By: Pamela P. Siller, MD

The Beginning

As a practicing psychiatrist, I am frequently asked how to engage an unwilling patient in mental health treatment. My response is unvaried, “It is very difficult. The desire to change must come from within.” Although the precipitant to change can take many forms, it usually involves some degree of psychic pain or discomfort, as change is neither easy nor comfortable. The next step involves a willingness to explore the origins of the pain and/or take a leap of faith and try a new medication. Finally, the person must embrace their changed self.

Although depression and sadness are painful, mania can be enjoyable until it borders on psychosis. Traumatic events and breakups with friends or romantic relationships can often send a person into a tailspin. At times, the love of another and the desire to please can be enough of a catalyst for one to seek help. 

Engaging children and adolescents can be more complicated. Some, may not have the words or the emotional maturity to fully grasp the nuances of how they feel. Oppositionality and the desire to “fit in,” may be powerful factors. However, parental influence can be great.

“My daughter, Rochel, has stopped coming home for dinner. She ignores the family, has stopped showering and does not wear make-up or brush her hair… she’s only 19. When I speak to her, she yells at me and tells me that I don’t love her. Please doctor, can she see you? Can you give her some vitamins to help her?”

The Entrance

Oftentimes, I find myself faced with a patient who clearly does not want to be sitting in my office. At times, the person is forthright about their anger, occasionally to the point of rudeness. At other times, the aggravation is clearly etched in their faces, or displayed in their body language. Rather than becoming offended, I always remember that anger tends to become the default emotion for many different feelings and is frequently a manifestation of pain.

I have found it helpful to initially sympathize with the presumed discomfort of being brought to a physician’s office, without adequate explanation and being asked very personal questions. With luck, skill, and perhaps karma, my patients will often begin to use the office as an outlet for their feelings, often with initial trepidation and reticence.

It is important to recognize the origin of the reluctance to engage. It can be traumatic to recount a difficult experience, unnerving to leave oneself vulnerable, and daunting to ask for help. Furthermore, the initiation of medication may meet with further resistance, as pills bring their own stigma, preconceived notions, concerns of side effects, and fears of “losing the real me.”

Open discussion, communication, and education, combined with heartfelt praise for the patient’s display of strength for accepting treatment, is often reassuring and reinforcing.   

Rochel reluctantly entered the office with her head down, avoiding all eye contact. Although not malodorous, her hair was unkempt, her dress sloppy. Rochel initially announced, “I am fine; I do not need to be here!” After several minutes of silence, and commiseration around the awkwardness of being forced into an uncomfortable situation, Rochel was able to admit that her life had changed and her mother had a legitimate reason to worry. However, she refused to elaborate further and walked out.

Several follow-up phone calls and one week later, Rochel returned to my office. Although her demeanor had not changed, she was willing to discuss her feelings of hopelessness, worthlessness, and helplessness. She revealed that when she did not come home, she would frequently walk about aimlessly. Rochel refused to discuss any precipitant or timeline for her feelings but was willing to chance an antidepressant “to stop feeling this way.”

The Change

Although the resolution of painful feelings is unerringly positive, at times it can unmask previously overlooked symptoms. I have frequently seen the onset of obsessive-compulsive symptoms once psychosis was resolved as well as nightmares and flashbacks upon resolution of depression. This is frequent when the severity of the initial symptom overshadows the lesser feeling. I often provide reassurance that these new symptoms are not the result of the medications or a new “illness” rather they are surfacing as the person is beginning to heal. Receiving therapy at this time is of the utmost importance. I liken medication to a Band-Aid over a wound, initiated to facilitate healing from the top so that a scab can form. True healing must be from the inside out, at the root of the problem, which can best be accomplished by individual or group therapy with a clinician whom the patient trusts.

Rochel was prescribed Sertraline (Zoloft) and had a follow up appointment three weeks later. The change was marked as she was now well groomed and able to make eye contact when interacting with others. However, Rochel described vivid dreams, centered upon death. As this was very disturbing, Rochel asked if there was any new medication that could address this. Although initially reticent to the idea of individual therapy instead of a new medication trial, Rochel was soon able to accept the idea as she now felt hopeful that change could occur and had enough energy to attend weekly sessions.

After the Change

The therapeutic process can be arduous, long, and complex although the benefits are immeasurable. True happiness is precious and should never be taken for granted. Often, those who have suffered from a mental illness or transient symptoms cite fear of a relapse. Sometimes, people wonder who they truly are, and “which self is real?” I frequently find myself explaining that everyone is multifaceted. Just as we act differently in the many roles we play, so too do we have complex feelings that emerge when we are faced with different challenges and joys. Getting to understand ourselves, and the changes that emerge, can be a truly remarkable experience.

Rochel attended individual therapy during which she was able to process an experience where she witnessed the sudden, unexpected, and (to her) frightening birth of a baby while taking a walk. Her feelings associated with this event resurfaced when she began to feel pressure to date and consider marriage. After she began to understand her feelings and recognize her reactions, her symptoms resolved, she was able to stop her medications, and “graduate” from treatment as she was able to heal from the inside.

 

Pamela P. Siller, MD is a Board-Certified Child, Adolescent and Adult Psychiatrist who provides medication management as well as individual and family therapy to children and adults. She maintains a private practice in Great Neck, New York. Dr. Siller is also the Director of Child and Adolescent Psychiatry at the Interborough Developmental and Consultation Center in Brooklyn, and an Assistant Professor of Psychiatry at New York Medical College. She also provides psychiatric evaluations for the NYC Department of Education.Dr. Siller can be reached at 917-841-0663.