Why Patients Deserve Special Respect

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The stigma of mental illness lingers despite the carloads of Xanax-filled vials in the pockets and purses of America. The notion of life as an easily mastered enterprise persists. When the going gets tough, the tough get going — so we are told. Those who cannot, by force of will, get through difficult events unaided are thought to lack the right stuff.

I disagree. There is a quiet heroism in admitting you need help. Opening yourself to a stranger requires courage.  Awareness of your limitations is humbling. If all this were easy, therapists would observe lines leading to our turnstiled offices. Traffic pile-ups would slow the route.

Don’t get the wrong idea. The people who seek treatment are indistinguishable from everyone else. They range from rich, famous, and gorgeous to a more unremarkable lot. They are your neighbor and your friend. They might have been you and they may yet be you.

The best of them are willing to do anything to change their lives. They risk, cry, and expose their naked psyche. They meditate, think, try new behaviors and revisit old ones. They confront themselves in the darkness.

They look in the mirror for reasons beyond hair arrangement and shaving.

You may say you’ve been through worse than they and came out better, all without the crutch of psychotherapy or medication. Can you be certain? There is no calculus to compute your pain and measure your suffering against others. When you invent one call me, for then you can say you did it all alone, by the superior force of your will against the greatest odds.

Those faced with severe anxiety or mood disorders know things too terrible for words: endless sleep disturbance, perpetual unease, and (in the case of depression) minute-by-minute misery fraying the cord binding them to life.

You would not want to feel as they do if you could, and if you could the experience would not be as you imagined. You’d live inside of a monster who lives inside of you, consuming joy until your former self is gnawed away. Living the experience would lead you to repent any prior judgment, but shame might mute your apology. When patients choose to live and fight in spite of their calamity, the rest of us can only bow before them. To heap scorn on those souls who display courage even they themselves doubted adds to their misery. The crowd owes them encouragement instead. We diminish ourselves by withholding it.

Judgement, however, is hard to escape. A young married man who was a therapy-virgin told me he thought unfaithful males are weak in their lack of resistance to temptation. Yet he had never been severely tempted by a woman to whom he was drawn since his wedding; never had to turn from the scent, sensuality, and softness of another with seduction in her eyes. His thoughts on the subject were largely abstract and observational. What value might one give his opinion? No more, I suspect, than the rest of us when we say, “I would have done that” or “He shouldn’t do this” as we witness the battlefield of life from a safe distance, like the chest-beating bravado of old men who send young men and women to war.

The same gentleman, by the way, was a brilliant extemporaneous public speaker, but struggled to make a phone call. We are frail creatures, no? A lack of experience in counseling, like other opportunities one hasn’t had, puts negative judgment on a slippery slope to irrelevance.

Among those who think therapy deserves its stigma are at least a few who choose another way of living, less heroic than they think. There you will note plenty of avoidance, alcohol use, nightly marijuana trances. Some of their marriages are endured rather than enjoyed. You will discover those with few friends and jobs they wish were better. Anger and depression reside among them disguised. In other words, their lives are not so different than those of the pilgrims to the counselor’s office, except …

People who search for a therapeutic remedy face the imperfection not only in themselves, but in life. They tend not to live with the illusion that faith, by itself, will transform this mortal coil and their place in it, even if they await a more distant reward.

Perhaps most admirable of all, the most dedicated clients wish to learn: to do new things, explore the psyche, reexamine their past, and travel to the unnamed, undiscovered country. They are discontented with their present life and the majority wish to move beyond blame — though blame they may — and take responsibility for change.

Winston Churchill said that “Democracy is the worst form of government, except for all the others.” Maybe therapy is like that: the worst remedy for unhappiness, except for doing nothing; a painful attempt to face the truth and reorder your existence, modify relationships, and pour yourself into a vessel on which you’ve written: “This has value. This is worth my best effort.”

If you find a better way, let me know. Until that time, hats off to those who take Socrates to heart: “The unexamined life is not worth living.”

The top photo is called A Life of Theater Photo: Sadness –Final Chapter. It is the work of Gabriel S. Delgado C. and sourced from Wikimedia Commons.

 

Why Loved Ones Refuse Therapy and What to Do About It

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You’ve tried — with your friend, your spouse, your adult child. You made the case for counseling. Some hem, some haw, some say they will, but don’t. Others just refuse.

Why?

A few reasons to consider and what you might do about it:

  • Stranger danger. Suspicion of strangers is deeply rooted in the human race, derived from our primitive beginnings and ever-present con-artists. Your friend’s personal experience of betrayal may be a key factor.
  • Saving face. Much in life depends on reputation. How many of our parents admonished us to hide the family secrets and “be sure you don’t tell the neighbors!” Men, in particular, want to project strength, the better to succeed in the world of work and win a desirable spouse.
  • The doctor doesn’t care. He is only in it for the money and measures his patients’ value by the size of their bankroll. Should counselors then give treatment away and make their living after hours by standing on street corners with hat in hand?
  • I’m afraid my employer will find out. I can’t risk it. If you use insurance, the insurer will know your diagnosis, as will every such company in the linked system. They are not supposed to reveal anything to your employer. However, if you work for someone with few employees and his premiums go up the next year … ?
  • Therapy is for the weak, a crutch for the spineless. A therapist argues instead that facing your demons and working to change are signs of strength, not evidence of frailty: an indication of courage, not its absence.
  • I don’t believe in the value of looking back. Sometimes therapy doesn’t require it, but a historical evaluation can remove the bolder from your backpack and allow you to move ahead with pace. On the other hand, baseball’s Satchel Paige said, “Don’t look back, something might be gaining on you!”
  • Emotional pain. Whatever reasons are given, the prospective client can be unconsciously timorous at opening painful issues — digging up a grave bursting with undead horrors of the heart and memory.
  • I’m a logical person, not into feelings. I can solve this logically. Such statements are uttered most often by those who aren’t as logical as they think.
  • A real man does things, he doesn’t talk about them. But what if he doesn’t know what to do after trying everything?
  • Fear of change. Most of us find discomfort in new challenges, in or out of treatment. Yet change can’t be avoided unless you want to wear the same clothes in the same size and color the rest of your life; and continue to travel to the same job site even after your employer bars the door.
  • Fear of the mystery. The counseling office is a bit like the inner sanctum of a haunted house — a place of strange rites and secrets, incense and shadow play, frequented by the ghost of Sigmund Freud. The person who wants control will find few guideposts. Will a wizard cast a magic spell on him?
  • Fear of medication or hospitalization. Though you can’t be forced to take meds as a rule, some are terrified they might hear the doctor recommend it — or worse, a hospital stay.

What’s to be done? I received calls from spouses who wanted to make an appointment for their mate. This is rarely useful. If the individual lacks the courage or motivation to seek treatment himself, the likelihood of his appearance at the appointment is a coin flip at best.

Begging and pleading have their limits, too. The more you push, the more therapy becomes your agenda, not the person you care about. You own it, he doesn’t want to buy it. The more you pester or threaten, the faster he runs. If he does attend a session, his motive is to placate you, not heal himself.

Sometimes it helps to enlist the persuasive talents of one who is respected by the prospective patient: a clergyman, best friend, or close relative. The danger here, however, is an unauthorized revelation to a third-party interpreted as a breach of trust. A similar risk occurs when you plan an “intervention:” getting several friends and family members together to encourage and explain their concern to the doubtful potential client. This technique is more often used with alcohol and drug abuse problems, and is easier to rationalize when the person’s life is out of control and in danger.

I am not speaking here of people who are at risk of harming themselves or others. Thus, legal remedies to force the issue are not available. If your steady expression of loving concern cannot turn the tide, waiting might be the only alternative. The accumulation of pain perhaps will do what you can’t.

You are left in a difficult situation: straining your patience when everything in you wants to scream.

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Most of us spend a good part of our lives wishing others were different: more loving, kinder, attentive to us in a way rarely offered; with an intensity and compassion that finally permits the auditor to “get us.” We want the love of this one, the respect of that one, and wish another would take our words to heart. We think and plot about attracting the dark stranger, selling the human product (ourselves), and winning the vote of the crowd.

The good news here is the presence of one person we tend to ignore. While we work on others to change, he remains in the shadows. We don’t need to run after him, persuade him, make an appointment to meet six weeks in advance, and cause his face to turn in our direction. His visage greets us in the mirror every morning.

When others resist our efforts to influence them we are left to change what we can about ourselves — what we may and what we must: our attitude, emotions, and reactions to the one who refuses treatment — and to the rest of life as well.  The transformation begins whenever we want. The process of self-modification can persist as long as we live. Unlike changing the loved one, however, the necessary alterations are in our hands.

The most important opportunities in life sometimes have been there all along. We wait for the other to wake up while what is changeable in ourselves awaits its own awakening. Imagine standing at a crossroads: one path leads to a darkling state of perpetual hope or desperate preoccupation with a person you can’t control. You pass the time alternately gnashing your teeth or imagining what life might be like if only he changes. The other road directs you to a house of natural light and mirrors revealing all sides of the one human you do control. This workshop evokes the hard work of the master sculptor in everyone, the painstaking job of reshaping our basic stuff.

Become your own work of art.

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The second image is a Ladies Watch Case photographed by Zeigerpaar and sourced from Wikimedia Commons. The bottom photo comes from the Bristol RA Gallery Festival of Stone Sculpture.

 

Dealing with People Who Say Therapy is a Crutch

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It is so easy to judge. Legions of “friends” and acquaintances evaluate your decision to enter treatment. Some signal thumbs up and applaud your courage. Others gesture thumbs down and render disapproval:

It’s not as bad as he thinks.
He needs to suck it up.
I’ve been through worse.

While many people are understanding, critical voices say you betray weakness by reaching for this “crutch.” Surprisingly, those who have experienced a similar problem are often less empathetic than the rest. If your friend also got over a traumatic accident like yours, research says he is probably less sympathetic than people who were lucky enough not to have had that piece of bad luck. The closer your experience is to one the other person triumphed over, the more likely he is to think your adversity is manageable. A pity, because when you reach out to the buddy you expect to be most soothing, you might discover he comforts you not.

Sometimes we must give up on such “friends.”

Nature fashioned us to survive. Like athletes trained to forget their failures quickly, we are more content if we get past the pain of remembrance. Thus, our own photo-shopped recollection of triumphing over the bad breaks of life can make us less sensitive to fellow-men when those traumas are akin to ones we once endured. Arm-chair chest-thumping is like the braggadocio of a political office-seeker who tells us how easily he would fix a national problem if only he were in office — condemning the effort of those who now grapple with the job. The sideline of life is a place where judgment produces cheap and imaginary victories rarely duplicated once the judge steps out of his robes and into the game himself.

It is not the critic who counts; not the man who points out how the strong man stumbles, or where the doer of deeds could have done them better. The credit belongs to the man who is actually in the arena, whose face is marred by dust and sweat and blood; who strives valiantly; who errs, who comes (up) short again and again, because there is no effort without error and shortcoming; but who does actually strive to do the deeds; who knows great enthusiasms, the great devotions; who spends himself in a worthy cause; who at best knows in the end the triumph of high achievement, and who at the worst, if he fails, at least fails while daring greatly, so that his place shall never be with those cold and timid souls who know neither victory nor defeat (Theodore Roosevelt, 1910).

Adding to our misfortune is the tendency to condemn ourselves. History offers examples of people who triumphed in extreme situations. We get the sense such folks are plentiful because they are the objects of story and song — as numerous as the apples on a fruit tree. If we buy-into the ease with which people survive and thrive we compound our already miserable state by observing the contrast with our own plodding struggle.

From the therapist’s chair, survival and persistence are, by themselves, heroic. Perhaps not the heroism of a Shakespearean tragic figure like Coriolanus, but admirable nonetheless.

I treated just such people in my therapy practice. For a time, sometimes for months or years, they were immobilized by the hammer blows of fate. Signs of resilience and the will to fight slowly emerged. Not always, but often.

The art of life is more like the wrestler’s art than the dancer’s … it should stand ready and firm to meet onsets which are sudden and unexpected.” (Marcus Aurelius, VII, 61).

Like the athlete thrown to the floor, in time you must get up.

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The moment of resurrection is different for each of us. On the wrestling platform of life no referee demands a speedy rise. Ah, some in the audience will criticize, but they do not writhe in your anguish or see the torn sinews beneath your skin.

The effort to stand again is not over until you say so. Those who judge are unaware (or have forgotten) how they would react in a similar situation. Some resort to a kind of cheap self-flattery to quell anxiety at the possibility of themselves experiencing your adversity. “Oh, I would have been able to handle that” is soothing to say and makes them believe they are resilient and brave, but is lots easier from the grandstand than on the field.

Your misfortune is also a cruel opportunity, but an opportunity nonetheless: to triumph over fate. Sometimes victory is just persevering.

When Shakespeare’s flawed hero Coriolanus was banished from Rome, his mother lamented his departure. He attempted to console her with words she taught him. The perspective he learned from her was that a crisis was a chance to distinguish himself as better — more heroic — than the average person:

Where is your ancient courage? you … used

to say extremity was the trier of spirits;

That common chances common men could bear;

That when the sea was calm all boats alike

Show’d mastership in floating …

In other words, it is easy for us to sail along without concern when the water is smooth.

You who are in pain would give up the suffering if only you could. Now, however, you will find out who you really are. The rest of us are waiting for whatever challenge drops on us for the chance at such knowledge. I am not suggesting we seek it. Yet, once fate arrives, do battle in whatever form you can however weak you feel. Even if taking a breath is, for now, all you can muster.

For those of you in the fight of your lives, I salute you.

The Wikipedia “Fight Back!” logo is the work of Kasuga-commonswiki.

Be Prepared: Reactions from Friends, Family, and Lovers When You Get Therapy

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Sometimes the standing ovation is a long time in coming.

Sometimes those expected to be most supportive of you are just the opposite.

Sometimes those you think are on your side are actually working against you.

When even your family dog looks doubtful, then you are really in trouble!

Who am I talking about?

A few of your friends and relatives when you enter therapy; especially, if you begin to make significant progress.

The Boy Scouts of America have it right: be prepared.

Therapy still carries a stigma in some quarters. Men, in particular, tend to believe that they should be able to handle problems without a “crutch;” that talking too much about “feelings” is not the thing that a “real man” does. For these people, going to a therapist is thought to be a moral failure — a weakness of the will.

Parents, too, can be threatened by an adult offspring’s decision to enter treatment. The public stereotype of counseling is that you will be required to explore your childhood and that, before long, you will blame your parents for everything.

An exaggeration, of course.

But, the more likely that your problems do have something to do with your parents, the more likely that they might discourage your efforts to engage in treatment.

On the other hand, unsupportive parents can use your decision to seek professional help as evidence that you are “broken.” Your need of counseling can be counted as “proof” that there is something wrong with you (as opposed to themselves or to your siblings who have not sought this kind of assistance).

But what if you suffer from alcohol or drug abuse or addiction? Surely everyone would want you to overcome this, wouldn’t they?

Not so fast.

You probably have friends and family who “use and abuse” substances, as well. If, in the course of treatment, you try to cut-back or become abstinent, little approval will follow from this group. Rather, you will find yourself with as many or more offers of drinks and drugs, as well as pressure to resume the same behavior as before, lest the change be seen as an indictment of this group and the habits of its members.

Comments like, “what, do you think you are too good to have a drink with us?” or “it’s only one drink,” or “geez, it’s really great weed; you’d really love it,” or “let me buy the drink” are commonplace. This is why such relationships inevitably either break down or the person attempting to change himself “falls off the wagon” due to social pressure and criticism.

It is also a part of the reason why support groups for addiction like AA (Alcoholics Anonymous) are so important in providing the understanding, back-up, and encouragement that is lacking elsewhere.

Even if your treatment doesn’t involve alcohol or drug abuse, you may discover that parents or lovers will try to become “back seat drivers” of the ongoing discussion between you and your counselor. Some of them will wish to know all the elements of your private conversations, including the most intimate details.

This can be a problem. People frequently go to therapists because they have issues that are tremendously painful or embarrassing to confront. It can be hard enough to open up such matters with a psychologist without the knowledge that you will be debriefed at home. If your partner or parent “requires” you to talk about those delicate subjects, it can discourage you from speaking to the therapist about them, or even engaging in treatment at all.

Sometimes mom or your spouse will go so far as to suggest that your revelation of family secrets and any negative commentary (about them) to the therapist is a personal betrayal of your family bonds and obligations.

For the record, there are many times when therapeutic conversations must be absolutely confidential and free from the review of other interested parties. Your therapist knows this and will not divulge information without your clearly directed permission (unless you are dangerous to yourself or others). You should not feel compelled to make regular reports to spouses, friends, parents, or other relatives simply because they want you to.

And what if you do change, with or without the encouragement or support of the people closest to you?

They do not always welcome those changes.

If you have been docile and passive in relating to loved ones and you now become assertive and independent — not willing to “go along in order to get along” — people who used to manipulate you will be frustrated. Should you now be capable of standing up for yourself, saying “no” — refusing to be hostage to others’ disapproval or direction — you must expect that there will be “push back.”

“You’ve changed — you’re not as nice as you used to be. Therapy has made you selfish. I liked the way you were before,” and similar comments can be expected.

If they can, some of these alleged “friends” will make every effort to have you retrace your steps and resume the second-class status that has been yours historically. If, however, you withstand their efforts to restore the relationship to its previous terms, some of them will adjust to the “new you” and accept the change as a good thing for you, or a least something that is tolerable.

Others, however, will end the tie they have with you, or diminish their contact and availability to you.

Yes, you will be rejected. And, the rejection can make you wonder whether all the time, expense, and therapeutic effort were worth it. Grieving will be necessary.

But, if you can persevere, you should be able to find new friends who are healthier for you and less self-interested, while at least some of your old friends will stick around and be more enjoyable to be with.

It can be quite a disappointment to find that some of those you hoped would be most happy for you and encouraging of your growth are the least supportive.

But, as the old saying goes, “with friends like that, you don’t need any enemies.”

Opt for change and hold your ground. If you cling to your dysfunction in order to keep these pseudo-friends, you have chosen their needs over your own.

The best of your friends and family will want what is best for you.

Always.

The apparently disapproving visage of Brittany Dog is the work of Uber Phot. It is sourced from Wikimedia Commons.

What Do Antidepressants Really Do?

I believe that the oldest reference to an antidepressant medicine comes in Homer’s Odyssey, which “could not have been completed much before the end of the eighth century B.C” according to Richmond Lattimore. The reference occurs when Menelaos (brother of Agamemnon),  Telemachos (son of Odysseus), and others are grieving the loss of friends and relatives in the Trojan War. Helen, the wife of Menelaos, is also present. It was her departure to the walled city of Troy with Paris that triggered the assault on that fortress to retrieve her. Having since returned to her husband, she wishes to salve the emotional pain of the men who are gathered at her home. The passage reads as follows in Lattimore’s translation:

“Into the wine of which they were drinking she cast a medicine of heartease, free of gall, to make one forget all sorrows, and whoever had drunk it down once it had been mixed in the wine bowl, for the day that he drank it would have no tear role down his face, not if his mother died and his father died, not if men murdered a brother or a beloved son in his presence, with the bronze, and he with his own eyes saw it.”

That would be a potent brew indeed. But the idea of it prompts me to say a few words about what an antidepressant can and cannot do, for there is much misunderstanding on this point. And, by the way, the first real antidepressants only became available in the 1950s.

An antidepressant does not make you giddy about your life or impervious to emotional pain; it doesn’t make you forget bad things. In other words, it is not what Helen of Troy administered. If an antidepressant is working well, it helps put a floor under you. That is to say, many people with depression feel as though there is nothing holding them up (metaphorically speaking), no bottom to their suffering.

An effective medication creates that bottom, relieving them of the sense that they are without any support underneath them. It reduces their suffering too, makes them less prone to crying, less exhausted, and less subject either to over-eating or having no appetite, and usually able to sleep better. In other words, the medicine helps you tolerate life and helps normalize that life.

Some people, including quite a number who shy away from psychiatric medications or medication or any kind, actually are attempting to “doctor” themselves with drugs or alcohol.

There is danger here, naturally.

You probably know some of the dangers, but one I want to mention in particular is the depressant-effect of alcohol. It might make you feel better in the short-run, but in the long-run it is likely to fuel your depression, not to mention create a dependency.

As the old Chinese expression goes, “First the man takes the drink, then the drink takes the man.”

I suspect that you know someone who believes that psychotropic medication (and perhaps psychotherapy too) is a crutch. There is no denying that being treated for emotional problems can produce negative judgments and a stigma. Moreover, historically speaking, insurance companies have paid less well for therapy and psychotropic medication than for “physical” illnesses. That has just changed in 2010, but the stigma won’t be legislatively erased by the US congress, as was achieved by “parity” legislation that now requires equal insurance coverage of both physical and “mental or nervous” conditions.

Yet some categories of depression are certainly just as “physical” as an imperfect gall bladder is, for instance. Specifically, Bipolar Disorder, also called Manic-Depressive Disorder, is one such biologically-based psychiatric category where medical intervention is often enormously helpful, if not essential.

Would you want your severely diabetic loved-one to avoid the “crutch” of necessary medication? If your answer is “no,” then you shouldn’t be put-off by treating a biologically-based depression with a proper medication to stabilize his mood.

Nonetheless, it is true that many depressed individuals do not have any biological flaw or chemical imbalance, but rather are reacting emotionally to difficult life circumstances such as repeated losses (e.g. divorce, job loss), unfinished grief, or abuse of one kind or another. Very often psychotherapy is able  to successfully treat these people without the benefit of medication. Indeed, sometimes patients are too quick to obtain antidepressant prescriptions which take the edge off their feelings enough to reduce their motivation to address difficult life circumstances, including repetitive patterns of behavior that lead to unhappiness.  In that event, they will risk having to stay on antidepressants lest they fall back into depression.

For those patients, on the other hand, who successfully address their issues in psychotherapy, antidepressants may never be needed or, if they are used, might be required only temporarily.

If you are seeing a therapist for depression, talk with him about medicine for your condition, especially if you feel that you need immediate relief or are having suicidal thoughts. Beware equally of therapists who never want their patients to go on medication, as well as those who always do.

I should mention that while many depressed people obtain medication from their family or primary-care physician or general practitioner (GP), this isn’t always the best source of psychotropic mood-altering substances. While some GPs are both comfortable with and experienced in prescribing such medication, some are hesitant or unsure. The latter group may be less adept at identifying the precise antidepressant which is best for you given your particular symptoms; moreover, their hesitation can cause them to give you too low a dose to obtain a therapeutic benefit.

A good psychiatrist, by contrast, is absolutely up-to-date on everything about the medications available to treat you, adept at identifying which of the available antidepressants is the best fit for your particular situation, and knows how to get you to a therapeutic level of the medicine as quickly as possible. Since those in pain so often feel as if there will be no end to their suffering, and since antidepressants often take a several weeks to produce relief, getting the medicine right as quickly as possible is very important.

If you do choose to obtain medication, be sure to educate yourself about your condition and the possible side-effects of the medication being suggested. Not all physicians are good about describing those side-effects before-hand, even including the sexual side-effects produced by some antidepressants. Be your own advocate. Don’t be passive in treatment. It is your body, it is your life.

Last I heard, you only get one of each.