Although there are hundreds of different psychotherapies, certain fundamental ideas are common to them all. Among these are the concepts of naming and renaming. I can illustrate these tactics with a literary example.

In Shakespeare’s Hamlet, a ghost claiming to be his dead father tells Hamlet he was murdered by his brother, the current King, and orders Hamlet to avenge his death. Hamlet delays, seeking more proof. The King sends Hamlet away to be secretly murdered. Hamlet foils the plot, decides the King is a villain, returns, and—after three hours dithering on stage—kills him. Scholars have long debated the reasons for Hamlet’s hesitancy and failure to act.

Some years ago, I took part in a trip to England guided by a Shakespeare scholar. After we had attended a performance of Hamlet, our tour group had a spirited discussion about whether Hamlet’s indecision could be explained by a diagnosis of clinical depression. Many of those present believed that it could. Didn’t he, in his famous to-be-or-not-to-be speech, contemplate suicide? The inhibition and helplessness of his dysthymia, they argued, would explain his inability to act on his ghost-father’s demand for revenge. I contended he was not depressed and here’s why...

1. In 1600, depression was called melancholia. Where we would say, “I’m depressed,” someone of that era would say, “I am melancholy.” So: was Hamlet melancholy?

Shakespeare’s Hamlet dates from around 1600 and his protagonist appears in Act I with all the trappings of melancholy: black clothing, sighing, tears, “the dejected haviour [behavior] of the visage.” The photo shows an actor in his Hamlet costume, with all the melancholic signs. The photo below shows an actor in his Hamlet costume, with all the melancholic signs.

But wait: the height of fashion among aristocratic men of that time period was to adopt a melancholic dress and demeanor. They wore dark clothing with open collars and unbuttoned robes or doublets, affecting a disheveled appearance and world-weary poses with sad expressions. (Perhaps in our own time those who dress in the Goth tradition make a similar fashion statement.) This “melancholic style” was considered a sign of great poetic feeling and intellectual depth, a stereotype with which Shakespeare’s audience would be very familiar. In short, Hamlet strikes a melancholic pose but his fashionable outfit doesn’t mean he’s depressed.

2. Hamlet is mourning his father’s recent death. In his 1917 paper, Mourning and Melancholia, Freud differentiates the two states: “In mourning, it is the world which has become poor and empty; in melancholia it is the ego itself.”

Hamlet is unequivocal about which state he experiences. For example:
  • In Act I, he observes, “How weary, stale, flat and unprofitable/ Seem to me all the uses of this world.”
  • And later (Act II), he says: "… it goes so heavily with my disposition that this goodly frame, the earth, seems to me a sterile promontory...” 
Clearly, it is his world that is, as Freud said, “poor and empty,” and not Hamlet himself. He is contending with grief, not depression.

3. And then there is the seemingly suicidal rumination of the “to be or not to be” speech.
Here again, Hamlet’s thoughts are not those of someone struggling with the mental pain of true depression. Rather the soliloquy reflects his wish to be relieved of a heavy burden: what to do about the ghost’s demand for revenge.

He doesn’t speak directly about this dilemma. Instead, he generalizes about the many frustrations and indignities of life.:
  • “the slings and arrows of outrageous fortune” and
  • “the thousand natural shocks/ that flesh is heir to.”
Again, his focus is the world, not his inner mood. He rejects suicide as a solution to these afflictions because death is “The undiscovered country from whose bourn/ No traveler returns,” and the possibility of more dreadful troubles in the afterlife “makes cowards of us all.” No thanks, Hamlet concludes, I’ll stick with the problems I’ve got. A wise choice, not a melancholic decision.

But Hamlet is only a play, so whether the Prince is depressed or not really doesn’t matter. In psychotherapy, however, the incorrect identification of an affective state can create unnecessary problems. We sometimes encounter patients who confuse “depression” with a variety of other emotions. They may tell us:
  • “I’ve been depressed since my grandmother died.” (No, like in Hamlet, that’s grief.)
  • “My team lost in the playoffs. I’m really depressed!” (No, that’s unhappiness.)
  • “That tearjerker movie left me so depressed!” (No, that’s sadness.)
  • “I’m depressed because I didn’t get a raise.” (No, that’s disappointment.)
  • “I can’t afford a new cellphone. It’s really depressing.” (No, that’s frustration.)
Confronted with these misapprehensions, our first task is to help the patient accurately identify the dysphoric state. This correction not only allows us to focus our therapeutic effort on the appropriate target, it also helps the patient to better understand his or her own reactions. In the worst case, it avoids the temptation to consider an “antidepressant” as a helpful intervention. None of these mischaracterized emotional states would respond to a drug.

So, back to the idea of naming and renaming...

Merely naming a set of symptoms provides clarity and a focus of exploration. As above, naming Hamlet’s emotional distress as “grief” not only explains his mood; it allows us to better understand his later behavior. If he were in therapy with us, we might examine his ambivalence about his ghost-king father as a basis for his indecision or challenge his negative overgeneralization about the world’s “emptiness.”

Renaming is an intervention that helps define a therapeutic problem in a more accessible manner. If we renamed Hamlet’s “indecision” as his sense of justice—being right about his uncle’s crime must precede any possible revenge—we could help him resolve his dilemma with much less vacillation. The play would no longer be a masterpiece, but it would save years of unnecessary therapy.

File under: The Art of Psychotherapy, Therapy Humor, Musings and Reflections