Living in the Doldrums

The Lived Experience of Dispiritedness in Later Life

R

esearch into subthreshold forms of depression is an emerging area of study in the mental health field. Some of the more common terms used by researchers and practitioners to describe subthreshold conditions of depression include minor depression, mild depression, and subsyndromal depression (Rowe & Rapaport, 2006). Others have suggested such syndromes as depression without sadness or depletion syndrome (Blazer, 2003).

Although the diagnostic systems of the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR) (American Psychiatric Association [APA], 2000) and International Classification of Diseases (IDC-10) (World Health Organization, 1993) have improved the recognition of depression  through the development of criterion symptoms, the diagnostic criteria inadequately capture the  nature and range of dysphoric syndromes. Judd, Rapaport, Paulus, and  Brown (1994) were among the first to note that “substantial numbers of individuals, either identified as ‘depressed’ or referred for evaluation by other clinicians, frequently do not qualify for formal mood disorder diagnosis when rigorous standardized research diagnostic methodology is applied” (p. 18). This finding was also supported in Mental Health: A Report of the Surgeon General (U.S. Department of Health and Human Services, 1999).

Blazer (2002) believes that in later life, minor depression may not be a single entity; instead, many syndromes are captured by the construct. Lack of consensus on how to define milder syndromes of depression has slowed clinical and research progress (Kroenke, 2006; Rapaport et al., 2002). Increasingly, researchers and clinicians are viewing milder syndromes of depression as part of a continuum of depressive conditions; however, more research is needed to better understand this broader range of depressive syndromes (Kessing, 2007; Rowe & Rapaport, 2006).

Background

Depressive syndromes in later life are a frequent source of emotional suffering and contribute to decreased quality of life in older adults (Blazer, 2002, 2003; Lyness et al., 2006). Minor and subsyndromal depression are more com- mon than major depression in a variety of settings (Charney et al., 2003; Hybels, Blazer, & Pieper, 2001; Lavretsky & Kumar, 2002; Lyness et al., 2006). Minor depression is major in its prevalence and impact (U.S.  Department of Health and Human Services, 1999, p.346). Lyness et al. (2002) found that patients with minor depression had poorer health outcomes than those who were not depressed, although their outcomes were better than those with major depression. A follow-up study confirmed that older adults with minor depression had a five times greater risk of developing major depression and had greater functional disability after 1 year (Lyness et al., 2006).

Research should focus on both minor forms of the depressive experience and on the existential features of depression in later life. Blazer (2002) stressed the importance of awareness of the existential aspects of late-life depression, which include themes such as meaninglessness, isolation, hopelessness, loss of freedom, helplessness, and death that not only concern older adults’ experience but also reresent an  existential concern. Blazer (2002) also pointed out  that “existential depression does not fall within our usual diagnostic nomenclature but rather cuts across many different depressive syndromes” (p. 190). The purpose of this study was to investigate the lived experience of dispiritedness, a common and milder depressive syndrome in later life that also uniquely captures existential features of depression (E.K. Bugental & Bugental, 1984; Butcher, 1996; Butcher & McGonigal-Kenney, 2005; Jourard, 1971).

Dispiritedness is a common expression and human experience, reflected in statements such as “I lost my spirit,” “My spirits are low,” “My spirits are broken,” “I feel dispirited,” and “This will raise your spirits.” The Oxford English Dictionary (1989) defines dispirited as “deprived of its essential quality or vigor...cast into or characterized by low spirits; discouraged, disheartened, dejected” (p. 814). Synonyms include sadness, dejected, downhearted, downcast, discouraged, low or lowness, low spiritedness or spiritless, and despondent.

The phenomenon of dispiritedness has its origins in the writings of Jourard (1971), who initially described dispiri- tation as a phenomenon related to, yet different from, depression, emphasizing the  subjectivity of dispiritedness. The theory asserts that individuals are inspirited when they have hope, meaning, purpose, and value in existence. Events that make  individuals feel unimportant, worthless, hopeless, low in self-esteem, isolated, and frustrated are dispiriting and can often result in the belief that  existence is meaningless (Jourard, 1971). He also described dispiritedness as feeling limp, lackluster, without hope or identity, given up, worthless, and unimportant, with individualsbelieving that existence is absurd and meaningless. Illness and aging were specifically mentioned as potentially dispiriting processes. Jourard (1971) contended that social conditions, such as forced retirement, might be so devoid of opportunities for inspiriting satisfactions that individu als can become dispirited.

Building on these ideas, E.K. Bugental and Bugental (1984) felt that despite the abundant literature on depression, their orientation in existential-humanistic psychotherapy and experience in clinical practice required a different interpretation of depression. They characterized dispiritedness by feelings of sadness, pessimism, and futility and viewed being in low spirits as a common, normal human experience (E.K. Bugental & Bugental, 1984). J.F. Bugental (1980) did not believe dispiritedness was common to all depressions. Although the experience of dispiritedness may address milder states of depression, dispiritedness may also be prolonged and more profound in some situations (E.K. Bugental & Bugental, 1984). Both Jourard’s and Bugental’s descriptions of dispiritedness were based on clinical observations and theoretical work rather than being grounded in research.

Throughout the psychiatric literature in the 20th century, there have been few references to dispiritedness and virtually no mention of low spirits as a feature of the depressive experience. Yet, health care professionals in mental health settings will use the phrase in low spirits to describe clients’ moods or emotional conditions. Despite this, little research has investigated the nature of dispiritedness in later life, and thus the experience is not well understood. Anecdotal descriptions of dispiritedness (J.F. Bugental, 1980) and previous research (Butcher, 1996) have  found that existential themes such as emptiness, uncertainty, isolation, and a loss of meaning are associated with the experience of dispiritedness. A dearth of phenomenological research focuses on the lived experiences of mild syndromes of depression among older adults. A review of the litera- ture uncovered one relevant but unpublished dissertation that focused on the experience of older adults living with subthreshold depressive symptoms. Ten older adults living in a rural area were interviewed, and  phenomenological analysis uncovered eight essential themes of subthreshold depressive symptoms: feeling useless versus keeping busy, less energy or ability to motivate self, keeping to oneself, feelings that come and go and are distractible, loneliness, sadness, sleep changes, and internal problem-solving conversation (Hostetter, 2003).

Although dispiritedness may be considered a milder form of depression (Butcher & McGonigal-Kenney, 2005) and the prevalence of subsyndromal, subthreshold, and minor depression in later life is high in community samples, the phenomenology of minor forms of depression are poorly understood and underrecognized (Blazer, 2002; Kumar, Lavretsky, & Elderkin-Thompson, 2004; Lyness, King, Cox, Yoediono, & Caine, 1999). The intent of this study is not to develop a set of diagnostic criteria for dispiritedness in later life but to describe the essential structure of the lived experience of dispiritedness in a population of older adults using van Manen’s hermeneutic-phenomenological method as a means to gain a deeper understanding into its existential features.

Method

Phenomenological research is ideally suited as a method of inquiry for developing a deeper understanding of the existential features of human experiences and is a widely used qualitative method to make things stand out in new ways. Phenomenological research is informed by an existential philosophical underpinning and is guided by an understanding of existential concepts such as the  meaning of existence, consciousness, temporality, freedom and choice in life situations, meaninglessness, finitude, subjectivity, isolation, and relatedness (J.F. Bugental & Kleiner, 1993; May, Angel, & Ellenberger, 1958; van Kaam, 1969; van Manen, 1997).

van Manen’s hermeneutic-phenomenological research method has been particularly influential in  investigating lived experiences associated with health-illness experiences because his method  clearly articulates the interrelationship of phenomenology, hermeneutics, and semiotics, using a scientific process of research that incorporates textual reflection and enhances understanding of everyday human experiences (Ray, 1994; Walton & Madjar, 1999). It is an appropriate scientific, rigorous method for analyzing phenomenological data collected from various sources (Giorgi, 2009). Van Manen (1990) suggested six research activities for human science research:

• Turning to the phenomenon.
• Investigating the phenomenon as it is lived rather than how it is conceptualized.
• Identifying essential themes that characterize the experience.
• Articulating the phenomena through a process of writing and rewriting.
• Remaining wholly committed to the  phenomenon  of study.
• Analyzing the parts and the whole of the study.

These procedures include the use of reflection; developing themes from personal descriptions;  interviewing; observing; discovering etymological origins and idiomatic phrases of the phenomenon; and using literature, poetry, art, and music to enhance the interpretive process. The process of reflection  requires the researchers to question their assumptions and set aside beliefs about the phenomenon. Reflective writing involves the researchers’ search for the hidden meanings and truth in the text or narratives.

Consistent with the aims and the researchers’ philosophical underpinning, this study used van Manen’s (1990) hermeneutic-phenomenological method of systematic inquiry (Table 1) to uncover and describe the structure, the internal meaning, and the essence of the everyday lived experience of dispiritedness among adults in later life as a means to better understand the deeper meaning of the phenomenon.

Generating Data: Existential Investigation

The researchers explored the etymological and idiomatic phrases of dispiritedness, as described in the background literature. Dispiritedness was used as a starting point for an in-depth simultaneous concept analysis as outlined by Haase, Leidy, Coward, Britt, and Penn (2000). The authors formed a consensus group with two other mental health experts and conducted an extensive concept analysis by reviewing the research literature on concepts that may be related to dispiritedness, including major depression, powerlessness, despair, hopelessness, helplessness, demoraliza- tion, chronic sorrow, and sadness. The completed matrix was then submitted to a panel of peers for critique. The results of the simultaneous concept analysis revealed that dispiritedness was related to the concepts in the analysis but was clearly a distinct experience with its own unique critical attributes. For example, on the basis of the findings from the simultaneous concept analysis, dispiritedness is characterized by being a more mild, common, and transitory experience than major depression, despair, or chronic sorrow, and a more complex emotion than sadness, power- lessness, or helplessness.

The researchers then used critical attributes from the concept analysis results to engage deeper into experiences of dispiritedness by locating and exploring descriptions of dispiritedness and aging in literature, art, music, and film. For example, they examined and dialogued about distinctiveness of dispiritedness in literature on aging and depression in prominent books such as On the Edge of Darkness: Conversations About Conquering Depression (Cronkite, 1994), Speaking of Sadness: Depression, Disconnection, and the Meanings of Illness (Karp, 1996), Unholy Ghost: Writers on Depression (Casey, 2002), Noonday Demon: An Atlas of Depression (Solomon, 2001), and Darkness Visible: A Memoir of Sadness (Styron, 1990). The authors listened to blues music while reading the lyrics of “sorrow in song” expressed in traditional blues (Gioia, 2008, p. 22) and viewed major motion pictures depicting notions of dispiritedness, such as Cocoon (Howard, 1985), in which dispirited older adults live in a retirement community.

The experiential descriptions of dispiritedness from participants for this study were generated from transcribed interviews from a previous study (Butcher, 1996) on dispiritedness. The original study was completed by Butcher (1996) as a single observer and used Rogers’ (1988, 1992) science of unitary human beings as the conceptual and interpretive lens. Although reanalysis of qualitative data is not common practice methods triangulation as a process that can help “overcome the intrinsic bias that comes from single methods, single-observer, and single theory studies” (Denzin, 2009, p. 313). A classic example of methods triangulation is Wolf ’s (1992) A Thrice-Told Tale: Feminism, Postmodernism, and Ethnographic Responsibility, in which three ethnographic texts are presented, each written in a different style from a different interpretive perspective with different outcomes, yet all three were based on data from the same set of events the author experienced while living in a village in northern Taiwan nearly 30 years earlier.

In comparing different approaches to phenomenological research, Wojnar and Swanson (2007) recommend using an interpretive method when wanting to examine the contextual features of phenomena in a way that blends the meanings and understandings articulated by participants with a particular frame of reference of the researcher. This was the case with the original study, which used the unitary field pattern portrait research method (Butcher, 1998, 2005). Unitary field pattern portrait is an approach to inquiry in the interpretive phenomenological tradition. Its purpose is to create a unitary understanding of the dynamic kaleidoscopic and symphonic pattern manifestations emerging from the pandimensional human and environmental field mutual process of a phenomenon associated with human betterment and well-being from the perspective of Rogers’ science of unitary human beings (Rogers, 1988, 1992). Unitary field pattern portrait is a theory-driven interpretive or hermeneutic-phenomenological method in which every step of the method is guided by the postulates and principles in Rogers’ unitary nursing science. Thus, the themes, referred to as unitary themes, are expressed in the theoretical language of Rogers’ (1988, 1992) nursing science.

As a way to develop a deeper understanding of the universal essences of an experience without a particular theoretical interpretive lens, Wojnar and Swanson (2007) suggest using a more descriptive phenomenological approach. Van Manen (1990, p. 9) specifically states the purpose of his method is to “seek universal meaning” of “subjectively felt” lived experiences rather than how a researcher abstracts or theoretically interprets the experience.

When using data from one study for reanalysis in another study and engaging in methodological triangulation, it is important that the methods of data collection are consistent (Patton, 1990). The data were originally collected using face-to-face hermeneutic-phenomenological interviews. The interview style in the unitary field pattern portrait method was built on van Manen’s descriptions of data generation (Butcher, 1994). Both methods used a hermeneutic-phenomenological conversational, informal open-ended interview style consistent to foster spontaneous generation of questions and conversations that explored the experience, perceptions, and expressions of dispiritedness. Although the initial investigation on dispiritedness was a theory-driven phenomenological approach to inquiry, in this study, the researchers needed to set aside any preunderstandings, beliefs, biases, assumptions, presuppositions, and theories (van Manen, 1984). To assist in facilitating this process, one of the authors (M.L.M.), who had no preunderstanding of the science of unitary human beings or the unitary field pattern portrait research method, completed all of the coding and initial naming of themes.

Ethical ProtectionsThe study was approved by the university’s internal review board. Participation was voluntary,  and all of the potential participants were informed in person of the purpose, procedures, potential risks and benefits, measures to protect confidentiality, and of the right to withdraw from the study at any time without jeopardy. Care was taken to provide comfort and confidentiality of all participants throughout the research process.

Participants and Setting

The research method used intensity sampling, consisting of information-rich cases that manifest the phenomenon of interest intensely (Patton, 1990). An assumption of this study was that individuals who identified themselves as being in later life and having experienced low spirits can provide the best description of the phenomenon. The criteria of dispiritedness from the literature review were used to assist the researchers in determining whether potential participants actually experienced dispiritedness rather than another experience. There were no specific exclusion criteria regarding the potential participants’ gender, ethnic background, or medical health status.

All of the participants were referred to the researchers; 5 participants were referred by family members, 2 were referred by a minister, 3 were referred by the  participants’ coworkers, and 1 was referred by a psychiatric clinicalnurse specialist. The individuals who referred the potential participants were familiar with this study, had an understanding of the terms low spirits and dispirited, and identified the potential participant as being a good candidate to talk about the experience. The researchers then contacted the participants, explained the study’s purpose and procedures, and asked the participants if the term low spirits or dispiritedness had any meaning for them. All participants enrolled identified with the term  dispiritedness and were willing to describe their experience.

All of the interviews were conducted by the first author (H.K.B.) during a 3-month period in the southeastern United States. Eleven older adults (9 women and 2 men) participated in this study; participants’ ages ranged from 52 to 93 (mean age =  73). The sample size in the original study was determined by continuing data collection until there was saturation of the data, meaning that no new themes emerged from the data analysis. Although saturation was reached after the ninth participant, two additional interviews were conducted. In this study, saturation also occurred after analyzing data from the ninth participant, but all 11 interviews were transcribed. Demographic  data for the sample are listed in Table 2.

All of the interviews were audio recorded and lasted between 40 and 70 minutes. Interviews were  held in a setting chosen by the participant. Seven interviews were conducted in the participants’ home, three were conducted at participants’ workplaces, and one was conducted in a  participant’s hospital room the day before discharge. Four participants lived alone, 4 lived with their spouses, and 3 lived with one of their children. Three interviews were conducted in homes located in rural areas, two interviews were conducted in homes located in a major city, and  two interviews were conducted in homes located in the city’s outer suburbs. One participant lived with a spouse in an apartment in a retirement community.

Although some general questions were formulated  in advance, genuine dialogue cannot be planned and emerges from a stance of genuineness. Examples of general questions concerning the experience of dispiritedness included:

• How would you describe what it is like to feel dispirited?
• Describe any feelings you may have had when feeling dispirited.

• How do you know when you are in low spirits?
• How do things change when you feel dispirited?
• What helps you most when you are in low spirits?
• Do things around you look different when you are in low spirits?
• What happens when you experience this?
• How would anyone know you were feeling dispirited?
• If you could draw or paint a picture of  dispiritedness, what would it look like?

In addition, participants were asked to identify a single word, particular music, poem, story, or phrase that describes the nature of dispiritedness. The interview continued until participants reported they had nothing further to say. Interviews were transcribed verbatim.

Conducting Thematic Analysis

All 11 transcribed interviews were read numerous times to grasp a sense of the whole, and the text was independently coded by one of the authors (M.L.M.) using van Manen’s (1990) selective  highlighting approach with QSR NUD*IST NVivo software version 2.0 (1999). After the text was coded, the researchers met to review and reach consensus concerning the coding and sorting of highlighted passages into categories. After all 11 texts were coded, the researchers met on eight different occasions, engaged in phenomenological conversations to reflect on the meaning of the codes in relation to the texts  as well as other sources of literature on dispiritedness, performed and reviewed linguistic transformations, agreed on the final sorting codes into common themes, and reached consensus on the language and meaning of the essential themes.

Scientific Rigor

Scientific rigor was assured by following Lincoln and Guba’s (1985) criteria for trustworthiness by establishing credibility, dependability, and confirmability through strategies such as  prolonged engagement, maintaining an audit trail with NVivo, using multiple sources of data, peer debriefing, and methodological as well as researcher triangulation. Researcher triangulation was met by reaching consensus on the selected statements, codes, and final themes. Methodological triangulation was conducted by finding congruence between the themes in this study and those themes in the original study (Butcher, 1996). The researchers used multiple sources of data because some participants shared artwork or poetry they had written to capture their description of dispiritedness. The participants’ descriptions of the art and poems were transcribed and included in the analysis. The researchers also compared the findings to descriptions of mild and major depression from memoirs on depression, art, music, and film used in the simultaneous concept analysis. One of the limitations of the study was that because the study was a secondary analysis, the researchers were unable to go back to participants to review the narrative analysis; however, member checks were conducted in the original study.

Results

A total of 433 thematic statements describing the  ex- perience  of  dispiritedness  in  later  life were identified and guided by van Manen’s processes of hermeneutic-phenomenological refection. The 433 statements were organized into 21 subthemes, which were then synthesized into 7 essential common themes (Table 3). The essential structure of dispiritedness in later life was revealed as:

• Arising From Life’s Trying Transitions.
• Feeling Disengaged From Meaning.
• Experiencing a Restricting Loss of Vigor and  Anima- tion.
• Feeling Forlorn Bewilderment.
• Moving Between Engagement and Disengagement.
• Remaining Faithful to Enduring Connections.
• Engaging in Day-to-Day Living.

These essential themes and the subthemes (identified in italics) are described in detail below.

Arising From Life’s Trying Transitions

The first essential theme reflects that dispiritedness arises from life’s trying transitions. This  theme indicates that dispiritedness is experienced during both normal aging processes and unfavorable  situations common to all individuals. For example, one participant said that dispiritedness is “a normal reaction to something else that’s going on in your life.” Another participant noted that “[feeling] low in spirit comes…from adversity, when things are not going right in your world.”

According to participants, dispiritedness arises amidst transition into life’s later years. Participants described feeling low spirited during common age-related transitional experiences, such as menopause and retirement. One person said:

I’ve been around a long time…but there comes a time when you are not as intimately a part of [your work environment] as you may have been…it’s just a natural…transition…. When the retirement incentive came out…[I thought]…they’re just waiting to get rid of the old [employees].

Being in low spirits is also associated with transition through adverse events, or losing the cherished amidst life’s difficult situations. Events including divorce, the physical or psychological death of a loved one, illness, financial struggle, job insecurity, and other instances of feeling “trapped by the circumstances” were associated with dispiritedness for participants. One participant stated, “The lowest I ever got in spirit [was when] I was working for a dealer running the shop and they [took my job] away from me and gave it to another person.” Another participant said:

Things like deaths, and when you don’t see people when they move away and you lose touch with them, it makes you feel sad and sort of low in spirit…. Looking back and remembering those who were here and are not now, you miss them so, and there are a lot of times you wish that you could just see them for a minute, you know, just for a little, a touch again.

Feeling Disengaged from Meaning

The second essential theme indicates dispiritedness is feeling disengaged from meaning. This theme reflects feelings of emptiness, loss of meaning and purpose, feeling devalued, sensing a simultaneous  separation-connection with caring relations, and low thoughts of self. Participants asked themselves about the meaning in their lives and described “the sameness of [life] day in, day out, day in, day out” during experiences of dispiritedness. One woman described it as living in “Dullsville.” One participant summed up feeling disengaged from meaning with the following statement:

It’s an absence of meaning or kind of wondering “What’s the purpose of this?” Either of my being in this situation or the situation itself. It’s kind of like not knowing how to think ahead, to pull yourself out of it…it’s sort of an absence of something very meaningful.

Participants described sensing a void to be filled. They described feeling “real empty inside” and that “something was missing in life.” When asked how he would depict dispiritedness, one participant responded, “I would draw a person…the head would be empty, the chest…and belly would be empty, and it would be just an empty figure… nothing there.”

Another subtheme is a loss of meaning and purpose. This aspect was evident when participants described feelings of identity loss and a diminished sense of satisfaction and meaning as they pursued daily tasks. For example, one person stated that during moments of dispiritedness, “there comes a sense of…a loss of  identity…you don’t have the sense of being…you’re just here.” Another participant said, “It’s like you don’t have a sense of direction or purpose.”

For several participants, the loss of meaning and purpose was related to feeling a lack of recognition for personal contributions to life. For example, one individual stated, “When you are not feeling valued, you can be dispirited.” Another participant said, “I do have a sense of wisdom, but nobody else seems to care.”

Another subtheme of disengagement is feeling detached and attached to caring connections. Participants indicated feeling a loss of connection and a separateness with the outside world, yet  acknowledged that the connections did indeed remain. One person commented, “When I am dispirited,I continue to be aware of the aliveness of  the world and what is going on in it…what is  happening to other people in it…but I don’t feel a part of it.”

The last subtheme is dissatisfaction with one’s sense of self-worth. During moments of dispiritedness, participants were dissatisfied with themselves, felt as though something was wrong with their characters, and felt inadequate. “I’m not worth very much…. As you get older…you’re not able to do the things you wanted to,” said one woman. Dispiritedness is “a lack of worth of yourself…you’re just not a real person.”

Experiencing a Restricting Loss of Vigor and Animation

Participants felt a restricting loss of vigor and animation, which refers to a missing spark in life, diminished hope for the future, expressions of feeling down in the dumps, being stuck in an endless time, and a loss of vitality. This loss was reflected in one participant’s words:

Older people all of a sudden know that they can’t do things anymore. They look at themselves, I look at myself in the mirror and I think, “Ugh, what happened to you?!” You know, what happened to that spirit, that liveliness? It’s not there.

The first subtheme reflects their experiences of feeling numb to life’s animating force. One participant stated, “You just don’t feel anything anymore.” Other participants described it as “that spark [that’s] missing in…life.” The following comment exemplifies what inspiritedness is, shedding light on the meaning of dispiritedness: “A drive sort of spells it out…if you have a drive for something, if you have something  you’re looking forward to that’s driving you, you’re pretty well up there in spirits.”

Another subtheme demonstrates participants’ blurred sense of hope for the future during moments of dispiritedness. Participants asked themselves, “What do have I to look forward to?” The third subtheme, feeling mired down and lowly, highlights participants’ experiences of being “down in the dumps” and “in the doldrums.” Dispiritedness can feel like being pulled down into “a deep well.” The next subtheme, sensing a timeless restriction, was described as feeling as though time drags and feels endless. Participants described this feeling as “not knowing how to think ahead, to pull yourself out of it” and “dragging your feet through water.” It “restricts you” and “weights you down somehow.”The last subtheme is depleted energy. Participants described feeling burnt out, commenting that “you’ve given so much, there’s nothing more to give. You’re just wiped out.” To an onlooker, a dispirited person  “would  slouch and... look like they went through the wringer.” The environment “would be a landscape that’s been burned out, and the trees are bent and broken, burned and charred.” One participant noted that “[when you are dispirited] you can’t rejuvenate anymore, there’s nothing to rejuvenate with.”

Feeling Forlorn Bewilderment

Forlorn bewilderment is feeling incapable and powerless, apprehensive of what lies ahead, and adrift and out of place. One participant commented:

You’ve been pushing that rock up and instead of just coming back down, it rolls over you as it comes down…you got to go try and put it back up again until you just get so sick of pushing that rock up the hill you don’t care whether it ever gets to the top or not anymore. You just stop.

Participants felt a sense of helplessness as they attempted to change or influence a situation. One individual said, “You’re trying to escape the situation…one that you can’t do anything about…[then you feel] trapped  in it.” Anxious anticipation of the feared manifested in participants’ comments that reflected feeling dreadful about aging; they described having a general  sense of anxiety and worry or concern about things that are admittedly out of one’s control. One participant stated, “I have a perfect dread of getting older…[of ] ending up in a nursing home or something like that.” Some of the participants felt threatened by the sheer thought of the aging process.

Feeling lost and out of sync with life’s rhythm is another feature of this essential theme. When dispirited, participants described that things seemed out of place and that they were unsure what to do or which way to go. One person said, “I’m out of step with whatever is going on in my life.” Another participant stated, “When I feel in low spirits, the whole world seems out of kilter…whatever’s going on, you’re not with it.” Another participant another described this as “being in a thick fog.”

Moving Between Engagement and Disengagement

Another essential theme of dispiritedness is moving between engagement and disengagement; this movement, as a whole, is encompassed in experiences of feeling dispirited. This theme reflects an oscillation or fluctuation between being involved and connected to the isolation participants felt when dispirited. Participants described dispiritedness as something temporary, “something that you can be in and out of very fast.” In contrast to depression, “dispiritedness  is…[defined] by periods you go through” and “it doesn’t stay with you.” Furthermore, this fluctuation between engagement and disengagement is best depicted as a rhythm; one person said, “Dispiritedness has got its highs and lows…we have to create a balance in life.” Another participant stated:

It’s like being in a valley. And I go down, but what brings me out [is] a tape of my mother that we had made when I went back home to visit. My sister, my mom, and myself were talking on that tape. I can listen to that tape, and it will bring me right back out. I can be right down in the valley there and I can stay there for a day or two, and I can come right back out.

Remaining Faithful to Enduring Connections

This essential theme indicates that dispiritedness is holding connections that nourish the  spirit, persevering through feelings of wanting to give up, and holding steadfast to a strength-giving, nourishing life force or higher power. One person indicated that her way of remaining faithful to enduring connections was through “seeking solace, for whatever might be bothering me, in other people. The things that can change that dispiritedness often come from a response from someone else that lets me know there is a connection.”Participants described that through times of dispiritedness, they stayed connected to attachments  that brought them consolation. Some found comfort through connections with people at work or their jobs themselves, family, and animals, whereas others described their attachments to  music and water. One woman described  gardening activities and “watering, or being in the water” as therapeutic. “I love to go to the ocean…that’s a very refreshing, respiriting kind of thing.” Holding their connections reflected their perseverance through feelings of wanting to give up. Participants indicated that even through moments of dispiritedness, there is “a definite sense of keeping on” although one may not want to. One participant said, “I’ve never given up…I have been in low spirits and at times felt like giving up, but I had a wife and children to think about.” One person clearly articulated that, despite feeling physically poor and thinking about the nearness of death, “I don’t want to give anything up. I like what’s here.” None described complete resignation. Many turned to a higher power or life force for sustenance, strength, and clarification. One participant stated, “My faith makes me aware of who I am [and] why I’m  here…[I can] have hopes for a better future.”

Engaging in Day-to-Day Living

Engaging in day-to-day living is the final essential theme of dispiritedness; this theme reflects  passive participation in daily activities. Participants described maintaining a sense of control to participate in everyday living while living a life of quiet desperation. In other words,they indicated they were able to remain functional in their daily lives, rendering their low spirits difficult for outsiders to readily identify. One person said, “With depression,…people are stuck…they just can’t get out and do what they need to do. I wasn’t exactly like that, I was able to come to work, do all [of ] the things I normally do.” Participants were “able to guard against [being] too deep in [dispiritedness].” One participant described the worlds of dispirited individuals as looking “like a cold winter rainy day. Drab. Nothing [is] fun or funny….food [doesn’t] taste good [but] you eat to maintain your strength.” When asked how observers might know if one is dispirited, participants indicated that they might not, that dispiritedness can be hidden and remain undisclosed. Engaging in day-to-day living is best captured by the following words of one participant:

There are plenty of days when I don’t feel like…doing those things that are expected of you in the world, but I do. I’m not so empty…that I can’t carry on with the things of life in this world and meet those expectations of the world and experience some joy and gratification.

The structure may be summarized by combining the essential themes as follows: Dispiritedness in later life arises from life’s trying transitions and is characterized as being disengaged from meaning, a restricting loss of vigor and animation, forlorn bewilderment, and moving between engagement and disengagement while remaining faithful to enduring connections and engaging in day-to-day living.

Discussion and Implications of Findings

Blazer (2003) suggested that we carefully consider the boundaries between “true” clinical depression and the less severe (perhaps adaptive) depressive symptoms in older adults. The results of this phenomenological inquiry have provided a deeper understanding of the existential features of a mild depressive syndrome and differentiated dispiritedness from other depressive syndromes. Participants in this study did identify with the experience of having “low spirits,” and all felt dispiritedness was not as severe as depression. Application of van Manen’s (1990) method placed  emphasis on the existential features of dispiritedness, whereas the original study interpreted the themes from the perspective of Rogers’ (1992) postulates and principles (see Butcher, 1996). In the current study, existential themes of emptiness, loss of meaning and purpose, feeling devalued and lost, and  disengagement were found to be features of dispiritedness. Participants spoke of dispiritedness in terms of a loss of the “life force,” “energy,” “drive,” or “spark of life.” They also described feeling “drained,” “tired and exhausted,” “wiped out,” “burnt out,” and “depleted” asbeing associated with dispirited times. The idea that dispiritedness is experienced as dwindling vitality and liveliness also supports J.F. Bugental’s (1987) idea that dispiritedness is characterized by “a lack of energy or motivation” (pp. 51-52). One participant described this as “When you’re dispirited you look slouched and your expression on your face looks like you have been through a  wringer.” An “empty well” was a metaphor used by one participant to describe feelings of energy loss and emptiness.

Feeling forlorn bewilderment, another existential theme that emerged from the data, has not been fully explored in the extant literature on dispiritedness and its features. For example,  expressions of feeling detached or out of sync with life’s rhythm supported the works of those who identified disconnectedness as an essential feature of dispiritedness (E.K. Bugental & Bugental, 1984;  Jourard, 1971). However, bewilderment speaks more to the feelings of being lost and “having no control,” feeling that “life is in limbo,” or “not sure where I’m going.” Participants stated they had little sense of purpose or direction; one said it was like “not knowing where I belong…I don’t know what to do with myself anymore…I feel like I’m dragging around.” Another participant stated that “tomorrow does not have any meaning, the future looks fuzzy…I have to push myself.”

Findings from this study supported the literature on dispiritedness, associating dispiritedness with a loss of meaning. Meaning is associated with having purpose, intention, aim, function, and significance. Having the intention for direction and purpose is essential for developing a meaningful life. E.K. Bugental and Bugental (1984) viewed dispiritedness as a condition of blocked  intentionality. Dispiritedness contributes to a sense of meaningless because the intention to realize and to actualize one’s potential is blocked. A loss of spirit is a loss of meaning, significance, value, and purpose. One participant stated that “spirit has meaning in the living,” and another participant stated that “dispiritedness is an absence of something meaningful in life...a sort of emptiness comes at a time when life does not seem very meaningful.” Statements such as “I have no sense of purpose or direction” and “What I have to give is no longer wanted” also reflected loss of meaning and purpose.

The DSM-IV-TR (APA, 2000) is not specific to  older adults; it may therefore be crucial to consider using additional criteria when assessing for a depressive disorder. For example, Gallo and Rabins (1999) indicated that somatic complaints for which a medical etiology cannot be found may be indicative of a depressive disorder in older adults. However, participants in this study did not describe somatic symptoms concurrently with their experiences of dispiritedness. Rather, they indicated that one of the most prominent features of dispiritedness is a sense  that one has lost meaning in life or that one feels disengaged from meaning; this feature is existential rather than somatic in nature. Statements such as “what I have to give is no longer wanted,” “the life force seems like it is missing, leaving a sense of emptiness,” “dispiritedness looks like a nothingness,” “everything seems kind of empty, as if there is a hole in my life,” and “it’s a sort of emptiness and comes at a time when life does not seem meaningful” reflect the feeling of meaninglessness experienced during times of dispiritedness.

Whether  meaninglessness, emptiness,  disconnected- ness, and diminished hope are present as a feature in more severe depressive syndromes or as an essential feature of dispiritedness, Blazer (2002) believes it is vital that clinicians working with older adults recognize, understand, and therapeutically address existential themes to adequately serve and address the concerns faced by older adults. Meaning-making strategies such as journaling and reminiscing, as well as constructivist, narrative, and existential approaches to therapy (Carlsen, 1991; Neimeyer & Mahoney, 1995; Rosen & Kuehlwein, 1996), are useful for addressing existential themes in those who are dispirited. Other meaning-making  strategies include  having older adults read or learn about role models of those who are aging successfully. Participants also identified strategies they used to transform dispiritedness into inspiritedness, and these same strategies may be helpful to others struggling with dispiritedness. Some of these strategies include remaining active and engaged in activities that are sources for personal enjoyment, staying connected to family and friends, and maintaining a sense of hopefulness. Health care professionals can facilitate these strategies when they encounter older adults who are dispirited.

In addition to revealing existential features of depression, another significant finding from  this study is the identification of dispiritedness as a distinct syndrome from those currently classified in the DSM-IV-TR (APA, 2000). J.F. Bugental (1980, 1987) and Jourard (1971) did not clearly distinguish depression from dispiritedness; although both authors stressed dispiritedness, they often used the terms interchangeably. Current depressive disorders are  major depressive disorder (MDD), dysthymic disorder (DD), and depressive disorder, not otherwise  specified (NOS). Symptoms common to all three may include: (1) depressed mood, (2) diminished interest or pleasure in nearly all activities, (3) psychomotor agitation or retardation, (4) in-somnia or hypersomnia, (5) weight loss or gain, (6) fatigue, (7) feelings of worthlessness or inappropriate guilt, (8) diminished ability to think or concentrate, and (9) recurrent thoughts of death (APA, 2000). The three disorders differ depending on how many of the ssymptoms are present during a specified time frame. For example, according to the DSM-IV-TR (American Psychiatric Association,2000), MDD is defined as having five or more of the nine symptoms listed (one symptom must be either symptom 1 or 2) during a 2-week period, whereas DD is defined as having two or more of symptoms 4 through 8 and/or feelings of hopelessness for at least 2 years. Depressive disorder NOS includes premenstrual dysphoric disorder, postpsychotic depressive disorder, major depressive episodesuperimposed on psychotic disorder, depressive disorder due to a medical condition or substance abuse, minor depressive disorder, and recurrent brief depressive disorder. A diagnosis of minor depressive disorder requires at least two and no more than five of the nine listed symptoms for a 2-week period. Although minor depression affects functioning in physical, social, and psychological capacities, impairment is less severe than MDD. A diagnosis of recurrent brief depressive disorder requires episodes to last 2 days to 2 weeks at least once per month for 1 year.

Participants in this study did not describe symptoms characteristic of the DSM-IV-TR  (APA, 000) depressive disorders, such as insomnia or hypersomnia, weight changes, psychomotor agitation or retardation, diminished ability to think or concentrate, feelings of excessive guilt as manifestations of dispiritedness, or recurrent thoughts of death. Although feelings of emptiness, depleted energy, and decreased interest were described as features of dispiritedness, the experiences, perceptions, and expressions of dispiritedness were not described as being present most of the day, nearly every day for a 2-week period. The findings indicate that dispiritedness did not last as long as depression, with participants stating that “it’s something you can move in and out of a little easier” and “you can be in and out of it very fast.” One participant said, “Low spirits do not last as long as depression,” and another participant stated, “I can be in that valley for a day or two.” Thus, the fluid and temporary nature of dispiritedness reveals a lucid distinction from the criteria outlined in the DSM-IV-TR (APA, 2000), which require that symptoms are present for a minimum of 2 weeks to identify the presence of a depressive disorder.

The exception is  recurrent  brief  depressive  disorder (depressive disorder NOS), which lasts between 2 and 14 days. During this period, individuals experience five or more of the nine symptoms with the same severity as that which is experienced in MDD. These periods of depressed mood “cause clinically significant distress or impairment in social, occupational, or other important areas of functioning” (APA, 2000, p. 779). Beck and Alford (2009), in their recent update of their classic text on depression, also identify changes in one’s activity level such as retardation or agitation, or vegetative changes such as anorexia and insomnia, as classic attributes of depression. In addition, Beck and Alford (2009) do not include the existential fea- tures of dispiritedness such as meaninglessness, emptiness, disconnectedness, and diminished hope as attributes  of depression, adding further support for dispiritedness as a distinct entity from depression.

Participants in this study did not experience remarkable distress or impairment in social, occupational, or other important areas of functioning. In fact, they did not “give up” but continued to participate in work and daily activities. Several noted that unlike depression, individuals who are dispirited are able to remain functional in their daily lives, rendering it difficult for others to identify. Participants described ways they continued to engage in day-to-day living and remain faithful to enduring connections. For example, participants’ comments included statements such as “I never quit caring and I never gave up,” “I feel like I could just give up…I feel it for a time, but I push it away; you can’t let it in,” “Dispiritedness is not giving up,” “You feel like giving up but you can’t,” “My hope is challenged and I come close to giving up, wanting to give up, but not allowing myself to give up,” and “I don’t feel like getting out of bed but I get out anyway.”

Another clear distinction between dispiritedness and more severe forms of depression is the intensity of the experience. The most vivid descriptions of the experience of major depression are in published  personal accounts. For example, in his memoir, Styron (1990) distinguished the “familiar, manageable  doldrums” (p. 7) from major depression, which he  described as a “hopelessness even more than the pain that crushes the soul” (p. 62). The description of depression as an “actual pain” like “drowning or suffocation” (Styron, 1990, pp. 16-17) is a common description of more severe depressive syndromes. The association between pain and depression is a theme that runs throughout the accounts of those who have suffered from major  depression  published  in  Journeys with  the Black Dog: Inspirational Stories of Bringing Depression to Heel (Wigney, Eyers, & Parker, 2007). In his memoir on depression, Solomon (2001) also stated, “perhaps depression can be best described as emotional pain that forces itself on us against our will…. Depression is not just a lot of pain; buttoo much pain can compost itself into depression” (p. 16). None of the participants in this study associated emotional pain with dispiritedness.

Conclusion

Dispiritedness, as described by older adults participating in this study, is a phenomenon that clearly differs from the depressive disorders described in the DSM-IV-TR (APA, 2000) and may be differentiated from other extant criteria used to identify depression in older adults. Thus, the results support the notion that dispiritedness is a distinct  syndrome. Although dispiritedness may be present during episodes of depressive disorders, dispiritedness may be experienced without the presence of a depressive disorder. In other words, there is not necessarily a connection between  dispiritedness  and clinical depression since participants were able to continue to remain engaged in their usual activities; however, dispiritedness that persists may lead to mild or more significant symptoms of clinical depression. As a syndrome  present within depressive disorders, dispiritedness captures existential features such as feelings of emptiness, disconnectedness, and meaninglessness.

The findings from this study support prior recommendations that health care professionals be cognizant of and focus on the emotions of the individuals they care for (Williams, 2000). Diagnostic criteria pose a limitation in that they do not inform professionals about the experience of depression or dispiritedness. When given the opportunity to share their experiences with a caring other, participants in this study vividly articulated their experiences with dispiritedness.  Participants indicated  that  dispiritedness arises amidst transition into life’s later years, emphasizing that it is a normal and common experience belonging to all human existence. They spoke about changes they were experiencing in their later years, supporting Jourard’s (1971) assertion that dispiritedness is associated with events such as losses that are experienced in the process of aging. Participants discussed losses, including the loss of work through retirement; partners, family members, and friends; mobility, energy, and physical health; and feeling needed. Such events, commonly experienced in one’s later life, were associated with the experience of being “in low spirits.” These findings also echo Williams’ (2000) position that feeling disillusioned, down in the dumps, and in the doldrums at times in later life is far from being pathological or unhealthy. These experiences are, in fact, the embodiment of the dilemmas and existential predicaments that all human beings inevitably face.

references

• American Psychiatric Association. (2000). Diagnostic and statistical manual of mental disorders (4th ed., text rev.). Washington, DC: Author.
• Beck, A.T., & Alford, B.A. (2009). Depression: Causes and treatment (2nd ed.). Philadelphia: University of Pennsylvania Press.
• Blazer, D.G. (2002). Depression in late life (3rd ed.). New York: Springer.
• Blazer, D.G. (2003). Depression in late life: Review and commentary. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 58, 249-265.
• Bugental, E.K., & Bugental, J.F. (1984). Dispiritedness: A new perspective on a familiar state. Journal of Humanistic Psychology, 24, 49-67.
• Bugental, J.F. (1980). The far side of despair. Journal of Humanistic Psychology, 20, 49-68.
• Bugental, J.F. (1987). The art of the psychotherapist. New York: Norton.
• Bugental, J.F., & Kleiner, R.I. (1993). Existential psychotherapies. In G. Stricker & J.R. Gold (Eds.), Comprehensive handbook of psychotherapy integration (pp. 101-112). New York: Plenum.
• Butcher, H.K. (1994). A unitary field pattern portrait of dispiritedness in later life (Doctoral dissertation). Dissertation Abstracts International: Section B. Sciences and Engineering, 55(11), 4784. (UMI No. DA9508120)
• Butcher, H.K. (1996). A unitary field pattern portrait of dispiritedness in later life. Visions: The Journal of Rogerian Nursing Science, 4, 41-58.
• Butcher, H.K. (1998).     Crystallizing the processes of the unitary field pattern portrait research method. Visions: The Journal of Rogerian Nursing Science, 6, 13-26.
• Butcher,  H.K.  (2005).  The unitary field pattern  portrait  research method: Facets, processes, and findings. Nursing Science Quarterly, 18, 293-297.
• Butcher, H.K., & McGonigal-Kenney, M. (2005).  Depression  and dispiritedness in later life: A ‘gray drizzle of horror’ isn’t inevitable. American Journal of Nursing, 105, 52-61.
• Carlsen, M.B. (1991). Creative aging: A meaning-making perspective. New York: Norton.
• Casey, N. (Ed.). (2002). Unholy ghost: Writers on  depression. New York: Harper Perennial.
• Charney, D.S., Reynolds, C.F., III, Lewis, L., Lebowitz, B.D., Sunderland, T., Alexopoulos, G.S., et al. (2003). Depression and Bipolar Support Alliance consensus statement on the unmet needs in diagnosis and treatment of mood disorders in late life. Archives in General Psychiatry, 60, 664-672.
• Cronkite, K. (1994). On the edge of darkness: Conversations about con- quering depression. New York: Doubleday.
• Denzin, N. (2009). The research act in sociology: A theoretical introduction to sociological methods. Piscataway: Transaction Publishers, Rutgers: The State University of New Jersey.
• Gallo, J.J., & Rabins, P.V. (1999). Depression without sadness: Alternative presentations of depression in late life. American Family Physician, 60, 820-826.
• Gioia, T. (2008). Delta blues. New York: Norton.
• Giorgi, A. (2009). The descriptive phenomenological method in psychology: A modified Husserlian approach. Pittsburgh, PA: Duquesne University Press.
• Haase, J.E., Leidy, N.K., Coward, D.D., Britt, T., & Penn, P.E. (2000). Simultaneous concept analysis: A strategy for  developing multiple interrelated concepts. In B.L. Rogers & K.A. Knafl (Eds.), Concept development in nursing: Foundations, techniques, and applications (2nd ed., pp. 209-229). Philadelphia: Saunders.
• Hostetter, C.M. (2003).     Subthreshold depressive symptoms in elders: A phenomenological exploration (Unpublished doctoral dissertation). University of Texas Health Science Center at San Antonio.
• Howard,  R.  (Director). (1985).  Cocoon [Motion  picture].  United States: 20th Century Fox Distribution.
• Hybels, C.F., Blazer, D.G., & Pieper, C.F. (2001). Toward a threshold for subthreshold depression: An analysis of correlates of depression by severity of symptoms using data from an elderly community sample. The Gerontologist, 41, 357-365.
• Jourard, S.M. (1971). The transparent self. Toronto, Ontario, Canada: Van Nostrand.
• Judd, L.L., Rapaport, M.H., Paulus, M.P., & Brown, J.L. (1994).     Sub-syndromal symptomatic depression: A new mood disorder? Journal of Clinical Psychiatry, 55(Suppl.), 18-28.
• Karp, D.A. (1996). Speaking of sadness: Depression, disconnection, and the meanings of illness. New York: Oxford University Press.
• Kessing, L.V. (2007). Epidemiology of subtypes of  depression. Acta Psychiatrica Scandinavica, 115(Suppl. 433), 85-89.
• Kroenke, K. (2006). Minor depression: Midway between major depression and euthymia. Annals of Internal Medicine, 144, 528-530.
• Kumar, A., Lavretsky, H., & Elderkin-Thompson, V. (2004). Nonmajor clinically significant depression in the elderly. In S.P. Roose & H.A. Sackeim (Eds.), Late-life depression (pp. 64-80). New York: Oxford University Press.
• Lavretsky, H., & Kumar, A. (2002). Clinically significant non-major depression: Old concepts, new insights. American Journal of Geriatric Psychiatry, 10, 239-255.
• Lincoln, Y.S., & Guba, E.G. (1985). Naturalistic inquiry. Newbury Park, CA: Sage.
• Lyness, J.M., Caine, E.D., King, D.A., Conwell, Y., Duberstein, P.R., & Cox, C. (2002). Depressive disorders and symptoms in older primary care patients: One-year outcomes. American Journal of Geriatric Psychiatry, 10, 275-282.
• Lyness, J.M., Heo, M., Datto, C.J., Ten Have, T.R., Katz, I.R., Drayer, R., et al. (2006). Outcomes of minor and subsyndromal depression among elderly patients in primary care settings. Annals of Internal Medicine, 144, 496-504.
• Lyness, J.M., King, D.A., Cox, C., Yoediono, Z., & Caine, E.D. (1999). The importance of subsyndromal depression in  older primary care  patients:  Prevalence  and  associated  functional  disability. Journal of the American Geriatrics Society, 47, 647-652.
• May, R., Angel, E., & Ellenberger, H.F. (Eds.). (1958). Existence: A new dimension in psychiatry and psychology. New York: Basic Books.
• Neimeyer, R.A., & Mahoney, M.J. (Eds.). (1995). Constructivism in psychotherapy. Washington, DC: American Psychological Association.
• Oxford English Dictionary (2nd ed., Vol. 4). (1989). Oxford, England: Clarendon Press.
• Patton, M.Q. (1990). Qualitative evaluation and research methods (2nd ed.). Newbury Park, CA: Sage.
• QSR NUD*IST NVivo 2.0 [Computer software]. (1999). Doncaster, Victoria, Australia: Qualitative Solutions and Research International.
• Rapaport, M.H., Judd, L.L., Schettler, P.J., Yonkers, K.A., Thase, M.E., Kupfer, D.J., et al. (2002). A descriptive analysis of minor depression. American Journal of Psychiatry, 159, 637-643.
• Ray, M.A. (1994). The richness of phenomenology: Philosophic, theoretic, and methodologic concerns. In Morse, J.M. (Ed.), Critical issues in qualitative research methods (pp. 117-133). Thousand Oaks, CA: Sage.
• Rogers, M.E. (1988). Nursing science and art: A prospective. Nursing Science Quarterly, 1, 99-102.
• Rogers, M.E. (1992). Nursing science and the space age. Nursing Science Quarterly, 5, 27-34.
• Rosen, H., & Kuehlwein, K.T. (Eds.). (1996).  Constructing realities: Meaning-making perspectives for psychotherapists. San Francisco: Jossey-Bass.
• Rowe, S.K., & Rapaport, M.H. (2006). Classification and treatment of sub-threshold depression. Current Opinion in Psychiatry, 19, 9-13.
• Solomon, A. (2001). Noonday demon: An  atlas of  depression. New York: Scribner.
• Styron, W. (1990). Darkness visible: A memoir of madness. New York: Random House.
• U.S.  Department  of  Health  and  Human  Services. (1999). Mental health: A report of the surgeon general. Washington, DC: Author.
• van Kaam, A.L. (1969). Existential foundations of psychology. New York: Doubleday.
• van Manen, M. (1984). Practicing phenomenological writing. Phenomenology and Pedagogy, 2, 36-69.
• van Manen, M. (1990). Researching lived experience: Human science for an action sensitive pedagogy. Albany: State University of New York Press.
• van Manen, M. (1997). From meaning to method. Qualitative Health Research, 7, 345-369.
• Walton, J.A., & Madjar, I. (1999). Phenomenology and nursing. In I. Madjar and J.A. Walton (Eds.), Nursing and the experience of illness: Phenomenology  in practice (pp. 1-16). London: Routledge.
• Wigney, T., Eyers, K., & Parker, G. (Eds.). (2007). Journeys with the black dog: Inspirational stories of bringing depression to heel. Crows Nest, New South Wales, Australia: Allen & Unwin.
• Williams, S.J. (2000). Reason, emotion and embodiment: Is ‘mental’ health a contradiction in terms? Sociology of Health & Illness, 22, 559-581.
• Wojnar, D.M., & Swanson, K.M. (2007). Phenomenology: An exploration. Journal of Holistic Nursing, 25, 172-180.
• Wolf, M. (1992). A thrice-told tale: Feminism, postmodernism, and ethnographic responsibility. Stanford, CA: Stanford University Press.
• World Health Organization. (1993). The ICD-10 classification of mental and behavioural disorders: Diagnostic criteria for research. Geneva, Switzerland: Author.

. . .