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Thursday, March 28, 2024

Life Hurts

Posted by fxckfeelings on February 2, 2012

The fact that treatment is seldom as good as we want or need it to be isn’t so bad. If we can’t always make things better with treatment, and we’re willing to accept that fact, we’re no longer burdened with responsibility for figuring out answers and making things better in the first place. Our real job isn’t finding a perfect cure for what ails us, but figuring out whether treatment is better than no treatment. And if treatment only does so much, we can take credit for whatever we do to manage the hopeless mess that’s left for the rest of our not-so-bad lives.
Dr. Lastname

My 15-year-old son needs treatment for his irritability. He gets unbelievably angry over small things, to the point that he ups and goes to his room. He agrees that things are basically OK and he’s sorry afterwards, but it happens at least once a week. We have a happy home and he has friends in school and gets good grades. I think it’s his mood that’s the problem and it causes him and our family a lot of pain. My goal is to figure out how to get him some help with psychotherapy and/or medication.

Just because someone’s in pain doesn’t mean he needs help. Pain is just part of the complete life package, along with joy, hunger, death, etc.

Of course, you’ve got less to lose and more to gain from treatment if his irritability has caused bruised knuckles, broken sheetrock, and a growing familiarity with your local police. Pain is a normal part of life, but serving life in prison isn’t.

What you’re saying, however, is that, aside from his verbal explosions, he remains in physical control, does self-motivated time-outs, retains good relationships, and has no trouble focusing on work and getting it done. No pill could improve upon that.

So, if he’s handling his pain well, getting things done, and engaging in life, then making him get treatment for his irritability may make a bigger deal of his problem without necessarily providing relief. It’s a sad fact, but neither talk therapy nor psychiatric medication reliably improves irritability—just sometimes and more often than placebo.

It’s always possible that his irritability foreshadows a mood disorder that will eventually get worse and might be prevented or disarmed by beginning medication early. The trouble is, we have no way of telling whether he’s at high risk, and the medication has risks of its own, as well as being costly. The risks from antidepressants aren’t great, as far as we know, but there’s always the risk of what we don’t know because our tools for examining the long-term effects of medication on the brain are limited. If you try an antidepressant, ask yourself whether it’s helpful enough to be worth that risk.

As for most mood stabilizers, like Lithium, Depakote, and Abilify, the risk is much higher than for antidepressants (although you wouldn’t think so if you didn’t listen carefully to the end of Abilify commercials). Sometimes, pain treatment is worse than pain, and shouldn’t be considered without a careful assessment of the risk and rewards. From what you’ve said, the risks of most mood stabilizers dwarf the rewards by a mile.

Psychotherapy can be harmful if his shrink doesn’t accept the fact that treatment has limits. Find someone who can accept the possibility that your son’s irritable outbursts are unavoidable and coach him on managing them if they can’t be cured—though, clearly, your son is already a good manager himself.

In the end, the decision is yours, and various treatments might be helpful. If you accept the possibility, however, that treatment for painful conditions is not always better than no treatment, then you will weigh risk against benefit, regardless of how you feel, and make a good decision. After all, it’s risky to overestimate the power of medication and treatment, but it’s riskier to underestimate your son.

STATEMENT:
“It breaks my heart to watch my son have a meltdown and I’m terrified of what can happen to a teenage boy with an anger problem. I know he’s a good kid, however, and he’s showed an amazing ability to keep it together socially and academically. If a treatment seems to help him and be worth the risk, I’ll support it. If it doesn’t, I’ll support the many good ways he’s dealing with his temper and help him develop even stronger anger-management skills.”

My son is a nice kid, but his ADD makes him completely irresponsible. He seems motivated about getting his college degree, but, even when he takes his medication, he always comes late to lectures, leaves assignments to the last minute, and doesn’t get problem sets finished. He was asked to take a semester off because his grades slipped and he seemed out of control. Now that he’s back at home, he pays no attention to his bank balance and has bounced a lot of checks. When I confront him, he’s sincerely apologetic, but then he does the same thing the next day. I just wish I could get him to stop lying and care about what he’s doing.

If you can’t help someone with love and medication (see above), it’s normal to assume that he doesn’t really want to get better and your goal is to find the key to motivate him. The trouble is, some people who are motivated (and medicated) are nevertheless unable to perform.

They feel ashamed, apologize, avoid, feel more ashamed, and so on. They seem sleazy and unmotivated. The problem is that, if you treat them as if they’re sleazy and unmotivated, you make them worse.

The sad fact here is that medication can usually sharpen attention and make learning easier, but it can’t correct the executive function problems that make it hard for many people with ADD (and others) to get things done and deal with unpleasant priorities. Yes, you need character and willpower, but you also need some help from your brain, and some brains are too “in the moment” to be pushed into planned, prioritized activities, even when the will is willing and the attention razor sharp.

In that case, your goal isn’t to get your son to stop lying—he’s not purposefully dishonest, just permanently flakey—but to disarm his shame while helping him face the full extent of his disability. Forget about his lying, insincerity and apologies. Make it clear you’re not interested in the merry-go-round of avoidance and remorse and instead want to examine the power of whatever makes him fuck up in spite of the fact that he doesn’t really want to. That said, your goal is to help him find ways to manage himself.

Don’t let him present himself as a bad guy who could do better if he’d just try harder, because the evidence says otherwise. In reality, he’s a good guy with a permanent impairment, and it will take him a lot of work to get a handle on it.

Ask him if he’d like a wake-up call in the morning, or whether he should compose a daily log of his lateness to see when it’s better or worse and whether it’s responding to interventions, including medication changes. The more you talk about his lack of control as a fact, the more you challenge the shame that reinforces avoidance. Too bad he’s fucked, but there’s lots to be done. Most of us have weaknesses we have to work hard to manage, but most involve food and don’t involve bank fees.

Once you limit his responsibility and yours for what he doesn’t control, you’re free to bear down on the one part that he does have some power over. You don’t expect him to change his disability or understand why he has it—it is what it is—but you’re confident he can work on managing it, and that, with hard work and discipline, he can gain the control he needs and lose the shame that’s holding him back.

STATEMENT:
“It’s hard to watch my son’s overly sincere apology for behavior that cost us half a year’s tuition, knowing that, if he hadn’t lied about what was happening, we could have helped him, and that he’ll do the same thing again. Nevertheless, he wants good things for himself and has a legitimate problem that is worse than a poor attention span. I will talk to him about the good things he can do with a bad problem, and urge him to seek coaching rather than moral reform or absolution.”

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