Convincing the Stubborn to Accept Mental Health Care
Just say YES. Ideas for treatment acceptance.
Posted Oct 14, 2011
About a year ago, a reporter from the Wall Street Journal called me and asked, "What is the ONE THING I can tell a depressed person to convince that person to accept treatment?" The ONE THING? I told her that each person is unique. What works for one might be damaging for another, not unlike parenting. There is no ONE THING. She didn't like my answer. She wanted a sound bite, a magic bullet. Not surprisingly, I didn't make her column.
The reporter's question reminded me of a Viktor Frankl quote about a person's search for life's meaning. Frankl reminds us that as life and circumstances change, our purpose for being changes. Asking someone her purpose in life is analogous to asking a master chess player "What's your best move?" The answer depends on the environment and the person. The pieces and their position on the board determine the optimal approach.
I encountered the ONE THING question again yesterday in a session with a bright and caring group of residents at the University on Pennsylvania. One resident knew of two people who clearly needed mental health care, but refused treatment. She'd tried cajoling, logic, but nothing seemed to work. I waxed philosophically that finding the right approach is often art rather than a science. I usually answer this question with a catch phrase, be consistent and persistent. The question came up later in the day, in a public talk. I woke up this morning realizing people deserve a better answer.
Yes all people are unique, but there seem to be five phases of depression management, not unlike the phases of grief. Sometimes these phases don't go in order and sometimes a single person bounces back and forth between the phases. So I still hold that there is no ONE THING. But, it seems reasonable to suggest SOME THINGS that work and might be leveraged in different situations.
Phases of Depression Management
Phase One - Unaware: Huh? These weird physical changes could be depression? Sometimes all a person needs is someone else to highlight the obvious. Don't assume that a person can connect the dots between depressive symptoms and depression as a treatable disease. I didn't. In 2001 I went to my general practitioner and complained of insomnia, weight loss, lack of appetite, loss of pleasure in things I loved. I didn't know then to call these symptoms "depression." My doctor ran some blood tests and told me there was "nothing physically wrong." My sister-in-law Paula Hersh was the one who listened to the symptoms and made the connection for me.
The AFSP has one of the best symptom lists for depression I've seen: http://www.afsp.org/news-events/in-the-news/could-you-be-suffering-from-depression-and-not-know-it. Try this. Give the person specific examples of how her or his behavior has changed and explain why you think this indicates depression. Help him or her get the name of a reputable psychologist. Dial or watch the person dial to get the appointment. Offer to drive the person to the appointment. Depression is a disease of withdrawal. Just telling someone you think s/he is depressed doesn't necessarily help. You have to push to get the wheels moving. Once in motion, the person will likely take over and learn to propel solo. But often nothing will happen if the depressed person is expected to start the process.
Phase Two - Denial: What? Me, depressed? No way! Sometimes a person needs repeated exposure to the same idea from various sources before the person accepts the idea. Be consistent and persistent. Enlist the help of family and friends.
In 2005, I went off medication because I felt if I were spiritually and mentally whole, I shouldn't need an antidepressant. My psychiatrist begged me not to go off medication, but I did it anyway. I did fine until 2007 when the perfect storm of elements arose to set off my depression (for me these are consistently: a time of transition/extreme uncertainty, prolonged gray weather that sets off my Seasonal Affect Disorder, and a physical injury that prevents me from exercising). In January of 2007 my husband begged me to see my psychiatrist and go back on an antidepressant. My depression seemed clear-cut to him. I refused, telling him my tears were due to hormonal fluctuation, he didn't understand me, was insensitive, etc., etc. My depression worsened, but I didn't want to accept that the depression was back. In April, my good friend Dr. Susan Sugerman took me by the shoulders and shook me. "Are you crazy? You tried to kill yourself! Do you want to go back there??" After that, I got help. My depression was so bad I had to have ECT again to recover. My guess is if I had returned to the antidepressant in January, when the symptoms were mild, I could have avoided the serious episode. It took the consistent badgering of my husband and friends echoing the same message before I took action.
Phase Three - Resistance: Okay I'm depressed, but I don't need medication or professional help to solve my problems! I will pray/meditate/eat organic foods to recover. I discussed this situation with my friend psychologist Walter Matweychuk. He suggested the following: Support the good life choices people are making, but suggest they do them in combination with professional help/medication. Think about this comparison - some people recover from serious infections without the use of antibiotics. Without antibiotics, however, infections take much longer to heal. Refusing antibiotics can put a person at greater risk for more serious infection, even death. Why not use all the resources at your disposal? Prayer/meditation/exercise/better nutrition AND cognitive behavior might cut recovery time in half. Add the right medication and recovery time might be halved again.
Having seen numerous psychologists and psychiatrists, I believe one of the reasons people avoid the mental health system because they see it as a quagmire of experts and medicine that often fails to get the job done. Depressed people often don't start psychotherapy because they're afraid they'll spend the rest of their lives on the couch like Woody Allen. This does happen, but it's possible to be a smart Consumer of mental health. Set reasonable goals with a therapist and/or psychiatrist and set a timeframe to accomplish that goal. Too many people go to the same psychologist for YEARS and still have the same problems. Would you do that with any other doctor? Of course not. You'd get a second opinion or try a different approach. The type of therapy or the medication might not be right, but the Consumer needs to be proactive and honest. When the Consumer takes ownership, s/he can optimize the resources available to reach a state of health.
Phase Four: Flakiness: I know I need to exercise, take my medication, sleep more to stay well, but I just don't feel like it. Remind the person that we're all human. Try to remember that every day is a do-over. Heck I go around the country talking about how I manage my depression and I fall off the wagon too. I don't sleep enough. I get over committed. I promise myself time to meditate and then that time evaporates because I say "Yes" to something I don't want to do. Think Scarlett O'Hara: there's always tomorrow. Get out of bed and try again.
Phase Five: Acceptance: Wow, I guess depression is something I have to manage the rest of my life - this is depressing as hell! Yeah, I'm with you on that one. Scary too. What if my depression returns? I've had three major depressive episodes - the statistics tell me that a future episode of depression is likely.
So what do I do? I try to do the things I need to do to stay well so repetitively that they become habit, almost instinctive. For me this isn't a big deal anymore. Think about it, every time I get on a highway there is a far greater probability of a serious accident than me becoming depressed and killing myself. Do I think about dying when I get on the road? No. I put on my seat belt, adjust my mirrors and try to do the best I can. Depression is the same way. If I do my best to live as fully as possible today, that's all I can do.
And you know what? My life isn't only free of depression, it's full of joy. I got to see Nellie Cruz hit a walk off grand slam home run to win the game last Monday night. I was THERE. I saw the most phenomenal live sporting moment of my life. If I completed my suicide in 2001, I would have missed that along with a long, long, list of joyous moments. So my advice? Stick around. Try SOME THINGS. If those don't work, try some more. You never know what can happen.
For more information about Julie Hersh or speaking engagements, check out her website www.struckbyliving.com