Early in therapy, a young woman I treated for depression described her ideal relationship with a man. “If I had my way,” she said, “I wouldn’t do a thing, except clean the house and talk on the phone. He would make all the decisions. He would pick where we go, what we do, who we see.”
Because I have been taught that independence is both psychologically healthy and personally rewarding, I immediately doubted that my patient could truly be content with the life she had described. “Have you ever had a relationship like that?” I asked skeptically.
“Until he broke it off,” she said. “But I’d go back in a second.”
My mind went through all the diagnoses I have memorized from the official diagnostic manual published by the American Psychiatric Association. I began to think that she was suffering from dependent personality disorder, a condition marked by low self-esteem and submissive behavior. I resolved that whatever the diagnosis, the success of therapy would be measured partly by an increase in her self-reliance.
After her depression had lifted, I helped her to find the roots of her unusually dependent feelings in the lack of safety she experienced as a child of violent, unpredictable parents. She was interested in the connection, but she also made it clear that it was not her goal to become independent.
“If I have to, I guess I’ll work,” she said. “But I’d rather do nothing. That’s what I like.” She paused and smiled. “Does that make me crazy?”
The answer to that question might depend more on prevailing public opinion than on science. Three years into psychiatric training, I have yet to help a patient become comfortable with a desire that runs counter to contemporary social values. I’ve begun to worry about becoming an unwitting proponent — and subtle enforcer — of mainstream thought and behavior.
I am aware that I embody and ascribe to those values. As someone drawn to the medical profession, with its rigid hierarchy and emphasis on academic honesty, I began my training already comfortable with conventional expectations. My ability to complete more than a decade of regimented study confirmed my prowess at working independently, meeting expectations, and deferring gratification. Merely by my example, I could be relied upon to give voice to some of what our society cherishes.
I have been supported in this by the inherent structure of psychiatric care. For instance, presenting the exchange of money as an essential component of the therapeutic relationship tends to legitimize only those things that can be bought. Furthermore, helping patients look for hidden meaning — such as displaced anger — in lateness to appointments reinforces the idea that punctuality reflects emotional health, when in fact it might indicate compulsiveness or even obsequiousness. And on the psychiatric inpatient wards where I trained, all patients were made to progress through a series of privileges, reinforcing the notion that satisfying authority figures is a prerequisite for freedom.
This role as social gatekeeper is not new to psychiatry. By the early 1900s, leaders in the field were anxious to exert influence beyond the walls of mental hospitals. They hoped that psychotherapy could be an agent for the betterment of society, an instrument of social change that would ameliorate problems such as alcoholism, prostitution, and delinquency.
My discomfort comes from the fact that these goals are largely unstated today. Yet they are clearly incorporated in the diagnostic categories by which we classify patients. In rushing to use the language of medicine — forgetting we carry with us a heritage steeped in morality — we run the risk of defining socially accepted conduct as health and unfashionable or unconventional lifestyles as disease.
The fact is that psychiatry does not change only through scientific discovery. Our perspective as clinicians changes with the times. Not so many decades ago, when attitudes toward women were different, certain behaviors that are now considered normal, such as assertiveness, were regarded as neurotic. In the 1950s, my patient’s yearning for a completely dependent lifestyle would probably not have been thought the least bit pathological.
More recently, homosexuality was listed as a mental illness by the American Psychiatric Association in the late 1970s; by the early ’80s that was no longer the case. Changing public attitudes fueled by the civil rights movements of the ’60s and ’70s, not new scientific discoveries, led to a major change in the way most psychiatrists regard and treat gay men and women.
The entire domain of personality disorders incorporates a Western work ethic. For example, the APA’s diagnostic manual describes passive-aggressive personality disorder as follows:
People with this disorder habitually resent and oppose demands to maintain a given level of functioning. This occurs most clearly in work situations, but is also evident in social functioning. The resistance is expressed indirectly through such maneuvers as procrastination, dawdling, stubbornness, intentional inefficiency, and “forgetfulness.” These people obstruct the efforts of others by failing to do their share of the work.
There is no question that such patients suffer because they are social outcasts. The danger is that contemporary psychiatry, with its increasing emphasis on biology, suggests that abnormal brain structure and chemistry lie at the root of many “disorders.”
There are lessons to be culled from some of the symptoms and the behavior of disturbed patients. A man I treated for mania, a mental illness marked by grandiose behavior, increased energy, and social indiscretions, was in the habit of giving his money away to anyone who asked.
“You’ve got to stop giving out money on the street,” I told him, referring to his propensity to walk up to complete strangers and hand them a five-dollar bill.
“Stop? Why?” he asked incredulously. “I only give away what I don’t need.”
I realized that his values might be lauded in a more just world. In patients like the dependent young woman, we may also find hope for a kind of intimacy most of us fear and a lesson in the limits of rugged individualism.
Maybe some people fail to meet social demands because the demands themselves are flawed.
This essay previously appeared in the Washington Post.
—Ed.
