How to Interfere with Therapy When Your Loved One Has Anxiety or Depressionby Monica A. Frank, Ph.D.
Most of the time parents and spouses of individuals with depressive or anxiety disorders truly want to assist in the treatment. However, sometimes their efforts may interfere due to lack of understanding or due to fears and their own internal pressure to make the situation better. So often family members may have their own irrational thinking that might influence the person with the disorder. Therefore, if you have a loved one with anxiety or depression, you may need to examine your behavior to prevent interference with their improvement. The following is a list of ways that family members interfere with treatment and some ways to change these behaviors.
1) Be Critical of Progress in Treatment. Family members may be critical of progress in treatment for various reasons including fear of the person not improving, inability to handle change, or a general tendency to be negative, critical, blaming. Somentimes criticism can even be disguised as "kindness" or "loving concern." For instance, "I'm just saying this because I'm concerned about you, but you don't seem to be making enough progress." I once had a mother who brought her adult son to me who had severe depression and stated to me "I would be happy if only he didn't spend all day in bed." Once he had achieved that she came back to me saying "I would be happy if he just could help around the house." Again, once he was able to do that she made another request "I would be happy if he just..." After four or five of these "disguised demands" I began to realize how he must feel. No matter what he accomplished, she never praised or focused on the accomplishment but on what he needed to do next. And she was never happy! He became discouraged and started sinking back into the depression.
Frequently, family members are so fearful of what will happen if progress is not made that they focus too intently upon evaluating any sign of lack of progress in therapy. Even though evaluating therapy progress is important, it's difficult to do so from the outside. Often, prior to behavior changes, cognitive and emotional changes must occur. Those may not be evident to outside observers.
2) Consider Only Recent Progress. Therapy does not proceed in a straight line. It is often erratic. There will be hills and valleys in treatment. Often, the person feels worse before they feel better because they may be dealing with difficult emotional issues or having to face fears. Assessing progress based on their most recent behavior may discount the long-term changes. In the example above, the mother didn't keep in mind how far her son had come. Instead of focusing on the fact that he had been so severe at one time that he couldn't get out of bed, she focused only on what he had done recently. The individual with the disorder needs to feel pleased about the progress they are making, but if the focus is only on the recent progress or lack of progress they are likely to feel discouraged.
3) Be Intrusive. Such as making decisions for the patient or warning them about dangers if they make the wrong decisions or checking up on them all the time as if they are incapable of making adequate decisions. Many times the person with depression or anxiety already feels inadequate or a failure. If they also get this message from you, albeit indirectly, they feel justified in this irrational self-assessment. You may need to give them space to make decisions and to make mistakes so that they can learn to trust their own judgment and ability to deal with the world.
4) Punish Them for Disrespect or Disobedience. Whenever they express themselves, their anger, their disagreement, punish them. Even though it may be very subtle punishment such as a disapproving look, it still is effective in stifling attempts to try. When they first start dealing with their emotions they may not be very good at expressing themselves or handling anger so they need encouragement not punishment. Early in my career working with Obsessive-Compulsive Disorder, a wife brought her husband to me because he was so engaged in obsessions and compulsive rituals that he lost his job and couldn't function in the simplest of ways. She wanted me to "fix" him. However, as I worked with him I began to realize that many of his rituals were related to attempts to avoid emotion. For instance, if he was angry about something, he would instead focus on his fear of germs and excessive hand-washing. So, I felt he needed to express his anger to his wife. This angered his wife because she wanted him to get rid of the obsessions and compulsions but she wanted him to remain the passive, non-confrontational husband he had always been and refused to see how the two were intertwined.
5) Let Them Control You and Your Lifestyle. This includes living your life based on their needs and wants, not taking care of yourself or getting involved in your own activities, and being available for them whenever they might need you. Allowing their illness to control your life is not healthy for them or for you. It teaches them that it is okay to make the depression or anxiety the focus of their lives. To truly become more in control of the disorder it needs to have a realistic priority and not be the center of attention. For instance, a diabetic needs to watch their diet, take their medicine, manage stress, and exercise; however, they don't identify themselves by the diabetes but recognize the importance of other aspects of their lives. As a result, the illness does not take precedence over living their lives.
6) Refuse to Recognize the Chronicity of the Disorder. Believe that someday they will be "perfect" and no longer have an anxiety or depressive disorder. Although they may reach a point that the illness is not the controlling center of their lives, the belief that they have to be "cured" and prevents full participation in treatment. Therapy is based on accepting the illness and learning ways to cope with it and making those methods part of their lifestyle. Too often, people who believe that they are "cured" when they start feeling better stop using their coping skills and will relapse as a result.
7) Take Them From One Expert to Another. Certainly, a good therapist/client match is important for a good working relationship. But if you've been to several therapists with good reputations, the problem may have more to do with avoidance of treatment than with the therapists. Therefore, this may be a situation in which you need to set limits regarding working with the therapist even though it may be difficult. Often, the more unpleasant the therapy is the more effective it may be because the person is addressing the problem directly.
8) Try Every Medication Looking for the "Miracle" Cure. Only with mild and sometimes moderate illnesses do people with depressive or anxiety disorders experience complete relief from the symptoms due to medication. After trying a few medications, it may be best to get stabilized on a medication regimen and then concentrate on cognitive-behavioral therapy. The odds of a medication helping significantly decreases each time a new medication is tried because the medications are not that much different. However, if a medication is helpful but a side effect is interfering with the effectiveness, then perhaps a different formulation may be more effective.
9) Refuse to Attend or Cooperate with Treatment Because You're "Not the One With the Problem." Many people are intimidated by psychotherapists because they are fearful of examining themselves. "He doth protest too much" is certainly applicable in this situation. Individuals who are psychologically healthy are willing to look at themselves and their behavior non-defensively, and to make changes. The therapist is not trying to blame you or criticize you, he/she is trying to develop a solution to the problem. Sometimes that solution may involve you. Realize that you are asking a lot for your loved one to make changes and be willing to make changes yourself.
10) Don't Set Limits and Stick by Them. Just because someone has a disorder, doesn't mean they have permission to be irresponsible or to control someone else's life. In order for a situation to be bearable, you need to set limits. For instance, "If you are late, then we will leave without you." As we discussed above, you can't stop living your life. But sometimes that means setting some firm limits even though the person may be tearful or frightened or angry. And once you set limits, you need to implement them. "I understand you are afraid of having a panic attack if I leave the house, but you have learned skills from your therapist and you need to use them because I do need to leave the house.
11) Be Controlled by Their Anger. Individuals with anxiety or depression may become angry when they have to face difficult situations. If their anger controls you and makes you back down, then they are able to avoid the situation. Also, the anger becomes reinforced as a method of getting their way. For instance, a child with a school phobia may throw a temper tantrum to avoid school; if this works, they are likely to do the same again and may also generalize to other situations.
12) Make Things Too Comfortable. Make sure they have everything they desire so they have no incentive to make changes. Cook, clean, give them money, make life easy. One of the saddest situations I've dealt with as a therapist was a client who had Obsessive-Compulsive Disorder. This brilliant, engaging woman was so fearful of making mistakes that she engaged in checking behaviors almost all day. She lived with her mother who supported her financially and emotionally. The mother even engaged in some of the checking rituals for her such as checking to make sure the doors were locked and the stove turned off. Through therapy, this woman was making progress but the process was painful as she had to confront her fears. One day she told me she wanted to quit therapy and said,"I really have it easy. I don't have to work or do anything around the house. I really don't have to face these fears because my mother will take care of me. Therapy is too hard."
13) Live in Fear that They Will Commit Suicide. Some parents and spouses don't set limits or make things comfortable or avoid anger because they are fearful that their loved one will commit suicide and they will feel to blame. However, by avoiding these things due to fear they are enabling other self-destructive behavior such as not trying to deal with the problems. Also, in reality they don't have control over suicidal behavior. Suicide in unpredictable, and therefore, uncontrollable. Even though suicide is higher among people with depressive and anxiety disorders than it is among the general population, it is still a very tiny percentage of people which makes it unpredictable. If this is a genuine concern, it's important for a mental health professional to be involved to assess routinely and to guide you.
14) Refuse To Accept Your Own Problems. Anxiety and depressive disorders have a genetic connection; they tend to co-occur in families. Sometimes a parent may have an anxiety or depressive disorder they are refusing to recognize which tends to transfer the burden on the child. Also, spouses may have problems that may interact with the anxiety or depression. Therefore, it is important to understand when your problem might interfere and or interact and to confront your problem. You are expecting your loved to do somehthing difficult and to address their problem. You should not expect any less of yourself.
15) Believe They Can Just Stop. Many people don't understand depressive or anxiety disorders. They believe that the individual is just not capable of handling everyday problems. Or they may even believe that the behavior is deliberate in order to avoid responsibility or to irritate. This type of belief tends to cause criticism and blame which only serves to make the person feel worse and helpless because they can't just stop or change. Therefore, it is critical to truly understand the nature of these disorders, to recognize them as medical conditions such as diabetes or heart disease which may need lifestyle changes in order to address, but are nevertheless physical conditions.
16) Don't Be Supportive. Along with not understanding the illness may be the tendency to not recognize how difficult it can be when the individual is in therapy and trying to address the problems. Your loved one needs you help him or her recognize the accomplishments and to appreciate the effort. When you give them compliments or encouragement they are likely to continue even when therapy may become difficult and they want to quit. Support is not enabling. Support aids them in confronting the issue, not with avoiding the issue as enabling does.
17) Believe the Disorder is Their Fault. This is the tendency to assign blame, to believe that they just don't have enough willpower or that the disorder is a punishment from God. Such a focus leads to self-defeating beliefs in which the individual tends to criticize themselves and feel worse which does not create positive change. The idea of the lack of willpower or lack of motivation needs to be viewed differently. For instance, maybe the individual lacks the necessary skills and they need to be taught. Or maybe the anxiety is too high and they need the assistance of medication and/or a supportive person to help them face fears. But most of the time, unless there is reinforcement to remaining ill such as the earlier example, people do not cause the disorder or refuse to address the problems, but they might not always know what to do.
18) Want Them to Get Better, But Don't Want Them to Change. When people address the depression and anxiety, it typically means addressing a lot of related issues. The person can't just deal with the depression or anxiety, because they also need to deal with triggering factors. Sometimes those triggering factors can mean changes that are going to affect other family members such as the example above about the man needing to express his anger. Or maybe the person needs to focus more time and attention on taking care of him or herself such as doing stress management or yoga classes and this takes time away from the family. Be prepared that changes may affect you in negative ways too but are necessary.
19) View the Disorder as a Sign of Your Failure. Just as the individual with anxiety and depression is not at fault for the problem, you need to recognize that you are not at fault. Unless you have been physically or emotionally abusive, you did not cause the problems. Although some of your behaviors may affect the individual or interact with the problems, these behaviors did not cause the depression and anxiety. If your feelings of failure are strong, you may need to learn how to challenge these beliefs because such feelings may contribute to your loved one feeling guilty in turn.
By keeping the above issues in mind and perhaps obtaining your own therapy, if necessary, you will be better able to assist your loved one in treatment and less likely to interfere.
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Dr. Monica Frank