Reflections From A Chair

I’ve just finished the first draft translation of Pierre Janet’s “THE OBSESSIONS AND THE PSYCHASTHÉNIE, Book 1.” This turned out to be one of those things I’d never have done if I knew what it entailed from the start. It’s 468 pages in length and required 4 hours a day for the past 7 months. So, here I’ll note some of my methodology in case somebody else takes on a similar project, maybe it can save them some time and trouble.

First, this would not have been possible for me to do without the internet. Google books has a copy of this book digitized, view it here. I downloaded that, which saved an enormous amount of typing.

My approach was to read the text first and get a general idea of the translation. Next I copied, usually 3 or 4 sentences at a time, the digitized text and fed it into three different translation engines.  After a lot of experimentation, the 3 engines that I found best, in order of helpfulness, (your experience may vary) were:

1) Reverso
2) ImTranslator
3) FreeTranslation

Though I generally love all things Google, Google Translate was not very helpful in translating sentences. It does, though, do a good job on single word translations or monkeying around with various definitions of short phrases. The same was my experience with the Bing translator. There are a number of other translation engines out there, but I didn’t find any of them useful.

Next, I copied each of the engine translations and pasted them into a notepad. I compared each for accuracy. Then I would check the definition of each word in online dictionaries. Again, those that I found most helpful are listed in order of importance:

1) Sensagent
2) WordReference
3) Google Translator

Once more, there are any number of other French to English dictionaries out there. In my own experience, I rarely found them helpful. I even paid for a subscription to the Oxford Language Dictionaries Online, yet I found the free versions of Sensagent and WordReference to be superior. And, of course, I have a few of the standard reference hard copy dictionaries.

With some frequency, this was not sufficient to render a good translation. My next recourse was to the forum at WordReference. I usually found my question already asked and answered. On a couple of occasions, I posted my question about the translation and was deeply impressed by the helpfulness and thoroughness of the response. For example, for the life of me, I couldn’t understand what Janet was talking about regarding a method of urinalysis. I posted the question and was taken aback by the abundant assistance from the forum members. You can see that post here. All I can say is wow. The other forum members went so far out of their way to help a complete stranger, me, as to read an obscure chemistry journal from the late 1890′s so that the translation would be technically correct. Wow.

Sometimes, when all the above failed, it was necessary to plug a word or phrase into Google itself and see what came back. For example, the words “pays du tendre” don’t make much sense when strictly translated. Reverso brings back the translation as “country of the soft.” Hmm. Toss that phrase into Google and we find that it was a literary and intellectual movement in 17th century France. This sort of fishing expedition was required more often than one might think.

There are some other internet-related techniques that I picked up along the way, but these were the main ones, the most helpful ones.

Now I plan to take a break from the translation, then come back to it and proof read it. In the meantime, I’m paying someone, much more adept in French than me, to check the translation against the original. After that, I’ll either look for a publisher or just post it in the blog.

In response to a recent request, I am posting my translation of Janet’s analysis of Nadia in his book, The Obsessions and The Psychasthenia. The original version, in French, can be found here. This selection begins on page 33 and carries on to the top of page 41.

One or two quick comments. I would encourage the reader to recall that this was originally written in 1903. Many terms in psychiatry have undergone significant changes since that time. So delirium, for instance, today has a quite more restriced meaning than it did 107 years ago. Also, his writing style should be taken in the context of the early 20th century. If anyone finds a difficulty in my translation, I would be indebted if you informed me of it.

Janet is here making a differential diagnosis on a very ill woman named Nadia who is initially thought to have an eating disorder. Janet is, at the same time, illuminating his conception of obsessions and psychasthenia.

I would strongly encourage the reader to review the thoughtful and knowledgeable comment about this case submitted by James Meadows.

Without further delay, here it is:

5. – The obsessions and impulsions of the shame of the body.

This idea of contempt of oneself, this obsession with personal dissatisfaction is often on the physical person, on the body. Patients in whom we find this dissatisfaction with their bodies are very numerous, they form a unique group that we could not suspect the importance of before seeing them frequently. You could call them all “ashamed of their bodies.” The most complete have an obsession on their whole body in all its parts and thus their general obsession is divided into a number of small specific delusions. Others go less far in the same line and their obsession with shame is not primarily the body, but it is systematized on this or that part, this or that function of which they are particularly ashamed. I will first pay particular attention to a remarkable case that gives an overview of the first group, and then I shall choose a few specific examples that show the shame concerning this or that function.

A curious observation, that it is unfortunately impossible to present without going into countless details, is that of Nadia (166), a girl of 27 years, whom I managed as much as possible for more than five years. This girl came to me with the somewhat superficial diagnosis of hysterical anorexia. This diagnosis was justified simply by a more than bizarre diet that the patient imposed upon her family for years and by the appalling scenes she made when they tried to change her regime. She prescribed to herself two soups a day in a light broth, egg yolk, a tablespoon of vinegar and a cup of an extremely strong tea in which she had put the juice of a whole lemon, carefully pressed. They had been able to discover, which was not difficult, that she had imagined this regime in the fear of getting fat, and they concluded a hysterical anorexia.

Hysterical anorexia is already by itself a very strange disease, which is far from being fully elucidated. In its typical form, it is not as common as we think and confirmed hysterics frequently present this phenomenon among their countless accidents. Vomiting, regurgitation, various spasms of the esophagus, stomach, diaphragm, muscles of the abdomen also determine the eating disorders and are much more common than anorexia itself. In the presence of a case of complete refusal of food, we must, if I do not make a mistake, be wary and think that mental disorders of varying severity may be more likely than hysteria itself.

In any case, we admit for the present this hysterical anorexia; to make the diagnosis it is necessary to find at least a certain number of characteristic symptoms. Of course, it would be good to find clearly hysterical phenomena either currently or in the historical record. Unfortunately, we know that this symptom is frequently isolated, at least in its early stages. If you cannot find the signature of hysteria, it is my opinion that the refusal of food has two main characteristics.

1° You must note the complete or nearly complete suppression of hunger during almost all of the illness. This loss of hunger is often accompanied by considerable disturbances in the feelings of the mouth, either for taste, or even for touch, of anaesthesia of the pharynx, by disturbances of the movements of jaws and cheeks, anaesthesia of the esophagus and probably the stomach with or without the spread of this anaesthesia in the skin of the epigastric region. Is the loss of hunger directly related to these various anaesthesias of the mouth, the esophagus, the stomach that often but not always accompanies it? It is a problem that I discussed at length in my lectures at the Collège de France on the consciousness of the body and its functions. Without being able to go into this discussion here, I shall say only that the anaesthesia of these organs, when it exists, contributes to the elimination of hunger and, consequently, it plays a role in the diagnosis of hysterical anorexia.

2° A second symptom, more curious and much less analyzed, although it was pointed out long ago, I think is also important: that this exaggerated need for physical movement that accompanies true anorexia. Patients move constantly, make great walks, dance in the evenings, push themselves too hard in a thousand ways and there are as many scenes to retain their exaggerated walks as for refusing food. This symptom has been interpreted in various ways. Lasègue sees the result of a calculation: “these people,” he said, “are afraid to be taken as patients; they fear that we might use their weakness as an argument to force them to eat and so they simulate great activity.” Mr. Wallet regarding two curious observations, sees a technique by the patients to augment their weight loss. They do the exercise, as they drink vinegar, to lose weight. Without denying the role that such reasoning may have played in some special cases, I can accept only that this great, general symptom always depends upon reflections, in fact, quite complicated.

In some interesting observations that I discussed in my classes, I could show that the exaggeration of movement sometimes comes earlier than refusal of food and therefore precedes all these arguments. In a very curious case, a reasonable woman of thirty-five years, comes to me seeking treatment, and therefore does not seek to deceive. In her anorexia, which is very rare, is a repetition and it proceeds by fits and starts. Following an emotion, she feels excited and shaken up as if she was carried off like a feather. She has the need to gesticulate, to speak, to walk. She no longer returns to her home, but she still continues to eat, while saying she does not feel the need for more “because she is strong enough without it.” Then two days later, she was disgusted with “useless” food and she began to refuse to eat.

One approaches the truth by saying that muscular anesthesia and especially the anesthesia to fatigue plays a role in this perpetual motion. I think we must go further and say that in this feeling of euphoria there is a genuine excitement in connection with the emotions of a particular mechanism, if one prefers anatomical language, a true excitement of the cortical motor system. This stimulation seems to play a significant role in the loss of the feeling of hunger, perhaps more important than that of anesthesia in the stomach, because hunger, before the feeling of the involvement of various reflexes of nutrition, is a general feeling related to the impression of weakness and exhaustion. In any event, it does not suffice that a young girl refuses to eat or even that she obviously has the fear of getting fat for us to call her condition a hysterical anorexia. It is also necessary, in addition to the various symptoms of hysteria that we can see, that there is a considerable decrease in the feeling of hunger and an exaggeration of movements. Was it so in this patient, Nadia, to whom I return?

This patient, who was examined many times with great care, never presented the slightest signs of hysteria. She has no decrease of sensitivity, not in the epigastric region or in the rest of the body. In her history there is noted an appalling anger, but she is described as free of attacks of hysteria. What is more important, she has no true anorexia at all. She has perfectly preserved the feeling of hunger. Often, it is true, in the last period of illness, hunger is masked, because there are inevitable stomach problems after years of this regime, but usually Nadia is hungry, she even gets very hungry. This is reflected first by her actions: from time to time, she forgets herself until she greedily devours everything she encounters. In other cases, she cannot resist the urge to eat something, and she takes the cookies secretly. She feels horrible remorse for this act, but she resumes it all the same. This can be seen even better by her very curious secrets. She acknowledges that she needs to make a great effort to go without eating. “She is a heroine to have been able to resist for so long a time… Sometimes I spent hours thinking only about food, I was so hungry: I swallowed my saliva, I bit my handkerchief, I rolled on the floor, so much I craved to eat. I was looking in books for descriptions of meals and great feasts, and I tried to cheat my hunger by imagining that I tasted all these good things. Really, I was absolutely starving, and despite some failures with cookies, I know I had a lot of courage.” Is it hysterical anorexia that she speaks of? In addition, in no way does Nadia present the unrest of hysterical movement. It is interesting to note that she makes the precise reasonings of which Lasègue speaks. She sought to work well, to walk to her courses so that her mother was not worried about her refusal of food, and the exercise made her lose weight, but that cost her a painful effort that she did only by necessity; most often, and especially now, she wants to stay quietly in her room and feels no need to walk and spend her strength. The disease is therefore different: the refusal of food is only the result of an idea or a delusion.

This idea, if one considers it in a superficial way, is evidently the fear being fat. Nadia is afraid of becoming strong like her mother; she is anxious to remain lean, pale, only that pleases her, is in harmony with her character: of her continual anxiety, she is afraid of to have the swollen face, to puff, to have big muscles, to get a better complexion. One must take great care to avoid making compliments on her health, a blunder by her father who, seeing again her at the end of some months, said that she looked well which began a serious relapse. We must be prepared to answer the questions that she constantly poses: “Please, tell me what you really think? Do you find that I have big, round and pink cheeks since I am eating more? Out of the kindness of the heart, tell me and console me, I beg you. Did you find me as thin as other times? Do me the pleasure of telling me that I shall always be thin… Look, today I was in a hansom cab that did not walk, the horse could not drag me, it’s because of these chops you make me eat. I beg you, reassure me.”

But this obsession is not at all an isolated and unexplained obsession, as sometimes happens in hysterics. It relates to a system of extremely complex thoughts. First, stoutness is not only considered from the point of view of an interest in one’s looks: it presents to the patient something immoral. She always repeats: “I do not want to be pretty, but I would be too ashamed if I became bloated, it horrifies me and if by misfortune I got fat, I would not dare to let anyone see me, neither in the house nor in the street, I’d be too ashamed …” And notice that it is not the obesity itself that appears to her to be shameful. She loves people who are very stout and finds that it suits them, but for her it would be immoral and shameful. This is not just stoutness, but also it is all that is linked with the act of eating that deserves this character.

She began to refuse to eat with other people: she must eat alone, as in secret. Truly, if one can permit such a comparison, she hides to eat, she is embarrassed to do the act in front of someone, as if asking her to urinate in public, and, moreover, she recognizes that the comparison is fair. When she happens to eat a little more, she is still in hiding; there are protests to pardon her as if she had committed an indecency. At the time of the Christmas holidays, she took the liberty of tasting some boxes of chocolate sent by her friends. She wrote me more than ten letters on this subject, confessing as a crime each of her bonbons, trying to explain, by a feeling of greed or curiosity, an act that she regrets so much. She would have been very ashamed if they had surprised her in the act. Not only must they not see her while she eats, but they must not hear her as well. Mastication is something so vile that, if you could hear her, it would make her go underground. Here again, it is not the behavior of eating in general that she despises: you can eat in front of her; she found nothing reprehensible in that, on the contrary, she is happy to offer something to people who come to see her. But it is the chewing to her “that makes a special noise, ridiculous and disgraceful. I am willing to swallow, but do not force me to chew.”

We should not believe that this shame limits itself to being overweight and to the act of eating. Nadia has other torments.

Although she is thin and has rather pretty traits, she is convinced that her face is not only bloated but also red and covered by spots. As I did not succeed in seeing these so-called spots, she declared of me that “I know nothing and I do not recognize spots that are between the skin and flesh.” Anyway, they give her an abominably ugly face and although she has no vanity, a self-respecting person cannot allow such a face to be seen. Alongside the refusal of food has developed another delusion that has been too little noticed, it is the fear of going out into the street. There are horrible scenes in order to go out for a little while, by closed carriage. It is necessary that the coachman and the housemaid look away when she rushes into the carriage. She goes out more easily in the evening, in deserted places, where there are few risks of her being seen. Even in her room, if I let her do so, she would maintain a semi-darkness and she is always situated in the darkest corner, her back turned to the light. If they did not stop it, she would not delay in, as a patient whom I knew, living in complete darkness.

If her face embarrasses her so, the other parts of her body are left far from indifferent. Since the age of four years, she claims, she has been ashamed of her size, because they said to her that she was big for her age. Since the age of eight years, she began being ashamed of her hands which she finds long, ridiculous. Towards the age of 11 years, as she wore short skirts, it seemed to her that everybody looked at her legs and she could no longer endure them. She needed put on long skirts and then she was ashamed of her feet, then of her too broad hips, of her arms with big muscles, etc. Of course, the arrival of puberty singularly aggravated all these strange feelings. Menarche made her half-mad. When she started growing pubic hair, she was convinced she was alone in the world with this monstrosity and up to the age of 20 years, she plucked “to remove the savage ornament.” The development of breasts especially aggravated the obsessions, because fears about modesty were added to the old ideas about obesity. At this moment, especially, she began completely refusing to eat and no longer want to show herself. By all means possible, she tried to conceal her sex, of which she is particularly ashamed: her blouses, her hats, her hairstyles should be closer to the male costume. She cuts her hair half-long and curls it and she would like to have the appearance of a young student. It should not be thought that here is a sexual inversion, as is assumed too quickly in such cases. She would be as ashamed to be a boy as to be a girl. She would like to be without any sex, and she would even like to be without any body, for we see that all parts of the body determine the same feeling of which the refusal of food was just a very partial manifestation.

What is deep down the dominate idea that determines these singular assessments? Modesty certainly plays a considerable role and this feeling is pushed to quite an extreme. Not since the beginning of childhood could she undress in front of her parents and until the age of twenty-seven, she had never consented to be auscultated by a doctor. But she combines with it a crowd of things: vague guilt feelings, reproach relating to greed and all kinds of possible vices. She herself blends in an especially more interesting feeling, that we already noticed about the preceding obsessions and that will become more and more important with our Scrupulous. “I did not want,” she says, “to put on weight, nor to grow, nor to resemble a woman because I would have liked to remain always a small girl.” It is obvious that this desire to remain a child played a considerable role, for what she always dreaded is to develop, more than to actually get fat. But why this desire? The reason for this strange desire is summed up in one word that many patients repeat to us: “Because I was afraid of being less loved.” Deep down, this is the idea she has, when she is afraid of being ugly, of being ridiculous. “They will laugh at me and love me no more. They will discover that I am not like everybody else and they will love me no longer. If they could see me well in full light, they would be disgusted and not love me anymore.”

This desire to be loved, this worried fear that one does not deserve the affection that one so desires mingles certainly in this case with the ideas of possible faults and fears of modesty to produce this obsession with body shame and all the impulses to refuse food, to lose weight, to hide oneself that we have just seen. It will be used again in the following observation.

© Translated by Michael W. Adamowicz, LICSW, LLC. All rights reserved 2010.

A partial explanation for the delay between posts is that I am devoting all my free time to translating Pierre Janet’s Les obsessions et la psychasthénie. It is a very lengthy work and the translation is a wildly time-consuming project.

In doing that, I came across a reference to distinguishing between depressive and anxiety disorders based, partially, upon the degree of certainty that one is damaged. This, you may recall, was the topic of a number of my posts about a year ago. Those posts began with a review of the book Joker One. And then continued on in an analysis of Romeo and Juliet.

In any event, Janet provides a hint that he thinks along the same lines on page 25 of Les obsessions et la psychasthénie. Here is a translation of what he says:

“It is not her only regret, because she is equally dissatisfied with the things for which she can consider herself responsible. It is unnecessary to emphasize each mental function: all the questions we pose to Claire have the same answer, how she speaks of her memory or her reasoning, imagination or even of the acuteness of her vision, it will always be the same thing. She is not good, she is not polished, she is not affectionate enough, she is not smart enough, not active enough, and not more capable of feeling; she is no longer good for anything. If we press too much to show her exaggerations, she always answers by this argument: “You did not know me in the past; I was hundred times better, softer, more patient, more intelligent, etc. I have not only lost the will and conscience, but I lost everything that made my intelligence.” Taken to this degree, these obsessions bring to mind the madness of melancholy and is, in fact, at least by its content, a melancholic delirium. Only when we study the form taken by these obsessions, shall we see what separates the Scrupulous [obsessives] from the melancholic [depressed]. This can be anticipated here in a word. This is because the melancholic is deeply convinced of its degradation, while Claire is very far from completely believing everything she says or thinks about this subject.”

When I get further along in the translation to where Janet becomes more specific on this topic, I will detail it in a future post.

Couples Therapy for Robert and Julia (Romeo and Juliet)

Julia and Robert have come to my office. We are discussing their desire to elope.

I’ve just asked Julia if there is any way that her parents would agree to delay her return to their home island in Portugal.

Julia: I tried to get my father to delay my trip. He went crazy on me. This is exactly what he said: “You’re going to São Miguel. And if you don’t go on your own, I’ll drag you there. You disgust me, you little bug! You worthless girl!”

I cried and cried. I said, “Father, I’m begging you on my knees, be patient and listen to me say just one thing.”

He just wouldn’t listen. He went on and on. “Forget about you, you worthless girl! You disobedient wretch! I’ll tell you what. Go to the airport on Thursday or never look me in the face again. Don’t say anything. Don’t reply. Don’t talk back to me.

“I feel like slapping you. Wife, we were cursed when we had her. She disgusts me!”

My mother and my assistant tried to help me. It was useless. The longer he yelled, the angrier he got. His last words to me were:

“If you don’t act like my daughter, you can beg, starve, and die in the streets. I swear on my soul, I will never take you back or do anything for you. Believe me. Think about it. I won’t break this promise.”

Then my father stormed out of the room.

Me: What did you do then?

Julia: I begged my mother and my assistant for help. I said, “Mother, don’t throw me out! Delay this trip for a month. Or, if you don’t delay, make my travel plans to my grave.”

Me: Did you mean that? Do you want to die instead of returning to São Miguel?

Julia: Yes, of course I mean it! How can I marry Robert if that happens? I’d rather die than live without him! If everything else fails, at least I have the power to take my own life.

Me: But what if they insist that you leave on Thursday or get thrown out of the house?

Julia: I have a plan for that.

Me: Can you share your plan with me?

Julia: Well, it’s not really my plan. I went to the parish priest after the fight with my parents. He’s from the islands and I thought he might have a solution for me.

Me: What did you say to him?

Julia: I said, if you who are so wise can’t help, please be kind enough to call my solution wise. Then, I showed him my knife. I told him, I’ll solve the problem now with this knife. Love joined my heart to Robert’s. Before I go to São Miguel and am married to another man, I’ll kill myself. You are wise and you have so much experience. Give me some advice. I want to die if what you say isn’t the solution to how I can be with Robert.

Me: What was his plan?

Julia: This is what he told me to do. He said:

“Tomorrow night make sure that you are alone. When you’re in bed, take this vial, mix its contents with liquor, and drink. Then a cold, sleep-inducing drug will run through your veins, and your pulse will stop. Your flesh will be cold, and you’ll stop breathing. The red in your lips and your cheeks will turn pale, and your eyes will shut. It will seem like you’re dead. You won’t be able to move, and your body will be stiff like a corpse. You’ll remain in this deathlike state for forty-two hours, and then you’ll wake up as if from a pleasant sleep.

“Now, when your father comes to get you out of bed on Thursday morning, you’ll seem dead. Then, as tradition demands, you’ll be dressed up in your best clothes, put in an open coffin, and carried to the church. Meanwhile, Robert will come here, and we’ll keep a watch for when you wake up. Then we’ll seal the coffin and nobody will be know that you’re not in it. That night, Robert will take you away to New York City. This plan will free you from your shameful situation as long as you don’t change your mind, or become scared like a silly woman and ruin your brave effort.”

Me: (I look at Robert) You know about this plan? What do you think?

Robert: I trust the priest. We’ve both known him forever. If this is what he thinks is best, then I’m willing to try.

Me: But suppose the medicine is too strong? Suppose Julia doesn’t wake up from the coma or suppose that she dies instead?

Robert and Julia together: It will work.

Me: But the priest is not a doctor. Suppose something goes wrong. Robert, how would you feel if something bad happened to Julia?

Robert: Well, I’d be the one to find her. So I’d just drink the same poison, and kiss Julia good-bye. That way I’d die with a kiss.

There’s no other way. Either we do what the priest suggests or she leaves the country next Thursday.

Me: (to Julia) You know about his plan to suicide if you die? Do you approve of it?

Julia: I wouldn’t say that I “approve” but I can understand it. I’m not worried, I’m not going to die so he won’t have to either.

Me: Suppose we try to come up with a different plan. If we could find one, would you agree not to take the priest’s advice?

Robert: For me, I’m in favor of our plan. We’ve already discussed it. We both think it’s our only option and that it will work. No offense, but I trust my priest more than I trust you.

Me: Julia, what do you think?

Julia: I agree with Robert.

Me: Julia, you mentioned your assistant. She seems to know about your situation. What does she say?

Julia: Well, she was helpful in the beginning. But then she agreed with my parents. She said, “Since things are the way they are, I think the best thing to do is leave for São Miguel.”

Me: So you don’t think that she could help us come up with an alternative to your plan?

Julia: No.

Me: There’s nothing, then, that can replace your current plan?

Julia: No.

Robert: Can’t think of anything.

Me: Well, to be honest, this plan makes me nervous. It sounds too close to a suicide pact. Or that’s what could happen, anyway, if even the smallest thing goes wrong.

Robert: (talking over me) Well, it’s our only way to be together and we’re both willing to take the risk.

Me: Oh, gee, I forgot to tell my receptionist something. I’m really sorry but I need to step out for a second. I’ll be right back.

I go to the receptionist and ask her to call 911 for me. I tell her that the couple has a suicide pact and needs to go to the hospital for evaluation.

When I go back into the room, I going to explain what I’ve just done. Both of them are very angry. They threaten to bolt from the office. I explain that the police will be here before they get to the street. I also explain my rationale for calling the police and rescue. Their pact was too dangerous. My duty is to preserve their health and well-being. Therefore, I had to call the police. I offer to continue treatment after they are safe and stabilized.

Julia breaks into uncontrollable sobs. They make all sorts of objections and threaten to sue me for violating their confidentiality.

After a few more minutes, there is a knock on my door and the rescue team comes into my office.

It will surprise no one that I am not as bright as Shakespeare. Try as I would, I could not resolve the dilemma that Shakespeare created for Romeo and Juliet with a smooth therapeutic move. Just as in the play, the resolution could only come from drastic measures.

The Chorus tells us this in the opening Prologue: “For the next two hours, we will watch the story of their doomed love and their parents’ anger, which nothing but the children’s deaths could stop.”

This was not my intended treatment outcome. However, I have no alternative. I tried several versions of this post. I used every way that I could think of to solve their dilemma without involuntary hospitalization. None of it, though, rang true to the situation or the dialogue from Romeo and Juliet.

Their circumstances are too acute and progressed. Neither of them, in my opinion, can be trusted not to act on their plan. They might even devise a more risky, impulsive course.

As Robert says, they trust the priest more than me. Our therapeutic alliance is in its nascent stage and still weak. Their thinking is concrete and action-oriented. Interpretations of their situation and plan do no good in this case. For instance, I might try to point out to Julia that her plan has at least as much to do with parental rejection as it does with love for Robert. She plans to do to herself what her father threatened. Instead of his threat that she “beg, starve, and die in the streets,” she was planning a death in her own bed. Julia would laugh at me for that interpretation. The therapy has not progressed to the point where she could use such an explanation.

Furthermore, even on a more concrete plane, they reject my offer to help problem-solve and find other options.

Neither of them can identify a trustworthy external support. That is, of course, except for their parish priest. And he designed the plan to enter a drug-induced coma.

I have found few internal resources that either of them has to self-sooth or to improve their judgement and insight. They are both overwhelmed.

Their anxiety is fueled by a fear of losing one another. Additionally, for Robert, the fear of a return to deep depression is intense. The anxiety is propelling them toward ever more dangerous and hastily conceived actions.

Even though their plan stems from anxiety and is in itself intensely anxiety provoking, it keeps their hope alive. Seeing their plan as foolhardy would leave them without hope. And that would place them on the threshold of depression. So, rather than see the reality of their situation and cope with it accordingly, they lunge into anxiety and near irrationality.

I do not want to give the impression that all cases of anxiety guarding against depression lead to such an outcome. Recall Donovan Campbell; he certainly did not meet the criteria for psychiatric hospitalization.

Hospitalization could go either way for Robert and Julia. It might make them more emotionally and cognitively available for treatment. Or, they may lose their trust in therapists and shun any further therapy. At the least, the families will find out about their plans to wed. Any immediate repercussions of that can be handled in the safety of the hospital.

If any readers can suggest a viable alternative to involuntary hospitalization, I’d be appreciative.

I want again to acknowledge that the overwhelming majority of the dialogue for Robert and Julia comes verbatim from No Fear Shakespeare’s modern translation of Romeo and Juliet.

This is the seventh post in this series. If you are just starting in this series, then it would help you to read at least the fifth post to get the background on today’s discussion.

As a refresher, this is a “case study” of Robert. He is a single male in his early twenties. Robert was recently in a Major Depressive episode and now presents with anxiety. The precipitant to the depression was Robert’s unrequited love for a woman. The anxiety came in the context of falling in love at first sight with a second woman. Robert is seeking treatment to help him plan an elopement with the second woman, Julia.

Robert’s situation is a mess. For the past two days, Robert has acted impulsively. He was not using good judgement or insight. Julia has plans to return to São Miguel, a Portuguese island, and may marry a man there. Both Robert’s and Julia’s families intensely dislike each other. None of their parents would approve of the marriage. Further, Robert is at high risk for a relapse back into Major Depression. Ominously, Robert says that he would rather kill himself than live without Julia. However, today there is no inclination to suicide and he anxiously anticipates happy days in the near future.

We are still in Robert’s initial evaluation. I am about to present him with treatment options. In the last post, I ruled out offering him help in problem solving his elopement.

There is possibly another way to meet Robert’s request for a speedy resolution to his anxiety symptoms and improving his ability to plan the elopement. That would be a referral for a psychiatric medication evaluation.

I could suggest to Robert that he see a psychiatrist. He can ask about medication for the anxiety and the depression. An anxiolytic might provide relief from most of the anxiety symptoms within a half-hour of ingesting it. Freed of the anxiety, he could think more clearly. Robert could then probably figure out for himself how to marry Julia. The anti-depressant, on the other hand, would take 4 to 6 weeks before having an effect.

Perhaps, though, the anxiety serves more masters than we have seen so far. Symptoms can have a pig pile of underlying motivations. More formally stated, Robert’s anxiety might be overdetermined. That is, the ego is trying to satisfy a number of demands on it through the one symptom of anxiety. We have already seen that Robert’s anxiety is a defense against a return to depression and the possibility that time and events (e.g., Julia’s return to São Miguel) would prevent him from marrying the woman he loves. Let’s see if there might be other factors in his anxiety.

Robert says that he is anxious in large measure because he wants to be married as quickly as possible. He can then be with the woman he loves. He says that he wants it so badly that he cannot think straight. However, one potential subconscious purpose that the anxiety may serve is exactly the effect it is wreaking. Maybe one point of the anxiety is specifically to disrupt or prevent Robert’s elopement.

There are many reasons why Robert might subconsciously use anxiety to derail his marriage plans.

In Freud’s “The Ego and the Id,” he writes “…the ego seeks to bring the influence of the external world to bear upon the id and its tendencies, and endeavors to substitute the reality principle for the pleasure principle which reigns unrestrictedly in the id.” The reality confronting Robert stands directly opposed to marrying Julia. Robert is aware of this. His desire to elude reality accounts for some large measure of his haste to wed. Robert’s ego could use the anxiety as a means to bring reality to bear on his impulses.

Furthermore, the marriage would bring parental disapproval and rejection. The anticipation of this disapproval and rejection may cause some anxiety. He can also anticipate his own guilt feelings about breaking their rules. Expecting guilt in the future produces anxiety as well.

Freud puts it this way in “The Ego and the Id:”

“As a child grows up, the role of father is carried on by teachers and others in authority; their injunctions and prohibitions remain powerful in the ego ideal and continue, in the form of conscience, to exercise moral censorship. The tension between the demands of conscience [what Robert knows he ought to do in the eyes of his parents and society] and the actual performances of the ego [Robert's scheme to marry Julia without his parents' blessing or knowledge] is experienced as a sense of guilt.”

After all, his parents do seem concerned about him and love him. His father has said: “If we could only find out why he’s sad, we’d be as eager to help him as we were to learn the reason for his sadness.” (Act 1, Scene 1, Page 8 ) His mother also expressed concern for him: “Oh, where’s [Robert]? Have you seen him today? I’m glad he wasn’t here for this fight.”(Act 1, Scene 1, Page 7) We can reasonably assume that hurting his parents would cause guilt for Robert. Therefore, the anxiety would be protecting him against hurting his parents and the guilt that he would experience for bringing suffering to them.

We could hypothesize a number of other subconscious uses for the anxiety. But we’ll leave it here for the time being.

There are many instances where it is desirable to remove or reduce severe anxiety as quickly as possible. In those cases, anxiolytic medications are very useful. I think, though, that Robert is better off without the immediate introduction of medications. Removing the anxiety removes some of the emotional barriers to carrying out his impulse-ridden plans. That is, in my judgement, it is in Robert’s best interests not to elope in the next few days.

Getting some Klonopin or Xanax or another anxiolytic today would be roughly the same as helping him problem solve the marriage today. For the same reasons I ruled out helping him problem solve the elopement, and the reasons mentioned here, I would not want him to get the medicines now.

Some bad situations have unseen benefits. In Rhode Island, the state where I practice, it takes about six to eight weeks for a new patient to get in to see a psychiatrist. Usually that is thoroughly undesirable. But not this time. Such a lengthy wait means that I can refer Robert to a psychiatrist today. However, he won’t get an appointment any time soon. That, in this case, is a good thing. It will buy some time to work through the complexities of his crisis.

Now I can tell Robert his diagnosis: Panic Disorder without Agoraphobia. I provide him with some information about this illness. In addition, I give him the names and phone numbers of several psychiatrists.

I then have to tell him to expect about a two-month delay before he can get an appointment.

Obviously, Robert does not like this recommendation. He sees time as an enemy. Two months is far too long to delay his elopement. For one thing, Julia will be out of the country by then. There will be no wedding if that happens. Depression lurks there.

Honestly, I agree with Robert. Two months is too long to wait for a remedy to his problems. He is in a lot of emotional pain and turmoil. I also agree that the situation is complex. It needs to be broken down into its component elements and sorted out. Moreover, there is another person involved, Julia. And in her, I find an option that might satisfy everyone.

I suggest to Robert that we schedule another appointment, as soon as can be arranged. If I get a cancellation, the appointment can be as soon as tomorrow.

I also propose that he bring Julia to the next appointment. We can get her point of view. After all, it is her elopement/wedding, too. At the least, a couples session would give the two of them a chance to look rationally at their situation and to get to know one another better.

In the short-term, my goal is going to try to find an alternative to an abrupt elopement. Perhaps Julia can defer her trip to Portugal. Or maybe between the two of them, they can identify the parent or another authority figure who is most likely to be sympathetic to their situation. We could then try to enlist that person as an ally to the couple. Potentially, that third person could come in at the third session. At this point, I am not sure what assistance Julia can be. But starting couples counseling is the best option I can think of at this point.

In the long-term, I want to provide Robert with treatment to address his vulnerability to both depression and anxiety. Providing successful short-term couples counseling around the elopement may be the best way to engage him in therapy.

In the next post, I plan to take a brief look at another possible explanation of Robert’s anxiety: adult anaclitic depression.

If you are just picking up on this series, you might do well to start by reading at least the last post. Today’s post will refer extensively to the last one.

To review where we are in this “case study,” Robert has come to my office about 36 hours after meeting a woman. He and she have fallen in love at first sight. Robert was in a Major Depression until meeting her. His condition is now one of anxiety verging on panic.

The couple’s situation is fraught with dangers. Julia is soon to return to a Portuguese island and possibly marry a man there. Both Robert’s and Julia’s families are at odds with each other. Each of the families would forbid the marriage. Last, and certainly not least, Robert could fall back into a severe depression if the new relationship fails.

Just as Romeo sought out Friar Lawrence to help him solve his dilemma with Juliet, Robert has come to my office to get help with his situation.

This is a tricky case to bring to a successful conclusion. Robert wants a quick and practical solution. He insists on planning his elopement and later announcing the fait accompli to their families. He is not seeking on-going therapy. Robert believes that all he needs to do is marry his love, tell the families and the rest will more or less sort itself out. He is an impetuous young man. Robert will not tolerate me dilly-dallying with clinical nuances.

In Shakespeare’s play, “Romeo and Juliet”, Friar Lawrence provides the service that Romeo requests: help getting married. To be fully fair to the Friar, he does say to Romeo “Go wisely and slowly. Those who rush stumble and fall.” [Act 2, Scene 3, Page 4] But, despite any misgivings, the Friar marries the couple.

This course of action has a terrible outcome. Romeo, as we know, suicides when he believes that his new bride is dead.

“Come, bitter poison, come, unsavory guide! You desperate pilot, let’s crash this sea-weary ship into the rocks! Here’s to my love!
ROMEO drinks the poison.
Oh, that pharmacist was honest! His drugs work quickly. So I die with a kiss.” [Act 5, Scene 3, Page 5]

From a clinical point of view, this tragic end came from overlooking both the underlying psychological conditions and the real external stressors. Marrying Juliet may temporarily alleviate Romeo’s anxiety. The marriage gives him the false belief that the external dangers are vanquished. Moreover, eloping does not address Romeo’s vulnerability to severe depression.

In one sense, it would be easy to help Robert problem solve an elopement. Let’s play this option out for a moment.

After all, I am human. It would be hard to resist this good looking, articulate young man’s impassioned pleas for help now, today. Then there is his seductive, raw belief in true love. On another front, if I practiced in an HMO or a capitated system, there would be pressure to get this case done with the least expenditure of resources. Long gone are the days when the first four sessions were considered to be the initial evaluation. Active treatment started only with the fifth session after an exhaustive collection of psychosocial history and mental status evaluation. That was then.

Quite possibly, Robert’s treatment could be completed in the first session. I open my laptop computer and google “marriage requirements RI.” Google then helpfully provides me with the link to About.com’s summary of the Rhode Island marriage laws. The requirements, as it turns out, are pretty simple.

My next step is to print the page and give a copy to Robert. Together, we plan how he and Julia can meet each of the steps necessary to get married. I encourage Robert to take written notes on the back of the page. Ten minutes later, we are done. Robert feels a great sense of relief to have a concrete plan. He thanks me profusely and leaves without scheduling another appointment. I have a sense of satisfaction in providing almost immediate relief for his symptoms and giving him the treatment that he requested.

The technique of improving a patient’s problem solving abilities is certainly a valid clinical tool. According to Wikipedia, this method has been studied for over 100 years. Mills, Reiss, and Dombeck have written about improving a person’s “self-efficacy.” This is the “belief in your own effectiveness as a person, both generally in terms of managing your life, and specifically with regard to competently dealing with individual tasks.” Positive self-efficacy helps to “decrease people’s potential for experiencing negative stress feelings by increasing their sense of being in control of the situations they encounter.” Thus, the choice of improving Robert’s problem solving skills for the task of getting married to Julia appears, at first glance, to be a good tactic.

However, I would do well to recall Romeo’s fate in my treatment recommendations for Robert.

As Mills, Reiss, and Dombeck also point out, “The perception of being in control (rather than the reality of being in or out of control) is an important buffer of negative stress.” In Robert’s case, helping him to problem solve how to elope only improves his perception of being in control. It does virtually nothing to address the real world stressors and his risk for depression.

Moreover, the odds are that the passion will fade for Robert and Julia. Acevedo and Aron studied various types of love and the outcomes in their article “Does a Long-Term Relationship Kill Romantic Love?” They found that:

“Results from the factor analysis and correlations with satisfaction support the notion that in long-term relationships, romantic love and obsession are quite distinct: Romantic love (without obsession) is positively associated with relationship satisfaction, but the obsessive aspect is negatively associated with it.” (p.61)

At the time when Robert enters the office, he is quite obsessed with Julia and his quest to marry her. He barely mentions her personal qualities. In fact, Robert and Julia know very little about each other. They have little information or shared experiences upon which they can ground their romance.

As Friar Lawrence observes about Romeo’s love for Juliet:
“Young men’s love then lies
Not truly in their hearts, but in their eyes.” [Act 2, Scene 3, Page 3]

Acevedo and Aron’s work indicates that even without the tragic outcome in the play, Romeo and Robert’s loves are likely to be short-lived.

Problem solving the elopement, then, is likely to yield only a temporary relief of anxiety and leave the much bigger problems lurking in the background.

The following is my own impression and is not a valid legal opinion. If a clinician did choose this route, I do not see that the families would have any firm basis for legal recourse against the clinician. The practice of improving problem solving and self-efficacy is well established. In addition, there are many, many intervening variables between the time of the interview and the outcomes of either suicide or falling out of love. Those variables would make it difficult to pin the blame on negligent treatment. In the lawsuit of Palsgraf vs. Long Island Rail Road, an employee helped a man get on a moving train. This resulted in a domino effect ending with the injury of a woman. The court ruled however “If the harm was not willful, he must show that the act as to him had possibilities of danger so many and apparent as to entitle him to be protected against the doing of it though the harm was unintended.” The families, I think, would be hard pressed to show that the clinician either intended harm or could reasonably see the “possibilities of danger so many and apparent.”

In summary, helping Robert problem solve his elopement would be what Robert wants. A “successful” one-session treatment would please any cost-conscious administrator. Problem solving is also a well-documented clinical strategy. There seems to be little legal risk to the tactic.

However, for all the reasons mentioned above, it would be in Robert’s best long-term interests not to give him what he thinks he wants. The trick is going to be in convincing Robert to tolerate the anxiety and hold off on his impulsive plan.

In the next post, we will investigate other treatment options for Robert.