DR. REDIGER: Some people—such as the patient in the case report I submitted (Case Report 1)—are paralyzed by dread and anxiety. Two years ago their house was like an ATM machine, but now they feel trapped and worry that they can’t meet the mortgage payments.
DR. REDIGER: An economic recession is stressful because money represents power, control, and survival. The recession is not just about money. It’s about security, identity, and loss of face.
DR. KAUFFMAN: The evidence is pretty clear that financial losses are a risk factor for suicide, especially among men.2,3 You can go up and down Maslow’s hierarchy of needs and see what money means to people. I’ve also noticed that economic stress is a trigger for my clients with posttraumatic stress disorder. They feel out of control of a situation they thought they controlled.
DR. PALMER: An economic downturn can trigger learned helplessness. A construction worker has applied to 50 different construction companies, and none are hiring. He concludes, “I have to wait until the economy turns around, and then I’ll get another job in construction because that’s what I do.” He thinks he doesn’t have enough money or isn’t smart enough to get a degree, or whatever.
DR. REDIGER: And that’s another reason why someone with a history of trauma might experience a reactivation. Learned helplessness can be an aspect of chronic, repeated trauma. A person learns not to try any longer.
DR. PALMER: An inflexible perfectionist would probably have the most difficult time. A person who feels “there are rights and wrongs in the world, and the right thing is that I should be working. My family has grown accustomed to a certain lifestyle, and it’s my job to keep that up.”
DR. REDIGER: “If I work hard, this should be given to me.”
DR. PALMER: Right. A person with more flexibility might think in terms of problem-solving. “I worked in construction (or whatever), and now I can’t get a job. Therefore, I’ll go into a different field and take a lesser salary. The family will have to cut the budget, and the kids will go to a public college instead of a fancy private college.”
Suicidal contractor ‘can’t imagine working for someone else’
Mr. D, age 38, was admitted to our inpatient service in October 2008 with no psychiatric history but worsening depression and anxiety. He was thinking seriously about suicide by carbon monoxide poisoning. A paternal uncle and 2 paternal cousins died by suicide.
Mr. D reported GI complaints and chronic headaches. He had been married 11 years and had 3-year-old twins. He talked about financial problems and increasing debt at his construction business of 15 years. Instead of asking for help, Mr. D had ignored his accountant’s warnings and buried himself in work.
At admission, he was experiencing crying spells, insomnia, and hopelessness. That day he took 16 aspirins, 5 hydrocodone/acetaminophen tablets, and 4 lorazepam tablets to treat an intractable headache. He denied this was a suicide attempt but admitted to poor judgment.
During hospitalization, he received fluoxetine for depression and lorazepam for anxiety and insomnia. Prominent themes in psychotherapy included self-blame and isolation.
As his financial problems increased, Mr. D had borrowed money without completely disclosing his difficulties to the bank. He also felt ashamed because his 2 brothers were not facing financial problems. Creditors were knocking on the door of his home, demanding payment. He felt angry and humiliated that his wife and children were subjected to this. He felt certain his home would soon be in foreclosure.
After 3 weeks, Mr D was discharged to a partial hospital program with prescriptions for fluoxetine and short-term use of lorazepam. After 5 days he was re-admitted with suicidal thoughts. He had filed for personal and professional bankruptcy, but he could not imagine working for someone else after so many years of running his own business.
As treatment for his depression progressed, he began to develop greater insight into how his avoidant and isolative style of problem-solving contributed to a situation that left him vulnerable. He became more interested in cognitive-behavioral techniques for dealing with self-destructive thoughts and began to allow his stepfather (a retired corporate chief executive officer) and his wife to help him solve some of the practical problems facing him.—JEFFREY REDIGER, MD
Putting losses into perspective
DR. KAUFFMAN: Here’s where a cognitive-behavioral intervention with a goal to increase the flexibility—not just content—of thinking can help. You can ask patients, “What is most important to you? Is it money? Or is it your relationship with your family?” Or you could ask questions such as, “In the challenges you’re facing, what opportunities are there for you to do things that matter to you?”