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 hate life. What is the most reliable and painless way to commit suicide?

You hate life, and I hate the kind of dangerous, self-lacerating whining that makes a painful life seem meaningless, when it isn’t.

Hating life is an understandable feeling, whether the problem is a hateful life or your own, reflexive intolerance of life’s general hatefulness. There’s no doubt that life is sometimes hateful, some people’s lives are more hateful than most, and some good people are more sensitive to its hatefulness.

There’s more than enough hate to go around, and you can’t help how you feel.

Any time you let hateful feelings shape your goals, however, you’ll make life more hateful (after a brief burst of genuine satisfaction) and destroy what’s left of your self-esteem.

Yes, taking your hate out on yourself may give you the satisfaction of protesting life’s unfairness and heaping guilt and contempt on your so-called friends. What it also does, if you think about it or survive to see what happens next, is define your life as a reaction to your hurts and the people you value least. It both fuels and destroys, hateful little fucker that it is.

What you really want (and what your survivors will try to do) is to remember the times you did better things and followed your own values. It’s not as exhilarating as being a nihilist, but exhilaration is, by its nature, short-lived. You shouldn’t be.

During its short run, hate is a lot more attractive and satisfying than reminding yourself about what you stand for and thinking about values and consequences. That’s why you need to work on building a philosophy and preparing for hate before it arrives, instead of boarding the hate train and then finding the will to get off.

You can do that by going to the right church or temple (one that doesn’t waste too much time on holy this or ecstatic that), hanging out or reading about people who’ve made the same journey, or getting the right kind of therapy. DBT (dialectic behavioral therapy), which borrows heavily from Jewish, Christian, Buddhist and 12-step ideas about living with anger, can be particularly helpful.

Therapy or no, you can find ways to keep your hate (and my hate for your hate) under control.

STATEMENT:
Here’s a statement for taking pride in good hate management. “I know what it’s like to hate life, but I won’t let myself forget what I value about life and my own ability to make it better. I can’t escape hate; but I will make myself strong enough to protect myself from its destructiveness and use its energy for my own goals.”

I feel like it’s finally time to confront a serious problem I’ve had for years; when I drive, I become filled with rage. My mother was the same way, and it was scary. She was never violent and neither am I, but the amount of anger I feel can’t be healthy, and I don’t want my daughter to do the same thing. I want to feel less furious.

I hope you’re not expecting therapy, a pill, or some Tibetan meditative experience to take away your anger, because it probably won’t.

Whatever causes anger—mommy’s genes, bullying by your older brother, or one rotation too many around a Boston-style rotary—it’s usually yours for life by the time you’re old enough to write me a letter.

Sure, psychotherapy may help, but my rule of therapy thumb is, if it hasn’t helped in a few months, move on. Therapy just isn’t that powerful (not even in my Harvard hands), and sticking with it when you’ve got anger to control delays your acceptance of the red-hazed reality you need to start managing.

What I’m really advocating isn’t to give up on therapy, but to give up on the idea that it will make you feel better by taking your anger away. Instead, use therapy (like DBT, see above) to help you manage anger.

I know you’ve probably seen kung fu monks master their anger by thinking pacifist thoughts while smashing bricks, and maybe you think channeling your rage into big muscles and loud thuds will improve your control while intimidating your tormentors into not cutting you off you in the first place.

Wrong, young grasshopper. The only reason martial monks don’t get sued for everything they own by everyone they lay a finger on is that they’re monks and own nothing. For the rest of us, the slightest adult physical altercation, combined with martial training, is as bad as a car-crash without insurance or witnesses: an endless goldmine for lawyers (and shrinks) at your expense.

So now that you’ve abandoned all hope of ever getting rid of your anger, you’re ready to improve your ability to manage it. Instead of tailgating those who dare offend your road-warrior sensibilities, learn to shut up and back off until you have a chance to think and decide whether a battle is worth fighting (almost never) and, if so, how to do it most effectively (by never appearing angry).

Feeling angry is unhealthy because it raises your blood pressure, but expressing it is even more unhealthy because it causes you endless misery that raises your blood pressure higher for longer.

You can’t control the former, but you can learn to get a handle on the latter (even if you can’t break a brick with your fist).

STATEMENT:
Here’s a statement for taking pride in frustrated rage. “I hate the way other drivers ignore the road rules, put my life in danger, and never get punished. Teaching them a lesson would make them think twice about driving like assholes. My goal in driving, however, is to get from one place to another as safely as possible, without being endangered or diverted by people whom I least respect. I’m proud of my ability to eat my anger and never, ever fight.”

I’ve been a complete, stinking failure since I graduated from college. My job pays well, but I hate it with a passion because I’m treated like shit. Then again, I don’t have the skills to find anything better, though I’ve tried. My drinking has kept my girlfriend from moving in, and, since I’ve never loved anyone else, that means I’ve never had a relationship that works. I don’t really have friends because I’m too nervous to let anyone really know me and I work too hard to meet anyone (at that job that sucks). Now I wonder whether I’m being honest with you, or just whining and slinging bullshit. My goal is to be someone else.

It never ceases to amaze me how people who launch into the most brutal monologues of self-criticism would never allow their friends to talk such shit about themselves in their presence. The only thing they truly fail at is holding themselves to the same standards they hold others.

Your tirade makes you sound like the Yankees fans who can’t stand it when their team isn’t number one. When the Yankees are losing, they always find someone to blame: the owner for paying too much for bad players, or the slumping batter for not caring enough about the game to deliver value for his multimillion dollar salary.

In reality, sometimes other teams are better and hard-driving players slump, and it’s better to ride it out than to rage. The same goes for life in general, because blaming yourself and cursing your performance isn’t going to make it any better, and, unlike the Yankees, you can’t afford the reinforcements.

If you succeeded in hating yourself like this in front of a friend, he’d not just tell you to shut up, but express respect for the strength and courage it takes to work hard at a job you hate so that you can be independent and have some money.

He’d credit your persisting in a job search despite rejection and a bad economy, and express hope for a girl-friendship that has so far survived your drinking problem. He’d admire the other friendships you’ve started, despite your shyness.

Well, I’m not your friend, so I’m going to skip straight to telling you to shut up. I don’t like to hear people be mean to themselves. Don’t do it in my presence. Besides, I’m a Sox fan.

Your goal is not to indulge self-loathing, but to bottle it up and treat yourself with respect. No, I don’t know why you feel that way and I’m not too interested in exploring that question unless you’re willing to stop, now.

Not wait until you feel like stopping, because you can guess how much regard I hold for feelings and the fallacy that bottling them up can kill you. If Girardi had kept his feelings bottled up on Monday, he wouldn’t have gotten tossed from the game (and surely he wouldn’t have dropped dead from a feelings attack).

Thinking like a Red Sox fan—enjoying a losing team on a good streak—is usually more healthy. When the drive for dominance doesn’t trump loyalty, be it to a sports team or to yourself and your values, then losing sucks less, winning feels better, and more fun is had.

STATEMENT:
Here’s a statement. “I can’t help feeling self-critical, but I will use objective measures to judge how well I’m doing. I will deny expression to self-hate, even if it makes me turn red and develop acne. I will respect myself for legitimate achievements, whether or not they make me happy or rich. I’ll be positive about what I need to do to improve.

I love all my kids, but I don’t know where I went wrong with my youngest son. His older siblings are all accomplished and ambitious; two are married with kids, and one hasn’t had time because he’s finishing his medical training, but he and his girlfriend seem serious. Meanwhile, my youngest hasn’t lived in one place for more than two years, let alone held a job for more than a month, and all he seems to excel at is spending my money and wasting time. I don’t think he’s drinking or using drugs; he just isn’t successful at anything but fucking around. My goal is to get my son’s head out of his ass.

You’re entitled to worry about unlaunched kids who can’t (yet) make a living or misfits who haven’t found their way in life. You can worry, be impatient, or feel resentful; but, as a parent, you are never, ever entitled to get nasty.

Remember (and if you don’t remember, look it up), Archie Bunker was an asshole who made it harder, not easier, for the younger generation to get started by constantly expressing criticism and contempt. He enjoyed venting, and vented poison, so don’t follow in his reclining footsteps.

If your values—self-reliance and hard work— are worthwhile, you will do a much better job of pushing your son in a good direction by praising his strengths and supporting whatever you think will carry him forward. Let life teach him that bad directions take him nowhere. If you tell him, he has to prove you wrong, so let life carry the bad news.

I know, I know, the “real” problem with fucked-up kids is that their precious, testicularly underweight liberal parents never told them they were fuck-ups. Well, that sounds an awful lot like whining to me.

Like one of them liberals, you’ve shared your feelings with your son, and all they’ve done is make things worse. You’re too angry to stop yourself, so let me; Shut up.

He might be a fuck-up, but he’s your fuck-up, so stop cutting him down and start to actually help. Your words will carry much more weight if they make you sound like you’re on his side, which is where you’re supposed to be.

STATEMENT:
“You’ve got imagination and I admire the way you stay clear of drugs. I’m not one of those parents who wants you to do anything that will make you happy, because I think there are bigger issues, like having enough money to support yourself and fight off the crap that life will throw at you, particularly after I’m dead and there’s no financial umbrella. Even now, we can’t support you except in emergencies. So, as much as I hope you will find a happy career, I’m more interested in your developing the strength to make money from shoveling shit, if necessary, because you’re a good person and I want you to be strong and independent.”

I’m a 58-year-old gay man and it’s a long time since life has been any fun. I’ve been single for some time (with no real prospects of a relationship), my friends don’t seem to have time for me, and at the end of a hard day’s work running my own business, I’ve barely broken even and have nothing to look forward to but spending the evening alone. That’s when the depression closes in and I can’t stand living. I write all this because I know that I’m a miserable failure, and that facts, not depression or any other mental illness, are behind my reasoning. I mean, when I tell my few close friends how I feel, they tell me I’m being too hard on myself, but if you’re almost 60, alone, and a financial mess, doesn’t that mean you’re a loser? My goal is to be real about myself.

Sounds like your goal isn’t to be real about yourself, it’s to be mean to yourself because you’re in a bad mood. If you were to reread the above paragraph when your mood wasn’t so shitty, you’d see your treating “facts” with the same care as Bill O’Reilly.

So, to quote Bill, Shut up, I don’t want to hear it. You wouldn’t talk like that to a friend, or even probably your worst enemy, so don’t do it to yourself.

Sure, the pain in your life is real, but there’s a monster in most of us that speaks up when we’re hungry or poor or lonely and says, “Look what a mess you got yourself into, you worthless piece of shit.”

If you’re smart and have high standards and a well-developed sense of style, the monster will comment on the bad clothes, dull conversation, and depressing colors; it’s very specific and discerning, because it’s the meanest side of yourself. It will give meaning to your pain, alright, by telling you that it means a lot and it’s your fault.

It’s your job to keep that monster from influencing your values. I assume you’re working hard on your own business, because you care about being independent and self-supporting.

I also assume you have old friends, because you care about friendship and maintaining relationships, regardless of whether someone is wealthy, clever, or stylish. You haven’t mentioned doing anything wrong; you’ve just described the kind of bad luck that often happens to everyone at one time or another, with or without depression, or a partner, or a great job.

If you have good values, be prepared to use them. If you want to talk “facts,” remind yourself how hard you work at your job and your friendships. Your goal isn’t to get me or anyone else to confirm that you deserve to feel bad; it’s to keep your perspective and not let the negative thinking of loneliness and bad luck undermine your sense of pride.

STATEMENT:
“My life sucks right now, but I respect what I’m doing. I work hard and stand by my friends when all my efforts are relatively unrewarding and, on top of that, I’m fuckin’ depressed. I can’t wait for my luck to turn but, until it does, I wouldn’t want to do anything differently, and that’s what counts.”

I have struggled with bipolar disorder for almost ten years now, but sometimes I can’t see the point. The last time I was admitted to a hospital, I was actually raped by another patient, and the whole experience left me with fears and nightmares I just can’t get over. I’ll never let my family or a psychiatrist put me in a hospital again. My goal is to find a psychiatrist who will give me the support I need so that I will never, ever have to go into a hospital.

If you had diabetes and got the best possible supportive care from the best physician in the world—you could even marry her—you might still need hospital treatment if you got an infection, overdosed on peeps, or just fell into a manhole.

So, while you have every right to feel traumatized by your assault, don’t paint yourself into a corner because of it. When it comes to this anti-hospital stance, (or pro I-need-to-be-nurtured-very-carefully-or-else), you have to shut yourself up.

Thinking about the risks logically, it becomes clear that you probably wouldn’t get raped a second time, and there would be steps you could take to make it more unlikely. So, in reality, you aren’t facing a choice of rape vs. death, but rather terror vs. death.

Terror or death is a decision most of us face every morning before we get on the subway; that’s life. There would be no other choice.

Unfortunately, you can’t change the way rape gave you nightmares, and you can’t avoid the possibility that you’ll find yourself in the same neighborhood. What you can do, however, is bear the terror—the fear of fear—so that you can promise yourself the best possible care and manage yourself as carefully and respectfully as possible.

Your goal shouldn’t depend on finding the kindest or most available psychiatrist, or extracting promises about what he or she would never allow to happen. Your goal should depend instead on your own ability to ignore fear while benefiting from your bad experiences to make good treatment decisions.

Yes, bad things might still happen, but you can be sure you will have done everything to protect yourself while taking the risks necessary to manage a bad illness. If you go to the hospital, something bad might happen, but if you need care and you don’t go, something bad is guaranteed.

STATEMENT:
I may never be able to shake the rape nightmares or promise myself that a mood swing won’t become catastrophic and push me into a loony bin. I can swear, however, that I’ll take reasonable care of myself and that, when I’m well, I’ll try to focus on living life, caring about friends, and ignoring pain, regardless of whether I can get it to go away.

Living with my mentally ill 30-year-old daughter is wearing me out. My wife and I can never leave her alone, but we also can’t take her with us because she gets uncomfortable when she’s around people she doesn’t know and says inappropriate things in a loud voice and has to get up and leave. The problem isn’t her, though, it’s my wife, who is so worried about what will happen if we put her in a half-way house with other sick people that she can’t think clearly about it. We’ve got some money, but if we paid for my daughter to have her own condo and a nurse to keep an eye on her, the money wouldn’t last long. Then again, if she continues to live with us, we won’t last long. My goal is to get my wife to see that we have to get her into a state-supported program, for her sake and ours.

You hope to get your wife to see that your mentally ill daughter needs to live independently, but if you were making any progress in that direction, you wouldn’t be writing.

Let’s assume then, at least for the moment, that your hopes are false and your wife can’t let go, and if she can’t let go, she’ll always be thinking of new ways to make your daughter feel more comfortable and better understood. Which makes your goal a more and more distant dream.

It also means less legitimacy for other priorities, like preparing your daughter for life after you’re gone, or tending to your own needs or the needs of other kids.

When your wife’s approach wears you out (and it will, if you aren’t a saint), you’ll get angry and then she’ll blame you for making your daughter feel unloved and causing conflict that makes her sick.

As such, your wife’s not letting go will make things worse, as will your own refusal to let go of pushing your wife to let go. So, let’s stamp out your presumably false hope and ask how to make the best of things if your wife won’t change course.

First, figure out what you think is the right way to proceed, given the limitations of your resources and the nature of your daughter’s illness. Whatever you do, don’t expect what you have to do to feel good, because whatever it is, it won’t produce a cure or happiness, and won’t provide the guilt-blocking pleasure of unrestricted giving.

Then get advice from experts about her illness and what public benefits exist. Talk to other parents who have dealt with this issue, and count your savings. After that, put together a plan that represents the best compromise for dealing with two absolutely unavoidable and insoluble problems: the riskiness of independence when you’re mentally ill, and the costliness of long-term care when you’re not super rich.

Finally, ask yourself what you can do to implement this plan without your partner’s help, while encouraging her to join you if she chooses. You need to be able to stand by your plan so that her fears or criticism won’t paralyze you or draw you into argument.

You can’t reassure your wife that things will turn out well, but you can show her that you believe your way is best. If you appear calm about your plan and confident that you’re doing the right thing, she may eventually feel less responsible for all the bad things that could happen to your daughter and better able to do what will work best in the long run.

STATEMENT:
I have a duty to push our daughter towards independence while also attending to other responsibilities. I know this will cause her pain in the short run and deprive her of help I wish I could afford, but can’t. If I put together the best plan I can, however, I can take pride in being a good parent and offer that confidence to my wife and daughter as an alternative to fear.

My wife and I recently retired and we’ve been looking forward to a good life together, but recently I noticed she’s been getting forgetful and I wonder if she’s developing Alzheimer’s, which runs in her family. I hate to admit this, but I don’t think I’m capable of taking care of someone with Alzheimer’s, even if it’s my wife, whom I love very much. I can’t talk to her about it, because I don’t want to frighten her, and most of the time when I think about what to do, I just want to get away. Should I persuade her to get an evaluation so it can be treated? My goal is to do something to prevent this disaster from happening.

Getting into a panic with the goal of preventing Alzheimer’s is as useless as being paralyzed with fear over anything you can’t help, from the Rapture to the weather forecast to the Red Sox prospects in 2010.

Yes, you can urge your wife to get a physical and whisper to the doctor that she seems a little forgetful, and that will get him/her to check out curable causes of memory loss, like vitamin deficiency and depression.

At that point, believe it or not, you’ve done your job. If you press further by urging her to get cognitive testing and trying all available treatments, you may well make your lives worse.

A better goal for almost all the chronic problems of aging is to do what you can to treat them and then forget about them. You don’t want her to become her illness; you want her to live her usual life as much as possible.

For most people with memory loss, there’s no impending disaster. It’s only later, if and when it becomes severe, that people lose their personalities and require constant watching.

In your wife’s case, later may be a long, long time away. Meanwhile, you’ve got a life together that you don’t want to ruin by worrying about something that may not happen. Your goal is to fight fear, do what’s necessary for a possible illness, and live life as usual.

Your goal also isn’t to be extra nice to her; forgetfulness can be irritating to live with, and if you try too hard to be nice, you’ll get extra nasty. Instead, just try not to be mean, and give yourself credit when you can keep yourself in check. That’s always helpful in marriage, whether your spouse is demented or not.

STATEMENT:
Reassure yourself. “If there’s something that will actually help my wife with her memory, I’ll do it. Otherwise, it’s business as usual for as long as possible.”

My son was diagnosed with severe depression when he was a freshman in high school. I know it’s supposed to be a hereditary disease, but neither I nor my husband have any history of it; we both come from stiff-upper-lip backgrounds, and when our son attempted suicide, we were completely taken by surprise. He was also doing drugs, and we didn’t know it. He’s doing much better now, seeing a therapist weekly, but I still worry about his going off to college next year. He doesn’t share much with us, but I know he wants to do what’s “normal.” I don’t want to intrude on his relationship with his therapist or undermine his confidence or make him feel pressured, but we need to decide whether he’s ready to go. My goal is to make the right decision without hurting him in the process.

You can’t protect your son from of having an illness and all the trauma that goes with it, so for your own sake, and against all your instincts, don’t try.

On the other hand, if you try too hard to avoid all potentially painful issues with your son and stick to being stoic and reserved, you’ll be helping him avoid the hard choices he has to make, instead of doing your job.

Life is hard, precisely because it includes illness and drug abuse on top of the usual high stresses of being adolescent and finding a way to be independent. It’s a clusterfuck, and you’re the motherclusterfucker; you’re all in this together.

You’re right, you need to make decisions about whether he’s ready to go to college, but if you guess wrong, he’ll get pushed into relapse and a worse sense of loserness. Then you’ll be out a big chunk of tuition that will have done him no good and won’t be there later, when it might help.

In other words, on no level can you afford to be squeamish about dealing with the issues of his illness and drug abuse just because you’re afraid of hurting his self-esteem. Life is responsible for hurting his self-esteem, and while you gave him life, the transference of responsibility doesn’t work that way.

Instead of trying to make things right, try to prevent further damage. You’ve got painful topics to discuss, but that’s why you became parents: to experience a new level of pain. Starts from childbirth and it’s only downhill from there.

You don’t have to be critical or grim or sad to discuss this issue. Yes, you have to push the sad fact that he has not one but two chronic conditions—depression and a weakness for drugs—but, having accepted that, you’re free to celebrate the good work he’s done and talk about realistic options.

It’s possible to push your son towards making good decisions without shoving him into a wall. Don’t be afraid of doing the heavy lifting parenting can require; time to forget your upper lip and, instead, stiffen your resolve.

STATEMENT:
Here’s a formula. “You’re recovering nicely from a bad bout of depression, but we know that the brain can take a long time to recover fully and that you’ll always be vulnerable to relapse and, probably, drug abuse. Life is hard, and that’s the way it is. Now, you’re doing your job perfectly; you’re sober, you work as hard as you can at school, and you use therapy to get stronger. Let’s look at how you’re doing with your current course-load, get input from your teachers and therapist, and consider how much structure you’re likely to need next year and whether it’s time yet for you to live away from home while continuing your work.”

I love my parents, and we have a good relationship, but if the issue of my sexuality ever comes up (I’m a gay man), all hell breaks lose; my mother sobs about how the family name is going to die, my father pleads for me to try and find the right woman, your typical Jewish soap opera. I know they’re not really bigots and all the hubbub comes from a place of concern, but enough already, you know? None of us is getting any younger, I’m not getting any less gay, and yet they refuse to tone it down. My goal is to get my parents to calm down about the issue before it drives me away completely.

The tough part about having loudly protective parents, as opposed to quietly protective ones like the mother above, is that loud is harder for parents to control, once they’ve gotten into the habit.

People always say that telling the truth is important, but in reality, telling the truth is more gratifying than important; unbottling all of your feelings and unbottling all of your hard liquor have a similar emotional result (and similarly damaging long-term effects).

This truth urge is especially strong for some people when they become parents; it feels right, somehow, to smite the person they’re trying to protect. It expresses all feelings at once, love and hate, protection and punishment. It’s a lost weekend of honesty.

If they were too restrained, instead of too verbal, you’d have an easier time. Then again, Jews wouldn’t be Jews and the Mediterranean would be a basin of peaceful civilization, instead of a crusade magnet for the entire world. [Full disclosure: if you missed it before, Dr. Lastname is of the tribe.]

As such, don’t make it your job to stop an honesty drunk; you can just try, and be ready to get out of his/her way if you can’t get through. If you try too hard, you’ll prolong the juicy, emotional battle all crusaders are itching for, and everyone gets hurt.

Instead, try diplomacy. Show them there’s a better way to be protective, and that they don’t need to worry because you’re pretty good at protecting yourself. In other words, honor their parental functions without addressing their negative feelings.

Think of it as an endless process that may not succeed until your parents are too old, tired, or senile to keep up the war—you (I-srael) versus your family (Parents-stine). L’Chaim.

STATEMENT:
A business-like and formulaic manner can help you keep your emotions under control and provide you with a ready exit. “I know you worry that being gay will prevent me from having a normal life and expose me to lots of pain and trouble that I wouldn’t otherwise have, but the same could be said about being a Jew; it’s not for those who wish to lie low and play it safe. I can’t say there isn’t pain, but thanks to you, I’m ready to manage the problems and pursue what’s important, which is still work and friendships and being a Mensch. So genug, enough has been said, things are going well, and fear is not helpful.”

I’m fine now (I’m 14), but I’m trying to figure out how to deal with a crazy father who physically abused me until a couple of years ago—that’s when my mother finally figured out what was happening and had me come live with her. The trouble is, I guess you could say my father doesn’t see reality the way other people do and he never remembers hitting me. In his mind, when he’d hit me, it was because I was trying to destroy him, so what he tells the judge is that he loves me and that my mother is a raging alcoholic who has brainwashed me to hate him (my mother stopped drinking after the divorce, years ago) and he really believes what he says. My goal is to get him to stay away from me and convince others that his version of reality isn’t real.

Kids aren’t the only ones who have trouble accepting the fact that we often can’t protect ourselves from scary crazy boogeymen, particularly when the craziness isn’t obvious, and the boogeymen are family.

We’ve said it here before: certain crazy people are not obviously crazy and are particularly good at persuading other people to see them as injured victims because they truly, truly believe they are, no matter what really happened. It’s a kind of sickness for which no one has the cure, and nobody feels sicker than the victims in the wake of these sickos, who don’t necessarily feel sick at all.

So cops, judges and social workers often can’t figure out who is telling the truth for a long time. Meanwhile, they often make mistakes and put restrictions on kids and families that hurt everyone and cost more money than the family can afford. It’s a sad fact of life, but they’re trying to do the right thing.

The system usually works to try and protect the weakest party, and when you’re aggressive, even if you’re just aggressively trying to get people to see the truth, you make sickos look that much more weak and innocent. It’s unfair, but pushing hard to express the truth will often push it underground.

So Dr. Lastname’s advice for kids is the same as for adults: don’t think that expressing your emotions sincerely and eloquently will solve the problem. If your father is sincere and has a good lawyer, he’ll persuade the judge that you have, possibly, been brainwashed by your mom, and they’ll treat you like a poor, emotional kid who deserves pity but doesn’t really know his own mind. Then everyone will spend lots of time visiting shrinks. Thanks for the business, but no thanks for the bullshit.

First things first, give up on the goal of convincing others, and try instead to make positive sense of this experience and prepare a statement that you could, if necessary, read to your father.

The less anger and fear you put in your statement, the more it will help others get at the truth. I’m not saying you shouldn’t have negative feelings—of course, they are what they are—but the goal of your statement is to keep out the negative feelings without in any way holding back on the facts of what really happened.

You might not make his sickness go away or get people to see the truth, but being clear, honest, and emotionless is the best protection against the boogeyman.

STATEMENT:
Here’s an example. “I think it’s a bad idea for us to spend time together. I know you care about me and want to see me, but I think you forget about the bad things that happen when you get upset and lose your temper. You forget about (put in details, including bruises and dates). I don’t want to hurt you and I want you to be happy but I don’t think we should spend time together until I’m old enough to protect myself from your temper. Sincerely.

I’d like to get help for my wife’s younger sister because she drives the family crazy. Simply put, she’s a lying drug-addict, and my wife’s parents are always trying to help her in a way that ruins things for the rest of us—they give her money, pressure my wife and me to accept her at family events, and then make us feel guilty if we don’t want to see her. She’s totally poisonous as she is, but I know she can’t help herself, and I’d like to get her real help, not just hand-outs and pretending everything’s OK, so we don’t have to continue like this.

Your goal is just as bad as your wife’s parents’ goal, because you’re both assuming that your sister-in-law can be helped when all the evidence points the other way. They’re throwing their money away at her directly, you’d be throwing your money away at “real help” she isn’t ready for. It’s a lose/lose.

Really, everyone wishes your sister-in-law could be helped, but proceeding on that assumption when it’s not true is a good way to make things worse, and that’s exactly what you’re complaining about.

The sad fact is, treatment is often hopeless. You know that’s true for lots of medical problems, from cancer to Crohn’s disease, so why not accept the fact that it’s equally true for everything else.

Instead, stick with the realistic hope that she’ll change someday, and that you (and others) will have an opportunity to help. It might happen, but it’s not something that you can make happen or are responsible for.

In the meantime, don’t blame her, because there’s a good chance she has as little control over the problem as you do, even though it’s her body and her problem. Blame life, it sucks more reliably than anyone or anything else.

Now that you’ve listened to me and given up on your goal of getting help for your sister-in-law, realistic thinking suggests some positive things for you to do. Since you’re not responsible for saving your sister-in-law or protecting your parents-in-law, you can bow out of family events you don’t really want to go to.

Ignore feelings of guilt or responsibility. You’d help if you could, but you can’t, and there are other important priorities, like going on with your life and enjoying time with those you love.

STATEMENT:
Prepare a statement that responds to the most guilt-provoking accusations you can imagine. “I’m concerned about my sister-in-law and take full responsibility for helping her whenever possible. One thing I’ve learned, though, from watching her parents do a wonderful job of trying to help her is that, for the time being, it’s just not possible. When it’s not possible, we do more good by distancing ourselves from her problems so as to limit their harm and provide her with more incentive to change. Distancing ourselves from her problems does not mean distancing ourselves from her. The better we protect ourselves, the more welcoming we will be if and when she begins recovery.”

When I broke up with my girlfriend, I felt like I didn’t have a choice; she was smothering me, she made me feel guilty and like a bad person all the time, and I just couldn’t take care of her anymore. We’d been together for a relatively long time and I had reached the end of my rope (she’d even started hitting me and breaking things in our apartment). The problem is now that I feel even worse because, in the months since I ended it and she moved out, she’s started getting high a lot and has threatened to kill herself more than once. If she goes through with it, I don’t know what I’ll do with myself. My goal is to feel less awful about breaking up with her (which I did to feel less awful).

As a not-sociopath, you can’t feel less than awful about your ex-girlfriend’s drugging, depression, and self-destruction.

It’s the feeling responsible, as well as awful, that will not only do nothing to help her recovery, but will also turn your sorrow into well-entrenched, call-the-doctor depression. So…Dr. Lastname here, how can I help you?

You might think it’s good to take responsibility for the feelings of those you love; it’s a necessity if there’s something you really need to do for someone who’s helpless, like a kid or an invalid, or if you’ve done something wrong to cause those feelings.

On the other hand, life is hard for everyone, and most of the pain you’ll cause others is not something you or they control. Assuming responsibility for that pain is a way of pretending you could control it and make it right, which is a false hope that will prevent you and her from moving on.

Also, if you take responsibility for pain you can’t help, you’ll wind up blaming others and getting nasty, which will cause pain that you actually are responsible for, and then things get truly impossible.

The bad things she’s done and is doing (for love of you) are not your fault, but they’re not her fault, either. What they are are her problem, and, sad fact, your love seems to make it worse.

So don’t let guilty feelings affect your beliefs and don’t express them when you communicate with her, assuming that you do communicate, even if it’s with a look or through friends. You can’t stop feeling guilt, but you can stop guilt from controlling your actions. Stop feeling responsible, so you can stop calling on people like me.

STATEMENT:
Here’s a statement that pushes both of you to make the best of a sad situation while killing any hope that guilt will ever bring you back together. “We’ve both tried everything to make our love work and it can’t and now it’s time for us to move on. We’re both sad and it’s too easy to think about what either of us could have or should have done but that’s a dangerous, negative direction to go in. We both need support and nurturing, from ourselves and our friends, while we pick up the pieces, learn valuable lessons, and start a new life.”

My daughter is just starting high school. She’s had emotional problems since she was a toddler, and her current diagnosis is OCD (eating disorder, cutting, wild mood swings…it’s a mess). My wife is very easy-going with her, but also doesn’t really set any rules or limits, and I end up being the bad cop all the time. Having a teenage daughter is supposed to be hard for anyone, but as the only enforcer trying to take care of a girl with a bunch of problems I can’t understand, I’m in hell. At this point, as much as I hate to admit it, I hate my daughter—she’s impossible, angry, and just mean—and I’m jealous of how easily my wife gets along with her, and angry that she makes it my job to do all the discipline, and my feelings are an ugly mess. My goal is to love my daughter, like any normal dad.

While it may make you feel like shit, it’s not a sin to hate your daughter; it’s hard to feel warm and fuzzy all the time for an adolescent who’s probably rather verbal (and maybe physical) about how much she hates you—but it is a sin to be mean to her, and your feelings sure make it painful to be her dad.

Parenting under these circumstances is about as hard as it gets—it’s extreme parenting. You don’t need to bungee off any cliffs to encounter a day full of high suspense and drama, not knowing whether you’ll keep your behavior under control (hers, of course, you won’t).

This bad chemistry problem happens a lot to adoptive parents who have less familial experience with the kind of temperaments their kids present to them (no good deed goes unpunished). You’re one of the lucky biological parents to get stuck in this situation.

The pain of having no warm feelings and being angry much of the time is horrible, but feeling responsible for those feelings is much worse, so don’t.

You don’t hate her because you like to hate, but because of many factors over which you have zero control, including your daughter’s temperament, your wife’s personality, and your own reflexes. This isn’t your kind of kid, so you’re responsible only for making the best of it, and keeping her alive and safe.

Put your guilt aside, and you can applaud yourself for the hard job you’re doing and be more inventive about it. Nope, your goal isn’t to have positive feelings for your daughter (although you can still hope it will happen someday, and, honestly, I’ve seen it work out that way). It’s to do a good job of parenting someone you don’t like—that’s what defines a true professional—and respect yourself for doing a hard job under beyond-Mountain-Dew-level “extreme” circumstances.

STATEMENT:
Here’s a statement to draw the line on guilt-provoking accusations, whether emanating from you, a therapist or, after intensive psychotherapy, your daughter. “There’s nothing I value more than being a good, warm parent, but we have to play the cards we’re dealt, our personalities are not a great match, and it causes both of us lots of pain. I don’t apologize and neither should you, because I think we both do a good job of keeping that pain under control. I do lots of good parenting, in spite of those negative feelings, and they haven’t stopped you from having a good relationship with your mom and doing many good things, so I think we’re doing well, all things considered.”

I have a dedicated husband, three teenagers, a nice house, a well-behaved dog—it’s not a bad life—but I’ve had a nagging sadness my entire life, and I still do, despite all the good things I’ve got. I deal with it, admittedly, by drinking a bit. I wouldn’t say I’m a drunk, and my drinking doesn’t interfere with my parenting or my marriage anymore than my mood does, but I know that what I’m doing is self-medicating. My husband wants me to see a shrink because he thinks I should take real medication for depression, but if my drinking doesn’t mess up my life, and if, despite all I have, I can’t be happy, anyway, then I don’t understand what makes one medication better than the other. My goal isn’t to be happy, just to withstand my misery, my way, right or wrong.

I understand that chronic depression, which is what we call “nagging sadness” in the biz, isn’t fun. It can make you grumpy, negative, unmotivated, scattered, and lousy at whatever you’re trying to accomplish.

All that’s excluding the pain, so no wonder it can demoralize you into seeing a negative future for yourself. It’s enough to make you want to turn “what the fuck” into words to live by.

If there was some way to relieve your pain that was risk-free and didn’t affect your other life priorities, that would be wonderful (for you—the aforementioned biz would probably dry up).

Sadly, said riskless, perfect painkiller, psychic or otherwise, hasn’t been invented yet, which is why depression relief requires hard choices and can’t be your only goal.

Clearly, you’ve got other goals than depression relief, or you wouldn’t have the good family you do. Good families take lots of work, so I suspect you’re good at putting the goals of work and family-raising first. Being strong about these goals can’t make your depression go away, but it can keep depression from affecting what’s important, and that’s an accomplishment to be proud of.

Drinking hasn’t done you any apparent harm, but your decision-making method is dangerous. You didn’t weigh risks and benefits, and you didn’t mention the fact that drinking, in the long run, tends to make depression and anxiety worse, and doesn’t protect your brain from the risk of long term damage that depression is now known to cause.

Don’t tell yourself there’s no point in giving up your only source of happiness for the sake of a future that will never be happy. You don’t make most of your decisions that way, and it’s a bad example for your kids.

Do what’s right in the long run, even when there’s no light at the end of the tunnel, or at least consider doing what’s right, even when the long run doesn’t feel worth it, but you know it is.

You might feel like you’re damned if you do, damned if you don’t, but that’s your damned feelings talking, not your values.

STATEMENT:
Here’s a statement to guide your drinking decisions. “Alcohol gives me relief from depression and hasn’t done me any harm. But I know the risks from using alcohol increase over time and my future matters, (even if I don’t feel like it does), so I will keep looking for and considering lower-risk alternatives and try to make whatever decision is best for me and my family.”

I’m conscientious and hard-working and I don’t need a lot of praise from the boss—I’ve been in my line of work for a long time—but the thing that’s gotten me in trouble in the past, and what’s threatening my position at my current office, is that I hate it when someone acts like they’re doing more work than I do and the boss agrees. I need this job and I’m good at it, but I don’t want to lie down and roll over when someone says I’m a slacker and deprives me of respect I deserve. My goal is to keep my job and that means not letting anyone ruin my good reputation.

In a fair world, we’d all get respected for the hard work we do. The need to get respected is basic: most large companies do elaborate reviews, wasting tons of time, to make sure it happens; it gets most married couples fighting, sooner or later; it got Rodney Dangerfield to stretch his collar for decades.

So of course you know that the right to get the respect you deserve…doesn’t actually exist. That’s a fact of life, and it really hurts, but the best thing you can do is do what you think is right and hope that someone notices. That, and maybe hire someone good at PR (and acquire a taste for shit, since, sooner or later, at some point in your career, you’re going to be eating it, buffet-style).

I know, your friends tell you to stand up for yourself, and your company assures you that their HR department is there to help anyone who has been treated unfairly.

As your e-doctor, however, I’m telling you, bullshit. If you’re complaining to me, chances are that you’ve tried to speak up and it hasn’t worked. Worse, it’s drawing fire.

Yup, that’s what often happens, and it’s not because bosses and HR staff are insincere and evil, or at least not usually. People aren’t evil, they’re stupid; they speak different languages, then look at the same thing and come to opposite conclusions neither side can understand.

If you’re really good at describing someone else’s evil abuse of power and your abuser can’t see the abuse, but understands how you see him, you know what will happen—it’s the law of conservation of victimhood—it will come right back at you.

He’ll work harder to compile new instances of your slacking and you’ll have new fodder for outrage, less job security, and more reason to see a lawyer, thus making worker-boss divorce almost inevitable.

You want justice, you’ll get unemployment. The real injustice is that conscientious people often hurt the most over this issue, while a real slacker wouldn’t care.

Your goal should never be justice, but making the best of a shitty situation and keeping your job, if you have to, for as long as necessary. That means eating shit, smiling, and not letting moral outrage and helplessness stop you from searching for better work (or gathering evidence of mistreatment in case you can use it some day).

See a lawyer, by all means, to see what it takes to make a good case. Your goal, though, is to maintain your steady diet of shit and smile until the legal case is in place, if it ever is. In the meantime, stay strong, quiet, and well-stocked with tic-tacs.

STATEMENT:
Here’s a statement for quittin’ time. “I do a good day’s work for no respect and it hurts. I can’t change it and I can’t find another job. But the reason I work isn’t to get respect, but to make a living, and if I do that under difficult circumstances, I deserve more respect from the person who knows what’s going on, and that’s me.”