Manufacturing depression

by Gary Greenberg

  And above all else, the diabetes doctor doesn’t have to tell the patient that he is getting better. Which is what they kept telling me at Mass General. At the end of my fourth visit, George Papakostas finished jotting in his notebook and told me that my Hamilton score had dropped to fourteen, from my baseline of eighteen. This was the week after he had asked me about the thirty days of symptom-free living that I’d apparently been missing out on because of my disease. Had I heard him right? I asked. How long did he say I should be feeling good?

  “For at least a month,” he said.

  Then I asked him why he wanted to know.

  “People, when they’re depressed,” he answered, “they get a sort of recall bias. They tend to feel that their past is all depressed.”

  Which meant, I wanted to point out, that depression is more like an ideology than an illness, more false consciousness than disease, and that telling me I was getting better was like dispatching propaganda from a new regime.

  But this wasn’t the only way in which Papakostas was telling me what my disease consisted of or what health would be like. He also did it through the tests. They asked me about my sleep and appetite; they asked me if I felt guilty; they asked me if I thought my life had been a continuous process of learning, changing, and growth. They gave me zero points for seeing myself “as equally worthwhile and deserving as other people” and three for “thinking almost constantly about major and minor defects in myself.” You don’t have to be a weatherman to know which way that wind is blowing.

  In this respect, the tests aren’t much different from the advertising—only the ads can be smarter than the tests. “Prozac isn’t a ‘happy pill,’” Lilly’s first ad reassured. “It isn’t a tranquilizer,” nor would it “turn you into a different person.” It would just have you “feeling sunny again.” “Your life is waiting,” Paxil reminded people, and “once they got back to themselves,” as the Zoloft ad put it, “they would appreciate life even more.” “Welcome back,” was the Prozac slogan—to yourself, it seems, to the person you were supposed to be all along.

  When Papakostas added up my Hamilton numbers and concluded that I was getting better, he didn’t have to say in what way that was true. It was already in the air. And when he asked me, “Are you content with the amount of happiness that you get doing things that you like or being with people that you like?” he didn’t have to tell me outright that this was the whole point: that to be healthy, to be back to yourself, to occupy the life that’s been waiting for you all along, was to be content. Which is a deep philosophical statement, and one that seems at odds with a consumer society and an economy that depends on our never being content, at least not too content to think that there is always some other happiness you could be pursuing at the mall. But he didn’t make this claim as a philosopher. He made it as a doctor. So we didn’t have to talk about any of that.

  And Christina Dording didn’t even have to mention contentment on my last visit. She just had to look in the binder, riffle the pages, and say, chipper as always, “Give me one second here.” She paused and then smiled. “Look at your scores. Nice response.”

  I wasn’t sure whom she was congratulating, but there wasn’t any question who—or what—was responsible for my improved mental health. Or so I found out when she started talking about my next visit.

  “Next visit?” I asked. “I thought this was the last.”

  “You’re not coming in for the follow-up?” She seemed surprised and hurt and a little incredulous, as if no one with such a nice response would pass up the opportunity to get even better. I asked her if the follow-up would be any different from what we’d been doing. It wouldn’t, she said. So I declined.

  But she wasn’t done with the subject. By then we’d adjourned to an examination room, where she was performing a cursory physical. “I think you’ve done very well,” she said as she looked into my eyes with a scope. “You’re much improved.”

  But if the treatment made me better, I wanted to know, then why did I need any more follow-up than buying some fish oil at the Whole Foods conveniently located next door to her office? And for that matter, how did she know that it was the fish oil at all? How did she know I wasn’t on the placebo?

  I asked her if I’d been on placebo or drug. “I don’t think we unblind the study,” she told me, looking again through my binder. “No, not in this one. No unblinding.”

  I protested. “I don’t get to find out?” Had no one ever asked this before? I wondered. And was it possible that being much improved could have no other meaning than that the drug had worked its magic? Wasn’t that what the study was supposed to find out?

  “No,” she said. “But you had a good response.”

  I didn’t see the point in arguing, but a few months later, I called the doctor in charge of the fish oil study. I asked him why Dording had offered to keep me on the fish oil when she didn’t know if I’d been on it in the first place, and why neither of us was allowed to find out. He explained that clinical trials remain blinded so that researchers don’t get tipped off by associating certain patterns of response with certain outcomes and thus start behaving differently toward patients whose condition they have deduced. But, he told me, seemingly unaware that he was contradicting himself, it is common practice for the doctors to “take their best guess” and offer follow-up accordingly.

  I wasn’t going to let this mystery stand. I didn’t know if I was really better. Some days I thought so. I wasn’t feeling content exactly. But sometimes, on some days, there was some ineffable feeling, a flicker of belief, a floor beneath me that kept me from plunging into darkness, where I could stand and catch and hold love and goodness, dwell with it and feel, if just for a moment, that life wasn’t only cruel and stupid. Eventually, I’d find myself paging through the familiar catalog of discontent, thick now with age and experience, but even then somehow less certain that this was the life that was waiting for me, this was the self I’d always come back to, this was the darkness that welcomed me. And maybe it was the fish oil that was making me feel that way.

  Or maybe not.

  I had some extra capsules. I sent them off to a commercial lab. The report came back a couple of weeks later. There wasn’t a drop of fish oil in them. I’d been on the placebo.

  CHAPTER 13

  EMBRACING THE MODEL: COGNITIVE THERAPY

  Of course, Papakostas and Dording didn’t mean to hornswoggle me. They were convinced that the drugs work, and that their conviction is a matter of fact and not faith. And to the extent that they were aware that they were using placebo effects, it was undoubtedly to bolster their patients, to give them hope. They weren’t really trying to sell anything. That’s why I have had to resort to these literary tricks—deconstruction and interpretation of what they say and of the ad campaigns that shape the meaning of their words—to shed light on their invention.

  That’s one of the great advantages of being a psychiatrist. George Papakostas may think that he and his colleagues love language, but ever since they decided that psychoanalysis is bunkum, or at least not the science for them, they don’t really have to take language seriously. They don’t have to articulate what exactly their notion of health is, or what philosophy lies behind it, beyond vague bromides about resilience or leading questions about contentment. There is, however, a group of depression doctors that trades in language, and they leave nothing to the imagination when it comes to spelling out what they mean by healthy. They’ll tell you exactly what the good life is and how and why depression has robbed you of it.

  I’m hearing all about it right now from Dr. Judith Beck. We’re role-playing, and I’m doing my version of Ann, the patient I told you about earlier. She’s the woman whose depression was worst when she was doing the best, when she was shining at her job or saving lives on an ambulance crew or sorting out a bookkeeping disaster at her church. Ann might join a club that would have her as a member, but not without telling its membership director that he’d made a terrible mistak
e and that the invitation would ruin a perfectly good organization. And she would definitely—I have firsthand knowledge of this—tell her therapist that while he seemed a good judge of many things, and a decent guy to boot, his apparent affection for her diminished his stock severely. After that, she’d probably stop at Burger King and grab a Whopper and fries, go home and eat some ice cream and then sit back and wait for her gallbladder to start to pound in her belly—an orgy of eating and pain that she would tell me about in excruciating detail the next time I saw her. And as she did, as it became clear that my attempt to find a nugget of gold glinting in the foulness of her emotional life had driven her to this bout of self-abuse, I would have to resist the sharp temptation to tell her what Freud said about how the self-reproaching melancholic is undoubtedly correct in her self-assessment. I would find myself agreeing with her that it was a huge blunder to try to find something to love in her.

  Ann, in short, was a therapist’s nightmare, a nightmare that right now I am inflicting on Beck. I’m discovering that it is much more fun to be Ann than it is to be her therapist. You can really torture someone this way.

  Judy Beck has short dark hair and hooded eyes that look right at you without staring. She’s not having anywhere near as bad a time as I would in the real-life version of this conversation. Partly that’s because it is hard for me to fully summon the awfulness of Ann; while I may know depression from the inside, and am always up for some self-laceration, I have never hated myself the way she does, so I can’t quite exude her toxic misery. But it’s also because Beck is familiar with people like Ann, and here on her home turf—the Beck Institute for Cognitive Therapy and Research, where she and her staff are teaching the basics of cognitive therapy to me and twenty-nine other therapists from around the world—she is calm and confident as she demonstrates why she is one of the world’s leading experts in the treatment of depression and why cognitive therapy is one of the very few nondrug treatments for depression that have been validated in clinical trials.

  The non-profit institute is named for psychiatrist Aaron Beck, Judy’s father, whom everyone here, including his daughter, calls Dr. Beck. We met him a few days ago, watching as he conducted a therapy session. Afterward, he came into the room in which we’ve spent this week to answer some questions.* He’s almost ninety years old. He probably once was taller and straighter than he is now, but he still wears a jaunty bow tie and fashionably oversized glasses and delivers his nimble answers with wit and charm in a strong, clear voice.

  Aaron Beck developed cognitive therapy in the early 1960s. A psychiatrist trained in psychoanalysis, he was, as he put it, “caught up in the contagion of the times”—which included efforts by the National Institute of Mental Health and the Group for the Advancement of Psychiatry to implement “systematic clinical and biological research”—and “prompted to start something of my own.” He dabbled in the diagnostic reliability field, but his big opportunity came unexpectedly when he undertook research into the dreams of depressed patients. Freud’s theory of melancholia predicted that repressed anger would turn up in dreams, but Beck found something different: “that the dreams…contained themes of loss, defeat, rejection, and abandonment, and the dreamer was represented as defective or diseased”—an exaggeration, he pointed out, of the themes of their conscious life. And unlike Ann, most depressed patients responded well when they succeeded and were praised, at least under experimental conditions. Perhaps, Beck concluded, it had been a mistake to look past the patient’s manifest self-reproach and toward a latent hostility directed toward others. Instead, he suggested, the problem was the negative thoughts themselves, which in turn kindled the recalcitrant unhappiness of the depressed person.

  Something had gone wrong with the patient’s inner life, Beck thought, but it wasn’t related to the relentless discord among ego, id, and superego, to dark forces and incestuous longings, to the clash of Eros and Thanatos or of civilization and instinct. Instead, it was to be found in the schemas, the dysfunctional beliefs that structured a patient’s experience and shaped his distorted cognitions. Where Freud saw a self groping around in a dark and treacherous inner landscape, lit only by the ego’s dim light (and, in treatment, by the slightly brighter lamp of a talented analyst), Beck saw a self with the potential to process information accurately, to map the inner and outer world and navigate successfully through their obstacles—and whose pathology could be discovered and corrected through a straightforward technique that used Socratic questioning instead of Freudian probing.

  Beck based this therapy in part on behavior therapy and in part on the cognitive science that was then emerging at the intersection of linguistics, philosophy, and computer science. In cognitive therapy, he explained,

  therapist and patient work together to identify the patient’s distorted cognitions, which are derived from his dysfunctional beliefs. These cognitions and beliefs are subjected to empirical testing. In addition, through the assignment of behavioral tasks, the patient learns to master problems and situations which he previously considered insuperable, and consequently, he learns to realign his thinking with reality.

  Beck’s theory didn’t ignore the past—indeed, the troublesome schemas are often laid down in childhood, by trauma and deprivation and all the other varieties of parental failure. But if your mom and dad will fuck you up, once you see how, there is no point in dwelling on the particulars. In his talk to us, Beck recounted the story of Lot’s wife as a cautionary tale about encouraging patients to explore their pasts. The point of recollection in cognitive therapy is not to delve into all the possible meanings of a memory, or the way that personal history reveals the confusion of forces that makes us human, but to identify the original distortions, correct glitches at their source, and restore the patient’s operating system to tip-top shape.

  Judy Beck is demonstrating just how this works by drawing a picture on a whiteboard. She’s trying to help Ann with the crushing self-loathing she felt after an ambulance call in which she had revived a man in cardiac arrest. As Ann, I’ve just told Beck that I hadn’t really done anything to deserve praise, that I probably broke some of his ribs, and it was all just dumb luck, nothing to do with me, not evidence of my competence, and certainly not praiseworthy—which means that if I allow my crew to compliment me, I’m just fooling them, which really makes me a terrible person.

  “It’s almost like there’s a part of your mind that’s shaped like this,” Beck says, indicating the diagram on the board. “Like a Pac-Man, but on its side. Inside this part of your mind is this idea, ‘I’m incompetent.’” The Pac-Man’s mouth is rectangular, not a jagged ellipse as in the original.

  Beck explains that neuroscientists have not yet found a place in your brain that looks like the Pac-Man; the drawing “just helps us understand it better.” Then she asks Ann to tell her about something incompetent that she has done recently. I oblige with a story about the next emergency call after she revived the man, and how she parked the ambulance on the wrong side of the yellow line at the hospital loading dock.

  “And when you did this, did you ask yourself, What does this mean that I parked on the wrong side of the line? Does it mean I’m competent, that I’m incompetent...”

  “I just thought it meant I’m stupid.”

  “So, automatically. You didn’t even think about it. So here we have some information—you parked on the wrong side. It’s almost as if that information was in a Negative Rectangle.” She draws a rectangle. “You see how the Negative Rectangle can fit right into this part of your mind? It’s like every time a Negative Rectangle goes in, it makes this idea ‘I’m incompetent’ a little bit stronger.” She draws an arrow. “Almost anything that happens that could possibly mean you’re incompetent, I think that information goes straight into your mind and immediately, automatically, you start to feel incompetent. You don’t even think about it. Do you think I could be right about this?”

  I nod.

  Beck turns now to Ann’s lifesaving. “Di
d you think, Does this mean I’m incompetent?”

  “I thought that everyone who was telling me what a good job I did just didn’t know the truth.”

  “And what do you see as the truth?”

  “The truth is that most of the time I don’t bring the people back and I think I just got lucky.”

  “So isn’t this interesting? Here we have some positive data.” She draws a triangle next to the Pac-Man. “The positive data is in a triangular shape, you see how this can’t get into a rectangular opening? In fact, in order to get in, it’s got to change its shape. It’s got to change into a Negative Rectangle, so now it can fit in.”

  Beck draws a triangle on the board. She asks Ann how many times she was late for work last week.

  “None.”

  “So every day when you got to work on time, what did you say to yourself?”

  “Here I am.”

  “So you didn’t say this is a sign of competence?”

  “People are supposed to get to work on time.”

  “So here we have five potential Positive Triangles, where you got to work on time, because not everybody actually gets to work on time, but you didn’t take that as a sign of competence. This positive data just bounces off. This way of processing information isn’t your fault, just your automatic way, which I can help you learn to override.”

  Beck is going by the book here. Which makes sense, because she wrote it. Although Cognitive Therapy: Basics and Beyond was assigned for this seminar, I can’t say I’ve read it recently, but I do remember it well from when I was a college professor teaching a course that surveyed the various schools of psychotherapy. Cognitive Therapy was a hit with my students. After the maddening uncertainties of psychoanalysis, the quasi-fascism of behavior modification, and the touchy-feely vagueness of existential-humanistic therapy, they really appreciated Beck’s bullet lists, her step-by-step instructions and verbatim scripts and you-can-do-this-too optimism. And above all, they liked her rational approach, her implicit reassurance that we were equipped to make sense of our lives.