Dear Dan,
Recently our beloved son Kenny, just 19, ended his three-year struggle with depression by taking his life.
Despite the fact that it's been almost half a year, I think of him constantly. Memories of him flood my mind all day long, especially when songs come on the radio. I still cry because the music gets me. I think to myself, Kenny liked this song.
We go out to a restaurant and see something on the menu and I think Kenny would have liked this. We all do this, including my husband and my daughter.

I drive through town and see things that remind me of him. I go into his room and it still smells of him. I have the last outfit he wore and I haven’t washed his sheets. I go in there because it makes me feel sad and happy at the same time. It makes me feel close to him.

Can you please tell me if the pain will lessen? When does it stop, and when does it get easier? When is it ok to let go?

I am torn apart by so many emotions, especially anger. I even feel angry at Kenny sometimes and that is hard. Your heart is angry but your head tells you he was sick. I

 feel angry at some of my family and some people in the community. If Kenny had died from cancer, I would probably feel less alone right now. Some people were very supportive and caring, but others were silent.
I haven’t gone to the grocery store or church since Kenny died, the memories are too painful.

 I don’t want to see anyone.I am also worried about Kenny’s sister. All these months later and she still has not yet cried for Kenny’s loss. All of us need help.
Thank you.
Trish  

Dear Trish,

I am so very sorry for your loss and your sense of isolation.

Whenever we experience trauma, we feel alone and the pain of the alienation can be excruciating.But when you lose a child to suicide, the isolation is so much worse. It's too terrifying for anyone to imagine. And in today's world, the risk of losing a child to suicide or anything else feels much higher and more frightening. So we turn away from our fear and helplessness, and turn our backs on you.
In psychological terms, six months is like yesterday. Your brain cannot fathom what has happened let alone what it means or how to cope with it. That's why these unexpected thoughts and emotions land like a tsunami. I'll bet you sometimes forget that he's gone, and then it starts all over again. And for most parents who lose a child, the guilt can feel soul-crushing; they ask themselves if they did all they should have done.
Of course you are angry at Kenny. After all, he left you in a violent way. Same with your community and your family. It must feel as if they also have left you.
Sometimes the unconscious experiences death as a murder when something evil has stolen someone precious from our lives. In the last scene in Miss Saigon, the main character’s lover commits suicide in front of him. As he cradles her in his arms, he lets out a bloodcurdling scream of grief and rage. That is the kind of scream your whole family must feel.
In Alcoholics Anonymous, a famous saying is “One Day at a Time.” Anyone in crisis will tell you that sometimes it's one hour at a time, one minute at a time. The task is to live the next moment and then do it again.
And letting go? You will never let go, and probably don't want to. Most parents I have worked with tell me the pain is excruciating but they wouldn't want to part with it as that pain is their connection to their child.
Over time, your connection to Kenny will have more texture than trauma. The pain will always be there, but there might also be warm affection, quiet longing and even gratitude for the years you had together. But that takes a long time. Not work, but time.
In the meantime…
As you know from what happened to Kenny, 90 percent of suicides happen to people with some form of mental illness, typically depression. So I understand your anxiety about your daughter, because depression has a genetic link and stress increases one's risk for a depressive episode. Do what you can to help her feel safe enough to share her feelings. But be aware that males are three to five times more likely to commit suicide than females.
We haven't heard a word about your husband’s feelings or the state of your marriage. I am sure he is in terrible pain. Men tend to be less expressive, which can add stress to a marriage that’s already stressed.
So you’re right. All three of you need help.
I would recommend your family try a few meetings of “Compassionate Friends,” a self-help group for families who lost a child. And I would recommend family therapy with someone who is skilled in dealing with this kind of trauma.T
There is so much more to say and so little space to say it so I have another offer. You could use me as a resource and stay in touch via e-mail and web chats.

Trish will be joining me on Tuesday's web chat

Hi Dr. Dan:
How does one be in a relationship with a narcissistic parent?
I am an only child and my parents were divorced when I was 8. My mother passed away from illness when I was 21 so my father is all I have. He has some health issues but none that would keep him from working. He chooses not to work, and live off the government on social security. 
I can go on and talk about the false suicidal threats he pulled, the number of times I gave him money, a place to live, etc…
And it's not just financial. I have also been in a parental role emotionally. My father has never had much interest in my life.
Recently I was telling my father about a treatment I was going to start to treat for a skin condition. He interrupted me in mid-sentence to tell me about his friend's child. I realized that his self-absorption was even more severe than I realized.
Yesterday was my birthday and he did not bother to call me or see me. This was a first but no surprise. I'm wondering how I should proceed. Do I not call him on this? Do I ignore him on his birthday?
I think the bigger issue is how much I give to a parent who gives so little back? I invite him over for dinners, take him out to eat, get him presents on father’s day, etc... I guess I do this out of my own guilt and fear of losing a connection with him. Deep down I have a fear of him dying. I realized this a few years ago when he used suicidal threats to manipulate me.
I’d appreciate any thoughts on how to handle this.

Tired daughter 

Dear tired daughter:
Although your father may be depressed, he shows many signs of a narcissistic personality disorder. Those with this disorder believe they are “special.” They require excessive admiration, display an unreasonable sense of entitlement and lack empathy.
Personality disorders are notoriously difficult to treat because like your father, these people with these disorders don’t think they have a problem. So they rarely seek treatment. When they do, they usually lack the commitment required to begin modifying one's personality
.I understand that you are angry at his manipulation and that he cares more about himself than his only child. And I understand the terrible imbalance in this relationship.

But your letter tells me more about his behavior than it does about you. You are the one who is suffering

.If I were to ask you what you really wanted, you might say boundaries. But as I read your letter more carefully, I hear your continued devotion for this man and fear of his death, I wonder if what you really want is something beyond boundaries. Maybe you have an unspoken longing for the father you may have wished for since you were eight years old.

 Perhaps your tenacity is about something you have carried deep inside your heart for many years: Hope.

 I am sure you know in your head that he won't change, but maybe your heart doesn't know that because it is just too painful. I would suggest the real source of your suffering is unrelenting hope.

You've had three significant deaths in your life. A divorce is like a death to an eight-year old child, and of course your mother's death came when you were 21. I am sure in whatever way you did, you acknowledged and grieved for these losses.

 But the one death you have not dealt with is the death of your dream to have the father you want.

Once you stop fighting with him and for him, what's left? Then you would be in a relationship with a man who is emotionally unable to connect, a man who, because of whatever defect, is incapable of compassion.

You would be in a relationship with a man who is broken and in many ways childlike. If you can mourn this loss and relate to this man as he is, he might feel less dangerous to you. And you might be able to set boundaries without resentment.

One more thing. I would suggest that your fear of his death might be about love. Despite his outrageous behavior, it sounds as if you still love this man.

Love is not a zero-sum game. Love without expectations feels good. Love with expectations causes suffering. Once your dream for the father you've always needed has died, you might find yourself able to love the father you have.

I hope so.

Dear concerned husband,

Sometimes marital problems are mostly because of one person.  Sometimes, but not often.  Certainly this is the case with the abuse or violence where one spouse feels unsafe in the matter.  If you haven't harmed her physically or psychologically, nevertheless If your behavior is so irritating to your wife that she will not go into therapy until you have done some work, so be it.

On the other hand, if she is willing to go into therapy with you, I would recommend that.  Very often in marital therapy I have one spouse working for an entire session, sometimes two or more on their issues.  That way the observing spouse can get to see and understand you from a different perspective.  Because after all, the goal is not just behavior change, the goal is mutual respect and understanding.  I am sure your wife would also benefit from talking to a therapist about her marriage with you sitting in the room.  It would help you understand the impact of your behavior beyond her surface reaction.

I hope that helps

Dear Doctor Dan,
I am a faithful reader of all things Gottlieb, so I am hoping you could advise me about some distressing issues in my life. 
How can I go about helping my daughter find a therapist for my grandchildren who are ages eight and five?  Their parents recently divorced and the older child is having real problems with sleeping overnight at his dad's house.  He says he is ok with spending time with daddy but does not want to stay away from home.  He has no trouble sleeping overnight at my house but has done that since birth quite a lot.
My daughter says that her ex tells her that the child "has to learn to cope" and that is what they have been doing.  I think it will take a matter of time and will resolve itself,  but I also think they could use some counseling to deal with this issue and other divorce related things. 
Can you guide me so that I may guide her in steps to find a compatible counselor 
Thank you
concerned grandmother 

dear concerned, 

Your letter brings up several issues, so let's talk first about what needs to be done and then we can talk about what you can and cannot do to help make it happen.

Although divorce harms all children, according to the American Association for marriage and family therapy, only 25% of children of divorce have serious long-term emotional difficulties.  Although this is a very high percentage, keep in mind there is a good chance your grandchildren will be okay without intervention.

But there are many things parents can do to help mitigate the effects of divorce.  The first and most important issue is safety.  All children need safety in the wake of this upheaval, but especially young children.  And children find safety in consistency and predictability.  Much as possible, schedules should remain the same week in and week out, especially in the months following a divorce.

Most children of divorce feel that the bottom has just dropped out of their lives and that everything they knew to be true is no longer true.   So your grandchildren need to be reassured with words and actions that they are loved by both parents and both will take good care of them.  So both parents must be very careful not to cancel plans and to show respect to one another in front of the children.

I often tell divorced parents that they must love their children more than they hate each other.  Therefore they must develop a workable plan that gives children easy access to both parents.  And of course, no parent should never ever speak angrily about their child's other parent.  At best, it sets up a loyalty conflict for the children.  And worst, children feel they have lost both parents.

Believe it or not, I would not recommend counseling unless they are showing signs of distress.  Signs to look for include
·         acting younger than their chronological ag
·         moodiness
·         sleep difficulties
·         acting out in ways they hadn't before
·         problems with friends or school
·         irrational fears and compulsive behavior.

Many children of divorce will show some of these symptoms in the short run, but if they persist, it's time to seek help.  But I wouldn't automatically seek counseling and here's why: children of divorce already feel pretty alone and wonder if there is something wrong with them which may have broken up the family.  If they are "sent" to therapy, the process itself could reinforce that belief.  I believe that if younger children of divorce need therapy, it should be family therapy unless there is a compelling reason not to.

Finding a therapist?  Make sure the therapist is trained in marital and family therapy.  But even so, not all family therapists are trained in working with small children, so you need both.  You should be able to find one in your community through the American Association of Marriage and Family Therapy.  Alternatively you could look up your State Psychological Association or National Association of Social Workers.  But please make sure whatever therapist you find is trained in both divorce and working with young children.

So now we come to you and what you can do. First, divorce is a trauma not just for parents and children, but for grandparents also.  Just like your grandchildren, you may have gone through these years thinking that your children and grandchildren were safe and secure.  And now this.  I have spoken with so many grandparents of divorce children whose hearts are broken by what's happening to their children and grandchildren. It feels the stakes are so high and you feel so powerless.

I will assume you have a good relationship with your daughter, but it's also important that you maintain at least a respectful relationship with your son-in-law and avoid criticism or blame.  If your daughter wants to do so, listen to her with compassion and empathy, but please try not to reinforce her resentment or help her feel like a victim.  As I am sure you know, if you were to get in the middle, the outcome is never good.  I've talked before on these pages about how and when to offer advice to our adult children, when it's respectful and when it is intrusive.  And I have said that within very broad limits, we have to respect the resilience and problem solving skills of our adult children.  But when grandchildren are involved, it gets more complicated.

Feel free to tell her about your concerns, but please don't push as your daughter feels vulnerable enough.  Offer to be an additional resource for your daughter, grandsons and even your son-in-law.  If you are able, spend extra time with the children it might help everyone out.  And perhaps you could even include the other set of grandparents in some of the social activities.  It would certainly make the children feel better.I hope this helps and I wish everyone healing.   

Hello Dr. Dan,



I watched the movie, “The Soloist” tonight about Steve Lopez’ relationship with Nathaniel Ayers, the inspirational homeless musician in LA.  I’m thinking you may have seen the movie/read the book.  There are some very compelling scenes depicting some schizophrenic episodes with Nathaniel hearing voices that  clearly distract him from reality.  I’m wondering if, from your experiences and expertise, you can share your insights on the authenticity of the movie, especially regarding the relationship between Ayers and Lopez and the mental illness symptoms of many of the homeless people depicted in the film.



I’m a Theology teacher in a Catholic high school and in my Senior classes, we study homelessness—the realities, the impact, the causes and consequences.  I’m thinking that this movie may be useful.



I look forward to any insights you can offer me, Dr. Dan.



Peace and blessings,

Suzy Eyler

  Dear Susie Eyler,

As you may know, schizophrenia is one of the most disabling of all of the psychiatric disorders.  It affects over 2 million people in this country and about 15% of them are either on the streets or in prison.  Like we saw in the movie, first symptoms occur in men in their late teens and early 20s, later in women.  The hallucinations and delusions that you saw may be the most dramatic symptom of schizophrenia but far from the only ones. These symptoms make most with schizophrenia fearful and withdrawn, but sometimes they can become terrified of what happens in their minds.

And because those with schizophrenia look and act strange and appear timid and frightened, they are at high risk to become victims of violence, especially if they are in prison or on the streets. 

We have known for a while that schizophrenia is a brain disorder that is based in genetics, we are still pretty far from understanding the exact causes.  But that doesn't mean it's untreatable.  New medications are coming out every day with more awaiting approval from the FDA.  There have also been improvements in our understanding of what psychosocial treatments are more effective.  Some of the cognitive therapies are also showing promise.  And with good and consistent treatment, it is estimated that after five years 50% are improved enough that they are able to function independently.  Another 25% are improved but require ongoing supportive therapies.  Of the remaining 25%, about 15% of them are hospitalized.  Sadly, suicide accounts for the other 10%. 

But those statistics are for people who receive treatment.  People who have supportive networks to make sure they get the treatment they need.  And that is not the case with many people who have schizophrenia or other major mental illnesses.  They are left to the care of public institutions that are overburdened, underfunded and unable to effectively meet the needs of those who need their services most.

    Which gets us to Nathaniel Ayers in "The Soloist"

  Given the Hollywood requirement for both drama and relative simplicity, I think they did a pretty good job of portraying schizophrenia fairly.  But what they did beautifully was to portray the humanity behind the illness.

I discovered this as a brand-new psychologist in 1969 when my first patient, Norma, shuffled into my office for the first independent psychotherapy session of my career.  Norma had schizophrenia and had carried the diagnosis for 30 years.  I was 23 years old at the time!  Of course, I had to prove to both of us that I was a competent psychologist who would treat her.  As soon as we started talking, she nailed me.  She told me in her own confused way that I had no idea what I was doing and that I was making it up!  Of course, she was right.  But she wasn't angry or hostile about it as I might have been if the situation was reversed.  Instead, she was more playful which enabled me to get comfortable with the relationship we had rather than the one we were supposed to have.  Norma and I didn't communicate well with words, often we didn't understand each other's language at all, but there was a connection.  Sometimes when the words stopped, we looked in each other's eyes and smiled.

Norma never really got better, and a couple of years later, I heard that she died on the streets.  I cried as I would have hearing any friend had died.

20 years later I was working with a 20-year-old girl who was suffering with depression and an eating disorder.  One day she said "I feel like my soul is a diamond locked inside of a malignant tumor."  Hearing that, I thought of Norma and my eyes welled up with tears.

If Norma's mind was clearer, I am sure she could have said the same thing.  And my guess is that most people living on the streets could also say the same thing.

You see, in my mind, these are not street people or schizophrenics, these are people who experience their lives the same way my 20-year-old patient did.

And our responsibility as a community is to know that and do whatever we can to see that diamond.

  

Dear Dr. Dan,

I've been facing a very painful realization about the impact my work is having on me. I counsel cancer patients both in person and online. I’ve been doing this for years and always felt so good from reassuring people about their diagnosis and care options since I had to go it alone when I had this cancer. But I feel like I’m getting burned out.

I’m discouraged that the therapies are not more effective and that sometimes I have this private knowledge that I know someone will die. I don’t know how oncologists do it.I also worry about being older and how much future I have left and whether I’m living enough for today. I have trouble sleeping at times too. I think about “my” patients a lot, especially one I’m working with who has a recurrence.

How do I distance myself from my work yet remain compassionate and caring? Christine I contacted Christine as I felt I could not do justice to her letter without knowing her a little better. I learned that 20 years ago when she was pregnant with her son, she was diagnosed with a very dangerous type of cancer that carried an unclear prognosis. She had little support from family or friends and felt very much on her own. Finally she found a wonderful oncologist who not only treated her but became a friend and mentor.

Shortly thereafter, she developed a helpline for patients to call and receive the kind of guidance and support she needed when she was diagnosed. She told me that over the years, she has felt deep compassion for the hundreds of people who have come to her with this disease whether they’re low risk, in the fight of their lives, or needing hospice care. 

When I asked her to describe what causes her the greatest pain, she said:“The losses weigh on me. Like when I ran across the email address of a patient I worked with who died.

I’ve started to think too much about the end of my life, that I could find myself with a recurrence. I am not great at living in the moment as I preach to patients.

I sometimes have a tough time coping with the usual anxiety in life, like when my son went to college last year.” 

Dear Christine,

What you are describing is technically called compassion fatigue, which is rampant in the healthcare field.

Compassion fatigue is more likely to happen to people like you who care deeply and want to do the best they can for everyone they see.  People with this condition often feel chronically tired, irritable and lack joy in their lives.

Many leave their jobs, or worse, protect themselves by not feeling compassion anymore. Sadly, we see the latter all too often in healthcare.  

The best way to begin dealing with this is to do what you have done — opening up about your sadness and confusion and asking for help. Sharing these emotions with kindred spirits is a good way to care for yourself.  

Like many who have experienced adversity, you have nurtured yourself by using your experience to help others. That's an essential way to survive trauma, but not so good if this is your only method. 

Compassion fatigue is about not having enough compassion for one's self. Patients often come to my office visibly distressed or exhausted. So before they start talking, I invite them to rest for a few minutes, catch their breath and find themselves. Often they begin to cry. I offered compassion that they desperately needed but didn't know it. 

Christine, please check in with yourself and do it often. Just know how you feel in any given moment and find compassion, even love for the person you are.

If you feel helpless, confused, sad, tired or frightened, let yourself have those emotions and care for the woman who is having them. If you can do that, you will have a better sense of what you need and will be more likely to give it to yourself.  

To me, the larger, most compelling issue is about life and death. Because of your experience and great compassion, I wonder if when a patient dies, you feel yourself looking at your future. And now the loss of your son and possible loss of your job may have you staring at that nightmare that began 20 years ago.

I invite you to sit still and make direct eye contact with your nightmare. What if you found out you didn't have much time to live?

What changes would you make?

Imagine this is your last summer and you will see the leaves change colors soon, perhaps for the last time.

Far from being a morbid experience, you might feel sad, but very alive.

Many years ago, I took a course in mindfulness meditation and a fellow student confided that she had stage three breast cancer and didn't expect to live much longer. I asked her why she would take a course like this at this stage, and I'll never forget her answer: “All my life, wherever I was, I was always somewhere else. In the time I have left, I want to be where I am and experience it fully.” 

Christine, I wish that for you and for the rest of us