Qualitative Sociology, 16, 4, 337-359
Taking Anti-Depressant Medications: Resistance, Trial Commitment, Conversion, Disenchantment
David A. Karp
This paper documents the meanings attached to taking anti-depressant medications. In-depth interview materials from a sample of persons diagnosed and treated for depression suggest that taking doctor-prescribed drugs involves an extensive interpretive process about the meanings of having an emotional "illness" The data and analysis extend previous studies on the meanings of taking psychotropic drugs by showing how those meanings change over the course of the depression "career" An individual's changing responses to psychiatric medications can be described as a socialization process having radical implications for self-definition. The four stages constituting this socialization process and central to the analysis in the paper are: resistance, trial commitment, conversion, and disenchantment. Each of these stages is discussed in terms of its impact on personal identity. The implications of the presented data for challenges to the medical model are discussed.
The purpose of this paper is to explore the symbolic meanings attached to taking anti-depressant medications. The decision to embark on a course of drug taking is not a simple matter of unthinkingly following a doctor's orders. In fact, a patient's willingness to begin a drug regimen and to stick with it involves an extensive interpretive process that includes consideration of such issues as the connection between drug use and illness self definitions, the meanings of drug side effects, attitudes towards physicians, evaluations of professional expertise, and ambiguity about the causes of one's problem. As Conrad (1985) points out, available studies rarely deal with such issues and so explain non-compliance only from a doctor-centred perspective. This view improperly slights the range of responses patients make to drug use.
The perspective taken in this study fits with a general literature in social psychology arguing that the subjective experience of taking drugs is deeply connected with individual and collective interpretations about the drug taken. Among the classic studies on the subject are Alfred Lindesmith's (1947) analysis of heroin addiction and Howard Becker's (1963) study of marijuana smokers. These studies attest to the validity of the symbolic interactionist (Karp and Yoels, 1993: Hewitt, 1991; Reynolds, 1990) notion that the meaning of all experiences, including drug induced physiological experiences, requires labelling and interpretation. Becker, for example, illustrates that one must "learn" how to smoke marihuana. Aside from adopting the correct techniques for ingesting the drug, one must learn to perceive the effects as pleasurable. The effects of marihuana are not intrinsically pleasurable and in order to continue using the drug persons must rely on a subculture of fellow users who help to provide positive interpretations of the drug's physiological effects.
The case of anti-depressant medications is especially valuable for analysis because these drugs are linked with the meaning of emotional experience. They are designed to alter "abnormal" moods and emotions. If there is a question in patients' minds about the value of taking medications for such clearly physiological problems as epilepsy and diabetes, decisions about taking drugs for "emotional illnesses" are still more problematic. Despite the psychiatric profession's clear adoption in recent years of a biochemical paradigm for understanding emotional problems, it is, we shall see, far from clear to patients whether their emotional problems warrant designation as an illness requiring biochemical intervention. (1)
In addition to the huge medical literature on the therapeutic efficacy of psychotropic medications, social scientists have documented clear social patterns in their use. Studies have, for example, focused on the way psychotropic drugs are marketed, how prescription patterns relate to variables such as gender and age, cross cultural differences in the use of mood altering drugs, the social control implications of psychoactive drug prescribing, the role of these drugs in the medicalisation of psychological conditions, and patterns of use and abuse among patients (for a wide-ranging review of research on psychotropic drug use, see Cooperstock and Parnell, 1982).
Social scientists became especially interested in the role of tranquillisers beginning in the late 1970s as their use was increasingly seen as constituting an emerging social problem (Gabe and Bury, 1988). Even among these researchers, however, only a small subset were systematically investigating the meaning of psychotropic drugs from the subjective point of view of the individuals taking them. Employing qualitative methods, these few researchers began to fill an important void by "focus(ing) on the meanings attached to prescribed drug use, and relat(ing) these meanings to the ways in which users of these drugs manage their everyday lives. . ." (Gabe and Thorogood, 1986: 737; see also; Cooperstock and Lennard, 1979; Estroff, 1981; Gabe and Williams, 1986; Helman, 1981).
The current paper builds on the work cited above in two ways. First, research on meanings to patients of licit psychotropic medications has been restricted nearly exclusively to a class of medications called benzodiazepines (a host of "minor" tranquillisers used primarily to control anxiety, tension, and insomnia). The previous focus on this class of drugs is warranted by their widespread use and the increasing evidence that they can create problems of both psychological and physiological dependence (Petursson and Lader, 1986). Although some of the respondents in this study might also be taking benzodiazepines such as Valium and Xanax, my discussion with them about medications centred instead on a class of drugs called tricyclic anti-depressants. Within the last fifteen years there has been an extraordinary expansion in the use of antidepressant medications. Although their users must cope with sometimes difficult side-effects, anti-depressant medications, in contrast to benzodiazepines, are said not pose problems of physiological habituation. Along with this important difference, we might speculate that depression carries a different and "more serious" cultural meaning than does anxiety. Thus, the meaning of taking anti-depressants may differ significantly from that of taking anti-anxiety agents.
There is a second and more conceptually substantial way in which this investigation departs from earlier work. Although prior research clarified how patients understood and legitimated their use of psychotropic drugs in a global way (for example, as a resource for helping them to fulfil family and work roles), this research did not explore how the meanings attached to psychotropic drugs change over the period of their use. An important premise of symbolic interaction theory is that the meanings of objects, events, and situations are constantly being renegotiated and reinterpreted (Blumer, 1969). Correspondingly, this paper argues that the use of anti-depressant medications articulates with a more general depression "career" path characterised by ongoing redefinitions of self, illness and, here, the meaning of medication itself.
In an earlier paper (Karp, 1992) I identified clear stages in the evolution of an illness consciousness among depressed persons. Certain events in the course of an illness become critical identity markers that reflect a profound shift in how persons see themselves. Anselm Strauss (1992) refers to these moments as "turning points" in identity. At such junctures persons are transformed in a way that requires a redefinition of who they were, are, and might be. The data to follow illustrate that the eventual decision to take medications was a major benchmark in the way my respondents came to see themselves, the nature of their problem, and their images of the future. The consequent decisions to continue and then eventually to stop a drug regimen are complicated and sometimes the product of years of confusion, evaluation, and experimentation.
Although it would do violence to the complexity of persons' responses to drug treatment to say that everyone moved through absolutely determined stages of interpretation, the stories I heard suggest clear regularities. These "moments" in the way respondents simultaneously tried to make sense out of drugs and their illness include an initial resistance stage during which they were unwilling to take anti-depressant medications. However, despite their ideological and psychological opposition, those interviewed eventually became desperate enough to try medication and thus capitulated to the advice of medical experts. During a second period of trial commitment, individuals express a willingness to experiment with drugs for a short period of time only. Having made the decision to try medications, they begin to accept biochemical definitions of depression's aetiology. Such a redefinition is critical in becoming committed to a medical treatment model. For several, taking the drugs has a marginal or even negative impact on their problem. However, by now even these individuals have become converted to a belief in biochemical explanations of depression and begin a search to find the "right" drug. Finally, even those who experienced a "miracle" and felt "saved" by medication eventually have other episodes of depression and become disenchanted with drugs. They feel a need to get off the drugs "to see what happens," to see whether they can "go it alone."
The body of this paper will analyse the details of persons' thoughts and feelings as they progressively move through the stages of consciousness described above. These stages suggest parallels with published descriptions of the recruitment, conversion, and deconversion of individuals to a variety of religious groups (Robbins, 1988). Respondents' stories which centre on feelings of desperation, lack of perceived meaning in life, and then sometimes experiencing a "born again" miracle, bear an instructive resemblance to accounts of involvement with a range of religious groups. Like religious conversion, conversion to a bio-medical version of depression's causes and proper treatment is accomplished through a socialization process (Balch, 1985) which entails a radical transformation of identity, a "process of changing a sense of root reality" (Heirich, 1977: 10; see also Snow and Machalek, 1984; Greil and Rudy, 1984). In what follows, I will explore, where informative, the similarities between adoption of religious and medical versions of reality.
METHOD AND SAMPLE
The data reported on in this paper are part of an ongoing research project designed to document the subjective experience of depression. The first stage of the research involved a year and a half of participant observation in a self help group for persons with depression (Karp, 1992). This initial study was concerned with how group members, through their talk, created an ideology or rhetoric for making sense of their common dilemma. Although group discussion covered a range of topics, certain questions and themes kept recurring as group participants worked toward consensus about the meaning of their shared condition. From among the array of topics that came up in group discussion, members returned over and again to four key themes: the difficulty of getting a proper diagnosis for their problem, evaluation of personal responsibility for causing depression, assessment of the effectiveness of therapeutic experts, and interpretation of psychotropic drug experiences. This participant observation exercise sensitised me to underlying interpretive dilemmas posed by depression and the need to have directed conversations with persons in order further to unravel how those with depression construct their illness reality.
Between August, 1991 and May, 1992, I conducted the 20 in-depth interviews which constitute the basis for this paper. A number of avenues were used to solicit interviewees. Initial interviews were done with personal acquaintances whom I knew had long histories with depression (10 cases). In addition, advertisements were placed in local newspapers and this strategy yielded a number of responses (6 cases). Finally, after each interview respondents were asked to describe my study to friends whom they knew had histories of depression and to refer names of willing participants (4 cases). In all instances, only those who had been officially diagnosed and treated by mental health professionals were included in the study. As with any project based on in-depth interviews, no claims can be made for the statistical representativeness of the sample. It can be said, however, that the current sample contains variation by gender (8 males, 12 females), age (20s = 4, 30s = 6, 40s = 8, 50s = 2), occupation (8 professionals, 5 white collar workers, 2 blue collar workers, 4 students, 1 unemployed person), and religion (6 Jews, 10 Catholics, 3 Protestants, 1 Buddhist). All but three of the respondents are college educated and all, with the exception of one East Indian, are white.
Each of the taped interviews lasted a minimum of one and one half hours and most ran for well over two hours. In several cases two interview periods were required to capture the complexity and richness of persons' experiences. Each interview began by asking persons to trace the history of their experience with depression from "the first moment you realised that something was wrong with you, even if you did not initially define the problem as depression." This broad opening question normally led to conversation that provided systematic information in the following areas: description of what depression is like, the experience of hospitalisation (13 cases), views on whether depression should be considered an "illness," feelings about therapeutic experts, relations with family and friends, the influence of depression on work, coping strategies, and feelings about using psychotropic medications. While the goal was to obtain information in all of these areas, the time given to each topic was dictated by the particular contingencies of each person's "story."
Although it is impossible to know what information persons might have withheld, I found it remarkable how candidly most of those interviewed appeared to speak about their experiences, including such difficult topics as child abuse, drug addiction, work failures, broken relationships, and suicide attempts. Several times, interviews were punctuated by tears as persons recounted especially painful incidents. In every case, I reserved time at the end of the interview for respondents to "process" our conversation and to communicate how they felt about the experience. Nearly everyone expressed gratitude for the chance to tell their story, often saying that doing the interview gave them new perspectives on their life. Several also indicated that they were motivated to participate in the study because they wanted others to hear what depression is all about. They expressed sentiments similar to one woman who told me why she responded to my newspaper advertisement:
“I thought maybe I could say something that might help people who are depressed. . . [I want] to encourage us as human beings to make more of an effort to respond to each other. [I want others] to see. . . the connection we have with each other and the effect we can have with each other. I want people to hear that part of the predicament of depression is isolation and that anybody can do something about that. [I want people] to feel that they are empowered. . . that everybody can do something, that every person probably knows someone who is depressed, and everybody can do something; you know, be a little kinder or something. It can really make a difference.”
Consistent with the logic of producing grounded theory (Glaser and Strauss, 1967), this study did not begin with explicit hypotheses to be tested. Instead, I began with broad sensitising questions about the explanatory frameworks persons employ to negotiate the ambiguity of having an affective disorder. The goal of analysis was to identify underlying patterns or commonalties in the way respondents described what it is like to live with depression. As each transcribed interview was scrutinised for themes, it shortly became apparent how central taking drugs is to the depression experience. The stages constituting the basis for analysis in the pages to follow constitute a parsimonious framework for analysing a large volume of the collected data.
INTERPRETING THE DRUG EXPERIENCE
There is considerable variability in the time persons take to move through their individual depression careers. In large measure these variations relate to how early in life trouble with depression begins and then whether bouts with depression are chronic or intermittent. Several of the persons interviewed realised, in retrospect, that they were deeply troubled from ages as young as four or five, and others did not experience "serious" depression until early adulthood. Consequently, some of those interviewed move into the therapeutic worlds of counsellors, therapists, psychiatrists, and drugs by their teenage years, or even earlier. Others go for years before their trouble is diagnosed as depression and only then embark upon a course of therapy. However long it took the respondents to recognise and label their difficulty as depression, their eventual treatment by physicians involved use of prescribed medications. As indicated earlier, an individual's response to medication can be described as a process of unfolding consciousness and identity change consisting of four broad stages: resistance, trial commitment, conversion, and disenchantment.
On rare occasions persons with whom I spoke sought out physicians explicitly to obtain anti-depressant medications. Perhaps this will increasingly be the case as both psychiatry and pharmaceutical companies "educate" the public about the nature of depression and as drugs like Prozac are touted in the media as revolutionary cures for depressive "illness." Normally, however, the idea to take medication is first raised by a therapist or doctor, a suggestion that is met with considerable resistance. Typically, respondents offered a number of reasons for initially resisting drugs. Some described themselves nearly identically by saying "I'm the kind of person who doesn't even believe in taking aspirin for a headache." Others were appropriately concerned about the unknown and possibly long-term effects of powerful medications. It is interesting that even respondents who had earlier in their lives experimented with all kinds of drugs (for example, marihuana, cocaine, and LSD) were opposed to taking these drugs. Without denying their stated reasons, there appears to be a central underlying dynamic to their resistance. Taking an anti-depressant medication would require a dramatic redefinition of self. Taking the drug would be a clear affirmation that they were a person with a stigmatised emotional disorder. In this respect, a willingness to begin a regimen of psychiatric medications is far more than a simple medical decision. It is a decisive juncture in one's self-redefinition as an emotionally ill rather than merely a troubled person.
“I didn't want to be told that I had something that was going to affect the rest of my life, and that would only be solved by taking pills. It was sort of definitive. I had a label and it was a label that I thought was pejorative. I didn't want to be this quietly depressed person, that there was something wrong with me. And it was sort of a rebellion in that [I said] "No it isn't, I'm not like that. I don't need you and your pills.””
“My internist said, "You're depressed. You need an anti-depressant." I mean, I didn't understand the word exactly. She sent me to (names a psychiatrist) for anti-depressants. I went to (names psychiatrist) and said "I don't need anti-depressants, but I do need somebody to talk to." Drugs. I was against drugs. I didn't understand them either. But if he would talk to me, maybe we could work our way out of it.”
“I have to tell you, there was a battle on this (taking drugs) because I am the type of person, if I have a headache I'm stoic about it. I won't take any kind of a pill. And so all of this was against my better instincts.”
“So I get in there (the psychiatrist's office) and she says, "I think we should put you on medication, on anti-depressants, don't you think?" [And I'm thinking] "Where did that come from?"
For several respondents the first clear communication that they needed medications followed a crisis that pushed them into a psychiatrist's office or, sometimes, into a hospital. New patients often perceived doctors as unwilling to pay significant attention to their feelings and were, as they saw it, altogether too eager to prescribe medications. Especially in hospitals, respondents sometimes acutely experienced the paradox that psychiatrists didn't want to spend much time hearing about their feelings despite the fact that it was their bad feelings that forced them into the hospital. As individuals often saw it, their problems were situational and their souls were wounded. Such a perspective on the causes of their misery did not seem to square with the assessment that they had a disease in the form of unbalanced brain chemicals and should be treated with medication.
While persons suffering from depression often express anger towards those whom they view as implicated in the creation of their problem, I was surprised throughout these interviews by the virulence of the animosity expressed toward psychiatrists. Eventually, many of the persons interviewed found psychiatrists whom they trusted and from whom the benefited. However, early in their treatment, individuals saw psychiatrists as oppressively evangelistic "true believers" in biochemical causes of depression, a view that they did not then hold. Their initial negative evaluation of psychiatry and psychiatrists is caught in the frequency and regularity with which respondents angrily labelled their doctors as "pill pushers."
“This particular doctor was such an asshole. He sounded like a used car salesman for anti-depressants. He was just like so gung-ho. "Oh yuh, you're the typical depressed [person], here's the drug that will cure you. Let me know if you go home and just want to kill yourself or something. We'll try something different for you." And I hated him. I just really hated him.”
“There was something, too, like all of a sudden everything having a cure. That really bothers me. I mean, I didn't mind taking the medication when it was appropriate, but just to overdo it, I'm really uncomfortable with that.”
“You never see a doctor in a hospital. I mean you see mental health workers and, you know, the doctor sort of, you know, walks in once a week and dispenses pills and then walks back out. You know, he's a very regal kind of figure who is untouchable.”
“Everything can be cured with a drug. Everything. They've got a drug for everything. Most [psychiatrists], they like to tinker with the body through these drugs, rather than trying to, you know, have people express what they're feeling. They just took one look at me, and pronounced me depressed, and wanted to put me on a battery of anti-depressants.”
“[1 feel] a real disenchantment with the traditional psychiatrists like the one that I had, and the ones who resort very quickly to pills. And I certainly have doubts about the degree to which the doctors are hooked up with the drug companies.”
By the time patients arrive for treatment in doctors' offices or hospitals they have already moved through a number of changes in self definition. When asked about the unfolding of the recognition that they were depressed, individuals ordinarily describe an early time of inchoate feelings of distress, followed by the feeling that "something is really wrong with me," and then to some variant of "I can't continue to live like this." Even after a crisis severe enough to precipitate hospitalisation, individuals are, as we have seen, still resistant to taking medications. Resisting medication is a way of resisting categorization as a mentally ill person. However, the depth and persistence of their misery proves great enough that, under the proddings of physicians and sometimes other patients and family members, individuals begin to waver in their resolve not to take medication. Several persons described themselves as eventually "coming around" to the decision to take drugs because they became willing to try anything to diminish their suffering. Over and again respondents described their capitulation to medications as a consequence of the desperation they felt.
“But I also didn't want to do it [take drugs] because I felt such shame. I fell like, "Well I'm not depressed, someone else is depressed." Like I couldn't believe it was me. It was like some wonder drug or something. And I was thinking, "No way, I don't want to jump on this bandwagon." I was so scared of it. I felt like five years from now they'd find out that it gave me cancer or something. I just didn't want to take medication at all. But then at the same time I wanted so desperately for something to fix me. So I was just willing to try anything. He just said, "Give it a week, think about it."“
“I was very leery of it [taking medications]. I mean I was concerned about what the effects might be and I didn't like the idea of putting myself on some sort of medication, but at a certain point it just seemed to me that I had to try it and the problem was so great that I really wanted to do anything that would alleviate it.”
“The big Prozac controversy. . . scared my parents and scares my girlfriend. It kind of scares me, if you read about this stuff. But by that time I am so convinced that "shit, anything if you're depressed is better than being depressed." I knew I had to do something.”
“And in fact, I never wanted to take the drug. I mean I took the drug because I believed it would keep me alive.”
“I couldn't drag myself around any more. I couldn't sleep. I didn't eat. . . I just felt physically like there was something wrong with me, and that I had to stop and I think there is a physical component, because now that I've been on medication long enough I think it has helped.”
In an especially evocative comment a respondent equated taking the medication with "swallowing" her will.
“I have a hard time taking medication. . . I don't like taking pills. I didn't like taking aspirin. I mean, I've generally been very conservative at that, so I kind of swallowed, you know, my will and that's when I took Prozac.”
The moment individuals decide to try medications is decisive in beginning a reorientation in their thinking about the nature of their difficulty and of their "selves." Putting the first pill into one's mouth begins both a revision of one's biochemistry and one's self. Social psychologists have long understood that embarking upon a new life direction, especially one that departs from earlier held views of reality, requires the construction of a new "vocabulary of motives" (Mills, 1972) and new "accounts" (Lyman and Scott, 1968) for behaviour. Labelling theorists (Lemert, 1951; Becker, 1963), for example, argue that eventual commitment to a new subculture involves successive redefinitions of self made in response to others' labelling and to one's own changed behaviours. Rather than understanding behaviours as always being propelled by clear motives, we know that behavioural changes often precede motive productions. Taking the medication is the beginning of a process of a commitment to biochemical explanations of affective disorders.
In his well-known paper entitled "Notes on the Concept of commitment," Howard Becker (1960) illuminates the idea that commitments to new ways of life do not happen suddenly, all at once. Commitments are built up slowly, gradually, and often imperceptibly through a series of "side bets" or personal decisions, each of which seems of little consequence. Persons, for example, may become committed to work organisations through a series of side bets such as paying into a pension plan, accepting a promotion and new responsibilities, buying a home based on current income, and so on. As Becker explains, each of these apparently independent decisions is like putting individual bricks into a wall until one day it suddenly becomes clear that the wall has grown to such a height that one cannot climb over it - a commitment has been made that is not easily reversed.
The decision to take a medication is sometimes preceded by a negotiation with doctors about how long one is willing to try it. Here the analogy to involvement with religious groups may be profitably drawn. In their paper on modes of conversion to religious groups, Lofland and Skonovd (1983) describe five different "conversion motifs" which vary in terms of such factors as the degree of pressure involved in the conversion, the length of time involved, and the degree of emotional arousal during the process. Along with intellectual mystical, affectional, and revivalist motifs, the authors describe an "experimental" conversion motif that corresponds to this juncture in the drug taking process. In experimental conversions there is "a relatively low degree of social pressure" as "the recruit takes on a 'try it out' posture" (Lofland and Skonovd, 1983: 10). Negotiations reflect patients' ambivalence about psychotropic drugs and signal both to physicians and to themselves that they have not yet accepted doctors' definitions of them as having a biochemically based illness,
“And so then I started taking this Prozac. And the only reason I would take it is that he promised I would only be on it for three months. I ended up being on it for nine months, probably longer, nine or ten months. If I had known that, I don’t think I'd ever have gone on it because I just didn't want to put any kind of substance in my body.”
“The psychiatrist. . . said, "Look, I just think you should stay on it through the end of the year, you know, and then you can go off it." So I decided. . . I wasn't thinking of it quite so blatantly, but I was sort of thinking. "All right, I'll just take this eight months and see what happens."“
Negotiations aside, taking medications coincides with a growing acceptance of official medical versions about the causes of depression. Everyone who suffers from depression feels obliged to construct theories of causation in order to impose some coherence onto an especially hazy, ambiguous life circumstance and to evaluate the extent to which they are responsible for their condition. Although it is impossible ever to fully resolve whether nature or nurture, or some combination, is responsible for depression, every person I interviewed eventually accepted in greater or lesser degree a biochemical explanation of depression.
Adoption of the view that one is victimised by a biochemically sick self constitutes a comfortable "account" for a history of difficulties and failures and absolves one of responsibility. On the negative side, however, acceptance of a victim role, while diminishing a sense of personal responsibility, is also enfeebling. To be a victim of biochemical forces beyond one's control gives force to others' definition of oneself as a helpless, passive object of injury. Holstein and Miller (1990: 120) comment that "victimisation. . .provides an interpretive framework and a discourse that relieves victims of responsibility for their fates, but at a cost. The cost involves the myriad ways that the victim image debilitates those to whom it is applied." The interpretive dilemma was to navigate between rhetorics of biochemical determinism and a sense of personal efficacy. However, everyone with whom I talked eventually adopted some version of biological causation of depression, as the following representative comments illustrate.
WELL, DO YOU FEEL LIKE A VICTIM?
“I would say that yuh in me, [it is] my brain chemistry that is prone to depression and that, given like the amount of trauma in [my life], it really added up and had no way to pass or flow and really built up. And like the drug helps it to flow or something. And then the way that I understand I'm no longer on it [medications] is that it's [the brain chemistry] kind of working OK on its own right now.”
YOU SEEM TO DOUBT THE PSYCHIATRIC MODEL OF ILLNESS.
“I don't doubt it. I don't know. You know, I'm not a psychopharmacologist and I'm going to say "It's this problem with serotonin uptake in my brain," and I'm not a psychoanalyst and I'm going to say, "It's you know, the Oedipal whatever." But I feel that it's an illness because it's something you don't have any control over.”
“Depression is, I think, its own entity within me. I mean it's chemical. Back in 1983 they gave me a blood test and said, "You're depressed." And I believed them, you know?”
“There was a sense of relief to a certain extent when I started finding out that the medication was helpful, because then I could say that this certainly partly is a chemical problem, and that I'm not a looney tunes, and I'm not, you know, it's not a mental illness, which really sounds bad to me. I think I'm much less negative about it than I was, even in 1982. But at that time the fact that there might be a chemical imbalance that was being rectified by medication was of great comfort to me.”
“Well, you know, as a result of that more recent one, more recent depression, I've kind of come around more to the biochemical explanation.”
“I think there was a certain point when the chemical thing just took off on its own. I think before that I had a chance to impact on it. It was much more interactive. Once it took off on its own I needed medication. There wasn't anything else that was going to get me out of that.”
“Of all the things that happened there [in the hospital], what I will say was very impressive to me is that the people who are running the program are on anti-depressants, and they became role models for me. Anyway, here was a woman high-powered, high-energy, she's written a book, she's been on Good Morning America, she runs this program. She's on anti-depressants. She goes, "Hey, it happens sometimes. You need it. So take it and shut up." I mean, she just says, "Get on with your life. So your chemistry's out of whack. So what! That's why we have this medicine. So take it."“
“Got a cold? Take Vitamin C! Got depression? Take the damn anti-depressants!”
Conversion: Muddle or Miracle
Once patients have accepted and internalised a rhetoric of biochemical causation they become committed to a process of finding the "right" medication. Such a discovery often proves elusive as persons enter upon a protracted process of trial and error with multiple drugs. This process is often extremely confusing as persons deal with a variety of side effects ranging from such relatively benign problems as dry mouth, constipation, and weight gain to more dramatic experiences like fainting in public places. In several interviews drug "horror stories" were a prominent theme, as in the case of a hospitalised woman whose therapy, along with drugs, consisted of physical exercise.
“I was on every drug under the sun. Just everything (said with exasperation). It was like a cocktail. I mean I was really out of control. . . I'll never forget this little vignette where they would drug me and say, "Well, you've got to get out there and be more active. . . I'll never forget - tennis. . . I was so drugged up I could barely see my fingers and this therapist took us out to the tennis courts. He was hitting balls and I couldn't even see the ball. This asshole, I couldn't even see and he's worried about my backhand. It's stupid. You know, at the time I don't think I thought it was too funny. I thought, "What's wrong with me." So things went from bad to worse.”
Sometimes individuals stayed on a medication for months that had no discernible positive effect or which they perceived only modestly influenced their condition. The search for the "right" drug seems analogous to a process of serial monogamy in which individuals move through a series of unsatisfying, bad, or even destructive relationships, always with the hope that the right person will eventually be found. Just as individuals internalise the notion of romantic love with its attendant ideology that one's perfect mate is somewhere in the world, respondents maintained their faith, in spite of a series of disappointments, that they would find the right medication.
“Anyway I think I continued on the imipramine, but they gave me other drugs. Out of all the drugs that I had I can't say that anyone really made me feel better. You know and I can only say that when you find the right drug you really know. "Oh, this is what it means to be better." But I do remember it wasn't imipramine.”
“It's [names drug] been effective and I haven't felt the need for anything else. But I also have the feeling, "I wonder if there is something better that I could take a lower dose of that would be effective." Or, "Isn't there something else now that might be better." I always feel that way (laughs).”
I'm feeling very hopeless [right now]. I'm still taking the Trazadone. I'm also taking an anti-anxiety drug once in a while and I feel like I'm treading water. I'm waking up at five o'clock in the morning even with the Trazadone. I wake up in horror that, you know. I'll be a bag lady, that I'm not going to be able to get through my work day today. Every once in a while I wonder "Have I tried enough stuff. Is there something that would work better?"“
Many of those interviewed never find a drug that dramatically influences things for the better. These people continue to take the medications, but remain only partial believers in biochemical explanations. However, equal numbers among the respondents interviewed describe the "miracle" of medication. It is among these persons that the metaphor to religious conversion is most apparent. For them, the drug truly provides a "revelation" because it makes them feel "normal," often for the first time in their lives. In these instances, any trace of uncertainty about the biochemical basis for their problem disappears. Finding the right medication is, in fact, described as a spiritual awakening, as an ecstatic experience.
“All I can tell you is, "Oh my God, you know when you're on the right medication." It was the most incredible thing. And I would say that I had a spiritual experience.”
“So I started taking this Trazadone. It may have been a week or two. I had never experienced such a magical effect in my whole life. It was just magical. Thoughts that I had been having. . . I had been having these horrible, tortured depressed thoughts and the only thing I can say is that they just stopped being in my head and it was like they had run around in my blood and I just didn't think that way any more. And I started thinking better thoughts, happier thoughts. It was very clear to me that it wasn't the same as being high. Astonishing. It was wonderful. . . After two weeks. I mean, it was just magical. My life began to change profoundly at that point.”
“And then I start seeing this therapist last September twice a week and he recommends going to see a psychiatrist. I go to him and he recommends Doxepin and I start taking that. And then at the end of November it just kind of kicked in. It was a miracle. It really was. Quite extraordinary.”
“Well, I'd had a headache for four months and they treated that with Amitriptyline. And then I changed doctors. I went to the (names a university) health plan. Anyway, I saw a psychiatrist and had been seeing her for a while and I guess probably giving all the classic symptoms that I didn't know existed. And finally she said, "Well, you know, I think one of the problems here is that you're depressed and I'm putting you on Imipramine and see if that's going to work." And when it started working it was like a miracle. It was just like "wow." I know specifically of other times I was very depressed and then when I got out of it I would describe to people "I feel like I've come out of a tunnel."“
While there is a danger in relying too heavily on one biography, it seems worthwhile to present in some detail the dialogue I had with a respondent whose words express particularly well the complexity of depression, the powerful effects of a medication in providing new and plausible realities, and even the uncertainty about "giving up" depression. Although it is not within the province of this paper to offer a full discussion of the "positive" features of depression, several respondents claim that the agony of depression has been instrumental in their spiritual growth. One unanticipated aspect of depression revealed in the interviews is the connection between depression and spiritual life. Several persons in my sample have seriously experimented with Buddhist teachings which they claim, more satisfactorily than Western religions, understands the place of human pain and suffering. Others connect their depression with creativity and insight. The following woman, quoted at length, is a writer. Her comments illuminate the breathtaking impact of feeling normal after years of non-stop pain, the religious-like dimensions of the drug conversion experience, and the uncertainty attached to giving up any long held identity, even one that has been deeply troublesome. Our conversation went like this:
HOW WOULD YOU DESCRIBE THE EXPERIENCE OF PROZAC?
“I went on Prozac. I was like, cracking up, a couple of years ago, and sort of got back to the mental hospital - time number five. And I think the psychiatrist I was seeing, she didn't know what to do with me, so she sent me to this. . . psychopharmacologist, and he prescribed Prozac for me, and within five days, it was very, very strange. . . I mean, it was hard to explain, but, I was just incredibly fearful and anxious, and I really at that point was going to kill myself, because I just was like, "Forget it." You know, "I've worked too hard and tried to conquer this thing too much, and I can't do it." And there was a tremendous amount of anger. But within five days of going on the Prozac it was like the obsessions reduced, and it was a very weird feeling. What was strange about it was that it took away the feeling of depression that I've had in my stomach for years, ever since I was a little girl. It was gone. And I remember not wanting to tell anybody about it, because I thought, this is really strange. . .”
NOT WANTING TO TELL ANYBODY BECAUSE?
“Like, "I think this is working." I was kind of like, "Jesus Christ, what's going on here." Because I'd been on medications that never had done anything for me, and this was so dramatic. . . It was also very dramatic because I was on the brink of really cracking up, and then within five days I wasn't anywhere near cracking up. And actually, it's interesting, because I loved it, but I also wanted to go off of it, because I was sure it was going to take away my creativity.”
SO, IT'S BACK TO THE PAIN/CREATIVITY LINK.
“Oh, because I couldn't write. I was used to being in an anxious state all of the time, and suddenly I didn't care as much about my writing any more. That was what the weird thing was. It [writing] didn't mean as much to me. Nothing meant as much to me. In a way that was incredibly freeing. And at the same time, I built my whole identity around being a person who was, you know, driven, intense, and I tried sort of whipping myself up into an intense state, you know, and it didn't work.”
YOU MEAN, SOMETHING THAT YOU HAD NO TROUBLE WITH BEFORE. . .
“It [the intensity] wasn't there and as much as I hated it before, I also felt like it was who I was, and the Prozac took it away, and I remember thinking, "This is very nice. I should take this when I go on vacation, you know, and [otherwise] get me off of this stuff, because this is going to make a moron out of me."
SO WHAT'S THE END OF THE STORY? STILL TAKING IT?
“Well I remained on it, but the course is kind of rocky because then I was a convert to Prozac, and I was like, "This stuff is incredible." I was thinking, "This stuff is just the greatest stuff I've ever taken in the world." I mean, "this is a miracle." And I would think, "This is a miracle." And it was a miracle, it really was a miracle to me. For that one year, I was so happy. . . And at this point the Prozac has become so intertwined with the millions of meanings that I've given it. Even a God [meaning] for a while.”
As Max Weber (1947) pointed out years ago, even charisma becomes routinised. Persons' commitment and conversion to drugs is completed when those drugs become a routine part of their daily life. The process of adopting the medical version of depression's proper treatment is accomplished when the respondent's initial resistance to drugs completely vanishes. What normally started out as a tentative and ambivalent experiment with medications typically becomes a taken-for-granted way of life. In effect, the persons interviewed have undergone a socialization process that has transformed the meanings to them of medication. The negotiated experiment begun with trepidation has become institutionalised, habitualised, and ritualised. To use the vocabulary offered by Peter Berger and Thomas Luckman (1967), a once alternative and alien "symbolic universe" has become an accepted and seemingly immutable reality. That is, taking medications now appears as an absolutely unquestioned feature of daily reality. Consider the casualness with which those initially opposed to drugs sometimes come to regard them.
“What's interesting to me about the drug now, or at least my attitude toward it, is that I regard it almost as a food supplement. It's just something I eat that's going to have a certain effect. So I don't quite see it as unnatural the way I used to.”
“And then I decided. "Hey, this stuffs pretty good, you know? I can be happy or be less anxious and do productive work." So I thought. "OK. I'll stay on it forever." So it was a total turnaround.”
“[Now] taking medication is pretty much just a reflex.”
“I'm convinced maybe I have to take it for the rest of my life. I'd certainly rather feel like this than feel like that, and if it's two little pills I've got in my mouth every day that makes me stay this way, then so be it.”
Disenchantment and Deconversion
Those who study conversions must include in their analyses the factors that sometimes account for the disenchantment, defection, and deconversion of large numbers of persons from their respective groups or belief systems. Some persons, of course, retain their commitments to alternative realities over the long term. Equally, though, are those who come to question the utility and correctness of the explanatory schemas with which they had experimented and then fully embraced. Of course, even converts stand at different places on a continuum of commitment. Some are never fully convinced of the value of new behaviours and beliefs, are easily disenchanted with new problem-solving perspectives, and return relatively quickly to old perspectives and identities. A few among those studied stayed on drugs for only a short time, deciding that they were not sufficiently effective to put up with noxious side effects. After experimenting with medications, these persons were easily able to return to the view that their problems were environmentally based and that drugs would not be their salvation. The failure of a belief system is much more devastating, of course, when persons had embraced it unreservedly. This was certainly the case for those who had experienced a drug miracle, but who subsequently suffered a relapse. The young woman writer quoted earlier described her response to the eventual failure of the drug after her ecstatic revelatory experience.
“Then I decided I was going to go away to Kentucky and live in Appalachia for two months and do an internship in interviewing women down there. And then again I thought, this is the kind of thing I can do, because now I'm on Prozac and I won't freak out, whereas before that kind of change would have freaked me out. And I went, and I freaked out, and that's when I completely like, relapsed . . . Now I have a somewhat more balanced view of the Prozac in that I can become obsessive, anxious, depressed on it, even very obsessive and anxious and depressed. It's not a miracle drug. 11 hasn't saved me. And it's been a long time coming to terms with that. It helps somewhat, sometimes, and that's where it's at. And, I did for a while think, I am going to be cured. . . It was the ultimate disappointment. You know, it was connected with an intense sense of loss and a sense of redemption, and I do not overstate [things]. It really was that.”
The complexity of stopping medications is evident in the fact that even when they do not appear to fundamentally alter depressive feelings, respondents sometimes become psychologically dependent upon them. Once having experimented with the drugs and having accepted biochemical definitions of their condition, persons feel uncertain about stopping. Whatever their current problems, several individuals were afraid that things might deteriorate if they stopped taking the medications.
“I'm afraid to not take it, but it really hasn’t done much of anything.”
“I mean, it's almost to the point now where I take it sometimes but like I really don't feel like I have the need for it. But I'm sort of afraid not to take it. . . I'm on such a low dosage [now]. He's (doctor) got me on one pill a night. And it's taken, you know, ten years [to get to that point].”
“If I had listened to myself I would have just said, "Screw the medication." But also I think I was probably afraid, afraid that if I went off them completely that I would get worse, and I guess there is some evidence for that.”
“I have a number of friends that are on anti-depressants and we talk about. . . taking medication, and what happens to you, when you lose your bag on your vacation [or something] . . . You know, [what would happen if] you lose your meds. I always carry them onto the plane because I'm afraid of getting all screwed up, because I don't sleep.”
And sometimes persons are afraid to stop the medication because they believe their systems have become too physiologically dependent on them.
“I'm on anti-depressant medicine right now, have been since '83, around there, and I wanted to go off them and I can't. There's no way I can go off them. There is just no way. I would have to spend six months to a year pretty much in a very controlled environment, as my body, my nervous system reacted to not having the stuff.”
Ultimately, the respondents in this study, like the epilepsy patients interviewed by Conrad (1985), become, at the least, ambivalent about the role of medications in dealing with their difficulty. They may feel dependent on the drugs and worry about the consequences of stopping, but they also begin to question the wisdom of staying on the medications. Just as Conrad's epilepsy patients eventually discover that the medications are not the "ticket to normality," it eventually becomes apparent to sufferers of depression that a medical "cure" is not forthcoming. In both instances, patients become disenchanted with the side effects of the drugs, begin to question their efficacy, experiment with dosage levels and sometimes decide even to stop taking them. Conrad describes a number of non-compliance responses of epilepsy patients which reflect efforts to regain control over their illness. He notes (1985: 36) that "[self] regulating medication represents an attempt to assert some degree of control over a condition that appears at times to be completely out of control." His findings certainly seem generalisable to the case of depression, as the following comments illustrate:
“I guess I myself was curious to see what would happen if I were to stop taking it. Partly my wife didn't like the idea that I was on a drug. She's concerned about long range effects and I guess I was a little concerned about that too.”
“I wanted to go off it all along and it started giving me headaches. I wanted to get off it already.”
“I had gained a lot of weight on the pills. I was always a very thin person and here I was carrying forty more pounds. My sense of physical identity was damaged and I wanted out.”
In other cases individuals finally rebel against taking medications as a way of reclaiming selves that they believe have been lost because of their involvement with anti-depressant medications. These persons who vow never to go on the drugs again have plainly had a deconversion experience.
“Now in between the new and the old [medications) there would be a period when they would take me off the thing. And my friends during that stretch without fail would say "You seem like yourself again." And if I had listened closely I would have said, "Gee, the implication of this is that these pills are fucking me up." [Finally] I would go in and say "Can I get off it? Can I get off it?" And he would say, "Try it longer." Finally I thought "I'm not going to ask this son of a bitch any longer. I'm just going to take myself off it." And I did and he either forgot about it or didn't raise it. I just took myself off. . . [And] I will never take another fucking pill in my life. And I'm not generalising to other people. . . But for me, I had gotten so fucked up with this stuff that I will never do it again.”
“I mean, I put my foot down about the Trazadone. I was at the point where I could say, "I'm just going to stop."“
Although the persons quoted in this paper may stand at different points in their drug taking careers, most commonly move through a socialization process which involves overcoming initial resistance to drug taking, negotiating the terms of their treatment, adopting new rhetorics about the cause of depression, experiencing a conversion to medical realities, and eventually becoming disenchanted with the value of medications for solving their problems. This process bears a strong similarity to descriptions of religious conversion and deconversion. That is, one's willingness to begin, sustain, and sometimes stop a doctor-prescribed regimen of anti-depressant medications must be understood in the broader context of adopting a new, identity-altering view of reality; namely; that one suffers from a biochemically based emotional illness. For this reason, the experience of taking antidepressant medications involves a complex and emotionally charged interpretive process in which nothing less than one's view of self is at stake.
The process described in this paper helps in thinking about some of the social psychological dynamics that are part of the "medicalisation" (Conrad and Schneider, 1985) of society more broadly. Implicitly, the analysis throughout this paper refers to an ongoing struggle between professional and lay definitions of illness, reality, and self. As several observers (Derber, Schwartz, and Magrass, 1990; Gross, 1978; Lasch, 1980) have noted, the behaviours of persons in today's "post-industrial" society are dominated by "experts." Experts advise us on virtually every aspect of our lives. Experts follows us through the life course. They are there when we are born and follow us each step along the way, right down to our graves. To be sure, "the relation of the expert to modern society seems. . . to be one of the central problems of our time, for at its heart lie the issues of democracy and freedom and the degree to which ordinary men (sic) can shape the character of their own lives" (Freidson, 1970: 336). And dominant among these experts are physicians who tell us when our bodies and selves need repair and the proper procedures for doing it.
The data in this paper illustrates the power of the "medical model" in defining the appropriate response to emotional problems. The medical model begins with the easily accepted assertion that normalcy is preferable to abnormalcy. However, normalcy then becomes a synonym for health and abnormalcy a synonym for pathology. Health and pathology, in turn, are defined in terms of the presumed scientific, objective, unbiased standards originating from experimentation and laboratory research. Because it is better to be healthy than to be sick, the medical model supports physician's decisions, whether requested or not, to provide health for the patient. By defining certain characteristics of the human condition as "illness," and therefore in need of cure, physicians also provide themselves the right to explore every part of the human anatomy, to prescribe a myriad of curative agents, and frequently, to compel treatment.
The medical model is used to support the political reality created by a coalition of physicians, teachers, judges, and other health professionals. Peter Berger and Thomas Luckmann (1967) refer to this coalition as "universe maintenance specialists." These specialists from different disciplines set the norms defining proper and improper behaviour, deviant and conforming behaviour, normal and pathological behaviour, sick and healthy behaviour. Thus, therapy "entails the application of conceptual machinery to ensure that actual or potential deviants stay within the institutionalised definitions of reality . . . This requires a body of knowledge that includes a theory of deviance, a diagnostic apparatus and a conceptual system for the 'cure of souls' " (1967: 112).
Nowhere, of course, is the struggle over definitions of illness reality and, literally, the mind of the patient more apparent than in psychiatry. The materials presented earlier illustrate that acceptance of medical versions of reality is not an automatic thing. Psychiatric patients are initially resistant to illness definitions of their problem and "come around" to prescribed medical treatments only with great difficulty. Although everyone described in this paper eventually capitulates to medical versions of reality, their conversion is incomplete as they lose faith in the efficacy of drug treatment and sometimes rebel against it altogether. It seems reasonable to speculate that as part of a general and increasing "democratisation" of professional/client relationships, resistance to medical authority will become more intense. Moreover, the terrain of this struggle over reality is most likely to be in the psychiatric arena where the legitimacy of a purely medical model is most suspect.
Laypersons' suspicions about the efficacy and legitimacy of experts' definitions of reality is reflected in the emergence of the "self help revolution." In some respects, the self-help revolution reflects the full-flowering of the therapeutic culture. In self-help groups people turn to others afflicted with the same personal troubles and try, through conversation, to "heal" themselves of what they perceive to be their shared problem. An illness rhetoric (often implying biological causation) is sometimes joined with a spiritual vocabulary (as in programs like Alcoholics Anonymous) positing that "recovery" requires surrendering to a higher power. Thus, the self-help phenomenon derives its allure, in part, by combining elements of therapy with elements of religion and science. It is a powerful brew that has drawn the faith of millions. As might be expected, the response of mental health professionals to the self-help phenomenon has been lukewarm (Powell, 1987, 1990). While many mental health professionals are legitimately concerned about the wisdom of laypersons treating themselves, we should not miss the point that the self-help idea threatens their own claim to exclusive expertise about a number of mental health problems.
The persons interviewed eventually realize that doctors, despite their best efforts, will not clear away their confusions about depression. The socialization process described in this paper involves hope that medication will provide the solution to their problem. In most cases, however, this optimistic attitude was replaced with disillusionment and sometimes anger. The failure of medical treatments for depression provides fertile soil for the emergence of self help groups which offer the view of affective disorders as troubles that must ultimately be remedied by the individuals who suffer from them (Karp, 1992). Such a definition suggests an anti-psychiatry ideology that demands, at the very least, a greater democracy between doctor and patient in efforts to treat the problem. The data and analysis in this paper point to some of the areas of conversation that are likely to become central in the working out of the "identity politics" (Anspach, 1980) inevitably a part of depression's treatment.
1. In the 19605 and 19705, social scientists such as Erving Goffman (1961) and Thomas Scheff (1966), along with psychiatrists like Thomas Szasz (1970) and R. D. Laing (1967) challenged the notion of "mental illness." The power or their analyses notwithstanding, there has been a virtual revolution in psychiatry in the last ten to fifteen years resulting in the hegemony of biological explanations for affective disorders and a nearly universal consensus among psychiatrists that such disorders are most effectively treated with drugs. While there are occasionally social and medical scientists (see for example, Breggin, 1991) who try to renew the debate, their voices are increasingly harder to hear as the medicalisation of emotional difficulties has picked up an overwhelming momentum in recent years.
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Direct correspondence to David A. Karp, Department of Sociology, Boston College, Chestnut Hill, Massachusetts 02167.