A Growing Sense of Futility About Communicating My Sense of Futility

I started seeing a new psychiatrist in July 2010.  At an early session I told him that I felt that everything was futile: that I had given up on life.

Yesterday, August 24, 2010, I told my psychiatrist that I would like to work, but that I had bad experiences in the past and I feared that I would re experience the same difficulties in a new work environment.  My psychiatrist suggested that I try volunteer work.  He acknowledged that there was a probability that I might encounter difficulties but said that if I don't try I will never know what possibilities there are for me.

In general medicine a doctor assesses the risks of a negative outcome associated with a course of therapy or behavior and will try to avoid that negative outcome or advise the patient to avoid the negative outcome.  If surgery poses a risk of a negative outcome, the doctor will advise against it and suggest alternatives such as medical therapy.   If a woman has a high risk of breast cancer, a doctor will advise the woman to guard against a negative outcome by having routine mammograms.

Why would my doctor -- in total disregard of my past negative experiences in the workplace and in disregard of my high risk of experiencing mobbing in the workplace -- try to persuade me to defy the odds and hope for a positive outcome.  Would a doctor say to a patient: "Smoking carries a high risk of a negative outcome, but I know how much you love to smoke, so maybe you should smoke and hope for the best.  Some longtime smokers live well into old age."

It's as if the doctor is substituting his fantasy of a positive outcome for my actual reality: I got fired from my last two jobs after experiencing mobbing, I am at high risk of mobbing, and I fear experiencing a recurrence of mobbing (which is a symptom of post-traumatic stress disorder, a recognized consequence of mobbing).  The doctor is providing advice that evidences no expertise.  An intelligent surgery resident might offer the same advice to me.  My doctor's advice avoids the following issues: What does he know about the phenomenon of mobbing?  What does he know about people who are at high risk of mobbing?  What does he know about the psychological consequences of mobbing for the target of mobbing?  The doctor's general, common-sense advice is a shell game.  His advice does not address my reality; his advice is based on his fantasy or confabulation of a positive outcome.

Be that as it may.

A rape victim tells her psychiatrist that she is now afraid of men; she is unable to date and dreads a man touching her.  The doctor says: "Statistically speaking, few men rape women.  You should feel free to date men, secure in the knowledge that you will not get raped."  The fact is that the woman suffered a trauma and is experiencing the consequence of that trauma.  It's not a matter of rationality or statistics.  The issue is trauma and its consequences.  The woman's reality is trauma and fear.  What does the doctor know about the trauma of rape and its consequences?  What does the doctor know about the proper therapeutic approach that will best address the woman's reality?

I told my psychiatrist that I have a severe psychiatric disorder.  He replied, "I have patients with severe psychiatric disorders who work."  My response?  "Good for them."  I don't work, and simply persuading me to work is not therapy.  Some women who are raped are later able to have normal relations with men.  Other women may develop a fear of men.  The question is how do you treat a female patient who experienced rape and is experiencing the consequences of that rape in the form of fear.  It is irrelevant that there are rape victims who have normal relations with men.

A cancer patient does not respond to a chemotherapy agent, despite the fact that a majority of patients do respond.  Does the oncologist say: "I don't know what your problem is.  I have other patients who respond to  this drug."  A doctor needs to look at a patient as a representative or member of a group of patients, identify that group and apply knowledge derived from a study of that specific group.  In general medicine if a patient does not respond to a specific treatment, the doctor needs to investigate the group of patients who do not respond and chart a course of treatment that addresses the specific characteristics of that group.  It is irrelevant that there are patients with do respond to a therapy.  What does the literature say about the patients who do not respond to that therapy?  I was mobbed, I suffer the consequences of mobbing in the form of fear of re-entering the workforce.  What does the literature say about those particular patients.  It is irrelevant that there are people with severe psychiatric disorders who work.

Psychiatrists frequently compare a patient to the general well population or occupationally-adjusted or socially-adjusted population.  That's not medicine.  That's pedagogy.  That's what parents tell their four year old child. "Johnny, all the other boys and girls are doing the right thing, but you are not.  You need to act like the other boys and girls."   In a medical model, the parent would identify what Johnny has in common with similarly situated children and look to that cohort for guidance.  In pedagogy, you compare the problem child to the normal, adjusted child.  In medicine, you compare your patient to a group of patients with the same illness.

In medicine you identify the disorder and look at the literature that discusses that specific disorder.  A psychiatrist who has a female patient who was raped and is afraid of men needs to look at the cohort of rape victims who develop a fear of men.  It is coercive to tell that patient that most rape victims are able to date; it amounts to treating the patient as if she were a child.

The schizoid patient struggles with an internal sense of futility.  Gratifications and successes in the real world do not alter the schizoid's deep-seated feelings of futility and meaninglessness.  Fairbairn wrote that "the familiar term ‘depressed’ is frequently applied in clinical practice to patients who properly should be described as suffering from a sense of futility." He saw in the schizoid dilemma a threat of loss of the object (and of the self) regardless of whether the individual attempted to love the object or attempted to withhold that love, and thus "..the result is a complete impasse, which reduces the ego to a state of utter impotence. The ego becomes quite incapable of expressing itself; and, in so far as this is so, its very existence becomes compromised. …the characteristic affect of the schizoid state is undoubtedly a sense of futility."

My psychiatrist needs to appreciate the sense of futility that torments schizoid patients, of which I am a representative.  He also needs to address my specific experiences and the specific consequences of those experiences.  How does a psychiatrist treat a mobbing victim --a schizoid mobbing victim -- who has developed an aversion to the workplace?  What does the literature say about that particular group of patients?