Friday Counseling Issues: A Ramble

I’ve worked two full weeks now since the end of my Christmas break.  It’s amazing how fast the time is going. Christmas was such a great time, having all nine of my grandkids together.  It just went too fast.

Anyway, today I’m thinking about a couple of things that some of my clients are dealing with. Both are difficult to manage, for the client and for the therapist.

OCD is a combination of two things:  Obsession is what goes on in the brain, and compulsion is the resulting behavior.


Some obsessions have their roots in actual events, usually somewhat traumatic. For instance, someone who gets caught in a stalled elevator may develop obsessive thoughts and fears of any small, enclosed place.  Those fears could result in compulsive behaviors such as never going into a building that has elevators; avoiding any enclosed place such as a public bathroom stall; or avoiding any room that has no windows. The person who suffers from this type of obsession may be compelled to check at least three times (pick any number) before entering a building, to make sure there are stairs, windows, and more than one door.

Veterans who come home from active duty having suffered, perhaps, traumatic brain injuries in an IED blast could very well have Post-Traumatic Stress as well. Any loud noise triggers a startle response. They may go into immediate defensive mode if they hear a car backfire, or even a balloon popping nearby. The obsession is the blast noise; the compulsion can become as serious as refusing to ever leave their house or even their own bedroom.  No TV, no music, no loud talking. If there are children in the home, they learn very quickly to play quietly.

Obsessions that are rooted in actual events are easier to treat than obsessions that have no apparent connection to reality. Take, for instance, a young man who is obsessed with the idea that he is too thin, and is unappealing to girls.  His obsession with his weight compels him to strip down several times a day, leaving his clothes in another room, making sure that he is touching nothing when he steps on the scale to make sure his weight hasn’t dropped below, say, 175 pounds.  If it should drop below that arbitrary number, he immediately begins to eat the most fattening foods he can find, and then he worries about getting a flabby belly so he does 100 crunches.  His whole day can be taken up with these obsessive-compulsive behaviors. He can’t keep a job.  He has no social life. Yet, the truth is that he is a fairly good-looking man with a normal body weight.  He is pleasant and kind, but he’s convinced that he’s a freak.

People who have OCD are often perfectionistic, which of course only makes their problem worse. There was a beautiful young woman who came to see me because her boss was threatening to fire her.  The problem?  She was too slow.  She had to type every document three times;  each document had to be proofread three times; if something was to be mailed, she had to fold it three times, put it in the envelope three times, check the address three times, position the stamp three times before gluing it down. As you can imagine,  she took three times as long as all the other girls in the secretarial pool.

What was her obsession?  She believed that if she did not take these precautions, she would make a mistake that would close down the multi-billion dollar company she worked for and collapse the economy of the whole USA.  Seriously.   She really believed that.

How do we help people who suffer?  And believe me, suffer is not an overstatement.

This is one of the few problems in which I insist my client see the doctor and get some good anti-anxiety medication. Once that is established, we begin working with Cognitive Behavioral Therapy, which addresses the obsession head on. Once the obsession begins to lose its power, the compulsions also begin to fade.

I’ve made it sound so easy.  It isn’t. Obsessive thought patterns are well-established and very difficult to remove.  It takes great strength of character to kick obsessions to the curb.

If you know someone who struggles, please don’t make fun of him; don’t tell him to just get a grip.  He wants to, he’s tried to numerous times.  He’d give anything to live your normal life, without all the fears and time-consuming rituals he feels compelled to perform.

So, not really a ramble after all.  I’m done.  And I’m not feeling terrific, so I think I’m going to go gargle some cider vinegar and maybe go back to bed.


More on Medication for Depression

There is a third class of antidepressants known as MAO Inhibitors, or MAOI’s.  You can read all about them here:

As with the others, the targets of this class of medication include serotonin, dopamine, epinephrin–all the so-called “feel-good” chemicals that the brain produces.

The question I’d like to address today is, “If depression can be treated without medication, then why take the pills?  Wouldn’t it be better to get to the root of the problem instead of just masking it?”

There are some assumptions in those questions.  I hear the questions a lot, because unfortunately, there is still stigma attached to taking medication for “nerve problems,”  or “emotional problems.” People of faith worry about depending on medication instead of God, believing that if they could just pray enough, read the Bible enough and deal with whatever their lack of faith is, they’d get better.  What follows is how I answer all that in my office, usually in a first or second visit with someone who is typically depressed, anxious, and embarrassed to be sitting in a “shrink’s” office.  This could take several posts to really get the job done, I’m not sure.  We’ll see!

So, let’s pretend you’re sitting in my office, we’re getting to know each other, and I’m seeing clear indications of depression.  The first thing I’m going to do is reassure you that you’ve made a good choice to find some help; that you certainly are not alone in your misery, and that it WILL get better. About this time, I will point out that there’s a box of tissues sitting right behind you on the back of the little sofa you’re sitting on.

Once you’ve told me your story, or at least enough to get us started, I’m going to ask you about the stressors in your life.  That question always gets me a wide variety of responses, from floods of tears to anger to uproarious–but sad–laughter. The reason I ask that question is that more and more clinical evidence is pointing to the reality that anxiety comes first, then depression.  Anxiety is just another word for fear.  Every single one of us deals with some level of anxiety at some point or points in our lives. It can stem from marital relationships, extended family, an obnoxious neighbor, illness, financial stress, job stress– to just about anything else you can think of. These are anxious times we live in, but that’s nothing new.  The folks who lived through World War I  thought it was Armageddon.  It was supposed to be the war to end all wars.  Those who endured through the Holocaust thought nothing could ever be worse, and then the atom bomb and nuclear warfare became something new to fear.

On a much smaller, but far more personal scale, most of us experience anxiety just in the routine of our daily lives, rarely thinking about the predictions of world-wide disaster.  The disasters at home are far more consuming. So you, sitting in my office, begin to tell me that you can’t sleep, that you often have sweaty, heart-pounding moments when you think you’re going to die; you can’t get a deep breath, you feel buzzy and faint, and then it passes and you’re terrified of the next attack.

Which takes us to a conversation about anxiety, panic attacks, anti-anxiety meds, and whether or not to use those meds. Please understand that not everyone who experiences depression will experience extreme anxiety and panic attacks.  It can be a part of the total picture, but it doesn’t have to be.  Sometimes, people who live with panic attacks have some deep trauma that has never really been addressed.  This can be Post-Traumatic Stress Disorder, common among military veterans and victims of childhood sexual abuse and/or rape; victims of natural disasters like tsunamis, hurricanes, and so on.  There are special treatments for this type of problem, including EMDR, which is a specialty of mine.  You can google it to find out more about it.

All right.  Just a quick note about anti-anxiety meds and then we’re done for today.  Here is a list of the most common medications:

  • Alprazolam (Xanax) – approved for GAD, panic disorder; used off-label for agoraphobia with social phobia
  • Chlordiazepoxide (Librium) – approved for anxiety (in general)
  • Clonazepam (Klonopin) – approved for panic disorder; used off label for anxiety (in general)
  • Diazepam (Valium) – approved for anxiety (in general)
  • Lorazepam (Ativan) – approved for anxiety disorders (in general)
  • Oxazepam (Serax) – approved for anxiety (in general)

GAD, by the way, stands for General Anxiety Disorder.   These medications are almost always prescribed “as needed” and can be helpful in calming you down if you suffer from panic attacks. Also, several of the common antidepressants are considered anti-anxiety as well.  Sometimes a physician will prescribe both, suggesting the anti-anxiety be used only when absolutely necessary.

And yes, I know there’s a lot of controversy about all this.  Be patient.  I’ll get there eventually!