Explanations – 1: Finding a Guide

I’d like to think of the search for the causes and treatments of depression as the tracking down of a killer, a good yarn like the fascinating medical mystery stories The New Yorker publishes from time to time. But we’re a long way from the end of such a story, and those tales can only be written in retrospect, after it’s clear the great discovery has been made, the mystery solved. It looks more and more as if there is no single discovery to answer all the questions, only multiple lines of research leading to treatments of great promise. Those treatments add to the store of useful tools, but none of them quite gets the job done. The search continues, and we try to make do with what it yields.

One of the most interesting guides to this search and the recent history of treatment strategies is Dr. Peter Kramer. He is now so well known as a result of Listening to Prozac and his other writings and media work that it’s automatic to refer to his books in any list of helpful references. I’d like to comment on what it is in his writing that has been so important to me. It’s a continuing challenge to a lay person to sort through the vast amount of available material and get clarity about what it all means. It’s much easier to get hopelessly confused by conflicting claims and theories. I look for people I can trust for help, and Kramer is someone whose writing inspires that trust.

He does it by his remarkable honesty. As a psychiatrist in active practice, he responds to each patient under his care as an important witness in the search for answers, someone whose observations about their own illness may shed light on the limitations of the prevailing theories and treatments. Most importantly, he is not afraid to discuss his own missteps and to learn deep lessons about his practice from each one. That is rare in any profession, but to that capacity he adds a fluent writing style that sets out the clearest and most searching explanations I can find for the varied theories about depression and its causes.

His chapter on stress, for example, in Listening to Prozac is a characteristic blend of compelling material from many sources. His driving concern is always to ask, as his title implies, what we can learn from the observed impacts on patients of the newer medications. He is skeptical of the explanation of depression based on the neurotransmitter system in the brain but is constantly working to separate the proven core of accurate observation from the claims that have not been supported by experience. Then he applies the knowledge gained from the new approaches to the treatment preferences generated by the psychoanalytic model. He takes the reader along with him as he reflects on what types of therapy work in certain cases. I find these open-minded observations tied to practice helpful as I think about the choices in treatments I need to make. In that sense, reading his work is empowering to someone who is trying to be an activist in his own treatment.

Listening to Prozac was intended to focus more on the way the transformative powers of that drug influenced our culture and how we think about the self. The recent Against Depression looks more closely at major depression, but he continues to draw his subject into the broad cultural context of how society has regarded and dealt with this condition. In fact, it’s partly a manifesto on the need to look at depression as a disease and disabuse our thinking of more romantic or moral interpretations.

The most powerful and moving sections capture the changes patients experience in treatment and what can be learned from their stories. One chapter describes the sudden and dramatic change for the better some depressed people undergo, what he calls the “return.” He tells the story of one of these patients whose recovered or returned healthy self presented a much different personality from the depressed one he had come to know in treatment. At the moment he was expecting some praise or thanks, the restored patient rebuked him instead. She was angry that he had taken that ill self too seriously, humoring it, dealing with it as if it were the real her. “With Margaret, in employing the most basic elements of therapy – empathy, tentative interpretation, the search for meaning – I had in effect sided with the illness and against the person Margaret was in health. The feelings I had underscored for Margaret were foreign to her. She experienced them, she reported them, but there is a sense in which they were not hers.” (p. 27) This was one of many incidents which convinced him that depression had to be understood as disease.

As I’ve noted elsewhere in this blog, the recognition that behavior under depression is illness rather than the true self has been one of the hardest lessons for me to believe. The power of the disease is such that many of us suffering with it tend to accept its miserable persona as who we really are and continually blame ourselves for not getting better. But this remarkable story of Margaret helps in another way. It gets at something I’ve often experienced, the ability of depression to split the self into parts. At times, elements of my awareness and behavior become inoperative, and another force takes over that can paralyze me when I most need to act. There are times when I’m totally lost in depression and not my healthy self at all. At other times, though, I retain awareness of that frightening dynamic of one self pushing the other out of the way. It is just these strange experiences with depression that Kramer’s writing helps me to explore. That’s part of the search for answers that isn’t going to end anytime soon. And the search itself is a tactic that helps beat the isolating impact of the disease. It connects me, however indirectly, with others struggling to understand the nature of this condition, whether as patients, researchers or practitioners. Kramer is one of the most helpful interpreters of what that search is all about.

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