I don’t mean to sound unreasonable here. Insurance companies have every right to figure out how to spend their money; that’s just the price we pay for placing our health care in the invisible hand, and every therapy dollar we coax out of it is a small miracle. You can’t blame health care managers for favoring cognitive therapy, not when it’s advertised to take half the time of traditional therapies. Nor can you blame the media for reporting breathlessly on this “scientifically proven” therapy. Or universities for hiring cognitive therapy researchers, who can bring in government money for investigating ESTs, over adherents to other schools. Or the professional journals for running article after article touting the virtues of the therapy without paying much attention to the bell jar problem, or to the statistics indicating that caution is in order. Intentionally modeled on drug therapy, fashioned as a kind of verbal bolus targeted at cognitive symptoms, an antidepressant without side effects or pharmacological Calvinist implications, cognitive therapy just fits in too perfectly with medicine’s magic-bullet aspirations to be resisted, no matter what the numbers really say.
* * *
Cognitive therapy resembles antidepressants in one other way that Beck probably didn’t intend—and that he surely doesn’t mind. By succeeding as a treatment whose active ingredient is targeted at a specific pathology, it provides a backdoor validation of the idea that depression is a disease. It also provides a benefit for the disease model that the drugs don’t. Drug manufacturers are vague about exactly what it means for people to “get back to themselves” or just what kind of “life is waiting” for them. It’s enough to reassure people that their medication is only going to restore them to “health”—rather than to remake them—and leave it at that. But cognitive therapy is very clear about who we will be when we are cured: smoothly functioning processors of information, resilient navigators of life’s ebbs and flows who can “take off those tinted lenses and see the world for what it really is,” as Leslie Sokol exhorted us, and get down to business.
After four and a half days in this airless room, I still haven’t accepted the idea that the world really is a place that offers up nothing I can’t handle, if only I can restructure my negative thoughts and shed my self-doubt, that when I repair the glitches in my software, I will finally be able to make it. Indeed, I’m chafing against Beck’s and Sokol’s relentless can-do optimism, weary of their talk of coping skills, their agendas and strategies, their paperwork. Their model of life as a series of challenges to be managed efficiently is as bland and disappointing as this suburban office building. It just doesn’t do justice to the perversity of our nature or to the seemingly limitless tragedy on which it feeds.
Which is why I’m not going along with Judy Beck right now. That’s easy to do in my role as Ann, who was nothing if not perverse. After she tells Ann about her Negative Rectangles and Positive Triangles, Beck asks, “Do you think this is true, that your mind does work this way?”
“I think you’re just trying to get me to set the bar lower.”
“What does that mean exactly?”
“Either I’ve got you fooled, or you’re trying to fool me. You’re trying to argue me out of something I wasn’t argued into in the first place.”
“Well,” Beck says, “let me apologize. Because I wasn’t trying to argue with you at all.”
I am silent. I have no idea how Ann would respond to that. I know what I would say: “HUH?” Because arguing is exactly what I think has been going on here, not just in this role play, but for this whole week. After all, they call their examination of a patient’s thinking “Socratic questioning,” and didn’t Socrates seek to argue his students into the correct position by posing questions to which he already knew the answer?
Still, I can see Beck’s point. She’s not arguing. In fact, she’s taking her own medicine, looking for the problem not in Ann’s contrariness (or mine), but in her own cognitive apparatus. She breaks out of character to explain this to the class. “I think what happened in the role play is that I started this process too early with her,” she says. “She doesn’t buy this yet.” But Ann’s resistance is probably futile. Beck addresses her again. “We have to be really careful that I not sell you a bill of goods. I don’t want you to start seeing reality differently if it’s not realistic,” she says. “On the other hand, I don’t want you to sell yourself a bill of goods and see everything as negative if it’s not really that way. Anyway, could we send this piece of paper home with you and you think about it a little bit and we can talk about it more next week?” That’s not arguing. It’s just waiting for Ann to come to her senses.
There’s no need to argue about what is right here in front of our eyes. If Ann just realizes that her way of looking at the world isn’t working, if she just thinks about it a bit, if she just listens to this self-assured and calm woman who doesn’t seem a bit troubled by her own success, she’ll understand that the problem isn’t out there, in an economy that doles out reward and punishment in strange and unequal measure, in a nature that doles out a case of rubella at the worst possible time, in a world where fluke often trounces honest toil, in which it is possible for a woman to learn, on the very same day, that her mother is dead and her father is not her father, where anyone can meet the fate of Job at any moment; the problem is in here, in the faulty cognitions that prevent us from seeing the world as the benevolent place that it really is and moving on to the next item on our agenda.
This may not sound like positive thinking to Leslie Sokol, but the father of positive thinking would surely have a different opinion. Ten years or so before Aaron Beck began to craft cognitive therapy, Norman Vincent Peale was saying things like, “The basic reason a person fails to live a creative and successful life is because of error within himself. He thinks wrong. He needs to correct the error in his thoughts.” And “The world in which you live is not primarily determined by outward conditions and circumstances but by the thoughts that habitually occupy your mind.” And “A man’s life is what his thoughts make of it.” And “An inflow of new thoughts can remake you regardless of every difficulty you may now face.” And finally: “If you think in negative terms you will get negative results. If you think in positive terms you will achieve positive results.” The Power of Positive Thinking first appeared in 1952 and ministered to the demoralized, especially to the demoralized businessman, the one who was feeling downtrodden despite his successes, who had given in to circumstance. Peale wanted that man to understand that he could always pick himself up, shake off his losses, and reinvent himself. He wanted him to remember that in America, if you put your mind to it, anything is possible.
Unless you’re depressed. Indeed, this is the essence of depression, why it’s a pathology. What the cognitive therapists spell out, and what the psychiatrists only imply, is that depressed people, all depressed people—the melancholic and the neurotic, the endogenous and the reactive, the dysthymic and the majorly depressed—have in common their demoralization, their inability to see a limitless horizon, their despair over the possibility that their longings will never be satisfied. They have stopped pursuing happiness.
What reassurance there is in this idea that a properly functioning mind is one that is always able to get on with the business of living! Peale, like the Becks, shifts the burden of demoralization from the out there to the in here in exactly the same way that Eliphaz did with Job, but then they go him one better. Because the modern person can do more than shrug his shoulders and figure that God knows what he is doing; he can use the principles of science to call himself sick and take the cure. If he takes off those tinted glasses, he won’t see anything he’s not equipped to see and then meet with resilience. He doesn’t have to settle for Job’s choice between bitter denunciations of the terms of existence and awe in the face of the whirlwind. Because, evidently, God (or is it nature? or just the brain?) meant for us to be happy.
What a felicitous coincidence—to be an organism designed for happiness in a land dedicated to its p
ursuit! And here is another way that cognitive therapy helps us understand depression’s wild success in the marketplace of ideas about us. Because to be told that depression is a disease is to be reassured that when we are discouraged, we are not really sick at heart. We are just plain sick. Which means we can get better. We don’t have to look back at the fire that once rained down on us or outward to the inhumanity inflicted in the name of our prosperity or forward to the certainty of our own suffering. We don’t have to be stunned at the cruelty—or, for that matter, thrilled by the tragedy—of life on earth or worried that pursuing happiness the way we do is also pursuing destruction. We can be healed. We can get our minds to work the way they are supposed to. And then we can get back to business.
CHAPTER 14
THE NEW PHRENOLOGISTS
I should have quit while I was ahead. My clinical trial ended well for me, I thought, at least for the me for whom I was rooting all along, the one whose depression has some meaning and whose failure to take antidepressants is not a mistake that puts me and my family at risk. The raw material out of which depression is manufactured—the idea that this pageant of selfhood, the stories we cobble together out of our lives, and the epic of history that all those stories together make is all just a byproduct, an illusion manufactured by our molecules, something to keep us busy while they go about their business of dividing and replicating—is repellent to me. It’s demoralizing. It’s nearly intolerable. Who wants to be the tail of some electromolecular comet?
So I was happy to have my ontological commitments confirmed by Harvard scientists. The cognitive therapy expedition, on the other hand, was a more measured success. The method didn’t prove itself ineffective, but the conditions of its effectiveness, its dependence on our very peculiar social arrangements and on the corporatism that has come to dominate our self-understanding, were unmistakable. I got a glimpse of the finishing room in the depression factory, the place where the last touches are put on the gleaming new self. Much as I could see the appeal of resilience, of being able to get down to business no matter what, I also wasn’t ready to “buy in,” as Judy Beck put it. I wanted to leave my capital where it was.
There’s no double-blind test to verify that my view is right (or wrong). Which is why, I must confess, I was pleased when the lab called and told me that I’d been on the placebo. Score one for the good guys, I thought. And why the relative ease with which cognitive therapy showed itself to be a method of indoctrination into the pieties of American optimism, an ideology as much as a medical treatment, was a relief. And why, as I looked back at where this idea about depression came from in the first place, I was gratified to find that it came from us, that its history is not that of a law of nature slowly revealed but of an invention, of aspiration and compassion and the determination to alleviate suffering, and that the human voice, however muted, can still be discerned behind the clanking machinery. Not only because I proved, to myself anyway, that I wasn’t entirely crazy to think that depression was invented and not discovered, but because it meant that the climate of opinion still was not fully formed, that there could be a break in the weather.
Like I said, I should have quit while I was ahead.
Of all the evidence that the depression industry is selling a bill of goods, perhaps the strongest is the problem that has been there all along: the fact that depression is nothing more or less than its symptoms. The American Psychiatric Association’s claim to have solved this problem with the DSM-III was only a renewal of the promissory note that Emil Kraepelin had issued eighty years earlier. Even the highest priests of psychiatric orthodoxy will, at least in private company, admit that they haven’t resolved this conundrum so much as legislated it out of existence. “The DSM-IV… has 100 percent reliability and zero percent validity,” Thomas Insel, the director of the National Institute of Mental Health told psychiatrists gathered for the APA’s annual meeting in 2005.
Did rank-and-file psychiatrists, upon hearing from America’s psychiatrist in chief that their diagnoses were fraudulent, stop doling them out? Did they stop delivering their version of Frank Ayd’s speech along with their prescriptions? Did the drug companies stop comparing depression to diabetes? No, they did not. But then again Insel’s candor wasn’t intended to convince his brethren to repent their zero-validity ways. It was to announce the happy news that redemption from the Kraepelinian purgatory was at hand.
Brain imaging in clinical practice is the next major advance in psychiatry. Trial-and-error diagnosis will move to an era where we understand the underlying biology of mental disorders. We are going to have to use neuroimaging to begin to identify the systems’ pathology that is distributed in each of these disorders and think of imaging as a biomarker for mental illnesses… We need to develop biomarkers, including brain imaging, to develop the validity of these disorders. We need to develop treatments that go after the core pathology, understood by imaging. The end game is to get to an era of individualized care.
The holy grail of psychiatry, according to Insel, was in sight—literally. Their vision extended by scanners like MRI and CT and SPECT and PET, doctors would soon be able to peer into the brain and find there “the basic pathophysiology of each of the major mental disorders.” Psychiatry, recast as clinical neuroscience, would then be able to claim to have found what lies behind the symptoms, what makes mental disorders diseases. And having identified the targets with precision, psychiatry would be able to “emerge once again as among the most compelling and intellectually challenging medical specialties” and be “integrat[ed] into the mainstream of medicine.” Perhaps even more important, it would be on its way to a world in which everyone has his own disease and his own personal magic bullet.
Insel wasn’t saying when these halcyon days would arrive, but at least one doctor thinks the future is already here. Daniel Amen has been using single photon emission computed tomography (SPECT) to find biomarkers for mental illnesses for fourteen years. He’s a casually dressed man who, despite his baldness, looks younger than his fifty-six years. A Lebanese-American who grew up Roman Catholic, converted to Pentecostalism while he was a soldier in Germany, and got his undergraduate education at an Assembly of God Bible college, Amen was a member of the charter class of the Oral Roberts University School of Medicine. “I was suspicious that they accepted me because of my last name,” he once wrote. “The first graduate of their medical school would be Dr. Amen.”
Amen has made the transition from psychiatry to clinical neuroscience, and he’s practicing the new discipline right now, detecting psychopathology in my brain. He’s looking at a set of SPECT-generated photos taken over the past couple of days at his office in Orange County, California. Amen’s waiting room is crowded, mostly with adolescents and their parents; three women behind the reception counter are answering phones and clacking away on computers. A display case features Amen’s books and DVDs: Healing the Hardware of the Soul; Change Your Brain, Change Your Life; Magnificent Mind at Any Age. They’re all for sale at the desk.
Everyone here is kind and friendly. The receptionist smiled at me and touched my hand as she took my paperwork and my check—$3,250, which covered two scans and two hours with Amen. The woman who recorded my psychiatric history yesterday seemed genuinely moved when I described my struggles, and Mike the nuclear medicine technician apologized for the pinch when he punctured my arm with an IV line for the radioactive dye that would allow the camera to capture the blood flow in my brain.
Yesterday, Mike injected the dye while I was attending to my concentration task—sitting in front of a computer, hitting the space bar every time a letter flashed onto the monitor, unless it was an X, in which case I was supposed to refrain. I found this nearly impossible—the tedium alternately made me inattentive or impulsive. Today, he hit me up and then told me to sit in the darkened room and do nothing for fifteen minutes—not even fall asleep, which was a little tricky given that I’d been forbidden caffeine (and all other psychoactive drugs) for the past two days.
On both days, I lay down afterward on a hard table in a chilly room while a nuclear-sensitive camera circled my skull, snapping 120 photos of cross sections of my brain. The prints Amen is holding are computerized reconstructions of the SPECT scan, and they’re giving up my secrets.
He leads with the good news. “Your brain is really healthy,” he says. He’s showing me how he knows that, pointing to various parts of the picture, talking about temporal lobes and basal ganglia and regional cerebral blood flow. I’m having a hard time following him. I’m distracted by the picture itself, the yellow and pink and purple and green hues melting into one another on the pockmarked surface of my brain. I wasn’t expecting my brain to look so much like a tie-dyed moon rock.
But maybe that’s not the only reason I’m distracted. The good news told, and the disclaimer given that it would be silly to make a diagnosis based on brain scans alone, he says, “You probably have ADHD,” using the abbreviation for attention deficit/hyperactivity disorder. We’ve moved on to the active view of my brain, in which it shows up as a helmet-shaped latticework woven from threads of deep blue and red. Behind some sections of the grid are white bundles wrapped in more red and blue threads. “When you concentrate your cerebellum drops fairly dramatically,” he says, holding two versions of the same view and pointing to the relative lack of red strands in one of them. “Normally, it stays the same.” And he can see my depression too. “It’s this triad—cingulate gyrus, basal ganglia, thalamus.” He’s connecting areas of the lattice with his pen. “Your cingulate is up, which usually means your serotonin is low, and the basal ganglia usually goes along with anxiety.”
Manufacturing depression Page 34