There are stalwarts to whom such emotional insight is meaningless. “Who cares about motives and origins?” asks Donald Klein of Columbia University, a leading psychopharmacologist. “No one’s knocked out Freud because no one has any theory one bit better than all that internalized conflict. The point is that we can now treat it; philosophizing about where it comes from has not so far been of the slightest therapeutic usefulness.”
It is true that medication has set us free, but we should all care about the origins of illness. Steven Hyman, director of the NIMH, says, “For coronary heart disease, we don’t just write a prescription for drugs. We also ask people to limit their cholesterol and we give them an exercise regimen and dietary counseling and maybe stress management. Combinatorial process isn’t unique to mental illnesses. The medication-versus-psychotherapy debate is ridiculous. Both are empirical questions. It’s my philosophical prejudice that the two should work well together because the medication will make people more available for psychotherapy, will help to initiate an upwards spiral.” Ellen Frank has conducted a number of studies showing that therapy is not nearly as effective as drugs for taking people out of depression, but that therapy has a protective effect against recurrence. Though the data in this field is complicated, it suggests that the combination of drugs and therapy works better than either one alone. “It’s the treatment strategy for preventing the next episode of depression,” she says. “It’s not clear to me how much room there’s going to be in the future of health care for an integrated view, and that’s scary.” Martin Keller, of Brown University’s Department of Psychology, working with a multi-university team, found in a recent study of depressives that less than half experienced significant improvement with just medication; that less than half experienced significant improvement with cognitive behavioral analysis; and that more than 80 percent experienced significant improvement after being treated with both. The case for combination is pretty well incontrovertible. Exasperated, Robert Klitzman, of Columbia University, says, “Prozac should not obviate insight; it should enable insight.” And Luhrmann writes, “Doctors feel that they have been trained to see and understand a grotesque misery, yet all they are allowed to do is hand out a biomedical lollipop to its prisoners and then turn their backs.”
If real experience has triggered your descent into depression, you have a human yen to understand it even when you have ceased to experience it; the limiting of experience that is achieved with chemical pills is not tantamount to cure. Both the problem and the fact of the problem usually require urgent attention. It may be that more people will get treated in our pro-medication era; overall public health may go up. But it is terribly dangerous to put talking therapy on the back burner. Therapy allows a person to make sense of the new self he has attained on medication, and to accept the loss of self that occurred during a breakdown. You need to be reborn after a severe episode, and you need to learn the behaviors that may protect against relapse. You need to run your life differently from how you ran it before. “It’s so hard to regulate your life, sleep, diet, exercise, under any circumstances,” comments Norman Rosenthal of the NIMH. “Think how hard it is when you’re depressed! You need a therapist as a sort of coach, to keep you at it. Depression is an illness, not a life choice, and you have to be helped through it.” “Medicines treat depression,” my therapist said to me. “I treat depressives.” What calms you down? What exacerbates your symptoms? There is no particular difference, from the chemical standpoint, between the depression that has been triggered by the death of family members and the depression occasioned by the demise of a two-week affair. Though extreme responses seem more rational in the first instance than in the second, the clinical experience is nearly identical. As Sylvia Simpson, a clinician at Johns Hopkins, said, “If it looks like depression, treat it like depression.”
When I started heading in for my second breakdown, I had terminated my psychoanalysis and was without a therapist. Everyone told me firmly that I should find a new one. Finding a new therapist when you are feeling up and communicative is burdensome and ghastly, but doing it when you are in the throes of a major depression is beyond the pale. It is important to shop around for a good therapist. I tried eleven therapists in six weeks. For each of my eleven, I rehearsed the litany of my woes, until it seemed that I was reciting a monologue from someone else’s play. Some of the potential therapists seemed wise. Some of them were outlandish. One woman had covered all her furniture with Saran Wrap to protect it from her yapping dogs; she kept offering me bites of the moldy-looking gefilte fish she was eating from a plastic container. I left when one of the dogs peed on my shoe. One man gave me the wrong address for his office (“Oh, I used to have an office there!”), and one told me that I had no real problems and should lighten up a little bit. There was the woman who told me she didn’t believe in emotion, and the man who seemed to believe in nothing else. There were the cognitivist, the Freudian who bit his nails for the length of our session, the Jungian, and the autodidact. One man kept interrupting me to tell me that I was just like him. Several seemed simply not to get it when I tried to explain to them who I was. I had long supposed that my well-adjusted friends must see good therapists. What I found out is that many well-adjusted people with straightforward relationships to their husbands or wives establish lunatic relationships with weirdo doctors for the sake, one can only presume, of balance. “We try to do studies of drugs versus therapy,” Steven Hyman says. “Have we done longitudinal studies on bright therapists versus incompetent ones? We are really Lewis and Clark in this area.”
I eventually made a choice with which I have been very happy since—someone whose mind seemed quick and in whom I saw glints of a real humanity. I chose him because he seemed intelligent and loyal. Given my bad experience with the analyst who had broken off our analysis and kept me from taking medication when I desperately needed it, I was guarded at first, and it took me a good three or four years to trust him. He has been steadfast through periods of turmoil and crisis. He has been entertaining during good times; I place high value on a sense of humor in anyone with whom I spend so much time. He has worked well with my psychopharmacologist. He has in the end persuaded me that he knows what he’s doing and that he wants to help. It was worth trying ten other people first. Do not go to a therapist whom you dislike. People you dislike, no matter how skilled they are, cannot help you. If you think you are smarter than your doctor, you are probably right: a degree in psychiatry or psychology is no guarantee of genius. Use the utmost care in choosing a psychiatrist. It is mind-boggling how many people who would drive an extra twenty minutes to use a preferred dry cleaner and who complain to the manager when the supermarket runs out of their favorite brand of canned tomatoes seem to choose a psychiatrist as if he were a generic service-provider. Remember, you are at the very least placing your mind in the hands of this person. Remember, too, that you must tell the psychiatrist what you cannot show him. “It’s so much harder,” Laura Anderson wrote to me, “to trust someone when the problem is so nebulous that you can’t tell whether they have understood you; it’s harder for them to trust you too.” I become incredibly controlled with psychiatrists even when I am feeling midnight miserable. I sit up straight and I don’t cry. I represent myself with ironies and interject gallows humor in a peculiar effort to charm the ones who treat me, people who do not in fact wish to be charmed. Sometimes I wonder whether my psychiatrists believe me when I tell them how I’ve felt, because I can hear the detachment in my own voice. I imagine how they must deplore this thick social skin through which my real feelings penetrate so slightly. I often wish that I could emote fully in the psychiatrist’s office. I have never managed to define the space of therapy as private. The way I can talk to my brother, for example, eludes me with my doctors. I suppose it must be too unsafe. Just occasionally, preciously, a glimmer of my reality makes it through in essence rather than via description.
One of the ways to judge a psychiatrist is to observe how well he se
ems to judge you. The art of an initial screening lies in asking the right questions. I did not sit in on confidential one-on-one psychiatric interviews, but I did sit in on a large number of hospital admissions, and I was amazed by how varied the approaches to depressed patients seemed to be. Most of the good psychiatrists I saw would begin by letting a patient tell his story and would then move briskly on to highly structured interviews in which they looked for particular information. The ability to conduct such an interview well is among a clinician’s most important skills. Sylvia Simpson, a clinician at Johns Hopkins, established in the first ten minutes of an interview that an incoming patient fresh from a suicide attempt had bipolar illness. This woman’s psychiatrist, with whom she had been in treatment for five years, had not established this extremely basic fact and had prescribed antidepressants without mood stabilizers—a regimen known to be inappropriate for bipolar patients, in whom it often causes mixed agitated states. When I asked Simpson about this later, she said, “It took years of steady work to arrive at those interview questions.” Later, I sat in on interviews with recently homeless people conducted by Henry McCurtiss, chief of psychiatry at Harlem Hospital. He spent at least ten minutes of each twenty-minute interview taking incredibly detailed housing histories from his patients. When I finally asked him why he was pursuing this matter so arduously, he said, “Those who have lived in one place for long periods of time are temporarily homeless for circumstantial reasons but are capable of living well-regulated lives, and they require primarily a social intervention. Those who have moved around constantly, or who have been homeless repeatedly, or who can’t remember where they’ve lived, probably have a severe underlying complaint and require primarily a psychiatric intervention.” I am lucky to have good insurance that pays for me to make weekly visits to a therapist and monthly visits to a psychopharmacologist. Most HMOs are keen on medications, which are, comparatively speaking, cheap. They are not keen on talking therapies and hospitalizations, which take lots of time and cost plenty.
The two kinds of talking therapy that have the best record for the treatment of depression are cognitive-behavioral therapy (CBT) and interpersonal therapy (IPT). CBT is a form of psychodynamic therapy— based on emotional and mental responses to external events, in the present and in childhood—that is tightly focused on objectives. The system was developed by Aaron Beck of the University of Pennsylvania and is now in use throughout the United States and most of Western Europe. Beck proposes that one’s thoughts about oneself are frequently destructive, and that by forcing the mind to think in certain ways one can actually change one’s reality—it’s a program that one of his collaborators has called “learned optimism.” He believes depression is the consequence of false logic, and that by correcting negative reasoning one may achieve better mental health. CBT teaches objectivity.
The therapist begins by helping the patient make up a list of “life history data,” the sequence of difficulties that have led him to his current position. The therapist then charts responses to these difficulties and attempts to identify characteristic patterns of overreaction. The patient learns why he finds certain events so depressing and tries to free himself of inappropriate responses. This macroscopic part of CBT is followed by the microscopic, in which the patient learns to neutralize his “automatic thoughts.” Feelings are not direct responses to the world: what happens in the world affects our cognition, and cognition in turn affects feelings. If the patient can alter the cognition, then he can alter the concomitant mood states. A patient might, for example, learn to see her husband’s preoccupation as his reasonable response to the demands of the workplace rather than as a rejection. She might then be able to see how her own automatic thoughts (of being an unlovable jerk) turn into negative emotion (self-reproach) and identify how this negative emotion leads to depression. Once the cycle is broken, the patient can begin to achieve some self-control. The patient learns to distinguish between what actually happens and her ideas about what happens.
CBT functions according to specific rules. The therapist assigns lots of homework: lists of positive experiences and lists of negative experiences must be made, and sometimes they are put on graphs. The therapist presents an agenda for each session, continues in a structured fashion, and ends with a summary of what has been accomplished. Facts and advice are specifically excluded from the therapist’s conversation. Pleasurable moments in the patient’s day are identified, and the patient is instructed in the art of including emotional pleasure in his life. The patient should become alert to his cognition so that he can stop himself when he ventures toward a negative pattern and shift his processing to a less harmful system. All this activity is patterned into exercises. CBT teaches the art of self-awareness.
I have never been in CBT, but I have learned certain lessons from it. If you feel the giggles coming on in a conversation, you can sometimes stop yourself from laughing by forcing your mind to some sad subject. If you are in a situation in which you are expected to have sexual feelings you do not in fact have, you can push your mind into a world of fantasy quite remote from the reality you are experiencing, and your actions and the actions of your body can take place within that artifice rather than in the present reality. This is the underlying strategy of cognitive therapy. If you find yourself thinking that no one could ever love you and that life is meaningless, you reposition your mind and force yourself to think of some memory, no matter how narrow, of a better time. It’s hard to wrestle with your own consciousness, because you have no tool in this battle except your consciousness itself. Just think lovely thoughts, lovely, wonderful thoughts, and they will sap the pain. Think what you do not feel like thinking. It may be fake and self-delusional in some ways, but it does work. Force out of your mind the people associated with your loss: forbid them entrance to your consciousness. The abandoning mother, the cruel lover, the hateful boss, the disloyal friend—lock them out. It helps. I know which thoughts and preoccupations can do me in and I exercise caution with regard to them. For example, I think of lovers I once loved and feel an aching physical absence and know that I have to pull back from those thoughts and preoccupations and I try not to conjure too many images of a happiness that existed between us and that is in its material form long over. Better to take a sleeping pill than to let my mind run free on sorry topics when I lie in bed waiting for sleep. Like a schizophrenic told not to listen to voices, I am always pushing these images away.
I once met a Holocaust survivor, a woman who had spent more than a year in Dachau and who had seen her entire family die in the camp. I asked her how she had managed, and she said she had understood right from the start that if she let herself think about what was going on, she would go crazy and die. “I decided,” she told me, “that I would think only about my hair, and for the whole time that I was in that place that is all I thought about. I thought about when I could wash it. I thought about trying to comb it with my fingers. I thought about how to act with the guards to make sure they didn’t shave my head entirely. I spent hours battling the lice that were all over the camp. This gave my mind a focus on something over which I could exercise some control, and it filled my mind so that I could close myself off from the reality of what was happening to me, and it got me through.” This is how the principle of CBT might be carried to an extreme under extreme circumstances. If you can force your thoughts into certain patterns, that can save you.
When Janet Benshoof came to my house for the first time, she awed me. A brilliant lawyer, she has been a leading figure in the struggle for abortion rights. She is by any standards an impressive person—well read, articulate, attractive, funny, and unpretentious. She asks questions with the practiced eye of one who can read the truth fast. Utterly self-possessed, she spoke of depressions that laid her impossibly low. “My accomplishments are the whalebones in a corset that allows me to stand up; without them, I would be only a heap on the floor,” she said. “Much of the time, I don’t know who or what it is that they are supporting, but I
know that they are my only protection.” She has done considerable behavioral work with a therapist who has addressed her phobias. “Well, flying was a bad one,” she explains. “So he took me on planes and monitored me. I was sure I would run into someone I hadn’t seen since school and I’d be with this fat man in a shirt bursting open at the seams and I’d have to say, ‘This is my behavioral therapist, and we’re just practicing taking the shuttle.’ But I must say that it worked. We went through exactly what I was thinking minute to minute and we changed it. Now I don’t have anxiety attacks on planes anymore.”
Cognitive-behavioral therapy is broadly used today, and it seems to show some significant effect on depression. There seem also to be extremely good results from interpersonal therapy, the treatment regimen formulated by Gerald Klerman, at Cornell, and his wife, Myrna Weissman, at Columbia. IPT focuses on the immediate reality of current day-to-day life. Rather than working out an overarching schema for an entire personal history, it fixes up things in the present. It is not about changing the patient into a deeper person, but rather about teaching the patient how to make the most of whoever he is. It is a short-term therapy with definite boundaries and limits. It assumes that many people who are depressed have had life stressors as the trigger or consequence of their depression, and that these can be cleaned up through well-advised interaction with others. Treatment is in two stages. In the first, the patient is taught to understand his depression as an external affliction and is informed about the prevalence of the disorder. His symptoms are sorted out and named. He takes on the role of the sick one and identifies a process of getting better. The patient makes up catalogs of all his current relationships, and with the therapist defines what he gets from each one and what he wants from each one. The therapist works with the patient to figure out what the best strategies are for eliciting what is needed in his life. Problems are sorted into four categories: grief; differences about role with close friends and family (what you give and what you expect in return, for example); states of stressful transition in personal or professional life (divorce or loss of job, for example); and isolation. The therapist and the patient then establish a few attainable goals and decide how long they will work toward them. IPT lays out your life in even, clear terms.
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