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Psychiatry and Society
by Keith Russell Ablow, M.D.
January 1997

The Character of Mental Illness

My patient, a woman just past 50, broke into tears in my office. Her 19-year-old daughter, she explained, had just left home vowing never to speak with her again. Her relationship with her younger daughter, an adolescent, was also strained. Her marriage, while stable, had always lacked passion and given her little joy. "I can't eat or sleep," she wept to me. "I've lost weight. I can't focus on anything. I'm a bad person."

It was clear to me that my patient was suffering from major depression, symptoms of which include tearfulness, impaired sleep and appetite, and low self-esteem. The depression seemed to have started with the breakdown of relationships she valued. But, by talking with her over the course of several weeks, it also became clear to me that she was largely responsible for these losses. Her daughters were struggling with my patient's inability to let them to think for themselves and her obsessive need to control every aspect of their lives.

After learning more about my patient's own development I understood why she had intruded on her daughters' autonomy: As the product of alcoholic, unreliable parents, she herself had been prevented from developing a strong sense of individuality. She had chosen a "practical" husband, rather than a soul mate, and was relying on her role as a protector, confessor and teacher of her daughters to distract herself from an empty internal psychological world. If her children became independent adults, she would feel alone and barren, stripped of the emotional insulation they provided.

My patient recognized this truth about herself, but she found it impossible, even once antidepressant medication had relieved her severe symptoms, to look inward for solutions to her predicament, repeatedly blaming her daughters' callousness and selfishness for her sense of isolation. She said she lacked the courage to make positive changes in her life.

After many months of therapy, and her continuing failure to allow her younger daughter any independence, I came to agree with her. She could not muster the courage to change. Moreover, I came to believe that her lack of determination to face the facts about herself had made her vulnerable to depression in the first place. Her weakness of character had been the growing place for mental illness.

During medical school, I was taught that depression had nothing to do with a patient's character. Major mental disorders, my professors told me again and again, were just as random as diabetes or hypertension. They were quirks of genetics and physiology that could strike anyone. Assertions that depressed or alcoholic or psychotic patients were weak, or flawed, or different from the general population in any way, were worthy of condemnation. I echoed that view through my residency and the first years of my practice.

The boom in biological psychiatry and managed health care (with its severe limits on psychotherapy) further foster the notion that treating mental illness is a simple matter of matching the right drug to a particular symptom, leaving the patient as a bystander in his or her own care. The philosophy is that it matters what a psychiatrist is treating, not whom he or she treating.

But now, having treated a few thousand patients, I am beginning to wonder whether some forms of mental illness are more likely to strike individuals who lack strong character, and whether some of these individuals can be helped by being encouraged to take personal responsibility for their symptoms and their healing.

Another patient of mine was a depressed man in his 30s who had stopped working, constantly brooded over suicide and was providing little emotional or financial support to his young son. No combination of antidepressant medications seemed powerful enough to help him restore his mood and recapture his energy.

"You may have to start back to work while you're still feeling quite low," I told him. "Just getting into a dally routine again could help relieve your symptoms. And being available to your son may be one way to start restoring your self-esteem,"

"There's no way I could do that," he said, with some irritation. "Half the time, I can't even convince myself to get up in the morning."

"You'll have to convince yourself," I told him. "Because the alternative is your getting sicker and sicker. And people are relying on you to help pull yourself out of this. You have a duty to get better."

Telling a depressed person to help pull himself out of depression would be condemned by many clinicians. The notion that a mentally ill person is involved at all in his or her illness has become unpopular. But I believe my urgings were one reason my patient did start back to work. As his depression improved over time, I continued to remind him that he had the capacity and responsibility to influence the course of his illness.

There is no question that depression can drastically deplete one's energy and motivation. But I have witnessed patients like this man recapture their health partly through dogged persistence and determination to restore the activities and relationships that had sustained them. Is it wrong to suggest to such individuals that their prognosis depends, in part, on what they are willing to endure on the road to health--how much character they can show in the face of adversity?

When depressed patients complain that they feel worthless, should we always dismiss these feelings as the meaningless byproducts of a chemical imbalance? Or might it be that patients are trying to communicate real—albeit exaggerated—dissatisfaction with themselves characterologically, making a plea for someone to identify the weak links in their personality structure so that more solid ones can be forged? Perhaps depression is sometimes a kind of characterological alarm, alerting patients to the need for a reassessment of the ways in which they have been living their lives.

Psychiatry has been so cautious not to blame psychiatric patients for their disorders that we are well on our way toward cleaving them from their illnesses entirely, disempowering them from participating in their own healing. We seem to be telling them to sit back and let Prozac, Zoloft or Effexor do all the work.

Keith Russell Ablow, M.D., born in Marblehead, Massachusetts in 1961, is a psychiatrist, author and journalist. Dr. Ablow graduated from Brown University, the Johns Hopkins School of Medicine and the Tufts/New England Medical Center with a Residency in Psychiatry.