Stabilized, however, is not cured. While taking medication, Carol
still followed her old patterns of cheerful selflessness. She was less frantic
about it, but the medication did not enable her to stand up for herself. The
pressure inside her continued to build, and she had to find some other way
to express it. Often it would be by stopping her medication and precipi-
tating a hypomanic or depressed episode. Eventually her psychiatrist
referred her to me for therapy to find out why she wouldn’t stay with treat-
ment that was obviously effective.
Carol’s treatment had been effective for one part of her disorder. On
the medication, she no longer had drastic mood swings, but she was still
suppressing her own feelings to avoid conflict with other people, letting
the latent content of her actions express what she was afraid to say directly.
Carol’s story illustrates once more the difficulty of trying to specify
what depression reallyis. Her disorder is a clear case ofall of the above.
She’s plagued by chemical imbalance, loss, anger turned inward, internal
conflicts, external stress, and just about everything else that depression
can be. Carol is not particularly unusual. Depression is a disorder of many
levels, physical and psychological; somehow, we have to deal with all of
them. The ones we leave out come back to haunt us.
Being a therapist in the age of serotonin is not easy. In the early days
of my training, professors would laugh at the crackpots who thought mental
disorders were caused by brain chemicals. Now they laugh at crackpots
who don’t. Fashions change, yet at any given moment, we act as if history
were nothing but prologue for the age of enlightenment in which we now
live. The pronouncements of the old order seem dated and a bit silly.
Before we knew much about the brain, therapists speculated about the
mind. Every disorder was supposedly caused by unconscious, psychodynamic
processes in which everything represented something else. To make matters
worse, different disorders can have the same dynamics. You’ve probably rec-
ognized that, though Carol’s symptoms are not like Jane’s panic attacks, they
both seem to arise from the same internal conflicts over expressing aggression.
You might ask: If therapists are so smart, why can’t we figure out
which conflicts cause which disorder?
The reason we can’t, and never could, is it doesn’t work that way.
Conflicts don’t cause disorders—they are the fuel that runs them, and
sometimes causes them to explode. If you throw a match into gasoline,
everyone knows there will be an explosion, but who can say whether the
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