Friday, October 24, 2008

The Value of a Powerful Therapeutic Alliance

I am falling deeper and deeper into depression; again. I feel so helpless as I feel myself falling farther and farther down. I went to my appointment with Dr. X yesterday, and all the way there I kept thinking: "I have had enough, I cannot take this anymore. I am quiting everything: medication, therapy, and if that doesn't work, life.

I sit down in my chair, across from Dr. X. and I feel an intense shame come across me. It is as though I feel not worthy to be in his company, to take up so much of his time, to have him see me for so long. I feel that same shame right now. How can I get so much help, and such good help, and still remain unwell?

I sit facing Dr. X. and I feel certain I must be exhausting to him. I must frustrate him so much. I cannot imagine how he manages to meet with me week after week, after week. How, after seeing me crash, seeing me unable to manage simple tasks, seeing me fail over and over again, how can he not be intensely frustrated, or in my mind even worse; how can he not have given up hope for my ever becoming well?

I manage to ask him if I frustrate him. He explains frustration is not the right word; sadness, a sadness that you would feel for a friend, or family member who remains chronically sick, that is closer to how he feels.

I feel touched by his saying that. No one except my Mom, when she was alive, has ever said that to me before. No one says they are saddened by my struggle to become well. My family mostly tries to make me believe that everyone has depressed days, shifting moods, anxiety, etc. That depression is normal. This makes me feel completely misunderstood. I am certain this state of mind is not "normal". They assure me I am strong and need to step out of this hole I am stuck in. Either that or they say "get a job", as thought that will fix me.

Even my Mom used to say I needed to accept my illness, get a job and I would become better. My husband says I am sick because I focus too much on my depression, am in therapy, and take antidepressants.

People without this illness have no concept of what it is like to struggle, and then often to even lose the ability to struggle. Life is hellish, empty, frightening, worthless, hopeless. I wake up everyday hoping today is the day, but most often I realize and know it will never end. It has been part of me for too long.

Sometimes I wake and think: " Today is the day this MDE will end". I have glimpses of joy, moments of laughter throughout the day, but after the moment ends it feels as thought the moment is mocking me; laughing at me, not with me, showing me a moment in time that will only ever be that: a moment, a split second of freedom, an infinitesimally small break in the darkness.

I sat in my appointment yesterday, ashamed of who I have become, wanting so badly for Dr. X. to know who I have the potential to be. In the moments we talk I believe he may know my real self. He may understand I am a better person than the one I have become. Actually he sounds like he accepts both of me: the sad one and the bright and joyful one. In fact, it appears he sees us as neither one or the other. It seems he sees the real me through the sadness. During the time I sit in that chair, across from Dr. X, I feel that the sad and joyful me are seen as one and the same.

I am not two people. It is not fake for me to be joyful for a few hours and barely able to move the rest of the day. Dr. X even says it is not a facade when I laugh gleefully at my puppy running and jumping for a Frisbee, and moments later feel sad. My sadness, and fatigue, and amotivation, my wanting to sleep all day are all symptoms. We will continue to work to address these. He seems confident that wellness is a possibility, that I will not be stuck in this hell forever, that we can, at the very least, help me lengthen and intensify the good moments.

I feel myself laugh when I think of my dog. He is bringing so much joy, and at least some fresh air and exercise into my life. He drags me out of bed, deserves a walk and play time. I am fully responsible for his care. Which at times seems overwhelming, but also is a responsibility that protects me and gives me energy.

Dr. X and I begin to talk about how we, as Dr. and patient, interact. He begins asking me questions I do not know how to answer. He asks me how my interaction with him differs from my interaction with a friend. I try to express how a friendship is a two way relationship and we have a one way relationship. I feel distanced from him by that separation; the him and me.. The game we play has rules and strict boundaries. The playing field looks different to each of us. We are playing entirely different games and I do not completely understand the rules. I only know there are strict boundaries that I need to guard.

I feel intensely uncomfortable asking him questions. I feel like it is not my place to question. That is how I was brought up. Call people Dr. Sir, or Cst.,Cpl, Sgt, Staff, or Inspector. They ask the questions. You answer them. I try to ask him questions like he seems to want, but I feel awkward and nosy. He insists I keep asking. I'm thinking it is a type of behavioural therapy. He wants me to see and believe he is a person like any other, that he cares about me, that I can ask him anything.

All I keep thinking is he must think I am a complete loser. I bet doctors make fun of people like me. Sit in their offices and laugh about how bizarre people like me are. Over coffee, having conversations that begin with: "You would not believe the patient I had today...". I feel scared people do not like me, make fun of me, are secretly talking about me behind my back.

At the same time I feel so disrespectful of Dr. X. for even thinking he might be like this. How rude. How unthoughtful am I to think this man, a man who has always been there for me, who is consistently caring and goes out of his way to help me, how can I even think he would be like that? I feel like I have hurt his feelings for even suggesting this might be possible.

I cannot, however stop worrying that he will give up on me, or that he is exhausted by me, or simply cannot take it anymore. It is always what happens. I wear people out. They leave me. I even used to ask my Mom, every time I spoke with her, if she loved me. As though her actions never screamed those words loud and clear. They always did, but something inside me felt I was unlovable.

My husband and I have been together 16 years and everyday I think he wants to leave. Everyday I ask him: 'Do you love me"? and everyday he answers yes, but I cannot believe anyone would love me, or care deeply and honestly for me. Not really.

This is what I need to work on in therapy. I need to learn to believe I am likable and worthy of people caring about me, and for me. This is where a powerful therapeutic alliance is intensely important. If I can work through my conflicting feelings about Dr. X., maybe I can reflect the behaviours and beliefs I learn onto the rest of the relationships in my life. Even if I am scared, what I do know, is that Dr. X is the safest person with whom I can to practice and relearn better personal and social skills.

7 comments:

Handsome B. Wonderful said...

I wish I could give you a hug and sit and talk with you. It must be frustrating that even your husband doesn't get it. I have ignorant family members but thankfully not my wife. Know that I think about you everyday. I am pulling for you.

I relate so much to this:

I have glimpses of joy, moments of laughter throughout the day, but after the moment ends it feels as thought the moment is mocking me; laughing at me, not with me, showing me a moment in time that will only ever be that: a moment, a split second of freedom, an infinitesimally small break in the darkness.

So true. That's exactly how I feel everyday. I wake up depressed have an average day with blips of good joy and then a lot of depression. I hate how I get depressed after therapy even if therapy went well.

Ugh.

Lola Snow said...

Its too easy to feel guilty for having those good moments. To fall into the trap of judging the whole illness by one moment, and feeling that the rest of the time cannot surely be that bad if you can touch happiness at all.

It is cruel to be so close to something but to be unable to keep it permanently.

You will get through this, but only if you keep believing that you will. That's part of the deal, because I don't think you can get better if you stop believing that it's possible. Part of "better" is the believe itself.

I believe in you.

Lola x

s said...

He is really good. Take a look at this: He explains frustration is not the right word; sadness, a sadness that you would feel for a friend, or family member who remains chronically sick, that is closer to how he feels.

It sounds like he is really able to separate what might be unhealthy tendencies (the ones you describe, to be frustrated etc) from the higher ones - to be sorry about your situation.

...As opposed to so many who really do get frustrated and sick of people. There are always patients who you will be tired of, but the point is, it's not THEIR fault, it's yours.

One has to be very careful to not blame the patient for the disease or for not getting better, while keeping the fact that they have a refractory illness separate from your skills as a doctor. You can care and be upset that treatment isn't working, but you can't take it too personally as a failure, or you'll burn out.

...And then of course there's the other option, when they can't get it under control: blame the patient and take it out on them, change diagnoses to untreatable illness because your treatment is failing... (Ahem)

Aqua said...

HBW: I just read your post and it sound like we struggle with many of the same things. Sometimes the BEST therapy triggers a lot of difficult issues to deal with. That's where my blog comes in. I try to work through those issues hers. It really helps. I can see you do that too. You are an inspiration.

Lola: Your message to me here is heartfelt. You are right. I need to keep believing I can get well. It's just really hard to do when I try, and try and try...really sucks. So you know, I believe in you too. You are struggling so hard. I find myself cheering you on. You go girl!

S: I agree. He is good. I am blessed with him. I read the article you posted about Dr's blaming the patient when the patient does not improve. It was so true in so many ways. I see you aren't one of those Dr's...and that will make a huge difference in many people's lives.

When you said "And then of course there's the other option, when they can't get it under control: blame the patient and take it out on them, change diagnoses to untreatable illness because your treatment is failing... (Ahem)"

I think you hit the nail on the head for your experience with your pdoc. Maybe you should bring the article about blaming the patient...and your comment to your next session....I'd like to be a fly on the wall for that conversation;>) Or maybe you could explain that at least 10% of people's mood disorders are refractory to treatment...or did he miss that lecture?
...aqua

s said...

Thank you for your comment about me not being like that. I hope I'm not, but eveyrone has the things that get on their nerves and that they don't have patience for.

I thought about sending that article, but he doesn't even read what I write, so why would he read that. I think I'd rather just discuss it...and I think that might be easier as I now am so much more stable mood-wise and won't go ballistic.

Also, I'm starting to see things from his point of view now that I'm out of the crazy mood situation. I can see how wild my behavior and my rages were. And remember, I never go to him during the in-between times. And not responding to the standard drugs for those symptoms...well, maybe it was reasonable to think it was a psychological issue rather than a biological one.

Sort of. An experienced doc, I would think (though remember, psych is far from my field), should be able to differentiate. But if you've never seen the person normal, and they aren't hospitalized where you hear from family or something that this is highly abnormal for them...and it's been going on for almost a year...well, you might think that way.

I don't know how to bring all this up. Whenever I do, he gets all defensive and everything goes to hell. I'm wondering if maybe it's worth it to just ignore that part and continue with him for whatever that's worth...

Maybe this should be a post.

Annie said...

I think I understand what you are going through. I hesitate somewhat to say this for fear I will minimize what you are feeling. But I feel sadness for you as well because I have been in a similar place and know the hurt and pain. When I look back I recognize that much of the thoughts and feelings were the depression and not the core of me. When I am not depressed the core of me can come through and I feel better.
I hope this makes sense to you. I mainly want you to know I am thinking of you. Peace, Annie

Aqua said...

S: yes write a post...Please!

Annie: Thank you. It sounds like you understand. Part of the difficulty is that I get periodic glimpses for a day or two here and there where I see the real me come to the forefront and she exudes joy and wonder and accepts and readily opens up to the love from others and she openly gives love to others. I feel heartbroken each time the real me disappears. It is almost worse for having fleetingly experienced the me I want to be and obviously (for periods of time)can be.