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    The Price of Prozac
    Healing in a Time of Terror
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Healing The Soul in the Age of the Brain
Becoming Conscious in an Unconscious World

by Elio Frattaroli, M.D.

Chapter 5.
The Swimming Pool and the Quest

                                    You who are on the road
                                    Must have a code that you can live by
                                    And so become yourself
                                    Because the past is just a good-bye
—Graham Nash, “Teach Your Children”

                                    Man is made by his belief. As he believes, so he is.
—Bhagavad Gita

A Fix for the Brain Versus a Home for the Heart

When I first gave the lecture that appears in Chapter 4, I had been working on this book for about a year and a half. But it was actually almost five years earlier—in the last week of March 1990—that the book first began to take shape in my mind. It all started when an issue of Newsweek appeared with a Prozac capsule on its cover—just where the picture of a person should be, I thought. It was not only the cover of that issue that got my attention, though. It was also the brief note, buried in its obituary section, announcing the death of Bruno Bettelheim. “If Dr. B wasn’t dead already, this would definitely kill him,” I thought ruefully. I knew how much Bettelheim had always deplored what that Newsweek cover was so blatantly glorifying: our drug culture and its quick-fix mentality.

The ironic coincidence of Prozac’s much-heralded arrival on the cultural scene together with Bettelheim’s scarcely noticed departure epitomized for me the predicament of our society. It meant that everything Dr. B stood for—and everything I cared about as a psychiatrist and as a person—was being lost in our cultural frenzy for the quick fix. To me this loss felt very personal. You see, it was Bruno Bettelheim—“Dr. B” to his students—who first taught me about healing the soul and inspired me to want to become a psychiatrist.

I had worked for Dr. B in the early 1970s at the University of Chicago’s Sonia Shankman Orthogenic School, the residential treatment center he created for emotionally disturbed children.1 Under Bettelheim’s guidance, the School was an extraordinarily loving and nurturing place, a place of healing and growth for the staff as well as for the children. In one of his books, Dr. B described the Orthogenic School as a home for the heart, and that’s very much the way I experienced it. It became my model for what psychotherapy should be: a place dedicated to fostering the inner life, a place of love and respect—an I-Thou relationship—in which we can feel what we truly feel, and so become who we truly are.

The End Is in the Beginning

One of Dr. B’s most memorable and useful teachings was that “the end is always in the beginning.” By this he meant that the assumptions, attitudes, and expectations with which we approach a therapeutic encounter or life situation define how that encounter or situation will evolve.

Alfred Flarsheim, another of Dr. B’s students, reported a wonderful illustration of this lesson, taken from ethologist George Schaller’s book Year of the Gorilla.2 It seems that Schaller (whose writings inspired Dian Fossey) had been able to collect far more detailed observations of the behavior of free- living gorillas than any previous scientific observer. Schaller attributed his unprecedented success to the simple fact that he had decided not to carry a rifle. This forced him to be sensitive to the gorillas’ subtle behavioral signals and allowed him to get quite close to them without making them feel threatened. Earlier, less successful observers had gone into the jungle armed with rifles because they assumed (incorrectly) that gorillas were dangerously aggressive and would make unprovoked attacks. The end is in the beginning. Schaller ended up with different results because he started out from a different assumption. He assumed that the gorillas would not be dangerous as long as he treated them with respect. So he began without a rifle and ended up discovering that he didn’t need one. In contrast, the ethologists who carried rifles found that they did need them. In other words, they found exactly what they had been expecting: that gorillas were too dangerous to observe closely, and sometimes attacked and had to be shot. But these observers had created rather than discovered this confirmation of their preconceptions. It was not the gorillas’ innate aggressiveness that had prompted them to attack. Rather, the observers themselves had inadvertently provoked the gorillas to attack by their thoughtlessly intrusive behavior and bearing—influenced by the false security and sense of invulnerability they took from their rifles.

Schaller’s experience is relevant for psychiatry. Just as the rifle reflects the ethologist’s preconceived assumption about gorillas, so medication reflects the psychiatrist’s preconceived assumption about symptoms. The end is in the beginning. The possibility of prescribing medication, like the availability of a rifle in the jungle, fosters the tendency to bring premature closure to an encounter. It affects the psychology of the psychiatrist in such a way that he is unlikely to get close enough to the patient to obtain an in-depth understanding of whatever symptom seems to be calling for medication. He is unlikely to learn more than what is necessary to confirm what he already assumed, that indeed this is the sort of symptom that requires medication.

Psychiatrists today are far less tolerant of the unknown (and our fear of it) than we were when we had fewer pills in our therapeutic “arsenal.” We now cling to the security of the prescription pad, the white coat, and the Medical Model. We take the formal history and mental status, assign the diagnosis with its proper five-digit code number, prescribe the proper pill, describe its major side effects, and monitor blood levels, all based on the latest scientific data. This ritualized activity serves, along with its official purposes, to insulate us from our own anxiety by emphasizing the distance and the difference between us and our chemically imbalanced patients.

It is worth comparing this dehumanizing I–It attitude with the humanizing I–Thou attitude taught by Bettelheim:
Just as the patients have to learn that they possess all the necessary resources within themselves to get well, staff members must become able to comprehend that within them resides all the knowledge necessary to understand the patient.... [T]wo main principles ... were the essence of many staff discussions. The first is that “The patient is always right”—that is, nonsensical as his behavior may seem to us, it makes excellent sense to him—and the second, that an understanding of what this meaning to him may be can best be approached or directly derived from our own inner experiences. What we have to do is ask ourselves the question: What conditions would induce me to engage in exactly the type of behavior which seems irrational or otherwise deviate in the patient?3

Psychiatry and the Philosophy of Life

Bettelheim’s approach is the very heart of the Psychotherapeutic Model. It understands symptoms as meaningful expressions of the self, in marked contrast to the Medical Model, which treats symptoms as dangerous and alien to the persons who have them. The difference between these two attitudes toward symptoms reflects a deeper difference in attitudes toward people. The Psychotherapeutic Model is grounded in the similarity—the common humanity—between physician and patient. The Medical Model is grounded in scientific research, in which the doctor treats the patient as an object of detached observation.

How did psychiatry end up with two such radically different approaches to treating people and their illnesses? Because the psychiatrists who follow either approach start from radically different philosophical beliefs and values. The end is in the beginning, and what ends in the psychiatrist’s choice of treatment begins in his choice of philosophy. I don’t mean the kind of philosophy located in unreadable books written by dead intellectuals. I mean what philosopher Jacob Needleman calls “real philosophy”: a living organization of experience, a set of implicit assumptions, deep, often hidden, in the grain of our personhood, that is the basis both for our way of life and for our attitude about the meaning and purpose of life.

Not that psychiatrists are generally aware of how their treatment decisions reflect their philosophy of life. In fact, most psychiatrists will tell you they simply use whatever treatment “works best.” They like to think of their treatment approach as strictly pragmatic, and would rather leave philosophy out of it. But philosophy is not like an American Express card. It is impossible to leave home without it. There is philosophy implicit in everything we do, though it remains, for the most part, outside of our awareness. What looks on the surface like a pragmatic choice of the treatment that works best is, at a deeper level, a choice of philosophy. What we think works best depends on what we are trying to accomplish, which in turn depends on what we think is worth accomplishing, which depends ultimately on our all too often unconscious philosophy of life.

Philosophy and the Art of Bicycle Riding

I learned this lesson the hard way one Sunday afternoon about fifteen years ago, when I tried to pick the method that would work best for teaching my son how to ride a two-wheeler. It was a beautiful crisp fall day, and the last thing on my mind was philosophy. Standing there behind Gregory, my hands on the back of his bicycle seat, I could almost hear the theme song from the old television show Father Knows Best playing in the background.

“Okay, start pedaling and don’t look back,” I said optimistically. Famous last words. The bike kept tilting and Gregory kept looking back, complaining loudly that I wasn’t holding it steady enough. I snapped back at him that I couldn’t keep the bike straight if he wouldn’t look ahead and pedal harder.
“But what if you let go and I fall?” he pleaded.
“I won’t let go until I know you won’t fall.”
“But how will you be able to tell?”
“Just turn around and pedal!”

Before long, I had a backache, Gregory had a headache, and we decided to pack it in and try again the next day. We slouched back to the house, Gregory grumbling reproachfully that he would never be able to ride without training wheels and I cursing Robert Young (the dad in the TV show) under my breath.

Next evening when I returned home from work I was surprised to see Gregory happily pedaling his two-wheeler up and down the driveway. “Look, Dad, no training wheels!” He explained that Evan, an older boy who lived next door, had taught him how to ride the bike.

“How did he do that?” I protested, aware that I ought to be sounding more pleased.
“Simple! He told me that to ride a two-wheeler, the first thing you have to do is fall down a lot of times.”

I knew immediately that there was something important in this little episode, but it was not until the third or fourth time I told the story that it dawned on me it was really a story about unconscious philosophy. Those who are unaware that they have a philosophy are condemned to act it out on their children. Gregory and I had come to grief over an unexamined and misguided philosophical assumption. When I stopped to ask myself why I had failed and Evan had succeeded, I recognized that my teaching had been guided by my anxiety—and by Gregory’s—that he would fall down. Our goal (implicit in this shared anxiety) had been not simply that he learn how to ride a two-wheeler, but that he do so without ever falling down. The end is in the beginning. We had failed because we started from the assumption that falling down would be bad. Evan had succeeded because his philosophy involved the opposite assumption, that falling down would be good.

Perhaps most people would not ordinarily consider the assumptions “Falling down is bad” and “Falling down is good” to be philosophy, but in fact they are the central tenets of the two major philosophies of life and—not coincidentally—also the basic premises of the two major models of psychiatry.

The Swimming Pool

The first philosophy, according to which falling down is bad, I call the swimming-pool philosophy. Paul Stookey, of the folk group Peter, Paul and Mary, captured the essence of it when he said, “You know what swimming is to me? It’s staying alive when you’re in the water.” But what really brought the meaning of this philosophy home to me was a comment made by a classmate and close friend of mine one gray December afternoon many years ago, as we stood together at the edge of our college swimming pool, contemplating the twenty-five-yard lap lanes that stretched out before us.

“You know,” Ron said, “life is a lot like swimming laps. You put your head down, you dive in, and you go back and forth and back and forth and back and forth. Every once in a while you bump into someone, and you say ‘Excuse me.’ Then you put your head down again and go back and forth and back and forth and back and forth.”

According to the swimming-pool philosophy, the purpose of life is to stay afloat, to function smoothly, maintaining the equilibrium of the status quo. Bumping into other swimmers is to be avoided as much as possible. In other words, falling down is bad.

The Quest

The second philosophy, according to which falling down is good, I call the quest philosophy. Also known as the perennial philosophy, it is symbolized by the Arthurian myth of the quest for the grail.4 The quest is an adventurous seeking of a higher or better state. According to the quest philosophy, the purpose of life is to pursue this higher state—enlightenment, wisdom, self-actualization—by progressing through a series of difficult, dangerous trials. The successful mastery of each trial brings the seeker to the next level in his or her gradual ascent toward the ultimate goal, which, though it may be unattainable, is inherently worth pursuing. But the process of undergoing a trial inevitably involves some error. You can’t find your way to a higher level without learning from your missteps. Falling down is therefore good.

The Swimming Pool and the Quest in Psychiatry

From a child falling down while learning to ride a bicycle to a patient having a “breakdown” while learning to navigate the life cycle is but a short metaphorical step. Just as different attitudes toward falling down lead to different methods of teaching a child to ride a bike, different attitudes toward psychiatric symptoms lead to different models of treating a patient with mental illness. The Medical Model exemplifies the swimming-pool philosophy that falling down (disequilibrium) is bad. It views psychiatric symptoms as “chemical imbalances”—disruptions of neurophysiological equilibrium—that should be “fixed” quickly with medication lest they cause further disruptions of psychosocial “stability” and “adjustment” (i.e., bumping into people). In other words, the Medical Model considers symptoms as a kind of falling down that is bad: unfortunate and unnecessary spills from the cycle of life.

The Psychotherapeutic Model, in contrast, exemplifies the quest philosophy’s premise that falling down is good. It views psychiatric symptoms as manifestations of inner conflict—unconscious emotions trying to become conscious against the internal forces of resistance—presenting opportunities for growth that should be facilitated in a psychotherapeutic process that respects the need to bump into other people (and thereby become more conscious) through transference. In other words, the Psychotherapeutic Model views symptoms as a kind of falling down that is good—necessary trials in our quest for self-actualization.

Falling Down Is a Way of Growing Up

Just as a father who believes that falling down is bad will try too hard to control his son’s equilibrium on a bicycle, and thereby interfere with the boy’s learning, so a psychiatrist who believes that symptoms are bad will try too hard to control his patient’s chemical and emotional balance, and thereby interfere with the patient’s growth. As Alfred Flarsheim put it, “In order to operate without trying to control a patient we must have confidence in his potential for spontaneous maturation and development.” Medical Model psychiatrists try to take control with medication because they do not have this confidence. They are aiming not to facilitate maturation and development, but simply to return the patient to his previous level of functioning. They view the patient as someone having trouble swimming laps, not as someone facing an important trial in his quest. You bump into somebody, you say excuse me, then you put your head down again and get back into the swim. Given this philosophy, it makes sense to try to remove the symptom as quickly as possible because it did derail the patient from his previous level of functioning and it interferes with his regaining that level again. But the end is in the beginning. If we start with a different philosophy, then we will end up with different treatment methods, and different results.

Psychotherapeutic Model psychiatrists start from the assumption that symptoms are the very embodiment of the patient’s potential for spontaneous maturation and development. Their goal is to facilitate the maturational process that is already inherent in the symptom. They view disequilibrium, whether manifest in obvious symptoms or not, as a natural and inevitable result of the inner conflict that is intrinsic to human nature. Developing a symptom is a necessary step toward integrating that conflict, a way of focusing the disequilibrium and calling our attention to it, and thereby initiating or furthering a psychotherapeutic process. Seen from this point of view, symptoms are the place where growth happens, human nature’s way of waking us up and stopping the world so that we can get out of the pool and climb into the quest. Disequilibrium, falling down, and bumping into people are good. Indeed, from this psychotherapeutic perspective, they are not merely good but essential to a fully human existence.

To Be Human, the First Thing You Have to Do Is Fall Down

In describing this important difference between the swimming pool and the quest in psychiatry, I am writing in the belief that if psychiatrists and patients really understood that they were making swimming-pool choices and neglecting the very real alternative of the quest, many of them would want to reconsider their assumptions. But I am also writing as a person who believes that most of us, most of the time, live our lives in the swimming pool without quite realizing it. I consider the choice between the swimming pool and the quest in psychiatry therefore to be a special case of a much larger choice that each one of us must make about how consciously we want to live our lives.

Here again, it is instructive to think about the story of Genesis, which tells of how consciousness was born in the very first falling down. From the perspective of a swimming-pool philosophy, Adam and Eve’s existence before the Fall was the ultimate ideal, an endless floating in the unconscious equilibrium of eternity. There was no disruption, no change, no desire, no choices to make, and no death, because there was no time. The impulse toward a higher consciousness—the desire for knowledge of good and evil—was disruptive to this blissful condition and therefore considered bad.

From the perspective of a quest philosophy, on the other hand, life before the Fall, however blissful, was not a fully human life. Adam and Eve were in a state of limited, infant consciousness, without the freedom to choose, without responsibility for their actions, and without self-awareness. Their forbidden desire for the knowledge of good and evil then transformed their existence into a quest. It propelled them out of eternity into a world of time, marked by a new adult awareness of the restless, ever-changing dialectic of inner conflict: the uneasy conjunction between their joyful experiences of love and creativity and their exciting but disruptive experiences of lustful desire and self-aggrandizing ambition.

If we think of this falling down and this quest as something Adam and Eve could have avoided by making a different choice, we have misunderstood the point of the myth. The Fall is not itself a choice, but rather the beginning of the possibility of choice—what Kierkegaard called “the possibility of possibility.” Adam is Everyman. Eating the forbidden fruit is growing up and becoming conscious. We all begin to do it sometime during our “terrible twos,” when by saying “No!” we reject the infant paradise of undifferentiated communion with mother. This “original sin,” our first act of defiance, is also our first act of self-definition and the beginning of our self-awareness as separate individuals. But it is only the beginning, because our first and enduring reaction to this “possibility” of self-awareness is to try to cover it up and then hide from it, as Adam and Eve tried to cover up and hide from God. To grow into full human consciousness requires not only the defiant awareness that we are willfully alienated from others but also the shameful awareness, and ultimately an acceptance of the fact, that we are naked—alienated from ourselves in a state of inner conflict. To achieve this level of self-awareness we need the repeated trials of the quest, falling down again and again until we overcome our need to hide from ourselves and learn to recognize, and so become, who we really are.

Symptoms and Self-Actualization

Under the Medical Model, then, symptoms are seen as a kind of fall from grace, unwelcome, destructive intrusions on the smooth course of day-to-day life. Under the Psychotherapeutic Model, symptoms are seen as necessary shocks that lead to recognition, important trials in a painful but rewarding quest for self-actualization that begins with our first “no” and continues through the entire course of human development. In this view, symptoms are manifestations of inner conflict: disguised expressions of forbidden unconscious emotions, uneasy compromises between our conflicting needs to hide from ourselves and to become ourselves. In that sense they represent an attempt, only partially successful, to integrate the conflict between the swimming pool and the quest—between our need to maintain stability by keeping ourselves unconscious, as if we had never desired the forbidden fruit, and our need to reap the rewards and punishments of Adam’s fall, as we grow into a more fully human consciousness.

These very different attitudes toward symptoms imply correspondingly different ideals of mental health. The Medical Model’s attitude that symptoms and disturbing emotions are bad implies an ideal of mental health as a “steady state”: the capacity to be stable, to maintain chemical (and emotional) balance and social adjustment. The Psychotherapeutic Model’s attitude that symptoms and disturbing emotions are good implies an ideal of mental health as an evolving process: a capacity for growth, a lifelong progression of emotional and moral development, expanding consciousness through enriching new experiences of emotions that were previously forbidden (repressed).

How Did Psychiatry End Up in This Muddle? It’s Freud’s Fault!

This deep split in psychiatric attitudes toward illness and health has very real and potentially dangerous practical consequences—like the seemingly unbridgeable gulf between the Technocrat’s and the Cowboy’s approaches to Bill. It reflects psychiatry’s ongoing failure to resolve its own inner conflict, to integrate the opposing values of the swimming pool and the quest. It also illustrates quite vividly how those who do not remember the past are condemned to repeat it. For, you see, the rift between the Medical Model and the Psychotherapeutic Model is by no means a new one. Surprisingly enough, both models originated more than a century ago in the theories of one man, Sigmund Freud.

Freud’s clinical understanding of mental illness was always that of the Psychotherapeutic Model, informed by a quest philosophy and framed in terms of inner conflict, but there was always a strong Medical Model current in his thinking as well—a need to explain his clinical observations in biological terms. In fact, his primary theoretical model during the first half of his career (1890–1915)—the so-called libido theory—was actually the original psychiatric theory of chemical imbalance. Like the Medical Model today, it pictured the soul or mind (Seele) as equivalent to the brain, and tried to explain anxiety and the symptoms of mental illness in swimming-pool terms as a disruption of neurochemical equilibrium.

Freud’s Swimming-Pool Philosophy:
The Libido Theory and the Constancy Principle

Freud defined libido as a specific form of neurological energy belonging to the sexual drive. He hypothesized that increasing the amount or “charge” of libido in the neurons of the brain produced pain, whereas decreasing—“discharging”—it produced pleasure. Discharge could be interfered with in two ways: by inner conflict or by simple sexual frustration. In either case, when the quantity of undischarged libido reached a certain critical level—producing a chemical imbalance—it would either “spill over” in a toxic physiological process that was experienced as anxiety or be diverted into the formation of a neurotic symptom. In other words, anxiety and/or symptoms were by-products of a libidinal imbalance—an excess of libido in the neurons that could not be discharged normally.

Freud’s neurophysiology was wrong, of course, because he developed his theory in 1897, long before anything was known about how neurons actu- ally work. We now have a more refined picture of chemical imbalance as a disproportion between “transmitter” molecules (serotonin, for instance) and “receptor” molecules in the synapses where nerve impulses are transmitted from one cell to another. But this great advance in scientific knowledge has told us nothing at all about how a chemical imbalance in the brain could possibly produce a disturbing experience in the mind or soul. In fact, the idea that chemical imbalances cause mental illness is no more scientific today than it was in 1897.

In that sense, Freud’s theory had a distinct advantage over current neurological theories of the mind, in that he was well aware of his philosophical assumptions and never mistook them for scientific facts. He referred to the libido theory as a metapsychology precisely in order to indicate that it was a philosophy rather than a science. He explicitly defined its swimming-pool assumptions in the form of a hypothesis he called the constancy principle. According to the constancy principle, all psychological processes are designed (by evolution) to maintain a low-level steady state of energy (libido) in the neurons. The point of this evolutionary design—and implicitly the purpose of life and the goal of mental health—was to avoid pain and seek pleasure by maintaining a comfortable low-energy state of libidinal equilibrium. This meant avoiding external stimulation (which produced an unpleasurable increase in libido) and quickly discharging any internal excitation that arose directly from the sexual drive. In other words, “Keep swimming, but only hard enough to stay afloat. Try to stay in your lane and not bump into other swimmers, but when the inevitable collision does occur, make it a quickie and get back into the swim. Falling down (libidinal imbalance) is bad, so keep pedaling (discharging libido) and don’t look back.”

Freud’s Quest Philosophy: The Principle of Eros

The problem with the constancy principle—or pleasure principle, as Freud soon began to call it—was that the purpose of life it defined boiled down to the pursuit of the most immediate gratification. Freud’s mind could never come to rest in the amoral hedonism of such a philosophy. He began to ask himself, why, if the soul is really operating solely on the premise that falling down (unpleasure) is bad, did his patients have such an apparently perverse need to trip themselves up. Where did they get their relentless compulsion to punish themselves and otherwise subvert their own hedonistic purposes, to unnecessarily deny themselves pleasure and put themselves into painful high-energy states of inner tension? Then, too, why weren’t all states of inner tension experienced as painful? Why were they so often experienced as pleasurably stimulating and exciting? Why did people so regularly prefer the complex, high-energy state of love, for example, to the simple discharges of lust? Indeed, if it were not for the increased excitement involved, why would a person ever want to dive into a swimming pool or take the training wheels off his bicycle in the first place?

Ultimately, just as Gregory and I discovered that the premise “Falling down is bad” was a misleading guide for learning to ride a bike, so Freud eventually realized that his libido theory was an inadequate foundation for a science of human nature. In order to explain all those motivations that violated the constancy principle, Freud had to introduce a second principle of motivation, the principle of Eros, which he borrowed from Plato’s Symposium. Freud described Eros as a kind of life force, essentially the opposite of the constancy principle: stimulus-seeking rather than stimulus-avoiding, tending toward higher rather than lower levels of energy and complexity. Where the aim of the constancy principle was to reduce libidinal tension through discharge, the aim of Eros was to resolve tension through integration. Where the constancy principle was a principle of stability, Eros was a principle of growth.

Close but No Cigar

As you might imagine, the path that took Freud’s thinking from the constancy principle to Eros was more convoluted than the brief outline I have just given would suggest. He found it difficult to give up the materialistic assumptions of the constancy principle and to embrace the spiritual implications of Eros. What he needed, and what psychiatry still needs today, was an integrated theory that includes both sides of human nature: the Flesh and the Spirit, the physiological needs of the swimming pool and the soul’s need for the quest. As I will discuss in Chapters 14 and 15, Freud spent his entire career trying to develop such a theory, and in the end came very close to achieving it. But the almost-integrated theory he ended up with gradually fell apart after his death, as different groups of his followers each began to emphasize a different aspect of his theory and almost everyone missed the overall point of what he had been working toward.

Erik Erikson and the Eight Stages of Life

Probably the closest anyone came to developing the kind of integrated theory to which Freud aspired was psychoanalyst Erik Erikson, whose model of human development is still the clearest, most comprehensive and accessible statement we have of the Psychotherapeutic Model’s overall quest philosophy.5 The one limitation of Erikson’s theory is that it doesn’t explicitly address the mind–body question—how the neurological and the spiritual are integrated in human nature. The great strength of the theory is that it does explain how our swimming-pool need for emotional equilibrium and social adjustment is integrated within our larger need for self-actualization through the struggles of the quest.

Building on Freud’s mature theory of inner conflict (between the It and the I that stands above), Erikson pictured life as a progressive struggle to in- tegrate the conflicting needs of the swimming pool and the quest—the need for stability versus the need for growth, the need to remain unconscious versus the need for consciousness. These needs remain with us throughout the course of development, says Erikson, but the quality of our integration changes as we grow toward self-actualization. We may never fully become ourselves, but we do tend to get better at it as we progress through the eight stages of the life cycle. Here’s how it happens: As we move from infancy to old age, we face a series of “stage-specific” conflicts between what we aspire to—the goals of the quest—and what pulls us back—the swimming-pool fear of falling down or bumping into people. During the first year of life, the basic conflict is trust versus mistrust. During the toilet-training period it is autonomy versus shame and doubt. Then follow initiative versus guilt dur- ing the so-called Oedipal period (ages four through seven); industry versus inferiority during the grade-school years; identity versus diffusion during adolescence; intimacy versus isolation in young adulthood; generativity versus stagnation in the middle years of adulthood; and, finally, integrity versus despair in the years of maturity and old age.

All these Eriksonian conflicts revolve around the common theme of desire versus inhibition—an ambivalence based on our (incipient) shame- ful awareness that good and evil are inherent in our own desire. Each of Erikson’s “goods” can become evil if the desire for it is carried too far. Each of his “evils” can in turn serve the good by protecting us from the danger of carrying our desire too far. But the danger is different at every stage. It changes as we grow, as does the level of consciousness required for mastering the danger. That is why, as Erikson observed, people tend to have different sorts of breakdowns—and different sorts of healing experiences—at different stages, depending on which of the eight stage-specific conflicts they are struggling with at the time and on how successfully they have mastered the previous ones. Even though a person might have superficially similar symptoms as a teenager and again as a forty-five-year-old, for instance, the symptoms will likely have a very different meaning in terms of the person’s quest. The symptom-producing conflict in each case will be different, reflecting the unique issues and emotions that belong to that particular stage of the person’s life.

I have not yet had the opportunity in my career to see the same patient both as a teenager and as a forty-five-year-old, but I have seen the same symptom, with different Eriksonian meaning, in a nineteen-year-old daughter and a few years later in her forty-five-year-old father. My work with these two patients illustrates how symptoms serve to crystallize the conflicts of particular developmental stages, and how the Psychotherapeutic Model understands and treats these symptom-producing conflicts as trials in the patient’s quest.
Example 1: Identity Crisis
Anne was the young woman I described briefly in Chapter 2, who became suicidally depressed after being raped while in her first year of college. As you may recall, Anne did not tell me about the rape during the first two months of her hospitalization. Instead, she tried to keep up an image—what Jung would have called her persona, and psychoanalyst D. W. Winnicott would have called her False Self—essentially the image of herself as her parents would have wanted to see her. This in itself was not unusual. Each one of us has such a False Self, a mask we wear in our dealings with other people (and too often with ourselves) that reflects a tendency to comply with the needs and expectations of others—to live according to someone else’s idea of how we should live, the way a child lives according to his parents’ rules and needs. This orientation is sometimes called extrinsic motivation. To the extent that we are extrinsically motivated—as we all are to some degree—we are dominated by a swimming-pool need to hide in a superficial Eden of conformity, taking care not to bump into people, and not to make waves. But Anne’s need to hide in such a False Self conformity was extreme, to the point that she felt herself to be unreal, as if there was nothing to her except her False Self image. She felt this way especially after the rape. Her parents would never be able to accept her now, she believed, and she doubted that I would be able to accept her, either. Although she tried valiantly to present herself as she always had (and as she believed her parents would have wanted), she could not escape the devastating feeling that the rape had destroyed her image, and her “self” along with it, forever.

Anne’s depression thus represented a failure or loss of identity, a feeling that she was nothing—and had never been anything—but an image, a mask now shattered beyond any possibility of repair. But that was only the swimming-pool meaning of her depression, and the identity she had lost was only her “conformist” identity. In terms of the quest, her depression was not only a loss of that old identity (a falling down that was bad) but also an attempt to find a new identity (a falling down that was good). After all, the inner person who actually felt Anne’s depression, who could be aware of herself as nothing but a false image and could feel depressed about that, must herself be more than that false image. No mere image can be aware of itself, or notice that it is missing something. In that sense, Anne’s depression was a new and genuine experience of her True Self—an inner self, born out of the ashes of her old image, that could discern the difference between image and substance. This True Self was intrinsically rather than extrinsically motivated, needing to live for herself rather than for her parents. She still felt the devastating pain of her depression—the mixture of anxiety, shame, and sadness over losing her familiar self-image—but in that pain she could recognize the sound of her innermost being crying out for something more real, more genuinely hers, to care about and live for.

Anne became able to let herself feel and talk about both meanings of her depression as she began to experience the hospital, and her relationship with me, as a safe haven where she was free to feel whatever she felt and be whoever she was. This happened gradually once I told her (probably a week or two into her hospitalization) that I kept getting the feeling in our sessions that she was far away—emotionally disconnected—and seemed to be going through the motions of psychotherapy mostly to please me, rather than talking about anything that felt really important to her.

In Eriksonian terms, Anne’s depression was a symptom of a classic adolescent “identity crisis.” It embodied the conflict between her swimming-pool need to lose herself in living to please her parents and her quest need to find herself by rebelling against them. In terms of the first need, Anne’s depression meant that her life was no longer worth living, because her parents could never again be pleased with her. In terms of the second need, it meant that she would have to change, because her life was no longer worth living as she had been living it. The first meaning belonged to her unconscious swimming-pool philosophy, the second to her unconscious quest philosophy. In deciding to tell me about the rape, then, she was not only taking a great personal risk but also making an important philosophical choice: to take her pain more seriously than her image, to think of her depression not as a sign of her failure to be the person she should have been, but as a sign that she needed to become who she really was.

Depression As Rebellion

Erikson’s concept of identity crisis has become so much a part of our cultural idiom that we now take it for granted that adolescents will need to rebel against their parents in order to find themselves. That such a rebellion can take the form of a clinical depression is less obvious, and seldom recognized when it happens, even by psychiatrists. What could depression have to do with rebellion, after all? If anything, it seems quite the opposite of rebellion. But to a psychoanalyst, that is precisely the point: depression seems the opposite of rebellion because it is a rebellion turned inward, a symptom of inner conflict between the impulse to rebel and the need to conform. We are nowadays so used to thinking of depression as a biological illness without psychological meaning (or, if we do think about it psychologically, as a problem of low self-esteem), that we have forgotten this older, wiser view of depression as anger turned against the self. Whether or not it is a disorder in the brain, in the soul depression is always an expression of unconscious anger toward someone else, repressed and turned inward against the self, creating a state of inner conflict that is experienced as self-hatred (which certainly does lower self-esteem). But in the process the depression provides an indirect outlet for that repressed anger, as a disguised, unconscious rebellion—a refusal to participate (disguised as an inability to participate) in the life that makes us so angry.

People who are living with a depressed person, or trying to treat one, can often feel this disguised rebellion in the form of a subtle nonverbal reproach, an implicit complaint leveled against anyone who wants to help the patient “get over” the depression. I got a distinct impression of such a nonverbal message from Anne during the early weeks of her hospitalization. It was an emotional undercurrent that I could feel as part of my sense that she was far away and going through the motions. Trying to engage with this faraway person each day in our psychotherapy sessions, I would get the sense that, by staying depressed and distant, she was fighting me off. It was as if she felt my efforts to help her were intrusive and her depression was a way of saying, “I won’t go along with this. Don’t even try to get into my head. I won’t let you therapize me!”

The Rage to Cure

I realized that I could have been misreading Anne. My sense of her depression as a rebellion could have been a projection of my own subtle therapeutic frustration—my unconscious “rebellion” against her depression. Whenever a psychotherapist or psychiatrist has too great a need to cure his patients—in order to prove his own worth, for instance, rather than out of concern for what the patient needs—he will tend to become easily frustrated and intolerant of patients who don’t get better quickly. Freud called this tendency furor sanandi—“the rage to cure.” It is both an essential ingredient and a universal problem in the motivation of all who are drawn to the helping professions, and one of the primary reasons why all psychotherapists and psychiatrists need psychotherapy for themselves. Until they learn to recognize and come to terms with this rage to cure, therapists generally have trouble distinguishing their own needs from their patients’ needs. In this case, however, I was aware of the danger and was fairly confident that I was reading Anne correctly—that it was her repressed rebelliousness I sensed in her depression and not a projection of my own frustrated need to “therapize” her. Any doubts I had on this score were quickly settled once I began to see Anne with her parents in weekly family therapy sessions.

Unconscious Adolescent Rebellion

In working with adolescent patients in the hospital, I have found that meeting regularly with the family—the patient together with the parents and sometimes siblings—is essential. It gives me a firsthand experience of the emotional atmosphere in which my patient has been living and allows me to identify and intervene in dysfunctional patterns of interaction that may be contributing to my patient’s illness. In my meetings with Anne and her parents, this definitely proved to be the case. What particularly struck me—and what convinced me that Anne’s depression was indeed an unconscious adolescent rebellion—was the great difficulty her parents had accepting that their daughter was sick. Simply put, Anne’s father and mother did not believe in mental illness, especially not for someone in their own family. As they saw it, being depressed was simply an excuse for being weak. They had both had very difficult lives themselves, they told me, and had always managed to cope. They prided themselves on being able to suppress or ignore all painful emotions, and to tough it out in the face of any problem life could throw at them. But their daughter’s unyielding depression and her inability to cope with it were now posing a formidable challenge to their whole way of life. When Anne was first hospitalized, their urgent mission was to get her back on her feet and back to college as quickly as possible. When this didn’t happen, they became frustrated, embarrassed, and increasingly angry—victims of a parental version of furor sanandi. In the family meetings they began to blame Anne for not pulling herself out of her depression, and became openly skeptical of my “talk therapy,” which to them seemed nothing more than another excuse for her to wallow in her problems. But when Anne finally told them that she had been raped (shortly after she told me), they were jolted out of this disapproving attitude and suddenly felt horrible—anguished for their daughter and furious at her attacker. They could now understand that she had been traumatized and were able, for a while at least, to stop blaming her and show their love by supporting her decision to go to the police and press charges against the man who had raped her.

Initially, it was a great relief to Anne that her parents did not blame her for the rape as she had feared they would. She gradually came to realize, though, that their unexpected support did not really represent a change of heart for them. As loving as it was, their support remained predicated on their need for Anne to be strong—a fighter, not a quitter—and on their intolerance of what they perceived as weakness. They seemed surprised and dismayed when her decision to take action against the rapist was not enough by itself to relieve her depression. I explained to them that the rape was not Anne’s only problem; that the most important source of her depression was a deeper and older unhappiness within herself. I warned them that she might need several more months of intensive treatment in the hospital and that if she didn’t deal with this unhappiness now, she would remain vulnerable to repeated depressions and possibly another suicide attempt in the future. I told them, quite simply, that her life was at stake.

Anne’s parents grudgingly accepted that she needed to stay longer in the hospital—I hadn’t left them much room to do anything else—but it went against the grain of everything they believed. Her father soon began to preach again to Anne about the necessity of being tough. “I know you feel like you can’t handle going back to college after what you’ve been through,” he would say, “but you have to try. Giving up is absolutely the worst thing you could do. Sure it’s hard to be depressed, but that’s the way life is, and the only way to deal with it is to tough it out. Hell, your mother and I are depressed every day of our lives. Do you think it’s easy for me to get up and go to work every day? Three out of four days I wake up in the morning and think I’ll never be able to put on a suit again, or look at another tax form in my life. But then I wash my face, have a cup of coffee, ask your mother to give me a good kick in the pants, and I’m out the door and on my way through another day. Do I like it? No. Is it necessary? Absolutely.”

Conscious Adolescent Rebellion

For weeks, Anne would listen to these exhortations and feel horrible about herself, unable to respond to her father. “He’s being so polite in our meetings with you,” she would tell me privately, “but I know what he’s really thinking—that I’m a worthless wimp. He has no clue that being honest about what I really feel—the way I’m learning to do with you—takes more strength than anything he’s ever done in his life! Oh God, I know that’s a terrible thing to say, and I have no right to say it, but it really is how I feel sometimes.”

Being able to use her sessions with me in this way, to articulate the differences between her father’s opinions and feelings and her own, without fear of disapproval from me, was immensely helpful to Anne. It eventually led to her being able to risk her father’s disapproval by objecting out loud to the way he was lecturing her. She explained to him that the kind of depression she was struggling with was not something she could overcome with a cup of coffee and a kick in the pants. Nor was it simply a reaction to the rape. “You say I’m not being tough, but to me, what I’m doing is a lot harder than what you want me to do. I’m trying to face the fact that something has felt wrong in my life for a long time. It just doesn’t make sense to try to force myself back into a life that wasn’t working to begin with. Why do you think I became bulimic two years ago? It was because I couldn’t stand my life!”

In thus confronting her father, Anne was able for the first time to feel the rebelliousness that had previously been unconscious in her depression. This was a tremendous sign of progress, but it also made Anne feel so anxious and guilty that she had a recurrence of her old symptoms of bulimia. Such a regression into an old pattern of illness is not an uncommon reaction to the danger of too much progress and is all part of an overall growth process—two steps forward, one step backward. In fact, it occurred to me that Anne’s “eating disorder” had itself been an early expression of the same impulse for growth that was now much more obviously embodied in her identity crisis. The alternation of binge eating and vomiting was a kind of bodily metaphor for an ambivalence that she was not yet ready to be aware of at a psychological level. The binge eating symbolically reflected her need to remain dependent by taking in all her parents’ goals and values as her own. The vomiting reflected the opposite need, to reject—spit out—her parents’ image and expectations of her and so begin the difficult task of becoming herself.

This is the sort of inner struggle that every adolescent must go through in order to grow up. The struggle doesn’t always produce psychiatric symptoms as it did in Anne, but when symptoms do occur, it is important to remember that they are part of the solution rather than part of the problem. In Anne’s case, her bulimia had been the first thing that forced her to notice, at least briefly, how unhappy she really was. She had tried to ignore this warning, however, and to keep it hidden from her parents. She had even managed to suppress her bulimic behavior when her parents did discover it. But when the rape then shattered her already tenuous balance, instead of falling back into her bulimia she fell forward into a new symptom—depression—that actually represented an advance in her development. In becoming overtly depressed, Anne began to feel her unhappiness in a way that she could no longer ignore. In becoming incapacitated she forced her parents to pay attention, too. Thus, the shift from bulimia to depression brought the conflicts, both within herself and between herself and her parents, more clearly into consciousness. This was a sign of growth, a shift from acting out her conflicts toward experiencing them emotionally and so being able to talk about them in a way that her parents could begin to understand.

As you would expect, the eventual result for Anne was by no means a complete rejection of her parents’ values, but rather an integration of what she had genuinely learned from them with what came more uniquely from her. This integration did not happen easily. In fact, once Anne began to disagree openly with her father in our weekly family meetings, not only did her bulimic symptoms return but there followed several unsettling months of sometimes bitter arguments, during which it seemed that neither of Anne’s parents might ever be able to appreciate what she was trying to tell them. But as she gradually became more effective at articulating and arguing for her own goals and values (around issues like how she dressed, who her friends were, when she would go back to college, whether she would live at home or on campus, what she majored in), her parents could not help but respect her for the strength of her convictions. Nor could they fail to notice that in standing up for herself with them, she was also gradually coming out of her depression. Although they continued to view her need to remain in the hospital as a weakness, they gradually discovered that they could amicably agree to disagree about this, with a sense of mutual respect and acceptance. Anne was then able to leave the hospital (after eight months altogether) and get on with her life. In fact, she blossomed. I did continue to work with her for another year of outpatient psychotherapy, but her growth very quickly became a self-perpetuating process in which I was no longer needed.

Symptoms Are Part of the Solution, Not Part of the Problem

It was an awe-inspiring privilege to be able to witness Anne’s healing and growth from such an intimate vantage point. I would like to think that I was important for a while in facilitating her inner process, but I suspect that the most important thing I did for her was simply to allow her human nature to take its own course, along a path that I knew had to pass through her depression. In thus recognizing the growth potential contained within her symptom, I was following another important precept I had learned from Bruno Bettelheim: Respect the symptom. Bettelheim taught that symptoms are adaptive, creative achievements, the best solution a patient has so far been able to come up with to the otherwise unmanageable problems of his or her existence. However painful or disruptive a symptom might be, Bettelheim assumed that the patient would not have gone to the (unconscious) trouble of creating that symptom unless she needed it. To respect the symptom, then, meant to recognize that it was serving an important purpose, and it meant also to respect the person who had (unconsciously) created the symptom to serve just that purpose.

In this formulation, Bettelheim was himself following a much older teaching, part of the most ancient tradition of medicine. From Hippocrates to Freud, the wisest physicians have taught that symptoms are a manifestation not of a disease but of a healing process—what the ancients called the vis medicatrix naturae, or “healing power of nature.” In the Hippocratic view (about which I will have more to say in Chapter 13), disease was a disharmony of conflicting humors and elements, and symptoms were the organism’s attempt to establish a new harmony. Freud expressed the same idea by saying that symptoms are unconscious attempts to resolve inner conflict—the product of a “compromise” between the unconscious emotion trying to become conscious and the internal resistance that seeks to keep it out of awareness. In other words, as with Anne’s depression, all symptoms are attempts to harmonize the conflicting needs of the swimming pool and the quest—the False Self’s need for stability and conformity versus the True Self’s need for self-awareness and autonomy—in the overall service of growth.

Unfortunately, in the Age of the Brain, psychiatrists try to cure patients by removing their symptoms, not realizing that those symptoms may be acting unconsciously to heal the patient. Most psychiatrists today would start Anne immediately on an antidepressant and discharge her quickly from the hospital, hoping to get her back on her feet. In so doing they would be unwittingly supporting her False Self, reinforcing her parents’ message that depression is a sign of moral weakness, and discouraging her from taking seriously her own inner life. She might never mention the rape, and would probably never become aware of the nature of her differences with her parents. Not only would she miss the opportunity to learn and grow from her illness, but her parents would miss an opportunity to learn and grow from it too.
Example 2: Midlife Crisis
Three years after I had last seen Anne, I got a call from her father, Joe. Anne was doing wonderfully, he assured me, but he now had a problem of his own that he needed to see me about. He had been having an increasingly difficult time at work for the last few months, he said, and on that morning something had snapped. He woke up feeling worse than he had ever felt in his life. The effort it had taken just to force himself out the front door had left him shaking, drenched in a cold sweat. He could not bring himself to get into the car and drive to work. In fact, he felt as if he might never be able to return to work again. So he came to see me.

“It suddenly occurred to me that maybe my situation was not so different from Anne’s,” he told me. “I’ve never forgotten what you said back then about how sometimes having a breakdown is the best thing that can happen to you if it helps you recognize that your life is on the wrong course and that you need to change it. At the time—I guess you remember—I thought that was a pile of bull, but it certainly turned out to be true for Anne.... Well, I guess I’m not too proud to learn something from my daughter. You know she’s been on me for a while now about my drinking. She says if I’m drinking this much, then there must be something I’m not dealing with. Well, today I think I realized what that is. I hate my work. I’ve always hated it. All those lectures I used to give Anne about how important it is to keep functioning—I know I was really trying to fight my own temptation to give up. For years I’ve been trying to convince myself that things will get better, that the problem is this client or that client, or maybe my boss. But my clients have changed and my boss has changed and it’s never gotten any better. The fact is, I never really wanted to be an accountant in the first place. I don’t think I’m even very good at it. The problem is, I don’t feel as if I’ve ever been any good at anything, or that I ever will be.”

It turned out that Joe did have a significant clinical depression, severe enough that it was not only impossible for him to work but difficult to motivate himself to do anything else, either. Just the process of getting to my office seemed to exhaust him. He wanted to try psychotherapy because he had seen it work so well for Anne, but it soon became clear to both of us that his depression, unlike Anne’s, was interfering with his ability to concentrate, so that he couldn’t focus his attention enough to make good use of psychotherapy. We therefore agreed to try an antidepressant, and within a few weeks he felt more at ease, was able to eat and sleep better, think more clearly, and make better use of his psychotherapy. But the antidepressant did nothing to change how much he hated his job, or to alleviate the sense of dread he felt whenever he tried to imagine himself going back to work. He continued to feel generally demoralized and down on himself a good deal of the time, and it was unclear to what extent this was an ongoing depression, not fully relieved by medication, or to what extent it was a natural psychological reaction to being existentially lost. Either way, Joe was still too depressed to work, so he took a temporary disability leave from his job and resolved to spend the next several months using his psychotherapy sessions to figure out what he really wanted to do with the rest of his life.

Nel Mezzo del Cammin di Nostra Vita ...

As Dante first described it almost eight hundred years ago, midlife crisis is like a “dark forest,” encountered “halfway through our journey of life,” in which we lose our sense of direction—the “straight path” that up until then we have followed. Something goes wrong that overwhelms us for a time, bringing us to a halt and forcing us to reevaluate our position. For most people, the jolt comes from such common calamities as the loss of a job, a sudden disability, the death of a parent, an extramarital affair, marital discord or divorce, the biological clock running down, or an empty nest. Or it may come simply from the dawning awareness of aging and mortality. In any case, the combination of the stressful event and our reaction to it—usually an episode of depression or anxiety disorder—makes us feel that we can’t go on any longer as we have been. We are forced to stop and ask ourselves whether the life we have been living is the life we truly want to live.

And so it was that Joe, halfway through the journey of his life, was now forced to stop and consider the frightening question of whether he should change his career. Up until then he had always thought of his work simply as a job, a way of making a living, in which his all-important purpose was to achieve social and economic security and stability for his family. In this he had been following an unconscious swimming-pool philosophy, seeking primarily to maintain the equilibrium of a conformist, extrinsically motivated False Self. But Joe’s depression now forced him to consider the possibility that work could and perhaps should be an intrinsically motivated choice of his True Self. From the perspective of a quest philosophy, a career is not a job but a “vocation”—a life work to which we are called by our deepest needs, aspirations, and values, a way of actualizing our full human potential. In that sense, Joe’s depression and midlife crisis crystallized for him the universal conflict between the swimming pool and the quest. He felt torn between his need to maintain stability by returning to the security of the job he hated at the accounting firm and his need to grow by following his inner calling.

This picture was further complicated by the fact that Joe had recently been promoted to a supervisory position, and in fact it was just at that point that his work had begun to feel especially intolerable. “Maybe I’m just being a coward,” he worried. “Or maybe I just don’t have what it takes to be a supervisor. I hate being in a position where I’m expected to criticize other people’s performances and then have to deal with all their flak when they don’t like being criticized.” It occurred to me that Joe might be suffering from a classic “success neurosis,” that the sudden increase in power and prestige of his new position had provoked unmanageable anxiety from which he then had to retreat by becoming depressed. If so, then his inner calling might actually be in the direction of being a supervisor, where he would have to face the fear of his own power and become more of a leader, learning to deal more effectively with people; whereas his psychological stability might be best served by returning to his previous accounting job, with its more manageable, predictable problems. As it turned out, neither of these alternatives really matched the way Joe felt. When he thought about it, he realized that even the responsibility of being a regular accountant—trying to satisfy the Internal Revenue Service, the clients, and the firm—had always felt quite oppressive and demoralizing to him. It reminded him of the way he had felt as a child, trying to satisfy the unreasonable and inconsistent demands of his parents. Being expected then to take on additional responsibilities as a supervisor had simply pushed an already intolerable situation past the breaking point.

Joe realized further that most of the activities he had really enjoyed in his life involved using his hands—doing carpentry, plumbing, and painting around the house, for instance, and developing his own photographs. He liked working alone and he especially liked being his own boss—feeling responsible only to himself. He recalled that much earlier in his life he had dreamed of going into business for himself but had never permitted himself to take the dream seriously. He had been too afraid of failure. Unconsciously, he equated the idea of being his own boss—and becoming his own person—with repudiating the demands of his parents and so becoming a failure in their eyes. He had thus remained stuck in the mind-set of his adolescence, too afraid of displeasing his parents (for whom he then substituted the IRS, his clients, and the firm) to take the risk of doing what he needed to please himself. In that sense his depression was a kind of delayed but necessary adolescent rebellion, the beginning of a crucial developmental shift from the swimming pool to the quest, from the extrinsic motivation of living for his parents to the intrinsic motivation of living for himself.

In terms of Joe’s old swimming-pool philosophy, his depression had meant that his worst fear had come true—he was a failure. But he now discovered that, in terms of his newly emerging quest philosophy, this failure felt strangely liberating. Having hit bottom, with nowhere to go but up, Joe no longer found it so frightening to think about starting his own business. He didn’t need to make much money at this point in his life, because Anne was about to graduate college and begin working, and his wife was doing well at her own job. So after weeks of deliberation and several false starts, Joe decided to follow his vocation. He put ads in all the local papers and set up shop as a handyman/jack-of-all-trades, hoping eventually to be able to specialize in cabinetmaking. Once he began to get his first small jobs, he discovered that he loved the work every bit as much as he had thought he would and that his customers were eager to refer their friends to him. With that, the last traces of his depression faded and he was able to discontinue the antidepressant.

The Purpose of Symptoms Is Healing the Soul

My work with Anne and Joe was informed by my Psychotherapeutic Model belief that falling down is good—that the crises of mental illness are like the trials of a quest, important opportunities for personal and spiritual growth. The idea is that there is a psychotherapeutic process inherent in the life cycle, a series of stresses that force us to reexperience and reintegrate our inner conflicts, sometimes in a way that produces symptoms of mental illness, always in a way that challenges us to confront ourselves as we really are. It is only in suffering and struggling with these challenges that the soul can heal itself and grow. As we reintegrate our conflicts at successively deeper levels, we become stronger, wiser, and in fact better people—better in the sense that we are more conscious of our own emotions, and therefore less driven by automatic reflexive (unconscious) personality tendencies (aimed at maintaining our swimming-pool equilibrium) and freer to react to other people with the empathy of the Golden Rule. For Anne this meant (among other things) overcoming her automatic mistrustful tendency to put a distancing wall between herself and other people and discovering the satisfaction of talking to people about (and trusting them to understand) what she really felt. For Joe it meant overcoming his automatic tendency to lecture Anne about the proper way to live and discovering that he actually had something to learn from her about the quest.

From this point of view, both Anne’s and Joe’s depressions were necessary growing pains—crises of identity and of vocation that were integral to their struggles toward self-actualization. If, as I believe, all psychiatric symptoms are in the same way part of the healing/growing process, then the question of whether a psychiatrist should use medication or psychotherapy or both becomes secondary to the much more important question of what philosophy is guiding his overall approach to the patient. With Joe I had no hesitation in using an antidepressant. With Anne, following the same philosophy, I thought it was particularly important not to use one. However, if Anne were to have another episode of depression at some point in the future, I would be open to the possibility that her circumstances might be different and that an antidepressant might be helpful. In each case, I try to think about medication and the patient’s need for swimming-pool stability within the larger context of the quest—what the patient needs at this particular moment in his or her life to further his or her growth as a person.