Emmons, Kimberley K. Black Dogs and Blue Words: Depression and Gender in the Age of Self-Care. New Brunswick, NJ: Rutgers UP, 2010. Print.
Black Dogs and Blue Words contributes to a burgeoning corpus of scholarship offering accounts of singular mental illnesses such as hysteria, anxiety, and posttraumatic stress disorder. Emmons’ monograph focuses on depression, and, while hers is not the first to do so, her book differs from other studies of depression on several accounts. Emmons’ discourse-centered approach examines the interrelationships of personhood/gender/mental health and illness and demonstrates how language shapes and reflects gendered depictions of the depressed self. On matters of depression, Emmons suggests diagnosis takes place in the absence of diagnostic tests, for example, X-ray imaging and blood work, such that the language of diagnostics makes depression visible: how we talk about and depict depression reflects and shapes contemporary attitudes toward mental health and illness.
For Emmons, language patterns in the discourse of depression such as definitions and metaphors (“the black dog of depression”; “the blues”) encode archetypes and models for the gendered self, and individuals learn how to represent themselves through these language structures (5). As a rhetorical scholar, Emmons intends “to interrogate the rhetorical forms—the definitional words, metaphors, typical stories, and genres—through which depression is expressed, experienced, and treated, in order to understand the gendered illness identities that are available for adoption and, perhaps, rhetorical adaptation” (5). In this regard, Emmons treats the discursive terrain as a rich rhetorical environment for marshalling critical interpretive tactics and responses to cultural norms and stereotypes in the discourse of depression. Emmons carries out her investigation of language patterns in the discourse of depression through corpus-based analysis. The corpus is extensive: a collection of 147 articles, cartoons, comics, and pharmaceutical advertisements from Newsweek and the New York Times (published between 1995-2005), information materials from the National Institute of Mental Health (NIMH), and the Psychology Today newsletter Blues Buster. Emmons supplements these texts with first-person depression memoirs such as William Styron’s Darkness Visible: A memoir of Madness and Elizabeth Wurtzel’s Prozac Nation: A Memoir, as well as semi-structured interviews with two distinct groups of women: four mental health care practitioners (a psychiatrist, a social worker, a psychiatric nurse, a psychologist), and mental health care consumers (university students). Emmons’ accessible style makes the book appropriate for a wide range of readers—humanities and social sciences scholars, health care professionals, and publics—interested in how the language of depression encodes gendered messages about health and illness. The book would be of particular benefit to university instructors and students of scientific communication and rhetoric, particularly rhetoric of health and medicine, and would make a substantive contribution to a syllabus of the sort Emmons designs, in her concluding chapter, for the medical humanities.
The Introduction establishes the rhetorical framework for the chapters. Central to Emmons’ project is the identification of self-doctoring diagnostic practices that position individuals as both “expert” and “patient.” In the role of expert, an individual assumes the diagnostic authority and expertise usually granted a medical professional on matters of health and illness, and, in the role of patient, the health-information seeker measures and evaluates the self using an array of diagnostic tools, for example, self-diagnostic quizzes and checklists on patient advocacy and pharmaceutical company websites. However, Emmons argues that practices of self-doctoring take place within the boundaries of biomedical psychiatry and as such delimit the language of depression and reinscribe traditional gender roles. The standard against which a woman self-measures—women are more likely than men to search for health information—comes from the language and texts she encounters (189 n.2). Some of the language of depression targets girls and women, encouraging self-diagnosis and self-medication and fostering “a rhetoric of patient self-empowerment” in the realm of mental health and illness (3). At the same time, tropes of self-empowerment contribute to bodily self-regulation and surveillance: the female body becomes both the subject of the woman’s own research project and subject to the discourse of medicalization from physicians, pharmaceutical companies, and the media.
Chapter 1 presents depression as “a rhetorical illness: it functions persuasively in our collective and individual consciousness” (6; emphasis in original). The accumulation of linguistic patterns, social responses, and rhetorical appeals through which individuals express their experiences constitute the discourse of depression, and individuals articulate their gendered illness identities through available patterns of expression. Direct-to-consumer advertising (DTCA) slogans like “Talk to your doctor” and symptoms checklists proliferate in the social realm and publics uncritically adopt the linguistic typifications of pharmaceutical advertising for medications like Prozac, suggests Emmons. As a consequence, in first-person memoirs, “the rhetorical landscape of depression is, at times, indistinguishable from the topography of medication” (19). Participation in the discourse of depression often precedes medical consultation and sometimes substitutes for medical expertise altogether, yet practices of self-doctoring take up the tropes of psychopharmacology and offer individuals limited interpretive resources for the articulation of the self outside these cultural familiars.
The first chapter includes an historical overview of the American Psychiatric Association’s (APA) Diagnostic and Statistical Manual of Mental Disorders (DSM). The all-too-brief analysis (four pages) of the four editions and two text revisions of the nomenclature (DSM-I, 1952 to DSM-IV-TR, 2000) focuses on how the authoritative manual coordinates the discourse of depression. Emmons argues that DSM-III and subsequent editions locate the ethos of scientific objectivity in the standardized descriptions derived from data collection and suggests that the diagnostic criteria encourage self-assessment and self–monitoring according to the manual’s organizing principles. Emmons’ historical critique of the professional aims and goals that give rise to the various editions of the APA’s manual reveals how the “vocabulary of data collection” serves the professional discourse community’s research-driven commitments but may not translate to the clinical domain in the service of patients (22). The critique demonstrates the productive value of a critical stance toward the language and purposes of the DSM, yet how the author situates the DSM in relation to her own corpus remains unclear.
In Chapter 2, Emmons outlines the differences between self-doctoring practices, whereby an individual uncritically performs the gendered illness identities represented in discursive constructions of depression, and her recommendation for practices that engage in “a rhetorical care of the self” (58). In place of self-doctoring practices that entail “the submission of an isolated self to biomedical discourses and institutions,” Emmons advocates adopting a critical stance toward available cultural representations and intervening in these stereotypical characterizations of the depressed self in personally meaningful ways (58). On this view, the term rhetorical signals the conscious awareness of self as separate from available discursive representations of the depressed individual. Rhetorical draws attention to situation and audience and attends to the possibility for social action in response to the discourse of depression. A rhetorical understanding of self-care views discourse as central to an individual’s negotiation of personhood as a social endeavor and provides options—counter-valued tactics of diagnosis and intervention—to help “articulate depression” (in two senses: to pronounce and to join with a structure, and determine what illness and health mean for particular individuals in particular times and places) (34).
Rhetorical self-care requires that individuals go beyond available self-constructions based on circulating gendered illness identities (monological) and, instead, make use of rhetorical structures—metaphors, narratives, genres—to develop a more complex, critical (dialogical) stance. With these distinctions and possibilities at hand, Emmons undertakes a nuanced and sustained analysis of two pharmaceutical advertisements. At this point, the theoretical groundwork laid out in the earlier chapters together with rhetorical analysis produces substantive findings. Emmons demonstrates how the scripted narratives of pharmaceutical advertisements promote gendered illness identities and along with biomedical psychiatry promote isolation and self-doctoring practices that reinscribe scripted themes and characters without recourse to counter-valued illness identities. Analysis shows how adopting a rhetorical stance toward self-care encourages a dialogical relationship with the discourse of depression.
Chapters 3 and 4 continue the close analysis of language begun in the preceding chapter. In Chapter 3, Emmons identifies terms of art central to the discourse of depression: condition, disease, disorder, and illness, and analysis shows how modifiers help establish the illness identity as a fixed state rather than a complex field of dynamic processes and experiences (chronic, severe, cyclic, recurrent). Emmons argues that with the publication of DSM-III the term disorder becomes an organizing principle for the biomedical orientation of the manual and constitutive of biomedical psychiatry. On the other hand, the author finds multiple and changeable definitions of depression in the public texts she examines. She suggests that “strategic impression” of definitions for the illness itself and for the accompanying constellation of symptoms work together with diagnostic ambiguity—the fuzzy borders separating illness from wellness—and, as a result, imprecise language facilitates pharmaceutical interventions (63). That is, the “vague syntax of lay definitions” create occasions for self-doctoring, inviting individuals to consider whether they too might be depressed (65). The pharmaceutical invitation to consider the self as ill, however, constrains diagnostic and curative responses to a biomedical intervention—filling a prescription—rather than constituting a more complex rhetorical situation through which individually meaningful representations of illness and wellness emerge. Definitions, then, provide a site for rhetorical intervention, and a critical examination of definitional practices offers a way to understand, and perhaps counter, available illness identities.
In Chapter 4, the author moves away from definitions to investigate the figurative resources of the English language. In the discourse of depression, Emmons finds that metaphors emphasize personal responsibility and isolation and elide opportunities for social and community-based involvement. Tropes of isolation directed at women confine them to the domestic sphere and isolate them from family members—often their children. Pharmaceutical advertisements deploying these tropes depict medication as returning the women to their domestic social networks: to the normative, gendered sphere of activity and identity. Often illness metaphors take the form of domesticated animals (“the black dog”; “le chat bleu”) who take up residence in the home alongside the depressed self “suggesting that the illness ought to be domesticated rather than eradicated” (102-103). These animal familiars never stray far from the depressed individual, bringing the discursive self into alignment with the illness.
Emmons notes that memoirists such as Styron and Wurtzel internalize metaphors of geography, topography, and architecture, and first-person memoirs often narrow the contours of depression to conform to over-simplified neurological and biochemical explanations couched in mechanical metaphors: drugs act as “keys” fitting into the “locks” of neurotransmitter receptors without accounting for the experience of depression. Despite findings that demonstrate the ways in which figurative language reinscribes gendered illness identities and positions the isolated individual within biomedical discourse, Emmons argues that, while depression remains an ambiguous term in her corpus and promotes uncritical practices of self-doctoring based on definitional practices, “metaphors for depression evoke more contextualized definitions” (93). Thus she suggests that examining metaphors within the context of the narratives that produce them provides possible spaces for rhetorical adaptation.
Analysis in Chapter 5 focuses on stories of depression. Narratives, whether first-person memoirs or pharmaceutical advertisements, depict the gendered self in social scenes. A Zoloft advertisement appropriates visual tropes from cartoons and comic strips and borrows the hallmarks of narrative structure to tell “Kathy’s story”—Kathy (a white, lip-stick-wearing, spherical creature) is 41 and lives in Irvine, CA (123). Like the memoirs in Emmons’ corpus, Kathy’s story uses the first-person pronoun to describe her self-doctoring practices: “I went on the web and discovered that Zoloft is the number one prescribed brand of its kind. So I asked my doctor about Zoloft” (123). At the end of the story, medication returns Kathy to social functioning and restores her gendered performance (grocery shopping with her child, sitting on the couch next to her husband). While the Zoloft advertisement delimits illness identities by bringing them into role alignment with circulating cultural stereotypes of healthy women, Emmons discovers moments of critique in the interviews she conducted with women, and notes that storytelling forms an integral part of the experience of depression for these women.
Chapter 6 draws on scholarship in rhetorical genre studies to critique diagnostic checklists. Emmons returns to the DSM, specifically to the current diagnostic criteria for Major Depressive Disorder (DSM-IV-TR), to show how direct-to-consumer advertisements and pharmaceutical websites appropriate the discourse features to fashion their own symptoms checklists, promote their products, and encourage prospective patients to perform their own diagnoses. The symptoms checklist adopts the linguistic terminology and structures of the diagnostic criteria, and adapts the genre to new contexts and purposes. The checklist translates biomedical psychiatry’s diagnostic criteria into a list, narrowing the discursive field and reducing the experience of depression to checked and unchecked boxes. Emmons’ genre analysis shows how pharmaceutical checklists draw on the textual conventions of the codified, authoritative language of the DSM diagnostic criteria to structure social interactions and promote self-diagnosis. In the process, symptoms checklists become popular and powerful cultural artifacts and illustrate how, in the age of self-care, language helps construct self as a site for medical and pharmaceutical intervention.
By way of conclusion, and from within her own sphere of rhetorical competence, Emmons proposes a thought experiment: a university curriculum for an interdisciplinary seminar in the medical humanities that fosters critical discourse and reflection, promotes tactics of self-care, and enacts a dialogical approach to understanding the discourse of depression. In doing so, Emmons inhabits the rhetorical stance she advocates, identifies and outlines one such critical tactic of self-care, and demonstrates how rhetorical competence informs rhetorical action.
Emmons’ book makes important theoretical contributions to scholarship in rhetoric of science, rhetoric of health and medicine, and the medical humanities. At times, however, the sheer number of texts and text types impede the rhetorical force of the analysis. Following the thread of analysis through the corpus of news media texts, government information materials, consumer interviews, practitioner interviews, Blues Buster newsletters, and first-person memoirs of depression sometimes dilutes rather than distills the arguments. However, when Emmons undertakes sustained analysis trained on a particular text or two, for example, analysis of the pharmaceutical advertisements in Chapters 2 and 5 and the diagnostic checklists in Chapter 6, the rhetorical methods produce insightful analysis and fruitful conclusions.
Black Dogs and Blue Words offers a timely critique of the discourse of depression. The DSM is currently under revision, and the APA anticipates a publication date of May 2013 for DSM-5. The draft diagnostic criteria for psychiatric diagnoses including eight classifications under the rubric “Depressive Disorders” are available for public review on the APA DSM-5 website (http://www.dsm5.org). Emmons’ rhetorical approach to the discourse of depression provides a resource for critical readers (mental health professionals and consumers/publics) negotiating the shifting discursive terrain of the diagnostic language of depression and the multiple and diverse textual mediations of self. The book provides invaluable tactics for mental health care practitioners and consumers wanting to develop their own rhetorical competence and a critical stance in relation to the language of depression.