Therapeutic Rapport

October 5, 2009 — Mike

Once in a while, during a session with a person with substance problems, my mind wanders. I may begin thinking that I’ve heard this all before. I might get frustrated with the excuses for the slip last week. I might even get to the point of a quick daydream.
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At these times, I recall a night long ago to try to help me get back to my therapeutic rapport with the patient.

When I was 15, I played on my school’s soccer team. I had only average skills. Nevertheless, I loved the game.

That year, the school’s girl’s athletic association invited the boys on sports teams to a roller-skating party. I didn’t have a girlfriend at the time. It sucks to be 15 and not have a girlfriend. The roller-skating party seemed like a good chance to try to impress one of the girls.

As the party drew closer, it assumed more and more importance for me. I was pretty good at roller-skating and thought the party was a good place to show off. By the night of the party, I was excited and anxious.

For reasons I no longer remember, my parents were less enthusiastic about me going to the party. I recall a lot of bargaining on my part. They relented and drove me to the roller-skating rink.

By the time I got there, many of the other boys and girls were already skating. I quickly rented a pair of skates, put them on, and headed to the rink. After three steps, I fell backward.

It hurt, a lot. I had never before broken a bone. However, as I lay on the floor I knew with a clear certainty that I had broken my right wrist. Embarrassment and shame competed with pain for first place in my head.

Cautiously but quickly, I got up and headed for the snack bar. It was important that I try to get out of there with as little fanfare as possible. I asked the woman behind the snack bar for ice. She didn’t have any. She gave me a cup of soda and suggested that I put that on my arm. The woman did have a phone, though. I called my parents and asked them to pick me up really fast. They were on the way out to a party and were frustrated that they had to cancel their plans.

I removed my skates with my left hand and returned them for my sneakers. I waited for my parents in a corner by the snack bar. My right arm was on the counter, the now warm cup of soda pressed up against my wrist. Just stand here and try not to let anyone notice you, I thought to myself.

Jenny, a long time friend, skated up behind me and playfully hip checked me against the counter. My right arm was pushed into the cash register. What was a barely tolerable, throbbing pain became a shrieking lightning bolt of agony.

Trying to remain cool, I told Jenny that my arm was busted and that she was hurting me. There, my secret was out. Damn. Jenny was good about it. She apologized for hurting me and asked if she could help me.

Just then, my parents arrived. I said good-bye to Jenny and quickly left with my parents. My arm hurt like hell. I wanted to stop somewhere, anywhere and buy ice. My parents thought it would be best to get to the hospital first and get ice there.

In the emergency room, I tried to hold on to my tattered dignity. The nurses and doctors were nice. I tried to be polite and to wait patiently. My arm was eventually x-rayed. Even I could make out the fracture of my right wrist in the x-ray. The doctor said that the fracture needed to be set before putting on a cast.

I never liked getting an injection. Nonetheless, the nurse brought the doctor a tray of syringes and Novocain. My teeth clenched as he injected the anesthetic into several spots around the fracture. The doctor said that it would take a few minutes for the stuff to work. He’d come back in 10 minutes to set the fracture and give me a cast.

My parents were in the exam room with me. We spoke idly until the doctor’s return. My pain was lessening but my fear of “setting the bone” grew. I didn’t know what that meant. However, I did know that I didn’t want anybody to touch my wrist.

The doctor came back. I put on my brave face and said that I was ready. He took my wrist in his hands and squeezed.

The polite and somewhat preppy boy on the exam table suddenly became something out of The Exorcist. My parents were strict about swearing. So, of course, behind their backs I had mastered that art. At the top of my voice, I put together the crudest string of words I could muster. If I could have spun my head around 360 degrees and then hurled projectile vomit into the doctor’s face, I would have.

The tone in the small room changed dramatically. It seems that doctors don’t appreciate being cursed out. He told the nurse to take my parents to the waiting room. I got scared again.

A second nurse unbuckled my belt and pants and told me to roll over. I heard the doctor ask the nurse for Demerol. Great, another shot. This time in the butt. I was grateful that the pain in my arm was now so intense because I did not even notice the next injection.

The doctor and nurse left the exam room and told me they would be back soon.

In what seemed to be a remarkably short time, I started to feel good; very good. There was no pain in my arm. All my anxiety and fear left me. Being in that exam room was quite nice. The colors and lights seemed warm, embracing. I smiled. Who cared if I fell and busted my arm in front of every pretty girl jock in my school? Who needed a girlfriend anyway? I was happy. It was good to have a broken wrist and Demerol coursing through the bloodstream.

By the time the doctor returned, I was high. Flying. The doctor set the bone quickly. The warmth of the ace bandage soaked in plaster was soothing as the doctor wrapped my hand, wrist and forearm. He could have done anything at that point. My hatred of the doctor from a few moments ago now was a warm friendship. Just as long as he kept the Demerol flowing.

I don’t remember much about the ride home. I do recall feeling at peace with the world. That night, sleep came easily. The next day, the Demerol was gone and my physical and emotional pains returned.

All these years later, this memory is what I turn to when I begin to lose empathy for any of my patients who have addiction problems. A drug, Demerol in my case, had taken me to a fine and great place. It evaporated all my pains, physical and emotional. The experience was effortless. I knew for the first time that a drug could change every aspect of how I thought and felt. Bliss was only an injection away.

Just as I instantly knew that my arm was broken, I knew immediately after the Demerol that I could be an addict. No matter what else I did in my teens and twenties, I never went close to an opioid.

In my thirties, I severely herniated the disc between C5 and C6. The pain was nauseating. I slept sitting in a chair for six months because I could not tolerate the pain when I lay down. My doctor asked if I wanted something for pain. Due to the intensity of the pain and the length of time before physical therapy was completed, he explained, there was a good chance that I’d become dependent upon a narcotic. He said that over the course of several months, I’d gain tolerance to the drug and he would have to increase the dose to get the same effect. In the end, I’d have to go through withdrawal. I remembered the sweet rapture of Demerol and said no thanks.

Very, very easily, at any point along the way, I could have made a different decision about opioids and me. I just think I was lucky. After the Demerol, I was acutely aware of my vulnerability to the drug. The place that Demerol took me to was seductive and intoxicating. It scared me. It still scares me.

It could be me on the couch in somebody’s office talking about my urges and cravings; how the drugs take everything away, even if for only one night. However, I had fear of losing myself in the drugs. And I am just lucky. With any small shift in fate, I could have made an impulsive decision and ultimately wound up in somebody’s office, a jail cell or a grave. A number of my friends and some relatives have traveled those other lonely and tragic paths.

These are some of the thoughts help me recover my rapport with the patient and get back into the therapeutic alliance.

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Restraint

September 25, 2009 — Mike

Some years ago, I was running errands in Providence and North Providence. Much like today, it was an unusually hot, humid Fall day. Eventually, I got hungry and thirsty. I remembered an Italian bakery in the area. It was in a rundown neighborhood but had great calzones. I drove to it.
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Once inside, I took my place in line at the counter. There were around twenty people in the bakery. Some, like me were in line; others ate at small tables.

Out of the corner of my eye, I saw a neatly dressed, cute, young black girl walking toward me. She was maybe 8 or 9 years old. I didn’t recognize her and wondered why she was looking at me.

She walked right up to me. In a clear, matter-of-fact voice, she said “You’re the man who grabbed me and held me on the floor at the hospital!”

It felt like everything stopped in the bakery and all eyes turned on me.

The girl was right, of course. I remembered her as soon as she said that I had restrained her. Her statement was a fair representation of what had happened.

That didn’t help my situation much. A pretty, young girl, with no malice, had just introduced me to the patrons and staff of the bakery as the man who grabbed her and held her down on the floor.

My hair is long and runs 3/4 of the way down my back. That morning, I was in a rush. I hadn’t taken the time to put my hair into a ponytail. I was in the process of renovating my house and was dressed in torn sweat pants and a grungy t-shirt. I was unshaven and sweating in the heat of the day. In short, I looked pretty much like a mess. That day I was more interested in running errands and working on the house than in making good first impressions.

Given what the girl said to me and my appearance, I couldn’t really blame anybody in the bakery if they thought I was a dangerous creep.

I squatted down a bit to get more towards eye-level with the girl. I asked her how she was since the last time we met. She told me that she felt a little happier. I asked if the hospital had helped her and she said not really. I said that I was glad to see her and hoped that things got better for her. We spoke for a few more moments.

By then it was my turn to order. I got a coke and a calzone. I got it to go instead of eating at one of their tables.

Let me offer a little bit of history. I worked in a psychiatric hospital for about 15 years and much of that was spent in the emergency room, or patient assessment service as it is now called. This girl was brought in for an evaluation. I did the initial assessment of her. At the end, she asked me if I thought she needed to be there. I said that I thought the hospital could help her. She did not like that response and tried to elope from the evaluation room. The room that we were in had doors that opened to a hallway and to the ambulance entrance. To stop her, I restrained her until other staff came and helped.

The girl was quickly admitted to the hospital and I did not see her again until maybe a year later in the bakery.

As part of my duties at that hospital and in various other of my jobs, I have been in more restraints than I can now count. While not commonplace, restraints happened with regularity. Usually, I did not think much about them afterward. To my knowledge, none of people I restrained was ever physically injured. I got hurt only twice. Except for those two instances, I didn’t see much point in thinking about the restraints after they were over. Although I will admit that for years, I watched my rearview mirror on the drive home, sat facing the entrance in restaurants, and took similar precautions. A fair number of people that I restrained or was involved in involuntarily hospitalizing made threats about what they planned to do once they left the hospital.

Clearly, this girl had a different attitude about the restraint. She was frightened, in a strange place against her will. The hospital was filled with strangers and she only wanted to go home. I physically stopped her from that. I can’t say for sure, but I believe it was the first time any professional had ever restrained her. So, for her, the event was unique, novel and wholly unwanted.

And that’s how she remembered me. I was the guy who grabbed her and held her on the floor in the hospital. She wasn’t angry with me. I don’t think she held a grudge because we chatted fairly easily for a few moments in the bakery. Yet it seems fair to say that she didn’t think I was a nice person.

She did not remember me as the clinician who spent an hour gently talking with her about her life. For her, I was not the man who suggested that the hospital could keep her safe and help her to feel better. Her memory of me was not one of jointly finding her strengths and trying to build her sense of self-confidence and optimism. All that is, however, what I remember of the time we spent together in the hospital’s ER.

In the bakery, I was in a strange place filled with strangers. She seemed quite at ease there. Maybe she lived in the neighborhood. I guessed so at the time because she was not accompanied by an adult. When she said that I had grabbed her, I felt ashamed, embarrassed and afraid. I did not know how the other people in the bakery would react. I feared a scene or worse. In addition, I felt badly because she seemed not to understand my situation in the bakery or at the hospital. I greatly wanted to turn and run out of there.

All in all, this was a very neat reversal of positions, courtesy of fate.

A number of years ago, the hospital made a policy that all restraints are reviewed with the patients once they become safe. But that could be done by staff that were on a different shift and had only second hand information about the restraint. I never reviewed that restraint with the young girl. She was sent to the children’s unit and I assume staff went over the event with her some time later. However, only she and I knew firsthand what happened in the room. Just the two of us knew the emotional bond that formed during the hour-long evaluation and was ruptured by the restraint.

Her memory of me remained as the guy who grabbed her and put her on the floor.

As I say, I left the hospital several years ago. I have no knowledge of their current policies on helping patients process being restrained. Perhaps they have included at least one of the staff actually in the restraint into the review with the patient. That would be a good thing, I think.

Why does this memory surface again now? There is no chance that I am aware of that I’ll be in a restraint any time soon. I don’t think it’s because it’s a similarly hot and humid day in early Fall. I do know that I am about to use a different type of coercion with a current patient. That’s something that I don’t like to do at all. However, I can’t come up with another option to keep him safe. Perhaps this memory has come to try to help me see my plan from his perspective. Alternatively, maybe I’ve been in a position of power with somebody else recently and pushed it too quickly out of awareness. Whatever event that was, the memory could be prompting me to pay more attention to it.

I’m not sure at the moment.

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Object Relations Theory and Anaclitic Depression: 1

September 16, 2009 — Mike

Anaclitic Depression or Anxiety Defending Against Depression

Today, I will start to explain the difference between an anaclitic depression and anxiety guarding against a depressive episode. We will open with a beginner’s introduction to object relations theory.

For this post, it’s not necessary to have read the previous posts. If you’d like, you can read the fifth post for a bit of background. However, again, that is not a requirement for understanding this post.

To understand anaclitic depressions, it is quite helpful to know a bit about object relations theory.
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Right from the start, let me acknowledge that I have difficulty writing about object relations theory in a simple, conversational style. For me, it is like conveying the experience of a warm sunny day while using the language of quantum field theory. Nevertheless, if we are to explore how anaclitic depression may relate to anxiety as a defense against depression, then we need some object relations theory.

Melanie KleinTo try to save us all some hardship with this topic, I will use a metaphor. Granted this metaphor is limited. For a more technical and historical explanation of object relations theory, you can start with a nice review by Sam Vaknin, Ph.D. Scroll down the page a bit and start at “XV. Narcissism and Schizoid Disorders – Melanie Klein.” For further information, you can also read Wikipedia’s entry for object relations theory and Victor Daniel’s website.

Imagine a large amphitheatre. On the stage is Robert. More accurately, Robert’s ego is on the stage. Behind him, instead of scenery and curtains, is the real world where he interacts with other real people. In front of him, the seats are occupied by all of the people with whom he has had significant experiences in the past. These are not the actual persons but are his representations of them. For example, his first grade teacher actually may have cared deeply for him and been a good teacher. However, in Robert’s experience, she was scary and hard to please. Therefore, his representation of her is frightening. This audience consists of the memories of his life.

To his left are the warm, loving people. It is from them that Robert gets self-soothing, guidance, support, etc. In the center are neutral figures. On the right is where the harsh, critical, angry and destructive persons sit.

To complicate things a bit more, the same person can have multiple representations. Robert’s mother can be seated on the left based on the time when she calmed him after a nightmare. But she can also occupy a seat on the right. This would be an unintegrated memory of the time that she wrongly accused him of a theft and punished him unjustly.

Depending on what is happening between Robert and the real world, the audience can shift. Some people will move their seat to the other side, some stay where they are, some may even leave the theater.

In a reciprocal fashion, and this is important, how the audience is arranged in the seats influences the way that Robert interacts with the real world and stores new memories of his experience.

Sometimes the audience is polite and accepting. They don’t interrupt Robert. They wait for him to address them or to recall them in memory. Consider this as a Zen moment. His object relations are in alignment with his experience of the world and criticism is suspended.

Other times, the audience can be intrusive. Out of the blue, a rotten tomato is thrown at Robert’s head. A torrent of unexpectedly harsh criticisms of his performance interrupts his dealings with the real world. Or, perhaps, a gentle, soothing sense of acceptance and love sweeps over him as he reads a novel late at night.

On still other occasions, the audience may start arguing among themselves.

Now the members of the audience may not all be exactly human. Granted, the most advanced of them look completely human. These patrons are well known to Robert and he sees them as reliable and fairly predictable. He has known them through good times and bad. Robert knows these patrons well. He sees them as reliable and fairly predictable.

Some in the audience look only mostly human. Their features are somehow not quite fully developed. Robert only knows one side of them. This part of the crowd can be confusing and unpredictable to Robert.

Then we have gooey, blob-like creatures. They are the least advanced persons in attendance. These are the raw, primitive introjects. Some are scarier than Frankenstein. Others are purely and exquisitely pleasurable and intoxicating. Even the gratifying blobs can be dangerous, though. There is a threat that they can consume you in their gooeyness. (Think of the allure of an urge to regress back to being a coddled, dependent child in times of high conflict.)

In our metaphor, the more psychologically advanced a person becomes, then the more that the audience will look fully human. It is likely that the psychologically mature person will not have multiple representations of significant persons. Instead, the mature person will have integrated the various experiences with, say, his mother into a coherent whole.

If Robert regresses or if a person is psychologically immature, then the audience begins to look more like the gooey blobs. There will be multiple representations of the same person, split off from each other. The blobs can unexpectedly shift positions depending on what is happening either in the real world or in the audience itself.

This should be adequate for our current purposes. There are many elements left out of this metaphor. For instance, I did not mention the drives interacting with the audience. Nor did I get into how object relations mesh with the various structures of the mind, e.g., the superego or the id. (Hints: gooey blobs are raw expressions of the drives in the id, but some might also be in the superego, and usually they are part object (as opposed to whole object) representations. Well-formed humans are in the superego or ego ideal. The left side is fueled by the libido and the right side is powered by the aggressive drive. Those in the middle either are decathected or are unrelated to the current experience with the world.) As I said, this stuff gets complicated fast. For now, we’ll leave this metaphor as it stands.

For quick reference, I made a pictorial representation of this metaphor. You can view it here.

We will now briefly leave object relations theory. In the next post, I will move on to anaclitic depressions.

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Anxiety as a Defense Against Depression: Part 8

September 9, 2009 — Mike

Couples Therapy for Robert and Julia (Romeo and Juliet)

Julia and Robert have come to my office. We are discussing their desire to elope.

I’ve just asked Julia if there is any way that her parents would agree to delay her return to their home island in Portugal.
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Julia: I tried to get my father to delay my trip. He went crazy on me. This is exactly what he said: “You’re going to São Miguel. And if you don’t go on your own, I’ll drag you there. You disgust me, you little bug! You worthless girl!”

I cried and cried. I said, “Father, I’m begging you on my knees, be patient and listen to me say just one thing.”

He just wouldn’t listen. He went on and on. “Forget about you, you worthless girl! You disobedient wretch! I’ll tell you what. Go to the airport on Thursday or never look me in the face again. Don’t say anything. Don’t reply. Don’t talk back to me.

“I feel like slapping you. Wife, we were cursed when we had her. She disgusts me!”

My mother and my assistant tried to help me. It was useless. The longer he yelled, the angrier he got. His last words to me were:

“If you don’t act like my daughter, you can beg, starve, and die in the streets. I swear on my soul, I will never take you back or do anything for you. Believe me. Think about it. I won’t break this promise.”

Then my father stormed out of the room.

Me: What did you do then?

Julia: I begged my mother and my assistant for help. I said, “Mother, don’t throw me out! Delay this trip for a month. Or, if you don’t delay, make my travel plans to my grave.”

Me: Did you mean that? Do you want to die instead of returning to São Miguel?

Julia: Yes, of course I mean it! How can I marry Robert if that happens? I’d rather die than live without him! If everything else fails, at least I have the power to take my own life.

Me: But what if they insist that you leave on Thursday or get thrown out of the house?

Julia: I have a plan for that.

Me: Can you share your plan with me?

Julia: Well, it’s not really my plan. I went to the parish priest after the fight with my parents. He’s from the islands and I thought he might have a solution for me.

Me: What did you say to him?

Julia: I said, if you who are so wise can’t help, please be kind enough to call my solution wise. Then, I showed him my knife. I told him, I’ll solve the problem now with this knife. Love joined my heart to Robert’s. Before I go to São Miguel and am married to another man, I’ll kill myself. You are wise and you have so much experience. Give me some advice. I want to die if what you say isn’t the solution to how I can be with Robert.

Me: What was his plan?

Julia: This is what he told me to do. He said:

“Tomorrow night make sure that you are alone. When you’re in bed, take this vial, mix its contents with liquor, and drink. Then a cold, sleep-inducing drug will run through your veins, and your pulse will stop. Your flesh will be cold, and you’ll stop breathing. The red in your lips and your cheeks will turn pale, and your eyes will shut. It will seem like you’re dead. You won’t be able to move, and your body will be stiff like a corpse. You’ll remain in this deathlike state for forty-two hours, and then you’ll wake up as if from a pleasant sleep.

“Now, when your father comes to get you out of bed on Thursday morning, you’ll seem dead. Then, as tradition demands, you’ll be dressed up in your best clothes, put in an open coffin, and carried to the church. Meanwhile, Robert will come here, and we’ll keep a watch for when you wake up. Then we’ll seal the coffin and nobody will be know that you’re not in it. That night, Robert will take you away to New York City. This plan will free you from your shameful situation as long as you don’t change your mind, or become scared like a silly woman and ruin your brave effort.”

Me: (I look at Robert) You know about this plan? What do you think?

Robert: I trust the priest. We’ve both known him forever. If this is what he thinks is best, then I’m willing to try.

Me: But suppose the medicine is too strong? Suppose Julia doesn’t wake up from the coma or suppose that she dies instead?

Robert and Julia together: It will work.

Me: But the priest is not a doctor. Suppose something goes wrong. Robert, how would you feel if something bad happened to Julia?

Robert: Well, I’d be the one to find her. So I’d just drink the same poison, and kiss Julia good-bye. That way I’d die with a kiss.

There’s no other way. Either we do what the priest suggests or she leaves the country next Thursday.

Me: (to Julia) You know about his plan to suicide if you die? Do you approve of it?

Julia: I wouldn’t say that I “approve” but I can understand it. I’m not worried, I’m not going to die so he won’t have to either.
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Me: Suppose we try to come up with a different plan. If we could find one, would you agree not to take the priest’s advice?

Robert: For me, I’m in favor of our plan. We’ve already discussed it. We both think it’s our only option and that it will work. No offense, but I trust my priest more than I trust you.

Me: Julia, what do you think?

Julia: I agree with Robert.

Me: Julia, you mentioned your assistant. She seems to know about your situation. What does she say?

Julia: Well, she was helpful in the beginning. But then she agreed with my parents. She said, “Since things are the way they are, I think the best thing to do is leave for São Miguel.”

Me: So you don’t think that she could help us come up with an alternative to your plan?

Julia: No.

Me: There’s nothing, then, that can replace your current plan?

Julia: No.

Robert: Can’t think of anything.

Me: Well, to be honest, this plan makes me nervous. It sounds too close to a suicide pact. Or that’s what could happen, anyway, if even the smallest thing goes wrong.

Robert: (talking over me) Well, it’s our only way to be together and we’re both willing to take the risk.

Me: Oh, gee, I forgot to tell my receptionist something. I’m really sorry but I need to step out for a second. I’ll be right back.

I go to the receptionist and ask her to call 911 for me. I tell her that the couple has a suicide pact and needs to go to the hospital for evaluation.

When I go back into the room, I going to explain what I’ve just done. Both of them are very angry. They threaten to bolt from the office. I explain that the police will be here before they get to the street. I also explain my rationale for calling the police and rescue. Their pact was too dangerous. My duty is to preserve their health and well-being. Therefore, I had to call the police. I offer to continue treatment after they are safe and stabilized.

Julia breaks into uncontrollable sobs. They make all sorts of objections and threaten to sue me for violating their confidentiality.

After a few more minutes, there is a knock on my door and the rescue team comes into my office.

It will surprise no one that I am not as bright as Shakespeare. Try as I would, I could not resolve the dilemma that Shakespeare created for Romeo and Juliet with a smooth therapeutic move. Just as in the play, the resolution could only come from drastic measures.

The Chorus tells us this in the opening Prologue: “For the next two hours, we will watch the story of their doomed love and their parents’ anger, which nothing but the children’s deaths could stop.”

This was not my intended treatment outcome. However, I have no alternative. I tried several versions of this post. I used every way that I could think of to solve their dilemma without involuntary hospitalization. None of it, though, rang true to the situation or the dialogue from Romeo and Juliet.

Their circumstances are too acute and progressed. Neither of them, in my opinion, can be trusted not to act on their plan. They might even devise a more risky, impulsive course.

As Robert says, they trust the priest more than me. Our therapeutic alliance is in its nascent stage and still weak. Their thinking is concrete and action-oriented. Interpretations of their situation and plan do no good in this case. For instance, I might try to point out to Julia that her plan has at least as much to do with parental rejection as it does with love for Robert. She plans to do to herself what her father threatened. Instead of his threat that she “beg, starve, and die in the streets,” she was planning a death in her own bed. Julia would laugh at me for that interpretation. The therapy has not progressed to the point where she could use such an explanation.

Furthermore, even on a more concrete plane, they reject my offer to help problem-solve and find other options.

Neither of them can identify a trustworthy external support. That is, of course, except for their parish priest. And he designed the plan to enter a drug-induced coma.

I have found few internal resources that either of them has to self-sooth or to improve their judgement and insight. They are both overwhelmed.

Their anxiety is fueled by a fear of losing one another. Additionally, for Robert, the fear of a return to deep depression is intense. The anxiety is propelling them toward ever more dangerous and hastily conceived actions.

Even though their plan stems from anxiety and is in itself intensely anxiety provoking, it keeps their hope alive. Seeing their plan as foolhardy would leave them without hope. And that would place them on the threshold of depression. So, rather than see the reality of their situation and cope with it accordingly, they lunge into anxiety and near irrationality.

I do not want to give the impression that all cases of anxiety guarding against depression lead to such an outcome. Recall Donovan Campbell; he certainly did not meet the criteria for psychiatric hospitalization.

Hospitalization could go either way for Robert and Julia. It might make them more emotionally and cognitively available for treatment. Or, they may lose their trust in therapists and shun any further therapy. At the least, the families will find out about their plans to wed. Any immediate repercussions of that can be handled in the safety of the hospital.

If any readers can suggest a viable alternative to involuntary hospitalization, I’d be appreciative.

I want again to acknowledge that the overwhelming majority of the dialogue for Robert and Julia comes verbatim from No Fear Shakespeare’s modern translation of Romeo and Juliet.

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Anxiety as a Defense Against Depression: Part 7

August 31, 2009 — Mike

This is the seventh post in this series. If you are just starting in this series, then it would help you to read at least the fifth post to get the background on today’s discussion.

As a refresher, this is a “case study” of Robert. He is a single male in his early twenties. Robert was recently in a Major Depressive episode and now presents with anxiety. The precipitant to the depression was Robert’s unrequited love for a woman. The anxiety came in the context of falling in love at first sight with a second woman. Robert is seeking treatment to help him plan an elopement with the second woman, Julia.
Venus, Cupid, Folly, and Time
Robert’s situation is a mess. For the past two days, Robert has acted impulsively. He was not using good judgement or insight. Julia has plans to return to São Miguel, a Portuguese island, and may marry a man there. Both Robert’s and Julia’s families intensely dislike each other. None of their parents would approve of the marriage. Further, Robert is at high risk for a relapse back into Major Depression. Ominously, Robert says that he would rather kill himself than live without Julia. However, today there is no inclination to suicide and he anxiously anticipates happy days in the near future.

We are still in Robert’s initial evaluation. I am about to present him with treatment options. In the last post, I ruled out offering him help in problem solving his elopement.

There is possibly another way to meet Robert’s request for a speedy resolution to his anxiety symptoms and improving his ability to plan the elopement. That would be a referral for a psychiatric medication evaluation.

I could suggest to Robert that he see a psychiatrist. He can ask about medication for the anxiety and the depression. An anxiolytic might provide relief from most of the anxiety symptoms within a half-hour of ingesting it. Freed of the anxiety, he could think more clearly. Robert could then probably figure out for himself how to marry Julia. The anti-depressant, on the other hand, would take 4 to 6 weeks before having an effect.

Perhaps, though, the anxiety serves more masters than we have seen so far. Symptoms can have a pig pile of underlying motivations. More formally stated, Robert’s anxiety might be overdetermined. That is, the ego is trying to satisfy a number of demands on it through the one symptom of anxiety. We have already seen that Robert’s anxiety is a defense against a return to depression and the possibility that time and events (e.g., Julia’s return to São Miguel) would prevent him from marrying the woman he loves. Let’s see if there might be other factors in his anxiety.

Robert says that he is anxious in large measure because he wants to be married as quickly as possible. He can then be with the woman he loves. He says that he wants it so badly that he cannot think straight. However, one potential subconscious purpose that the anxiety may serve is exactly the effect it is wreaking. Maybe one point of the anxiety is specifically to disrupt or prevent Robert’s elopement.

There are many reasons why Robert might subconsciously use anxiety to derail his marriage plans.

In Freud’s “The Ego and the Id,” he writes “…the ego seeks to bring the influence of the external world to bear upon the id and its tendencies, and endeavors to substitute the reality principle for the pleasure principle which reigns unrestrictedly in the id.” The reality confronting Robert stands directly opposed to marrying Julia. Robert is aware of this. His desire to elude reality accounts for some large measure of his haste to wed. Robert’s ego could use the anxiety as a means to bring reality to bear on his impulses.

Furthermore, the marriage would bring parental disapproval and rejection. The anticipation of this disapproval and rejection may cause some anxiety. He can also anticipate his own guilt feelings about breaking their rules. Expecting guilt in the future produces anxiety as well.

Freud puts it this way in “The Ego and the Id:”

“As a child grows up, the role of father is carried on by teachers and others in authority; their injunctions and prohibitions remain powerful in the ego ideal and continue, in the form of conscience, to exercise moral censorship. The tension between the demands of conscience [what Robert knows he ought to do in the eyes of his parents and society] and the actual performances of the ego [Robert's scheme to marry Julia without his parents' blessing or knowledge] is experienced as a sense of guilt.”

After all, his parents do seem concerned about him and love him. His father has said: “If we could only find out why he’s sad, we’d be as eager to help him as we were to learn the reason for his sadness.” (Act 1, Scene 1, Page 8 ) His mother also expressed concern for him: “Oh, where’s [Robert]? Have you seen him today? I’m glad he wasn’t here for this fight.”(Act 1, Scene 1, Page 7) We can reasonably assume that hurting his parents would cause guilt for Robert. Therefore, the anxiety would be protecting him against hurting his parents and the guilt that he would experience for bringing suffering to them.

We could hypothesize a number of other subconscious uses for the anxiety. But we’ll leave it here for the time being.

There are many instances where it is desirable to remove or reduce severe anxiety as quickly as possible. In those cases, anxiolytic medications are very useful. I think, though, that Robert is better off without the immediate introduction of medications. Removing the anxiety removes some of the emotional barriers to carrying out his impulse-ridden plans. That is, in my judgement, it is in Robert’s best interests not to elope in the next few days.

Getting some Klonopin or Xanax or another anxiolytic today would be roughly the same as helping him problem solve the marriage today. For the same reasons I ruled out helping him problem solve the elopement, and the reasons mentioned here, I would not want him to get the medicines now.

Some bad situations have unseen benefits. In Rhode Island, the state where I practice, it takes about six to eight weeks for a new patient to get in to see a psychiatrist. Usually that is thoroughly undesirable. But not this time. Such a lengthy wait means that I can refer Robert to a psychiatrist today. However, he won’t get an appointment any time soon. That, in this case, is a good thing. It will buy some time to work through the complexities of his crisis.

Now I can tell Robert his diagnosis: Panic Disorder without Agoraphobia. I provide him with some information about this illness. In addition, I give him the names and phone numbers of several psychiatrists.

I then have to tell him to expect about a two-month delay before he can get an appointment.

Obviously, Robert does not like this recommendation. He sees time as an enemy. Two months is far too long to delay his elopement. For one thing, Julia will be out of the country by then. There will be no wedding if that happens. Depression lurks there.

Honestly, I agree with Robert. Two months is too long to wait for a remedy to his problems. He is in a lot of emotional pain and turmoil. I also agree that the situation is complex. It needs to be broken down into its component elements and sorted out. Moreover, there is another person involved, Julia. And in her, I find an option that might satisfy everyone.

I suggest to Robert that we schedule another appointment, as soon as can be arranged. If I get a cancellation, the appointment can be as soon as tomorrow.

I also propose that he bring Julia to the next appointment. We can get her point of view. After all, it is her elopement/wedding, too. At the least, a couples session would give the two of them a chance to look rationally at their situation and to get to know one another better.

In the short-term, my goal is going to try to find an alternative to an abrupt elopement. Perhaps Julia can defer her trip to Portugal. Or maybe between the two of them, they can identify the parent or another authority figure who is most likely to be sympathetic to their situation. We could then try to enlist that person as an ally to the couple. Potentially, that third person could come in at the third session. At this point, I am not sure what assistance Julia can be. But starting couples counseling is the best option I can think of at this point.

In the long-term, I want to provide Robert with treatment to address his vulnerability to both depression and anxiety. Providing successful short-term couples counseling around the elopement may be the best way to engage him in therapy.

In the next post, I plan to take a brief look at another possible explanation of Robert’s anxiety: adult anaclitic depression.

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Anxiety as a Defense Against Depression: Part 6

August 26, 2009 — Mike

If you are just picking up on this series, you might do well to start by reading at least the last post. Today’s post will refer extensively to the last one.

To review where we are in this “case study,” Robert has come to my office about 36 hours after meeting a woman. He and she have fallen in love at first sight. Robert was in a Major Depression until meeting her. His condition is now one of anxiety verging on panic.

The couple’s situation is fraught with dangers. Julia is soon to return to a Portuguese island and possibly marry a man there. Both Robert’s and Julia’s families are at odds with each other. Each of the families would forbid the marriage. Last, and certainly not least, Robert could fall back into a severe depression if the new relationship fails.

Just as Romeo sought out Friar Lawrence to help him solve his dilemma with Juliet, Robert has come to my office to get help with his situation.

This is a tricky case to bring to a successful conclusion. Robert wants a quick and practical solution. He insists on planning his elopement and later announcing the fait accompli to their families. He is not seeking on-going therapy. Robert believes that all he needs to do is marry his love, tell the families and the rest will more or less sort itself out. He is an impetuous young man. Robert will not tolerate me dilly-dallying with clinical nuances.

In Shakespeare’s play, “Romeo and Juliet”, Friar Lawrence provides the service that Romeo requests: help getting married. To be fully fair to the Friar, he does say to Romeo “Go wisely and slowly. Those who rush stumble and fall.” [Act 2, Scene 3, Page 4] But, despite any misgivings, the Friar marries the couple.

This course of action has a terrible outcome. Romeo, as we know, suicides when he believes that his new bride is dead.

“Come, bitter poison, come, unsavory guide! You desperate pilot, let’s crash this sea-weary ship into the rocks! Here’s to my love!
ROMEO drinks the poison.
Oh, that pharmacist was honest! His drugs work quickly. So I die with a kiss.” [Act 5, Scene 3, Page 5]

From a clinical point of view, this tragic end came from overlooking both the underlying psychological conditions and the real external stressors. Marrying Juliet may temporarily alleviate Romeo’s anxiety. The marriage gives him the false belief that the external dangers are vanquished. Moreover, eloping does not address Romeo’s vulnerability to severe depression.

In one sense, it would be easy to help Robert problem solve an elopement. Let’s play this option out for a moment.

After all, I am human. It would be hard to resist this good looking, articulate young man’s impassioned pleas for help now, today. Then there is his seductive, raw belief in true love. On another front, if I practiced in an HMO or a capitated system, there would be pressure to get this case done with the least expenditure of resources. Long gone are the days when the first four sessions were considered to be the initial evaluation. Active treatment started only with the fifth session after an exhaustive collection of psychosocial history and mental status evaluation. That was then.

Quite possibly, Robert’s treatment could be completed in the first session. I open my laptop computer and google “marriage requirements RI.” Google then helpfully provides me with the link to About.com’s summary of the Rhode Island marriage laws. The requirements, as it turns out, are pretty simple.

My next step is to print the page and give a copy to Robert. Together, we plan how he and Julia can meet each of the steps necessary to get married. I encourage Robert to take written notes on the back of the page. Ten minutes later, we are done. Robert feels a great sense of relief to have a concrete plan. He thanks me profusely and leaves without scheduling another appointment. I have a sense of satisfaction in providing almost immediate relief for his symptoms and giving him the treatment that he requested.

The technique of improving a patient’s problem solving abilities is certainly a valid clinical tool. According to Wikipedia, this method has been studied for over 100 years. Mills, Reiss, and Dombeck have written about improving a person’s “self-efficacy.” This is the “belief in your own effectiveness as a person, both generally in terms of managing your life, and specifically with regard to competently dealing with individual tasks.” Positive self-efficacy helps to “decrease people’s potential for experiencing negative stress feelings by increasing their sense of being in control of the situations they encounter.” Thus, the choice of improving Robert’s problem solving skills for the task of getting married to Julia appears, at first glance, to be a good tactic.

However, I would do well to recall Romeo’s fate in my treatment recommendations for Robert.

As Mills, Reiss, and Dombeck also point out, “The perception of being in control (rather than the reality of being in or out of control) is an important buffer of negative stress.” In Robert’s case, helping him to problem solve how to elope only improves his perception of being in control. It does virtually nothing to address the real world stressors and his risk for depression.

Moreover, the odds are that the passion will fade for Robert and Julia. Acevedo and Aron studied various types of love and the outcomes in their article “Does a Long-Term Relationship Kill Romantic Love?” They found that:

“Results from the factor analysis and correlations with satisfaction support the notion that in long-term relationships, romantic love and obsession are quite distinct: Romantic love (without obsession) is positively associated with relationship satisfaction, but the obsessive aspect is negatively associated with it.” (p.61)

At the time when Robert enters the office, he is quite obsessed with Julia and his quest to marry her. He barely mentions her personal qualities. In fact, Robert and Julia know very little about each other. They have little information or shared experiences upon which they can ground their romance.

As Friar Lawrence observes about Romeo’s love for Juliet:
“Young men’s love then lies
Not truly in their hearts, but in their eyes.” [Act 2, Scene 3, Page 3]

Acevedo and Aron’s work indicates that even without the tragic outcome in the play, Romeo and Robert’s loves are likely to be short-lived.

Problem solving the elopement, then, is likely to yield only a temporary relief of anxiety and leave the much bigger problems lurking in the background.

The following is my own impression and is not a valid legal opinion. If a clinician did choose this route, I do not see that the families would have any firm basis for legal recourse against the clinician. The practice of improving problem solving and self-efficacy is well established. In addition, there are many, many intervening variables between the time of the interview and the outcomes of either suicide or falling out of love. Those variables would make it difficult to pin the blame on negligent treatment. In the lawsuit of Palsgraf vs. Long Island Rail Road, an employee helped a man get on a moving train. This resulted in a domino effect ending with the injury of a woman. The court ruled however “If the harm was not willful, he must show that the act as to him had possibilities of danger so many and apparent as to entitle him to be protected against the doing of it though the harm was unintended.” The families, I think, would be hard pressed to show that the clinician either intended harm or could reasonably see the “possibilities of danger so many and apparent.”

In summary, helping Robert problem solve his elopement would be what Robert wants. A “successful” one-session treatment would please any cost-conscious administrator. Problem solving is also a well-documented clinical strategy. There seems to be little legal risk to the tactic.

However, for all the reasons mentioned above, it would be in Robert’s best long-term interests not to give him what he thinks he wants. The trick is going to be in convincing Robert to tolerate the anxiety and hold off on his impulsive plan.

In the next post, we will investigate other treatment options for Robert.

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