Not having enough

[F0nzie]

How do you guys address patients that claim they are depressed because they do not have x, y, z? Common items include money, cars, houses, attractive partners, and prestigious jobs. Assume you do not have time for psychodynamic psychotherapy.

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[heyjack70]

"If only I had a Ferrari I would be happy."

Clearly it's a matter of perspective because lots of people without a Ferrari are very happy. I would focus on the things the person does have that they like, the things they like about themselves, and the things they are good at and like to do. I would work a behavioral approach and try to increase the frequency and duration of time the person spends with the things they like. I would tell them we are working on learning to like who they are in the present.

If that didn't work, the patient would clearly need dynamic therapy 3 days a week. Cash only.

 

[wolfvgang22]

I've been getting more blunt lately and just saying "Well, I don't have a medication for that problem" with a smile. Then I say "I see you're not doing any therapy so far and that's at least 50% of getting better. You do want to do the best treatment, right?", and then refer them to the LCSW for bi-weekly therapy the patient may or may not attend.
Now if I could just get other doctors in the community to stop prescribing Xanax 1mg PO Q8H PRN for dysthymia and then referring that patient to me, that'd be great.

 

[birchswing]

OK, so I'm not a psychiatrist, but this is what I'd tell myself:

What would it feel like if you had X? What would be different about you and the way you see yourself? Now, how can you get that feeling without X? You'll only ever be as successful as you feel good about yourself right now. The future is only an idea. No one lives past now.

 

[OldPsychDoc]

If that didn't work, the patient would clearly need dynamic therapy 3 days a week. Cash only.

Gotta make your payments on that Ferrari, after all...

 

[Ceke2002]

I'd probably try and utilise some explanation of Maslov's heirachy of needs and build from there.

 

[erg923]

All those items are signs of accomplishment and/or status. Existential crisis is a common and quite legitimate form (and cause) of psychic distress. That said, psychiatry is probably the last thing that person needs.

 

[cookymonster]

I'd feel inclined to let the patient know that the hedonic impact of having things one deems important is something that study after study shows is extremely overrated... at least if you aren't poor and have all your basic amenities met. But seeing how unlikely that would be to move them, I'd probably give them this TED talk to watch and ask them what they think.
http://www.ted.com/talks/dan_gilbert_asks_why_are_we_happy?language=en

 

[smalltownpsych]

Wishful thinking and commiserating is an immature and ineffective way of coping with emotional distress. Call it what it is and let them know that the only way to get those things and feel better about themselves is to do something productive. Simple but not necessarily easy.

 

[watto]

My microecon prof used to say "how many of you guys want a Porche?" and we would raise our hands and then he'd ask "how many of you have a Porsche" and none of us would raise our hands and he'd say "you don't really want a Porsche then."

 

[Shikima]

I've been getting more blunt lately and just saying "Well, I don't have a medication for that problem" with a smile. Then I say "I see you're not doing any therapy so far and that's at least 50% of getting better. You do want to do the best treatment, right?", and then refer them to the LCSW for bi-weekly therapy the patient may or may not attend.
Now if I could just get other doctors in the community to stop prescribing Xanax 1mg PO Q8H PRN for dysthymia and then referring that patient to me, that'd be great.

This.

Additionally, you could use MI techniques in developing discrepency which takes minutes.

 

[F0nzie]

Great replies.

I have just recently been thinking about several scenarios where patients experience the full spectrum of depressive symptoms (poor appetite, insomnia, anhedonia, lack of energy...) They do not want meds. In certain instances I feel they are desperately trying to make sense of their experience with clinical depression by attributing it to something that makes sense to them. ie. I feel sad, must be because I don't have X. Then they get X and still have the same set of depressive symptoms but now since they already have X they're depressed because of Y. At times it seems almost untouchable by any type of psychotherapy and it's like listening to a broken record.

 

[vistaril]

How do you guys address patients that claim they are depressed because they do not have x, y, z? Common items include money, cars, houses, attractive partners, and prestigious jobs. Assume you do not have time for psychodynamic psychotherapy.

Well if a patient is telling me they are depressed because they don't have the car they want, I'd try to work with them to see if we can develop a game plan to get them on track towards getting that car.

 

[F0nzie]

Well if a patient is telling me they are depressed because they don't have the car they want, I'd try to work with them to see if we can develop a game plan to get them on track towards getting that car.

Valid direction. I've seen depressive symptoms resolve with a goal oriented and coaching approach. It's not part of our training but sometimes people need that kind of direction when they are overwhelmed.

 

[F0nzie]

I'd feel inclined to let the patient know that the hedonic impact of having things one deems important is something that study after study shows is extremely overrated... at least if you aren't poor and have all your basic amenities met. But seeing how unlikely that would be to move them, I'd probably give them this TED talk to watch and ask them what they think.
http://www.ted.com/talks/dan_gilbert_asks_why_are_we_happy?language=en

The happiness research is interesting. While treating depression may make a person happier, happiness isn't our area of expertise. The family counselor at my clinic likes to show these videos to our patients. Personally I think it's great for anyone.

When I think of patients wanting to be happy I remember one of my attendings interviewing a depressed alcoholic patient. The patient said "I just want to know how I can be happy". My attending replied "I know. But we are not going to figure that out today".

 

[nitemagi]

I often turn to those goals of "more money" or "more whatever," and use that to guide them into thinking of what they'd do with it. That gets them future oriented, and opens up the thing AFTER the materialistic goal. "I'd travel." "I'd buy a house." "I wouldn't have to worry about X." A lot of the time it can clarify what they're really worried about, as well.

I also use a good amount of sarcasm and humor in therapy. Many people can gain perspective when you joke about it. Assuming the bond is there and you've tested it out. "

Another approach is to read between the lines, i.e. see what's behind the goal. Is it that they want prestige, or to feel important? To feel free or not stuck in a day-to-day grind? To feel loved? To be envied by their peers? What does that goal represent? That's a clearer angle to explore.

Erg is right, a lot of this can be steered back to an existential crisis, and there is existential therapy. Sometimes ppl just want meaning in their life. I disagree that going to a psychiatrist is the wrong thing. It's as wrong as going to a psychologist for CBT would be expected to solve this. It's about the approach, not the degree.

 

[milesed]

I tell them that that are simply trying to fill a bottomless pit with "things". Once they have A, they will want B. It comes down to finding joy, not happiness, from things that money cannot buy.

 

[smalltownpsych]

Great replies.

I have just recently been thinking about several scenarios where patients experience the full spectrum of depressive symptoms (poor appetite, insomnia, anhedonia, lack of energy...) They do not want meds. In certain instances I feel they are desperately trying to make sense of their experience with clinical depression by attributing it to something that makes sense to them. ie. I feel sad, must be because I don't have X. Then they get X and still have the same set of depressive symptoms but now since they already have X they're depressed because of Y. At times it seems almost untouchable by any type of psychotherapy and it's like listening to a broken record.

That fits with Erg's conceptualization of existential crisis being the issue and I think when he said psychiatrist was wrong place to go might have meant medications would be the wrong way to go. I love dealing with those types of cases so long as patient is willing to begin doing the work and Nitemagi is right on the money with the direction to dig deeper. If this is a high functioning person going through an existential crisis, then recognize that it will also hit on some of your own existential fears and beliefs. If they are just a concrete thinker that really believes having X will make them happy, then do we really have an answer for that? Like one psychiatrist that used to work here would say, "I can't fix stupid". He wasn't referring to IQ, either.

 

[erg923]

I tell them that that are simply trying to fill a bottomless pit with "things". Once they have A, they will want B. It comes down to finding joy, not happiness, from things that money cannot buy.

That seems to be imposing your values and beliefs on the patient, no?

1. Some people are/will be happy once they have obtain x, y, and z. Haven't you ever been to LA? The cliche notion that posessions can't provide real happiness seems noth naive and dumb. I LOVE my home and I am happier owning it/being there. 2. I think not having a independent method of tranportsation, a decent home, or job that provides a some sense of accomplishment or indentity are very legitimate reasons to be ill at ease. It seems sensless to try to "convince" them otherwise.

 

[F0nzie]

That fits with Erg's conceptualization of existential crisis being the issue and I think when he said psychiatrist was wrong place to go might have meant medications would be the wrong way to go. I love dealing with those types of cases so long as patient is willing to begin doing the work and Nitemagi is right on the money with the direction to dig deeper. If this is a high functioning person going through an existential crisis, then recognize that it will also hit on some of your own existential fears and beliefs. If they are just a concrete thinker that really believes having X will make them happy, then do we really have an answer for that? Like one psychiatrist that used to work here would say, "I can't fix stupid". He wasn't referring to IQ, either.

I think the million dollar question is...is this truly an existential crisis that would benefit from deeper work or just a clinically depressed person that is somewhat cognitively impaired. Obviously we do not want to invalidate their experiences.

But let's say I'm hungry or sleep deprived or having some basic biological need. I get irritated and start saying bad things about how McDonald's runs their operations. I stop and realize, no the service here is pretty good. I am just hungry. I eat and subsequently better. I do not necessarily need to talk about the meaning behind anything... just being plain irritable and attributing it to McDonald's rather than acknowledging that I am simply feeling like crap. Externalizing?

I have had patients with all sorts of "existential crisis" that spontaneously resolve on antidepressants. And I'm like... so what about your frustration with not having X. And they're like "I don't know". (This is just a subset of individuals that respond in this way).

I am all about psychodynamic therapy. I offer it in my practice and I think it's a great framework but in some scenarios I think it's just a waste of time.

 

[Shikima]

I don't have enough money. Too much debt.

 

[smalltownpsych]

I think the million dollar question is...is this truly an existential crisis that would benefit from deeper work or just a clinically depressed person that is somewhat cognitively impaired. Obviously we do not want to invalidate their experiences.

But let's say I'm hungry or sleep deprived or having some basic biological need. I get irritated and start saying bad things about how McDonald's runs their operations. I stop and realize, no the service here is pretty good. I am just hungry. I eat and subsequently better. I do not necessarily need to talk about the meaning behind anything... just being plain irritable and attributing it to McDonald's rather than acknowledging that I am simply feeling like crap. Externalizing?

I have had patients with all sorts of "existential crisis" that spontaneously resolve on antidepressants. And I'm like... so what about your frustration with not having X. And they're like "I don't know". (This is just a subset of individuals that respond in this way).

I am all about psychodynamic therapy. I offer it in my practice and I think it's a great framework but in some scenarios I think it's just a waste of time.

When deeper therapy is not wanted or patient is unable to benefit from it because they are not psychologically minded, then become more directive. "As your doctor, I can tell you that money will not make you happy so in the school of Bob Newhart therapy we would say - Stop It!"

 

[F0nzie]

Been enjoying Bob Newhart's appearances on the big bang theory.

 

[milesed]

That seems to be imposing your values and beliefs on the patient, no?

1. Some people are/will be happy once they have obtain x, y, and z. Haven't you ever been to LA? The cliche notion that posessions can't provide real happiness seems noth naive and dumb. I LOVE my home and I am happier owning it/being there. 2. I think not having a independent method of tranportsation, a decent home, or job that provides a some sense of accomplishment or indentity are very legitimate reasons to be ill at ease. It seems sensless to try to "convince" them otherwise.

My point was not about missing necessities, but one about senseless consumerism. This is what the OP appeared to be asking about.

 

[smalltownpsych]

My point was not about missing necessities, but one about senseless consumerism. This is what the OP appeared to be asking about.

Senseless consumerism? I didn't get that from the OP. Especially given later posts about false attributions of depression. I think your own bias is showing.
Also, in reviewing the post it referred to attractive partners and prestigious jobs as well as possessions.

 

[erg923]

My point was not about missing necessities, but one about senseless consumerism. This is what the OP appeared to be asking about.

Not having money, tranportation, a home, or a partner that you are not physically in no way striks me as "senseless cosnumerism." All those things are important elements of what it means to be sucessful in western cultures. If I was missing one of these, I would likely be longing a bit as well. Would you not?

 

[wholeheartedly]

I think the above few posts illustrate that it's probably important to figure out what's behind the "want" or need.

I'm not a psychiatrist, but I'd imagine a slightly different approach is taken when someone doesn't have money (for the fancy car as a status symbol). vs someone who doesn't have money for say student loan debt or an underwater mortgage and feels trapped by it. Or wanting a job they feel fulfilled by. There are very different motivations and mind sets behind those things.

 

[shan564]

I've been getting more blunt lately and just saying "Well, I don't have a medication for that problem" with a smile. Then I say "I see you're not doing any therapy so far and that's at least 50% of getting better. You do want to do the best treatment, right?", and then refer them to the LCSW for bi-weekly therapy the patient may or may not attend.
Now if I could just get other doctors in the community to stop prescribing Xanax 1mg PO Q8H PRN for dysthymia and then referring that patient to me, that'd be great.

+1. I usually respond with something like "I wish I could give you a pill for that, but let's focus on the things I can help with..."

 

[nitemagi]

+1. I usually respond with something like "I wish I could give you a pill for that, but let's focus on the things I can help with..."

I remember being in this position as a resident.

But want to emphasize that when we respond in this way, we are reinforcing our role as just med prescribers. Not that all psychiatrists want to do more than that. But these interactions are still therapeutic opportunities.