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"A Diagnosis Not Exactly in the Book"
Several years ago, a man came to me for a psychiatric consultation after he had lost his job. He explained that he had recently been fired — or, in the pyrotechnic language of Wall Street that he used, his "desk had been blown up."
The company had shut down his investment group's computers with no warning and, after permitting the executives to gather up a few personal possessions, security officers had marched them to the door. The company called it a "business restructuring," but it sounded more like a police raid to me.
Hearing the story, I assumed that the event, in and of itself, had been traumatic for the patient and precipitated the consultation. But amazingly, this was not an issue for him. In fact, he saw it as standard operating procedure in his profession and casually noted that there was nothing personal about its brutality.
What disturbed him was that several years earlier he had gone through a similar "downsizing." He was worried now that he might somehow have brought these firings upon himself; after all, it was two firings in a six-year period. Perhaps, he suggested, he was unconsciously self-destructive or had a problem with interpersonal relations of which he was unaware.
"It makes me feel like a loser," he said miserably, flashing me the L sign, thumb and forefinger spread wide apart. As he held up the telltale L, I found myself reflecting back on the infamous letter A, the Scarlet Letter, and pondering our newer alphabet of social shame. "I felt humiliated telling my children," he said, "or even my friends. I know it makes them think of me in a different way, and maybe they're right and I blew it."
I was struck by my patient's sense of culpability — but not altogether surprised. I had seen enough similar cases to realize that the assumption of personal responsibility for ill fortune is endemic in our culture. I see women who blame themselves for "picking" a partner who later betrays them; patients with serious, often hereditary, mental illnesses who are convinced that it is a personal failing not to be able to cure their symptoms by willpower alone. And there are the legions of parents who believe that their children's every wrongdoing must reflect poor parenting — ignoring the effect of peers, teachers and the child's natural endowments or lack of them.
These people, and many of the rest of us, seem to have a hard time with the idea of fate or, to put it less grandly, with acknowledging that many life events are beyond our control. We celebrate people who overcome obstacles, and we make success the arbiter of personal worth.
Bad outcomes, in such a system, bespeak personal inadequacy. And when things go wrong — as they inevitably do — the credo of self-determinism leaves us in a fix. Often, at this juncture, people turn to psychiatrists in hope that "self-knowledge" will remedy things. The virtues associated with accepting fate — endurance, dignity, discipline, perseverance — are barely in our cultural lexicon.
As the new patient and I began reviewing his personal history, we searched for problematic patterns. We went over his attitude toward his work and relationships with his bosses and co-workers.
Listening to his narrative, I was acutely aware that retroactively assigning cause is a slippery business. You can always find something suspicious "through the retrospectoscope," as they say in medicine. Inevitably, some issues will emerge from anyone's life story.
The task for the psychiatrist lies in assigning a weight to such problems. It involves separating pathology from normal variation. In addition, and often more difficult, it requires separating pathology that patients are comfortable with from that which is distorting their lives in painful ways.
But in my patient's story there was nothing strongly pointing to self-sabotage or even run-of-the-mill social ineptitude. In fact, the main question in my mind was why he had come to see me at all. I listened closely, wondering if there was some hidden agenda that had brought him to my office. None emerged.
At the end of the consultations, I delivered what seemed to me good news — the closest thing a psychiatrist comes to giving someone a clean bill of health.
He sat still, looking anxious. "So you think that I'm not doing this to myself; you think it just happened to me?"
I nodded.
He reflected silently on this unexpected turn of events. Finally, he drew himself up and said, "I'm not sure if that's better or worse."
I laughed. "Maybe both?"
After a pause, he began to look relieved. "So I should just continue looking for another job?"
I nodded.
-- Anna Fels, M.D., New York Times
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