Thanks for having some fun with me for the Halloween episode last week. This one will be a regular Q&A episode. I wanted to give a quick shout out to my buddy Speeks Geak for hooking me up with the new intro and outro beat. Check him out over on Twitter. For this episode, we have questions about bipolar depression, how to break up with a therapist, and what to do when your loved one forgets family members.
Questions for this week:
- What is bipolar depression? How is it different than “regular” depression?
- How should I tell my therapist that I don’t want to work with them anymore? How do I get my files from them?
- What can I do about my grandparent with dementia not remembering their spouse?
What is bipolar depression? How is it different than “regular” depression?
This is actually a pretty easy one to answer. The term bipolar depression is a little bit of a misnomer. Clinically, it’s not a different disorder than regular major depression. It is just depression that happens within the context of bipolar disorder.
That being said, let’s talk a little more about what bipolar is, which should help to clear things up a bit. Bipolar used to be called manic-depression because it consists of two “phases” of depression and mania. The defining feature of bipolar is the manic phase, but most people also have depression. That’s where the names really come from – that switch back and forth between mania and depression.
To be clear, not everyone simply swings back and forth between them. There are sometimes periods of relative normality or someone can live with depression for most of the time and have rare full blown manic phases. You can also have mixed phases in which there are symptoms of both mania and depression, which can be really tough.
So, bipolar depression is not necessarily a different issue; however, it’s important to pay attention to due to the fact that it exists within the context of bipolar. There can be roll over symptoms, or effects on someone’s life when they are coming off of a manic episode. There is also a much greater risk for substance abuse in individuals with bipolar and a great number of them have other issues like ADHD.
The reason drug companies talk about bipolar depression as if it’s a unique syndrome is because you don’t treat bipoloar depression with SSRIs – that can actually send them into a manic phase. Typically you would use mood stabilizers or antipsychotic medication, which is a whole different can of worms, but it basically serves to lessen the swings and bring things down to a more manageable state.
When approaching things therapeutically, you would certainly want to know whether someone suffers from major depression by itself or if they also have manic episodes as well because that would inform the techniques that you use. For instance, you want to work on establishing healthy consistency and rules for their behavior rather than continually pushing them to do more and more like you might do in depression, because in a manic phase they might overwork themselves or take your ideas way too far. You also have to acknowledge that in bipolar, depression is often influenced by the manic phase. They may be having reactionary sadness for poor decisions that they have made or things that they did to their body while manic.
It’s the same constellation of symptoms, but it’s just a different context.
How do I break up with my therapist? Is there a “proper” way to do it? Should I write something official? What happens to my file when I leave a therapist, do they get to keep it? Do I get a copy of their notes? A little background: I was desperate and I figured “cool he has a PhD” and he started me on left and right hand writing exercises to “speak to my inner child.” But if I’m having an issue I need to discuss that day, I never feel I can discuss it or work on it. He tends to cut me short and say “okay lets do some work.” He’s older and can’t hear well so I have to repeat myself a lot. He tends to focus on little things he doesn’t understand rather than listening to the context of what I am saying. EX: I end up having to explain what a podcast and it’s purpose in society, etc. thus completely digressing from the topic and using up our time. Last week I was discussing how I don’t want to speak to anyone and am annoyed when people try to be nice and interact with me. He asked “is it that time of the month?” I don’t really care about the inappropriateness of the question because I think he was just trying to figure out if it was hormonal. I’m angry that it was the first conclusion.
Let’s answer an easy question first. The rules are different depending on where you life, but here in CA a psychologist is required to keep your records for 7 years after termination of therapy (or 7 years after you turn 18 if you are a minor).
You always have a right to your healthcare information. However, its important to know that there are generally two different kinds of notes that a psychologist will have – progress notes and process notes. Progress notes are the ones that go in your file or your online records system. Often times they are pretty minimal – the date, the length of session, broad topics discussed and techniques used, and other relevant diagnoses. Basically the minimum needed. Some people are more thorough, but that’s up to them. Everyone has a different style.
Now process notes are usually what would be kept in the psych’s little notebook or pad of paper. These are notes that nobody else ever has access to. It’s their own personal notes for their memory or their brain storming. They might write down quotes, ideas, questions for future sessions and things like that. These are generally not identifiable – most people will use aliases for their clients. Nothing you need to worry about being dug up or given out.
What would mainly be interesting to you would be any evaluations including the initial evaluation – that would have more detailed information that another healthcare provider could use. To request this, you would simply ask for a copy of your file, including any evaluations conducted. He might offer a summary if he thinks that would make more sense for you, but you have the right to your entire file if you really want it by law (again this is locally informed – check the laws for your area).
Now let’s get to your main question – how to break up with your therapist. There is not right or wrong way to do it. You could call or email and say I’d like to end our sessions together, please mail or fax a copy of my records, including any relevant assessments or evaluations. You could also do it in person. Most therapists or psychologists will offer you a final session to wrap things up. That’s up to you if you would like to go. They cannot hold your records hostage, though.
Now that that’s out of the way, let me talk a little bit about your experience. I’m sorry to say, friend.
You got a shitty old therapist.
It sounds like he comes from an old school psychoanalytic background stemming from Freud. That whole left and right hand writing things is a give away. This stems from ideas about bilateral stimulation and trying to integrate the parts of your brain – what most research ends up showing about things like this is it’s the other parts of the exercise that make a difference – not the techniques. For instance I already talked about EMDR which involves rapidly moving your eyes right to left while discussing your trauma – well it’s the repeated exposure to your trauma that makes a difference, not the eye movement.
We are all allowed to have our own style of therapy, within reason, but this is just so clearly not a good match. Match is really important and it’s 100% valid to want someone that you don’t have to explain every single thing about your modern life to.
The fact that he jumped to the question about your cycle rather than actually trying to understand the situation is frustrating and pisses me off. He’s not the one for you, so I support your decision to move on.
Please don’t let this spoil you, though. There are a lot of great therapists out there and sometimes it just takes some searching. I encourage you to use the tools that I mention in this post. You can browse through people that accept your insurance (if you have it) and look for someone that might be a better match. Your expectations matter. Don’t give up!
Do have any advice about my grandfather not recognizing my grandmother? I read the blog post you done recently about your patient who thought his partner was an imposter, but wondered if you have any thoughts on what to do in the situation where he doesn’t recognize her? He often thinks she is his sister who died years ago, and when he asks where she is, he will point at a picture of them on their wedding day 60+ years ago. When my grandmother tells him she is his wife and she’s right there, he often becomes very agitated and verbally aggressive. We are coping as a family with most symptoms, but this is something no one seems to know how to deal with. Any ideas?
Man that’s a tough situation. I do have quite a bit of experience with this, as I see a majority elderly population in my day job and a great number of them have Alzheimer’s disease, which is where you will primarily see this type of issue.
Just to clarify what Alzheimer’s is – it’s a degenerative brain condition in which the actual neurons in your brain break down and leave behind plaques and tangles. It starts in the temporal lobes of the brain, which is primarily involved with memory and language, and then spreads. It’s something that has no cure and inevitably makes the person nonfunctional and ultimately kills them.
Short term memory is the first type of memory impairment that happens, while spreading to long term memory in the later stages. They may forget or mix up deeply ingrained autobiographical info or family members. One vital thing to recognize is that this is a symptom of the brain degenerating. They are not trying to be difficult or stubborn. They also do not have the ability to fully understand their difficulties. That’s a symptom of the disorder. The brain breaks down and is no longer able to recognize the problem it is having. That’s why this can be so frustrating or agitating for them. They don’t understand why everyone is telling them that they are wrong, because they can’t appreciate the mistake that they made.
The advice that people give about dealing with this is inconsistent because it’s an uphill battle, but sometimes little tricks work. For instance, you could create a photo timeline for them; rather than just a picture of your grandmother, make a timeline of pictures with names and dates underneath starting from when they first started dating, through their marriage, and on until the present. This can sometimes help prompt them to remember; however, if they are advanced enough even this might not help.
It’s also important to realize that just because they may mix you up or not recognize you does not mean that they don’t care about you or that they are unhappy that you are there. Arguing with someone or trying to convince them of the truth often just causes agitation. What I would suggest is try to empathize and redirect.
Rather than pushing the issue, just say “Well okay, I’m sorry about that, but we are here now – could we maybe sit with you for a while. Would you like some water, maybe grandma could go get your some water while I wait with you?”
Try to identify with what they are feeling and focus your attention on that rather than the absolute truth of the situation.
No question about it, it’s tough and really hard to watch. This is why Alzheimer’s is such a difficult disease. This is something that often happens, and at a certain point there is no solution to it. I would encourage you to find the best ways of redirecting his attention. For instance, maybe there is some music from the time period around when they got married that you could play?
Your grandmother could say “You know what song I used to love? Listen… and then turn it on as a distraction.”
Again I’m sorry that this is happening, but trust me when I say that he is in a much better situation, even with this difficulty, because people that love him are involved with his care. I see so many circumstances where that is not the case.
Just keep trying your best. There is no perfect answer.