PHILADELPHIA—In his address to the 2002 Annual Meeting of the American Psychiatric Association, Elio Frattaroli, MD, opened with a recitation of what he termed “Hamlet delivering Shakespeare’s most famous description of depression.” Dr. Frattaroli, who maintains a private practice and is also Assistant Clinical Professor of Psychiatry at the University of Pennsylvania, Philadelphia, promised to return to the matter of the play shortly but first touched upon the subject of his own book, Healing the Soul in the Age of the Brain.

“The book’s message is that healing the soul is the root meaning of the word psychiatry, but in the age of the brain, most psychiatrists have lost all sense of that meaning,” he said. “We deny the existence of the soul, and we think of our task not as healing—making whole the divided self—but simply as adjusting brain chemistry.” His book argues that the “quick-fix goals and conformist values and positivist science of our so-called medical model have in effect double-blinded us to the most important needs of our patients and to our true calling as physicians.”

Ironically, Dr. Frattaroli added, “these same conditions have also provided managed care with the perfect excuse for managing us right out of existence.” If prescribing pills is the only thing psychiatrists know how to do, and if scientists are willing to certify that’s all that people need, then psychiatrists are replaceable by primary care physicians, nurse practitioners, and psychologists willing to receive extra training, he argued, asserting his belief that “for psychiatry to survive, we must reexamine our goals, our values, and our science. We must change our model of practice from a medical model that’s focused on brain and behavior to a psychotherapeutic model that’s focused on persons and their feelings.

“I’m not saying throw out the medical model,” he clarified, “but it must be integrated. If healing the soul means making whole the divided self, then the primary task for psychiatrists today is to recognize and heal this division within ourselves.”

MODERN HAMLETS AND THEIR PSYCHOSES

“We all pay lip service to the idea of integrating the biological and the psychological. Everyone wants to be bio-psychosocially correct,” Dr. Frattaroli said. “But how integrated would your treatment approach be if Hamlet came into your office and said the words with which I began my talk today?

“There he is, in your office: Hamlet, the avatar of Freudian inner conflict, poster child for civilization and its discontents, modern man in search of his soul. And let’s say he also has weight loss, early morning awakening, and diurnal variation of mood. How would you treat him? Would you think of this depression as a chemical imbalance for which he needs medication, or would you think of it as an emotional conflict for which he needs psychotherapy? Would you consider treating him with both medication and psychotherapy, and if you would, what would your treatment goals be? Remember that how you intervene is going to have a major impact on the course of Hamlet’s life. It’s going to affect not only his HAM-D score, his chemical imbalance, his mood and self-esteem, it’s going to affect his relationship with all the other characters in the play. It’s going to affect the way he treats Ophelia and Polonius, for instance, in a way that could change their fate, and it’s going to affect the way that he thinks about killing his uncle, in a way that could change the very future of Denmark.

“In other words, we’re dealing here with a bio-psychosocial dilemma of the first magnitude. With all those variables and all those lives hanging in the balance, how is a psychiatrist supposed to know what to do?”

Dr. Frattaroli posited that the only way the complexity of Hamlet’s dilemma could be appreciated “is by feeling the impact of that dilemma within ourselves. As we listen to Hamlet’s story, his dilemma becomes our dilemma, and our emotional response becomes evidence about his mental state. That’s why it’s so utterly important for psychiatrists to know how to be in touch with our feelings. It’s only through our feelings that we can get past the bio-psychosocial platitudes and evidence-based rationalization and meet our patient as a person,” he added.

THE PLAY’S THE THING

During the past 400 years, millions of people have listened to Hamlet’s story and have been able to identify with his experience, Dr. Frattaroli said. They understood Hamlet’s depression “as an emotional crisis in his quest for truth, love, and moral integrity. An expression of his noble struggle with ‘the slings and arrows of outrageous fortune’—ie, his dysfunctional family and society—and also with an impossible combination of inner stresses: profound grief, righteous outrage, malicious vengefulness, unrequited love, disturbing sexual passion, existential anxiety.”

Even modern psychiatrists tend to think about Hamlet that way outside of their practices, Dr. Frattaroli allowed. “But just let a person like Hamlet walk into our office and fill out a Beck’s Depression Inventory, and suddenly his problem is reduced to a chemical imbalance. That’s how superficial and dehumanizing—or as Hamlet would put it, how ‘weary, stale, flat, and unprofitable’—our current psychiatric thinking has become.”

For the “large and growing number of psychiatrists whose practice is limited to 20-minute, once–a-month medication checks,” Dr. Frattaroli asserted that his theoretical representation is an accurate picture of how the “vast majority of psychiatrists trained in the last 15 years” would think of a patient like Hamlet. “What other picture could there be?” he asked. “They have no choice but to think of Hamlet’s depression as a chemical imbalance because they’ve never been taught to think of it as an emotional conflict. It wouldn’t occur to them to ask Hamlet how he felt about his father, or his mother, or his life. They wouldn’t know what to do with that information, they wouldn’t have time to do anything with it, and they wouldn’t consider the information relevant to understanding and treating Hamlet and his depression.”

According to Dr. Frattaroli, this dehumanizing way of thinking about human suffering as a chemical or neurological problem rather than as an emotional problem “reflects a crisis not only in our society but in our culture as a whole. It isn’t just psychiatrists who would be eager to put Hamlet on Prozac. Our whole society is looking for quick fixes and easy explanations to help us evade the anxiety of the human condition, the anxiety that is inherent in self-awareness. Psychiatry caters to our fear of self-awareness by offering to medicate our distress so we don’t have to feel it, by focusing solely on the physical and the external—brain and behavior—and ignoring the emotional and the spiritual, the essence of who we are.”

EXAMPLES GROSS AS EARTH

“If you look at every type of society, you see the same dehumanizing trend,” said Dr. Frattaroli, continuing his analysis of this problem as a cultural phenomenon. There is “an overemphasis on the physical and the external, and an underemphasis on the inner life. In our pursuit of material possessions, physical appearances, creature comforts, and addictive pleasures, we’ve all been culturally conditioned to use the physical and the external as quick fixes to distract us from our deeper emotional and spiritual needs. The life of our culture is way out of balance: far too much action, far too little reflection; doing rather than feeling; fixing rather than healing.”

This conflict between doing and feeling expresses itself conveniently as the conflict between two different models of psychiatry, he observed. “There’s the medical model as we currently have it, which focuses exclusively on the needs of the brain, and there’s the psychotherapeutic model, the model I’m advocating, which treats the needs of the brain in the larger context of the needs of the soul, focusing on the process of getting in touch with feelings as a path to consciousness, as an experience where the needs of the brain and the needs of the soul come together.”

HAMLET—A NOBLE MIND HERE O’ERTHROWN?

“The imbalance between doing and feeling is really a universal problem, a problem of human nature,” Dr. Frattaroli said. “That’s why I began with Hamlet, who I think most people would agree represents something universal in human experience and who definitely had a problem with the balance between doing and feeling.

“Hamlet was raised to be a man of action, a swordsman, a warrior like his father, who appears in the opening scene of the play as a ghost wearing battle armor. This ghost represents Denmark’s culturally sanctioned values of war, conquest, domination, and retaliation,” he explained. “The pressure Hamlet feels from the ghost to avenge his father’s murder by killing his uncle represents in part these cultural values that equate violence with manliness, but it also reflects Hamlet’s own tendency towards violent vengefulness—the part of him that’s like his father, that’s driven to embrace his father’s values. The part of him, for instance, that’s capable of impulsively killing Polonius and then feeling no remorse at all about it.”

Seen in this light, “Hamlet’s depression begins to look not like an illness but like a sign of health. By interfering with his impulse to carry out the ghost’s demand, Hamlet’s depression gives him time to reflect, to recognize his own unique individuality. It expresses the part of him that wants to say no to business as usual, that values feeling over doing, reflection over revenge, love over hate,” Dr. Frattaroli said. In his depression, “Hamlet begins to get in touch with a core self that’s different from his father, that resists being taken over by his father’s values, and that feels oppressed by these values, both in Denmark and in his own inner state.”

By immobilizing the prince, Hamlet’s depression shifts his inner balance away from action and towards reflection, opening up the possibility of new growth, Dr. Frattaroli observed. “The problem is that in the end, his depression fails him in spite of its healing function. When he learns that Rosencrantz and Guildenstern have conspired to have him murdered, Hamlet is jolted out of his depression. He is remobilized, and he then moves very quickly to take his revenge, at the cost of his own life.”

TO BE OR NOT TO BE DEPRESSED

Dr. Frattaroli’s depiction of Hamlet exemplified one of the central issues of his book. “I view depression not as a disease but as a symptom of an underlying emotional conflict, and I believe that this symptom embodies an unconscious impulse towards healing,” he explained. This view is central to what he called the “psychotherapeutic model of healing,” and is “different than our usual psychiatric view of depression as a physical disease, a chemical imbalance, a psychological disposition based on a genetic defect.”

To think of Hamlet’s depression in these terms, “as a healing symptom rather than a disruptive disease, representing the best that is in him rather than the worst, does turn psychiatric thinking on its head,” he noted. “Among other things, it’s just a whole new way of thinking about the genetic basis of mental illness. We typically assume that if a symptom has a genetic basis, as depression does, then that symptom must be a genetic defect, an evolutionary mistake. But if the symptom is part of a healing process, then it would make more sense to think of it as a genetic adaptation, an evolutionary success.”

The only reason to think of a symptom like depression as a defect “is that it’s so disturbingly painful, and we would prefer not to feel that pain, so it’s more comforting to think of it as a genetic mistake rather than something that’s hardwired into human nature,” he added. “Yet the truth is, we have no psychiatric evidence whatsoever that any psychiatric symptom is a genetic defect rather than part of the natural healing process.”

Other medical symptoms, such as fainting, coughing, and fever, have been genetically programmed to serve an adaptive healing function, he observed. It is plausible that depression, anxiety, and other psychiatric symptoms “have been hardwired into the genes through a slow evolutionary process that is ultimately beneficial to the survival of the species.

“But if this new point is really as plausible as I claim it is, why isn’t it more widely understood and accepted?” he wondered. The answer, Dr. Frattaroli proposed, is that genetic adaptation is thought of as a biological symptom facilitating survival through a purely biological mechanism. In psychiatry, however, “we’re dealing with bio-psychological symptoms that facilitate survival through a primarily psychosocial method, so we can’t see the adaptiveness of a psychiatric symptom through our usual biological lenses.

“We need new lenses that are truly bio-psychosocial,” he said. “Through these more integrated lenses we can see that our individual and cultural imbalance between doing and feeling is a serious threat to the survival of the species and that the evolutionary design of depression, anxiety, and other psychiatric symptoms is that they function to correct this imbalance.

“For Hamlet, for patients, and for ourselves, psychiatric symptoms are adaptive because they shift our inner balance. They interfere with doing. They make us hesitate to act and force us to pay more attention to what we’re feeling.”

TO RAVEL ALL THIS MATTER OUT

According to Dr. Frattaroli, the medical model views psychiatric symptoms as disruptions of neurophysiological equilibrium that should be fixed quickly with medication lest they cause further damage to psychosocial stability and adjustment. The psychotherapeutic model, in contrast, views psychiatric symptoms as manifestations of inner conflict. It sees them as “unconscious emotions trying to become conscious against the internal forces of resistance, presenting opportunities for growth that should be facilitated by the psychotherapeutic process.”

A psychiatrist who believes that symptoms are bad “will try too hard to control his patient’s chemical and emotional balance and thereby interfere with the patient’s growth,” Dr. Frattaroli remarked. “Medical model psychiatrists try to take control of their patients with medication because they don’t have confidence in their [patients’] ability to grow. Their aim is not to facilitate maturation and development but simply to return the patient to his previous level of functioning.”

Psychotherapeutic psychiatrists, however, “start from the assumption that symptoms are the very embodiment of the patient’s potential for spontaneous maturation and growth. Their goal is to facilitate the maturational process that’s already inherent in the symptom. They view disequilibrium, whether manifest in obvious symptoms or not, as the natural and inevitable result of the inner conflict that is intrinsic to human nature. Developing the symptom is a necessary step towards integrating that conflict, a way of focusing the disequilibrium and calling our attention to it and thereby initiating or furthering the psychotherapeutic process,” he said.

From this point of view, “symptoms are the place where growth happens,” Dr. Frattaroli closed. “Indeed, from the psychotherapeutic perspective, they are not merely good but essential for a fully human existence.”

—C. Justin Romano

Suggested Reading
Frattaroli E. Healing the Soul in the Age of the Brain. New York, NY: Viking Press; 2001.

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