Unprivatizing: A bridge to learning

Virginia Leigh Hamilton Crowe, RN, MS, Ed.D.
Jeanne Ellen Bitterman , MA, MA, Ed.D.

Abstract

Depression is a complicated condition situated in a cultural
environment that often impedes learning. The purpose of this
grounded theory study was to better understand depression from
the perspective of those who are living with depression. Data
were collected from many sources including document review and
autobiographical literature; however, the primary data were
collected through in-depth interviews. Fifteen individuals,
thirteen women and two men, who felt they had learned both
about and from their depression volunteered to participate in the
primary interview process. Analysis of the data generated
categories, properties and the core concept of unprivatizing.
Through theoretical coding a process of learning about one’s
depression emerged which suggests that learning about one’s
depression can be experienced as a transitional and meaningmaking
process that occurs over an extended period of time and
facilitates development.

Background

The disease of depression remains a great mystery. It has yielded
its secrets to science far more reluctantly than many of the other
major ills besetting us. (Styron, 1990, p. 11)

Depression, or depressive illness, is often referred to as a
constellation of disorders that depict a condition or disease which
disrupts a person’s mood, behavior, physical well-being, and
thought (National Institute of Mental Health Depression
Brochure, 2000; O’Connor, 1997; Thompson, 1996). Depressive
illness is most often attributed to a complex interaction between
physiological, psychological, and sociocultural factors (Mazure,
Keita, & Blehar, 2002; Murthy, 2001; Surgeon General’s Report
on Mental Health, 1999). Depression is not a rare phenomenon
nor is it without significant cost.

According to the National Institute of Mental Health (NIMH)
(2000), in any given 1-year period, 9.5% of the population will
suffer from a depressive illness. The World Health Organization
(WHO) notes that major depression presents the greatest burden
of disease for women and is a leading cause of disability globally
for both males and females (Lopez et al., 2006; Murthy, 2001). In
the United States, Major Depressive Disorder (MDD) is a leading
cause of disability and produces one of the highest medical costs
of all behavioral conditions (Goldman, Nielson, & Champion,
1999; Hasin, Goodwin, Stinson, & Grant, 2005). It is most
difficult to calculate the significant personal and family costs
associated with depressive illness, specifically given that one of
the most indefinable and devastating of these costs is suicide
(Dumais et al., 2005; Goldman, Nielson, & Champion, 1999).

The Surgeon General’s Report on Mental Health (1999)
states that more than 80% of people with depression can be
treated successfully with medication, mental health therapy or a
combination of both (Goldman, Nielson, & Champion, 1999;
Mazure, Keita, & Blehar, 2002; Murthy, 2001; O’Connor, 1997).
The difficulties dealing with depression include the underdiagnosis
and cultural stigma associated with mental illness; the
complex interaction between physiological, psychological, and
sociocultural factors; and the numerous yet often elusive and
compounding contributors and triggers to depressive episodes.
Thus, to become aware of, acknowledge, and continue learning
about depression and how it interacts with one’s life are daunting
tasks (Beck, Tush, Shaw, & Emery, 1979; Burns, 1999; O’Connor,
1997). And while much is known about what the experts believe
is important to teach the depressed individual (Beck, Tush, Shaw,
& Emery 1979; Burns, 1999; O’Connor, 1997), little is known or
understood about the essential process of learning about
depression from the perspective of those living with and learning
about their own depression. The purpose of this study was to
explore the experiences of those who are living with and learning
about their own depression and better understand their process
of learning about depression as it unfolds over a continuum of
time.

Methodology

This study was situated in the constructivist interpretivist
paradigm aligned with the “goal of understanding the complex
world of lived experience from the point of view of those who live
with it” (Denzin & Lincoln, 1998, p. 221). The rigorous and
emergent analytic characteristics of grounded theory were
especially applicable to the process of learning about depression,
which is embedded in social situations and influenced by
individuals as well as organizational structures. A basic tenet of
grounded theory is that “all is data” (Glaser, 1998, p. 8). In
alignment with this tenet, data for this study were collected from
several sources, with the foremost source being interviews with
individuals who have experienced depression. Other data sources
included document review (depression information available to
individuals online or in physician’s offices), autobiographical
literature, from which the original themes developed, and two
data collection instruments used with interview participants – a
Demographic Data Sheet and Learning Audit Tool, both
developed by the authors for the study. The primary participants
were 15 individuals who, by design of inclusion criteria, had
experienced more than one episode of depression, who were not in
an acute stage of depression, who had access to help if needed,
and who felt they had learned from and about their depression.
The participants were obtained through self-identification,
referrals, and snowball sampling.

The Theory of Unprivatizing

Individuals with depression often veil their symptoms and
keep their experience private. Recognizing and learning about
one’s depression is difficult and inhibited by privatizing
influences. These privatizing influences, such as the near normal
characteristics of depression, familial beliefs, and societal
minimizing, are many, varied, and often synergistic.
Furthermore, these privatizing influences are embedded in and
supported by a cultural and societal stigma against mental
illness. As the individual’s symptom veil begins to weaken, the
medicalization of depression provides a language and access to
support the unprivatizing process; leading to learning and
development.

The core variable of the theory, unprivatizing, is identified
by specific changes in the individual’s actions and attitude.
Behaviors such as obtaining an outside view, seeking consistent
discourse, and developing the ability to critically reflect are noted.
In addition, an attitudinal awareness and acknowledgement of
the limitations and weaknesses of the culture emerges. These
changes appear to happen initially in a sequence (stages) which
occurs over time and becomes iterative. This process greatly
facilitates the individual’s awareness and understanding of their
own relationship with depression. In addition, growth and
development in frames of reference often occur, making these
frames more useful for living and decision making. The individual
often outstrips the care professional in their ability to understand
their depression.

The transition to integrating is identifiable by specific
changes in the individual’s actions and attitudes. Behaviors such
as an unbending intention to persevere, reflect, learn, and
unlearn habits of mind and patterns of behavior that no longer
serve are noted. In addition, an attitudinal awareness and
acknowledgement of the limitations and weaknesses of the
clinicalization or medicalization of depression emerges. These
changes appear to happen in an overlapping and iterative process
which occurs over time and further facilitates the individual’s
awareness and understanding of their own relationship with
depression, as well as, their personal understanding of being and
living. Transformative learning is a characteristic of this period;
individuals identify and critically scrutinize long-held and
previously unexamined beliefs and assumptions supporting
further growth and development.

Privatizing

I was still holding everything together so well that the people
around me had no clue. (primary participant, 2006)

The condition of privatizing is characterized by the intentional or
unintentional veiling of one’s depressive symptoms from self,
from others or from both. It is also characterized by very little
learning related to one’s depression other than unintentional—for
example, content knowledge related to symptoms and treatments
from advertisements on numerous television and radio
commercials and programs. Privatizing occurs within the
generalized context of cultural and societal stigmas of mental
health issues. As noted previously, this stigma is deemed by
many as a key factor inhibiting ones awareness and further
learning. However, many other covariant privatizing influences,
such as the characteristics of depression and familial beliefs, are
identifiable as well. Unprivatizing influences are also recognized
in this phase. These influences, specifically symptom veil
weakening and the medicalization of depression, support the
beginning of transition from the privatized state.

Privatizing Influences

Personal shame or embarrassment of one’s depression is
common as is cultural disgrace Through acts of actual, observed,
or experienced societal punishments such as job loss, rejection or
exclusion. Together, these pragmatic and specific influences
support privatizing of the individual’s depressive symptoms and
symptom veiling; thereby inhibiting awareness and
acknowledgment of depression. In addition, less overt variables
are also significant privatizing influences. These include societal
minimizing of depression (as when people offer “simple” solutions
like increase exercise) and depression guilt, which can originate
from either oneself or can be stimulated by others (or both). This
guilt may be epitomized in disguised-advocacy inquiries such as,
“You have such a beautiful family and home. Why are you
depressed?”

Individual and family beliefs or assumptions, perhaps more
hegemonic in nature than not, may also support symptom veiling
in more subtle, yet equally effective, ways. Examples of collusion
with depression to veil symptoms and privatize pain include the
exuberant individual embedded in a stoic and quiet familial
culture, a young mother who perseveres diligently beyond her
physical strength to support her family, or the family that loves
each other but does not share private matters.

Characteristics of depression then compound the situation.
As noted in the Surgeon General’s Report on Mental Health
Issues (1999) and experienced by many, depression is extremely
complex and has no singular identifiable cause. Yet the symptoms
of depression are described as ordinary feelings such as sadness,
fatigue or loneliness. In addition, for many individuals,
depression has been a long-term partner, bringing a normalcy to
this state of being. Together, these factors inhibit discernment of
depression by creating a “haze” that makes it difficult to identify
when normal ends and depression begins.

Further confusing this situation is the negative reinforcing
cycle inherent in many depressive symptoms and described by
some individuals. For example, one is fatigued with depression,
which leads to lack of movement, which leads to increased
fatigue; or an individual feels sad, which leads to withdrawal,
which leads to isolation, which leads to more withdrawal and
more sadness.

Unprivatizing Influences

Suppression or veiling of symptoms, from self or from others,
for a long period of time becomes increasingly difficult. Often
individuals experience an increased intensity of their symptoms
with a resultant inability to control symptoms, such as tears or
anger, in desired situations. These periods of increased intensity
of symptoms or unexpected loss of control indicate a weakening of
the symptom veil and are often a significant factor that leading to
recognition of depression—a recognition coming both from within
and without, from self as well as from family or friends.

The current cultural medicalization or pathologizing of
depression—such as classifying of depression as a disease,
successful recent pharmacological treatments, and increased
knowledge of depression pathophysiology—has provided an
alternative perspective and unprivatizing influence upon the
pervasive context of the cultural stigma surrounding depression
and mental illness. In addition, increased public awareness and
knowledge of depression through public health education and
medical marketing have given the public a common language to
discuss depression. As a result, it has become easier to talk about
symptoms and successful treatments, and to build awareness of
relatively easy access for help via the primary care physician.

Transition

There is no singular path or means by which an individual
can become aware of and acknowledge his or her depression. It
goes without saying, however, that finding a path is necessary if
one is to learn about depression. Although not always an
identifiable event at the moment, or even similar for all
individuals, the experience of conceding and recognizing
depression appears to occur within a definable range of conditions
over a continuum of time, and is eventually identified as central
to the transition from privatizing to unprivatizing.

For some individuals, detecting symptoms and identifying
them with depression occurs almost concurrently and can often
be associated with a very specific and memorable moment in
time. For some individuals, the concurrent experience is driven
by individual self-reflection and awareness. For others, the
awareness comes more as a surprise and is sometimes first
recognized by someone with an outside view (e.g., a healthcare
worker or a family member).

Others become slowly aware of depressive symptoms and
depression over a period of time. Individuals are less able to
pinpoint awareness and connect it with acknowledgment because
it is more of an unfolding process. Rather, the individual
experiences a slow dawning of awareness that the sadness,
aloneness or pain one consistently feels might be depression.

For some individuals, the unfolding process is a linkage of
trends, such as inappropriate crying on the way to work, fatigue
and laziness. For others, the unfolding is an unlinking of often
interdependent and confounding symptoms. Over time,
individuals begin to unlink their depressive symptoms from other
simultaneously occurring symptoms, events or illnesses, such as
unlinking depression from anorexia. This can be a tedious and
difficult process, and the unlinking does not negate the
interdependence or synergistic nature of the other concerns.

Unprivatizing

I think there’s something incredibly valuable about talking about
depression openly and learning to articulate your own depression
and having somebody with empathy listen to you and be gentle
with you. And I think that does help you to judiciously share. It
helps you to understand when it’s appropriate, when it’s safe.
(primary participant, 2007)

Unprivatizing also occurs within the generalized context of
cultural and societal stigma toward mental health issues;
however, the stigma appears to be less influential in this phase,
which is clearly characterized by engaging an outside view. In
addition, an acute awareness of the limitations and weaknesses
of the culture emerges and is given voice.

Actual societal barriers within the culture, often enhanced
by an unchallenged appreciation for individualism, are
acknowledged and noted as impediments to mental health and
wellness. Limited mental health access and reduced therapeutic
visits (e.g. 10 minutes a visit) are examples. Unprivatizing
involves three stages: Start Talking; and, Self-knowing. Although
the stages are depicted as being linear and described as almost
stepwise, they become somewhat fluid and recursive. The first
stage, Start Talking, occurs initially either before or concurrent
with Help-finding. Self-knowing follows after both Start-Talking
and Help-finding. After initial experience of all three stages, the
stages become iterative and flexible.

During unprivatizing, individuals value outside views, seek
out discourse, and are able to critically self-reflect. Primarily
during the first two stages, individuals gain much depression
knowledge, mostly through informal self-directed learning. This
general knowledge pertains to the medical model of depression as
a disease, common symptoms associated with depression, and
current medical standard interventions, such as talk-relational
therapy and medication. The third stage, Self-knowing, is
distinguished by increased learning which occurs primarily
through experiential learning and is centered on one’s knowledge
of his or her unique personal experience with depression.

Start Talking

The beginning of the start talking stage, for most (although
not all) individuals is recognized as a clearly defined moment in
time. At such a moment, the subject of depression is broached,
either directly or indirectly, with another individual or
individuals and an outside view received. The movement toward
unprivatizing and sharing one’s story can be on the continuum
ranging from either a very linear direct approach or a very
circuitous indirect approach. The direct approach
straightforwardly recognizes and situates one’s depression. The
indirect approach involves first talking about another issue,
condition or situation and eventually turning to the issue of
depression or depressive symptoms. For example, this might
occur while talking about another condition, such as Adult ADD,
or describing a related symptom, such as anxiety. The setting of
the stage for disclosure appears to require establishing a safe
environment and most often occurs with a professional or trusted
friend or family member.

Help-finding

The Help-finding stage is characterized by discovering a
method to support continued awareness and initial learning
about one’s depression and also involves an outside view. The
healthcare system is the most likely—although not the only—
place to find help. Primary care providers, mental health
professionals, and specialists are common supports in the Helpfinding
stage. However, friends, family or religious leaders,
separately or in conjunction with each other and the healthcare
system, may also be utilized for support.

Although Start Talking and Help-finding differ, they may
coincide. The time in which individuals begin to talk and obtain
an outside view of their experience might overlap with their
pathway to help. Others find a gap, and so the experience
becomes much more of a hunt or journey to find supports for
learning about depression. One reason for this gap, other than
the individual’s desire for it, is that depression can easily become
entwined or linked with other conditions and hence hidden.
Therefore, the depression is not easily identifiable, creating a gap
between expression, recognition, and help-finding.

Another reason for the gap comes from the healthcare
system, which can unfortunately be experienced as an
impediment that thwarts and delays oft times by misdirection,
mistreatment or misdiagnosis. Other impediments from the
healthcare system include lack of access (i.e., inability to schedule
a timely appointment), poor service experience, and insurance
limits or rejections. In worst-case scenarios, the healthcare
system might even cause harm as a direct result of medical
intervention.

There is a noticeable “fit factor” within the Help-finding
stage. This “fit factor” appears to have three aspects: a fit with
personal beliefs, a fit with an individual’s specific situation and
desired characteristics, and a fit with wanted structure. A good fit
corresponds with an individual’s personal religious or
philosophical beliefs and is also compatible with the unique
situation and desired characteristics of the individual. For
example, if one is part of a bi-cultural family living in different
countries, a multi-national awareness might be desirable. Or if
one is a professional, then an understanding of professional needs
and requirements would be essential. Overall, a noncondescending
and supportive, yet also challenging, environment
is most desired. In addition, the type of structure favored is
related to fit. Help-finding might be short-term, as in meeting
with someone once or twice, or long-term help over several
months. Structure needs might be acute and episodic or
continuous and systematic. A bad fit can inhibit learning and
cause delay, if not damage.

Self-knowing

Self-knowing is characterized by the individual’s growing
knowledge of the unique manifestation of depression in their
lives, as well as the specific characteristics of their relationship
with depression. Environmental, relational, and meaning
precipitants are explored. These precipitants or contributors are
multiple, non-hierarchical, and converging. Symptoms are more
clearly identified; physical, emotional, and self-worth symptoms
merge into a distinctive and unique symptom complex. For some
individuals, symptom progression is eventually recognizable. An
individual, personal, and unique “depression footprint” emerges.

Interventions are created, analyzed, and adapted. These
individualized interventions range from minor changes in diet
and exercise to major lifestyle changes, from learning specific
skills to situational avoidance, from creating a life history to
psychodrama . One’s own physiology, in relation to and apart
from depression, is studied and becomes more understandable.
Others, also become more acutely aware of the unintended
aftermath of their depressive episodes, such as damage to their
relationships, may seek to learn about healing this damage.

Transition

Although the phase of unprivatizing is distinguishable from
integrating, the actual transition between the two is less clear.
Since integrating is a more inclusive, overlapping, and iterative,
then perhaps the transition is as well. Three characteristics,
however, do appear evident in individuals who move to the third
phase. First, the clinicalization or medicalization of depression
becomes insufficient to contain and describe the entire lived
condition. Second, transformative learning (Mezirow, 1991, 2000),
at least at the process level, becomes evident. Third, the
individual characteristic of an unbending intention to persevere,
reflect, learn, and unlearn habits of mind and patterns of
behavior that no longer serve is asserted as a coherent
commitment.

Integrating

Part of it was learning for me…learning that I had gifts and I had
things to contribute. Learning that they were worthy, and that
they’re notable and that they should be used instead of shrugging
them off and not believing in me or them or truly the outcome of
what they could do.(primary participant, 2007)

Integrating is much less influenced by the ever present cultural
and societal stigma of mental health issues and characterized by
an acknowledgment of the limitations of the medicalization of
depression. This phase is further distinguished by the entrenched
value of and developed structure for personal reflection and for
obtaining a consistent outside view. Integrating also consists of
three stages: Self-discovery,Self-caretaking, and Meaningmaking.
These stages overlap and are integrated. In addition,
they are distinguished by profound personal awareness. The
learning in integrating, however, is centered not on depression as
much as on the individual’s being in the world—situating his or
her essence, nature, personality, and behavior, both healthy and
unhealthy, in context.

Self-discovery

In the stage of Self-discovery, participants identify their own
patterns of behavior that often exacerbate or contribute to their
depression, such as unrelentingly self-judgment, striving for
perfection, over accommodation and minimizing hurtful behavior.
Furthermore, assumptions and beliefs that can contribute to
depression, or drive unhealthy or uncomfortable behavior
patterns, are surfaced and examined; for example, changing from
a dichotomous thinking of “I either succeed or I fail—there’s no in
between” to a more understanding and compassionate stance
with oneself; or, the realization that laziness is not experienced
fatigue and resting, nor love expressed by over-accommodating in
relationships.

In addition, individuals in this phase become more aware of
what they value and from where they draw energy. For example,
being aligned in “heart, mind, and body,” deriving energy from
being creative or spending time with nature or animals. Finally,
although not lastly, individuals in this stage often seek and learn
about their worth and purpose; for example, becoming aware that
unfulfilled dreams and goals were related to, although not the
total cause of, ones depression; or learning to not only to
recognize one’s gifts core to one’s being, but also to appreciate
(and act on) their worth.

Self-caretaking

Learning in the phase of integrating is not solely focused on
depression (as it is in unprivatizing); however, in the stage of selfcaretaking,
a profound learning occurs about one’s relationship
with and sharing of his or her depression. Individuals in this
stage learn to disclose their experience with depression more
thoughtfully—a “wise” unprivatizing. This wise unprivatizing
contains two aspects. First, there is a judicious management or
“being strategically authentic” and acknowledging the potential
effect of cultural stigma against mental heath issues, while not
deciding to disclose solely on that issue. The other aspect of
“wise unprivatizing” is related to the oxymoron-like
characteristics of depression as both complex and near-normal,
both common and unique. Individuals who learn about their
depression know the insipid nature of the condition, how common
it looks, how complex it is, and how easily it can be missed. They
also know well their unique “footprint” and share it wisely with
others who love them and help them feel safe. This wise
unprivatizing creates a vigilant comrade, who willingly shares
the responsibility with the individual to continually observe for
that “footprint.” It is quite contrary to the phenomenon of codependency.

During this stage, individuals also move from a depression
focus to a “being” focus, and learn to change personal and
ingrained patterns of behavior or habits of mind, often becoming
more comfortable with joy and embracing more compassion
toward their own selves. While the old habits might have served
the individual well in the past, they no longer do so. Synergistic
to this learning of changed behavior is learning to recognize one’s
physiological, psychological or social needs independent of
depression, and then to take actions to fulfill them.

Finally, individuals learn to consciously challenge
assumptions and then purposefully choose to hold, revise, and
even abandon them. These assumptions or beliefs might be
personal, such as beliefs about one’s unique ability, intelligence or
core being; or they might be cultural, related to one’s being or
place within the culture. They might also be familial or societal
beliefs about appropriate behaviors or patterns of contemplation:
such as reflection on one’s heterosexuality, examination of
dichotomous thinking patterns, or a critical investigation of the
traditional beliefs of one’s profession or practice. The assumptions
may or may not be associated intimately with the experience of
depression, but they are all associated with the matter of living.

Meaning-making

The meaning-making stage of integrating consists of two
approaches: making sense of depression and reaching out.
Individuals struggle to make sense of depression in their lives
often by utilizing multiple frames. Some individuals make sense
of the experience by identifying the individual benefits of selfdiscovery.
For example, identifying that self-knowledge stems
from one’s experience with depression or that depression,
although not wishing it on anyone, can be a great teacher. Other
individuals make sense of depression in a socio-cultural or
familial context, identifying cultural oppression and suppression
of emotions as contributors to depression, along with trauma such
as physical or sexual abuse, neglect, and abandonment.

In addition, many individuals make sense of depression in a
physiological manner, such as the familial tendency associated
with depression. Others understand their depression, at least
initially, through the use of the medical model of depression—
describing it as a “disease of distortion”—as “treatable” but not
“curable.” Finally, some individuals describe a religious or
spiritual approach to making sense of their depression. Some use
a more traditional religious frame, describing both God and the
devil in depression; others assume a more undefined, less
traditional spiritual perspective.

Reaching out to others about the depressive experience is
identified as a significant second dimension to meaning-making.
Two reasons surface the desire to share. First, sharing one’s story
with individuals who also appear to be experiencing depression
seems driven by compassion. It is highly personal, and most often
occurs with family members or close friends. Second, helping to
increase awareness of depression and mental health in one’s
culture and society is more akin to social action, which may
challenge and change the prevalent paradigm of mental health.
Neither reason is done carelessly; both spring from the
mindfulness of cultural and societal stigmas, as well as one’s own
health. Although reaching out publicly is characterized by
concern, caution, and forethought, it is also noted as empowering.

Discussion

A significant discovery of this study was the transitional
learning process that the participants underwent as they learned
about their own depression. This transitional process fits and is
relevant to the literature and research on the phases and
transitions within the experience of depression (Amankwaa,
2000; Beck, 1993, 2002, 2006; Regev, 2001; Schreiber, 1995,
1996). The discovery of the phased learning process expands
current theory on the experience of depression by making more
visible the less understood perspective of “how people actually go
about understanding and organizing their recovery from
depression” through learning (Ridge & Ziebland, 2006, p. 1038).

In privatizing, awareness and acknowledgment of depression
by the participants in this study were inhibited by multiple
confounding psychological, physiological, sociocultural, and
depression-specific factors, which are also noted in the depression
literature (Amankwaa, 2000; Beck, 1993, 2002, 2006; Beck et al.,
1979; Burns, 1999; Goldman, Nielson, & Champion, 1999; Kessler
et al., 2003; Murthy, 2001; O’Connor, 1997; Pignone et al., 2002;
Regev, 2001; Schreiber, 1995, 1996; Surgeon General’s Report on
Mental Health, 1999). Learning about one’s depression is boxed
in by these forces and does not effectively begin until privatizing
ends. This inhibiting of learning by lack of awareness and
engagement in experience is recognized and supported in the
adult learning literature (Boud, Cohen, & Walker, 1993; Brew,
1993; Jarvis, 1987, 1992; Kolb, 1984; Mezirow, 1991, 2000).
Specifically, the research of Jarvis (1987, 1992) on meaningful
and meaningless experience and non-learning helps explain this
evident lack of learning in the participants.

Although a difficult process, all individuals in the study
transitioned from privatizing into unprivatizing. The transition
was often stimulated by a disjuncture in their experience and
supported by their exposure to the widely available and medically
reliable information on depression. This disjuncture in experience
and interaction with an extant body of knowledge initiated helpseeking,
provided an alternative perspective, enhanced
communication, and facilitated learning. The impacts of such
disjuncture is well documented in the adult learning literature
(Boud, Cohen, & Walker, 1993; Brew, 1993; Jarvis, 1987, 1992;
Kolb, 1984; Mezirow, 1991, 2000) as well as in the depression
literature (Hanson-Lynn, 2005; Karp, 1994; Moreta, 2007).

In the Unprivatize phase, individuals began dealing with the
complex and problematic issue of their depression by interacting
with others, engaging their emotions, and acting on their
experience. All individuals in the study utilized a self-directed,
informal, experiential learning which is described in the adult
learning literature as well (Boud, Cohen, & Walker, 1993; Jarvis,
1998; Kolb, 1984; Marsick & Watkins, 1990). The result was
deeper learning and a more expanded meaning perspective
entailing a reconstructed and more useful frame for making
meaning of their experience with depression (Merriam &
Caffarella, 1999; Mezirow, 1991, 2000).

Not all individuals in the study transitioned into integration,
which is characterized not only by a challenge to the clinical
pathologized view of depression, but the ability and practice of
the participants to reflect on perspectives, both theirs and others,
associated with depression and worldviews. The depth of this selfdirected,
informal, experiential learning led to a profound
personal awareness centered not only on the individuals’
experience with depression, but with their constructed being in
this world; this then supported transformations of their prior
meaning perspectives. This perspective reflection is noted in the
depression literature associated with recovery (Granek, 2006;
Ridge & Ziebland, 2006; Schreiber, 1995, 1996) and noted in adult
learning literature related to transformational learning and
development (Brew, 1993; Merriam & Caffarella, 1999; Mezirow,
1991, 2000).

Merriam and Caffarella (1999) note that “to extract deeper
and more expanded learning from some of our most difficult
times, adults often need an extended period of time and the active
support and caring from others” (p. 108). That was the case for
the individuals in this study as their learning occurred in phases
over time, was supported by a safe environment, and facilitated
by an outside view. The result was a profound and more complex
learning through difficult times.

Limitations

This exploration into a number of personal experiences of
individuals with depression yielded not only information on how
these individuals became aware of and acknowledged their
depression, but also on what and how they continued to learn
about their depression over time and about the factors that
facilitated or impeded their learning. Both privatizing and
unprivatizing emerged rather early as conceptual categories of
importance with many related sub-categories and properties. The
concept of “unprivatizing” was not recognized as the core variable
until late in the coding process. This led to further theoretical
sampling to develop concepts and categories related to the
continuing learning process of integrating. This concept is
perhaps not as well developed, or saturated, as unprivatizing, yet
it is sufficiently developed to be included in the emerging theory.

Conclusion

I would say my whole life has transformed in the last seven years,
where I felt I was living life from an ocean of depression and able
to get to the surface periodically—and now I feel like I live my life
in the sunshine and periodically I step into some deep pool and go
[laugh] whoops, I need to get myself out of this. So it’s been a
lifelong sort of transformation of the way I experience myself
within it. (primary participant, 2007)

This study contributes to the small but growing body of grounded
theory research using qualitative data which is focused on the
relevant issue of personal meaning that people attribute to
depression and how they understand and organize their
experience of living with and recovering from depression.
Merriam (2004) notes that the link between development and
learning is clear in transformational learning theory and that
growth and development are recognized outcomes of
transformational learning. The growth and development of all the
participants in the present study were evident by the
reconstructed manner in which they made meaning of their
relationship with depression. For some, the development also
entailed a deep shift in their frame of reference, a transformation
to a more developed meaning scheme which was more useful and
complex, more connected to self and to others, and more reflective
of assumptions—both personal and cultural, both prescriptive
and paradigmatic.

The contribution of this study provides an enlarged
framework from which to view learning about one’s depression as
a progression over time verses a quantitative knowledge
dumping. It provides actionable items which could be used to
assist learning, such as the unique foot print and the fit factor.
However, to the authors, the most valuable contributions are
encouragement to providers and adult educators, as well as
individuals who are experiencing depression, and their families,
to take hope that learning matters, meaning can be found,
recovery can happen, and growth can occur. Life can be worth
living.

Authors

Virginia Leigh Hamilton Crowe, RN, MS, Ed.D.
Principal, Hamilton Consulting, LLC
Email: VLHC@HamiltonC.org
Jeanne Ellen Bitterman , MA, MA, Ed.D.
Lecturer, Teachers College, Columbia University

Acknowledgements

To those who shared their time and stories with us, words are not
enough to express our admiration and appreciation. The first
author also wishes to thank her sponsor, valued colleague and coauthor,
Jeanne Bitterman, for your unwavering support and
continued belief in me and this work. To Barney Glaser, Ph. D.
for the discovery of grounded theory and your perseverance to
make it accessible to all who desire to learn we offer our immense
gratitude. To the attendees at the New York City Fall 2006
Grounded Theory Seminar, where the primary researcher was a
“troubleshootee”, I thank those of you who supported me in my
attempt to “just do it.” And finally I would like to acknowledge
Judith Holton for her perseverance, wisdom, and experience.

References

Amankwaa, L. C. C. (2000). Enduring: A grounded theory
investigation of postpartum depression among African-
American women. Ph.D. dissertation, Georgia State
University, Atlanta, GA.

Beck, A. T., Tush, A. J., Shaw, B., & Emery, G. (1979). Cognitive
therapy of depression. New York: The Guilford Press.

Beck, C. T. (1993). Teetering on the edge: a substantive theory of
postpartum depression. Nursing Research, 42(1), 42-48.

Beck, C. T. (2002). Revision of the postpartum depression
predictors inventory. Journal of Obstetric, Gynecologic,
and Neonatal Nursing, 31(4), 394-402.

Beck, C. T. (2006). Postpartum depression: It isn’t just the blues.
The American Journal of Nursing, 106(5), 40-51.

Boud, D., Cohen, R., & Walker, D. (Eds.). (1993). Using experience
for learning. Buckingham, UK: Open University Press.

Boud, D., & Walker D. (1993). Barriers to reflection on
experience. In D. Boud, R. Cohen, & D. Walker (Eds.),
Using experience for learning Buckingham, UK: Open
University Press, pp. 73-86.

Brew, A. (1993). Unlearning through experience. In D. Boud, R.
Cohen, & D. Walker (Eds.), Using experience for learning
Buckingham, UK: Open University Press, pp. 87-98.

Burns, D. (1999). Feeling good: The new mood therapy. New York:
HarperCollins.

Depression.com. (2006)
http://www.depression.com/types_of_depression.html

Dumais, A., Lesage, A. D., Alda, M., Rouleau, G., Dumont, M.,
Chawky, N., Roy, M., Mann, J. J., Benkelfat, C., &
Turecki, G. (2005, November). Risk factors for suicide
completion in major depression: A case control study of
impulsive and aggressive behaviors in men. The American
Journal of Psychiatry, 162, 2116-2124.

Glaser, B., & Strauss, A. (1967). The discovery of grounded theory:
Strategies for qualitative research. Mill Valley, CA:
Sociology Press.

Glaser, B. G. (1978). Theoretical sensitivity. Mill Valley, CA:
Sociology Press.

Glaser, B. G. (1992). Basics of grounded theory. Mill Valley, CA:
Sociology Press.

Glaser, B. G. (1996). Gerund grounded theory: The basic social
process dissertation. Mill Valley, CA: Sociology Press.

Glaser, B. G. (1998). Doing grounded theory: Issues and
discussions. Mill Valley, CA: Sociology Press.

Glaser, B. G. (2004). Remodeling grounded theory. The Grounded
Theory Review, 4(1), 1-22.

Goldman, L., Nielson, N., & Champion, H. (1999). Awareness,
diagnosis, and treatment of depression for the Council on
Scientific Affairs, American Medical Association. Journal
of General Internal Medicine, 14, 569-580.

Granek, L. (2006). What’s love got to do with it? The relational
nature of depressive experiences. The Journal of
Humanistic Psychology, 46(2), 191-208.

Hanson-Lynn, J. A. (2005). Help-seeking with postpartum
depression: A retrospective analysis of women’s experiences
of PPD and their help-seeking process. Psy.D. dissertation,
Argosy University, Seattle, WA.

Hasin, D., Goodwin, R., Stinson, F., & Grant, B. (2005).
Epidemiology of major depressive disorder: Results from
the National Epidemiologic Survey on Alcoholism and
Related Conditions. Archives General Psychiatry, 62,
1097-1106.

Jarvis, P. (1987). Meaningful and meaningless experience:
Towards an analysis of learning from life. Adult
Education Quarterly, 37(3), 164-172.

Jarvis, P. (1992). Paradoxes of learning: On becoming an
individual in society. San Francisco: Jossey Bass.

Karp, D. A. (1992). Illness, ambiguity and the search for meaning:
A case study of a self-help groups for affective disorders.
Journal of Contemporary Ethnography, 21(2), 139.

Kessler, R., Berglund, P., Demler, O., Jin, R., Koretz, D.,
Merikangesw, K., Rush, J., Walters, E., Wang, P., et al.
(2003). The epidemiology of major depressive disorder:
Results from the National Comorbidity Survey
Replication (NCS-R). Journal of the American Medical
Association, 289(23), 3095.

Kolb, D. (1984). Experiential learning: Experience as The Source
of Learning and Development. Upper Saddle River, NJ:
Prentice-Hall.

Lopez, A., Mathers, C., Ezzati, M., Jamison, D., & Murray, C.,
(Eds.). (2006). Global burden of disease and risk factors.
Washington, DC: The World Bank, and New York: Oxford
University Press.
Marsick, V. J., & Watkins, K. E. (1990). Informal and incidental
learning in the workplace. New York & London: Routledge

Marsick, V. J., & Watkins, K. E. (2001). Informal and incidental
learning. New Directions for Adult and Continuing
Education, 89, 25-34.

Mazure, C. M., Keita, G. P., & Blehar, M. C. (2002). Summit on
women and depression: Proceeding and recommendations.
Washington DC: American Psychological Association.
Available online at
www.apa.org/pi/wpo/women&depression.pdf

Merriam, S. B. (Ed.). (1993). An update on adult learning theory.
San Francisco: Jossey-Bass.

Merriam, S. B. (1998). Case study research in education: A
qualitative approach. San Francisco: Jossey-Bass.

Merriam, S. B. (Ed.). (2001). The new update on adult learning
theory. San Francisco: Jossey-Bass.

Merriam, S. B. (2004). The role of cognitive development in
Mezirow’s transformational learning theory. Adult
Education Quarterly, 55(1), 60-68.

Merriam, S. B., & Caffarella, R. S. (1999). Learning in adulthood
(2nd Ed.). San Francisco: Jossey-Bass.

Merriam, S. B., & Heuer, B. (1996). Meaning-making, adult
learning and development: A model with implications for
practice. International Journal of Lifelong Education,
15(4), 243-255.

Mezirow, J. (1991). Transformative dimensions of adult learning.
San Francisco: Jossey-Bass.

Mezirow, J., & Associates. (2000). Learning as transformation.
San Francisco: Jossey-Bass.

Moreta, F. (2007). The initial help seeking experiences of women
with depression. M.S. dissertation, Long Island
University, The Brooklyn Center, NY.

Murthy, R. S. (Ed.). (2001). The World Health Report: 2001:
Mental Health: New understanding, new hope. Geneva,
Switzerland: World Health Organization.

National Institute of Mental Health (NIMH). (2000). Depression
brochure. Bethesda, MD:
http://www.nimh.nih.gov/health/publications/depression/s
ummary.shtml

O’Connor, R. (1997). Undoing depression. New York: Berkley
Books.

Patton, M. Q. (2002). Qualitative research and evaluation
methods (3rd Ed.). Newbury Park, CA: Sage.

Pignone, M., Gaynes, B., Rushton, J., Burchell, C., Orleans, T., &
Mulrow, C. (2002). Screening for depression in adults: A
summary of the evidence. Annals of Internal Medicine,
136(10), 765-776.

Regev, M. (2001). The experience of postpartum depression: A
grounded theory study. Ph.D. dissertation, The University
of British Columbia, British Columbia, Canada.

Ridge, D., & Ziebland, S. (2006). “The old me could never have
done that”: How people give meaning to recovery
following depression. Qualitative Health Research, 16(8),
1038-1053.

Schreiber, R. S. (1995). (Re)defining my self: Women’s process of
recovery from depression. D.N.S. dissertation, State
University of New York, Buffalo, NY.

Schreiber, R. (1996). (Re)defining my self: Woman’s process of
recovery from depression. Qualitative Health Research,
6(4), 469.

Styron, W. (1990). Darkness visible. New York: Random House.
The Grounded Theory Review (2009), vol.8, no.1
52
Surgeon General’s Report on Mental Health. (1999). Mental
health: A report of the Surgeon General. Washington, DC:
U.S. Department of Health and Human Services (DHHS).

Surgeon General’s Report on Mental Health. (2001). Mental
health: Culture, race and ethnicity—Supplement.
Washington, DC: U.S. Department of Health and Human
Services (DHHS).

Thompson, T. (1995). The beast: A journey through depression.
New York: Penguin Putnam.

Facebooktwittergoogle_plusredditpinterestlinkedinmail