Why Empathy Does Not Cure Depression

A parent writes to therapist Lori Gottlieb asking how to deal with his or her youngest son. I note that the parent, named Chris, is not identified by gender. We do not know if Chris is a mother or a father. We do not know whether Chris is short for Christopher or Christine. Gottlieb does not seem to care, but surely the way a father approaches a depressed child, even an adult child, differs markedly from the way a mother does.

Perhaps the young man is depressed because his primary parent does not know whether it is a man or a woman?

If a father, outreach might involve going fishing together, going to the ballgame together, even playing golf together. When a young man feels isolated, like  failure, a father can work to make him feel like one of the guys. As we shall see, this will be one of the young man’s problems. If a mother tries the same kind of bonding, the young man will consider it to be infantilizing. If a mother shows caring concern for someone who is mentally ill, it will be read as demeaning. 

If a father asks pertinent questions about job searches or grad school it will be seen as constructive. If a mother starts questioning the young man’s emotional well being, he will feel insulted.

The only hint we have is that the young son is torqued over the fact that his two older brothers were not sufficiently sensitive to his apparently manifest distress. They tried banter, but apparently it did not work. They might have tried ignoring his depressed state and aiming for some brotherly bonding, as in the examples given above.

In the end the young man felt that his brothers were dismissive of his mental illness. Or perhaps they were dismissive of him. Did they go bowling and not invite him? Did they exclude him from conversations about baseball or the stock market? 

For the record, here is the letter:

About 10 months ago, my young adult son returned home, appearing distraught over a broken relationship. Before this, he had moved back to his university city to be with his girlfriend, who was entering her final year, and he spent four months trying to get a job and develop social networks, and being committed to the relationship.

It appears he was unsuccessful on all fronts, and my previously sunny, gregarious kid slumped into a mood matching the cold, dark winter weather in which he was living.

He returned to sunny California just prior to Christmas, but struggled with sadness, anxiety, and generally feeling lost. It was clear to me that the issue was not simply a breakup and he should have come home much sooner. My other two sons returned home for the holidays, and we tried to make the best of a difficult situation. My other sons are several years older, one is married, and both live far away and are established in their careers.

My youngest son has since returned to graduate school and appears to be making progress on his mental health. He has seen the odd therapist, but tends to only seek help when he hits a low point, which thankfully comes increasingly less often. To my surprise, though, he came home last weekend and stated that he was still angry about how dismissive he felt his brothers were last Christmas.

I find myself annoyed that my son appears to be so self-absorbed that he can’t see how he affected those around him (and continues to). We all walked on eggshells over the holidays, and while he sees his brothers’ banter with him as insensitive, I see it as an attempt to engage without triggering. I don’t want to upset my son, but I also want him to know that it might not be fair to blame those around him—in my mind, we have all worked pretty hard to help him out.

Should I let my son know how I feel? This entire experience has given me an appreciation for the extent to which mental-health issues can affect families.

Chris

This being the case, we can count on a therapist, even a good therapist like Gottlieb, to begin with a dose of empathy. In truth, psychologists like Yale professor Paul Bloom, have been arguing against the profession’s obsession with empathy. So, we consider Gottlieb’s efforts to stoke parental empathy a sign that she is not yet in the game.

She wants Chris to know that his or her son is sick. Later she will say that he might as well have cancer. Which is absurd and not helpful. Surely, he does not need pity. Or chemotherapy.

Anyway, Gottlieb does show that empathy makes it impossible to treat patients. For instance, to use an example that everyone will understand, what if you break your arm and go to the emergency room. Do you want a physician who has broken an arm and who feels your pain or do you want a physician who knows how to set broken bones? If you are a woman delivering a baby and something goes wrong do you want a physician who has delivered a baby or a physician who knows how to solve the problem? Fair enough, the one does not preclude the other, but the former is trivial, while the latter is essential. Might we not want to say a word for objective distancing?

Here is Gottlieb arguing for empathy:

To help you decide what to say to your son—not just about his recent comment, but also more generally—let me share with you what patients with depression have told me they wished their families knew.

First, depression isn’t an attitude. It’s an illness. The person who feels achingly sad can’t just cheer up (or laugh at holiday-dinner banter). The person who feels lethargic can’t just go exercise (or perhaps even get in the shower). The person whose perspective is clouded by negativity can’t just see the full half (or tenth) of the glass. The person who wants to be alone can’t just go out with some friends to a movie. The person who has trouble concentrating can’t just get things done—chores, bills, deadlines—in a timely manner. The person who feels irritable can’t just not snap at others occasionally (despite often feeling guilty afterward, thereby adding to the self-loathing sometimes characteristic of depression). The person who feels hopeless can’t just rationally envision a better future.

Do you really believe that treating the depressed patient as hopeless is helpful? Any therapist who accepts the depressed patient’s sense of his own incapacity as real is helping to mire the patient in depression.

Gottlieb seems to have forgotten the lesson Aaron Beck learned many years ago when he, a young psychiatrist, was treating a depressed hospitalized patient who said that she could not get up and walk to the door. He accepted that she could not walk across the room but he asked her whether she could put one foot on the floor. When she could, he asked her if she could put her other foot on the floor. And so on. In the end she succeeded in walking across the room… and she did it because Beck did not feel empathy for her condition. He set about helping her to overcome it.

As for Gottlieb, she thinks that the young depressed man is in a foul mood because his brothers do not feel his pain. She thinks it’s like having cancer. Does she also think that he needs chemotherapy?

I want you to consider that your son isn’t “self-absorbed”—he’s in pain. And what he’s telling you is that he felt his brothers were ignoring his pain, and nothing is lonelier than being utterly alone in one’s pain. If your son had cancer, maybe he’d feel angry if everyone at the dinner table ignored the fact that he was bald and couldn’t eat and had lost 50 pounds—but maybe, too, these feelings would be more understandable to you. Likewise, ask yourself, if he had cancer, would you feel resentful of how hard you’ve worked to help him out? Would you compare him unfavorably with his brothers, as you have here by pointing out in your letter that his brothers are thriving in their relationships and careers in a way he’s not? (Would you write, “His brothers, who have never had cancer a day of their lives …”?)

As it happens, if you look at the text of the letter, the brothers were trying to be especially sensitive toward his depression. And not the other way around. So, maybe he wanted to be treated like one of the guys, not like someone whose bad moods needed empathetic balm.

So, he wants to be one of the guys, not a cancer case. And that means, try ignoring his foul mood and inviting him to play ball or to go to a movie. If he rejects the invitation, tell him that he has to go, because it's a family outing and it would not be the family if he were not there. If he still refuses, drag him out.

Gottlieb wants the brothers and the gender non-specific parent to let him be honest about what he is going through. It’s the wrong approach, but allow her:

Communicating to him, either verbally or nonverbally, that his feelings are irrational or overblown will prevent him from being honest with you about what he’s going through, and that’s a dangerous situation, because you want a person in pain to reach out, not to isolate even more.

She advises treating him like a pathetically weak patient. This is precisely the wrong approach:

So what can you say? Try any of these: I’m interested in how you feel. Tell me more about what bothered you last Christmas so that this year things go better. I’m sorry you’re having a bad day—that sucks. I’m glad you got some restful sleep last night. (Progress that seems small to you will seem big to someone with depression.) 

In the end she wants the boy to feel loved. Seriously. If anything will make him feel worthy of pity, will make him feel pathetic, this is it:

All of this sends a very different message from I can’t believe how self-absorbed you are or You don’t appreciate the help we’ve given you or You’re being overly sensitive about what happened at Christmas last year—yet it accomplishes something very important. It sets boundaries for what you can realistically do so that you aren’t neglecting your own care or sense of how you’d like to be treated, and it communicates unequivocally that while depression can feel like a burden, your son himself is not a burden—and that you take him and your love for him seriously.

So, both of the approaches in that paragraph are wrong. Treat the young man like a brother, do things with him, do not belabor his bad moods. Make social contact with him by discussing matters that have nothing to do with him or with his problems. Better to discuss the weather or the forest fires than to make him feel like a loser.