We have lost all perspective about what is truly terrible

This wasn’t just plain terrible,
this was fancy terrible.
This was terrible with raisins in it.
-Dorothy Parker

More and more of my clinic time is devoted to evaluation and treatment of depression and anxiety rather than sore throats, coughs, UTIs and sprains/strains.  An outbreak of overwhelming misery is climbing to epidemic proportions in our society.

A majority of the patients who are coming in for mental health assessment are at the point where their symptoms are interfering with nearly every aspect of their daily activities and they can no longer cope.  Their relationships are disintegrating, their work/school responsibilities are suffering, they are alarmingly self-medicating with alcohol, marijuana and pornography or whatever seems to give momentary relief.   Suicidal ideation has become common, almost normative, certainly no longer rare.

Things seem terrible.  And not just plain terrible.  First-world-problem-terrible with raisins in it.

We have lost all perspective about terrible.

Terrible is what happened to the Philippine people in the midst of the most horrific typhoon this month — losing everything from their lives to shelter to any means to stay warm, fed and secure, much less find medical care.

Terrible is what happens in numerous countries where political oppression sends refugees across hundreds of miles and borders to seek asylum in foreign lands.

Terrible is what happens when hundreds of thousands are dying from AIDS,  leaving behind their infected orphans to fend for themselves and care for each other.

Terrible is trafficking of human beings for power, gratification and money.

There is plenty of just plain terrible and most of us have no clue what it feels like.  We are so absorbed in our own scratches from the ubiquitous thorns of life, grousing about the raisins that pop up in our own version of terrible,  oblivious to the relative comfort with which we are graced daily compared to most of the world’s population.

Sometimes I think the best treatment for anxiety and depression has little to do with correcting brain chemistry or getting to the right cognitive behavioral insights to beat back negative thoughts, but rather to spend a year digging wells and latrines for those who have never used one.

It is spending hours caring for the detoxing or the dying to see what misery really looks like.  It is understanding how the fight for basic survival after an earthquake, a hurricane, a typhoon, a flood, a tsunami,  makes life even more precious, rather than thrown away as if it is something you can simply upgrade or exchange for a new version.

Maybe, just maybe, when we reach in deeply, even sustaining the scars that come with everyday living, we can look past the thorns to the fruit.  We may bleed getting to it.  Maybe then the raisins don’t seem quite so terrible after all.

Emily Gibson is a family physician who blogs at Barnstorming.

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  • NewMexicoRam

    I call it the results of raising the Dr. Spock generation.
    Problems are always due to the fault of another.
    Patients expect to be pampered.
    Medicaid is a right, with no expectation of having to pay anything.

    • Rob Burnside

      I think you’ve got Freud and Spock mixed-up. Coming of age in the 1960s was far from easy. We got off to a very bad start with President Kennedy’s sudden demise and it was downhill from there. Good music, however. Books and movies, too. You really ought to take a closer look, and try to d.c. the negative vibe.

  • Thomas D Guastavino

    Several years ago a 22 yo patient was refered to me for back pain. While reviewing her PMH it was noted that she was on full SS disability for, of all things, obsessive-compulsive disorder. 22 years old on full boat SS disability for OCD! Thinking it was wrong we checked and found out is was true.
    Since then not a week goes by when we see another patient with a similar story and the trend is only getting worse. Is it any wonder why we have, as aptly stated, “Lost all perspective of What is Truly Terrible” ?

    • whoknows

      seems it’s easier to pay for their life time of disability instead of treat their psychiatric problem. are these pts now part of the medicaid population?
      Do you feel this is some sort of trend if you see this every week? How sad. You can fix their back but not their head!

      • Thomas D Guastavino

        Trend has definitely been worsening. OCD, Anxiety Disorder, Depression, all have become roads to lifetime SSD which qualifies for Medicare and Medicaid. Given the subjective nature by which these diagnoses are made it becomes obvious that this is a recipe for disaster. Also, I rarely find any true organic reason for the back pain so rarely can it be fixed.

        • whoknows

          thank you. I always got the idea that it was virtually impossible to get SSD and that they deny claims most of the time.

          • Thomas D Guastavino

            Physical SSD is still difficult. Mental SSD apparently not so difficult.

          • whoknows

            That’s really unfair.

          • Thomas D Guastavino

            Indeed

          • whoknows

            Do you have patients with severe physical problems and pain that are unable to get SSD? I know you are not a pain doctor but being an orthopedist just wondered.
            Just aside to any surgeons interested. I was listening to a recent interview of one of the general surgeons who saw Kennedy after he was shot. What was most amazing was he said that in all of Parkland Hospital there were only 4 surgical attendings at that time employed by the hospital. I thought that was odd. Now there are probably 40 surgeon attendings I would thnk at any major hospital. Interesting interview. It was on the plastic surgery website.

    • LastoftheZucchiniFlowers

      I often wonder what makes a young person with EVERYTHING ahead of them desire a future of SSI which is truly a pittance? Is not working really preferable to a fulfilled life of meeting goals, travel and the simply excitement of youth? The phenomenon baffles me in the extreme since the SSI payments/Medicaid should not even be on the radar screen of a young, otherwise healthy human being. Perhaps they should have mandatory volunteer services at a place like St. Judes? Real human tragedy has a way of reorienting a person’s skewed world view.

  • maggiebea

    The folks who first worked with Vietnam Vets dealing with PTSD often said that the first thing to do to lift depression and persistent thoughts of terrible (after checking to see if your body is intact) is to find somebody who needs help, and help them. Before there was ‘professional psychotherapy’ for Vets, there were work teams going to disaster sites to help clean up.

  • Rob Burnside

    A fine blog, reminding me of one of my favorite Golden Books–the story of the Chirkenduse, who said, “It’s all in the way you look at things.” More often than not, he and you are right! Thanks, Dr. Gibson.

    • M.K.C.

      Having had my memory tweaked by your comment, I just spent 15 minutes of my lunch hour searching for, and listening to, the audio of the 78rpm kiddie record of that, narrated by Ray Bolger with music by Alec Wilder (one of Sinatra’s favorite early-career arrangers). Hahaha! What a way to brighten up an otherwise gloomy Monday. G_d bless the Internet!

      • Rob Burnside

        Trying same right now!

      • Rob Burnside

        Wonderful! And realized I’d misspelled “Churkenduse.” Everything we needed to know was in the Golden Books.
        Next stop: “Scuffy the Tugboat”!

  • DoubtfulGuest

    We’re not always in a position to know what someone is going through. Sometimes those first world problems are a cover for something much worse.

    Either way, part of the cure is to get off our duffs and help others. Besides the perspective-broadening and breaking the cycle of negative thoughts, there are further benefits. Opportunities to form healthy relationships for the right reasons. Developing self-confidence, a sense of purpose and accomplishment. There’s really no down side.

  • http://counselinghumanism.blogspot.com/ CortneyM

    I think the problem in our culture is that we assume people know how to cope because atrocity isn’t the norm here. Coping isn’t just saying, “Hey, could be worse, I could have lost half of my family to genocide.” A lot of it is getting support from family and friends – from whom we’ve done a fine job of disconnecting thanks to social networking and extreme emphasis on “independence.” One of the most effective outlets for sadness is…people who care.

    That said, everyone is responsible for learning to cope even if they’ve never learned to do so and even if their social supports are poor. I think one of the better responses to people who don’t appear to have significant reasons for their distress is to accept their defintion of catastrophy without judgment (without judgment being the big one) and prompt them to seek care from a therapist or religious leader or support group or some entity that will give them warm and fuzzy feelings.

  • FEDUP MD

    If this is so, then why is depression and suicide so rampant among physicians? After all, we of all people should know what is “terrible” and yet we have higher rates of mental illness than the general population. As someone who lost a colleague to suicide recently, I find your post offensive. He worked with the sickest of sick babies, and surely had perspective about the worst that could happen to people. Posts like yours which stigmatize the real pain of dysfunctional brain chemistry perpetuate the stereotype of mental illness. Is this why my colleague never sought help and none of us had any idea, because he was worried he would be judged by other physicians with your attitude? I hope your attitude does not fliter down to your patients, for many of them are truly suffering despite your dismissive attitude.

    • DoubtfulGuest

      Good points. I’m so sorry for your loss. The premise of this post can be taken way too far, that’s for sure. I think Dr. Gibson was talking more about people who express a certain attitude, and maybe feelings of entitlement to go with it? Also, you’d know better than I would, so please excuse my ignorance, but I wonder how much physicians not being able to meet their own basic needs contributes to depression and suicide? If anyone goes too long without nutrition (fuel) or sleep, to me that is as serious as folks in developing countries who don’t have clean water. And that, while you constantly extend yourselves for others — basically absorb people’s suffering, and have nowhere to turn for support?

  • DoubtfulGuest

    Yes, and there’s often more to it than the doctor can see right away. The snap judgments are dangerous for patients.

  • Sharon

    Apparently the author has no idea just how severe OCD can be….and as if those who are severely depressed don’t already know there are those who are “worse off” and are probably already feeling a sense of shame for the way they feel….nothing like invalidating or minimizing their pain….

  • M.K.C.

    Also by Dorothy Parker:

    “Razors pain you;
    Rivers are damp;
    Acids stain you;
    And drugs cause cramp.
    Guns aren’t lawful;
    Nooses give;
    Gas smells awful;
    You might as well live.”

    So there you go.

    • whoknows

      Wasn’t she also the one that told pushed the nurse’s call button while in the hospital and said, “good now we won’t be interrupted”.

  • http://joannevalentinesimson.wordpress.com/ ValPas

    Amen! Spend a year somewhere with no indoor toilets or no nearby grocery stores, and you’ll come back very grateful for what you have. All the medication (self- and otherwise) may be contributing to the skewed idea of what’s terrible, as well.

    • FEDUP MD

      My colleague just got back from years of volunteering in third world countries, where she sacrificiec her life savings and her youth. She has watched children die in front of her for want of items that cost cents. She spent all of her savings (I also gave her money because she is my hero) and even ended up adopting some orphans who were on the brink of death. She certainly should know better than any of us armchair referees what is terrible. She just admitted to me that she is deeply depressed and on antidepressants since coming back. She is one of the nicest and bravest and strongest people I know (a far better person that I am, I think) and I am glad she thought to share with me that I would not be judgmental of her illness like so many here who have never had it have been.

  • DoubtfulGuest

    Yes, and for the record I would like to see much wider coverage of this important issue.

  • Rob Burnside

    I have to agree, but I also think minimizing can be a defense mechanism, a way of protecting oneself from potential harm. The same would be true of “being judgmental.” Of course, that doesn’t help the patient much, but the other side of the coin is that revulsion and depression can be cumulative. Not contagious, but almost as much of a threat over a thirty year career. I’ve frequently struggled with nagging depression since retiring from the fire service, and I firmly believe my twenty years of D&D exposure plays a big part. There was no escaping it. No way to rationalize or minimize it. In health care, increased patient workloads mean increased exposure to despair. There’s no getting around that, either. Sabbaticals would help, however.

    • DoubtfulGuest

      That’s a good comparison, RB. My dad was a firefighter. I know what you mean. Kudos to you for having taken on on such a tough job.

      • Rob Burnside

        I wanted to be an art teacher, DG, but had a family to feed. Is your dad still living? I hope so.

        • DoubtfulGuest

          Yes, he’s retired. :)

          Kudos to art teachers, too. Mine was a fantastic role model and we still talk occasionally.

          But, yes, I heard a lot about D&D growing up, maybe too much. He gave a great presentation to my Brownie troop about fire safety. Showed us a melted telephone they recovered from one house where people were killed. Made a strong impression!

          • Rob Burnside

            The melted telephone! If you’re ever in the Tribeca section of Manhattan, look for the fire station used in “Ghostbusters.” Ladder 7, I think.
            They have a wall full of melted phones! Best to your dad. I scared my kids, too…forgive us, please!

  • JR

    Yeah that’s right! The reason the suicide rate is going up is because people are just big babies without real problems. Sure, the CDC says “suicide rates tend to correlate with business cycles, with higher rates observed during ties of economic hardship” but what do they know? It’s not like we’re facing hard economic times in this country after years of economic growth that seemed unstoppable. I mean, just because “in 2009, the number of deaths from suicide surpassed the number of deaths from motor vehicle crashes in the United States” doesn’t mean that we should pay attention to people with depression! They just need to gain some perspective!

    Note: The above message contains sarcasm.

    Seriously though – who tells their doctor their life story? People have trouble talking to their therapists about the things that are bothering them, are they going to tell their doctor?

    • whoknows

      there is also not good coverage for psychiatric care.

  • drjoekosterich

    In Australia like the USA we have encouraged a culture of complaint where everything and everyone is to blame if I dont have a perfect life. Whatever happened to life’s ups and downs and some resilience?

  • fatherhash

    isn’t that like saying that an oncologist shouldn’t judge cancer until they have suffered from it themselves?

    this author, as a family physician, seems to have dealt with mental illness enough to know a little about it. perspective likely can help many patients and i would not blow it off so quickly.

    • http://www.dollyrouge.ie/ Kat (dollyrouge.ie)

      Would an oncologist write such a judgemental post about their patients with cancers likely caused by their lifestyle? Would they be complaining about having to provide them with evidence based treatment when what they really needed was lifestyle advice/perspective?

      Hardly.

      • fatherhash

        sometimes, the treatments(whether tough love or chemotherapy) are not pleasant.

  • Sue Wintz

    With all due respect, I think you’re missing the obvious: that those that are coming to you for help have their own experience of “terrible”. I’m not a doctor; I’m a board certified professional chaplain. Yet I know through my clinical expertise that those living with depression and anxiety are living with physical, emotional, and spiritual distress that requires compassion, not a judgment or lecture. It sounds to me like your practice would benefit from having a chaplain, social worker, or other practitioner that understands mental health issues on staff so that person can be properly assessed and treated. If you are unable – or unwilling – to treat those who come to you for help, then it is your responsibility to ensure that there is someone in your practice who will meet them with compassion and care.

    • Leroy Boy

      We can always find someone who suffers more than us…..and they more than them….is that then a blanket excuse to say suffering is has no excuse?

  • LastoftheZucchiniFlowers

    Emily is correct in that we (all of us) suffer from the occasional lack of perspective, yet it seems to be a matter of degree and time spent in the self-absorbed negative vortex that reveals who is the winner and loser in the work of life. It’s all too human to host our own pity party…but what has meaning is the ability to hear about the typhoon in Tacloban and then quickly ‘snap out of it’. When our problems, whatever they are, are compared with these colossal horrors, things have a way of assuming their correct proportion. Those who cannot, for whatever reasons ‘count their blessings’ feel quite incapable of emerging from their bleak centrifuge . It is important to teach children at an early age that in life, some are simply more fortunate than others. These children (OUR children) will then grow up with the (grudging) understanding that life is NOT FAIR. There is no greater lesson we can teach them, since once they accept that maxim, they will be armed with the skills to make progress each day over the valleys and mountains knowing that the process and the journey itself are truly where the ‘rewards’ lie. Emily makes a point well worth noting.

  • Rob Burnside

    Seems it might have made you stronger,Meyeti. I think your generation did have it hardest of all. What the country needs is one generation without war. It might catch on…

  • maga_bee

    And this is why, for 10 years, I went without adequate care for my depression, which was (unbeknownst to me) caused by serious PTSD from very traumatic and long-term childhood abuse.

    Seeing doctors who either told me flat out to suck it up (I was a successful person in my 20s, they’d say, and pretty at that!), or would quickly write me a script and shove some samples in my hand of the latest anti-depressant (but would do it with a labored sigh and no indication of the need to follow-up), was enough to make me stop telling doctors anything about my crippling depression.

    If someone would have taken me seriously, maybe there wouldn’t be years of devastating mistakes, suicide attempts, and horrible coping mechanisms that left many people hurt and struggling to pick up their own pieces left in my wake.

    So though it’s nice to confirm that my paranoia about some doctors wasn’t all in my head, how dare you.

    Yeah, some people are just entitled assholes who are bummed because their dog has a UTI. But some of them are dealing with things so massive they can’t even grasp it, much less tell you about it in the 10 minutes you’re able to give them, I’m sure replete with the same sighs and forced smiles I was given by the doctors who just assumed I was an entitled pretty girl who didn’t know what to do with her life.

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