An Unexpected Sight in the Rearview Mirror

It is unusual, at age 75, to suddenly view more than 50 years of struggles in an entirely new light. Mr. Z, a careful and conservative man, has a history of recurrent serious depressions, which had been understood as autonomous, seemingly unrelated to the events of his life. These had been treated with medication and supportive psychotherapy. I was thus astonished when in a recent session he suddenly offered a compelling psychological explanation for every depression he had experienced—and a couple of childhood illnesses as well.

Mr. Z came to see me when he was in his early 60s, after his prior psychiatrist closed his private practice. Unless there is something of unusual concern, he comes in for a half session about every 6 weeks, almost always telling me that he’s doing fine, typically saying that not much of significance is on his mind. I have the impression that he expects these sessions to have a magical ability to help prevent recurrences of depression. We chat about his business and his family, his hobbies, and his need to keep busy. He has owned a small business for many years and has no thoughts of retiring. Occasionally I renew his bupropion prescription.

While the treatment is largely supportive, I have been well aware of Mr. Z’s tendency to contain himself emotionally, and to take a rather dour, self-punitive attitude toward himself. When the opportunity has presented itself I have pointed this out to him, and he acknowledges it. Despite viewing his emotional life with some suspicion, he occasionally mentions a dream. A dream in the session prior to the remarkable one I will soon describe involved Mr. Z driving a car that was skidding on an iced-over pond. Initially it sounded scary and dangerous, but as he elaborated the circumstances, it appeared that he was “letting himself go” a little bit, allowing himself to lose control in a situation in which it was safe and he would not crash into anything, a rare relaxation of the usual restrictions.

In the following session, Mr. Z came in with another dream. In the dream a customer of his from decades earlier complained to Mr. Z that his products were no good. He wanted to return them, a significant financial problem. Starting at the surface, I asked Mr. Z if there had been any problem or difficulty that had preceded the dream. The answer was no. But Mr. Z knew enough from our prior exchanges to then pose the opposite question: had there been something favorable, with the dream expressing his characteristic self-punitive attitude? He answered his own question: “Now that I think about it, the day before the dream I had just been thinking how great things are—my kids and grandkids are all doing well. My wife is healthy. Business is good.”

Mr. Z, newly struck by the reality of his self-punitive attitude toward success and enjoyment, suddenly began to reconsider his depressions. His first depression was after his first semester of college. He had gone to a top college he hadn’t expected to get into. At the end of the semester, “I realized, hey, I can do this,” and then he got depressed. His next depression came just after he graduated and got married, nearly simultaneous events about which he was very pleased and excited. A depression in midlife followed the death of his mother from Alzheimer’s disease. He was aware of feeling guilty at his relief when she finally died. Amazed at these revelations, I said to Mr. Z, “What about your depression nine or ten years ago, after you and I began to work together? I could never understand what might have precipitated it.” His reply was immediate: “I had two maiden aunts I was taking care of as they declined. I was due to inherit from them. I felt very guilty about it.”

Having established the role of guilt over pleasure, success, and relief in every one of his depressions, Mr. Z might have rested on his laurels, but he wasn’t done. As a child he was fascinated with trains and boats. (As an adult, Mr. Z has a phenomenal knowledge of the history of railroads in his region.) He now recalled that there were two great, much-anticipated journeys of his childhood, one by boat, one by train. A frequent and happy traveler on boats and trains, at the beginning of each of these longed-for trips he suddenly got sick with nausea and stomach cramps, events he now understood as anxious punishments for anticipated pleasures.

Not given to flights of fancy, Mr. Z harbored no illusions that these realizations would dramatically alter his life. But now he tries to make use of the essential observation about how his mind works. He takes a bit more pleasure in his successes. He wonders if a pessimistic conclusion or feeling has arisen in reaction to something favorable. Will this bit of self-knowledge help to prevent future depressions? Time may tell.

Many factors contribute to depressions. Many, but by no means all, are psychological. Yet, especially in this era of brain and biology, we must always be aware of the mind—and allow for it to surprise and amaze us.