Thursday, 21 April 2016

How do you you know when you are ready to go off anti-depressant medication?

I had a client come in to see me today whom I had not seen for some time.  She was wanting to touch base about going off her anti-depressant medication which she had been on for about a year.  She wondered whether it was right timing and was worried that if she went off, her old symptoms could return.  Not unlike many, she had started her journey on medication rather reluctantly, feeling as if she had failed in some way because she had not been able to manage her symptoms on her own. Yet, she could not deny that the medication had really helped her and had made a significant difference to her quality of life. She started the session off by saying: "You have to write a blog on how do you really know if you are better?"  My thought was, this is a really good question to write about as I have been asked it many times. After all, when medication has been containing symptoms for a long time, how can one predict whether or not they will reappear once the medication has worn off?

Most physicians these days will suggest that if you go on an anti-depressant medication for anxiety or depression that you stay on it for about a year.  This is because empirical research has shown that while you might feel considerably better after a couple of months, it is best to stay the course for another 4 to 5 months if you want to avoid relapse.  Once you have done this though, and you have been feeling good for quite awhile, how do you know when it is time to try doing without?   For some, it is a scary venture and some reassurance would be nice. Unfortunately, the answer is that while you can up the ante on being successful, you never really know how you will do without medication until you put it to the test.

It is definitely wise not to go off medication when you are in a crisis or major transition.  It is also not a great idea to go off medication if you live in Manitoba and it is the middle of winter! Another rule of thumb is that it is best to wean off medication gradually rather than going off cold turkey.  That way you can avoid adjustment reactions.  If your physician does not offer you guidance on this, pharmacists are often very knowledgeable about methods that work best for weaning off medication. How you will fare, however, is often only discernible through the practice of trial and error.  If you don't get a re-occurrence of symptoms, you are O.K. to go.  If you do, then more likely than not, you have weaned off prematurely and need to stay the course for a while longer. When you go off, do not make the mistake of expecting to be able to assess in a couple of days or even a week whether there has been any negative fall out.  It can take a good month before you might be able to determine how you are faring without medication.

Anti-depressant medications work by accumulating in your system.  It takes 4 to 6 weeks to determine whether an anti-depressant medication is effective and so, it will take at least that long for it to leave your system so that you can properly assess how you feel without it.   If you go off and intrusive symptoms come back in a disconcerting way, do yourself a favor and don't beat yourself up about it.  Appreciate instead that you have learned that the medication was in fact helping you.  When you have been on medication for a year or more, it may well be hard to tell if it is having any impact at all.  Also, appreciate that there is medicine that can help you and go about the task of adding to your repertoire of positive coping skills and making some lifestyle changes ( i.e., exercise, proper diet, good life/work balance).  If you have been on medication and you have not seen a therapist, know that the research is consistent.  People whose symptoms are severe enough to warrant medication have the best long-term results if they not only take medication but do therapy as well. This only makes sense when you think about it.  Medication can only reduce the intensity of your the symptoms.  It cannot address the source of your problems; nor can it help you to learn better coping skills. Also know that about one quarter of people who go on anti-depressant medication will need to stay on it long-term; they may even have to stay on it for life.  These often are the people who have struggled with depression/anxiety since childhood or adolescence and where there is a strong family history and thus, biochemical aspect to their illness.    

As a psychologist, I would say that I am fairly conservative when it comes to suggesting medication. After all, my specialty is helping clients get to the root of their problem and in teaching people better coping skills not, psycho-pharmacology.  I do know a lot about how medications work because often I see clients over time and on a more regular basis than their physician would.  In the United States, some psychologists prescribe medication.  If the truth be told, I would prefer not to.  I have learned, however, through experience not to be close-minded about the benefits of medication.  As many seasoned therapists know, sometimes a client's symptoms are so severe that psychological methods will not work without a biochemical assist to help them get onto more stable ground. When symptoms have become severe and unwieldy; for example, when a person is suffering severe panic attacks or is unable to focus, think clearly or process information properly, a therapist cannot be effective in using talk therapy alone.  Sometimes, this is evident from the start because the symptoms are so clearly overwhelming.  At other times, the therapist and client have given therapy a shot and it becomes apparent that they will be stalled until the symptoms are no longer so crippling.  When such is the case, recommending that a client consult with their doctor about the advisability of giving medication a trial to decrease the intensity of their symptoms is the number one priority.  Contrary to what some might think, anti-depressant medication will not make you into a "zombie".  In fact, if you go on medication and feel like you have gone numb or your emotional world has become flat, then more than likely, you are on the wrong medication.  Medication is also not a "happy pill". When an anti-depressant medication works well, it takes the edge off symptoms and in fact provides a window of opportunity for therapy to be effective. This is when the two, talking therapy and medication, interface in the most ideal way.

Monday, 4 April 2016

Are you the child of a narcissistic parent?

Only recently have we begun to understand the impact of having grown up with a narcissistic parent. Parents who are narcissistic carry damage from their own upbringing and as a result, have a difficult time seeing outside themselves and being able to empathize and tune in to their own children's feelings.  Typically, the narcissistic parent's emotional needs were not well met growing up.  As a result, rather than being able to see their children as the unique people they are, parents with such tendencies see their children as extensions of themselves and so unconsciously, superimpose their own needs and wishes onto their children. They unthinkingly assume that it is the child's job to think, feel and behave as they desire.   They believe that it is only correct that the child carry out their dreams and wishes and achieve their version of success.  If this does not occur, the parent may well feel insulted or offended and may interpret their child's behavior as betrayal, resulting in feelings of disapproval, anger and even rage. Typically, this is not a conscious process.  In fact, narcissistic parents often view themselves as very generous and well meaning.  They do not see themselves as self absorbed and fulfilling their own needs at the expense of their children. This does not mean, however, that there are not serious consequences for the child of a narcissistic parent as regards her own personal growth and development.  

From the moment a child is born, the way she learns about herself is through what is called "mirroring" on the part of parents and other primary caregivers.  Mirroring occurs when the parent reflects back to the child in an accurate way what they are feeling and experiencing.  For example, the parent sees signs of fatigue in the child and says: "Honey, you seem tired. Maybe you should lie down for awhile."  Through this feedback, the child learns: "Oh, so this is what it feels like to be tired."  The child comes to understand what she feels and thinks through this process of ongoing feedback from parents.  A narcissistic parent, however, is limited in their capacity to mirror accurately and pick up on the cues that the child is sending.  They are so consumed with their own unmet needs that these consistently over-ride and are superimposed onto the child. Not only are narcissistic parents unable to see their child clearly for who she is but they make the mistake of projecting their own needs onto their child.  For example, the narcissistic parent may so badly need the child to become a successful dancer in order to fulfill their own unfulfilled dreams and desires that they lead the child to believe that this is her true calling and if she does not take this route, that somehow she is a failure or disappointment.

Such parenting makes it exceedingly difficult for the child of a narcissist to come to know who she is and what she really thinks and feels.  She must continually push aside her own personality in an effort to please the parent and provide the mirror image that the parent needs.  The message the child receives is:  "You will only be loved if you are compliant with my wishes".   If she fails to obey the parent's wishes or tries to set her own goals for her life, she may be overtly punished, frozen out or even ostracized for a period of time.  Not only is the child's growth stunted but the child of narcissistic parents internalizes a sense of defectiveness or "not feeling good enough." This is inevitable in light of the fact that as much as she may try to please the narcissistic parent, the child cannot possibly be and fulfill the parent's needs and wants and so she will fail again and again.  The child of a narcissistic parent is incapable of understanding at such a young age that when she is being criticized and disapproved of, that it is the parent's expectations that are impossible and off the mark. Typically, all she is able to understand is that she has somehow failed and has been unable to do it good enough or "right enough".  She inevitably ends up believing that she is deficient in some way for not being able to gain her parent's approval.  Often, she internalizes a deep sense of shame about this failure, turning the anger and frustration against herself.  It can take years into adulthood before she realizes that the type of parenting she received was wrong and that it was the parent who was imperfect, not her.  Having grown up without a sense of goodness, later on in life, she is likely to gravitate toward a partner who is unavailable, critical or withholding, just like the narcissistic parent was.  She is at risk of ending up catering to her partner and trying to keep him happy even when it means squashing her own needs.

One of my earliest mentors used to talk about children of narcissistic parents as "moon children".  I came to believe that this was a wonderful metaphor to powerfully convey the parent-child dynamic when a parent is narcissistic.  Picture one of those diagrams of the solar system where the sun is at the center of the solar system surrounded by the moon and all the planets.  The narcissistic parent is like the sun.  They are the center; the source of light for all that surrounds them.  The child of the narcissistic parent, on the other hand, is best symbolized by the moon.  The moon has no light of her own.  She is totally dependent on the light from the sun.  Her only means of being visible is by reflecting the light of the sun.  And so it is that the child of the narcissist is only acknowledged and seen when she reflects the parent's desires and wishes.  Otherwise, she remains invisible and in darkness.   Therapeutic work can not only shed light on this darkness and help repair the damage by providing corrective, accurate mirroring and empathy but it can also be a powerful vehicle in helping adult children of narcissistic parents to discover their own truth and identity.