Friday, November 17, 2006

Walking the Dog

After I posted yesterday about my depression flare-up, my dear friend Claire sent me this New York Times op-ed piece by Andrew Solomon:
"Despite medical advances in the last 20 years that have greatly improved our ability to help those who suffer from depression, we lack an effective system for administering care. Only a very small percentage of depressives who seek help receive appropriate treatment for their condition. Research often stalls short of being translated into useful medicine. Depressives continue to be stigmatized, which makes their lives even more difficult and lonely. Finally, many sufferers are left to spiral, unsupported, into despair because their insurance companies refuse to pay for treatment.

"These problems are similar to those cancer patients once faced, and the best way to address them might be similar as well. We need a network of depression centers, much like the cancer centers established in the 1970s."
I'm all for a network of depression centers; I think that's a great idea, although I'm not sure I agree with Solomon that depression continues to be stigmatized. If anything, I think it's become a household word, right up there with certain male performance problems that also used to be discussed -- if at all -- in hushed whispers behind closed doors. Depression as malady-du-jour, though, may have the effect of trivializing the illness, always a risk in a pharma-crazy society anyway. Depressed? Pop a pill! Nothing to it!

Cancer's in no immmediate danger of being dismissed this way. I don't mean for a second to deny the devastation of the disease; I've lost friends to it, and my mother's survived both breast cancer and lung cancer. But because there's no quick fix for cancer, or even the perception of one, there aren't cheery little pop-a-pill-and-you'll-feel-better ad campaigns.

Instead, cancer's produced a rhetoric of heroism. Cancer patients are invariably described as "brave," even when they don't want to be. When my mother was being treated for breast cancer, this drove her nuts. "I'm not brave! I'm doing what I have to do. It's not like I have any choice!" Even so, cancer survivors like Lance Armstrong achieve iconic status. Military metaphors abound: cancer treatment's always "a battle," and patients either "win the battle" or "succumb after a long, brave battle."

And then there are all those blasted ribbons. Is anybody else heartily sick of perky colored lapel ribbons for every cause under the sun? Has anybody else completely given up trying to keep all the colors straight? Gary and I went grocery shopping recently, and I picked up a box of coffee filters adorned with a pink breast-cancer ribbon. Coffee filters fight breast cancer? What the hay? This brand filters carcinogens out of your coffee?

The first ribbons I remember seeing were yellow ones, probably during the Iran hostage crisis; according to Wikipedia, the yellow ribbon has a long history -- dating back to 1917 -- in military and political conflicts. Given that history, I don't think the connection to cancer ribbons (even though ribbons now signal all kinds of other things, too) is an accident. Cancer patients are, in a sense, prisoners of war, held hostage by an enemy force. It's easy to see cancer this way because it's an invasive illness, often with clearly visible battle lines drawn on x-rays and CT scans. Cancer cells are "other," hostile mutations bent on overrunning the body's defenses.

As I've said here before -- in a discussion with Will Shetterly that I can't locate at the moment -- I have trouble with battle metaphors for illness. I prefer the metaphor of the journey, with illness as a foreign country which, for all its perils and pains, may also be a place to learn new skills and meet new friends. Sometimes we get to return from that journey and come back home, at least for a while; sometimes the foreign country is the end of our travels. But since everyone's travels in this world will end one day anyway, I don't think it's helpful to imply that people who've gone on to their final destination have lost a battle, or are losers in any other sense. I've heard too many people who were ill vow to "keep fighting" even when they were exhausted and clearly needed rest instead. I suspect that in at least some cases, military imagery encourages patients to push past their limits, instead of honoring their own needs.

Battle metaphors, though, are undeniably sexy. They thrill us; they get our adrenaline going. And that means that, in some twisted way, cancer's sexy, or has been made sexy for the sake of raising money and awareness.

Depression's not sexy. It's common as dirt and every bit as dull. Depression's boring, both for the patient and for everyone else in the vicinity. For one thing, there aren't visible battle lines. Depression isn't an invasion by foreign or mutated cells. If anybody's come up with a sexy metaphor for neurotransmitter imbalances, I haven't heard it yet. There are, of course, famous literary metaphors: Styron's Darkness Visible, Churchill's "black dog." I'm quite fond of the latter; I've tried to domesticate my dog, to train it to heel. When my depression starts howling, I tell myself, "Okay, time to walk the dog," with "walk" as a shorthand for self-care. That's not very sexy, though: nobody's going to start wearing chartreuse pooper-scoopers on their lapels. The very dailiness of depression, and of other long-term chronic illnesses, mitigates against dramatic metaphors.

My "dull as dirt" simile above suggests another metaphor, an agricultural one: depression as the field in which our pain germinates and bears the fruit of compassion. This metaphor is both daily and seasonal, and works well to describe the condition. But it's not very sexy, either.

We don't have depression heroes. We don't have depression icons. There actually is a green ribbon for childhood depression (of course there is), but I had to do a Google search to learn about it. What we have instead is a pop-a-pill mentality that reduces depression -- and male performance problems, and lots of other things -- to the status of a headache.

I'm not sure there are any simple solutions to this situation. As I've said, I don't like battle metaphors, and the metaphors I do like aren't likely to raise anyone's adrenaline levels. But I do have a request: if you know someone who needs to walk the dog every day, offer to come along for companionship and support, even or especially if it's raining out. You may learn things about the neighborhood you never knew, and when you get back, you'll be newly and deeply grateful for that cosy armchair and the roof over your head.


  1. Depression is contagious. The sufferer feels helpless, often irrationally so, and that makes those around them feel helpless themselves - nothing they do does any good! Or it can make them angry, when the sufferer point blank refuses to pull themselves together. If they are lucky, those around do not understand what is going on inside the sufferer - and a good thing too, I don't want ANYONE going there.

    But that militates against understanding, which equally militates against effective treatment. We're back to my 'human beings are discrete variables' riff here.

    You can't touch the depression cell the way you can the cancer cell, and what is real yet nonreal worries the living daylights out of us all. Yet it is still real. I no more imagine the darkness than you do.

    A good friend of mine's daughter is plumbing the depths again - she's young, she's beautiful, she's talented, she has a great job, she has a partner who worships thec air she walks on. Yet still she spends days sobbing for no reason she can articulate. No, depression is not 'sexy' (what an utterly appalling word in this context, so bereft of any real relevance or meaning except in the minds of those who would transform complex reality into into pre-digested pablum) but she is suffering as much as any cancer sufferer and the false belief that there HAS to be a pill for it only makes her suffer more.

    Hopefully our children will have learned more.

  2. A lot of interesting thoughts in one incredible post!

    I, too, have "fought the demon" of depression (sorry, couldn't resist). It may sound silly, but I miss the days of "stigma" for depression, because then "everyone" didn't suffer from the "heartbreak of depression" (or was that psoriasis)...

    Depression can be a very isolating thing, and when it is flaring up, it can be devestating. Many years ago I agreed to be admitted to an inpatient center when I had a severe flare up, because I thought it would help. All it did was make me realize how sick some people out there really are, and how awful some of the meds they can give you for depression truly are.

    The fact that you see your flare up for what it is is an encouraging sign; it is when you can't see the forest because of all the trees that depression can get really scary...

    For what its worth, I'm wit you on the ribbons, too. That an the silly armbands... I had to laugh when I was handed a rainbow ribbon theother week to "highlight the dangers of DVT".... Eventually, you won't be able to stand up due to the weight of all of the ribbons you are carrying...

  3. Thanks for the comments!

    Martyn: Your friend's daughter will be in my prayers.

    John: Yes, I'm glad I can recognize it. But I've also had people say briskly, "Well, recognizing it is most of the battle!" which means they expect it me to be getting over it any second now.

    Re inpatient treatment: I've had many friends hospitalized for various psych conditions, both in Reno and elsewhere, and I do NOT want to get anywhere close to that. (Luckily, I never have been close, even at my worst; I hope that trend continues!) This is one of the things that keeps me on track in terms of self-care.

  4. 'Recognising it' is just the first blow in the battle (to use the military metaphor I affect to despise) However, we know how long it can take to make the recognition, and how dark and endless the night can seem before that tiny light shines. Fear may be all we have to fear, but does that make us any the less afraid?

    Moira and Helen would thank you for your prayers. It works. Maybe not immediately, maybe not in the way we expect, but it does work.

  5. Anonymous9:07 PM

    Susan, take this chance to walk the hills with Gary. Yes, you swim, etc., but get outside. Methinks the "castle" of your intellectual mind might betray the "butterfly" of your soul.


  6. I think cancer is the death narrative of our time, the way consumption was the death narrative of the Victorians -- it's the death we dread and know the shape of.

    Depression is a horrible incapacitating thing, and I'm very sorry it's a problem for you and I hope you pass through the dark country soon and come out into the sunlight.

    I know Peg Kerr has had a lot of help from a light box, and has written about it on her livejournal.

    Oh, and my aunt is reading The Necessary Beggar and it's only the second fantasy novel by someone other than me that she's ever enjoyed, but she really is enjoying it. (The other one she liked was McKinley's Beauty. She has bounced off everything else I've tried her on.) So you can consider that a successful genre outreach.

    Jo Walton

  7. Will Shetterly pointed me to your post.

    Thank you for writing so clearly and imaginatively about this.

    You've given me two metaphors that I can take into my own life.

  8. Anonymous12:40 PM

    It's a little strange, your disdain for those colored ribbons, when your site is tagged with the cyber version of the One campaign's white armband.

  9. Sharon: I'm going for a walk right now! (Although not with Gary, since I can never keep up with him.)

    Jo: Thanks for commenting and for the good wishes, and for telling me about your aunt. I hope she continues to enjoy the book! I've been recommending Farthing to all kinds of people.

    Grey: I'm glad you found the metaphors helpful -- and by the way, I love your site! Beautiful masks! I made a mask of my own and wrote a post about it called
    "Fledgling;" you can find that in the August archives.

    Anon: True, but it's only one ribbon, and it's also clearly labeled, so you don't have to guess what it means!

  10. Anonymous3:36 PM

    I don't walk with Bill either for the same reason. However, I do walk on dirt -- for some reason it helps my soul more than paved paths -- also kinder on my old knees.


  11. The hardest fund-raising job I ever had was fund-raising for science.
    Breast cancer and prostate cancer research had too much funding (meaning more moeny than there were projects) but basic research, the research that might help to cure ALL cancers still goes underfunded.
    Because "fighting breast cancer" is a soundbite, or "sexy" science whereas research into viruses that penetrate the blood-brain barrier, not so much.
    The sad thing is that most of the pink-ribbon money doesnt even go into research for a cure but into "awareness" - encouraging self-exams and regular mamograms. Good things, but perhaps not as effective as providing free mamograms for the uninsured, or helping poor women pay to "fight" breast cancer. IMO.

  12. The pink armbands aren't really that silly. Mine reminds me to ask health care professionals to use my right arm for blood pressures and needles. And if I walk 60 miles and help raise 50 million from the city that I live in I'm thanking God that breast cancer research is overfunded. It means that now there is a targeted therapy to use because the cancer returned. Oh, and by the way. Depression is so common among cancer survivors it's almost expected.

  13. Emmy: If pink (or any other color) armbands serve a practical purpose, I'm all for them. My point was that there are now so many of them that they tend to fade into a blur, and thus have -- at least for many people -- lost their effectiveness.

    And yes, depression's very common among cancer patients, and patients with any other serious illness. But how many people say, "You're doubly heroic for dealing with cancer and depression!" For that matter, how many cancer fund-raising drives show patients who've lost all their hair and are violently ill from chemo? That doesn't sell: pictures of smiling, "heroic" survivors do. During her two bouts of cancer treatment, my mother didn't want to have to live up to anybody's expectations of what "heroic" looked like, and I suspect that many other cancer patients don't, either.

    Question: Is any of the cancer money that's being raised going to awareness campaigns of depression among cancer patients?

  14. Susan, I like your dog metaphor. I seem to be getting lots of not-so-subtle reminders to practice self-care this week, and the dog metaphor is something I may borrow because, as I take care of Julio, I can relate that to the need to take care of myself. Sometimes, the RSD image is supposed to be the dragon, but that seems too big to me.

  15. Hi, Nickie! RSD as a dragon: now that's pretty scary! I think I'd prefer a dog, myself. Although Julio might be indignant at being considered the same species as RSD!

  16. Like your mother, I didn't feel especially brave for having gone through breast cancer the first time. And I don't feel especially brave for having to face it down again. However, the Susan G. Komen Foundation funds things such as and Look Good Feel Better that did help while I was sick not only with my self image while bald but with getting me talking to other women with breast cancer. It also is the largest private fund for research and funded a lot of the research for the next chemo that I will be doing. It also underwrites programs like the mobile mammography busses that provide convienient and sometimes free mammograms to women in my community. If nothing else, just the fact that I'm so willing to be outspoken about my disease has prompted one of my co-workers to get a base line mammogram. She found out that she had breast cancer and it was found in a very early stage. That makes it worth it to me. And monies from the Susan G. Komen foundation are underwriting the social worker and the nutrionist at the cancer center that I go to. The money is well spent. This isn't like the monies that were sent to the coast for hurricane relief and everyone affected is looking around and wondering where it went. In the world of breast cancer the words "This program is being funded by a grant from the Susan G. Komen Foundation" with a pink and black cameo is everywhere.

  17. Thanks for the new comment, Emmy! I agree that the Komen Foundation isn't a godsend.

    I'm wondering how you feel about the battle metaphor. Is that how you pictured your own experience with cancer? In this comment, you talk about "facing it down," which sounds more like standing your ground against a scary street punk than like combat -- but maybe I'm reading too much into this.

    In any case, if thare are any metaphors or imagery you found helpful, I'd be interested to hear them.

  18. Anonymous8:46 AM

    My personal metaphor for the place I disappear to is "the black hole in the forest". When I am having my typical depression (I am bipolar II, mixed states, Dx'd in 1988)I am in the forest. When I am lower than I ever thought possible I am in the hole. I lived in that hole along with 3 bouts of serious physical illness (and 2 back surgeries)for about 5 years straight. I allowed myself one hospital visit. I never want to repeat that experience. I felt trapped and paranoid (not my normal self even at my worst) and felt that being forced to deal with people sicker than myself did me no good in my personal treatment. I was more fearful after hospitalization and it was a year before I left the house. I still ride on a depressive edge at all times, but journaling helps me more than any of the meds do. I have found that I can literally trace the "episodes" in my life and for some reason in my mind helps ME to not stigmatize MYSELF. I believe that we pick up a sense of guilt because many people in fact see depression as a character flaw. We're "lazy or unwilling to pull ourselves up by the bootstraps, and just buck up, put on our big girl panties and just deal with it". My first cousin is like this. She actually thinks I take "too many pills" for something that I "ought" to be able to just simply keep it all at bay through "positive thinking". Depression is at best tedious. I challange any so-called "normal" person to live in my head for just a week. A day. They couldn't handle it, and I would not wish it on anyone.

  19. Anon,

    Thanks for the comment, and for your metaphors!

    With time and luck, the people who "don't get it" can be educated. One of my best friends from college, when I first told her I was depressed, said, "You're not depressed; you're just lazy." But that was years ago, and when I told her about my current flare-up last week, she said, "I really hope you feel better soon. Do you want to come to my house for Thanksgiving?" (That wasn't practical, but I really appreciated the invitation!)

  20. As someone who is now off antidepressants for the first time in over ten years, I wholeheartedly concur with this post...

    ...and I think that last paragraph is brilliant, a literary masterpiece.

    I don't know if I'm "cured", in "remission" or if my middle aged neurotransmitters have finally reached a balance they were unable to reach before.

    Great post.

  21. ChapJohn7:47 AM

    Thanks for the blog. I'm new here, so pardon my clumsy thoughts.

    In the world of spiritual care, we often struggle with whether a patient/friend/fellow traveler IS something or SUFFERS FROM something (fill in your own metaphor or descriptive terms). It seems logical to me, and quite helpful, to move away from the military metaphors and into the journey narrative, taking to heart that one of the dynamics of that foreign country is the emotional and psychospiritual issue of depression. If i AM something (am defined by it) perhaps it is also an element that calls to my baseline shame issues or shames me, even in my letters home (communication) from this alien place. . .

    I need to meditate about this, to give it space to grow ---


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