Question:

Dr. Raj,

A close friend of mine has been seeing the same psychologist every other week for over 4 years.  This friend is college educated and intelligent. He does not abuse drugs or alcohol.  He has a problem with anger management, often reacting out of proportion to events.  His reaction can range from melancholy to temper tantrums that include shouting insults.  He can go up to six weeks without having what I call a “melt down”.  How do I know this?  Because I have actually tracked his mood swings on a calendar over 12 months.  The melt downs can last 2 days, 1 week or he may have one very few days for 2 weeks.  Then, he will recover and appear happy and content for 2 to 6 weeks.  I know this is probably bipolar disorder.  Or maybe it is post traumatic stress, since he grew up with domestic violence between his parents.  The point is…my friend does not appear to be “getting better” in light of all the therapy he has gotten.  I can see no changes in his behavior!over the 3 1/2 months I have known him.  I know my friend speaks openly to his doctor and is honest to a fault.  He does realize he has problems with self esteem, depression, mood swings and handling his anger.  I know not every doctor is the same caliber, too.  What type of therapy should my friend be getting? Talk therapy? Cognitive behavior therapy?  What strategies can you suggest?

Answer:

Dear iNTj,

It does seem that you have a lot of insight into your friends problems and that you genuinely care about his well being.  You mentioned that he see’s a therapist every two weeks, how often is he seeing his psychiatrist?  What is the working diagnoses that his psychiatrist is treating?  Is he on any psychiatric medications and have any helped?

We now know that the most effective treatment will address the Biological-Psychological-Social domains individually.  What this means is that once, the presenting problem is understood, a health care practitioner should address each of these domains to get the most effective treatment response. The Biological domain usually involves medication management, the Psychological involves getting into psychotherapy and the Social domain involves looking at and understanding social factors that are contributing to the persons presenting complaint(s) i.e. family dynamics.

Remember that it takes time to correctly diagnoses and understand the dynamics of human behavior.  I know this can be frustrating for many individuals but the number of diagnostic tests in psychiatry are limited.  Our most useful tool is obtaining a through history from our patients and their families in order to come up with a working diagnoses and over time it is verified or adjusted.  Many times I hear from people, “My Psychiatrist only spent 2 minutes with me, how could he have correctly diagnosed me?”  My response to them is usually to find someone else who will spend the time obtaining the proper history to properly formulate a treatment plan.

As far as therapy goes, I think going every other week is not as effective as going every week.  In my opinion, much happens in two weeks and the session usually becomes about “catching up” versus working on insight.  Their are also many different types of therapy that range from working on supporting the individual to working on insight around internal conflicts.  Their are also therapies that focus on one’s thoughts (Cognitive Behavioral Therapy) as well as being more mindful about one’s behaviors (Dialectic Behavioral Therapy).  Which approach is best is dependent on the individual who is entering it.  As a general rule of thumb those in treatemnt do better than those who are not in treatment.

Thus, I commend your efforts in understanding your friend’s current challenges but remember that he must make the commitment to find the appropriate answers.  You can not do his work for him but only support him along the journey.  He’s lucky to have you in his life.