The Noonday Demon (19 page)

Talking therapies come out of psychoanalysis, which in turn comes out of the ritual disclosure of dangerous thoughts first formalized in the Church confessional. Psychoanalysis is a form of treatment in which specific techniques are used to unearth the early trauma that has occasioned neurosis. It usually requires a great deal of time—four to five hours a week is standard—and it focuses on bringing the content of the unconscious mind to light. It has become fashionable to bash Freud and the psychodynamic theories that have come down to us from him, but in fact the Freudian model, though flawed, is an excellent one. It contains, in Luhrmann’s words, “a sense of human complexity, of depth, an exigent demand to struggle against one’s own refusals, and a respect for the difficulty of human life.” While people argue with one another about the specifics of Freud’s work and blame him for the prejudices of his time, they overlook the fundamental truth of his writing, his grand humility: that we frequently do not know our own motivations in life and are prisoners to what we cannot understand. We can recognize only a small fragment of our own, and an even smaller fragment of anyone else’s, impetus. If we take only that from Freud—and we can call this motive force “the unconscious” or “the disregulation of certain brain circuits”—we have some basis for the study of mental illness.

Psychoanalysis is good at explaining things, but it is not an efficient way to change them. The massive power of the psychoanalytic process
appears to be misspent if the patient’s goal is an immediate transformation of general mood; 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. The psychodynamic therapies that have grown out of psychoanalysis, however, do have a crucial role to play. The unexamined life can seldom be repaired without some close examination, and the lesson of psychoanalysis is that such examination is almost always revealing. The schools of talking therapy that have the most currency are the ones in which a client talks to a doctor about his current feelings and experiences. For many years, talking about depression was considered the best cure for it. It is still a cure. “Take notes,” wrote Virginia Woolf in
The Years,
“and the pain goes away.” That is the underlying process of most psychotherapy. The role of the doctor is to listen closely and attentively while the client gets in touch with his true motivations, so that he can understand why he acts as he does. Most psychodynamic therapies are based on the principle that naming something is a good way to subdue it, and that knowing the source of a problem is useful in solving that problem. Such therapies do not, however, stop with knowledge: they teach strategies for harnessing knowledge to ameliorative use. The doctor may also make nonjudgmental responses that will allow the client sufficient insight to modify his behavior and so improve the quality of his life. Depression is often occasioned by isolation. A good therapist can help a depressed person to connect with the people around him and to set up structures of support that mitigate the severity of depression.

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 seems 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.