Each morning and evening, when I push an antidepressant capsule out of the foil strip, the same conversation goes on in my head.
Do you really need to take these? You’ve been fine for a couple of years now. Surely, you can start reducing them.
But you’re well on them. That’s why your psychiatrist said you should stay on them, at least for a little longer.
Yes, but is this the real you? What would you be like without them? Wouldn’t that be the real you?
But this is the real you. Why can’t you accept that? That despairing individual isn’t who you really are!
I’m a psychiatrist who’s experienced recurrent episodes of depression, sometimes quite severe, since my 20s. At medical school, I was extremely anxious and needed psychiatric help. Nonetheless, I found it easy to speak to patients with mental health problems—which encouraged me to pursue a career in psychiatry myself.
During the 33 years that I practiced, when I was well, I was always certain that psychiatry was the right career for me; at other times, I’ve considered myself to be a total failure, despite evidence of my success as a doctor and academic. There were even periods when life no longer seemed worth living.
Since then, psychodynamic and cognitive behavioral therapy have helped me make many necessary changes in my life, but they’ve been insufficient in preventing relapses. And while medication has helped me considerably—and I’ve seen it help many people in my practice—I’m still ambivalent about taking the pills.
During my training as a psychiatrist, no one taught me about ambivalence. If mentioned at all, it was called “being indecisive,” but indecision—and its cousins procrastination and “resistance”—are merely ways ambivalence manifests itself to the outside world. It’s so much more than that.
The Swiss psychiatrist Eugen Bleuler described ambivalence as “a phenomenon whereby pleasant and unpleasant feelings accompany the same experience,” and explained how “ambivalent feelings come when ideas remain at different levels of consciousness.” In other words, you may think you know exactly what you believe or feel about something in your life, but another set of beliefs is constantly trying to thwart that understanding. That’s the case with me and my pills: I know that medication does help me. But, through years in therapy, I’ve come to realize that underneath that knowledge is my desire to be seen as a strong individual, who doesn’t need help from anything or anyone, and who should feel ashamed for needing support.
For a long time, I believed I was alone in holding such conflicting views about my self-worth, including whether I was even any good at my job as a doctor, so it was comforting to discover, through discussions with my training group, that many of my colleagues struggled with them, too. If we can’t confront our own myriad contradictions with some degree of self-honesty, how can we expect the same from our patients and clients?
Buried Personal Dilemmas
During my psychiatric training, I worked at a clinic with people with drug and alcohol problems, and I frequently witnessed patients’ ability to express two completely opposing views about a problem they were facing. Jim, for instance, was a single parent whom I’d been working with for several months. “I’ve got to be honest with you: heroin is ruining my life,” he told me. “I’m desperate, Doc, I’ve got to stop.” His wife had died from an overdose, and he was at risk of losing custody of his two children to social services.
I was ready to start discussing what we could do next, when he continued, “But there’s absolutely no way I can manage without it. I’ll fall apart.” He didn’t even seem to notice that he’d just completely contradicted himself within the space of a few seconds, until I gently drew his attention to the contrasting statements, and how hard it was for me to make sense of them. Perhaps he could help me?
He paused, and I could see he was taken aback by my question. Eventually, he replied, “I don’t really know, to be honest, but I do know I need help.”
Ambivalence about change is often at the core of what we used to call “resistance” in therapy. So often I’ve seen this seeming refusal to change dismissed as “lacking motivation” or “unwillingness to work” in a session, when in fact the patient may be stuck in a painful place, trying to make sense of why it’s so difficult to move forward. Exploring the barriers to making changes in our lives takes time, strength of mind, and determination. That’s because ambivalence isn’t, as we often assume, a matter of simple indecision or stubborn resistance, but a symptom of a core personal dilemma or struggle with who we are.
In my professional life, I’ve learned that simply confronting a person expressing such views with the need to make the right decision (like to stop using drugs) usually leads them to list the reasons they can’t. Instead, what I’ve found most helpful is the work of Bill Miller, the psychologist who developed Motivational Interviewing, a process to help people overcome ambivalence and start making changes in their behavior. I began to gently encourage people stuck in ambivalence to explore, nonjudgmentally, the reasons why they might want to remain as they were, as well as the reasons they may want to try something different, such as stopping smoking or even beginning therapy. I made clear that it was entirely their choice.
Miller said that you “learn what you think as you hear yourself say it”—which for me is a straightforward way of describing how we might explore, rather than dismiss, our buried thoughts. The ideas we rehearse in our heads, like my inner conversation about staying on the pills, may simply be thoughts about ourselves we’re ashamed to be having or are uncomfortable sharing.
In my personal life, identifying and grappling with ambivalence has always been more challenging than recognizing it in my patients. My relationship with my mother was never close, but my relationship with my father had been warm during childhood, and then broke down in my teenage years. When he died after a second heart attack, just after I left medical school, we were almost estranged.
For years afterward, I could admit only how angry I felt about his early death, while the opposing feelings—how much we’d loved each other—remained buried deep in my psyche. Because I’d failed to explore these complicated feelings, I’d failed to grieve.
Unconsciously, I was torn between allowing myself to be successful in my career to please my father even after his death and willful self-destruction by giving up on any possibility of happiness in my life. Now I realize how much we were alike: warm-hearted but quick to anger, with a tendency to be disappointed when others—or ourselves—don’t live up to our impossibly high standards. Early in my career and in the throes of depression, despite working harder than ever to help my patients, I failed an important professional examination. Then, after beginning therapy and once again making some progress in my life, I found myself contemplating suicide after the breakdown of a new relationship for which I’d deserted my marriage. I was caught in ambivalence about life and death.
It took a patient and empathic therapist to help me feel safe and emotionally held enough to begin to explore those opposing feelings. Many therapists would’ve found it difficult to tolerate the petulant anger I directed at him. His ability to reach out to me and acknowledge the battle going on inside me was lifesaving. I’ll never forget the moment he said, “You know, I think your father loved you very much, but he probably had great difficulty saying that.” The emotional knowledge I gained through his words in that moment was far more effective than any simple explanation of my problems would’ve been.
I saw that my father and I had been trapped in mutual ambivalence toward each other, and that I’d almost certainly been trying to recreate that relationship in the difficult transference with my therapist. This insight was oddly perplexing, given that I’d spent the previous two years working with patients with complicated grief. My intellectual understanding of others hadn’t translated into an ability to recognize my own difficulties.
The Hopeless Pursuit of Perfection
Because ambivalence is rooted in deeper levels of uncertainty about our value to others in the world and whether we’re worthy of love and attention, mere intellectual understanding or professional training doesn’t make it disappear.
After 33 years as a psychiatrist, and a quarter of a century after my revelations about my ambivalence toward my father, I was struggling to recover from yet another episode of depression and trying to make decisions about how to spend my life after retirement.
I was stuck in a dilemma over whether to move away to live in Scotland and see much less of my husband, who was still working in England and taking care of his (difficult) elderly mother, or stay with him and try and support him. He insisted he didn’t want me to stay, but I could see that he was irritable and stressed much of the time. I’d been diagnosed with chronic kidney disease and wanted to get on with the rest of my life, so I began to spend more and more time alone in Scotland, where I’ve always felt at home, even though my husband and I missed each other very much.
I’m one of those people for whom, as psychologist Albert Ellis said, “there is invariably a right, precise and perfect solution to human problems, and . . . it is catastrophic if this perfect solution is not found.” But a solution wherein I could both be with my husband and get on with my post retirement plans just couldn’t be achieved.
While I was wrestling with that decision, I came across a short work by historian Kenneth Weisbrode in a bookshop in Manchester. Called simply On Ambivalence, it turned out to be one of the most helpful books I’ve ever read on the subject. Weisbrode writes about how ambivalence lies at the very core of who we are as human beings. Its impact is subtle, but nevertheless potentially devastating, because it’s related to our desire to achieve the “best” in life, for ourselves and those we care for—and so it doesn’t necessarily present as a deficiency that should be remedied.
Perfectionism, Weisbrode writes, plays a part in driving ambivalence, which he says comes from too much ambition: “Optimization becomes a fetish. Wanting the ‘best’ means that we must have both or all and are reluctant to give up any option lest we pull up the roots of our desire.”
We now live in a society where that perfectionism—the desire to be and have the best—is increasingly prevalent and encouraged. If we simply want something enough, we’re told that it’ll happen. Our mantra becomes: Everything is possible. I will find the perfect solution to this problem. I just need to keep thinking about the options and trying to work it out.
As we struggle to carry out this impossible task, we suffer. Yet, even then, we may not admit to ourselves how hopeless the pursuit of perfection really is: we just hover in ambivalence, waiting for life to begin, ruminating about what is the best way forward and never finding the answer. For many, including myself, it’s a recipe for depression. In the end, I’ve learned that the only way to manage my ambivalence is to practice the art of being honest with myself, diving deep to identify and challenge those ideas and wishes that would otherwise remain hidden yet still have the power to threaten my stability.
As mental health professionals, we’re particularly at risk of seeking to bolster our self-esteem by caring for others, especially if we suffered less-than-adequate emotional nurturing in our own childhoods. Inevitably, our efforts sometimes fall short, and no ideal outcome is possible for our patients and clients. In those situations, we may risk becoming stuck, ambivalent about our ability to carry on as clinicians and, if not, what to do with our lives. When we’re doubting our very worth, we may need help acknowledging not only our uncertainties and limitations, but our strengths, too, to help us escape that cycle of endless rumination.
I’ve had to admit that part of me views myself as weak for needing antidepressants—but at the same time, acknowledging vulnerability may be a sign of strength. I’m coming to terms with the truth that there are no simple choices in life.
PHOTO © ISTOCK/SKYNESHER
Linda Gask, PhD, FRCPsych, is Emerita Professor of Primary Care Psychiatry at the University of Manchester, UK, and a writer. Her blog is “Patching the Soul.” Her latest book, a memoir of recovery from depression, is Finding True North: The Healing Power of Place.