Question: A teenaged reader from the southeast sends her reaction to meeting her new therapist for the first time (I've condensed and summarized her remarks):
"I've been depressed for a long time, sometimes feeling self-destructive, sometimes very isolated. I have some very unusual thoughts and experiences, which sometimes scare me. I don't say much about this to my friends--what's the point? When I do, they worry about me, and sometimes tell me to see a therapist. But when I've told my parents something about how I feel and asked if I could see a therapist, they've either ignored me (as is often the case) or told me that I didn't have any real problems compared to lots of other people so I should just get over it. They don't get along well, and each is more or less totally absorbed in his or her own life. Sometimes they make me angry and upset, especially when I need their help or support and they ignore me. I am an artistic person, and I wonder whether some of these unusual experiences, which involve visualizations, come with being artistic.
This summer, an arts camp counselor said that I was clinically depressed and should see a therapist. She called my parents and told them. They agreed; I guess they believed her where they hadn't believed me. Finally I went to see a therapist, relieved that at last someone would listen to me. But when I met him, it was a disaster. He talked to me in the third person, which really bothered me--do you do that? He seemed condescending. He wants me to take medication, but I don't want to. Taking medication seems so mechanical; "you're depressed, take pills." If people are spiritual, shouldn't we be bring that into trying to solve our problems? Are people just machines, to be fixed with chemicals? There were a lot of unspoken subtleties about the meeting, which I might have liked, but I didn't feel that I had been really listened to. What about this therapist?
Answer: There are a lot of questions here, and they raise a lot of issues about psychotherapy and human nature. It's important to emphasize that I can't provide diagnosis or treatment by e-mail, or provide a second opinion about a client whom a colleague has seen and I have not. What I can do is to address some of the general questions that you raise.
A therapist should be concerned about his client's safety, able to connect with her personally, and able to help her grow. There are three points here:
About spirituality and medication: I don't think there's anything unspiritual about taking medication, for example, if you have an infection and need an antibiotic. The same goes for taking medication if you have an emotional illness. The question is whether one really needs it. (There I go, talking in the third person, so I guess the answer is yes, I do that too.) Certainly, we do have a tendency to use medicine too much in our culture; we want to throw a pill at everything. On the other hand, some people have gotten very sick indeed, and even died, because they didn't take medicine when they should have. The gifted founder of the Muppets, Jim Henson, if I remember correctly, died of an infection which he hadn't sought treatment for in time to save his life. Whatever being "spiritual" means, it doesn't mean not taking medication when one needs it.
In physical medicine, the patient's perception of the doctor often has a lot to do with how willing she is to accept treatment, and even with how successful the treatment is. The same thing happens in psychotherapy, where the relationship between doctor and client can make a great deal of difference. A client might not want to take medication recommended by a therapist whom she felt wanted to control her, even though the medication might be helpful. Or, she might feel that the therapist wanted to control her when he was only trying to help by recommending medication. If a therapist could make a better empathic connection with her, so that she felt more secure and affirmed, she might be more willing to accept medication. She might be able to manage with a milder medication, or a lower dose, or even none at all. But then, some clients won't feel secure or affirmed with anyone, or anyone who sees things differently than they do. Who's right--client or therapist, or both in different ways? Without knowing the people and the situation there's just no way that I could develop an impression about what seems to be happening. That's why I don't try to do diagnosis or treatment over the internet: the only way to get the information I need is to be directly involved.
I usually try to work without medication, preferring for people to heal themselves with their own resources whenever possible. But they have to want that too, enough to be willing to take care of themselves physically, avoid self-destructive behavior, and do the emotional work in and out of psychotherapy necessary to making progress in their self-observation, self-knowledge, and self-management. Sometimes clients have needed to use medication for a temporary period of time, to help them manage emotions that they couldn't manage with their own resources until they became calmer and more insightful and learned better ways of coping with the problems of self and world that are causing distress. I have often advised clients that it's time to consider whether medication might not be indicated; usually that has prompted them to make more efforts at self-management, but sometimes it has led to taking medication that really helped. Sometimes I have insisted that a client should take medication because I was deeply concerned for his or her safety. At least one client ended her work with me over this issue.
Current research seems to indicate that medication and psychotherapy together are more useful for seriously depressed people than either by itself.
I think it's really great that you are seeking help, and encourage you to keep at it. You might look at my earlier column on "Selecting a Therapist" for some additional related thoughts.
Disclaimer: Please note that absolutely nothing in this column in any way constitutes psychological diagnosis or treatment; it is not intended to do that and could not possibly do so. Readers with mental health concerns or emotional distress are advised to consult a local mental health professional in person. Lists of local psychotherapists can be obtained from the state and national offices of the American Psychological Association, the American Psychiatric Association, and the National Association of Social Workers.
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