On Running Out of Feelings, and What to Do Next

Hello, internet.
This is where I come to spill my secrets, right?

Sometime between last week and this one, I went numb–ran out of feelings. I think it was somewhere after the third friend in forty-eight hours contacted me with questions about leaving abusive relationships, between finals and Steubenville and painful anniversaries and suddenly having a living situation that went from Absolutely Planned to Horrifyingly Tenuous. Oh, and it’s my last day of therapy this week.*

And that’s the simple stuff.

Add in friends who need a Social Kate who smiles and has opinions and wit and does not resemble a posed block of wood. Sprinkle in academics, and taking a quarter off to work at a small agency that expects a lot from me.  Roll it all in the stress of attending a competitive university where everyone Accomplishes Things that can be itemized on a resume–things that don’t contain scary words like atheist…and feeling anything outside Ron Weasley’s teaspoon involved too much work.

So I just started feeling numb.

It’s awful. I hate it and I go round and round between being irritated at not feeling anything, and getting angry about it…and then giving up because even anger feels muted and exhausting. It’s not terribly unusual–when you run out of emotional energy, that’s how it goes. It sucks, and I know I’m not the only one who gets this. So here’s how I minimize suckage. (The technical term, ya know.)

Lists

An idea stolen from someone–either the indomitable Captain Awkward or Keely. Each day gets two lists. List One: everything I have to accomplish that day in order to prevent the week from crashing and burning, and nothing more. Anything else you accomplish goes on List Two.

List Two starts out empty, and you have no obligation to fill it. It can be empty at the end of the day, and you will still have survived and accomplished important things and can sleep easily. If there is anything on List Two, you get to feel proud of it. You have gone above and beyond. Congratulations! Well done, you.

Excuses ahead of time are your friend.

Because the socially appropriate answer to a concerned “How are you feeling?” is almost never “My brain is being awful and I can’t feel anything and also everything fell apart last week.”, stock phrases are your friend. Among my favorites:

I haven’t been sleeping quite right, thanks for asking!
Because this is true even if it means you’ve been sleeping constantly and your brain feels like fuzz.

Oh, you know, long week. [Tired smile.]
Where a “long week” is defined as any set of days where life was hard and not worth explaining.

I’m a little out of it right now. It’s probably [related thing that may or may not explain your actual problems.]
Poor finals. I’m constantly blaming them–this is my most used phrase. I actually rarely find exams overwhelming, but they’re a fabulous explanation for why I’ve developed the habits of your average hermit crab.

Sorry, I have a touch of a stomachache.
People with stomachaches tend to get all silent and huddle in the corner of any given gathering, trying to force their gastric juices to cooperate. I don’t particularly advocate lying, but if this gets you out of an nosy stranger’s headlights, I approve.

This terrible clip art is not the Feelings Police

This terrible clip art is not the Feelings Police

Numb is okay.
There are no Feelings Police. They will not come find you and lecture you into submission for not possessing the correct emotional range. Feeling numb is weird and uncomfortable and unpleasant, but it goes away and you can survive it. Give yourself permission to feel as bad as  you do, to nap as long as you need to, and to feel a little hollow.

Be greedy.

And along with that, be greedy. Will taking day off to paint your nails and consume only popcorn make you feel better? Do it. Will skipping that party to play videogames in your room feel better than pretending to feel social? You suddenly have new plans for the evening. Within the limits of your wallet and abilities, do whatever seems as though it could improve your day.

Hide in groups.
The thing about large groups of people is that you can get lost in them. Everyone else will jump about and make noise and try to figure out how to split the check when Susan ate half of the onion rings that Johnny ordered, David and Sarah split an entree, and Jacob only brought large bills.  And you can just sit there. Let everyone else have wild, sweeping feelings. There’s less pressure to say interesting things when everyone else is being exciting. You can tune out, drop in for the occasional murmur of agreement, and still be holding up your little corner of being social.

Update: Puzzles
Stephanie explains.

—-

So there it is. Ideally, these will work this time around, and I’ll kick the fuzzy-brain feels sometime before the end of my spring break.  What do you do?

* NU requires that I take the coming quarter off from classes to work Monday-Thursday, from 9-5. Therapy is only available Monday-Thursday, from 9-5. I’m sure there’s a witty name for the choice between skipping my lunch hour to get therapy and not having therapy for an eating disorder, but right now I can’t manage to find it.

The Weight Requirement, and Other Ways We Diagnose Anorexia

This is a post that’s been a long time in coming. Unfortunately, every time I start it, I get upset and then have to leave it alone. So here we have it: what’s wrong with how we diagnose anorexia. Now with less ragequitting!

Anorexia has a weight requirement.

Refusal to maintain body weight at or above a minimally normal weight for age and height, for example, weight loss leading to maintenance of body weight less than 85% of that expected or failure to make expected weight gain during period of growth, leading to body weight less than 85% of that expected.

PROBLEMATIC.

Please, someone define what a normal weight is. Because I know this totally isn’t controversial. Using BMI? It doesn’t account for muscle mass, so you’re leaving out  anyone who’s particularly athletic. Using clothing sizes? Ahahahahahahaha. 

Even supposing we had some accurate scale of normal height-to-weight ratios, should a diagnosis rest on a weight? If I’m restricting caloric intake, and I drop under 85%… Bingo, I have anorexia. Ding ding ding and all that. The next day, I enter treatment, or I eat a particularly large meal, or retain a little water, and suddenly I’m at 86%. Have I suddenly developed a disorder that is markedly distinguishable from what I had on Monday? I think not.

The emphasis on being excessively thin is also in the second criteria:

Intense fear of gaining weight or becoming fat, even though underweight.

Anorexia does not just happen one day, when you stop eating and magically, everyone can tell! This, like lots of the criteria, seem to be waiting to diagnose after the disease has progressed significantly.* That’s dangerous.

This is particularly true for people who start at an above-average weight. We fetishize the idea of heavy people losing weight through whatever means possible, up to and including unhealthy ones. (Biggest Loser, anyone?) It’s going to take an especially long time for family and friends to notice such severe weight loss–and of course, they’ll probably praise and reinforce it along the way–and all the while, the disorder will become more entrenched, wreaking havoc on the body it inhabits.

Amenhorrea

In postmenarcheal females, amenorrhea, i.e., the absence of at least 3 consecutive menstrual cycles. A woman having periods only while on hormone medication (e.g. estrogen) still qualifies as having amenorrhea.

Defined as non-menstruation for three cycles, this is competing with weight measurement for least helpful criteria. For one, it isn’t useful for anyone on hormonal birth control (withdrawal bleeding is not the same as getting your period). For two, it’s a fairly useless metric. Only cisgender women who can ovulate, are not pregnant, and who have reached puberty, but not menopause can use it. (Also, you qualify for this criteria automatically if you’re on birth control. Say what?) Further, there’s not a lot of research suggesting that amenhorrea occurs in a standardized way, or that it represents the severity of deprivation. Luckily, this is heading out with the publication of the DSM-5.

Waltzing between diagnoses.

In the span of six years, I met criteria for…

Anorexia nervosa (purging type)

Anorexia nervosa (non-purging type)

Binge Eating Disorder (BED)
Note: this is a proposed conditional diagnosis, given separate status from BN and AN. 

Bulimia Nervosa (non-purging type)

Eating Disorder Not Otherwise Specified (EDNOS)

…that would be all but two of the ways one can have an eating disorder. This suggests that we may just be quantifying eating disorders incorrectly. Those qualifying for anorexia diagnoses are automatically going to fall into EDNOS as they recover and gain weight (and consequently, no longer meet the first criteria for AN). Should we rename EDNOS as “Anorexia in Remission?” No, because then you leave out the others who were diagnosed as EDNOS for other reasons, such as not qualifying for a bulimia diagnosis. If EDNOS is made up of lots of people with very different manifestations of disordered eating, can we do any useful research about the diagnosis? Will we be able to draw any useful conclusions? Probably not.

And why does it all matter? After all, society recognizes that refusing to eat is bad, right? It matters because the research doesn’t look at “a population of women who have refused to eat at some point”. It looks at “300 female patients who had been diagnosed with anorexia in the last calendar year”. That means how we assess treatment, how we examine the genetic basis, how we study the disorder is a product of how we describe it.

And we’re doing it wrong.

*Also, the face of anorexia, besides being almost always a thin woman, is always white and upper class. Incorrect, and a scary myth to perpetuate.

Psychopathology Sum-Up: Bulimia Nervosa

[This is a guest post by Tetyana Pekar]

Tetyana is about to defend her MSc in Neuroscience at the University of Toronto. She is passionate about making eating disorder research more accessible to the public. She writes the Science of Eating Disorders blog where she aims to make sense of the latest findings in eating disorder research for lay audiences. She can be reached at tetyana@scienceofeds.org.

What is bulimia nervosa?

Bulimia nervosa (BN) is a serious eating disorder (ED) characterized by cycles of bingeing and compensatory behaviors. The most common compensatory behaviour is self-induced vomiting, but others include laxatives, diuretics, fasting, and excessive exercise. It is a common misconception that all BN patients self-induce vomiting—not so, while most do, there is a sizeable minority that does not (Keski-Rahkonen et al, 2009).

Individuals with BN are typically normal weight or overweight. This isn’t by chance; it is almost by definition. If someone binges and purges but is underweight, they will most likely be diagnosed with anorexia nervosa (AN) binge/purge subtype. Importantly, these diagnostic categories are not static, distinct groups, as over 50% of those diagnosed with restricting type AN cross over to bingeing/purging type within 5 years of ED onset, and about one-third cross over to BN (Eddy et al. 2008). So, take these diagnostic categories with a grain of salt.

Prevalence & Mortality

EDs have a high mortality rate, but keep in mind that prevalence and mortality statistics always depend on the duration of the study, the study size, and the population studied (among other things). However, most studies converge on a lifetime prevalence of BN somewhere between 1-2% (0.9-1.5 among women and 0.1-0.5% among men) (Smink et al., 2012).

The standardized mortality ratio (bulimia patients/normal, age-controlled population) for BN varies from ~2-5 (Arcelus et al., 2011). In one study of 906 individuals with BN, 3.9% died in the mean follow-up of 19 years, with suicide accounting for 23% of those deaths (Crow et al., 2009).

Causes

As much as people like the point the finger at the media and ‘thin culture,’ this explanation cannot be the whole story. After all, we are all exposed to images of thin models, and yet only 1-2% of women experience BN at some point in their lives. What is it about this percentage of women that makes them susceptible to BN?

Certainly, genetics plays a role.

Family studies are useful for determining if a particular disorder aggregates in families, though they cannot decipher if that aggregation is due to genetic risk factors of shared environmental factors (such as an over-emphasis on weight and appearance). These studies have shown that first-degree relatives of BN patients have a 4.4-9.6 higher likelihood of having BN than relatives of healthy controls (Kassett et al., 1989; Stein et al., 1999; Strober et al., 2000; ).

Twin studies are another good way to delineate the effects of genes and environment. These studies have shown that between 54-83% of the variation we see in BN is accounted for by genetic effects (Bulik et al. 1998, 2010; Kortegaard et al. 2001; Wade et al. 1999). (Note, this DOES NOT mean genes cause 54-83% of the disorder.)

This does not mean there are genes for BN (genes code for proteins, after all). However, commonly occurring temperament and personality traits might account for some of the genetic risk factors. Traits such as perfectionism, obsessionality, sensitivity to reward and punishment, and impulsivity often occur before ED onset and persist following recovery for many patients (Kump et al., 2004).

In addition, neurotransmitter systems, such as serotonin and dopamine, appear to modulate a lot of the traits associated with eating disorders. Indeed, serotonin might play an important function in the development of BN (and, along with the effects of estrogen, might partly explain why females are much more likely to suffer from EDs than males.)

It is almost important to emphasize that EDs are not “Western” disorders that arise solely due to an overemphasis on thinness. To provide just a few examples, blind women are not immune to EDs, and Iranian women living in Tehran exhibit similar levels of disordered eating behaviours as their counterparts in Los Angeles.

Behaviour does not occur in a vacuum. Genetics and environment both play a role. (For more on causes, see this post.)

Comorbidities

Eating disorders are generally highly comorbid with depression and anxiety disorders (Blinder et al., 2006). As mentioned earlier, patients with eating disorder tend to score high on perfectionism, neuroticism, impulsivity (particularly for BN patients), harm avoidance and obsessive-compulsive disorder. Among BN patients, the most common personality disorder appears to be borderline personality disorder (Sansone et al., 2005).

Treatment & Outcomes

Treatment for BN can include outpatient, inpatient, and/or residential treatments, among other things. As readers of FtB are well aware, any hard to treat diseases and disorders always attract pseudoscientific treatments. So, what treatments are evidence-based?

SSRIs, interestingly enough, have been shown to be effective in reducing the frequency of bingeing and purging in BN patients compared to placebo, particularly fluoxetine/Prozac (reviewed in Flament et al., 2012 and Hay et al., 2012). Cognitive-behavioural therapy is also widely considered to be an evidence-based treatment for BN (though, I have my reservations) (Murphy et al., 2010). In the end, the most important thing is to have a strong therapeutic alliance between the patient and the treatment team/therapist, as well as motivation to change.

In terms of outcomes, the results depend on length of follow-up, duration of illness, and sample population (i.e., how sick are the patients?). However, one large review found that about 45% of BN patients fully recovered, 27% improved, and 23% had a chronic course (Steinhausen et al., 2009).

Problems with the DSM

Compared to the problems with anorexia nervosa (AN), there are not as many. However, here are two things that annoy me:

  • Arbitrary frequency and duration criteria (2x/week for 3 months) (This will be reduced to 1x/week in the DSM-V.)
  • Too focused on weight (“compensatory behavior in order to prevent weight gain” and “self-evaluation is unduly influenced by body shape and weight”). These can certainly be true, but they don’t have to be. Bingeing and purging can just be a tool to regulate emotions.

Common Myths

Here are some other common myths that I haven’t mentioned yet:

  • BN patients throw up everything they eat. No, but some do, sometimes. The frequency and extent of behaviours varies a lot.
  • BN patients should just eat 5-small meals a day. Well, yes, but the problem has got nothing to do with not knowing how to eat well in theory.
  • BN is on the increase. Actually, studies suggest is pretty stable or even decreasing.
  • It is an effective weight control method (i.e., it is safe). I suppose, if you are okay with the plethora of medical complications (including death).

And one that bothers me the most:

  • BN is just about vanity. Actually, for me, bingeing and purging is incredibly anxiety reducing, and I’m usually symptomatic when I’m stressed, overwhelmed, or feel like crap about myself (not productive enough, for example). A sense of calmness and tranquility often follows self-induced vomiting (and I’m not alone in feeling this way).

Hopefully I’ve covered the basics. If you want to know more about BN, feel free to ask me questions in the comments, send me an email or check out BN-related posts on my blog here.


Tetyana was diagnosed with restricting type anorexia when she was in grade 10, started bingeing and purging at the end of first year in university. Her eating disorder has been all over the place, and she enrolled in outpatient treatment in high-school. She will be attending Women in Secularism conference. (Where I finally get to meet her!) You can follow her on Twitter.

Previous Psychopathology-Sum Ups:

Specific Phobias
Bipolar Disorder
Types of Antidepressants

Psychopathology Sum-Up: Specific Phobias

It’s Friday, which means a mental health summary. This post is about so called ‘specific’ phobias, which excludes social phobia. Another Sum-Up will deal with that. 

The Overview:

Specific phobias are a category of anxiety disorders. (Anxiety disorders also include OCD, Post-Traumatic Stress Disorder, and Generalized Anxiety Disorder, among others.) Specific phobias are can be seen as the Mad Libs of anxiety: “fear of [insert a noun here]”. The fear is paralyzing, and often interferes with normal functioning, but most are easily cured. In fact, this makes them unusual–one of the only disorders where upon discovery, we know what to do, and we know you’ll most likely be cured.

Specific phobias are also fairly common, and occur most often in adolescence. When the phobia interferes with functioning, people are quite good about seeking treatment. Otherwise, most people avoid the trigger (sometimes going to great lengths), and live their lives. Common phobias include flying, enclosed places, heights, dogs, escalators, spiders, and snakes. (NIMH)

Phobia Treatment:

Blood/Injury/Injection Treatment: Fear of needles, blood, wounds, injuries, or some combination thereof is known as BII. In severe cases, just reading about injuries, even in fiction, can cause wooziness. Treatment is actually different from other phobias, because it’s hard to unlearn fainting. Clients are taught to tense all of their muscles at once when triggered, which raises blood pressure.

Exposure Therapy: Exposure therapy can work in a single day, which is kinda cool. Of course, it takes all day, but no other therapy is quite so simple. Client and therapist both decide on a series of experiences from mild to very scary, and work through each. For instance, looking at a picture of a snake, then talking about snakes, imagining a snake, being in the same room as a snake, being near a snake, and finally, holding a snake. Update: Cuttlefish expands on this very very well–there’s a few types of ET, and they’re very different from each other.

Cognitive therapy: Talking through excessively fearful thought processes and challenging them. This is often combined with exposure therapy.

Medication: Never been shown to be effective.

Important Note: Just because phobias are irrational fears and easily treated does not mean you should badger, mock, or otherwise force someone to face their phobia. It’s rude and callous. Don’t do it.

Things Specific Phobias are Not:

Disliking things: hating dogs is not the same as being scared of them.

Rational fear: I think we can all agree that it’s rational to fear the idea of a plane crash, or developing a terminal illness. However, it’s slightly less rational to refuse to look at planes because of a fear of plane crashes. Phobias are irrational fears.

If any information is incorrect, please note it in the comments! However, I am going to ask for citations. I have access to journals as a student, so no worries if it appears behind a paywall. Also, please chime in with your own experiences, misconceptions, myths you’ve heard, and any book suggestions!

Previous Psychopathology Sum-Ups:
Bipolar Disorder

Responding

Brief post today, as I write a not-so-brief paper and study for finals. 

I’ve been writing a lot about what not to do with respect to mental illness disclosure, so this quote from Jesse on how to respond when a friend shares, is a useful counterpoint.

So the best thing to say forever and always (no matter how repetitive it sounds) is “I love you, I care about you, and I am sorry you struggle with this. I hope to see you get better/am glad to hear that you are recovering.”

Brilliant and multipurpose.

How To Respond Badly

Sharing problems is hard to do. Our society values being “drama-free” over dealing maturely when drama–as it inevitably does–happens. We’re supposed to fix it ourselves, or just ignore it. Because that’s what you do, right? (If I ever meet whomever made up the stupid rules of society, we are going to have Words.) As a result, we somehow manage to avoid talking about how to respond helpfully to someone with capital ‘B’ Bad News. We’re self-indulgent creatures, after all, and we’ll do all sorts of mental gymnastics to avoid staring a situation in the face and recognizing that it’s just rotten. It’s less bad than you think it is! It’s fixable! You’re going to be fine!

No.

Some things are terrible, and all you can do is sit with them and look at how horrible they are. People hurt and die and damage each other for no discernible reason.
It’s just true.
It just happens.
Want to make it hurt less? When someone tells you something rough in their life, don’t do any of these:

Explain how you totally don’t have that problem.

Please, take a few seconds to picture this conversation for me:

Jane: I just got hit by a car! Can you come to the ER so I can have someone there to listen and hold my hand and make sure everything goes okay?

Jeff: Oh, that sucks! I totally look both ways when I cross the street, and I had a near miss last week with this awful driver, but Sally pulled me out of the way. In fact, I’ve never been seriously injured. I never want to be in that much pain or dealing with doctors, and I’ve heard that getting bones set is just miserable!

This is unlikely to the point of hilarity, right?

Right?

A lot of human interaction is trying to relate to each other, and when you simply cannot understand why someone has to deal with That Awful Thing that makes no sense, it’s quite easy to shift gears from sympathy to “but that’s never happened to me!”.

I catch myself in it all the time. One second I’m agreeing how awful it is when professors play favorites, and then suddenly I’m talking about the way my sociology professor always learns everyone’s names. That is the conversational equivalent of ignoring the bleeding person in front of you while you make sure you haven’t broken a nail.

Make an only-slightly-related joke to diffuse tension!

Disclaimer: this could actually, maybe, possibly work for people with a radically different sense of humor and conversational skills than me. I just haven’t met anyone like that. Ever. So factor that into your strategic deployment of humorous non-sequitors. 

When I’ve geared myself up to disclose something, it’s an emotional experience. I often practice before, write down important things, talk it over with trusted friends, and then stress, stress, stress. Sometimes that last step is so overwhelming it inhibits me entirely. So when I say something that makes me feel like I’ve been tangled up in knots, it’s a big deal.  Trying to rearrange my face into a pleasant laugh is so far down on the list of appealing activities it’s spending time with the penguins of Antarctica.

Give me advice I didn’t ask for.

I have to pause here, dear readers and tell you about one very well meaning acquaintance, who, upon hearing me off-hand mention that I was recovering from anorexic tendencies, looked very distraught. They stopped in their tracks and said, with a deadly serious expression, “That’s really bad! You should really try to eat more!” 

Luckily, they caught me on a very good day, and I burst into hysterical laughter instead of uncontrolled sarcasm. Eating more! As a solution to starving myself? Could it be?!

We’d all like to think we’re offering The Best Advice You’ve Never Heard Before. It’s going to fix every problem and cure cancer. Nope! By the time you’ve nerved yourself up to share something that leaves you vulnerable, you’ve probably…you know…thought about fixing it some.

We live in an individualistic society, and being strong and independent is valued. (If I had a nickel for every time someone told me they didn’t want to seek help for a medical or psychological condition because they were going to figure it out/push through it….I’d have really saggy pants.) Commit some variation of this phrase to memory:

That sounds [synonym for bad]! I’m really sorry. Do you want to talk more about it, or be distracted, or are you looking for suggestions for dealing with it?

The subtext: I heard you, I care about you, and I care so much that I’m going to do exactly what you think would be most helpful. And if that advice is completely new or original and you just cannot stand to let it go unsaid, begin here:

I think I might have an idea that could help. Do you want advice?

And then, if they say no, please, please, for the love of cheesecake and chocolate, please keep it to yourself. It’s not about you. It’s about your friend who hurts and needs you to listen to them and their needs. Your need to say some words is trumped by their need to be heard.

Gone

I’ve been gone for a few days, in part because I started school, and in part because there was a tragedy at school. I couldn’t muster interest in Internet Words when I wasn’t even able to offer useful words to people right in front of me.

Which brings me to this.

I’d like you to do something for me. It might just be for me.
Or you might use it to help someone else later.

Take out your phone (or, if you’re reading this on your phone, congratulations on efficiency!)
Open your contact list, or whatever, and type an ‘A’. Hit the space bar, and then type in ‘Suicide Hotline’.
The extra first letter means that the number will always be at the top of your contacts–useful in an emergency, and a good reminder that you have it.

The actual number to use will vary, but here’s a (very incomplete) list:

US of A: 1-800-273-8255
The Netherlands offers online therapy, as well as phone-in services.
The UK: 08457 90 90 90
Australia: 13 11 14
Israel has Mental Health Aid hotline(s) for a variety of different language speakers. Click the link to find the correct one.

So put it into your phone.  Acknowledging suicidal ideation is messy and complicated, and too often we decide it’s easier to pretend they aren’t really serious, they couldn’t be that depressed. Don’t do that. Call this number. Hand over the phone.

You don’t know what to say? You don’t have to. You just have to take them seriously, and try to get them the help they need. This is a first step.

Do it for me?

Feel free to add numbers for other countries in the comments 

The Friend Manual: Part I

Part II
Part III
Part IV 

I am a friend to some lovely brilliant people with mental illness. I also have my own experiences with persistent brainfail, and some really wonderful friends who show up and give me hugs, talk me through the worst nights, and know that when I say I’m not doing so well and need space…I really need space right then and there.

I also have acquaintances who cannot do this. For them, when I want to say “I am incapable of normal interaction right now, please come back later.”, what actually comes out of my mouth is “Oh man, I have a really bad headache.” I am sure that these people, who have always meant well–and include Don’t You Know That’s Bad For You Person and Sometimes I Forget To Eat Too Person–would be shocked, shocked to hear that they’ve said tactless things. After all, that’s how it works–you don’t realize.

Don’t want to be that person?
Have a friend with mental illness?
(Chances are, you probably do.)
Want to make your friend feel like a valued part of society that you care for? If the answer to this is no, artist Ologies has this for you.
With that idea in mind, I’ve put together some basic  ideas for being the best human being you can for someone who’s just told you they have Disorder X.

A Most Important Caveat: It may be that your friend has no interest in discussing anything past the original disclosure. Please make sure to continually check that they are comfortable answering questions….and emphasize that they can tell you to stop at any time, or refuse to answer personal questions they are uncomfortable with. When I feel that I cannot leave or postpone conversations once they’ve begun, I will do anything to prevent them from starting in the first place. Safe spaces aren’t safe when they don’t have an exit.

1. Words Matter More Than Anything
So they found the words to tell you how they feel? Pay attention. Words are the best way we know to get others inside our heads, and the words they use to describe their experience are the most important tools they are giving you. She feels fragile? That’s not the same as depressed. So he is feeling depressed? That is not called feeling sad. I feel most understood and valued and listened-to when I hear someone work within the bounds of how I’ve described my feelings.

You said you were feeling like you had no momentum. Do you still feel like that? Will you feel better if I take you out to dinner and we catch a movie? Or would that make you feel like you have to pretend to be enjoying yourself?

2. Do. Not. Assume.

I know that one of the most basic human instincts is to relate to one another by shared experience. Do not try this.

So, you had that one friend with bipolar disorder that one time back at that one place? Cool story, bro. I can assure you that I am not that friend. In this particular example, there’s the problem that there’s two expressions of bipolar disorder. Didn’t know that? That’s cool. You don’t have to. All you have to know is that I am Me, and that Me is not the same as That Other Person With Disorder X.

3. You Don’t Have to Be Their Therapist

You know them so well, and if you could only get them to consider… No.

Stop right there.

I get it, and you do have a special frame of refernce, but Stop It. Now. Make like a pumpkin and squash that feeling.

4. No, Really, Please Don’t Try to Be A Therapist

If you’re my friend, we have a give-and-take. Sometimes I listen to you talk about that one time you tried to explain an Important Thing to your mom/boyfriend/girlfriend/professor and they Just Didn’t Get It, and sometimes you listen to me grouch about my stressful day at work. We trade off on this, and if we didn’t, I would be a bad friend, and it would be totally fine if you called me on it, or just decided to find the right kind of friends.

This is not how therapy works. Therapists and counselors and psychologists get paid the fancy money to do things like get mad when their clients don’t do their homework and ask really personal questions, and as a result, their clients can expect that they will be given attention, that their problems will be the focus, and that if they don’t seem to be getting the right kind of help, they can fire the therapist. The friendships are far more complex, and as a result, you don’t get to fire your friends, and you don’t have to pay them.

5. I Mean It. You Aren’t A Therapist.

Really, if there’s anything you take away from all these words, let this be it. It will be painful, uncomfortable, and probably downright annoying. You aren’t qualified, and I’d rather have my friend.

What you can do is offer to find local counseling centers. Take me to my appointments if I can’t get there, or give really big hugs when I leave them and I still feel bad. There are therapists out there, and lots of them. Possession of a dusty degree in psychology or that one textbook from freshman year Intro Psych does not somehow negate your Friend Identity. Even if you were a therapist, you should never ever try to treat your friends. So really. Don’t do that.

I started this post, and suddenly I was sitting around with two thousand words on my computer. Part II will be coming soon–in the meantime, leave me suggestions for things I have left out or could have said better!