CHAPTER 8

THE MOOD DISORDER SPECTRUM

Nancy is a 44-year-old female whose father is Japanese American and whose mother is White A partner in a lar!e"
presti!io#s law firm" Nancy decided to see$ o#t therapy with %r T#c$er" a renowned psychoanalytic psychiatrist"
&eca#se 'my life has all the trappin!s of s#ccess" &#t at times ( feel a sort of )oid or emptiness'
Tho#!h of mi*ed ethnicity" Nancy loo$ed Asian" with a ro#nd" soft face and lar!e" almond-shaped eyes Her hair
was dar$ &rown and a&o#t half !ray Nancy was short and pl#mp +he wore little ma$e#p and styled her hair in a
plain" soft" sho#lder-len!th c#t Nancy,s clothes were e*pensi)e and well made" &#t they seemed to &e chosen not to
&e noticed All her clothes were in ne#tral colors with no patterns or accents Nancy wore little -ewelry. what she did
wear was conser)ati)e and e*pensi)e
PERSONAL HISTORY
Nancy was the eldest child of three" with a &rother / years yo#n!er and a sister 4 years yo#n!er +he was &orn and
raised in +o#thern California in a middle-class s#&#r&an family Nancy,s father wor$ed as a patholo!ist at a lar!e
medical center" and her mother was a n#rse #ntil Nancy was &orn" when she &ecame a f#ll-time mother Nancy
descri&ed her family as &ein! close" &#t different 0oth si&lin!s were married with children Nancy,s &rother" a phar-
macist" was married to a White woman who was an architect They had two children Nancy,s sister" a teacher was
married to a White man who was also a teacher They had three children All of Nancy,s family contin#ed to li)e in
+o#thern California
An iss#e that came #p early in therapy was ethnicity Nancy &ecame )ery #ncomforta&le tal$in! a&o#t it &#t said
she &ro#!ht it #p &eca#se it ne)er !ot tal$ed a&o#t within her family Nancy reported that she was raised to &e White
When as$ed what that meant" Nancy stated that her family ne)er really tal$ed a&o#t or ac$nowled!ed her Japanese
herita!e Nancy recalled a !reat deal of shame associated with &ein! Japanese +he reported that she loo$s the most
Japanese" her &rother loo$s somewhat Japanese" and her sister does not loo$ Japanese at all
0eca#se her father was a doctor" they had more money than most other Japanese families 0eca#se of this and
&eca#se her mother was White" they li)ed in mostly White" #pper-middle-class s#&#r&an nei!h&orhoods
( remem&er loo$in! aro#nd my school and nei!h&orhood and e)eryone was White" so ( fi!#red ( m#st loo$ the
same and &e White" too ( had no one &#t my father aro#nd me who loo$ed li$e me ( really don,t thin$ ( had an
#nderstandin! of what ( loo$ed li$e #ntil ( was a teena!er We wo#ld occasionally ha)e e*tended family !et-
to!ethers with my father,s family-yo# $now" weddin!s and st#ff (t was weird to see all these Asian faces 1ost
of my father,s family were m#ch less acc#lt#rated than my father They still li)ed a m#ch more Japanese life
1y father was the only one of his si&lin!s to !et a professional de!ree or to marry a non-Japanese
1y mother is a &ea#tif#l (rish woman +he has a#&#rn hair and !reen eyes +he met my dad while they were
&oth wor$in! at 2C3A 1edical Center +he had mo)ed o#t from 0oston to the West Coast to attend 2C3A Her
family is one of those lar!e (rish families +he is the &lac$ sheep of her family Her family ne)er really accepted
my dad or their marria!e Not only was my dad Japanese" &#t he was not Catholic 1y mom,s family c#t her off
after she married my dad +he sometimes loo$s sad when we tal$ a&o#t !randparents and st#ff" &#t she ne)er
tal$s a&o#t her family 1y mom is ama4in! in that ( thin$ she tried harder than my dad to help #s #nderstand
o#r Japanese side
1y dad wor$ed a lot and was not aro#nd m#ch when we were !rowin! #p That was pretty common &ac$
in the ,56s and ,76s He does not li$e to tal$ a&o#t anythin! that is ne!ati)e or painf#l +o" as yo# can ima!ine
there are a lot of family secrets and shame He and his family were in one of those internment camps d#rin!
World War ll ( didn,t $now anythin! a&o#t this #ntil ( was in se)enth !rade and we were st#dyin! World War
ll ( remem&er readin! a&o#t the camps in my te*t&oo$ and &ein! horrified and then !oin! to as$ my dad if he
$new a&o#t this sl#ff ( can still see his face" he loo$ed so sad when he told me-and ( thin$ he was act#ally )ery
ashamed a&o#t it-that he and his family were in those camps 0eca#se of my #p&rin!in!" ( didn,t as$ him any-
thin! more a&o#t it" and he didn,t offer any more information"
( remem&er tryin! to wrap my l/-year-old mind aro#nd this information and not &ein! a&le to #nderstand
it all 1y mother was finally the one who told me a little a&o#t what had happened to my dad 1y !randparents
were first-!eneration Japanese 1y dad was &orn in 3os An!eles" as were all of his si&lin!s" so they were citi-
4ens 0#t ( !#ess that didn,t matter &ac$ then 1y !randparents owned a small farm" which they had wor$ed hard
to &#y When they were interned" they lost e)erythin! A co#ple of my dad,s si&lin!s were a&le to mo)e to the
1idwest and li)e with friends or relati)es" &#t e)eryone else was ta$en to 1an4anar 8ne of my #ncles ser)ed
in the 44/nd infantry di)ision and was $illed in Normandy 1y dad was in -#nior hi!h school when he was
interned After / years he was a&le to !o li)e with some relati)es in the 1idwest" where he was pretty m#ch on
his own He !ot into colle!e when he was 97 and went on to medical school When he !rad#ated from
medical school there was still a lot of pre-#dice a!ainst the Japanese" so he was not allowed to treat patients
0eca#se of this" he decided to foc#s on patholo!y ( don,t thin$ he e)er really li$ed patholo!y" &#t he wo#ld
ne)er
admit that
E)ery once in a while now my dad mi!ht mention somethin! a&o#t the camps" &#t it is #s#ally in the form
of a story or !eneral information There is an #nderlyin! way of &ein! within the Japanese c#lt#re-yo# can
ne)er complain or feel sorry for yo#rself This way of &ein! was definitely part of the way ( was &ro#!ht #p +o"
yo# can ima!ine how hard it is to come in for therapy and sit and whine and complain a&o#t my life-it !oes
a!ainst e)erythin! ( was &ro#!ht #p to &elie)e
( remem&er &ein! may&e : or 8 years old and ha)in! some $ids send me some hatef#l notes These notes
were of swords drippin! &lood with the words '%ie Jap' or of #!ly caricat#res of Japanese people" yo# $now
&#c$teeth" !lasses" etc ( remem&er &ein! really h#rt and scared &y these notes" &#t also really ashamed ( re-
mem&er hidin! these notes in my wallet so my dad wo#ld ne)er find them" &eca#se they wo#ld h#rt him ( was
afraid to throw them away &eca#se ( was afraid someone else wo#ld see them and $now my shame ( co#ldn,t
tal$ to anyone a&o#t these thin!s
( &ottled a lot of this h#rt and an!er #p inside of me 1y &rother acted it o#t He was pretty wild and didn,t
p#t #p with anythin! from anyone He $ind of had that sam#rai mentality a#!mented with an #!ly (rish temper
He decided fairly yo#n! that he wanted to em&race &ein! Japanese 1y parents made a wise decision and
decided to channel all of that an!er and hostility into martial arts 1y &rother st#died all the martial arts and
&ecame )ery accomplished at all of them He seemed to relate to the Asian rit#als (t seemed that &ein! Japanese
added to his life in a way that made him &etter He is &rin!in! #p his $ids to em&race their Japanese herita!e He
is the only one of #s $ids who has Japanese friends or has )isited Japan
( thin$ that &eca#se my sister does not loo$ Asian she did not ha)e to deal with any of the ne!ati)e st#ff my
&rother and ( had to deal with +he and my mother are a lot ali$e They ha)e the same personalities 1y sister is
a perfectionist" &#t she also mana!es to -#!!le her career and children This perfectionism and more than f#ll life
ma$e her rather demandin! of the people close to her +he e*pects e)eryone to share her )ision and )al#es +he
has a really $ind and compassionate heart" &#t has tro#&le e*tendin! fle*i&ility to those close to her (t is inter-
estin! in that my mother is a perfectionist and needs to do thin!s correctly all of the time +he has a hard time
allowin! people to ma$e mista$es" too +he has her own pace and way of doin! thin!s and doesn,t li$e anyone
to tell her differently 1y mother !ets a lot of stro$es from &ein! perfect Howe)er" she has a hard time with crit-
icism +he will ne)er admit she may ha)e made a mista$e (t,s interestin!" &#t ( thin$ my mom &elie)es she is
Japanese +he has lost her (rish self +he,s act#ally more Japanese than my dad
( remem&er when ( was really little my mom was always preocc#pied with my &rother and sister 1y mom
had three $ids in 5 years; J#st as one of #s was !ettin! o#t of diapers" another wo#ld &e &orn 1y a#nt came to
li)e with #s for a co#ple of years when ( was yo#n! +he was a lot yo#n!er than my dad. she m#st ha)e &een
-#st 98 or so when she was li)in! with #s +he was !oin! to colle!e and spent her free time &ein! a sort of nanny
to me and my &rother +he was !reat ( remem&er thin$in! that she was ma!ical" &eca#se she co#ld do all this
ama4in! st#ff 1y dad was wor$in! all of the time" and my mom was o)erwhelmed with my yo#n!er &rother
and sister" so my a#nt sort of too$ me #nder her win! +he,s the one who ta#!ht me to tie my shoes" s$ip rope"
and ride a &i$e After she finished colle!e" she mo)ed to the 1idwest to !et married ( was de)astated No one
really e)er tal$ed to me a&o#t what was happenin!" and then she was !one ( remem&er sittin! in my room thin$-
in! ( m#st ha)e done somethin! wron!" or else my a#nt wo#ld ne)er ha)e left (t still h#rts to tal$ a&o#t it now
After she left" ( was pretty lonely
1y si&lin!s and ( ha)e ne)er tal$ed a&o#t pre-#dice and racism ( !#ess it,s that shame thin! ( ass#me they
!ot hit with a lot of weird st#ff" too 0eca#se all of my friends were White" ( ne)er tal$ed a&o#t this with any-
one ( do remem&er tryin! to tell a co#ple of my colle!e friends a&o#t it once 8ne was !ay and the other o)er-
wei!ht They &oth immediately went into stories a&o#t their own &attles with pre-#dice ( &ac$ed away (
remem&er &ein! conf#sed and then really $ind of mad 0oth of my friends didn,t really #nderstand 1y !ay
friend co#ld chose to -#st not tell people he was !ay" and my o)erwei!ht friend co#ld diet-( co#ldn,t do any-
thin! ( remem&er someone once tellin! me that ( wo#ldn,t &e accepted in Japan &eca#se (,m half and half (
!#ess ( always sort of li)ed with the &elief that ( wo#ld ne)er &e accepted anywhere" e)er ( $now my mom,s
family s#re wo#ldn,t accept any of #s;
+ocioc#lt#ral theorists &elie)e it is e*tremely important to ta$e social stressors into acco#nt when wor$in! with
clients from minority !ro#ps Acc#lt#ration is the process of adaptation thro#!h which minority !ro#ps identify with
the ma-ority c#lt#re There are two ma-or theories of acc#lt#ration The meltin! pot theory states that acc#lt#ration
helps people ad-#st to li)in! in the ma-ority c#lt#re &y acceptin! the )al#es and c#stoms associated with the main-
stream c#lt#re The &ic#lt#ral theory &elie)es that ad-#stment is fostered &y identification with &oth traditional and
host c#lt#res (t is important to meas#re acc#lt#ration when wor$in! with or dia!nosin! anyone from a minority
c#lt#re
9 How acc#lt#rated do yo# thin$ Nancy is< 8n what do yo# &ase yo#r opinion<
/ %o yo# thin$ Nancy has acc#lt#rated #sin! the meltin! pot or the &ic#lt#ral method< Why<
= What f#rther information wo#ld yo# li$e in order to &etter #nderstand Nancy,s le)el of acc#lt#ration<
4 How acc#lt#rated do yo# thin$ Nancy,s family is< Why<
a Her father<
& Her &rother<
c Her sister<
5 What impact do yo# thin$ ethnicity will ha)e on Nancy,s o)erall therapy<
As ( tal$ a&o#t this" ( thin$ (,m !ettin! an idea of why ( p#lled into myself ( !#ess ( see myself as sort of a t#r-
tle ( p#ll into a shell to protect myself from re-ection Howe)er" in all honesty" ( thin$ ( p#ll into my shell when
( don,t really need protection Honestly" ( wo#ld only !et hit &y re-ection may&e 9 percent of the time (t,s $ind
of a defense a!ainst a '-#st in case' re-ection (t,s weird" &#t this pre-#dice st#ff and personal re-ection st#ff has
a way of hittin! yo# when yo# least e*pect it >o#,ll &e happily !oin! alon!" sort of tr#stin! life" and then
03A118" ri!ht &etween the eyes-someone hits yo# with a hatef#l comment or &lows yo# off or whate)er >o#,re
ne)er ade?#ately prepared for it +o" at a )ery yo#n! a!e ( de)eloped a sort of system of protection 0#t &y doin!
that" ( limit myself ( don,t allow myself to ta$e ris$s for fear (,ll &e h#rt ( ha)e ne)er let anyone in close eno#!h
to really h#rt me" so ( really can,t #nderstand what (,m so afraid of (n addition to ha)in! this shell" ( also ha)e
a whole arsenal of defenses to $eep myself safe
( don,t e)en $now if (,m lonely or #nhappy 0#t ( can,t remem&er e)er feelin! any really stron! emotion"
incl#din! happiness ( !#ess ( feel -#st sort of n#m& ( don,t thin$ anyone feels partic#larly close to me ( ha)e
a few friends" &#t they don,t really $now me We mainly -#st do thin!s to!ether-yo# $now" !o o#t to eat" see
plays" concerts" etc We don,t really spend m#ch time tal$in! a&o#t o#rsel)es. we mostly tal$ a&o#t o#r wor$
1y friends tend to &e other lawyers. some are married" some di)orced" some sin!le" men and women ( !et as$ed
o#t on dates occasionally" &#t always say no 1y mom wo#ld li$e me to !et married and ha)e children-to her
that,s the most important thin! in the world The fact that ( am )ery s#ccessf#l career-wise doesn,t really co#nt
in her &oo$ &eca#se (,m not married with children 1y dad is pretty disconnected and has ne)er said anythin!
one way or the other
( ha)e another confession to ma$e This will so#nd really pathetic ( ha)e &een wor$in! for my law firm for
o)er 96 years ( ha)e &een a f#ll partner for 4 years ( !et a lot of )acation time as part of my &enefits pac$a!e"
@&#tA ( only ta$e a wee$ or two a year" and then only when ( !et press#re to do so ( ha)e years and years worth
of )acation time stoc$ed #p The really pathetic part is that ( can,t thin$ how to #se it When ( ha)e ta$en )aca-
tion time" ( end #p at home doin! pro-ects or st#ff ( tried !oin! to E#rope with one of those to#rs a few years
a!o and had a misera&le time ( really ha)e no friends who ( can )acation with ( wo#ld no more )acation with
my family than ha)e a root canal ( am not a real social person" so it is )ery diffic#lt for me to ma$e friends eas-
ily And ( can,t thin$ of anythin! (,d li$e to do ( ha)e lots of money" &#t nothin! to spend it on
1y speciali4ation is ta* law +chool was always )ery easy for me When ( was a senior at +tanford" ( had to
ma$e a decision as to what ( wanted to do with my life 2p #ntil then ( had st#died this and that" mainly -#st da&-
&lin! ( was always )ery interested in medicine ( really en-oyed all of my science and math classes and consid-
ered !oin! to medical school The reason ( chose not to do that was that ( didn,t want to &e a part of a system that
had screwed my dad ( do#&t that he thin$s of it that way" &#t ( do 0eca#se of his herita!e he had to spend his life
po$in! aro#nd dead &odies and analy4in! &ody parts rather than !ettin! to treat patients ( $now that lo!ically this
wo#ld pro&a&ly not e)en &e an iss#e today" &#t ( !#ess on some le)el ( didn,t want to &e any part of it
(n my family there really was no choice a&o#t p#rs#in! an ed#cation and a profession (t was #nspo$en" &#t
ass#med 1y family was not rich" &#t my parents had sa)ed a lot of money for all of o#r colle!e f#nds We were
allowed to chose any colle!e we wanted to !o to and to chose any !rad#ate school 1oney was not a consider-
ation ( do#&t many people nowadays ha)e this l#*#ry (n my family we ne)er too$ !rand )acations" and my par-
ents always dro)e their cars #ntil they co#ldn,t &e dri)en any f#rther" and we didn,t li)e in a lar!e ho#se 1y
parents did all of this in order to sa)e for colle!e +o" yo# can see why it was -#st ass#med we wo#ld !o to col-
le!e 3#c$ily" all of #s $ids had the &rains to e*cel in school 1ay&e it was that Asian emphasis on ed#cation
( ended #p in law school &eca#se ( was mad at medicine +t#pid %on,t !et me wron!" ( li$e law" (,m -#st
not passionate a&o#t it 3aw seemed the ne*t &est alternati)e ( went to Har)ard 3aw and !rad#ated in the top 5
percent of my class ( was hea)ily recr#ited &y many firms &eca#se ( was an Asian" female" ta* specialist" who
!rad#ated Har)ard 3aw ( ne)er too$ a lot of pride in my accomplishments-it was all -#st e*pected ( don,t
remem&er e)er en-oyin! school-it was -#st somethin! ( did ( went to parties occasionally" &#t ne)er really
en-oyed them ( li$ed !oin! o#t with a small !ro#p of friends" to dinner or the mo)ies ( ne)er really dated d#r-
in! my time at +tanford or Har)ard
( chose the law firm ( am with &eca#se it was &ac$ on the West Coast" close to my family" and it was hi!hly
presti!io#s ( earn an enormo#s salary and ha)e e*cellent per$s (,m )ery !ood at what ( do. in fact" (,d say ( am
the &est they ha)e doin! ta* law now Partly that,s &eca#se ( de)ote my life to my wor$ ( ha)e no attachments
or distractions and can foc#s completely on my wor$ At times that seems to &e eno#!h" &#t then ( wonder
A!ain" ( don,t !et -oy from my wor$ ( !et pride from doin! an e*cellent -o& ( !et satisfaction from my wor$
0#t ( don,t !et happiness
( feel fiat ( don,t cry or feel at all sorry for myself 0#t" there are moments when ( am aware of feelin!s of
emptiness ( !#ess yo# wo#ld call those feelin!s sadness 0#t (,m not s#re what ( am sad a&o#t ( do remem&er
feelin! stron! feelin!s of sadness and an!er and ra!e when ( was yo#n!er ( also remem&er conscio#sly p#shin!
those feelin!s down &eca#se they did nothin! &#t h#rt me When ( p#shed those feelin!s down" ( thin$ ( may
ha)e p#shed all my feelin!s down
Act#ally now that ( am tal$in! a&o#t it" ( !#ess ( ha)e always felt rather sad (,)e always tho#!ht of it as
$ind of a !ray hea)iness ( remem&er loo$in! at other people la#!hin! and !ettin! e*cited and thin$in! it was
stran!e that ( ne)er did that There are times when this feelin! of !ray hea)iness is stron!er than other times
%#rin! these times ( ha)e tro#&le sleepin! ( can,t seem to t#rn off my mind and !et to sleep" or (,ll wa$e #p
really early and not &e a&le to !et &ac$ to sleep Either way (,m e*ha#sted and $ind of clo#dy mentally ( find
myself eatin! a lot of s#!ar and fat and not ha)in! the ener!y to wor$ o#t. ( #s#ally !ain wei!ht These periods
last a&o#t a wee$ e)ery co#ple of months They,)e &een -#st a part of my life for as lon! as ( can remem&er
TREATMENT
%r T#c$er referred Nancy for a complete medical e*amination" d#rin! which it was disco)ered that Nancy had a low
thyroid readin! 3ow thyroid can ca#se some of the symptoms that Nancy had descri&ed Nancy was placed on
+ynthroid" a thyroid replacement medication %r T#c$er also recommended Nancy try ta$in! Pro4ac to help alle)i-
ate her depressed mood so she co#ld foc#s on the serio#s wor$ of doin! therapy
Nancy had so#!ht o#t %r T#c$er &eca#se of his rep#tation as an eclectic psychoanalyst +he had heard !ood
thin!s a&o#t the doctor from some collea!#es at wor$ %r T#c$er e*plained that the way he wor$ed wo#ld &e to help
her #nderstand some of her am&i)alent feelin!s toward important people in her life He e*plained that m#ch of the
an!er she had toward people and sit#ations she had #nconscio#sly t#rned inward onto herself When she was a&le to
t#rn her an!er o#tward" thro#!h )er&al e*pression of her feelin!s" that an!er wo#ld stop &ein! directed a!ainst her-
self (t was this an!er t#rned inward that was ca#sin! her feelin!s of depression and emptiness
%r T#c$er also &elie)ed that a lar!e part of Nancy,s depression was a form of !rief she felt toward the loss of
an important early relationship This !rief was different from normal !rie)in! &eca#se she was &lamin! herself for
the loss Nancy,s self-&lame may ha)e &een ca#sed &y her a&sent father" o)erwhelmed mother" or departed a#nt +ince
Nancy was the oldest child" she wo#ld ha)e &een dethroned &y the &irths of her yo#n!er &rother and sister Her si&-
lin!s wo#ld ha)e re?#ired that Nancy,s mother foc#s on their needs" possi&ly i!norin! Nancy Nancy may ha)e
&lamed herself for this loss of parental affection" which in t#rn increased her feelin!s of worthlessness and low
self-esteem
0eca#se he was an eclectic psychoanalyst" %r T#c$er wo#ld also prescri&e medications to help Nancy" as well
as #sin! co!niti)e-&eha)ioral methods +ome of these methods wo#ld &e #sed to help &#ild self-worth thro#!h new
relationships and !oals %r T#c$er wo#ld also help Nancy e*plore her need to &ecome self-act#ali4ed Nancy had
always li)ed #p to e)eryone else,s e*pectations of herself +he had ne)er deeply e*plored the thin!s that wo#ld add
passion to her life %r T#c$er &elie)ed that Nancy was as$in! for help to learn to ta$e ris$s and to come o#t of her
self-imposed e*ile
0eca#se of the nat#re of psychoanalytic psychotherapy" this wo#ld pro&a&ly ta$e a !reat deal of time Nancy
wo#ld need to commit to comin! for therapy at least three times a wee$ for at least a year This type of therapy is not
as lon!-term or intensi)e as traditional psychoanalysis" &#t it is still lon!-term and intensi)e Nancy a!reed to all the
terms of therapy and seemed happy and relie)ed to finally &e addressin! these iss#es that had tro#&led her for years
7 What DSM-N dia!nosis wo#ld yo# !i)e to Nancy<
a A*is (B
& A*is ((B
c A*is (((B
d A*is (CB
e A*is CB
: What do yo# see as the stren!ths and wea$nesses of the psychoanalytic interpretation of Nancy,s depression<
8 How wo#ld a h#manistic-e*istential therapist )iew Nancy,s pro&lem<
D How wo#ld a h#manistic-e*istential therapist wor$ with Nancy in therapy<
96 How wo#ld a co!niti)e-&eha)ioral therapist )iew Nancy,s pro&lem<
99 How wo#ld a co!niti)e-&eha)ioral therapist wor$ with Nancy<