Every now and then, someone comes into one of the support groups I attend or encounters me online and talks about how their family has decided to apply tough love. They are not alcoholics nor do they use illicit drugs. The parents or spouse are reacting to symptoms — usually the lack of motivation to exercise, take care of themselves, etc. The helplessness of the patient does not matter to them. They may not understand that it takes time to recover from a mood disorder or they may deny its existence. If you’re now taking medication, you should be better now, right? Or maybe they think it is time that you “got out into the real world”, suffered what “everyone” else suffers.
So they apply a philosophy that they heard about — maybe from friends, maybe from a therapist, maybe from Bill Milliken’s 1968 book or one of the many self-help guides that have replicated the idea which is called Tough Love. At its best, it is merely setting good boundaries — “sorry, but if you are going to use the money I give you for food to buy street drugs, I am not going to subsidize you”. But in American culture, it too often means employing cruelty to be “kind” whenever the patient doesn’t act in a way that the caregiver doesn’t like. And many caregivers make the mistake of thinking that the symptoms of the disease are something that the patient can control. You are depressed, they might reason, because you don’t exercise You are sleeping all day because you are a lazy good for nothing.
When they apply tough love in this situation, they are abdicating their responsibilities as a parent or a spouse. First of these is to understand the illness. Psychiatrists, for example, see the lack of motivation to exercise less as a cause than as a symptom. Studies show that exercise doesn’t do a lot to pull people out of depressions. A systematic review of the literature on exercise’s effect on depression found:
Exercise is moderately more effective than no therapy for reducing symptoms of depression.
Exercise is no more effective than antidepressants for reducing symptoms of depression, although this conclusion is based on a small number of studies.
Exercise is no more effective than psychological therapies for reducing symptoms of depression, although this conclusion is based on small number of studies.
The reviewers also note that when only high-quality studies were included, the difference between exercise and no therapy is less conclusive.
Attendance rates for exercise treatments ranged from 50% to 100%.
The evidence about whether exercise for depression improves quality of life is inconclusive.
People in the throes of depression have a problem when it comes to exercise: they don’t feel like doing it. And when they do, it doesn’t help that much. When I had a particularly severe episode, I dragged myself out of bed long enough to walk around the block in the middle of the day. This enormous mass (I weighed 290 pounds) pushed itself to walk based on the folk theory that it would do me some good. I will say that it helped keep my muscles from atrophying, but I can’t recall that it made me feel better. The atmosphere felt like a gelatin that resisted every step I took. When I got home, I returned to my bed and allowed the cats to resume their former places atop of me. The worst part of the depression lasted two to three weeks. The full effects did not dissipate for nearly a year.
The lifelessness affected my mind and my body. I craved the pleasures one gets from eating one’s favorite food, listening to one’s favorite music, etc. but I did not experience them. If asked to color the sensations in my limbs, I would choose gray. A long argument between what I knew what was good for me and what my being felt like doing culminated, at long last, in the resolve to hike. When I started hiking, every muscle in my body resisted movement. I would drive to my favorite trail head, park the truck, and then spend several minutes just persuading myself to get out of the truck. The first fifteen minutes of my trek were invariably hard. The toes of my feet seemed to want to point backwards and launch into a run back to the car except that even the blessing of a downhill portended struggle and tediousness.
Tough Love addresses this issue by identifying the patient as having chosen to become depressed. Words like “lazy” and “stubborn” get applied. No helping hand is offered. No time is spent listening and understanding what the patient is going through. No encouragement is given. Blame is invoked and it is placed on the shoulders of the person living with the depression. Their mood disorder is misapprehended as an addiction; its symptoms are viewed as choices.
I think laziness is an issue here, but it is not on the depressive that the label needs be placed but on the person who decides that they need to do nothing loving. When Americans use the phrase, they put the emphasis on “tough” which translates all too easily into mean, abusive, and selfish. Tough love sends the message “I don’t care about your illness. Your behavior is driving me nuts.” So some will go so far as to starve the patient or demand her or him financial help when he or she is unable to care for him or herself.
One mother shared her story with me: “Everyone kept telling me use tough love with my son – now I feel as though I was kicking him when he was down – when he needed me most. He was 33.
My son had mental illness – his self medication was alcohol – AA people would tell me I needed to seperate myself – let him hit rock bottom – not let him live with me any longer – and because I was trying everything I could to get well – I gave out the tough love – I made him leave – I told him if he was drinking he couldn’t come back. In the last month of his life he was telling his social worker that he didn’t think he could live alone because the voices were starting to be his own voice telling him to hurt himself – she of course couldn’t / wouldn’t tell us that – and I think he thought if he asked to come back to my house I would say no – he felt alone – someone told me that rock bottom sometimes for someone with addiction and mental illness is death – my son fought to get well – but I believe he felt that he was a burden to me and his brother and sister – tough love is not always the answer – it is not always what someone needs. Sometimes knowing that someone is there for you no matter what shows you are not battling alone. I will forever go through the would have – could have – should haves – I will never know if I had him here with me if he would still be with us…every single case, every single person has something else they need – there is no perfect solution – for my son there was just the perfect storm.
Others have told me their own horror stories of being treated with tough love. One woman told me that she tended to withdraw when she was subjected to it — her symptoms got worse. Speaking for myself, when my mother told me that I had to start paying rent — even though I had no job or disability check — I escaped by moving up to northern California on the little savings that I did have and spent six months of my life house homeless, meaning that I was living on people’s couches. I came very close to finding myself in worse straits and it was only through the help of friends that I was able to find something. But I remember lying in bed for days, unable to devote even an hour or two of my life to writing resumes, sending out letters, and making phone calls. When I did start working again, I dragged through my days. I was not one of those people who didn’t believe he needed help: I sought out the help of counselors. But the tough love of my mother also declared that one had to pull oneself up by one’s boot straps. One distrusted psychiatrists because — as some AA fanatics proclaim — they are just out to get you addicted. So I didn’t get help until I was 36 and then only for depression. Eleven years later, I received my truest diagnosis which was bipolar disorder. At last I found myself getting better.
I have often wondered if my mother’s “tough love” was an extension of the abuse that haunted my childhood and teen years. My mother had a fear of getting caught. She feared that psychiatrists would uncover the treatment she and my other family members accorded me. She made sure that I wasn’t bruised on any part of the body that might show. She wouldn’t send me to counseling because of the law requiring therapists to report cases of child abuse and neglect. As she aged, she took to blaming everything that had happened to me in my family of origin on my father. The disruptions caused by my bipolar depressions, my manias, and my ADD were written off as “character flaws”. It was always the easy, exculpating answer that she chose. When she set the rent, she set it too high for me to pay — even with a good job. She wanted me out of the house, it was clear. And when she was alone, she spent her retirement on trips to Russia and other parts of Europe.
She did soften when I needed to restore my mouth from years of neglect. But I never felt I could turn to her for emotional support. She had her ideas about what was good for me and she never bothered to check with me to see if she was right.
My story isn’t unusual. Even addiction experts question the effectiveness of tough love. The industry built around adolescent boot camps boasts of its success rates, but it leaves its failed cases out of the statistics. Kids die when counselors treat them as mere whiners. When they return home, the problems resurface because none of their family members bothered to examine their own attitudes and behaviors. Boot camps seem a lot like outsourced child abuse to me. That they haven’t been shut down betrays an unhealthy authoritarian streak in American family life, a meanness that will not be abandoned because its perpetrators are addicted to it.
I do support the establishment of healthy boundaries in a family. One of the strategies for dealing with someone in bipolar mania who will not seek help is to wait for her to crash into a depression when she will listen to the news that she has a problem. There are people living with bipolar disorder and other illnesses who are violent when they don’t take their medications: taking steps to ensure your own safety — including getting restraining orders and changing the locks on the doors — is reasonable. A patient living with his parents who is spending his disability check on video games and otherwise freeloading off his parents needs a wake up call. Drugs and alcohol have no place in the life of those of us who live with mood disorders so a ban on keeping them in the house is appropriate. But tough love doesn’t stop at these things. “The tender mercies of the wicked are cruel”, says the verse. And many practitioners of tough love believe it is all right to lambast people living with mood disorders on any grounds whatsoever. The only criteria that seems to matter to them is that the behavior bothers them. Assailing a person for symptoms beyond their control isn’t love, it is sadism.
>My thanks to the people of Advocates for People Living With Mental Illness group at Facebook for their insights.