Never Waste a Good Depression: Family Therapy Challenges the Seductive Shortcut of Psychiatric Drugs

The widespread use of psychiatric drugs reduces important conversations about the problems of being human while limiting our options for problem-solving.

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Once upon a time, a long, long, time ago—in the 1970s and ’80s—there was a great deal of curiosity and an upbeat mood among many in the psychotherapy professions. The field of family therapy had become a global movement, with clinical work and research being conducted all over the world. Much of this work looked at how relationship patterns, especially family dynamics, contributed to what showed up as “symptoms” in one person. Depression, anorexia, behavioral problems in children and other common symptoms of mental distress were explored and treated, often successfully, as interpersonal problems. No one had heard of “chemical imbalance.” Families were treated in therapy for “relationship imbalance.”

Marital Counselor Taking Notes At Therapy Session With African American Spouses, Holding Blank Clipboard, Filling Information Form At Marriage Counseling Meeting With Blank Couple, Cropped Image

It was during the 1980s that I met and trained with my mentor, the legendary Dr. Salvador Minuchin. It was through my work with Sal, as we called him, that I learned how mental distress was often a product of subtle, often hidden disturbances in the dynamics of the family. This was an exciting way of working, a humane model that empowered families, looked for health, and put families, not the doctor, at the center of the healing process. Since that time, I have treated many couples and families, and as a teacher of family therapy, have supervised many more cases. I continue to be impressed with the resilient healing potential that resides within most families.

The following is the case of a young woman, Julie, who came to see me thinking that she had a chemical imbalance. She had been depressed for the last couple of years, and had been on several different antidepressants, without much change. This story shows how depression lives in the land of relationship.

Julie showed up at my office looking like an old woman trapped in a young woman’s body. Despite her natural beauty—a lustrous mane of red hair and searching, dark brown eyes, Julie looked shrunken, turned in on herself. She thought individual therapy might help her with what she called her “depression and mood disorder.” She wondered if she had a chemical imbalance.

During the first few sessions, I was trying to get beneath the emotional surface of this rather flat affect, sweet-voiced, unhappy woman. I learned that Julie had been thinking a lot about her ex-boyfriend, whom she described with a hint of longing as “bipolar.” It sounded to me like she missed the intense highs and lows that were the hallmark of their relationship.

She added, “But I was exhausted by all the emotional drama by the time we broke up.”

I got the impression that, despite the upheaval, this relationship made her feel alive. She described the “relief” she felt when she met David, her live-in boyfriend for the last six years. I asked her to invite David in for the next session.

Shortly into the first meeting I was struck by the almost corpse-like quality of this couple. They sat nearly motionless, suffering under a veneer of politeness. This was one of the quietest couples I had ever seen. David, a slim young man with an impish grin and an intense gaze, had moved to the East Coast from Southern California. At our first meeting he impressed me as a kind, gentle guy who looked like he tried to maintain the peace at all costs.

My first impression of the couple—actually, the second impression—was that they were fighting like cats and dogs, only really politely. I remarked, “You guys are really going at it,” which probably sounded crazy since they were sitting quietly on my pink couch. Most striking was David’s exaggerated calm. For some strange reason he thought he could convince me (and Julie) that he “didn’t mind” that she regularly spurned his sexual moves, or that he could give up his previous identity as a Party Animal for a sedate existence in front of the hearth. They were like two old people. Two grouchy old people.

In the next few sessions, I began to challenge David’s politeness with Julie, letting him know I wasn’t fooled by his pretense at not caring. To me, David seemed depressed. When I suggested this, he didn’t disagree.

I said, “The problem is, you’re a pretender. You pretend you don’t want anything from Julie. You don’t make any requests. You have no demands. In fact, you don’t seem to expect or want anything from Julie, one way or another. That’s a recipe for depression.”

Julie nodded.

I looked at David. “I’m not talking about her depression. I’m talking about yours.”

Julie added, quiet fury in her voice, “I have absolutely no idea if he cares about me one way or another. He falls asleep in front of the TV every night. He goes along with what I want to do, but I have no idea what HE wants. I’m not sure why we’re in this relationship.”

She added, “This wasn’t the guy I fell in love with.”

THAT guy, according to Julie was a fun, prankster, party guy. I said, “It sounded like maybe you needed to tame him a bit, but this much?”

Could she un-tame him now? Slowly, David began talking about his acquired caution with his girlfriend.

“I worry about Julie’s mental health. She’s been depressed, so I try to stay out of the way, not add any more weight to what she’s already dealing with. And she had a panic attack a couple of years ago, and that really scared me. I’m not sure she can take much stress.”

I wanted to get to know David, to get a better sense of where his tendency toward emotional caution came from. He described his own mother as boisterous and opinionated.

He said, “I could never win an argument with her.”

David’s parents divorced when he was a teenager, and it sounded like David reacted by burying his anger. He talked about how he hated fighting, especially because of what he saw from his parents. He described his dad as emotionally unpredictable.

David said, “My old man would fly off the handle for no reason.”

These memories sounded raw for David, and he clearly went out of his way to avoid being anything like his old man. But his aversion to fighting and his strenuous politeness with Julie ended up creating another, different kind of problem. He now had a very depressed girlfriend on his hands. Like many guys who become overly protective and conflict-avoidant in their relationships, David needed to learn that his emotional caution, though perhaps well-intentioned, was experienced as cruel indifference by his girlfriend.

David’s carefulness felt extremely painful to Julie. Every lively relationship requires some element of risk-taking, of exposure or vulnerability. Otherwise, couples can end up feeling like strangers to each other. This was the relationship in which Julie’s soul was drying up.

She looked at David: “You make me feel like I’m not attractive to you. I feel so awful about myself, like I’m not even worth caring about. You don’t even want to have sex with me anymore. Why are we together?”

Just so we don’t put all the weight on David, we are reminded that all intimate relationships are a duet, a co-created piece of music. Julie, too, helped shape their hands-off relationship dance, though she didn’t know it. This was vividly captured by an incident a few months into the therapy.

David opened the session saying, “We almost had a fight this past week.”

I joked, “Oh, no, how terrible!” They realized by now that I was rooting for them to a good old-fashioned heated argument.

David recounted how they were in the kitchen preparing a sauce for a spaghetti dinner, and he tried to show Julie a new way to chop onions.

David said, “I’m a good cook, it’s something I love to do, and she acted like I mugged her! So, I backed off.”

Julie remembered this slightly differently:

“I was busy chopping the onions and David just inserted himself into what I was doing. It annoyed me and I told him so!”

David’s interpretation: She won’t let me teach her anything. Better stay in my lane. As we talked, they recognized this as was an all-too familiar pattern. Julie raised her hackles, David retreated. He was scared to stand up for himself, which, of course, made Julie (inwardly, unconsciously) furious. She didn’t get mad, though. She just got depressed. This conflict-avoidance demonstration henceforth became known in our therapy as “The Episode of the Un-Chopped Onion.” This couple desperately needed to learn to fight.

Over the course of the next few months, using “The Un-Chopped Onion” as the North Star, David helped Julie to understand her power over him. She held some strong beliefs about “how things should be,” and David sensed that she didn’t want to be challenged. Beneath Julie’s apparent vulnerability lay a very strong woman with strong ideas. She was actually quite powerful despite her apparent fragility. Julie was shocked to learn that her boyfriend had grown afraid of her. He wanted to avoid upsetting her at all costs.

David began responding to the therapy by beginning to take a few risks with his girlfriend, both in sessions and outside. He coaxed her out of her comfort zone socially, got her to go with him to some of his favorite clubs, where they danced and partied like when they had first met. Julie responded to his new level of connection at first warily, but then began to clearly enjoy her new boyfriend. And they started fighting more, which showed up in the therapy session. A few times in the office, when tensions arose, the fur would fly. But no harm done. Their relationship had come alive. About six months after I first met them, Julie mentioned in passing that she had stopped taking her antidepressants. She was feeling much better.

I must admit, when Julie first came to the office, I wasn’t sure I could be helpful. She seemed so stuck, convinced that her depression was biochemical, and not really in touch with what her mood, or her life, was about. When David came in, I saw the stuck-ness belonged to the relationship, not just Julie. This couple was in trouble, and I wasn’t sure I could help Julie and David come alive with each other. I had the idea, as I usually do, that if the relationship feels alive, that translates to a person’s individual experience. The mood of a relationship is infectious.

In the therapy, I knew I had to challenge David’s hands-off, pseudo-polite, no-needs posture with Julie. I realized from experience, both professional and personal, that being with a guy who seems to have no needs is incredibly painful for a woman. It creates a profound disconnect, one which burrows its way into the relationship and can stay there, creating depression in one or both partners. I began to feel hopeful early in the sessions mostly because David was so responsive to my challenges. When I told him that he was a “pretender,” that I knew he had needs, he didn’t deny it. More than that, he seemed to welcome a chance to look at himself, both as a boyfriend and in terms of his own background. If he had been less curious or engaged in the therapy, the outcome probably would have been different.

My next small therapist anxiety related to Julie. When I saw, after the “Un-Chopped Onion” incident, that she was a powerhouse in her own way, I wondered how she would respond when she learned that David was scared of her. I didn’t know if she would cling to the role of victim, or if she would be open to learning about her contribution to the couple’s dismal state. At first she was stunned to hear about her power in the relationship. She didn’t know she had any impact on David one way or the other. Then she seemed to feel relieved that there was something she could do differently to change what was happening between them. Julie reacted to this discovery as if it empowered her, and it helped me to guide the therapy in what turned out to be a helpful direction.

When Julie first came to see me, she was like many of the people we see in therapy who seek help for depression. Bringing Julie’s boyfriend into the therapy, and reframing her depression as dynamic, relational, and within their capacity to change had a healing impact on this couple. This story shows one of the ways symptoms like depression live in the world of our intimate relationships

Most of us are like Julie and David, in that we don’t know how to see the subtle but profound dynamics in our relationships when we’re inside them. These folks functioned well in society, had jobs, lived apparently normal lives, but the rhythmic undercurrents of the couple were pulling the relationship tensions underground, where they festered. Though Julie’s depression was her ticket of admission for therapy, once her boyfriend joined the sessions, she, and they, had a chance to learn about the pain hidden in their relationship. This paved the way for Julie’s recovery from what she thought of as an individual problem of mood.

The story of Julie and David, including Julie’s recovery from her depression is not an anomaly. In my many years treating couples and families, I have seen many similar cases. Julie’s depression was reframed and treated as a relationship issue. This meant that both people became patients, not just Julie. One side effect of this way of working is that the depressed person is de-stigmatized. They are no longer seen as having something wrong with them that needs to be fixed, but in fact, they are more like a lighthouse, signaling that all is not well in the land where they live.

This stands in sharp contrast to the prevailing “brain chemistry” model of depression and other syndromes of distress. When a depressed person, or anyone with psychological symptoms, is isolated from their natural habitat and treated with medications, it reinforces the idea of an illness belonging to only one person, rather than the relational system. This is one way that a family avoids knowing about itself and its dysfunction. This person may become the scapegoat for the family disturbance. When that person is reinforced in his or her role as sick, this in turn absolves the family from having to address its own underlying problems, reinforcing a dysfunctional family homeostasis.

The language of modern psychotherapy provides a powerful tool in selling the idea of a “brain chemistry” problem. It suggests the promise of certainty, declaring a biological basis for our moods, our distress, our distraction. The problem with the “chemical imbalance” metaphor is its persuasive power, which is intimidating and represses imagination. It implies that no one should feel powerless. No one should suffer or feel mental pain. The sophisticated scientific pretense of psychiatric language creates an illusion that human experience can be quantified or measured. When we believe we can measure experience, we feel smarter and more self-assured.

Reducing human experience to a set of symptoms which can be relieved by medications has now been built into our national mindset. But how do cultural patterns of reliance on psychiatric medications affect our intimate relationships, including family and marriage? Medicine has virtually no language for talking about marriage, parenting, love, or soul. How does our fixation on medications interfere with growing and creativity, with freedom and responsibility? It is not a problem if medications are given to Robert, to Mary, to Joanne, and to Matt. The problem is that giving medication to large populations interferes with conversations about the world we live in (context) and the relationships in which we are involved.

Such widespread and easy reflexive use of psychiatric drugs changes the consciousness of our culture, reducing important conversations about the problems of being human while limiting our options for problem-solving. The idea that we can quantify human experience is seductive because it reduces ambiguity about our relationships and ourselves. Suppressing conversation about ambiguities is a way to suppress freedom. The seductive shortcut of psychiatric medications interferes with the frustration and bafflement that can deepen our understanding about ourselves and our experiences. These explorations about what it means to be human are inevitably clumsy and awkward, often ending in ambiguous thought-provoking questions.

Ambiguity in personal experience is often experienced as pain. It is seen as uncaring for a health practitioner to allow pain. Many of the current psychotherapy models, including the various behavioral therapies, are focused on reducing symptoms with techniques, checklists, and goals. Physicians, especially, are taught to relieve pain, and they feel derelict in their duties if they fail to relieve suffering.  If a person is confused and distressed about life, the biomedical framework offers a name/diagnosis for the distress. With the re-branding of emotional suffering as disease, physicians now are taught to treat Mr. Smith’s depression as if it were like diabetes, complete with a checklist of symptoms. Responsibility for relief rests in the hands of the person with the license to write prescriptions. The only problem is that these symptoms are subjective and cannot be measured. We empathize with the demands on these professionals; these well-intentioned doctors, and practitioners of all types, feel tremendous pressure to not just stand there—do something.

The biological framework applied to mental health does not so much reflect human experience as reframe and simplify it. It is a conservative, somewhat fundamentalist viewpoint that says the unknown, the mystery of being, and emotional suffering, are to be found the brain, in the synapses, and the genes. Medications sometimes provide an apparent solution to the inevitable distress that comes from the deep loneliness of being human, from our deep struggles with the people in our lives. Expanding our psychotherapy framework to include a person’s intimate relationships offers a humane, effective and empowering approach to health and healing.

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Mad in America hosts blogs by a diverse group of writers. These posts are designed to serve as a public forum for a discussion—broadly speaking—of psychiatry and its treatments. The opinions expressed are the writers’ own.

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Amy Begel
Amy Begel is the coauthor of the book Diagnosis Human, a book of family therapy case stories. She is a family therapist who trained with one of the creators of family therapy, Dr. Salvador Minuchin. Amy is on the teaching faculty of the Department of Family Practice, the Institute for Family Health at the Mount Sinai School of Medicine in New York City. She maintains a private practice in New York and New Jersey.
David Keith
David Keith is coauthor of the book Diagnosis Human, a book of family therapy case stories. He is Professor Emeritus of Psychiatry at SUNY Upstate Medical University. He has been in practice for 45 years. Dave collaborated with Dr. Carl Whitaker, considered to be one of the important forefathers of the family therapy movement for over 20 years. Dave co-edited Family Therapy as an Alternative to Medication: An Appraisal of Pharmland and is the author of Continuing the Experiential Approach of Carl Whitaker: Process, Practice & Magic.

1 COMMENT

  1. Yup pretty much (cue the usual critiques of neoliberalism with the attendant damage it does by reducing people to atomized individuals driven by physicalist determinants, the question is how to move in a different direction [and what direction that would be]).

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