I was sexually abused quite a bit by my dad (and am de-repressing memories right now, fun-fun). I am realizing that I am very fearful of the people I love, and avoid them. Honestly, if I didn’t need to bond to keep from going insane, I would never have a close relationship, because anyone I care about enough can destroy me. But I’m in a lot of pain from loneliness as it is.

Many people believe there are tons of benefits to confronting your past, namely that it will teach you something that will bring catharsis to your present. The common notion being that if you can figure out what went wrong then you can avoid being victimized again.

The problem here is that reviving memories of sexual abuse by your dad will also bring back the old feelings of helplessness and having no choice, which, of course, is the opposite of your situation as an adult, so the lessons are the opposite of useful to your life now.

You’re not examining the past to drown yourself in feelings of helplessness, but to assure yourself that you can protect yourself from abuse.

Also, as an adult, your love for your dad may leave you with a dangerous sense of comfort and familiarity with low-boundary, exploitative sleazebags. In other words, your dad may have given you a tendency to be drawn to people who aren’t trustworthy, and who are worth being fearful of. I’m sure there are people in your life who aren’t scumbags, but your history makes you especially vulnerable to them.

It’s hardly surprising then that your world, as you see it as an adult, will seem full of both loneliness and dangerous people who can’t be trusted. Don’t criticize yourself then for being fearful of relationships or lonely; fear is a good protector, until you get strong enough to protect yourself.

So, as you examine your past, a therapist’s support for your pain and trauma may not be enough to counterbalance an ingrained conviction of helplessness. You may need an additional shield against that conviction before awakening the sleeping dragon of your memories.

One way to get stronger is to approach your past with less feeling and more thought. Develop specific standards for screening potential friends and lovers and use them to override any instincts to get together with, or over-involved with, the wrong people. In other words, if you want to remember your father’s worst traits, look for those traits in people before you decide whether or not they’re worthy of your friendship. Once you convince yourself that you’re a reasonably good self-protector, you can approach your memories with less fear of being swept away.

Find a therapist who’s a good relationship coach, or a therapy group whose members have some wisdom with difficult or exploitative relationships. Don’t force yourself to re-experience memories of abuse until you know how you’d manage it as an adult.

Don’t assume, because you’re fearful of the ones you love, that you’re bad at relationships or that they’ll turn out badly. You’re right, relationships are potentially dangerous, but your awareness of that fact and willingness to get some coaching and training can protect you and eventually help you find friends and lovers who deserve your trust.

Learning from/dealing with the past can be helpful, but beware of the risks, particularly if you (and a therapist) focus exclusively on painful emotions for which you still haven’t developed defenses.

If you want to look back, don’t lose sight of your present ability to spot and avoid guys like dear old dad; then you can learn from and use your memories, instead of being haunted by them.

STATEMENT:
“Because of the past, I may never feel secure about relationships. Once I learn how to detect abuse and avoid abusers, however, I can find friends I can trust, even if my fears remain.”

My friends can’t stand my girlfriend because they say she steals from me to feed her habit, but we’ve been together for 3 years and I can’t help feeling she’s the best friend I have. It’s true, she has a drug habit that she can’t control, and money sometimes disappears from my wallet, but it’s an illness and it’s no good to blame her for it. It doesn’t change the fact that we love one another. Aside from her habit, I know I can trust her. I truly believe our love is a positive factor in helping keep her habit from getting worse. My goal is to help her, of course, while getting my friends to see that she’s a real person, not a drug addict.

Relationships can always be dangerous if you focus too much on the other person’s feelings, or your own, without stopping to think about your other priorities in life. She might make you feel like a hero, feel like you’re a healing saint, feel guilty if you can’t do what she asks, etc. If you focus on that instead of whether or not this relationship is ruining your life, you’re doing it wrong. The more sweet, sensitive and generous your temperament, the worse your peril.

The opposite of caring too much for someone isn’t, of course, to be selfish; it’s to be responsible for your other goals, the ones that arise from your values, interests, and other obligations, including your job to take good care of yourself. You need money for your own education or rainy day fund or, simply, survival during hard times. You deserve to be loved for more than your ability to give.

Go back to basics and think about your own standards for a good relationship, as if you were advising a friend. Yes, you’d say, you need love and good chemistry, but you also need someone who can cover your back, take care of things when you’re disabled, help you on your way, and work well with you in a crisis. You’d have to agree that, without those standards, you’ll team up with someone who can suck you dry and undermine your stability in a very unstable world.

Love is a drug and it can addict and ruin your life and other relationships in a way that puts meth to shame. That’s why, rather than getting into a discussion of how wonderful it feels, you’d urge your friend to think about what he wants a relationship for and how it will help him do what matters.

Forget about what your friends think and put aside your desire to help your girlfriend; instead, focus on what you want to make of your own life and trying to be a good person in a crazy world. Remember who you are and then see where this relationship fits. You’re not a saint, you’re a boyfriend, and if you want to do what’s best for both of you, you won’t even be that much longer.

STATEMENT:
“I love my girlfriend and want to save her from drug addiction and I don’t mind her faults, but what comes first are my own standards for being a strong and self-reliant person that are not dependent on any one person’s love or approval.”

Approximately three years ago I realized my psychiatrist preferred other patients and liked other patients more than me. That realization was incredibly devastating to me. I want to deal with this reality, however, my psychiatrist keeps denying this is the reality and will not openly admit he does indeed prefer other patients. Part of me that hopes (wishes) this truly is not the reality (him preferring other patients) and I TRY to believe that what he says is the reality! However, I simply can’t believe him. I have told him I can’t believe something that I think isn’t true. Even though he has helped me immensely in many ways, and I’m extremely attached to him, I have lost trust, confidence and faith in my psychiatrist over this issue. I think he is preventing me from having the opportunity to deal with reality by denying he prefers other patients. I have a need to hear him say, “Yes I do prefer other patients and your observations/perceptions about this have been accurate.” I think if I hear him say these words I could actually work to deal with it. Since he’s obviously not prepared to say this, MY GOAL is to somehow “detach” from him, stop therapy with him and move on and forget about it.

When you do therapy right, a shrink is like a thesis advisor, helping you explore the toughest issues in your life until your work is complete.

If you lean on therapy too much, however (sometimes through no choice of your own), a shrink is a crutch, which makes deciding when and how to end therapy much more complicated. Remove the cast too early, and you still can’t walk on your own.

So, while it’s a reasonable goal for you to reduce your attachment to your psychiatrist, it’s only worth doing if you think you’ll get through it intact.

The truth is, it’s never a great idea to get attached to psychiatrists or therapists of any kind unless you think it’s really necessary; we cost a lot, the meetings don’t last long, and we’re not all that friendly, really, judging from the way we talk about one another. Most importantly, whatever you imagine you’ll eventually get from the relationship, like unconditional love or feeling like a favored child, doesn’t usually happen.

If what you think you’re getting, however, is a mental stability that you might not have otherwise, then you may be better off sticking with your shrink, regardless of feeling humiliated or rejected by not being his favorite.

As to wanting him to tell you where you really stand in his patient hit parade, ask yourself whether you’ll really be satisfied with his answer; if he tells you that you have “most favored patient” status, you’ll doubt whether he means it, and if he tells you that he likes someone else more, you may not feel so hot about that, either.

That’s the problem with most people who have unsettling doubts about someone they’re close to; they become obsessed with confirming their fears until their doubts damage the relationship and, voila, their fears are confirmed. Instead of going that route, it’s better to shut up or change the subject. Since you’ve been on that route for so long, however, that’s going to be tough.

For now, find goals for your treatment that are less dependent on how you and your psychiatrist feel about one another. Ask yourself what you’d like to change, and look at your psychiatrist as Professor Problems, whom you’ve hired to help you make that change. Judge him as you would any teacher or tradesman, not just by whether you get along but by how well he’s doing the job you hired him for.

In the end, you may manage your strong attachment more safely and effectively if, instead of stopping therapy abruptly, you focus on what you want your hired guy to do for you and confine your conversation to this topic. Make it less about how you feel about one another and more about what you want him to help you do.

If you can’t get past your fixation on his favorites, you should probably look for someone else. After all, this Professor Problems has got you thinking too much about him and you, instead of your true field of study—living life more effectively.

STATEMENT:
“My feelings for my psychiatrist are full of doubt, mistrust, and hurt, but there’s no way, after more than 3 years of trying, that I can make those feelings go away. What I can do, however, is decide whether the value of treatment is worth putting up with those feelings and, if so, start to see him as seldom as possible while using what I’ve learned from treatment to live my life.”

I can tolerate the fact that my son lives with a drug addict, but it’s hard. He’s a good-hearted kid who believes his love will eventually win her over to sobriety. Meanwhile, she never stays clean for long and always winds up stealing from him and prostituting to feed her habit. As a result, though my son works hard, they never have enough money and always wind up skipping out on the landlord or squatting. I make sure he has enough to eat, but I can’t give him anything without its winding up in her hands. He defends her when I call her a thief and a whore. My goal is to rescue him, and I’m getting nowhere.

You want to save your son from a destructive girlfriend and he wants to save her from herself and since you’re both going about it all wrong, allow me to save you a lot of trouble.

You can’t help anyone by taking responsibility for their fates or feelings; in fact, the more you push them with anger or urgency, the more they define themselves by pushing back, rather than by figuring out what they need to do for themselves. If you want to help, you’ve got to control your urges, much as you want them to control theirs.

So instead of making it your goal to save him, try to build his ability to save himself. Instead of pulling him from his girlfriend by damning her faults, respect his love and altruism while encouraging him to think about where it leads and how it conflicts with the other good things he wishes to do in this world.

If you know what it’s like to want to save someone whom it’s not in your power to save (and you do know this topic), share your awareness of how easily the saving obsession can endanger your other goals, commitments, safety and security. Tell him that you once thought that love can heal vulnerable souls, but that it doesn’t. Suggest that he will have a little more power to help her if he builds his independence, keeps his money out of her hands, and provides her with support when she’s clean.

If he objects that the only way to support her is by showing her consistent love and support, insist that you agree, excepting what he means by “love.” You believe it takes more love to do something good for someone that they won’t like than it does to give them what they want, which, if they’re addicts, is almost always bad for them.

So, instead of pulling him away from her, insist that he will do more to help her by doing the right thing himself, welcoming her when she accepts his values, and keeping his distance when she doesn’t, or can’t. In other words, setting a good example is the best way to set him straight.

STATEMENT:
“It kills me to see my son bleed himself dry for a sick, selfish, undeserving shithead of a girlfriend, but I respect his strengths and I can show him how to love someone without taking responsibility for his or her self-destructive behavior.”

I always suspected that I was attracted to women more than to men, but I liked my husband, and we’ve been good companions for the past 20 years. It hurt him deeply, however, that I wasn’t interested in him sexually and finally, when he pressured me to tell him what was wrong, I told him I thought I might be gay. Now he feels I lied to him, that our marriage has been meaningless, and he wants a divorce. Our life together is over and I feel totally to blame, like I’ve let down my husband and betrayed our marriage. What can I say to make amends?

There’s one important step people sometimes forget to take before making amends– asking yourself what you’ve done wrong.

Obviously, your husband is hurt and he thinks you’re to blame, but, as we’ve said many times, that’s the whole point of marriage—having someone to blame. Real sin requires knowing that you have something to hide, and that doesn’t seem to be the case.

With only 3 shopping days left until Yom Kippur, you might wish to remind yourself that the Day of Atonement, when Jews make a special effort to examine our sins, begins with a thrice-repeated statement claiming that no one should ever be responsible for vows they can’t keep.

In other words, life is often impossible and it’s not rationalizing to say you can’t be responsible for what you don’t control– it’s Old Testament.

So look what you’ve done with your (newly coined) homosexual feelings. You haven’t been unfaithful, or blamed your lack of attraction to your husband on his being fat. If you kept a secret from him, it was because you also kept it from yourself, and in spite of your uneasiness, you forged a 20 year relationship. That’s a major accomplishment for both of you.

So don’t let your sexual identity shock shake your confidence; you’ve taken a step forward that allows you to be more self-accepting and spontaneous. While it damages your husband’s matrimonial ideal, it shouldn’t diminish your pride in what both of you have done with the marriage so far, or your hope in what it might become in the future, if your husband calms down.

After all, this doesn’t need to be the end of your relationship; you maybe not have been a great sexual partner, but you’ve always been a great partner, and there’s no reason not to continue to be great friends.

STATEMENT:
“I wish our sexual chemistry and my sexual identity were less complicated, but I feel my husband and I have been good partners, not because of my lying, but in spite of it. I wish it didn’t hurt to face these sexual realities but I’m glad we did and think we can be better friends now that I no longer have to hide who I am.”

I would like to stay off pain pills and I attend AA meetings regularly, but I get the pills from an old friend of mine who also goes to the meetings. She’s been sick with HIV and needs all the support she can get, so we wind up hanging out and then getting high. I wish my husband gave me a little more credit for trying to stay clean, even if I haven’t been successful. It’s hard to say “no” to spending time with a dying friend.

Forget for a moment why other people think it’s bad for you to take pain pills; instead, do your own assessment, not just for whether the pills are bad, but for whether or not amends are in order.

Obviously, the good side is that they make you feel better and you enjoy passing time with a sick friend. Then again, pain pills have a magical ability to kill pain while also causing a ton of it.

Start with a checklist of possible negatives, so you won’t miss the big picture. Include the weekly cost and whether the pills interfere with your ability to work, either directly or by risking a positive drug screen. Ask friends and family whether they see a negative effect on your behavior, and ask yourself whether your focus on feeling better has pushed aside other priorities, like being a good friend or parent.

Finally, assess your friendship with this friend in the same way. Ask yourself whether this is a friend who, in addition to being fun to hang out with, is someone you can count on. Look carefully at whether the feel-good focus of the friendship excludes the more important priorities above.

You need to find your own reasons for being sober, and the strongest reasons will come, not from your need to please your husband or meeting-mates, but from your sense of what it takes to be a good person. As the AA saying goes, you are the reason for your own sobriety. If you’ve used drugs a long time, however, you tend to be super-aware of how other people feel about you and relatively insensitive to your own standards. Those standards give you the reasons to stay clean.

Remember, however, that standards aren’t the same as sentiments. You may feel like a good woman for supporting a sick friend—a nice sentiment—while failing to meet important commitments to manage your health, work, family and other friendships.

Be careful not to bullshit yourself, or your good deeds will, surprise, get you little appreciation or, more importantly, little self-respect. If keeping your friend company keeps you from doing the right thing, then, like the pills themselves, you’re causing more pain than you’re preventing.

STATEMENT:
I feel good when I can help out an appreciative pal and share some good times, but if I want to keep my relationships with people who really care about me, I need to put commitments ahead of good feelings.

There’s a guy on my team at work who drags everyone down, but the boss does nothing to confront him, and it really prevents us all from doing good work. This guy does just enough to get by, and he sucks up to the other guys, so they’re somewhat protective of him. Meanwhile, he’s dismissive with me and the other women on the team and has a way of passing the buck to us, losing what we give him, and then blaming our hormones if we complain. No surprise here, he’s a heavy stoner and smokes during the day, but everyone at work seems to think it’s no big deal. I like the job and the people, but I’m afraid that complaining to our boss will be seen as petty and disloyal to our team. I don’t mind telling this guy to his face that I’m unhappy with his work and attitude, but it would just make him even nastier and impossible. At the same time, I don’t want to be silent just because the boys don’t respect what I’m saying. What can I do to make this work?

When you’ve got a job where you like the work and the people you work with, it’s natural to feel that the bad behavior of a single jerk shouldn’t be able to ruin it for you (and everyone else), let alone a lazy, sexist jerk with a drug problem.

Trouble is, his behavior can totally ruin it for you and everyone else unless your boss or other co-workers are reasonably good at managing his behavior instead of just avoiding conflict and sharing dumb jokes.

Unfortunately, as you may have noticed, they’re not really rising to the task so far, and that’s something you don’t control. At least it seems you’ve been good about controlling your own rage.

That’s important, because if you vent your frustration about his provocative behavior, you may make the boss and this guy’s buddies defensive, in which case they’ll bind together and focus on you and your buzzkill woman-logic as the problem.

There is a way to provide the missing ingredient, however, by creating a positive context for discussing the group’s accomplishments and the problems that get in its way, while keeping your negative feelings under wraps. Instead of talking about this guy’s slacker status, endless stash or jerk behavior, list specific actions, attitudes and episodes of hard work that represent the team at its best.

Then discuss this guy’s negative behavior generically, as the kind of thing people do because they get tired or carried away (not high or dickish), but which is nevertheless a threat to the group. Avoid condemnation, blame, or moral criticism, because, as much as you might hate this guy, it doesn’t help your case to make it personal. Simply express your concern that actions such as his can have a bad impact on the group’s performance and you’d like to see things get better.

If you’re not moralistic, you don’t have to prove your point or win a war; after all, people may or may not agree with you, or may change their minds later. You can only hope this guy sees what you mean and can change what he’s doing, because you’d like to see him succeed too. He’s a member of your group and you respect his strengths (even if his many weaknesses drive you nuts).

In effect, give the group the benefit of your administrative vision and hope it resonates with them and/or your boss. If you can focus enough on the good possibilities and keep your description of bad behaviors objective and impersonal, you’ll get through to some people who might have run away from your anger.

If not, at least you’ll know you’ve done your best and maybe planted a seed that will grow later (and NOT into a marijuana plant).

STATEMENT:
“I think my co-worker is a nasty, condescending, lazy jerk, but I still have hopes for the work our team could do and want to see how far we can get in spite of him. If I can persuade people to share my vision of our possibilities and the need for better behavior, without focusing on the jerk as a bad guy, maybe we can do better. In any case, I will not let myself be drawn into criticism and blame.”

My daughter is a sweet stoner who expects very little of herself but makes a basic living and gets by. She’s a lovely kid who’s bright but never did well in school and now works in retail. She’s responsible and carries her weight, but barely covers her expenses and has no ambition to do anything but linger in the service industry and continue to get high. I feel guilty for wanting more for her and not really accepting her as she is, and I know that criticism won’t help. What can I do, if anything, to get her motivated?

You have good reason to worry about an unmotivated, pot-loving kid. Life is hard, and pleasure-loving grasshoppers have few resources to draw on when their luck turns bad, other than their motivated ant/parents. Your daughter may see herself as independent, but you know how she’s going to wind up if/when her money runs out.

That said, you’re right that it won’t help to criticize her for ingratitude, thoughtlessness, or a lack of discipline. For one thing, she probably feels bad that she hasn’t found a better niche—even Jeffery “The Dude” Lebowski has his moments of regret—and for another, the more you make her feel like a poorly performing kid, the more she’ll need to toke up.

You don’t have to let yourself get frozen between silence and anger, however, if you can bring up the issue constructively, and keep the aforementioned negative feelings out of the conversation. Unlike the case above, though, you’re more supervisor than co-worker, so you have the ability to go straight to the source with your concerns.

Begin by acknowledging her strengths–a winning personality, willingness to work for her living, and ability to enjoy herself–then avoid the temptation to talk about choices and responsibilities. After all, you can never be sure how much choice she has about her habits and lifestyle or how hard she’s being pushed by her biology (both towards smoking ganga and away from motivation in general).

Then express your vision for a better future, which is that she should build more security for herself, given the fact that the economy always eventually goes bad, Murphy’s Law rules, and America is not known for its safety net.

Remind her that many self-labeled misfits find interesting things to do later in life, and that their years as misfits are usually not caused by laziness or mistakes, but by the fact that life doesn’t present everyone with a neat, work-hard-and-you’ll-get-there career. It’s not fair, and many good people are misfits, but the big danger is that she’ll feel too responsible for her situation, give up, and get stoned, rather than remain open to them.

Pot-smoking may reduce her opportunities or not, so urge her to evaluate for herself whether it reduces her initiative and ability to get things done. To do so, she will probably need to stop for a while and see what happens. You’re not telling her to stop forever or that pot-smoking is bad, simply that you want to be sure she’s managing herself objectively, rather than letting anxiety or her need for relief direct her priorities.

In the short run, you may make no difference. In the long run, good coaching can help her to think objectively about her life, appreciate her strengths, monitor problem behaviors, and sustain her self-esteem.

She’s not a bad kid, she’s just not making good decisions. You have the ability, however, to push her towards better methods of decision-making, if not better decisions. Alas, The Dude can only abide so much.

STATEMENT:
“I sometimes feel my daughter has failed to get started in life and that the fault is mine, but I know I’ve given her a good home and that there are many good people who have trouble finding a niche. I will continue to coach her on good life management, respect myself for doing that job, and refuse to hold myself, or her, responsible for results we don’t control.”

For years (e.g. 9 years or more) our marriage has been almost completely sexless. Within the past few years, affection has largely gone out of the window too. Our relating is often bitter, and this happens in front of our poor 8-year-old son, too. I don’t think I can feel attracted to my husband again, even though I think we could be friends if he hated me less and trusted me more. My goal is to have a relationship with my husband that does not f*ck up our son, or a “healthy” separation from him which causes the minimum of damage to him (our son).

When affection and sex seem to have worn out of a marriage, you might immediately wonder whether or not the marriage is over. That, however, would be jumping the gun—a premature evaluation, as it were.

Before you go deciding a sexless marriage means no marriage at all, consider whether you’ve done all you should to fight marital fatigue.

That’s the fatigue that sets in from feeling like you’re carrying more weight than your spouse, letting him know, finding out he feels the same way, kindly offering to take over his job, and arguing to a standstill until things blow up again. It’s unavoidable in most marriages, at least those that do heavy lifting; after all, the main reason for marrying is to have someone to blame.

The “work” of staying married is to shut up about your negative feelings while trying to start something positive, like talking, or eating, or really anything that doesn’t involve finger-pointing. If you don’t, sex tends to stop. If sex stops on its own, the positive conversations are what keep the relationship alive.

Don’t figure out why you don’t feel like having such conversations; the reason maintaining marital intimacy is work is that you don’t feel like it when you start doing it and figuring out why just postpones the inevitable and makes it more difficult to start. Your efforts will either work or they won’t, but if they don’t, they will at least assure you that you’ve done your job and aren’t to blame for the great divide.

You may have good reason for believing your husband’s negative feelings are to blame, but don’t share that view, regardless of how true it is. If you want to improve things, talk about his positive contributions and what you’d like to improve. If he continues to act mean and surly, that’s too bad; you know you’ve done your best and your criticism is not responsible for his mean and surly side.

You may also have good reason for believing your husband’s behavior is hurting your son, and that’s another line of reasoning to keep to yourself. Criticizing the impact of your partner’s bad behavior on your child’s well-being has one reliable result—war—and to avoid war, you need to follow basic rules of diplomacy: describe his good parenting contributions and, after assuming good intentions for his bad behavior, suggest that it may be having a bad effect. Again, if there’s a surly reaction, it’s on him.

Your goal then is to keep your own fire under control and not add to his. That’s about the best you can do to keep things friendly: avoid amplifying hostility. If you’ve done what you can and the evaluation comes back negative, then unfortunately, your conclusion isn’t premature, but forgone.

STATEMENT:
“If things are as unfriendly as they are between me and my husband after I’ve tried all known forms of marital resuscitation, then I’ve got a sad fact to accept. I guessed wrong about how well he and I would get along in the long run, but that’s the only thing I’ve done wrong. Now I’ve got to figure out what’s best for me and our child and do it without a negative word. That, at least, is worth aiming for. “

I was always good friends with my girlfriend, even when she was into drugs, (that was before we were dating), because I knew she was basically a decent person and we got along really well. After she cleaned up, we became a couple and we were doing really well, but then she started back on drugs again, and I got nasty with her, and she decided I was mean and controlling and couldn’t be trusted and then walked out. I know we had something special. I love her and I’m good for her. My goal is to figure out how to revive what is basically a positive relationship.

For whatever reason, nurturing guys love to get paranoid, fucked-up girls to trust them. They’re the kind of guy/suckers who tend to worship at The Church of Our Savior of the Sad Sexy Lady. And become professional therapists.

Finding a trusting girl is like picking out a dog at the pound: just roll her over on her back (figuratively speaking) and see if she snarls, and if she doesn’t, you’ve met your new best friend. One thing that’s true with dogs and people is that it doesn’t matter if it’s genetic or traumatic; the trust you see is the trust you get.

Although it hurts to lose her, you’re better off not trying to win the trust of someone who’s put you on probation, unless the probation is for very, very good reasons. If the crime is that you hurt her feelings with angry words or criticism of her drugging, then ask yourself whether it meets your definition of a crime.

Remember, having to apologize or redeem yourself for the crime of causing pain, as opposed to a real crime, will have you feeling guilty and responsible for someone else’s feelings (and drugging) forever. If marriage is about having someone to blame, pursuing the trust of an untrusting, damaged girl is about love-slavery and blaming/hating yourself.

As long as your goal is to re-establish a trusting relationship, you’re asking for what you can’t have (cue the Rolling Stones) while simultaneously painting a target on yourself. Instead, you should just credit yourself with making a good try. After all, you thought you knew her and were more than willing to tolerate her baggage, but you couldn’t overcome her weakness for drugs and tendency to see critics as enemies, both of which problems started long before you came on the scene.

You can be sad that it couldn’t work, but you can’t blame yourself, and you shouldn’t bother blaming something that happened in her past or yours. It won’t change the present, and in the present, you two don’t work. The future’s not looking too bright, either; before you start hoping she can improve, use your common sense.

To improve, she must meet 4 criteria. First, she has to see that she has a problem that is truly hers. Second, she has to want to control her impulses, not express them. Third, she has to want to do this for herself, not for you. And, fourth, she has to be lucky enough, and strong enough, to accomplish this task.

What you’re saying is that, given this challenge, she blames her drugging on your disrespect and dumps you, then she’s 0 for 4 with an F on the improvement test. It’s not the answer you want, but it’s the answer you need (cue Rolling Stones again).

Instead of fighting to nurture your broken beloved, learn what you need to learn. No matter how much you love someone, you can’t change their negative behaviors or give them the will or skill to manage them. Date people for who they are, and if they don’t measure up, move on. If you stop trying to be the Sexy Lady Savior, you’ll find true salvation.

STATEMENT:
“I love this girl more than I’ve ever loved anyone and I feel her pain; but I’ve given our love a good try and I know it can’t succeed because I can’t heal her and she shows no sign of being able to heal herself. I respect my love and my ability to accept her, let go, and move on.

I wish I could be sure that my daughter is getting the right treatment for my grandson. He’s 7-years-old and been diagnosed with Bipolar Disorder and his doctor started him on a drug called Abilify, which has some nasty side-effects. I’ve read on the internet that Abilify can be harmful to kids and I wish my daughter and her husband would think twice before allowing themselves to be talked into using it, but I don’t want to intrude into their decision. My goal is to make sure my grandson isn’t harmed.

Never ask someone if they’re sure they know what they’re doing, because if they weren’t sure, you wouldn’t need to ask in the first place.

If you do end up asking your daughter why she’s exposing her son to a dangerous medication, not only will she answer yes, but she’ll give you an annoyed earful as to how she’s doing the right thing, how you don’t know what you’re talking about, and how you should just mind your own business.

She might not know what she’s doing, but neither did you when you opened your mouth.

If you want to talk to your daughter about your concerns, it’s possible, but only if you stay away, not just from provocative questions, but the negative emotions that push them out your mouth.

Instead, follow your usual procedures for conducting a risk-benefit analysis by asking about circumstances that might be endangering your grandson’s safety, and thus justify the Abilify decision.

Ask if she’s worried that he might hurt himself or do some serious damage or if he sounds like his mind is melting down. In other words, ask her the questions that she should be asking herself as a parent responsible for making a difficult decision about her son’s health.

Usually, you’ll find out that something spooky was happening and that no one could think of a treatment other than medication that could make your grandson safe or stop him from having crazy thoughts. So, while it’s bad that he’s in danger and no one can think of a quick, safe treatment, at least the treatment decision makes sense.

That’s the way medication like Abilify is usually used; it’s not prescribed as a safe treatment after doctors have made a definitive diagnosis, but as a not-so-safe treatment that might stop even-more-dangerous symptoms arising from a mental disorder. Definitive diagnoses don’t yet exist for mental illnesses and anybody who tells you differently is trying to sell you something (maybe even some Abilify).

If nothing scary has happened to your grandson, then, yes, you’ve got to wonder why his parents (and a doctor) think a high risk medication is worth trying. At this point, it’s OK to wonder out loud, as long as you don’t imply that someone is being mean, stupid or careless. For example, you could ask your daughter if she thinks the doctor’s worried that something dangerous could happen in the near future if your grandson doesn’t take this drug.

If it turns out your daughter isn’t worried, point out the side effects and ask her if she thinks the risk is worth it. You’re sure you know what you’re doing, and with the right questions, so will your daughter.

STATEMENT:
“My grandson’s treatment seems like dangerous overkill, but I’ll push my fear aside while I ask good, rational questions about their reasons for being worried about his health and safety and offer them a rational model for making tough treatment decisions.”

I’m worried about my son’s drug abuse, but I feel I’ve got no right to speak up about anything in my home. Five years ago, my husband found I was a secret drinker, and since then, he acts like anything I have to say is a stupid lie. I cleaned up my act because I hated the lying and wanted to be a good mother, but I’ve felt like I’m on probation ever since, and it’s hard to speak up. How can I help my son?

One of the worst things about a bad habit, like addictive drinking, is that shame of drinking drives you to drink. As vicious cycles go, it’s quite effective.

Here, you’ve done the hard work of getting sober in spite of the cycle and the shame, and for all the right reasons, but the stigma lingers on and drives you, no longer to drink, but to muzzle yourself when you have good right and reason to speak up.

It’s too bad your husband doesn’t trust you, but that’s no reason not to trust yourself. Of course you can’t be sure that you won’t drink again, but you can be sure that you know a great deal about addiction and that you’ve found the strength to stop for many years now. You deserve credit, and he (and you) would be wise to recognize your strength.

You also have a great deal of wisdom about drinking that you can share with your son, but don’t offer that wisdom via an impassioned plea for sobriety, backed by the authenticity of your personal experience. That’s the kind of pressure that usually turns people off and ends conversations/chances to help.

As noted above, however, you can often talk comfortably about touchy topics if you keep negative emotion to yourself. So, instead of telling him that he’s scaring you or making a mess of his life (as you did), ask him whether he thinks he’s drinking too much and what measures he would use to make that assessment, talking frankly about the measures you used to judge your own situation, which (as you mentioned) were your sense that lying was hurting your marriage and preventing you from being a reliable mother. Those were yours; encourage him to define his.

Just by talking frankly about your own experience, you’re dispelling the shame of drinking. You’re telling him that you don’t disrespect yourself for being a drunk; you’re proud of yourself for what you did with your alcoholism and you’re encouraging him to put aside secrecy and shame and think about where he stands.

Don’t share your emotions, share your process and support, and don’t let shame or your husband hold you back.

STATEMENT:
“I’m worried about my son’s drinking and ashamed of my own; but I know I can’t control his drinking and sharing my feelings will make it worse. Instead, I’ll try to teach him how to think about his drinking, assess its impact on his life, and make his own decisions about it. To do that, in spite of how I really feel, would be amazing.”

Given all my issues, I’m not doing so badly, although it’s true I have a $400/week speed habit. Even with that though, I’m doing well at a demanding, high-powered job, meeting all the overtime demands, and then, at quitting time, when I’ve gotten paid and don’t want to feel bored or alone, that’s where speed comes in. A few years ago, I had a crazy, manic mental breakdown and they started me on medication, which I’ve taken regularly, but I’ve been doing fine ever since, my mood is great, the speed hasn’t bothered me, so I don’t see why I can’t start cutting back on the meds. That’s my goal: to feel OK without meds.

Whether it’s bad for you to use speed or stop your bipolar medications depends a lot on what you believe you need for your future survival, assuming that you care about it.

Since I don’t think that’s a safe assumption, let’s assume you’ll at least consider caring about it after you read my response.

In the present, it’s fun to party, and a bipolar personality may give you more social attractiveness and more energy for completing all-night work assignments. As years go by, however, your party-going friends are unlikely to stick around when the weather is no longer fair, and employers that exploit your extra energy will be quick to outsource your job out-country as soon as possible.

After that, you will have nothing to hang onto when the speed runs out, you’ve got nothing to do, your party friends won’t see you without a door charge, and the bipolar crash hits, as it must, sooner or later, with all its usual force and fury.

You’ve been told that reducing bipolar medication and using speed may not hurt you right away, but they shorten your remission time and speed the day of your next relapse. The problem is, once you hear the first part of that sentence, you probably ignore the second half.

What you should be hearing is that other people want you to wake up and take care of yourself before it’s too late, because they can’t do it for you. Instead, what you hear is that other people want you to stop doing what you like to do and you wish they’d go away.

By “future survival,” I don’t mean feeling better, making the pain go away, or not getting caught. I mean protecting yourself when your luck turns bad, the jobs dry up, your parents are dead and gone, and the money runs out.

And don’t think I mean that your life will turn bad simply because of the speed or medication decisions—if only it were that simple, Nancy Reagan. Life turns bad on its own due to the prevalence of bad luck, whether you substitute speed for your medications or not. The question is, how well will you be prepared to cope with it when the next batch of shit arrives.

So, if pleasure is your goal and you’re living in the moment, which is common for people with your illness, then congrats. But if you’re thinking of living past tomorrow or even the week after, you need to wake up the guy in charge and consider what you’re taking meds for, pleasure, pain, and all.

STATEMENT:
Here’s a statement that offers you the protection you deserve. “It’s hard to put up with the exhaustion and stress of work, particularly without the relief and pleasure of speed to look forward to, but I want to be proud of the way I take care of myself, even if I have to endure pain along the way, because that’s what will get me through the hard times.”

I used to screw up a lot before I started taking Ritalin, and my husband always gave me a hard time, both for the things I promised to do and then screwed up and the ways I tried to cover up the screw-ups, but for the past 2 years I’ve been pretty responsible and honest. I think I’m still doing well, even when I stop Ritalin from time to time when I don’t have any projects that require steady attention; but recently my husband told me that I’m less available emotionally when I don’t take my medicine, and I wonder whether I should take it all the time. My goal is not to slide back to the way I was before.

Who knows what comes first: paying more attention to what people think because you’re hiding a screw-up, or hiding your screw-ups because you care what people think.

It’s no wonder that, even years after you get your screw-ups under control, you still measure how well you’re doing by how other people react. If you want to stop going around in circles, it’s time to stop.

As every married person knows, there’s a big difference between wanting to please your partner, and having to please him or her. Wanting to is healthy. Having to means you don’t feel you have a choice, your self-esteem is held hostage, and, ultimately, you’ve lost a sense of freedom you can regain only by the secret defiance of, you guessed it, screwing up.

It sounds like you know what the medication does for you, how it might harm you, and when it’s worthwhile to take it, regardless. You’re not starting or stopping it because you feel like it, but because you’ve measured the odds. That’s the mark of a good management decision.

That said, you’re allowed to forget about your husband’s feelings and use the same method to decide whether taking medication is necessary to being a good wife. Remember, no medication, including Viagra, is risk free. It won’t be good for your marriage if you take on that risk to please your partner, than because you think it’s worthwhile.

Define what it means to be a good-enough wife in terms of the time and attention you believe you should offer, not in terms of whether your performance pleases your husband—unless you feel your husband is the ultimate judge of your performance. If that’s true, the health of your marriage might have issues of its own.

STATEMENT:
Here’s a statement to protect yourself from being overly responsive to the feelings of your significant other, at the expense of your own judgment. “I’ve heard your concern that I’m less emotionally available when I don’t take stimulants, but I’m determined not to take them unless absolutely necessary, so I’ve looked hard at what happens to our relationship when I stop them. In my opinion, I no longer screw up on my commitments and I’m reasonably available, even if somewhat distractible. So I think we’ve got a good thing going, even when I don’t take stimulants, and that I should continue to keep them in reserve.”

Most people thing my mom is really fun, if a little flaky and emo, but they don’t see how crazy and mean she gets when there’s no one around but my brother and me (my parents are divorced). When she’s in a bad mood, she tells us we’ve been mean to her, and reminds us of things we’ve said that hurt her, and tells us how bad we are until we’ve apologized, and then she forgets it ever happened. There’s one cousin who’s seen what she gets like and I rely on him to remind me that it’s OK, she’s crazy, but the other day he seemed charmed by her and then, when I complained, he told me I had to get over her and not be so angry, and now I feel totally unsupported. My goal is to get someone to understand what’s going on.

Nothing gets people more stirred up than dramatically pitched false accusations and punishments by a powerful, inescapable, totally two-faced authority, like your mama.

The good news is that, while you’ve got the makings of a perfect soap opera, it sounds like you’re not getting swept away by it.

The trouble with soap operas, of course, is that they trap the good guys into endless rounds of angry, hurt reactions to crazy bad guys. In the process, they take up huge amounts of time and energy for tears and talk, talk, talk before, finally, there’s a glimmer of comfort and validation…before the cycle starts all over again.

The process leaves no time for any other (boring, make-a-living) activities or relationships, positive or negative, and the good guys’ angry responses and efforts to expose the villain usually make them more vulnerable to slander in an endless vicious circle.

So enjoy validation if it comes your way, but don’t seek it out too intensely or your life will become ready for daytime. Besides, even if somebody sees what your mother’s really like, her behavior is not going to change. Sadly, you drew her number in the mother lottery and won a nut job.

Not to be indelicate, but, as you might have guessed, your mama sounds a little crazy. On the positive side, that basically means, while her behavior is erratic and sometimes cruel, it’s not personal, just like your cousin says.

She’s not motivated by anything except a blip in her brain, so keep that in mind when you’re tempted to “fight back,” because you can’t win against crazy, no matter who acknowledges how crazy she is.

Your goal then isn’t to out your mother as a witch from hell, but to keep doing whatever you think is positive, good for you, and likely to spring you free, like getting your schoolwork done, keeping busy with out-of-house activities, and keeping these goals in mind when she does blow up and accuse you of untold (and likely fictitious) evils.

There’s more good news in that it sounds like that’s what you’re doing; you’re not describing angry, “cry-for-help” drug-downing or cop-defying behavior that will accelerate the soap opera cycle at the expense of your health and future independence.

You’re moving ahead, regardless of anger and turmoil, and that’s what you need to do. Forget exposing her two faces, because nobody will be happy if the soap hits the fan.

STATEMENT:
Here’s a standard business plan for growing up with a closeted witch. “I’ve got good reason to believe I don’t do bad things unless she gets me mad, and I can’t stop her from getting me mad, even if the world knows it’s her fault, so I’ve got to believe in myself and pursue my regular goals, like schoolwork and building a life. I can’t expect to be happy when she gets going, but if I can keep my mouth shut and fight the temptation to join her in big, dramatic scenes, I’ll be doing a good job and acquiring an excellent training in how to be a therapist.”

I’m a psychotherapist with a small but thriving practice. I’m also recovering from an addiction to pain meds (please note: I cannot prescribe medication, nor can anybody in my practice, so there’s no ethics violation there, I got my pills like any other druggie would). I’ve been completely sober for three years now, but I’m afraid to be open about my problem with almost anyone, including my family, because I can’t see how people would respect or want to get help from someone who was as messed up as I was (and I know most drug counselors are addicts, but I think this is different). The problem is, I feel more stressed than ever. I’m burning out on my practice because I’m always staying late and trying hard to make sure everyone is settled before I let them out of my office. And I feel terrible about not spending enough time with my family, and I never have time for myself. I feel I’m in danger of slipping, but there’s no escape.

Your drug use might be under control, but right now, your life isn’t.

Your life is being managed by your need to do a perfect job and keep your patients safe and happy. Meanwhile, you’re running out of gas, losing credibility with friends and family, and slipping closer to the pit of pain pills.

You’re not at the wheel, your desires are, and we know where that road leads. Caring too much about how people feel and doing a perfect job are what got you into this mess in the first place.

You can’t make people happy, particularly if you’re a shrink. Patients are unhappy; that’s why they’re patients. So far, there’s no cure to life sucking, so, like a good physical therapist, your job is to use your time efficiently to offer coping tools. After that, it’s quitting time.

Sometimes people are helped; but sometimes they’re disappointed. Your job is to do a good professional job and then move on to other responsibilities.

Then there are patients who want to hold someone responsible for their unhappiness, and their therapist is target number one. They know you haven’t done enough, or you’ve done the wrong thing, or you need to do more. If you react too much to their beliefs, you’ll never leave the office.

Of course, you can’t stop being sensitive, because that’s your nature; I might as well ask you to start writing with your other hand or grow a foot overnight. Instead, accept your sensitivity and learn to manage it.

You need to take pride in how you manage your weaknesses and, to do that, you must first acknowledge them, not disown them. Out yourself and lay claim to the management credit you deserve.

STATEMENT:
Here’s a management directive. “I always feel better if people respect me and are happy with my work; but I will not let that need interfere with my building better self-control, limiting workaholism, and doing what I think is right to balance my life. The greater my weaknesses, the more right I have to be proud of what I’ve done with them and intend to do.”

When my mother starting dating my soon-to-be-step-father, I was upset. It’s not just that my father had only died six months earlier, but that this guy was clearly a user and a nowhere near good enough for her. I’m in college, so at least I didn’t have to live under the same roof as this jerk, but I’ve already gone out of my way to avoid him and it’s really annoyed my mom that I haven’t tried to get along with him. Plus it means I’ve spent last time with her, and we used to be really close. When she told me they were going to get married, I freaked out, and now she’s says that if that’s how I feel then I’m not invited to the wedding. I think what my mom and I need is a face-off to get everything on the table and sort out this mess. My goal is to get my mom back.

You’ve got every reason to worry about your mother’s taste in men and its impact on your relationship; after all, her choice has the potential to cause you (and possibly her) great pain, at a time when you’re grieving your father’s death.

Unfortunately, however, all you can do is worry, and after that, you’re fucked. There’s nothing you can do to make things better and lots to make things worse.

Sometimes people feel that grieving entitles them to special consideration, but those people are delusional.

Loss triggers the worst in everyone bereaved, which becomes a chain reaction. Death is hard, but so is life, and you don’t get to cut in entitlement line.

If you go with your feelings—and you’re entitled to them—you’ll make things much worse. You want a face-off because you want to believe you could get through to your mother in a one-to-one conversation. Confrontation is supposed to be “empowering,” which is usually code for, “a giant waste of time.”

You’ll tell her she’s being stupid and insensitive to your feelings, and she’ll tell you you’re an immature brat, and you’ll both repeat yourselves several times at higher volume until the talk is over and no subsequent talks will be scheduled until her third wedding anniversary (or, as you see it, her messy divorce).

Remember, Hamlet had it even worse. True, he had even more reason to be angry (his stepfather had murdered his father and was eager to get him out of the way, the play he wrote for his mother failed to get his point across and got bad reviews, etc).

Being a character in a play, however, he naturally had lots and lots of feelings, all of which he communicated, and his family situation definitely deteriorated as a result. You see, there’s lots you can learn from Shakespeare, namely, ye shall shut up.

Your broader goal isn’t to vent your spleen and get mama back (which won’t happen), but to minimize the damage to yourself and avoid drawing your mother and fiancé together in an alliance based on her fight with you.

Instead, keep your feelings to yourself. Lie low, finish your studies, eat cake at the wedding. Choose peace with your mother over your worries and righteous indignation, because no matter how much you hate her choices, choosing to suck it up is probably what your father would want.

STATEMENT:
Here’s a statement to keep you on course. “I’ve lost the family that I thought was my rock. I don’t know when I’m going to stop hurting. What mattered most to my dad is that I finish my studies and try to support Mom and if that’s impossible, try to stay out of fights. I can’t salvage or rescue my family or stop the pain but if I can keep on course, with all the sadness, loneliness, and irritation I feel, I’ll have accomplished something amazing.”

I was a real fuck-up when I was in high school; I cut a lot of class, got high a lot, got my girlfriend pregnant…she ended the pregnancy, but it was a huge mess. My oldest and only son is now 13, but he’s already becoming a chip off the old block. We’ve always gotten along so well, and I thought we were still getting along, but then I found pot in his room and my wife said she found a condom wrapper in the trash. We live in my wife’s small hometown, so nobody knows about my history, but now my son is going to have to walk around with that reputation, nevermind that he might ruin his future or end up with child support. My goal is to get my son to snap out of it and not fuck up his future.

It’s great that you and your son are good buddies, and that you understand him well, so don’t wreck things by trying to over-control his choices.

Yes, of course you’d like to save him the pain you went through, and you’re terrified of what might happen if he lacks the luck that kept you out of serious trouble. If you act on your feelings, however, you’ll turn your buddy into an enemy, and probably a nightmare.

Look at the bright side; he’s still at home, and you have lots of opportunity to give him good advice and back it up with incentives that are extra strong because he’s relatively dependent. (It’s much harder after he has a car and job).

You understand his problems, having had them yourself, so if you can just keep your emotions safely under wraps, you can be the good coach you never had yourself—you’re in his own live-in “scared straight,” without the scaring him part.

So, in order to be useful to him, start by creating a boundary between what you think will help your son and what your feelings want you to express that would not be helpful.

It’s helpful to discourage marijuana use with whatever monitoring and enforcement system you like, but it’s not helpful to tell him he’s bad, ungrateful or defiant (even if he is), or to present your efforts as punishment, or to generally give him a bad guy to rebel against.

It’s helpful to discourage unsafe sex and unsafe relationships, the latter being those that are overly close and therefore likely to blow up with lots of rage, misery, and distraction. It’s not helpful to tell him he’s got to follow your rules or else.

As an overall rule, it’s helpful to share your own vulnerability to the needs and desires that are pulling at him and state your reasons, based on experience, for not giving in to them.

It’s not helpful to portray yourself as morally superior or as a frightened protector of his image in town. He doesn’t need a visit from the ghost of ruined reputations future. Sure, you’re more his dad than his friend, but being his dad doesn’t make you his judge. Be reasonable, and he might just follow your lead.

STATEMENT:
Give yourself a pep-talk before trying it out on him. “I shouldn’t be surprised that my son has my own impulsivity and eagerness to try everything, and those are good qualities if he can learn how to manage them. It will be no easier for me to control his behavior than it was for my parents with me. Judging from that experience, I’ll get nowhere showing him anger or fear. So I’ll choose my battles carefully and explain my limits in terms of their long-term benefit and try to look calm and friendly, regardless of how I really feel, and hope for the best.”

I have a 30-year-old patient whom I’ve been seeing in weekly psychotherapy for 6 months and he had a terrible history of sexual and physical abuse and years in state care. Amazingly, despite all his trauma and several prior failed treatments, he settled into a trusting relationship with me. He tells me I’m the first person he’s bonded with, and he’s been able to stop using cocaine, and, for the first time, sees some hope for himself. The problem is that he just got a new job, and I’m not covered by his new insurance plan. He wrote me a letter telling me how much he feels his recovery depends on continuing the treatment we’ve started and I feel professionally obliged to put his welfare ahead of my financial needs, but I’d like to get paid. My goal is to do right by my patient, and not trigger the feelings of abandonment that underlie much of his negative behavior, but I’m not sure how long I can afford to see him for nothing.

There are many therapists who believe the best thing you can do for a troubled patient like this is to “be there,” providing the steady acceptance and secure relationship that they need for healing. I’m not one of them.

The sad fact is that the healing power of currently available treatments is vastly over-rated and a good example of false hope and the harm it can cause.

What’s wrong is that our treatments, in terms of demonstrated effectiveness, are all rather weak, and it shouldn’t be surprising; we do our best, but life, such as it is, is a bitchmonster from hell. You can’t undo the past, change personality, stop drug cravings, or even guarantee that you’ll be available next week.

Look where you’re going with this treatment and “mind the gap,” as they say on the London Underground, because, as ideal a healer as you seem right now, there are many ways this dynamic could get tripped up.

For example, unexpectedly, you and/or your treatment rub the patient the wrong way. It may be that you fail to live up to an impossibly high ideal or that you have a bad day and say the wrong thing. When that happens, trust disappears and with it, your patient’s rationale for healing.

You try to stay calm, remain empathetic, and ride out the storm while resenting having your personality dissected for an unpaid hour. If your anger shows, it gives your patient more reason to feel victimized and find a therapist who can help him recover from his latest trauma/treatment.

Another common outcome is the “Bill Murray Morass,” whereby he continues to feel strongly that treatment is beneficial and can’t imagine living without it, and you, and this continues for many years, while you continue to feel responsible and indispensable. “What About Bob?”, indeed.

You and “Bob” could argue that treatment has benefited his control over negative impulses, but it has also fostered a sense of dependency and fragility that will surface if, God forbid, you should die first, or, more likely, he just changes his mind.

So don’t buy into his idea of your precious relationship. If he liked you, it proves he has the capacity to like another therapist. There are many fish in the sea, many therapists in his insurance directory. If he depends on that positive feeling to stay sober or maintain a positive idea of the future, he’s in trouble, and so are you.

Your goal is for him to build up ideas for staying sober and fighting off despair that are not dependent on a single relationship or good feeling, and that can stand up to rejection and depression. In other words, you want to “be there” for your patient, but you don’t want to be the only thing between him and oblivion. Don’t beget a Bob.

STATEMENT:
Our relationship has been positive, but it’s important for you to manage negative beliefs, despair, and anger when you’re not feeling closely supported, and our stopping treatment gives you just such an opportunity. You have the capacity to form a positive relationship, so I’m confident you’ll do well in shopping around for a new therapist. Meanwhile, it’s good for you to focus more on the ideas than on the individual, because it’s your own ideas and the way you use them that will give you strength to manage yourself. I’m confident that this will work out well.”

I have a new patient who’s a young woman, college freshman, who was sent to therapy by her parents after her roommate turned her in for cutting her arms and drinking too much. After a fair amount of discussion, I started her on a medication trial and explained to her that these pills take a while to work (if they work at all), but it didn’t sink in, because after a week she’d had enough with feeling tired and hungry, especially because she still felt depressed and anxious. Not long after that, she declared that therapy in general was a waste of her time and she could stop drinking and self-mutilating on her own. Part of me thinks that it’s not my job, or anyone’s job, to sell her on treatment if she’s not ready, but I admit, there’s a softy side of me that doesn’t want to let her off the hook just so that she can really hurt herself or get kicked out of school. My goal is to get this kid to give treatment one more chance.

It’s tempting to tell a young woman with obvious problems that she should stay in treatment, but don’t. This is not the time to listen to your softer side. Of course you wish she would feel better and stay positive, but first, you and she must accept your lack of control.

If psychiatric treatment—medication or psychotherapy—were more reliable and effective, maybe it would be worthwhile to give such advice. More often than not, however, the first trial of treatment doesn’t work or causes side effects and patients who are already angry and disappointed about their life expectations are then quick to feel that their negative beliefs have been redeemed.

Your goal isn’t to get her to stay in treatment; it’s to give her tools to make rational and positive decisions about treatment. You don’t want her treatment decisions to depend on her positive relationship with you (see: above Bob) or an initial positive result. You want them to depend on her own ability to weigh risks and benefits and do what’s right.

It’s easier to help her think realistically about treatment if you crush false hope up front. You are obviously well aware that treatments of any kind rarely bring about a “cure.” I’m often reminded, when patients cite a pharmaceutical add touting a particular medication as “effective,” that the scientific meaning of the word is the opposite of its meaning in plain English.

In the language of science, effective means “better than nothing,” not “helpful most of the time.” Life is tough and so are most psychiatric problems. Unfortunately, so is your patient’s attitude.

Ultimately, you want her to know that, while you don’t care which decision she makes, you do care a great deal that you make she makes that decision rationally. Being soft won’t work, so be hard, or really, be honest, not emotional or sentimental.

STATEMENT:
Here’s a speech for encouraging her to take good care of herself and use treatment appropriately. “I wish I could tell you that treatment will ease your pain, but it often doesn’t. Given the fact that depressive feelings often come from genes and that we don’t have a cure, it’s not surprising that they tend to come and go and then return, even when a medication or other treatment has been very helpful. So the main goal of treatment isn’t to make you feel better, but to make you stronger and better able to tolerate your condition, much as if it were diabetes. You can get stronger by choosing the right psychotherapist or therapy or 12 step group and also appropriate friends and readings, because the right choice can make you stronger, and the wrong choice won’t. Medication is worth trying if your symptoms are hurting or threatening to get you canned. There’s a risk that each medication will cause side effects or won’t work, but you don’t want to make a choice about meds because you love or hate them. You want to weigh the risks of not taking them and the possible benefit of their working. If I were in your position, I’d definitely be trying them, but it’s your call.”