Measuring up (part II)–justifying mediocrity

It has always been a struggle, both as a parent and as a therapist, to watch kids justify their behavior.  There is lots of explanation and theory about why people do this, but trying to conceptualize this in a way that made sense for a kid has been difficult.  I’ll get kids in the office that cut class because other kids do it.  That smoke cigarettes or pot because “everyone is doing it”.  Steal because it is “what we do”.  It turns into the justification for every act that is self-destructive, counter-culturish, or against the wishes of parents, teachers, therapists or any other adult.  We have all tried the extraordinarily lame “if they were jumping off a bridge would you do it too?” comment.  That aaaaaaallllllways seem to make a difference, doesn’t it??!!??  Kids who are in this frame of mind are very immune to reason.  I have tended to feel that what I had to say makes little difference in what happens outside of my limited time with them.  It dawned on me the other day when I was having that same sort of conversation with a kid that what I was dealing with is the flip side of the other self-esteem issue that I often deal with–the measuring up issue that typically effects adults (see blarticle on Measuring Up in the May, 2007 archives).  Instead of trying to measure up to other’s inordinate expectations of them as adults often do, these kids seem to have internalized a negative sense of themselves that is soothed by comparisons to other’s negative and self-destructive behavior.  They then use that as a justification of behavior that adults are trying to get them to stop.

 For example, I have had very smart kids who dumb themselves down to other kids as a way of fitting in.  The identity of being “the smart kid” may be too uncomfortable to him or her.  If you are feeling depressed and not good about yourself, it is, in a way, easier to purposefully sabotage your academic progress and do poorly (or set yourself up to do poorly) rather than risk the possiblility of doing well, getting complements etc.  I have kids who smoke pot and justify their behavior because all the other kids are doing it.  Never mind that you have mental health issues that are effected by the THC, and that you have demonstrated poor judgement while on it.  Instead of measuring yourself against the best that other people expect from you or the best that you observe in others, they seek the worst/least in others and allowing themselves to drift down to that level.

This has been seen in classrooms for years.  If you get a kid with some learning issues and without much of a backbone and put him in a special ed class full of kids with disruptive behavior, you can bet dollars to donuts that the kid will begin to display significant behavior problems.  You put a kid with mood issues in the hospital and they learn how to cut.  Instead of lifting themselves up, or displaying leadership to the kids around them, they fall in line with the negative aspects of things and begin to copy those negative behaviors, justifying it as “what everyone else does”.

Truth is, not everyone does it.  Not everyone smokes pot.  Not everyone has sex.  Not everyone else steals.  Not everyone else curses like a truck driver.  If you gather around yourself a limited number of people who engage in negative behavior, then your world will appear to you as if “everyone does it”, when, in reality, you have purposefully selected a group of kids to justify your behavior.  That is very different from “everyone”.  You have supported your mediocrity by selecting to hang out with mediocre people.  You know that 4 ft yard stick in my office???  I have one that is 2 ft long, too.  That, it seems, is the analagous symbol to those who purposefully figure out how to NOT live up to their potential.  If you compare yourself to a room full of idiots, it’s much easier to feel smart.  Problem is, you start acting like an idiot.  If you compare yourself to a heroin junky, smoking pot seems almost good.  It’s just a mind trick you are using to justify what you want to do.  It’s a stupid argument.  Just as stupid as that typical parental bridge comparison.

The question that I pose to you is, what are your strengths and weakness?  How are you going to capitalize on your strengths so that you can do well in life?  How are you going to work on your weaknesses so that you grow in those areas and develop them into strengths?  How are you going to keep you from falling into that trap of self-justification  with the two ft yard stick so that you don’t end up justifying your way out of school, or into a psych hospital, or into juvenile hall, or into a grave???  You certainly have the ability to do all sorts of self-destructive acts.  The question is . . . why?  What are you trying to say???  What are you trying to hide about yourself???  How are you going to communicate these issues in a (God forbid) straight forward, positive manner that may actually result in some positive change in your life?????????

Your choice.

I’ll be waiting.

High Blood Pressure with Effexor

The following comment/question brings up a number of issues that are important.  I reprint the following without editing . . .   

I have been on effexor xr for a long time. it’s the only thing that works.

I recently spiked a high BP. I thought I might be going through perimenpausal symtoms. I think my BP went up because I took an herg to clear my skin called seabuckthorn. Well, I thought I researched it good. It is abundant in 5HTP. So i mixed the two not knowing it. never the less , My dr took me off effexor xr, my dose was 300mg. Now I am on Celexa, it is terrible. I have migrianes, chest pain, tired . dizzy , want to sleep .I am on 80mg. still have signs of depression. Migrianes. Effexor never did this. can he up the dose anymore and try it at night. We just went to 80mg 4 days ago. Does Celexa take a longer time to work? I hate it. I am on BP medication toprol XL . not helping with angina or migrianes either. also take clonzepam. 3 mg a day . I have under alot of stress lately with my 15 yr old daughter who has attempted suicide 3 times. She is always keeping me going. I take fish oil , vitamins, trying to eat better.feel like it wears off. and them I am up getting a loritab for the pain. half of a 5/5 to sleep. tranq don’t work anymore have to go for higher dose. with effexor only a little tranq. I think the stress made my blood pressure go up. I have OCD and PTSD. This celexa stinks . I was told I should have tried lexapro. it is newer. But the same effects? never had to many effects with effexor. Worked quick. Boy I suffered after mixing 5htp with effexor. I was on smaller dose of effexor . was trying to get off.rihgt now it not a good time. Would like to try 5htp . felt good for about 4 days and then went into seratonin syndrome with effexor. Which probably made bp go up to. plus seabuck has high level of vit E. I noticed that my left foot started to blow up. I gues there are some people who can only take dry E. I know you have to introduce E slowly. Take 200 mg right now. hope to get up to 400mg a day. I am a mess. thanks for the help. miss the effexor. it worked.  –LA

First and most important, what is with the chest pains? You and your doctor must be 100 % certain sure they are not cardiac pains.  If that is not the case, you need to go to have a full cardiac work-up to make sure.  I’ll proceed from here assuming the chest pain is non-cardiac.  For me, the answer here lies in the first sentance . . . “the only thing that worked was Effexor”.  So many times we try to re-invent the wheel.  If you did well on the Effexor for a long time and only got significant side effects when the herbal preparation was added, you deserve a new trial of the Effexor.  You should be free of confounding factors (no more herbals for now) and you should have your BP checked at regular intervals.  The dose of Celexa that you are taking is too high for my comfort (40 mg is the typical top dose) and, anyway, isn’t doing a thing for you.  You sound like you are a mess.  You mentioned Lexapro.  It is doubtful that switching from the high dose of Celexa to Lexapro is likely to do anything more for you than Celexa.  Think receptors . . . high doses of Effexor hits two receptors (serotonin and norepinephrine).  Celexa and Lexapro only hit serotonin, no matter what the dose.  An option might be Cymbalta (also a dual-acting agent), but, again, why try to reinvent the wheel.  If Effexor worked really really well in the past, I would try that first.  While Effexor can increase blood pressure, anti-hypertensives are protective against that.  If your BP is currently controlled, you are still a candidate for Effexor. 

Another observation, I would suggest that EVERYONE let their doctors know about herbal preparations that they are considering trying.  Just because they are “natural” does not mean they are safe, especially when taken with other pharmaceuticals.  If the doctor does not know what to tell you, then you need to do more homework and educate your doctor.  Chances are, you may still get a blank stare (we are not taught about herbal preparations at all in medical school) but at least you educate yourself and the doctor, and you might (maybe) avoid a situtation like this in the future.

–Dan Hartman, MD

Which requires a higher dose of medicine, anxiety or depression?

A therapist writes in with the following question: 

I had a disagreement with a psychiatrist. I’d thought that in using SSRI’s to treat anxiety–social phobias, social anxiety, etc.–LOW doses are usually given. (5-10mg of Celexa/day). Treating depression usually requires HIGHER doses, (20-60mg Celexa/day).  She maintained that higher doses of SSRI’s are required to treat anxiety, higher than those used to treat depression. Can you comment?
Aaron S., MA

I’m afraid I’m going to have to disagree with both of you.  The effective dose of antidepressant to treat the patient has less to do with the disorder and more to do with the individual patient.  Some patients require larger doses to treat their disorder, some get by with less.  There is no specific trend to suggest that anxiety disorders, per se, require either higher or lower doses.  It depends on the patient’s physiology and there is no way to gauge that.  Underlying the different response patterns is a complex combination of differences in metabolic rates (some patient’s livers metabolize the medicine faster than others), gastrointestinal absorption patterns, and differences in innate neurophysiology.  Now when we treat a patient’s anxiety with antidepressants, it is not uncommon to need to be gentle at first.  Remember what you are doing when you give a patient an SSRI–you are blocking the natural recycling process and allowing a greater amount of the neurotransmitter (serotonin in this case) to be present between the nerve cells.  That can, especially at first, cause a transient increase in anxiety in some patients.  The remedy for that is to back off the dose and go more slowly.  The ultimate dose that will be effective for the anxiety, however, is very individual and is completely unpredictable.  Note also that this initial anxiety from antidepressants is not uncommon in depressed patients without anxiety.

The one exception to this rule is the treatment of OCD.  This disorder classically requires larger doses of SSRIs for longer periods of time in order to achieve clincial response.  For example, with Celexa, it would not be uncommon to use 60 mg to treat OCD (standard high dose is 40).  A more typical medicine would be Prozac, Zoloft or Paxil.  But again, you tend to need the higher dose range (even above the typical FDA max doses).  In addition, you must wait longer before considering the med trial a failure since response might not kick in for 3-4 months.

Dan Hartman, MD

More side effects than help for anxiety

C. writes in about the difficulty he has getting the right medicine to help his anxiety: 

I have tried 3 different meds for anxiety – effexor (37.5) , lexapro (10mg) and toprol all have given me severe headaches and I haven’t taken any meds in six weeks and I continue to have severe headaches and generalized weakness. Why do I get these headaches after taken these meds and why do I still have headaches and generalized weakness?

What you describe above is a limited trial of two SSRI’s (remember that low dose Effexor functions like an SSRI) and a trial of an anti-hypertensive (the Toprol).  The side effects that you describe are certainly possible with the antidepressants, but I would describe the lingering symptoms as unusual.  I’m not sure what the thought was behind the use of the Toprol.  It is possible that the headaches and weakness are from your anxiety (I assume that this continues) which can sap your energy and make you feel physically pretty lousy.  I would urge the following:

1. Routine bloodwork to make sure that there is nothing else going on that could be causing the described symptoms.  Labwork should include items such as a thyroid screen,  and a screen for Epstein-Barr/chronic fatigue,

2.  A visit to the neurologist.  If your family doc can’t figure out the headaches, you need a headache specialist (typically a neurologist).

3.  You should attend therapy to address stress management issues and relaxation techniques.  These, by themselves, can go a long way to addressing the above physical symptoms as well as your symptoms of anxiety.

4.  If the anxiety continues to be significant for you, your psychiatrist could evaluate you to see if use of a benzodiazepine is recommended and safe.  You can review the various blarticles on this page to educate yourself about them. 

If I can give you any word of encouragement it is for you to realize that you have received almost no treatment for your symptoms so far.  There are many other options available for you, both medicine and non-medication options.  Let me know how things turn out.

–Dan Hartman, MD

Tapering Lamictal

Patricia writes in the following question: 

I need advice on how to taper off of Lamictal. I am taking 100 mg a day. I would appreciate your thoughts on this.

Lamictal is an easy medication to get off of, as long as you don’t need it!  Any time you stop a medication, you must consider the possibility that you really need it to feel as good as you do . . . even if you feel pretty lousy.  It may be providing some measure of support that, once removed, will leave you feeling terrible.  Deciding to stop a medicine is a decision that should be discussed with the prescribing physician.  I also think it is a good idea to have a support person out in the real world that knows.  That way, if your insight goes before your mood does, someone can kick your butt back into treatment. That person can be a parent, an adult child, a spouse, a close friend.  It has to be someone you will listen to. 

Since Lamictal is a medicine that is used for depression (most commonly for Bipolar Depression) you must consider the possiblility that you might get depressed.  Non-phamacologic ways to avoid depression should be used to give you the best chance possible to stay reasonably happy.  By exercising, eating right, getting enough sleep, working with a therapist, reading good books, and practicing your spirituality (whatever that is for you), you increase the chances of doing well off medicine.

So, you have talked to your doctor, you have talked to a friend, you are doing all the ‘right’ things . . . how do you get off Lamictal.  I always like to go slow if I have the time.  I will assume that you have been on the medicine for about a year and are doing well and have no specific side effects of concern.  This is the best case scenerio, of course.  I would decrease you dose by 25 mg every two weeks or so.  That way you are off in about 6 weeks.  If you need to get off quicker, you can speed it up.  You can slow it down if you and your doctor want to play more conservative. 

One final note, I’m sure you are aware of the risk of rash with Lamictal.  This risk is NOT associated with a decrease in dose, it is only associated with an increase in dose.  While you must go slow in the titration up, you do not have to on the way down.  BUT, if you start having trouble, you cannot zzzzoooooommmm back to the high dose.  You must resume the titration schedule and go back up slowly.

I wish you well!

–Dan Hartman, MD

Benzodiazepines and the art of self adjusting medications–how to drive your psychiatrist bananas

In responce to my blarticle about the limits of usefulness of Klonopin, e-chimp writes in with the following barrage of thought provoking questions and comments: 

What’s your opinion on the thin line between mis-use and self-medication? Say someone’s prescribed a small supply of 2mg diazepam, finds that this dosage does nothing and adjusts it up to a higher dose than prescribed? Would you class this as mis-use? If a patient admitted that they’d done this, would you prescribe it at that level or refuse to continue to prescribe it due to concerns with potential abuse?

I have another question, which I suspect will be more controversial. I’ve found benzodiazepines fairly ineffective in dealing with anxiety. I have, however, found a drug that does help. This drug happens to be codeine. Obviously this isn’t something that is usually prescribed for psychiatric conditions and, indeed, I haven’t been prescribed it. Now, in one sense I’m abusing an opiate, because I use high doses in a way that hasn’t been authorised by a doctor. In another sense I’m self-medicating, because it certainly does help lower anxiety and it’s often a better choice than self-injury. This is a very occasional thing, so tolerance and addiction aren’t an issue. I have no interest in increasing the doses I use in frequency or amount. Would you class this as use, mis-use, abuse or something else? If a patient told you this, would you be wary about prescribing other drugs to them? Obviously prescribing opiates for this sort of thing would be dangerous for the prescriber due to the politics surrounding the issue; aside from that, do you think opiates should be investigated as psychiatric drugs?

WOW!!!

I’ll address your first paragraph and then the second.  Self-adjustment of the dose of benzodiazepine (whether it is Klonopin, Xanax or Valium (the above mentioned diazepam), is as predictable as sunrise.  I would guess that a large majority of the patients who get a prescription for this class of medicine take a little more or a little less, depending on how they are doing.  Because of the nature of the medication, it can be changed in that manner and still provide benefit for the patient.  That strategy is not effective for, say, antidepressants, mood stabilizers or antipsychotics, because they need to be present in a consistent way to provide for the blood levels that provide the benefits.  This is not always true, however.  There is something to be said for consistent administration of the medicine.  Especially when it comes to Klonopin.  If I hear that someone has a repetitive pattern of feeling good and droping their dose of medicine and then runs into a string of days where they feel more anxious and have to take more, ddduuuuuhhhhh . . . take the medicine on a consistent basis.  Do I refuse to treat patients who self adjust their medicine? No.  Unless I feel that they are abusing it.  But that, again, is all about communication.  For example, if someone is prescribed Klonopin 1 mg at bedtime and comes back in and tells me that it didn’t work so he started taking it twice a day and it did work, I will prescribe him Klonopin 1 mg twice daily.  We will have a talk about self adjusting meds and the benefits of giving me a call . . . but I don’t yell.  If that same guy comes back in and says, it stopped working as well so he started taking three mg daily . . . I start to get worried.  I may go up . . . but I am worried and I will have a serious chat about my concerns.  Further adjustment upward after “the second talk” may be cause to discontinue the medicine and try something else. I don’t refuse to treat, I change MY treatment strategy.  As we have discussed on this site before, some people get transient benefit from these meds and start sponging them up without getting clinical benefit.  If that starts to happen, it is way better to catch it early and start diverting attention and patient expectations toward another avenue of treatment.  If not, you do end up with a hefty benzo addiction.  Discharge from my care will happen if you are lying to me (no therapeutic relationship there) or are getting additional benzos from another doctor (again, can’t split the thereapeutic relationship).  In cases like that, I am just being used for my prescribing ability . . . not as an agent for life improvement.  It is all about communication and honest, just like any other successful relationship.

Now, codeine for something other than pain . . .

I am intregued.  But nervous.  I did have one adult patient who suffered from chronic focus and concentration difficulties that were unresponsive to any medication that he was given.  On his own, he found he did better when he took narcotics for his (very ligitimate) back pain.  He went on to use the narcotics for both purposes, ended up getting hooked on them and then having to detox off.  This is a standard story for narcotics and pain management.  It is unlikely that narcotics, as they are now formulated, will ever hit mainstream psychiatric practice because of the liability of addiction that they have.  Would I feed into that and prescribe them? It all depends on the relationship.  If I have a relationship that is honest and trusting with my patient, and they are doing all that I ask them to do (from a conventional standpoint) and still use unconventional approaches occasionally because they work do I sacrifice the whole relationship for principle? Probably not.  I may go overboard in my documentation and make sure that there is good communication about the intervention between me, the family doctor, the patients family, etc, so that all are on board with the atypical intervention and all questions are answered etc.  Then I would monitor and document over time. 

Again, it is all about relationship.  Honest and open and trusting relationship.

–Dan Hartman, MD

Quiting Klonopin–sometimes more is not better

Those of you who follow along faithfully in my writing know that I am a reasonable fan of the anti-anxiety tranquilizers–the benzodiazepines.  While some docs I know prescribe them only under duress, I find them a useful option when my patients are suffering from extreme anxiety.  Those docs who are reluctant often have a history of being burned by a patient (or patients) who have misused the medicine or have become inappropriately dependent on them.  I tend to think that not prescribing them at all is like throwing the baby out with the bath water.  That said, there are patients who cannot and should not take them.  The trick is knowing when to refuse to prescribe them.

A unique challenge is presented by the patient who is very very anxious, and not getting any relief from even high doses of benzos.  Despite the high rate of successful treatment with these medicines, some patients stand out as treatment resistent. For example, I will typically start Klonopin at a dose of 0.5 mg daily for one week then move up to 1 mg daily if needed.  This takes care of 90-95% of my patients.  Another few percent of patients will respond when I move the dose up to 1.5 or 2 mg daily.  Above that, my antenna start wiggling.  Some people, it seems, just get no relief from these medicines–or get partial relief which teases them into wanting more and more.  My experience is that if you do not get adequate partial relief or full remission of anxiety with 2-3 mg of Klonopin, it is unlikely that this is the medicine for you.  Rather than stay with an inadequate treatment, it is better to get off Klonopin and try something else.  By that, I don’t necessarily mean another benzodiazepine.  For most (not for all), one is as good as another and if one does not work, the rest will likely not work.

When benzos don’t work, it may be time to re-evaluate the patient and make sure the diagnosis is correct.  It may be time to try a atypical antipsychotics (such as Seroquel).  It may be time to try off-label options such as Neurontin.  It is definitely time to re-evaluate the non-pharmacologic issues in the patient’s life and aggressively address them in therapy.  Life-style adjustments that include more exercize, more time outside, more stress-free activities and more fun are very important.  Internal thought and attitude adjustments need to be addressed as well.  Changing how you process and how you think about issues can go a long way to decreasing your anxiety responce to life.  Getting over anxiety (or even just dealing with it) is a lot of work.  Just throwing medicines at it is typically not the best solution.  Taking an active role in addressing the root cause (if there is one) and changing your mental and physical responces to your anxiety typically is the best solution.

–Dan Hartman, MD

Depression during Interferon Treatment for Hepatitis C

Most of you who regular readers of this blog do not have to worry about this issue. But psychiatric patients are at greater risk of having Hep C.  While 2% of the general population has Hep C, 20 % of persons with severe mental illness have Hep C.  Regardless, any patient who faces treatment for the virus must also consider what is for many the most frightening side effect of interferon treatment–depression.  Not everyone who is treated develops symptoms of depression that meet DSM-IV criteria for depression, but a significant proportion does.  Data from various studies show that the rate of depression runs from 21% to 58 % with major depression developing at a mean of 12 weeks (range of 1 to 32 weeks).  And those who don’t develop full syndromal criteria for Major Depression can struggle with subsyndromal depression.  Manic symptoms such as elevated mood, irritability, insomnia, increased speech, racing thoughts etc can also emerge during treatment.  Suicidal thoughts are concerningly high as well, effecting as many as 43% of patients in one study.  Interestingly, however, not all studies have shown a correlation between previous psychiatric symptoms and the emergence of mood symptoms during Interferon treatment.  In patients with a previous psychiatric history, the most common psychiatric side effects of treatment with interferon/ribavirin are irritability and anxiety (in 33-45%), insomnia (in 30-40%), depression (in 20-31%) and impaired concentration (in 10-17%).  Aggressive behavior, psychosis and suicide was seen in less than 1%.

The mechanism behind the development of mood symptoms is not clear.  It may possibly decrease CNS tryptophan level by disrupting the mechanism by which this serotonin building block is transported across the blood-brain barrier.  Decreased serotonin would result in symptoms of depression and irritability.  It may also act to disrupt central hormonal feedback systems or more directly alter neural functioning.

Should a prior history of psychiatric symptoms or fear of psychiatric complication prevent you from seeking treatment for Hep C.  ABSOLUTELY NOT.  When indicated, antiviral treatment should proceed.  It is suggested that patients who have a past history of depression or are experiencing symptoms of depression should be put on antidepressants prophylactically to prevent treatment emergent worsening of their symptoms.  While studies have shown that Celexa and Paxil are safe and effective, most antidepressants seem to be as well.  I have used the SSRI’s and the dual-acting agents (Effexor and Cymbalta) and have also used Wellbutrin as an augmenting strategy in patients with resistent symptoms and/or a great deal of fatigue/concentration loss. It is really about being reasonably cautious.  I would suggest that any patient who enters antiviral treatment should be seen by a counselor on a regular basis for the first few months (at least) of treatment.  Regular screening for mood symptoms should occur and there should be a low threshold for referring a patient for a psychiatric consultation.  Antiviral treatment for Hep C is so important for long term managment of this illness that psychiatric issues, or fear of psychiatric issues, should not be allowed to get in the way.

My thanks to Drs Martin, Krahn, and Balan and Rosati CRNP for their article in the November 2006 issue of Current Psychiatry from which the above statistics are derived.

–Dan Hartman, MD

Cognitive Restructuring–getting rid of the old tapes?

A member of our studio audience writes in with the following problem.  I have edited out some of the entry for brevity’s sake.

My father has been married seven times & recently got engaged to #8. However, less than three weeks later they were also done. My dad has literally cheated on all his wives & all his girlfriends. This makes me obsess over the fact that “all men cheat.” Logically, though, I know that isn’t true.
However, I have an immediate physical and emotional reaction every time some touchy subject (like pornography) comes up with any man I’ve ever had a relationship with.
It has happened again with my current boyfriend. I know he’s only fanticizing about women in porn. On the other hand, he has had a history of cheating in the past. (Of that, he says, he was young & stupid, and has learned his lesson). My irrational – oh, yes – I KNOW they’re irrational – thoughts make me believe “well, if he’s fanticizing about another woman – what’s to stop him from going out and finding another woman?” Even though he was “young & stupid” there’s no denying he’s done it before. What I really want to know is this: could my father’s behavior really be the root cause for all these nutty and irrational fears and feelings? If so, how can I learn to let that go so that I can have healthy relationships?
 I hope you can give me some guidance as to how I can help myself – and if necessary – what type of mental health doctor I should consider seeing.

The quick answer to your question is “yes”.  It is likely that your father’s behavior is the root cause for some (if not all) of your nutty and irrational fears and feelings.  If you can imagine for a moment that we all keep within ourselves the “ideal” image of what something should be like.  The perfect vacation, the perfect car, the perfect job, child, parent, boyfriend etc, etc.  This ideal (I don’t mean “perfect” here, I just mean ideal like “what we think it should be like”) is what we compare our reality to.  If this ideal is too perfect, you cannot live up to it.  This is a set up for disappointment.  For example, if you have an image of an ideal friend and your real friends don’t live up to this ideal, then you will be chronically disappointed in your friends.  If your “ideal” is too flawed, your reality may too easily live up to the ideal.  You won’t necessarily be happy, but you will also not necessarily be disappointed.  For example, if your “ideal” for a friend includes behavior such as lying or stealing from time to time, you will tolerate friends who lie and steal from time to time.  You might not like it, but you will tolerate it.  We each tend to move around in our own little universe comparing our situations with our internal pictured ideal of what things should be.  That then tends to drive our mood one way or another.   Your situation is obviously more complicated.  The “ideal” father that is pictured in your head is a cheat. But, you REJECT that picture as your ideal–but you cannot get it out of your head.  With every boyfriend that comes into your life, you then compare them to the “ideal husband figure” that you learned from your father and assume (on a subconscious level) that they will be like him.  Any feature of that boyfriend that remotely reminds you of your father (for example, the ancient history of cheating on someone, or the viewing of pornography) will be used as confirmation of their similarity to your father and bring about the same feelings of anger/fear/anxiety/or whatever that your father induces in you.  You will then likely find yourself protecting yourself by pushing your boyfriend away to minimize the chance of your getting hurt by him.  The therapy treatment for this would be cognitive therapy with the goal of restructuring your internal “ideal” of what a father/husband is (cause your father ain’t no ideal nothing) and supporting you as you do realistic evaluations of your boyfriends behavior.  The therapist that does that should be skilled in cognitive behavioral therapy.

Now, just because your father was a jerk and you have certain sensitivities does not mean that all of your sensitivities are necessarily wrong.  If you don’t want your boyfriend to view pornography and fantasize about other women, it is reasonable to ask him not to.  If he cannot do that for you, he is not the man for you.  Drop him now and find someone who is more responsive to your needs.  Couples in relationships need to be able to ask their partners not to do things that are directly upsetting to them.  Partners need to be able to be sensitive to the needs of their significant other and respond accordingly.  A therapist can help you determine what expectations are reasonable if you are not sure.  I wish you well.

-Dan Hartman, MD