment recommendation and their assessment that the patient is not, in fact, malingering or hopeless) (Dowrick, 2009, p. 226).

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If the current tendency to use medical models to explain emotional distress becomes more culturally ingrained, it is likely that there will be decreased engagement with non- biological determinants of emotional well-being (Marmot, 2005; McGorry, Nelson, Goldstone & Yung, 2010; Patel, Flisher, Hetrick & McGorry, 2007; Steffens et al., 2005). The increasing dominance of biomedical explanations of distress has a natural tipping point where non-biological explanations no longer make sense. Should that point be reached, multifactorial models of distress are likely to be effectively deemed obsolete.

Prior to this worst-case scenario, ongoing reliance on medical models of distress are likely to have a significant effect on individual mental health treatment decisions, with medical treatments seeming more logical and robust than psychological or social interventions (Dowrick, 2009). In addition, a cultural orientation towards biological explanation may reduce the capacity for doctors and their patients to use evidence-based

RVU practice to decide on treatment as what counts as ‘effective’ would be artificially narrowed by the discursive limits of affective disorder discourse.

Ongoing medicalisation of affective disorders may place government-funded programs with a social or psychological focus at risk of funding cuts. Should such a shift occur, it is likely to have a greater effect on individuals who, due to their lack of funds, are dependent on government-funded services.

While there is no indication of turning the tide of medicalisation in Australia, such shifts are possible. For example, in the United Kingdom the National Health Service no longer recommends medication for sub-threshold or mild depression as antidepressants have minimal effect in these instances (CBS News, 2012). While these guidelines are still quite new, it seems likely that they will affect how depression is understood and treated in the United Kingdom (National Institute for Health and Clinical Excellence, 2009). Academics and activists advocating for a similar shift in Australia could use LIAM as a mechanism for identifying how, within our current affective disorder culture, to best argue for such a change in policy orientation.

An awareness of LIAM may also be beneficial for professionals working on public mental health campaigns as it may assist them in identifying effective presentation of health promotion messages. At a minimum, these professionals should take into account how the dominance of medicalised understandings of distress may affect the nature of future campaigns.

This discussion of implications of the research demonstrates how LIAM could be a valuable analytic tool for mental health workers who are engaged with health promotion or the treatment of clients. LIAM’s value is, however, dependent on it remaining associated with its theoretical presuppositions. One of these presuppositions is that the ‘affective disorder experience’ is the result of a complex relationship between a range of biological, psychological and social factors, and that these factors cannot be separated from the narration of lived experience. This assumption was supported by the findings of the analysis, which showed that although accounts were often over-simplified, multiple factors were still affecting the lived experience of the author. Thus, although LIAM – and the findings of the thesis – are not a model of emotional distress, they

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nonetheless are valuable tool for assessing the validity and utility of other models and approaches.

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Mental health researchers have proposed many multi-factorial models that posit biological, social and psychological contributors to emotional distress (Pilgrim, 2002; Merkel-Keller, 2006).45 While these models are certainly more nuanced than simplified biomedical accounts, there is great variation between them, with some being significantly more useful than others. Nor are all models empowering or appropriate:

The alleviation of distress and suffering in general practice does not simply involve a shift of medical gaze from the biomedical to the psychosocial. Invoking the psychosocial is not intrinsically empowering. (Dowrick, 2009, p. 212)

The substantial variation between biopsychosocial models is particularly apparent in understandings of ‘the social’. Such variation is a reflection of differing understandings of the nature of emotional distress and a consequence of differing political orientations, specifically the difference between individualised and social explanations of suffering (Luhrmann, 2001). At one extreme, there are models that limit ‘the social’ to the material constraints and life situation of a particular individual (e.g., being poor or a victim of domestic violence). At the other extreme are models that more fully embrace a social constructionist understanding and conceive of ‘the social’ as including the epistemologies and ontologies that influence the lived experience of affective disorders. To demonstrate this difference, compare the more limited understanding of ‘the social’ in Schotte et al. (2006) or O’Mahen and Flynn (2008) with the more social constructionist version found in Lafrance (2009) or Foster (2007).

Biopsychosocial models are valuable because they represent affective disorders as caused by several co-occurring, and typically co-dependent, factors. While they sound

ST"#-- .#)(#--* /&.#0 (!! ' (.1#."." ,) ,#--/ -,#- #(." ." -#-:*,.#/&,&3 ,)/(." ",. ,#-.#-) B!))C') &) #-., --="#& ().#, .&3, &. .)." , - ," +/ -.#)(:."#-,/'#(.#)(#-( (!! ' (.1#."." #'*&#.#)(-) ." , - ,"*,)$ .= RVW good in theory, the corpus suggests that the application of biopsychosocial models in Australia tends to be poor, with most only addressing an individual’s life situation and coarse instances of social influence. Consistent with Fullagar’s (2008) analysis of the biological bias in beyondblue’s website and Fullagar and Gattuso’s (2002) findings regarding emphasis on biological determinants in Australian mental health policy, analysis of the corpus suggests that the biopsychosocial model is routinely collapsed into an oversimplified biological account that does not take into account the richness and multifaceted nature of individual lives, nor the influence of narrative on lived experience. This collapsing is not unique to Australia, and is also critiqued as a major weakness of current mental health treatment in the United Kingdom (see Dowrick, 2009; Pilgrim, 2002).

Given the centrality of narrative to the lived experience of affective disorders, existing biopsychosocial models would be more complete and might prove more effective if illness narratives were understood as a central aspect of the ‘social’. Specifically, it might be useful to emphasise the significance of narration (not to be confused with ‘thought patterns’) in the affective disorder experience, a position found in some psychoanalytic and narrative therapy approaches but minimised in mainstream conceptions of these disorders (Morgan, 2000; Newman, 2010; Penwarden, 2006; Wirtz & Harari, 2000). At a clinical level, a focus on narrative may provide a mechanism for mental health professionals and their patients to negotiate the ‘tremendous collision between undifferentiated alienation and despair, and the everyday business of clinical problem-solving’ (Dowrick, 2009, p. 84). However, while narratives are central to individual experiences of affective disorders, addressing distress will be ineffectual if it is not coupled with a reduction in the social and material causes of suffering. Without this simultaneous alteration of narrative and life circumstance, we risk advocating that people merely ‘think better’ about their suffering, a tenet of some CBT that is particularly abhorrent (Greenberg, 2010; Pilgrim, 2011, p. 121, 124). Narrative approaches to distress must therefore include efforts to address the social injustices that often impel and accompany emotional distress: poverty, discrimination, social disengagement, isolation and violence.46 This focus on social location has been championed by feminist scholars who locate women’s SU),#-/--#)() ." &%) (!! ' (.1#."-)#&#--/ -#(/-.,&#(' (.&" &."*)&#3: - ../-):/&&!,:()/(!HQOOTI= RVX

emotional distress in the context of the gendered oppression within their lives (see above). A focus on social injustice, although justified by the centrality of narrative in lived experience, is primarily a moral claim. The claim has two moral underpinnings. First, that the material and systemic causes of suffering are the primary responsibility of the community in which that suffering occurs. And second, that to suggest that distress resulting from injustice can be alleviated through changing only the narrative constructions of the sufferer is a form of victim-blaming. As an alternative to this destructive form of narrative engagement, we may do better by aiming for ‘[a] more holistic understanding [of depression that] would attend to the social determinants of misery and would involve exploring the patient’s individually attributed meanings’ (Pilgrim & Bentall, 1999, p. 272). Such a model of engagement might, at an individual level, encourage greater consideration of social responses in treatment. At a social level, this focus on both material and narrative concerns might result in government programs aimed at reducing the incidence of affective disorders by addressing more thoroughly the social contributors to distress. At present, however, the dominance of medicalising discourse means that this holistic application of a narrative approach is implausible in Australia.

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This project has provided valuable insight into how individuals who identify as having an affective disorder represent their experiences in published narratives. The nature of the project means that certain areas were not discussed in the thesis. Specifically, this study does not address treatment effectiveness or symptom prevalence, but rather provides insights into the rhetorical construction of affective disorders within published accounts.

In addition, although the chapters are bookended by short narrative fragments, the study is not auto-ethnographic, as the research is focused on the analysis of published narratives. The purpose of these fragments was to be an antidote to the detached nature of the analysis and to remind the reader of the suffering that affective disorders cause; their inclusion does not have any wider methodological significance.

RWO Due to the focus on published narratives, the analysis has certain limitations. First, as discussed in the methods chapter, authors of corpus materials tend to come from certain social groups; they represent themselves in ways that strongly suggest they are overwhelmingly white, able-bodied, middle-class and heterosexual. Such narrow demographics mandate caution when applying the recommendations outlined earlier in this chapter, as significant sections of the Australian community are not represented within the corpus.

Second, the use of LIAM may have resulted in distortions of the corpus. The grounded theory process which enabled the identification of the three key rhetorical functions required that as these functions were identified and attention be given to them. Such strategic emphasis, while mitigated by an ongoing reflection on whether the theoretical frame fits the data, unavoidably resulted in an uneven focus being given to particular rhetorical aspects. Despite this, the analytical focus on legitimacy, integrity and authority is, overall, a strength of the thesis as it is an original and constructive mechanism for examining affective disorder narratives.

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While LIAM appears robust, it would be beneficial to apply the model to other data sources to check whether it is useful for material outside the corpus. Initially, this type of research should involve other Australian material, although ultimately it would be beneficial to see whether it would remain useful in other countries, particularly across cultures.

There are three themes identified in the corpus that were not examined in this thesis that could be further examined in future research. First, it would be beneficial to examine the relationship between affective disorders and consumer culture, specifically the way that financial resources dictate access to professional care and how individuals require surplus funds in order to engage in most self-care activities (e.g., eating well, regular exercise, going to the beach). Second, it would be valuable to understand how loneliness affects the lived experience of affective disorders and how this alters the rhetoric within authors’ narratives. Third, it would be interesting to further analyse the

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data for themes that were noted in the thesis but not substantially elaborated on, such as the use of suicide ideation as a severity indicator and the meanings given to the side effects of medications.

Three projects with different methodologies could be used to further investigate the findings of the thesis. In response to the domestic violence findings outlined in Chapter 11, an interview study of violent Australian men with depression and their partners would be appropriate as a method to determine the extent that depression diagnoses are used to justify violence. As a way of furthering the engagements with identity, epistemology and ontology that are scattered through the thesis, it may be appropriate to use a linguistic analysis of speech and written text in order to compare the knowledge claims and world view of consumer advocates, patients and health professionals. A more generalist project might involve using a mixed-method cross-cultural comparison of understandings of affective disorders, in order to further understand the seeming disparity in the use of medicalised discourse in Australia and other western countries.

The thesis methodology is an example of the emerging practice of analysing internet postings in qualitative research projects (Seale, Charteris-Black, MacFarlane & McPherson, 2010). Researchers who are contemplating projects involving qualitative investigation of unsolicited internet data may benefit from taking heed of the lessons learnt in this project, especially regarding ethics committee approval. As such, this thesis may function as a blueprint for some future research using this promising methodology.

Overall, the analysis of published affective disorder narratives has demonstrated the centrality of three rhetorical effects – legitimacy, authority and integrity – in narratives of depression, anxiety and, to a lesser extent, mania. Within the Australian context, legitimising statements are central to many affective disorder narratives. This dominance is both a result of, and a contributor to, the reliance by Australians on biomedical explanations of distress. In a time of global and environmental upheaval it seems telling that there remain such limited ways of telling sadness.

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%%#-3*()'!#)+($''*)$$'%( ?===8?==F As identified through the Australian Libraries catalogue. Excludes those selected for the thesis corpus.

Allen, M. (2006). Out of joint: Depression, my family, and me. Burwood East: Memoirs Foundation Inc. (Australia). Arthur, S. (2006). One mother's journey. Joondalup: Ocean Publishing. Aylmer, G. (2007). Dragon ... my tale. Kensington Park: ARD Press. Barrett, J. (2009). On the right track: A journey from clinical depression to health and happiness. Kingsley: JK Barrett. Beddoe, R. (2007). Dying for a cure: A memoir of antidepressants, misdiagnosis and madness. Sydney: Random House Australia. Beeston, R., & All, M. (2008). Now that you are back: A journey through depression. Sydney: Blue Bottle Books. Best, F. (2007). Poor me no more. Moorooka: Boolarong Press. Browne, J., & Manifold, H. (2008). In my room: You can't see me because I don't wear black. Myaree: The Black Dog Project. Cootes, A., & Wilson, G. (2005). My brush with depression. Essendon: Pennon Publishing. DeLorger, T. (2004). The other side of the looking glass: Living with depression. Kensington Park: ARD Press. Dickins, B. (2009). Unparalleled sorrow: Finding my way back from depression. Prahran: Hardie Grant Books. Duffus, J. (2005). What do you do when the mirror lies? A young girl's pathway to womanhood with anorexia nervosa. Townsville: Janet Duffus. Fettling, L., & Tune, B. (2005). Women's experience of postnatal depression: Kitchen table conversations. Melbourne: IP Communications. Green, D. (2003). Toast: A story about fighting the Berowra bushfires and coping with post-traumatic stress. Berowra: David Green. Hall, J. (2009). The man behind the uniform: One man's struggle with post-traumatic stress. Laurieton: JC Hall Publishers.

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Harvey, A. (2001). If depression is not a dirty word, why am I so ashamed? Canberra: Ginninderra Press. Janovic, M. (2000). Dealing with panic attacks and psoriasis: A true life story. North Booval: Le-mar. Johnstone, M., & Parker, G. (2005). I had a black dog: His name was depression. Sydney: Pan. Jones, E. (2008). Into the darkness, into the night. Canberra: Ginninderra Press. Kelly, M. (2000). Life on a roller-coaster: Living well with depression and manic depression. East Roseville: Simon & Schuster. Limbrick, L. (2008). Stepping out of darkness: One woman's triumph over depression. Sydney: Ark House. Malone, H. (2008). The battle within. Yeronga: H. Malone. McArdle, J. (2008). A long way from hell. Burleigh: Zeus Publications. Mercieca, T. (2009). The upside of down: A personal journey and toolkit for overcoming depression. Footscray: T. Mercieca. Norris, D. (2008). Just a normal mum: A journey through chronic pain and depression. Hobart: Uniprint. O'Connor, L. (2007). The lights aren't on, but someone's home: A journey from depression to bipolar. North Parramatta: Louise O'Connor. SHE for PND. (2008). Write from the heart: Personal stories of post natal depression. Mandurah: SHE for PND. Scott, D., & Hallam, S. (2001). Making Mummy better: A child's experience of postnatal depression. Richmond: Spectrum Publications. Smith, L. (2009). I'm so together, I'm falling apart : An inspirational true story about the cost of living up to everyone's expectations while ignoring your own. Sydney: Ladbroke Grove Publishing. Sollitt, M. (2006). Catastroscopes: A creative and adventurous Australian bloke's battle with clinical depression and Anno Domini. Hartwell: Temple House. Speers, D. (2009). Called to hope – overcoming depression. Burleigh: Zeus Publications. Stevenson, P. (2006). Postcards from ground zero. Burleigh: Zeus. Williams, B. (2007). I need a bandaid for my brain. Taylors Beach: BL Williams. Zawatsky, J. (2000). There's a light at the end of the tunnel. Sydney: Random House Australia.

RWS

%%#-3"))'( Coding example: A = Cause A8 = Situational distress A8a = Others are luckier than me

Tree Branch Twig A Cause or mode 1 Genetic of description 2 Imbalance in my brain chemistry 3 Childhood 4 Thoughts 5 Choice 6 Trauma 7 No reason to feel like this 8 Situational distress a Others are luckier than me b Mistakes c Loss 9 Let down by others B Metaphor 1 Darkness 2 Blackness 3 Lack of colour 4 Vice/crushed 5 Grey 6 Non-human agent a It b Black dog 7 Fog 8 Inescapable (e.g., locked room, trapped) 9 Journey 10 Lost C Experience 1 Emptiness 2 War / under seige 3 Masking 4 Suffering 5 Dissociation/hallucination 6 Confusion 7 Numb 8 Mania 9 Irrational thought 10 Loneliness 11 Never-ending 12 Crisis 13 Hope 14 Exhaustion

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15 Fear 16 Self-hatred/poor self-esteem 17 Crying 18 Swings 19 Failure 20 Powerless 21 Overwhelmed / no control 22 Physical symptoms 23 Sad D Rehistoricising 1 Looking back, I now see a I did it, you can too b Need to share 2 It's a gift a Empathy E Illness 1 It's just the same as other a Diabetes characteristics physical illness b Cancer 2 Physical imbalance = a more severe form of depression than emotional causes 3 NOT just the blues 4 Depression does not = craziness 5 Depression does not discriminate 6 You are more than your depression 7 It has a name 8 Not your fault 9 Drugs/alcohol 10 Can’t change 11 This will pass / acceptance F Treatment 1 Treatment = taking back control 2 It's strong to ask for help 3 Antidepressants a Medication is not ‘natural’ 4 Diagnosis 5 Hospitalisation 6 Counselling 7 Professional loop a Need a professional b Talk to your professional c Get a new professional 8 Be positive 9 Knowledge is power 10 Counselling and medication combo 11 Hang in there 12 Baby steps

13 Alternate therapies G Reality 1 There is a non-depressed you to

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be re-discovered OR Depression is part of you 2 Depressed thoughts are not true (non-depressed thoughts are true) 3 Depression is a profound experience of humanity 4 Lost self 5 You deserve a good life 6 Truth will set you free / need to talk H Stigma 1 Non-depressed people cannot understand 2 I was ashamed

3 Masculinity/gender a Relationship breakup/unhappiness b Single/relationship c Effect on interpersonal d They love you I Plot 1 Increasing depression 2 Anxiety 3 Suicide a Ideation b History c Effect on family d Stay alive for the kids/family 4 Wisdom 5 Self harm 6 Can’t cope anymore J Random 1 Learning to say no topics 2 Mental illness is not normal 3 Mental illness as a social category K Connections 1 Does anyone else? 2 Please help me 3 You are not alone 4 I do that too 5 What’s happening to me? 6 Don’t know what to do

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