At What Point is There No Hope Left?

I volunteered to teach a class today. I was dreading teaching the whole time beforehand, even as I drove to the studio. While I was teaching I felt some relief; I was too distracted by the complexities of the lesson to think about how much I wanted to die. The second I touched the door to leave I was exhausted and fell once again into myself and all the hell that brings with it.

When I look objectively at what I have tried to do to to help myself make the depression go away it frightens me. It scares me that I have tried so much, and so many things, and still nothing is consistently helping my depression dissipate. My mood still continues to cycle, I still feel angry and frustrated and depressed, anxious and panicky, and can't sleep, or sleep too much, eat too much, avoid everything, have difficulty leaving the house, doing things, cleaning, cooking, laundry, dishes, sex, lose interest in everything, lose hope...All this never goes away for any length of time. When it does it feels like temptation threatening to drown me as soon as I begin enjoying myself. I feel like Satan sits and waits for a good mood to begin inside me...and then BLAMO! he whacks me upside the head just to show me I am still lost to hell. Paradise; a life of enjoyment and happiness, is lost.

It gets to the point where I begin to ask: Is it worth it? Am I worth it? There is a lot of money, medication, time and effort, both on my part, and the part of others, going into helping me become well. If, as I suspect, I will always cycle in and out of depression: What is the point of all this trying? From a utilitarian perspective it makes no sense at all to keep me here.

Why take medications? Why continue in therapy? Why continue living? If life is going to be as hard as it has been these last 7.5 years and the two years, with a two month reprieve before that...and the too numerous to remember episodes of depression before that, if life is going to be this hard a struggle forever...why keep trying? At some point don't you just give up and say it will never get better. Live with it, accept it, give in, or die. Dr. X said let him carry my hope, but at what point is that futile? At what point to we both concede to having been beaten by this illness? If you review all I have tried you will think the same thing:

1. 19: Journals filled with writing

2. 304: Number of blog entries

3. 425: Psychotherapy sessions with Dr. X. (give or take a few)

4. 21250: Minutes of therapy with Dr X

5. 14.75: years in my life lost to depression (conservative estimate)

6. 6.2: Number of years spent unemployed because of my depression

7. 104: Number of days on top of the 6.2 years lost employment because I could only manage working 4 days/week

8. 29: Number of years underemployed because of my depression

9. More than 8640: Number of pills bought to try to treat my depression if prescriptions were all one pill per day (many weren't/aren't)

10. 288: Number of bottles of pills purchased

11. Hundreds: of Visits to the pharmacy

12. 33: Number of psychotropic medications tried**

13. 9: Number of different vitamin/supplements tried

14. 8: Number of ECT sessions received

15. 177: Approximate number of months I have spent depressed in my lifetime

16. 5384: Approximate number of days spent depressed

17. 40: Number of years spent anxious and wanting to hide

18. 36: Number of years I remember having difficulty sleeping

19. 6: Number of therapists I have seen

20. 3: Number of psychiatrists I have seen

21. 2: Number of psychiatrists/ therapists I connected with

22. 1. Number of Psychiatrists, Doctors, Health Care Workers I trust.

Supplements/Vitamins I have tried/++Supplements/Vitamins I am currently taking:

1. St. John's Wort


2. Valerian


3. Salmon Oil (took 6 grams/day)


4. L-Tryptophan 2grams/day


5. Iron supplement twice daily++


6. B100 Complex (B1 100mg) ++


7. B12


8. Folic acid 1.0 mg


9. 100mgs of each B vitamins++


10. Multivitamin++

SSRI's

1. Prozac 60 mgs
2. Paxil
3. Celexa
4. Effexor
5. Luvox
6. Zoloft

Novel Anti-depressants:
7. Wellbutrin.
8. Remeron
9. Moclobemide

Tricyclic Antidepressants:
10. Nortriptyline
11. Amtrytiline (took for trauma symptoms...for 5 days after a traumatic incident)
12. Desiprimine

Anticonvulsants/Mood Stabilizers:
13. Lamotrigine 200mg
14. Lithium
15. Epival
16. Gabapentin
17. Lithium (800-1200mg)
18. Carbamazepine (800-1000mg)

Benzodiazepines:
19. Clonazepam
20. Diazepam
21. Lorazepam
22. Temazepam

Beta blocker:
23. Propranolol

Other:
24. Low dose Doxepine
25. Clonidine

Atypical Antipsychotics:
26. Seroquel
27. Risperdal
28. Olanzapine

Hypnotics/Sleep Medication

29. Trazadone (25/50mg/100mg/200mg/300mg)
30. Zopiclone (7.5mg/15mg)

Stimulants:

31. Ritalin
32. Dexedrine (tablets and spansules 5-20mgs)
33. Modafinil

Note: Also tried numerous combinations of above medications

Am I doing something wrong? Am I making things not work? If so What? and Why? Does this happen to other people? Am I the only one who never gets better? Why? I used to want so badly to live a beautiful life. Now I have no desire to live.

Fear and Desire

First, before anyone reads this I want everyone to recognize that while I periodically have feelings of love/lust and always care for Dr. X; I believe these are reflections of the difficulties I have with romance, connection and lust in my "real" (i.e. outside therapy) life.

This topic is very difficult for me to write about, but I also believe it is very important to dissect and address the feelings I experience.

While I respect and care deeply for Dr. X as a person and psychiatrist; I feel he is an extraordinary human being...I do not REALLY love Dr. X. I don't really even know him. (It feels kind of sad to say that)

I see him an hour a week and we talk about me. He has strict boundaries and I definitely respect those boundaries. In fact, I am probably more cautious of the boundaries than most Drs, because Dr. X is extremely valuable as a psychiatrist to me. I have no trouble recognizing I am transferring love onto him, rather than feeling love for him. I believe this is a common occurrence in therapy. I also believe gaining insight into my feelings, and why I have those feelings, for my therapist can help me.

The reason I brought the love/lust/caring thing with Dr. X. is not because I wanted him to know how I feel about him...I think he could have guessed that. I am not very transparent. The reason I brought the topic up is I believe it reflects and shows me difficulties and patterns and relationships in my life that need changing. I believe in acknowledging my feelings I have the opportunity to open up at a deeper level than I have ever been able to in therapy. I also believe this needs to happen before I can set about making changes to the relationships I am having trouble with. I think the love I feel for Dr. X. is a reflection of the love and connection I am missing in my "real" life (vs. life in therapy).

I thought it might be helpful to brainstorm some of the real life connections/disconnections that lead me to desire the love of my pdoc. By writing them here I will have a list of things to discuss and work on in therapy.

I came upon a very powerful statement about transference the other day. I have turned it into a question for myself:

What are the feelings the patient has towards the therapist? Examine the feelings the patient has and how they relate to unconscious motivations, desires and fears.
Conscious/Unconscious Motivations that Lead to My Feelings:

• I feel listened to. How could I not feel attracted to someone who listens carefully to what I say; someone who listens not only to what is being said, but also wants to uncover what is not being said. In my real life love relationship I feel unheard, undervalued, and ignored.


• I feel safe. I feel I can say pretty much anything with Dr. X. He never gets mad at me, never yells at me, never challenges my opinion in an angry way. My spouse always seems angry at me.


• I feel cared for. by Dr. X. He is always thoughtful, kind and compassionate. In my real life love relationship I feel the target of a huge amount of anger and frustration. I feel like my husband goes out of his way to avoid me. Much of the time I feel lonely when with him.

Conscious/Unconscious Desires that Propel My Feelings:

• I desire the love of a kind man. Dr. X is like this, always. I recognize it is his job to be this way, but I have NEVER encountered a man like this...ever. It would be hard not to have feelings for someone who, every time you see them, is kind, and thoughtful.
  I used to enjoy casual encounters. On some level I miss the excitement and newness of casual sex. I get bored in my sex life. Dr. X is a powerful "taboo". This excites me. It is the IDEA of a prohibited encounter that excites me.


• I desire a man/woman who wants to spend time with me and who shows me that. I feel wanted (as in I don't feel rejected) in therapy. I often feel rejected by my husband in many areas of our relationship. He calls me greedy for wanting too much sex, or ignores me when we are together, or is angry at me all the time.


• Dr. X seems to enjoy many of the cultural things I do (music, art, intellectual pursuits etc). My husband could care less. It is a chore to get him to participate in cultural events. I feel like we have little in common. I would love a partner who liked to do some of the same things as me.


• Dr. X never seems uncomfortable with my sexuality. Rather he normalizes the desires I have that may seem out of bounds to some. My husband is good like this too. He is really open minded...but he gets jealous. I like to flirt sometimes. It feels like harmless fun to me because I never have the intention to take my flirtation to the next level. I am just flirting as a form of fantasy. I get angry when my husband wants me to stop being a sexual being with anyone but him. I don't mean my having sex with others...though I miss that...I mean innuendo and flirtation, just for the fun of it


• I love a man who is an authority figure. Dr. X is this to me...though we have tried and tried to help me lose that feeling. Part of my sexual psyche craves someone in control, someone who knows what to do, someone who has power over me, someone who "forces" me to do things I do not want to do., etc. I have created a fantasy world where people in my life, other than my husband are doing this for me. I recognize both that Dr. X is not like this with me. He really has tried and tried to help me feel like an equal, but something about how close I feel to him makes me want him to be. This is a weird pattern of behaviour in that, on some level, it reflects my feelings towards my father. He was intensely controlling and my feelings of having an authority figure "force" me to do something, or tell me what to do are holdovers from both my childhood and from how my dad still treats me. I suppose, given my father's authoritative behaviour I always have had a difficult time making decisions for myself. I have an ingrained need to be given the answer, the activity, the way of being. This has slipped over into my sexual fantasy life.

Conscious/Unconscious Fears that Lead to My Feelings:

• I am afraid I am unlovable and cannot love. I feel like I have never been loved by a partner. Likewise, I have never felt "love" for any partner. I care about them, lust after them, am obsessed with them, excited by them etc., but I don't think I have ever truly loved or felt loved. I am not sure why. I think I am so scared I will be rejected that I neglect to allow myself to feel and show love.


• I am afraid my marriage is a sham. I fear I have spent from 27 to 43 (16 years) trying to hold together, repair and survive a marriage that was not meant to be. I am terrified that my husband stays with me just because he doesn't want to hurt me. I am scared we both stay together because the other choice is too difficult to decide and take action towards.


• I am afraid I have become old, depressed and unattractive. On some level, my desire for an "other" reflects my fear I will never be interesting, or desired by anyone else.


• I fear dying and not having experienced true love. Or having missed out on opportunities to exchange an intense and everlasting bond with someone else.

Disclosure

(**Note: I misunderstood Dr. Shock when I wrote this blog post. He agreed with Dr. X's type of disclosure. Misunderstood or not, his thoughts were the catalyst for my writing about this topic and it felt good to get it all out of my head. Thanks Dr. Shock).

You may have picked up from my blog that I am not only in therapy, but I am also intensely interested in the therapeutic process: The patient/therapist relationship, how that alliance affects therapy and how powerful a catalyst for change and growth a relationship with a trusted therapist can be.

This post is inspired by my curiousity about that process. Recently Dr. Shock has written a series of posts about the Dr./Patient Relationship. They are all very interesting. I find myself both agreeing and disagreeing with one aspect of the Dr/Patient relationship he believes in. He disagrees with a Dr's self-disclosure (in particular when speaking of a psychotherapeutic relationship).

I for the most part agree with him. I think it is important for me as a patient to be able to project my difficult relationship communication problems onto Dr. X. When Dr. X "becomes" my Dad, like in my recent post "Letting Go of the Past", I am able to reflect afterwards and learn from the experience. It is during those moments when I learn the most.

I have had therapists who spent much of my session comparing their problems to mine, telling me everything about themselves. These have never been helpful therapeutic relationships to me. They begin to feel like they turn into therapy for the therapist instead. Dr. X. is not like that. He is very good at limiting self disclosure to almost nothing. While I have an intense desire to know him better, I appreciate that he reveals little to me, he is whoever I need him to be at any given time.

Recently however, he did disclose to me that he has been unwell, and that it appears he has MS. Dr. Shock finds this disclosure uncalled for (**Here is where I misunderstood Dr. Shock' position about Dr. K's disclosure...he actually agreed with Dr. X disclosing his illness ...read his comments and the posts on his site).

Here is where I disagree with Dr. Shock and the following disclosure about my past will explain why. (If you happen to read this Dr. Shock I would be really interested to know how you would manage a situation like this after reading some of why I think this self disclosure was imperative for my well being.)

I have had numerous situations that have intensified my fears of abandonment. The following were probably a few of the things probably the straw that broke this camel's back:

My Dad left my Mom when I was almost 17 years old. I came home from school one day and my Mom as gone. I had no idea why, or where she went. she just disappeared. It was traumatic.

A week later she returned home and suddenly my Dad disappeared. Although I discovered he had moved into his own apartment, again, there was no explanation as to why he left. I was distraught, confused and felt intensely abandoned both times. As the weeks wore on I began to fall into my first depression, but I had no time to help myself, because my Mom was disappearing too, only in a different way.

She began to drink, stopped eating, wouldn't get out of bed all day, began leaving us at night to go drink, lost weight to the point she began to appear anorexic, became so angry she was hard to be around (she is was usually the most calm and compassionate, loving person I have ever encountered). In a word she became severely depressed as a result of my Dad leaving. She desperately needed a job as she had no money of her own.

My Dad had always taken care of us financially. She could not get work, or manage to renew her licensing requirements to become an RN again because she was too sick. When asked my parents if we could see a counsellor, they both responded "it was none of my business. It was between them"

All I knew for years was that my Dad left. I had absolutely no idea why, or why he never came home. He was just gone. I made up all kinds of things in my head..." I was a difficult child, he didn't like me, he couldn't handle my sisters and I, he had just decided one day that he did not want to be with his family, etc." I felt intensely abandoned, sad, lonely, let down, ashamed that I had been such a bad person that I made him leave us. I had destroyed our family.

I felt abandoned by my Dad, but even though my Mom was physically still around, she was gone. She was inconsolable. She was one of those women who married for life. Divorce and remarriage were not options. It was so sad to watch such a beautiful, strong, and loving Mom become nobody without her husband. Without Dad she disappeared into severe depression for at least 10 years and remained moderately to mildly depressed until the year she passed away.

Two years after my Dad left I could not handle the feelings I felt for losing both parents, for not understanding why it had all happened, so I left home to get away from those feelings. I ran.

Four and a half years and three cities later I phoned my Dad and a man answered the phone. Suddenly, it became absolutely clear why my Dad had left my Mom. He was gay. For the first time in years I felt an intense sense of relief and understanding. I finally understood why no one would talk about it. It was the typical shame issue too many people feel about being gay.

Unfortunately, that was not true. My Dad had remarried, and now had a whole new family, a new wife and two sons, without telling any of us. He had left my Mom for a woman he had been dating for a couple years while still living with us. I can't even express the shock, and feelings of betrayal I felt, and to this day feel. My father marries without telling us, allowed us to suffer feelings of abandonment and fear we were the cause of him leaving, when all he could easily have explained what was going on. Maybe not when he first left, but at the very least before he married.

The woman he married was an absolute bitch. I rarely say that abut anyone, but she was the equivalent, and perhaps worse than, the epitome of the evil stepmother. She would draw you in, get you to reveal your souls deepest feelings and then use those to bait my Dad, and to make him angry at us. My little sister used to have to go stay with my Dad very couple weekends. She could hear my Dad's wife yelling at him about how he had to get rid of her. How she did not want my sister there, ever.

She destroyed any hope that my sisters and I could ever have a relationship with my Dad. My Dad has never once mentioned why he left Mom, or even the fact that he did. He never once stood up for us in front of his wife, or any other time tha we know of. Any attempts over the years to talk with him about his leaving and how it affected us ended in our being immediately silenced. This (among other things) left all his children with no ability to have any kind of trusting relationship with him.

What does this have to do with Dr. X's disclosure? Everything. Given I so often, so easily, and so strongly project my father onto him any sudden disappearance on his part, without my understanding why, would cause me to relive those feelings of abandonment, disingenuity, and deceitfulness all over again. Any trust I had in him would be gone, and I am not sure it could ever be regained, especially if I found out he knew, and had known for some time, that he might have to stop work for a while, or "disappear' for a while.

I am working so hard in therapy to learn that I can trust others, that people are genuine, that not everyone will leave me or outright lie to me, or lie to me by leaving out information. It has taken years for me to trust Dr. X. and to begin to feel safe.

On top of my Dad's deceit, and my intense sense of abandonment surrounding the way it all happened, I recently lost my Mom. She had been the only person in my life outside of therapy who really, really supported and understood me and my depression. She became ill with pancreatic cancer and died within 2.5 months of her diagnosis.

I am still having an intensely difficult time dealing with, not just her loss, but the swiftness of her death and the traumatic act of watching her die: watching her try to cling to her children, seeing her try so hard not to abandon us. The intensity of her will to survive, even after she fell into the final throes of death, gasping for air for hours, trying to communicate, when her ability to talk was gone, watching her not wanting to abandon this world and all she loved in it was so traumatic I don't think I will ever recover from the unwilling and unexpected abandonment of someone I loved so much.

Dr. X. needed to tell me he was ill to preserve the integrity and trust in our therapeutic relationship. He needed to show me he valued me enough to be honest and forthright about his potentially needing to cancel, or rearrange appointments. I needed to feel I was important enough for him to be open with me about WHY he was unable to see me; that it wasn't because he didn't want to see me, or because I was a difficult patient, or because he wanted to get rid of me. I needed to know I was not being abandoned and that I would be taken care of in his absence. Dr. X.'s decision to disclose his illness and the potential it had for him possibly needing to take time off work periodically was only decision he could have made given my background and the issues I have been dealing with.

The Blog as Therapy

This post was inspired by a comment made by Dr Shock on my recent post titled: "Letting People In" .

I found his comment very thought provoking. He said: "...what is interesting is how can a blog help besides "getting it of your chest", what are the therapeutic factors. Another important topic is how can a therapist use the blog for the therapy. Especially when doing a more psychodynamic psychotherapy. For cognitive therapy [CBT] with housework it is relatively easy, you can monitor the progress but with more psychodynamic therapy based on psychoanalytic principles such as transference and counter transference and defense mechanisms it is difficult to use the blog together with the therapeutic sessions."

I was intrigued for a few reasons. I agree that a blog, shared with a therapist, for CBT, would be fairly straight forward. In a CBT situation the blog could be used as a documentation and reference for the activities, goals the patient is accomplishing.

I am not 100% sure I understand what Dr. Shock was referring to when he said " but with more psychodynamic therapy based on psychoanalytic principles such as transference and counter transference and defense mechanisms it is difficult to use the blog together with the therapeutic sessions", but if I understand his comment correctly, I think I believe the opposite . I believe a blog is an incredible way for the patient to clearly layout their defense mechanisms and for the Psychiatrist to have a much more in depth and detailed view of his/her patient's transference. If the blog is two way; one written by both the patient and the pdoc, I could see tremendous value for the therapist to also recognize their countertransference more clearly.

I am very interested, and in fact believe I have been utilizing my blog, more and more to enhance my therapy experience. Second to that my hope is that those who read my blog will see how I struggle and work through different difficulties in therapy; how I depend upon a safe therapeutic experience, a consistent and trustworthy psychiatrist, to both ensure, and allow me to be completely open and honest in therapy. I believe that is the cornerstone of good therapy. If I am not safe to say anything and everything, then I cannot work through the things I have the most difficulty with.

Here are some of my ideas/experiences/hopes for using my blog as therapy:

My experience thus far:
My blog has always been a means by which I both prepare for my therapy sessions and debrief myself AFTER my therapy sessions. This debrief allows me to absorb what I have learned in therapy; to retain the lesson.


My thoughts about my therapy sessions are often much more intense after I leave the session. In the 50 minute session I am so focused on interacting that I find it difficult to clearly reflect on the dynamics happening between Dr. X. and I, or around a specific subject. I often feel so emotional I cannot think straight. While in a highly emotional state I become reactive instead of reflective. To me, what happens between Dr. X. and I; the feelings while we discuss something, my reactions to him etc. are like a microcosm of my feelings and reactions to people in the outside world. Our interactions replicate difficulties in my life. This is super important for me to recognize and work through. My blog assists me with this.

Ideas to enhance my experience and my therapy via a blog:

I have some ideas about how to use a blog to enhance my therapy sessions even further, with each idea I have pros an cons I need to consider:

Idea #1: Keep my current blog and use it IN therapy sessions.

I was thinking of asking Dr. X. if we could together spend the first 10 minutes of my sessions reviewing my weekly blog postings. The next 40 minutes could be spent reviewing what was read/discussed:

Pros:

• I wouldn't forget to tell Dr. X things like I do now
• He would have a really clear record of what I'm thinking/feeling
• I often find it easier to write about a topic, rather than bring it up in therapy. I often use my blog as practice to get brave enough to open up and tell the truth, or explain how I really feel.
• My feelings, thoughts, experiences etc. are clearly laid out,
• I could list any medications side effects (I always forget to tell him things),
• I could clearly list any interpersonal difficulties, successes etc.
• I could make a simple list of discussion topics,
• If he wanted, he would have access to the information later( he takes notes, but if he missed something he thinks might be important, the information is there).
• I could express in clear details what I wanted to achieve in my session (I often get side tracked)
• I believe he would see transference, projection issues etc. even more clearly than he may already...because sometimes I am more shy or embarrassed to say things in person.

Cons:

• Privacy (from my employer, my insurance company etc.)
• Ethics on his part in terms of what he keeps in his files about me
• Boundaries would have to be really clear with me. I.e. I would not expect him to read my blog on his own time. It would be part of our therapy sessions

Idea # 2: Start a new Co-blog

This idea was inspired by an Irvin Yalom story about how, after each therapy session, he and a patient wrote a brief synopsis about each of their experiences, learnings, understandings etc. in that session. They then shared what they wrote at the beginning of the next session. It was intriguing how each picked different components of the session as meaningful. It seemed like a really interesting way for a patient to learn to fully understand their behaviours and experiences from a third part perspective.

I thought maybe Dr. X. and I could set-up a private blog; with the two of us as co-bloggers. Maybe we could shorten our sessions to 30 minutes and then each of us would be responsible for utilizing 20 minutes sometime during the week for each of us to blog about the experience. At the beginning of each session we would debrief what was blogged by each of us.

Pros:

• I often leave my sessions and think, what was Dr. X. trying to tell me,
• What did I miss?,
• I'm not quite sure I understood what we talked about.
• Maybe Dr. X. experiences that too.
• It would be a great way to remember and/or clarify lessons, ideas, sharings, understanding, misunderstanding etc. etc.

Cons:

• Privacy...I checked out to see if you can set these blogs to a private setting. It appears you can, but I need to find out if private blogs are "googleable", if they are really safe to be 100% open about EVERYTHING, like in therapy.
• Unsure how the Canadian medical system would view and reimburse Dr. X. for this type of therapy. I would not do this if he couldn't be reimbursed the same as he is now. (I have heard of a new system being introduce in Canada whereby Drs can communicate online with patients on a patient pay per contact basis)
• A co-blog would be really cool and groundbreaking for others to view therapy sessions in progress...I can imagine it as a really interesting teaching tool for psychiatrists and therapists in training, and for patients in therapy themselves, but privacy in therapy is really a huge part of why I (and I assume many others) are able to discuss certain things.

Idea # 3: Co- Blog as a means of identifying transference/countertransference/defense mechanisms etc.

I think the co-blog would provide the perfect opportunity to address some of these psychodynamic issues.

Pros:

• You would have to really trust your therapist/pdoc, as there would be no deniability about what was said...it is written down for each of you to see.
• I see tons of defense mechanisms on my part when I both write and read my blog. My current blog has been a wealth of information for myself, and, if I remember to bring it up, for my pdoc while we discuss these in therapy.
• Conscious and unconscious thoughts, of both patients and Drs/therapist may become more evident when they are seen on the page.
• Dreams are there to review and analyze more clearly (I am a great believer in my dreams telling me things, so this is important to me).
• Feelings could be clearly written about, there for posterity and further discussion and clearer understanding
• What you write would open doors to both the therapists and the patient's perspectives. What Irvin Yalom discovered was that what he thought was intensely important to his patient was often not the case at all. Often what mattered to the patient, what inspired the patient was some aspect of Dr/patient the relationship that came out in therapy; a gesture of kindness, or respect; a moment where the patient felt really understood.
• Identifying these could really have the potential to add value to therapy and really move the patient's therapy forward.
• Alternately, it could also really help therapists identify what really makes a difference to their patients.

Cons:

• Privacy...again...for this type of therapy to help it has to be very clear that what is said remains between Dr. and patient.
• If there was not an intense sense of trust between the patient and therapist difficulties might arise in what was written (although with the trust I have with Dr. X., even though I am afraid sometimes, I think I would feel safe and secure in this type of therapy)