The Omnipotent Word of Medical Diagnosis and the Silence of Depression:An Argument for Kristeva’s Therapeutic Approach
In cases of depression where linguistic meaning has collapsed, there is good reason to believe that a long-term strategy for recovery must include rehabilitating the depressive person’s capacity for meaningful speech. This requires that the patient participate actively in interpreting her own pain. In this essay, I argue that medical diagnosis can tempt patients, particularly women, to circumvent this process of interpretation. To explain this danger, I draw on Julia Kristeva’s clinical analyses of depression and recent studies on the correlation between depression and self-silencing.
Julia Kristeva, women and depression, medical diagnosis, self-silencing, Dana Crowley Jack
1. Introduction: Depression and silence
It is common today to think about depression as an illness best understood and thus best managed by medical specialists. Indeed, the medical language of [End Page 1] depression increasingly provides people with a way of signaling to others that what they suffer from needs no further elaboration. It is what it is: hormonal, genetic, a disease, words whose authority is all the more accepted the more they’re left up to specialists to interpret. Such an approach to managing sadness has its appeals. Insofar as such diagnoses can help people manage symptoms that make their lives unlivable, there is great value in them. And insofar as people suffering from depression feel overwhelmed and out of control of their symptoms, it is natural to want to accept a medical account that lends the authority of science to that experience. Less obvious, however, is how the power of the verbal diagnosis itself can contribute to the therapeutic effect. The swift intervention of medical resources—hospitals, clinics, crisis centers, all with well-managed protocols and steady teams of dutiful professionals capable of dispensing wonder drugs—can provide a depressive person with a sense of great, albeit temporary, relief irrespective of the drugs’ effects. For these reasons and despite studies that suggest the limited success of biomedical approaches to depression, many of those who struggle with depression are nevertheless receptive to the biomedical interpretation and treatment of their condition.1
Women constitute the majority of this group. Indeed, a recent study reports that one in four American women are currently using antidepressants compared to 15 percent of American men.2 This fact alone would seem to suggest that women who suffer from depression find value in the biomedical approach. What is appealing about this strategy to the patient in the throes of depression is, however, exactly what should give feminists pause, and that is how silent the patient often is throughout the process of diagnosis and treatment.
This silence is not obvious from all interpretive standpoints. Indeed, authors like Kimberly K. Emmons (2010) are right to draw our attention to the veritable proliferation of talk about depression in recent years, including especially talk guided by direct-to-consumer ads about depression created by pharmaceutical companies (34–53). This silence comes clearly into view, however, when we examine the situation from a feminist critical-theoretical standpoint. Inhabiting a feminist standpoint in this context means acknowledging that the attachments that women typically have to others take a different, more normalized, and thus often more intense form than the attachments men typically have.3 And while a feminist standpoint requires that we refrain from pathologizing these attachments, insisting on the theoretical validity of a [End Page 2] relational self-understanding that best captures the lived experience of many women, it also means recognizing that women’s attachments to others take place today in a social context of inequality where they are encouraged to silence their own needs and concerns and where they often choose to remain silent rather than risk the negative consequences of speech.4 Indeed, this picture of women’s silence has come more clearly into view in light of recent studies spearheaded by feminist psychologist Dana Crowley Jack, which demonstrate a direct correlation between depression and the tendency to silence the self. This tendency consists of a relational pattern where one regularly judges oneself based on external standards; puts the needs and desires of others above one’s own; inhibits self-expression and action to secure relationships and avoid conflict, retaliation, and loss; and, as a consequence, experiences being divided from one’s self (Jack 1991, 29–36; Jack and Ali 2010, 5). The roots of these habits begin early in a girl’s childhood, Jack suspects, when girls are encouraged more than boys to attach to their mothers and to seek reassurance and support from others. Later, several cultural norms will lead some women to adopt a strategy of self-silencing in an attempt to protect valued relationships that come into conflict with their own interests. In a society where women are expected to be self-sacrificing, ignoring their own needs and silencing their own self-expression will seem like a viable strategy for women to maintain the relationships they value. Jack’s findings show that habits of self-silencing tend not only to correlate with depression, a finding that has been replicated by numerous studies with women around the world, but also to make recovery more difficult.5 This is because, when ensconced in these habits and in the kind of culture that fosters them, a woman is more likely to avoid expressing her grief to others and seeking social support for herself, which are vital to recovery.
From a feminist critical-theoretical perspective then we ought to pay close attention to those women who struggle with depression and who—through isolation and self-silencing—withdraw in certain ways from verbal interaction and other crucial components of linguistic self-expression. To listen carefully to women who withdraw in this way is to pay attention to firsthand accounts of depression such as that of Maud Casey (2003) when she writes, “Unfortunately to be depressed is not to have words to describe it, is not to have words at all, but to live in the gray world of the inarticulate, where nothing takes shape, nothing has edges or clarity” (178). [End Page 3]
At the same time, occupying this feminist standpoint also requires that we consider how these habits are further enabled by the hierarchical interaction of common biomedical treatment, a connection that, at this point, has received very little scholarly attention.6 Such habits predispose a woman to accept the interpretation of her doctors, whose authority is flanked by the symbolic prestige of their profession and the unique performative power wielded in their speech. After all, the doctor’s diagnosis literally has the power of prescription.7 Put into a prescription, it authorizes medication. Scribbled onto a note, it can excuse her from worldly obligations: job, school, and so on. It prescribes how others in the crisis center or the hospital are to act around the individual. All of this contrasts with the patient’s sense of her own language as something that never manages to work well since she cannot communicate to others why and how she grieves. By contrast, the power of medical interpretation is great. Its performative magic is especially spectacular when its authority to prescribe action works within institutions where an individual is otherwise often without a powerful advocate: the prison, the courtroom, and so on. Such authoritative performative speech has the power to confront institutions that can otherwise appear omnipotent, hence the appeal of the doctor’s interpretation for the woman to whom language appears broken. With the doctor’s diagnosis, she can remain silent. She has no need to venture into the realm of meaning making, trying to bring to words exactly what stirs through her. The doctor authorizes her silence and gives it a name, which she only needs to utter.
The power of psychiatric language is evident in diagnosis and prescription alike. Just as medical diagnosis allows a woman suffering from unspeakable emptiness to remain within the affective field of the body, withdrawn from the linguistic process, the drugs she is prescribed do so as well. The authority of the doctor’s speech is transmitted metonymically into the drugs the patient accepts, giving them special meaning.8 Her acceptance is, more than likely, a rather silent one. She accepts the drugs orally—using her mouth to ingest the doctor’s speech. If it is also verbal (i.e., if she agrees to the treatment), it is not likely to be a long deliberation, as oral ingestion is psychologically easier for her than conversation. She remains withdrawn from speech until the end of the depressive episode’s duration when she feels stable enough again to return to her normal worldly affairs. She leaves having not actively contributed to the interpretation of her condition, and being protected from the pain of interaction [End Page 4] soothes her such that, along with the medication, her disposition is temporarily improved. If the doctor prescribes a regimen of counseling as aftercare, she is likely to accept the doctor’s suggestion but is not likely to show up for those talking sessions.9 What is there really to say? All of this talk won’t do anything. Nobody gets it, but the drugs help her to survive.
Undoubtedly, there are times when immediate survival requires putting trust in medical authorities. I argue, however, that in the many cases of female depression where isolation and self-silencing have contributed to the collapse of linguistic meaning, there is especially good reason to believe that a strategy for long-term healing must include, rather than avoid, rehabilitating the depressive person’s capacity for meaningful speech. This requires the patient to participate actively in interpreting her own experience, a process—as I will explain—that is nevertheless aided by the assistance of an empathetic other. To make this case, I will draw from the analysis of depression offered by Julia Kristeva (1989) in Black Sun: Depression and Melancholia. After presenting Kristeva’s explanation of why deep sadness is often accompanied by a withdrawal of language and bringing her theory into conversation with Jack’s model of self-silencing, I will describe how Kristeva’s therapeutic approach offers a more effective way of helping women who are suffering in silence than the diagnosis-based medical model offers.
While my ultimate purpose here is to contribute to an understanding of the conditions that enable those who are depressed to heal, I hope, along the way, to shed light on what it is that drives so many women to accept the word of medical diagnosis as omnipotent and why, for some, this acceptance is nevertheless uncertain. It may seem as though the first question, the question of what drives people toward diagnosis, has already been sufficiently addressed in the literature. Indeed, we now have several compelling explanations of the cultural and symbolic power of psychiatric discourse, including notably that explanation offered by Michel Foucault (1965) in Madness and Civilization.10 He provides us with a genealogical account of how psychiatric discourse has come to speak the truth of human sadness, that is, how it has developed the sovereign authority to represent and analyze sadness, to tell us what it is, how it works, and what to do about it. Foucault even speaks about this as a kind of silencing that takes place when the psychiatric discourse on mental illness in general becomes the privileged episteme. He writes: [End Page 5]
In the serene world of mental illness, modern man no longer communicates with the madman: on the one hand, the man of reason delegates the physician to madness, thereby authorizing a relation only through the abstract universalization of disease; on the other hand, the man of madness communicates with society only by the intermediary of an equally abstract reason. … As for common language, there is no such thing; or rather, there is no such thing any longer. … The language of psychiatry, which is a monologue of reason about madness, has been established only on the basis of such a silence.(x–xi)
Foucault’s genealogical account suggests that it is the representational power of psychiatric discourse that compels people to seek and accept diagnoses. What his account does not explain, however, is what it is about rationalizing representation in itself that is desirable, nor does it address the ambivalent relationship that many people—particularly those women stuck in the cycle of self-silencing—have toward this rationalizing representation. In fact, Foucault cannot address this ambivalence if he holds on to the strong claim that a person’s experience of suffering has always been perfectly accounted for (i.e., abstractly universalized) by psychiatric discourse. By contrast, Kristeva’s work sheds important light on why people, particularly women, desire representation for their suffering in the first place, such that the cultural significance of diagnosis is appealing, and, more to the point, why the desire some have for this representation is conflicted and self-defeating. Because such considerations are anterior to answering the question of what healing depression requires, I develop them at length in what follows before returning to the question of healing.
2. Kristeva’s account of silence in depression
As I have suggested, those who have adopted habits of self-silencing often welcome medical diagnosis and prescription, not only because of the practical benefits to having such authority on their side but because, in their seemingly univocal power, these forms of speech allow them to remain silent and to avoid the process of self-expression. But rather than accounting for this phenomenon entirely through an analysis of the symbolic power of biomedical discourse, what we need, I’ve suggested, is a deeper look at what makes some people, particularly women, receptive to such authoritative discourse to begin [End Page 6] with. To answer this question, I turn to Kristeva’s Black Sun and, in particular, to the explanation it offers about what sustains habits of self-silencing, what Kristeva describes as a “withdrawal from language.”
Like many others, Kristeva recognizes that the roots of that overwhelming emptiness known as depression reach deeper than the losses that trigger it: the death of a loved one, an illness, a betrayal, a setback at work, and so on. Indeed, as Sigmund Freud (1975) explains in “Mourning and Melancholia,” whereas in mourning one can easily name the source of one’s grief, the melancholic person appears to suffer from something ineffable, that is, a loss she cannot name. Indeed, even the physician has a hard time articulating what is lost. According to Freud, “One cannot see clearly what it is that has been lost, and it is all the more reasonable to suppose that the patient cannot consciously perceive what he has lost either” (243). Seen only in this light then, depression can be bewildering to some who rightly observe that the force with which depression takes over a person’s life is disproportionate to the trigger itself. Such disproportion is even an important criterion for diagnosing depression according to the current American Psychiatric Association’s (2013) Diagnostic and Statistical Manual of Mental Disorders (DSM-V).11
Now, the fact that depression is disproportionate to any trigger leads many nonspecialists to conclude that the cause of a depression is ultimately internal and subjective, that it is “all in the head.” And in a culture that views women as the more fragile, sensitive sex, the fact that women experience depression twice as much as men seems to lend support to this popular view of depression.12 But this popular view runs into problems on a couple of points when we start to pay attention to the patterns of self-silencing. First, it ignores external causes that may be long in the making and, along with this, the vicious cycle that such an external cause may have set into motion. But a depressive response can become so exacerbated by feelings of low self-regard and impulses toward isolation that whatever initially precipitated the reaction seems quite insignificant in comparison to dealing with its effects. Second, this popular view that depression is all in the head describes as an entirely internal tendency something that women have more than likely developed as a response to external factors. That is, if women are twice as likely to experience depression, then rather than assuming that it is something in women’s nature that leads to depression, we ought to see if there are things happening to women that lead them routinely to develop this “internal” landscape. On both points, Kristeva’s account of depression is insightful. It sheds light on how silence can [End Page 7] exacerbate suffering to a point that it overshadows the original cause, and—when interpreted alongside Jack’s theory of self-silencing—it accounts for the high rate of depression in women without attributing causality to a woman’s “nature,” which is more than likely the effect and not the cause of cultural stereotypes.
Rather than taking the source to be internal, Kristeva understands depression as a compromise formation that develops in an attempt to deal with loss. While several emotional setbacks can trigger depression, Kristeva argues that the force of these setbacks can be traced back to another deeper, more ongoing loss, what she calls the loss of the archaic preobject. Importantly, this is not a loss that occurs at any one point in time but is ongoing. This has two primary senses for Kristeva. First, it is the ongoing loss of the infant being’s narcissism. In early narcissism, one does not see that the world is for others too, as one does not yet know any real lack or limitation and is not yet self-conscious. To experience an external world that is not me, however, even if it is a necessary and vital insight, is a blow to the early narcissistic self. Second, Kristeva describes this ongoing loss as a loss of a certain relationship to the mother. The mother is set up as the preobject as the infant being “clings to another, perceives it as a supplement, artificial extension, protective wrapping” (16), that is, at a time of utter vulnerability when the infant requires the protection of another being from whom it cannot yet distinguish itself. Putting these two together, the loss of the preobject then is the loss of a gestalt that preexists a world of subjects and objects, a world structured by an awareness of my separation from others. In sum, to understand oneself as an individuated subject, Kristeva argues, one must undergo a difficult transition away from two things: an early narcissism upset by self-consciousness and an erotic attachment to the mother as preobject. Following Freud, Kristeva calls this transition the negation (Verneinung) of loss (42–46).
For Kristeva, the negation of the loss of the archaic preobject is necessary, not only because of a cultural emphasis on individuated subjectivity and not only within the history of sexual contract and heterosexual family relations (where I am forbidden to keep my mother as my love object) but also as a necessary feature of any life wherein meaning is set forth between people through language. This is because meaning requires a transformation away from the infant gestalt in which no otherness exists. It requires language, which ensures that the meaning of things will lie not in their immediacy but in their expression.13 This difference, between immediacy and meaning, not only is a part of [End Page 8] the subject’s development of self-awareness but is also vital to her development as a communicator. Kristeva describes this as the abyss or the break that is a structural necessity in speech. She writes: “Our gift of speech, of situating ourselves in time for another, could exist nowhere except beyond an abyss. Speaking beings, from their ability to endure in time up to their enthusiastic, learned, or simply amusing constructions, demand a break, a renunciation, an unease at their foundations. The negation of that fundamental loss opens up the realm of signs for us …” (42). On this account then, it is not just a particular historical culture that requires one to cope with the loss of the archaic preobject, but the development of meaning itself.
Into what then does one transfer one’s erotic investment when one grows away from the infant union with the preobject? Here again the answer has two parts. First, Kristeva answers that one must transfer some erotic investment from the mother onto a new object of affection. This can take the form of affection toward and identification with an ideology or a group, but, in most cases, it will also mean affection toward another person.14
Second, one copes with the loss through a process of linguistic identification, becoming someone for whom meaning (including one’s own meaning) is found in the adventure of signs as explored in interpersonal contexts and not just in the immediate plentitude of preobject life. In this, a person can develop a way of managing the loss of the archaic preobject. Having suffered the loss, linguistic identification enables the psyche to live on, assuring itself, “I have lost an essential object that happens to be, in the final analysis, my mother. … But no, I have found her again in signs, or rather since I consent to lose her I have not lost her (that is the negation), I can recover her in language” (43). Thus, Kristeva follows Freud and Jacques Lacan when she says that it is symbolic identification that “insures the subject’s entrance into the universe of signs and creation” and, in so doing, enables a “triumph over sadness” (23).
At the same time, Kristeva is much more sensitive to how precarious this process of linguistic identification can be. Indeed, Kristeva parts ways from her psychoanalytic predecessors in insisting that the negation of loss, the transformation away from our initial attachments, is never complete. Kristeva captures this idea well when she insists, contrary to Freud, that there is no sharp distinction between mourning and melancholy. For her, all mourning (i.e., negation of loss) must include a kernel of melancholy (i.e., attachment to the archaic preobject). All meaning remains bound up with a loss—what she called in the passage I quoted earlier “a break, a renunciation, an unease at [End Page 9] their foundations” (42). In the context of linguistic identification then, this means that we never manage completely to recover the prelinguistic gestalt as an object of our own consent. Such attempts to “triumph” once and for all over loss are self-defeating. One will always need to negotiate between being relationally constituted as a subject and realizing from time to time that the other’s needs and desires are not my own, that my needs and desires are not hers. At times, this process will feel like loss. For Kristeva, however, as we shall see, the survival of the subject requires that one bear this loss so that new experiences of meaning—linguistic and interpersonal—can be opened up.
3. Women’s silence and its consequences for depression
As we have just seen, Kristeva argues that all of us must undergo a labor of mourning, to some extent, as part of the normal development of subjectivity, since the subject must always reckon with its relational constitution. Yet, it is easy to see that there are several contingent social circumstances that make participating in language more difficult for some than others. After all, the triumph Kristeva describes is not accomplished by transcendent attitude alone. There are social circumstances beyond our control that help or hinder our efforts to negate loss through linguistic identification. Although Kristeva fails to develop this point in her work, it is an important one, particularly for understanding the gendered dimension of depression. After all, in identifying myself as an object in language, I am constrained by the terms that are available to me, and thus “I” will wax and wane with the flux of symbolic authority enjoyed by those terms of identity I choose. I may undergo the process of linguistic identification much more seamlessly if I can be made to fit easily into a set of identity categories popularly in use in my culture (i.e., terms that allow me easily to claim for myself some professional identity, gender identity, familial role, political ideology, etc.) and if I can express myself fluently in the language(s) available to me. Such norms will be gendered, however, which means that I can triumph in linguistic identification if and only if I undergo a process of gendering—a process that is both formative and constraining.15 Thus, I remain dependent on others even as a speaking being, just as I was in infancy. I cannot self-diagnose if there is no convention of self-diagnosis. Likewise, I will not express frustration or pain if there is nobody who will listen to [End Page 10] me, recognizing the validity of description, or if I fear retaliation for expressing myself. The point is that this process of negation (the negation of the loss of the archaic preobject) is not simply the triumph of some individual mind, indifferent to social constraints. If our words are to have power, we must still cling to others, not unlike how the infant clings to its mother.
While Kristeva does not sufficiently examine the way that circumstances such as these can foster or hinder linguistic identification, she is more perceptive when it comes to other ways that gender bears upon a person’s ability to negotiate loss through linguistic identification. Throughout her work, Kristeva has explored the particular struggle that females tend to have with this process of loss. They struggle, she believes, because, in trying to negate the loss of the mother in the way described above, they end up trying to negate aspects of feminine identity that they themselves will typically possess. So, to the extent that a woman identifies as female, she will continue to be what she feels she is expected to develop beyond and, in a heteronormative culture, she will continue to love what she is not supposed to love. As Kelly Oliver (1998) puts it: “Whereas the son splits the mother in order to unify himself, if the daughter splits the mother she splits herself” (63). To the degree that she cannot manage this paradoxical demand successfully, a woman who has learned to defer to the needs of others will give her own life to let the archaic preobject live on. In comparison with what she perceives has been lost—this ineffable, archaic bond—language will seem false and meaningless.
As we have just seen, drawing from Kristeva’s account of depression allows us to recognize how gender, a factor largely beyond the control of an individual’s attitude and irreducible to an object of consent, contributes to a person’s propensity for depression. Jack’s theory of self-silencing, however, sheds further light on the cultural forces that hinder women’s speaking, blocking them from processes of recovery through linguistic meaning making. In a recent volume that demonstrates the existence of this correlation in diverse cultures around the globe, Jack and Ali (2010) explain how, for many women around the world, habits of self-silencing lead to depression. “When followed,” they write, “these self-silencing relational schemas create a vulnerability to depression by directing women to defer to the needs of others, censor self-expression, repress anger, inhibit self-directed action, and judge the self against a culturally defined ‘good woman”’ (5). Psychologist Laura S. Brown (2010) recognizes the role that these relational schemas played in her own mother’s struggle with depression decades ago: [End Page 11]
My mother had no internal permission to take the time and money that she needed to heal emotionally, with “selfish” being one of the worst epithets that could be hurled at a woman in that era. Selfishness, silencing the self in favor of what were constructed in the social narrative as the more valued, and allegedly conflicting, needs of her family, was the order of the day for my mother and other women like her.(336)
Although it emerges as a defense strategy intended to avoid painful conflict, self-silencing behavior eventually takes its toll on a woman’s life. Indeed, the consequences of living with these habits become so dire that they tend eventually to overshadow whatever initially triggered the need for these defenses. David Karp in Speaking of Sadness (1996) makes a similar point about the unintentional effects of isolation as a response to emotional setbacks:
Immediately, the urge to withdraw, to be alone, seems sensible when “it hurts even to talk,” as one person described the difficulty of interaction. However, withdrawal turns out to be a false emotional economy. Although providing emotional respite from social obligations that seem impossible to carry out, withdrawal’s long term effects are negative. Like drugs that have good short term effects and debilitating long term consequences, social withdrawal becomes part of a crucible melding fear and self-loathing, a brew that powerfully catalyzes hopelessness. Hopelessness, in turn, makes the urge to withdraw even more powerful. And so it goes—a truly vicious cycle.(36)
What Karp describes here goes for all self-silencing behavior, any form of which inevitably exacerbates the pain of an emotional setback, allowing that pain to spiral viciously out of hand, catalyzing hopelessness as one grows more and more mute. And, above all, this is because such behavior blocks the way to recovery through interpersonal linguistic meaning making, which is essential to healing. In light of this, we can return to our earlier discussion of the disproportionality of depression relative to any trigger. While in the face of this disproportionality it is common to hear nonspecialists say that depression is all in the head, the account I have given here suggests instead that the struggle a person has in mourning a loss or overcoming emotional setbacks cannot be traced back to her own purely internal agency since being an active meaning maker in one’s life depends on several conditions that are not up to that person—notably, social circumstances affecting the efficacy of her speech and the likelihood that she will give voice to her suffering. Thus, it is clear that the [End Page 12] transition away from ineffable loss and into the life of language that Kristeva describes is much further out of reach for some than it is for others. Women regularly struggle with this transition because of several social conditions that encourage them to stay silent. In addition to the above concerns pertaining to language, we must consider here the socioeconomic patterns of caretaking that encourage women to stay home in the private sphere, where they typically have less interaction with others outside of the family. We should also consider here the idealization in many cultures of the selfless mother who always puts the needs of her family before her own, a role that is usually important to the sense of self that women who are stay-at-home mothers develop. Studies have suggested that both circumstances correlate with depression in women (Zoellner and Hedlund 2010; Stoppard and Gammell 2003). Social conditions such as these allow women to slide even more deeply into self-silencing, into even that “gray world of the inarticulate” that Casey (2003) described (178). As Kristeva puts it in Black Sun: “In the best of cases, speaking beings and their language are like one: is not speech our ‘second nature’? In contrast, the speech of the depressed is to them like an alien skin; melancholy persons are foreigners in their maternal tongue. They have lost the meaning—the value—of their mother tongue for want of losing the mother” (53).
It is no wonder then that silence is often a prominent feature of depression. Emil Kraepelin, a contemporary of Freud’s, noticed this when he observed that those who are depressed “do not give information on their own initiative,” and when they do, their speech is “mostly low, monotonous, hesitating, even stuttering,” their writing “often indistinct and sprawling” (Kraepelin 2000, 270). Such a withdrawal from language presents a problem for the work of psychoanalysis, which, of course, requires the patient to open up through speech and to respond to the speech of another. According to an interview written after Black Sun, Kristeva says that it was this problem that most motivated her work in the book. The problem, as she puts it, is that, “if the depressed person rejects language and finds it meaningless or false, how can we gain access to his pain through speech, since psychoanalysts work with speech?” (Kristeva and Grisoni 1996, 80). Kristeva goes on to explain that she considers the strategy she developed as a response to this problem her greatest contribution to “the way psychoanalysts listen to depression” (80). Such listening will, as it turns out, require a particular kind of speech from the analyst herself. We turn now to examine what such a strategy of listening entails and how it differs from the way that medical diagnosis engages a patient. [End Page 13]
4. Kristeva’s therapeutic approach: Listening to the discourse of the depressed
Earlier, I described how, for Kristeva, there is no mourning that completely overcomes its attachment to what is lost. In this way, she resists Freud’s distinction between mourning and melancholy, preferring to view mourning as an ongoing process of linguistic meaning making that is never fully complete, never completely triumphant. In this way, the negation that Kristeva deems vital to healing is not a simple renunciation of prelinguistic life. Kristeva’s approach to interacting with depressed patients reflects this understanding. At the basis of Kristeva’s therapeutic strategy lies the observation that, although people who are depressed often appear withdrawn from language and meaning making, their symptom formations nevertheless offer a kind of discourse that can be read and that is potentially meaningful to them and others. Yet, based on what we have seen so far, we know that this language can only be meaningful when set forth in a way that does not force it to assert itself autonomously, essentially denying the infant’s clinging condition. Two things are required to avoid this result. First of all, there must be another there who attempts to empathize and identify with the expression of the symptoms. In Black Sun, this other is an analyst, but not an anonymous, distant observer or experimenter. As Kristeva says in Intimate Revolt (2002): “With depression, more than in any other analytical situation, the analyst is solicited to mobilize his/her listening, his/her unconscious, in an intense identification with the patient …” (20). Next, to help the patient interpret her own condition, Kristeva explains that one needs to look for an encrypted form of expression at work in the patient’s affective display.16 She explains in Black Sun that the speech of people suffering from depression is “a mask—a beautiful façade carved out of a ‘foreign language.’ Nevertheless,” she continues, “if depressive speech avoids sentential signification, its meaning has not completely run dry. It occasionally hides … in the tone of the voice, which one must learn to understand in order to decipher the meaning of affect” (55).
To illustrate the point, Kristeva describes her experience with a patient named Anne, a professional anthropologist who suffered from frequent bouts of extreme sadness and withdrawal from meaningful activities. Despite her ability to function quite normally, even successfully, in her career and in her social circle, Anne would frequently experience major depressive episodes [End Page 14] during which she felt utterly disconnected from all of these projects. Kristeva reports that, after meeting and talking with Anne several times, she began to have the impression that the verbal exchange between them was merely leading to a rationalization of the symptoms but not a working through of them. When Kristeva asked her about this, Anne confirmed that she felt she spoke “at the edge of [her] words,” while the “bottom of [her] sorrow” remained “unreachable” (56). Anne was therefore able to function in the session, exchanging words, but she experienced these words as futile in reaching the depths of her sorrow. Kristeva explains:
I could have interpreted those words as a hysterical refusal of the castrating exchange with me. The interpretation, however, did not seem sufficient, considering the intensity of the depressive complaint and the extent of the silence that either settled in or broke up her speech in “poetic” fashion, making it, at times, undecipherable. I said, “At the edge of words, but at the heart of the voice, for your voice is uneasy when you talk about the incommunicable sadness.”(56)
In recognizing the intensity of meaning in the woman’s affect, Kristeva allows the patient to participate in how her sadness is articulated. While the patient cannot express her sadness in words, Kristeva finds that she nevertheless expresses her loss in other ways: not only in the voice, but, if we look through the entire case study, also in her body language and even in the clothing she wears. All of these suggest to Kristeva the beginnings of an interpretation that Anne is giving to her own depression. Kristeva’s task as an analyst is to recognize the potential meaning of these clues and, with them, to initiate a dialogue, bringing them into verbal expression.
These clues, one will notice, are found in the affective dimension of Anne’s speech. This observation is important for understanding both what is happening in depression and how healing can take place, for we see that, first of all, instead of accepting symbolic language as compensation for loss, the depressed person clings to an affective display for meaning. It is the affective display that is cultivated in lieu of a bond to signifying language. In this way, the heavy feeling of sadness is actually functioning as a kind of substitute, a new object of attachment that arises in exchange for what is lost.17 Because of this attachment, no offering of symbolic representation alone will suffice as a therapeutic method. Rather, one must engage the person at another level where a meaningful expression of suffering is already beginning to unfold. [End Page 15]
As the later chapters of Black Sun illustrate, we can find a similar expression of loss underway in such works of art as Hans Holbein’s The Body of the Dead Christ in the Tomb. Kristeva believes that in works such as this, which emanate a working through of loss through grief, we find precisely that mediation of loss underway in the depressive condition: an imaginary synthesis of representation and the unrepresentable void. As Kristeva says later in This Incredible Need to Believe (2009), one finds in these forms of the imaginary “recognition of the right to pain” (81). Such recognition functions not as an antidepressant but as a “counter-depressant,” Kristeva says, steering one away from absolute attachment to the inexpressible preobject and a long-term withdrawal from language by engaging the discourse of depression on its own terms. Kristeva’s approach to listening to the discourse of the depressed takes its cue from art in this way. As with the interpretation of the analyst, these “counter-depressants” can help bring inexpressible loss into expression by mourning rather than relinquishing the attachment to the archaic preobject. In the work of art, this mourning takes place through “a device whose prosodic economy, interaction of characters, and implicit symbolism constitute a very faithful semiological representation of the subject’s battle with symbolic collapse” (Kristeva 1989, 24).
However, just as the synthesis underway in the artistic process must finally be externalized and objectified in a work, one that can be recognized by others as an expression of suffering, so too must the one quietly representing her loss through silent affect eventually externalize this process and share it with another. Otherwise, this effort to express loss can be deadly since, as Kristeva describes, the desire for suicide emerges when one is overcome with longing for unification with the silence that now lives in the place of the lost object. So, while it is a necessary ingredient for effectively surviving deep loss, the interpretation of this wound that is underway in the affective display of depression is not enough by itself to prevent self-inflicted death. This is why Kristeva insists on transposition into the sphere of interpersonal, linguistic meaning making. But again, this does not mean that cultural and linguistic representation are superimposed onto the meanings generated by the imaginary, but that the imaginary must be genuinely integrated into the symbolic. Sara Beardsworth (2004) takes this point to be essential to Kristeva’s argument in Black Sun: “The central thesis for Kristeva’s account of melancholy is, therefore, the necessity of a symbolic form-giving that integrates the most archaic, or primitive, recording of loss/emptiness within the symbolic field: culture and [End Page 16] language. Put otherwise, the imaginary is a necessary component of culture” (109)—necessary, that is, if culture is to be meaningful and livable.
For Kristeva then, the cointerpretation of painful affect that takes place in analysis offers a way of effectively mourning rather than simply relinquishing all attachment to the archaic preobject, that formative relational bond. This healing technique, as we have seen, takes its lead not just from the clues that patients themselves provide about the meaning of their suffering but from the therapeutic potential of artworks that represent suffering in a way that symbolic representation cannot, resisting in the end any final, ultimate compensation for the loss they represent. The balance between these two poles—between speaking and silence, meaning and loss—is a difficult one, of course. And, as we have seen, it is easy to get pulled completely to one side or the other, as those who fall into habits of self-silencing know. But, on Kristeva’s account, it is no less than meaning itself—and, in particular, our ability to find meaning as a relational being—that is at stake in this balance.
5. Conclusion: A critical perspective on diagnostic speech
Having traced out what, according to Kristeva and the literature on self-silencing, leads some women to withdraw from linguistic, interpersonal meaning and to cling to the silence of depressive affect, and having described Kristeva’s own therapeutic strategy for recognizing and healing this suffering, let us now consider the effects of Kristeva’s strategy alongside those of medical diagnosis, as previously discussed. In particular, we must examine how speech works in each case—whether it reinforces the withdrawal from language and meaning making that occurs in self-silencing or instead encourages a new enterprise in interpersonal communication. To be clear, in drawing this comparison, I do not mean to suggest that all practitioners who engage in diagnostic and prescriptive speech rely exclusively on diagnosis to understand their patients’ suffering, eschewing other forms of interaction. There has been, however, a clear shift in recent decades toward diagnosis and pharmaceutical treatment and away from psychotherapeutic approaches such as Kristeva’s that focus on long, in-depth dialogue.18 In light of this shift, there are three important points of comparison that must be made. [End Page 17]
First, in Kristeva’s strategy, the analyst’s words lack omnipotent, illocutionary power; in fact, they fail unless the patient herself verifies them by responding to them. The analyst aims only to open up a path of self-interpretation for the patient, one that arises immanently through the communicative exchange. In implicating the patient into the meaning making process then, the patient must do more than consume the words. By contrast, the speech of diagnosis and prescription requires no recognition on the part of the one diagnosed nor, for that matter, any self-interpretation. It locates the meaning of the patient’s symptoms in a referential world that is already established (a certain page in the DSM-V, for example) and thus gives the patient no drive to try to bring the intense affectivity of her sadness into words. It does nothing to counteract, that is, the legacy of self-silencing that many women carry around with them. But the process of self-expression, even if difficult for many women, is, as we have seen, necessary for healing from depression.
This brings me to the next point of comparison. While the omnipotent speech of diagnosis positions the physician as a separate, idealized other, the relationship with the analyst is much more intimate. This is important because an idealized other will function as a mere substitute for the lost preobject, another object of unmitigated attachment. To interact with an idealized other then, cannot help a woman learn to negotiate between her deep relationality and her separateness from others. In Lacanian terms, such an interaction arrests desire, the life and the elaboration of which is ongoing (Lacan 2002, 520).19 Indeed, one will often need diagnosis, but if desire is what pursues meaning at the limits of symbolic representation, then nobody desires diagnosis. Meanwhile, one certainly can desire to interpret one’s suffering for an empathetic other. Indeed, this kind of interlocutor stirs up the desire for speech. And this is why, for Kristeva, the analyst must empathize with and identify with the patient—engaging in what psychoanalysts call “counter-transference”—in order for the patient to relate to her own speech anew. As Kristeva puts it in Intimate Revolt (2002), “The language of the depressed person, until now felt as emptiness because cut off from affective and vocal inscriptions, is revitalized in and through this interpretation and can become a space of desire, that is, meaning for the subject” (23). In comparison, diagnostic and prescriptive speech does not leave the speech of the one diagnosed charged with desire and meaning. [End Page 18]
Third, we have seen that Kristeva’s therapeutic strategy encourages a genuine synthesis of sorrowful affect and symbolic representation. It does this not through subsuming the former entirely into the latter but by offering what Kristeva calls “recognition of the right to pain.” Diagnostic and prescriptive speech, however, does not offer such reconciliation. As Foucault explains in the passage from Madness and Civilization presented above, because of its symbolic power, the physician’s diagnostic speech functions as the rationalization and the abstract universalization of psychical suffering. It thus assigns a name to what resists articulation, what—particularly in cases of self-silencing—clings to ineffability. But the effects of forgoing real reconciliation can be dire. The demand to identify with diagnosis can require such an act of assertion over the primary drives that many will instead cling fiercely to them when they are wounded by or afraid of loss, attaching fiercely to the mood of sadness instead of working through the experience with others. For them, it will be easier to swallow pills than to speak about their suffering. As they are deprived of expression, silence remains the last connection they have with that archaic loss.
What ought we to take away from this comparison then? Throughout this paper, I have tried to show why some people find it especially difficult to work through suffering and loss through verbal interaction, why it is that many people—particularly women—are more comfortable staying silent than venturing into linguistic meaning making. We have also seen that such a disposition often leads to and greatly exacerbates depression. For this reason, it is important that clinicians and anybody offering support to people in a depressive condition be aware of what kind of verbal interaction tends to foster these patterns and what tends to challenge them. But this problem is not always evident for those in this supportive role. It is easy, after all, to confuse the resignation of one’s own meaning making capacities with genuine consent through verbal interaction. After all, one’s acceptance of diagnostic interpellation would seem to indicate that one has embraced that self-understanding, finding genuine self-expression in it. This is not to say that we should abandon the use of diagnoses completely, but rather that those in supportive roles, particularly clinicians, ought to maintain a critical perspective on the kind of meaning that diagnostic speech provides to those who are depressed. We must check to see whether such speech is actually offering the person a way to reconcile with loss and to find meaning or not, and this means turning a critical eye toward habits of verbal interaction that are often taken for granted in the [End Page 19] medical world today. It also means paying great attention to silence, in the way that Kristeva does with Anne, understanding what she wants to say about her life in remaining quiet. Cultivating such a critical perspective in the care that we give will not single-handedly cure or prevent depression. But, I believe, it is an important part of making loss and pain livable.
To conclude, in light of the tendency of depressed persons, especially women, to detach from the process of interpersonal meaning making as they suffer, we can see that there is much to recommend about Kristeva’s therapeutic strategy. By contrast, while medical diagnosis and the actions it enables are certainly necessary at times when a person is in crisis, there is good reason to worry about the way medical diagnosis leaves a woman struggling with inexpressible sadness out of the process of interpretation, assigning a name to her suffering in a way that allows her to stay silent. The task that this comparison sets before us, however, is not an easy one. In the interest of long-term healing, it suggests that we allow ourselves to feel more vulnerable and to linger in the pain of loss, patiently undertaking the labor of its expression, something to which modern Western cultures, in their obsession with strength, productivity, and efficiency, grow increasingly unaccustomed. Moreover, as Kristeva’s work suggests, the challenge of helping each other through this process won’t be met by a strategy of nonintervention, by simply striking out diagnostic discourse and expecting that those now suffering in silence will suddenly speak for themselves in its place. Instead, interventions are needed to open up a space where people desire to give creative, intimate expression to their suffering. In that activity of expression, sadness becomes livable.
Carolyn Culbertson is an assistant professor of philosophy at Florida Gulf Coast University. She regularly publishes articles in twentieth-century and contemporary Continental philosophy. She is especially interested in theories of language within the Continental tradition. Her articles have appeared in journals such as Continental Philosophy Review and Comparative and Continental Philosophy.
1. Recent placebo studies have suggested that pharmaceutical antidepressants are not, by themselves, an effective treatment for depression. For a discussion of these findings, see Allan V. Horwitz and Jerome C. Wakefield’s (2007) The Loss of Sadness (191) and Dana Crowley Jack and Alisha Ali’s (2010) Silencing the Self across Cultures (55–56).
2. The 2011 study, conducted by Medco Health Solutions, analyzed claims data from 2.5 million Americans over the previous decade. The findings were discussed in the Huffington Post (Bindley 2011). The gender disparity in both the diagnosis of depression and the use of antidepressants is not new, however. In 2004, Linda M. Blum and Nena F. Stracuzzi discussed the significance of the fact that between 67 to 80 percent of Prozac users at that time were women and that women were, in general, twice as likely to use psychotropics as men (271).
3. This conception of what a feminist critical-theoretical perspective entails is indebted to the work of two very influential feminist psychologists, Carol Gilligan (1982) [End Page 20] and Nancy Chodorow (1978), both of whom explore the deep moral and social implications of distinctive features of female childhood development in cultures where females are the primary caretakers.
4. This double bind takes place, for example, when women must choose whether to report unfair treatment in the workplace or keep it to themselves. A study by Lilia M. Cortina and Vicki J. Magley (2003) reveals that the psychological and physical health costs for those who stay silent about mistreatment in fear of retaliation are even worse than for those who speak up and suffer retaliation.
5. Tanja Zoellner and Susanne Hedlund, for example, conducted a study on German women that used Jack’s Silencing the Self Scale to compare degrees of self-silencing in healthy, depressed, and agoraphobic women. Zoellner found that healthy women scored significantly lower on the Silencing the Self Scale (M = 71.6) than depressed women (M = 100.6), with agoraphobic women scoring in the middle (M = 83.8) (Zoellner and Hedlund 2010, 112).
6. A report published on women and depression by the American Psychological Association (Mazure et al. 2002), for example, mentions both the relatively high use of antidepressants by women and the link between depression and a common female “cognitive style” in which one tends to “neglect the self in efforts to please and serve others”—called “unmitigated communion” in the report (8)—but fails to address how this cognitive style might be an impacting factor in the high antidepressant use reported. One article that does address the connection is Richard Gordon’s (2010) “Drugs Don’t Talk: Do Medication and Biological Psychiatry Contribute to the Silencing of the Self?”
7. I am highlighting here a connection between two senses of the word prescription: first, a written direction for the preparation and use of medicine and, second, the action of giving an authoritative rule.
8. This observation follows in the footsteps of other authors who have analyzed how meaning is constructed in the context of depression. Recognizing the difficulty in light of the lived ambiguity of depression, Emmons (2010) turns to the metaphors that people commonly use to make sense of depression. While Emmons primarily focuses on metaphors in speech, she focuses at one point on what medications come to symbolize for some patients. She explains:
Manning and Solomon have been silenced by illness; the medications they ingest, however, seem to have gained a voice, or at least the ability to convey meaning. Solomon writes, “Every morning and every night, I look at the pills in my hand: white, pink, red, turquoise. Sometimes they seem like writing in my hand, hieroglyphics saying that the future may be all right and that I owe it to myself to live and see.” Though the pills appear to be in an unknown and ancient language, they nevertheless convey hope, sanity, and a sense of future, which Solomon himself has lost.(120)
This is to say that medication can acquire symbolic meaning for a person, just as it can for a society. [End Page 21]
9. This suggestion is not meant to distract from other reasons that the vast majority of people in America diagnosed with depression and taking antidepressants today do not pursue any kind of psychotherapeutic treatment, even when recommended to do so by a physician. Insurance companies in the United States prefer cases to be handled as quickly and as cheaply as possible, and, when compared to the prescription and management of antidepressant treatment by primary care physicians (see note 18 below), the costs and time required for psychotherapeutic treatment by a specialized therapist are almost always higher (Gordon 2010, 65; Mazure et al. 2002, 29).
10. For more recent books that describe the recent turn to pathologizing and medicalizing different experiences of sadness, see Horwitz and Wakefield’s The Loss of Sadness (2007) and Ethan Watters’s Crazy Like Us (2010).
11. In the DSM-V, such symptoms as insomnia, decreased appetite, and diminished pleasure in activities are not indicators of depression unless they appear “nearly every day” within a two-week period, that is, unless they appear disproportionate or abnormal.
12. While women may be more likely to self-diagnose and self-report as depressed in many cultures, this two-to-one disparity is still strikingly consistent across cultures, suggesting that some aspect of women’s experience regularly leads to depressive symptoms (Gater et al. 1998; Stoppard 1997; Ussher 1992).
Language makes it possible for me to represent an object outside of myself; it enables me to symbolize a loss of my mother, that is, my separation from her. … For those who “successfully” realize the separation, language arises to enable them to symbolize the sense of loss and suffering which ensues. Thus language, becoming more than a pure transparency, paradoxically brings each subject back to the mother once again, putting each individual in “touch” with the world. This is to say that: I know words are only words, but at the same time I believe that these same words are a true link with objects—this is dénégation.(100)
14. I said earlier that a feminist critical-theoretical standpoint requires that the self is relational and that we refrain from pathologizing deep social attachments in the way that Freudian psychoanalysis might lead us to do. In light of this, I will emphasize here that, even if one must overcome an infantile state of attachment in order to develop more complex interpersonal, linguistically mediated relationships, this does not require one to detach from one’s mother in the sense of withdrawing love and care.
15. In her article “Language and Women’s Place,” Robin Lakoff (1994) examines the difference between language patterns typically used by men, patterns that tend to dominate in the public sphere, and language typically used by women. She describes the psychological, social, and economic costs for women of having to adapt continually from one to the other: “If she refuses to talk like a lady, she is ridiculed and subjected to criticism as unfeminine; if she does learn, she is ridiculed as unable to think clearly, [End Page 22] unable to take part in a serious discussion: in some sense, as less than fully human. These two choices which a woman has—to be less than a woman or less than a person—are highly painful” (282).
16. The use of affect in this paper is narrower than the sense the term has in Freud’s work, where it refers to all dynamic processes of the psyche. Following Kristeva’s own use of this term, I use it to refer to any perceivable gestural behavior (e.g., body language, ways of speaking) indicative of the dynamic processes of the psyche. For this reason, I will occasionally use affective display interchangeably with affect.
During the weeks my mother spent in Illinois, my sister would sleep over on occasional nights. In her white nightgown with lace fringe around the neck, she was a radiant beauty. … She was my fairy-tale princess and my tentacles slithered out of their alien pod, wrapping themselves around her. “I want to go back to the hospital,” I would whisper to my mother trying to sleep next to me. “I want to die.” “I want to go home,” I would say to my sister as she rolled over to hold my shaking hands. The three—hospital, death, home—became interchangeable. “Tell me what’s going on,” my mother would whisper back, her warm body charged and ready like a nightlight, glowing with the possibility of emergency.(178)
18. Several events over the last forty years have led to the rise of medicalized psychiatry, including notably the Health Management Organization (HMO) Act of 1973, which triggered the explosive growth of quick, low-cost pharmaceutical treatments offered by general practitioners with no expertise in mental health. For an excellent discussion of these events, see Kevin Aho and Charles Guignon’s (2011) article, “Medicalized Psychiatry and the Talking Cure: A Hermeneutic Intervention.”