I often have patients come to my office and say things like “I can’t get out of bed in the morning” or “I can’t take this any more.” It is clear that what they are saying is that they are having a very difficult time with some aspect of their lives and that they feel incapable of conducting their lives as they wish. But it also seems that when mental health issues are involved both patients and therapists must wrestle with the difference between “I can” and “I will.”
I find that I have to be very careful when I challenge my patients about whether they really have the ability to manage their lives. Intellectually, I know that the vast majority of my patients can do much more than they feel they can. They may say, “I can’t get out of bed,” but if there were a fire in their home they would escape easily. They may say that they can’t make themselves take a shower, but I have no doubt that if I were able to pay them $1000 for a shower, they would be able to take one. They may truly believe that they are unable endure the thought of a past trauma or embarrassment, but they involuntarily re-experience them many times each day. Still, it is easy to be seen as uncaring in confronting this felt helplessness. After all, who knows the patient better than the patient? On what basis can I purport to know his capacities better than he does?
My experience as a mental health professional (and the pooled experience of my peers throughout the years) gives me a more objective vantage point in evaluating my patients’ problems. This is not to say that my patients subjective experiences are not important. They are. But it is to say that the subjective experiences of my patients frequently lead them to underestimate their abilities and overestimate their disabilities. Aaron Beck wrote a wonderful account of his work with a severely depressed man who had been bed bound, though he had no neuromuscular problems keeping him in bed. He wrote of using cognitive therapy to gradually and sensitively lead his patient to test his abilities and make decisions about whether his limitations were due to inability (“can’t”) or difficulty being motivated (“won’t”). Over the course of several hours, Dr. Beck and this patient tested his ability to move his feet, legs, and back against minimal resistance, gravity, and forceful resistance. They talked about what goals the patient’s movements might serve, like being able to go the the Coke machine and get a soda. And at last, after several hours, this man who initially claimed that he “could not walk” was walking with assistance to the Coke machine. He learned an important lesson with Dr. Beck. We often fool ourselves into thinking we can’t do something when the truth is that we simply will not try (for whatever reason — anxiety, depression, being oppositional, being undermotivated, being tired, etc.)
I try to encourage my patients not to lie to themselves. We all should be careful about what we say we can and cannot do. We should also be truthful about what we will and will not do. It is true that I cannot pick up an automobile unaided. I also cannot fly unaided, hold my breath for over 2 minutes, or calculate cube roots in my head. My willingness to do these things is immaterial. I can, however, walk up to the edge of the Grand Canyon and dangle my toes off the side. I can also drive west Texas roads at over 100 miles per hour. There are many things that I can do, but I will not. There are many reasons why I will not do things that I am capable of. They may be too dangerous. They may be immoral, unethical, or illegal. They may be inconsistent with the type of man I am and that I choose to be. They may not be consistent with my goals and values. Therefore, I may (and will) refuse.
The problem with “can” and “will” often comes in the grey areas between them. I say, “I can’t” in order to imply that there should be no further discussion. When my wife calls for me to help he with the computer, I answer, “I can’t. I’m watching my show.” I tell a little white lie. While it is true that I cannot be both in another room helping with the computer and in the living room watching my show, I could (if I wanted to) choose to help my wife and miss a little of my show. If I were to be more truthful (and willing to risk revealing myself to be more shallow and selfish), I could have answered, “No, I want to watch my show.” By hiding behind “I can’t” I try to hide my unruly will from myself and (hopefully) my wife.
I think a similar thing happens in mental illness. For those who have experienced the near paralysis of will that occurs in some cases of anxiety, depression, and psychosis, it is scary. A part of ourselves that has been under our control for years suddenly resists us. We try to do the simplest daily activities but find ourselves immobile and inert. For many, the least scary explanation for this is that we “can’t” do what we would normally do. We are sick, and once our sickness goes away and our body recovers we will resume our usual activities. It is much more confusing and worrisome to realize that our muscles are working, our nerves are intact, our thoughts stream on, our emotions are rebellious (but how important are mere emotions?), but our mental ability to will ourselves into action is pitifully weak. It is easier to hide behind “can’t.” We have no sure explanation for “won’t.”
So what do we do? What avenue of escape do we have when we find we have retreated to the comfortable lie of “I can’t”? There may be more available choices than this, but the one I have seen most successfully used by my patience is DEFIANCE. My patients who refuse to let their emotions define their abilities generally do well and do well faster. When my patients feel their emotions telling them that “they can’t,” they respond with “I’ll show you what I can and cannot do!” When their anxiety tells them to stay inside, they go outside (for a little while). When their depression tells them to stay in bed, they get up and sit in their living room. When their feelings say that they are burdens and are bringing their families down, they make special efforts to participate in family functions. When they are tempted to say, “I can’t,” they either get up and do it or they say what they would rather do. They do get tired. They do need rest. They are often frustrated by not having the strength and endurance to do all of the things that they previously did or by having to put so much effort into willing themselves to act. But they never give up control of their lives. They do not easily accept the judgement, “I can’t.” They place great hope and trust in “I will.”