My friends tell me I’m too good to my ex-wife because I always take care of her when she’s in town by giving her a place to stay, feeding her, and tending to her medical needs. Even our kids say she uses everyone, promises everything, and gives back nothing, and, after many years of marriage and an equal number divorced, I know they’re right. I argue back that it’s not smart for me to antagonize her after she’s promised me half the estate she inherited from her dad, but they tell me that she never keeps her promises and she always figures out a way to blow her money on impressing new acquaintances and going on shopping sprees. My goal is to find ways to protect myself and maybe satisfy my friends’ concerns without fighting with my ex- and maybe losing her bequest.

God bless the giving people of the earth—kindergarten teachers, foster parents, 02% of psychiatrists—but I’ve said many times that, no matter how saintly their exterior, the givers’ biggest recipient of generosity is often their immediate feelings.

Let’s face it, giving feels good (partly because it offers peace of mind to the persistently guilty), and that means it’s bad, at least under some circumstances. Giving too much, like any source of good feelings, is dangerous to you and detrimental to the object of your charity.

When you experience the joy of giving, you may be ignoring other personal responsibilities. You may also be enslaving yourself to someone who senses your secret addiction and threatens you with guilt if you don’t do what s/he wants.

Admit it, you’re not taking care of your ex- for her inheritance—you’d probably kill yourself helping her without a cash reward—but now that it’s in the picture, it should be a strong motivator to help less, not more. After all, the big risk here is that you’ll feel bitter if/when she dies and leaves you nothing, either because there’s nothing left or she gave it to her new best friend. Now your bullshit excuse is bullshit in more ways than one.

Meanwhile, your current relationship with her makes her too important, interfering with your ability to find better friendships. Giving can make a compulsive giver very passive, like a waiter (or worse, a manservant).

The opposite of giving isn’t overindulging yourself or aggravating your ex; it’s giving sensibly while considering all your responsibilities. There’s nothing wrong with being kind to your ex, but there’s no need to give unless you think it’s necessary and can afford it, meaning that you’re mindful of your own needs as well.

Ask yourself whether there’s a big trade imbalance between your exports and imports with her. If, when she comes to visit, you think the relationship is unbalanced (meaning she doesn’t put in the time and attention you would expect from a friend), then it’s not good for you.

If your relationship is one-sided, offer a plan for balancing it. Tell her you believe your relationship will work better, in the long run, if you readjust what you and she contribute. She could do this by creating a trust fund to protect your bequest, or making some regular or hourly gift for your services. You’re not critical of her character or past actions, just trying to protect a valued relationship from being spoiled by a destructive imbalance.

If she tells you that she’s entitled to your services and that you’re the one who is ungrateful and un-giving, don’t argue. Simply express your belief in what you think is best for the two of you and insist on your right to agree to disagree.

Don’t throw your friends and other family under the bus to give everything to the one person who doesn’t deserve it. Generosity may give you a buzz, but the cost doesn’t justify any of the rewards, real or fabricated.

STATEMENT:
“I believe it will do nothing but good to equalize the give and take of my relationship with my ex-wife and that it does no good to let fear, guilt or worry about her feelings control what I do. If she refuses to accept what I believe is a reasonable proposal and blames me for destroying our relationship, I will bear the pain of her criticism knowing that we’re both better off putting the manservant into retirement.”

My brother drives me crazy in many ways, but nothing is more infuriating than when he decides to attempt to be generous. He remembers my birthdays and urges me to tell him what I’d like him to get me, but then he doesn’t get around to buying it until my birthday is long past, if at all. The problem is that he has money, I don’t, and if I ask him for something, it’s probably because I can’t afford it myself. Then again, if I really, really need it, I have to get it for myself somehow, which then offends him (and pisses me off). He tells me I’m overly sensitive and paranoid about delays he can’t really help. If I offer him reminders, he acts like I’m nagging him and moves even slower. He’s always been competitive—is he rubbing in his success or just totally oblivious? Should I just stop expecting things from him altogether and get some space?

Poverty and neediness have a way of inspiring resentment and injury. If someone denies you when you’re poor (particularly when you’re not used to being poor), it feels like a personal insult that you should have avoided and should never tolerate again. So it’s entirely possible to feel shafted and shat upon by someone who basically has more good to offer than bad and doesn’t mean to hurt you.

If your feelings take over, you may drive away your pain-in-the-ass brother (assuming he’s not a total jerk), leaving you poorer and madder. It’s like a poverty riot that burns down your own neighborhood.

So put aside your poor-guy feelings and do a business-like evaluation of what your brother has to offer, taking care to value the ways you can count on him (if any) and the things you enjoy about his company. Feeling insulted is not as important as what you think about his ability to be a good friend (sometimes) and to add meaning to your life, simply by being your brother.

While you’re at it, examine whether he does his bait-and-delay to other people. Poverty makes neglect feel personal, but he may be treating you the same way he treats everyone.

If he’s a jerk who usually takes more than he gives (see case above), then you’re right to pull away. It’s sad, but the best you can do.

If, however, he’s not all that bad, then learn to suck up the pain of being a downwardly mobile member of a lower economic class and make the best of your relationship. Not to please him or your family, but for yourself.

STATEMENT:
“I can’t help being poor and having a brother who’s late on delivering stuff I really need, but I won’t let a little pride and/or fury get in the way of a relationship that I value.”

I have a friend who has a history of being diagnosed with depression, self-mutilation and, recently, suicidal thoughts. She was forced to seek treatment with a counselor in HS (now 24-years-old) whom she said was no help, and now she says she won’t ever seek treatment again because it won’t help her. She acknowledges she has issues that need addressing, but she doesn’t believe in mental illness diagnoses, states she just needs to “deal” with it. However, all we talk about is how much she hates her life, hates feeling this way but isn’t willing to do anything about it. I’ve told her she’s an adult, and makes her own decisions and no one can force her to do anything, but I’ve been very honest with my concerns about her, and that she needs help. I don’t want to treat her with kid gloves or enable her but I also don’t know how much I can push her, since I know its her mental illness that’s clouding her view of the world/reality. How can I continue to be a good friend without beating my head into a wall and enabling her?

For many people, “help” and “cure” have become interchangeable words, as if good motivation and proper treatment will always make things better (tell that to the common cold).

Sadly, the help your friend needs, just like a cure for what ails her, may or may not exist, depending on her luck, the severity of her issues and whether she sees them as hers or just a reaction to other people.

Regardless of treatment, the normal course for severe problems like depression, eating disorder, and urges to hurt yourself are the same; off and on, for many years. There is certainly no cure, and very rarely can anyone provide the help to stop recurrence completely.

Don’t then assume that treatment would make your friend feel better if she were “willing to do something about it,” because, unfortunately, this might not be true. After all, she was willing to try something, and it simply failed to take.

Instead, find out what she knows about the various kinds of treatment available to her and what she thinks about their possible benefits and risks. If she lumps them all together as useless because the one didn’t work, you have good reason to warn her against the power of negative thinking when people are in pain and/or depressed.

If you can persuade her that depression-pumped negative thinking has clouded her judgment into fearing and avoiding options that are worth exploring, you’ve also provided her with some excellent cognitive therapy and shown her that she needs it—a beneficial trifecta. If not, you’ve shown yourself that she’s too negative to be logical, you’ve been as helpful as you can be, and you just can’t get penetrate her depressive pseudo-logic.

Never buy the idea, however, that you have to get better to get better. If she has, in actuality, exhausted all likely treatments and nevertheless keeps trying to work and be a good friend, respect what she’s doing, because that’s what beating an illness is all about.

It’s easy when treatment works, but the true heroes are the ones who keep on going when it doesn’t. If you’re there for her during that struggle, that’s the best kind of help there is.

STATEMENT:
“I hate to see my friend suffer and I’m worried that she could do herself serious harm, but I know that mental illness and negative thinking can brainwash good people and that help, from me or a professional, is not necessarily the answer. I will always insist that there is a hopeful way forward, but accept the fact that she may not agree and that argument is not helpful.”

I can’t stand the way I’ve become a disorganized idiot when I used to be incredibly good at juggling multiple responsibilities. I’m only 35-years-old and, while becoming a father has been stressful, it shouldn’t have destroyed my basic organizational abilities. Admittedly, I ‘ve been through a major depression or two, but I’m in a good mood now, I love my work, I’ve got a great wife, and my life isn’t a lot more complicated than it used to be. Nevertheless, I ruminate over tasks that go nowhere, get distracted before I get important things finished, forget my priorities and miss important meetings. I’m a mess, I’m an incompetent ditz, and I hate it. Medications haven’t helped so far, and neurological tests show nothing. There must be something that will give me back my competence.

If there was some way to restore your mojo, you probably would have found it by now, because you’ve had yourself evaluated and tested, and you’ve tried treatments and nothing has worked. In other words, here lies your mojo, may it rest in peace.

It’s sad, but I’ve seen this kind of acquired ditziness happen to people who’ve had a bad depression or two, as well as to people who’ve been concussed. Things may get better in the long run.

Meanwhile, a part of your brain has shut down, even though you feel normal in every other way and nothing shows up on an MRI. Only a voodoo doctor will notice the missing mojo, and your insurance won’t cover all the chicken blood that likely requires.

On the plus side, there’s lots you can do to help yourself if you stop trying to turn the clock back and substitute your old brain for the one you’ve now got. Yes, it’s humiliating, but so is a colonoscopy. Accept it, and you can keep yourself in the clear.

You can ask your wife and friends for help, take a course on organizational techniques, buy a to-do calendar book to write down priorities and create a schedule. You can also put alarms into your smartphone, and set up habits for checking your book, your messages, and your checkbook. Accept the need to learn simple, dumb-looking methods for doing things you used to accomplish intuitively, and you may be able to compensate 100% for your dysfunction.

Ambitious perfectionists fight this notion, because they want to control their lives in their heads. They get mad at themselves for losing control, then depressed, then more dysfunctional, and then more depressed. They also keep me from becoming unemployed.

Fighting your ambitious nature will not be easy, but remember, your goal isn’t to be who you were; it’s to be organized enough to make a living, run a family, and keep your life together, that’s all. The next step is to accept that what used to feel like “that’s all?” is now “that’s a lot.”

STATEMENT:
“I feel like a brain-damaged ex-whiz kid, but my real goals haven’t changed. If I can force myself to endure rehabilitation, and become competent enough to keep my major commitments, it will be the biggest achievement of my life so far.”

I need to find a doctor who will tell my daughter she needs to take her medication. She’s always had a problem with depression, and she did well in high school when she took antidepressants. Now, however, she’s 24 and very reactive to however she’s feeling, whether it’s not getting out of bed, or not working, or feeling dizzy and deciding it’s the medication and stopping it. My husband and I can’t get her to stick with anything, and she won’t listen to us in any case, so our goal is to get you, or some professional, to tell her what she needs to do.

Whenever parents want a doctor to tell their kid what to do, you can be pretty sure they’ve lost faith in themselves and overestimated the power of communication/a medical degree.

And no, it doesn’t matter how old the kid is or how many Harvard degrees the doctor has; the doctor doesn’t have more power than the parents, no matter how powerless the parents feel.

In your case, I don’t know whether your daughter can be induced to take her medication, but I do know that she’s not going to be persuaded by the authority of a doctor at the age of 24 if her own experience and your words haven’t done it by now.

The probable reason for her unresponsiveness, by the way, isn’t stubbornness or a lack of respect, but a lack of control over her own impulsivity (probably enhanced by depression). In other words, it’s not clear she can make herself take medication regularly, even if she sincerely believes she needs it. At some point, other impulses take over, like the impulse to stay in bed indefinitely.

Fortunately, even though persuasion is probably useless, you have other tools that a mere doctor can’t touch. You can access them if you believe you know what your daughter needs, regardless of what she has to say about it.

For instance, if you believe that she needs to get up early and follow a daily activity regimen, then let her know that’s what you’ll pay for. If she says she’s too blah, tell her you know it’s hard, but she needs to try, and that she might be able to do it if she puts together a schedule and asks friends to help her keep it.

If she argues that she can’t do it until she feels better, tell her that you don’t know when she’ll feel better, so she’d better start trying to keep busy now, and maybe that will help her feel better later. Your tone should say that you believe what you believe, and there’s no point in arguing.

If she tells you that you don’t know what she needs, tell her that you’re the mother and you have a good idea what she needs. Don’t ask a doctor to be the authority– get whatever information you need from the doctor, and then assume you’re the authority. At 4 or 24, your kid needs to hear the same thing; you’re the mommy, that’s why. End of discussion.

If your incentives don’t work, don’t blame her or yourself, because, again, you don’t know whether she’s too sick to have the control she needs. By putting a priority on self-control, however, you provide her with a blueprint for moving forward that is not reactive to negative feelings or thoughts or painful side-effects.

You’re urging her to embrace goals that arise from her values and that she can stick with, regardless of how she feels or how much she accomplishes. Knowing medicine isn’t as important as knowing your daughter and what’s best for her. If she won’t listen to me, you can, and I’m telling you you’re the most qualified professional for the task.

STATEMENT:
“I’d like to think my daughter could respond to persuasion from someone she respects, but I suspect it’s not true. I’ll push her towards doing as much as she can, regardless of how she feels, and hope that incentives for good habits will take over where persuasion has failed.”

I need an answer about what’s wrong with me, medically. I’ve always been healthy and athletic, right into my early 70s, and if there’s something I can do to improve my health, I’ll do it. Along with my husband, I ran a small company before I retired, and I’m good at getting things done. Lately, however, I’ve been having bowel problems and dizzy spells and fatigue that no one can explain, and I’ve gone to some terrific doctors. It’s gotten me down, and I haven’t been exercising or getting out as much as before. I need some answers about my medical problems so I can get going and get my old life back.

The weak side of being a great problem-solver is that it’s hard to change your expectations when you hit a wall, and old age is a wall. You’re accustomed to believing in the value of hard work, perseverance, intelligence and ingenuity. That’s a dangerous belief when their value happens to be zero.

What happens when hard work, and your belief in hard work, don’t work, is that you feel like a failure, try harder, and feel worse. You can’t undo the effects of aging, but you can always make them worse. I’m sure that isn’t a comfort, but it’s the truth.

Give yourself credit for getting yourself the best medical care, and then suck it up and admit that there’s nothing more you can do to get a diagnosis or find a cure. Cry if you must, but then figure out what comes next (besides death, which is everyone’s sad conclusion).

What comes next, once you give up on getting to the bottom of your medical problems, is using your good, well-developed discipline to get yourself going and re-claim as many of your old activities as possible. If being strong means achieving great results every day, then you may never be strong again. If you decide, however, that being strong means achieving all you can with limited equipment, then you’re about to become stronger than you’ve ever been.

Once you accept that there’s no curative treatment for aging or mortality, you can explore a wide range of treatments, including medication, that may improve your symptoms. Nobody lives forever, but there are plenty of ways to live a little better, and do what’s meaningful despite diminished capacity, at any age.

STATEMENT:
“It feels like a defeat to accept the limitations of age, but it’s actually a bigger defeat not to. Once I’ve completed a reasonable search for a definitive answer, I need to stop myself from searching further and re-order my priorities. I’ve got defective equipment and correcting the defect isn’t my department. I will do my best with the equipment I’ve got.”

Are there varying degrees of bipolar? My son is 21 and just diagnosed in Sept 2010. He is a student, a swimmer with his university and a likeable, good-looking guy. He is medicated (lithium and Zyprexa) and is doing pretty well. He complains about concentration issues. I just feel sometimes like I need to be reassured that this is manageable and that there are positive stories of other people with bipolar. I hope and pray that he will lead a fulfilling life, marry and have a family. We are all just trying to adapt to this diagnosis.

Not only are there varying degrees of “bipolar,” there are probably various kinds as well, but we don’t know enough about what’s going on biologically to say. Like the Supreme Court once said of obscenity, you know it when you see it, but it takes many forms.

Basically, the word “bipolar” doesn’t have a lot of meaning other than as a description of someone who had an over-the-top episode of wild, excited, high-risk, inappropriately-undressed behavior that then, most probably, was calmed down by lithium.

Since we don’t have a biological definition of bipolar, we’re forced to use the word to describe the unluckiest cases, the ones who have the most severe symptoms that last the longest and come back the most often, simply because they’re the ones that are easiest to categorize.

There are probably lots of mild or brief cases that don’t get included in the definition, so the diagnosis seems to imply severe symptoms and a difficult future, when, actually, there are probably lots of mild cases. So yes, you’re right, he may not have it as bad as people think when they hear the word “bipolar” (which is to say, he will probably doing a lot better than Charlie Sheen).

In addition, whatever causes bipolar illness often seems to make people particularly creative and gives them a gift for communicating. It’s common among writers and actors, like Stephen Fry and Carrie Fisher, who have described working and enjoying life despite the disease.

Don’t pin all your hopes on his having a mild form of the illness, however, because that kind of hope guarantees despair if he’s one of the unlucky ones. Hope for the best, but reserve a good portion of your hope for the way that he responds to the worst, if that’s what happens.

He’s a good guy who may not be able to return to university until his concentration returns, so focus on his ability to cope with the waiting and frustration. Don’t see him as someone who dropped out of college, but as someone who enrolled in the course of “crippling illness 101.” Since you’ll be his professor, here’s your syllabus.

Praise his ability to bear pain and humiliation and still make the most of each day. Remind him that recovery and a normal life, however desirable, are beyond human control, and that what you care most about is how hard he works to deal with adversity.

For homework, encourage him to take his meds, see his friends, swim, and do everything normal that his brain will let him do. Tell him he is certain to get a good grade as long as he pushes himself to do his best, regardless of the limitations imposed by his concentration issues, as long as he keeps his clothes on.

STATEMENT:
“As much as I want my son to live a normal life after his bipolar episode—and he may very well—I will avoid pinning my hopes on a result we can’t control. I will stay positive about the way he deals with his recovery, particularly on those days when his condition is worse but he continues to be himself and do his best.”

I need to understand why my 18-year-old daughter dropped out of college without letting us know that she never attended classes and then, when we found her a job, she started out well and then started leaving early so she could go home and play videogames. I can understand that she’s not ready for college and was ashamed to let us know that she didn’t want to go, but I can’t understand why she flaked out on a job she likes. My goal is to get her into therapy so she can figure out what’s wrong and get started on her life.

It’s possible that your daughter’s flake-out behavior is due to a treatable cause, like anxiety or unexpressed feelings about her family or herself, and, if that’s true, psychotherapy with a good listener may well help. Or it’s possible she just flaked out.

The trouble is that kids with nice thoughtful parents who are good listeners have often had a chance to express their feelings and still find themselves avoiding situations they need to face. In that case, sensitive-listening therapy may have little to add.

Be prepared then for the possibility that her avoidant behavior doesn’t improve with sensitive listening, whether from you or a therapist, and that she has a bad habit that, regardless of its cause, is hard to stop. If so, you’ve got trouble and it will take more than talk therapy to get her on track.

Most of the therapy will need to come from you, and it will consist of good incentives for her to keep busy and meet her commitments. The good news is that, the better you do it, the more you’ll save on therapy fees. The bad news is that it takes time and training, particularly at first.

Learn how to identify and monitor the behaviors that matter most, including meeting her work commitments and doing chores that a reasonable roommate would do. Then apply your incentives while keeping discussion to a non-emotional minimum.

You can’t let her wear you down, and you can’t take it personally. As we’ve said before, you’ve become the supervisor for a very mellow half-way house. Your job is to keep your parolee on track so she can re-enter society, bleeding hearts need not apply.

So your goal, as usual, isn’t for her to be happy (though you wish she was happily working); it’s for her to do what’s good for herself, which may make her fairly unhappy in the short run.

In the worst case, she may always be prone to ducking out under stress and then ducking out more because of her shame at ducking out. Once you accept the fact that your daughter has ducking-out syndrome, however, you can help her accept herself, overcome stigma, and make use of the tools you’re offering.

Along the way, encourage her to make use of similar tools and advice from other sources, including therapists. Just remember—and this is coming from a costly therapist—that she’ll get more out of therapy when she’s ready to use it to help manage her negative behavior than to understand the cause or relieve the pain she’s trying to avoid.

STATEMENT:
“I hope therapy can help my daughter get a grip on her avoidant behavior but, if not, I’m prepared to accept the fact that her self-discipline is poor and provide her with strong management and supervision. My hope is that acceptance and incentives will get her going and that eventually she will make it her own business to improve her shaky self-control.”

Please Note: In responding to suicidal goals, as in the case below, we do not presume to offer emotional support. If you’re at risk of hurting yourself, you should, of course, go to an emergency room, discuss your state of mind with a professional, and decide how much support you need in order to remain safe. In most of the cases we encounter, however, our correspondents are not simply suicidal; they are familiar with treatment and have come to believe that it won’t help. Often, we must agree that their feelings are unlikely to change in the near future. What we try to demonstrate, however, is that negative feelings create falsely negative and hopeless beliefs and that there are ways to recover your strength and perspective, even when the pain won’t let up.

I’m considering suicide. My life is a joke. I am in my late 30s and female and I have never had a relationship with a man. Several men have used me for sex and at least 2 of them begged me not to tell any of their friends they’d had sex with me. I’ve never been loved, been held, been listened to, been cherished. I’ve just been used like a toilet. On the outside I’m pretty. I can hold a conversation and I have a reasonable number of friends. But I hate myself and I don’t feel good enough. I was abandoned by both parents and I was raped for the first time when I was about 2-years-old. It’s like men I meet can smell the self-hate on me and they treat me accordingly. I do not have even one person in my life who cares about me or who I could trust. My friends are there to go for drinks or dinner with me if they can find nothing better to do but they are not there to be supportive ever, in any way. What is the point of me continuing to live?

It’s horrible to feel that you don’t belong to the human race, except for your ability to satisfy the needs and cravings of jerks.

Remember, however, that those feelings almost always beget more falsely negative beliefs, particularly about relationships. Whether or not you’ve done anything wrong, you feel infinitely rejectable, comfortable in the company of jerks, and anxious around people you respect, since you know they will reject you for your anxiety and fundamental worthlessness.

You distrust other people, but it’s your feelings and instincts that are far more suspect. In turn, you can’t trust your feelings to guide you in relationships (even more so than the rest of us).

If you do, you will seek out jerks and excoriate yourself after real or imagined rejection, and of course, life will appear meaningless and full of relationships that always end badly. Being needy strips away the friendship filters that would otherwise keep jerks away and it makes non-jerks look like jerks or, even worse, like people whose rejection would be devastating.

For instance, after starting to trust a potential friend, you might be so hurt after noticing that she was slow to answer your calls, even if that dearth of calls was due to a busy work week or broken phone, that you would feel you could never trust her again and would feel like hurting yourself. It’s hard to make real friends when your own sensitivity is such an enemy.

Don’t give up, because there are other ways to build a more rational, positive set of beliefs that can protect you from dark feelings, even if they can’t ease the pain. They don’t require you to risk a relationship; all you need do is assess your own response to the hardships of your life, using reasonable criteria for judging your effort and the difficulty of your accomplishment.

If, while bearing the scars of neglect and abuse, you’ve picked up skills, earned a living, and treated people decently, you’ve accomplished something you have good reason to admire. Forget whether anyone else knows, understands, or respects what you’ve done. Then forget the fact that you continue to hurt like hell, (when you’re not feeling numb). You know what you know, and it’s your opinion that matters most.

If only therapy could help you make better choices and avoid negative distortions, or at least give you a sense of being respected and valued; but it often doesn’t work that way. Instead, relationships with therapists often fall victim to the same false beliefs that ruin potential friendships.

Because of your age, I’m assuming you’ve tried therapy and it hasn’t worked. You aren’t alone in having that experience, but it is possible to see beyond it. Don’t be surprised if a relationship- or emotion-focused therapy or support group hasn’t helped. Don’t give up hope, because there are other approaches that can help you grow stronger.

DBT (dialectic behavioral therapy) is a kind of cognitive-behavior therapy that can help you maintain your perspective and fight negative thoughts and actions. It’s taught as a course, and discourages participants from sharing strong feelings or engaging in intense relationships. As such, it doesn’t offer relief from loneliness, but it does provide ideas and mental exercises to root your self-worth in your own values and actions and thus protect your beliefs from distortions caused by fear, sensitivity, and loneliness.

When emptiness consumes you, it’s almost impossible not to feel like a disposable loser. If, however, you can make an honest assessment of your accomplishments, and acknowledge that there has also been triumph and survival despite tragedy, you will get stronger and find reasons to live and respect yourself.

If you review the things that you’ve done without the approval or involvement of others, jerks and not, you’ll see that you’re not just a member of the human race, but an exceptional one.

STATEMENT:
“I’ve never found a friend and often feel that life has no meaning; but abuse left me determined to be independent, treat people with respect, and be a good person, and I value what I’ve accomplished, regardless of self-hate or loneliness. I will build self-respect on my own actions, and hope that someday I will have the strength and luck to find a friend.”

My mother only has one sibling, but I’ve never met my uncle because he’s had severe agoraphobia for the past 30 years. My mother says that it started right before he graduated high school (he stopped talking to his friends, stayed in his room more, washed his hands compulsively, etc.), and it’s been going on since then. The only person he regularly communicates with is my grandmother, who also supports him, and while he sometimes talks to my mother, he doesn’t let her see him, and, like I said, I’ve never met him because if I’m in the house he won’t talk to anyone or leave his room (this is how he treats anyone who isn’t my mother or grandmother). My mother says that my uncle’s too macho to admit he has a problem, and “too Italian” to ever leave his mother’s house. I guess my problem is that my grandmother isn’t in the best health, and I know that nobody else in the family has the resources to take care of my uncle when she’s gone. Plus, I mean, he’s sick, so my goal is to get my uncle some help.

If almost every chronic illness is a test of character, agoraphobia is one of the most challenging. The fear goes far beyond anything you’ve experienced; think of it as a migraine headache where, instead of pain, you’re flooded with fear and the only relief is to hide out.

Yes, there are treatments that can dull the fear and help people recover their lives, but they take effort, they’re not a cure, and, somewhere along the line, they require people to leave their caves and endure some additional anxiety. It’s no wonder many people with severe agoraphobia will accept tranquilizers or use alcohol, but will not stick with any other kind of treatment, particularly if they have to leave home to get it.

So don’t blame your grandma or your uncle or put responsibility on anyone, including yourself, to get help. That bird has flown, leaving much pain and helplessness behind. Respect your grandma for carrying an extra load and your mother for bearing the sorrow of losing her brother.

Now that you’ve given up on helping your uncle directly, however, consider an alternative. Ask yourself whether he would accept behavioral treatment if he had no place to stay. Consult with experts and find out what would be available to him if he were flushed out of his hideout.

Obviously, eviction would make him more anxious in the short run, and might make your grandmother and mother guilty and anxious as well. If you believe there’s a positive alternative, however, encourage them to consider offering it to him. Urge them to trust their idea of what would benefit him in the long run and to ignore their gut response to seeing him in pain.

If they’re ready to push him out, good for him. If not, your mother will encounter this option further down the line, after your grandmother dies and the family can no longer afford to keep her house/his prison.

You’re right to fear for your uncle’s health and your family’s future, but as long as fear imprisons your uncle, you are all, to some degree, stuck.

STATEMENT:
“I’m sorry my uncle has a painful mental illness and I don’t want to add to his pain, but his current dependence on the family can’t last forever and he might do more for himself if he had less support and more encouragement to man up and get treatment. There are 2 generations ahead of me with responsibility for his care; but if, after learning more, I think they’re overprotecting him, I’ll let them know I respect them for caring for him, I’m concerned about what will become of him when grandma is dead, and I have a plan that might allow him to get stronger, regardless of his fears or urges to disappear.”

I don’t consider myself a lazy person—I take care of the kids and sell some of my paintings—but my husband isn’t crazy about selling cars and would really like to stay home and take care of the kids himself, so he’s always making remarks about having to carry the harder load and asking me if I could find a way to make more money. I’ve tried to find better-paying work, but I’m dyslexic, and what I’m doing is probably about as good as it gets, given my skills and the flexibility I need for the kids. Anyway, he’s been nastier lately because car sales are down and it’s getting to me. My goal is to get him to stop putting me down.

You can’t stop someone from putting you down—haters gotta hate, as the kids say, even if the hater is your husband, and most husbands are haters, at one time or another.

On the other hand, just because someone you love is trying to put you down doesn’t mean you have to take their criticism to heart and sink, doomed unless you can get them to take it back and promise never to do it again.

There are usually two obstacles to staying buoyant. The first is the emotional impact of being put down, which causes you to act like a slacker or a jerk, which loses you your self-respect and makes it impossible to stand up for yourself to yourself. When you don’t even have your own back, you’re in trouble.

The other problem is that, as with most people, the pain of a partnership besieged by too little money and too much childcare has its own illogical power to make you feel like a failure, even when you’ve done nothing wrong and everything right. To further paraphrase the kids (in a dated way)—no money, most problems.

You assume that, if you were successful, you’d be happy and your spouse would be happy with you, which is bullshit, of course, but that’s what happens when you use happiness as your rating system.

One good thing you’re telling me is that you haven’t let feelings of failure or anger slow you down—you take care of the kids and do your work, regardless—so now all you need to do is get used to the idea that successful parents often feel unhappy and get no respect from their spouses. See: Homer, Marge, Hillary, etc.

Forget about happiness and your husband, and judge yourself the same way you would judge a friend, by whether you’re doing a good enough job with what you’ve got. Don’t hold yourself responsible for doing things that your brain isn’t equipped to do.

Remember the dyslexia—you can’t cure it and there are certain jobs it won’t let you do. Don’t pay too much attention to the outcome, which you don’t control, but to the process, which you do.

Finally, give yourself a bonus. Assuming you’re doing a reasonable job as a partner, you should also pat yourself on the back for carrying another burden: putting up with your husband’s complaints. You deserve, as the kids say, mad props for staying afloat.

STATEMENT:
“I know you feel you bear an unfair load in this family, particularly when we’re short of cash, but I’m proud of what I do, and I think you’re doing a good job, and the only thing that’s isn’t so hot is your focusing on what I can do better when I’ve already told you I’ve considered your advice and disagree with it and don’t expect us to agree. So I think I’m doing both of us a favor by insisting that we respect ourselves for the work we’re doing and let the other matter drop.”

I know I always feel super-responsible for my brothers and sisters, maybe because our parents died when we were young, but we’re all pretty close and, and, at the same time, independent, except for one sister with Downs Syndrome who lives in a group home. I’ve never minded bringing her to stay with me for the weekends, but lately she’s becoming demented and it’s getting me down, because she’s irritable and sleepy and it’s hard to get her to participate in things and I hate feeling angry at her. My goal is to find the patience to take good care of her.

The more you love someone who is now dementing, (which happens early and rapidly with people with Downs Syndrome), the more impossible it is to feel kind, gentle, supportive, and, in the end, like you’ve ever done a good enough job.

For one thing, the more demented they get, the more they complain, show their unhappiness, and expect you do take care of them, even if, when they were strong and in possession of their strength, they encouraged you to live your own life.

To whatever degree your nurturing instincts drive you nuts until you can make the crying baby stop crying, you’ll feel terrible, and that’s on top of the terrible you feel for watching a loved one decline. It’s an emotional car crash.

For another thing, few people are comfortable with how irritated they get or how well they control their irritation; you can understand how elder abuse can take place. Most of us don’t abuse our elderly relatives, or come close, but we can’t keep our irritation totally hidden and the guilt is hard to bear.

The biggest danger is that, between your guilt and inability to ever feel you’ve given enough, you keep giving, more and more, until you’re drained dry and not taking care of yourself and your other family members are criticizing you for being a grump whenever you see them, if you ever do. That’s the point when people are often referred for treatment.

The answer, as usual, is to ignore your feelings and rate yourself reasonably. In this case, reasonably means helping your sister to the degree that helping her really has a positive impact, while keeping in mind your other obligations, both to yourself and others.

Forget about whether you can make your sister happy or whether you need to prove your love by knocking yourself out. Given her circumstances and your own, the best outcome isn’t good. If you can achieve mediocre results, however, while doing things the way they ought to be done, you’re in the running for brother of the year.

STATEMENT:
It’s hard to feel like I’ve honored my love for my sister, and taken good care of her, when she’s never happy and so often irritating; but I see to her safety and I make her happy when I can and, to do so when the process is painful and thankless is an achievement to be proud of.

I decided recently to listen to my friends and family and see a psychiatrist about my depression, but I don’t know whether I’ve made the wrong decision, or whether I’ve just chosen the wrong doctor. Basically, I decided to get help because I feel helpless, but my doctor wants me to do a lot of the work myself and doesn’t really help that much. It’s not just he wants me to ask myself a lot of questions (and answer them—if I had the answers, would I really be paying him?—but also deal with my insurance company and read up on the medication he suggests (he tells me about them, sure, but he says I owe it to myself to read up on them on my own, and that doesn’t make sense to me since he’s a doctor, knows everything about the pills, and he could just tell me himself). My goal is to figure out whether therapy is worth it, or whether I’m just getting help from the wrong source.

I hate to sound like your psychiatrist, but ask yourself what you have a right to expect from treatment, given what you know about its limits and your resources for paying for it.

If you want, you can spin things positively by saying that you’ve heard about good new treatments that can really help and that you’ve got great insurance that you pay a ton of money for. Of course, you’d probably be full of shit.

You don’t need to do months of research to know that no treatment has yet been acclaimed as a cure for mental illness or any other life- or personality-related problem.

Plus nothing you’ve read (or probably haven’t bothered to read) about the effectiveness of any current treatment implies that it works 100 percent of the time or that the treatment, if medical, is safe from possible side effects.

In addition, every method of “screening” for depression that you’ve heard about involves a questionnaire, right, rather than a blood test or scanning machine, which means that the burden for enduring, measuring and tracking the results of a trial of treatment falls, inevitably, on you the patient. And those are unfortunate facts of life whether you’re rich or poor, smart or stupid, board certified or not.

That’s the next problem: you’re not rich. And while you bristle at having to deal with insurance limits, you can’t afford insurance that would give you unlimited mental health treatment because it doesn’t exist. All insurance puts a limit of some kind on the amount of treatment you get and, unless you know what that limit is, you’ll use up your resources too quickly and have no idea about what, if anything, entitles you to more.

In addition, insurance limits your doctor’s fees and the amount of time s/he can afford to spend on a visit, so don’t fall for the professional who is ultra-amiable until your money runs out. Instead, look for someone who gives you what you most need in as little time as possible. In other words, beware smiles and frills because they may drain your limited resources.

Depressed people like yourself also tend to get negative and helpless ideas, which make them act negatively and passively, which makes them yet more depressed. That’s why mental health clinicians will push you to challenge your negative assumptions, learn more positive ways of thinking about your problems, and put the breaks on the depressive cycle.

It’s a cognitive kind of psychotherapy and is very helpful, although it’s often unpleasant in the beginning because you need to clamp down on your natural instincts. It’s a mental workout to make your non-depressive muscles stronger. No pain, no gain.

So yes, therapy of all kinds can be worth it, but you’ll be the one doing much of the work, not because someone else is slacking, but because mental illness sucks and both treatment and the resources to pay for it require careful management—by you.

Now you just have to decide what’s harder—doing the work or doing nothing. It might not be what you want to hear, but there’s no psychiatrist out there with a better offer.

STATEMENT:
Here’s a statement to keep you positive about a negative treatment process. “It’s hard having an incurable illness and knowing that the treatments are iffy, take a long time, and can easily use up my insurance before helping me, but I owe it to myself to give every reasonable treatment a try and become and good resource manager because that’s what I have to do.”

I’ve been in therapy for five years, and while I like my therapist a lot, I’m moving soon (my girlfriend got into grad school on the west coast), so I’m ending my treatment with her. She asked me recently though whether I was going to continue my treatment in my new town or whether I thought I’d taken it far enough, and I realized I honestly don’t know. She had some suggestions in terms of determining when and why to end therapy, but to be honest, they didn’t really help. I’ve been in therapy long enough that I don’t really remember how I coped beforehand, and while I feel much less tormented than I did when I began therapy, I’m not sure if my state of mind will crumble once I’m no longer getting help. How do you think one can determine when therapy has run its course, or whether there’s more to be done?

There’s a simple way to figure out how much talking psychotherapy you need: imagine paying full fee for it.

Before you crunch the numbers, ask yourself why you started therapy in the first place. Forget self-improvement, introspection, or generally pondering your bellybutton. Figure out what’s so bad about the way you feel and/or handle your life that you need to continue to spend lots of time and money on changing it.

Having failed to solve your problems over the past 5 years, you should wonder whether you can realistically expect a cure in the next year (no way) or whether you need maintenance treatment to keep you from slipping backwards (which is what you’ve been wondering all along).

At the same time, go back to the original question and ask yourself how much you can afford to spend on treatment each year and whether you should hold a few sessions in reserve for use in emergencies.

Unless you’re rich, don’t waste time worrying about how stopping treatment will make you feel. Instead, try stopping and see what happens. Even if you miss your therapist’s support, lose confidence, and re-experience your nervous stammer, suck it up, give it time, and the earth will continue to turn.

Next, think of therapy as a course that’s supposed to give you a specific marketable skill in exchange for your hard-earned debt. Don’t think like a college kid; you’re not there to party, please your parents, or become cool. If the first few sessions don’t deliver what you need, drop the class.

If you do have ample insurance coverage for therapy, don’t let it make you forget basic resource management skills. For one thing, many insurance policies are stiffening the limits on outpatient psychotherapies and are about to force you to do the above.

For another, being an active manager protects you from unnecessary dependence and time-wasting. Give your therapy specific goals, then examine how close to those goals you’ve come.

If therapy is more about discussion, then save the insurance hassle and start a search for a fun hairdresser. You can get your hour of talk and never have a bad hair day.

STATEMENT:
Here’s a statement that keeps you focused on making the best of limited resources instead of going for all-you-can-eat and then feeling deprived and abandoned. “I like psychotherapy and feel it’s been good for me, but it’s time, before it eats up more time and/or money, to think hard about how badly I need it, how well it’s working, how much is necessary, and how much I can afford to pay for it. The more I answer these questions for myself, the less likely I am to depend on experts to tell me what I need.”

I recently started going to a doctor for my depression. She thinks I should take pills, I’ve seen lots of articles about how antidepressants don’t work and the main reason they’re prescribed is because of the huge investment that big pharmaceutical companies have made in producing and marketing them. It makes sense to me that there are better natural, holistic solutions that get played down by the medical establishment because they can’t make money for anyone and threaten the profits made by those companies. My goal is to find treatments that work best, not the treatments that server the corporate interests.

The problem with most criticism of current drug treatments is its hopefulness; it implies that there are good, effective, cheap and low-side-effect treatments for depression (that are being suppressed). If only principal clause of that statement were true.

Sure, a magic bullet, holistic or otherwise, would be great (there are lots of other unsolved and incurable problems I can work on, so I’m not worried by the hit my business will take).

The truth is, however, that current treatments are time-consuming, weak, often costly, sometimes risky, and not guaranteed to work

Please resist the temptation to change the subject to tell me why current treatments are costly and often ineffective. You’re entitled to be angry about that sad fact, as about any other of the tragic, unfair and irritating facts of life, like tailgaters, the fact they cancelled “Firefly,” and almost anything having to do with hospitals and health insurance.

As much as I agree with you, I don’t want to hear it; you’ve got a job to do, and anger is a distracting escape from facing what you need to deal with if you’re going to manage treatment decisions for depressive illness. Instead of getting mad at your hand, play the cards you’re dealt.

Your treatment choices for depression aren’t that complicated…once you accept the fact that there’s no way to tell in advance which treatments are going to work or what side effects you’ll encounter. If you’re not in a hurry (i.e., if your depression isn’t about to push you out a window or immediately end your relationship with wife and family), you begin with non-medical treatments, like cognitive behavioral therapy, exercise, and diet and life-style changes.

If the symptoms are severe or longstanding or coming back after previous bouts, then you also experiment with antidepressant medications. This isn’t because Pfizer decrees it so, but because non-medical treatments are unlikely to perform miracles and an antidepressant medication improves your chance of recovery, even though it also has possible side effects.

If you want to try holistic remedies first, by all means, go ahead, but approach those treatments with the same care you would conventional ones; do your research to see what the data show in terms of results and what the side effects might be. Most data are inconclusive, but if you believe the treatment is working, then take that placebo to the bank.

Either way, you know the major principle of risk management: the more desperate your condition, the greater risk (pain, side-effects, cost, etc.) you should be prepared to bear in your effort to manage it. Draw on your own experience of your symptoms, their severity, and their impact on your life, as well as what the experts tell you about them, to decide how desperate you are.

It’s not a big pharma conspiracy against your health; your options just aren’t that great, and you have to figure out which one will work out, if not perfectly, then best.

STATEMENT:
Include your doubts about medication in a statement that focuses on management, not resentment or silly hopes for hidden cures stashed away in a cave with Sasquatch. “If I ever decide to use medication, it will be because I’m desperate and other methods haven’t worked. At that point, I’ll try to figure out their benefits and risks by looking at scientific, controlled studies, not emotional statements based on single cases or uncontrolled, badly selected patient populations. I will consult specialists and authorities to explain why they place faith in particular data or don’t like someone else’s data; but I will then make up my own mind, shutting out my emotional response to charisma or sincerity or a desire to include everyone’s opinion. When it comes to decisions about my health, I deserve a good, objective risk manager—me.”

I know the tranquilizer I take is addictive and interferes with my memory, but it’s the only thing that works when I get really anxious, and the other drugs I’ve been given for anxiety made me sick and didn’t work. I’m anxious because I’m stressed by some unusual recent events, which I’m sure I’ll get over in time, and then I won’t need to take medication. So my goal is to get the medication that works for me and avoid the stuff I know is going to make me sick.

It’s wonderful to get relief from severe anxiety, which is a terribly painful and frightening sensation. So I hate to make you more anxious by telling you that, unfortunately, there’s no good, safe medication that provides rapid relief.

The medications that provide rapid relief pose high risks of addiction and impair memory and balance, and the medications that are safer don’t provide rapid relief. That’s not very reassuring, but if you don’t cowboy up and face that fact, you’re in for trouble.

Remember, anxiety isn’t the worst thing that can happen. Much worse is what anxiety can make you do, like avoiding whatever stirs it up, medicating with alcohol, and making it your goal to feel less anxious. Given these dangers, your real goal is to do what you can to reduce anxiety while not letting it change what matters to you.

Don’t stop trying alternatives to addictive drugs because previous trials failed—that’s anxiety whispering its lies. It tries to tell you that everything that caused you pain in the past should be avoided now and in the future.

If you find yourself listening to that shit, you desperately need some cognitive therapy to help you straighten out your thinking. You can get it from books or a therapist or hanging out with anxious people who have learned how to manage their fears. There isn’t an actual Anxiety Anonymous, but there are groups like it.

If you stay with your current plan, you’ll not only lead a restrictive life, but you’ll tend to choose immediate relief over long-term advantages, whether it’s in treatment, jobs, or relationships. At that point, your anxiety is managing you, and that’s a real cause for worry.

STATEMENT:
Here’s a statement to keep you strong. “I need to develop new methods for dealing with anxiety because, as much as I wish it weren’t true, anxiety will always come back, eventually, and the tranquilizers that give me great relief in the short run will cause problems if I take them for too long. There are lots of non-medical techniques I should learn; and, if they aren’t sufficient, there are lots of non-addictive medications I should try that have a very low risk of causing serious harm. I need the courage to do what makes most sense to me, not what my anxiety would prefer.

I’ve been getting increasingly nervous about my aging parents, particularly because my mother, who’s a very vigorous near-90, likes to ignore the real risks of continuing to vacation in their old, 2 story, roughing-it country home. She loves to garden, take vigorous walks, build fires, and keep to the same routine she had when she was 40. I know I’m a nervous person—I’m a nurse, and I’ve had to deal with an injured leg since childhood—but I’m haunted about what could happen to her if she fell down and it’s no place for my dad, who’s very frail after a stroke. When I said something to her yesterday about how she should hold onto my father’s arm when he walks, she told me to mind my own business. I’m the only one of the kids who lives nearby, so their safety is my business. How do I get her to understand she needs to be more careful?

It’s understandable that you worry about your parents, but even if they were both freakishly healthy and lived in a hermetically sealed bubble, the sad fact is, they’re both going to die.

[Moment to process.]

Yes, your aging parents are lucky to have a caring child nearby, particularly someone who’s medically educated, as you are. You also know, however, as someone who’s lived with a crippled leg, how necessary it is to take risks if you want to live a full life and how important it is to make those risk-management decisions yourself.

Your goal isn’t to breathe easy, knowing that your parents are safe as can be, or make yourself responsible for their safety. As much as you’d like them to be safe, they can’t be, so those goals would drive you and them crazy (and provide me with a steady income).

Now that you know you can’t make them safe or ease your own fears, you’re ready to think creatively about realistic risk management, knowing that bad things (like death, but lesser things, too) will happen.

Your goal isn’t to prevent those bad things from happening, but to help your parents do whatever they’re willing to do to prevent them, then forget about them, and live their lives (and let you live yours).

Instead of nagging them to be more careful, offer to get them professional advice on how to manage risks from slips, falls, fainting spells, medication mistakes, and assorted worst-case scenarios.

If that doesn’t work, leave their doctor a message encouraging him/her to do the same and if that doesn’t work, take a course yourself and do what you can. Then, you’re finished and enjoy the veggies from the garden.

STATEMENT:
Here’s a statement for keeping your responsibilities in check. “As much as it would hurt to see my parents injured and as much as it scares me to think about it, I respect their determination to live independently as long as possible, despite the risks. I can do more for them by offering good advice than by inducing guilt. I will take pride in doing this job well, regardless of whether they accept my advice. Indeed, the less I can do and the more helpless I feel, the more pride I’ll take in not letting my management interfere with their choices.”

Two years ago, my wife was diagnosed with Type 2 diabetes. We’re both overweight, but she also used to be a smoker, so her health’s always been more of an issue than mine. We were both warned that if we didn’t get better eating and exercise habits, we’d be in trouble, and now she knows her diabetes puts her at much higher risk of heart disease, hypertension, infections, and kidney disease. Well, two years later, and I’ve started taking the dogs on long walks, stopped eating from the vending machine at work, and lost some weight. My wife, on the other hand, hasn’t really changed her habits at all. She says she’s eating less crap at work, but at night she’s making the same unhealthy (delicious) stuff we’ve always eaten, and she always says she’s too tired to walk with me. I don’t know what I can do aside from nagging her, and that’s not working, so I’m really worried that she’s going to go downhill fast and that I’ll lose her. My goal is to get save my wife from herself.

As much as you’d like to keep your wife around as long as possible, you know that your influence over her health habits is limited, and trying to control her health will cause you more conflict and probably drive both of you to an earlier grave…which contradicts your purpose.

Unlike the concerned daughter above, you don’t have the luxury of ignoring the inevitable; she can’t make her parents immortal, but theoretically, you can help your wife to change her habits. If you’ve ever tried to change any of your own habits, however, you know it’s never really that easy.

Weight control, for example, should be easy because putting food in your mouth and swallowing are supposedly voluntary actions. In reality, people don’t have that much control over their habits or their health. Ask anyone who’s eaten at Cinnabon.

It takes great effort, not everyone can do it, and other legitimate priorities, like raising kids and making a living, get in the way. Biology is powerful, and our bodies are designed to survive famine, not taste-bud seduction.

Accept that she has a chronic, incurable illness and you’ll start to be more helpful. Instead of nagging, offer advice on impulse management and eating better (but don’t force that advice, because then you’re back to square one).

If that doesn’t work, ask her doctor to do the same, and if that doesn’t work, learn CPR, read up on living with a diabetic, and enjoy your time together. After all, you don’t want to ruin the quality of your relationship for the sake of a little more quantity.

STATEMENT:
Here’s a nagging-restraint statement. “It’s hard to watch my wife’s unhealthy habits, but I’ll do more for her by keeping my feelings to myself, offering advice if she wants it, and enjoying her while I’ve got her. A good marriage always requires tolerating the pain of traits you can’t change, and this is more of the same.”

My psychiatrist thinks I should increase my medication, but it already makes me sleepy and has caused me to gain 10 lbs. If anything, I’d really feel better getting off it entirely, because I hate being dependent on it. For the time being, I know I need it, because I’ve barely recovered from my last depression, but even thinking about increasing the dose makes me feel depressed. I’ve seen this doctor throughout my entire illness and she’s been very good with me up to this point, but now that I don’t agree with her I don’t know what to do. I don’t want to have to take more medication.

It’s much easier to have an agreeable disagreement if you’re not pushing someone with your emotions; after all, lawyers use evidence, not tantrums, to win a case.

Still, it’s hard not to push with your emotions when the issue is personal and scary. Unfortunately, you don’t have a choice.

If you don’t put your emotions, you’ll sound (even to yourself) like a kid who hates needles. Your doctor will then feel like you need protection against your fears and impulses, and so will become even more insistent and condescending (and afraid of a liability lawsuit when your fear turns to anger).

That attitude will make you feel more like a helpless kid who isn’t being heard, and long story short, it’s a vicious circle we’re all familiar with, and it requires you to shift approaches, not give in.

Besides, if you’re pushing someone with your emotions, you’ve got to wonder whether you’ve conned yourself into doing what you want, rather than what’s best for you.

Switch your language (and maybe your way of thinking), list risks and benefits, and prepare a list of the questions you need answered to make a good decision. Put your feelings aside, put facts first.

No one likes medication, but it’s your job to know enough about the possible course of your long-term, incurable mental illness to judge whether the beneficial promise of a given medication outweighs its costs and sluggish, chubby side effects.

Becoming educated about your illness and its treatment is the only way to avoid being a medical victim who feels helplessly reliant on a doctor’s judgment.

If you want to have a discussion with your doctor that doesn’t sound like you’re trying to escape the ouch of your camp shots, learn what your odds are for relapsing and whether resuming meds at the beginning of a relapse can be counted on to stop your symptoms before they damage your life and/or your brain. Also, find out what the chances are that a higher dose will make a positive difference in the short or long run.

Don’t forget to ask what evidence the doctor is drawing on for his answers. Then you’re prepared to announce your verdict as a responsible adult.

STATEMENT:
Here’s a formula for a worst case, high risk disagreement. It alludes to your fears but sticks with a managerial point of view. “I know that rejecting your recommendation carries a 10 percent higher chance of relapse, that there’s no guarantee that we can stop a relapse once it’s started, and that relapse can cause a little brain damage. But I’ve weighed these odds against the risk and side-effects of the medication and my own conviction that I’m less vulnerable to relapse now and I’ve chosen to keep the dose where it is and wean off in the not-too-distant future.”

Admittedly, I’m a neurotic, depressive guy—I’m a New Yorker, I’m normal here—but when I had a shitstorm a year ago when my girlfriend left me and my job changed/became horrible, I started going to a therapist. It was helpful to rant and get some perspective, but now I really think I’ve come through the other side of the situation and don’t need therapy anymore. My therapist, on the other hand, thinks I still have a lot of work to do, because we never really talked about my relationship with my father (not great) or why I had trouble with my ex-girlfriend. Thing is, I don’t really think my dad has anything to do with anything, and I know what my problem is with my ex-: I chose badly. How do I convince my therapist I’m ready to leave and that there’s nowhere deeper to dig?

There are always therapists out there who, when it comes to accepting the fact that people are the way they are and treatment is a limited tool, need more therapy than their patients do.

What your therapist may have trouble facing—more so than you—is that your treatment has produced all the change and relief that it’s going to, despite the fact that you still have pain and other problems.

Many therapists can’t accept imperfect results. They feel they’ve failed if they can’t help you and, so as long as you’re suffering, they’ll look for a deeper level of change.

If they could bring themselves to accept you the way you are and let go, they could also become more creative about teaching you methods for minimizing the harm your behavior can cause. Obviously, this is not the case here.

So prepare for your decision by gathering data about whether or not it’s really time to stop. See your therapist less often, or take a designated break, and see what happens.

If you slip back into that shitstorm feeling, your goal is to figure out what the treatment was doing to help you, whether you can get that help for free from any other source and, if not, how often you need to see your therapist to sustain the benefit.

If, after running that test, you decide to stop treatment but don’t want to get drawn into a fight with your therapist in which you sound like you’re trying to avoid your homework and your therapist sounds like a concerned adult, there are 2 options.

You can lie, and tell your therapist you’re feeling better and last night you had a dream about a happy bird flying high above the clouds and missing its nest down below but confidently soaring towards the mountains in the distance where your dad and ex-girlfriends were waiting to give you a hug.

Or.

You can be straightforward and truthful, telling your therapist exactly what you told me, backed by the results of your experiments with withdrawal, and stick to it.

After all, you’re an adult who can make your own decisions, and your therapist will have to accept your decision. And if s/he can’t seem to cope, s/he’s the one who needs time on the couch.

STATEMENT:
“I know I’ve still got problems but I think I’ve got what I’m going to get from this treatment and I’m managing things well enough. I wish I were less grouchy but I don’t think that’s going to happen and, meanwhile, it’s not doing me any harm. I’ll always look for new ideas about how to manage my problems but, for now, I don’t think I need more psychotherapy.”