Manufacturing depression

by Gary Greenberg

  But even if I weren’t familiar with the book, I’d have gotten most of its contents from psychologist Leslie Sokol, a Beck Institute staffer who has done the majority of the teaching this week. She’s taught us how to help a patient identify Automatic Thoughts and record them on a Dysfunctional Thought Record, how to use the Downward Arrow to point to the Core Negative Beliefs that lie beneath them, how to chart the mental journey from belief to thought to emotion and behavior on a Cognitive Conceptualization Diagram, how to fashion an Alternative Response or other Compensatory Strategy that will, repeated and reinforced, lead to Cognitive Restructuring. She’s told us about the Negative Triad—regret about the past, unhappiness in the present, despair about the future—about Task Interfering Cognitions and Task Oriented Cognitions (“Stop TICking and start TOCking,” she says), about Key Cognitions and Situation-Specific Thoughts and Affect Shifts, about the importance of Activity Schedules and Coping Cards. She’s shown us video of other therapists in action, passing papers back and forth across the table at which they sit with their patients, following the steps of a cognitive therapy session—the Mood (and Medication) Check, the Bridge from the Previous Session, Setting the Agenda, the Review of the Homework, the Discussion of Agenda Items, Assignment of New Homework, the Final Summary, and the Feedback. She’s reassured us that this isn’t just some cult of positive thinking. “The key is not to teach people to be more positive. The key is to have an accurate perspective on what’s going on.” She’s argued that the problem for depressed people is that “nothing in life is a neutral situation,” that their Negative Bias needs to be replaced with neutrality, their inadequate coping skills with new strategies, that when this is accomplished, when they have a good Cognitive Conceptualization of themselves, when they are able to process information as accurately as their mental apparatus is designed to do, they will become resilient, and that this is the goal because “the resilient person is the person who is going to make it.”

  Sokol seems like someone who has made it. She’s around fifty, blond and bright-eyed and trim, her skin scrubbed to a glow. She wears well-tailored suits, talks fast, leavens her PowerPoint with Family Circus cartoons and her patter with fresh and funny anecdotes from her private practice, and delivers it all with panache. She could probably sell iceboxes to Eskimos, and she makes no bones about the sales part of her job. She doesn’t call it that, of course, but she tells us repeatedly that we have to “socialize the patient to the model,” and it’s clear that this is what she’s doing with us. “If we’re asking them to embrace the model,” she says, “we have to already understand and believe in the model. I’m a believer and I’m here to make you a believer.”

  There’s something refreshing about this ideological candor, even if I’m finding its particulars hard to embrace. Every therapist is selling a view of the world, or at least of suffering and its relief, but few articulate it so clearly, and with such certainty. This clarity and single-mindedness is in fact part of the program. “Self-doubt is contagious,” she said, striking a theme she will sound all week: that ambivalence—about the model, about our cognitive abilities, about our prospects of making it—is the enemy that stops depressed people from getting reality just exactly right and therapists from staying on the empirically validated, doctor-tested cognitive therapy path. And if we stay on the straight and narrow, we will be amply rewarded for our faith. “My hope is that over the week you’re going to see that if you understand the model, if you understand the problem though the model, you’re going to know what to do to treat anybody that walks through the door.”

  That is a very powerful pitch. Therapeutic outcomes are dependent in part on allegiance effects, on the extent to which a therapist believes in what he is doing and conveys that confidence to his patient. So a claim to be in possession of a universal method is good for a therapist’s business. Commerce, in fact, has been on Leslie Sokol’s mind ever since she started the week by saying, “Let’s get right down to business.” Not the business of the Beck Institute, which is certainly successful, but the business of living, of making it in a world that constantly throws up obstacles. “We’re not here to cure you. We’re here to teach you how to cope,” is what she suggested we tell our patients as we socialize them to cognitive therapy. “We’re here to help you more effectively navigate life. We’re here to say that when bad things happen, you’re going to be equipped to deal with them so they don’t get the best of you.” Therapy is not only the venue in which these management skills are taught; it’s where they are embodied. “You need empathy, but it’s not enough. You get to work,” she reminds us. “We’re here to accomplish work. And every time we meet here, we’re here to get something done.”

  This is also a powerful idea, and while I’m not exactly embracing the model, I am painfully aware of the fact that I’ve never talked to Ann or any patient about Automatic Thoughts or Core Beliefs, never swapped papers with them or assigned them Coping Cards or diagrammed their Cognitive Conceptualizations. All week, in fact, I’ve been wondering if this is connected to the futility of those dismal hours I spent with Ann, to my inability to say whether I accomplished work with Ann. Now that I see what it means to set an agenda and pursue it, I’m not even sure I actually set out to do that in the first place with Ann—or, for that matter, with anyone else.

  And if I did, it isn’t the kind of work Beck and Sokol have been talking about here. Ann once told me about a dream she’d had in which five red tractors were planted vertically in the ground, and she single-handedly uprooted and knocked them down. We had one of our few fruitful discussions that day, about this dream’s multiple resonances with her emotional life. Most obviously, the dream referred to her resentment over the fact that her father refused to allow her to drive the tractor on her family farm (men’s work, he said), but there was something much more important. Ann’s family (three siblings, two parents, five tractors) had been uprooted when Ann’s youngest sister was institutionalized and they moved from the farm to the city to be closer to her. The sister had multiple birth defects, the result of a case of rubella that Ann’s mother had contracted while pregnant—and which she had caught from Ann. You can imagine the conflicts this would create, the shame a child could feel over her role in such a catastrophe, the sense of power it would bestow upon her, the rage at being displaced and the self-reproach for causing it and the confusion between them. The dream was such a near-perfect distillation of these themes that even Ann could see it. And when she did, it certainly felt like work, but I have no idea how it would come out on these diagrams. More to the point, it would be hard for me to say right now exactly what we were accomplishing in that conversation.

  I thought I knew at the time. Just as I did when Eliza—the woman who learned on the same day that her drug-addicted mother had died and that her father was not the man she had thought, and whose grieving had outlasted the DSM’s dispensation for bereavement—told me a story about strawberries. We had been talking about how when Eliza was fourteen, her mother, Mary Ann, had taken up with a new man, a crystal meth addict and dealer, announced that she was finished being Eliza’s mother, and ordered her out of the house immediately. Eliza knocked around for a while, actively resisting a life like her mother’s (Mary Ann had become pregnant with Eliza when she was sixteen and lived mostly from man to man and bar to bar), until she was taken in by someone she knew from her church. She got a GED, a degree from a technical college, and, eventually, a job in her profession.

  One day, Eliza told me about a time when Mary Ann came to visit her for a weekend, almost ten years after she had kicked her daughter out. The visit ended abruptly, with both of them in tears. “It always ended badly,” she said, “because her visits brought up a lot of issues for me. About what a pathetic excuse for a mother she was and how I needed her anyway, things like that. A couple of days later I was having friends over, and I guess the buildup from the weekend hit me all of a sudden. I was slicing some strawberries. I have no idea why this trigge
red it. But all of a sudden, it hit me that my mother was lost to me and I was never going to get her back, and I just collapsed in tears.”

  Eliza began to cry, just a little. “I just don’t want to cry about this anymore,” she said. “I didn’t want to cry about it then. It just puts a knife in your heart.”

  “Maybe that’s why it happened when you were slicing strawberries,” I said.

  “With the knife and the heart-shaped strawberries? That’s funny.” She laughed. “Are you going to go all Freudian on me?”

  “This is a pretty remarkable thing,” I answered, dodging her challenge. “That you were talking about cutting strawberries and you came up with this metaphor of a knife jammed in your heart.” (And why did I say “jammed”? Was the strawberry image contagious?)

  “Yeah,” she said, sarcastic. “I’m brilliant that way. Maybe as I was cutting the strawberries I was thinking, My mother’s put a knife in my heart.”

  “I don’t think you were thinking that. It’s just the way it was for you.”

  She was silent—reconsidering, I think. “Yeah, maybe, maybe. God, I never thought about that. But it’s funny that the visual memory of me cutting those strawberries is so emblazoned into me.”

  “But you know, I wonder if it’s also her heart,” I said.

  “What do you mean?”

  “That you want to cut. What is the response to a mother who is a pathetic excuse for a mother?”

  I’m not sure exactly why I said that. It was something about inverted hostility, about how the once absent, now dead, and still longed-for mother is nearly impossible to be angry with, so there is no other place to put the knife besides into her own heart. Maybe I was just socializing Eliza to my model. Maybe I just wanted her to get angry with her mother because it fits into my theory about how the world works. That’s the thing about being the kind of therapist I am. I’m always catching a case of self-doubt.

  And right now I have a whopper. Against all of Judy Beck’s polished technique, all her sharp distinctions, all her careful plotting and planning, I’m wondering if I’ve failed my patients and myself, if I’ve frittered away twenty-five years of my life and millions of their dollars by focusing on the tractors and the strawberries and all their possible meanings, by the inescapable and sometimes intentional inefficiencies of this method, by my nearly willful avoidance of anything resembling accomplishing work, by my possibly blind and certainly unscientific belief that the best we can do is to integrate all that we can of ourselves into a good story, even the thoughts that don’t make sense and the desires that are horrifying or the feelings that shock. Because right now all of that murkiness doesn’t seem to stack up to Beck’s clarity of purpose and her method for getting there.

  Nor can whatever I’ve been doing all this time, and whatever has come of it, compare to one fact, documented in clinical trials and endorsed by the mental health industry and government alike: that when it comes to depression, cognitive therapy gets results. Empirically validated results, results that give psychologists a place at the depression feeding trough, that both capitalize on and strengthen depression’s status as a bona fide disease, and that warrant cognitive therapy’s inclusion in the American Psychiatric Association’s standards of care—which means that by not practicing it with Ann (or anyone else who is depressed), by worrying about the strawberries and the tractors, I may be guilty of malpractice. So who am I to argue?

  I’m not entirely exaggerating about the potential legal consequences of not practicing therapy by the book, at least when it comes to depression. Just ask the doctors at Chestnut Lodge, a psychiatric hospital near Washington, D.C., with a long and venerable history. In 1979, Rafael Osheroff, a forty-two-year-old doctor was admitted to the lodge, complaining of anxiety and depression. He’d been under treatment for the past couple of years; his psychiatrist was none other than Nate Kline, who thought Osheroff was getting better. But Osheroff didn’t agree, at least not enough to keep taking his tricyclic antidepressants. He became disabled and ended up in Chestnut Lodge, where the house brand was psychoanalysis. When he didn’t improve after seven months of that, his family moved him to a Connecticut hospital where he was promptly diagnosed with a psychotic depression and put on antipsychotics as well as tricyclics. His condition improved noticeably within three weeks, and three months later he was discharged.

  By then, however, Osheroff had been in the hospital for nearly a year and his life was in ruins. His second wife had left him, his first wife had gotten custody of their two children, his hospital had yanked his accreditation, and his partners had kicked him out of their practice. In 1982 he sued Chestnut Lodge, claiming that their failure to put Osheroff on drugs was negligence. Five years of arbitration and appeals and hearings that included testimony from leading psychiatrists like Frank Ayd and Gerald Klerman ended with an out-of-court settlement in Osheroff’s favor.

  Because it never went to trial, Osheroff v. Chestnut Lodge didn’t establish any official legal precedents. Its impact on the profession was nonetheless profound. According to Edwin Shorter, “The case left the strong impression that treating major psychiatric illnesses with psychoanalysis alone constituted malpractice…Any clinician who henceforth treated patients as Chestnut Lodge had Dr. Osheroff ran the risk of incurring heavy penalties.” Not only that, Shorter says, but psychiatrists, chilled by the outcome, began to abandon their notebooks and couches for prescription pads and more traditional office furniture, creating a vacuum that was filled by the psychologists and social workers and other non-physician therapists. Sixty years after they had wrested psychoanalysis from Sigmund Freud, doctors evidently could barely wait to hand it back over to the lay analysts.

  But the case had an even more direct impact on the treatment of depression. Osheroff had gone into Chestnut Lodge at the height of psychiatry’s thrash over DSM-III and filed his lawsuit just after it was published. In the new psychiatric world, with its diagnostic specificity and its magic-bullet drugs, therapists’ difficulty in passing scientific muster was a new kind of problem. As Gerald Klerman, writing in 1990 about the Osheroff case, put it:

  If a pharmaceutical firm makes a claim for the efficacy of one of it products, it must generate enough evidence to satisfy the Food and Drug Administration before it can market the drug…No such mandate of responsibility exists for psychotherapy. Anyone can make a claim for the value of a form of psychotherapy…with no evidence as to its efficacy.

  The moral of the Osheroff story, Klerman said, was that it was time to require of psychotherapies what Kefauver-Harris had required of drugs: proof that they worked.

  It’s not that no one had tried to do that. In 1936, in fact, a prominent American psychologist, Saul Rosenzweig, published a paper examining therapy outcomes and concluded that all forms of therapy, competently practiced, were equally effective. Rosenzweig lifted the subtitle for his paper—“Everyone Has Won and All Must Have Prizes”—from the dodo bird’s verdict on the race in Alice in Wonderland. That might have been an unfortunate choice. His conclusion has gone down in history as the dodo bird effect—not an embarrassment of riches, that is, but just plain embarrassing.

  In 1975, a team led by psychologist Lester Luborsky subjected the dodo bird effect to modern statistical methods. They looked at studies comparing one therapy to another, therapy to no therapy, psychotherapy to drug therapy, and time-limited to interminable therapies and concluded that all indeed must have prizes.

  Luborsky also determined that there was nothing specific to a given therapy that accounted for its success. In part this was because the therapists generally chose the outcome measures, but even when the measure was an objective test (like the HAM-D), the dodo bird effect held. Luborsky suggested an explanation: “The different forms of psychotherapy have major common elements—a helping relationship with a therapist…along with the other related, nonspecific effects such as suggestion and abreaction [Freudian jargon for emotional catharsis].” These common elements—nonspecific facto
rs—accounted for therapy’s success.

  Luborsky’s work got updated from time to time, using increasingly sophisticated and impenetrable statistical techniques, and the result was virtually always the same. Something like three-quarters of patients are better off with therapy than they were without it. Patients themselves ratified this result, at least they did in a survey that appeared in Consumer Reports. There was “convincing evidence that therapy can make an important difference” the magazine reported, adding that the most important factors were “competence [of the therapist] and personal chemistry”—not the particular school the therapist subscribed to or the techniques he employed. The conclusion is inescapable: to the extent that therapy succeeds, it’s due not to the particular help that’s offered, but rather to the fact that something is offered in the first place, and by a person whom the patient expects, and believes, will help. Therapy, no less than drugs, works by the placebo effect.

  This shouldn’t be a surprise. To the extent that it is understood, the placebo effect seems to be the result of a patient’s entering into a caring relationship with a healer, which is a much more explicit feature of psychotherapy than of general medicine. Nor should this be bad news. It just means that when therapists listen with empathy, when we offer support and understanding, when we help people to pick up their pieces and fashion a story out of them, to make as much sense of their lives as they can and to withstand the uncertainty of whatever is left over, when we provide a space in which they are free to be just as confused and demoralized and ambivalent as they really are—that when we do all that, and when we do it well, it really does help. It would no doubt be better to have a world in which we therapists weren’t necessary, where narrative coherence wasn’t so hard to come by and people weren’t driven into private rooms to plumb the depths of their fears and their hopelessness, but that’s not this world, so having those rooms, and the professionals who occupy them, is the next best thing.