Letter to Robert Whitaker

I wrote the following letter to Robert Whitaker, author of Anatomy of an Epidemic. 

Dear Mr. Whitaker,

I wanted to first of all thank you for your book. I read it when I was having a difficult time with my OCD symptoms and was considering taking antidepressants. Your book, along with a few others, convinced me otherwise. Given that these drugs appear to have dramatic side-effects, both short- and long-term, and aren't particularly effective, I am grateful that I did not go down that path. I am now doing significantly better.

Your book, as well as other books, advocate for a shift away from treating mental illness with drugs towards a therapy-based paradigm of care. While I wholeheartedly agree that drugs are not the answer, I also see many potential problems with a therapy-based paradigm. It seems to me that therapy is frequently advocated for, like drug-based care has been advocated for, without thorough analysis of it's dangers and benefits, as well as an thorough understanding of its philosophy towards treating mental illness.

If I may share my personal experience, my first foray into therapy was about 8 months ago. I didn't know I "had" OCD, all I knew at the time was that I was finding myself extremely anxious about strange things. My first therapist failed to accurately "diagnose" me and failed to offer any sort of effective treatment. I found myself getting worse over the few months that I saw her. My second therapist has been extremely helpful both in accurately assessing my "condition" and offering effective, science-based treatment. The caveat, however, is that he has repeatedly suggested medication for me to supplement his treatment, which I have refused.

My sense, from my limited experience, is that two problems can readily occur in therapy: First, therapists can fail to offer effective treatment as a result of not drawing upon the scientific data and tools that psychology research provides us. This can result in harm to the patient. And second, therapists can offer effective, science-based treatment. However, those most likely to offer science-based cognitive-behavioral treatment are also most likely to see drugs as playing an essential role in an effective treatment plan. I don't believe that the science-based psychology is functionally distinct from psychiatry--the two work together oftentimes to offer treatment in tandem. It is sometimes difficult to get good psychological treatment while refusing drug treatment, as it's easy for the therapist too see the patient as uncooperative or to see the refusal to take drugs as symptomatic of the underlying mental illness.

I was wondering if you had considered the difficultly of getting effective, science-based therapy while attempting to avoid psychiatric "care." I would be very curious to know anything that you've come across in your research or if you have seen anyone else explore this topic.

Thanks for a wonderful book,

Thinking of Myself as Well

I've been starting to think of myself as more and more well again. It's hard to say what causes what, but thinking of yourself as well and actually doing well seem to go hand in hand.

This is part of the reason, I think, why my therapist's suggestion that I take antidepressants bothered me. Admittedly, I tell him all the ways in which I am not doing well--all the ways in which I am failing to appropriately manage my anxiety. But it's somewhat discouraging to overall feel better than I have in months and be told that I'm still not well enough.

But I am in charge of whether or not I think that I am well, not my therapist.

Frustrated

I'm frustrated with my therapist. He brought up medications again. I didn't really want to engage and I kind of made that clear. He kind of pressed me. I didn't want to fully engage him the sense that I didn't think it would be a good use of my time. So, I made the worst possible choice and half engaged him. At the end of the appointment I think I seemed flustered. I failed to answer a question because I was only half paying attention. He then asked me how I was feeling and I said I was fine. I wish I hadn't lied, but I didn't know what to say.

I don't know why I'm so frustrated. I guess he's well-intentioned, but I think he's wrong and I think all the arguments he presented me with were stupid. I guess I wish I had been more direct, so I'm frustrated with myself a bit too. Sigh. My next appointment isn't for two weeks. I have an urge to bring this up at my next appointment, but it's a waste of time and I will probably be over it by then.

I think I just want my therapist to be ideologically aligned with me. The thing is, he's a good therapist and I shouldn't expect to find someone who is fully aligned with me.

Crazy

There have been a number of people over the years for whom I have thought, "things would just be better for you if you took antidepressants" or "you're just doing such and such because you're a little crazy." I no longer these things for the most part. My own struggles have really changed how I think about being so-called crazy. These sorts of comments are dismissive and too simplistic.

But since my thinking on these matters has changed, I frequently find myself frustrated with people who don't understand what it means to struggle--either with a poor mental state or with some physical ailment. Struggle creates an ability to empathize even with people who have vastly different experiences, I believe. This ability to empathize is clearly lacking in some.

For example, a few weeks ago, I encountered someone who said that this other person she knew just needed to take his anti-psychotics again. There didn't seem to be any exploration of why this person stopped taking them or what the effects were of taking them long-term. Even if they worked wonders for this guy, there may have been a number of reasons to not continue.

More recently, I was talking a friend about a mutual friend who is a bit eccentric. This acquaintance seemed to think that this friend was a combination of naive, crazy, and lonely. The eccentric behaviors were seen as a means of attention getting.

Since I used to make such comments, I understand where they're coming from. I assumed that modern pyschiatric medications worked long-term with relatively few side-effects and that a decision to stop taking or not take them was symptomatic of the underlying psychiatric condition. I also saw no reason previously not to behave "normally," so behaving outside of the norms was obviously the result of illogical thinking. So many assumptions with so little data!

It's very easy to be dismissive of people thought to be mentally ill, regardless of whether they are ill, because any behavior that is considered abnormal is attributed to the mental illness. This has been shown to be the case on a clinical level: A lot of the emotional side effects of antidepressants and discontinuing them were initially attributed to the underlying illness. It was only when these medications were given to "normal" people that they realized the side effects were real.

But it's also certainly true on a social level. Most people don't really want to get inside the heads of those who are thought to be mentally ill, because of course their thinking is pathological! Understanding their thought process won't accomplish anything. Best to just tell them what to do since you're thinking is clear and theirs isn't.

The reality is, I think, that many formerly or currently mentally "ill" people have a lot of insight. Obviously, this depends on the "illness" and severity. But in my experience, people who have struggled with their emotional state have more compassion and empathy for others who are struggling. They understand what it means to struggle and that there aren't simple answers. And of course, having struggled with your mental state, doesn't mean that you're not self-aware. You're capable of knowing what helps you and what doesn't and what to do when you're having a rough time. Just because your thinking isn't productive or clear 100% of the time, doesn't mean that you're not qualified to help yourself. In fact, you are the most qualified to help yourself because you're the best acquainted with your issues.

I wonder about these people who are dismissive of "crazy" people. I find it hard to believe that they have never legitimately struggled with their mental state in their lives. I'm sure that they have at one point or another. I don't want to make the same mistake of over simplifying them and their position. But I wonder, do they just conceptualize their struggles as simply situational? Or perhaps the severity or the length of the struggle wasn't great enough or long enough to revise their thinking. Or perhaps calling other people crazy is a defense mechanism. Who knows? Regardless, I don't think they've thought particularly clearly about what it means or what it's like to be mentally "ill." They're certainly not approaching mental "illness" with a lot of compassion.

Therapy Jealousy

I sometimes get jealous of my friends who actually talk to their therapists about things. Like they have some problem in their life and they go talk to their therapists about it. And their therapists listen and give them advice and they feel better. Or maybe their therapists just give them some things to think over that will help point them in the right direction.

My therapy sessions are nothing like this. My therapist does not know anything about my day-to-day problems. He knows nothing about my relationship or the dynamics at my job. I don't talk to him about sex. He doesn't know what I value in life and what I don't give a shit about.

The thing is, this is okay. I think my therapist is very good, in part because he is so direct and to the point. We work on a specific issue I'm having and don't dabble into anything else.

I have no problem with talk therapy--it's been shown to work just fine for a number of things. However, I don't think it would be good for me unless perhaps I had a talk therapist who could tell me when my talking starting sounding like obsessing.

Nonetheless, part of the reason I went into therapy was that I needed more support in my life. I get support in the sense that my OCD and skin-picking symptoms are lessened, but not really any emotional support outside of these limited topics. I'm kind of jealous that I don't have an impartial person to talk to about my problems. 

More than that, a few of my friends can casually mention, "my therapist said such and such" or "I'm going to talk to my therapist about that." I never say these things, not because I'm a closed person, but because there never is a good way to drop into a conversation what my therapist says or what I'm planning to talk to my therapist about. I suppose I worry that I come off as more closed than I really am.

An Over the Weekend Obsession

I had an obsession over the weekend. It was bad and it reminded me of what it feels like to be fully immersed in one: really shitty.

The situation was that something shitty happened at work Friday. I was able to let it go for the day, but when my partner got home from work, I launched into the whole story. I found myself getting angry and I couldn't let it go. I exercised and still couldn't let it go. I tried to sleep and still couldn't let it go. I eventually fell asleep, but Saturday morning I woke up early and it was there. I cried about it Saturday afternoon while trying to enjoy myself on a hike. Saturday night I told my friend about it and she recommended I take action. Sunday morning it was still there and I decided to write an email about the situation to my boss. It took me forever, I wrote it, and after some deliberation I sent it. I was anxious after sending it, but I definitely experienced significant relief. I was able to move on to other things.

The thing is, I didn't regret sending the email. I didn't see it as a pointless compulsion, like driving home to find that the door is already locked. At the same time, I know I was having an obsession. I wanted to write the email because I knew it would provide relief.

So, the question I have for myself is can I make difficult decisions without obsessing? I ultimately think it was a really good decision. But I just don't know how to come to those sorts of decisions without obsessing. Ack. I don't know how to live my life.

More on BFRBs

I just took a bath and thought about my last post.

My therapist says that perfectionism is what ties OCD and BFRBs together--a sort of perfectionism. I had never thought of my behaviors in this context. My desire to pick and pull stems from a desire to make things smooth, look better, and be more perfect. I would have said relief-seeking was what tied them together, but perhaps relief-seeking is considered to be symptomatic of perfectionism.

In any case, I was thinking about the whole ramblely paragraph in my last post regarding my unwillingness to think things that I don't believe to be true. I just realized that this is symptomatic of a sort of perfectionism: "my thoughts must be logically consistent at all times." Now what do I do with that?

I guess I want to know more about behavioral therapy at this point. Maybe perfectionism isn't something I can easily address directly. Maybe I can only address the problematic behaviors that stem from it--i.e. BFRBs and OCD.