If you had a pain in your leg that wouldn’t go away, you probably wouldn’t hesitate to go to the doctor, and that doctor would help you pinpoint the pain and give you a variety of options to deal with the pain, and hopefully one would be simple and mostly successful, and ta-da: better leg.
Sadly, persistent psychic pain is less easy to pinpoint, and the brain is basically the human body’s junk drawer; science has a rudimentary idea of what you can find in there, but the exact location of most things therein is unclear. That makes it hard for the doctor to provide you with new information or definitive treatment that will cure your pain, and even harder for you to know when it’s smart to go to the doctor in the first place.
Still, even if brains are far more complicated and less understood than limbs, deciding whether you need mental-health treatment is basically like making any other medical resource decision, taking into account what you can afford, how much your problem interferes with your life, and whether obsessing about it will do more harm than good.
Perhaps because mental health treatment is misperceived as mysterious, people assume it has magical powers ranging from rooting out most kinds of unhappiness to turning you into a flake. In reality, of course, unrealistic expectations lock you into unachievable goals, so count on your own experience and judgment to decide whether treatment is meeting your expectations or likely to do so anytime soon.
If you have anxiety and depression after a loss, it’s easy to assume that the loss caused your pain, and that talking with friends and healing with time is all you need. This may actually be the case if you haven’t been depressed or anxious before, the loss is terrible, and there’s no one around whom you can really talk to. To paraphrase R.E.M., everybody hurts sometimes, so not everybody needs to see a doctor about it.
Most likely, however, your symptoms aren’t new and have persisted in spite of good talks with supportive friends and family. That’s why it’s wishful thinking to believe that treatment can stop symptoms quickly or entirely and prevent them from coming back. Instead, you can expect talk therapy to provide support—help you fight negative thoughts caused by depression, anxiety, and life—and give you a tool for managing your symptoms this time and after future episodes.
Since choosing the wrong person to love is often a key part of heartbreak, look for a positive coach or therapist who can help you nail down the lesson to be learned and figure out some new procedures to help you find better partners and keep you from making the same mistake, while also fighting negative thoughts arising from depression.
As far as looking for the right therapist, do remember to actually look; too many people make the mistake of picking the first name off the list provided by their insurance company and assuming that if things aren’t working with that therapist that means therapy doesn’t work for them, period. Finding the right therapist takes time, and it’s like picking out a good mentor. Look for someone who is interested in teaching the topic you think you need to learn and who has a positive way of motivating you while accepting your particular learning style.
As for meds, it’s always your choice to decide whether they’re necessary; if you think that shrinks can hold your nose and force pills down your throat, you’re mistaking them for veterinarians. Sometimes, the choice to try medication is simple; i.e., if your symptoms don’t let you get out of bed in spite of warm support and good coaching. It’s the same choice you would make for any chronic, severe medical problem, so don’t get moralistic and blame yourself for whatever decision you think is negative.
If others say you need help but you don’t really see what they’re talking about, congratulations for being able to experience suffering without feeling any pain. Obviously, you care about the impact of your behavior on others, even if you don’t have an instinctive ability to feel it or see what it is, and would rather make your wife happy than take your talents to the circus.
Ask yourself whether your grumpiness affects the roles you value the most and in which a little misplaced anger can do a lot of damage, to your parenting, partnership, and maybe leadership. If you don’t think crankiness has much effect, then it’s just an annoying-yet-harmless personality trait, like constantly soliciting high fives or ending every sentence with a question mark. If you do think being crotchety is holding you back, then look for a therapist who seems able to help you spot what you’re doing when you’re angry and manage your behavior more effectively.
If treatment changes your feelings and makes you less depressed and irritable, more power to you, but don’t consider yourself or treatment a failure if that doesn’t happen. Some people are grumpy and poor at self-observation, even when they’re also smart and life is going well. If treatment doesn’t change the source of your problems, you deserve great credit for deciding to improve how you manage them.
If you can’t get a treatment like couples therapy to persuade your deadbeat spouse that he needs to stop drinking and come home after work, remember that your treatment goal is not to change him, because it’s impossible, but rather to see whether he can be encouraged to change. And of course, despite how much your therapist might encourage sharing, remember that insults and character attacks, no matter how justified, rarely make for good persuasive tools.
In this case, your therapist agrees with your complaints but can’t get through to your spouse any more than you can, even without the insults, so stop blaming yourself for feeling needy and angry and not getting your husband to see your point of view. A professional couldn’t get a better result, and they needed nothing but the copay.
Now, instead of trying harder to get him to see the problem, figure out what you want to do about his faults. Find a therapist who blocks you from ruminating about could-haves and should-haves or sharing anger, helplessness, or complaints about your husband, and instead helps you build up your resources and consider your options.
Whether it’s your current couples therapist or a new one, choose someone who can help you announce your intentions to your husband without further efforts to persuade, bully, or defend. Then, whether or not your announcement gets through, you’ll know you’ve done your best to save your marriage while protecting yourself and your kids from an early-stage deadbeat alcoholic.
Try any kind of treatment you think might help, but don’t try the same thing again and again or assume that it would have worked if it were done properly. Instead, use failed treatments to limit your expectations and teach you what you have to live with. Allow yourself to explore your options, whether that means different types of therapy or just different doctors.
If you’ve objectively assessed the severity and impact of your problem and decided it needs attention, it won’t take you long to find out what you need to know about treatment, assuming you’re not scared to read articles, ask questions, and weigh risks against benefits. Then you’ll know what kind of expertise and personal qualities you’re seeking in a doctor, as well as how to measure progress, so you can find the combination that will, ta-da, make you and your brain (mostly) better.
Quick Diagnosis
Here’s what you wish for and can’t (always) have from treatment:
• Insight to change your life and improve your behavior
• New, better, or more confidence
• A wrenching catharsis that will ease your sorrows and teach you to enjoy life, moment to moment, while you’re still alive and not yet dead
• Happy, conflict-free relationships with the Assholes in your life
Here’s what you can aim for and actually achieve:
• Identify how much control you have over whatever’s ailing you, with or without treatment
• Develop a good idea of what treatment does and doesn’t have to offer and what its risks and costs are
• Develop your own reasons for determining whether higher-risk, higher-cost treatment is worth pursuing
• Make treatment decisions that are worthwhile, whether or not they get you a good result
Here�
��s how you can do it:
• Determine rationally whether your problems are worth getting treatment for, or would actually get worse with too much attention
• Ask questions and do a little research to figure out what treatments have to offer and the risk and cost of trying them
• Shop for a therapist thoughtfully
• Evaluate the effectiveness of a particular treatment, and its costs and side effects, without assuming that a poor result is anyone’s fault
• List your criteria for considering treatment worthwhile, aside from its making you feel better
• List your criteria for stopping treatment to see whether or not you continue to need it
Your Script
Here’s what to tell yourself/friends/your therapist about your treatment decisions.
Dear [Self/Concerned Friend/Therapist Who Would Like to Take Me On],
I feel like I should be able to [feel/do/relate/function/pitch] better than I do, but I won’t let [frustrated ambition/comments of others/peer comparisons] get me to waste time on treatment unless I believe my problems will possibly [cost me my job/drive away my spouse/cause me to burst into tears or rage in the middle of ordering a burrito]. If I think treatment is necessary, I have no doubt I can learn enough about it to decide what’s [worth trying/inappropriate/total bullshit] and whether the risk and cost are worth it.
Basic Treatments, Defined
While we try to avoid shrinky jargon in this book, there’s no way to avoid it when describing the different types of therapy, many of which (e.g., CBT, DBT, psychopharmacology) sound to the average person like the names of chemical weapons used in Vietnam.
Below we explain these terms by giving a brief description of several therapies, including how likely they are to be covered by insurance, who performs them, their negative aspects, and a one-to-ten rating on the BTPS, aka, the “bullshit-to-pragmatic scale.” According to the BTPS, a therapy with a rating of one is totally flaky and subjective (e.g., new age crystal-type bullshit, relying on willpower, etc.), and a therapy with a rating of ten is supremely objective, measurable, and unbiased (e.g., a kind of therapy that hasn’t been invented yet and is performed by a robot, but some existing therapies get close). Ratings are based on the assumption that the patient is a willing and eager participant in therapy; if not, he’ll rate everything as 100 percent bullshit anyway.
Of course, you can always learn more about each treatment by discussing it with your primary care doctor, looking online, or talking to friends about their own therapy experiences, but for now, here are the basics.
Therapy Basics
Done By
What It Is
Drawbacks
Old-School Talk Therapies
Insurance Friendly?: Sworn enemies—insurers think it’s unfocused and endless and its therapists believe insurers want to rip off patients. BTPS: 3 or 4
Psychiatrists (MDs), psychologists (PhDs), social workers, nurses, the professional hand-holders on Hoarders (see chapter 4). Hereafter referred to as “those in all major clinical disciplines.”
Therapist asks “How do you feel?” followed by painful silence, followed by the therapist’s suggesting squirm-inducing reasons for what you did or didn’t say or why you get angry when you’re really sad or vice versa or something about your mother, etc.
Still popular on TV and among older clinicians, but younger clinicians have more faith in cognitive and behavioral techniques. Not very popular among most patients, who want direct answers and have less patience for painful processes that take forever to show results, especially when it’s on their dime.
Current Talk Therapies
Insurance Friendly?: Yes, but only if there’s a measurable goal and a willingness to stop every few sessions for progress reports. BTPS: 4 to 6, depending on the therapist
Those in all major clinical disciplines, but talking more like consultants or teachers than stereotypical shrinks.
Therapist asking questions and giving advice, support, and criticism. Basically a professional friend who is legally prohibited from gossiping to others or even acknowledging they know you.
It isn’t standardized—very dependent on the talent and steadiness of the shrink and whether you’re on the same wavelength.
Psycho-pharmacology
Insurance Friendly?: Yes, if the prescriber doesn’t overuse expensive medications when cheap generics are available. BTPS: 7
Psychiatrists and nurses only, at least in most states.
Quick visits centered on assessment and prescribing medications that can reduce depression, anxiety, distractibility, crazy thoughts, and hallucinations.
Visits should, but don’t always, include talk therapy about your attitude, illness, and medication. Also, medications are frequently unreliable (fail to work), weak (some symptoms remain), and have side effects.
CBT (Cognitive Behavioral Therapy)
Insurance Friendly?: Usually, at least for a few months. BTPS: 7
Those in all major clinical disciplines, but more often psychologists and social workers than MDs.
Identifies standard negatively distorted thoughts usually caused by anxiety, depression, and other conditions, and then teaches you mental and behavioral exercises for fighting their impact on your beliefs and habits.
No quick relief, but makes you feel stronger if you do CBT exercises, negotiating with and dismissing the negative thoughts that make you feel bad in the first place.
DBT (Dialectical Behavior Therapy)
Insurance Friendly?: Same as above. BTPS: 7
Those in all major clinical disciplines, with special DBT training.
A kind of CBT that focuses on thoughts of despair, self-hate, and self-injury and teaches a set of thought-and-behavior exercises for staying positive and not giving in to dangerous impulses.
Doesn’t immediately reduce your urges to hurt yourself, leave your family, or generally blow up your life. Instead, makes you less likely to actually do any of those things.
ECT (Electroconvulsive Therapy)
Insurance Friendly?: Surprisingly, yes. BTPS: 9 (Was once low—it was tried for whatever ails you until the 1970s—but now very high)
Doctors in hospitals.
A method for causing seizures in people who don’t have epilepsy, because seizures tend to clear up depression (as was probably discovered thousands of years ago). Only administered in hospitals under anesthesia.
Impairs recent memory and requires lots of time and money, because you need to be anesthetized first so the seizure won’t hurt you. However, trust that it is nothing like the bullshit shown in One Flew over the Cuckoo’s Nest.
TMS (Transcranial Magnetic Stimulation)
Insurance Friendly?: Nope—high price, hard-to-prove success rate. BTPS: Probably higher than insurers think
Those in all major clinical disciplines.
A painless method for applying intense magnetic fields to specific areas of the brain, it may help depression without requiring anesthesia or causing memory loss.
Not cheap, not welcomed by insurance, not backed by tons of research. It may require many daily sessions followed by refresher sessions.
Couples or Family Therapy
Insurance Friendly?: Again, depends on whether there’s a focus and time limits. BTPS: 6 (Was low at 4, when all individual problems were blamed on the family. Now not so bad at 6, but still, depends on the therapist)
Those in all major clinical disciplines.
Meeting as a couple or family, uses many different techniques to identify problems and conflicts and get people to work together on solutions.
Not guaranteed to keep things from exploding (think Jerry Springer), particularly if the therapist gives people too much encouragement to air, or fart out, their grievances and share their feelings (see analogy on page 234).
Freudian Psychoanalysis
Insurance Friendly?: Not even a little bit. BTPS: Just check out a book of New Yorker cartoons
Used
to be psychiatrists (MDs), now those in all major clinical disciplines who have received years of training in specialized institutes that teach the theories of Sigmund Freud (1856–1939), granddaddy of talk therapy.
Lying on a couch, usually several times a week, with your back to a relatively silent therapist, you are asked to talk about whatever comes into your mind and then analyze it with the invisible therapist’s guidance. Just as Freud did it. Mothers are a frequent topic.
Costly and slow, but impresses some people as very interesting and stimulating, so if you like that kind of thing and have the money ($50K/year) to spend, enjoy.
Jungian Analysis, aka, Analytical Analysis
Insurance Friendly?: Insurance providers are allergic to anything analytic, so no. BTPS: Let’s call it creative and interesting
Those in all major clinical disciplines, but with years of training at specialized institutes that teach the theories of Carl Jung (1875–1961), frenemy of Freud.
Like Freudian analysis, except Jungian analysis asks the patient to focus on dreams, myths, and folklore-based archetypes so they can become one with the unconscious. PS: Jung might have had schizophrenia.
Equally costly and slow as Freudian analysis, but impresses some people as very interesting and stimulating, if you like that sort of thing (and the Deptford Trilogy by the legendary Canadian author Robertson Davies).
Primal Scream Therapy
Insurance Friendly?: NO! AARGH! I HATE YOU, MOMMY! BTPS: Calibrates the low end of the scale, along with Scientology
Those in all major clinical disciplines, but mostly well-meaning psychologists with MAs or PhDs.
Nearly extinct method (popular in the 1970s), held mostly in padded rooms where patients were encouraged to work out their childhood trauma by having tantrums and generally losing their shit.
F*ck Feelings Page 33