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questions for psychotherapist Robert Saltzman, Ph.D., Todos Santos, Cabo San Lucas, Baja California, Mexico

Dr. Robert Saltzman of Todos Santos, Baja California Mexico conducts a psychotherapy and counseling practice devoted to mental, emotional, and physical healing; psychological wellness, self-understanding, teaching of non dualilty, and encouragement of spiritual unfoldment. In addition to his private practice, Dr. Saltzman hosts an email question and answer forum devoted to questions about psychology, counseling and psychotherapy, physical, mental and emotional wellbeing, problems of living, or just about life in general, with answers from the psychological perspective.

Please be aware that the information on this website is not intended to replace the personal relationship between patient and physician or therapist, and that Dr. Saltzman's replies to questions are not a substitute for psychotherapy. If you are seriously troubled, it is your responsibility to seek help from a qualified therapist who will meet with you personally.

In order to deal fairly with the increasing volume of mail, the protocol for submitting questions for "ask dr. robert" has changed. As a first step, please post your question on the Dr. Robert Forum where it may open a discussion among forum regulars--many of whom bring intelligence, experience, and wisdom to these conversations. I check in on the forum regularly, and will contribute if and when necessary. As of January 5, 2011, the Forum now includes a real-time chatroom.

Rcently, Dr. Saltzman published a memoir called Awakening Never Ends which speaks about his work as a psychotherapist and spiritual teacher, about spiritual awakening, and about what the experience of "enlightenment" or non-duality is not. .

Non Duality Magazine has just published an in-depth interview with Dr. Saltzman about his experiences with spiritual awakening, spiritual teaching, and the nature of so-called "nonduality:" "In this very moment—which is all there is--things are as they are and cannot be any different. This is obvious. But if someone ignores or habitually denies that obvious truth, that person will always be creating a hypothetical alternative variation to what is—a "better, improved" version. But that does not and cannot exist, and so is not real. When we believe in and pursue things which are not real, we suffer. Belief in things which are not real is the principal source of suffering (and of seeking). When that is seen, the seeking stops, not because "I" stop it, but because the very seeing of that process takes the energy out of it. When seeking stops, likes and dislikes lose importance." ---Robert Saltzman
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Dear Dr. Robert,

Your interview in Non Duality Magazine was fascinating. As I was reading it, something occurred to me that I would like to mention. It has to do with the compulsion to look for something better, a way out, a greener pasture somewhere else, etc. Throughout human history, there were periods of intense suffering and difficulties to meet life's challenges but people always found a way to cope. They have often turned to religious authority to provide the answers, a shelter, or perhaps an escape. Suggesting to someone to embrace life as it is, including all of its aspects, is usually met with resistance on some level. There is a constantly reinforced tendency to sleepwalk through life, fill it with content, and get out of it as much as we can before the expiry date. This is all obvious. What most of us forget to do in the daily rush is to remember to stop and look, really look mindfully, how amazing the manifested world is. We take for granted that it is just there, every morning somehow appears as a playground for our activities. But what a work of art it is! The patterns, textures, creatures, experiences, and sufferings, all happen in the stream of consciousness, a river of boundless energy, mysteriously coming out of the no-thingness. Isn't this by far the best "movie" ever? ...and we have the best seats in the theater to use the analogy. Funny thing is that screens today have replaced reality and are separating us from it.

There is also an issue I have with terminology. Specifically, the term ego as used by many popular gurus in some spiritual traditions, like Advaita, who paint it as the compulsive thought machine and root of all problems that must be removed to reach a spiritual attainment. The use of this term is very different from Freud's definition of the ego concept - the rational aspect of the mind - that people in the West are perhaps more accustomed to. You mentioned somewhere, if I am correct, that we need the ego and without it would be in a coma. Is it synonymous with the sense of separate self, the subject-object duality? Can we exist and evolve without thought? Perception of self, individuality, is a function of the self-preservation instinct and as such exists not only in humans but all other species. Of course, humans have brought individuality very far.


Hello, David—

Thank you. I am glad you enjoyed the interview. I enjoyed giving it.

You wrote,  "The patterns, textures, creatures, experiences, and sufferings, all happen in the stream of consciousness, a river of boundless energy, mysteriously coming out of the no-thingness. Isn't this by far the best "movie" ever?

Yes. This is what Walter Chappell, my teacher, was able to convey to me. Not the idea of it, but the experience, moment-by-moment, of it.

As for the ego question, it is not a matter of the "sense of separate self, the subject-object duality." Clearly that exists, is a part of experience, and does not require nullification or any kind of self-conscious "transcendence," if that were even possible. I understand that often the spiritual seeking kind of person imagines that part of awakening involves the disappearance of that sense of a separate self. That is not really what I am pointing to when I point to an—for want of better lingo—"awakened perspective," but rather the understanding—not a state of mind which can change suddenly and often (how quickly will an insult or a perceived threat change yours?) but the actual deep understanding—that in this moment, things are as they are, and cannot be any different.

It is against the backdrop of that paradox, not by imagining something better and "cleaner," that "awakening" has to arise.



Dr. Robert,

Further on the topic of ego. As I understand it, the term is used to describe identification with form, hence your term "mis-identification". The ego avoids/negates the present moment because it cannot conceive of the formless so it is doomed to keep searching for some illusory idea, which it cannot find, therefore it is never satisfied. It continually tries to find a fixed point in the river of being because it fears for its existence.

The confusing part, aside from the Freudian usage, is how this narrow definition of ego relates to one's personality and rational thought—i.e. our public identity. I can choose (have to choose, really) to use the mind as a tool for rational thought to be able to function in the world. In an unawakened state ("sleep mode"), 'I' am lost in thought and unaware of the present moment. Once I become conscious of thought, a separation begins that becomes a stepping stone and I start to notice the selfing game as it is played out moment by moment, shifting focus from what is experienced to who is experiencing. This can apparently go on for a long time without any qualitative change, unless some further understanding (as you point out) or practice takes it to the next level.

To be awake, I must remain present for what is happening in an open way without judgment and attachments and, as you mention, to allow what is to BE. I have to release everything so that it is all freed from me—my clinging, judging, etc. The release part is the trigger and it just happens somehow (the 'AAAH' moment), removing the filter of delusion. I become aware of awareness—my private identity—while the ego, not able to withstand the light of consciousness, becomes hidden away. The question is what happens to it and do I really care?

The following is an excerpt from Douglas Harding's article "On Being Aware":

"Yes, you've got it! You see with total clarity Who and what you've always been, namely this Disappearance in favour of others, this Emptiness which is aware of itself as no-thing and therefore all things. How could we not see this most obvious of all sights, once our attention is drawn to it?

Congratulations! You're enlightened! You always were."

But now comes the hard bit. Seeing what you really are is just about the easiest thing in the world to do, and just about the most difficult to keep doing, at first. Normally, it takes months and years and decades of coming back home, to the spot one occupies (or rather, doesn't occupy--the world does that) before one learns the knack of remaining centred, of staying indoors, of living from one's space instead of from one's face."




Well, whether I am using the word "ego" to mean "identification with form" or not depends on what you mean by "form." I generally use the word "ego" to point to a version of "myself" which is comprised of those aspects of the body over which we seem to have conscious control, plus the body's autobiography, the latter being the story I tell myself about who and what I am and what my place is in the apparent world and its apparent organization. This is not quite the standard usage, but what we are discussing here has little or no place in standard ego psychology either.

No, I do not believe that you can choose to use the mind as a tool for rational thought. Rational thought happens when it happens in response to whatever triggers it. Ego then falsely takes credit for "directing" the mind to think rationally, but this is what ego always tries to do—take credit for whatever "doing" occurs. And ego, by the way, is usually far from "rational." For example, ego habitually locates itself in the center of reality, which is not at all rational.

All of this is very complex and difficult to discuss, David, because what would make sense to one person, in one condition, will make no sense at all to someone else in a different condition. This is why the bulk of my teaching takes place one-to-one. For example, when I say no one is to blame for anything, some people grasp that immediately—notwithstanding how truly foreign that idea is to the normal way of understanding what a "person" is—while others cannot get to first base with that idea. Since I do not know where you, personally, are with all this, I will try to address your question, but this is only a shot in the dark really. If you were sitting here with me, we could feel our way into this, but in print it is not at all the same. Also, to sit with someone who is in an awakened state can be "catching," at least for the moment, and words on a page are not at all like that. That said, David, here goes:

Awakening just happens. You do not have to do anything. You do not have to release anything. And the ego does not become hidden away. Everything is just as it always was, except that the "myself" which seemed so obviously factual, so indisputably here at the center of "my" experience, and the doer, creator, and liver of "my" life, is seen to be a ghost in the machine. Life just happens. No one is doing it. No one ever did. From another angle, awakening is the simple recognition that in this moment everything is as it is and cannot be any different. In other words, no one is making anything be this way, and there is no explanation, no rhyme nor reason to any of it. THIS, including myself, is what the entire universe is doing, and there is no one with the power to stand apart from that doing anything different. All of THIS, being life itself, simply arises as it must, and I am that.

I don't know anything about Douglas Harding, and I am not moved by the quote to google him. This "Guess what? You are already enlightened" stuff is flowing quite freely nowadays, but I cannot really buy it. That is more of a word game than anything else. Yes, it is true on a certain level, but that level is not one which can inform someone who is seeking awakening in the way that you are. I prefer not to use the word "enlightened" at all. Awakening is the understanding that the very idea of a "myself" which can become anything is pure reification—making a solid "thing" that is, out of a conceptual point of view. The concept of becoming is ego, and exists only as a story I tell myself. In other words, an "enlightened person" does not refer to anything real. It is simply another facet of the daydream called "myself," which now becomes a fantasized "enlightened myself." When that daydream is seen to be based upon an empty concept (what a mathematician would call "an empty set"), one is awake. Ego will still be there, and will even notice the "awakeness," but then immediately will try to take credit for it, or dispute it, or deny it. This is called "drinking knockout drops."

I like your use of the word "knack." I remember trying as a boy to get my Duncan Yo-Yo to "sleep." I saw other kids doing it, but could not catch on to the knack. Then, suddenly, I got it! It was as easy as pie. Nothing to it. In fact, it was hard to make it not sleep. That is what residing in silence and emptiness is like. I really cannot not do it, even if I wanted to. Oh, I can distract myself with some activity or whatever, but the substratum of all of that never really disappears, and I certainly never have to make any effort to notice it or "reconstitute" it.

If you remember that you cannot acquire that knack through any effort whatsoever, you will be just about as close to the crux of this matter as words can go.

Beyond that, the best that anyone can do is to try to prepare the ground for the knack. The best approach to that, in my experience, is remembering as often as possible that prior to thought, prior to feeling, "I AM." In other words, I am that to which or in which thoughts, feelings, emotions, and objects—including "my own" body—become apparent moment by moment. In different words, I am the emptiness into which all these phenomena appear. If you will do that—a simple question of remembrance, nothing more—sooner or later, without conscious effort on "your" part, a shift will simply occur, and you will be awake, perhaps only for a brief moment, perhaps longer. No problem. That experience is one observation, one "dot." Later, another mini-shift into—for want of a better term—"impersonal awareness," yields another observation, another "dot." Once that begins to happen, David, it is just a matter of connecting the dots.

Does that help?


Dear Dr, Robert,

I, like so many others, have been on the spiritual path all my life. I have also been a therapist for 28 years.  I have reached a point where it seems there is just nothing left to do.  I say I have stopped trying but that isn't even possible with the conditioning of my mind.  I know that what I am seeking is present right now, right here but I seem to keep getting in my own way.  Got any help or suggestions for me?

Thanks for all the wisdom you are sharing and goodness in your heart. 


Dear Marilyn--

So you and I are in the same line of work.

Please give this little article about awakening a read, and then if you have questions I will try to address them:

Be well.

Hi Robert,

I read your article about awakening.  I also read your correspondence with James . I think he is me.  I have seen and read Adayshanti for a couple of years now and I like what he has to say.  I am also reading Nisargadatta's book I AM THAT.  I find so much comfort with him. . . so simple and to the point.  I guess what I don't have is a personal teacher or support person to talk with and I miss that.  I have had several but I seem to have lost them along the way.  What you wrote about trying and not trying struck a chord with me.  I think I have stopped trying at all because:

1. trying gets in the way and

2. I haven't known what to try anymore. 

I am out of "trying juice" I think. I have, for as long as I can remember, felt the presence of myself inside of me (if that makes any sense at all).  When I was little I remember remembering and seeing a light whenever I would close my eyes.  It seems to me like what I am seeking is here right now,not even a breath away. Problem is sticky thoughts still capture me at times and emotions get triggered. Nisargadatta says to always remember I Am That and little by little everything else dissolves. Could it really be that easy?  Thanks for your response.  All comments gratefully invited.

ask dr. robert saltzman


We have not met, so this will be the best I can do at a distance. I hope you do not imagine that I have some special magic to dispense. I really do not. If you were sitting here with me, and you and I could go into this deeply, as one does in psychotherapy, possibly I could help more, but words on a page go only so far.

That said, you seem stuck in what I call "mis-identification," by which I mean that you imagine that "you" are your body, your name, your personal history, your sex, your gender--all that stuff. I do not think that reading Nisargadatta will help with that at all, but probably only deepen the mis-identification, since now you seem to think that there is someone who can "dissolve" things by means of some practice, as if you and what needs to be "dissolved" were two separate "things." But they are not two separate things, and nothing needs to be or can be dissolved "little by little." Awakening has to be now in this very moment or not at all, and does not consist in dissolving anything.

You say that sticky thoughts still capture "me," as if you were somehow separate from the thoughts, as if some "me" existed that "has" thoughts. But that is not the case, and that seems to be the root of your difficulty. That separate "me" is simply another thought which cycles through awareness constantly, and which you constantly reinforce in a multitude of ways. To repeat, there is no me which has "sticky thoughts," and if she could only stop having them would then be awakened. "Me" is a sticky thought. The stickiest!

The thinker is the thought, not some separate entity which "has" thoughts. As long as you continue to divide the two, you will never see the freedom you desire, because that freedom does not result in leaving anything behind, or discriminating "good" from "bad," but in surrendering completely and totally, with no resistance whatsoever, to what is seen, felt, and experienced moment by moment as the one and only "reality." There is no other "you" except in your imagination which is also only thought.

The freedom you desire—and I certainly respect the desire, by the way—is here right now, and consists in being exactly what you are with no idea of improvement or of attaining or becoming anything else. Anything else you imagine you might be or could be "if only" is the impediment. Just stop!

A "you" who becomes awakened or liberated does not exist, never has, and never will. When awakening happens, "you" will not be there to see it, because the awakening occurs in the very instant that "you" is seen for what it is, a total delusion, a complete mis-identification, in which awareness, which belongs to nobody, and which is as empty and pristine as a movie screen, begins to imagine that it is whatever movie (thought) is projected upon it. The screen is not changed one whit, no matter what is projected upon it, and you—the real you--are that: the pristine screen, not the movie.

You, as an entity, do not exist. That so-called "myself" is nothing more than thought (the movie). When thought stops, "you" are not there, only awareness (the screen) is there, and the screen is not "yours," and never has been. That is why Nisargadatta said, "No wonder you are so unhappy. You spend 99% of the time thinking about yourself, and that does not exist."

I hope this helps.

Be well,


ask dr. robert saltzman

Hi Robert,

Thanks for your reply.  I am just reading it over, and  I feel completely nuts reading what you said. Not new to me, but it really hit home like a punch to the gut for some reason.  It is like you took a big stick and smacked a hornets nest.

Gratefully yours, Marilyn

ask dr. robert saltzman

Hi, Marilyn--

Well, this sounds good. If anything I wrote hit home at all, I am pleased to hear it. Far better a hornet's nest than a sepulcher.

The entire spiritual dilemma, you know, boils down to only one problem—denial. Denial that everything which is born will die. Denial that everything I want to keep—identity, possessions, friends, family, lovers, health, life—will be lost. That denial, that continual avoidance of this simple, basic, undeniable truth, obscures my true nature by forcing everything I do and everything I think to serve an unconscious strategy—a strategy of denial--so that instead of simply living, which means allowing whatever is to be, and whatever arises to arise, I continually attempt to protect myself against the pain of that simple truth: nothing that I think I have, nothing that I think I am, has any permanence whatsoever. It never did, and it never will.

Everything, Marilyn, even my imagined "self," awakened or not, dies in every moment, to be replaced in the next moment with a new version of what I think I am. Because such total impermanence is terrifying, we paper it over by creating a story of who I am. A story, we imagine, can continue. But that story, which is only a thought-form, obscures what I really am: the endless awareness in which that story, along with everything else, is born and passes away.

In each moment, Marilyn, be honest. There is nothing, absolutely nothing, to which you can cling for security. Accept that fact--for it is a fact--accept that pain, stop telling yourself the story of denial, and all will become clear without any effort whatsoever.

Be well,


For a personal consultation with Dr. Saltzman in Todos Santos, send an email, mentioning briefly your reason for wanting a meeting, and your hours of availability.

Rcently, I published a memoir called Awakening Never Ends which speaks about my work as a psychotherapist and spiritual teacher, about awakening with the help of my teacher, Walter Chappell, and about what the experience of "enlightenment" or non-duality is not. If you are interested in this kind of thing, I invite you to give it a look.

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Dear Dr. Robert,

I live in the United States, I have lived with a man from mexico city, mexico for almost 2 years, I have just found out that he has touched my daughter, I am devastated , I love him with all my heart, and i want to hurt him bad for touching my daughter. I am confused as to what to do.

At church, the sermon last sunday was to forgive, god created us out of dirt, and made us in his image, jesus died for our sins, jesus even forgave mary magdelene the prostitute, maybe you know this, I don't know if I am trying to justify myself for wanting to help him, I don't know , no one even in my family can believe it, they all loved him too.

I told him to go away , go back home to mexico and never come back, but i can not do this without knowing he will get help, I have told his oldest brother everything that happened, his brother has 4 daughters, he has assured me he would watch out for him and get him help.

I would like to know if you know of any such doctors or could refer me to a doctor for therapy to help him so this wouldn't happen again. If he went to jail here if he didn't get killed, I doubt they have counselors, in this area who speak spanish and could help him, but he is also illegal and I have been told they would just deport him anyway.

To save my daughter the trauma, I just want him to go away. But I cant stop my feelings, he has helped me so much until this happened. I want him to get help, I would like to send him the name of a doctor who could help him in his city, and ask of there confidentiality laws, or if he admits he needs help what do they do to him in mexico.

Please help me and respond soon. Lisa


To begin with, Lisa, I am sorry for your troubles. It must be a horribly painful experience to learn that your daughter has been sexually abused by a man you have loved and trusted.

I do understand your desire to try to get therapy for this man, but I am afraid that on that score I have bad news for you. In my experience, and in my professional opinion, it is very unlikely that such a person can be helped in any significant way by psychotherapy or by any other kind of treatment. Almost without exception, men who abuse young children will continue to do so no matter how much therapy they may receive. Often such people pretend to have been helped by therapy, and some may even believe that they have been helped, but almost always they offend again at the earliest opportunity. In fact, your daughter is probably not this fellow's first victim; there may already have been many for all you know.

In my opinion, the only proper treatment for such people is to keep them away from children forever. The only way that you can help with this is to make totally public what this man has done, so that at least other parents might be warned, and so might have the possibility of protecting their children from him. You should begin by immediately reporting this crime to the police. This man should be arrested and dealt with by the proper authorities, not by you or by his family, who most likely would try to shield and protect him. In other words, it is not your boyfriend who needs to be protected, but the innocent girls of this world who are his possible next victims.

You will not be protecting your daughter from trauma by sweeping this crime under the rug. She already has been traumatized by the abuse. Now she, and you, not your boyfriend, need therapy, and I urge you to get it. You will need therapy to resolve the conflict you feel between your love for this criminal and your love for your daughter. You must be feeling terribly guilty yourself for having brought this monster into your home and having exposed your daughter to him. I know this was not your fault, but you don't know that yet, and therapy will help you to know it. Your daughter's state of mind needs to be investigated, and, if necessary, treated by a person experienced in child sexual abuse. This is urgently important since the trauma she has suffered will only fester and continue to damage her all the more if it is swept under the rug as you so far have done.

In my opinion, as I read your letter, you are correct in suspecting that you are misunderstanding and using religious teachings on forgiveness in order to justify avoiding taking proper action in this case, which is to report your boyfriend to the police immediately.

To begin with, Mary Magdelene was not a child molester; she was a prostitute, which in those days was not even a crime, but simply a social function, a way of earning a living, that is. As I understand the Mary Magdelene story, Jesus favored her among all of his disciples because he loved her--perhaps even physically (although this is controversial). In loving her, and in accepting her as a spiritually realized person--a truly loving person, that is--part of Jesus' message was simply, it seems to me, that sexuality and its satisfaction between consenting adults is not a sin, but a natural and normal part of human life. Unfortunately, the corrupt Council of Nicea, convened for political reasons more than 300 years after Jesus' death, completed distorted the Jesus message, making Jesus into a "god" rather than understanding Jesus as a spiritually realized teacher, a man, that is, but a man who understood and practiced the blessing of love. And once Jesus is seen as a god, not a man, the rest of us become "sinners," and our normal behaviors, including sexuality, sins.

When Jesus taught forgiveness, he was not saying that crimes should be swept under the rug, as you are trying to do, but that we should understand that people do what they must, based upon heredity and environment, and so, ultimately, are not responsible for their crimes. In other words, as I understand Jesus' message, forgiveness means to grasp and understand that in each moment things are as they are, and cannot be any different. That is the meaning of the words "forgive them, Lord, for they know not what they do." But this does not mean that child molesters should not be imprisoned. In other words, I can forgive your boyfriend because, as a psychologist I know that he is psychopathic, or, at the very least, horribly emotionally distorted, and so was just doing what he had to do, what he was programmed by genetic inheritance and by upbringing to do. This is what Heraclitus, also a man--not a god--who lived some five hundred years before Jesus, meant when he said that "character is destiny." But forgiving your criminal boyfriend does not mean that he should be allowed to run free in Mexico under the questionable supervision of his brother.

If it were possible, in my view, child molesters should get the "one strike and you're out" treatment. Ideally, as I see it, this fellow should be locked away forever with other child molesters. Forgive them, yes. Given them treatment, yes, but behind bars. Allow them a second shot at another child, definitely not!

If you are religious, and believe that there is a third factor besides heredity and environment which determines behavior, a factor which can be called divine grace, enlightenment, the love of God, salvation, or whatever, then pray for your boyfriend that he is somehow rescued by grace from the necessity to repeat this behavior. But even if you do believe in such a thing, that does not mean that a child molester be allowed to run free to offend again.

Please do the right thing. Report this man today. If you do not, you will simply compound the guilt you already feel. If you do not understand this, imagine how you would feel if you fail to report him, and allow his brother to take him on, and then learn later that he has harmed another little girl, or many little girls. Sorry, but this is the truth.

Be well.

Dear Dr. Robert,


THANK YOU, Ingrid Morales


There are two possibilities here, and both need to be checked. The physical symptoms your describe might be signs of an underlying physical illness, and your sister’s tiredness, dizziness, and sadness may be other symptoms of this physical problem; for example, she might be anemic. Or, your sister might be depressed, and the physical symptoms could be manifestations of her depression. I think this second possibililty is much more likely.

In any case, your sister needs to be examined by a physician as soon as possible. If he or she cannot find any physical cause for your sister's symptoms, I would suggest that she meet with a qualified psychologist as soon as possible. At her age, depression sometimes leads quickly to suicide before anyone else realizes just how ill the depressed person is, so I do suggest that you act on this right away.

Be well.

Dear Dr. Robert,

To begin with, I should probably explain myself, even though this is about a friend. I am in high school. I am, according to others, smart. My grades are mostly B's simply because I am too lazy to do anything other than show up and complete the tests. I was recently diagnosed with depression and put on medication by a psychiatrist. I try to be very open-minded. I don't have a problem with anyone's opinions, and I allow their opinions to influence me, but not much. I make my own decisions and come up with my own ideas based on what I know. I suppose this is one of those situations where I don't know much.

I have this friend. I would say she is very smart. However, unlike me, she works to get the best grades in the class. There has always been something about her that annoyed me. We could never really get along just right. After not talking to her for awhile, I decided I was ready to try and be rational about the whole thing again. So I emailed her. We have this weird thing going on. All our emails are like mini-novels. Each one fills my inbox up about one percent. They're all about what we believe in, and our friendship, and our "problems".

My friend thinks she has a mental disorder. The first time this came up was when she told me she heard voices. It was right after her sister came home from college because she was anorexic. She told me they were getting worse, and that they made her do stuff. She gave them names. She told me mostly about the evil one. She told me it wanted her to stop eating like her sister. She told me she was scared that she'd listen to the voice again. Then randomly throughout the night, she'd just tell me not to let her go anywhere, because the voices were telling her to do evil things.

At first she said she thought she had multiple personality disorder (this is now called dissociative identity disorder? maybe?). She said that she looked it up and it said it was caused by extreme trauma as a child, and that this trauma may not be remembered. She then decided she must have experienced some traumatic event and forgot about it.

Later, she found out about me cutting. A day later, she kept making a big deal out of the voices now telling her to cut. It's not like I put the idea in her mind. She has plenty of friends who cut. I'm just the only one who knows about the "voices".

Then, she kind of left the voices alone for awhile. We started talking about how I had depression according to all my counselors and people like that. Then, a couple days later, she was scared that she was depressed. She kept talking about how her dad has some form of depression (I don't know what it's called. She doesn't either. I think it may be something that starts with a D. It's like major depressive disorder or whatever it's called, but it doesn't count as an episode), and how she was scared that she was developing it too. She told me about how her dad is "sometimes depressed", as in he takes the medication every so often whenever he feels depressed, but doesn't have a major depressive episode. So then she was talking about how she said she felt like she was getting it too. Like how you can sometimes tell when you're going to get a cold because of the stuffed up nose the day before. I didn't really understand that, but I'm not her. I know I didn't think I was going to get depressed. I didn't even realize I was until people told me I was, and there wasn't really any warning or even a situation I can think of that triggered it. Apparently some grandparent or great-grandparent had depression, so they think I may have just randomly had it in my genes. And my mom has pmdd or something like that. (Sorry if this is getting kind of long).

Well, I told my friend I wasn't sure if she had depression, and I couldn't be anyway because I didn't go to school and study it. So she asked me to tell her the symptoms. And she asked what medication I was on. I told her the medication and she went to the website for it. There, she found an "Are You Depressed" test. She took it. She got very severe depression for her results. She told me to take it. I got severe. I was actually honest on this one. When I was first kind of wondering if I really did have depression I took a similar test, and tried to convince myself that nothing was wrong with me, and lied on a few of the questions. I still got moderate depression even with my lying, so I gave up on that. But all the questions were about symptoms of depression. The next email I received from her was all this stuff that she'd never told me about how she wakes up at abnormal times and can't fall asleep after that, and how she sometime! es isn't hungry, and is tired all the time. Basically all the physical symptoms of depression in the test.

Somehow, she then decided she wasn't sure what mental disorder she might have. So I went to this site that describes the symptoms of mood disorders, personality disorders, etc. I took a few symptoms from each disorder and asked her if she was ever like that. She said yes to things like having an excessive and irrational fear of something, or feeling a need to have someone with her, or having nightmares. She answered no, or gave an unclear answer on questions that asked if she ever used people fro her own benefit, or if she thought she was special, or if she did violent things to people. I went back and looked after she answered (I didn't tell her why I was asking; I wanted her answers to not be based on her looking at a site, choosing a disorder she liked, and then answering accordingly) and she had enough symptoms to have pretty much every major disorder except schizophrenia (although if she does indeed have depression as she says she may, it could be schizoaffective), avoidant, and antisocial.

I'm a paranoid person. I don't trust anyone. However, even if I don't trust them, I like to try to give the benefit of the doubt. If she says she is lonely all the time, I will listen. So I tried to help her and figure out what disorder could potentially be the cause of her "problems". But even though I help, I don't know if I really and truly entirely believe what she is saying. I don't want to say that she's making it up. It's just that, with our new honesty policy, she tells me there is nothing more she loves than attention. (I'm kind of the opposite. I hate attention. I have way too much of it.). And she always comes into class with the exact same look of pain on her face. It is probably just me, but it always seemed to me like it was only real half the time. Like she was trying to get our sympathy or something. I don't know. I'm probably wrong. But she always complains of headaches, or being too cold, or "not feeling good". If one friend comes in upset because! e she broke up with her boyfriend, this friend always gets annoyed. Like someone is stealing her sympathy or something. It's kind of annoying. If I'm unhappy, even a little, and I let any of it show on my face, she immediately gets all pouty and does that thing where she stares downwards while talking. This is kind of hard for me, because I am depressed, and sometimes I'm unhappy because of that. So I have to be careful not to let it show.

I don't know. I don't want to think that she's faking any of this. I'd like to believe her and try to get her help for her "disorder" (whatever it may be), but I don't think I entirely believe her. It just seems like a bit much of a coincidence how her level of happiness corresponds with other people's. Like her randomly getting "anorexic" for a day or two when her sister came back. She did admit to being a little jealous of her sister for getting attention for it, but said she'd never try to get attention in such a negative way, because she is better than that. But she's better than everything. Or at least it seems that way. She's always been considered by friends to be almost perfect.

She always writes about how her parents make her feel terrible and depressed. I told her they're supposed to do that. We're teenagers, and they're parents. She gets all upset and sad when her parents say she should improve her grades because she had a B on her report card. She said ! she was more upset about her bad grade than anyone else was about their bad grades. I mean, they're parents. Aren't they supposed to do that? My mom is loud and seems angry all the time, and the sound of her voice makes me shiver, but isn't she supposed to be like that? She's a parent. She has a right to try and control my life. She did create me, after all. Her only mistake was letting me take over some of it.

But now that I have sufficiently wasted a large portion of your time (assuming anyone would even bother to read this far), the main point. Am I justified in thinking she may be faking some of this? Or am I just being my usual excessively paranoid self? Does she need help? If I told someone about her symptoms she says she has, and that she thinks she's depressed, would this help her? She thinks she would benefit from being on some sort of medication, but claims she doesn't want to be on them because she wants to be independent. (I kind of want to know how that fits in with her answer to a question saying that she is very dependent). Is there something wrong with my thinking, or hers, or am totally wasting my time writing this all down? I don't want to deny that she has a disorder, but I'm not totally believing it, and I guess I just need someone else's opinion before I go and do the obvious thing and tell the guidance counselor about her and the voices and feeling depressed and stuff.


A person who despises signing anything with her own name

Dear Anonymous--

Thank you for writing. Your letter, which purports to be about helping your friend, really seems to me to be much more about finding the help know you need, and apparently are not getting. Your very first words, "To begin with, I should probably explain myself," suggest this quite clearly. In fact, I read your letter as a cry for help to which I will attempt, given the obvious limitations of this email protocol (we have not met, and there is much about you I do not know), to respond. But first, a word about your friend.

I cannot, without a personal interview, diagnose your friend, but everything you have written about her is suggestive of serious disorder, including, perhaps, the onset of schizophrenia, which requires, as you know, immediate evaluation. Hearing "voices" is a major red-flag which simply must not be ignored. Yes, your friend may be malingering or feigning illness as an attempt to attract attention or sympathy, but that kind of behavior calls out for treatment anyway, so in any case your friend needs help. As a practical matter, I cannot say at a distance if reporting her condition to a school official is the best way to go or not. Perhaps it would be better to begin by speaking seriously with her--not from a diagnostic point of view, but simply by telling her that you are concerned about her and that you believe she should speak with an expert about her inner life. This is something you will have to determine for yourself, but your friend seems to be in a dangerous condition, and, as her friend, you are correct in your feeling that you ought to try to help her. You seem bright enough and aware enough of mental health issues to puzzle this out somehow. If you cannot come up with anything which seems better, then by all means speak to the school counselor, since anything would be better than simply ignoring your friend's distress.

Now, to your situation. You say that you have been diagnosed with depression and prescribed medication by a psychiatrist. But is that the extent of your treatment? If so, your psychiatrist is, in my opinion, guilty of malpractice, since, given what you have written to me, you are in urgent need of much more than simply a prescription for some pills. I suggest, and in fact urge you to seek the best psychotherapist you can find, and get into treatment immediately.

I have written elsewhere, but will repeat here, that medication alone is not a sufficient approach to treating depression. Medication, if it is indicated, must always be accompanied by competent psychotherapy of some kind or other, and the first step in treating depression is not handing the patient a prescription, but rather the establishment of a positive therapeutic relationship between therapist and patient in the context of which the patient can reveal safely the kinds of things your letter touches upon. In years past, psychiatrists routinely established that kind of relationship with their patients, but now that antidepressant medications have become relatively safe, effective, and available, many psychiatrists have been converted into little more than pill pushing machines who do not treat people, but only symptoms. This is profitable for the psychiatrists, since it allows them to see and charge several patients per hour instead of only one, and also it relieves them of the "burden" of having to share in detail the suffering of another human being, which is something that many of these cold fishes are not willing to do. Of course, not all psychiatrists have fallen into this sad state--in fact, there are some wise and kind people still practicing that profession in the more holistic manner--but in my experience, many psychiatrists in the twenty-first century are people who either have succumbed to greed, or else simply are not capable of offering any help beyond symptomatic relief via drugs. I hope your psychiatrist is not one of these, but I suspect that he or she may be, since, as I said, you clearly have not been receiving the kind of help you most urgently require.

Without meeting and getting to know you personally, I will not discuss in full detail why I feel so strongly that you are in trouble and require expert help, but I will touch on two points, and leave it to your obvious intelligence to understand and do something about your situation. In the first place, your reference to "cutting," is extremely worrisome, particularly since you state it in a tone which seems intended almost to normalize that behavior. Self-injurious behaviors, such as taking a razor blade to your own body may serve many purposes in the psychic economy--expressing anger which one is afraid to manifest openly; escaping from emptiness, depression, or feelings of numbness or unreality; preventing suicide; expressing or repressing sexuality; continuing abusive patterns from earlier childhood; attempting to remind oneself of physical reality as a way of dealing with feelings of depersonalization and dissociation; establishing a feeling of uniqueness or of being somehow special; etc.--but in your case, again without really knowing you, I suspect that self-injury is a way of being "in control", in other words, an attempt to deal with an internal sense of powerlessness, helplessness and anger. I make this assumption, which is admittedly a bit of a leap, based in what you wrote about your mother:

"My mom is loud and seems angry all the time, and the sound of her voice makes me shiver, but isn't she supposed to be like that? She's a parent. She has a right to try and control my life. She did create me, after all."

You seem to be saying here that parents have a obligation to frighten and dominate their children. Do you really believe that? If so, I can understand why you would find relief in self-injury, which would allow you to convert your psychological pain into physical pain that might seem more understandable and controllable. Perhaps you also use cutting as a form of self-medication since physical injury promotes the release of endorphin hormones which can counteract anxiety and depression. Further, you may feel that by "taking control" of your own body in this way, you are thereby establishing a boundary between your self--both contained in and symbolized by your physical body which you, and only you, are permitted to harm--and your mother, who may be able to "cut" you with words, but may not cut you physically, since only you have that right.

If you were my patient, we would take time to explore these feelings and particularly the profound philosophical misunderstanding which seems to underlie them--all the time you would need, in fact, to come to your own awareness of that misunderstanding--but here I do not have that luxury, so I will simply state it:

Your mother did not "create" you. Your mother had sex with someone, one of the eggs in her uterus (which egg she also did not create) was fertilized, a fetus developed, and later, sometime after the birth of that fetus, awareness came to feel that that particular body was "you." Your mother did nothing to create "you" except to do what most people do--act out their sexuality for their own purposes, motives, and satisfactions.

Personally, I do not imagine that any of us was "created," but rather that each of us simply arose in the world, or, it might be better to say arose out of the world, in the same natural way that all the other aspects of this world arise: fish from the sea, roses from a rose bush, etc. Who was the rose's mother, after all?

To me, it feels important that you understand this point. If you imagine that your mother created you, in the way a painter creates a canvas or a potter a pot, you are ascribing to her far too much control, and even ownership, over your life. It is getting to be time for you to grow up and take control of your own situation. I recommend that you begin to reduce your emotional enmeshment with your mother--I say "enmeshment" because your mother's voice is not just unpleasant to you, but can make you shiver, as you wrote--by getting the therapeutic assistance you need to establish proper boundaries between you and her. Then, I think you will not need to "cut."

A second point which suggests to me that you need therapeutic help is your obvious fascination with mental illness. Apparently you have familiarized yourself with the names and diagnostic criteria for various ailments, and your approach, not just to yourself but also to your friend, is frankly diagnostic, almost as if you were her psychiatrist. (By the way, since you like this stuff, the word you were looking for in regard to her father is "dysthymia").

As an intellectual exercise, there is nothing wrong with learning and wanting to understand some of these matters, but the tone of your letter suggests to me that your interest is not at all intellectual, but rather an attempt at self-diagnosis and self-understanding. Both the tone and the content of your letter which you chose to send to me, a depth psychotherapist, suggest that you suspect your problems involve more than just depression, and that you are searching for a proper diagnosis as a way of trying to deal with your problems. It would be wrong of me to offer a diagnosis based only on your letter, and I will not do so, but I will say that getting a real diagnosis, which I believe will involve more than just depression, and finding real and effective treatment, which will certainly require more than just medication, is a good idea, and most definitely not a do-it-yourself project.

I hope this helps, and I wish you well.

Be well.

return to ask dr-robert archives

Dear Dr. Robert,

My wife and I have been married for six years. I am 34, and she is 29 years old. For the first year or so we were happy together, but then we began arguing, at first about small things, but then more and more about important matters. The arguments gradually got worse until we seemed never to have a single day without a fairly bitter fight. Our sex life suffered terribly since my wife says she cannot be interested in making love with someone who obviously dislikes the way she is, so now we fight about that too.

Seven months ago we began couples therapy with a local counselor who was recommended to us by a friend of my wife. We see her twice a week, so by now we have had at least fifty meetings with her. These are expensive and time-consuming, but I would be willing to pay the price, both in money and time, if I thought the therapy was helping, but it isn't. This counselor seems to do little more than listen to us talk about our complaints, and this has gone on and on now for, as I say, fifty hours or more. She makes almost no recommendations to us, and the ones she makes seem to do more harm than good.

When I complained to her last week, she told me that "these things take time," and told me that given the amount of discord in our marriage we should not expect quick results.

I am beginning to suspect that this counselor is not helping us, and may even be making things worse. What would you advise?

R.W.--New York, N.Y.


Thank you for your question which I think will be helpful to many people since this is a very common experience in therapy, particularly couples therapy. Unfortunately, there are many incompetent people claiming to be able to help couples to resolve their relationship problems. One reason for this is that anyone can claim be be a "counselor," regardless of training or qualifications. Another is that the "counselor" can always blame failures on the incompatibility of the couple while taking credit for whatever successful outcomes might arise.

Without having seen your counselor at work, or at least having more details, I cannot say for certain that she is unqualified, but your report of having put in over fifty hours of therapy without feeling any better makes me suspicious. Usually, there is some improvement, both in the way couples regard one another, and in the way they communicate with each other, after between 5 and 10 hours of effective therapy, sometimes sooner.

You did not give details about the kind of therapy your counselor is providing for you, and this is vitally important. Many approaches to counseling couples have proven to be either ineffective or downright counterproductive. Often these are approaches used by untrained, self-styled "counselors, or counselors working within religious traditions such as pastors and priests who use the hammers of obligation and scripture to try to force the couple into compliance with some kind of "spiritual" ideal, but some well-trained psychologists, who should know better, also fail to approach this kind of work in the right spirit and with the right tools.

In my experience, there is only one really effective approach to couples counseling, and it has nothing to do with giving advice, teaching so-called "communication skills," or offering verses from the Bible or other religious texts. Now, some couples simply should not be together, and no amount of counseling, no matter how effective, can improve that kind of relationship. which, as I see it, is destined to fall apart. But if a couple has some reasonable foundation for a relationship, the approach that often can bring sanity and happiness to their lives together is based on a kind of depth analysis (that is, consideration of childhood experiences in ones family of origin) of both parties to the relationship.

In other words, the psychotherapist will work with each person in turn to try to discover what "old tapes" are being reenacted in the present day context of the relationship. This has two great benefits. In the first place, it gives the person being analyzed a new perspective on his or her complaints, showing that they really are not the fault of the partner. And, at the same time, the partner, witnessing the old pain of his or her mate, learns to feel much more sympathy and tolerance for the behaviors that before seemed so annoying.

This approach does not always work, but often it does, and only a few hours of therapy should be sufficient to demonstrate that it is working.

A recent article in the New York Times approached this topic in a useful way, and I take the liberty of quoting it below.

Be well.

From The New York Times, April 19, 2005:

Married With Problems? Therapy May Not Help

Each year, hundreds of thousands of couples go into counseling in an effort to save their troubled relationships.

But does marital therapy work? Not nearly as well as it should, researchers say. Two years after ending counseling, studies find, 25 percent of couples are worse off than they were when they started, and after four years, up to 38 percent are divorced.

Many of the counseling strategies used today, like teaching people to listen and communicate better and to behave in more positive ways, can help couples for up to a year, say social scientists who have analyzed the effectiveness of different treatments. But they are insufficient to get couples through the squalls of conflict that inevitably recur in the long term.

At the same time, experts say, many therapists lack the skills to work with couples who are in serious trouble.

Unable to help angry couples get to the root of their conflict and forge a resolution, these therapists do one of two things: they either let the partners take turns talking week after week, with no end to the therapy in sight, or they give up on the couple and, in effect, steer them to divorce.

"Couples therapy can do more harm than good when the therapist doesn't know how to help a couple," said Dr. Susan M. Johnson, professor of psychology at the University of Ottawa and director of the Ottawa Couple and Family Institute.

One couple, in Boonton, N.J., saw two marriage counselors over 13 years.

"One therapist hurt our marriage and actually a caused our separation," said the husband, Jim, who did not want his last name used out of concerns for his privacy.

"She told my wife, 'You don't have to put up with that,' " referring to his battle with alcoholism, he said.

To be sure, many couples credit counseling with strengthening their marriages. And therapists say that they could save more marriages if couples started therapy before their relationships were in critical condition.

"Couples wait an average of six years of being unhappy with their relationship before getting help," said Dr. John Gottman, emeritus professor of psychology at the University of Washington and executive director of the Relationship Research Institute in Seattle. "We help the very distressed couples less than the moderately distressed couples."

In the last few years, efforts to find ways to save more marriages and other long-term relationships have increased.

With an experimental approach called integrative behavioral couples therapy, for example, 67 percent of couples significantly improved their relationships for two years, according to a study reported in November to the Association for the Advancement of Behavior Therapy.

Instead of teaching couples how to avoid or solve arguments, as traditional counseling techniques do, the integrative therapy aims to make arguments less hurtful by helping partners accept their differences. It is based on a recent finding that it is not whether a couple fights but how they fight that can destroy a relationship.

Especially encouraging, all of the couples in the study were at high risk of divorce. "Many had been couples therapy failures," said Dr. Andrew Christensen, a professor of clinical psychology at the University of California, Los Angeles and the lead author of the study.

But some experts who were trained as couples therapists have now become so disillusioned that they question the value of couples therapy in any form. They say that couples are better off taking marriage education courses - practical workshops that teach couples how to get along and that do not ask them to bare their souls or air their problems to a third party.

Two large nationwide marriage education programs, Practical Application of Intimate Relationship Skills and the Prevention and Relationship Enhancement Program, offer such workshops.

"When I was a practicing therapist, I was like a judge listening to each partner tell why the other was ruining the marriage," said Diane Sollee, a former couples therapist who founded Smartmarriages, a clearinghouse of marriage education programs. "There was a lot of crying. Marriage education classes are more empowering."

Developed several decades ago mainly to prevent marital problems in newlyweds or engaged couples, marriage education programs are now attracting couples who have not been helped by couples therapy but who want to try one last thing before deciding to divorce.

How effective these programs are is unclear.

Some studies indicate that couples who take marriage education classes have a lower divorce rate than couples who do not take the classes.

But Dr. Gottman, who uses marriage education workshops and couples therapy, has found that workshops alone are insufficient for 20 percent to 30 percent of couples in his research. These couples have problems - like a history of infidelity or depression - that can be addressed only in therapy, he said.

Couples therapy, also called marriage counseling and marriage therapy, refers to a number of psychotherapy techniques that aim to help couples understand and overcome conflicts in their relationship.

It is conducted by psychologists, psychiatrists and social workers, as well as by marriage and family therapists.

Three types of couples therapy have been found to improve people's satisfaction with their marriage for at least a year after the treatment ends.

The oldest approach, developed more than 20 years ago but still widely used, is behavioral marital therapy, in which partners learn to be nicer to each other, communicate better and improve their conflict-resolution skills.

Another, called insight-oriented marital therapy, combines behavioral therapy with techniques for understanding the power struggles, defense mechanisms and other negative behaviors that cause strife in a relationship.

With each method, about half of couples improve initially, but many of them relapse after a year.

A relatively new approach that studies have found highly effective is called emotionally focused therapy, with 70 to 73 percent of couples reaching recovery - the point where their satisfaction with their relationship is within normal limits - for up to two years, the length of the studies.

Dr. Johnson, who helped develop emotionally focused therapy in the 1990's, said that it enabled couples to identify and break free of the destructive emotional cycles that they fell into.

"A classic one is that one person criticizes, the other withdraws," she said. "The more I push, the more you withdraw. We talk about how both partners are victims of these cycles."

As the partners reveal their feelings during these cycles, they build trust and strengthen their connection to each other, she said.

Surprisingly, Dr. Johnson said, until emotionally focused therapy came along, therapists were so intent on getting couples to make contracts to change their behavior that they did not delve into the emotional underpinnings of a relationship.

"It was like leaving chicken out of chicken soup," she said.

Dr. Johnson's latest research, completed in January, included 24 of the most at-risk couples, people who were unable to reconcile because their trust in each other had been shattered by extramarital affairs and other serious injuries to their relationship.

"These injuries are like a torpedo," she said. "They take a marriage down."

The study found that after 8 to 12 sessions, a majority of the couples had healed their injuries and rebuilt their trust.

Most important, these gains lasted for three years. "It's very satisfying to know that we can make a difference with these couples and that it sticks," Dr. Johnson said.

Alice, a library program coordinator in Honesdale, Pa., credits her couples therapy, which focused on emotional issues, with getting her and her husband to reunite after a yearlong separation.

"The marriage counselor brought us back together," she said.

Alice, who did not want her last name used out of privacy concerns, said an important catalyst for their reunion was the therapist's asking each to think about the ways that the other person wanted to feel appreciated and loved. Gradually, she said, she has come to see that her husband's needs were different from her own.

"Going back to this exercise is one thing that has gotten us through hard times," she said.

Researchers have begun to identify which qualities in a couple make for a lasting relationship. The findings challenge some common assumptions - that couples who fight a lot are beyond help, for example.

Over more than two decades of videotaping and analyzing the behavior of happy and unhappy couples, Dr. Gottman has found that all couples fight and that most fights are never resolved. What is different between happy and unhappy couples is the way they fight.

The happy couples punctuate their arguments with positive interactions, he said, like interjecting humor or smiling in fond recognition of a partner's foibles. The unhappy couples have corrosive arguments, characterized by criticism, defensiveness and other negative words and gestures.

Of course, even the happiest of couples can get nasty sometimes. But Dr. Gottman has found that as long as the ratio of positive to negative interactions remains at least five to one, the relationship is sturdy. When the ratio dips below that, he says, he can predict with 94 percent accuracy that a couple will divorce.

Dr. Gottman says that couples therapists can use this information to help keep couples together. "You can't just teach a couple to avoid conflict," he said. "You have to build friendship and intimacy into the relationship. If you don't, the relationship gets crusty and mean."

But not all marriages are salvageable, therapists say. "Some people are fundamentally mismatched, and they can't benefit from therapy," Dr. Gottman said.

Others - beyond the scope of couples therapy or marriage education programs - are people with personality disorders and relationships marred by violence and intimidation.

"We have nothing to offer them," he said.

Couples therapy is designed to be relatively short term: 26 weeks or less.

"The vast majority of my patients do better after 5 to 10 sessions and are satisfied. The cycle of blaming is interrupted," said Dr. John W. Jacobs, a psychiatrist in New York and author of the 2004 book "All You Need Is Love and Other Lies About Marriage."

Dear Dr Robert,

I am a 21 year old male. Ever since I was a toddler I've suffered from serious anxiety, depression, and sleep disorders, among other things. I would fall out of my bed every night until I was 8, and I wet the bed until I was 11. I was terrified of being alone until I was 10. If I found myself in that situation I would have panic attacks and freak out until I found someone that I knew. I also recently remembered having a recurring nightmare until age 8 where I would be sitting alone in a field on a swing, and a monster-like creature would walk towards me and I would be unable to move from the swing, as much as I wanted to. These days I'm extremely paranoid and anxious, and can't seem to become close with people without hurting them. Putting all of this together, it seems like I might have been abused as a young child. I have no memory of such an event, however. Would it be possible to completely forget abuse and still have it affect me so seriously? Do you have any suggestions on what I should do from here?

Thanks very much for your help.


Thank you for your question. Yes, it is possible that your symptoms are the sequellae (after effects) of child abuse, but those symptoms may have other causes as well. It is true that your symptoms are suggestive of some kind of post-traumatic stress disorder, but the stress may or may not have been abuse of you personally. If you witnessed some kind of violence, particularly directed toward a loved-one, or even if you were exposed to loud and violent sounding arguments between your parents, for example, your young self might have been stressed sufficiently to have become symptomatic in the ways you describe. Witnessing a bloody accident might also produce such post-traumatic stress symptoms, especially if your parents or other care-givers thought it was "wiser" not to discuss it afterwords.

It certainly is possible that you could forget abuse or some other stress and still be suffering the after effects. In fact, the less such events are remembered consciously, the more likely that symptoms such as yours will be produced. One way of looking at this fact is that psyche must find ways of communicating her needs to the conscious personality, and if she cannot do it through remembrance and recollection, then she may resort to symptoms as a way of attracting attention. [I speak of psyche as "she" to honor the Greek myths which are the source of our word "psyche."] This is one reason why self-help approaches to psychological problems, such as the ones advocated by people like "Dr. Phil." are useless or even harmful. As we know from physical medicine, treating symptoms without considering the underlying causes is either useless or worse, since the real problem remains buried and must find other, possibly more severe, ways of expressing itself.

I should mention that certain mental health workers, probably due to childhood issues of their own, seem wrongly predisposed to finding child abuse--particularly child sexual abuse--in any patient who complains of the symptoms you have experienced, and, in a kind of foolish circular reasoning, put forth the lack of remembrance as a kind of proof that the abuse really happened. Over time, this kind of psychologist, who really is guilty of malpractice, may convince a patient who has not been abused that abuse took place and is the cause of the symptoms. Therefore, for someone with symptoms such as yours, it is vitally important to work with only the best possible psychologist or other therapist. If anyone even mentions child abuse in the first session, find a new doctor!

In my experience, one of the best approaches to your kind of situation is treatment by a psychologist trained in Kohutian self-psychology. This is a form of psychoanalysis developed in the 1970s by Heinz Kohut who was a Freudian analyst, but found that Freud's theories were not particularly helpful for your kind of problem. In any case, some kind of depth psychoanalysis, and not simply counseling, would be my recommendation. In other words, I recommend that you do not begin with drug treatment for the symptoms, and I also recommend that you do not consider working with anyone who begins by looking for child abuse. If there has been abuse, it will come out naturally in the course of proper treatment. You might be in touch with a local hospital to ask for a list of psychologists who specialize in self-psychology, or perhaps you can consult the internet for a list of self-psychologists in your area.

Be well.

Dear Dr. Saltzman,

I just read your interesting and informative reply to a question posed to you about depression, and I wonder if you could elucidate me about the case of my mother, who has been going through several depressions--or relapses into the same depression --during the last 5 years or so. I am reasonably acquainted with the problem of depression (though I am not a psychologist nor a psychiatrist), but my mother's case seems to have its peculiarities.

She is 66 and has divorced my father almost 6 years ago; she didn't like him nor the life he gave her, and according to her and to most people around her this was the best she could have done. She lives alone in Portugal, has her own house and a reasonable pension for Portuguese standards. She has a son (that's me) and two daughters; I live in The Netherlands, talk to her on the phone once or twice a week, visit her at least once a year in Portugal, and she comes to stay with my wife and I for two or three weeks every year; my sisters live about an hour away from her and have busy lives but have always kept contact with her, visiting her regularly (once a week at least in the case of my elder sister, about once a month in the case of my other sister), inviting her out occasionally, etc.

We love her very much and have supported her in many ways--emotionally as well as financially--but have also been somewhat tough with her in some respects. This is especially true of my two sisters, who are becoming increasingly fed up with her because of her general "attitude" (which I will describe below); during the last month their relationship with my mother has become particularly strained, and my elder sister has even threatened to sever relations (she hasn't called my mother for two weeks and has made clear that she doesn't want to see her nor hear from her in the near future); the other one, however, in spite of an increased harshness in her dealings with her, has actually visited my mother more often - at least every weekend -, took her to the doctor, cooked and shopped for her.

My mother has had breast cancer about 8 years ago (no mastectomy, only partial removal of tissues) and recovered well. Her sight is quite poor, but until very recently she could watch TV, go to the cinema, and even read with a special projecting apparatus my elder sister bought her. I should perhaps add at this point that my mother is reasonably well educated, likes to read, and has lucidly (as I could judge from our conversations on the phone) read several books during last Summer, for example.

Her mother died four months ago; although this was not exactly unexpected, for my mother it was yet another blow, and I think she feels remorse for not having visited and phoned my grandmother (who was in an elderly home) as often as she was supposed to. In recent years she has had a more or less active relationship with a married man, a childhood friend who I think was one of the few persons with whom she socialized, going out for dinner, etc. Recently, however, their relationship has been strained, probably due to my mother's illness, and I think they do not see each other very much (though they still keep contact).

My mother has a sensitive and somewhat whimsical and fussy character (with respect to people, food, household rituals of cleaning, eating, etc.), suffers from what I would call a spiritual addiction to medicines, vitamins, food supplements, teas and all sorts of potions which promise a happy and healthy life(almost running her own pharmacy and medicating herself), and is rather indolent and cowardly when it comes to facing up problems (since my sisters and I can remember, she has always tended to deal with problems by hiding from them or else by turning to others for help, which explains the long, unhappy marriage she endured before finally - spurred and helped by us - divorcing my father); but she has good qualities as well, which - however blurred they seem to us from the perspective of the recent events - my sisters and I still acknowledge and appreciate.

My mother has been on and off antidepressants for the last 5 years or so. She has been to several doctors (psychiatrists and neurologists), and has taken a variety of medicines, none of which had any lasting effect, and very few of which had any positive effect (Prozac, I think, was one of the best, but only up to some point). On the basis of a purported knowledge of antidepressants, she has several times decided to discontinue, or simply never actually started taking, some of the medication prescribed by some of the doctors. She is, however, aware of the danger of abruptly stopping the medication, and in fact seems to dread it.

Now to the symptoms: She complains constantly about her life, her health, her financial situation, etc., and she drains everyone's energy while doing so. She exaggerates to the extent of turning her existence into an absurdly hopeless and painful predicament. She is self-centered, showing no empathy towards other people nor interest in anything else besides her misery; in particular, she is far from being gleeful with the fact that she is going to be a grandmother soon - my elder sister is pregnant and the birth is due in April, but on the other hand she is constantly worried about going to the hairdresser, about the way she looks, etc. She is insecure and afraid of going out, she says, and in the last two months or so she practically stopped going out and has her shopping made by a maidservant who comes once a week. When I last saw her I noticed she had a general lack of interest, less appetite than usual, and lack of concentration, but on the other hand that she still couldn’t help meddling with what was going on in the kitchen, with the way we cooked, washed, etc. I should add that she seems quite lucid to me, that she can memorize things (e.g. the date of the elections in Portugal), and that she acknowledges her mental condition - it seems to me that her brain is simply tired and/or functioning at a lower rate.

We think she takes pleasure in worrying us, and that she uses all sorts of stratagems to get our and other people's attention, which is why we have been recently very hard on her. She says she doesn't eat because she lacks appetite or because she has no food at home; but the fact is that she has several people (the maid, my younger sister and my uncle) at her beck and call who have bought her food - and can buy her food whenever she needs it. She often says she would like to die, and the other day she told me she tried to open her wrists but didn't succeed because she has "no more blood in her veins" (a nonsensical expression I don't know to interpret - as the onset of madness or another token of childish, attention-seeking behavior). These are examples of what we would call a form of, or attempt at, 'manipulation'. In a word, she seems willfully intent on putting herself in a helpless, unsustainable situation.

She has recently got into the habit of calling an ambulance and going to the hospital where she is seen by doctors, invariably prescribed new medication, and then sent home. I spent two hours on the phone with her last week, trying to encourage her and to find out what her symptoms were; she said she felt she was going mad, expressed again her usual preoccupations, but this time talked very little and seemed desperately in need of having someone around to talk to and listen to, which I found quite unusual (she is not really the kind of person who likes to hang on the phone for hours). Last Saturday she called an ambulance and went to the hospital once more, and this time she was admitted (not to psychiatry though). Yesterday I talked to one of the doctors on the phone who told me she is lucid but a "bit confused", and that it is too early for diagnostics. I am aware that my mother may be suffering from a severe form of depression. However, my sisters and I cannot help thinking that her problem may lie more in her character than in any illness proper, and consequently blame and accuse her of being a selfish and mean - and indeed rather monstrous, if depression were really excluded - human being. In all the descriptions of depression I have read, I have never counted this form of 'meanness' and 'selfishness' among the symptoms, so I wonder if you could say something about it. Another thing I ask myself (the doctors we have talked to were very evasive on this point) is whether a treatment with antidepressants is really something desirable in her case, since such medication seems to do more harm than good to her. I really think that antidepressants can actually make things worse in certain cases because they essentially work by diminishing mental activity (or at least some part of it), while mental activity is sometimes crucial for the maintenance of an active and reasonably exciting life.

I would be most grateful if you could provide us with any information, and if possible give us some advice on how to act.



dr-robert: Thank you for writing. Your question is complex, but seems to simplify itself into two different basic questions: first, what is going on with your mother? And second, what are the ethics of dealing with a mean-acting older person, particularly a parent, when one is not certain whether the mean actions are part of a mental illness or simply selfishness and lack of concern for others.

I will try to help with both questions, but first, I would like to correct one misapprehension which you expressed in your letter. You wrote that, "antidepressants can actually make things worse in certain cases because they essentially work by diminishing mental activity." Although the exact reason that antidepressants like Prozac work is still not known, it is certainly not by diminishing mental activity. If anything, Prozac and other SSRIs (selective serotonin reuptake inhibitors) stimulate mental activity since they allow the neurotransmitter serotonin to remain longer in the synapses (the junction points) between nerve fibers in the brain, which tends to allow more information to travel along the neural pathways. The SSRI class of antidepressant medications have side-effects which can be unwelcome, but diminishing mental activity is not one of them so far as I know.

Now, naturally, without personally interviewing your mother, I cannot properly diagnose her condition, so all that follows is based only on what you have written, and may or may not correctly apply to your mother. That said, and, again, based on what you say, she seems to be suffering from at least a moderately severe depression, possibly a very severe one, which has persisted over time. This kind of depression certainly requires treatment, and it does not seem that your mother has received adequate treatment. This kind of case usually is best treated with a combination of antidepressant medication properly prescribed and managed as to dosage, side effects, and beneficial effects, along with at least weekly counseling. If your mother cannot afford private psychotherapy, I wonder if there are local resources that can provide it at low or no cost. In any case, she should be in the hands of a competent counselor of some kind, be it social worker trained in psychology, a psychologist, or a psychiatrist.

As for your mother’s strange behaviors and words, such as, for example, the suicide attempt and her subsequent explanation that it failed due to a lack of blood in her veins: some kinds of depression can be accompanied by mental confusion or even thought processes disordered to the point of psychosis. At a distance, I cannot make that determination, but it is possible that she has difficulty with what sometimes is called "reality testing." Her statement that she felt that she was going mad needs to be taken seriously and investigated carefully, particularly when suicide is a possibility. Often suicide occurs when someone feels madness approaching and cannot stand the idea of "losing it," or when some voice in the madness suggests suicide as a solution to the disordered thinking. These features of her situation also need the attention of a competent psychotherapist who will understand what kind of treatment is required.

So far as I know, "meanness and selfishness" are not normally considered features of depression, but rather--when they are pronounced—may be considered features of certain character disorders, as, for example, narcissistic personality disorder. If your mother was also mean and selfish earlier in life as she is now, she may be suffering from a personality disorder in addition to depression. Or, she may be under such strain from the depression that she has become totally self-involved and impatient in ways which were not present in her earlier days. Once again, a diagnosis from a distance is not feasible. But this kind of behavior calls for a competent professional opinion as to options for treatment.

Now, as to the ethical question: If I read and understood your letter correctly, you seem to be feeling that if your mother's hurtful behaviors towards you and your sisters really are symptoms of mental illness, you would be prepared and able to suffer them, and to forgive them, but that if those behaviors are simply character flaws, then you and your sisters would feel justified in your reproaching of her. In a certain way this makes sense. As I understand what you are saying, if she is really ill, and if the meanness and selfishness are symptoms of the illness, you will treat her as a person who is not responsible for her symptoms, and will try support her as best you can, but if she is simply a selfish, ill-mannered shrew, then you will confront her with her behaviors. The problem is that there really is no bright line between these two categories, that is, one category (ill) seems to run into the other (nasty) with no clear way to tease them apart.

How much to put up with from your mother is the kind of question which cannot be answered by advice from an expert. The best I can do is to suggest that you open your heart to the fullest extent possible, and try to give your mother whatever you can without compromising your own feelings of integrity and self-worth. Sometimes in cases such as this it is helpful to see the task of withstanding bad behavior and insults as a kind of spiritual practice in which, remembering and understanding that the behaviors and remarks cannot really apply to you (since if your mother saw who you really are, she would treat you with more respect), you withhold criticism and simply let the troublesome actions roll off your back as water rolls off a duck's back. This may seem difficult at first, but may become easier as one feels less enmeshed emotionally with the person in question.

A propos: you might consider some short-term counseling for yourself just on this theme of possible excessive emotional enmeshment (which is not love, but prolonged, unresolved attachment) with your mother.

I hope this will help to clarify your situation.

Be well.

Dear Dr. Robert--

I read and followed your advice on dietary changes for physical, mental, and emotional steadiness. I began this change ten weeks ago, and recently I have noticed that I feel very much better than I did when I was eating in the old way. To put it in simplest terms, I am just happier, and I feel physically and emotionally lighter just as you said. Also, my thoughts are not so often depressive as they were before. So thank you for publishing this good advice.

Now I have another question. I noticed on your homepage that your site is dedicated, among other things, to "spiritual unfoldment." I would be very interested in learning more about that. Would you please explain what you mean by spiritual unfoldment, and please give some suggestions for spiritual unfoldment as you did for physical, mental, and emotional steadiness.

---T.H.G., Lahti, Finland

dr-robert: Thank you for your letter. What I mean by "spiritual unfoldment" is the possibility in the human being of finding a center which is more than just "myself," a center which seems to embody a level of wisdom, empathy, creativity, humor, and joy which is missing in the ordinary, everyday personality, a center, that is, which is not the outcome of thoughts, attitudes, and ideas, but which seems to exist prior to thought. Once this center is somehow intuited by the ordinary self, "unfoldment" refers to the ever-expanding experience of finding meaning and value in living more from that greater center and less from the demands of the everyday personality as it expresses itself in thoughts, fears, and desires. To put this in somewhat grander terms, that which is finite, time-bound, and subject to death, becomes aware in some way of the underlying ground of being which feels infinite, timeless, and everlasting.

I say that this center must be intuited by the ordinary self because intuition is a human faculty which functions beyond the region of conscious thought, and so may provide a kind of bridge between thought and the underlying ground of being. I like to use the word "unfoldment," because it suggests that this process involves the unfurling or unwinding of something that is already present but needs to be opened up in order that it may function to the fullest within the individual life of each person. If you have ever seen the leaf of a large fern uncoiling, this may provide a good visual metaphor.

Unfortunately, general advice on nutrition is easier to offer, and much easier to convey in words than is advice on fostering spiritual unfoldment. This is because advice on what kind of foods are most useful for maintaining a healthy body can be based on scientific research, and so can be factually demonstrated, while spirituality or spiritual unfoldment cannot even be examined factually, much less proven scientifically.

For example, we now know that substances in the cocoa bean provide a powerful antioxidant action which slows the oxidation and breakdown of HDL cholesterols, causing them to remain longer in the bloodstream. This is a fact which can be shown by means of exact measurement. Since HDL cholesterols are beneficial to the circulatory system, adding cocoa to the diet should benefit total bodily health, and recent studies demonstrate that this is true. Therefore, I would feel confident in suggesting that one might consider adding a tablespoon or so of unsweetened cocoa powder to the daily diet (I would stir this into yoghurt or add it to a fruit drink perhaps). And unless one is allergic to cocoa, this practice ought to be a good one for anyone.

But even assuming that one accepts that spiritual unfoldment is possible, that trying to encourage spirituality is desirable, and that advice on how to promote spiritual development can be conveyed at least to some extent in words, without knowing where you are in your own understanding and without hearing about your own specific attitudes towards the meaning that may be found in the human experience of living and dying, it is difficult for me to suggest what you might do next to "unfold" spiritually. This difficulty in generalizing about inner life is one of the chief reasons why individual, personalized psychotherapy is so valuable. In private, and in an atmosphere of safety, acceptance, trust, and understanding, these subtleties may be entertained so that their finer nuances become apparent without the necessity of resorting only to words on a page, or to a one-sided talk to a general audience.

Numerous gurus, guides, and spiritual teachers, to say nothing about the gang of self-help authors eager to sell books, offer advice on this matter, but many of the people who come to me for therapy have not found such advice to be particularly helpful. In fact, many have found such advice to be demeaning, misleading, or confusing, and have come to psychotherapy partly in order to try to sort out the confusion or heal the damage. This happens, I believe, because the advice of such gurus and spiritual teachers almost always refers either to some traditional religious practices which are to be followed more or less blindly regardless of individual temperament or individual need, or else refers to what that particular teacher believes has been helpful in his or her own approach to spirituality. But my experience tells me that each person must find his or her own way to "unfold," and that following a doctrinal religious system or the generalized advice of a guru is not likely to do the job for most people. As the brilliant sage, J. Krishnamurti put this, "Truth is a pathless land."

In my advice on dietary changes which you have been practicing, I said , "Everybody is different, and every body is different, so without a private consultation, I cannot give you person-specific advice . . . but I will offer some general principles that can help almost anyone." I will try to do the same here as regards your question about spiritual unfoldment, but only with the understanding that, unlike my generalized nutritional advice this advice about how to approach spirituality will certainly not apply to everyone, and that without knowing you personally I am able to speak only in the most general way. In fact, my suggestions, being generalized, may not be the best thing for you (indeed, this is the point I have just made about the methods imparted, usually in an authoritative tone, by so many gurus, guides, self-help authors, and spiritual teachers), so please take what follows merely as suggestions to be tried out in the spirit of experiment, certainly not as gospel.

That said, one way which may help to create a basis for further spiritual unfoldment involves working with two practices at once. The first requires an ongoing, honest, non-judgmental observation of one's own life, behaviors, and personality patterns with a view towards feeling and noticing barriers to further psychological and emotional development (not, by the way, trying to remove the barriers, just feeling and noticing them). The second practice is to ask oneself as often as possible this one simple question: "Who am I?" In other words, I am recommending that you might like to try two practices which seem to be useful and helpful for many people: self-observation, and self-investigation.

By "self-observation" I mean watching oneself as if one were watching a friend for whom one feels a certain affection, but whom one also is able to see with a certain detachment and objectivity. For example: suppose that someone makes a remark that I find insulting, and I begin to feel angry. If I am practicing self-observation, instead of focusing my attention on the insulting remark and upon the motives of the person who made it, I will instead simply watch my anger as if observing a phenomenon which I want to understand better. In other words, it is not the insult that I wish to focus upon, nor do I wish to prove to myself that the insult does not apply to me, nor do I want to focus upon the personality and possible character flaws of the person who made the remark, but rather I want to watch my own habitual process of dealing with perceived insults by becoming engaged in anger and self-justification. This is why this practice is called self-observation. And I will apply this same attitude of non-judgmental self-observation to all of my behaviors, thoughts, and emotional states whenever possible. You might begin with this, for example: when speaking, notice your own tone of voice. Just notice it, without judging. Try this for an entire day, and see what happens.

By "self-investigation" I mean discarding the conventional and normal ideas that "myself" is my body, my name, my personal history, my membership in a family, my profession, my nationality, or whatever, and approaching the question afresh. Simply ask, "Who am I?" And do not accept any answers. Just keep asking.

Perhaps these two procedures seem simple-minded, and, from a certain point of view, I suppose they are, but like my nutritional advice, you can try them for a while, and see if you like the results.

Be well.

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Dear Dr. Robert,

I am presently seeing a psychotherapist here in Los Angeles. I began seeing her in April of this year; when my insurance ran out, in July, I began seeing her less frequently, once every 3-4 weeks.

I had been in a relationship that ended about 12-18 months ago. He had a lot of anger issues and was extremely inflexible. Nonetheless, I loved him very much and was very hurt when he left. We stopped seeing each other in January for about 6 months, during which time he was seeing someone else. We reconnected this past summer after that relationship ended, trying to be friends, but I found myself having feelings for him again. One day he calls and says he needs therapy. Without thinking, I recommended my therapist, and left her a message that he’Äôd be calling. I wasn’Äôt even sure if he'd call her. He said he had other referrals.

Well, he took to therapy so well he was seeing both my therapist AND another therapist in August and September. When I next saw my therapist, I found it very awkward, because I was conflicted about my relationship with him, and it was difficult to talk with her about it, knowing she was seeing him. She said she was sorry, she usually would call and make sure the current client was aware of the possible pitfalls of the referral, but didn't this time for various reasons. She said as her first client, I was her priority. I'm not sure if she said she’Äôd terminate him if I asked, but that was the take-home message I got, and that reassured me.

I soon realized that my ex-boyfriend was primarily in therapy in order to get back into the good graces of the woman he had been seeing (eventually it worked.) I began to realize that sharing a therapist was really was becoming an issue for me. When I would talk to her about him, I found myself reading into what she was saying ’Äî was she trying to steer me this way or that because she had information I didn’Äôt? When he behaves as if he thinks I still have romantic feelings for him, is that insight, ego or is it possible she's planting that idea because of things I tell her in confidence? If she suggests I shouldn't see him, and then he stops calling, I wonder, is she suggesting this to him as well? i.e., is she becoming a player in our relationship, unwittingly or otherwise? Even if her behavior is impeccable, it creates an environment where I find it difficult to trust. The whole thing seems a minefield that makes the therapeutic environment feel unsafe. In order for therapy to be effective, you have to believe that the therapist is your trusted ally in all things; I don’Äôt know who’Äôs "side" she's on anymore. Is it humanly possible to be neutral? I’Äôm only seeing her once every 2-4 weeks now. He sees her every week and pays more. Is she more willing to lose me as a client because I pay less?

First I suggested to him that he discontinue with my therapist and just see the other therapist; instead he did the reverse. He feels like this is my problem, not his, and I need to work it out myself. I then brought it up with my therapist; but she feels that no ethical boundaries have been breached, that there is no conflict of interest and that this is simply an opportunity for me to deal with the feelings that this "pushes up" for me. I find it bothers me so that I don’Äôt address other issues I'd like to be working on. I don't want to continue paying to appeal to her to see my point on this. I feel like the man who has caused me so much pain in recent years has now invaded my one sanctity where I go to try to process that.

I'm wondering what you think is appropriate professional behavior in a situation like this. Is it perfectly okay for her to be counseling my ex-boyfriend on how to make the relationship with this woman (that he left me for) work? I can’Äôt think of any solution other than for her to tell him she's very sorry, she made a mistake, it's become a problem and she’Äôs unable to continue but is happy to refer him to someone else. She appears to feel this is unnecessary and is not offering up any other solution. I need some objective feedback on what is appropriate in such a situation? I used to think she was a great therapist, a godsend. Now I am at the point where I feel like I may look for someone else because neither of them are willing to make an adjustment; and frankly, I resent I should be the one who suffers for a mistaken gesture of generosity.

Your professional opinion appreciated. Thanking you in advance,


dr-robert: The subject line of your email was "A question about professional ethics," but your question does not seem to be so concerned with the ethics of your therapist as with the pain you are feeling about your previous boyfriend having left you for another woman. Or, to look at this another way, I wonder if you would be questioning the ethics of your therapist if, after a period of therapy with her, your boyfriend had decided that you really were the woman for him and had told you that he wanted to get back with you. In that case, I imagine you would have been grateful to your therapist for being your "ally in all things," as you put it, and for having gotten for you what you really desired.

This is not to say that your therapist has behaved properly. At a distance, and without much more information, I really cannot make such a determination. Providing therapy for both members of a couple who have been romantically involved previously is not inherently unethical, but may be unwise, depending on the emotional maturity of the people involved, including the therapist. This kind of work, which, due to a scarcity of competent colleagues in this area of Mexico, I often find myself doing, usually involves many sticky complications. For example, regardless of age or sex, one's therapist often takes on the flavor of a parental figure with whom one still has unresolved emotional issues. This is a normal part of psychotherapy which arises eventually in almost any therapy conducted over time. But if you are "sharing" your therapist with a previous lover, you may begin to feel a kind of sibling rivalry for the parental affections of the therapist. If the therapist is not wise enough to handle this extra baggage, you may start to feel rejected by him or her, to feel, that is, as if you are coming out second best in the rivalry for the parent's affections. If this happens, your feelings for the previous lover, which ideally should be tapering off through a kind of mourning process supported by the psychotherapy, may instead be constantly reinforced and energized by older emotional material having to do with childhood competition.

If your therapist really did tell you that "as her first client, I was her priority," that was a mistake. Such a statement simply sets the stage for the kind of rivalry I have just mentioned, and if true, suggests that the therapist may be confused about her own motivations. A therapist who is determined to work effectively and ethically can afford only one priority: the physical, mental, and emotional healing of the person sitting in the office at this very moment. It does not matter who was first to find this therapist, or how. It does not matter (should not matter, that is) who pays more or less. It does not matter (should not, that is) who is more or less attractive or simpatico to the therapist. The moment she accepted your ex as a client he was (or should have been) on a equal footing with you or any other client. Instead of telling you that, "this is simply an opportunity for me to deal with the feelings that this 'pushes up' for me," it might have been more helpful for your therapist to discuss with you your idea that "the therapist is your trusted ally in all things." This is not correct. It is a bit confusing to write about this due to the many possible meanings of the word "I," or in this case, "your ally," but I will try.

The "you" that wants an "ally in all things" is what I would call the ego-self. In this case, the ego-self seems to have wanted the therapist to be an ally, or more accurately a co-conspirator, in regaining the affections of the ex-boyfriend. But conspiring with a client to help her get what she (the ego-she) wants is not the proper role of the therapist. Whether a boyfriend is regained or lost forever is not particularly important therapeutically, although I do understand, and sympathize that for you it feels very important. In my view, the point of therapy is not for the client to achieve some particular desire in the material world, but rather to become more aware of the deeper levels of his or her own being--the part of one's experience that is more than the ego-self, that is, the being, I might say, which was here before you ever heard the word "boyfriend." Through awareness of this self which is prior to the ego-self, and within the field of which the ego-self arises, various obstacles to physical, mental and emotional healing are removed, so that such healing can take place naturally and organically, leaving one more prepared to take life as it comes--to surf the waves of experience, one might say, instead of drowning in them.

In my view, it is the destiny of the human being to become self-sufficient and to realize a sense of being which is deeper than the ego-self and its desires. The best therapy, as I see it, aims not at helping the client to gain what he or she desires materially or socially, but rather at helping to remove impediments to understanding so that the focus of one's efforts can change from getting what I want, to being who I am. From this perspective, it is not the job of the therapist to be the ally of the ego-self, but rather a kind of coach or friend to the deeper self, helping to remove obstacles, encouraging perseverance, and dignifying the inevitable struggle to find meaning in life.

Before closing, I will address three of your immediate questions:

1. "Is it humanly possible to be neutral?"

Yes, but your therapist may not have achieved such a state. If you feel that she favors your ex, there are two possibilities. First, she may really be neutral, but you want more than neutrality. Perhaps what you really want is, as you wrote, "an ally in all things." Second, she may not be up to this kind of situation. It might be helpful to discuss this in your next session, not from the point of view of your feelings, but rather by asking her to come clean about hers.

2. "Frankly, I resent I should be the one who suffers for a mistaken gesture of generosity."

Resentment is absolutely poisonous to your own physical, mental, and emotional well-being. Harboring resentment is like eating rat poison: first it will make you sick, and, if you keep it up, it will kill you. Whatever you have to do, please eliminate resentment. Make it your first and most important goal. Hint: gratitude dissolves resentment.

You may hate to hear this, but judging from your letter, I do not view your having shared your therapist as a gesture of generosity, but rather as an understandable and subtle form of manipulation based on the hope, perhaps unconscious or unacknowledged, that your therapist who was supposed to be your ally, would help you get your ex back.

3. "I can't think of any solution other than for her to tell him she's very sorry, she made a mistake, it's become a problem and she's unable to continue but is happy to refer him to someone else."

There is another solution. You find another therapist, and get a complete fresh start based on where you are right now. I understand that you might feel that you would be losing all the work and background material that you have established with your present therapist, but in my experience, that is not what would happen. If you find a competent therapist (and, sadly, there are many who do not qualify), I think you will find that your therapy, instead of being set back, might jump immediately to a better level.

Be well.

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ask dr-robert

questioner: I'm 25 years old, and my fiancee is 23. We live in Beirut (Lebanon), but I lived in the U.S. for couple of years. Beirut is struggling between two very different cultures... a very conservative one, and a very western one that is influenced by France. There is almost no censorship in Lebanon... You can turn on the tv at 10 at night, and there you see an x-rated movie... the American rap music is uncut, and you can hear them swearing on the radio... All of the magazines that we get from France, like "Prestige" which is a fashion-female magazine are filled with couples having sex, and naked men and women. I'm a very shy person, and I've never had sex before... It's probably cause I think my penis is too small. Well, nobody can convince me otherwise, because it is.

My fiancee is a virgin, and she said that she hasn't seen any penises in her life, but I know that's not true because I caught her lying a couple of times. I think she lies to me because she knows how sensitive this subject is to me.

Anyway, I'm very insecure about the size of my penis, and I'm acting crazy to prevent her from seeing any naked men cause I don't want her to compare my penis to other penises. Well, if the government doesn't do the censorship shouldn't I? I mean if she compares my penis to every other penis that she sees, she'll know that I'm smaller than any of them, and she's going to think of me less of a man. I know this sounds crazy, and I am acting like crazy, but I just can't stop doing it... please help me fast.

---[name withheld, Beirurt, Lebanon]

dr-robert: This is a question that comes up often in psychotherapy. Since for many men, particularly younger ones, the size of the penis is equated with masculinity, if a man believes that his penis is small, he may feel that he is less "manly" than someone with a larger penis. Also, he may feel that sexual partners will be dissatisfied with him as a lover, and that they may be inclined to desire sex with a man whose penis is larger.

Some counselors and therapists try to treat these feelings of inferiority by arguing and attempting to convince their clients that size does not matter, and indeed, an important study by Masters and Johnson (1966) did indicate that sexual satisfaction both for the man and for the woman [this was a study only of heterosexuals] did not depend at all on the size of the man‰'s penis. But I think that argument is not particularly helpful to a man who doubts that his penis is large enough, whatever that may mean to him.

The argument that size does not matter is not helpful to such a man, in my view, because it is not true. To begin with, on a purely physical level--a mechanical level one might say--as long as the penis is not too large (so large, that is, as to cause discomfort to the woman) a larger penis will stimulate more of the woman‰'s vaginal erogenous zones, and so will tend to produce a greater level of arousal. But this is just a matter of friction, and good sex involves much more than friction, of course. On a more mental level, there is in human beings a tendency to appreciate things for their size alone--not just the penis, but almost anything--and so, just as there are men who imagine that women with large breasts are somehow "sexier" than women with smaller breasts, there are women who simply enjoy fantasizing about, looking at, or touching larger penises, and believe that a larger penis makes a man more attractive. These are facts, and there is no advantage in disputing them.

Now, since you believe that your penis is too small, and since believing this has caused you, as you wrote, to behave in a "crazy" way, I believe that a more helpful approach would address your feelings in particular, and not simply deal in generalities about whether or not size matters. I will attempt to do this, but I do want to say first that a written answer cannot provide the counseling or psychotherapy you need. Based on your letter, I believe that you will require professional therapy to heal this tremendous and irrational wound to your self-esteem, and I urge you to seek that kind of therapy as soon as possible, certainly before marrying your fiancee, which you should do, in my view, only when you are feeling happy about the relationship and secure in it. I imagine psychotherapy of this kind is available in Beirut. For your sake, I hope that it is.

To begin with, I wonder how you came to believe that your penis is not large enough. There is, of course, a great variation in penis size, just as there are great variations in most physical dimensions of human beings, but the situation with the penis is confusing, and different from the situation with other bodily dimensions, and I want to explain why. The average length of the flaccid (that is, non-erect) penis has been found to be around three inches (7.5 cm.) or perhaps a little more. Some penises are much larger, and some much smaller, but a curious fact about the penis is this: penises which are smaller when flaccid, increase much more in size when erect than do larger penises, which tend to increase less in size when they become erect. In other words, penises which are larger when soft, usually do not increase much in size when erect, but penises which are smaller when soft, can increase greatly when erect. This is why the vast majority of penises, when erect, measure around six inches (15 cm.), more or less, in length, even though when flaccid there is a substantial variation in size.

Now, for a man who is worried about the size of his penis, this unusual fact is important to understand, because many men, particularly heterosexual men, have had little experience in seeing other men with their penises in an erect state. Normally, one sees others' penises in the locker room or shower room, or perhaps standing at the urinal, times at which those organs are in the flaccid state in which any variation in size is much more pronounced. Other factors come in to play here too. A smaller man¬â¬€ˆ†s penis will seem larger than the same size organ would on a larger man. And the penis of a man with a flat belly will seem larger than that of a man with more fat around the middle. The point is this: if a man has observed other men¬â¬€ˆ†s penises mostly in the flaccid state, he really does not have as much basis for comparison as you might imagine. A man¬â's penis may appear smaller than many when flaccid, but might "catch up," at least part of the way, when aroused.

In your case, although you may have not seen them "in the flesh," you have looked at many erect penises through having viewed pornography, possibly more of it than was really good for you. But for various reasons looking at pornography does not provide a good basis for comparing your penis size to the normal or average size. To begin with, the producers of this stuff have an almost unlimited population from which to select men whose penises are unusually large (just as they can select women with unusually large breasts if desired). They can select also for the kind of lean, flat-bellied physique which emphasizes the penis. And then they can use all kinds of tricks of the trade such as trimming the pubic hair to make the penis appear more prominent, or selecting certain camera angles or certain lenses to exaggerate the size of the man¬â¬€ˆ†s organ. In other words, if you are comparing your penis to the ones you are seeing in pictures, you are treating yourself and your penis unfairly.

As I say, the average size of the erect penis is around six inches (15 cm.). If your penis, when erect, is anywhere near that size--over four inches long (10 cm.) let¬â's say--you are well within the average range. Perhaps, like many men, you wish your penis were larger, and imagine you would have more self-confidence if it were, but please remember that almost everyone wishes for personal assets of some kind or another which he or she imagines are lacking: better looks, stronger muscles, more athletic talent, a higher IQ, larger breasts, and on and on. Yes, in a certain sense a large penis may be a social asset of a kind, but so is a warm and winning smile, or a way with words. At some point, all of us must learn to accept ourselves as we are, including one's body, one¬â¬€ˆ†s thoughts, one's fears, one's desires--all of it.

Of course, this is easier said than done, and that is one of the main reasons why good professional counseling or psychotherapy can be so helpful. One of the results I find in almost all the counseling and therapy work I do is that my clients improve, sometimes dramatically, in their ability to accept themselves as they are, and in their ability to enjoy being themselves regardless of whatever limitations they may believe they have. Once again, I feel quite certain that you would benefit from this kind of psychotherapy, and I urge you to seek it.

Now, suppose the size of your penis when erect really is much less than normal--in other words, that you are correct in saying that you have a very small penis--then what? Once again, truth is best, so I will not make that tired old argument that size does not matter. If your penis really is very small, the plain fact is that you probably will not be any woman's ideal sex fantasy. Not every man can be James Bond after all. But that does not mean that you cannot be a fine and effective lover who can satisfy a woman, father children if you like, and have a happy marriage. This is where the Masters and Johnson study which I mentioned earlier comes in. Although there really are some woman for whom a large penis is very important, they are in the minority. For most woman I have known, both personally and professionally, penis size is way down the list of what makes a man attractive. Personal qualities such as intelligence, kindness, understanding, sense of humor, ability to enjoy life, ability to love and be loved in return, capability to earn a living and to be independent, willingness to take responsibility for the welfare of another person or a family, and many other personal qualities, usually rate much higher on the list than penis size. Skill and tenderness in lovemaking also will rank much higher on most women‰'s lists than penis size, and this skill depends on being able to care about and to tune into a woman‰'s feelings, on being able to use your body--all of it, not just your penis--in order to give her pleasure, and on being able to delay your orgasm until she really is pleased. If you can learn to do these things, she is likely to be happy in bed, and so are you.

Since the size of your penis cannot change (unless you believe all those spam e-mails which promise a bigger organ if you will send money), the most positive thing to do, as I see it, would be to work on those other areas instead. If you develop some of those qualities which women find so important, it is quite likely that you will find a woman who will want to love you and your penis.

Now this woman may or may not be your fiancee, and that is why I agree with you that attempting to keep her from seeing other men in the nude is "crazy," as you put it. You know, I think that I really do understand some of your feelings about this matter, and they aren¬â¬€ˆ†t "crazy" at all. No one likes to be compared and found wanting. We all want to feel good about our bodies, and many men wish for a larger penis, just as many women wish for larger breasts or a better figure. The "crazy" part--and that¬â's your word, not one I usually use--lies in imagining that you can have a happy marriage while constantly fearing that your fiancee may see a man naked, and so finally learn that some men have larger penises than yours. I am concerned also that your doubts about your fiancee's honesty might grow and become unmanageable if you do not address this situation before committing to marriage.

A much wiser course of action, in my opinion, would be this: sometime soon when you are alone with your fiancee and feeling intimate, you might say to her, "You know, I have always felt that my penis is not large enough. It really bothers me, because I know that some men have penises which are bigger than mine." You would say this in the spirit of trying to open up a conversation on this topic. If you can handle this, I imagine that it might help both of you a lot. If you feel that you cannot handle this level of honesty and self-disclosure, some good professional counseling or psychotherapy will help to prepare you for it. Again, I hope this kind of therapy will be available in Beirut. I want to recommend also that before going any further with marriage plans, you and your fiancee get some premarital counseling with a competent couples counselor. This work should include a discussion about sexual needs and sexual desires, both yours and hers. I hope you will understand that these cards must be on the table if you want the best chance at marital happiness.

Be well.

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questioner: Thank you for putting the letter from Liza and your answer on your website. That was an upsetting time for me, since the same person who did that to her tried it out on me too, and I was tempted because I wanted to advance spiritually, but fortunately did not act on it. I also was sexually abused as a child and have been feeling guilty for years about not forgiving [my abuser], so reading what you said about not forcing forgiveness was very welcome. I saw the truth in it right away.

I was sorry that your last talk was canceled, because I really wanted to hear about the two types of meditation which you said you would take up in the final talk.

I've asked other yoga teachers about the two types of meditation, but no one seems to know what that is about. Could you say more about it please.

---[name withheld by request]

[The writer is referring to a series of talks on the psychology of yoga and meditation given at a workshop for hatha (physical) yoga teachers. The last talk was canceled when the workshop ended early.]

dr-robert: Yes. In this space I cannot cover the entire content of the fourth talk, but I will say something about the two kinds of meditation. First, it is important to distinguish between meditation practice and a meditative state. Meditation practice is a directed, intentional activity with rules, procedures, and methods, while meditative states are naturally occurring mental-physical-emotional rhythms which arise spontaneously and disappear spontaneously like the wind in the trees. A meditative state may arise while one is "meditating" (the practice), but such a state may arise at any time at all, and really is not connected to "meditation" (practice). Conversely, one may practice meditation exercises for a long time without such an authentic meditative state ever arising.

Meditative states can be noticed subjectively as a change in point of view, and also may be measured objectively as changas changes in brain waves and in brain chemistry as well as other physical changes. In other words, they are very real states, which are felt inwardly, and also can be verified scientifically.

These naturally occurring meditative states seem often to be associated with a kind of relaxed and open awareness which is both wider-seeing than normal, and also nonjudgmental. This kind of state has been described as choiceless awareness, in which it is felt that things simply are as they are and cannot be any different. In other words, the usual attitude that one manages life by choosing between one thing and another disappears, and everything is seen as already perfect (not necessarily perfect in the sense of "good," but rather as inevitable and connected to everything else). For many such moments are experienced as highly desirable, valuable, and liberating, or possibly even as sacred. For our purpose here, it is important to notice that these states arise spontaneously, and that intending them does not cause them to occur.

Thus, meditative states, which are normal states of mind, have little or nothing to do with meditation practice, which is not a normal state of mind, but a kind of medicine or treatment. To be clear about this, in the same way that you as a hatha yogi might decide to practice the hands to feet pose for twenty minutes in the morning in order to restore spinal elasticity and improve blood flow to the brain, a meditation practitioner might decide, in order to attain a deeper spiritual awareness, to gaze at the flame of a candle while attempting to empty the mind of all thoughts. And just as the hands to feet pose is not a natural posture, but a kind of medicine for the body, the meditation practitioner regards candle gazing as a kind of medicine for the mind.

Now one does not take medicine unless there is some level of disease, and so if I am not troubled by spinal inflexibility or impaired circulation, I may not need to practice hands to feet. Instead, I will simply go through my ordinary day, moving naturally, enjoying my flexibility and good circulation, quite probably without really noticing them. And the very same thing is true of the medicine called "meditation practice." If, in my ordinary life, I am relaxed, and present, in other words if I am "at ease." then there is no dis-ease, and I will not even think about practicing meditation. Instead, I just enjoy the sense of presence, allowing things to be as they are in this very moment, probably without even noticing that I am doing so.

It is only when one feels some dis-ease, fear of death for example, or a longing to be free of suffering, or the nagging of some spiritual ambition such as wanting to be reborn into a better life, that one will think of taking the medicine called "meditation."

Now if medicine is needed, taking it is a good idea, but one ought to be careful first in deciding that medicine really is needed, and second, assuming it is needed, in choosing the right kind of medicine to take. The right medicine at the right time may help, but the wrong medicine may cause harm, perhaps a great deal of harm.

And this is where we arrive at the two types of meditation (practice). One type aims at stilling the mind, attempting, that is, to tame the wildness of the so-called "monkey mind" (always jumping from one thought to another). This is the type of practice typified by candle gazing, chanting, controlled or strenuous breathing exercises, repeating mantras, etc. The other type aims at cultivating the kind of choiceless awareness which characterizes naturally occurring meditative states. Normally in this second type of practice, the instruction is simply to watch without judgment whatever arises, both internally and externally. In other words, one does not try to calm the monkey-mind, but rather to notice its movements with bare attention (neither approval nor disapproval).

I imagine you can see that these are two very different kinds of medicine. The first kind involves a kind of self-hypnosis in which the focus of awareness is narrowed more and more until one becomes absorbed in the object of concentration (the flame, the mantra, the breath). The second type, when practiced with intelligence, favors a kind of awareness which is extremely unfocused. It is unfocused because it has no intent, no object, no goal, no ambition at all except to notice what is.

In my experience, the first type of practice encourages escapism, delusion, and trance states. Since self-induced hypnotic states can feel "special" and out of the ordinary, this kind of meditation may deceive the practitioner into imagining, without any basis, that he or she has attained something special, something "spiritual." Then the ego is really off to the races, and all kinds of harm, such as the sad events you mentioned, may ensue. This is not to say that concentration exercises should never be practiced, but rather that they are a very strong kind of medicine, deceptively so, and should, in my opinion, be practiced only under constant, experienced supervision. This potential for delusion was always known, and the older sources on meditation practice stressed it, but when meditation hit the mainstream in the 1960s and became another item in the spiritual supermarket touted as a panacea for all ailments, the dangerous potential of such practices was swept under the carpet.

The second type of practice, which stresses calming down, and simply noticing whatever arises, is a gentler, less dangerous kind of medicine. This practice, which is called "insight meditation," requires neither special sitting nor any special circumstances. It is a kind of open-eyed, accepting, broadened attention which may be practiced anywhere no matter what is happening. For example, while standing in line at the post office, or having dinner with friends, one simply notices ones current emotional state or physical posture without judging as to "good" or "bad." To be clear, there is nothing esoteric at all about this medicine, and one is not seeking a meditative state or seeking anything else* one simply notices, in a completely ordinary way, as much as possible about what is in the present moment.

Nevertheless, even insight meditation is medicine, and when the dis-ease is cured, one ought to stop taking the medicine. If I imagine that there is some future "advanced" state of consciousness, and that I must keep practicing in order to arrive at it, then I will never stop taking the medicine. I will have become addicted. Like the horizon which recedes as fast as one approaches it, and so can never be reached, the "advanced" state can never be reached either. As soon as that becomes clear, no more medicine is needed.

Be well.


*If one is practicing "meditation" in order to attain any goal at all besides simple insight--for example freedom from suffering, a better rebirth, saving the world, gaining merit, or finding God--then genuine insight becomes impossible. Ambition itself precludes nonjudgmental bare attention, since everything will be judged in comparison to the future ideal one desires to attain. If one is not ready to abandon ambition, it may be better to seek accomplishments not in meditation, but in the outer world where accomplishments are not so easily fantasized, where others may resist you, and where disillusionment quickly follows attainment of desires. Then, when the futility of living for the future becomes more apparent, one might take up meditation practice from a more useful perspective.

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questioner: Your page on proper nutrition was great. I followed the links, and learned a lot. But you did not mention anything about overweight and weight loss, and that's where I need help. I have tried many different diets for years, but still I am overweight, and nothing I try seems to work. What do you recommend?

dr-robert: I advised healthy dietary changes for improved physical, mental and emotional stability, but did not recommend a diet specifically for weight loss, and this is why:

Essentially, there are three reasons why someone would be overweight. The first of them is simply eating too much of the wrong kinds of foods due to bad habits or lack of proper nutritional information. Secondly, weight gain might be one symptom of an underlying medical condition such as hypothyroidism, or Cushing's syndrome. But usually--almost always in fact--being overweight results from one simple cause: chronic overeating for emotional reasons combined often with insufficient exercise.

Although overweight due to underlying medical conditions is fairly rare (1% or so), if one does not seem to be overeating but still gains unwanted weight, those conditions must be ruled out.

If the problem really is just lack of information, the information is simple, and I will state it now. Forget Atkins, forget Ornish, forget Protein Power, forget Beverly Hills. Forget all of the so-called weight loss diets. Since they focus on quick weight loss, not on healthy nutrition, they are all harmful to one's health in one way or another*, and they are ineffective in the long term; even if one loses weight, only very rarely will the new, thinner physique be maintained over time. "Going on a diet" is the wrong way to approach this matter, and almost guarantees failure. The word "diet" when properly used does not mean a weight-loss plan; a diet is simply what one eats. In other words, all of us have a diet already, we do not need to "go" on one.

The way to come to the proper weight is simple. Get some real physical exercise every day, eat less, and base your diet on the principles stated on the ask dr-robert page and the links you mentioned. In other words, move your body as it was intended to move, and refine the diet you already have. In addition, it has been found that when wanting to lose weight, it is helpful to add more dairy products and other sources of calcium to the diet, to avoid fatty foods, to avoid sugar, white flour, and other refined carbohydrates, to cut down on alcohol if you drink, and to stay away from the starchier vegetables such as potatoes. Except for a few fine points, that's about it.

But this kind of information is not much help the chronic overeater, because almost always habitual overeating is an emotional problem best treated, like smoking, excessive drinking, or other drug addictions, by intervention on the psychological or emotional level, not just with good advice about food and exercise. The advice may be good, but until one is emotionally ready to commit to weight loss and subsequent weight maintenance, the advice will not, really cannot, be followed consistently.

In fact, habitual overeating is even more complicated to deal with than smoking, alcohol abuse, or other drug addictions, and this is why: a drug addict can come to the point of abstaining from the drug of choice while still craving it, but the overeater does not have abstention as a option. One cannot simply swear off food as one can with cigarettes, alcohol, or other drugs. All of us must eat, and so the temptation to consume a bit more is always there right on the plate, in the fridge, on the shelf, or on the menu.

If you want more information about overweight and how to deal it effectively, holistically, and with the emphasis on mental, physical, and emotional health, you can find some good leads, including recommendations about diet, exercise, and even some healthy recipes here at the weight control info center, and here with Dr. Andrew Weil. If you are the kind of overeater who cannot be helped by information alone, I suggest making an appointment with me for personal counseling which will include an individualized nutritional program as well as therapy aimed at being able to make an emotional commitment to a healthier body, a more tranquil mind, and a happier life.

Be well.


*The Atkins diet in particular is just criminal--nothing more than a commercial scam which has been perpetrated for years. It is a diet which, if followed, immediately deprives the body of the micronutrients required to prevent cancer, heart disease, and other serious ailments. If you simply must have a complete diet plan, and do not want to seek individual nutritional counseling, try the South Beach diet which at least includes a variety of healthful foods.

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Sometimes for no apparent reason I begin to feel terribly sad and lonely, and I wonder if life really is worth living. A friend told me that my brain chemistry was off, and gave me some of her Zoloft [antidepressant medication] but taking it did not seem to help at all. My friend said that if I really was depressed, the medication would have made me feel better, so she says I am not depressed, only sad because of things that have happened in my life. She said that depression is a disease, and not just feelings of sadness. But what is the difference between sadness and depression, and, even though the Zoloft did not help, could I still really be depressed?

dr-robert: Your letter raises many questions, and I will try to take them one by one. But the most important point is this: depression is not merely sadness. True depression is a serious condition which, without proper treatment, almost always gets worse. And, the longer depression is allowed to continue without proper intervention, the harder it becomes to treat.

Now, "depression" is not just one particular condition, but rather the word is applied to many different combinations of states of mind, bodily experiences, and emotional attitudes. For example, Person X, in mourning for a beloved partner, relative, or dear friend, might feel extremely sad for a long time, and might also wonder if life is worth living without the continued presence of the beloved, but this person might not be depressed in the sense of suffering from a disease which needs medical attention. Ordinarily, with the passage of time, the normal healing process inherent in mourning comes full circle, and the sadness will change into acceptance, understanding, and, often, a richer view of life. If help is needed, some psychotherapy might be appropriate, usually without the use of medication.

Someone else, Person Y, might apparently feel much less "sad," than Person X, but other indications would tell a trained professional that Person Y is depressed in the clinical sense, and that both psychotherapy and medication are required--perhaps urgently.

A third person, Person Z, might have few feelings of sadness at all, or none, but still might be depressed in a way which will require treatment. Depression is not always marked by feelings of sadness. Sometimes depression manifests through other symptoms, such as loss of interest in life, inability to enjoy activities previously enjoyed, sudden changes in eating and sleeping patterns, sudden weight gain or weight loss, feelings of unworthiness, and many other indications which will suggest to the professional that treatment for depression may be indicated.

This is all to say that your friend, while probably well-intentioned, has misled you. Depression is a complicated group of disorders, and without proper training and a detailed interview no one can properly diagnose depression nor properly rule it out. If you suspect that you are suffering from depression, it is important to seek professional help as soon as possible. I say "as soon as possible," because some types of depression worsen quickly without appropriate treatment, and depression itself may damage the brain in ways which are still mysterious. If the sadness or other symptoms are accompanied by ongoing feelings that life is not worth living, which may be a form of suicidal ideation, seeking help is particularly urgent.

Your friend misled you in another way too. Even if medication is indicated, depression should never be treated with antidepressants alone. Numerous studies suggest, and all of my responsible colleagues agree, that any chemical treatment must be combined with psychotherapeutic counseling in order to produce optimal results in treating depression, and that psychotherapy is the first step, not medication. So even if you had responded in some way to the Zoloft, you would still not have been receiving the proper treatment. This is because deficiencies in brain chemistry do not cause depression as many people believe. Such deficiencies in brain chemistry are just as likely to be the results of previous mistreatment, abuse, and other real life experiences which damage the brain, and alter its chemical balance, resulting in depressed thinking. This common misunderstanding (a version of the old question: "which came first the chicken or the egg?") produces a world of confusion in the popular attitudes towards depression which, these days, imagine that depression can be cured simply by taking pills.

To repeat this important point: proper treatment of depression begins with a psychotherapeutic interview. Then, if medication is necessary, it will be accompanied by counseling aimed at improving point of view. If your medical doctor tries to give you antidepressant medication without also suggesting some form of professional counseling, as some unfortunately are doing these days, in my opinion you should find a new doctor. If you go to the testimonials page you will be able to read what my colleague, Dr. Najar, of Cabo San Lucas, a medical doctor, has to say on this subject.

If you suspect that you may be depressed, a good first step would be to fill out this on-line questionnaire, and this one. If you score very low on both, you may feel fairly confident that you are not severely depressed. But, if your score is not low, and if life has felt unsatisfactory for a prolonged time, and continues to feel that way, I would suggest an interview with a trained psychotherapist (not a new-age kind of counselor, nor a guru, and certainly not a well-meaning friend). Such an interview, which should not require more than a single meeting, ought to be able either to diagnose depression or rule it out. In addition, even if depression is ruled out, such an interview could prove to be the starting point for a course of therapy aimed at improving your perspective on the value and possibilities of this often-challenging experience we call "life."

I cannot leave this topic without addressing your friend's having shared her medication with you. That was not a good idea. Zoloft is not aspirin, and fooling around with brain chemistry is not a joke. I know that here in Mexico such medicines are readily available without a prescription, but that does not mean they are safe to use without proper medical supervision, including a complete physical exam prior to beginning the medication. I hope you will understand this take it to heart.

If you wish to discuss your situation with me personally, please make an appointment.

Be well.

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questioner [Liza,a visitor to Todos Santos, was abused by someone claiming to be a spiritual teacher. The "teacher" told her that by having sex with him she could advance more quickly]: I have a tendency to blame myself and be angry with myself for being so naive and letting this happen. I do recognize that it wasn't my fault. I was the trusting student. But it is just hard to forgive myself, and even harder to forgive him. I know that it is healthy, important and good to forgive people. . . . I know that I have a lot to work on myself and I want to try to stay present, clear and without grudges, sadness or anger. . . .

dr-robert: One of the problems with sexual abuse is that sex itself often feels good, and can be enjoyed simply as a physical sensation. Then, the person who has been abused might feel somehow responsible and guilty for the part of the transaction that was enjoyed.

People like [name withheld], who are needy, deeply injured, and in denial of their pain, often defend against their injuries by claiming powers (such as being able to teach or to “do good”) which they really do not possess. Then, in the guise of teaching or doing good, this kind of abuser makes emotional demands--a kind of psychic vampirism--on people who do not have strong boundaries against that kind of attack. In this form of abuse, which really is like a vampire's bite, abusers may be trying to suck the good out of the victim, and also may be trying to put some of their badness into the victim, thereby imagining that they are ridding themselves of it.

I give you this psychological background to underscore that you are not way responsible for what happened to you, and also to explain why you might be feeling heavy and depressed as you said. This is an old modus operandi of [the abuser]. He has acted it out often, and has always told the young women that he "loved" them. Yes, Liza, due to some of your past experiences, and because you are a person who has a natural need to be trusting and open, you were easily fooled, but that is certainly not your fault, and by continuing the therapy we started, you will be able to grow in wisdom and will learn to make boundaries that can protect you better.

Forgiving those who have injured us is important, but forgiveness must not, and really cannot, be produced by force of will. If forgiving is attempted as an obligation, the person doing the forgiving may be injured on subtle levels. Just as you cannot force yourself to love (love simply arises, or not), you can not force yourself to forgive. However, as a farmer prepares the ground for planting in order to make more likely a good crop, you may able to prepare the ground for the flowering of forgiveness.

You could try preparing this ground by observing carefully that you, just like all of us, tend to get lost in ego. That's all. Simply become aware of and watch your own egoic, self-centered concerns: fantasies, schemes, fears, and desires. Then you will understand how others can do the harm that they do. If you will practice this kind of non-judgmental self-observation, you will find that compassion, both for yourself and for others, will naturally develop. Then, from that ground of compassion, real forgiveness, a forgiveness based on understanding, simply arises without direct effort on your part.

As for staying "present,” and “clear," please do not misunderstand this vital point: "Being present" does not mean to be without anger, grudges, or sadness, but rather to be aware of whatever you are feeling and thinking, including anger, grudges, sadness, or any other state. In other words, Liza, the state of presence is not an ideal state that one achieves sometime in the future after one has become calm, compassionate, and without anger, greed, lust, etc. Not at all. The state of presence is here right now. Always right now. All one can ever do is to notice that state and reside in it.

Be well.

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