Self-care, Self-love, Self-esteem and all the other Selfs

Fads/trends appear in every field of medicine, and will typically appear where research is scant or inconclusive, and disease and treatment poorly understood. Hence psychiatry is particularly prone to it, the diagnoses can’t be confirmed by biological markers or lab tests, rather it’s dependent on a therapist’s observation of signs and symptoms. We call psychiatric pathologies syndromes and disorders, not diseases after all. It’s easy to turn to Fads of treatment when we desperately want to help, and patients aren’t responding to standard therapy. But what are the current fads and what’s the problem?

There is an argument to be made regarding the over-prescription of drugs in psychiatry – at least the prescriptions are monitored and recorded, however. But how patients are being supported and counseled in therapy rooms is not. Think about it - if even scientific researchers have been proven to be unable to see their research in an objective light, how can we think therapists go into sessions unbiased? Of course, we will take with us our own notions and beliefs, we are human beings, regardless of what the early Freudians said about being blank screens. Freud argued that “the doctor should be opaque to his patients and, like a mirror, should show them nothing but what is shown to him.”

Before I became a mother I counselled a particular patient every week over the better part of a year, because she had symptoms of depression resulting directly from her relationship with her daughter who suffered from a borderline disorder. This is a personality disorder which almost inevitably negatively affects the people who care about the affected patient. In every session, we discussed something the daughter had done that caused the mother sleepless nights - or an empty wallet. The relationship from my point of view was detrimental to the mother’s mental health, and I supported the wish to sever ties with the daughter. At the end of every session, she seemed resolute to doing this, and slightly relieved. One day, out of the blue, I received an email from her saying that she wanted to discontinue therapy, even though she agreed with me on the cause of her symptoms, she couldn’t come to terms with our strategy. I racked my brain, I hadn’t done anything wrong, I had counseled exactly how I had been taught. When something causes you to only experience negative emotions, you cut it out of your life – similar to how a surgeon would cut out a growth. After all, you should surround yourself with people who give you positive energy, right? Even if that means not having contact with family members.

This has in recent years become frighteningly frequent. A study out of Cambridge University discovered that 75% of participants had no contact with their mother and/or father. And 78% of those had received help from a counsellor or therapist [1]. This begs the question, what governs what we are counselling?

According to the WHO, depression is the leading cause of disability worldwide, and after the pandemic, the numbers on depression and anxiety just sky-rocketed. That we have a problem is clear, and it has to have been brewing for a long time to get to the numbers we are seeing today. That is why I think its important to investigate these psychological and cultural fads we tell ourselves and our patients. We live in a time where everything is oriented towards the self. We will do everything to nurture this self. Anything that we see as a hindrance to our momentary well-being, comfort and feeling of self-worth, deserves to be cut out or moved away from.  We see the community and its institutions as means to support and encourage everyone’s self and self-expression. Where it used to be that we are all responsible for the upkeep of our community and the institutions around us, today, if one’s family, or marriage, or school is causing us headache, we cut it out, find another that has a more positive influence on our well-being. Find one that fits our self better. The group to which we seek to belong should support the self that we want to express today (the feeling might change tomorrow but we pretend it’s permanent), no critical questions asked. This type of thinking took root and has evolved since the early 70’s, and is to be found in any mainstream psychology/psychiatry platform today. Self-care, self-love, self-esteem, self- worth, self- image, you name it. You are perfect just the way you are, and if that’s not how you feel, you need therapy. Imagine if your dentist would say that! You also go to a psychiatrist because you’re in pain. Then you’re being told, you’re fine just the way you are, the problem is you don’t believe it, you only have to learn to love yourself. Try to google “self- care”, and read all the ways you can decrease your stress and anxiety according to professionals. Some of the advice, like sleep, nutrition, physical rest has its place when dealing with a crisis. Bubble baths, meditation, self- talk however? “Cut toxic people out of your life”? If those are the only weapons in your arsenal to help you love yourself, you will be in therapy for a long time. We should rather counsel self-improvement, for therein lies hope of a better future. That’s where we can exhibit control. Counsel self-sacrifice and doing good for others, and encourage sympathy and acceptance towards the people you deem toxic.

I cannot count, how many patients have told me in the first session, verbatim, “I want to be happy, as happy as I remember being as a child”. This is a tall order, maybe impossible. Children are care-free and thus can experience this frolicking-in-the-field happiness that we miss as adults. But if you have a life with content and meaning, it by definition will not be care-free. I think we have to move away from the overinflated self that is being given so much space in our culture and ultimately in the therapy room. It is our duty to ask what truly is in our long-term interest- why? While so many are suffering broken families, be they self-inflicted or the result of divorce or tragedy, the therapist is increasingly being brought in to the equation as substitutes. So, our responsibility is greater than ever, and we have to triple check that we are not counselling quack.

Even if breaking ties with a family member leads to a feeling of momentary relief, I can’t imagine a longitudinal study would show evidence of it leading to long- term happiness. The knowledge that family is something permanent and constant is comforting, and causes stability. Tearing on those ties should be done with extreme caution and based on solid evidence. If you cut a tie to a family member, spouse, a friend, or even a group you’ve long been part of, that will surely cause almost irreparable damage. As doctors we take the Hippocratic oath to first do no harm. Shouldn’t we think much more carefully about these issues that surf through our therapy rooms than we do? At least as carefully as we would choose an antidepressant? One could argue it is somewhat less effort to discontinue a medication, than to put a family bond back together.