Saturday, August 11, 2007


This one's been simmering in my brain for a while. With our sidebar voters telling us they like psychotherapy posts, I figured it was a good time.

So my very confabulated patient comes to therapy in a state of acute distress. His wife died unexpectedly only weeks before; he is tearful, angry, and sad with heart-wrenching poignance. He's lost his appetite, he pines for her, he misses her and sometimes things as trivial as a commercial she'd commented on will make him burst into tears. On the flip side, he's back at work, taking care of his kids and their needs, and while he's distraught, he's not feeling guilty or suicidal or having anything very strange happen. He has no history of psychiatric disorder and he has a lot of support from family and friends. While everyone is concerned and trying to help him cope, no one has commented that his reaction to this tragic event is any thing other than what one might expect. In a word, the patient is grieving.

Acute grief alone is not usually a reason people seek psychiatric treatment. I listen, I offer some reassurances, and while I'm happy to be there for him, there is not much to do. Time will help. Time will help a lot, but it may take a lot of time.

"What made you feel you needed to see a psychiatrist?" I asked. I tried to say it gently, not as What You Doing Here? but simply as a question of Is There More To This?

"Losing my wife," he said, "Has brought up some old stuff for me."

His stories poured out. It was a difficult one with lots of early losses, family chaos with some periods in foster care, neglect and abuse. A lot of struggles, and a lot of room to create psychopathology. But there was none-- this was a man who owned his own business, had devoted employees and friends, a single marriage of many years, children of whom he was proud, in short-- a full and functional life. That's not to say there hadn't been hard times or that he'd never struggled as an adult, or even that life was perfect, but he didn't have a mental illness and he was able to love, work, and sustain meaningful relationships.

The question, I thought, and maybe I even said it, wasn't why this man was having problems now, it was why hadn't he had problems before.

"You've had a lot to deal with, " I said (--that's about as profound as I get).

"Yeah, but what can you do? I'm not much for dwelling in the past, but lately, I've been thinking about this stuff again."

He's right, of course, that if one can put the past aside and deal with life as it comes, that's better. It's when the past gets in the way of the present and future, or when the patient just can't move on, that it becomes mandatory to explore it in therapy. I'm left to wonder, though, why some people are crippled by stories that don't sway so far from the norm of what life deals, and others soar after enduring the extremes.

He came for a while, told his stories, grieved intensely. Mostly I listened, often I wanted to cry myself.


Rach said...

I'm left to wonder, though, why some people are crippled by stories that don't sway so far from the norm of what life deals, and others soar after enduring the extremes

Dinah... I've spent many an unsuccessful therapy session trying to figure out the same thing...

And what I've come up with is something along the lines of the following: the "normal" baseline that each of us experiences is so different and unique from everyone else that we don't necessarily know what is developmentally, socially and pathologically "normal" or not. As a psychiatrist, I'm sure you're in a much better position to objectively evaluate people's experiences and whether they are considered to be maladaptive or otherwise outside the realm of usual life experience. But for most people (including myself) what do I know? I just know what I'm living through at that time... And so what do I do... I trudge a little further forward and hope that all hell doesn't break loose.

Aqua said...

This is where I start thinking the difference exists, not in the person's life events, but in their genetic and biological make-up.

I think I had a pretty good upbringing. I had some problems; a super authoritarian, borderline physically and mentally abusive, policeman father; moved to a new town every 2-3 years for his work while growing up; became the "rebellious cops daughter" so I could fit in; problems with alcohol and binge drinking at 13; parents divorce comes out of nowhere at 16; I begin having lots of bad relationships/outrageous casual sex.

...But I saw many of the people around me doing the same things/going through the same things.

On the other hand I had an unbelievably supportive and loving Mom, great sisters, lots of friends, was outgoing, vivacious, hard working. Graduated from university with 2 degrees, Worked at a high level, well paid job for years...and then I just fell apart at 35-36 and I cannot seem to dig myself out of this latest depressive episode.

My depression's have always just come on suddenly and for no apparent 18 I would just suddenly get depressed for weeks, then I'd have a period of feeling great (sometimes invincible), then a few months of depression...cycling ad infinitum...and each episode seemed to get worse/last longer (this happened numerous times) and then at 29 a MDE for couple years, at 31 another year or so in an MDE and now at 42 I've been stuck for 6 years in this MDE. I'm so severely depressed that most days I have a hard time functioning.

I don't deal well with stress, but I feel I have an inordinately sensitive stress:stressor response ratio. I always have been highly sensitive since I was a kid. I think that is inate in me and maybe has made me less resilient than others.

My childhood was no worse off than most people's and probably better off than a lot of people's. I think the difference for me is my biology...which impacted my stress response, which made me react in certain ways to stressors.

I also had numerous head injuries as a kid too (had a concussion at 6, another possible concussion at 16 when I knocked myself out diving into the pool, and a bad car accident ending in a concussion at 17 and I wonder if those have affected my mood stability/and lability.

I'm noy saying psychosocial and/or environmental situations did not impact my mood, but for me I am certain it is more than that.

Interesting topic.

Aqua said...

I forgot to mention that my family has a history of psychiatric illnesses: On Mom's side: uncle and cousin have bipolar disorder, Mom had MDE for years after my Dad left... G'ma on antidepressants for years

On Dad's side: G'ma had panic and anxiety attacks, had a hyperthymic personality and was an alcholic, also G'pa a wild alchoholic and Dad drinks and has had one (that I know of) diagnosed panic attack...Which seems totally out of his character/persona as the "in control". Period. Policeman. Go figure.

I suspect my family history points towards a genetic predisposition for the MDE's, the bipolarlike cycling and the anxiety problems I have.

Anonymous said...

Oh gosh, I need to clarify here: I do believe that psychiatric illnesses are caused by biology (genes, whatever, call me when the answer comes in) and that childhood relationships likely have nothing to do with the development of many psychiatric disorders.

These early relationships, however, are often the focus of discussion in psychotherapy, and I do believe they influence the patterns of relating that people carry throughout life.

Anonymous said...

And in Portugese

Funny story from my life:
My younger teenager asked what I'd blogged about today. I told her "Resilience." Later, she asked what I wrote about Resilience. I gave her a quick summary of the post, to which she said, "But what does that have to do with Brazillians?"

Anonymous said...

This is really interesting Dinah.

I have often wondered the same thing! I had a bit of an unsuccessful childhood, in various ways, but I try to keep a lid on it.

I try very hard not to make the same mistakes that I made before and that my family made. Maybe it's a self-awareness thing?

Right now I'm writing a book and some memoirs of my childhood and I've been thinking about trigger points.

For me they've been when my children reach the ages where I had some profound experience as a child.

I have to step back and take stock and realise where the feelings I have are coming from and then try to consciously choose whether or not to let them surface.

Heather W. Reichgott said...

On "what can you do"--
I've had a few moments in pastoral counseling recently when I've had to just say to the parishioner "ok, the reaction I'm having is because you just told me all this stuff that is normal for you, but it's new for me. I don't expect you to be as shocked or overwhelmed as I am just now. In fact, I think you're handling it great. So why did you bring it up today?"

They don't give us minister types nearly as much training in counter transference and all that. But yes, many times, the best I can come up with is "whoa... that's a lot you've had to deal with."

(wife of Gerbil, who got me hooked on shrink rap via the podcasts.)

Sarebear said...

Nice pic of what looks to be Goblin Valley, Utah! I was just there in late June (oy, the heat!!!) and it was marvelously strange! I felt guilty for my mind's tendency to see phallic shapes, but really, how could it not? I've had a couple pics in a post draft for a while now, that I haven't finished the post on.

If you've seen Galaxy Quest, a part of that movie was shot in Goblin Valley. If it hadn'tve been for my stupid knee (that I'm probably having a laparoscopy on this week, aned these x-rays I have of it are funny) I would've gone down into the "goblins" too.

Probably would've looked alot less like a forest of giant penises (or penii?) from down there . . . . it's been awhile since you've worked in the MNP tag, so I just had-ta. (Clink, you are involved in a good pun (not involving MNP) in a comment I just made in the duck post on Rach's blog; I mention this because I know you like a good pun!)(

Anyway, sorry to ramble, I need to go to bed. I'll actually have an OT comment soon, depending on how this stretch of days off from work my hubby has that luckily coincide w/my daughter being away!

Zoe Brain said...

There are lots of quiet heroes in the world, dealing with this kind of thing. The death of a spouse, or worse, the death of a child.
How do they do it? And how can we help?

Aqua said...

I definately didn't think you thought otherwise. In my post I was just thinking about resiliency and its reasons for being in some and not in others. (although I think many who survive a serious mental illness, especially when medications and/or therapies aren't working...are pretty darn resilient:>)

I was just thinking that the difference between one person who resiliently gets through a horrific life seemingly unscathed and the person who ends up with a full blown mental illness when they seemingly had a pretty good life has much to do with biology and genetic

...and maybe the people in between, the people who need therapy, but may not have a mental illness, are somewhere in they had the biology or genetics, but not both, or they had both, but where brought up in a good environment.

Or maybe they are headed towards a mental illness and therapy is an intervention to help them take steps to avoid that tipping point.

That's how I look back and see my life...I could manage just so long, and with just so many stressors...and then it all fell apart.


Anonymous said...

Hmmmm..very interesting topic. I find myself just like the fictional patient. Sometimes I have even had to ask myself, "Why do I not react in a negative way to this stressor?" I have to agree that it must be genetic. I do see a shrink, because of situational stress--cancer, etc. A lot of times I wonder why I am there at all. I like to think it is because I am getting the chance to do some good personal work like seeing my life in the future as a widow, or trying to see what is most likely going to happen with my husband's cancer so I am not slammed with shock. Still, a lot of my sessions are about what friend's would talk about. Music, travel, kids, etc. The best thing is that my Dr. does justify my grief over losing someone to cancer. The unfairness of it all. there is nothing else to say about it. It is just life..and I hope that I am expanding my horizon and growing as an individual.

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Anonymous said...

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Your Mother said...

I'm left to wonder, though, why some people are crippled by stories that don't sway so far from the norm of what life deals, and others soar after enduring the extremes.

You mean, psychiatry/therapy doesn't have the answer? Interesting!

Anonymous said...

John P. Wilson has a chapter in one his books (The Post-traumatic Self) that is all about resilience. It is hard to disagree when he writes that it arises from a confluence of many factors (duh)but overall, he tends too much to the tautological in his arguments.

Heck, if we could not rely on tautological reasoning, there would be fewer psych patients and fewer shrinks. lol

Anonymous said...

I like reading your posts and I usually post under my own name but to save face (my husband's face) I think I need to publish this anonymously.

My husband's family is unlike my own and I am having a hard time dealing with some issues and them. Recently I have heard some horror stories that only exist on the after school network on television.

My husband is having difficulty remembering large chucks of his childhood. It is not something he has mentioned before, but he has been mentioning them little by little after the death of his mother. (I might mention here that he refused to go to her funeral although I begged to go with him.) He remembers good times with his grandparents but rarely remembers one good thing about his life with his parents or siblings.

I am worried to death about him. It seems that when he talks with his family via phone, his problems or thoughts seem to intensify.

I've told him I think he needs to see a psychiatrist and not just "talk things over with me," since I am so close to him.

Mind giving a little brief free psychiatric advice?

NeoNurseChic said...

Very good post - I like it, and it's made me think. I've actually been thinking about a comment since I first read the post. So I'm going to try to leave a comment and see how it turns out! I feel like my thoughts on this are still sort of forming.

The thing is, I have always considered myself to be pretty resilient in my own way. My college piano teacher said that I was the most tenacious student he'd ever had - and I think my own tenacity often is the reason for my resilience. But then, I think to myself - I grew up with both my parents married, loving family... But those things under one roof does not equal a life without struggle and challenges.

When I was in high school and trying to get to a psychologist, my mom would say to me that if I couldn't handle these "simple" problems, then she worried about what would happen to me when I hit life's big hurdles. I guess, in a way, she was worried that I was not resilient at all. It's kinda funny - but I've always been activity intolerant - I almost passed out in Disney World Magic Kingdom after we spent the day prior in Epcot - all because it's too much for my body. I don't tolerate extremes in temperature, hunger, thirst, fatigue very well - physically. And the physical breakdown for me leads me to be emotionally fragile at times.

But then I look at the last 6+ years....what I've been through. I went from straight A's to barely keeping my head above water because I spent long periods of time in the hospital, going to doctors offices, and basically overhauling my entire life to accomodate a sudden change in my health. However, I still graduated with honors twice. I lost almost all of my friends. I learned to be very self-sufficient because I had to be. I probably still talk to my parents far too many times a day - all because when I lost almost all of my friends, I needed someone to rely on emotionally...and fortunately, they were there for me. Getting the headaches and ending up in the hospital really were the small changes compared to the things they impacted - it was like the domino effect in my life - or the flap of a butterfly's wings causing a tidal wave on the other side of the earth. That's been the story of my life the last 6+ years - one tiny change causes a whole cascade of huge challenges and hurdles.

So I go to my psychiatrist 1-2x a week. Recently, I was discussing my medical history with a pediatric endocrinologist, and he said to me, "And what about the mental health part? Surely you're facing the depression and anxiety that come with all of these things." He was one of the first doctors I've ever spoken to who commented on how all of these things might impact my psyche. Hugely... I used to tell people that I only went to a psychiatrist to cope with living with a chronic, disabling illness, but that's not really true anymore. Much of what we discuss and deal with has nothing to do with having an illness at all.

So am I less resilient than I thought? My mom used to say to me that she knew people coping with cancer who didn't need to see a therapist - and here I was just coping with these much smaller problems and I felt I needed to talk to someone. I don't think it makes me less resilient. I am resourceful... I have survived persistent suicidal thoughts for years. For that, I am resilient. I have continued to live in spite of all the things that have taken place in my life. Sometimes all I do is live, but even that is surviving on some level. I would love to get to the point where I am thriving and doing well, without those things inhibiting my life any longer, but I don't know when or if that will be. I look back at the challenges that I have overcome - and the things I have accomplished in spite of those challenges - and I hope that it inspires somebody else faced with a similar set of challenges. It hasn't been pretty, but I have continued to survive.

So it's not resilience how you are discussing it - how someone goes through unspeakable tragedies and comes out without any mental illness... I have come out with depression, anxiety, ADD (well, the ADD - has nothing to do with the rest of it!). But I don't see myself as less resilient. I see myself as more resilient for continuing to survive and continuing to live my life in spite of the challenges that have been thrown in my path, designed to take me down. I have dreams for how I wish I could live - but given what little energy and reserve I have, I think I do pretty well!

Sorry for the length. This was an excellent post which made me reflect quite a bit. Hope I didn't bore everyone to sleep...and hopefully people aren't sitting there rolling their eyes thinking I should be less self-centered and introspective! I can't help it at times I guess - I try to focus my energy on others all the time, but so much of what has gone on in my life forces me to examine things deeply! I know I'm not the only one!

Take care,
Carrie :)

Olive said...

So, I think the real million dollar question is, regardless of why some people have more resilience than others, for those who don't have much, is it something that can be taught?

Sarebear said...

I've been away, so I've missed the boat on this one. Apparently I've got some catching up to do, but here's some hugs for you three.

Ducking out now,