Depression as an Embodied Experience: Identifying the Central Role of the Body in Meaning-Making and Identity Processes

Abstract

Α significant part of the psychological research on mental health and illness is interested in how the body can impact one’s mental health. This impact is primarily explored using a biomedical framework, in studies that examine the body’s role in the emergence of a mental illness, the ways it can signify the presence of an illness (i.e. physical symptoms) and, finally, its role in the treatment process. Within this literature, the body is conceptualised as an object that can be diagnosed and treated. The current study approaches the body as a subject in the experience of depression. Specifically, it demonstrates that the experience of depression is embodied and that the body mediates meaning-making and identity processes. Using qualitative findings from eight interviews with Greek-Cypriot adults diagnosed with depression, we demonstrate that participants make sense of depression through their bodies, as a painful, uncomfortable and agonising experience. Further, we discuss how the struggle to regain control over the body, experienced as hijacked by depression, leads to a disrupted relation with the self and the world that expands beyond the idea of the loss of self, as described in the literature. Theoretical and clinical implications are examined.

Introduction

Within psychological research on issues of health and illness, the body has a central role (Stephens, 2001). Ιt is mainly examined from a biomedical perspective, which treats it as a medium through which the world is experienced (Radley, 2000). This approach is also encountered in research on mental illness, in which biological factors and their links to the aetiology and treatment of such illnesses are explored (Beyer & Johnson, 2018; Dean & Keshavan, 2017; Trivedi, 2004). Yet, according to Husserl’s (1913/2012) distinction, such an approach addresses only one aspect of the body, that is, the body as an object. Meanwhile, it overlooks its role as a subject that interacts with the social world in a dynamic manner. Not only are the meanings ascribed to one’s body moulded by contextual influences, the body itself can contribute to meaning-making (Baerveldt & Voestermans, 1996; Stephens, 2001; Svenaeus, 2014), that is, to how individuals make sense of their experiences (Zittoun & Brinkmann, 2012).

Despite calls for research acknowledging the embodied aspects of one’s experience and how the meanings ascribed to it are moulded by the body, psychological research remains dominated by studies approaching the body as an object. Thus, it has been criticised for not truly overcoming the Cartesian dualism (Radley, 2000). Influenced by dualistic notions about the separation of the mind from the body (Ryle, 1949/2009), for many years, psychologists explored features of the brain: mostly cognition and lately its neural basis (Boone & Piccinini, 2016; Schwartz et al., 2016). The study of the body was left to fields like medicine and biology (Radley, 1991). In this cognitive-based research, the mind is often treated as an impartial information processing machine independent of the body (Meteyard et al., 2012) and the social context (Danziger, 1990).

The theoretical framework of embodiment, or Embodied Cognition (Niedenthal et al., 2005), emerged as a response to amodal theories of cognition, encouraging a shift to the study of the body as a subject. It supports that the way in which individuals perceive and experience the world and the self is shaped by the body (Baerveldt & Voestermans, 1996; Gallagher, 2005; Merleau-Ponty, 1965; Stephens, 2001). Apart from a physical ‘object’ through which information flows, the body is also an active agent shaping one’s interaction with the world and the meanings ascribed to it (Niedenthal et al., 2005; Ratcliffe, 2015; Svenaeus, 2014). Since each body is unique, these meanings can vary between individuals, even if they reside in similar contexts (De Mol et al., 2018). As Kuczynski and Mol (2015, p. 330) put it, ‘embodiment entails the synthesis of how we, as active agents, influence and are influenced by our biological and sociocultural worlds’. In this dynamic exchange, the body acts as the bridge between the two worlds (Kuczynski & Mol, 2015; Zatti & Zarbo, 2015).

Addressing the body as a subject holds implications for theory advancement; as it can elucidate how the body shapes meaning-making during illness and suffering, but also for clinical practice; as it can encourage a novel way of utilising the body to understand and treat mental illness. This is especially the case in depression where personal narratives suggest that body-related aspects are a key element of one’s experience (Danielsson & Rosberg, 2015; Ratcliffe, 2015; Rønberg, 2019). Apart from the phenomenological research reviewed below, thus far, the body’s involvement in depression has been approached as a way of identifying and accessing internal cognitive, affective and biological processes (e.g. Dean & Keshavan, 2017; Trivedi, 2004). Using findings from interviews with Greek-Cypriot adults diagnosed with depression, this article aims to explore the embodied experience of depression by demonstrating how the body features prominently in these experiences and mediates meaning-making and identity processes. Identity processes refer to the ways that individuals define and position themselves in the social world, in dynamic interaction with social others (Mead, 1934).

Below, we argue that qualitative methodology can shed light to experiences of embodiment and can highlight processes of self-negotiation and struggle for control, which go beyond the loss of self, discussed in related literature (Fuchs, 2005; Rivest et al., 2018; Woodgate, 2006).

The Embodiment of Depression

Body functions such as appetite and sleep disturbances are key diagnostic criteria for depression (American Psychiatric Association, 2013). Evidence from personal experiences with depression point to the body’s involvement through references to sensations of pain, tiredness, heaviness, drowning or numbness (Danielsson & Rosberg, 2015; Rhodes et al., 2019; Rønberg, 2019; Smith & Rhodes, 2015), and a sense of losing control over bodily functions (Apesoa-Varano et al., 2015; Fuchs, 2005; Rungreangkulkij et al., 2019). Existing research on depression and the body is largely focussed on the body’s role in depression’s clinical image (Trivedi, 2004), aetiology (Dean & Keshavan, 2017) and treatment (Beyer & Johnson, 2018; Michalak et al., 2012). This role is primarily explored through a biomedical perspective, which treats the body as a mediator between the world and internal processes (e.g. affect and cognition) that facilitates the diagnosis of depression (Radley, 2000). Though the body is central in this literature, it is approached as an object rather than a subject.

Limited phenomenological work around embodiment and depression has addressed its role as a subject. For Ratcliffe (2015; Colombetti & Ratcliffe, 2012), the experience of depression is linked to a disruption of the ways one experiences being-in-the-world. Ratcliffe (2008) proposed that pre-intentional affective states grounded in the body, which he labelled as existential feelings, can influence how one experiences and interacts with the world via dictating the kinds of possibilities one can access. The body shapes and is shaped by these existential feelings. Ratcliffe (2015) argued that although depression is commonly described as an affective and cognitive condition, it is a bodily one. He based his claims on evidence of physical symptoms encountered in narratives of depression and the similarities between the clinical presentation of depression and inflammation. He suggested that as the body transforms into a rigid and lethargic object, its transparency and effortless functionality are lost, causing a shift from noetic, that is, the feeling body, to noematic, meaning the felt body. In depression, it is through this altered body that the world is experienced; hence, it becomes ‘uninviting, difficult, daunting’ (Ratcliffe, 2015, p. 85).

Thomas Fuchs’ work on embodiment and depression is also noteworthy. Fuchs (2002, 2005, 2013; Fuchs & Schlimme, 2009) conceptualises depression as a corporealisation of the lived body, in which the body loses its transparency, becoming opaque, heavy and rigid. The body transforms into an obstacle that interferes with one’s capability to carry out simple daily tasks and hinders interaction with the social world. This loss of transparency interferes with bodily resonance, namely, the body’s ability to open-up to the moods, feelings or atmospheric traits encountered in the world (Fuchs, 2013). Consequently, in depression, the experience of being-in-the-world becomes disrupted and emotional resonance is blocked. This minimises one’s ability to connect with others emotionally, hence leading to the social withdrawal and loneliness encountered in depression (Fuchs, 2005, 2013). Taking Fuchs’ ideas further, Svenaeus (2014) proposed that in depression, the body not only loses its ability to resonate, it also becomes more attuned to certain moods including boredom, grief and anxiousness. Reinforcing Fuchs’ claims (2005, 2013), he described this as a change in how one experiences the world: being out-of-tune in a painful ‘unhomelike-ness’ (Svenaeus, 2014, p. 14). An ‘out-of-tune embodiment’ (Rønberg, 2019, p. 1) was also observed in Danish adults with depression who discussed the presence of various bodily sensations, along with an altered relationship with the body and one’s interaction with the world.

Likewise, Aho (2013) found that people with depression experience their body as heavy and rigid, feel unable to complete basic tasks, lose the ability to distinguish what is meaningful and feel that their sense of being-in-the-world has been altered (see also Danielsson & Rosberg, 2015, for similar findings). Doerr-Zegers et al. (2017) proposed that the core characteristic of depression is the disturbance of aspects of embodiment, namely, self, intentionality and time. The disturbance of the embodied self involves the disruption of one’s relationship with the body (i.e. depressed mood, heaviness of the limbs, generalised pain sensation and anxiety). Disturbances of embodied intentionality and embodied time involve changes in one’s relationship with the world (i.e. inability to feel pleasure, numbness) and biological clock, respectively (i.e. disturbances of sleep and appetite).

Interestingly, the involvement of the body is observed even in experiences of the first depressive episode (Smith & Rhodes, 2015). Its implication is encountered in the metaphors used by affected individuals (e.g. ‘half my heart has gone away’, p. 202), in references to dissociation from the body and in the physical manifestation of cognitive and emotional distress. In cases of chronic depression, there is a similar disconnection from the body and changes in the body’s materiality (i.e. rigid and incapable of performing basic tasks; Rhodes et al., 2019). However, in chronic depression, these disruptions are so intense that the body is experienced as disappearing.

Bodily changes appear to affect identity processes too. Fuchs’ work on disembodiment (2005; Fuchs & Schlimme, 2009) demonstrates that a diminished sense of self is perceived as the result of the body’s inability for affective resonance and connection with the social world due to corporealisation. Svenaeus (2014) also sees the disruptions in bodily resonance as having a negative impact on one’s identity, by restricting the self as to the meanings it can access. The diminished ability for self-making (i.e. ability to adopt different roles and identities) encountered amongst people experiencing depression is also linked to a difficulty to distinguish what is meaningful (Aho, 2013). Further, Rhodes et al. (2019) discussed how bodily sensations of numbness accompanied by a sense of inability to engage in the activities the individual wants cause one to experience the self as fading out of existence. The loss of self is commonly encountered in studies exploring experiences of depression (Rivest et al., 2018; Woodgate, 2006), and it has been linked to the loss of certain roles and identities (Ridge, 2009).

Despite these important observations, psychological research on the body’s role in depression is comprised mostly by quantitative studies treating it as an object (e.g. Dean & Keshavan, 2017; Joseph et al., 2021; Ramesh et al., 2022). Expanding the relevant literature through studying the body as a subject using a qualitative methodology can offer a better understanding of its role as a meaning-making agent. Within the phenomenological research reviewed above, the context’s role is discussed in terms of how changes in the body’s materiality alter one’s being-in-the-world and way of relating to others, thus impacting the meanings one can access. However, there is no discussion about wider contextual influences (e.g. cultural norms) and how they contribute to meaning-making. Thus, we propose that one way the embodiment literature can be enriched is via studying the subjective experience of depression and the meanings ascribed to it, acknowledging how wider contextual influences shape them and how the meanings generated by the body are rooted in and diffused by social interaction (O’Connor, 2017).

The relationship between the body and identity processes is another area that could be expanded. Growing evidence suggests that the body’s materiality and resonance negatively impact the self via restricting the roles and identities it can access (Aho, 2013; Fuchs, 2005; Svenaeus, 2014). Nevertheless, more research is needed to understand whether bodily changes influence the assimilation of depression to one’s identity (e.g. Karp, 2017) and whether the body is implicated in what is identified as a loss of self (Rhodes et al., 2019). Exploring the relationship between the body and the self in depression is thus a fruitful avenue for research.

Present Study

To address these gaps, we examined the subjective experience of depression among Greek-Cypriot adults diagnosed with depression. Our aim was to explore the meanings ascribed to it and the processes involved in their construction, using a qualitative methodology. Our epistemological stance combines elements from a phenomenological and a social constructionist approach, by focussing on how the individuals experience their reality and by conceptualising this experience as constructed through the dynamic exchange between the individual and the social world (Burr, 2015).

Here, we focussed on exploring the body’s role in mediating meaning-making and identity processes. We concur with claims that in cases of illness, such as depression, the body loses its transparency, which in turn obstructs daily functioning and leads to experiencing the body as no longer being controlled by the individual (Aho, 2013; Fuchs, 2005, 2013; Ratcliffe, 2015; Svenaeus, 2014). While we agree that the meanings one can access vary depending on such bodily changes (Fuchs, 2005, 2013; Ratcliffe, 2015; Svenaeus, 2014), we also believe that these meanings can vary based on the sociocultural context the individual is in (Burr, 2015), regardless of the state of the body. Regarding the relationship with the self, when the body is healthy and interacting smoothly with the world, the self is free to access different roles and identities (Aho, 2013; Svenaeus, 2014). Further, the individual is not faced with a new version of the self (i.e. the ill self). When the relationship with body is disrupted, the self is both restricted and placed in a position of having to negotiate a new identity. It is this latter aspect of identity processes that is overlooked in the existing literature, along with an exploration of how the experience of being controlled by something else (Aho, 2013; Ratcliffe, 2015; Rhodes et al., 2019) impacts such processes.

This study was conducted in Cyprus, an island in the North-Eastern Mediterranean area. In 2015, the prevalence of depression was 5.1% (WHO, 2017). The two main ethnic groups living in Cyprus are Greek-Cypriots (southern part) and Turkish-Cypriots (northern part). This project focussed on Greek-Cypriots. In the Greek-Cypriot culture, mental health issues and the use of professional treatments are stigmatised (Georgiades, 2009); thus, people experiencing psychological difficulties like depression avoid seeking help. When they do, rather than visiting mental health professionals, they often turn to general practitioners (Georgiades, 2009) or rely on the support of family members (Pierides, 1994) and religious practices. In matters of mental health, Cyprus stands between the East and West. Although there is a strong individualistic culture that holds individuals accountable for treatment, collectivist notions are also identified, as mental illness is largely contained within the family. Friends and family become highly invested in supporting the individual to facilitate recovery. Regardless, neoliberal ideas about self-governance and self-control (Philip, 2009; Teghtsoonian, 2009) over one’s body and subsequently one’s health are dominant in the Greek-Cypriot culture (Orphanidou & Kadianaki, 2020a). As for body-related concerns or symptoms, they are mainly treated as the property of physical health alone.

Methodology

This study was part of a doctoral research project examining meanings of depression within the Greek-Cypriot context, including the press (Orphanidou & Kadianaki, 2020a), public and people diagnosed with depression. Here, we focused on individuals with a diagnosis.

Sample

Guided by relevant research practices (Danielsson & Rosberg, 2015; Smith & Rhodes, 2015), we initially aimed to recruit approximately 12 participants from different age groups. This decision was shaped by an aim of the broader project to explore potential developmental variations. No age-related differences were identified regarding embodiment; hence, there is no related reference in the analysis. In the end, eight participants (six females and two males) between 19 and 69 years old were recruited using an opportunistic sampling approach. The final sample size was restricted by practical issues related to the COVID-19 pandemic (i.e. lockdown imposed on 24/03/2020) and the overall data management of all parts of the project. Participants originated from urban and rural areas across Cyprus. Three were undergraduate students, two unemployed, one retired and two homemakers. Since being diagnosed and until the interview, one participant received psychotherapy, two pharmacotherapy and five a combination of both. Six participants were in treatment when interviewed.

Inclusion criteria included fluency in Greek, recent diagnosis of depression (≤ 5 years) and absence of a comorbid diagnosis and of any form of cognitive impairment (e.g. dementia). The limit regarding the diagnosis date aimed to capture descriptions of recent experiences. For people over 40 years old, older diagnoses were allowed provided that the individual was still in treatment when interviewed. This adjustment was based on findings suggesting that being diagnosed at a younger age is more common because depression emerges predominantly in early adulthood (Eaton et al., 2008) and older adults are less likely to seek professional help (Conner et al., 2010). Three participants above the age of 40 had older diagnoses (year of diagnosis: 1973, 1989, 2002).

Procedure

The study was advertised on social media (i.e. Facebook), the University of Cyprus campus, community counselling centres, mental health professionals’ private practices and nursing homes. Snowballing was also implemented. Data were collected through semi-structured individual interviews, which were audio recorded. Four interviews were completed in the participants’ homes and four at the university campus. Interviews were conducted by the first author between May 2019 and March 2020 and lasted between 61 and 106 min (M = 90). Firstly, participants completed a self-report questionnaire collecting sociodemographics and mental health history. Next, to help them feel more comfortable with the process, they were encouraged to talk about their hobbies and interests (Bolderston, 2012) before being asked to respond to the questions. A semi-structured interview design was chosen due to its flexibility to explore both areas of interest (i.e. understandings regarding depression’s nature, aetiology, clinical image, prognosis, treatment and the impact of the diagnosis) and new topics that might emerge (Lyons & Coyle, 2007).

Analytical Procedure

The audio recordings were transcribed ¹ verbatim and anonymised by the first author. The transcripts were loaded to ATLAS.ti (version 8.2.4 for Mac) and read numerous times before being systematically coded by the first author. To guide this process, a coding scheme was developed using inductive and deductive approaches (for more details, see Orphanidou & Kadianaki, 2020b). The final coding scheme was comprised of 25 codes. Inter-coder reliability was assessed by having another trained coder code one transcript chosen at random (Hodson, 1999) and calculating Krippendorff’s alpha (kalpha = .82, 95% CI .75–.88; Krippendorff, 2004) by exporting data to SPSS (version 24). Points of disagreement were resolved through discussion amongst the coders (Saldaña, 2016).

The data were thematically analysed (Braun & Clarke, 2006) using the original transcripts. Thematic analysis was chosen due to its compatibility with the epistemological stance of the project (Willig, 2001/2013), but also to maintain consistency with the other parts. Relevant extracts were translated for presentation purposes. All extracts associated with each code were inspected to uncover common patterns across the dataset. The role of the body was captured by six codes: clinical image, treatment (self-management), treatment (psychiatric/medication), metaphors/images, identity and control. The analytical process led to three themes. The Relationship Between Depression and the Self captured participants’ continuous struggle to identify if depression is part of their identity or not, but also whether the self or depression is in control of the individual. Encountering Representations of Depression explored how participants’ representations of depression are formed through the interplay between their lived experience and the representations of depression held by social others. Depression as an Embodied Experience examined the dominant role of the body in participants’ experiences.

This manuscript aims to illuminate the embodied experience of depression and explore the body’s role in meaning-making and identity processes. Hence, it focuses only on the third theme. Our methodology inevitably approaches embodiment through language, thus losing aspects of embodiment expressed non-verbally. While this limitation is acknowledged, we consider this kind of research to be an important first step in understanding those aspects of the embodied experience of depression that are verbally expressed.

Ethics

This study was approved by the Cyprus National Bioethics Committee (EEBBK/EΠ/2019/09). Participants provided written informed consent prior to their enrolment. Data collected are bounded by confidentiality, and participants were informed about exemptions (i.e. when intent to hurt oneself or others was expressed). Participants were also informed about the study’s aims and procedure, the anonymity protocols implemented (i.e. removal of identifying information during transcription, use of pseudonyms) and their right to withdraw without any explanation. At the end, participants were debriefed and provided with referrals to mental health services they could utilise if their participation caused them any distress.

Analysis

The theme of Depression as an Embodied Experience was supported by data in all interviews and was sustained by two sub-themes: (a) The Body as a Meaning-Making Agent, which showed that apart from the physical symptoms characterising experiences of depression, the body actively contributed to socioculturally situated meaning-making and (b) The Distorted Relationship Between the Body, the Self and the World, which illuminated the body’s mediating role in identity processes and in shaping how participants viewed themselves and interacted with the world. Both sub-themes were supported by data in all interviews. Unless otherwise specified, similar data were observed across participants, and the most representative extracts are presented.

The Body as a Meaning-Making Agent

Findings showed how the body was an active mediator in the participants’ meaning-making processes. These meaning-making qualities became evident in the ways participants described what depression means to them, using several vivid images and graphic metaphors, which grounded depression in the body. Participants’ responses below showcase how these bodily sensations are not merely a symptom of depression but rather a way to make sense of their experience:

Konstantina: It’s like you are trying to cross a quicksand, umm those kinds of lakes, and you also have a weight on your back, pushing you downwards. It’s not enough that the lake is pulling you [down], you also have that thing on top of you.

Alexandros: […] it’s a prison that you entrap yourself on your own as I’ve said before. Umm, you can’t stand it any longer, you feel like you are melting, umm, [like] there are two walls that are pushing against you, pressuring you until they completely obliterate you. […] Umm, it’s also a pressure because, umm, you feel a weight on your soul, both internally and externally.

Vassia: It was a pressure like someone is squeezing you using, umm, […] a clamp.

Teresa: It’s a fall, that’s how I call [depression].

Participants’ descriptions constructed depression as an uncomfortable and agonising experience, reinforcing the painful aspects of corporeality (Fuchs, 2002, 2005). This way of portraying depression was common across all interviews and was the immediate response of any participant being asked about the meaning of depression. Though each participant objectified depression using a different metaphor (i.e. a weight, a prison, a quicksand, a clamp and a fall), all images depicted depression as experienced through bodily sensations including pain, pressure, heaviness, pull, inability to move and melting.

Each metaphor appears to correspond to a different type of experience and possibly symptom of depression (Ratcliffe, 2015). For example, the painful sensation of a weight could reflect an understanding of the world as filled with arduous tasks and thus be linked to anhedonia and low energy levels. The restrictive nature of a quicksand and a prison suggest the individual is prevented from engaging in desired actions, sometimes forcefully, as indicated by the reference to the clamp. Such restrictions could be linked to the inactivity encountered in depression. The use of the orientational metaphor (Lakoff & Johnson, 2003) of ‘the fall’ points to an unpleasant experience found at a lower affective state than non-depressive experiences. Such findings suggest that the body’s involvement in depression extends beyond mere physical symptoms. Rather, the body is consistently used as an agent ascribing meaning to participants’ experiences.

Beyond discourse, the gestures used by participants when explaining what depression means to them reinforced the body’s contribution to meaning-making:

Chrystalla: It’s like someone is holding your heart like this [tightens fist] and doesn’t let it beat. […] It’s a permanent pain that does not let you be, umm, function normally.

Vassia: I felt something tightening in here [places hands on temples].

The use of gestures (i.e. clenching fist and touching temples) illustrated how the body becomes actively involved in making sense of depression. The type of gestures used reinforced participants’ interpretation of depressive experiences as painful and restrictive, thus disrupting their daily ‘function[ing]’. The combination of metaphors and gestures indicates how one’s body is employed both in verbal and non-verbal ways to make sense of depression.

To make sense of the profoundly bodily nature of their experience, participants anchored it to ideas relating to physical health. For example, the bodily sensation of chest pain was interpreted by Alexandros as an indication of physical illness:

Alexandros: I couldn’t comprehend what I had and I was feeling that weight [on my chest]. I felt that I needed [some kind] of medication but I didn’t know which medication since all my movements, and my speech, umm, anything related to physical illness, umm, there was no problem. And this makes it difficult to arrive at the conclusion that you suffer from mental illnesses and not physical ones.

The strong sensation of physical pain caused by the ‘weight’ of depression prompted Alexandros to link his experience to physical health. This understanding was possibly shaped by a belief that is encountered in Western contexts, such as the Greek-Cypriot context, which supports that when discomfort arises in the body, it points to physical problems, whereas disruptions in affect and thought processes typically point to mental problems (e.g. Mehta, 2011; Tylee & Gandhi, 2005). The reliance on such Westernised understandings of health and illness points to how the exchange between the sociocultural context and the body can shape meanings ascribed to one’s experience.

The Distorted Relationship between the Body, the Self and the World

The embodied experience of depression was reinforced through evidence of a distorted relationship between the individual, the body and subsequently the world. In turn, these disruptions affected how participants interacted with their social context and perceived themselves. Participants described a sense of inability to fully control their bodies, almost as if the body no longer belongs to the individual. Such findings concur with research supporting that in depression, the body is experienced as no longer being controlled by the individual (Ratcliffe, 2015; Rhodes et al., 2019). Instead, it was experienced as controlled by the distinct tangible entity of depression. This is exemplified below where the use of personification constructs depression as a controlling entity (it) that prevents individuals from engaging in and deriving pleasure from the activities they want to do.

Chrystalla: It doesn’t let me do simple things. I mean [to do them wholeheartedly] and enjoy them. Whatever this may be. For example, go for a ride with my car, take a bath or eat or watch something or go outside. […] Everything [I] do, it’s done with pain. With discomfort, to put it more accurately. With discomfort, through force.

Melina: You may be trying to do [things] but it doesn’t let you. […] I wanted to get out of the house. [But] for a year and a half I couldn’t go anywhere.

Chrystalla presented a disrupted relationship with her body, which in turn had a detrimental effect on her daily functioning. Even seemingly simple, mundane tasks were transformed into unpleasant chores, demanding significant effort to be completed. Similarly, Melina discussed how she was unable to do the things that she wanted and used to be able to do, echoing Flora who explained that when depressed, ‘you cannot control yourself’. These findings elucidate the impact of bodily aspects over one’s relationship with the social world, thus supporting claims about corporeality in depression (Fuchs, 2005; Rønberg, 2019; Svenaeus, 2014).

The body can also influence one’s relationship with the self. Although in previous research, this controlling entity was described as external (Rhodes et al., 2019), in the current dataset, it was perceived to reside internally. By being the medium in which depression is housed, the body becomes interwoven in individuals’ efforts to figure out if depression is part of the self or not, thus shaping identity processes:

Konstantina: Umm, it’s weird but it’s something inside you that is eating you. I mean it’s not something external that okay, you will get rid of, expel it, leave it somewhere. It’s inside you and you carry it and you take it [with you].

The internal positioning of depression intensified the tension amongst depression and the self via sparking ambivalence. While participants were adamant about the distinctiveness of depression, at times, they questioned if it was truly something else or a part of the self, given its internal grounding. For example, at different times during her interview, Melina stressed how the person she was when depressed was clearly not her true self, yet the fact she was experiencing ‘pressure’ from an internal voice in her brain to attempt suicide made her question whether she (i.e. the self) was responsible for this behaviour:

Melina: Because of that thing that I’ve lived [refers to a traumatic experience], these are the commands that my brain is giving me. How else can I explain it? To make me want to do something bad, to hurt myself. Who is doing this? Me? […] Why was I about to do this thing? But I was feeling pressure to do it.

Melina’s uncertainty as to whether she or something else was controlling her body is reflected through the consecutive rhetorical questions used. Further, her reference to ‘commands’ and ‘pressure’ suggests that she felt like she was forced to do it. Here, a paradox is created as to whether the self is in control of the body, or the body is controlled by something different, which is nonetheless located internally. Such findings indicate how the body becomes a mediator in the disruption of the individual’s relationship not only with the world but also with the self as it fuels the uncertainty surrounding depression’s separation from the individual.

In addressing the distorted relationship with the body and the self, the re-establishment of control over the body was described as critical. This was achieved using professional and non-professional treatment options targeting the body. For example, Vassia supported that medication was crucial for re-establishing normal bodily functioning:

Interviewer: How come you decided to go to [the psychiatrist]? […]

Vassia: Since the most difficult [thing] was my sleep, that I could not sleep, umm, I said that this is where I need to go.

The body’s role in treating depression was also reflected in self-management approaches including engaging the body through exercise, going for a walk and following a ‘healthy diet’ (Thodoris):

Interviewer: Do you think anything else [besides professional treatments] could help?

Alexandros: […] Go for a walk in nature, be in contact, um, the direct contact with nature and animals, if you are an animal lover. Umm, going to the gym. As people say, endorphins [released] through exercise.

Flora: When I begin to think [about my problems] I do house chores, I go [for a walk] in nature and I am okay again. I walk, as much as I can.

Beyond highlighting the role of re-establishing control in helping participants address the distorted relationship with the body, these findings hint at the contribution of contextual influences. This was especially the case when participants clarified that amending this relationship and overcoming depression is their ‘responsib[ility]’ (Alexandros). For them, the individual’s role in the emergence, perpetuation and treatment of depression was central. Elsewhere (Orphanidou & Kadianaki, 2020a), we have argued that this overwhelming attribution of responsibility to the individual in dealing with depression is part of a neoliberal culture that can be found in Western contexts more widely and promotes ideas of self-governance of health and control over one’s body (Philip, 2009; Teghtsoonian, 2009).

Discussion

The findings discussed reinforce the significance of studying the body as a subject rather than an object. Specifically, they demonstrate that the embodied experience of depression leads us beyond physical symptoms acknowledged in diagnostic criteria and biological factors involved in depression's aetiology and treatment. As indicated by the first sub-theme, bodily aspects are critical in ascribing meaning to participants’ experiences (i.e. using bodily metaphors and gestures to construct depression as an agonising, painful and restrictive experience). Additionally, the second sub-theme illustrates how a disrupted relationship with the body (i.e. changes in the body’s materiality and the inability to control it) can influence the negotiation of one’s identity and interaction with the world. Findings expand the literature in several ways. Firstly, they showcase the body’s contribution both in meaning-making and in the overlooked area of identity processes. Secondly, they hint at the possible role of the sociocultural context in shaping these experiences. Lastly, they reinforce the central role of qualitative methodology when exploring experiences of health and illness (Gewurtz et al., 2016) in a way that accesses underlying processes and their sociocultural grounding (Willig, 2001/2013). Such access would not have been otherwise possible.

Regarding the body’s involvement in depression, current findings concur with existing studies indicating that the experience of depression is characterised by physical pain and generalised discomfort (e.g. pressure, heaviness and rigidity; Fuchs, 2005; Rønberg, 2019; Smith & Rhodes, 2015). But beyond that, they suggest that by approaching physical aspects merely as symptoms (e.g. Beyer & Johnson, 2018; Dean & Keshavan, 2017; Trivedi, 2004), researchers overlook the embodied experience of depression. Standing with researchers urging for a shift in psychological research examining the body (Fuchs, 2005; Radley, 2000; Stephen, 2001), this study presents how the body can imbue individuals’ experiences with meaning using images and metaphors grounded in the body, as well as bodily gestures.

Interestingly, the use of such images and metaphors highlights the social nature of embodiment, which is somewhat overlooked in embodiment literature (e.g. Danielsson & Rosberg, 2015; Fuchs, 2002, 2005). Though these images are inherently linked to the embodied aspects of the individual’s experience (e.g. physical sensation of heaviness or pulling), the meanings ascribed are also contextually grounded. For example, depression was objectified through metaphors of a fall and a weight pushing the individual downwards. Such orientational metaphors have a culturally shared nature where ‘up’ is linked to happiness/positive/good and ‘down’ to sadness/negative/bad (Lakoff & Johnson, 2003). Hence, the meanings ascribed to depression seem to emerge from the interaction between one’s lived bodily experience and the culturally grounded ways of making sense of the world. Acquiring a deeper understanding of these meaning-making qualities and the ways they are shaped by contextual influences is one goal that future projects should strive for.

Further, against claims for an overwhelming medicalisation of human distress, including low mood and depression (Horwitz & Wakefield, 2007), this study suggests that an emphasis on bodily aspects is not necessarily accompanied by a medicalised understanding of one’s experience. While ideas pertaining to physical illness were utilised, participants did not make sense of depression as a biologically based illness. Rather, they relied on beliefs that physical symptoms reflect a physical issue, an understanding which is often encountered in Western settings (Mehta, 2011; Tylee & Gandhi, 2005). We argue that evidence for participants’ reliance on the body, yet in a way that is separate from medical discourses, reveals why studying the body merely as an object is not enough and points to the need for acknowledging the contribution of wider contextual influences in making sense of depression.

Findings also illuminate a disruption in individuals’ relationship with the body and subsequently the world. Changes in the body’s materiality and the accompanying shift of bodily control disrupt the individual’s daily life in ways that simple and mundane tasks are transformed into strenuous chores. Meanwhile, interactions with others lose their pleasurable aspects. Such findings concur with arguments about the corporealisation of the lived body, which hinders individuals from moving towards desired actions (Aho, 2013; Danielsson & Rosberg, 2015) and thus feeling trapped in their own body (Fuchs, 2002, 2005, 2013; Fuchs & Schlimme, 2009). Further, they support claims for disruptions in the ways one relates to the world of others (Ratcliffe, 2015; Svenaeus, 2014). The findings also expand existing literature by showing that the distorted relationship between the body, the individual and the world is not only the result of changes in the body’s materiality but also due to experiences of depression as a controlling entity that hijacks the body. This shift of control alters one’s interaction with the world.

Moreover, this study demonstrates how the body and particularly the struggle for control over the body mediates identity processes. Depending on whether it is experienced as being controlled by the individual (i.e. normal relationship) or by depression (i.e. distorted relationship), individuals shift between feeling–not feeling like themselves. When one’s relationship with the body is re-established, it is experienced as a re-establishment of the self too. Meanwhile, contrary to findings that place this controlling entity outside the body (Rhodes et al., 2019), the conceptualisation of the body as the vessel in which the entity of depression is located identified in the data perpetuates the ambivalence regarding whether depression is part of the self or not.

These findings suggest that the exchange between the body and identity processes in experiences of depression is more complex than what ideas about the loss of self (Ridge, 2009; Rivest et al., 2018; Woodgate, 2006), the loss of affective resonance (Fuchs, 2005; Fuchs & Schlimme, 2009) and the restricted ability to access alternative roles and identities (Aho, 2013; Svenaeus, 2014) propose. Specifically, findings show that participants’ efforts to understand if depression is part of their identity demonstrate a struggle for control and a negotiation of the self. The contribution is twofold. Firstly, within the embodiment literature, discussions on depression have focussed mainly on sensory aspects (i.e. heaviness of the body) and to a lesser extent on how these sensations influence one’s identity (Aho, 2013; Fuchs, 2002, 2005; Fuchs & Schlimme, 2009; Svenaeus, 2014). Secondly, the literature on identity processes in depression is dominated by discussions regarding the loss of self (Rivest et al., 2018; Woodgate, 2006), whereas the possibility of a negotiation is rarely encountered (Apesoa-Varano et al., 2015). By bringing these two areas together, our findings point to a new understanding of depression where the self is not lost per se but constantly negotiated. Exploring these links further will help expand and clarify this novel area.

Lastly, the impact of the Greek-Cypriot context, particularly the neoliberal ideas about self-governance of health and self-control (Philip, 2009; Teghtsoonian, 2009) circulating in it, was also observed in participants’ struggle for control. The dynamic exchange between one’s experience (i.e. inability to control the body) and ideas regarding self-governance shaped conclusions that although the body is controlled by the entity of depression rather than the self, it is still one’s own responsibility to reclaim control and overcome depression.

Limitations, Implications and Future Directions

Studying embodiment solely through verbal data may seem contradictory. Indeed, our study highlights the role of the body through verbal data. Still, it needs to be complemented by other studies, which advance methodological designs that approach non-verbal aspects of embodiment such as gestures and posture through observations of the body in action (O’Connor, 2017). Beyond methodology, psychological theories about depression also need to account for the body’s contribution in ways that exceed biological attributions and neural pathways. Theorising depression as embodied can lead to a different view on aetiological and treatment understandings. For instance, it can help researchers identify if the altered relationship with the body precedes depression and is thus possibly involved in its development.

Findings hold implications for clinical practice too. Currently, pharmacotherapy is usually the treatment option to explicitly work with the body. Though some psychological approaches incorporate interventions that target the body via mindfulness-based treatment components (e.g. Hayes et al., 1999; Segal et al., 2002), within these frameworks, the body is not necessarily the focus of treatment. Instead, it is viewed as an access point or a medium that facilitates reconnection with the present moment, which in turn helps individuals develop awareness and openness when interacting with difficult emotions and thoughts. Findings suggest that addressing bodily aspects and restoring one’s relationship with the body should be a primary treatment goal.

Conclusion

Moving beyond biomedical understandings of the body as an object, this study illuminates another aspect of the body’s role in experiences of depression. Via approaching the body as a subject, it has shown how it can ascribe meaning to these experiences, mediate identity processes and shape one’s interaction with the world. Such an embodied understanding of depression holds important theoretical and methodological implications for the study of depression and novel contributions for clinical practice.