[Part I: The Locus of Responsibility]
Patients come into therapy because they are unhappy. In one way or another, they have determined that their life is not working and something needs to change. Most often, naive patients (ie, those who are new to therapy) want help making changes in their life that they hope and imagine will make them happy. Often enough, their level of understanding of the locus of responsibility extends no farther than the person or situation that is making them unhappy. It is how they respond to interpretive efforts and to attempts to offer insight that point to the direction of therapy and their future prospects. In effect, we evaluate the "psychological mindedness" of our patients.
[Disclaimer: When I write about patients, I typically disguise the facts such that there is no way that the actual person the case is based on can be identified. Any resemblance is coincidental.]
Evelyn was in her 20s when she first came to see me. She was a picture of misery, and complained of being deeply depressed. She was involved in a four year relationship with a man who treated her poorly. He was verbally abusive at times, often stayed away for days at a time, rarely paid his share of expenses on time, and when challenged on his behavior would typically threaten to go to one of the many other women he knew who would be more accommodating. Evelyn loved him and wanted to make their relationship work but he refused to consider couple's counseling. She felt abused and used, had begun to have trouble sleeping, and her work was suffering. Her family had suggested she see a therapist and get an anti-depressant.
She had a difficult background. Her father and mother had a terrible, contentious relationship, complete with alcohol abuse and physical abuse. Her father left when she was young and they had minimal contact through the years. A step-father, also a drinker, had molested her during a three year period before she turned 10 usually when he was drunk, though there was no actual penetration. Her mother became aware of the abuse and told him to stop but did not take any further action. Evelyn moved out when she was 16 to live with a boyfriend, the first of many who were indifferent or abusive to her.
Evelyn had significant strengths. She was bright, verbal, and a gifted student. She went to a highly selective college and graduated with honors. She was a hard worker, though lacked creativity in her work; nonetheless she was relatively successful in her work when we first met, though anxious about her recent difficulties performing her job adequately.
Evelyn was not only unhappy with her life but her unhappiness had curdled into depression. There is a difference, rarely appreciated by unhappy patients, between depression and sadness. We are sad when the world disappoints us, when we lose someone important, when we suffer a personal insult or injury. When we feel sad, there is almost always an admixture of anger, usually directed at the situation or person who is responsible for our sadness. We can use such anger to energize our response to the unhappy situation. If we fail a test and are angry at ourselves, we can use such anger to press us to work harder for the next test. If a lover is unfaithful, we can use the anger to demand changes in the relationship or break off the relationship and become available for a more appropriate and respectful partner. The depressed person does not react in such a way. When they suffer an emotional injury they become furious but turn the anger inward and often keep themselves unaware of the depth and intensity of their rage. Once held in, the anger attacks the foundations of the person's self-esteem. The student who failed now feels that they are too stupid to do well; there is no motivation to work harder but an acknowledgment of their inability to meet the challenge. Self-esteem plummets and depression sets in. The unfaithful lover is now not a boyfriend or girlfriend to be spurned but a sign of one's fundamental unworthiness. "He cheated because I'm not pretty enough; she cheated because I'm not virile enough." Once again, the assault on one's self-esteem becomes part of a depressive reaction.
[Please note that there are many types of "depression" some much more clearly constitutional than others. In my experience, especially since the advent of medically safe anti-depressants like the SSRIs, Prozac, Zoloft, etc, the tendency to use such medicines to treat sadness as opposed to depression has escalated exponentially. Most patients I see are unhappy yet interpret their unhappiness as depression. That may be worthy of a longer discussion at some future time.]
Evelyn was clearly on the edge between sadness and depression. I tried some mild trial interpretations to assess her potential for insight. I suggested to Evelyn that perhaps there was some reason she kept choosing men who hurt her. She demurred; he was so nice when they met, but then he turned. How could she have possibly known? I wondered if her early experiences with her father and step-father might have predisposed her to be drawn to men who reminded her of them in some way. She was horrified by the thought; none of her boyfriends were anything like her father or step-father. I inquired, what about their alcohol abuse? How was she to know they drank too much. They were so much fun when they started dating.
Evelyn could not imagine that she had a role to play in her failed and failing relationships. She insisted that she was depressed because her boyfriend was mean to her and that she should be given some medicine to make her feel better.
I offered her a choice of treatment approaches. I explained that the easiest approach would be to start an anti-depressant and see if that helped. However, I firmly believed that medication alone would not be sufficient or the best course for her. I suggested that her best chance of changing her unhappy situation and her tendency to continually find herself in unhappy situations would be through the combination of Psychotherapy and medication, when necessary. She might consider starting therapy alone and only add medication if and when it became necessary. I explained that the therapy approach tended to take longer and be more difficult but in the long run was in her best interests.
She insisted that she did not have the time or energy for therapy; medication would be sufficient.
I am a Psychoanalyst who is primarily interested in doing Psychoanalysis and Insight Oriented Psychotherapy. As such I do not offer Pharmacotherapy alone as a treatment option; when it is indicated, I refer the patient to someone who is more interested in such an approach. While there are many patients for whom such an approach is necessary or optimal, such as patients with major Psychiatric disorders (Bipolar, Schizophrenia) or people who have exhausted what benefits they can derive from Psychotherapy, have reached a plateau, and still require medication for optimal functioning, unless it is someone I have worked with personally throughout their therapy, I prefer to refer them out.
With a new patient who has never been in treatment, I firmly believe they should be offered an opportunity for a more definitive approach. In my experience in the clinic settings, I have suggested the option of a more intensive treatment to ~10-20% of the people I see there. Perhaps 10-20% of those patients have taken the opportunity.
Evelyn exhibits the most common types of outcome for those who choose the approach that cements them into the position of victim, granted minimal responsibility for their plight and minimal agency.
Evelyn ended up being seen at a local Mental Health Clinic. She started on a saga of medication and supportive therapy, at first meeting a therapist once a week for 45', later changed to once every two weeks and eventually once a month for 30'. Twenty years later, she has continued to be involved with a succession of men whose treatment of her mirrors the treatment she received from the boyfriend whose mis-use of her triggered her initial treatment. She has continued in employment significantly beneath her abilities, has neglected her health and physical appearance and begun to develop the diseases of abundance so common in our society. She is over-weight, with high blood pressure erratically treated, and pre-diabetic. She continues to be very close to her mother, has no relationship with her father, and continues to bemoan her unhappy lot in life when she sees her Psychiatrist (a personal friend) on a monthly basis.
She still does not see how her own behavior contributes to her problems and has remained a marginal contributor to society.
This is a very schematic description of a life story that I have seen over and over again at the clinic where I spend almost half my time. It is familiar and maddeningly sad.
In contrast, Lisa raged against her own despair, and overcame even greater odds. More about Lisa tomorrow: Lisa's Story
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