I was asked to see "Bob," a 16-year-old prep school student, who a month and a half earlier had been placed on a selective serotonin reuptake inhibitor by his family physician. The medication had been somewhat effective. He had been dysphoric periodically, and he still could get down, sometimes feeling very isolated. But overall, he was now OK when "doing things" with his friends. When Bob was alone for a few hours, he tended to have morbid thoughts about death. He felt the authorities at school had totally overreacted when the nurse misinterpreted some remarks he had made about death two months before he saw me. They immediately sent him home, insisting that he be put on medication, and did not let him return until his therapist, whom he had been seeing for a year, agreed Bob had never been suicidal.
Meeting Bob for the first time, I was struck by a false jocularity, an awkward quality he shared with his father, whom I briefly met in the waiting room. Both spoke slightly too loud and did not really give me a chance to be infected with their cheerfulness. Their eye contact and body language did not agree with this cheerful demeanor. They were on automatic pilot. Both looked a little frightened, which is not unusual when meeting a stranger, especially a psychiatrist. It was the cheerfulness that seemed off.
Bob's therapist suggested that he seemed to almost enjoy the darker side of things, especially conversations about death. The therapist wanted him to think more positively and gave him homework assignments to accomplish this. His negativity had tended to isolate him at his prep school, where conversation tended to the lighter side.
When Bob settled down and told me his story, the happy face dissipated, and we began to connect. Bob had been raised by his grandparents. He had never met his biological father and did not know who he was, and his mother was a drug abuser who had given him to his grandparents for adoption at infancy. He had met his biological mother a few times but preferred "not to think about her." However, he did think about his (grand)parents a lot. His (grand)mother had died two years before in her mid-70s after several strokes. He thought this was a good thing because she had suffered greatly in her later years. His (grand)father was 79 years old and also was not healthy. In my waiting room, he labored to catch a breath. My assumption was that he had emphysema. He sat in the chair with a broad-based posture, like he might fall off. There were not a lot of good years left. Bob told me that many of his parents' friends had died in recent years, as well as two of his aunts. He might soon be an orphan, and this got him down. It should be noted that his visit to the school nurse occurred shortly before Thanksgiving. He had been thinking about the holidays without his (grand)mother.
The issue for us is whether positive thinking is relevant in this kind of situation. Would it help him, or would it create more problems than it would solve? True, finding a positive outlook is helpful in any set of circumstances. If he could relax and let life's bountiful pleasures and rewards reach him; if he could turn off bad death thoughts and replace them with optimistic ways of thinking about life's mysteries -- who knows? Hope is always crucial. If only he were religious, that could put a positive spin on everything. Meaning and purpose would be restored. However, he wasn't religious and neither was his counselor. So he was left with homework assignments, which he diligently attended to. His counselor felt that his need to think about death was not only causing his depression but that his morbid thoughts were "obsessive" in nature. Given that Bob was trying not to be so negative, the negative thoughts were "intrusive."
It reminded me of another patient I saw whose husband left her after a 35-year marriage. She still could not get him off her mind eight months after his intentions about their future were made clear and four months after she began doing cognitive-behavioral homework assignments to clear her thinking of obsessive morbidity. In her case, the futility of this became clear at one of our medication visits. She told me how she had overreacted to playing terribly at her tennis game. She was not simply down about her poor play; she was down on herself for being down. As with Bob's case, her therapist seemed to imply that she liked being negative. I told this patient to be kinder to herself. If she needed to be down, it was perfectly fine. Anyone in her circumstances would not be enjoying a wonderful state of mind. It would take a little while -- maybe more than a little while -- until she would get back to her old self. Trying to be positive was unnecessary, certainly not as a standard to hold for herself. In the meantime, I told her we could probably medicate her into a state of relative comfort.
Obviously, Bob's need to talk about death was based on a real ongoing stressor in the here and now. It was going to have social consequences. Bob was going to be heavy-hearted, and those looking for a good time would most likely be able to identify his state with a glance. It would not matter if he talked about death or did not talk about death. True, if he could become a very funny guy, his popularity might improve. And for teen-agers, being acceptable to peers, getting asked to parties and having someone to sit with in the cafeteria are all important parts of gaining self-esteem. But even if his (grand)mother had not died and she was a healthy 75-year-old, it is unlikely that Bob's joke-telling abilities would have been greatly improved. He is not that kind of guy. Nor is his (grand)father. Their cheerfulness in social situations comes across as being "off." As for coming across with a relaxed persona, that is always helpful in dealing with people, and fluoxetine (Prozac) might do wonders for him in this regard, but, important as it is to teen-agers, I would like to drop this whole subject of how to seem positive to others and get to the real point of this article.
What if Bob were negative and enjoyed being negative and wanted to pull others into his negativity because he wanted company in that part of his experience? What if "misery loves company"? I would argue that Bob has a right to his morbidity. He needs to work through his experiences, and having someone, maybe more than one person, go there with him and understand, rather than react to his negativity like he is being a creep, is crucial to the formation of a solid identity and his later capacity for intimacy. True, many, perhaps most, of his friends cannot and, probably, do not want to go there. They do not really want to understand, which is certainly understandable. It would be futile for Bob to force the issue on others, and it might just be that there will be limitations on how close he can get to certain people. Maybe many people. It is very possible, however, that he might find a companion who can dig the "blues," and this could form a solid starting point for a relationship. I think of the character Mel Gibson played in the movie "The Man Without a Face," his calm guiding strength shaped out of suffering, able to help the teen-ager transform life's hardship into tolerable proportions with his dignity and vision.
That used to approximate the ideal in therapy. That was a "positive" outcome. Oh, none of us were ever as cool as Mel Gibson. But sometimes we were. All this focus on chemical imbalances and negative thinking! The old kind of therapy does not loan itself very well to short-term efficacy studies. The new scientific therapy loans itself all too well to short-term results. We live in a world of short-term corporate profits; a "Have a nice day" sensibility about our well-being.
DSM-IV provided a scientific discipline with its clearly defined syndromes, based on clearly defined symptoms. From there, the next logical step was empirically based treatments, based on the defined disorder. But the downside of DSM-IV is that it has tempted clinicians to force a diagnosis so that they can use a proven treatment (Sobo, 1999). Apparently, some clinicians feel that if a DSM-IV category cannot be assigned, there is no illness and therefore no justifiable treatment. Certainly, this is the position of HMOs, and at this point, treating DSM-IV symptoms has become the only thing that some psychiatrists will do. Everything else is not illness but problems in living. Bob qualifies for a diagnosis of depression not otherwise specified. Cognitive-behavioral therapy has been shown to work for depression. The issues I am raising in his treatment have nothing to do with DSM-IV, yet they are most certainly vitally connected to his treatment.
The point of DSM-IV was not to ignore clinical phenomena that are not categorized by DSM-IV. It was not to toss out decades of observations, thoughts, discussions and theories about the developmental and emotional needs of patients should their unhappiness not fit easily into modern categories. We are far too young in our science, far too ignorant of etiology to limit our field in this way. Ultimately, even our science will suffer if heuristic pathways are dismissed as not a part of our field. But, more to the point, our patients now, as much as ever, still turn to us for understanding, not cookie-cutter, one size fits all treatments. Is it sound clinical judgment to bypass hard efficacy data for a softer but, I believe, more relevant perspective? Or is this a bit of nostalgia that interferes with the work at hand? To me the answer is clear.
Sobo S (1999), Mood stabilizers and mood swings: in search of a definition. Psychiatric Times 16(10):36-42.