Change and Desperation

People come to a psychiatrist because they want to change.  At least that is what they think they want.  They get up the nerve to make an appointment, walk through the door– not a small thing!  In fact, considering that psychiatrists are supposed to be the doctors who deal with depression, anxiety, and ‘frailties’ of the mind, it is interesting how much dread they invoke in people!  I think the reason isn’t necessarily because psychiatrists have horrible personalities… at least I hope that isn’t the reason… but rather I think people fear going to psychiatrists for at least two other reasons.  The first is that people think that psychiatrists will ’see through them’– that we have some special ability to read minds, or determine what a person is REALLY thinking… the second and more important reason is that people tend to push their problems out of their awareness, and when they go to the psychiatrist they have to think about things that they would rather not think about.

There are other reasons, of course–  psychiatrists ‘ain’t what they used to be’, at least in my humble opinion.  They spend way too little time with people, selling their souls to the big systems that have them work on productivity, seeing too many patients for too little time.  And there is nothing worse than getting all worked up to go tell a person your problems, only to have the person totally ignore everything you are saying, or push you out the door before you even got started.  I wish people would just avoid those psychiatrists, because they are giving psychiatrists a bad name and ruining the specialty.

But that isn’t why I am writing… I am writing about change.  People come in saying they want to change… and then they fight that change from that point going forward.  I’m not complaining, because that is just how people are.  But it is something for people to be aware of, so that they understand why they keep making the same New Year’s Resolution year after year!

Because of resistance to change I usually aim fairly low in my expectations of the steps people will take… I don’t for example tell people who are depressed to ‘just start exercising’, and get mad when it doesn’t happen.  On the other hand there are times when it is possible to induce change, and I try to opportunistic– and grab those opportunities if they arise.  Such was the case with the patient I am about to talk about.  As usual, names and details have been changed a bit for privacy.

The patient, ‘Jane’, had been miserable for a long time.  Her husband doesn’t communicate beyond a grunt or two here and there;  Jane has given up a great deal of ‘power’ over the years, in part because she has a recurring substance problem that has been mild so far, but that gives her enough shame to buy into her husband’s comments that ’she has no right to complain’… about anything.  This is a tough situation for a person to be in, and a frustrating case for a psychiatrist.  The person in such a position is miserable, but not miserable enough to really do anything about it.  I can suggest things, of course– ways to foster communication, tips on relaxation, parenting suggestions… but for the most part people don’t take ‘advice’ to heart.  Now and then I will find an area where the person has a ‘blind spot’– were the person is seeing something in a distorted way, and if I can get the person to see it differently I might increase insight into a problem… this is trickier than it sounds, because I can’t just point it out to the person, as then it will be rejected.  But if I can make it come out in a way where the patient ‘discovers’ it, then it might stick.

Off track again… I should try to write in the morning, as late at night I tend to get a bit tangential.

Opportunism…  if the person gets desperate enough, THAT is when there is the possibility of change.  That is where I was today with Jane, after she wrote me this message:

Hi Dr. Junig,

I left a message at your office last week; but I was unable to get back to you —to get in as soon as possible.

Things feel like they are getting worse than ever…Financially and emotionally with Tom. It’s not only him. It is me. I just want to leave. For the last month the thought of leaving, just driving away to escape my life is a thought that I can’t get out of my mind.

I hate our unorganized mess and life and finances- and when I look around I start to feel like I am going to lose it. I just keep saying, this is not how my life was supposed to be…

Bill collectors are calling all the time. Our furnace isn’t working and Tom doesn’t seem to care. We are all living in the basement of my mom’s house now– pretty sad. I have no energy to do anything at all; except barely get by with the daily activities which are overwhelming. I have gained the 25 lbs over the past three months, strange because I never feel like eating anything.

My girls are the only thing that keeps me going every day. But they can tell there is something really wrong with me.

I used up the valium 2/day, took twice as much cause it didn’t do anything for me at the lower dose. I hardly ever feel relaxed or not un-nerved.

Please call!

My Reply: Again, this is one of those rare times when one swings for the fence.  A person with a ’small’ substance problem is not going to accept buying into a 12-step program;  people with addictions come in and say ‘doc, I’m so miserable from these drugs… I can’t stand it anymore… I’m broke, my wife left, I have no food in the house– I’ll do anything!  ANYTHING!!  Please, help me’.  I’ll ask them to check out one AA meeting during the next week– one hour, costing one dollar.  The person says ‘Oh no, doc, I can’t.  I have too much to do–  in fact, I’m not really all that bad.  Just forget I said anything!”  People hate AA– unless they know anything about it and have actually opened their mind to it– then they recognize just how effective it is, and they understand that it is NOT about finding sympathy, or whining about problems.  It is about courage, and follow-through, and responsibility, and ‘carrying one’s load’.  And it is life-changing.

OK… my response, finally:

Hi Jane,

I hear you loud and clear. I don’t have an easy answer– I don’t think there is one, because you would have found it by now if there was. But there should be reason for hope; if we look at your life there are reasons to be happy, at least moments of happiness– I don’t want to sound like I am making less of things because I don’t feel that way– I realize that things are really hard right now and you are totally miserable. But you have food and you have shelter– not great being in grandma’s house, but at least you have shelter…

I think about my own despair in 2001 when my addiction came to a head– lost my job and career, marriage sucked, kids didn’t know me, no hobbies, feeling totally stressed out and physically miserable. In my case there was addiction to focus on, which was lucky for me, because the 12 step program really does have the ingredients for some level of happiness— even when everything else is going wrong.

In your case, Jane, there are little things that will improve the situation for you, but I think it will take drastic measures to make a real change in your level of happiness. Anything short of that will be a temporary fix– at best—and you would end up back where you are now. Do you see my point? You need something that is ‘life-changing’– nothing else will make all those things better!

I hate to sound like a salesman, but a 12 step program is the only thing that is going to really help. The good news is that if you are truly desperate– desperate enough to open your mind– a 12-step program will potentially fix ALL of those problems. I know it seems like a stretch, but it really could. And it wouldn’t cost anything except a buck per meeting.

Will you consider that option? I would make recommendations on which meetings to go to– and the goal would be to get off the lorazepam. We have to do something about those anyway– they will only destroy you at the rate things are going. You can’t control them; don’t feel bad, because I wouldn’t be able to control them either. We have to get you off them because there is just no other option– you take them, run out, get sick…. they are not helping, and they are probably making things much worse.

Will you check out a 12-step program?

JJ

After a shot at the fences, people sometimes strike out. Time will tell…  we will take a big step forward… or I may never hear from this patient of two years again.

I’m tired… so… sorry, but this will have to be continued.  I don’t know the ending yet anyway!

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