To Give Up

I was a few months into my new position as the psychiatrist for an Amish mental health clinic. The psychiatrist before me was retiring. Before he left, he briefed me in the many ways I would need to adapt my practice methods to work successfully in the Amish culture. I followed his advice, and it did not take long to adjust to the vicissitudes of communicating with patients who only have a telephone in a shed down the lane or managing 20-minute med check visits with the typical entourage of patient, family members who include toddlers crawling around the room, and community members along for support.

It was not until I was half way through a routine med check visit that my first real clash of cultures occurred. The patient was a very depressed young Amish man. Fortunately, he was accompanied by a support person from the community who was experienced in “English” ways. I had just completed what I, in my hubris, felt was a masterful combination of motivational interviewing, behavioral activation, and CBT designed to address some dysfunctional thoughts and behaviors that were preventing him from fully recovering. At the end of my intervention, he looked at me and said, “I just need to give up.”

I was taken aback. Not just by the narcissistic injury, but also because those words coming from a very depressed young man made me concerned that he was heading down the path to hopelessness and suicide. Thrown off course, I lost some professional footing and said the first thing that came to mind, “No, don’t give up!” The young man looked confused. Thankfully, the English-savvy support person stepped in at that moment and explained that in Amish culture, to “give up” means to accept or submit to something. So we were able to return to setting some concrete goals and adjusting the meds, and we finished the visit on a positive note.

Since that interaction, I have encountered the expression “to give up” many times in working with the Amish. It is a phrase gravid with meaning. In the Amish community, authority is central. So in this phrase, the giving/acquiescing/accepting is upward toward the authority over them. To the outsider, the constant focus on submission to multiple rules and leaders seems onerous. Within the community, however, submission is most often seen as a source of identity, security, and support. The benefits of submission are especially true for those with mental illness. The way the church leaders and community members provide a network of support and accountability is heartwarming. Within this structure, people are supervised in taking their medications and meeting goals in activities of daily living. This allows Amish people with serious mental illness to have a family, hold a job, and remain an integral part of the community in a way that is unparalleled in the English world, where people with a similar degree of mental illness are often homeless and relying solely on underfunded government programs.

Despite my more sophisticated understanding, the phrase “to give up” continues to incite a visceral reaction for me. I spend most of my week in the English world, where the phrase “I give up” is uttered with a sense of hopelessness, which sets off my radar to check for thoughts of self-harm. But on Tuesdays, when I hear the phrase “I give up,” I have learned not to act on my initial internal reaction. I smile and say, “Yes, you need to give up.” I know that if these patients “give up,” they will step back into the river of support that will carry them to a better place.