Tag Archives: case study

DSM-5 And Somatic Symptom Disorder

Under DSM-IV, a “diagnosis” of somatization disorder entailed a history of physical symptoms for which, despite thorough medical evaluation, no satisfactory physical etiology could be established.  In DSM-5, this “diagnosis” was replaced by somatic symptom disorder.  This is essentially similar to DSM-IV’s somatization disorder – with one critical difference.  The newer “diagnosis” can be assigned even if there is an identifiable physical illness.  The essential requirement for the new “diagnosis” – indeed the only requirement – is that the individual is excessively or disproportionately preoccupied with the symptoms.  And who, one might ask, decides if a person’s preoccupation is excessive?  A psychiatrist, of course, whose vast training in drugs and ECT equips him with the wisdom, empathy, and insight to make such judgments.  As the eminent Dr. Biederman proclaimed in a public courtroom on February 26, 2009, a  psychiatry professor is second only to God in status and ability!

During my career, I worked with a great many people who were preoccupied with medical concerns.  Some of these individuals had serious illnesses, and my task essentially was to help them adapt to their medical status and still find ways to have a fulfilling and meaningful life.  In other cases, the matter was less clear cut.  Some didn’t seem to be all that sick, but I stress the word “seem,” because I didn’t know.  My fundamental perspective was that everything a client says should be taken seriously.  I found that in all cases, if I listened carefully, respectfully, and humbly, I could come to an understanding of the client’s perspective. 

I remember working with a young woman in her mid-20’s.  I’ll call her Julie.  She was truly terrified that she had cancer.  She had incurred the irritation of several physicians who accused her of wasting their time, and had been referred to a psychiatrist who gave her a “diagnosis” of hypochondriasis and prescribed an antidepressant.  The young woman chose not to fill this prescription, and instead came to see me.

We talked – or rather, she talked and I listened.  It emerged that during a one-year period, when she was five years old, three family members (an uncle, aunt, and grandmother) had died of cancer!  Obviously the feelings of devastation were crippling – not only for her, but for all the surviving members of the family.  So at the very time when she needed an enormous amount of support, her primary caregivers were themselves reeling in shock and grief.

What made things particularly difficult for Julie was the fact that the impending deaths were never discussed with her.  For her, as a five-year-old child, these individuals were just snatched away into oblivion – by this thing called cancer.  For Julie, there really was a bogey man under the bed.  And when she came to me for help, the bogey man was still there.  For me, whether Julie’s fear of cancer was “proportionate” or otherwise was never an issue.  I started from the simple premise that her fear was valid, from her perspective, and that my task was to help her manage this fear in a way that still allowed her to enjoy life and do the things she wanted to do.

After much discussion, she came to the conclusion that the way forward was: to recognize that because of her family history, she probably did indeed have an increased risk of contracting cancer; to take appropriate counter-measures (including diet and regular medical checks); but to not allow the concern to destroy her life.  Once she had formulated her objectives in these terms, she was remarkably successful in keeping her concerns about cancer in a reasonable balance.  I asked her if she had told the psychiatrist about the three family deaths.  She replied:  “No, he never asked about anything like that.”

The truly appalling thing about this is that the psychiatrist, within the context of his profession’s conceptual framework, was not being negligent.  All he needed for his “diagnosis” at that time was the DSM-III-R list of symptoms:

  • preoccupation with the fear of having a serious illness
  • no actual evidence for the illness
  • the fear is not allayed by medical reassurance
  • the fear has lasted for six months
  • the belief/fear is not of delusional intensity 

For psychiatry, that’s all that was needed to “make the diagnosis” and to legitimize the prescription.

The essential point here is that we humans are strange creatures.  During our childhood years we develop all sorts of ideas and feelings.  Some of them are helpful, others less so.  Some are disastrous.  But they are all understandable, if someone will take the time to listen.  Note that it was no part of my role to “fix” Julie, or even to say that she needed to be “fixed.”   Perhaps the most significant thing I said to her during the time we worked together was:  “If I had walked in your shoes, I would also be terrified of cancer.” My job was to provide an unhurried setting of trust and mutual respect in which Julie herself could explore the sources of her fear, catalog the extent to which it was derailing her goals and her relationships, and formulate remedial action.  At all times, Julie was in the driver’s seat.

But that is not the psychiatric way.  People whom psychiatrists consider excessively preoccupied with these matters are “diagnosed” with somatic symptom disorder, usually on the basis of a short interview and perhaps a five-minute phone consultation with a general practitioner.  And the patient is given neurotoxic pills – to correct the “chemical imbalance” or the “neural circuitry anomaly” or whatever trite and deceptive rationalization is current at the time.  And if, with the passage of years, the hapless client is irreparably damaged by the drugs, then there’s always a locked psych ward and ECT.

A Psychiatric Case Study. A Sad Story

One of the criticisms that I routinely make of psychiatry is that its primary agenda during initial evaluations is the assignment of a “diagnosis,” and that ongoing “treatment” consists of 15-minute “med checks,” during which drug regimens are changed and adjusted.  The essence of my criticism is that this kind of approach inevitably oversimplifies human problems, and in practice does more harm than good.

My contentions in this regard have from time to time been challenged.  It has been said that my portrayal of psychiatry is a kind of misleading caricature, and that in reality, psychiatrists do, in fact, concern themselves with human issues over and above “diagnosis” and drugs.  This debate will, of course, continue, but I recently read an article on Psychiatric Times that has some bearing on the matter.  [Thanks to Nick Stuart for the link.]  The title is Conduct Disorder, ADHD – or Something Else Altogether?  The author is Steven Dilsaver, MD, and the piece is dated October 11, 2013.  The article is a case study of the psychiatric “treatment” of an eight-year-old boy (John).

John was brought to an outpatient clinic because of “…highly aggressive destructive behavior and sleeping problems.”

It was noted that his “…parents had been killed in a car accident when he was 5 years old, and just a year later, he had witnessed the violent death of his uncle.”  John was being cared for by his aunt, who became ill during his “treatment” and could no longer care for him.  At this point, he was placed in a facility for homeless children, where he remained for about 10 weeks.  Then he went to live with his grandmother.

JOHN’S TREATMENT

Here’s a summary of John’s psychiatric treatment as described in the case study.

On the basis of the initial interview, John was assigned “diagnoses” of ADHD, PTSD (with hallucinations), and mixed episode.

Day 1.             Rx: 2 mg of prazosin (Vasoflex); 750 mg divalproex (Depakote); 10 mg of aripiprazole (Abilify)
Day 2.             follow-up phone call
Day 8.             no changes
Day 15.           Rx: aripiprazole increased to 15mg

John was “lost to follow-up,” with no treatment, while in the facility for homeless children.

Day 111.         Rx: prazosin 2mg; divalproex 750mg; aripiprazole 15mg
Day 129.         Lisdexamfetamine (Vyvanse), 30mg at 7p.m. added to treatment regimen.
Day 139.         Lisdexamfetamine discontinued following reports of aggression.
Day 143.         no changes
Day 158.         dexmethylphenidate (Focalin) 5mg added to drug regimen
Day 173.         dexmethylphenidate increased to 10mg
Day 185.         dexmethylphenidate increased to 15mg
Day 205.         last visit.  “John had been doing well for 3 weeks.”

The above is a summary.  The text of the article makes reference to reports from caregivers, blood work, and other details.  But it is clear that the “treatment” is conceptualized as the administration of drugs, and there is no reference to any other kinds of intervention.

Final Rx:         2mg prazosin; 750mg divalproex; 15 mg aripiprazole at 6p.m., and 15mg of dexmethylphenidate (7 pm).

Final diagnoses:  PTSD; bipolar I disorder (mixed episode in remission); and ADHD-combined type.

The final paragraph of the article is interesting.

“John presented a complex clinical picture. His behaviors might have led one to suppose he had ADHD-combined or primarily hyperactive type and conduct disorder. However, there was a strong history of trauma and an affective disturbance that included not only irritable but also depressed and euphoric mood along with grandiosity, and the results of the structured interview indicated that he formally met the criteria for both PTSD and mixed episode at presentation. If not for the use of a structured interview format, the features defining these disorders might have been missed and the child treated only for ADHD. His final diagnoses were PTSD, bipolar I disorder, mixed episode in remission, and ADHD-combined type.”

I think most of us on this side of the debate would agree that “John presented a complex clinical picture.”  But what is clear from the article, and especially the final paragraph, is that what the author meant by that was that John “had” more than one “diagnosis.”  It is also clear that “treatment” consisted of prescribing drugs and tweaking dosages.

The truly sad part of all this is that Dr. Dilsaver appears to believe that this “treatment” is what John, with his extraordinarily troubled history, needs.  We’ll probably never know what happens to John.  But we can be reasonably certain that these stigmatizing and disempowering “diagnoses” will follow and define him for years – perhaps for life.  We know that he will be identified by various official and semi-official figures as someone who needs to be “on meds.”  We know that attempts on his part to discontinue these dugs will be met with resistance.

We can’t predict the future, but, I suggest, the odds for John are not great.  At age 8, with his world shattered in an unbelievably horrific manner, he has been shunted into the marginalized siding of psychiatric chemical restraint, from which he may never escape.  If he hasn’t already, he will probably soon be given a disability “award” with all the implications of damage and reduced expectations.

This post is not just a criticism of Dr. Dilsaver.  After all, he’s a psychiatrist, and this is what psychiatrists do.  In fact, because psychiatry has been so successful in marketing and promoting its so-called illnesses, Dr. Dilsaver would have been open to censure and lawsuits if he had not taken these kinds of actions.  Until these professional, legal, and cultural pressures are changed, we will see more and more children “treated” in this way.

Part of the irony in this matter is that it is clear from the article that Dr. Dilsaver believes he has done good work, and seems proud of the fact that he didn’t miss the PTSD and bipolar “diagnoses,” and that he “treated” these “illnesses” successfully.

Incidentally, according to GoodRx, a month’s supply of John’s final drug regimen costs $779.  (prazosin $8; divalproex $17, aripiprazole $712, and dexmethylphenidate $42).

Conversion Disorder

In DSM-IV, conversion disorder is described as distressful symptoms (or symptom) of voluntary motor or sensory function that “suggest” a neurological or other illness even though no actual pathology is present, and there is reason to believe that the problem is psychological in origin.  It has sometimes been called hysterical blindness, hysterical paralysis, hysterical anesthesia, etc…  This diagnosis is being retained in DSM-5

Prevalence estimates vary from 1 in 10,000 to 50 in 10,000.

The Mayo Clinic offers the following treatment suggestions:  counseling, physical therapy, stress reduction, anxiolytics, antidepressants, hypnosis, and transcranial magnetic stimulation.

In my entire career, I have come across only one person who carried this “diagnosis.”  She was a small, frail-looking woman of about 40 who reportedly hadn’t walked for years, and was pushed in a wheelchair wherever she went.  Let’s call her Betty.

I encountered Betty in a county mental health center in the eastern United States.  The center was housed in a good-sized building with a large room on the lower floor that had been set up for training clients in various social and other skills.

Betty attended pretty much every day, and clearly enjoyed the various activities, but she had to be pushed everywhere in her wheelchair by a staff member or another client.

At some point Betty came to the attention of our behavior analyst who, having watched the dynamics for a few days, instructed the staff not to push Betty in her wheelchair, and also to dissuade the other clients from doing so.  This took some coaxing and persuading, as Betty was very well-liked.

For a day or two Betty sat rather forlornly in one place, but then it was noticed that she began to propel herself slowly by shuffling her feet against the floor.  As the days followed, she became more adept in this technique, and then it was noticed that she began standing up if she wanted to reach something, on the other side of a table, for instance.

I don’t remember how long it took – I think a few weeks – but eventually the wheelchair was left by the door on arrival, and she walked around the room normally for the rest of the day.

It’s tempting to see this as the staff tricking her into abandoning the wheelchair.  But, in my view, there’s a better way to conceptualize the matter.

For Betty, the wheelchair brought her some very important things:  human contact; care and solicitousness; a sense that she was valued; etc…  These are things that we all need, and that we learn to acquire in various ways.  For some reason Betty wasn’t finding these expressions of human comfort in conventional activities, and the wheelchair was a kind of prop which helped fill these needs.

What’s also important to note is that the staff didn’t try to coax or pressure Betty to leave the wheelchair.  They just created a situation where she could find the strength to help herself.  And she did.

The essential point is that the people who are labeled as mentally ill can usually find within themselves the solutions to their problems and a more fulfilling life if they receive the right kind of help.

Involuntary Commitment – A Case Study

Years ago I was director of a county mental health center in an Eastern state.  Shortly after taking the position, I became concerned that clients were being involuntarily committed too readily and without exploration of other options.  I issued an instruction that all such activity had to be approved by a middle manager before it could proceed.  This measure aroused enormous resistance from the front-line staff.

There was one client – let’s call him Charlie – who was committed to the State Hospital every year, usually in July.  Every July, he would become “agitated,” would scream profanities at his elderly mother, and break things around the house.  He carried a “diagnosis” of schizophrenia.

Mother would call the intake worker at the mental health center; the intake worker would visit the home, fill out the papers, get a judge to sign them, and take them to the sheriff.  Ten minutes later a squad car would pull up at the house; Charlie would walk out – generally calm – get in the car; and be driven to the State Hospital, where he would be kept for about three weeks.  Mother would breathe a sigh of relief, clean up the house, and take a well-earned rest from the burden of caring for her adult son.

Under the new system, the intake worker had to involve the middle manager.  He visited the house and found that Charlie was “freaking out” and mother was nervous and apprehensive.  So he suggested that mother come with him to the domestic violence shelter.  She was hesitant, but agreed.  There he explained the situation to the shelter staff, who welcomed mother with open arms.

The intake worker was furious.  It wasn’t fair, she said.  Charlie was the one who was being difficult – why should mother have to be “thrown out” of her own home.

The reality was quite different.  Mother was thrilled to find a safe haven and staff who listened to her and offered support and encouragement. Charlie had no one to scream at and was having to take care of himself (a new experience).  The manager visited him twice a day to confirm that he was OK.

When mother had been at the shelter for four days, Charlie sent her a message asking her to please come home, that he missed her, and that he would not be aggressive or violent.  With encouragement from the shelter staff, mother sent back a message to the effect that she was very comfortable at the shelter, and that she planned to stay at least a week – maybe two.

In fact, she returned home after nine days – to a situation the dynamics of which had been altered in fundamental ways.

The moral of the story is that the knee-jerk mental health response of shipping clients to the State Hospital at the first sign of trouble is not always necessary, and usually provides only a temporary fix.  The dynamics underlying and driving the problem behavior remain unchanged, and the problem behavior tends to recur.

Don’t Call Yourself That: The Harmful Effects of Negative Self-labeling

When we were young, most of us devoted a good deal of time and energy to squabbling with other children.  To the dismay of our parents, we because adept in the use of impolite language, and kept our stock of insulting words and phrases up-to-date.  As adults we are more socially sophisticated.  We no longer call one another rude names – at least not openly.  Tragically, however, many people go through their entire adult lives calling themselves names, which although not as vulgar as the insults of childhood, are considerably more destructive.

Tammy (not her real name) was a young woman who had recently extricated herself from an abusive marriage.  She was having difficulty detaching herself emotionally from her former partner and had been coming to me for weekly therapy sessions to help get her life back on track.  During one of these sessions she described herself as the sort of person who never finishes anything.

“Why do you say that?” I asked.

“That’s just the way I am,” she replied.  Her tone was one of resignation and defeat.

“Give me an example of something you’ve left unfinished.”

“I’ve got six unfinished baby blankets in my closet.  My baby is now four years old, and I haven’t finished one.”

We discussed the matter for a while, and I asked her if she would agree to finish one of the blankets and bring it to our next session.  She was very hesitant:  she didn’t have time; didn’t know if she had enough yarn; wasn’t sure if she could find her crochet hooks, etc… I pushed a little, and finally she agreed.

“You will finish one of the blankets this week and bring it to your next session,” I confirmed.

“Yes.”

“That’s a definite commitment.”

She was apprehensive, but she agreed.  “Yes.  I’ll definitely do it.”

We talked some more about the significance of the blankets, and I felt that she might be able to push herself further.

“Would you get rid of the other five unfinished blankets?” I asked.

“Get rid of them?”

“Right.”

“You mean just throw them away?”

“Or give them away; or use them for cat pillows; or whatever.”

“But why would I get rid of them?  They’re good kits – they cost money, and they’ll make good afghans.”

“Yes, but all they’ve done for the past four years is sit in your closet leering at you, telling you that you’re the sort of person who never finishes anything.”

She thought about this for a while.  Then she said:  “I hate to throw anything away.  I’m a real pack rat.”

“Will you get rid of them?”

“OK,” she nodded.  “I’ll try.”

“I’m not asking you to try.  Will you make a positive commitment right now to get rid of them?”

Tammy thought for a moment, then nodded.  “OK.  I’ll get rid of them.”

She came to her next session a week later with a completed blanket.  It was very colorful and well made.  Tammy was proud and delighted with herself.  I admired the blanket and then asked:  “Are you the sort of person who never finishes anything?”

“Oh, no,” she laughed.  “Not any more.  And I’m not a pack rat, either.  I got rid of the others – and five boxes of junk besides.”

“How did you get rid of them?” I asked.

“Two of them I hemmed off and gave to my daughter as doll blankets.  The rest I gave to a church sale.”

“How do you feel?”

“Much better.”

——————————————

Negative self-labeling stems for the fact that we all experience failure from time to time.  Our failures may be minor matters like not finishing a blanket; or major, like getting fired from a job.  We fail in all sorts of ways, for all sorts of reasons.

Sometimes we fail because we have bitten off more than we can chew; other times because we lack the necessary skills.  But whatever the reason, everybody has had some experience of failure, and everybody has to find a way of coping with these unpleasant experiences.

Obviously the most appropriate response is to acknowledge the shortcoming, take the necessary remedial action, and try again.  For instance, if I’ve spent two days trying to fix my dishwasher and it still doesn’t work, I should either call the repair service or brush up on my appliance repair skills.  Unfortunately this kind of honest, logical approach is not always adopted.  It’s easier to change our thoughts than change our skills, and many of us, when confronted with failure, expend more energy explaining and justifying than fixing. This is not really a matter of conscious deception.  It’s simply an easier way to deal with the problem.  If I’ve lost my job because of incompetence, it’s a lot easier to convince myself that I was fired because the boss wanted to hire his nephew than to accept the reality.  If I accept the reality, then I have to do something about my performance, and that’s not easy.  Most of us have practiced this kind of self-deception at least occasionally, though we can usually identify it far more readily in others than in ourselves.

Negative self-labeling is a particularly destructive way of avoiding the reality of failure.  Tammy, the young woman mentioned earlier, had in the past failed to complete various projects.  The healthy response would have been to take appropriate corrective action.  For instance, she could have forced herself to stick to one project even though she began to find it boring.  Instead, she continued with the dysfunctional practices and gave herself the label:  the-sort-of-person-who-never-finishes-anything.  This solved her immediate problem.  As long as she identified with this label, she was excused from the tedious business of finishing a blanket whose pattern and stitches had lost their novelty.  After all, she was the-sort-of-person-who-never-finishes-anything, and what more could one expect from a person like that.  This happens to be a fairly popular negative self-label, and people who have adopted it tend to reinforce the role in one another by swapping stories and by laughing together at one another’s excesses.  However, the matter is not really funny. The negative self-label becomes a kind of self-imposed disability, which relieves the individual of certain responsibilities, and eventually becomes so deeply ingrained that it is very difficult to shed.

Other negative self-labels that are frequently heard are:  I’m a workaholic; I’m a very angry person; I have a short fuse; I’m a couch-potato; I’m no good at making decisions; I’m a procrastinator; I’m a worrier; I’m a difficult person to live with; I’m a people-pleaser; I have no willpower; I’m not a morning person; and so on.  Each of these labels serves a purpose:  they excuse dysfunctional behavior and remove the incentive to improve one’s performance.

Negative self-labeling is sometimes defended on the grounds that a person has to accept the reality before he/she can change.  In other words, the individual is simply being honest.  In the example given earlier, for instance, it might be argued that Tammy has to accept the fact that she is the sort of person who never finishes anything.  Only if she accepts this reality will she be motivated to take corrective action.  The reality, however, is not that Tammy is the-sort-of-person-who-never-finishes-anything.  The reality is that in the past she left certain projects unfinished.  These are very different statements.  The latter is simply a descriptive statement about the past.  The former goes way beyond description.  It purports to explain and legitimize the past and, tragically, becomes a predictor and a determinant of the future.  The problem ceases to be a problem and becomes instead the expectation – the norm.  In the short term the negative self-label is an easy way out, but in the long term it becomes a self-destructive trap.

The trap, however, can be opened.  Recognizing the label for what it is – an excuse for avoiding a difficult task – is the first step.  The second step is to stop using the label, and the third is to tackle the difficulty.  This, of course, is easier said than done.  Change is not easy, and many people need help correcting these kinds of problems.  The help can come from family, friends, or, in extreme cases, from professional therapists (provided they are not wedded to bio-psychiatry).  But nobody has to accept a negative label.  Regardless of what a person may have done or neglected to do in the past, the future is filled with opportunities for change and growth.  Negative self-labeling severely limits this potential. People who identify with, and accept, negative self-labels, including psychiatric diagnoses, will never adequately explore their full range of possibilities, and will never tackle the challenges that life presents.  They insulate themselves from the risk and the pain of failure, but by the same action they cut themselves off from the joy and fulfillment of success.

If Depression Is Not An Illness, What Is It?

Elsewhere on this site, I have argued that depression is not an illness, but rather is an adaptive mechanism that encourages us to make changes in our habits or our circumstances.

I have written about what I call the seven natural anti-depressants:  good nutrition; fresh air; sunshine (in moderation); physical activity; purposeful activity; good relationships; and adequate and regular sleep.

But the question has often been posed:  Why does this adaptive mechanism apparently not work in some cases?  Why is it that for some people the unpleasant feeling fails to act as a spur to make changes, and instead the person sinks further into despondency and inactivity?

My general response to this argument is that in general, we do what we’ve been trained to do.  I’m using the word “trained” here in a very wide sense to include not only the habits instilled by our parents and other significant adults, but also the habits that were “taught” to us by our experiences.

I thought it might be helpful to illustrate this by sketching the progress of a person who came to me several years ago for help with depression.  To protect the person’s privacy, her name and various details have been changed.

Jean was 34 years old, married, mother of three children, and manager of a popular and successful restaurant.  She had been feeling increasingly despondent for a few years, and finally, on a friend’s recommendation, went to see a psychiatrist in another town.  He talked to her for thirty minutes and prescribed an anti-depressant (Paxil).  Her next appointment was in two weeks.  She told the psychiatrist that she wasn’t feeling much better.  He said give it time.  Two weeks later she was back in the office and told the psychiatrist that she was so down that she could see little point in going on.  He arranged for her to be involuntarily committed to a private mental hospital.

She stayed at the mental hospital for four weeks.  Her Paxil dose was increased and additionally, she was given an anti-anxiety drug.  She received art therapy, which consisted of sitting in a room with other residents painting pictures, and music therapy, which involved listening to music.  Every day she had group therapy.  This consisted of sitting in a group with eight or ten other residents and “just talking.”

At no time during the four weeks did anyone ask her why she was depressed.

On discharge, the hospital referred her to me because I worked at the community mental health center in her home town.

I scheduled two hours for Jean’s first visit, and we talked.  Or more correctly, I encouraged her to talk, and I listened. Here’s her story.

Jean was raised in a small mid-west town, the eldest of four siblings, in what she called a “conventional” family.  Her mother was a stay-at-home Mom, and her father worked as a manager at a feed store.  They weren’t wealthy, but with the frugality that was common for the time, they weren’t poor either.

In the home, her father was the boss to whom her mother deferred routinely.  Her mother was devoted to her husband and her children, and worked tirelessly pretty much all day.

Jean said that her childhood had the normal ups and downs, but that there were no great traumas or horrific incidents.  As the eldest daughter, she helped her mother a great deal with childcare of the younger siblings and with household chores generally.

At school she did well, finishing with a GPA of 3.5.  She had considered college, but decided against it.  She took a job waiting tables at a restaurant, and at age 20, married her high school sweetheart, George.  He worked as a mechanic.

About two years later, George got an offer of a better mechanic job at a town about 100 miles away.  They talked it over and decided to go.  Jean had no difficulty finding a job as a waitress.  They settled into their new surroundings fairly well, but Jean missed her family (especially her mother), and although she got along OK with people, she discovered that she was not too skillful in the area of making new friends.  (Up till then she had lived in her home town and her friends were ready-made, so to speak.)

They rented a home but within a year were able to make a down-payment on a home of their own.  The mortgage was high but with both of them working, they could manage.

Two years later Jean was promoted to assistant manager at the restaurant, and adapted to the new responsibilities without difficulty.

By this time life had settled into a routine.  George worked as a mechanic, and when he came home, he pretty much considered that his day’s work was done.  Two or three evenings a week he would go out to the bar to “unwind” with his friends.  He would mow the yard and a few other outdoor chores, but all the cooking, laundry, cleaning, etc., fell to Jean.  She accepted this as her womanly lot, and never complained – or even thought of complaining.

A year after buying their house their first child was born, followed by two more at two-yearly intervals. Jean adored the babies, and felt terribly torn at having to leave them with sitters and daycare when she went to work.

Then she was promoted to manager at the restaurant, and sometimes, if there were problems, she had to work late.

Meanwhile the children were growing, and their needs were becoming more complex.  Jean found that she was routinely getting up at five a.m. and seldom getting to bed before midnight.  Sometimes she would be doing laundry at one a.m.  She was drinking enormous quantities of coffee.

On her thirtieth birthday Jean realized the she was very unhappy.  This made her feel guilty.  After all, she had a good husband, three beautiful, healthy children, a great job, and a nice home.  What more could she rightfully expect?  She resolved to stop feeling sorry for herself (as she put it) and try harder.  She limped along like this for another four years.  During this time her two older children started getting into trouble at school, and her husband started “looking at” one of the secretaries at his place of work.  With regards to the latter, Jean decided that she had been neglecting her appearance, and resolved to pay more attention to make-up, dress, etc., and to work harder at retaining George’s affection.

By this time, for Jean, the meaning of life was simple:  try to keep it together; try to get through the day.

She had one close friend, Betty.  They got together for a chat about once a week, and during one of these sessions Jean started to sob disconsolately.  Betty, who had herself consulted a psychiatrist a few years earlier, recommended that Jean do the same.  And so to the pills, the mental hospital – and my office.

It didn’t take any great intelligence or insights to see why Jean was depressed.  What’s staggering about her case, however, is that neither the psychiatrist nor the hospital staff bothered to ask her why she was feeling down.  The reason for this is that as far as they were concerned, they already knew the reason.  She had a brain illness, and she needed to take pills “just like a diabetic has to take insulin.”  (Yes, they did actually say this!)

At the end of the first session, I told Jean that given the load she was carrying, it was not surprising that she was feeling down; rather, the surprising thing was that she was managing to cope at all.  She told me that she didn’t feel that the pills were doing her any good, but that she was afraid to stop taking them for fear that “they” would send her back to the mental hospital.  She explained that that had not been a positive experience, and that she didn’t belong there.

I suggested that she come back to see me weekly for a few weeks, and I made sure that she had our phone number in case she needed help outside office hours.  When she left the office, she seemed lighter than she had seemed initially, and she stated that it had been helpful just talking about things.  I suggested that she bring her husband to the next session if he was willing.

Next week she showed up on time with George.  I asked George for his perspective, and he said that he had known things weren’t great for about the last year.  He had had no idea what was wrong, but now that he knew Jean had a brain disease (and the pills to treat it), everything would be OK.

Somebody – I’ve forgotten who – once said that therapy is the art of presenting the facts to a person in a way that they can accept.  So I spent the next hour trying to let George hear the message that I had received loud and clear from Jean the week before.  It was clear, however, that Jean was reluctant to be particularly confrontive in this regard, and I was careful to respect her lead.  Towards the end of the session, however, I did point out that Jean was in effect working the equivalent of about 100+ hours per week.

George had been raised in a conventional household also.  Dad went out to work.  Mother was a stay-at-home Mom.  He felt that if his mother could do it, his wife should also be able.  I pointed out that his wife’s situation was not quite the same, in that she had a full-time job managing the restaurant.  To which George expressed the view that this wasn’t real work because all that managers do is sit around and tell other people what to do.  Jean listened to all this quietly and respectfully.

Next week Jean came in alone.  She asked me what I thought she should do.  I said that I couldn’t make her decisions for her, but that in my view it was clear that something had to change.  I explained that we all need some activities in our life that we enjoy and/or give us a sense of success.  I expressed the view that her life had become so grueling that even activities that otherwise might have been pleasant and rewarding were no longer so.  Jean agreed with this.

We spent the next few sessions exploring options – looking for ways in which Jean could reduce her workload and find more joy and meaning in her life.  Each week she would update me on what she had managed to achieve.  She began to feel better.  She started to smile, and her general demeanor seemed brighter and more positive.

On week eight she came in and told me that she had told George that she wasn’t going to do any more laundry – that from now on this was his job.  “Wow,” I said.  “How did he take it?”  “He didn’t like it at first, but then he agreed.”

And so it went.  On week ten she told me that she had been tapering the pills and wasn’t going to get any more.  On week twelve I expressed the belief that she probably didn’t need to come in any more.  She agreed.  She phoned me several months later and told me that she was still doing fine.

And Jean is by no means an isolated case.  Up till about 1950 or so, most mothers were stay-at-home Moms.  Then, for various reasons, this started to change.  Women entered the work force in large numbers and began to develop careers to an unprecedented degree.  All of which is fine, but it took several decades for our cultural ethos to adjust to this huge demographic shift.  Throughout my career I have worked with scores, perhaps hundreds, of women who, like Jean, were working a full job in the workplace and a second full-time job at home.  I don’t know anyone who wouldn’t find that depressing and debilitating.

But the mental health system seldom even bothers to ask the critical question:  “What’s got you down?”  In my experience, most people can provide clear, cogent answers to this question, and with a little encouragement can come up with remedies.

Nothing succeeds like success.  When a person realizes that he/she has solved one problem, they are empowered to tackle others.  Pills on the other hand, with their implied message of helplessness, disempower people and encourage excessive dependency.

Jean was not ill.  She was just over-worked and under-appreciated.  Her circumstances had changed drastically, and the skills, attitudes, and habits she had developed in her formative years were no longer sufficient to bring her a sense of joy, fulfillment, or success.

There are millions of women like Jean in America.  Many of them have been systematically deceived, disempowered, and drugged by psychiatrists.