The Noonday Demon (20 page)

The therapist begins by helping the patient make up a list of “life history data,” the sequence of difficulties that have led him to his current position. The therapist then charts responses to these difficulties and attempts to identify characteristic patterns of overreaction. The patient learns why he finds certain events so depressing and tries to free himself of inappropriate responses. This macroscopic part of CBT is followed by the microscopic, in which the patient learns to neutralize his “automatic thoughts.” Feelings are not direct responses to the world: what happens in the world affects our cognition, and cognition in turn affects feelings. If the patient can alter the cognition, then he can alter the concomitant mood states. A patient might, for example, learn to see her husband’s preoccupation as his reasonable response to the demands of the workplace rather than as a rejection. She might then be able to see how her own automatic thoughts (of being an unlovable jerk) turn into negative emotion (self-reproach) and identify how this negative emotion leads to depression. Once the cycle is broken, the patient can begin to achieve some self-control. The patient learns to distinguish between what actually happens and her ideas about what happens.

CBT functions according to specific rules. The therapist assigns lots of homework: lists of positive experiences and lists of negative experiences must be made, and sometimes they are put on graphs. The therapist presents an agenda for each session, continues in a structured fashion, and ends with a summary of what has been accomplished. Facts and advice are specifically excluded from the therapist’s conversation. Pleasurable moments in the patient’s day are identified, and the patient is instructed in the art of including emotional pleasure in his life. The patient should become alert to his cognition so that he can stop himself when he ventures toward a negative pattern and shift his processing to a less harmful system. All this activity is patterned into exercises. CBT teaches the art of self-awareness.

I have never been in CBT, but I have learned certain lessons from it. If you feel the giggles coming on in a conversation, you can sometimes stop yourself from laughing by forcing your mind to some sad subject. If you are in a situation in which you are expected to have sexual feelings you do not in fact have, you can push your mind into a world of fantasy quite remote from the reality you are experiencing, and your actions and the actions of your body can take place within that artifice rather than in the present reality. This is the underlying strategy of cognitive therapy. If you find yourself thinking that no one could ever love you and that life is meaningless, you reposition your mind and force yourself to think of some memory, no matter how narrow, of a better time. It’s hard to wrestle with your own consciousness, because you have no tool in this battle except your consciousness itself. Just think lovely thoughts, lovely, wonderful thoughts, and they will sap the pain. Think what you do not feel like thinking. It may be fake and self-delusional in some ways, but it does work. Force out of your mind the people associated with your loss: forbid them entrance to your consciousness. The abandoning mother, the cruel lover, the hateful boss, the disloyal friend—lock them out. It helps. I know which thoughts and preoccupations can do me in and I exercise caution with regard to them. For example, I think of lovers I once loved and feel an aching physical absence and know that I have to pull back from those thoughts and preoccupations and I try not to conjure too many images of a happiness that existed between us and that is in its material form long over. Better to take a sleeping pill than to let my mind run free on sorry topics when I lie in bed waiting for sleep. Like a schizophrenic
told not to listen to voices, I am always pushing these images away.

I once met a Holocaust survivor, a woman who had spent more than a year in Dachau and who had seen her entire family die in the camp. I asked her how she had managed, and she said she had understood right from the start that if she let herself think about what was going on, she would go crazy and die. “I decided,” she told me, “that I would think only about my hair, and for the whole time that I was in that place that is all I thought about. I thought about when I could wash it. I thought about trying to comb it with my fingers. I thought about how to act with the guards to make sure they didn’t shave my head entirely. I spent hours battling the lice that were all over the camp. This gave my mind a focus on something over which I could exercise some control, and it filled my mind so that I could close myself off from the reality of what was happening to me, and it got me through.” This is how the principle of CBT might be carried to an extreme under extreme circumstances. If you can force your thoughts into certain patterns, that can save you.

When Janet Benshoof came to my house for the first time, she awed me. A brilliant lawyer, she has been a leading figure in the struggle for abortion rights. She is by any standards an impressive person—well read, articulate, attractive, funny, and unpretentious. She asks questions with the practiced eye of one who can read the truth fast. Utterly self-possessed, she spoke of depressions that laid her impossibly low. “My accomplishments are the whalebones in a corset that allows me to stand up; without them, I would be only a heap on the floor,” she said. “Much of the time, I don’t know who or what it is that they are supporting, but I know that they are my only protection.” She has done considerable behavioral work with a therapist who has addressed her phobias. “Well, flying was a bad one,” she explains. “So he took me on planes and monitored me. I was sure I would run into someone I hadn’t seen since school and I’d be with this fat man in a shirt bursting open at the seams and I’d have to say, ‘This is my behavioral therapist, and we’re just practicing taking the shuttle.’ But I must say that it worked. We went through exactly what I was thinking minute to minute and we changed it. Now I don’t have anxiety attacks on planes anymore.”

Cognitive-behavioral therapy is broadly used today, and it seems to show some significant effect on depression. There seem also to be extremely good results from interpersonal therapy, the treatment regimen formulated by Gerald Klerman, at Cornell, and his wife, Myrna Weissman, at Columbia. IPT focuses on the immediate reality of current day-to-day life. Rather than working out an overarching schema for an entire personal history, it fixes up things in the present. It is not about changing
the patient into a deeper person, but rather about teaching the patient how to make the most of whoever he is. It is a short-term therapy with definite boundaries and limits. It assumes that many people who are depressed have had life stressors as the trigger or consequence of their depression, and that these can be cleaned up through well-advised interaction with others. Treatment is in two stages. In the first, the patient is taught to understand his depression as an external affliction and is informed about the prevalence of the disorder. His symptoms are sorted out and named. He takes on the role of the sick one and identifies a process of getting better. The patient makes up catalogs of all his current relationships, and with the therapist defines what he gets from each one and what he wants from each one. The therapist works with the patient to figure out what the best strategies are for eliciting what is needed in his life. Problems are sorted into four categories: grief; differences about role with close friends and family (what you give and what you expect in return, for example); states of stressful transition in personal or professional life (divorce or loss of job, for example); and isolation. The therapist and the patient then establish a few attainable goals and decide how long they will work toward them. IPT lays out your life in even, clear terms.

It is important not to suppress your feelings altogether when you are depressed. It is equally important to avoid terrible arguments or expressions of outrage. You should steer clear of emotionally damaging behavior. People forgive, but it is best not to stir things up to the point at which forgiveness is required. When you are depressed, you need the love of other people, and yet depression fosters actions that destroy that love. Depressed people often stick pins into their own life rafts. The conscious mind can intervene. One is not helpless. A fairly short time after I had snapped out of my third depression, I had dinner with my father and he said something that upset me, and I heard my voice go shrill and my words grow sharp and I was very much alarmed. I could see the trace of recoil in my father. I breathed deeply, and after a pregnant pause, I said, “I’m sorry. I promised not to yell at you and not to be manipulative about these things, and I’m sorry I did it.” This sounds rather namby-pamby, but the ability to intervene consciously does in fact make an enormous difference. A snappy friend once said to me, “For two hundred dollars an hour, you’d think my psychiatrist could go change my family and leave me alone.” Unfortunately, it doesn’t work that way.

Though CBT and IPT have many specific strengths, any therapy is only as good as the practitioner. Your therapist matters more than your choice of therapeutic system. Someone to whom you connect profoundly can probably help you a lot just by chatting with you in an unstructured environment; someone to whom you do not connect will
not really help you no matter how sophisticated his technique or how numerous his qualifications. The key things are intelligence and insight: the format in which that insight is communicated, and the type of insight that is used, are really secondary. In an important study done in 1979, researchers demonstrated that any form of therapy could be effective if certain criteria were met: that both the therapist and the patient were acting in good faith; that the client believed that the therapist understood the technique; and that the client liked and respected the therapist; and that the therapist had an ability to form understanding relationships. The experimenters chose English professors with this quality of human understanding and found that, on average, the English professors were able to help their patients as much as the professional therapists.

“Mind cannot exist without the brain, but mind can have influence on the brain. It’s a pragmatic and metaphysical problem whose biology we do not understand,” says Elliot Valenstein, professor emeritus of psychology and neuroscience at the University of Michigan. The experiential can be used to affect the physical. As James Ballenger of the Medical University of South Carolina says, “Psychotherapy changes biology. Behavior therapy changes the biology of the brain—probably in the same way the medicines do.” Certain cognitive therapies that are effective for anxiety lower levels of brain metabolism while, in mirror image, pharmaceutical therapies lower levels of anxiety. This is the principle of antidepressant medication, which by modifying the levels of certain substances in the brain changes the way a patient feels and acts.

Most of the things that go on in the brain during a breakdown are still inaccessible to external manipulation. Research on medical cures for depression has focused tightly on affecting neurotransmitters, mostly because we are able to affect neurotransmitters. Since scientists know that lowering the levels of certain neurotransmitters can cause depression, they work on the assumption that raising levels of these same neurotransmitters can alleviate depression—and indeed drugs that raise levels of neurotransmitters are in many instances effective antidepressants. It is comforting to think that we know the relationship between neurotransmitters and mood, but we don’t. It appears to be an indirect mechanism. People with lots of neurotransmitters bumping around in their heads are not happier than people with few neurotransmitters. Depressed people do not in general have low neurotransmitter levels in the first place. Putting extra serotonin in the brain does no immediate good at all; if you get people to eat more tryptophan (it is found in a number of foodstuffs, including turkey, bananas, and dates), which raises serotonin levels, that doesn’t help immediately, though there is evidence
that reducing dietary tryptophan may exacerbate depression. The current popular focus on serotonin is at best naive. As Steven Hyman, director of the National Institute of Mental Health, said rather dryly, “There’s too much serotonin soup and not enough modern neuroscience. We’re not organizing Serotonin Appreciation Day around here just yet.” Under ordinary circumstances, serotonin is discharged by neurons and then reabsorbed to be discharged again. The SSRIs (selective serotonin reuptake inhibitors) block the reabsorption process, thus increasing the level of free-floating serotonin in the brain. Serotonin is one of nature’s through lines in the development of species: it can be found in plants, in lower animals, and in human beings. It appears to serve multiple functions, which vary from one species to the next. In human beings, it is one of several mechanisms that control constriction and dilation of blood vessels. It helps form scabs, causing the clotting necessary to control bleeding. It is involved in inflammatory responses. It also affects digestion. It is immediately involved in regulation of sleep, depression, aggression, and suicide.

Antidepressants take a long time to cause palpable changes. Only after two to six weeks will the depressed patient experience any real result from his shifted neurotransmitter levels. This suggests that the improvement involves parts of the brain that respond to changed levels of neurotransmitters. Many theories are in circulation, none of which is definitive. The most fashionable until fairly recently was receptor theory. The brain has a number of receptors for each neurotransmitter. When there is more of the transmitter, the brain needs fewer receptors because the transmitter floods all the existing ones. When there is less of the transmitter, the brain needs more receptors to soak up every bit of available neurotransmitter. So increasing the amount of neurotransmitters would cause the number of receptors to go down and might allow the cells that had been acting as receptors to respecialize and take on other functions. Recent research reveals, however, that receptors do not take a long time to respecialize; in fact, they may alter within half an hour of a shift in neurotransmitter levels. So, receptor theory does not explain the time lag experienced with antidepressants. Still, many researchers hold to the notion that some kind of gradual change in brain structure accounts for the delayed response to antidepressants. The effect of the drugs is probably indirect. The human brain is stupefyingly plastic. Cells can respecialize and change after a trauma; they can “learn” entirely new functions. When you raise serotonin levels and cause certain serotonin receptors to close up shop, other things happen elsewhere in the brain, and those downstream things must correct the imbalance that caused you to feel bad in the first place. The mechanisms, however, are
completely unknown. “There’s the immediate action of the medication, which leads to some black box we don’t know anything about, which leads to a cure,” says Allan Frazer, chairman of the Department of Psychopharmacology at the University of Texas in San Antonio. “You get the same kind of results from raising serotonin that you get from raising norepinephrine. Do they lead into two different black boxes of function? Do they lead into the same black box? Does one thing lead to the other which leads to a black box?”