PsychSense: Sensible Psychological Solutions

Question and Answer

Anne Writes

I am worried about my brother, he is depressed and refuses to consider going for counseling or medical care.  What Can I do to help him?

Answer from Dr. Duffy:

It is very difficult to help someone who refuses help. First I suggest you encourage him to tell you what his objections are to getting help. Perhaps talking to you will help him clarify and overcome his fears or objections. If you have not already done so you may wish to give him information on depression as a real medical illness, not a weakness of character.  The Mayo Clinic website is a reliable, good source of such information. Perhaps it would be better to encourage a friend of his to discuss the situation with your brother and tell him what he is seeing. Often family members are not the best ones to convince another member.

If he still refuses or won’t talk about it, I suggest trying a little guilt. For instance, the effect of his depression on those he loves who love him. If he won’t get help for his own sake perhaps he would do it for those he loves.

If he still refusing dispite your efforts you need to set limits. This means not always  being available to help him or to listen to him.  Sometimes a type of tough love is called for in situations like this. You need to take care of yourself, and let him know that although you love him, this is what you must do for your own sake.

If you think he is suicidal you may need to call the police to have him forced to have a psychiatric evaluation. I know this will be difficult to do and he may be angry. However this may save his life.

My last suggestion is to give him information on fish oil. Some studies show this to be just as effective in treating depression as antidepressants. Many people are less resistant to taking  3-4000 mg of fish oil a day

Question From A reader

 Dear Dr Duffy,

Where do I begin? First, a little background: I am a 23 year-old female. I have been married for 4 years to a man that is 20 years older than I. We have had two children age 3 and a newborn. We plan to have more children. They are a wonderful family.

For several years I have felt frustrated and disappointed with life, although I realize that I am extremely fortunate and very blessed. There is an emptiness inside that seems to echo louder with time and yet I cannot put a finger on what is eating away at me.

 Earlier attempts at communicating with my husband regarding these issues have left me feeling weak, unimportant and angry. He doesn’t seem to hear me in anything that I say, so anymore I don’t say anything other than superficial conversing. While I am constantly surrounded by my immediate family I feel extremely alone.

 I have never been a morning person, however, I sleep in as long as my children will allow me and I dread the new day for the tireless effort that will be required. I love the evenings because the day is finally over and sleep offers one slight reprieve of the emptiness. Even simple tasks seem dreadfully difficult.

 I work at home but I avoid my duties and responsibilities as long as possible. The house is often in disarray and I can’t get my work done. It seems that most things that I start I cannot finish.

 One of the only things that gets me through the day is the thought of alcohol at the end of the day, after the boys are in bed. I can easily drink 20-30 ounces of wine in an evening and be able to function quite well.

My biggest regret is that I am breastfeeding, and while I try to time things in the evening so that he doesn’t nurse until the early morning hours, occasionally he wakes up before then and needs to feed. Each morning I resolve to stop drinking but the strong desire to slip into oblivion at the end of the day is too much to resist, and so the cycle continues.

 I used to create fantasy stories that I would live out in detail in order to escape the reality of this life. In a way I used it to cope with reality, and have always enjoyed the stories. However, since I have married and have children I have little to no time to engage in my fantasy worlds.

 When I do things I enjoy my husband gets angry because I am neglecting my other duties and shoots down the small enjoyment I had, so I am back to simply mulling through life and feeling miserable.

 I don’t feel that I can trust my husband with my inner feelings. I feel myself withdrawing from him. I avoid physical intimacy and have a strong desire (sometimes an uncontrollable urge) to pull back from his advances. Why do I avoid him; what is wrong with me?

•  How can I engage in life with joy and enthusiasm?
•  How can I rekindle my relationship with my husband?
•  How can I stop drinking and find something else to take its place?

 I do not want to live like this… and I pray that the Lord will help me through. If you have any suggestions, I would be very grateful.

 -Alone and desperate

Answer From Dr. Duffy 

Dear Alone,

 There are a number of things about your letter that I would like to respond to.

 First I believe you may be depressed. This could be postpartum depression or may have been present before as some of your comments suggest. Here are some things you said that make me concerned about depression.

• “Emptiness inside”
• “I used to create fantasy stories that I would live out in detail in order to escape the reality of this life”
• “The house is often in disarray and I can’t get my work done.”
• “It seems that most things that I start I cannot finish”
• “…sleep in as long as my children will allow me”
• “I dread the new day for the tireless effort that will be required”
• “I love the evenings because the day is finally over and sleep offers one slight reprieve of the emptiness.”
• “Even simple tasks seem dreadfully difficult.”

 Of course I cannot make this diagnosis over the internet, I encourage you to be evaluated by a mental health professional. You may need an antidepressant but it will not help much if you continue with the alcohol.

  Second: Your relationship with your husband. Although you start off saying what a wonderful family you have, you quickly talk about how unsatisfying your marriage is. It is certainly not the situation where you should have more children.

 My suggestion is that you tell your husband that you are very unhappy and the situation must be taken seriously or it most likely will get worse. Be honest about your feelings and worries. Couple therapy may be necessary. If he refuses to go you need to find a professional to talk to for yourself. This will help you to figure out what to do next and help you to answer your final questions.

 Third: Your alcohol intake. It sounds like you have a serious problem because you cannot stop despite multiple attempts and worries about breastfeeding. Many experts feel 2 drinks will not hurt the infant but anything over that may. (you are way over this limit!)

 The other issue is alcohol makes depression worse!  It is hard to know what comes first the alcohol or the depression. My suggestion would be to get some help to stop drinking first. This can be done through many programs and AA. You must do this and it sounds as if you cannot do it alone.

 Please get some help, for your own sake and for the sake of your children, and your marriage. I am truly concerned about you, and send you my best.

 Recently a teenage boy who jumped out of a dorm window while drunk left a local college campus and community deeply shaken. He will probably be paralyzed for the rest of his life.  After hearing about this I read a distressing study about teenage self-destructive behavior. The Child and Adolescent Self harm Study From Europe (Brunel University September 4, 2008) reveals more disturbing data about teenagers and cutting.

1.    One out of four cases is not reported and 25% had not told anyone else. How many do we not know about?

2.    Alcohol is a factor in one out of five cases, drugs in one out of eight cases.

3.    Six in ten self-harmers talk of suicide.

4.    Thoughts of self-harm are said to occur in 6 out of every 10 teenage girls and 1 in 10 boys.

5.    59% of these teenagers said they wanted to die.

How To Help

 Recognize those at risk

1.    Those with family history of suicide or self injury or risky behaviors

2.    Those who have been sexually, physically or emotionally abused.

3.   Those who are self critical, with low self esteem, depression anxiety, substance abuse problems and  eating disorders.

 4.    Teenagers who are impulsive with few problem-solving skills are at higher risk.  

 Prevention Involves Teachers, Families, Friends And Other Social Supports

1.  Teach coping skills in school and at home
2.  Encourage healthy social networks.
3.  Educate teenagers and adults about the problem.
4.  Promote programs to help teenagers develop healthy friendships and decrease secrecy.
5. Do not expect more from teenagers then they can do. Remember they are not always sufficiently mature enough to make high level decisions that require recognition of long term consequences.

 References:

Mayo Clinic Website: Self-injury

 Science Daily: September 7, 2008

Did you know that nearly 5,000 teenagers commit suicide each year and that suicide is the third leading cause of death among those aged 15-24 ?

There has been a number of teenagers suicides in the news lately that have been connected to bullying. Many of use are worried and frustrated about the rising problems in schools with bullying and teasing. The connection between bullying and teen depression and  suicide is becoming clearer.  It has been shown that teen suicide is often related to depression that can be worsened by rejection,  isolation,  being bullied, and not fitting in. 

I found what I think is a great video about a program to reduce bullying, teasing and foster acceptance in schools. It is a program worth looking at if your childs school is not addressing this issue in a serious ongoing, manner.  

Take a look!

Of course we can’t expect the schools to do it all. Here are some things that parents can do.

• Keep your children out of your marriage problems.  Certainly you need to talk to your teenager about what is going on because they are well aware of it already. Sometimes their imagination is worse then the reality so be honest with them .  Do not subject them to your fights and arguments or ask them to take sides. Try to remember that no matter how angry you are at your spouse, you both want whats best for your children.
• Acceptance of your teenager (not necessarily his/her behavior) is critical. Yes I love you and always will BUT I do not love that behavior and won’t allow it.
• Reassure him/ her that you love him no matter what.  Remind him that no matter how bad things seem you want to help and problems can be solved.
•  Listen to what they say, you don’t have to agree just acknowledge you heard and try to explain (briefly) why you disagree. No long debates.
• Even if you say it a hundred times, it helps to say ” I love you and will not let you do anything I believe will end up hurting you.”
• Ask him/ her to talk about her feelings. Listen carefully. Model this by talking about your own feelings ( I am frightened for you when I see you doing risky things)  (see my blog on listening)
• Do not make light of  problems ( relationships, thinking no one likes them etc.)  Avoid terms like “puppy love”, break up of relationships can be Very traumatic for kids and often is a precipitant to suicide.
• Do not give glib answers or get angry.
• If you are worried about your child, don’t be afraid to say the word “suicide.” Using the word will not “give him/her ideas” but will provide relief by saying its ok to talk about this.
  
• Remove guns from your home.
• Seek professional help. Finding a good therapist is difficult. Ask around, school counselors may be a good source of referrals but usually can not handle this problem on their own.
• Get help yourself to deal with this. Do not be ashamed of this problem, it is not uncommon enough.

There is a long complicated article in the NY Times today about suicide and impulsivity that is worth a read (if you can manage it.)

“Suicide autopsy” studies can give us lots of information, but no one really knows what goes through the head of a person just before he or she dies from suicide, it may be regret as suggested by one person interviewed by the author.

There are a few comments I would like to make about the article and suicide in general that are based on my own years of experience, and thoughts. If you can’t get through the article hopefully they will still make some sense to you.

In terms of the debate about impulsivity vs planned suicide; I believe that there is always an impulsive piece of suicide. People may have a long complicated plan in their head “just in case”, but it takes a trigger to finally push them over the edge. I wonder if sometimes this can be just the opportunity as well as it be the “last straw” type event. It is not an either/or choice.

One study indicated that victims of what look like highly impulsive methods of suicide (bridge, gun) often “display few of the classic warning signs associated with suicidal behavior” ” …jumpers have a lower history of prior suicide attempts, diagnosed mental illness…” It seems to me that these persons may have not been treated or recognized as being depressed which may put them at high risk.

Also the person who is most determined to kill them self may be less likely to let others know, due to not wanting intervention. Use of an almost guaranteed to succeed method, does not seem to me to be a sure sign of impulsivity.  Some people have been planning for a while and have chosen the method they believe least likely to fail, thus the use of a gun or a bridge.

I will never forget a man I saw years ago, who had given away all his possessions. He denied suicide, did not look in the least depressed, and had no psychiatric history. I would never have thought him to be suicidal.  If it hadn’t been for a family member who was very worried about his “generosity” with lack of explanation and forced an evaluation, I have no doubt this man would have killed himself. (He later admitted his intention).

Suicide is another one of those things we will never have all the answers for. There are many different motives and types of suicide: some with depression, some with psychotic thinking where voices are telling them to kill themselves, some with existential pain, some with physical pain, some with end of life issues. Some are carefully planned while others are impulsive. It is my belief that most have components of both.

Are we trying to categorize and understand something that may not fit into a neat clean framework? Our frantic efforts to figure things out are often attempts to control something we fear.

We certainly can help to prevent suicide, and we should keep learning, but we also need to acknowledge that there are some things we may never understand completely, and may never be able to control. Life and death are not so neatly black and white.

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