My 15-year-old son needs treatment for his irritability. He gets unbelievably angry over small things, to the point that he ups and goes to his room. He agrees that things are basically OK and he’s sorry afterwards, but it happens at least once a week. We have a happy home and he has friends in school and gets good grades. I think it’s his mood that’s the problem and it causes him and our family a lot of pain. My goal is to figure out how to get him some help with psychotherapy and/or medication.

Just because someone’s in pain doesn’t mean he needs help. Pain is just part of the complete life package, along with joy, hunger, death, etc.

Of course, you’ve got less to lose and more to gain from treatment if his irritability has caused bruised knuckles, broken sheetrock, and a growing familiarity with your local police. Pain is a normal part of life, but serving life in prison isn’t.

What you’re saying, however, is that, aside from his verbal explosions, he remains in physical control, does self-motivated time-outs, retains good relationships, and has no trouble focusing on work and getting it done. No pill could improve upon that.

So, if he’s handling his pain well, getting things done, and engaging in life, then making him get treatment for his irritability may make a bigger deal of his problem without necessarily providing relief. It’s a sad fact, but neither talk therapy nor psychiatric medication reliably improves irritability—just sometimes and more often than placebo.

It’s always possible that his irritability foreshadows a mood disorder that will eventually get worse and might be prevented or disarmed by beginning medication early. The trouble is, we have no way of telling whether he’s at high risk, and the medication has risks of its own, as well as being costly. The risks from antidepressants aren’t great, as far as we know, but there’s always the risk of what we don’t know because our tools for examining the long-term effects of medication on the brain are limited. If you try an antidepressant, ask yourself whether it’s helpful enough to be worth that risk.

As for most mood stabilizers, like Lithium, Depakote, and Abilify, the risk is much higher than for antidepressants (although you wouldn’t think so if you didn’t listen carefully to the end of Abilify commercials). Sometimes, pain treatment is worse than pain, and shouldn’t be considered without a careful assessment of the risk and rewards. From what you’ve said, the risks of most mood stabilizers dwarf the rewards by a mile.

Psychotherapy can be harmful if his shrink doesn’t accept the fact that treatment has limits. Find someone who can accept the possibility that your son’s irritable outbursts are unavoidable and coach him on managing them if they can’t be cured—though, clearly, your son is already a good manager himself.

In the end, the decision is yours, and various treatments might be helpful. If you accept the possibility, however, that treatment for painful conditions is not always better than no treatment, then you will weigh risk against benefit, regardless of how you feel, and make a good decision. After all, it’s risky to overestimate the power of medication and treatment, but it’s riskier to underestimate your son.

STATEMENT:
“It breaks my heart to watch my son have a meltdown and I’m terrified of what can happen to a teenage boy with an anger problem. I know he’s a good kid, however, and he’s showed an amazing ability to keep it together socially and academically. If a treatment seems to help him and be worth the risk, I’ll support it. If it doesn’t, I’ll support the many good ways he’s dealing with his temper and help him develop even stronger anger-management skills.”

My son is a nice kid, but his ADD makes him completely irresponsible. He seems motivated about getting his college degree, but, even when he takes his medication, he always comes late to lectures, leaves assignments to the last minute, and doesn’t get problem sets finished. He was asked to take a semester off because his grades slipped and he seemed out of control. Now that he’s back at home, he pays no attention to his bank balance and has bounced a lot of checks. When I confront him, he’s sincerely apologetic, but then he does the same thing the next day. I just wish I could get him to stop lying and care about what he’s doing.

If you can’t help someone with love and medication (see above), it’s normal to assume that he doesn’t really want to get better and your goal is to find the key to motivate him. The trouble is, some people who are motivated (and medicated) are nevertheless unable to perform.

They feel ashamed, apologize, avoid, feel more ashamed, and so on. They seem sleazy and unmotivated. The problem is that, if you treat them as if they’re sleazy and unmotivated, you make them worse.

The sad fact here is that medication can usually sharpen attention and make learning easier, but it can’t correct the executive function problems that make it hard for many people with ADD (and others) to get things done and deal with unpleasant priorities. Yes, you need character and willpower, but you also need some help from your brain, and some brains are too “in the moment” to be pushed into planned, prioritized activities, even when the will is willing and the attention razor sharp.

In that case, your goal isn’t to get your son to stop lying—he’s not purposefully dishonest, just permanently flakey—but to disarm his shame while helping him face the full extent of his disability. Forget about his lying, insincerity and apologies. Make it clear you’re not interested in the merry-go-round of avoidance and remorse and instead want to examine the power of whatever makes him fuck up in spite of the fact that he doesn’t really want to. That said, your goal is to help him find ways to manage himself.

Don’t let him present himself as a bad guy who could do better if he’d just try harder, because the evidence says otherwise. In reality, he’s a good guy with a permanent impairment, and it will take him a lot of work to get a handle on it.

Ask him if he’d like a wake-up call in the morning, or whether he should compose a daily log of his lateness to see when it’s better or worse and whether it’s responding to interventions, including medication changes. The more you talk about his lack of control as a fact, the more you challenge the shame that reinforces avoidance. Too bad he’s fucked, but there’s lots to be done. Most of us have weaknesses we have to work hard to manage, but most involve food and don’t involve bank fees.

Once you limit his responsibility and yours for what he doesn’t control, you’re free to bear down on the one part that he does have some power over. You don’t expect him to change his disability or understand why he has it—it is what it is—but you’re confident he can work on managing it, and that, with hard work and discipline, he can gain the control he needs and lose the shame that’s holding him back.

STATEMENT:
“It’s hard to watch my son’s overly sincere apology for behavior that cost us half a year’s tuition, knowing that, if he hadn’t lied about what was happening, we could have helped him, and that he’ll do the same thing again. Nevertheless, he wants good things for himself and has a legitimate problem that is worse than a poor attention span. I will talk to him about the good things he can do with a bad problem, and urge him to seek coaching rather than moral reform or absolution.”

While most mental health clinicians would feel guilty admitting this, I’ve been in the biz for long enough that I don’t give a shit and I need to vent. Most of the crisis calls I get from my psychotherapy practice are senseless and irritating; they’re from patients who feel bad because they forgot to take their medications, or drank too much or when they shouldn’t, or allowed their demons to wreak vengeance on their enemies, the nearer the better, self best of all. A few call me because they’re feeling suicidal (but won’t go to the hospital) and just want me to make them feel better, which is hard when it’s late and I’m tired, and often impossible just because I don’t have that kind of power. I try to be civil, but their calls leave me feeling helpless and wondering whether I’m doing any good. Discussing their responsibility for their behavior is useless, because it usually makes them mad or apologetic. My goal is to figure out what to do with crisis calls that are really a useless pain in the ass.

Many crisis calls you receive as a shrink do a good job of showing off a patient’s worst behavior. It’s like having partial custody of a colicky child.

It’s not that their distress isn’t real and severe—it is, almost always—it’s that it causes self-defeating behavior, like drinking or mouthing off or retreating from the world, which creates a jam that is extra hard to get out of.

Bad feelings cause bad behavior, bad listening skills and bad regrets about going into the therapy business instead of owning a Toyota dealership.

You’re right to wonder whether your response to crisis calls is helpful. Whether you realize it or not—and you seem to realize it—your words sound moralistic and angry, though for good reason. The more you care about your patients’ welfare, the more upset you get about what they’re doing to themselves and how it undoes all those good talks (and/or medications) that seemed to help. As you say, their negative feelings become contagious as you wrestle with your own fatigue, doubts, and fears about more calls to come.

Unfortunately, a moralistic tone usually makes people who’ve messed up feel more messed up. You judge them as having made bad choices, whereas they experience a rush of emotions and habits that sweep all choice away. Your intentions are good, but labeling your bad-behaving patients as irresponsible bad-choosers will usually make them feel like losers talking to their dads.

The good side is that you’ve given them a focus for their anger and disappointment that isn’t themselves. The bad side is that you may get an honorable mention in a suicide note.

If you truly believe in your observations, however, assure yourself that you’re not responsible for making the crisis caller less destructive. The threat to you isn’t the intrusion on your time, it’s feeling responsible for the mess they’re in, which you’re not. Their mess is out of your control, and theirs. Your only responsibility is to give them good advice and do what you can if they’re not safe.

Tell them what you think they eventually need to be able to tell themselves; it will pass, there are good things to do meanwhile, and they’ll sort out the cleanup when they’re better rested. If they’re not safe, they should take themselves to an emergency room.

Assure them you’ll work with them on increasing their self-control over anything they think they’re doing wrong, but it can’t happen now. Good night and good luck to them, and I hope it felt good for you to vent.

STATEMENT:
“It’s hard to stay calm when I see my patients fucking up their lives and then wanting me to make them feel better during my spare time, but my feelings are just a reflection of their feelings, and don’t have to get in my way. When I can’t help them, it’s too bad, but it doesn’t help to blame them, and we can make good use of the experience later, when we talk during work hours.”

As a therapist, I assume that my strongest weapons are kindness and empathy, but sometimes the process is exhausting and my family does not appreciate the amount of time I spend fielding patient phone calls off-hours. When I get desperate calls at dinnertime or late at night, they interfere with my family life, but I don’t believe in hanging up until my patients feel better. Many have been traumatized and go through terrible periods of emptiness and they need to know that someone cares. My family jokes, somewhat bitterly, that my patients have more access to me than they do. I feel unappreciated, tired, and torn in many directions. At least my patients feel that I care. My goal is to help my family see that I also care about them.

If empathy and kindness were as powerful as some therapists and Christians believe, the world would be a lot better than it is. As your family correctly observes, however, the calls keep coming, there are no cures, and What About Bob is coming down the road.

Ask yourself whether your patients are actually getting better, or just feel better because they’ve found someone nice to take their calls. If they are feeling better, figure out if it’s because they’re better at managing their own crises, or because you’ve confirmed their right to have a nice response whenever they need it. If it’s the latter, heaven help them when you’re not there (and help your family when you are).

It’s good that you’re kind and empathic; that’s why your family and patients like to spend time with you. What’s wrong, however, is that, in over-valuing the therapeutic impact of those qualities, you’re putting too much responsibility on yourself for your patients’ problems (see above). Realistic experience should tell you that kindness doesn’t cure. Neither (see above) does moralistic confrontation.

That is sad, and limits your powers considerably, but it also means you should keep calls short and treat them as evidence of your patients’ need for better self-management. If a patient is willing to try improving his/her self-management, that’s a great focus for treatment and the calls are grist for the mill.

If, on the other hand, a patient can’t see any possibilities for better self-regulation and wants nothing other than better treatment from others, your therapy won’t do any good other than providing him/her with a short-term fix and your family with an empty seat at the table. In that case, Forget Bob and return to the family fold.

STATEMENT:
“It feels right to soothe those who are in despair, and to help them carry their load, but I know that I can’t really carry anyone else’s load and that responding to repeated off-hours calls doesn’t help patients appreciate and make best use of their own resources. Without sacrificing my kindness, I will offer them ideas about how to manage their moments of disorganization and despair, and I will do that most effectively during treatment hours and not at other times.”

I was diagnosed with major depressive disorder and anorexia nervosa purging type a few years ago. Both of these issues had pretty much consumed my life during the years leading up to that diagnosis and have continued to be impairing ever since. I started cutting myself two years ago (it has become more frequent this past year), and I’ve had several panic attacks in the past several months. Fortunately, my overwhelming desire to commit suicide has subsided, although I still think of suicide and my death in general fairly often. In addition to my own issues, I have watched my mom slip into a state of psychosis during the past two years, triggered by the death of her father. She has become so depressed, delusional, and violent that my parents separated and sometimes I don’t even feel safe staying in the house with her—a few weeks ago my dad and I had to stop her from going through with a suicide attempt. The police were called, and I had to hold her arms down while she was clearly in a psychotic rage. At one point, she tried to stab my hand to make me let go. She was taken to a mental health facility where she stayed for a week, and now she’s furious at us for making her go there and hasn’t been much better since then. I feel like I never get anywhere with therapists because they just prescribe medicines that make me feel numb to any emotions or focus on my eating disorder so much that I never get to work through these other issues. I feel like my life is unraveling and it’s gotten so bad that, honestly, I don’t feel like I even want to fix it. My goal in telling you this is to figure out a way to help my mom and how to get through school while I’m dealing with this.

It may seem strange to hear this, for someone who suffers as much as you do from depression, anorexia, and the burdens of taking care of a very sick mother, but I think you’re doing an amazing job.

Yes, you’re chin-deep in shit, but you haven’t drowned, and that’s a remarkable accomplishment.

Your depression hasn’t made you hate people or blame them, and your anorexia hasn’t caused you to pretend you’re not sick, so you must have a solid hold on reality. There you are, with all your pain, finding the love to help your mother and the energy to go on with your studies. You’ve got good values and a big soul.

So you feel hopeless because treatment hasn’t done you much good, or, I should say, hasn’t done your symptoms much good. It sucks, but that’s the way it usually is when symptoms are as severe as yours. That doesn’t mean they won’t get better by themselves, or that a better treatment won’t come along. It does mean that, at least for the time being, you’re stuck with heavy-duty pain.

That’s not important, however, or at least not nearly as important as what you’re doing with that pain, which is, as I said, amazing, and there’s treatment that can help you distinguish between you and your symptoms. Any good cognitive treatment will help, whether it comes from a cognitive therapist, a good coach, or a friend with a positive attitude. One treatment that is aimed specifically at helping people with this much pain keep a positive attitude is Dialectic Behavioral Therapy, or DBT.

The inventor of this treatment, Marsha Linehan [link: https://www.nytimes.com/2011/06/23/health/23lives.html], suffered similar symptoms and, like you, managed to stay focused on the value of helping people and improving her own skills. She wound up inventing a kind of treatment that helps others do what she did for herself, and, like you, she found that helping others was a great way to keep her own demons in check.

It’s normal for you to feel that your life is unraveling, but trust me, it isn’t; your pain is a mess, but you’re doing a good job of bearing it and doing good things with it.

You are not your pain; you’re dealing with a lot of shit, but you are anything but. You’re the person who’s managing it while leading a good and meaningful life, and that’s not someone you should give up on.

STATEMENT:
“I may feel like a hopeless, deteriorating mess, but I love my mother and care about my education and I’m doing good things about both. I may not be able to stop my symptoms or save my mother, but life sucks and that’s not a personal failure. I haven’t let my symptoms stop me, however, and that’s why I’m doing well, even if my pain and my mother are doing badly.”

I have a great life and there’s nothing I care about more than my family, so I became really worried when, out of nowhere, I started to have horrible thoughts about murdering my children. I’m too ashamed to tell my husband. I’m not an angry person, and I love my kids and get along well with them, and I’ve never needed a shrink, but the thoughts keep me up at night. If there’s the slightest chance I could hurt my kids, I’ve got to do something about it, but I don’t know what to do. Please help.

Before you get crazy about having crazy, murderous thoughts, check out the risk factors for crazy murders. It’s not hard to do. What you’ll find out is that crazy murderers don’t just have intrusive murderous thoughts; they’re crazy as well.

By that, I mean they’re very detached, or they have strange ideas about their kids that they actually believe in, or they’re hearing voices, or going through extreme mood swings.

Ask yourself whether you fit the picture of people who really run amok. While I don’t know you, of course, my guess is that you don’t fit the picture at all, which means you run the same finite-but-small risk as your average Joe.

Trouble is, everyone who has intrusive, horrible thoughts without other symptoms of craziness is nevertheless terrified of losing control, so reassuring yourself is hard to do. What you want, of course, is total reassurance that the horrible thoughts will go away and that you’ll never, ever lose control; as you say, if there’s the slightest chance that you might hurt your family, you feel obliged to take definitive action. Unfortunately, you can’t. No one controls such thoughts, and trying to control them will just add to your helplessness.

Your goal then isn’t total reassurance or freedom from fear, but reasonable self-control and an ability to go ahead with your life in spite of fear. Assess the real risk you pose to your family and take steps to protect them if you think it’s necessary. Having done that (and realizing that your family is better off with you just the way you are, crazy thoughts and all), learn to bear your fear and go about your business, which isn’t easy to do.

If you want to tell your family about your symptoms, that’s the story you’d tell. You’ve got these crazy thoughts, but you’ve checked on the internet, and probably seen a shrink, and discovered you’re at no particular risk of doing harm, you’re just at risk of suffering from creepy thoughts. Reassure them that you have no intention of letting the crazy thoughts interfere with your normal activities and that, if you thought you were dangerous, you’d do whatever’s necessary to protect them.

As with the woman above, you are not your symptoms; a good mom can have crazy thoughts, and a great mom can carry on despite them.

STATEMENT:
“I feel like I’ve got crazy thoughts and might lose my mind but the truth is that I’ve checked out my symptoms and the part of my mind I’m losing is pretty small and insubstantial (although the process is scary and painful). Whether or not I can make my symptoms go away, I’m competent to manage them, keep everyone safe, and go on with my life, and that’s all I need to do.”

I have suffered from anxiety and depression much of my life. My most recent (and most devastating) bout was a couple of years ago, when I worked with a therapist and managed to heave myself out of it without the use of antidepressants (which I had been on in the past and want to learn to live without.) Now I find myself slipping back in. My biggest issue seems to be that I put too much stock in what others think of me or might think of me (I’m really good at fabricating things people might be saying about me.) I also had a baby last year, which has prevented me from pursuing my career fully, so when I hear of the successes of others (or see them on Facebook) I get very anxious and feel that the universe is unjust. I want to be a good mom, and I want to be good at my job, but I feel I am failing at both and resenting others who are great at either. I was made fun of a lot when I was a kid and I think I still carry some of this baggage around, like whatever decision I make is the wrong one because I’m basically a loser. How can I focus on myself and my own life without worrying about what everyone else is up to or what they may think about me?

While you already have a good idea of what to do about your negative thinking, you still need to protect yourself from two bad ideas that you express here. Unfortunately, those two ideas are also your “goals.”

First, disavow yourself of the notions that you should be able to stop depression without using medication and that you should find a way to be less, for lack of a better word, insecure. In doing so, you won’t be giving up—you’ll be giving yourself some relief.

The good idea, and better goal, is to train yourself to fight negative thinking, and there are lots of ways to do that. A therapist can help, but so can the right kind of friends, readings, church, and/or spouse. Though you can’t make the negative thoughts go away, you can assemble a strategy (and maybe team) to help you handle them.

Develop a routine for reminding yourself that you’re the one who’s managing your life and working with your unique gifts and disabilities, and that you’re the only one who can judge whether you’re doing your best. Then, when you start to compare yourself to the better gifted, give yourself a dose of positive reality. Nobody else can judge you, not even Facebook.

The sad truth is that depression could sweep you away, regardless of what treatment you use and how motivated you are in pursuing it. It’s scary, but it’s also liberating; you’re responsible for doing your best with depression, not making it go away. Cancer patients don’t set performance goals, and neither should you.

Instead, set your goals in terms of the process of managing, rather than the outcome, of recovery, using non-medical and other minimal risk treatments whenever possible. Then go ahead and choose riskier treatments if and only if you think they’re necessary. Don’t let fear or guilt prevent you from choosing what’s best for you.

Don’t always listen to your doctor, because your doctor doesn’t know how much pain your depression is causing or how much it has disrupted your work and relationships, so it’s your tough decision. All the doctor can do is tell you the relative risk of the treatment, compared to your symptoms, and what he or she would do in your place.

Embrace the fact that every parent with a career has to contend with bad feelings about difficult compromises. The challenge for you is to accept those bad feelings and the fact that there’s always someone out there who can do things better than you, then learn how to manage yourself positively and tell Facebook to go fuck itself.

STATEMENT:
“I don’t often feel good about my performance at home or at work, but that’s my nature. I’m proud I’ve taken on parenthood and that I’m doing OK, whatever my insecurities tell me. I know I try hard and that I’ve made good decisions and I will use those facts to lift myself up when depression tries to tear me down.”

I shouldn’t be writing you about my depression because I have no reason to be depressed. I’m a lucky person with a good job and great boyfriend. I eat a healthy diet, exercise every day, and work hard to stay healthy, mentally as much as physically. I had a severe depression as a teenager but I worked hard in therapy (and still do all I can to keep those negative thoughts at bay), took my medications as directed, and have been much better since. So now, 10 years later, there’s no reason I should be unhappy, tearful, and unmotivated to do anything but go back to bed, but no matter how much I exercise or try to stay positive, I can’t get ahead of this thing. I must have missed something. My goal is to figure out what.

The one big thing you’ve failed to understand is that depression, like most illnesses, can’t be controlled. You can be careful, do everything right, avoid giving into negative thoughts and actions, but still feel like shit. It’s not fair, but it’s the nature of the beast.

Just in case this sad fact depresses you, think about how, just like the person above, you’re depressing yourself even more by holding yourself responsible for staying healthy. Maybe you want to assume that awesome responsibility because you wish you had the power to stay healthy, but you don’t, because nobody does. Even those people who follow all the rules and work their butts off.

Luckily, staying healthy is not part of your job description; coping with illness is, so stop telling yourself you shouldn’t be depressed. What you should be doing is reviewing what you need to do to cope with depression, and realizing that you’re probably doing most of those things.

You sound like the kind of person who tries hard to keep working, relating, and parenting regardless of how you feel. If that’s true, you’re doing most of what you need to do already. You’ve probably talked things over and tried to figure out whether something’s getting you down that you don’t know about, which takes care of another basic self-management task.

Decide whether to try any new medications (see above case), using the same procedure you would use for weighing the risks and management of any treatment. Don’t be a sissy about your dislike for treatment—no one likes treatment—so just add up the risks and benefits, and don’t let fear make your decision for you.

Finally, keep working on how to think positively, beginning with the most positive statement of all: you aren’t responsible for your illness, and despite bad results, you’re doing your best. You’ll quickly discover you’re doing a much better job of coping with depression than you realize, and while the situation may still seem unfair, your efforts are all that matter.

STATEMENT:
“I never expected to get depressed again, but I realize now that I didn’t fail to prevent depression, I failed to give myself reasonable expectations and responsibilities. Now that I know what to do, I have little to fault myself for and I can be legitimately hopeful about finding new tools for managing depression.”

Please Note: Monday is also a fxckfeelings.com holiday. Happy New Year (and again, if/when it’s unhappy, you know the drill).

I’m a current student and I’ve sort of self-diagnosed myself as having an unusual kind of OCD. It started out four years ago when I was studying for an upcoming major exam. I had always been one of the few top students, but at one point in time in the midst of hours of straight studying, I couldn’t absorb any more info, and in a fit of frustration, a ball of emotions welled up and I actually said harshly in my mind to myself, “you shall FAIL!”, even though I’ve always tried to avoid such negative thinking. What came next was an unshakable, unexplainable, and annoying-yet-scary series of feelings, thoughts and emotions for the next few days and weeks. After that episode, I developed an irrational apprehension about me having “ruined” myself and my academic ability. To get myself back to my normal, anxiety-free mind when studying or doing anything related to studies, I imagined “transferring” the whole chunk of this mental mess on other stuff, whether it is the faces of people who did badly in academics in my field, to those I don’t like, etc. Still, my mind would automatically be inclined to have these random obsessions appear in my mind while studying, and it’s really prevented me from fully unleashing my full academic ability in subsequent grades. I really felt restrained and trapped by this, and my goal is to eliminate this strong-rooted (it’s been 4 years) mental condition that happens whenever I study and then makes it almost impossible.

Some OCD thoughts are crippling but come out of nowhere, like fear of contamination or making a mistake. While they often lead to compulsive rituals, like repeated hand-washing and fact-checking, you manage to keep studying. So, while you’re suffering, you’re still lucky.

The fact that your obsessive fears are tied to school may make them easier to deal with, because, unlike germs, school (usually) doesn’t go on forever.

School is built on mental constructs that attract obsessions like lint to a dryer vent; it’s got grades, grade-points, and exams that hinge on a word or the instructor’s interpretation of same. It invites obsession and obsessive argument, which can be torture, but at least it has an end date.

After school is over, you can find branches of almost every major profession that thrive on obsessional thinking, but you can also avoid them if you want; you’ll have choices beyond what courses you can take and how much to put on your meal card.

Also, the mental activity that sticks words in your mind as if they’re big, significant boulders is probably good for certain kinds of learning, and it’s not uncommon. Respected psychiatrist John Nemiah liked to point out that Martin Luther had a similar problem, and went on to start Protestantism (although his Catholic colleagues might not see this as a success).

The bad news, I guess, is that you’ll probably never “eliminate” your fear of certain intrusive thoughts. What you can do, however, apart from putting school behind you, is develop techniques for breaking into the vicious circle that enhances the power of whatever you’re afraid of.

In other words, if you’re afraid to think about something, you’ll think about it, and your fear will probably have a small negative effect on your performance, which will prove you’re right to fear the intrusive thoughts, which scares you even more. What a good cognitive therapist can offer you is a bunch of mental and physical exercises that either distract you from the vicious circle or remind you of your ability to deal with fearful events as they occur.

Get used to the idea that, like many people for whom ideas and words have a life of their own, you can be troubled by obsessive thoughts. You can’t get rid of them, or always prevent them from distracting you, but you can always stop them from changing your goals or failing to try your best and reach the finish line of graduation.

STATEMENT:
“I’m afraid that intrusive thoughts will prevent me from ever living up to my potential, but, if I have to live with them, I can do it. I will regard them as just one more weakness that I can learn to deal with as I go about pursuing my interests and trying to graduate and make a living.”

I do pretty well as project director at work, but I’ve always been troubled by thoughts that get in my head and just won’t quit. During the last year, I’d get haunted over and over again by the thought that I’d said the wrong thing to one of my colleagues and offended them. What I’d want to do was ask them if I had in fact offended them, but if they said no, I’d probably worry that my asking them had offended them, and I’d want reassurance about that, thus making it worse. Instead, I ask my wife, who listens carefully and reassures me…but then I think of something I left out of the story and ask her again, and make it worse at home instead of at the job. She’s a kind woman and understands I can’t help it, but, after a while, her patience wears thin, and then I worry about my marriage. My goal is to figure a way out of this trap.

A couple good things about your obsessive thoughts are that you’re used to them and they haven’t stopped you from succeeding at a tough, challenging job. The bad thing is that your technique for diminishing painful self-doubts has gained a hold on you and, if unchecked, could trap you in a dangerous vicious circle. Instead of washing your hands, you’re using the Purell of reassurance to wash your mind of guilt.

If you read up on obsessive compulsive disorder, you’ll learn that the behaviors for reducing painful thoughts (like your reassurance technique) are called “rituals” and they can get out of hand. The treatments for controlling them are a lot like the one invented by Mel Brooks’ comic alter ego, Dr. Haldanish, who cured a young boy of a paper-tearing habit by yelling at him not to tear paper. Which is to say, an absurd-seeming disorder has a similar therapeutic approach.

The goal of these treatments is, simply, to help you stop the ritual, even if this causes more short-term pain and doubt. The therapist may give you reassuring thoughts to repeat or exercises you can use to distract or calm yourself. In extreme cases, the therapist may actually accompany you and directly encourage you to refrain from the ritual (alas, Mr. Brooks doesn’t do house calls).

If you think there’s an element of truth in your concerns and that your speech with colleagues is too negative when you’re stressed or find yourself worried, angry, or unhappy, coaching would also be helpful. You may discover new ways to keep your statements positive, while being direct about tasks and responsibilities.

If you were really offensive, however, you’d be getting more criticism at work and at home, and you aren’t. On a professional level, that’s really your standard and it’s one you want to think about and reinforce as much as possible.

Your goal isn’t to make your doubts go away, though that would be nice; it’s to have respectful conversations at work, even when you’re stressed, and feel confident about your ability to have those conversations. And to keep all paper intact.

STATEMENT:
“It’s hard not to ask for reassurance when I’m haunted by doubts, but I have my own good standards for professional behavior and, so far, I know I’m meeting them. My job is to make them stronger while I tolerate the doubt that seems to be part of my brain chemistry.”

Helping my daughter pay the rent on a bigger apartment seems to have lifted her out of her depression and she’s much more active at her job, but she’s still not making enough money and I’m running out of cash. If I tell her that she has to take a roommate, I’m afraid she’ll just crawl under the covers again and we’ll be back where we started. It shouldn’t be that hard for her to make enough money, but it is. I’m mad and I’m stuck. My goal is to get her to make more money and/or understand that I can’t keep supporting her like this.

While you may think you’re giving your daughter money out of love, you’re actually doing it out of fear. That’s trouble, because when you give money out of fear, you’re usually being mugged.

Fear makes you forget long-term risks, like what you’ll do after you run out of money and the consequences for you, her, and other people who depend on you. Your love is infinite, but your finances aren’t.

You’ll also forget that your daughter may be able to do more for herself now than she could before. She may be able to tolerate more stress and access other resources if yours are less available.

Finally, your fear amplifies her fear and vice versa, until you both doubt that she’ll be able to survive without your current level of support, without there being any evidence of that, other than fear itself.

If you want to manage her disability, rather than be managed by it, you must continually test out what she’s capable of. If she’s stressed by looking for a roommate, coach her on how to do it or how to find a coach. If the roommate is hard to live with, advise her on ways to protect herself. If you protect her more than absolutely necessary, you’re just stifling her growth in the long run.

After all, you’re not responsible for relieving her stress, but for teaching her how to live with it. You’re trying to ensure her basic safety and security, and while you wish she could be happy, that’s not something you or she control.

If she’s afraid of slipping back into depression, point out the constructive things she’s doing to prevent it. Stress may make her feel overwhelmed, but that doesn’t necessarily cause depression or mean that she’s slipping back. It just that means life is hard.

Don’t let her panic incite yours. Instead, think up an emergency, affordable bail-out plan in case she has a bad relapse. Don’t share it with her, just remind yourself that you know what to do for her safety and that the pain she may experience as you cut her funding is an unavoidable part of her recovery and your solvency.

By giving no more than you think is necessary, you become a strong fear-manager and learn self-defense against an emotional hostage situation. Ultimately, that’s the skill you want to give her.

STATEMENT:
“I’m terrified of the stress my daughter will experience if I cut back on the money I’m giving her, but I’ve thought carefully about what she needs and I’m sure she’ll be stronger if she can cope with the stress and do more with less.”

My 22-year-old daughter is mildly retarded, but she’s pretty well taken care of. She’s not unhappy—she worries about things much less than I do—but I’m unhappy, because I’ve never felt comfortable with her. Most people think she’s sweet and docile, but my daughter very much has a will of her own; she doesn’t like to shower, she doesn’t care about other people’s feelings, and she has no idea of how people are reacting to her, or anyone else. I’ve tried hard to find a point of positive connection, and failed. Other people think I’m a great father, but I can’t get over the feeling that I never met this challenge and that there’s unfinished business between my daughter and me.

Regardless of whether your daughter is retarded, super-powered or “normal,” you can never be sure that you’ll like her. It’s so much easier to be her father if you do, but that’s never a guarantee.

It may be that no one would like her if they really knew her, but that doesn’t matter. It sounds like you’ve tried hard to like her, but you don’t, and it’s not in your control.

Given the lack of good chemistry, however, you should appreciate your achievement all the more. You haven’t punished your daughter or told her she’s a failure; on the contrary, you’ve taken good care of her. You’ve done your job under much tougher conditions than most parents have to deal with, and I don’t mean because she’s retarded, but because of your negative feelings for her.

The test of a good teacher isn’t how well she teaches the kids she likes, but how well she does with the kids she doesn’t like and how well she hides that fact.

If this were the movies, your business wouldn’t be finished until the two of you have a good hug. Since this is real life, it’s never finished, so every day, do your best to treat her with respect and friendliness. If you slip and get nasty, apologize. It’s one day at a time.

It’s certainly sad that you couldn’t like her more, but it’s not a failure. It’s a success that, in spite of that, you treat her right, and one that only a great father could achieve.

STATEMENT:
“I will never feel comfortable with my daughter and I will always suspect that, if I were a better person, I would; but I am who I am and she is who she is and I’ve done the best job possible given that simple fact of life.”

I have been struggling with performance anxiety for years. It was particularly difficult during university, where I saw three psychologists, including a campus counselor, who, while supportive, weren’t helpful. It got much better though when I was able to take control of a treatment group I was facilitating, where I could design the program and run it the way I wanted to. I enjoyed being the therapist who helps others, and the experience gave me confidence. Still, the anxiety has not been extinguished in all situations—when teaching and presenting at conferences, the anxiety in these two areas is just as high as it was previously. I have been managing this for a long time and I do not feel motivated to continue to place myself in situations where my anxiety is raised again so high that I experience nausea, stomach pains, dry mouth, etc., not to mention the exhaustion I feel after the anxious-provoking event has finished. I do have some mild/moderate social anxiety—I don’t like socializing in big groups unless I know the people, and this prevents me from making new social contacts and networking for my profession. I am well versed in exposure therapies and ACT and have used these to get me to the point I am at now, and I continue to use them. However, I don’t think my anxiety will ever improve beyond where it is now and I am too exhausted to continue to try. I guess I’m stuck and don’t know if I should try to find a specialist to help me to continue to force myself to network, push myself to present at conferences, and become an academic psychologist or move into working as a clinical psychologist in a private practice, where I would work more on my own and I would be happier and more relaxed but also know that I am avoiding the events that are anxiety-provoking.

Maybe being in the mental health business makes you feel more responsible for controlling symptoms of anxiety and becoming a role model for good mental health. It’s ironic, given that most people in our field are the worst role models for mental health. If we were totally sane, we’d just go into dermatology and rake it in.

If you are driven to perfection, it’s causing you to forget that certain symptoms, like anxiety, tend to be incurable, and that, if you’ve reached the point where you can’t make them better, it’s because you’ve done an amazing job of managing them and pushing yourself to the limit of what you can bear.

That you’ve pushed yourself so hard during a long educational process may have caused you to become academically institutionalized, i.e., to rate your progress by where you stand in the institution (not the other, less fun kind).

You’ve become the very model of an up and coming academic psychologist, but now that the institutional phase of your life is no longer a requirement, you have a wider array of options and no easy reference points. You don’t have to present papers or schmooze colleagues if you don’t want to; that’s not avoidance, unless presenting papers and schmoozing colleagues are part of the life you want to lead going forward.

You know what they call the PhD who came in last in his class? Doctor. Sure, it’s a nasty MD joke, but the fact remains that your degree sets you free, offering you many different career options and you’re now familiar with most of them. Ask yourself how much money you need and then rate your options according to how well they pay, and how much you might enjoy them. Then, when you consider the amount of anxiety each will require you to bear, you’ll know whether it’s worth it.

Remember, like its first cousin, depression, anxiety causes your brain to focus on helplessness and failure rather than achievement and courage. It will tell you that treatment has failed and that you’re a failure if you don’t act normal, but wisdom tells you that you’ve already accomplished your biggest academic goals, in spite of great obstacles, and reached the point where you can finally put your own spin on life.

Be proud of what you’ve done, and don’t mistake anxiety and fatigue for discouragement; they’re challenging you to recognize what you don’t enjoy doing, and there’s no shame in choosing the career path of least (torturous) resistance.

It’s up to you, however, to decide what’s meaningful enough to be worth the pain. If you can maintain a practice despite your own struggles, you’ll be a role model, with or without symptoms (or an MD).

STATEMENT:
“I feel like I’ve failed to conquer my anxiety, but in reality I’ve done everything I set out to do, other than get rid of my symptoms. Now I’m in good position to decide what I want to do next and confident that I can bear whatever unavoidable anxiety goes with that choice.”

Whenever I screw up at work, it causes a chain reaction of even more fuck-ups until fate mercifully intervenes. The most recent incident started when I miscalculated the logistics of a project and ended up forcing another department to work overtime to make up for it. The department head was understanding, but I was so pissed off at myself that I actually couldn’t sleep at night, and that made me late enough for work to miss at least one really important meeting, so now I’m of course thinking that this time I won’t get lucky and will actually lose my job. There’s got to be a way to fix this myself.

It’s certainly unpleasant to make mistakes (that make mistakes that make mistakes), but don’t lynch yourself before you conduct a proper trial. It’s possible that your pain is torturing you to confess to crimes you didn’t commit, just because confession makes you feel better and provides a cheap sort of redemption.

You don’t need a judge and jury to conduct a proper trial on your own conduct, just rules that you believe in (i.e., that you’d apply to a friend) and an ability to review your behavior.

You’d expect a friend to take reasonable precautions to avoid making the same mistake twice; your standards, after all, are for his conduct to be good enough, not perfect. So you wouldn’t assume his miscalculation, the overtime, or his missed meeting were easily avoidable unless he hadn’t followed procedures that he should have known about. At least, those are the rules I think you’d use, but you be the judge. It’s your trial.

Then ask yourself what you should do if the verdict from your trial is “not so bad” but your heart still proclaims you a loser who should embroider a scarlet L in your shirts. That’s when you have to give yourself some good coaching and dismiss your heart’s request for an appeal.

Remind yourself that challenging projects always expose you to the unforeseen and congratulate yourself for taking responsibility and working hard, and give credit to your boss and co-workers. Apologize, but only once.

Be aware that frustration and humiliation, like anxiety (see above), make you think of the should-haves and could-haves without regard to actual, reasonable responsibility. They trigger a lynch mob in your head, but you’re not just the law, but order, and justice will overcome.

STATEMENT:
“I feel frantic when things go wrong and I’m sure I could have or should have prevented it, but I’m also capable of deciding what my real responsibilities should be and standing by that decision.”

My wife suffers from non-medication responsive depression (we’ve done ECT’s, every med in the book, and she has a psychiatrist). She’s bitter and short to family; she goes off on the kids and then can turn around and be nice. I do all the work around the house, get the kids to activities, etc., and I’m wearing out. She comes home from work and just logs on her lap top and sits in front of the TV while I get dinner and clean up. She shows no affection towards me and I feel like a servant. When I complain or push her, she talks about killing herself and putting herself out of our misery (she’s been hospitalized several times) or just hurting herself (sometimes she cuts on her arms and legs). I’m getting to the point where I don’t like her anymore. She just seems to have given up. Nothing interests her, nothing tastes good…she gets no enjoyment from anything. What can I do? She’s in her forties, now, but she struggled with depression in her twenties and this current bout has been going on for 5 years. Her doctor and therapist are really committed to her, but it seems like she doesn’t care, like she enjoys being miserable. Sometimes I feel like I’m spiraling down with her, but I’m not going to give up. If I just stand by, she seems to just sink lower, but I can’t leave, because she’s said that the kids and I are the only reason she’s still alive.

If you’re like most married people, you become dependent on your spouse for a positive response, no matter how independent you are as an individual. You married her because you respect her opinion and take pleasure in her approval. You make her happy, everyone feels good. You see the problem here.

So it’s normal to feel bitterly disappointed and deflated when depression turns her into a grouchy, nasty, unappreciative, unaffectionate black hole who threatens suicide if you criticize her and never does her share.

It’s not just the lack of approval from her that’s bothering you, it’s the overabundance of disapproval, of you and everything else.

Unfortunately, the bitterness you feel in response to your unmet needs adds to her self-hate, creating a vicious circle of negative emotion that demoralizes everyone. Controlling that bitterness is the one thing you can do to improve what is an otherwise impossible situation.

First, pretend that she’s had a stroke that zapped the part of her personality that was warm, active, and responsive; your loss isn’t personal or preventable, and your needs are no longer plausible. Acknowledging these difficult truths now prepares you to assess, without hurt or a sense of failure, whether your family is better off with the two of you together or apart.

There are positive aspects to your marriage, like the fact that she contributes financially, and that, by staying alive, she helps the kids, and hopefully she does some parenting from time to time. She’s showing courage, whether she knows it or not. Maybe the advantages of staying together outweigh the many disadvantages you’ve listed above.

Whatever you decide is best, present it to her positively; tell her you know she’s trying and there’s probably love and affection in there somewhere, if the depression would only lighten up. Remember the person she was and talk to that person as if she’s still there but, like Sleeping Beauty, can’t wake up.

If you feel separation is for the best, let her know that you value and support her role with the kids and that what you are separating from is not her, but her illness. And if she threatens suicide, tell her that her threats are a factor in the separation.

When depression takes over your personality, it makes you do bad things, like putting your life in other people’s hands. If she could control that side of herself, she might improve her parenting and your partnership, even if her depression does not improve. Recommend DBT, a kind of therapy I often recommend, that helps people who feel terrible protect themselves from acting terribly.

Decide what’s for the best, don’t be a victim, and ignore blackmail. You may be a victim of her illness, but you’re also the man in charge who’s doing a wonderful job of soldiering on. If you do what’s best for you and your kids, then it doesn’t matter what she says now; the healthy part of her approves, even if it can’t be heard.

STATEMENT:
“I feel like I’m taking it from all sides and that all the love and nurturing I give my sick wife comes back as shit. I know, however, that her response is not her, but her illness. I have assumed a huge load as a single parent who must now go on alone without the love and support of a partner. I will make hard choices that she may see very negatively, as she sees everything. I will hold fast to my own vision of what’s best for the family.”

I’m writing because my husband wants me to. He thinks there’s something wrong with me, but I like being a little manic, so I haven’t taken my mood-stabilizer medication in 10 years. It’s true, I talk fast, I can’t hold a job, I’m irritable, and he’s had to put me in the hospital a couple times. On the other hand, I don’t hurt anyone and I like the way I feel, most of the time, except for one thing: he wants me to be the way I used to be and he’s always unhappy with me. I hate sleeping in the same bed, but he’ll give me a hard time if I move to another room. My goal is to get him off my back, so I agreed to write.

As noted above, when you’re married, you can’t help depending on your spouse’s approval, in some deep, hard-wired way, which means that, if you never seem to get it, you become a permanent rebel who cares too much to leave but feels better every time you do the opposite of what he wants. In the process, you lose track of your own priorities.

On the other hand, you know your priorities about your hypomanic mood. Keeping it natural and un-medicated is more important to you than holding a job, staying out of hospitals, and keeping your husband happy. That’s where you stand.

The problem is, you wish your husband would get used to the new (10-year-old) you, but that’s not going to happen. There’s no point in talking about whether he should accept you, just like there’s no point in talking about whether you should damp down your hypomania. He can’t help where he stands and neither can you.

So instead of writing to someone who’s supposed to persuade you to take your medication, face the sad fall-out from your decision. Don’t blame yourself; just ask whether the marriage is worth it, because clearly, your old marriage and the mania can’t co-exist.

On the one side, you’ve shared a lot of years together and your standard of living is probably better with him than without him, given that you’re on disability. On the other hand, there’s the mutual non-acceptance, which is hard for both of you to live with.

Whatever you decide, stop whining. You’re not to blame for a bad decision, and you aren’t a victim of bipolar disease, so don’t make yourself a victim of your husband’s non-acceptance.

If you want to continue to live with him, have the balls to stand by your decision. Tell him you’re sticking with the temperament you’ve got, you still want to live with him, you won’t talk to shrinks, and you’ll sleep where you sleep. If he wants to throw you out when he realizes, after 10 years, that you aren’t going to change, so be it. You don’t blame yourself for choosing to live with your hypomanic mood, and you don’t blame him if he wants to leave his life with you behind.

STATEMENT:
“I feel like I’ve ruined my marriage by deciding to do what’s right for me, but the decision has been costly in so many ways that I know I didn’t do it lightly or to spite my husband, so I respect my decision. Now I need to ignore feelings of guilt or wishes that he could accept me the way I am and instead accept him the way he is. Whatever I decide to do about our marriage, I’ll do what I think is best for us and never be a victim.”

I need to face the fact that I have trouble getting close to people. I recently had a close relationship with a guy I was crazy about, but I often get depressed and, when it happens, I get quiet, and he couldn’t stand it. I’m good at functioning when I’m depressed, it’s never stopped me from getting my work done, and I push myself to hang out with friends, but I can’t help the fact that I don’t have much to say and that I don’t really feel like laughing. I kept telling him it wasn’t personal, but he didn’t really believe me. My goal is to figure out how I can find a partner if I can’t really interact very well.

The biggest negative thought you can have when you break up with someone is to believe it’s because there’s something wrong with you, either because your boyfriend said it or because that’s what your brain is telling you.

Nobody says, “it isn’t you, it’s me,” and means it, so you shouldn’t, either.

Remember, it’s deep human nature to blame ourselves for crap that happens, be it a failed relationship or a failed baseball season. It’s your job, however, as your one and only chief protector, to put this assumption to a logical test.

You can blame yourself for making a bad choice, but not if there weren’t any clues that badness was happening; you have to look closely for the red flags that might have given you warning, like evidence that he was needy or had broken up prior relationships when the feedback tapered off. If none of that was obvious, then neither was your error in judgment.

If this is a type of guy you choose over and over again, however, then you’ve got a bad habit that needs fixing and you should see a shrink/coach with that purpose in mind. On the other hand, as seems the case here, if you didn’t have the experience or data to warn you, then you’ve had a valuable/miserable learning experience.

You took a course in the college of hard knocks where tuition is paid in pain. That said, you should give yourself a good grade.

So before assuming you’re no good at relationships, name your standards. I’m sure you know lots of good relationships where one partner or the other gets withdrawn at times, and unless you’re an unusually outgoing person living an unusually lucky life, it’s only a matter of time before you or your significant other gets hit with an illness, loss or trauma that causes a shutdown. The test of a good relationship isn’t its connectedness (or, at least, not connectedness alone), but its ability to tolerate periods of unavoidable disconnectedness that life will inevitably bring.

You might also blame yourself if your depression made you do negative things, like drinking or turning into a blob. Even then, you wouldn’t have good reason to blame yourself unless you could have done better, and sometimes depression leaves you no choice. In any case, you’re successful at keeping yourself going when you’re depressed, and that deserves credit, not blame.

What you’re left with is the sad realization that, from now on, you must choose boyfriends who aren’t too needy or overly sensitive to your mood. Unfortunately, they might not understand you as well as a needy, moody guy would, particularly if they’ve never been depressed.

On the other hand, they won’t get upset when you fall silent, other than to be sorry you’re hurting, and they might not notice unless you tell hem. Ultimately, it’s not you or them that’s to blame, it’s just that some relationships aren’t strong enough to survive bad circumstances. Luckily, you are.

STATEMENT:
“I feel like my depression killed the happiest relationship I’ve ever had, but my experience tells me I can be a good friend, whether I’m depressed or not, and that’s the only standard that matters. So I’ve learned that love requires more than mutual passion and I will never go out again with anyone who requires happy feedback and shows no ability to tolerate pain in the ones they love.”

I’ve become very uncomfortable with a friend who has been very good to me. He’s the one who, when I was depressed, took me to the hospital, even though I didn’t want to go. He was right, I was suicidal and I needed help, but now I feel like he’s so good and reasonable and I’m the idiot-child whose diapers he had to change. I imposed my problems on him when I was totally out of control, so seeing him makes me very uncomfortable and ashamed. How can I get past this feeling of inferiority and embarrassment?

If you’re one of those people who has to learn to live with depression—and you are—one of your most important tasks is to get over your shame. I mean, shame is probably an unavoidable feeling when you’re disabled and have nothing to offer anyone but trouble, or at least that’s the way it feels. Still, you know on a logical level that you can’t be blamed for something you can’t help, and you’d protect anyone else from blame if you knew they had such a problem.

So at some point when you’re thinking clearly, you have a moral obligation to yourself to stand up to the negative thoughts and feel proud of yourself for surviving a very painful time—with a little bit of help, or more, from a friend.

Don’t give power to the side of you that values control at all costs and blames you for losing it. We all have those feelings, but they turn nasty and mean whenever we fail to meet their performance standards. Unfortunately, their standards lie in performance alone, when other values are what are important.

Ask yourself then how you expect other people to behave when they’re super-depressed. You got over your pride and allowed a friend to save you. Give yourself respect, and give that friend the credit he deserves; if he didn’t judge you then, he won’t do it now. Your friend did what a good friend should do and what you would have done for someone else. Don’t let shame deprive you of that friendship or reward his kindness with distance and discomfort.

You can’t help feeling ashamed, but what you can do is give attention to what you and he did with the depression and give respect where it’s due. Don’t apologize or act on your shame; let him know you’re grateful, that he did exactly what you needed him to do, and that you’re proud you survived with his help.

Then talk about other things, be friendly, and give the old friendship chemistry a chance to reassert itself. You went through trauma together, and now you can help each other with the recovery.

STATEMENT:
“Depression always has a way of making me feel humiliated, but it can never really humiliate me as long as I fight it as hard as I can. I will take pride in my survival and in the good friendships I’ve nurtured that have helped me survive.”

When my wife is feeling fine, she’s a reasonable, hard-working, dedicated woman who believes in helping others, but then she gets into this grim, obsessed mood and knocks herself out and then gets mad about how people don’t respect or appreciate her and she just doesn’t care any more. Yesterday, she told the boss she didn’t care if he fired her, because she didn’t care. If he fired her, it would damage a career she really cares about and, besides, we need the money, but when I tried to tell her she needed to shut up, she told me she didn’t care about our marriage or about living any longer, particularly if I didn’t support her. What do I do to stop her from hurting herself?

As we’ve said before, there are a lot of people out there who either don’t believe in mental illness, or do believe it exists but don’t really understand what it is. The former usually believe in Xenu, the latter are baffled by “Hoarders.”

Either way, the easiest way to explain mental illness to those types is to describe the disease as a demon, and yes, it’s a sad fact that people are quicker to understand satanic possession over an actual illness, but such is the biz.

As for your wife, some good people get into very black, destructive moods that are hard to describe, even though most of us have felt it at some time in our lives. It’s the kind of mood when you’re ready to cut off your nose to spite your face (and then turn to a loved one, telling them they made you do it and you hope they’re satisfied).

Those good people have the demon, and, if it’s bad enough, it’s a kind of mental illness that can be sudden, random, and completely out of their hands.

Some people are more vulnerable to those moods because they’re particularly sensitive or perfectionistic; they forget their own priorities and lose themselves in doing a good job or caring for others or making someone else happy. If they can’t succeed, they get exhausted and flip out. It’s worse in the afternoon, or when they’re tired and haven’t eaten.

If you send them to their room, they’ll trash it, beginning with whatever they value most, to show you how little they care and how bad they feel—this is the cutting-off-your-nose business described above. There’s not much you can do to help someone who’s sick/possessed in this way except to try not to not make it worse.

Start with not trying to confront her; otherwise you’ll just become a target and foil for her negative emotions. Instead, let her know you appreciate her hard work, know how upset she is and share the feeling that life can suck. Offer her some hot chocolate and/or a foot massage.

Then tell her you support her quitting, but you want her to do it when she’s feeling better and can do it properly. If she hates you for saying that, tell her you’re happy to give her some alone time and take a walk. Then hope you come home to an intact living room.

Later is when you’ll discover whether she’s the kind of relatively normal demon-possessed person who has perspective most of the time and wants to work with you and/or a therapist to gain better self-control, or whether she’s a permanent victim who can’t get past her anger and is sure you’re responsible for it.

In the shrink trade, we call that kind of person a “bad borderline” or “severe character disorder.” We can’t help them, because that demon/disorder problem started when they were young, took over, and convinced them it’s always someone else’s fault.

From what you said, however, she’s got values and priorities that aren’t totally reactive to her anger, most of the time, and she doesn’t always blame it on you or the boss, so there are lots of things she can do to strengthen her rage-management. Medication sometimes helps, but in my experience, what always helps is “DBT”, a behavioral treatment that is a lot like AA, as explained in the book Skills Training Manual for Treating Borderline Personality Disorder, by Marsha Linehan.

Read what you can, talk to experts, whatever it takes to help you understand what’s going on. If you can see her illness as something she can’t help instead of Biblically evil or self-indulgent, you will feel less obliged to stop her attacks and better able to suggest management tools for keeping her demon/disease under control.

STATEMENT:
“I hate watching my wife self-destruct when she’s tired and enraged, but there’s only so much I can do without making it worse. I know the problem isn’t me and I’m sure it’s here to stay, so I’ll encourage her to work on managing it, particularly when she’s feeling better.”

My wife gets paranoid sometimes, in spite of the fact that, after every episode, she agrees she won’t let it happen again. She promises she’ll see her therapist and take her medication but then, for some reason, she decides the side-effects are unbearable and stops them without telling anyone. A couple weeks later, she tells me she can’t stand living with me and moves out. She also tells me they’re plotting against her at work and planting microphones in her desk and she’s going to go to her boss and, by the way, she thinks her psychiatrist has been talking with him about her so she won’t see him any more. She gets loony, and she sort-of knows it when she’s her usual self, but not when the madness is on her. My goal is to get through to her and prevent her from losing her job or leaving me for good.

Paranoia is hard to prepare for or prevent; it’s one of those disorders that makes you wish that it came with a rash or ache, because some very sane-looking people have paranoid ideas that are very plausible until you realize they’re talking about the aliens, FBI and/or Virgin Mary.

It sounds like your wife keeps her paranoia buried well enough for her to be a good partner most of the time, so treat her that way, despite the weird fears lurking behind her eyeballs. She’s a regular person whose “possessed” brain is whispering bad things in the background which you and she know aren’t real and aren’t her.

Of course, your feelings about the matter are strong–her relapses put you through hell—but if you push or infantilize her, you may trigger the paranoia, and you’ll be the target. So keep your intense feelings to yourself while making it easy for her to take her medications and see her shrink.

Have a plan B for the times when she loses it, so that you don’t lose it yourself; the calmer you are, the better you’ll be able to help her. Prepare yourself for the bad times when you have to go against all your spousal instincts and back off.

As you know from the times when she’s taking her meds, they’re not a cure and, so far, nothing prevents relapses. There’s no reason, however, to think that the relapses will get worse; and at some point, treatments will get better.

When relapses occur, however, don’t blame her or yourself. Treasure the times you have together when she’s herself and hope that her crazy spells will be brief and leave her career and relationships relatively undamaged.

Being a borderline and being paranoid are two very different things, but the rules for caring bystanders is the same; if you can’t avoid the illness, just do your best not to be a target.

STATEMENT:
“It’s awful to have my wife’s personality taken over by someone who fundamentally mistrusts me, but I know it’s not personal and we’re a good team when she’s herself. I can’t protect her, but I know the difference between her and her paranoia and maybe that knowledge will help her find her way home.”