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How Can I Tell The Difference?

Question:

My beautiful, bright and articulate 21-year-old daughter has recently returned from an 8 week integrated mood disorder program at a highly regarded hospital. She has been diagnosed with major depression, generalized anxiety disorder, panic disorder, social phobia, avoidant and dependent personality traits and possible eating disorder. She has been on medications and getting treatment from psychiatrists, social workers etc. for many years – her problems started in early childhood. My last major hope was the mood disorder program but that failed to help significantly. She has a lot of insight and understanding about her illnesses but she seems to lack any motivation to do anything to help herself. She does usually take her meds but won’t follow any of the other suggestions to get well i.e. support groups, some kind of structure in her life, eating properly. She attends her appointments because I take her to them, and agrees with the suggestions or advice offered but is unable or unwilling to follow through. Everything is too much trouble or too hard for her. A typical day involves sleeping, taking pills, sleeping some more and then at night getting up to eat and go on the computer. It is so sad and frustrating to watch a girl with so much potential continue to sabotage her own recovery. How can I tell the difference between her not being able to get better and not wanting to get better? Is it possible anyone would actually choose to stay that way?

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Answer:

Your letter captures the essence of parental experience (and perhaps more broadly, the invested caregiver’s experience) when parents (or caregivers) are confronted with their children’s significant mental illness. It is so very hard to watch another person you care for suffer, and particularly so when the “injuries” that are causing the problems are so well hidden as perhaps to not be there at all. You see the symptomatic behavior, but you don’t know fully how to interpret it. Is it malingering or is it a natural product of an illness. Is this willful laziness (am I being taken advantage of or manipulated by my child?), or is this process out of their control, and them innocent of any selfish or manipulative impulse. You’re willing to do most anything to support your child’s capability for adult independence, but it is effortful to provide this support. You will feel angry if it turns out that they could have pulled their own weight but chose not to do so.

Unfortunately, there is no easy and fast way to understand the difference between malingering manipulativeness vs. real depressive illness, particularly when the illness is so chronic and has so many aspects of “personality” and “motivation” build into it as your daughter’s seems to. You have to more or less come to appreciate that if this is a malingering person that you are dealing with who “need not be” such a burden but chooses to malinger anyway, then that is a sort of disorder too (although a different sort of disorder than pure depression for sure). Disorders need not be physical or neurological in nature to be disabling.

Rather than thinking about whether or not to be angry with your child depending on how able or disabled she may actually be, consider taking her disability and dependency at face value, and working instead towards maximizing the amount of independence she can manage. In order for her to become more independent, it will be necessary for you to carefully and gradually reduce some of the support you provide her, to see if she will pick it up herself. I’m not talking about not supporting treatment goals, but rather simpler things for starters, such as cooking meals and making beds. For example, if you normally cook for her, and you think she might cook for herself if you didn’t make it easy for her, maybe you can start there.

Helping your daughter to become more independent and active may also mean that you need to find ways to give up control, or rather the fantasy of control, over her life. This is a mental shift you might consider making yourself which could help you to feel less responsible for outcomes which are not ultimately things you can control. You’re in a “lead a horse to water” situation, in some respects. You’ve lead your daughter to treatment for years, and it seems she isn’t drinking it. Neither you nor the doctors and clinicians can force your daughter to become well. Regardless of what her illnesses may be; whether they are “real” or not, only she has the ability to get better, and then only to the extent that she really has that ability in the first place (based on the nature of her disabilities). If you can stop struggling to make her be different then she is you might find some small amount of peace. Your daughter too too may possibly gain new motivation as she realizes that you won’t do everything for her and if they are to get done at all, she’ll need to do them. No miracles will occur, I don’t expect, as this is a chronic situation, but even small changes might be appreciated.

I encourage you to seek out a support group for parents of mentally ill or disabled children, either online or through a local community clinic, and possibly also to seek out some limited psychotherapy for yourself as well. I believe it will help you to have an objective trained mental health clinician to talk to about your predicament for a little while.

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