At the recently concluded Oasis Conference – what a joy that was! – in my “Lessons Learned from a Tertiary Care Psychiatric Clinic,” I presented a case of a middle-aged depressed man who reported being dysphoric, self-deprecating and preoccupied by the meaninglessness of his life for as long as he could remember. Today I highlight one aspect of his case. He made a comment that has stayed with me since. After responding to tranylcypromine (an MAOI), he said, “I’m no longer depressed, but I’m still unhappy.” He was a man who had been in an existential crisis since childhood. He told me, “I remember in kindergarten, sitting there thinking, what’s the point of it all?” Once the mental anguish resolved with medication, he nonetheless remained without much of a life, other than being highly successful at his career.
I learned two related things from his case: First, as a clinician, it is not enough for me to focus only on minimizing or resolving a patient’s symptoms of their mental disorder(s); I must also focus on increasing their quality of life that may have been disrupted by the mental illness or, as in this patient’s case, had never been achieved. In other words, I had to not only help take away the “bad” but also add the “good.”
Second, I learned that sometimes it’s equally or even more effective to expend therapeutic effort on adding the good than on eliminating the bad. I realized the bad of the mental illness, with all its painful symptoms and dysfunction, is not on the same continuum as the good of a life well-lived. Some people with severe symptoms of mental illness nevertheless live lives filled with meaning, purpose, and to some degree, fulfillment. And, conversely, many people without mental illness live lives of quiet despair, meaninglessness, and purposelessness. How can this be? Victor Frankl had a concept of “despair equals suffering minus meaning” or “D=S-M.” Despair and loss of meaning may occur as a consequence of the mental illness, but also they may arise prior to or separately from a mental disorder. They may even be a cause of the mental illness. Thus, I believe in taking a balanced view, both addressing the bad of the mental illness and adding in the good of a life well-lived. Of course, sometimes these two categories overlap: taking steps to increase a patient’s self-worth may be identical to taking steps to decrease their worthlessness. But, even in this case, conceptualizing this focus in the positive (adding self-worth) can open up a clinician’s considerations to previously unconsidered options, as I’ll touch on below.
Here is my list of positive and life-affirming aspects that can be foci of therapeutic efforts. I also include the types of therapeutic interventions that can help achieve these outcomes. Use this list as a starting point for a list of your own making, one that reflects your experience and types of patients you treat. I mention different therapeutic approaches, like problem-solving therapy, without describing them here, which is beyond the scope of this missive. I’ll explain them in different communications.
Factors of Flourishing
- Agency and Control: There is little in life that is as conducive to a life well-lived than a sense of agency and control. And, conversely, one of the most depressogenic and anxiogenic situations for human and non-humans alike is to repeatedly experience a lack of agency and control. To thrive, we need to feel that we can 1) assess a situation, 2) deliberate on it, 3) develop a range of options, 4) choose one, and 5) take skillful action that gives us a fighting chance to reach the desired outcome. Oftentimes this process is slow and deliberate, as I outlined above, and sometimes it is non-conscious and nearly instantaneous. One of the features of depression and anxiety is that it leads to a conviction of non-agency and near-total lack of control. What can help a person rekindle their sense of agency and control is an affirming clinician who will guide the patient – like an auxiliary frontal lobe – to improved problem-solving and execution of a simple yet detailed behavioral plan. Indeed, one of the evidence-based treatments for depression is problem-solving therapy.
- Mastery: Persons who maintain a sense of agency and control are usually active in the world. They are more likely to seek out new experiences that often turn out to be rewarding (positively reinforcing) and challenging. Meeting the challenge despite difficulties leads to an increased sense of agency, control, and mastery. This furthers the virtuous cycle of more participation with and exploration of the world, leading to increasingly skilled performance. In addition to problem-solving therapy, behavioral activation techniques and targeted skill training are possible interventions to increase mastery.
- Security: A person with a strong sense of insecurity and uncertainty will often hunker down and stay close to home, minimize interactions with others, and lose the capacity to consider options broadly and creatively. (This is called cognitive narrowing, a fascinating topic on its own.) Intuitively, this makes sense: when you’re insecure, you want to hole up in your castle surrounded by your moat. However, as an ongoing strategy, “drawing up the draw-bridge” is maladaptive. For example, isolating from others will often leave a person more vulnerable. We all need friends, advocates, and allies. Also, this form of withdrawal from the world allows one’s world-navigating skills and confidence to atrophy. So, here again, gentle steps to move a patient out of their ever-constricting comfort zone is indicated. The same interventions as above are a good fit here.
- Meaning and Purpose: One of the most heart-breaking statements I’ve heard from patients – and I think I’ve heard versions of this dozens of times – is, “If I were dead, no one would even notice.” Thus, one of the most important interventions we as clinicians can make is to make the above statement not true: “If you were dead, many people would care, and they would miss you and grieve your passing.” The following intervention is one of the simplest and for some – many? – patients the most beneficial: encourage and prod them to take a volunteer position. For example, if you’re talking to a vet, have them become a peer counselor with the PTSD, addiction, or whatever other group is relevant. If you have a patient with schizophrenia have them volunteer to do chores at the day program or group home. (Note that many of these latter positions need to paid ones to avoid the potential of unethically taking advantage of patients to provide free labor.) If you have a depressed or anxious patient, such as with social anxiety, panic, generalized anxiety disorders, or agoraphobia, have them volunteer with a community organization or their religious community. Make it so that if that patient died, there would be dozens or hundreds of people at their funeral, people they touched through their efforts. Of course, a person with that level of connection is much less likely to die by suicide.
- Community/Belonging: Meaning and purpose are often closely allied with a sense of belonging to a relevant community. There are the “Immanuel Kants” of the world who may not need much of a community – as they commune with eternity – but for most of us an effective way to increase meaning and purpose in our lives is through participating with others. For a person who’s been isolated, a less challenging route to re-establish ties with one’s natural community is to contribute to it. Again, taking a volunteer position is a good route.
- Self-worth: One’s perceived self-worth is often (not always) a result of one’s perceived worth in the eyes of one’s relevant community. If you hold me in high regard, I’m much more likely to hold myself in high regard. This is not always the case, as exemplified by the imposter syndrome, but it nevertheless is effective for many. Consider how your patient can gain status with their community. Again, meaningful volunteer work can come to the rescue.
- Love/companionship: Beyond being a valued member of one’s relevant community, people often need one-on-one love and companionship. Explore what may be getting in the way of a patient who lacks them. Is there a history of abuse or trauma, mistrust of potential partners, a history of failed relationships, an isolated existence that does not provide access to potential partners, or lack of skill in attracting the “right” mate? Address these directly. There’s no beating love as a positive life factor. And, let’s not forget, a pet may be a lifesaver for isolated people, especially those whose lack of trust keeps them away from other humans. How many times have you had a patient say, “If it weren’t for my pet, I would have killed myself a long time ago”? I’ve had several.
- Touch: There are way too many people in the world starved for human touch. Its lack can be depressogenic, while its presence can be therapeutic. For many, being touched by others in other than the most minimal ways, such as handshakes, occurs only in the context of sexual activity. This may not be enough, especially when during sex a person feels more like an “it” than a “thou,” that is, more of a means to the end of another person’s sexual satisfaction than as a cherished partner. There are some patients who would benefit from what is called body psychotherapies that focus on touch, breathing, movement, and/or somatic sensing. Or simply, getting regular messages may help. And, of course, helping your patient develop the wherewithal to find an appropriate intimate partner would be best of all.
In coming posts I’ll discuss ways in which we as a field may be misconstruing the sources of depression and anxiety – too often as chemical imbalances – rather than understanding them as disturbances in an individual’s effective functioning in the world that are due to a combination of biopsychosocial vicious cycles whose components we can identify and intervene upon to disrupt them and introduce other virtuous cycles.
Let me know what you think. What interventions to “add the good” do you use?
“I think you can be depressed and flourish, I think you can have cancer and flourish, I think you can be divorced and flourish. When we believed that happiness was only smiling and good mood, that wasn’t very good for people like me, people in the lower half of positive affectivity.”
“If beautiful lilies bloom in ugly waters, you too can blossom in ugly situations.”
“Do what you can, with what you have, where you are.”
“I don’t need a friend who changes when I change and who nods when I nod; my shadow does that much better.”