Coming of Age on Zoloft (22 page)

Personally, I am an inveterate big-picture person, which made CBT’s granular tendencies feel hampering. But it wasn’t just that. The greater emphasis placed on the relationship between therapist and patient in psychodynamic therapy was something that I wanted and needed. A couple of months into our work, the thought occurred to me one day that John knew me better than anyone else ever had. An instant later, I reflected that that was absurd: I’d never even seen him outside of our two weekly hours in his office. But in a sense, it
was
true. The ritualized nature of our conversations allowed me to show and tell him things I’d never revealed to anyone else. In the grand scheme of things, these weren’t remarkable revelations. But we all have sides of ourselves we’d prefer to hide, wishes and fears we go through life vaguely hoping that no one else can see. And though nobody claims to know exactly why interpersonally oriented therapies work, I think that the experience of being able to manifest all that you find most dubious about yourself to another person—a person who doesn’t go screaming from the room but, actually, miraculously seems to see it all and care about you anyway—must have something to do with it. There is a standard line of jokes about therapy that have to do with people complaining that they feel pathetic paying someone good money just to listen to them, but the crazy truth is that inside of a good therapeutic relationship, it isn’t just about money changing hands; the therapist’s feeling for the patient is real. Over time, that capacity to care for and empathize with the patient is transferred, eventually becoming something the patient can do for herself. (Freud once wrote that in therapy, “Essentially, the cure is effected by love.”
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) When it works, it’s a profound and mysterious, maybe even mystical, process. No wonder it bedevils those who dream of “evidence-based psychotherapies” as standardizable as the dose of a pill.

IT IS OFTEN
said that psychotherapy in combination with medication is the best treatment for depression. These claims come from the many studies that have looked at medication and therapy (usually CBT), both alone and in combination, and compared with a placebo. The largest study of this kind with youth, the Treatment for Adolescents with Depression Study (TADS), sponsored by NIMH and completed in 2004, compared Prozac, CBT, and the two in combination against a placebo in a group of 439 youths aged twelve to seventeen who had moderate to severe depression. The study found that CBT and Prozac alone were each highly effective, while the combination provided a boost: at eighteen weeks of treatment, 85 percent of patients on combination therapy had responded, compared with 69 percent on Prozac alone and 65 percent on CBT alone. (At thirty-six weeks, the bump provided by combination therapy had decreased some, with 86 percent of the combination group responding, compared to 81 percent apiece for the Prozac group and the CBT group.)
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Besides being supported by data, combination therapy makes a certain kind of intuitive sense, particularly in cases of severe depression. Someone who’s stuck deep in a rut of ruminative thoughts or lacks the energy for basic self-care is less likely to benefit from psychotherapy than somebody who has a bit of energy for the struggle. (Commenting on the inappropriateness of talk therapy to achieve “an immediate transformation of general mood,” Andrew Solomon wrote, “When I hear of psychoanalysis being used to ameliorate depression, I think of someone standing on a sandbar and firing a machine gun at the incoming tide.”
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) Antidepressants, the reasoning goes, may be able to blast somebody out of an entrenched depression and put them in a place where they’ll be able to properly do the work and absorb the benefits of therapy. Therapy, in turn, can help that person cope with symptoms that remain. It can make them better able to take care of themselves and recognize their triggers, so that they become less likely to get depressed again, or quicker to seek help when they do. And it can give them the skills to adjust to life as a healthy person, bestowing what my interviewee Mark called “the skill set to handle a nondepressed self.” This learning/rehabilitation process might be especially important for people whose depression is long-standing and entrenched. Dan’s story gives a good example of what people mean when they say that therapy and antidepressants together make the best medicine.

Dan was twenty-eight, but in person he gave the impression of someone a few years younger, just pulling his life together for the first time. He lived in Brooklyn, and if you passed him on the street, what you would see is a typical urban hipster: full beard, band T-shirt, visible tattoos. Though he is an assimilated New Yorker now, Dan was born and raised in a tiny rural community in Nebraska. “I knew everybody in the whole town,” he told me. “It was all one culture, one type of person.” He remembers it as a comfortable and unchallenging social world—maybe verging on too comfortable. “When I was growing up, I was in such a sheltered environment,” he said. “I was never outside that bubble of protection. I didn’t have to understand how to deal with people, how to go to a party, talk to classmates, how to have these social interactions that most people have to have when they’re much younger than I was.”

Nothing in Dan’s upbringing prepared him for his transition to college. He attended a large, diverse university in the Northeast. Most things about his new school felt harsh and overwhelming: the cold, the crowds, the competitiveness, the freedom. Right away, Dan told me, “I started to feel depressed and socially inept.” During his first year at school, “I was withdrawn and introverted and shy, to a crazy degree. I wouldn’t talk to people who worked at the college, people who were in my classes. I had this feeling that I wasn’t on the same level socially with everybody that surrounded me.” Dan found that drinking helped him deal with his awkwardness and loneliness, at least in the short term, and he started doing a lot of it.

Eventually Dan sought counseling at the campus health center, where he attended therapy sessions for two or three months, and saw a psychiatrist who wrote him a prescription for Paxil. Dan said the Paxil definitely made a difference. “I wouldn’t say I was happy,” he said, “but I wasn’t nearly as deeply and darkly depressed as I was before.” He found the therapy sessions less helpful. Dan described himself as a “band nerd” in high school. When he got to college, he started teaching himself guitar and writing songs. “I felt that it was very cliché for this artist, and I did consider myself to be an artist, to be taking these drugs and writing all these sad songs and what have you,” he said. He spent most of his therapy sessions talking about his ambivalence about using antidepressants, particularly his fears that Paxil would dull his creative edge, while the therapist sat there, “just listening to what I said and writing notes, to determine what medication I needed to take.”

After college, Dan moved around the country for a couple of years. He didn’t have health insurance, so he stopped taking Paxil. It was only after going off medication, he said, that he fully realized what an impact it had been having on him. “It was a very sudden change I noticed,” he said. The problems he’d had at the beginning of college had never completely gone away, but after graduation they quickly got worse. He also developed problems with anxiety that he’d never experienced before: “just things like feeling like I was going to have a heart attack, or not being able to ride in cars because I was afraid that I’d jump out.” Over the next couple of years, he said, he tried to “psych myself out” of feeling that way, with mixed success.

In his mid-twenties, Dan settled in New York, where he landed a job working for a real estate developer. The money was good, but he still felt lost, and he was still experiencing symptoms. “It was the worst and best time of my life,” he said, “because I was doing well professionally, but it was a dark period of my personal life. And I was depressed. I’d started going into these cycles every couple weeks where I’d be severely depressed for a while, and then not. I was drinking all the time and surrounding myself with my friends. When I wasn’t with them, I was depressed. Even when I was around them I was depressed.” Dan grew to loathe his job, and his anxiety problem returned. He couldn’t sit still, so he’d slip out of the office and take walks, just wander the streets of Midtown for as long as he could get away with. “The anxiety thing had gotten progressively worse over the previous five or six years,” he said. “I got to a point where I really couldn’t deal with it anymore.” Dan found a psychiatrist and began taking SSRIs again. But the first few kinds he tried didn’t work, and when his anxiety and depression spun out of control, Dan ended up checking himself into the hospital. He stayed there for a few days, and started a new regimen of medications—adjusted over time, they now included a tricyclic antidepressant and a mood stabilizer. He was also assigned a therapist to work with after his release.

Dan has thrived since then. He told me that being in the hospital changed his point of view; for the first time, he began to think of depression as an illness to be treated, rather than a fate to be endured. The combination of medications he’s on now is great, he said. He feels balanced in a way he never did on the antidepressant he took before. Comparing the way he feels today with the way he felt on Paxil in college, Dan said, “Now is completely different. Now I feel like this is the best feeling I’ve had in my life, ever. And I absolutely feel now that I cannot stop taking medication, ever, really.”

But Dan doesn’t think that medication is the whole story of why he feels substantially better this time. Even back in college, he told me, he believed that he was dealing with two orders of problem. One seemed more arbitrary to him, more chemical, while the other felt like it was related to the things that happened in his life. While medication helped with the first kind of depression, Dan said, therapy has been more effective at dealing with the second. “After I started taking Paxil I definitely thought that there was a chemical issue, that it was certainly helping a bit,” he said. “The thing the Paxil helped me deal with was this overall feeling of depression, or like this really terrible mood out of nowhere. Let’s say I’m walking down the sidewalk and I’m suddenly insanely depressed [for no reason]. I’m just walking someplace and I’m having these suicidal thoughts. That kind of went away when I was taking Paxil.” And, he added, those feelings returned after he stopped taking medication. But even when he was on Paxil, “Certain events would still make me upset because I felt like I didn’t know how to deal with those things. Just the normal social development that most people go through fairly early in life, I was trying to deal with when I was twenty years old.” Even today, Dan says, medication takes away the “overwhelming or out-of-nowhere feeling of depression” that he believes is chemical, but it leaves the problems he thinks stem from his upbringing intact. And that, he said, is where his therapist comes in.

Dan told me he had been working with the same therapist since his release from the hospital; he described her as being “like a very confident, knowledgeable, wise friend.” He said that therapy was most valuable to him as a kind of reality check—pointing out that long-standing depression, and even medications themselves, had left him understandably confused about what it is to feel normal. “I think when you’re depressed,” he said,

and especially when you’re taking medication, a lot of times you’re very confused about “Okay, how do I feel about this situation? Is this the way I’m supposed to feel about it? Or is the medication supposed to make me feel not that way? What am I supposed to be doing? Am I depressed? Am I not depressed? Is this normal for a person to feel?” Especially when I was back [on medication], I was like “Is it normal for me to feel this way?” I have a very good therapist who’s very realistic and blunt, and she’ll say, “That’s totally normal,” or “That’s not.”

Dan explained that his therapist had been helping him figure out the way different factors in his life affected him, things that the turbulence of his life before—between depression, anxiety, his drinking, and stress at work—had prevented him from noticing. For instance, he said, she made him appreciate how much his real estate job really was contributing to his unhappiness. “She convinced me that the job had a huge role in the way I was feeling overall,” he said. “Whereas I had tried to justify a lot of the things that were happening to me in my mind by saying, ‘I’m drinking,’ or ‘It’s because I’m not good enough socially to cut it in that environment,’ or ‘My self-esteem is too low.’ ” She encouraged him to take his feelings seriously and leave that job for one that suits him better, and she convinced him to take a break from drinking. With the chemical aspect of his depression, the oppressive job, and the drinking habit gone, it was easier for Dan to observe what it was like to feel well, and to experiment with different ways of protecting his mood. “I can now say for certain that there are things that make me upset,” he said. “Certain movies, certain books, certain music. And now I have the awareness to say, ‘Maybe I shouldn’t go there,’ if I’m leaning toward that sort of mood.”

Dan said he was also using therapy to work on his self-image. “Over the last ten years, when I was drinking and when I was depressed, I saw myself as this very unhappy, unfriendly person, this very moody type of character,” he said. “And I would sometimes say that to people and they would completely disagree with me, like ‘What are you
talking
about?’ So over the years it’s become more apparent to me that my self-perception is very off base.” (It was hard for me, too, to imagine Dan as the brooding-misanthrope type. He was warm and unguarded, and made delightful company.) Dan said he was slowly dismantling his old identity and replacing it with a sense of himself that’s more accurate. “When I was younger it was very much a self-esteem thing, physical issues, but now it’s more about ‘How do people see me as a person?’ ” he said. “Do people see the depression and the moodiness and this underlying anxiety, or do they not?” He recrossed his legs on the secondhand coffee table in his living room, where we were sitting. “And I’m starting to realize that people don’t see that at all. But my therapist and I are still working on making me believe it.”