The Book of Woe: The DSM and the Unmaking of Psychiatry (29 page)

But there’s another possibility in the DSM, one that doesn’t ask me to look for the symptoms of ersatz diseases, but to pay attention to what Charlotte actually brings into my office: herself. Because Charlotte may be anxious and depressed and failing to adjust, but she is also the kind of person who arrives late for her appointment and then, as the clock approaches the end of her time, says, “You’re not going to throw me out of here now, are you?”

I tell her that we have to stop at the usual time, regardless of when we started. “Why does that feel like being thrown out?” I ask her.

“I can’t believe it. I killed myself to get here on time. Really, almost. I drove like eighty miles an hour. I can’t help it if the traffic was bad,” she says. “And anyway, what’s so important that you have to do?”

I don’t answer.

Her voice rises. “You don’t care about me, any more than a whore cares about a john,” she says. “And why would you? This is just your job. But why would anyone listen to me if it wasn’t their job? Look at me.” She sweeps her hand along her body, like a salesman demonstrating his product. “I’m fat and ugly and disgusting.” (She is actually trim and pretty, but this isn’t the moment to tell her that.) She has been fiddling with her hair the whole session, but now she’s tearing at it with such force that I can hear it ripping from her scalp and see strands falling onto the couch. “And you just pretend, and you’re not very good at it. You can’t wait to get rid of me.”

Which, at that moment, you wouldn’t blame me for saying, is sort of true.

That’s how Charlotte wants me to feel: like she feels, unloved and uncertain of herself and the others around her. And now that she’s landed her blow, she’s pulling even more frantically at her hair. “Okay, I get it. I’ll go,” she says. “And you don’t want me to come back, do you?” She rummages angrily in her purse, pulls out her checkbook, scrawls the check. But she is not only rebuking me. She’s also imploring me to assure her that her outburst hasn’t made me want to kick her out or punish her for being mean. Having made herself unlikable, she’s waiting for me to tell her that I like her.

Now, I might not go that far, but on the other hand, I didn’t kick her out of therapy. I’ll take a lot. Not because I’m a saint, but because this is what she is paying for: not indulgence exactly, but acceptance, the peculiar kind of love conveyed when I stand back from the action and participate in it at the same time, when I watch Charlotte flail and let her land her blows and respond to the pain she inflicts without taking it personally. And what I’m seeing when Charlotte is launching her attacks on both of us is not a disease. Neither is it an assortment of symptoms. It’s who she is, her character, forged out of the crucible of the family, that strange little enclave where we raise our young, each on our own, behind closed doors or in homes where, if you were lucky, there were the resources and the courage and the love that it takes to send a person into the world more or less intact, but if you were not lucky, if your parents were like Charlotte’s, so distracted by the exigencies of life in a strange new country, or so adept at ignoring what they could not afford to acknowledge, that a father could see his daughter as a sexual object and a mother could turn a blind eye—a lapse made even more unlikely, and yet somehow more inevitable, by the fact that the mother and her mother’s mother, as Charlotte found out recently, also grew up in incestuous families—if all those stars lined up and crossed you, then you too might have come to think that the disgusting thing that was happening was happening because you were disgusting, so disgusting that no one would care what was being done to you, you too might have figured that the best you could do was to shut up and take your lumps, and you too might have been seething all the time you were submitting. You might have been left desperate for love, and sure that you’d found it, until one little thing—an encounter with the tyranny of the therapist’s clock, his exercise of power over you, his disregard for your wishes—leaves you raging and unable to do anything but pour out the rage in a way that gets you rejected, unable to stop yourself, even as you watch yourself tumble, for maybe the millionth time, through that trap door in yourself and land in your own self-hatred.

Or you could be like the man whom Charlotte had married—Joe, I’ll call him. I met the two of them together when they came to see me about two years before the conversation I just described took place. Actually, they weren’t supposed to see me as a couple. Joe—eight years older, tall, good-looking, a wealthy businessman who wore his success on his monogrammed, gold-cuff-linked sleeve—had been referred by his lawyer, who thought it would look good to the judge if he was in counseling when his case came up. Of course, the lawyer didn’t put it that way. He just said something like “This guy could really use to be seen, if you follow my logic.”

It was hard to argue with that. Joe had been arrested after he’d punched a parking lot attendant in the face. He thought the worker had shown insufficient respect when he’d told Joe he couldn’t park where he wanted to. “Like it really mattered. Fucking moron!” Joe told me soon after he sat down, and before I’d had a chance to ask about the incident.

“That’s why you coldcocked him?” I asked. “Because he was a moron? Or just because he told you what to do?”

“Look, the space was empty. If he had bothered to think about it, if he wasn’t just going by some other stupid fuck’s stupid rules, then he would not have been hassling me,” he said. “It’s what’s ruining the country, the way people just follow rules without thinking, without figuring out if they should make an exception.”

“And he should have made an exception for you?”

“Of course he should have. I could have fit my car in there without any trouble. I know how to drive, for chrissakes. Any swinging dick can get into a car and step on the gas. But I’ve been trained. I did one of those week-long courses for Mercedes owners.”

Five minutes with this guy and I was already hating him. I changed the subject.

“Whose idea was it for Charlotte to come today?” I’d been surprised to discover her in the waiting room, the two of them perfectly dressed and groomed, flipping through back issues of
Home & Garden
. I was even more surprised when she followed him into my office.

“Both of us,” Joe said.

“But you didn’t tell me you wanted to bring your wife with you when you made the appointment.”

“Why? Is that a rule of yours?”

I guess I hadn’t changed the subject after all.

After I didn’t answer, Charlotte spoke up. “Actually, it was my idea to come. Joe was so upset about getting arrested and all, and then it got worse when he heard he had to come here. I thought there were certain things you needed to know, because you’d get totally the wrong idea if all you knew was that he’d punched some random dude. I thought you needed to know that Joe is a special guy, and how well he can treat people.” She put her hand on his knee.

“Don’t you think Joe can speak for himself?” I asked.

“Of course I can,” he said. “But I thought you would need proof that I wasn’t that kind of man.”

“Okay, well, it is a rule of mine. Not that spouses can’t be here, but that if you are here as a couple, then we’re going to be talking about your marriage or something like that. A joint business, a problem with your kid, a disagreement about your in-laws, or that you just can’t get along. But not as a character witness. My understanding,” I said to Charlotte, “is that Joe is here because he’s had this fight and this arrest,” and then I turned to Joe to say, “My guess is that this isn’t the first time someone who failed to appreciate you took it on the chin, Joe.”

“So what are you saying?”

“That if what you want to do is to figure out why this kind of thing happens to you, other than the fact that everyone else in the world is a moron, and what you can do about it besides punch their lights out, or why you are so afraid that everyone is going to dislike you, then I’m your guy. But if what you want is for me to help you or your lawyer win a case, or to make you feel like you deserve to be able to assault people, then I’m not. Because I’m sure there are reasons you feel that way, but I don’t think you deserve that.”

Joe stared at me for a second, probably the same way he stared at the kid in the parking lot. He stood up, pulled a money clip out of his pocket, tore off a hundred-dollar bill, and dropped it on my desk. “This ought to cover it,” he said. “I’ll tell my lawyer to find someone who can help.” Without a word, Charlotte stood up, too, and the two of them breezed out of my office. I can’t say I was sorry to see them go.

When she called me about a year later to tell me Joe had left her for a twenty-two-year-old woman and she needed to see me (“Because you were right,” she said. “You nailed what an asshole he was”), Charlotte was in the kind of agony that goes along with being a self, with having no choice but to be at the center of your world, and of finding nothing there but fear and self-loathing. But even as she began to get over Joe, and to understand that there is only the slightest difference between fitting another person like a hand fits a glove and sharing a pair of handcuffs, the anxiety and depression didn’t go away. They seemed less and less related to what had happened with Joe, more like the inevitable if regrettable outgrowth of who she was.

So I could diagnose her with GAD or MDD—she more or less fit those criteria—just as I could have diagnosed Joe, had he stuck around, with Intermittent Explosive Disorder, for he was surely a walking IED. But diagnoses like these don’t quite seem to do Charlotte or Joe justice, especially not when it seems so clear that what they suffered from wasn’t anything like the kind of illness that comes and goes like the common cold, or comes and stays like diabetes. Troubles such as theirs seem to arise out of their troubled selves. And as it happens, there is an entire section in the DSM devoted to describing those troubles, which the book calls
personality disorders
and defines this way:

A Personality Disorder is an enduring pattern
⁸
of inner experience and behavior that deviates markedly from the expectations of the individual’s culture, is pervasive and inflexible, has an onset in adolescence or early adulthood, is stable over time, and leads to distress or impairment.

The ten personality disorders listed in the DSM come last in the book. They also have their own diagnostic duchy, known as Axis II (as opposed to Axis I, where the rest of the disorders reside). This segregation, the book explains, “
ensures that consideration will be given
⁹
to the possible presence of Personality Disorders . . . that might otherwise be overlooked when attention is directed to the usually more florid Axis I disorders.” But I think the real reason lies in a more fundamental difference between the two axes. An Axis I disorder is what you
have.
An Axis II disorder is what you
are
. (Personality disorders share Axis II with mental retardation.)

Despite this crucial difference, personality disorders look like the other disorders in the DSM. Borderline Personality Disorder (BPD), for instance, the diagnosis Charlotte would qualify for, is a five-of-nine affair, with criteria like “frantic efforts to avoid real or imagined abandonment” and “markedly and persistently unstable self-image or sense of self.” Narcissistic Personality Disorder (NPD), another five-of-niner (including “grandiose sense of self-importance,” “sense of entitlement,” and need for “excessive admiration”), matches Joe pretty well. (And it’s not at all rare to find a borderline married to a narcissist.) But you can’t miss the Freudian echoes in these disorders.
Borderline
refers to the border between neurosis and psychosis, and
narcissistic
is a nod to Freud’s observation that some people treat the world as a mirror that they must shatter when they don’t like what it reflects.

But even if the names weren’t a dead giveaway, it would be impossible to conceal the fact that personality disorders are a throwback to the Freudian conviction that our suffering reveals the neurotic shape into which our timber is twisted by the psychosexual catastrophes of childhood and the impossible demands of society, and that treatment always involves a reckoning with those forces and the person they have made us.

The presence of personality disorders in the DSM preserves this old, officially out-of-fashion idea that personality underlies our difficulties. The book never comes out and says so, but Allen Frances wrote the personality disorders section of the DSM, and he’ll tell you unabashedly that this is the case. “
I think this is the best way
¹⁰
to see and treat most disorders,” he said. (Although it’s not the best way to get paid for treating them. Insurance companies don’t generally reimburse for those diagnoses, so even if you think that’s what you’re treating, you can’t tell them that.) But Frances was trained in those olden days, before the demands of science required psychiatry to distance itself from Freud by divorcing its account of our afflictions from their causes. It is as if the psychiatrists of his generation, the ones who saved their profession by meeting those demands, could not quite let go of the idea that who we are matters, and kept that thought alive on Axis II.

•   •   •

As Freud himself might have predicted, smuggling psychoanalysis into a DSM that claimed authority by purging it has created an internal conflict that yields no end of trouble.

“
I have never really been a doctor
¹¹
in the proper sense,” Freud wrote. That may be why in all his talk of neuroses and psychoses,
complexes and symptoms,
defenses and resistances, he remained uninterested in carving the psyche at its joints by naming its afflictions. He mostly ignored Kraepelin (who was a contemporary of his) and his parsing of mental disorders from one another. (Although he was pleased to pick up one of Kraepelin’s patients, Sergei Pankejeff, and turn him into the Wolf Man, title character of one of his most gripping case studies.) We all have parents, we all live stretched between instinct and conscience, between memory and desire, between brutality and civilization, so we all suffer degrees of the same illness; to have a personality is always to at least flirt with neurosis.