Why Some Patients Shouldn’t be Treated: When Therapy Can Make Things Worse

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Therapists are programmed to do therapy the way that surgeons are programmed to do surgery. For some of them, it can be the almost automatic elixir for whatever is ailing. But is treatment always a good idea? Here is a cautionary tale, a story of one occasion where I counseled someone to forego therapy with me — and why.

The woman was about 55 years old, still fit and attractive, with bright eyes and an engaging smile. She gave an impression of someone of inner strength and conviction. One imagined that she had her share of male attention over the years. But turning heads was not what she valued, entirely to her credit. No, she meant to make a difference in the world, to get some recognition for her work, to make a name and do something of value with her life. And she knew, by 55, that she probably had a limit on how much could be accomplished in her lifetime. After all, her parents had both died before age 70.

Although she had a loving husband and three children, something was missing. It wasn’t money since her family was well-fixed. She had a few good friends, so she wasn’t lonely, even if few knew the full extent of her complicated inner life. And her husband adored her, despite frustration that he couldn’t remedy her dissatisfaction.

He worried that she seemed to rely on alcohol too much, usually after dinner, never before. Drink was kind of a sedative, something that calmed that unsettled feeling that shadowed her much of the time. Anti-depressant and anti-anxiety medication had failed her; too many side-effects, she felt. You might say that she lived with an itch that couldn’t be scratched.

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Mrs. Half-Empty Lovely Life. Let’s call her that, or Mrs. HELL, for short. Because that is what her life was like, some sort of heavenly hell. She knew it was beautiful. She tried to persuade herself that she should be satisfied with it. She realized that she was incredibly lucky compared to nearly everyone else on the planet. People in her church admired her, her husband and children loved her, and everyone was healthy. But still she needed a few drinks at the end of the day — her only respite from the coiled spring of tension and disquiet that lived inside of her. Nothing seemed to scratch that itch I mentioned. And you might ask, where did that itch come from?

I learned about her early life in the course of an initial interview. She had been special, so her father had said. He was a minister who hoped to become a great man in his religious denomination. But he volunteered to be a chaplain in wartime and, however much this was a noble thing to do, it derailed his assent in the church hierarchy. Dad never achieved the exalted level of recognition he sought. Ah, but there was his daughter, born just nine months after he returned from overseas! What might be possible for her? She was his favorite and dad encouraged her to imbibe from the fountain of faith and ambition that sustained him. His church was a liberal one, so the assent of a woman just might be possible. That hope tied them together and his death left the task to her alone, the thing she knew he wanted for her and for himself.

In fact, she did become a clergywoman. But, at some point, her career stalled. Everyone thought she was great, or so they said. Everyone loved her sermons, or so they said. But somehow, when it came to advancement in her denomination, she never got as high as she thought she should. There was a rung on the ladder just out of reach. She remained a big fish in a small pond. She wanted to do something that people would remember. She wanted to be a bishop and, if truth be told, even more. There were important reforms to the church that she believed were desperately needed for the good of all. But her current position didn’t permit that kind of impact and she had her doubts about it ever happening.

Prayer, the thing that you might think would give her comfort, didn’t give enough. Wine actually gave more. The minister was reaching the point where she was pretty sure that the project — her dad’s project for her, but one she believed in fully — would not be achieved. Yet, she continued to plug away, trying to influence others with more power in the church to make some of the changes Mrs. H thought to be essential. She wrote letters advocating her ideas, brilliant and well-reasoned. “Oh, yes, thank you, we will give your suggestions every consideration,” they said. But the ideas never took hold. Perhaps sexism played a part in her frustration, but Mrs. H was mostly concerned with the goal, not the reasons why her conception of a reformed church institution went nowhere.

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The frustration brought her to consult me. She’d heard that I treated other ministers and had been helpful. We talked, even though she felt vaguely uncomfortable with the idea of seeking counseling; surely, she thought, her parents had raised her to be tough and God alone should be a sufficient source of reliance.

That reliance led Mrs. H to conclude that even if her ideas didn’t triumph in her lifetime, perhaps someone would eventually act on her vision of what the denomination might become. “I’d like to think maybe someday in heaven, I’ll be able to look down on all this and realize that what I did wasn’t in vain. I’d like to think that my efforts will have made a difference.”

I asked her about the solace that she gave to her flock and the value she put on that part of her life. Indeed, she acknowledged that it was important, but somehow it seemed too individualized, not sweeping enough, not the institutional change she was aiming for. Helping people one-by-one was all very good and important, but…

She could not give up the project. We talked about her alcohol use, the benefit of prayer, the possibility of trying meditation. She mentioned the anti-depressant side-effects and her sensitivity to medication. Her work made sharing her frustrations with people in her church community difficult. She did share them with her husband and a couple of other adults, but that didn’t provide more than temporary assistance.

Mrs. H talked a lot about her dad. How much she loved and respected him. How much he hoped that she would rise in the church hierarchy and make it a different and better place, one more pleasing to both man and God.

Dad’s devoted daughter often wondered what he was making of the antics on earth from his spot in heaven, her own struggles in particular. I asked her if she believed that he would want her to keep trying to advance her vision for the church or perhaps give up on the project that was causing her so much anguish. She knew that he wanted her happiness, she said in response. She was certain he would be chagrined at her frustration, but couldn’t imagine her father ever being comfortable with quitting on something important. Sure, he would tell her to give herself a break, but wouldn’t he really be disappointed? That is the way that Mrs. H thought.

This good woman had a life that some would say was blessed: a husband she loved and who loved her, great grown children and sweet grandchildren; a respected position and as many material things as she cared about. Yet she was gripped by something that defined her entire life, her relationship to her father, and her afterlife (as she envisioned it); something to which she had devoted close to 40 years of training, experience, and effort.

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In light of all this, what might therapy do for (or to) such a person? And what did I try to do?

I recommended another medication consult with a terrific psychiatrist. I said that we should meet again after that. When Mrs. H returned, however, she said that the psychiatrist could provide nothing that the previous physicians hadn’t already prescribed, those drugs that had produced intolerable side-effects.

When you’ve done psychotherapy for a long time, you get to know who is really open to change and who is not. As I saw it, Mrs. HELL was not open to giving up on the multi-generational efforts of her father and herself; she was not open to accepting defeat whether due to sexism, her own personal limitations, or even the shortness of life. And she was most certainly not open to questioning her religious faith or seeing any unfairness in God’s “plan” for her, even as much as none of it was sufficient to sustain her.

But what if, somehow, I had been able to find a way in — to get her to question one or more beliefs? Weren’t these like the pillars that hold up a building, however shakily? What if she came to see that her father should not have freighted her with the responsibility to carry on his mission? What if she began to recognize unfairness in the behavior of the church hierarchy or sexist discrimination in their treatment of her? Or, what if she came to think that she would never see the posthumous completion of her task from a lofty spot in heaven, either because her ideas would die with her or because heaven didn’t exist?

If Mrs. H came too close to any of that, she probably would have become even more depressed and unsettled than she already was. Therapy would have been too much like pulling on a loose thread in a sweater, only to cause the entire garment to unravel. She might have felt guilt for prematurely giving up on her father’s vision, internally conflicted about him, and doubtful of the fairness of judging someone who had been so good to her. If anything, it’s likely that Mrs. H would have blamed herself for “buying in” to a life that dad hadn’t actually demanded of her. Rage at the church might have contributed to her turmoil, especially the men who didn’t give her ideas due consideration; and made it harder to minister to her flock. And if Mrs. H somehow began to question the possibility of the kind of afterlife she had imagined, the entire edifice of her religious faith could have collapsed.

At some point in treatment she would likely have come to believe that she’d wasted the best years of her life, without a clear future plan or the time required to create and achieve it. Depression would almost certainly then intensify along with an increase in alcohol abuse. Therapy, if it could help, would take years, by which time even more of Mrs. H’s life would be behind her. Indeed, the fact of having to engage in a lengthy and expensive therapeutic process could well add an additional layer of resentment and regret.

I told this woman, lovely and bright, that I didn’t think I could help. Since she didn’t ask why, I wondered if she was hoping that I would say just that. I knew there were two reasons for my decision: I didn’t believe I could get her to look at herself and her situation in a new way; and, even if I could, it would be too destructive for her to do so.

I suggested that she continue to pursue possible psychopharmacological (medication) treatment as a first line of potential healing. I recommended some other therapists who might have a different perspective on her dilemma if she wished to try counseling with someone else. Put simply, I thought the grieving process of getting over the failed family project of reforming her religious denomination would have been worse than simply letting her continue to struggle. The treatment held the risk of drowning her. For now, at least, she was still above water. I suspected that as time passed her reliance on the idea of a heavenly victory would increase and provide more sustenance. I may have been wrong in my evaluation, but that is what it was.

The way I look at it, then and now, is that sometimes a well-intentioned act can cause damage. Take the following example. It is rather extreme, but it makes the point. A concentration camp prisoner tells the story:

I shall never forget how I was roused one night by the groans of a fellow prisoner, who threw himself about in his sleep, obviously having a horrible nightmare. Since I had always been especially sorry for the people who suffered from fearful dreams or deliria, I wanted to wake the poor man. Suddenly I drew back the hand that was ready to shake him, frightened at the thing I was about to do. At that moment I became intensely conscious of the fact that no dream, no matter how horrible, could be as bad as the reality of the camp which surrounded us, and to which I was about to recall him.*

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As Dante Alighieri knew, hell’s Inferno has many levels of pain — some better, some worse. Viktor Frankl, the writer of the concentration camp story, points to the risk of awakening people to misery that is even greater than the unhappiness they are currently experiencing. Physicians are instructed that they should “first, do no harm.” I always tried to remember that, even though I successfully treated a great many people, and rarely turned anyone away in the manner I’ve just described.

Therapists can be life savers. Literally. But, none of that changes the fact that sometimes the cure really is worse than the disease. Good therapists must know the difference.

For those who have tried therapy without good results, you may want to read this: What to do When Therapy Doesn’t Help.

The top image is a Surgeon Icon by Angelus. The second is a Man Scratching Back With a Back Scratcher by en:User: Archos. It is followed by a poster for the movie Side Effects, a production of Pritish Nandy Communications. Next comes, the Facade of the Cathedral of Milan, Italy by MarkusMark. Finally, a Bonfireby Madmatt52. All are sourced from Wikimedia Commons.

*Viktor E. Frankl, Man’s Search For Meaning: Revised and Updated (New York: Washington Square Press, 1984), 48.

2 thoughts on “Why Some Patients Shouldn’t be Treated: When Therapy Can Make Things Worse

  1. I have to disagree with you on some notions here. I do agree that sometimes therapy can make matters worse, but I feel the lady in this example needed a change in direction and tactics. First I would have asked her what her “message” was. Then I would have asked her which was more important: her spreading her message or reaching a level of prestige she/her father wanted? If her message was her goal I would have encouraged her to try different avenues to spread her message since her church wasn’t giving what she felt her due respect.

    Examples would have been encourage her to write her own book about her thoughts on religion so that way her “legacy” could live on even after her death. Or to meet up with fellow churchgoing women and start a women’s bible study group, which could possibly expand into starting her own church that preaches the gospel from a woman’s point of view. At least start a blog so she can share her ideas and reach out to others. After all, Picasso’s and Van Goh’s works weren’t appreciated until after their deaths. They were even mocked for their perspectives during their lifetimes but they did what they did not for the fame, but for their passion. I guess I would have her question whether she was doing this for power for because she truly loved it and felt she had something to share.

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  2. Thank you, Bob, and thanks for patiently waiting for me to respond. Since I wrote this story almost five years ago, I had to find time to reread it. You make good points and certainly there are always other things to try, one of the reasons I offered to refer her. The possibility of her mentoring someone who might achieve what she had hoped to would have been another path for her to consider. As I imagine you gathered, she was pretty rigid. Her goal had to be achieved in the way that fit with her dad’s vision, now her own. As to becoming the Picasso or Van Gogh of her religion, there is the opinion of no less than Nobel Prize winning psychologist Daniel Kahneman, that one of the surest paths to unhappiness in life is to set an impossibly high goal. Still, I did not try everything you suggested, so I am in no position to say with certainty what the results would have been. Sounds like you are a good therapist!

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