Tonight at 7PM EST – The Ashley F Miller Show Episode 3

Join me, Kate Donovan, and Adam Lee of Daylight Atheism as we talk:

Politics: Sterilization of Prisoners in California

Media: The Lone Ranger and the representation of Native Americans in film

Guest choice: The stigma of mental illness

You can RSVP to the “event” here and, when the hangout is on-air, it should send you a link of the YouTube page, or just come back here at 7 and the YouTube link will be up.

This is filmed in front of a live internet audience — if you’ve got input feel free to get in touch before or during the show by commenting here, on youtube, or on the event page.

It will also be edited and released as a podcast.

Podcast website: http://ashleyfmiller.libsyn.com/webpage

Podcast RSS: http://ashleyfmiller.libsyn.com/rss

Podcast on iTunes: https://itunes.apple.com/us/podcast/the-ashley-f-miller-show/id666564480

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: Types of Antidepressants

Weekly series! As per previous discussion, I will be publishing a big information blog on each Friday. Unfortunately, it’s midterms for me, which means a shorter post for you. Blame the paper(s) and exams and readings and stuff. I promise to be back on schedule next week. Also, I’ve commissioned a post on bulimia from Tetyana, who runs the spectacular Science of Eating Disorders blog, a skeptical look at research on ED’s.

Anyways, today we look at the types of antidepressants.

Selective Serotonin Reuptake Inhibitors (SSRI’s)

[Note to neurobiologists: I am simplifying massively here. I know that.]

These are the most popular medications for depression, and include a bunch of names you probably recognize: Zoloft, Prozac, Paxil, Celexa, Lexapro.

How do they work?

A general sketch of two neurons.

A general sketch of two neurons.

Neurons don’t connect directly to each other–they have a very tiny space (the synaptic cleft) between each end of one and beginning of the next. Neurotransmitters (like serotonin, dopamine, GABA, etc) are released from the presynaptic neuron, and partially absorbed by the postsynaptic neuron. The neurotransmitter that isn’t absorbed is mainly taken back by the presynaptic neuron. SSRI’s work by blocking the reuptake mechanism for serotonin, leaving more available serotonin in the brain, which seems to relieve depression in some people.

But, this is grossly oversimplified, and depression is not as basic as not having enough serotonin. In the words of Ozy, brain chemicals are not fucking magic.

Side effects of SSRI’s can include lack of sex drive, hyperactivity or lowered energy, etc. In some, these are so life-disrupting that other medications are preferred.

Serotonin-Norepinephrine Reuptake Inhibitors (SNRI’s)

SNRI’s include Cymbalta, Effexor, and Pristiq. They work very much like SSRI’s, except they inhibit both the reuptake mechanism for norepinephrine and serotonin.

The effectiveness of SSRI’s lends support to the Monoamine Hypothesis–an incomplete explanation for depression, suggesting that several neurotransmitter systems (including serotonergic) are responsible.  The hypothesis does hold up to scrutiny, but doesn’t explain why many antidepressants also help with anxiety and obsessive-type disorders.

Tricyclic Antidepressants

Color me happy to have done my research before publishing–turns out I didn’t have all of my facts straight. Tricyclics are antidepressants that operate somewhat like SSRI’s by inhibiting the reuptake of serotonin–but they also have a laundry list of possible side effects, and, like MAOI’s, are used more and more rarely.

Monoamine Oxidase Inhibitors (MAOI’s)

MAOI’s can be super effective! However, they come with hefty diet restrictions, and resultingly, are used rarely–mostly as a last resort.

People taking MAOI’s need to avoid all sorts of things, like pickled foods, most cheeses, wine, decongestants, and SSRI’s. Failure to do so can cause a stroke–the result of buildup of tyramine in the brain. Since other antidepressants are available, MAOI’s have fallen out of favor.

Norepinephrine and dopamine reuptake inhibitors (NDRIs)

Wellbutrin! NDRI’s are good because they usually don’t have the sexual side effects. They too, lend support to the Monoamine Hypothesis, by altering the dopaminergic and norandronergic pathways.

St. Johns Wort

Okay. This is alt-med, but it’s been gaining mainstream popularity. It’s one of those that might work on mild to moderate depression. And if taken without doctor supervision and with other medications it can cause you all sorts of problems. In combination with SNRI’s, it can cause Serotonin Syndrome–an excess of the neurotransmitter which overloads the central nervous system. It also appears to decrease the effectiveness of oral contraceptives, might cause problems if you’re breast-feeding, and oh, right, as an herbal supplement, isn’t all that regulated. What I’m saying is, self-prescribing this stuff is not a great idea, and right now, there’s not evidence that it works for major depression. But some people do use it, so I’ll include it.

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

Psychopathology Sum-Up: Bipolar Disorder

[Content note: brief discussion of suicide]

Weekly series! As per previous discussion, I will be published a big information blog about a specific mental illness on each Friday.

I know, today is not Friday. I’m publishing early because I’m excited, and also I want to get lots of feedback. Tell me what I’m not including, what other things you want to know, etc. If there’s enough questions, I’ll do a second follow-up post. Lastly, tell me if there’s terms I’m not defining that I should be. I really really don’t want to get wrapped around jargon here–it helps nobody.

The idea is to talk about what the diagnoses are and aren’t, common misconceptions, what treatment and outcomes look like, and so on. Though not all therapeutic orientations (the theory and approach behind a course of treatment) depend on or use diagnoses–and there’s some very good arguments against using the medical model of diagnosis–we do use labels to conduct research, and it’s worth learning what a mental illness is. I’m going to try to include any changes to diagnostic criteria as well as current debates.

This post is massive and organized in informational sections, so I’ve put it behind a jump.

[Read more…]

A National Database of the Mentally Ill

Subtitled: Has Anyone Here Heard of Client/Patient Confidentiality? No? No.

Today, the National Rifle Association had a press conference.

Wayne LaPierre, the Executive Vice President spoke, and I, recently relocated back to Texas for the holidays, slept through it.

Then I saw the transcript, sat bolt upright in my bed, and got ranty on the internet.

The relevant bit (emphasis mine):

 The truth is, that our society is populated by an unknown number of genuine monsters. People that are so deranged, so evil, so possessed by voices and driven by demons, that no sane person can every possibly comprehend them. They walk among us every single day, and does anybody really believe that the next Adam Lanza isn’t planning his attack on a school, he’s already identified at this very moment?

How many more copycats are waiting in the wings for their moment of fame from a national media machine that rewards them with wall-to-wall attention and a sense of identity that they crave, while provoking others to try to make their mark.

A dozen more killers, a hundred more? How can we possibly even guess how many, given our nation’s refusal to create an active national database of the mentally ill? The fact is this: That wouldn’t even begin to address the much larger, more lethal criminal class — killers, robbers, rapists, gang members who have spread like cancer in every community across our nation.

So, since the NRA seems long on rhetoric and short on facts, I thought I’d clear some stuff up for them.

Patient confidentiality exists even if you have mental illness.

Funny how that works, where you have rights still, when you have mental illness. Psychiatrists still have to follow HIPPA rules. In fact, notes on psychotherapy that are kept separate from medical charts are given even more protection. Was the NRA suggesting that we trounce all over patient confidentiality and require all diagnoses to be reported? Just the “dangerous” ones? Would someone like to clarify for me which ones those are?

Therapists are already required to report anyone who makes a credible threat, and warn any possible targets.

This is largely based on the Tarasoff Rule, which came out of Tarasoff v. Regents of the University of California. In essence, when a psychologist or therapist hears a client threaten harm, they are obligated to warn those people who may be in danger. “Protected privilege ends where the public peril begins.” This is one of several exceptions to confidentiality, which can be summed up as confidentiality except in instances of harm to self or others. (Which includes reports of child abuse while another child is in the home, risk of suicide, elder abuse, and any threats or injury or death to another.)

So, say there was a high correlation between being mentally ill and being violent. (There’s not.) And then say the Connecticut shooter was mentally ill and in treatment (As far as we know, he wasn’t.) And then, say he’d confessed his plan… oh wait, there’s already methods in place to deal with that. So your database does what now, NRA?

Not everyone with mental illness is diagnosed. 

So would you be requiring everyone to be tested for mental illness then? I mean, I’d be all over that if you didn’t then require that  the mentally ill be registered in a database à la sex offenders. 

Mental illness isn’t exactly uncommon. 

Twenty six percent of American adults meet criteria for a diagnosable disorder in a given year. That, for those of you inclined towards fractions, is one quarter of the population. Since I’ve noticed that it’s somewhat less than a quarter of the population that’s having trouble committing violent crimes with guns, I’m going to posit the radical notion that having mental illness and being near weaponry does not a killer make. Of course, there are some mentally ill people who shouldn’t be near guns. I’ll agree to that easily. There’s also some mentally sound people that we’d rather not have near guns.

Discrimination against the mentally ill is actually a problem. 

Nifty research here. (Abstract only if you’re not at a university, sorry.) Basically, the neurodiverse are more likely to be discriminated against by their employers and coworkers, as well as facing disadvantages in competing for jobs. So maybe we could try to avoid making that worse? Like say, by avoiding the creation of a searchable database of those with mental illness?

Note: I’m fully aware that some people with mental illness are violent. So are some neurotypical people. I’d be all over a psychometrically sound test of impulse control/aggression/etc, that tested abilities related to using a gun responsibly. Using science to determine safe gun owners–great! Using a highly stigmatized population to avoid discussing gun control–jerk move.

You are Not His Mother

This is excerpted and edited from something I put on Facebook. 

There is a horrible article going around. I am Adam Lanza’s Mother, it says.  It’s the story of a mother who has a mentally ill child.

I live with a son who is mentally ill. I love my son. But he terrifies me.
[…]
We still don’t know what’s wrong with Michael. Autism spectrum, ADHD, Oppositional Defiant or Intermittent Explosive Disorder have all been tossed around
[…]
I am sharing this story because I am Adam Lanza’s mother. I am Dylan Klebold’s and Eric Harris’s mother. I am Jason Holmes’s mother. I am Jared Loughner’s mother. I am Seung-Hui Cho’s mother. And these boys—and their mothers—need help. In the wake of another horrific national tragedy, it’s easy to talk about guns. But it’s time to talk about mental illness.

No.

She is not. She is the mother of a mentally ill child who is NOT the shooter.

She is taking the story of a child, who is, by her own narrative, quite scary to mother, and deciding to generalizing that to a man she knows nothing about.  When you do that, when you repost it or share it or hold it up as so inspiring and raw and important to relate to this tragedy, you are saying this:

“People who behave in the way that I am describing are just like Lanza”
“Children who do these things that I am describing turn into Lanza”
“My child has something like X/Y/Z Disorder and I think they’re just like Lanza”

Because when you say that the narrative of your child just like that of a mass murderer, and then you describe some characteristics, things we *do not know* of Adam Lanza’s behavior, you are perpetuating some dangerous beliefs.

Please, please stop.

I’m not going to EVER defend the actions of the shooter.

But I will defend to all hell the people who you’re painting with the same brush.

And in case it wasn’t clear already, I will not accept “but any discussion about mental health is important!”. Nope. Discussions that speak over those who suffer from mental illness, that make them The Other, or that stigmatize them and paint them as gangly children with overbites, are harmful, and nothing more. Please stop.

Secondly, if you are going to discuss Autism Spectrum Disorder/Asperger’s here, please go educate yourself first. I suggest here and here, but I would gladly welcome more links in the comments. 

When You Tie Shootings to Mental Illness

If you’ve read my work, you know I am massively for mental healthcare reform. Not just a little bit in favor, but balloons and blog posts on blog posts and boundless enthusiasm for it.

But you know when I’m really really uncomfortable talking about mental health?

Right now. 

Tragedies are horrible. They’re senseless.

School shootings are especially so. We hurt and we reach out and hug our children and try to make sense of everything. And always, always, we talk about schizophrenia, borderline personalities, bipolar disorder.

Adam Lanza’s mental health won’t be known. Not ever. There’s a lot of things we’d like him answer for–unclaimed Christmas presents and crying families and six year olds with cameras on them and reporters in their faces. We’d like to know why he did it. We want to know what was going on in that mind. There’s no explanation that will put this into perspective. Because, what kind of perspective could it be to understand what would drive you to kill children?

But I’m asking you–begging you, really, to not decide that Lanza had a mental illness. I’m asking you not to make “being a good person” the standard for mentally healthy.

Do not try to rationalize this away with mental illness. Stop talking about how it could have been schizophrenia, stop saying he had to have mental health issues. You do not know.

You do not know his state of mind. When you decide to armchair quarterback him, to stamp him with an “obvious” diagnosis, do you know what you are saying?

Here is a terrible thing. The only thing that could possibly cause someone to do such a terrible, tragic thing is to have This Disorder. Because only people with This Disorder could be so dangerous/awful/scary. 

And you, you people who want to look for signs of schizophrenia, who want to talk about how he ‘went crazy’, how he just needed medication, I want you to consider how much harder you are making it for someone to seek treatment.

I want everyone to seek the help they need, and I’d bet you do too.

I want the next person who hears things or sees things, or has invasive thoughts to reach out and have a place to land. I want them to be listened to and to find employment. I want their safety net to care for them and call on the bad days.

I don’t want them torn up with worry that they could be the next shooter, to isolate themselves because they ‘could be dangerous’. I don’t want their friends to worry for their lives. People with mental illness are four times as likely to be the victims of violence. They are more likely to suffer than perpetrate.

You want to care for the living? You want mental health care to be better? Stop making mental illness the scapegoat. You are causing stigma. You are making it harder. You are part of the problem. If today, seeing a therapist was free, treatment was covered as long as it was needed, do you think everyone who needed it would go? If the dominant narrative is that only ‘crazy people’  shoot schoolchildren?

I worked in a research lab developing and testing therapy for schizophrenia when I was 18, where in part, I interviewed participants and tagged along on treatment sessions. To this day, when I mention it–one of the best experiences of my studies–the common reaction is to ask about my safety. My safety from people who patiently let a teenager ask them incredibly personal questions for hours, who let me into their homes and lives. People with mental illness are not inherently dangerous. These attitudes are.

Mental healthcare needs to be better. That is a conversation this country desperately needs to have. Please don’t do it this way.

Note 1: If and only if a therapist who was seeing Lanza or family member  was to come forward and give his diagnosis, I would accept that. However, that doesn’t actually change the point about the narrative we spin about shooters. It’s dangerous and damaging.

Note 2: When you use mental illness as the reason for this shooting, you are ignoring a host of other societal factors that let him buy a gun, that let that gun he bought be a combat rifle.
EDIT: I know that it wasn’t his gun. This was written immediately after the tragedy. Yes, gun culture is still worth discussing.

Note 3: Assuming mental illness without any kind of evidence is also just plain bad skepticism. As if we needed another reason to stop doing that.

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.