Not in the Feel Better Business

Updated: Jan 9, 2020

Most folks we have met assume that the job of a psychiatrist or therapist is to help people “feel better.” It’s to make people feel less depressed, less anxious, and “happier" (whatever that really means).

But that really isn’t our job.

In fact, there are far simpler, cheaper, and more effective alternatives to psychiatry and therapy for reducing depression, anxiety, and increasing “happiness." You can find them on the local street corner or package store: alcohol for anxiety, cocaine for depression, LSD for boredom, what have you. All are incredibly effective at what they do, and do their job in only a few minutes. Why wait for days, weeks, or years for needed for professional treatment to work!

Or, if one is looking to feel better quick, skipping work or school may do the trick. Stopping work or school altogether might feel even better. Then there’s always gambling, impulsive sex, and even the X-Box. And you can always avoid seeing people who stress you out.

As psychiatrists and therapists, we simply can’t compete with this stuff, so we don’t bother trying.

But you can probably see where this is going. All the above strategies have the advantage of instant gratification and are undoubtedly effective in reducing suffering and “feeling better.” The problem is that they are short-term solutions that – when made habits –lead to longer-term problems, and subsequent increased anxiety, depression, and feeling worse in some way, shape, or form.

Can psychiatry or therapy help folks feel better in the long term? Maybe, but there are no guarantees. More to the point, getting people to “feel better” is simply not our goal. Dave Gill, MD (or Dr. Gill, Sr.) put it well:

“I’m not in the ‘feel better’ business, I’m in the ‘function better’ business.”

Unlike “feeling better,” “functioning better” is a tangible, sustainable goal.  It does not guarantee “feeling better,” but people who function better are more likely to have richer, more content lives in the long run.  Functioning better means healthier relationships, better performance at work, better management of stressful situations.  It means greater ability to see and seize life’s opportunities, and to handle life’s setbacks.

In short, feeling better (“happiness?”) is often, but not always, a side effect of functioning better.

One drawback to focusing on the functioning rather than the feeling is that learning to function better takes longer and often requires work. A second drawback is more counterintuitive: achieving better functioning often makes people feel worse in the short term.

Consider an 18-year-old young woman who wants to quit her heavy drinking because it is interfering with school and wreaking havoc at home with her parents. Suppose she decides to move from “feel better” mode to “function better” mode. She stops drinking, and, as one would expect, immediately feels worse. After all, the booze was working great for controlling anxiety, helping her sleep, and -- darn it – it just made her feel good!

If she sticks it out though, her school performance and relationships at home have a good chance of improving, as well as her physical health and a host of other tangible and intangible things. She’ll be functioning better and hopefully replace her heavy drinking with healthier habits. It’s a good bet – though not a guarantee – that she’ll probably end up feeling better in the end.

Or consider an anxious 12-year-old boy who wants to play baseball, but is terrified about having to perform in front of others.  His first step toward better functioning is to try out for the team. This is guaranteed (at least during tryouts) to make him feel terrified. The hope is that after the experience he’ll see that he survived the ordeal okay, which may encourage him to take chances and push through anxiety in the future. Should he learn to do this, he’ll have opportunities in life he wouldn’t otherwise have. (And maybe he'll even make the baseball team.)

So a good therapist might support an individual’s efforts to make these kinds of life changes in the pursuit of better functioning.

What about psychiatrists, though? What about medication? Many people assume my goal as a doc is to make people “feel better” through pharmacology. After all, they’re called “happy pills” right?

Nope, making people happy isn’t my goal either. If the medication I prescribe makes a patient feel better, that’s great. But it really is a bonus rather than the true intent.

A couple of examples of functioning better but feeling worse due to the use of medication:

Consider the 15-year-old girl with depression who shows a good response to an antidepressant, and initially feels much better. However, because she was depressed for a while, she had developed an attachment to being “unwell.” She’d grown accustomed to having her parents and friends dote on her and to an extent avoid responsibility. Suddenly, she’s functioning better, which is great. However, now she is faced with the pressure to give up her role as an "unwell child" -- if not from herself, then from others. She is now looking at increased responsibility and heightened expectations, something she is not accustomed to at all. Early on at least, it might even make her feel worse than when she started.

Or consider the 17-year-old bipolar young man who is in the midst of a manic episode, staying up for four days straight, working on an invention that he is convinced is going to make him billions of dollars. He feels great – I mean really, really great. But he stopped going to school, got fired from his job, and torpedoed his relationships with his parents and girlfriend. Some good psychiatric treatment and a couple of meds later, his mood and thinking return to “normal.” He’s furious because “normal” feels lousy to him compared to the way he felt when he was manic. But, he’s going to be able to function better, which will likely help him in the longer term.

So that’s what we do: we try to help our patients improve their functioning, regardless of whether or not it makes them feel better. People who function well tend to have richer, more content lives over the longer term, and that’s the best we can do.

Ultimately, we’ve achieved real success when our clients are functioning well enough that they don’t need us anymore. Save the occasional medication refill for someone like the bipolar 17-year-old, our services are no longer required. Our work is done. Next patient.

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