Treatment

Admitting You Need Help

You've finally acknowledged you can't go it alone. What now?

by John McManamy

The toughest challenge on the road to recovery is probably the first - that of admitting you need help. If you’re depressed, the guilt that may be a part of your illness may tell you that you don’t want to burden your loved ones, or that you don’t have a real illness worthy of medical attention. If you're hypomanic, the problem lies in the rest of the world and not you, and in mania you are beyond reason.

Then there’s the old denial factor. Who, after all, wants to admit they’re crazy? Who wants to own up to the stigma and the shame? Typically, it is only when we run out of options (and excuses) that we seek help. The best authorities on this are my own readers:

“What caused me to seek help?” writes Bill. “Almost losing my job and my wife.”

Tricia reports:

"Recently, I was forced to get help after experiencing two mania episodes. The first one I reasoned away that I was not ill. The second one I could not reason away and I had to look in the mirror and accept that I was bipolar and would be on medications for the rest of my life. Because of my resistance to deal with my illness, I lost a job and my apartment. I have also learned a tremendous lesson - things can always be worse and they can also be better. My illness is now something I live with in a healthy way. Taking care of it so I stay well. I am no longer hiding from my shadow self. Me and my shadow are working on becoming one."

Says Christine:

"When my depression started two years ago, I blamed it on everything around me: work, being a single mother with three kids, being lonely, although in a relationship with a man recovering from alcoholism."

It took Christine at least a year to be correctly diagnosed for bipolar disorder and put on the right meds. She concludes:

"I ended up losing my job, my boyfriend, making my kids feel confused and afraid. I am still trying to recover of all of it and unsure about the future. I only hope the road of my life will have less curves from now on."

Finally, this observation from Ginti, following several suicide attempts: “Probably the most bravest thing I'll ever do - I GOT HELP!!!”

Your Next Step

For most people, their default first port of call is their primary care physician. By far more prescriptions for antidepressants are written by this branch of the medical profession than by psychiatrists, often to people who insist on going to specialists and get expert lab work done for every other aspect of their health. Unfortunately, in a routine physical exam there is no time for more than a few cursory questions.

A 2001 UCLA study found that only 19 percent of a sample of depressed or anxious people they surveyed received appropriate treatment from their primary care physician. By contrast, 90 percent of those who saw a mental health specialist got proper care.

Unfortunately, for suicidally-depressed patients and floridly manic or psychotic patients, one's first contact with a psychiatrist is usually via the emergency room and a locked ward. Don’t be frightened by the prospect of being a prisoner. In all US jurisdictions, there are strict limits on involuntary commitment (generally only if you pose a risk to yourself or others), and it’s frightening how fast you’re no longer considered a danger when your insurance runs out after two days.

Those with premium health coverage are often encouraged to remain as inpatients for 30 days before they, too, find themselves miraculously recovered and sent out the door.

Hospital day programs may take up the slack, but again patients receive a clean bill of health the day their insurance runs out. Thereafter, psychiatric and talking therapy treatment is on an outpatient basis - that is until the next life-threatening crisis occurs.

Those who suspect they may have a mental illness are encouraged to make an appointment with a psychiatrist or talking therapist. A psychiatrist is an MD who has completed a three or four-year psychiatric residency. Emphasis is on on-the-job training rather than a formal curriculum. A psychiatrist is qualified to practice medicine and is authorized to prescribe medications, but there is no separate license to practice psychiatry. Psychiatrists, like other medical doctors, are answerable to state licensing boards for ethical violations and bad medical practice, but in practice this tends to be the psychiatrist’s word against the patient’s.

Psychologists are PhDs or PsyDs who have completed six or seven years in a doctoral program, comprising both a formal curriculum and supervised clinical work. They specialize in any of the hundreds of forms of talking therapy and (except in the state of New Mexico and Louisiana after taking additional training) are not licensed to prescribe meds. Psychologists are licensed and disciplined by state boards.

Counselors, therapists, and specialized social workers are generally people with master’s degrees (MA, MS, or MSW) and two or more years of clinical experience. Licensing varies from state to state.

Some psychiatrists also do talking therapy, but even the most meds-oriented psychiatrist needs to be a skilled talker and listener, as his or her knowledge of your illness is only as good as what you tell him or her. Because neither depression nor bipolar disorder leave a readily identifiable biological marker that can be spotted in a lab test, blood sample, or brain scan, a psychiatrist is largely dependent on what you say. Under ideal conditions, an insightful practitioner can elicit all the necessary information from you to make a precise diagnosis and initiate the type of treatment most likely to work for you. But in practice, for patients with bipolar disorder, it takes many years and a succession of doctors to figure out what is wrong. The onus, then, is very much on you to get your story right, which is not always the easiest thing to do while in the throes of a killer depression or out-of-control mania.

Anonymous describes her frustration:

"For years I had been going to doctors and they would tell me that I just needed to slow down in my every day work, try to get me to listen to soothing music, when I would visit the doctor I would try and try to tell him that wasn't the problem ...

"It just sends knives in me knowing that for approximately 10 years I had been going through all this with the doctors. It ended up I quit my job, and there are jobs that I will not be able to get because I got in trouble with the law over credit card fraud, so now I have a criminal record on top of everything else. It isn't fun to be mentally ill."

I find myself suggesting to readers who have contacted me to put their concerns in writing before their initial or next visit, for, if nothing else, this is a good way to organize your thoughts. Think of those times you felt depressed and write down what it felt like. Did something bring it on - say a relationship breakup - or did it seem to occur out of the blue? Did you feel like you couldn’t go on living? Did you entertain thoughts of suicide? Did you feel like you couldn’t get out of bed? Or, just the opposite, maybe you couldn’t get to sleep. Are you eating more or less? Not feeling your usual self? What’s different? Are you doing a great acting job hiding your distress from your friends and family and colleagues, or do they think you’re acting a bit out of character, too? Are your work and family and personal relationships feeling the strain? Provide details. Are you less patient with people lately? Short-tempered, angry, aggressive? Or perhaps the very opposite, submissive, guilt-ridden, and ready to give up without a fight. How long has this been going on? Have you felt like this at other times in your life?

A good psychiatrist will be asking these questions, but you can save both of you a lot of time and effort if you have your answers ready. Your psychiatrist will also probe for personal and family history, looking for more clues. Now is hardly the time to talk at length about past trauma and abuse, as this may destabilize some patients at their most vulnerable. It is essential, however, to inform your psychiatrist whether you are a survivor of trauma or abuse, as this can have a bearing on your treatment. Later on, in talking therapy, you can try to resolve trauma and abuse issues.

You will also want to write down what it feels like to be normal. If normal for you is feeling constantly depressed, that’s a very good clue. Also try to recall what it’s like feeling happy. Some people may have felt a little too happy in the past, which may be the only way your psychiatrist may suspect you have bipolar disorder.

Many people suspect they have bipolar disorder long before they see a psychiatrist. But even people who merely think they have depression need to focus on all those times they didn't feel their normal selves or felt too much like their normal selves. You might want to go back over those times in your life you would rather forget - such as embarrassing yourself in public or attacking your spouse or walking off your job or getting arrested - or where you were unusually productive - working 20-hour days, cleaning the house in the middle of the night, writing a term paper in three hours - and try to remember what you were feeling during the time and the times that led up to these events. If you felt you were smarter than the rest of the world, describe it. If you were in a raging white heat, fill in the details.

Admitting that there may be something wrong with you is one of the most difficult tasks there is. Add to that fear and ignorance and stigma, and you begin to appreciate why so few people seek help or get a correct diagnosis.

When I ask psychiatrists what they find works best in treating patients, many reply establishing a trusting relationship with the patient. These are the psychiatrists I would hire.

Without this trust, those degrees on the wall aren’t worth the paper they’re printed on. Your end of the bargain is to keep your psychiatrist fully informed and to stay on your meds and other treatments. His or her end of the bargain is to be there for you in a crisis day or night and work with you in getting well and staying well. If your meds aren’t working or you are experiencing bad side effects, you inform your psychiatrist rather than simply quit the drugs on your own. Together, the two of you can work on new doses and/or new meds. If he or she suggests adding a new med to your cocktail, by the same token, you should expect to be informed of the risks and side effects as well as the benefits. If you object to that med, he or she should respect your judgment. And on and on it goes, mutual trust and respect.

Sometimes, though, achieving a good working relationship may involve auditioning more than one psychiatrist. Writes Melissa:

"I went through 10 psychiatrists in one year until I found one able to call down to rock bottom and tell me the footholds up. That was luck. Otherwise I'd be sitting in front of television waiting for the next meal, the sound of doors locking behind me."

Misty, who replaced a psychiatrist she had a bad experience with another who was “who was very good, nice, knowledgeable, and didn't pry into things that weren't his business,” advises, “don't be afraid to fire a bad doc.” Amen to that.

Jan 25, 2005, reviewed Feb 10, 2008

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