Journal of Health Psychology

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A Bitter Pill: A Discursive Analysis of Women's Medicalized Accounts of

Depression
Michelle N. Lafrance
J Health Psychol 2007; 12; 127
DOI: 10.1177/1359105307071746

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A Bitter Pill
A Discursive Analysis of
Womens Medicalized Journal of Health Psychology
Copyright 2007 SAGE Publications
Accounts of Depression London, Thousand Oaks and New Delhi,
www.sagepublications.com
Vol 12(1) 127140
DOI: 10.1177/1359105307071746

MICHELLE N. LAFRANCE
St Thomas University, Canada
Abstract
Taking a discourse analytic approach,
this article explores how a biomedical
understanding is drawn on and
mobilized in womens accounts of
their depressive experiences. Through
talk of diagnosis, and by drawing
comparisons between depression and
physical illnesses, participants
constructed depression as a medical
condition with the effect of validating
their pain and legitimizing their
identities. However, participants
accounts also indicated an uneasy fit
between the objective discipline of
biomedicine and their subjective
experiences of depression. Without
tangible evidence to validate the
reality of their condition, speakers
were on precarious ground for talking
of themselves and their distress within
a biomedical frame. The social
construction of biomedicine and
stigma for marginalized forms
of distress are discussed.

AC K N OW L E D G E M E N T S . I would like to thank John McKendy

and two anonymous reviewers for their helpful comments on earlier drafts
of this article.

C O M P E T I N G I N T E R E S T S : None declared. Keywords

A D D R E S S . Correspondence should be directed to:
depression
M I C H E L L E N . L A F R A N C E , Assistant Professor, Department of Psychology, discourse analysis
St Thomas University, Fredericton, New Brunswick, E3B 5G3, Canada. medicalization
[email: lafrance@stu.ca] stigma

127
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JOURNAL OF HEALTH PSYCHOLOGY 12(1)
D E P R E S S I V E experiences are profoundly painful
and debilitating for sufferers. Moreover, depression
is widespread, considered to be the most common
psychiatric (mental) disorder worldwide (World
Health Organization, 2000). In attempting to make
sense of depression, diverse ways of understanding
have been proposed throughout history, including an
imbalance of humours, divine retribution, the result
of unconscious conflicts and, more recently, a prod-
uct of chemical imbalances in the brain (Jackson,
1986). This latter view, a biomedical approach, has
taken hold and currently dominates public discourse
of depression (Gardner, 2003). From this perspec-
tive, depression is the result of biological deficiency
and despite inconsistent and contradictory findings,
neurotransmitters are widely considered the most
likely source of biochemical dysfunction.
The prominence of the biomedical model is often
assumed to be a reflection of an accumulation of
incontrovertible scientific findings and knowledge.
Science, and its guise of neutrality in the systematic
pursuit of truth, wields immense rhetorical power
in public discourse. However, scholars have offered
another vision of science. From this other view, bio-
medical discourse dominates, not because it (or any
other regime for that matter) offers objective truth,
but because of its power to construct its particular
version of reality (Foucault, 1966, 1973). Thus,
depression has come to be widely considered a brain
disorder, not through overwhelming evidence, as
the pharmaceutical industry would suggest,1 but
because of the economic, political and institutional
power of medicine to shape our view of the world.
An emerging body of research has investigated the
ways in which depression has been represented as
a biomedical illness in popular media (Blum &
Stracuzzi, 2004; Gardner, 2003; Nikelly, 1995; Rowe,
Tilbury, Rapley, & OFerrall, 2003). For instance,
Gardner (2003) examined prominent consumer
depression manuals and explored how contradic-
tions in scientific research, and contestation among
researchers are distorted and glossed over in present-
ing depression as a known illness, with a known
singular cause (neurochemical imbalance). Blum and
Stracuzzi (2004) also found that popular periodicals
overwhelmingly employed the biomedical model in
presenting depression as an isolated and decontextu-
alized problem of the individual. As the authors point
out, women are more likely to be depressed and
to receive medication for depression. The gendered
messages inherent in their data were discussed as
128
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producing and policing womens bodies to enhance
their productivity, especially as workers in the new
economy. Similarly, in an analysis of American and
British pharmaceutical advertisements, Nikelly
(1995) found depression constructed as an illness
with women as its victims. Social and situational fac-
tors that may be involved in womens distress were
never shown. Critiqued across these studies are the
ways in which the biomedical model individualizes
and depoliticizes distress, obscuring the depressing
individual, social and political conditions of peoples
(and in particular womens) lives. Ultimately, this
way of understanding has the effect of pathologiz-
ing unhappiness, and encouraging consumers to
self-monitor and self-regulate with antidepressants.
Self-management in turn serves to maintain the status
quo while producing more productive citizens (Blum
& Stracuzzi, 2004; Gardner, 2003; Rowe et al., 2003).
The literature on media representations of depres-
sion exposes how a biomedical discourse is pack-
aged, marketed and sold. However, people are not
passive consumers of discourse. From a discursive
perspective, people are active in speaking themselves
and their experiences into being (Potter & Wetherell,
1987). Discourses can be seen as culturally spe-
cific sets of statements, meanings or metaphors that
produce particular versions of events (Burr, 2003;
Parker, 1992). Speakers draw on discourse in con-
structing different versions of reality. In turn, each
discourse brings different aspects of experience into
focus, positions the speaker in different ways and has
different implications for what should be done (Burr,
2003). Thus, while individuals can draw on different
discourses, at the same time, discourses contain a
range of subject positions which in turn facilitate
and/or constrain certain experiences and practices
(Willig, 1999a, p. 43). Therefore, individuals can
position themselves within discourse and can also be
positioned by discourse (Davies & Harr, 1990;
Harr & van Langenhove, 1991). That is, speakers
are simultaneously the products and the producers
of discourse. We are both constrained and enabled by
language (Edley & Wetherell, 1997 p. 206).
In this article, I explore how a biomedical under-
standing is drawn on and mobilized in womens
accounts of their depressive experiences. The accounts
of women were of particular interest since depression
is a gendered problem with women outnumbering
men at a rate of 2:1 (McGrath, Keita, Strickland, &
Russo, 1990). Moreover, depression is the leading
cause of disability among women worldwide (World
 LAFRANCE: THE MEDICALIZATION OF DEPRESSION
Health Organization, 2000). In addition, women are
more likely to seek medical attention for their experi-
ences of illness and distress, and more likely to be
given prescription medication when they do (Lorber,
1997). Therefore, women are not only more likely to
experience depression, but they are also more likely to
have their experiences medicalized. Thus, womens
accounts of their depressive experiences serve as rich
texts for exploring the ways in which a medicalized
account of depression is constructed in sufferers
accounts, and with what personal, social and political
consequences.
The approach to discourse analysis adopted in this
article is informed by the two central analytic tradi-
tions that have evolved in psychology. The first
approach focuses on a fine-grained analysis of the
action orientation of talk and is affiliated with eth-
nomethodology and conversation analysis (Antaki,
1988; Edwards & Potter, 1992). This approach tends
to focus on the details of what people do with their
talk and the rhetorical strategies people use to make
and counter claims. The second approach draws on
the work of Foucault and involves an analysis of how
discourses constitute particular phenomena and with
what political, social and personal consequences
(Parker, 1992, 1997; Willig, 1999a). While these can
be considered separate traditions, they are not irrec-
oncilable and a synthetic approach to analysis
has been proposed (Edley & Wetherell, 1997, 2001;
Wetherell & Edley, 1998, 1999) (for a justification of
this approach see Wetherell, 1998). A synthetic
approach combines attention to what people do with
their talk and the rhetorical strategies used to make
and counter claims, with a view to the broader sense-
making resources available within a particular cul-
tural context. In adopting this approach, the aim was
to ground the reading in a fine-grained analysis of
the local organization of talk, while at the same
time attending to the ways in which forms of lan-
guage serve social, ideological, and political inter-
ests (Parker, 1997, p. 285).2
Method
Participants
Participants were eight women who ranged in age
from 35 to 61.3 Recruitment of participants was con-
ducted in an urban setting in a semi-rural province
in Eastern Canada. Participants were recruited
through advertisement in the local newspaper and
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the distribution of flyers throughout the community.
Participants discussed having been depressed at least
once in their lives and all had been prescribed anti-
depressant medication by their doctors. In addition,
three participants had been admitted to hospital,
with one of these having had electroconvulsive ther-
apy. Five women also received some form of coun-
selling or therapy.4
Interviews
Semi-structured interviews lasting two to three
hours were conducted by the author. Interviews
addressed specific topics including participants
understandings and experiences of depression, how
they managed when depressed and how they subse-
quently became well. At the same time, interviews
were conducted in such a way as to allow partici-
pants to orient to issues or topics that were important
to them. During the interviews, special attention was
given to inviting participants to expand upon their
use of different words, expressions and patterns of
talk (Potter & Wetherell, 1987). While the interview
style tended to be more supportive than challenging,
inconsistencies in accounts were at times pointed
out in order to explore the limits of different ways
of accounting. All interviews were audiotaped and
transcribed verbatim (see Appendix for transcript
notation).
Analytic process
I began the analysis by simply coding for references
to depression, paying particular attention to instances
in which depression was constructed as a medical
condition.5 The analysis proceeded with an explo-
ration of the patterns both within and across the
details, features and effects of talk. Throughout
the analysis, the use and effect of various discursive
strategies were traced by paying attention to what
participants said, how they said it and to the functions
and implications of their accounts. I looked for con-
sistency and variability in participants language and
traced the use of various discursive features (such as
features of grammar, metaphor, agency and position-
ing) within each transcript as well as across all par-
ticipants transcripts. Files of codes were then created
to track each emerging pattern, noting which partici-
pants did and did not draw on each discursive feature,
in what context, and with what effect. In this way, the
analysis involved a detailed examination of the ways
in which depression was constructed as a medical
condition in participants accounts.
129
JOURNAL OF HEALTH PSYCHOLOGY 12(1)
Analysis
Participants drew on two key resources in their con-
struction of depression as a biomedical condition:
framing depression as a diagnosis, and comparing
depression to various medical conditions. Both of
these resources were used with the effect of validating
speakers experiences and legitimizing their identities.
Its got a name: depression
as diagnosis
The provision of a diagnosis is perhaps the most
central way in which experiences are medicalized.
An analysis of participants accounts of being diag-
nosed revealed remarkable consistency in the struc-
ture and effect of their talk. Participants who raised
the issue of diagnosis repeatedly constructed it as an
experience that brought relief and validation. As
illustrated in the following two excerpts, being given
a diagnosis is situated as validating participants asser-
tions that there was a problem.
P: It was a validation that I had never had
before and I had a na:me. It was like, you know,
its a bad attitude, its not. Im not . . . you know
maladjusted, Im not ill socially or whatever. Its
just Im depressed. And thats cool. Like it was
really neat to have a name for that. (Kate)6
P: I was reading this book [which listed the
diagnostic criteria of depression] and it was
describing what I was going through [ . . . ] and
all of a sudden I said Geeze, thats whats wrong.
Im depressed. Thats what it is. Just to be able to
put a name on it? Because there are times when I
thought I was different from everybody [ . . . ]
But what I found in that book, I found that when
you have the symptoms I had, that the way I was
feeling in my condition was normal. See? I wasnt
going crazy. (Dianne)
In these excepts, participants accounts of diag-
nosis have the effect of validating the reality of their
depressive experiences. By giving a name to their
distress, in addition to using the pronoun it,
depression is objectified and constructed as an inde-
pendent entity. That is, by invoking a medical diag-
nosis to account for their experiences, their pain
becomes real-ized. Further, being constructed as
having a reality of its own, depression is isolated
from the character of the sufferer. In these accounts,
personal flaw and biological flaw are presented as
competing hypotheses, and with the verification of
the reality of one (biological flaw verified through
130
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medical diagnosis), the other (personal flaw) must
be false. Thus, a medicalized understanding is
presented as normalizing depressive experiences.
According to Dianne, a diagnosis assured her that it
was not all in her mind; indeed, in a perverse way, a
diagnosis assured her that she wasnt going crazy.
Therefore, as illustrated in these excerpts, diagnosis
is drawn on with the dual effect of defending speak-
ers experiences and identities.
P: Something in me made me go to the doctor
and I went into her office and she sat down and
she said Whats the matter? And I said How
do you know if you are depressed? And she said
OK I have got ten questions to ask you. And I
was nine out of ten. [ . . . ] So she said, you
know, Youre depressed! Theres no way out of
it. [ . . . ] So anyway, fi:ne I said OK what do I
have to do?
I: How did you react to that?
P: I was so relieved. I was so relieved I thought
thank God! Theres something wrong with me!
Im not- there- its got a na:me. Like its not that
I am just a terrible, awful person who is unat-
tractive, like I guess I thought my only problem
was I didnt have a man in my life? (laughs)
(Cynthia)
As in the previous excerpts, Cynthias distress is
objectified and isolated from her character through her
talk of diagnosis. Verification of this position is further
built up through reference to diagnostic criteria and
the use of numbers as an objective measure of her dis-
tress (I was nine out of ten.). Reported speech or
active voicing (constructing ones account so that it
can be heard as the reported talk of another person)
has been examined as a discursive strategy through
which speakers can establish the objective reality of
a phenomenon (Hutchby & Wooffitt, 1998, p. 225).
With the reported speech of a medical authority, the
fact of Cynthias diagnosis is presented as the only
possible understanding, one for which there is no
way out.
If, as is proposed, the previous excerpts work to
legitimize participants pain and person by isolating
these from one another, then personal involvement in
ones own distress must pose a threat to the legitimacy
of both that distress and the individual. By construct-
ing depression as an independent entity (i.e. a bio-
logical condition), speakers defend against accusations
that they are responsible for their own pain (for
instance, by being weak, histrionic or malingering).
 LAFRANCE: THE MEDICALIZATION OF DEPRESSION
As Parsons (1951) pointed out, there is an expecta-
tion on the part of the person who is ill that she must
want to get better and exert every effort to do so; she
must work to overcome the illness by deferring to
the professional judgement of medical authority.
Otherwise, the person becomes suspect of malin-
gering and seeking secondary gains. The follow-
ing excerpt illustrates how blame and defence are
discursively interwoven throughout these accounts.
In Joannes account, diagnosis is used to defend
against potential challenges that she fabricated her
pain to get attention.
P: It was kind of a relief to have somebody say,
Yes, you have something seriously wrong, you
know, this is what it is. [ . . . ] Theres something
really wrong with me that they have even a name
for it [ . . . ] Its a sense of relief that there is
something there that people know about that you
know youre not the only person in the world
thats had it and you really do have something.
Youre not just making this up, you know. And
thats kind of good because people do have a ten-
dency to sort of look at you and say, well, you
just want attention. Well no, attentions nice, but
no, that was not the plan here. If I wanted atten-
tion I could dance on the table, I dont have to try
and kill myself. (Joanne)
Here, a diagnosis enables Joanne to speak of her
distress as something serious; something known
to be real since it is shared by others and identified
in a taxonomy (they even have a name for it). As
with the other accounts, Joanne notes the impor-
tance of having a name for her experience, con-
structing it as an independent entity. In talking
about her distress in this way, she wards against
having her experience constructed as merely her
own subjective (mis)interpretation. Further, she
defends against the accusation that she fabricated
depression for attention by drawing an extreme
contrast between the triviality of attention seeking
(and dancing on tables) and the extent of her despair
(and suicide). The use of this contrast has the effect
of further establishing the reality and severity of
her pain. Because participants accounts have the
repeated effect of negotiating legitimacy for their
distress and identities, depression comes into view
as an experience that requires such defence. That is,
depression can be viewed as a contested experience,
because in their repeated defence of depression in
their accounts, participants treat it this way (Wood
& Kroger, 2000).
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Its just like diabetes:
comparisons between
depression and medical
conditions
In addition to talk of diagnosis, a medicalized account
was further constructed through participants use of
comparison. The strategy of comparing oneself to oth-
ers (social comparison) has been explored as a way
of constructing ones identity and warranting claims
of authentic group membership (Widdicombe &
Wooffitt, 1990; Wood & Rennie, 1994). The com-
parisons drawn in the present study were not directly
between types of individuals, but between forms of
physical illness or dysfunction. In their accounts, par-
ticipants 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 depres-
sive experiences with biomedical conditions, womens
distress is situated under the purview of medical sci-
ence, and afforded the legitimacy granted therein.
P: I would like to see more women be honest
about it and lose their shame because it doesnt
mean- And this is something that Ive learned.
Im not a weak person because I have this, Im
not a bad person because I have this, I could just
as easily have, you know diabetes or blond hair
or red hair or long legs, I should be so lucky. You
know its just, its one of those things and theres
no blame associated with it (Kate)
Kates account is marked by moral language
(honest, shame, weak, bad, blame) and works
to defend against moral condemnation for her own dis-
tress. By equating depression with diabetes, blond
hair or long legs, depression is constructed as one
outcome of the roll of the genetic dice where her only
personal involvement is her luck of the draw. Drawing
on comparison in this way, Kate is able to construct
depression as an independent entity and herself as a
blameless victim of genetic inheritance. This position
is further defended through her use of stake inoculation
(Potter, 1996). By saying that she learned that depres-
sion is like diabetes and therefore free from blame, this
position is situated as fact rather than motivated by
self-interest. Comparison is used with similar effect in
Beas account.
P: So its right down the line, my mother,
my brother, myself, my niece, my son. Its hop-
scotch. [ . . . ] It certainly is hereditary. You know
131
JOURNAL OF HEALTH PSYCHOLOGY 12(1)
its . . . it is an illness the same as diabetes or a
bad heart or anything like that, high blood pres-
sure, its in the family (Bea)
In her account, Bea constructs depression as an
inherited medical condition, an illness the same as
diabetes or a bad heart. Her use of listing (my
mother, my brother, myself, my niece, my son)
serves to buttress this claim, presenting depression
as the unfortunate result of genetics. By comparing
depression to hereditary conditions such as dia-
betes and heart disease, Beas experience of being
depressed comes into view as something she was
destined to have, regardless of the circumstances of
her life. In fact, Bea rejects a life stress-based nar-
rative for understanding her depression. In the fol-
lowing excerpt, Bea maintains a medicalized
understanding in her story of being depressed as a
struggling and isolated 18-year-old mother of three
young children.
P: And when you have three little children like
that, not too many of your friends ask you out
for a cup of tea. Because they dont want those
kids coming in. So I mean I was like a trapped
animal.
I: Do you see that, that situation as being a con-
tributing factor to the depression at the time?
P: Well I think I did suffer depression. Because,
and again I say, if I was on Prozac way back then,
like I say to my boys, Id say, I know I would
have been a much better mother. Because I
would have put you in your snowsuits, we could
have gone for walks, we could have gone out and
made snowmen (crying) I could have made cook-
ies with you. You see? . . . I could have enjoyed
them. But they were just work. Laundry and
laundry and bedding and it was just, it was just
work work work work work no enjoyment eh?
(Bea)
Here, Bea described living like a trapped ani-
mal as a young mother of three. However, when
this line of accounting is brought to bear on the
cause of her depression, she upholds a medical
understanding. She responds to my suggestion that
her situation may have contributed to her distress by
reasserting that she did suffer depression. Thus,
a life stress-based narrative appears to threaten
the legitimacy of her distress as real (biological)
depression. Maintaining a medicalized account,
however, eclipses any consideration of how the con-
ditions of her life may have been depressing. She
states that if medicated, she would have been able to
132
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enjoy her children rather than see them as a source
of never-ending work. In this frame, hegemonic dis-
courses of femininity are upheld as she recollects
with distress, the lost opportunities to have been
a better mother: going for walks, playing in the
snow and baking cookies. Such a uniformly idyllic
construction of motherhood has been critiqued by
feminist scholars as pathologizing womens distress
and glorifying cultural constructions of women as
naturally geared towards caring and domestic work
(Nicolson, 1998; Stoppard, 2000; Ussher, 1991).7
Thus, as illustrated in this excerpt, while a medical-
ized understanding of womens distress may offer
legitimacy at an individual level, it also serves to
support and maintain the oppression of women.
The limits of the biomedical
model for legitimizing
depression
Talk of diagnosis and use of comparison can be
effective discursive strategies for legitimizing
depression and protecting ones identity. However,
participants use of these strategies also indicates an
uneasy fit between depression and a biomedical dis-
course. For instance, Beas insistence that depression
is an illness the same as diabetes or a bad heart was
preceded by a discussion of the illegitimacy of
depression as compared to other conditions.
P: if you suffer from migraine headaches or say
if you were diabetic you could say to a person
Oh, Ive got a terrible migraine again or My
diabetes is acting up. But with depression just to
say Oh Im depressed, that doesnt go with
people. Oh come on, come on you promised,
youre youre well, theres nothing wrong with
you, you promised, you can go, you can go.
See?
I: What do you think the difference is there?
P: With?
I: Between people being able to say Ive got a
migraine or my diabetes or and
P: Well, they accept that. But just to say, Well
Im depressed, ah, they feel well . . . good kick
in the butt. You can do it, get up and you you
can go. Theres nothing to prevent you from
doing it. [ . . . ] You havent got the flu, you
havent got the cold. Whats preventing you? So
they dont understand. (Bea)
In this excerpt, depression is compared to the med-
ical conditions of migraine, diabetes, flu and cold.
 LAFRANCE: THE MEDICALIZATION OF DEPRESSION
Where the latter are proposed as legitimate excuses for
inactivity or dysfunction, the former is not. In con-
structing an imagined dialogue between herself and an
unsympathetic other, Bea contrasts the ease with
which some sufferers garner understanding, and the
inability of those with depression to do the same.
Claims of distress (Oh Im depressed) are countered
with a barrage of dismissing retorts (Oh come on,
come on you promised . . . ). Without tangible evi-
dence that depression is outside ones control (Whats
preventing you?), the sufferer remains inseparable
from the suffering and is readily positioned as respon-
sible for her own dysfunction. In the following two
excerpts, depression is compared to medical condi-
tions with the effect of presenting depression as mis-
understood and stigmatized.
P: Its a hell of a thing to have. Its a really bad
thing. Id far sooner deal with any of my physical
ailments than I would depression. Depressions
hard.
I: What makes it so much harder?
P: Well, I find its so personal. Nobody can
understand how bad youre feeling. And like you
can go to a doctor, you got bad asthma, you cant
breathe? They can understand that. They can see
it, they can feel bad for you and they can really try
to help you without feeling so::rry for you. When
youre feeling depressed, people dont understand
they figure youve just got the blues and youre
not dealing with it. (Joanne)
P: The male employees have the heart attacks.
Theyve got this wound that they can bear and
people send them flowers and you know come
visit them in the hospital. Women have nervous
breakdowns. Nobody talks about that, no:body
sends you flowers, no:body comes to visit you,
no:body even barely talks to you because theyre
too scared to because you might fly off the deep
end. With men, [in a sympathetic tone] hey that
poor man has had a heart attack. (Emily)
Whereas comparison can be used with the effect
of legitimizing depressive experiences, in these
excerpts, depression is constructed as illegitimate
when compared to physical illnesses. A key for
establishing legitimacy within a medical discourse
appears to be the degree to which sufferers have
access to tangible evidence of the reality of their
distress and dysfunction. Joanne compares depres-
sion, a subjective personal condition, to asthma
which she states can be observed and therefore
understood (They can understand that. They can
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see it). Similarly, Emily constructs depression as
a stigmatized experience by comparing it to heart
attack, which leaves the afflicted with a wound to
bear. When the source of ones distress or dys-
function is directly observable, then the sufferers
character is not questioned and is deemed worthy of
sympathy and understanding. However, without
objective evidence that ones condition is beyond
ones control, sufferers pain and identities remain
suspect. To be exempted from everyday obligations,
the sufferer requires legitimation that only a med-
ical expert can provide (Parsons, 1951).
In an interesting discursive turn however, Bea,
Joanne and Emily are able to negotiate legitimacy
through their talk of depression as a contested expe-
rience. That is, by constructing themselves as
unfairly stigmatized and misunderstood, they are
able to present themselves as even more worthy of
sympathy. Social comparison can be used to show
how one is better off than some people, worse off
than others (Widdicombe & Wooffitt, 1990). In the
preceding accounts, speakers were able to construct
themselves and their distress as legitimate using the
strategy of social comparison and two different
versions of worse off. While challengers might
dismiss participants distress as less worse off in
terms of marginal group membership (i.e. depres-
sion is not real in the same way as other conditions
and so sufferers are not worthy of the same degree
of empathy), here, speakers are presented as worse
off because they are doubly victimized; once by
their depression and again by a society that dis-
misses their pain. In drawing on comparison in this
way, the speakers are able to negotiate legitimacy
for themselves and their otherwise contested expe-
rience of distress.
Although a medical discourse can provide speak-
ers with means of negotiating legitimacy for their dis-
tress and sense of self, the discourse is not without
potential problems. As previously elaborated, when
speakers draw on a biomedical discourse to account
for dis-ease experiences for which objective evi-
dence is not available (e.g. blood test, X-ray), they are
on precarious ground for legitimizing their experi-
ences and identities.8 For instance, Karen, in describ-
ing the intensity of her pain and distress, noted I
always had the feeling that people didnt believe me.
You know I just always thought they think Im faking
it. Moreover, a medicalized view provides speakers
with a narrow scope for understanding depressive
experiences. As illustrated in the following excerpts,
womens experiences of themselves and their despair
133
JOURNAL OF HEALTH PSYCHOLOGY 12(1)
are not always easily reconcilable within a medical-
ized account.
P: I was so relieved when the doctor said
Youre depressed because I thought oh thats
what it is and its not my fault. You know, I
thought, this depression is not my fault. Because
I thought everything was my fault before and
theres days that I still feel that way. [ . . . ] I still
have a very hard time forgiving myself. And
whether thats a symptom of depression or
whether that is just . . . what people are like, I
dont know. Can, can people have low self-
esteem and not have depression? . . . I dont
know, that I dont know. I guess, huh! I dont
know, maybe you can have low self-esteem . . .
but- I wish we could put- what I wish we could
do is like stick a thermometer in your ear and
check your serotonin level. (laughs) You know
what I mean? I wish a person could do that. So
they could look at a number of people and say
OK this person has this symptom and their sero-
tonin, you know youre down a quart. You know
what I mean?
I: Yeah
P: Then wed kno::w. But I dont know how
well, how we
I: We would know who was really depressed
kind of thing or-
P: Yeah! Or wed know if, wed know what
depression was more I think. Or wed know if,
yes, Im sure- I mean I know selfes- low self-
esteem is related to depression but is it necessary
in order to have depression, or is depression- is
a::ll depression is, is serotonin level? (Cynthia)
At the beginning of this excerpt, Cynthias refer-
ence to her doctors provision of a diagnosis serves
to disprove the hypothesis that she is to blame for
her depression. While this discursive move may
deflect blame, she is left with an apparently partial
understanding of her experience. In her talk, she
struggles to reconcile how she feels about herself (I
still have a very hard time forgiving myself) within
a medical conceptualization of her distress (is a::ll
depression is, is serotonin level?). She wonders
aloud if negative emotions and self-blame are a part
of her depression or a part of her character, and her
account alternates between competing conceptual-
izations of depression in which the sufferer is and
is not implicated. Unable to reconcile these two
incompatible understandings, she wishes for the
ultimate solution, a serotonin thermometer capable
134
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of providing the objective evidence required for
establishing her distress as real and her character
as blameless. The unavailability of objective means
for validating depressive experiences was also a
focus of discussion in Evelyns interview.
P: as I talk with other people about depression,
I find other people have said that to me. That they
find that theres no excuse because youre just
depressed, so thats no reason to lay around with
your feet up.
I: theres no excuse for not . . .
P: for not having dinner on the table, or the laun-
dry done, or trucking kids around and going to
parent/teacher interviews, and whatever because
youre just depressed. You know what I mean, like
you dont have a broken leg, you look fine, so.
I also found that in my recovery phase very diffi-
cult to handle, um when people would say how
great I looked. [ . . . ] So that added more pres-
sure that well, maybe its all in my head.
(Laughs) I said to [psychiatrist] one day [ . . . ]
I said I think maybe this whole things in my
head. And hes got such a great sense of humour
[ . . . ] and he looked at me and he said well,
where do you think it is, in your big toe? Like it
was just so funny. And I had to laugh. But it
makes- that just adds more pressure to you to get
better quicker. When people say how great you
look it ah on one aspect its a great compliment
but on the other hand it ah really adds more pres-
sure. Because if I look so damn good how come
I feel so crappy. And maybe it is all in my head
maybe Im . . . Im holding myself back like
maybe theres something Im not doing maybe
I::m not doing something to make myself well
quicker. [ . . . ] Whereas if you have a broken
le::g, well there it is. You know it heals on its
own. And you can see how its healing. But when
its depression nobody else can monitor it. So,
you know its just such a its the most difficult
thing to get over I ever experienced in my life.
(Evelyn)
The centrality of objective evidence for claim-
ing legitimate patient status is again at work in this
account. Without tangible evidence of the reality of
her dysfunction (you dont have a broken leg, you
look fine), Evelyn presents her claims of distress as
not credible. She is therefore left with no excuse for
not being able to function, which only further com-
pounds her distress. Whereas the task for the person
with an outer, visible stigma (e.g. those with obvi-
ous signs of illness or disability) is that of managing
that potentially discrediting information (Goffman,
 LAFRANCE: THE MEDICALIZATION OF DEPRESSION
1963), the person who is depressed appears to face
the very different problem of invisibility. The visible
evidence that Evelyn looked good overrides her
subjective experience of feeling bad, leading her
to the threatening conclusion that she is perhaps
responsible for her own pain. This untenable position
is resolved through the use of humour and her
re-adoption of a medical discourse. She appears to
resolve the question, Is my depression objective
(real) or subjective (fabrication)? with irony and
the double meaning of all in my head. While this
phrase would usually suggest that her pain was
made up, here she draws on the reported speech of
her psychiatrist as a credible arbiter of the cause of
her depression. In this way, she concedes that depres-
sion is all in her head the result of neurochemical
imbalance in the brain.
Discussion
The analysis of participants accounts reveals that
while a medicalized account offers some means
of validation, ultimately it provides cold comfort to
those seeking to legitimize themselves and their
depressive experiences. The incongruity between
the subjective experience of depression and the
objective discipline of biomedicine ensures that the
legitimacy of depressive experiences remain sus-
pect. Therefore, drawing on a biomedical discourse
to account for ones distress inevitably places
speakers on precarious ground for talking of them-
selves and their pain. In this section, the assump-
tions of biomedicine and how it produces
marginalization of a variety of dis-ease experiences
will be explored.
Assumptions of biomedicine:
when objective science fails
subjective experience
The medical model currently dominates public dis-
course of illness and health. In an extensive decon-
struction of the biomedical model, Gordon (1988),
identified two central tenacious assumptions in
western medicine. The first, naturalism, assumes
fundamental distinctions between nature/spirit,
body/mind and objectivity/subjectivity, with the
former of each pair privileged over the latter. Within
the assumption of naturalism, matters of the body
are considered more real than matters of the mind,
and the best way to know the true nature of reality
is through objective means. Accordingly, disease is
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identified through observation of data offered
directly by the body, rather than through the sec-
ondary and confounded means of subjective reports.
The second assumption, individualism, further
assumes the primacy of the individual and individual
freedom (Gordon, 1988). In order for humans to
reflect objectively on nature (and themselves) they
must be able to separate themselves from their sub-
jective and cultural context. Individuals are viewed
as independent from, and even imposed upon by the
societies in which they live. Disengagement from
social and cultural determination is not only a goal of
good science but also a goal of western life in the
form of self-actualization (Kitzinger, 1992). Western
individualism dictates that one should stand apart
from the crowd, exert ones own will and follow
ones own path. Self-determination is required in all
aspects of life, including ones own health. Thus,
health has become conceptualized as a commodity
that one has (one has good health) and a project for
the self to work on (Brown, 1999). Combined, the
assumptions of biomedicine have led to our present
conceptualizations of health and illness whereby it
appears that medicine has replaced the Church as
societys moral arbiter: disease is the contemporary
sin, and health the new religious salvation (Findlay &
Miller, 1994, p. 296). Accordingly, efforts to ensure
and maintain ones health have become a moral
imperative for the individual.
Thus, naturalism and individualism form a domi-
nant and mutually supporting set of constructs that
determine the nature of legitimate reality (materiality),
the legitimate way of knowing this reality (objectivity)
and the implications for those whose illness experi-
ences fall outside the parameters of these assumptions
(stigma and delegitimation). When an illness is
identified as having a clearly biological aetiology,
the illness is deemed legitimate and the sufferer is
seen as legitimately sick (Kirmayer, 1988). People
who are sick have the right to be excused from
responsibilities and are not to be blamed for their
illness. However problems arise for those whose
experiences of illness or distress fall outside bio-
medical criteria for legitimacy (i.e. those without
the requisite signs of organic pathology). Health
problems not adequately accounted for by problems
of the body are relegated to being problems of the
mind, and readily dismissed as not real (Good,
Brodwin, Good, & Kleinman, 1992; Radley & Billig,
1996). Furthermore, the construction of body and
mind as opposing poles of human experience raises
moral questions concerning volition, intention and
135
JOURNAL OF HEALTH PSYCHOLOGY 12(1)
agency, whereby problems of the body tend to be seen
as involuntary or accidental whereas problems of the
mind are typically constructed as voluntary or inten-
tional (Kirmayer, 1988).
Reliance on objectivity to delineate the reality
of a persons pain has as one consequence the dele-
gitimation of a host of forms of illness, pain and
distress, which do not have a clearly identifiable
physical aetiology. Moreover, the authority of bio-
medicine to locate truth and its guise of scientific
neutrality combine to ensure that it is the patient,
not the biomedical model, that is blamed, which
subjective experience does not fit within the bound-
aries of medical legitimacy (Kirmayer, 1988; May,
Doyle, & Chew-Graham, 1999). Thus, an untenable
situation is created whereby sufferers of multiple
forms of distress and pain are stranded from any
means of legitimation (Cohn, 1999, p. 195). Thus,
chronic, psychological and stress or lifestyle-related
illnesses occupy a morally ambiguous realm of
reality (Kirmayer, 1988, p. 62) and research on the
subjective experiences of such conditions are dom-
inated by the issue of sufferers struggles for legiti-
macy (e.g. chronic illness (Radley & Billig, 1996;
Toombs, Barnard, & Carson, 1995; Wellard, 1998),
chronic pain (Good et al., 1992; Jackson, 1992;
Kleinman, Brodwin, Good, & Good, 1992; May
et al., 1999), chronic fatigue (Cohn, 1999; Horton-
Salway, 2001, 2002; Ware, 1992, 1993, 1999), ver-
tigo (Yardley, 1997a, 1997b; Yardley & Beech,
1998) and depression (Rogers, May, & Oliver,
2001)). Kleinman summarizes the effect of such
pervasive delegitimation:
Delegitimation occurs in the course of various
chronic illnesses especially those that are stigma-
tized (such as schizophrenia, depression, epilepsy)
or not fully confirmed as legitimate (such as
chronic pain syndrome, chronic fatigue syndrome,
and many cases of Lyme disease and environmen-
tal allergies) . . . Delegitimation attacks the moral
order of local worlds. It is illness-enhancing, and it
also constrains the effect of treatment. Dele-
gitimation intensifies suffering. Indeed, it re-creates
suffering in a wholly other mode: illegitimate
suffering. (1995, pp. 181182)
Faced with the pervasive threat of illegitimacy for
ones self and experience, those who suffer from
marginalized forms of distress must negotiate the
assumptions of biomedicine in accounting for their
everyday lives. Patterns of discourse identified in
the present study appear at work in research across
a variety of health problems, including depression.
136
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2007 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
For instance, in their study of women who had been
treated for depression, Schreiber and Hartrick found
a remarkable number of women described their
depression as a biochemical disorder similar to dia-
betes (2002, p. 96). Similarly, in a recent study of
individuals experiences of depression in the con-
text of primary care, Rogers et al. (2001) reported
that there was evidence that people felt they had
the wrong type of problem and that the right sort
was essentially a physical one. For instance, one
participant in their study said:
When I get there [referring to doctors office], I get
the feeling that theres nothing wrong with me. I
wish I had got something physical to show.
Sometimes, when we are in the car, I hope we
crash. I really have hoped we crash and that I
wouldnt die, but that something would happen that
would give me a real reason for being off work and
feeling the way I do. (Rogers et al., 2001, p. 324)
Delegitimation was also a common theme in
Wares (1992) investigation of participants accounts
of chronic fatigue. She identified patterns of account-
ing used by participants to counter claims that their
condition was psychosomatic and therefore all in
their heads. Often, participants complained about
not being believed or taken seriously because they
did not look sick and were not visibly disabled.
Echoing the patterns of speech identified in the pre-
sent study, a participant in Wares study stated,
Because Im not in agony or carrying a broken
leg, theres always that little doubt, Well how
bad really is it? I tell youits bad. Its bad. Im
sure if I had a rash, or was vomiting, or my arm
dropped off, it would be a lot easier for people to
be nice to me. (Ware, 1992, p. 351)
A small minority of the participants in Wares
study said that their symptoms had been accepted as
real based on observable evidence (e.g. swollen
glands) or through construction of the condition as a
physical disorder. In countering delegitimation, par-
ticipants spoke in ways that either drew on observ-
able evidence of the reality of their condition,
or drew comparisons between their condition and
other well-known and unquestionably biological
ailments (Ware, 1992, p. 355). Similarly, in their
analysis of letters written to the temporomandibu-
lar disorders9 association in the United States,
Ostermann et al. (1999) noted that accounts drew
heavily on quantification (drawing on objective evi-
dence of the reality of distress) and construction of
 LAFRANCE: THE MEDICALIZATION OF DEPRESSION

the cause of the disorder as physical in negotiating
legitimacy for their pain and their identities as suf-
ferers. Again, these ways of accounting mirror the
accounts of the women in the present study and
reflect ways of talking that defend the legitimacy of
marginalized experiences of illness and distress.
Conclusion
Drawing on a biomedical discourse may provide
some means of legitimation, however depression does
not fit comfortably within this frame and ultimately
results in delegitimation and stigmatization. As a
result, individuals experiencing illegitimate suffering
appear not only to struggle with their experiences of
pain or dysfunction, but they also appear to suffer
from an ontological crisis. As Norma Ware high-
lights in her analysis of the dilemma faced by suffer-
ers of Chronic Fatigue Syndrome: The shame . . .
stems not from the fact of having an illness but from
being told that they do not. Their shame is the shame
of being wrong about the nature of reality (1992, p.
354). Attention to the details of participants talk
invites understandings of pain, illness and distress as
more than problems of the body machine or a tem-
porary break in an otherwise healthy existence
(Radley, 1993, p. 1). Rather, such experiences are
shaped by cultural assumptions and practices, and
fundamentally disrupt sufferers worlds and identities.
From a discursive perspective, illness and distress
come into view as inseparable from the moral order of
the cultural context and integral to the construction of
sufferers biographies (Kleinman, 1995; Radley,
1993). A shift towards a discursive perspective can
extend our gaze beyond a focus on biomechanical dis-
ease and that which can be objectively identified, and
towards an empathic witnessing of the person-in-
context (Kleinman, 1995).
By examining medicalized accounts of depression,
this analysis simultaneously explored how stigma and
delegitimation are worked up and resisted in sufferers
talk. Indeed, the very notion of stigma is problema-
tized by this analysis. Socially, the delegitimation of
certain forms of distress is often blamed on stigma.
This way of accounting off-loads the problem of
shame onto an ignorant public, and calls for greater
public education and awareness of the legitimacy of
these forms of distress. Ignored by this approach how-
ever, are the fundamental ontological and epistemo-
logical assumptions of the dominant medical
discourse that keep marginalization for such condi-
tions in place. Thus, the very notion of stigma has the
effect of re-instating the power of the biomedical
model. As long as naturalism and individualism
remain dominant assumptions for establishing the
legitimacy of ones experiences and self, efforts to
legitimize (or destigmatize) chronic health condi-
tions and mental illnesses are likely to be forestalled.
Instead, critical dialogue about the assumptions of
biomedicine is required. Otherwise, these assump-
tions are like water to a fish, taken-for-granted and
uncontested truths. When health care practices fail to
explain or heal, these assumptions remain invisible as
possible sources of accountability, leaving only the
patient to blame. This analysis reinforces the impor-
tance of community-based research and activism
aimed at disrupting the dominance of the medical
model and the subjugation of sufferers.

Appendix
Transcript notation
P, I The speaker is identified with (P) Participant and (I) Interviewer
(...) Discernable pause
no: semi-colon indicates an extension of the vowel sound
[doctor] clarificatory information
[...] information deliberately omitted
there italics indicates emphasis
but- a short cut-off in speech
.,?! Punctuation marks are used to mark speech delivery rather than grammar. A period indicates a
stopping fall in tone; a comma indicates a continuing intonation; a question mark indicates a
rising inflection; an exclamation point indicates an animated or emphatic tone.

137
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JOURNAL OF HEALTH PSYCHOLOGY 12(1)
Notes
1. For comprehensive critique of the research
and marketing behind the biomedical model
of depression, see Gardner (2003) and Healy
(1997, 2004).
2. Consistent with a synthetic approach to discourse
analysis, this research is conducted from a criti-
cal realist epistemological position (Parker,
1992; Willig, 1999a, 1999b).
3. The findings presented in this article form
part of a larger study involving interviews with
19 women who self-identified as having been
depressed in the past. The analysis presented in
this article is based on the interviews with eight
women whose accounts of depression revolved
around a biomedical explanation.
4. The degree to which participants drew on a med-
ical understanding of their depressive experi-
ences did not necessarily correspond to the type
of intervention they received. Of the original 19
participants, 11 participants did not construct a
medicalized account of their distress. Instead,
these participants talked of depression primarily
in terms of negative life events and personality.
Eight of these women had taken anti-depressant
medication, among whom two had been admit-
ted to hospital and one had been treated with
electroconvulsive therapy. Therefore, while
almost all participants had contact with a med-
ical approach, fewer than half of them con-
structed their experience within a medical frame.
5. While the original analysis attended to all ways
in which depression was constructed, the analy-
sis for the present article focused on medical-
ized accounts.
6. Pseudonyms are used to protect participants
anonymity.
7. While I fully support this critique, Beas account
reminds us that when women are encouraged to
forgo a medical explanation of depression, they
may also be faced with the promise of relin-
quishing a means of legitimizing themselves and
their distress, however limited this may be.
8. Although it is acknowledge that all language use
is flexible or precarious, some ways of speak-
ing may be more easily taken up and established
than others. Or, stated the other way, the adoption
of some positions may be more contestable than
others. Here, it is argued that a medical discourse
depends on objective evidence of pathology,
a resource unavailable to those suffering from
depression. Failing to meet this standard of legit-
imacy positions speakers on uneasy footing and
the degree to which they can claim legitimate
patient status within a medical discourse is
limited.
138
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2007 SAGE Publications. All rights reserved. Not for commercial use or unauthorized distribution.
9. Temporomandibular disorder involves pain and
dysfunction of the jaw (Ostermann, Dowdy,
Lindemann, Trp, & Swales, 1999).
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Author biography
MICHELLE N. LAFRANCE is Assistant Professor
of Psychology at St Thomas University in Canada.
Her research and teaching interests are in the areas
of depression, womens health and health
promotion.