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.

My husband worries a lot about my drinking and depression but, to my mind, I don’t think my drinking is a problem and I don’t think I’d be depressed if I wasn’t worried that he’d leave me. For the sake of our marriage, I’ve agreed to stop drinking for a while and go to AA, but I really feel that my drinking wasn’t causing me any problems and that I’m doing this to make him happy, which makes me feel weak and angry. I want to get him to accept me the way I am before I can’t take it anymore.

You’re in a tough spot, because partnership really can’t work without acceptance, and acceptance is not something you can control. The more you force acceptance, the harder it is to achieve. Accept that, buddy.

If you try too hard to get his acceptance, you’ll hide whatever you think he won’t accept, which means putting your drinking in the closet and going to the mall instead of AA meetings.

On his end, if he tries too hard to make the relationship work, he’ll pretend you’re not really drinking or that you’re going to change, which also means no real acceptance.

The sad fact of life is that you are never going to change who you really are, which, at the very least, is a girl who enjoys drinking, and he’s going to have to take it or leave it. On the other hand, if you present the issue positively and he considers it realistically, maybe acceptance will occur, now that you’re not forcing it.

That’s why your goal shouldn’t be to win acceptance from your love; it’s to find out if your love can be accepting. He doesn’t need to like your drinking, but you need to know whether he can accept that it’s part of your package and accept the whole deal.

Instead of getting him to accept you the way you are, begin by accepting yourself. Forget how much you like to drink and ask yourself, on the basis of your own experience and what you’ve read, whether drinking gets in the way of anything you hold dear, like your health or making a living or being a good woman and a good friend. If in doubt, stop drinking for a while and see if there’s any difference.

Once you know your own mind, lay things on the line with your husband in a positive way. Of course, if you’ve come to agree that you’re a lush, let him know that you want to stop drinking because you believe you need to, and not to please him.

Otherwise, state your differences positively while letting him know how much you’d like him to accept you, if he can. If he can’t, then that’s a sad reality you both have to accept on your own.

STATEMENT:
Prepare a statement of your own views that is not overly reactive to his. “I respect your concern for my drinking and regret that it worries you. I’ve looked hard at how much it affects my health, work, and friendships. In the end, I don’t see it as causing me problems and, as much as I love you, it won’t help our relationship to appease unfounded fears. I hope you’ll accept my decision. Meanwhile, I think we should drop the topic of my drinking and, hopefully, move on to other things.”

My daughter is severely bipolar and lives with us so my wife and I can try to make sure she takes her meds and doesn’t hurt herself. We aren’t always successful—she’s practically an adult now and hates when we parent her—so she stopped taking her meds because she thought she didn’t need them anymore. Now she’s extremely manic, maybe using hard drugs, and extremely irritable. We’re absolutely helpless and there’s nothing we can do because she won’t talk to us. Our goal is to get her to listen to us, stop drugging, and get back on her meds.

Mental illness makes all families helpless; after all, it’s hard to have a dialogue with someone whose brain is diseased, irritable, inattentive and unresponsive. You’d have better luck reasoning with a rabid wolverine.

If you believe that your only power derives from your ability to have a heart-to-heart talk with her, then you are, indeed, helpless. The good news is, you’re wrong. After all, you can help wild horses improve their self-control without first teaching them English. Thus, you, too, can become a bipolar whisperer.

As parents and landlords, you control a number of powerful incentives, like access to money, car, refrigerator, shelter, and, oh yeah, money. That doesn’t mean you can control her or her illness, but it does mean you can create some pretty strong reasons for her to do the good things she needs to do.

Set rehabilitation goals for your daughter that you believe are truly essential, which will probably include sobriety, doing enough household chores in order to live independently, controlling violent behavior, and stopping sudden impulses from affecting her safety or treatment. Add or subtract from these core goals, based on your own experience and other parents’ war stories.

Once you know your priorities, announce them and back them up with rules and incentives for following them. I said announce, not converse. If you’re too worried about her anger or hurt or lack of understanding, you’ll be ineffective.

Don’t pick a fight, but don’t hold back on saying what you think with friendliness, conviction, and optimism. Tone of voice is as important as content. Don’t end sentences with a rising, Valley Girl inflection that asks for approval. Use the same calm, assertive energy praised by Cesar Millan.

Yes, there’s a risk that she’ll do something dangerous or force you to ask her to leave, but a bipolar-veteran parent knows how to manage crises without appearing to panic. It’s a risk you need to take, and be prepared for, because the alternative is way worse than facing an angry four-legged beast.

STATEMENT:
You need a statement that says, “This is what we believe, here are the rules that are required for self-control and independence and this, very simply, is what will happen if you don’t follow them. There are no punishments and we do not believe you are being stubborn or childish; but we will withhold privileges and, if necessary, ask you to live elsewhere for a while if we think it’s necessary, either because your behavior makes it impossible for us to live with you, endangers your safety, or blocks you from making progress.”

I’ve been depressed for some time and could use some treatment, but my insurance has a big deductible, so I’ll be paying everything out of my pocket, which isn’t deep. My goal is to get treated for the least amount of money.

I’ll assume from your tone that depression isn’t making you suicidal or putting you at immediate danger of losing your job and/or family because, if it is, you need to forget about the cost of treatment and value the cost of your survival.

If depression is putting your life/work/family in danger, get a psychiatric evaluation, in an emergency room if necessary. Do not pass go, do not collect $200 (no matter how much you need it).

If that isn’t the case, there’s lots you can do to reduce the amount of money you spend on treatment…if you’re willing to spend some time, do some research, and use your common sense.

While the above question is quite short, the answer is anything but; looking for a treatment on any budget is a serious, involved process, so we have an involved, serious answer. Behold, our five step process that will help you with your depression without hurting your wallet.

Step one is telling your primary care physician (during a brief visit or even email) that A, you’re feeling low, B, you don’t have any physical symptoms (no fever, no weight loss), and C, you’d like to get some tests to rule out a physical cause of depression, like thyroid disease.

Tests will reveal if you’re feeling low because your glands, not your brain, are problematic.

Assuming your glands are good and your brain isn’t, step two is considering the options other than antidepressant medication, which, because it’s medication, always has a higher risk than non-medical therapies.

I’m guessing that medication is probably the last thing on your mind. It’s important to think about it upfront, however, because sometimes depression doesn’t wait for psychotherapy to work before causing severe pain and/or damage to your life, and medication always increases the odds for a better and faster (and sometimes cheaper) recovery.

Step two then, (postponing the issue of possible pills), is considering psychotherapies, including the how-do-you-really-feel-about-that kind. Many people assume this is the only kind since it gets lots of airtime on TV, where it uncovers exciting and unexpected changes of heart and inspires tears and plot reversals.

Despite what TV tells you, however, not everyone with depression needs psychotherapy. Psychotherapies are better at helping you manage depression than cure it, so it’s not surprising that many people with depression have had a number of psychotherapies.

Before considering a feelings-focused therapy, ask yourself and the people who know you whether there’s an issue you need to talk about. Remember, sharing your feelings with a professional is most effective if you haven’t done it before or your confidantes are unsupportive bozos and bartenders.

So, while the bad news is that psychotherapy is not a cure, the good news is that you don’t have to pay for it unless you think there’s a kind that’s worth trying. Either way, you save!

Your job is to figure out whether you (still) need one or more of them. If you want to save money, do your homework. It’s that, or pay a professional to do it for you.

If you decide that a feelings-focused psychotherapy is necessary, you may get a bargain at a state-subsidized community mental health center or a psychotherapy teaching institution. Don’t assume you should see a therapist every week, because you may get just as much bang for your buck by making the meetings less frequent.

You haven’t completed step two, however, until you consider other psychotherapies, particularly cognitive behavioral therapy or “CBT”, which is a good option if your negative thinking (caused by depression or being human) is making you more depressed.

Read books on the negative thinking caused by depression and anxiety (like The Feeling Good Handbook by David Burns) and decide whether you need to do thought exercises to stop your negative feelings from becoming negative beliefs or actions. If you find it useful, look for a therapist who “does CBT” or “DBT”, a form of CBT that focuses on thoughts of self-worthlessness and the desire to injure oneself.

Please note: we’re not recommending all kinds of self-help. In fact, if you see a self-help book about “healing the inner hurt,” run the other way as if it were on fire. If Dr. Phil recommends a book, we forbid it.

Step three is taking a break from the books and tuning up your diet and lifestyle. Exercise is a powerful antidepressant (the way you feel afterwards, not during, anyway). Vitamins and omega three fatty acids help, and, despite what most people think, drinking and drugs don’t, so learn to abstain.

Finally, read up on antidepressants while ignoring the eye-witness accounts of horrors and miracles. Consider the risks (fairly low, despite what Scientology says) and possible benefits (positive, but delayed and very iffy). Then, if you decide that the risks of staying depressed are worse than the medication risks you’ve read about, ask your primary care physician for an “antidepressant medication trial.”

Remember, you’re conducting a trial, not taking a cure. Note, quantify and record your symptoms and possible side effects over the next few weeks. (There are programs on Google that can help you do this). You’re the one who decides whether the new medication is doing more good than harm.

If a couple medication trials haven’t worked, the very last possible step, number five, is to get a referral to a psychiatrist and give him/her a list of the medications you’ve tried, the doses, how long you took them, and the good and bad things you noticed. You can find a psychiatrist on the cheap at the same clinics we sent the feelings-focused types to.

Follow these steps, and you’re on the road to dealing with/managing your depression. It’s not a cure or an easy answer, but it’s a start, and hopefully this is all the information you need to start on a good path to treatment without paying a pretty penny.

STATEMENT:
Here’s a statement of purpose that will counteract depressive helplessness and pessimism. “I don’t know why I’ve been feeling depressed and I may never know, but I know how to find any causes that are worth finding and to try the cheapest treatments first. I expect to run into a lot of dumb ideas about depression because many people want to believe they have the answer and an easy way to control it. Whether or not I can control it, I know that, by doing the research myself and using professional help whenever I think it’s necessary, I can do a good job of taking care of myself.”

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.”

I love my work, my kids, and my wife, but I have bipolar mood swings (and I’ve taken medication for years) that lead me to do things that get me into trouble. Recently, in spite of the medication, I felt a surge of energy and started to stay up late, sneak into my studio and paint. I’ve also started to drink again. I don’t want to change meds or let people know what’s happening because I want to keep my options open. I love the highs and the freedom, and I hate being told what to do, but I’ve got a demanding day job that doesn’t involve painting, and a wife who doesn’t like it, to say the least, when I’m not honest. So my goal is to get myself under control before people catch on to what’s really happening.

There are few fathers and husbands who can’t identify with the goal of wanting to feel special, have time to themselves, and avoid humiliating comments about eating, drinking, toileting or sleeping habits from their next of kin.

The fraction of these fathers who are dealing with mental illness and addiction to alcohol don’t want to be asked if they’ve been taking their medication or started drinking.

So, if your goal is to avoid immediate disrespect and hang on to your secret Van Gogh identity a little longer, then keep doing just what you’re doing.

On the other hand, if you want to avoid the long term chaos of going nuts, listening while your doctors try to find a mental hospital that also does alcohol detoxification and having your wife tell you that you’re not welcome home until you straighten out and maybe not then either…then you’ve got to give up on secrecy and come out of the out-of-control closet.

That’s because it takes a powerful part of your personality to make a good guy risk his health and marriage for the joy of a very, very good but relatively brief mood and paintings that will never reach Sotheby’s. It takes a demon.

Lots of people have demons—they pay my bills—and it’s a waste of time to figure him out instead of looking for ways to manage him better, all of which require you to face and ‘fess up to your (or should I say his) possession.

Sorry, but it’s almost impossible to gain control of a demon without acknowledging that he’s A, there, and B, can’t be extirpated or exorcised (except through lobotomy). That’s because he gains strength from being hidden.

So tell your wife and trusted friends about your problem, share your story with similarly possessed people, discard false shame, and do your best to keep the demon under control.

In recovery, they say you’re only as sick as your secrets; admit your secrets, and you can keep your demon at bay.

STATEMENT:
Here’s what you need to say to yourself (and others). “I’m living a good life, but it isn’t easy. My priorities are to make a living and raise a family, but there’s a part of me that wants to drink and paint and stay up late and enjoy the bipolar highs, and sometimes that part takes control, particularly when I think I’ve beaten him for good. Making my problem public is the best way to strengthen my self-control. I respect my willingness to humiliate myself for a good cause.”

My girlfriend and I keep breaking up without ever really getting together. She’s obviously interested in me, or she wouldn’t keep calling, and I can sense her sincerity. We have a good time together when we get a chance to go out. Whenever we’re at the stage of taking things to a new level, however, like we’ve been talking every day for a couple weeks, she’ll suddenly drop out of contact for a few days and then act like nothing’s happened and I shouldn’t expect her to be that available. A couple times when she dropped out, it was because she couldn’t decide whether to get back together with an old boyfriend. That’s no longer the issue, so I thought we were clear to go, but we can’t seem to take off. I’d like to know if I’m doing something wrong or if there’s a way she could get help.

Don’t trust your feelings to tell you whether someone is really interested. Feelings are easily fooled and love is blind; watch her feet and see what they have to say.

This girl’s feet are doing the cha-cha-cha, one step forward, one back, quick shuffle, one more back, one forward, another shuffle, and repeat. She likes to dance with you, but that doesn’t mean she’ll ever move forward or make you her number one partner.

If you trust your feelings, then you must ask yourself what you’re doing wrong, which keeps you stuck with her and introduces you to doubt, depression, and me. It costs you time and money to stay at the mindfuck disco.

Ask yourself what you’re dancing for. It’s not because you need to dance (though you do), but because you’re looking for a partner, which requires you to know what you’re looking for and keep your feelings out of it until you’re sure you’ve got a likely candidate.

One of the requirements—I know, it’s amazing that I can read your mind, but remember, I went to Harvard—is that someone has a good track record with relationships. No one who does the cha-cha-cha need apply, ever.

Don’t tell me that’s easier said than done. First, I’ll tell you it’s harder if you don’t do it, so you don’t have a choice. Second, given today’s theme, I’ll tell you you’re possessed by a demon who loves attention and wants to dance and you have a hard time keeping him in check.

Your goal is to make a solid, independent choice, regardless of your short-term needs. Cowboy up, be a grown-up and give yourself the benefit of solid, caring protection and a nice, sturdy, one-on-one waltz.

STATEMENT:
Here’s a statement, in case your demon (or sometime dance partner) asks why you can’t, at least, enjoy a nice, friendly talk. “I don’t think our chemistry is right for what I’m looking for, though we certainly have a good connection. Spending time with one another right now doesn’t take either one of us in the right direction.”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

As rabbi of a medium-sized temple for 10 years, I’ve enjoyed a good relationship with my congregation and I love the work. My problem is that I rely on the temple Board to decide whether I get a raise, and, during the last recession, there wasn’t one because everyone felt too poor to pay more dues. When, recently, I began looking at what rabbis of comparable congregations are making, however, I found that my salary is well below the mean, so I’ve been wondering how to become more active without appearing to be greedy, selfish or unresponsive to the problems of the congregation. One way that occurred to me was to do a “360 degree review” and ask everyone to give me feedback on how I’m doing, including the congregation, the board, and people who work for me. My goal is to get a high approval rating and use that to get a raise.

Unlike the woman earlier this week who was too afraid to rock the boat by asking for a raise (until anger made her want to torpedo the ship), you’re inhibited by guilt, empathy, and that certain Jewish ne sais quoi.

Still, no matter how tempting it is, don’t ask the congregation to clap if they think the rabbi deserves a raise. You’re a scholar and a leader, not Tinkerbell.

I know, it’s easy for a rabbi, or any figurehead of an organization, to rate him/herself by how a congregation responds as an audience; they may not clap, but they sure let you know how they feel, and a “360 review” seems like a good way to quantify your ratings.

You can do a good job as a rabbi, however, without necessarily getting good reactions or being able to control them. Instead of linking the value of your performance to the reaction of your audience, do a self-360, using as your criteria how well you do all the activities that are important to your job, without overemphasizing the obvious crowd-pleasers (although I’m sure your Purim service is hard to beat).

Then, link a raise in your salary to the market value of good-enough rabbinical services, and not to your current popularity, so you won’t be overly influenced by the ups and downs of congregational politics.

Sure, as a leader who is supposed to provide comfort, it’s easy to feel responsible for your congregation’s pain. As a rabbi, however, you should know how to distinguish between selfishness and legitimate self-interest.

You have an obligation to make a living, support your family, and get paid for your services, so it’s up to you to decide what your services are worth, and then allow your congregants to decide whether they’re willing to make the necessary sacrifices. Your instincts may be Rabbinical, but you have to think a little bit like a C.E.O(y vey).

Don’t ask the board whether your needs are legitimate; you’ve done the self-360, determined that you’ve done a good enough job, and made your own allowances for their current financial problems. Now it’s up to you to grow balls/pray and tell them the salary you deserve. If they think differently, it’s their job to explain why.

Be prepared to respond to the emotional questions that make you feel most guilty or insecure about your request. When you’ve answered your own guilt-provoking questions, your posture and voice will tell people that you’re at peace with yourself.

These questions probably include; “Do you feel that we aren’t taking proper care of your needs?” and “Why should you get more when others are making do with less?”, all of which are really asking, “Why is this Rabbi worth as much as all other Rabbis?” Lucky for you, you’ve figured out the answer.

STATEMENT:
“I’m requesting a raise because my current salary has fallen too far below what similar congregations are able to provide for their rabbis, taking into account the current bad economy and assuming that I’m carrying out my duties diligently and responsibly. My family has been feeling the pinch. I am very happy with this congregation and it is easy for all of us to forget about the salary issue, particularly when times are bad. But it’s necessary. Here are my data and here’s my idea of a fair salary.”

I’m a salesman and I love selling, but I’ve always had mood swings and I’ve never been that disciplined. For the last few months, and for seemingly no reason, I’ve been depressed, and it’s starting to destroy my life. I’m pretty good at putting on a smile, but people have started to notice that I’ve lost my bounce, and that just pushes me further down the spiral. I can’t get myself to do anything more than the bare minimum, so my numbers are going to be terrible. I can’t stand what I’m doing to myself. I need to get my control back.

Nothing feels more like failure than a depressive meltdown that makes smiling and/or talking to people a huge chore, and undermines the good work habits you’ve managed to put together. It feels shameful, personal, and avoidable. In reality, it’s none of those things.

When you’re a salesman whose earnings depend on the attractiveness of your personality, it’s hard not to rate success by the response of others to your self-presentation and take responsibility. The same is true for actors, politicians, and, you guessed it, rabbis.

Don’t believe those speakers and supervisors, however, who tell you there’s no limit to the persuasiveness of someone who stays motivated, focused and on message. Believing their words may help you when you’re a novice who needs to overcome shyness and learn how to talk to people, but once depression sets in, belief in your ability to control how others think of you will cause you shame and make you worse.

Your goal isn’t to control the way people respond to you, no matter how good you are at sales. It’s to accept your lack of control over the symptoms of a disabling illness, and respect yourself for dealing with it as well as you can, taking each day as it comes.

Decide for yourself whether you can do a good enough job, and what you need to do to get help. Then you’re ready to confront the worst thoughts you can imagine people having about you, knowing that you’ve done your best.

Before you can get deal effectively with your symptoms, you need to sell yourself on the fact that your depression is out of your hands.

STATEMENT:
I like this job and it requires a large amount of energy, which I can usually count on. Right now, however, I have an illness that prevents me from working at full capacity. While getting treatment, I’ll continue to work if I can, trying to do what’s most important. I hope that I’ll be back to normal as soon as possible. Meanwhile, I appreciate your help and understanding.

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.”

In the last ten years, I’ve heard voices in my head and most doctors describe my symptoms as psychosis, but nobody can tell me exactly what’s wrong, or find a medication that makes them go away, or really do anything but listen to me give them my laundry list of “how I’m crazy” and try to take the problem apart. In the meantime, I’m struggling to hold onto my job, my wife is struggling to put up with me, and my kids (now grown) just worry and get more distant. My disease stays the same, my life gets worse, my diagnosis goes nowhere. My goal is to figure out what is causing the symptoms, get a real diagnosis, and make real progress.

I wish the word diagnosis meant “we know what’s wrong and what to do,” but it often doesn’t, except in certain special cases. (Like, right now I feel safe diagnosing your reaction as disappointment.)

Very often, all a diagnosis means is that we recognize a group of symptoms that often travel together in the same social circle, and often get a little bit better when they’re treated with a particular group of medications. Tada.

That’s almost always true when the doctor making the diagnosis is a psychiatrist, because we know less about mental illnesses than almost every other kind of illness (and less about the brain then we do about any other part of the body).

We really should use some other word than “diagnosis,” but we don’t, because we love to think we know more than we do, which goes to prove that doctors are just as vulnerable to idiot false hopes as everyone else.

Some people put a premium on hope of any kind, but false hope is dangerous, because we pay for it with unrealistic expectations that lead to feelings of failure. You expect that, once you get the right diagnosis, you’ll get the right treatment, but I diagnose that assumption as bullshit.

In the psych business, if a treatment turns out to work, then you’ve got a sort-of diagnosis about what’s wrong. That’s as good as it gets.

The bad news is that the experts have much less to offer than you (or they) would wish, but the good news is that you can help yourself by doing a regular risk-benefit analysis of your symptoms and the various treatments, regardless of whether or not your symptoms fall under a neat umbrella or not.

Ask yourself how desperate you are to improve your symptoms, not just because you feel bad or want to be normal, but because they get in the way of what matters in your life, like work and relationships. Your treatment choices include some high risk options, so you need to decide, right from the beginning, whether getting rid of them is worth exposing yourself to the equivalent of cancer chemotherapy, or just Advil.

From what you say, it isn’t clear whether your symptoms are causing you nearly as much trouble as your shame of having them. If you can ignore them, get your work done, and have a decent conversation with your wife, then maybe they aren’t worth pursuing unless the treatment is fairly safe. On the other hand, if they’re driving you and everyone else crazy (them figuratively, you literally), then go for the big guns (“big” as in “risk of nasty side effects”).

Use what you know about treatments to classify them into low, medium, and high risk. Then review the treatments you’ve tried in the past to see whether there’s anything left, in any category, that is still worth trying.

If you’re really desperate for a diagnosis, here’s your second opinion from a real MD—you’re nuts. I prescribe giving up on naming exactly what’s wrong with you and moving forward on figuring out what treatments are worth what risk.

STATEMENT:
Now you’re ready to make your own decisions. Keep yourself on course with a set of directions: “My job isn’t to get rid of my symptoms, it’s to manage them as effectively as possible while going on with my life. I’ll compare the risk of treatment with the risk of having the symptoms continue. Once I’ve made my decision, I’ve done a good job, regardless of what happens to my symptoms, and, if they don’t go away, my job is to ignore them and avoid doctor visits and treatments unless I think they’re absolutely necessary.”

My 10-year-old son has afternoon tantrums that are really, really hard to watch. He screams, kicks, and cries, and nothing my wife and I (or anyone else) do can stop him or calm him down. We finally took him to a psychiatrist, and he told us our son’s probably bipolar, and that we should try one of those drugs you see on TV, but the side effects sound brutal. I don’t know if I want to put my son through that, but I do know things can’t continue the way they are now. Our goal is to make his tantrums better.

A lot has been made recently about the increase in cases of bipolar disorder among children. Some people are quick to point to household toxins poisoning children, while others think that drug companies are inventing problems to make a buck. The reality is probably something far less sinister—semantics.

Adults who get manic symptoms (that’s what we generally mean by the diagnosis “bipolar”, that and not much more) were holy terrors at a young age, so it’s tempting for well-meaning and helpless-feeling psychiatrists to wonder whether the adult symptoms could have been prevented with early treatment.

The trouble is, the number of kids with bad tantrums who eventually develop manic “bipolar” symptoms is probably pretty low, it’s hard to determine, and none of the experts can do more than make a rough guess.

So don’t get spooked by spooks, screaming, or diagnoses. As you learned above, the predictive power of a psych diagnosis is limited and doesn’t tell you much (we wish that weren’t true), and parents who live with a kid are usually much better able to make a risk assessment than a shrink who sees him for an hour.

For example, these tantrums seem really scary—and loud tantrums are rattling—but you’re not saying there’s a risk of serious injury to life, limb, pet, teacher, or classmates, so maybe the overall risk isn’t all that high (except in terms of eardrum damage, embarrassment, and fear). And if you’re afraid for his future, remember, there are lots of nice guys who were holy terrors at his age.

The other troublesome thing is that the medications that (sometimes) make bipolar symptoms better pose moderate risks themselves, particularly when they’re taken for longer than a few days. These risks (and don’t tune out the way you do when a cheery television voiceover recites a list of catastrophes as if they’re unlikely) include weight gain, diabetes, high cholesterol, and/or kidney or thyroid damage. That doesn’t include the long-term effects we don’t know about, since we’ve done no testing on what taking drugs like this can do to kids over time.

If, after a reasonable risk-assessment, you feel the situation is desperate, then the risk of trying these drugs despite the lack of testing might be worth it.

Review the types of treatment and their risks. There’s behavioral treatment, which is lowest risk and always worth trying, except when a kid is in too much danger and needs a locked room right now. The treatment is for the kid, of course, but you’ll be the main one doing it, so find a local kid-whisperer and get to work.

Sure, you can put “how are you feeling” talk therapy in the low risk treatment group, and sometimes it helps, but don’t keep doing it if it doesn’t, no matter how much you (and the therapist) wish it would help eventually.

There’s a group of low risk medications that might help (or hurt). What makes them low risk is that, if they hurt, it’s easy to stop the medication, and, from what we’ve seen so far, there’s rarely any permanent harm done.

Naturally, you’d love keep your kid healthy, but you can’t. So first think hard about how much danger his health is in, and then how much health he might lose if you try to make the original illness go away. It’s tricky and unfair, but so is life, no matter what your diagnosis.

STATEMENT:
Give yourself some upper-lip-stiffening advice. “I want to stop these terrible tantrums and protect my child from future mental illness, but my control over both those wishes is limited. So I’ll learn behavior management, get earplugs, assess the risks, make the hard decisions, and hope we can turn him over to his wife as soon as possible.”