Therapists Can Be Wrong

Therapists, like many professionals who work directly with clients, need to present themselves confidently in order to be effective, even when they’re not feeling very confident. It can be difficult for therapists to admit that they have or could be wrong, or that they don’t know everything. Like doctors and teachers and others, therapists worry that acknowledging their own limitations will erode their credibility and trustworthiness. When your livelihood depends on people finding you credible and trustworthy, that adds to the aversion of being wrong and admitting mistakes that virtually all of us already experience.

Yet we have to learn how to admit and accept that we are sometimes wrong–not only because it’s a foundation of accountability and ethical practice, but also because clients can often see through that facade, and they won’t like what they see. It’s difficult to trust someone who will never–can never–admit that they’re wrong.

This was going through my mind as I read one of my required texts for school, Psychiatric Interviewing: The Art of Understanding“Psychiatric interviewing” is really just a term for the process of therapists asking their clients questions, so the book covers a lot of very important ground. While I’ve found it useful so far, a few things irk me about it.

For instance, the author has a strange preoccupation with labeling clients using the article “the” in a way that implies uniformity. The text is laden with references to what “the paranoid patient” may do or how “the guarded patient” may behave in an interview. This type of language is not only dangerously vague (who qualifies as “the paranoid patient” as opposed to “a person who has some paranoid thoughts”? Who gets to make that determination, and using which measure(s)?), but stigmatizing to therapy clients and a potential source of bias for therapists. If you’re a young therapist who reads this book and gets all these ideas about what “the paranoid patient” may do, you may project these assumptions onto every client you work with who struggles with paranoia or expresses thoughts that seem paranoid to you. Assumptions are not necessarily a bad thing–and may even be useful in some cases–but you need to be aware of them as you work. Thus far in my reading of this book, it has not provided any cautionary notes about making assumptions. Even in my classes, in which we are often told not to make assumptions, provide little if any guidance on learning to actually notice these assumptions in practice.

Shea also recommends a few other techniques that I find excessively presumptuous. Take this example dialogue from the book:

Pt.: After my wife left, it was like a star exploded inward, everything seemed so empty…she seemed like a memory and my life began to fall apart. Very shortly afterwards I began feeling very depressed and very tearful.

Clin.: It sounds terribly frightening to lose her so suddenly, so similar to the pain you felt when your mother died.

Pt.: No…no, that’s not right at all. My mother did not purposely abandon me. That’s simply not true.

Clin.: I did not mean that your mother purposely abandoned you, but rather that both people were unexpected loses.

Pt.: I suppose…but they were very different. I never was afraid of my mother…they’re really very different.

A lot of therapists, especially those in the psychodynamic tradition, are understandably attracted to the idea of making this sort of “insight.” As Shea points out, when you get it right, it can build a lot of trust because the client feels understood in a very special way. It feels good to feel “smart” and insightful, to be able to read people like that. It can remind us that there really is something special we can do as therapists that others cannot. It probably doesn’t hurt that this, the therapy-via-Sudden-Brilliant-Insight, is usually the only kind we see represented in the media.

But a lot of the time, there really isn’t enough information to reach this conclusion. Therapists may make these leaps based on hunches, but that doesn’t mean there’s data to back it up. Sometimes the client will tell you so, but I think that a lot of the time, they will say, “Hm, I suppose you might be right,” because you are an authority figure and they want to believe you have the answers.

From the information given, you can’t reasonably jump to the conclusion that the client felt similarly when their wife left them and when their mother died. Those are very different types of loss, and even similar types of loss–two breakups, two deaths in the family–can feel very different.

Certainly there can be conceptual similarities between losing a spouse to divorce and losing a parent to death. It might even be worthwhile to explore them, but the therapist need not assume they felt “so similar.” If I were the client, I would’ve liked the therapist to say something like:

Between this and your mother passing away, it sounds like you’ve been dealing with a lot of loss. I’m wondering if losing your wife is bringing up any memories of losing your mother.

This resonates with me; it might not with other clients. That’s why sometimes the more important thing as a therapist isn’t what you say, but how you respond once you realize you’ve said or done something that strains the connection between you and your client. In this case, a responsive therapist might say something like:

I’m sorry, I didn’t mean to make assumptions about how you’re feeling. Can you say a bit more about how this loss feels different for you?

The client is the expert on their experience.

But instance, in the dialogue, the therapist doubled down on the (mis)interpretation, attempting to justify their response to the client’s disclosure. This leads the client to double down as well, justifying to the therapist why the losses feel different. They shouldn’t have to justify themselves that way.

Here is the thought I had, as both a provider and a consumer of mental health services, when I read Shea’s example dialogue above:

The failure mode of Brilliantly Insightful Therapist is Arrogant, Presumptuous Therapist.

Now, I don’t know if Shea is arrogant or presumptuous; I don’t know him but I would hope he isn’t. I do know that refusing to acknowledge missteps and misunderstandings can lead one to across that way, though. And that’s exactly what Shea refuses to do both in the dialogue itself and when he analyzes the dialogue for the reader:

Needless to say, this attempt at empathic connection leaves something to be desired. The patient’s attention to detail and fear of misunderstanding have obliterated the intended empathic message, leaving the clinician with a frustrating need to mollify a patient who has successfully twisted an empathic statement into an insult of sorts.

This probably infuriated me more than anything else in this text. Here, the failure of the interaction has been blamed entirely on the client. Shea has assumed that the client has taken his statement as an “insult” when there is no evidence of this; the client is merely correcting the therapist’s misinterpretation. It reminds me of how, often when I tell people they’ve made inaccurate assumptions about me, they respond by shrieking about how “upset” I am and how I take everything as an “insult.” Correcting someone is not the same thing as being “insulted.”

If this situation is “frustrating” for the clinician, then, I can only imagine how much more so it must be for the client.

There is no room, in this approach, for any acknowledgment that the therapist’s interpretations might simply be wrong. No room for the possibility that it’s not the client’s personal characteristics (“paranoid,” “guarded,” “histrionic”) that made this interaction fall flat, but the therapist’s presumptions and subsequent refusal to step back from them.

I discussed this particular example because it’s what came up in my reading, but it’s hardly the most egregious thing of this type that happens. Therapists who cannot conceive of the possibility that they’re wrong not only fail to help their clients, but can actually hurt them.

Since there are probably a lot more therapy clients (or prospective therapy clients) reading this than there are therapists, I want to be clear about why I wrote this. It’s not to discourage people from seeking therapy, but to arm them with the knowledge and language to advocate for what they need from their therapists, and to find therapists that suit their needs.

That last part is important. Some people may want a therapist who makes bold interpretations and takes that authoritative, explanatory sort of role. Personally, I think conducting therapy in this sort of way opens practitioners up to all sorts of bias and errors, which is one reason I want to avoid it both as a client and as a therapist. But if that’s the approach that resonates with you, then it’s likely to work a little better for you, because the most important factor is the client-therapist relationship.

Aside from that, the reason I write about problems in mental healthcare is the same reason I write about problems in feminism or atheism–to hold my own communities accountable. Anecdotally, I know that this sort of thing makes it difficult for some people to benefit from therapy, or even to want to access it to begin with. I’m not the only person who dislikes having an authority figure tell me things about my life without bothering to find out if their assumptions are even accurate.

I trust people more when they admit their mistakes.

 

Before You Speculate About Amanda Bynes’ Mental State

[Content note: mental illness, ableism]

I wrote a piece for the Daily Dot about the gleeful speculations about Amanda Bynes’ supposed mental illness.

Former child star Amanda Bynes hasn’t been having a good month. After being arrested for DUI in California, Bynes left her family and made her way to New York City, where she’s attempted to shoplift clothing twice, which she claims was a “misunderstanding.”

Bynes also gave an interview to In Touch magazine in which she apparently said that she believes there’s a microchip implanted in her brain that allows people to read her thoughts. She later made a series of tweets claiming that the interview was fake and that she will sue the magazine for calling her “insane.” Celebrity gossip websites have, of course, taken this story and run with it, speculating about Bynes’ mental health and diagnoses and treating the situation like a spectator sport.

Even if Bynes really did tell In Touch that she believes she has a microchip implanted in her brain that allows people to read her thoughts, that doesn’t mean it’s okay to call her “insane” or “crazy,” and I’m not surprised she’s angry about it. Words like that don’t just mean “displaying symptoms of a mental illness.” They connote ridicule, ignorance, and sometimes even hate.

They also place people with mental illnesses in a category apart from the rest of us, the ones who aren’t “crazy.” In fact, mental illnesses exist on a spectrum. Some people have a a few hallucinations or delusions during a time of extreme stress (or perhaps sleep deprivation). For others, psychotic symptoms are a struggle they must manage for their entire lives.

Are all of these people “crazy?” Is everyone who has ever had a random and totally irrational thought “crazy?” Is everyone who takes medication for anxiety, depression, or bipolar disorder “crazy?” Words like “crazy” and “insane” do not refer to any specific set or level of symptoms. They refer to someone we wish to hurt, ostracize, or laugh at.

How do you report a story like Bynes’ without perpetuating the stigma that people with mental illnesses face?

For starters, recognize that some things are newsworthy whether the person who did them is a celebrity or not; others are newsworthy only when they’re done by someone we’re already paying attention to—or used to pay attention to. People get DUIs and shoplift all the time, but when a famous person does it, that suddenly becomes a reason to write an entire news story. Someone having delusions is also not in and of itself interesting to the public—although, in a way, I wish it were, because maybe then people would know more about it and stigmatize those who struggle with it less.

Obviously, journalists have to make money. Sometimes that means writing stuff that sells, whether or not you personally think that this information is important to collect and provide to the public. However, oftentimes journalists—especially those who cover celeb news—shrug off all responsibility for choosing their subject matter by claiming that it’s “just what sells” or “what the people want.”

Read the rest here.

Venting About Your Problems Is Therapy’s Failure Mode

At least, it was for me.

The more I learn about how to conduct effective, evidence-based therapy, the more I understand why none of my attempts at getting therapy helped. (It is true that my depression is “in remission” or whatever you want to call it, but I don’t credit the few total months I spent in therapy with that development.)

Many people think that therapy is about paying a person to sit there and nonjudgmentally listen to you vent about your problems. Some of this might come from the prevalence of psychoanalytic thought in our culture, including in stereotypes about therapy and mental illness. Freud and his ideas are still very dominant in the many laypeople’s opinions about psychology. Specifically, I’m thinking of free association, a technique used in traditional psychoanalysis in which the client is asked to just say whatever happens to be on their mind, however silly or irrelevant it may seem. Free association is meant to inspire the client to reveal previously-repressed thoughts or feelings that both client and therapist are then able to learn from and understand.

I suppose that sometimes this can be useful, but other times or for other people, it may not be. The problem is that therapists operating from this perspective will be biased towards finding some sort of hidden meaning in the client’s free association whether it is there or not. If you asked me to free associate, I would probably just rant incoherently about how cool the buildings downtown are or cute things the children in my family say or how frustrated I am that whenever I enter a building I am always very cold because people use excessive air conditioning in this country.

And I’m sure an unscrupulous therapist could just assume that this means that I am obsessed with phallic-shaped objects or I am desperate to have children or I find that this world is too cold and unwelcoming and I long for the safe, warm environment of my mother’s womb. Sure. My own perspective is that the things that I happen to randomly think about when I am not directing myself (or being directed by someone else) to think about something in particular are rarely relevant to the major issues I have in my life. I will survive despite the prevalence of freezing-cold rooms in my day-to-day experience.

So it is with venting about my problems, which is somewhat similar to free-association in that one is asked to simply say whatever they want to talk about or are upset about at the moment. Yes, obviously, it can sometimes be very useful. I do not deny that whatsoever. A therapist may ask, “What’s been troubling you lately?” and a client might say, “My mother is sick.” Or they might say, “My children won’t listen to me and it’s making me mad,” and then the therapist probes a little more and the client reveals that the client and their partner are constantly fighting and contradicting each other and the children don’t know who they’re supposed to be listening to anymore.

The trouble starts when venting about their problems is all the client is ever asked or allowed or encouraged to do. Then you have a therapist who’s doing nothing more than what a trusted, patient, empathic friend could do. And while, to be fair, such friends aren’t as easy to find as we may wish they were, these are not skills that you need at least six years of higher education and at least one (possibly more) professional licenses in order to administer.

And that’s about all I recall doing when I went to therapy. Of course, because I was depressed, the things I vented about frequently had to do with depression in some oblique way. But the key thing on my mind as I headed off to my weekly appointments wasn’t necessarily, “I have depression.” It was, “I just had a fight with my partner and now I’m convinced they’ll dump me and I’ll be alone forever.” Or “I’m terrifying about this exam and if I don’t do well then I am a failure.” Or “I hate myself.” Or whatever.

And my therapists, for the most part, did succeed in creating a space where I felt slightly comfortable with sharing these things, and so I shared them. They would say, “What would you like to talk about?” and I wanted to talk about my conversation with my mother or how much I miss my siblings or my fears about my partner leaving me. The therapists would attempt to understand why I felt the way I did, but they did not seem to do much to change the way I felt, even though I continued seeing the same ones for a few months at least. By then, the real work of therapy should have begun.

Whereas what I’ve now been taught to do as part of my own training in mental healthcare goes more like this: A client comes to you. You ask for some basic information from the client about their life, family, history, cultural/ethnic/religious background, reasons for coming to therapy, and so on. You ask the client what they would like to accomplish in therapy. You tell them a little bit about your own therapy practice and what they can expect from it, and see if there’s anything that makes them uncomfortable or that they feel wouldn’t work for them.

Together, you set some concrete goals for therapy that are as measurable as possible. For instance, “I would like to stop having panic attacks when I leave the house.” Or “I want to find ways to deal with feeling very upset that do not involve self-harm.” Or “I want to learn how to approach people and make friends with them.” Or “My partner and I would like to find ways to manage jealousy.” If the client suggests goals that the therapist thinks are too vague, unrealistic, or dependent on factors beyond the client’s control (“I want to find a partner”), the therapist can discuss this with the client and help them adjust the goal so that it’s more manageable (“I want to get over my anxiety about asking people out on dates” along with “I want to learn ways to deal with feeling lonely”).

Then, the therapy progresses towards these goals. Every few weeks or so, the therapist and client assess how the therapy is going so far, and the client can weigh in on whether or not they think it’s helping, what concrete progress they feel they have made, and so on. The therapist may periodically administer scales or questionnaires that help gauge improvement in a slightly more objective way. The client and the therapist together can decide to adjust or change the goals if they want to, or introduce new ones as older ones are achieved. Being able to assess and adjust therapy as it’s going on, not just when it’s about to end, is very important.

Eventually, depending on the therapist’s style and the needs of the client, they may discuss termination, which is a word I hate that refers to the process of ending one’s work with a particular client. The client may feel that they’ve accomplished the goals they had, or that they’ve gotten as far as they think they can with a therapist and will be okay on their own now, or that they need to find a different therapist who may be able to help them better. Therapy should not continue indefinitely. The therapist and the client may agree to check in again in a certain number of months to see how the client is doing and whether or not they need to return to therapy.

Of course, this is just a template; everyone does it differently and not all clients may want or need all of these steps, but this is consistent with an evidence-based approach. This process holds therapists accountable by encouraging them and their clients to evaluate the therapy.

When I look back on my time in therapy, I wonder if I could’ve done a better job of making it work for me. Maybe I should’ve offered up specific changes that I wanted to see to the therapists, such as “I want to stop crying several times a week” or “I need to learn to be okay with being single.” (Both of these things happened without the help of a therapist, by the way.) But…I didn’t really know that I needed to do that. I saw my therapists as authority figures. I assumed they knew what they were doing, and that they would ask me for specific things if they needed to. I had only the vaguest ideas of how therapy is “supposed” to work, because my psychology classes mainly focused on theories and not on practice.

If you find yourself doing nothing but venting about your problems in therapy–without necessarily then developing any sort of plan to help resolve or cope with the problems–that’s a red flag. Venting can be therapeutic in its own right, but you shouldn’t have to pay for the opportunity to do it. Therapists have a responsibility to provide the best treatment they can; it’s literally in our code of ethics. You deserve that from your therapist.

The Sad Girls of Tumblr

[Content note: mental illness, depression, self-harm, suicide]

I’ve written before about the potential dangers of presenting depression and other mental illnesses as somehow attractive or appealing or more “real.” In a blog post dealing with the same issue, Spencer writes:

We love to romanticize depression. On Tumblr, browse the “#soft grunge” tag and you’ll find artfully edited photos of scars and Instagram-filtered pictures of cigarette cartons with phrases like “You’re going to die anyway” superimposed. “Soft grunge” treats depression and suicide like beautiful black roses–twisted, painful romantic ideals. We do it off of Tumblr too, like when we associate our favorite comedians’ or authors’ mental illnesses with their genius. Half the time, it seems, “tortured soul” is uttered in awestruck, not empathetic tones.

That post also links to another post, called “On Tumblr’s Romanticization of Depression,” by a blogger named Sarah:

Every time you reblog pictures of a computer screen that says “stupid sad girl” or Marlboro cigarettes with sticky notes pasted on them saying “because you broke my heart,” every time you contribute to a culture that makes depression seem like a quirky thing to add to your “about” section instead of a serious disorder with one of the highest death rates of any illness, you are actively making it okay for people to ignore their health problems and just be sad. That’s enablement.

People need to stop posting pictures of pills and tagging them #death, #suicide, #self hate, #soft grunge, and #pale. Trust me on this one, overdosing on pills: not really a good time. It’s nothing like the pictures of parties that are scattered all over your dashboard. A pretty blue-eyed boy will not come up to you when you’ve been lying in an ER bed for four hours because you can’t walk and tell you how beautiful you and your sadness are. Maybe that’s because you won’t be wearing pants at the time (I wasn’t), or maybe that’s because you’ll barely be able to speak because your mind is so distorted by the drugs. He won’t kiss your fucking scars. In fact it’s likely that nobody ever will, because seeing the mutilated flesh of someone you love is terrifying.

In a general sense, I agree. Spencer and Sarah make the point that seeing depression presented as sexy and alluring may discourage people from viewing it as an issue to work on, and while it should always be an individual’s choice whether or not to consider themselves “mentally ill” or to seek treatment for a mental illness, normalizing such pain and suffering probably doesn’t help.

But then I started thinking–how many of the people posting these things are depressed themselves, and how much moral responsibility should we assign to a person in the depths of mental illness to avoid presenting their own condition in a way that may encourage others to follow suit?

Sarah allows for this possibility, including a caveat:

Which isn’t to say that no girl with a soft grunge blog is actually diagnosed with depression (or any other mental illness), because I’m sure many are. And I think I can kind of understand the appeal. Feeling like you’re a part of something can be comforting, and so can seeing that other people feel the same way you do. When you’re in the healing stages of a mental illness, having support isn’t just important, it’s a necessity. But the soft grunge subculture doesn’t support the “Sad Girls” it idolizes, it enables them.

However, I’m not sure that really answers my question.

First of all, I take issue with the term “enablement” as used here. Professionals and others usually use this term to mean doing things that encourage someone else to behave self-destructively. For instance, someone may “enable” a friend’s problem drinking by constantly offering them alcohol or inviting them out to bars; a parent may “enable” a child’s preoccupation with getting high grades by grilling them about their grades and expressing disappointment at anything less than an “A.”

But I’m not sure what exactly Sarah thinks is being “enabled” here. If it’s depression itself, then that doesn’t make sense, because depression is not a risky or maladaptive behavior that can be enabled. It’s a mental illness. It could also be not getting treatment for depression, but I’m not sure that makes sense as a behavior that can be “enabled,” either. Not getting treatment for depression is, sadly, the default. True, if people’s Tumblr feeds were filled with age-appropriate, compassionate advice about seeking help for emotional distress, they might be more likely to do so. But in that case, the entire way the dominant culture approaches mental illness qualifies as “enablement.” In that case, every time a friend told me to “just cheer up!” or “just come hang out with us!” when I was feeling sad, they were “enabling” my behavior of not seeking treatment, because they were suggesting that depression is something that can be fixed by choosing to “just cheer up” or go to a party.

More to the point, I think that this view somewhat discounts the very realistic possibility that the people posting these “soft grunge” images are themselves depressed, and what this means about “enablement.” Who are they enabling? Themselves? Each other? Others who are more or less depressed than they are? Younger Tumblr users?

It’s complicated to me because I view this type of self-expression–the romanticization, the preoccupation with death, the attention-seeking (which I do not mean pejoratively)–as part of the mental illness itself. As a symptom, even. I haven’t seen any studies about this and have no idea which Google Scholar keywords could possibly help, but anecdotally, my experience with people who suffer from mood disorders is that some of them cope with the illness by viewing themselves and the illness in this way. Not all, obviously, but almost no mental illness symptom is shared by everyone who has that diagnosis, so to call something a symptom is not to imply that it’s a universal symptom.

It is sometimes comforting, especially when you’re scared and don’t know what’s happening to you and lack the knowledge to label it “depression,” to think of it as something special and even positive. This is especially the case when you’ve been steeped in a culture that glorifies a certain type of disaffected sadness, and ties it causally to greatness in art, music, and literature. So, even if the girls of the soft grunge subculture are enabling others, that’s only because they were first enabled themselves.

Some of it is a sort of sour grapes thing, too. You try to be happy, you can’t, everything hurts, and you think, fuck it, who wants that boring shit, anyway?

When I was in high school, I didn’t have a Tumblr (I don’t think it existed yet), but I definitely found these types of images appealing in some way. Maybe if something like Tumblr existed I would’ve even shared them. The reason they appealed to me was because they made me feel like the way I felt was a way of being more alive, not a way of missing things that other people got to have–joy, security, optimism, hope, self-esteem. And even if I didn’t meet the diagnostic criteria for depression at the time, I certainly did just a couple years later when I was diagnosed with it.

I don’t think that any of this necessarily makes promoting such memes and images ethically okay. Most of us have no problem condemning pro-ana/-mia blogs and forums, for instance, and this is really the depression/bipolar disorder version of that. (I suppose, though, you could argue that pro-ana/-mia materials are more dangerous than “pro-depression” materials, if you could even call these Tumblrs that.)

But it does mean that it’s not as simple as telling people to stop doing it.

I think the first step would be to start taking adolescent mental health seriously. It’s a serious issue. Most people know this, I think, on some level. But we still don’t take a preventative approach.

It’s expected that parents start taking their children in for dental checkups as soon as they have teeth. It’s expected to start seeing an ob/gyn for checkups as soon as you become sexually active. Why not taking that sort of proactive approach to mental health in adolescence–or even in childhood?

(Of course, all of that is bound up in issues of privilege and access, but even teenagers whose parents can easily afford and access mental healthcare often fail to receive it until things become very bad.)

So, yeah, in short, I don’t disagree with either of the perspectives I linked to. I just think it’s a little more complicated than I ever realized before. It’s easy to say, “Don’t romanticize depression! It encourages people to view depression as normal and healthy.” It’s harder to say, “Don’t show symptoms of your depression! It encourages people to view depression as normal and healthy.”

Open Thread: How Do You Practice Self-Care?

A teapot and a mug that says, "Write like a motherfucker."

90 degrees outside. No fucks given.

I’m going to give open threads a try! The folks who comment here seem to have a lot of interesting things to share, so I thought it’d be cool to have some threads where you can talk about yourself as much as you want.

The topic I’m starting with is self-care. Whether or not you have what could be called Mental Health Problems, everyone needs to calm down, unwind, or get their mind off of things sometimes. Different things work for different people, and sometimes something that seems really weird or counterintuitive will help someone.

Self-care is not a replacement or substitute for treatment (if you need it). It’s a way for people to cope with stress and jerkbrain, maintain recovery from a mental illness, or help manage mental illness symptoms if you have them. So none of these things are intended to cure or treat anything, and a lot of frustration tends to arise when people offer them up as “advice” for those with mental illnesses.

We each know best what helps us best. Here’s how I like to do self-care:

  • Hot tea. (Even in the summer. Must be because I’m Russian.)
  • Writing, even if it’s about something heavy.
  • Taking a hot shower, even if it’s just to have a place to cry in private.
  • Cleaning, organizing, doing dishes. My apartment tends to get cleaner the more life problems I’m having.
  • Going for a walk and listening to music. Unfortunately, I don’t get to do this so much now that I live in the city, where it wouldn’t be relaxing or necessarily pleasant. But my high school years, back in Ohio, were full of leisurely walks around the neighborhood.
  • Playing music. Now that I finally have a keyboard piano, I’ll finally be able to do that again.
  • Reading sci-fi novels or nonfiction articles. For some reason, it has to be one or the other. Nonfiction books don’t work, and short stories or poetry don’t work.
  • Watching something that tells a good story but doesn’t require careful attention. So, Star Trek and Doctor Who are in; West Wing and Damages are out.
  • Talking to a friend about something totally unrelated.

Some things that help lots of people but not me are: YouTube videos, animal photos, talking to someone about the thing I’m upset/stressed about, eating, video games (though I like them at other times), basically anything that’s supposed to be funny/uplifting. The first two are especially frustrating, because the first thing many people will do if I say I’m feeling down is send me YouTube videos and animal photos. Then I have to either pretend that it helped, or tell them that that doesn’t help. (Except sometimes. Hard to predict.)

 

What works for you? What doesn’t?

Towards A Better Conversation About Mental Illness

This is my latest for the Daily Dot, about how we can discuss mental illness more accurately, productively, and compassionately, particularly in the wake of tragedies like Robin Williams’ suicide.

After comedian Robin Williams committed suicide two weeks ago, fans took to the Internet to express their grief, as well as their admiration for his work. Whenever a beloved celebrity passes away, regardless of the cause, social media temporarily becomes a sort of memorial to that person, a chronicle of the ways in which they changed lives.

However, when the cause is suicide, a celebrity’s death also brings out lots of dismissive, inaccurate, or even hateful statements about people with mental illnesses. According to some, Williams was “cowardly” and “selfish” for committing suicide. Last week, Musician Henry Rollins wrote an op-ed for L.A. Weekly (for which he apologized over the weekend) in which he said that he views people who commit suicide with “disdain,” claiming that Williams traumatized his children. There was plenty of rhetoric about suicide being a “choice,” the implication being that it’s the wrong choice.

Comments like these not only misinform people about the nature of mental illness, but they are also extremely hurtful to those who struggle with it. As the Internet continues to respond to Robin Williams’ death, here are some suggestions for a better conversation about mental illness and suicide.

1) Do your research.

We all have a “folk” understanding of psychology, which means that we experience our own thoughts and feelings, interact with other people, and thus form our opinions on psychology. Obviously, noticing things about ourselves and the people around us can be an important source of knowledge about how humans work.

But it’s not enough. If you haven’t had a mental illness, you can’t really understand what it’s like to have one—unless you do your research. Depression isn’t like feeling really sad. Anxiety isn’t like feeling worried. Eating disorders aren’t like being concerned about how many calories you consume. Your own experiences may not be enough.

Before you form strong opinions about mental illness and suicide, you need to know what mental illnesses are actually like, what their symptoms are, what treatment is like, what sorts of difficulties people may have in accessing treatment or making it work for them. If you can make tweets and Facebook statuses about a celebrity’s suicide, you can also do a Google search. Wikipedia, for all its drawbacks, is a great place to start. So are books like The Noonday Demon and Listening to Prozac.

2) Never engage in armchair diagnosis.

Now that you have a good idea of what different mental illnesses look like, you should try to figure out who has which ones, right?

No, please don’t. Armchair diagnosis, which is when people who are not trained to administer psychiatric diagnoses try to do so anyway, is harmful for all sorts of reasons that Daily Dot contributor s.e. smith describes in a piece for smith’s personal blog:

The thing about armchair diagnosis is that it mutates. First it’s a ‘friend’ deciding that someone must have bipolar disorder because of some event or another. Over time, that’s mutated into an ‘actual’ diagnosis, repeated as fact and accepted. Everyone tiptoes around or gives someone sidelong glances and makes sure to tell other people. Meanwhile, someone is completely puzzled that other people are treating her like she’s, well. Crazy.

Whether the person you’re talking about is a celebrity or not, it is up to them whether or not to make public any information about their health. Mental health is part of health. While having a mental illness should never be stigmatized, unfortunately, it still is. People deserve to decide for themselves whether or not they are willing to disclose any mental illnesses they may have.

Even if someone commits suicide, that doesn’t mean we can come to any conclusions on which mental illness they had or didn’t have. First of all, not everyone who commits suicide could have been diagnosed with any mental illness just prior to it. Second, various mental illnesses may lead to suicide. Many online commentators, including journalists, simply assumed that Williams had depression. However, he may have also had bipolar disorder, in which depressive episodes are interspersed with manic ones. Williams himself never stated which diagnoses he had, so it’s best not to assume. Whatever he had or didn’t have, it is clear that he was suffering.

Read the rest here.

“Twitter Psychosis”? I’m Skeptical

[Content note: mental illness & delusions]

Over at the Daily Dot, I did some mythbusting about this alleged “Twitter Psychosis.” For whatever reason, it’s hard for me to pick out an excerpt, so I’ll just go with what I think is the most relevant part of this story, but you should go read the full thing to get the background:

Unlike most other published psychological research, the study about Mrs. C and “Twitter psychosis” is a case study— a type of research in which researchers study one particular person, or case. Something you should know about case studies is that they’re the least scientifically rigorous experimental design possible. There’s obviously only one subject or participant, and a particular person’s psychology is so idiosyncratic and impacted by so many factors that we may or may not even notice that it’s difficult to draw any firm conclusions. Unlike other studies, that compare some group to some other group, case studies don’t allow us to see what happens if certain conditions are different.

This study was further an observational case study, not an experimental one. In experiments, researchers change something or do something to the participants and see what happens. In observational studies, they can only observe what’s already going on. This means that it’s impossible to tell what causes the observed phenomena to occur.

That said, case studies are useful sometimes. When researchers are first discovering a new phenomenon, or when people with a particular condition are very rare, there might be no choice but to study a single individual. Observational studies in particular are useful when it’s unethical or impossible to tweak some variables to see what happens. Twitter psychosis, if it’s a real thing, is probably quite rare. We would have to study thousands of participants to find cases of it. And if Twitter really can cause psychosis in certain people, it’s clearly unethical to purposefully expose them to it to see what happens. So, case studies, including observational ones, are often the first step of studying something new.

My main concern with this type of research—and with other recent warnings by mental health professionals that the Internet (and social media in particular) can cause or aggravate mental illnesses—is that people dealing with mental health problems may be pressured by friends, family, or doctors to stay offline. Of course, sometimes staying off the Internet (or off social media specifically) can be a wise choice for someone for any number of reasons. However, the general trend of anti-tech alarmism makes it likely that “stay off the internet” will be a piece of advice too often and too easily given.

People with mental illnesses can be vulnerable to persuasion and even coercion by those with authority over them, including therapists and psychiatrists. If a person with a Ph.D. says, “I think you need to stay off Twitter,” they may take their advice without any grains of salt.

You might ask why this matters. It matters because the Internet can also be an incredible source of support and information for people with mental illnesses. Tumblr, in particular, is known for its supportive community, but it’s not the only one. Reddit has subreddits dedicated to every major mental illness where users can post stories, ask for advice, and support each other. Twitter’s hashtags make it easy to find tweets about your illness, and mental health organizations and professionals are very active there, posting supportive messages, advice, and news about clinical research.

And Facebook is where many people “come out” about their mental illnesses for the first time, finding it easier to share with many people at once rather than with individuals—but without having to show it to the whole world. (Incidentally, Facebook is also where I run a support group for atheists dealing with mental health problems, which many of the participants have told me has been really helpful.)

It’s possible that Twitter can trigger psychosis in some people with other risk factors, and researchers should conduct more studies to find how whether, how, and why this happens, and how it can be prevented. But we should be careful not to cut suffering people off from a potentially vital source of support.

Read the rest here.

 

Camping Trip Mornings

My favorite moment of any camping trip is the first morning.

I wake up in my tent having finally made it through a spooky and often uncomfortable night–air mattresses and sleeping bags are not my thing–and feel relieved. I can hear dry leaves and twigs crunching beneath footsteps, the thud of hiking boots on dirt and gravel. Water pours from a spigot nearby as someone fills a kettle or washes their hands. There are sleepy conversations, debates about breakfast and pleas for the kids to brush their teeth. Having never been camping with anyone besides my family and their boisterous, colorful friends, I’ve only ever heard these discussions in Russian. Camping, like baking, knitting, and skiing, happens in my native language.

Outside the smoke curls lazily from campfires that finally collapsed shortly before dawn. Pale morning sunlight filters through the canopies of the trees, catches the drifting smoke, stumbles over the tops of the tents, and finally lands in my little sister’s hair, glowing golden, as she pulls me over for breakfast.

The picnic tables almost sag with the weight of the food and drink. Last night’s empty bottles line the tables, but so do this morning’s omelets, sausages, bread, cheese, hardboiled eggs, bagels, fruit, and tea. People shove food into my hands. Water from last night’s apparent rain runs off the blue tarp that hangs over the tables, and I find a dry spot to sit with my paper plate.

And as I look out from my perch at this small piece of the world, the things that seemed so treacherous in the dark just last night–the things you trip over, the things you step into, the things that cast creepy shadows in the firelight–now look boringly normal. The perilous trek to the campground toilets now reveals itself as a short and simple path. The black water of unfathomable depth that I saw at the edge of the flashlight’s beam is just a pond. Dragonflies flit over it, and a frog croaks at its edge.

In the morning, everything suddenly feels safe and familiar again.

When I feel scared, uncomfortable, and alone, I sometimes think about those camping trip mornings, and about how the exact same things can seem so much safer in the sunlight. This visualization that is also a memory calms me down. I think about the transformation that happens at sunrise that first day, of threatening to friendly, strange to familiar.

That transformation is mirrored in my own life to a frustrating degree. People I once held my tongue around and felt anxious with become my closest friends. Streets I explored cautiously, my eyes darting around as though searching for threats, become streets I walk down proudly, yet casually. Things that seemed burdensome and inconvenient to do become routines: ignorable at worst, comfortable at best.

It may not sound like something you’d describe as “frustrating,” but I do, because I can’t seem give myself permission to not be okay with everything immediately. Why couldn’t I have immediately recognized that person as the lovely friend that they are? Why didn’t I see these streets as my home? Why couldn’t I always do these things easily and automatically?

It’s just not how my brain works. I’d venture to guess it’s not how most people’s brains work.

I wish I were someone who craved novelty, who relished the unfamiliar, who reveled in uncertainty. Someone who could cherish their memories without feeling desperate to relive them. But I am not that person. I want it to feel like the camping trip morning all the time. I want to wake up and realize that I know exactly where I am, mentally and physically. I want to stumble outside, rubbing the dreams from my eyes, and see the people I love there waiting for me.

And most of all, I want to feel that these are acceptable things to want.

“I’m a strong woman and I don’t need help.”

A common argument against interventions that aim to decrease harassment and violence against women–conference harassment policies, stronger anti-bullying measures on social media, and so on–is made by women and goes something like this: “I’m a strong woman and I don’t need to have my hand held.” Sometimes this is served with a side of “You’re the real sexist if you think that women are weak enough to need this.”

There are a lot of false assumptions layered in these statements. Namely:

1. That not needing certain protective measures makes you “strong” relative to others.

According to the fundamental attribution error, people tend to overemphasize the role of others’ internal characteristics and underemphasize the role of the situation they are in when trying to explain others’ behavior. In this case, many people observe others asking for harassment policies, trigger warnings, and the like, and attribute this to those individuals’ supposed “weakness” rather than to situational factors.

This discourse of “strength” when it comes to harassment and bullying troubles me. What I’ve generally found is that an individual’s ability to “deal with” harassment and abuse has less to do with how “strong” they are and more to do with other factors: social support, personal history of victimization, and feeling otherwise safe in the current environment, for instance.

Further, one’s likelihood of experiencing harassment and abuse in the first place has less to do with how “strong” they actually are, and more to do with how they are perceived by others. While individual factors have some impact on that, so do social categories that people use to think about others. Women with disabilities are extremely likely to be sexually abused because others perceive them as unable to speak up or get help, and because they perceive everyone else as unwilling to believe the testimony of a woman with a disability. Sadly, the latter is often true.

Therefore, feeling able to handle contingencies like sexual assault and harassment on your own, without help, is often more an indicator of privilege than superior personal traits. It certainly is for me. Part of having privilege is having difficulty seeing how other people may not have the same opportunities or experiences as you, for reasons that are not their fault.

2. That recognizing that some people(/women) need protective measures is bigoted(/sexist).

This is the gender version of another of my favorite bad arguments, If You Notice Race Then You’re The Real Racist. No, Real Racists (insofar as there is such a thing) are people who have managed to convince themselves that they “don’t see race” while continuing to judge and discriminate on the basis of it.

In the real world, there is sexual harassment and assault. In the contexts that we’re discussing, such as conferences and college campuses, sexual harassment and assault are most commonly perpetrated by men against women. Although harassment policies, anti-bullying measures on social media, and other initiatives of that sort have the potential to help anyone regardless of gender, most people correctly note that the initiatives are being created with female victims in mind–because that’s the majority, and because the loudest voices in anti-sexual violence advocacy tend to be women.

Noticing reality is not bigoted in and of itself. (But it’s possible to discuss reality in a bigoted way, obviously. For instance: “Women are the majority of sexual assault victims because men are slavering beasts” or “There tends to be more violence in neighborhoods where the residents are predominantly Black because Black people are more violent.”) If it is true that women are the majority of sexual harassment victims–and, according to current research, it seems to be–then it makes sense to be concerned with reducing sexual harassment against women.

But as I mentioned, such protective measures are useful to anyone who experiences harassment or assault, regardless of gender. When you say that such measures are by default sexist against women, you are assuming that all potential victims are female, and ignoring all the ones who are not. Although I do so hate to play “You’re The Real _____,” it is actually quite sexist to assume that men cannot be victims of sexual harassment or assault, and quite cissexist to assume that non-female, non-male people don’t even exist, as victims or otherwise.

3. That “strength,” whatever that is, is a quality that everyone ought to have, regardless of personal circumstance, and having it makes you clearly superior to those who don’t.

This is probably the main reason this response arises. A lot of people feel good about themselves when they position themselves as strong and independent and maybe a little bit better than those who can’t “take care of themselves.” In this way, the “I’m a strong woman” narrative is actually sort of a reasonable response to sexism. When you’ve been told implicitly and explicitly your entire life that you’re weak because of your gender, why not reimagine yourself as strong? Stronger, perhaps, than other women?

But when you say, “I’m a strong woman and I don’t need this,” what does that say about the women who are not “strong,” who do not consider themselves “strong,” who cannot be “strong” in the ways that you are referring to?

I was originally inspired to write this post after a discussion on my Facebook about an article that I posted about interaction badges. This is a measure implemented at some conferences for Autistic people to help them set boundaries around social interaction. Red badges mean, “Do not initiate interaction with me”; yellow badges mean, “Only initiate interaction with me if we know each other”; and green badges mean, “I would like to talk but have trouble initiating; please initiate with me.” The badges are very useful for people who sometimes have trouble reading subtle social cues from others or sending such cues themselves, which describes many people on the autism spectrum.

I posted about this idea and said that it would be a cool thing to implement at the conferences I go to–not just because plenty of ASD folks attend these conferences too, but because it would be helpful for lots of people neurotypical and otherwise. Predictably, someone said that they’re a “strong woman” and they don’t need this and so on. A friend of mine responded that, well, some of us aren’t strong, and some can’t set boundaries, and why do these people deserve to feel uncomfortable or even unsafe just because they don’t have the capability to be “strong” in this way? How is that fair at all?

There are plenty of legitimate reasons someone might temporarily or permanently lack the ability to assertively set boundaries. People with autism sometimes experience selective mutism, which means they cannot speak. People with social anxiety or similar conditions might panic and be unable to relax and find the words they need. In more extreme situations, sexual assault victims often experience a sort of paralysis that prevents them from being able to speak up and say “no.” This is a documented effect.

Setting boundaries is often exhausting, and different people have different amounts of energy (or spoons, if you prefer that metaphor) to do it. If colored badges make a space more accessible, why not? If you personally don’t need it, who cares?

4. That these protective measures are being implemented with the assumption that everyone needs them.

Actually, most people do not get harassed and assaulted at conferences or elsewhere. Some of the people who do get harassed and assaulted at conferences or elsewhere will have ways to cope and deal with that on their own, without using the resources made available to them by that space. When I was assaulted in college, I decided not to report it or utilize any campus resources for survivors because I didn’t feel that I needed them. When I was harassed at conferences, I decided not to let the organizers know, because I preferred to deal with it in other ways. To the best of my recollection, I have never used any formal procedure for dealing with harassment or assault, for my own personal reasons.

So, for various reasons, you may not need to use a protective measure in a given space. That’s great! Nobody implied that you, personally, need this measure. If you don’t end up experiencing harassment or assault, that’s obviously good. If you do, but you’re comfortable handling harassment or assault on your own, then you don’t need to avail yourself of the measures in place to help survivors. But not everyone is, for more reasons than I’m able to list.

This is why “I’m a strong woman and I don’t need this” ultimately falls so flat for me as an argument for or against anything. Claiming that harassment policies are useless because you don’t personally need them is no more sensible than claiming that a restaurant should not have vegan options because you’re not personally a vegan. And claiming that harassment policies somehow imply that all women (yourself included) are weak and need protecting is no more sensible than claiming that the mere presence of an elevator is accusing you of laziness.

There are people who sometimes need harassment policies and there are people who sometimes (or always) need elevators. If you don’t, ignore it and go about your business.

Or, better yet, understand that others may need help that you do not, and support them in their effort to get it.

~~~

I’ve previously written some other stuff related to this argument:

Also of relevance is the fact that the “strong woman” narrative has particular meaning and significance for women of color.

A Primer On Atypical Depression

At CONvergence two weeks ago, I and a few other people did a panel on myths about mental illness. It was really great, and I hope that there will be a video of it up eventually. At one point, I tangentially mentioned atypical depression, a type of depression that is sometimes contrasted with melancholic depression, or the “typical” kind.

Atypical depression is the type that I have, and that might be part of the reason it took me something like seven years to realize that I had depression at all. A few people have since told me that they didn’t even realize atypical depression was a thing. So I decided to write a brief overview of it in the hopes that more people who don’t have a name for what they’re going through might find a name for it.

There are some “classic” depression symptoms that most people think of when they think of depression: being numb or sad most of the time, being unable to take joy in things you used to like, insomnia, and loss of appetite and weight. You think of the person lying in bed unable to care about or take pleasure in anything.

Atypical depression has a rather different set of features. Instead of insomnia, you may have hypersomnia (oversleeping). People with atypical depression might regularly need to sleep 10 or 12 or even more hours. Instead of loss of appetite, you may overeat and/or gain weight. Instead of being numb or just uniformly sad, you have high mood reactivity, or mood swings. You may find that you’re able to enjoy things and feel happy when things are going very well, but as soon as things are neutral or even just a little bit bad, you feel horrible again. There are two other symptoms that are sometimes present: leaden paralysis, or the feeling that your limbs are very heavy and difficult to move, and high rejection sensitivity, which means being overly concerned about people not liking you or rejecting you, to the point that it impairs your social functioning.

Unsurprisingly, these different sets of symptoms mean that different types of antidepressants may work best for each type. I will quote Wikipedia here, since it’s sourced and there’s no good reason to rephrase it:

Medication response differs between chronic atypical depression and acute melancholic depression. Some studies[4] suggest that the older class of antidepressants, monoamine oxidase inhibitors (MAOIs), may be more effective at treating atypical depression. While the more modern SSRIs and SNRIs are usually quite effective in this illness, the tricyclic antidepressants typically are not.[1] The wakefulness-promoting agent Modafinil has shown considerable effect in combating atypical depression, maintaining this effect even after discontinuation of treatment. [5]

I don’t know how useful this information is to you if you think you may have atypical depression, but at least now you know that if your symptoms fit this pattern but your psychiatrist prescribes you a tricyclic antidepressant without further explanation, it might be worth bringing up this research. In addition, if SSRIs haven’t been working for you, you might ask your psychiatrist about trying MAOIs rather than a different SSRI or a higher dose of the same one.

In terms of therapy, I can’t seem to find any studies on the effectiveness of different types of therapy on the different types of depression (that may be because Google Scholar is actually a terrible search engine), but my educated guess would be that dialectical behavior therapy (DBT) would be extra helpful for atypical depression as opposed to melancholic depression. DBT is a type of therapy developed specifically to treat borderline personality disorder, which involves lots of mood swings, rejection sensitivity, and general troubles with managing emotions. DBT contains a lot of the same techniques as cognitive-behavioral therapy (CBT; the standard of evidence-based treatment), but it also emphasizes mindfulness and learning to cope with strong emotions. Atypical depression, with its mood swings and interpersonal issues, might be especially amenable to it.

To the extent that psychodynamic therapy is effective (actually, plenty of studies suggest that it might be), it might also be more effective on atypical depression than other approaches. Atypical depression tends to have an earlier onset, and people may experience it as an aspect of their personality that is rooted deeply in their life experiences. When practiced well, psychodynamic therapy may be useful for resolving these issues. But none of this is to say that standard CBT should not be tried.

During my senior year of college, I asked a professor who studies the neuropsychology of mood disorders whether or not he knew of any research on neurological differences between atypical and melancholic depression. After all, there’s been plenty of research on how depression affects the brain–in terms of active brain regions, neurogenesis (growth of new neurons) in various regions, and so on. Were all these studies really done using patients who might’ve had what looks like two nearly-completely different illnesses? Apparently. My professor wasn’t aware of any such studies, and I’ve only found one myself: some research that examined which hemisphere of the brain responds more to a particular face test, and in atypical depression patients, the right hemisphere was much more active than it was in melancholic depression patients and in non-depressed controls. The authors write, “This is further evidence that atypical depression is a biologically distinct subtype and underscores the importance of this diagnostic distinction for neurophysiologic studies.”

There also seems to be some evidence that atypical depression in particular is linked to thyroid dysfunction, which may explain some of the physical symptoms. However, the results seem to be rather complicated and confusing, and it’s definitely not a simple causative link.

Although the diagnostic criteria for depression contain both sets of symptom patterns and there’s even a special indicator for “atypical features,” the popular conception of depression is of the melancholic type, not the atypical type. This means that many people, believing that depression necessarily means “being completely miserable all of the time always,” may not realize that they might have depression and can benefit from treatment.

Atypical depression presents a classic boiling-frog problem. Because you are in fact capable of feeling happy for short or medium stretches of time, it can take a serious increase in symptom severity to realize that there’s anything wrong. Incidentally, as I mentioned, atypical depression also tends to have an earlier onset than melancholic depression, which means that you may spend your entire post-childhood life that way. For some people, certainly for me, it felt like it was “just my personality.” To make things even more confusing, the rejection sensitivity tends to be present even during periods of time when the rest of the symptoms are in remission. But when it comes to mental health, nothing is ever really “just your personality” if you don’t want it to be.

Hopefully, this overview will help people–at least the people who read this blog–broaden their awareness of what depression is. If there’s anything I missed in terms of research, by the way, please let me know. As I mentioned, my Google Scholar-fu is much worse than my Google-fu.