I went to see a new cardiologist the other day as I have been having ongoing blood-pressure difficulties that have been difficult, well, impossible to diagnose. After a brief wait, a nice-looking 50-year-old man walked in with his young intern trailing behind. They both took their respective chairs (hers near the corner) and he began the interview. The first thing that thing that struck me about this man was that he actually listened. He paused after my answers just for a second or two before he asked another question. The second thing I noticed was how exhausted this poor intern looked, and how hard she was trying to hold on to all the information that was coming her way. As the doctor moved closer to me in order to listen to my heart and take my blood pressure, he asked me another question about my symptoms. My answer seemed to take him by surprise as I don't think it fit in his diagnostic formulation. He sat quietly for several long seconds with his eyes closed and then continued our discussion. Towards the end, he made some recommendations and an interim plan and said goodbye. On his way out the door, I said to the intern that what she witnessed was an example of doctoring at its best. I told her how this man sat next to me with his eyes closed not afraid of not knowing what was happening. Not afraid to be confused, and caring enough to do all of that in my presence.

There wasn't time to tell her everything I wanted to tell her about caring in medicine and eye contact and the power of touch. I couldn't tell her how alone people feel in that examining room and whenever they see a cardiologist that it is about matters of the metaphorical heart also. I wanted to tell her that it takes courage, strength and self confidence for a doctor to be open to their own ignorance.

But I did have time to tell her that if she practiced medicine the way she just witnessed she would be more than a very good doctor. She would be a healer.

The following letter illustrates how depression affects every generation in the family. In our Web chat on Tuesday we will talk about the difference between depression and sadness and how to deal with both. And we will also talk about what family members can do.

Dear Dr. Dan

My brother is in his 40s and has been divorced for 8 years.  His heart was broken unbearably by his divorce as he was still in love and wasn't expecting this.  He is always just staving off the profound loneliness by throwing himself into his work (he is a teacher/administrator), marathon running and similar intense activities.  Over these past 8 years, I have been an ear for him to share his feelings with and he is very stoic but also forthright about his profound loneliness.  He cried deep, anguishing tears to me last night.  There are times to try and offer solutions but also, those times it is equally important to just listen and affirm the struggle and pain.  I sensed last night, all I could do was affirm his pain.  I hesitantly suggested that it is often darkest before the dawn and he reminded me I've been saying that for the last year.

I was afraid, frankly, that he was suicidal and I asked him if he would be alright tonight.  He said he was and reassured me that as distraught as he is, he wasn't considering doing anything harmful to himself and I believe him.

Can you offer me any advice to pass on to him, Dr. Dan?  It is so difficult to see him suffer

worried sister

After eight years of suffering, the problem goes beyond the very human experience of grief and loneliness and becomes a clinical issue of depression. Now, I don't want to oversimplify this and suggest that if he simply gets treatment for depression (generally psychotherapy and medication are pretty effective), that his problems will go away. On the other hand, if there is a clinical depression, it means his brain, the very organ he needs to work his way through this is impaired by an imbalance of neurotransmitters like serotonin.

I want to respect how he experiences his anguish as profound loneliness. I think loneliness is one of the great human fears. And most humans I know do what your brother does, work hard stay busy ruminate frequently and stay away from our demons. Almost everyone has experienced the difference between being alone and loneliness. One hurts and one doesn't. Loneliness causes anguish when we ache for something different than what we have right now. Loneliness is the pain of grasping for something that isn't there. We tell ourselves we can't survive without companionship. Or that we all are alone because we are defective or unlovable. Or is that this loneliness we feel now will last forever. But it is this ongoing mental activity that is stimulated by that grasping that causes the anguish.

Sometimes loneliness is universal, and sometimes it is a symptom of depression. When I suffered clinical depression years ago, loneliness and shame were with me constantly. Ideally, your brother can learn through psychotherapy that went his mind is racing, it's simply a racing mind rather than the voice of truth. And when he aches for something different, it's just an ache that feels sad and painful.

So that ideally he can become less afraid of his own mind. But even good psychotherapy cannot cure one's sense of loneliness and isolation. This must be done by expanding one's lens and caring for more than one's own pain. Your brother has many talents that could benefit others who suffer. What a great gift to the world if he could get involved with big Brothers or the Boys and Girls Clubs or any other charitable organization in which he could help others. I have found in my professional experience that reaching out to others not only helps diminish the pain of isolation, it can diminish the impact of depression also.

And your letter also brings up a very difficult issue of what can we say to a loved one who is depressed? Certainly becoming a cheerleader or motivator only creates more distance. Understanding and empathy are certainly the first steps, but you don't want to reinforce your brothers self-pity either.

When someone is feeling sad distressed, they typically feel out of control so the last thing you want to do is try to "take over". So I would simply ask him questions about the big picture: "what would you like with your life and how can I help?" Or would you like your life to be different and do you have any ideas about how to make that happen?

we will talk much more about these issues on Tuesday.

just read an article on psych Central, one of my favorite mental health webpages confirming what family therapists have known for years.  That children being raised in a home where a parent is depressed is at increased risk for a variety of psychological problems.Not only does depression make one parent less available emotionally, there is rarely discussion about what is happening in the family, leaving the children confused.  In these families, children tend to take on more responsibility than they should and frequently blame themselves for their parents’ unhappiness.Children, of course, are at less risk if parents get treatment for depression.  And some of the treatment should involve family therapy.  But just as important as the therapies is how the depression is viewed by the family. If it is seen as shameful, or a character weakness and never talked about, the children will continue to be harmed.  On the other hand if it is seen as is a brain disorder that is treatable, life gets more manageable for everyone.And speaking of brain disorder, from a genetic perspective, children of depressed parents are at increased risk for having their own depression.  As they grow, they should be made aware of signs and symptoms and risk factors. And it is critical for parents to role model the attitude that depression is what someone has and not who someone is.This study was done with depression.  But the same would hold true for any chronic illness in the family.  The more it is open and simply becomes a fact of life, albeit a difficult one, the less it becomes a burden for everyone in the family.http://psychcentral.com/news/2009/03/09/children-at-risk-when-parent-depressed/4613.html

Q:My concern is for the family of my grandson, who let their lives revolve around the him and have little or no life outside of caring for the him, managing his therapy sessions, researching the internet. He whines and screams until he gets attention, then stops. When he is not the center of attention, he starts the carrying on and stops when the focus goes back to him. The parents clearly find it easiest to give in. Now I worry for the marriage, with an aggressive, angry child in the house. I can't help but believe that the parents would benefit from some sessions with a family therapist, familiar with Autism. When they say how hard life is, I suggest getting professional help to learn to cope, and they always say, “You don’t understand, we have an autistic child.” They consult every ‘expert’ they can find, trying new diets, play routines, therapies but they don’t think they need help for themselves to learn to make a life with a special-needs child that includes a life for an adult couple. The marriage is clearly strained and I am so worried about a child who dictates everything that goes on in their home. A few words from you, please?
 Concerned grandmother  



Your concern is really threefold: what is the best way to deal with a child with autism and other disabilities?  How can parents care for their disabled child and care for themselves?  And finally, how do we deal with our adult children who we fear might be going down a destructive path?
As far as services available for children, there are many were ranging from special schools to intensive outpatient therapy and in-home therapies depending on the severity of the child.  And there are many  misunderstandings about autism and its cause which leads many parents to devote their time and resources to treatments that don't work.  For example, there is some anecdotal evidence about diets, chelation and nutritional supplements, but no solid evidence that they work.  Many parents have stopped giving their children vaccines because of the misunderstanding that they contribute to autism.  A dangerous choice based more on anxiety than evidence. I will be joined by an expert during the live webchat on Tuesday who will address these issues in more detail.
From your brief description of what's happening, it does sound like one of the treatments needed is a clear and consistent behavior therapy program that would benefit both your grandson and the parents.  And there are also programs to help parents more directly.  The good-looking foundation in South Jersey provides respite for families while their children are cared for (http://www.goodlookingfoundation.org/)
But as you imply in your letter, parents need to be willing to care for themselves in order to take advantage of these programs.  And anyone who has raised the child with a disability knows the tremendous sense of guilt and responsibility in the face of this daunting task of not just helping a child but protecting them from adversity.  Most parents I have dealt with have said things like: "I don't have time to think of myself, my child's needs are far more important than mine." What these parents don't understand is that when they are depleted physically, emotionally and spiritually, they are impaired.  Their decision-making is not good nor is their ability to nurture.  The Buddha used the phrase "compassion for self and others".  There is a reason why compassion for self comes before others.
And finally, how do you deal with adult children you are concerned about.  Briefly, we do it the same way we deal with this economic downturn.  We do whatever we can in whatever small ways we can and then we pray for the faith that our economy will return to sanity and stability. Share your concern with your children, offer to help in any way you can.  And then pray that they will return to enough stability so that they can care for themselves. It has been said that the most difficult part of loving someone is dealing with your helplessness in the face of a loved one's suffering.

Dear Dr. Gottlieb,

I have a "tween" daughter and 5 year old son. We all live in the middle east- My children both attend a British School and this country is rather lenient towards expats. Our community is one of the few that is almost entirely Westerners. Still, I am always concerned about what my kids are missing in this culture.

The one thing I regret is that my daughter will probably not have a prom (depending on whether I am still a contractor) because it is not allowed at the schools. School dances were a challenge and a joy in my memories. Before I go crazy coordinating the Expat Contract communities in neighboring friendly countries to give our kids dances and proms, I would like some information validating that Proms and school dances are actually good for my kid. I just don't think they are getting all of the socialization skills that we had in the US.

Regards,

Trying to do the right thing

 

Dear trying to do the right thing

I am quite touched by how devoted a mother you are. If all kids and others like you...

The answers to your questions are pretty easy. Proms and dances are good for kids. And your kids are probably not getting all of the socialization skills that are available in this country.

But I think you are asking the wrong question. The question that I think is most important is whether your daughter will be harmed or experience some form of social deficit by not having a prom. Clearly she won't be harmed and there will not be a deficit.

I understand this doesn't help you decide about whether you should do this on your own. If you do, it will probably be fun for the kids. But please keep in mind in my opinion, it's not a high-stakes issue.

In the big picture, your kids may be missing something by being in Kuwait, but I am sure there are also gaining something that US kids don't have.

I am a quadriplegic and have been since my girls were six and seven years old. When I look back on their childhood, I can think of all of the things they lost like not being able to play ball with me or the fact that I couldn't teach them how to ride a bicycle or drive. But then I think about all the time I spend with them reading books to them when they were little, just hanging out and talking to them and they were older -- things I never would have done if I was "running around". Just something to think about.

I wish all of you the best

Dan Gottlieb

Dear Dr. Dan,

Thank you so much for your reply.  I think that I will still look into perhaps hosting a multi-country Prom somewhere like Dubai, which is more tolerant of Western culture.
You know, as a parent it's so hard to ask for advice and then further to consider the advice credible.  The travel and culture that my kids have been exposed to is wonderful.  I wouldn't trade it for the world.  I actually have real vacation time and resources (though never enough) to give them more of the regular things.  It's a shame though that I couldn't give them this life in our own country.
I hear you about quality time.  It something that all parents need to remind ourselves is important in addition to the big deals that we try to give our children.  I'll work on that too!

Should you hear of any other scholars who may be doing research on any of the subjects we've discussed please keep me informed.

This poem is written by a woman named Joan to her mother who was dying of Alzheimer's.

Anyone who lost a loved one to Alzheimer's or any other type of dementia will identify with the sentiments.

Tentatively titled "Empty"

A year has gone

an eternity past

our lives as we once knew them

have ceased.

In your face I see the confusion,

in your eyes all that we once were,

all that we once shared

is gone…. emptied.

At times I feel you groping in your darkness,

searching for the light of connection…

a faint glimmer, a brief second of recognition

then as the impulse courses through the

circuitry of your awareness it shorts

then dies as I desperately try to hold it near.

If you had died

I could somehow place all these emotions

inside a prayer, raise my eyes to the heavens

and remain connected to you, to your energy, soul, you're being.

But you're not dead, not gone, just emptied, a shell

hardened, isolated, disconnected from everyone

you once showered so selflessly with your love.

I am left withrering, convulsing, cut off from my lifeline… but to you

it's all meaningless

even the tears that

fall down my face

confuse you.

 

This beautiful poem captures the anguish and the helplessness as she tries to grasp what is no longer there.

As my own father approached death, I watched parts of him slip away. As he aged I watched his skin color to gray, his hearing became weaker as did his vision. It was sad to watch him die, but his mind was clear and I felt like I was growing closer to him in the final stages.

My mother, on the other hand, had hydrocephalus and as the pressure on her brain increased, she became more confused. As Joan described, the confusion caused my mother to slip away as she no longer understood much of what was happening around her. It was almost as though she was slowly taking leave of her family, her life. And while this was happening, I felt something beyond sadness, almost an urgency to grasp her before she slipped further away. I recall how sometimes I had the impulse to scream out for her to come back almost like a child who believed his mother was in there somewhere. And with every visit, there was less of her there.

As we watch our loved ones to slip away with such indignity, most wish for the end to come more quickly. Most feel guilty about that. Most have to steal themselves to visit their loved ones. Most feel guilty about that. Most feel relief after the death and feel guilty about that also, complicating the mourning process.

Saying goodbye is never easy. But watching someone we love slowly lose their mind, is its own anguish.

Joan will be joining us Tuesday to discuss the poem, the emotions she went through then and how she is doing now since her mother has passed away. And I hope to hear your stories.

Dan

I am 74 years old.  A recovering alcoholic sober 22 years.   I grew up in a disfunctional family that included a father who broke his neck but lived.  He never worked again though.  I did not receive affection from my mother, my father was affectionate until the accident.  I am trying to give my adult children love and affection but I don't know how to do it.  Can you give me any suggestions. 

Nancy

Dear Nancy,

you've told me some facts about your life. But other than the fact that you are 74, what you've told me is about your history. I want to know who you are now. Are you a person with hope, fear, gratitude or regret? Are you insecure or perhaps angry at the injustice you've lived with? Are you someone who longs for love or someone who is at peace with where they are now. I could go on with my questions, but it is important to understand who you are at the deepest levels before we can talk about how to offer something called love to your adult children.

Believe it or not, I think there is something even more important than love and that is compassion. That's the ability to look deeply in someone's eyes and say "tell me about your life" and then listen for a long time. And while you were doing so, try to imagine that life is your life. Some would say that is an act of love, but whatever it is, it is precious and healing.

To offer that to your children would be a gift and I am sure something you can do. But more complicated would be to do the same thing for yourself. Because I imagine you've never received that kind of compassion either. So just take some time and look at yourself through compassionate eyes and wonder what is it like to be Nancy? The answer to that question will vary moment by moment, so please try to drop in on yourself several times a day. Over time, you might find a friend in there