The missing work of collaboration: using assemblages to rethink antidepressant action.
The first section of the article outlines how the depressed individual features in key biomedical and sociological debates about antidepressant action. Then, French philosopher Gilles Deleuze's assemblage concept, or "assemblage thinking," is introduced for its utility in moving analytic attention away from the depressed individual onto the collective body or assemblage, which is composed of both nonhuman and human elements. The ways in which assemblage thinking was brought into the research processes of a qualitative project exploring the wellbeing of people who take antidepressants are then outlined. Material generated in encounters with research participants (charts, photos and narratives) is drawn on to illustrate how antidepressants work through a series of collaborative connections. The paper concludes with a discussion of how this way of understanding antidepressant action enables new ways of thinking about depression, medication and recovery.
Antidepressant debates and the depressed individual
This section of the article outlines how the depressed individual features in the key biomedical and sociological debates about antidepressant action. The conventional biomedical account argues that neurotransmitter deficits occur and manifest in depressive symptoms such as anxiety and agitation. In response, antidepressants directly mediate the balance of neurochemicals in the brain and correct the deficient brain chemistry associated with depression. Western industrialized countries support this explanation of how antidepressants work (Ellis & Smith, 2002; World Health Organization, 2010). However, the biomedical account also attracts three kinds of debate. The first debate points to the undefined neurochemical action of antidepressants. Neuroscientists now consider outdating the highly-marketed "serotonin hypothesis." They are now investigating how antidepressants work at the level of the gene (Dreimuller et al., 2012; Vialou, Feng, Robison, & Nestler, 2013). The second area of debate addresses the extensive non-pharmacological or placebo effect identified in antidepressant clinical trials (Kirsch et al., 2008; Vohringer & Ghaemi, 2011). A third debate poses questions about the extent to which antidepressants are prescribed for conditions in addition to those for which they were originally designed. Most subjects of clinical trials are patients with major depression, and a depressive symptom rating scale is used to measure any clinical improvement (Williams & Mulrow, 2000). However, general medical practitioners (GPs) write the bulk of antidepressant prescriptions in Australia (AIWH, 2012) and most of these prescriptions cite the condition "chronic mild depression" (McManus, Mant, Mitchell, Britt, & Dudley, 2003). There are few clinical studies that look at the efficacy of antidepressants for mild depression (Ellis & Smith, 2002). The three debates highlight how the biomedical field sustains a series of open questions about how antidepressants work. These questions challenge the sufficiency of the conventional explanation of a linear, pharmacological action within depressed people.
Sociologists bring a different focus to investigating antidepressants. They examine how antidepressants work in the context of everyday life. However, like the biomedical debates, sociological studies mostly retain a focus on the depressed individual. They articulate how the specifically human capacities of thinking and feeling can mediate the experience of antidepressant use. A key line of inquiry explores how meanings are attributed to the medication, such as stigma and ambivalence (Barr & Rose, 2008; Garfield, Smith, & Francis, 2003; Malpass et al., 2009). Other sociologists (see, for example, Karp, 2006; Smardon, 2008) explore how narratives play a pivotal role in the reinterpretation of self that happens when medication is prescribed. Sociologists drawing on Rose's (1998) influential reading of Foucault also articulate how processes of self are instigated through medication use. Nikolas Rose (2007) argues molecular science has enabled the politicisation of life at the level of genes and cells. Given this, taking an antidepressant provides an opportunity for people to enact self-regulation in relation to biomedical authority. Such processes of self, in this analysis, include becoming active in response to the dominant neurochemical discourses (Fullagar & O'Brien, 2012; Rose, 2003). The depressed individual is enacted by these studies as an agentic and reflective person. The work to be undertaken by such a person is often cognitive and located in a rational register of experience. Some studies do focus on the emotion work involved in a depression diagnosis (see, for example, Fullagar & O'Brien, 2012). Broadly, however, the focus on the depressed individual perpetuates the distinction between the human work of mediating the experience of taking an antidepressant, and the pharmacological action of the medication. This distinction is perpetuated by a well-established sociological debate about how everyday life has become medicalized through the overprescription of antidepressants (Healy, 2004; Williams, Gabe, & Davis, 2008).
In Western industrialized countries, producing well-being involves the recognized mechanisms of pharmacological action or human effort. Antidepressant debates that focus on the depressed individual lend support to this conventional formulation. So, two modes of work are focused on when antidepressant-related changes are investigated: first, the (highly contested) neurochemical work of the medication within depressed people; second, the specifically human work of agentic individuals, mostly understood in a rational and cognitive register of experience. Both modes of work are connected to specific logics about causality. Antidepressant pharmacological action is explained using conventional causality. According to this reasoning, the inherent properties of the medication interact with other predetermined objects (like brain chemistry) to generate a predictable range of effects. The work of human effort is attached to a long-standing Western tradition that regards agency as a human attribute that resides within each person as a latent or expressed capacity (Bennett, 2010). Effects are generated in a linear way, by people activating and expressing their human agency. Investigation into antidepressant action is limited to discerning linear effects when only these framings of agency and causality are deployed.
Retaining a focus on the depressed individual encourages binarised debate about how antidepressants work--as either a chemical remedy, or chemical contaminant. The terms of these debates create positions for people who take antidepressants that are problematic for many. When couched as a chemical remedy, people who take antidepressants can be positioned as living with the stigma of a mental illness. Alternatively, when antidepressant action is seen to contaminate the human form, people are positioned as inappropriately masking everyday sadness and limiting the chance to optimize their human capacities. The social science approaches to antidepressants that retain the rational human agent can also have troubling implications for people who take antidepressants. One example is the body of studies showing how the pharmaceutical industry coconstructs the disease of depression and its treatment with antidepressants through "disease-mongering" (Elliott, 2003; Healy, 2000; Rose, 2003). People are characterized as either subjected by the dominant neurochemical discourses ("duped" by messages from pharmaceutical companies about the need to medicate mood states (Moynihan, 2002)), or actively negotiating them. The problematic dimension of this reading is that consumer choices are constructed as being subversive and negatively placed in relation to the status quo or being subjected and supportive of the status quo (Sedgwick, 2003). In doing so, it remains attached to a politics of blame.
This review shows how the depressed individual lies at the center of key sociological and biomedical debates about how antidepressants work. The depressed individual aligns with particular ways of understandings of agency, causality and work. That is, effects are generated in a linear way by pharmacological agents or through activating human agency. These concepts delimit how antidepressant action is investigated, in a debate that has reached a standstill and which attaches negative associations to people who take antidepressants. To progress investigation into antidepressant action, debate needs to occur on alternative terrain. Conceptual territory open to the possibility of forms of work beyond linear pharmacological action or the rational agent making cognitive adjustments is required. This line of enquiry has already been taken up in research that explores depression and the action of antidepressants as intersecting systems of biology, culture and society (Kleinman, 1986; Wilson, 2006). Keane (2011) identifies how sociological drug research is turning attention towards nonhuman actors in order to render visible drug subjects in addition to the user. The specific strategy pursued in this article builds on this work, shifting analytic attention away from the depressed individual (or the familiar sovereign subject). To do this it turns to the collective body or assemblage. The assemblage concept was selected because it reconfigures agency, causality and labor. It also enables an investigation that does not contribute to a commentary of blame about people who take antidepressants.
This section of the article introduces the assemblage concept or assemblage thinking and identifies the contribution this concept makes to investigation into how antidepressants work. The assemblage concept has been developed by Foucault, Actor-Network Theory, and Spinoza (McFarlane, 2011). Deleuze's elaboration of the concept is drawn on here (Deleuze & Guattari, 1987; Deleuze & Parnet, 2006). Deleuze (1925-1995) was a French philosopher who understood philosophy as the production of concepts. For Deleuze, an assemblage is a series of heterogeneous elements that are organized and held together through temporary relations. Assemblages continually form, decompose and change in processes, what Deleuze refers to as "becoming-other." To examine assemblages one might ask: how do the elements converge in a way that allows them to function together? How might the orderings endure and become stable through habit and repetition? However, this is only one dimension of assemblages. Deleuze argues that the forms assemblages take are always open and provisional. So of equal interest is finding ways to articulate an assemblage's "expressive potential" (Deleuze & Guattari, 1987), or in other words, the capacity of the assemblage to transform into something else. Therefore, the assemblage concepts allows exploration of both provisionality (or contingency) and structure within events (Marcus & Saka, 2006).
The assemblage concept formulates agency, causality and labor differently from how they are used in debates focusing on the depressed individual. This produces alternative conceptual terrain for the exploration of antidepressant action. First, agency is reconfigured as excessive to its conventional anchoring in the human subject. In assemblages, agency is not limited to subjects. Matter or material entities such as objects also have agency (Bennett, 2010). Different kinds of relations form between elements as they come together in temporary configurations. The characteristic properties of an element and its capacity to act--its agency--change depending on the place it takes up in the assemblage it is configured with (Anderson, Kearnes, McFarlane, & Swanton, 2012; Duff, 2013; McFarlane, 2011). Bennett (2010) convincingly makes this point when she shows how omega-3 fats have diverse actions in different populations. For drug researchers, disengaging action and agency from the individual human actor is a way of shifting debates about drugs from the moralized realm they are often conducted in (Keane, 2002; Wilton & Moreno, 2012).
Second, in assemblages causality does not operate in a linear way. Following the conventional reasoning about causality, a predetermined body and the known properties of the antidepressant interact to produce expected effects. Duff (2013, p. 168) identifies the problematic temptation of this logic to attribute "causal" responsibility to individual actors or factors in drug use. In contrast, in assemblages very contingent effects are created through the ways in which different elements in the assemblage come together. Causation happens within assemblages, in a nonlinear and emergent way (McFarlane,
2011). The concept of emergent causality has assisted drug researchers to show how drug effects are dependent on the ways in which factors encounter each other in a given situation (for examples of this line of thinking see Duff, 2013; Fraser, 2013; Fraser & Moore, 2011; Race, 2011). Following Deleuze's assemblage concept, agency and causality function in ways that contrast to their usual deployment in debates about antidepressant action.
Assemblage thinking can be used to investigate antidepressant action in new ways. This includes attending to the elements present in the event of antidepressant use and explicating the associations that exist between them. An additional dimension of Deleuze's conception of agency can be used in this kind of empirical inquiry. Deleuze (1992) stipulates that in addition to specific elements across an assemblage having different capacities to act, an overall assemblage also has agentic capacity (Deleuze & Guattari, 1987). The shape and structure of assemblages is determined by the kinds of associations that form between their elements. If an assemblage has organized secure and stable relations between entities, the overall assemblage will have a sharp boundary. The assemblage will have a limited capacity to enter into relations with other collective bodies or assemblages, a finite capacity to affect other bodies and be affected by them. The overall assemblage will have a small degree of affective capacity. In contrast, an assemblage that is mostly in a process of transformation and has disordered relations between elements is characterized by an increased openness to interaction with other assemblages and a high degree of affective capacity. So following Deleuze's thinking, an assemblage's agency--the action the assemblage can undertake, the relations it can enter into--is a property emergent from the formation of the overall assemblage. The power of this action is called "affect," an intensity or force that exceeds the subject (Massumi, 2002). Drawing on this dimension of assemblage thinking provides ways to discern the connections between the relational structure of an assemblage and the emergent subject forms, affects, collectives and drug "effects."
The assemblage concept also expands the terms available to think about work, or labor. This is the third contribution assemblage thinking makes to shifting the conceptual terrain for the exploration of antidepressant action. The previous section of the paper showed how work is often couched in terms of the action of neurochemical agents, or rational agentic humans. In contrast, in assemblages work can be conceived as the energy expenditure required to assemble the collective body, "the on-going labour of bringing disparate elements together and forging connections between them" (Li, 2007, p. 263). It is individuals in their contexts, for Li, who expend energy to create the associations between elements. Consistent with matter having the capacity to act in assemblages, the energy expenditure required for the maintenance of assemblages is extended in this paper to include the action of the nonhuman. The labor of nonhuman and human entities in forming connections to create assemblages is described here as "collaborative connective labor."
Qualitative inquiry into antidepressant action usually uses research methods underpinned by a rational human agent. This project required research processes that were consistent with assemblage thinking and actively destabilized the sovereign subject. In other words, a research design sensitive to the activity of elements and how associations form between them (Demant, 2009; Duff, 2012; Vitellone, 2013). The following section of the article outlines how assemblage thinking was brought into the design and processes of a qualitative research project with people who take antidepressants.
Assemblages and qualitative research
This component of the paper describes the strategy undertaken to make the methodology and methods for this project consistent with assemblage thinking.* The key strategy was to experiment with approaching every dimension of the research process as moments when assemblages configure. This orientation was extended to the research encounters with the eight research participants in this project. Four men and four women were recruited through Melbourne mental health advocacy organisations. All took antidepressants for mild-moderate depression. As a group they were diverse in terms of age, income and cultural background. However, they shared some key characteristics. They all were, or had been, professionals and most were tertiary educated. The data for this project emerged from the research encounters. In keeping with a Deleuzian approach, I see data as produced through the moment-to-moment configuring between all the components of the research events, including the reconfiguring of both myself as the researcher and the research participants (Michael, 2012; Stengers, 2000; Thrift, 2003).
A number of materials were included in the research encounters as another strategy to make the research methods consistent with assemblage thinking. I wanted to experiment with how different materials might enable and constrain how assemblages configured, so selected contrasting materials. The first material introduced was a wellbeing chart. At our first encounter the research participants were asked if they would like to tell me a story about how their wellbeing may or may not have changed over time. They were also invited to draw a line on a chart to convey how they regarded their levels of wellbeing at different times. The chart was a productive constraint on the assembling that happened during the research encounter. Drawing a line on a chart invited research participants to organize their memories into a logical sequence over time (Williams & Keady, 2012). Changes to wellbeing were attributed to specific life events or the strategies undertaken to mediate wellbeing, one of which was taking an antidepressant. Experiences of antidepressant use were conveyed using the conventional framing--that they worked as either a biochemical remedy or contaminant to optimal existence. The line encouraged a telling of experience that is selectively interpreted, where the subject is "centered" (Jackson & Mazzei, 2013, p. 262; Stephenson, 2005, p. 34). My position also moved towards being centered too, as a kind of health professional-researcher able to understand and use of these ways of categorizing experience.
The second material introduced to the research encounters was participant-generated photographs. At the end of our first encounter, the research participants were asked if they would like to create some photos to convey to me what was happening in their lives at different points during the timeframe indicated on their chart. They undertook this exercise willingly, on their own time. Taking the photographs was an affectively intense process for the research participants as they visited places and handled objects which evoked memories and feelings. This looser, less defined activity included the possibility of memories proliferating outside their conventional organization of narrative over chronological time.
The encounters with the photos contrasted starkly to those with the wellbeing charts. What mattered here was sharing and performing a range of affective states. Part of this communication was achieved by shaping the visual elements in the photos. The research participants used brightness and darkness to communicate times of high and low levels of wellbeing. They also created certain viewing positions for me to take up in relation to the photos (Lister & Well, 2001, p. 88; G. Rose, 2007, p. 41). During their sharing of the photos and accompanying story, the research participants did not require any verbal input from me. The position I moved to in these encounters was simply to be present, and witness what the photos conveyed as sensation or force (Csordas, 1994; Massumi, 2002). Images have the capacity to disturb or move the viewer in unexpected ways (Barthes, 1981). I was certainly transformed by my encounters with the research participants' photos. This sensitized me to how the contrasting materials in the research encounters--the charts and photos--enabled different kinds of assembling for all coparticipating elements, including my coparticipation as a researcher.
The research participants' commentaries on the charts were filled with conventional understandings of depression and antidepressant action. A very different series of relations to antidepressants emerged in relation to the photos. In the few instances where a photo featured an antidepressant, research participants conveyed the bodily connections of habit and attachment that formed in the moment of encountering the pill each day. They also communicated how the pill object evoked aesthetic responses, and the affects of comfort and relief. The contrasting ways in which antidepressants assembled in the research encounters showed me how the object coparticipates in the formation of a distinctive range of connections with other elements.
Following assemblage thinking, the analysis of this project needed to account for how connections form in assemblages. The analytic strategy was to think through the lens of contiguity relations between entities. This approach involves identifying the actual connections between things in contrast to the similarity-based relations that are predominantly used in qualitative health research coding strategies (Maxwell & Miller, 2010). The analysis of contiguity relations was extended using a second analytic device for explicating assemblages: modified versions of Clarke's mapping techniques, as outlined in her approach to a postmodern-inflected grounded theory (2005). Clarke's situational map (2005) was modified by limiting the coparticipating elements--human and nonhuman--to those in the research encounters. Elements of my coparticipation were included in the maps. This involved drawing on the notes taken after every encounter, the extended reflections written about each interaction and diary entries from the time. The material elements in the encounters were also emphasized. In addition, the relations between the elements were examined following Clarke's advice for making relational maps (2005). Making maps based on a connective analytic strategy allowed for identification of key elements in the encounters, and the coproduction of relations between elements.
The overall analytic then became moving between the components of the research processes--narratives, photos, specific encounters and theory--and seeing the connections made through these movements as generating assemblages. The analysis processes became focused on the ongoing exploration and creation of new collective bodies (Jackson & Mazzei, 2013). An experimental process was undertaken to find a vocabulary to describe formations as they came together. This involved articulating the coparticipating elements, the relational configuration across the assemblage, and the collective bodies' emergent formations and capacities. A series of coextensive assemblages were described, one of which configured during encounters with antidepressants. I called this assemblage "Becoming-Depressed." The next part of the article draws on the charts, photos and narratives from the research encounters to illustrate the elements that compose this assemblage, the relational configuration between the elements, and the capacities of its emergent formations. The production of this assemblage was possible due to the specific entities proximate to the research encounters. As I go on to show, the Becoming-Depressed assemblage generates a sensitizing concept, or a way along which to look, at antidepressant action. Additional empirical investigation would be required to determine the explanatory power of this concept in other situations.
Antidepressants facilitate collaborative connections
The empirical illustrations in this section of the article show that antidepressants work through a series of collaborative connections. They explicate the entities present during encounters with antidepressants and how relations of logic, habit, aesthetic response, and affective investment proliferate between them. Both human and nonhuman elements are shown to coparticipate in the work of forming associations between entities. The entity in the assemblage with the most capacity to coparticipate in forming associations is the antidepressant object. The assemblage that configures with the antidepressant, called Becoming-Depressed is described. The structure of the overall assemblage and its emergent formations are identified. These forms, it will be shown, constitute the emergent antidepressant effects.
The research participants in this project all had at least one stage of acute despair. At this time they sought help from a GP or psychiatrist who prescribed them an antidepressant. This involved engaging with the biochemical thesis of depression and drawing connections between moods and serotonin levels in the brain. During our discussion about her wellbeing chart Cameron--an energetic, fast-speaking woman in her early 30s--used neurochemical terms, definitions, and categories to account for her bodily changes over time. Discussing her chart, Cameron describes how her doctor suggested she might understand her despairing state as indicating depression:
I hated Australia, I hated my job. I had no friends, I had a serious rift with my father at the time. So I basically had nothing to get up for in the morning. I went to a doctor, in tears, and said, "I don't really want to live any more. I can't even see any point in going on." I was that despairing of my life basically. He sat me down and said: "You are very depressed."
The medication facilitates Cameron, and her prescriber doing the work to line up Cameron's states and her interpretation of them, with the terms of the neurochemical framework. Together they take on board the meanings of the neurochemical framework and constrain other explanatory frameworks, undertaking the work that Li describes as "authorizing knowledge" (Li, 2007, pp. 273-276). Cameron accepts a diagnosis of depression as an appropriate interpretation of her state of feeling. She then causally connects the diagnosis to her GP's identification of lacking serotonin levels in her brain. As she understands herself as having a medically-defined neurochemical lack, the next logical step is to take the drug that will remediate this lack. As she says:
I mean, if I had diabetes, I'd take insulin. I don't have serotonin, or I have low serotonin, so this brings me up to the same level as everybody else. You know I'm not perfect, but I feel like I'm functioning like a normal person, not like a neurotic.
The process of accepting a depression diagnosis and a need for antidepressant treatment has increased the number of logical relations Cameron makes between herself, her feelings, the neurochemical framework, and her prescriber. She actively engages with an explanatory framework that defines in advance the problem, the intervention and what will constitute a beneficial result (Li, 2007). Pain and suffering are interpreted as an illness requiring chemical treatment, so fixed relations are created between certain states of feeling, and pathology. The terms of a neurochemical framework have also provided Cameron with a series of categories she can use to understand herself and others: depressed/not depressed; serotonin sufficient/lacking; rational and irrational. Making and reproducing these dualisms creates difference between relations (Lazzarato, 2006) and again adds to the formation of fixed or non-reversible relations. By using the neurochemical terms, categories and definitions, Cameron has been able to find a way to articulate her life, and to access means of interacting with a social world that recognizes her. Cameron indicates the necessity of retaining some form of connection to a shared social reality (Deleuze & Guattari, 1987). Facilitated by the encounter with the antidepressant, Cameron and her GP expend energy to form logical relations between Cameron's state and the neurochemical framework. The following section highlights how in addition to this human expenditure of energy, the nonhuman element of the antidepressant object also coparticipates in the formation of collaborative relations.
This part of the paper illustrates how the antidepressant object cocreates relations of habit. A key component of antidepressant use is the habitual encounter with the pill each day, demanded by the prescription of daily use. For Steve, a quietly spoken retired public servant, forgetting his daily habit of taking the pill in the morning results in visceral reactions by the afternoon, including shakes and tingles in the hands and light thumping in the head. These symptoms indicate to him that he needs to take his daily dose, to ease his symptoms. In response to this unwanted state, Steve has a comprehensive repertoire of strategies to assist him maintain the habit of daily use. Steve indicated while discussing his photos that,
I've got them (antidepressants) all over the place. I've got them at Mum and Dad's, my sister's, my girlfriend's, in the car. Generally if I don't stay at home, there's sort of that little bit different routine in the morning. Say for example on holiday next week. Whilst I'm not going to have medication out for people to see, it's something I've already thought of. I'm very particular about brushing my teeth so I might put some black tape around the toothpaste or something like that.
In assemblages, the creation of habitual connections works to stabilize both the assemblage and the subject forms that can emerge from it (Delanda, 2006, p. 50). Steve is invested in avoiding the visceral effects of any disruption to the habit of daily use.
A feature of habit is that it requires less energy expenditure to enact: Repeated, expected action does not require decisions to be considered afresh each time (Mol, 2008). Rayna--a wiry, inquiring woman in her early 50s--considers a strategy such as meditation to work in a similar mode to her antidepressant. Both are effective responses to the states she wants to mediate: feeling overwhelmed; having too much chatting in her head; and being out of control. During her chart discussion Rayna said:
Another thing I think I've got a bit more in touch with, and I don't do it anywhere near as much as I should, is meditating. I do try to build up at least a few days of taking 15 minutes out to meditate. I mean, it is powerful but I just can't drive myself. I can't discipline myself enough to do it.
In comparison to the habit of taking a pill, meditation for Rayna requires a significantly increased degree of energy. This indicates how habitual contact with the antidepressant object mediates the collaborative connective labor required of the patient to form an association.
Habitual encounters with the antidepressant object involve bodily expenditure of energy. This contrasts to the rational register of labor usually examined in sociological studies about antidepressant use. When we met for the second time, Steve shared a photo he had taken of his bedside drawer, opened to show the pharmaceutical products he kept there. Explaining this photo to me, Steve said:
And in my bedside drawer--looks like its own pharmacy. Any day you open it, that's what you see. Now I'm in a relationship and have been for a while, the good thing is she knows everything. So I don't have to change that at all. For fear of her seeing something I don't want to, I'm not going to change, and she didn't want me to. There's a level of comfort in that. The fact is, that's my drawer, and for the foreseeable future that's how it will be. You know, I can reach in there in the middle of the night in the dark and I can, just by the feel of the packet, I would know what was what.
Steve's tone is one of quiet conviction as he conveys the sense of certainty and stability generated by having the drawer as an ongoing feature in his life. His encounter with the object is registered bodily--he can identify the drugs in the dark--indicating his direct bodily awareness forms a connection with the pill object. Steve's bodily senses and the materiality of the object expend energy together to form the collaborative connection. Another instance of nonhuman and human elements coparticipating to form collaborative connections happens when aesthetic relations form between the person taking the pill and the antidepressant object.
Rayna took a photo of her antidepressants in their usual position in her home, sitting on the countertop in her bathroom with her vitamins and some bracelets she bought on her last holiday overseas. She explains how the habitual encounter engages her viscerally, through evoking an aesthetic response to the scene created by the objects.
It's just funny, it's just the way it all sits on the bathroom countertop. You know, just in that arrangement. I sort of like the look of it, the arrangement you know, in a creative way. It's probably a bit of an arty arrangement too. Because I just do look at it. I suppose I'm a visual person and I look at the way things balance and, appear.
As an object the antidepressant provokes affects in Rayna--aesthetic pleasure, comfort, and satisfaction. Objects, like assemblages, have a power of action (affect) or the capacity to act. Things have the vital capacity to connect with other elements and to undertake collaborative connective labor. According to Elizabeth Grosz (2008) the materiality of objects enables their expressive qualities. The materiality of the objects in this scene expresses something to Rayna. This expression of affect cocreates the relation with Rayna; it is part of Rayna's aesthetic response to the objects as they are composed on her bathroom counter top. The antidepressant object shares the vital materiality of the vitamins and bracelets, indicating the scope non-organic objects have to become things that are, as Bennett describes, "vivid entities" (Bennett, 2010, p. 6). A respondent in Vitellone's empirical research on the syringe described the shooting gallery as "aesthetically pleasing" (Vitellone, 2010, p. 878). Rayna describes a similar response to the configuration of objects in their "arty arrangement." The syringe and antidepressant objects both can be seen to have expressive qualities that present an experience of affect, of aesthetic pleasure.
This final empirical illustration will show how--facilitated by the encounter with the antidepressant--prescriber and patient undertake work to invest affectively in the treatment. This work again contributes to the proliferation of stable relations across the assemblage.
Antidepressants are connected to the competing binary discourses that understand antidepressant action as a chemical remedy, or a chemical pollutant. Rayna is clear about how she positions herself in relation to these discourses. She indicates she is cognisant of the research that debates the biomedical efficacy of antidepressants: "I mean, I still wonder about the antidepressants, you know, the placebo stuff, the various research. And then the research that they don't do anything." However in the course of the same conversation she takes up a contradictory position, saying: "Well look, in the end, I don't care, you know, if you've got heart disease you take medication for heart disease.... if it works for me, that is fine." Rayna is simultaneously invested in, and has a clear position on, how the medication works to remedy her medically defined illness.
Cameron talks about the processes of developing a shared investment in the medication with her GP:
This time, I actually thought I was doing all right. But he went: "Nah." It's interesting how they worked, when I didn't want them. I don't know how that works, psychologically! I resisted them. I said: "I don't need them." He said: "Yeah, you do."
Cameron then accepted her GP's explanation that it was worth enduring her initial side effects, because the drug was going to make her feel a lot better. This process further reinforced her investment in the treatment. Together Cameron and her GP have done work Li describes as "forging alignments ... the work of linking together the objectives of various parties to an assemblage" (2007, p. 265). Yet simultaneous with Cameron's investment in antidepressants as providing her a chemical remedy, is her sense that it would be preferable to not take a drug or need a pill to be happy. She retains an investment in the idea that taking an antidepressant creates a body that is inferior--more polluted--than a drug-free human form. Mariam Fraser (2003) develops the groundbreaking argument that the serotonin hypothesis of depression, usually understood as representing a biomedical model of depression, instead participates as an unfinished object in events or assemblages of continuously changing relations. It is the particular openness of the hypothesis, she argues, that enables it to configure in different ways, in different kinds of events or assemblages. Rayna and Cameron connect to ideas about the action of antidepressants which are underpinned by the serotonin hypothesis of depression in a range of ways, indicating the partial status of the ideas. The openness around how antidepressants work enables Rayna and Cameron to form multiple and shifting relations to the serotonin hypothesis of depression. They can invest in a range of contradictory and coextensive positions, which increases the extent of their affective investment in the treatment. In turn, stable relations proliferate across the assemblage.
Becoming Depressed assemblage
This part of the article will detail the overall structure of the Becoming-Depressed assemblage and the formations that emerge from it. The assemblage is entitled Becoming-Depressed because, as I will go on to show, the subject form that is produced from the assemblage communicates and is recognized as a "depressed" person. This subject form differs from the orthodox understanding of a person who is suffering from depressive symptoms.
The empirical illustrations detailed above show how the antidepressant medication facilitates relations of affective investment, aesthetic response, habit, and logic. When configured as part of the Becoming-Depressed assemblage, the antidepressant entity works as an "operator" or "assemblage convertor" (Deleuze & Guattari, 1987). That is, as an element with an unusual capacity to contribute towards an assemblage's trajectory. In this case, the relations proliferating around the antidepressant element create an assemblage that is increasingly organized and stable. The prescriber, patient, and object coparticipate in practices that accelerate when the antidepressant object is encountered in the clinic or during daily use. The labor of these practices includes: the shared cognitive work of interpreting bodily change in relation to the neurochemical framework; the embodied work of sensing the object during habitual encounters; visceral, spontaneous aesthetic responses to the object; and the effort of affectively investing in competing discourses about antidepressant action. Crucially, the energy to form associations through these practices does not just originate from humans. The object also does work to form collaborative connections, by evoking affects. The labor of objects mediates the degree of energy required by coparticipating people to form associations.
Following the notion that antidepressants work through a series of collaborative connections, in this account antidepressant "effects" are the contingent, emergent formations of the overall Becoming-Depressed assemblage. The proliferation of organized and stable relations creates an assemblage with internal homogeneity, clear rules, and sharp boundaries. The Becoming-Depressed assemblage has a limited capacity to form relations with other assemblages and thus a low degree of agentic capacity. Consistent with this overall formation, the emergent subject form is unified and is recognized as a "depressed" person. Low-intensity affects--predominantly comfort and relief--emerge from the assemblage. Together, these formations constitute the emergent antidepressant effects.
Antidepressant effects are not only contingent upon the formation of the Becoming-Depressed assemblage. They are also sensed in relation to "the multiple assemblages that constitute 'a life' " (Anderson et al., 2012, p. 214). After times of acute pain and immobilization, a stable and low-affect formation is welcomed by the people in this study. The emergent subject form feels functional and connected to a form of social reality. As Walkerdine (2010) shows, containment is valued when life is also characterized by insecure situations. The people in this study also emerged from assemblages with contrasting affective capacities. So at times they emerged as enlivened, excited, content, and so on. For these research participants, the Becoming-Depressed assemblage is one in a series of continually changing assemblages. Viewed in this light, it is a transitory, productive and well-regarded formation.
The Becoming-Depressed assemblage continually comes into contact with other assemblages. Although it has limited capacity to interact with other assemblages, the force of an encounter can disrupt the relational configuration of the Becoming-Depressed assemblage. Steve describes how he was confident he was on the "right" antidepressant. But a life event happened--his marriage broke down--which, in his words, "sort of over-rode" the antidepressant "in a sudden and direct drop." He moved into a time where he attempted suicide. The force of this life event destabilized the temporary formation of the Becoming-Depressed assemblage, breaking down the connections between elements. At this time the antidepressant object is no longer configured with a proliferation of stable relations, so Steve can no longer ascertain antidepressant effects.
The research participants draw on the conventional pharmacological explanation to account for antidepressant effects. Cameron connects the increased stability in her life solely to the pill's chemical action. She makes a causal link between her antidepressant's neurochemical properties and achieving emotional control. For Rayna, increasing her antidepressant dose is a way to directly reduce her sense of rawness by "putting a little bit more of a buffer on it." Both women make logical connections between the action of the medication and changes to their affective states. In doing so, they are again adding to the number of logical connections across the assemblage.
New ways of thinking about medication, depression, and recovery
Shifting the analytic gaze from the depressed individual to the collective body or assemblage made up of nonhuman and human elements has provided fresh insight into how antidepressants work through a series of collaborative connections. Thinking with assemblages adds the missing work of nonhuman and human collaboration to the picture of antidepressant action. The article will now go on to discuss how this understanding of antidepressant action suggests new ways of thinking about medication, depression, and recovery.
First, thinking about antidepressant medication. The antidepressant action suggested here does not refer back to, or exist within, the depressed individual. Antidepressants work through a range of relations. The work to make these associations is collaboratively undertaken by nonhuman and human coparticipants. Human expenditure of energy to form connections is not only cognitive, but also undertaken through bodily registers of experience. This human coparticipation differs from the predominantly cognitive work of meaning-making and identity-formation pointed to by sociological studies as mediating the experience of antidepressant use. In contrast to the conventional pharmacological account, the effects of the antidepressant action described in this article are not linear, but emergent. Antidepressant effects are associated with the emergent formations from an assemblage with stable connections: low-intensity affects, limited affective capacity, and an emergent subject form that is unified and recognized as a depressed person.
The research participants drew on the orthodox pharmacological explanation to account for antidepressant-related change. This article suggests antidepressants work through a range of actions, only some of which can be traced to a pharmacological agent. Pharmacological agents can cocreate collaborative connections in the neurochemical dimensions of the Becoming-Depressed assemblage. However, this is but one aspect of the overall topography of relations composing the assemblage. It is insufficient, given the range of labor contributing to the collaborative connections that form the Becoming-Depressed assemblage, to attribute the emergent effects to pharmacological agents alone. Wilson (2006) uses a similar network logic to interpret psychopharmacological data on antidepressants. In her view, the pharmacological action of antidepressants reiterates neurochemical networks that traverse the body and the world it inhabits. It would be productive to further investigate how collaborative connections form between the social, material and neurochemical entities of the Becoming-Depressed assemblage.
The increasing rates of antidepressant consumption are generally explained as due to escalating rates of depression and more effective means of diagnosis. The notion that antidepressants work through collaborative connections points to an alternative explanation: that people are increasingly experiencing moments when they require stable associations between different aspects of life and the emergence of a (temporary) unified subject form. The research participants indicated how this is a desired formation after feeling lost to the world and despairing. The antidepressant object is pivotal to the proliferation of stable relations, and the formation of the Becoming-Depressed assemblage. However, the object is also connected to a depression diagnosis and the associated neuro-chemical imbalance. The stigma associated with these definitions is problematic for many. The article has shown how the Becoming-Depressed assemblage is composed by a range of elements and different forms of collaborative labor. This raises the question: Is it necessary to attribute neurochemical lack and mental illness to create an assemblage with a desired stable structure? The final component of the discussion will go on to explore these broader questions around how recovery is resourced.
A human model of ethics, featuring the intentional moral human subject, is usually used to assess interventions like antidepressants. Drugs effects are assessed as "good" if they enhance the sovereign body or "bad" if they pollute the individual. Disconnected from the depressed individual, this account is not concerned with drug effects within individuals. Instead, the material for ethical consideration becomes the formations that emerge from the Becoming-Depressed assemblage. Shifting attention away from the depressed person to the collective body or assemblage allows ethical examination to become "ethological" (Deleuze, 1992, p. 628). That is, the focus becomes the agentic capacities of the assemblage, instead of the agentic individual. This approach is an example of extending bioethical systems of assessment beyond a purely human model of ethics (Buchanan, 1997; Race, 2012; Rosengarten & Michael, 2009).
Using this approach to ethically assess antidepressants would require detailed examination of the capacities of the Becoming-Depressed assemblage. Deleuze's normativity is open to processes, becoming and differentiation (Braidotti & Pisters, 2012). This does not mean privileging transformative processes in assemblages, but giving careful examination to how assemblages form, decompose, and change. As Anderson describes, "a Deleuzean ethic based more on a thoroughly immanent attention to the qualitative capacities of assemblages" (2012, p. 215). In their discussion of the depression strategy, Diprose, Stephenson, Hawkins, Mills, and Race (2008) define a healthy body as one that is open to encounters with others. The authors understand the depression strategy to be harmful, because it limits the degree of openness bodies have to encounter with other bodies. However, here we see the Becoming-Depressed assemblage--with its limited capacity to interact with other assemblages or bodies--is welcomed after times of despair. This points to the importance of examining the capacities of assemblages as they occur in ongoing bodily experience (Anderson et al., 2012; Bissell, 2009).
Deleuze's ethical stance is that "life itself is a self-emerging process that aims at sustainable modes, times and forms of becoming" (Braidotti & Pisters, 2012, p. 2). This stance generates productive questions about how to understand and resource recovery processes, such as, how might we best facilitate sustainable assemblages for people after times of despair? In other words, how might the elements and connective labor required to produce the Becoming-Depressed assemblage be directed to more effectively maintain wellbeing? For example, could a resource like a shared framework to understand and describe experience be provided without evoking neurochemical pathology? The overall approach called for by this ethical stance brings what McFarlane describes as a "positive orientation" to thinking about how to best facilitate the formation of temporary stable assemblages. Taking into account the action of matter, this orientation extends to consideration of the ethical obligations of nonhuman actants.
Ethological assessment of nonhuman elements looks at the kinds of relations afforded by entities, in the assemblages they are configured with. The intervention of providing the antidepressant receives government support and medical sanction. The antidepressant is a pivotal cocontributor to the number of stable relations in the Becoming-Depressed assemblage. It also mediates the amount of energy required of people to form associations. The relations afforded by the object contribute to the formation of an assemblage with desired capacities, so can be assessed positively. However, this ethical approach also examines the kind of associations that produce harm (Duff, 2013). Antidepressants are already connected to a categorization of mental illness and non-reversible relations between pathology and certain affective states. A positive orientation encourages thinking through the possibility of an object that accelerates stable associations, without these built-in harm relations. Fraser (2013) illuminates how objects might be actively shaped toward harm-reduction outcomes. She shows it is possible to "design in" the already-existing social attachments of injecting people to the material objects of their equipment. Fraser notes that equipment "that acknowledges and affords different conduct and different relations will not guarantee new subjects, but it can make them 'slightly more' imaginable, slightly more available" (2013, p. 218). Applying this insight to the antidepressant object raises the productive question: Could the object be reconfigured to make more imaginable a subject who desperately needs more stable relations in life and seeks a unified subject form, but is not anchored to ideas about pathology?
If recovery requires the formation of sustainable assemblages, collaborative connective labor is positioned as a crucial resource. This article highlights all the collaborative connective labor that goes into the production of the Becoming-Depressed assemblage. The unified subject form, the depressed person, emerges from the Becoming-Depressed assemblage. At this time, the collaborative connective labour involved in this production is backgrounded, and relevant institutions confer the depressed identity via depression diagnosis and antidepressant treatment. So, the depressed subject form reinforces and stabilizes the institutions associated with depression--and without any recognition of the labor required for the depressed subject's production. In addition, the emergent effects" of the Becoming-Depressed assemblage are commonly attributed to the linear pharmacological action of the medication. This in turn reinforces the medication and lends justification to the profits directed towards the pharmaceutical and depression industries. A productive orientation queries how labor is accounted for in the production of the Becoming-Depressed assemblage. It suggests harnessing collaborative connective labor towards the formation of sustainable assemblages wherever they are needed or desired. One step towards this might be to acknowledge that forming stable connections plays a crucial role in recovery, and that this can be contributed to by nonhuman elements, as well as people.
Using assemblages to rethink antidepressant action provides a way forward from the impasse in the debates about antidepressant action that feature the depressed individual. Shifting attention away from the depressed individual and onto the assemblage contributes fresh insight into how antidepressants work through human and nonhuman collaborative connections. In doing so, a contribution is made to the contested and unresolved matter regarding how antidepressants work. This account of antidepressant action does not enact the depressed individual in its usual form, the sovereign subject. Therefore it also does not contribute to the problematic positions provided to people who take antidepressants by the conventional debates about antidepressant use--the negative associations of having a mental illness or not optimizing human capacities. In addition, new ways of thinking about depression, medication and recovery are suggested by this antidepressant action. These lines of enquiry can be explored using an ethological ethical approach, which does not evoke or enact the depressed individual. Qualitative research processes that destabilize the sovereign subject would support this approach. These strategies open the possibility of assessing interventions like antidepressants without further entrenching the stigma experienced by those who take the medication.
AUTHOR'S NOTE: The research reported here was funded by a Ph.D. scholarship (Melbourne Research Scholarship) from the University of Melbourne. I extend my grateful thanks to the Contemporary Drug Problems reviewers and editorial staff for their suggestions, which substantially improved the paper. For additional information about this article email: email@example.com.
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* This research project was approved by The University of Melbourne Human Research Ethics Committee (Approval No: 0717717).
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|Publication:||Contemporary Drug Problems|
|Date:||Mar 22, 2014|
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