What ADHD Actually Is, Part 2

Since I wrote part 1 of this series, I’ve had a lot of wonderful positive feedback from people with ADHD and suggestions for topics to cover in the future. I’ll address more of those here!

(If you haven’t read it yet, part 1 covers the definition of executive function and how it explains ADHD symptoms, along with information about hyperactivity, depression and anxiety in people with ADHD, helpful resources, and how to go about getting a diagnosis and treatment. I recommend reading it first.)

What’s the difference between ADHD and ADD? 

Before 1994, when the DSM-IV came out, the acronym ADD was used to refer to what we now call the “inattentive type” of ADHD–that is, the type where you don’t have hyperactivity symptoms. [1] Now, however, the term “ADHD” is an umbrella term that covers all of the types. Just because the “H” is in there doesn’t mean you have to have hyperactivity symptoms to qualify for that label. “ADD” is outdated and only typically used by people who got diagnosed before 1994. But if it makes sense to you, you can obviously stick to it.

Personally, calling it ADHD regardless of type makes much more sense to me because very few people with the disorder don’t have any hyperactivity symptoms at all–they just might not look like the typical bouncing-off-the-walls stereotype, especially in girls and adults of all genders. Hyperactivity can also mean needing to fidget a lot, or preferring physical/manual activity to intellectual labor. It’s also possible for some people to suppress all of their hyperactive impulses, which means that their observable behavior wouldn’t qualify for the hyperactive type. That doesn’t mean the impulses aren’t there, though, or that it isn’t taking them lots of energy to suppress them.

Why is the prevalence of ADHD increasing?

It’s difficult to obtain accurate data on historical prevalence of mental diagnoses for many reasons–underreporting (especially when it comes to childhood disorders, which parents might want to keep under wraps due to stigma), different research methods, different diagnostic criteria, and so on. According to the CDC, ADHD prevalence really is increasing, but they caveat that claim in the same way I just did. [2]

There’s a difference between more people getting diagnosed with a disorder and more people actually having that disorder. Greater awareness and improved access to mental healthcare could both lead to increased rates of diagnosis, even if the actual prevalence of the disorder has remained the same. I do think that things like that are impacting rates of ADHD diagnosis.

But I also think that a greater proportion of people would qualify for that diagnosis than 50 or 100 years ago, and I think it has to do with the greater role that executive function plays in modern society.

If you think about the types of things most people did for a living prior to the mid- to late-20th century, they didn’t require that much self-regulation. Farming, factory work, housekeeping, mending–these jobs are physically (and often mentally) demanding, but not in the same way as forcing yourself to spend hours at a computer correcting errors in a spreadsheet or researching funding sources. In fact, today, many people with ADHD strive in professions that rely on physical labor, creativity, lots of small bursts of social interaction, or other things that don’t require sustained focus on one thing.

It’s no accident that so many childhood ADHD diagnoses happen because a child can’t sit still in a classroom. Although our current education system dates to the 19th century (and has had shamefully few updates since then), children in the 19th century didn’t necessarily sit in a classroom from 8 AM to 4 PM. They missed school to help on the farm, taught younger classmates (think one-room schoolhouse), and left school altogether at much younger ages than today’s kids are required to stay until.

That doesn’t mean that our education system is the sole cause of increased ADHD prevalence, and that if we went back to some imaginary historic ideal, the prevalence would drop. (Although our education system is pretty shitty for a variety of reasons.) It just means that school and its demands on executive function often reveal ADHD symptoms that might’ve otherwise stayed hidden until later in life–for instance, when the demands of adulthood push people with undiagnosed ADHD to a breaking point.

Didn’t you say that overdiagnosis might still be a thing?

Yeah, I did. I mentioned in the first part of this series that a disorder can be both over- and under-diagnosed if we look for it in places it isn’t and don’t look for it in places it is. One place where we may look for ADHD too single-mindedly is in children who are “disruptive” or “unfocused” in school.

Plenty of researchers and clinicians have observed that children from violent and chaotic neighborhoods often get diagnosed with ADHD because they present with many of its symptoms. [3] However, in children as well as adults, those symptoms might also be coming from trauma, especially the complex trauma that develops when severe life stressors are constant from early childhood on. [4]

When the role of trauma is ignored, these children (who are typically from low-income families of color) often get slapped with the ADHD label, along with its cousin, oppositional defiant disorder (ODD). [5] Unfortunately, for children who are already bearing the burdens of racism and classism, these labels often serve to add on more stigma rather than help provide effective treatment. If you look at the criteria for ODD, they describe behavior that is completely rational and adaptive if many of the adults in the child’s life are violent, neglectful, and inconsistent. And if you look at the criteria for ADHD, they also describe what happens when undiagnosed PTSD limits your ability to self-regulate.

PTSD symptoms put a huge cognitive load on the brain. People with PTSD are usually hyper-vigilant, constantly looking for potential threats (often without realizing they’re doing it). Small disturbances or unpleasant surprises can cause strong reactions that seem excessive to others. When trauma comes from psychological abuse rather than physical violence or disaster, it can be even harder to notice when PTSD symptoms manifest.

A child who has complex trauma as a result of growing up amid violence and abuse is going to have serious issues paying attention in class and remembering their homework, along with maintaining healthy relationships with teachers and classmates and regulating their own emotions. On the surface, that can look like ADHD. But ADHD medication won’t help, and inappropriate use of ADHD medication on children can lead to those “zombie” symptoms everyone talks about. These kids need trauma-informed interventions, along with real structural changes that address racism, gun violence, poverty, and all of those myriad interweaving variables. No psychiatric label could possibly encompass that.

What’s the connection between ADHD and autism?

A lot of my friends have pointed out that they have been diagnosed with both ADHD and autism, and wonder what (if any) the connection between them is. I’ve also had lots of clients with both, although I obviously also know people with one or the other.

These disorders do co-occur more commonly than they would by chance alone. [6] Unlike mental illnesses, they both manifest in childhood and last for life (this is true even for people who don’t notice their ADHD symptoms until adulthood). They both involve executive dysfunction, and research suggests that some similar neural pathways may be involved in both. [7] They both tend to impact all areas of a person’s life, including school, work, relationships (platonic, romantic, familial, and others), self-care, personal pursuits, and so on.

This can make people stressed about figuring out which disorder they have, or if they have both. If this concerns you, remember that we made up these disorders and assigned sets of symptoms to them. They aren’t natural categories. Although diagnoses can be important for accessing treatment and support, the most important thing is identifying what it is that you struggle with and getting help with that.

If you have executive function issues, medication and/or coaching might help. If you have problems with talking over people and talking too much about your niche interests, it might help to get legitimate social skills advice (for instance, the excellent blog Real Social Skills [8]) or to seek out people who interact in similar ways to you. If you feel depressed or anxious as a result of the ways in which your disability impairs you or creates consequences for you in our (ableist) society, counseling can help.

Although there’s a lot of cool research going on involving brain scans and other relatively new techniques, that doesn’t actually explain why some people develop ADHD and/or autism and others don’t. It’s possible that the same set of root causes, both biological and environmental, can contribute to the development of both disorders.

Why can people with ADHD sometimes focus really well/get things done?

Remember, ADHD isn’t about being “unable to focus” or get things done. It’s about executive function. When a lot of executive function is needed to complete a task, people with ADHD will struggle with it. But when it isn’t, they may do very well.

Some situations in which people with ADHD may be very efficient or productive include:

  • when they’re really interested in the task
  • when it’s about to be due and panic kicks in
  • when it involves working with others
  • when they’re given a lot of structure

So, let’s examine each of these. Everyone has an easier time focusing on things they’re really interested in as opposed to things they find boring, and everyone generally finds it effortful to exercise their executive function. People with ADHD just find it harder than others. When you’re really interested in the task, you may not need to use executive function to do it. (You may need it to plan for or structure the task, though, which is why people with ADHD sometimes have difficulty accomplishing their over-arching goals even with stuff they’re really interested in.) Unfortunately, having issues with executive function can also make it more difficult to tear your focus away from something, which is why people with ADHD are prone to what’s called hyperfocus–spending too much time immersed in something to the detriment of other things that need to be done, including basic needs.

Remember, getting really into things you like doesn’t mean you don’t have ADHD. In fact, it could be good evidence that you do have it.

These principles also explain why so many people with ADHD procrastinate. It’s not just that they can’t get themselves to do the task in advance–it’s that procrastination works, but at a cost. When it’s the night before the 15-page paper you haven’t started is due and you’re completely panicking, executive function may no longer be necessary to get yourself to do the task. Other brain regions and processes take over–perhaps, for instance, the amygdala, which is involved in the processing of fear.

Social tasks can also be easier for people with ADHD to complete. The other people in the group may help them with staying on task, structuring the project, and perhaps doing the really boring parts that they don’t want to do. When working independently on a task, people with ADHD are liable to get stuck when they can’t motivate themselves to do a particularly boring or difficult task, or when they simply don’t know what the next step should be and get distracted by something more interesting before they figure it out. A team member may help them cross this hurdle.

Finally, people with ADHD may do very well with tasks when they’re given a lot of structure rather than having to create that structure for themselves. A person with ADHD may love their work (or studies, or whatever) and have few issues focusing on it, but effectively completing complex tasks requires being able to structure them–break them down into smaller tasks, put those tasks in the right order, and keep the big picture in mind rather than getting bogged down in one specific tiny part of the project. (Sometimes called microfocus, this can really get in the way of one’s goals.)

That kind of mental task requires executive function, too. Many people with ADHD do better in high school than in college because there’s more structure built in. For others, college provides enough structure, but work doesn’t provide enough. Still others luck out and find jobs in which structuring your own tasks isn’t required. That’s why many people with ADHD do well in or even enjoy working in retail or food service–as long as they can regulate their emotions well enough to avoid lashing out at irritating customers.

In sum, there are all kinds of situations in which the role of executive function is more minimal than it is in others, and many people with ADHD can thrive in these situations. That doesn’t negate the fact that they have a disability, or that it might still take them lots of effort and trial-and-error to get to that point.

People with ADHD can also learn to utilize the exact types of things that are hard for them–remembering to write things down, using planners, and so on–to make up for what they’re lacking in executive function. That, along with some other stuff I promised to get to (i.e. gender and ADHD), will be discussed in a future installment of this series.


[1] https://www.additudemag.com/slideshows/add-vs-adhd/

[2] https://www.cdc.gov/ncbddd/adhd/timeline.html

[3] https://www.theatlantic.com/health/archive/2014/07/how-childhood-trauma-could-be-mistaken-for-adhd/373328/

[4] https://www.nctsn.org/what-is-child-trauma/trauma-types/complex-trauma

[5] https://www.additudemag.com/oppositional-defiant-disorder-odd-and-adhd/

[6] https://www.additudemag.com/is-it-adhd-or-asd/

[7] https://nyulangone.org/news/tracing-neural-links-between-autism-adhd

[8] https://www.realsocialskills.org


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What ADHD Actually Is, Part 2
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What ADHD Actually Is

ADHD (or ADD, as it used to be called) is such a misunderstood disorder, especially among adults, that I figured I’d dedicate an article to clearing up misconceptions and helping folks who suspect they have it figure out what to do next.

First, some general principles that organize my thoughts on ADHD:

  • ADHD is a developmental disability, not a mental illness. (More on this later.) This means that it begins in childhood and lasts for life. Individual symptoms might wax and wane, and your environment may be more or less conducive to the way your brain works, but ADHD doesn’t get “cured.”
  • Therefore, you do not “age out” of ADHD. If you were (accurately) diagnosed with it as a child, you still have it.
  • It’s possible for a condition to be both over- and under-diagnosed. That’s not contradictory at all. It just means that we’re looking for it in places it isn’t, and we’re not looking for it in places it is.
  • Having ADHD does not mean you have to take medication, and not being helped by ADHD medication doesn’t mean you don’t have ADHD. Those are separate questions, and there are effective strategies for ADHD besides medication.
  • ADHD has neural substrates [1] (I hate using jargon, but there’s honestly no better way to say “a specific thingie happening in your actual physical brain blorb that relates to the behaviors or subjective states you experience and others observe,” so from now on, that’s what “neural substrate means), but like all disabilities, it’s also socially constructed in many ways. That means that culture and community influence how ADHD symptoms are expressed and understood. That means that we shouldn’t be surprised when ADHD presents differently in women, people of color, etc. Rather, that’s exactly what we should expect.

So, what is ADHD exactly? Here’s the only explanation that matters:

ADHD is a disorder of executive function.

That’s it. ADHD is not about being hyperactive, forgetting things, interrupting people, losing your homework, or any other specific symptom. You can have ADHD without exhibiting any of those classic behaviors, but everyone with ADHD experiences impairment of their executive functions.

What is executive function?

Executive functions are the brain processes that help you decide what to do and when to do it. Many of these processes take place in the prefrontal cortex, a region of the brain that evolved relatively recently and helps us with higher-order cognitive tasks.

There are lots of different executive functions, especially if you get really specific with it, but here are some examples:

  • inhibiting impulses that you don’t want to act on
  • temporarily storing information that you need to use or process (a.k.a., working memory)
  • choosing what to pay attention to
  • ignoring distracting stimuli, whether internal or external
  • figuring out what steps it would take to accomplish something
  • having a sense of how long things take (for instance, when you should start getting ready in order to leave on time in order to get somewhere on time)
  • sorting relevant information from irrelevant information
  • switching smoothly between thoughts or tasks (a.k.a., cognitive flexibility)
  • adapting quickly when a plan falls through or new information becomes available
  • paying attention to and noticing your feelings and impulses

All of us, including people with executive function issues, do these mental tasks all the time. Often they happen without conscious effort. For instance, when you read a book without getting distracted every time a car drives by outside, you’re using executive function skills. When you get dressed and leave the house in the morning, you’re using executive function skills.

There are many different components to executive function and they involve different parts of the prefrontal cortex, and other brain regions too. Executive function can be impaired by many other things besides ADHD, such as autism, inebriation, sleep deprivation (or, in my case, narcolepsy), and basically any mental illness. However, when you have depression, the executive function issues resolve when the rest of the depression symptoms do. When you have ADHD and depression, the mood issues might go away but the executive dysfunction remains.

How does executive dysfunction explain ADHD symptoms?

Let’s look at some typical symptom descriptions from the DSM-V criteria for ADHD [2]. First of all, I hate these because most of them are worded in a way that’s specific to children, and most of them just sound really negative and stigmatizing. But it’s what we have for now.

For instance, the phrase “makes careless mistakes” often comes up. “Careless” implies that the person does not care enough about the task, which is why they made the mistake. But that’s not how ADHD works. A person with ADHD might make a “careless” mistake for a number of reasons:

  • They were having trouble choosing what to pay attention to, and did not notice that they were making a mistake.
  • They didn’t realize that the area in which they made the mistake was relevant. It may be obvious to you, but it wasn’t obvious to them, so they didn’t make an effort to avoid the mistake.
  • They forgot a crucial piece of information that they would’ve needed to avoid the mistake and didn’t know how to go about finding out, or didn’t notice that they’d forgotten until it was too late.
  • They couldn’t make an accurate estimate of how long the task would take, and made the mistake or allowed it to remain in their rush to get the task finished.

Here’s another example: “often interrupts.” People with ADHD might interrupt others for different reasons, too:

  • They got so excited about what they wanted to say that they were unable to inhibit the impulse to speak.
  • They know that because of their impaired short-term memory, they will forget what they want to say if they don’t say it now–and they lack the cognitive flexibility to quickly find another way to solve this problem without interrupting.
  • They find it difficult to switch smoothly between speaking and listening.
  • They failed to pay attention to the fact that the other person was still speaking.

Other criteria for ADHD are simply examples of executive dysfunctions themselves, but sometimes diagnostic criteria aren’t very useful because they tend to describe how other people experience the person with ADHD, not how that person experiences their own life and their own mind. For instance, one of the most common things I hear from people with ADHD is “I just feel constantly overwhelmed, like I can’t manage my life and keep up.” That’s nowhere in the diagnostic criteria, and if you said it to a therapist they might assume depression or anxiety. (Which many people with ADHD have, more on that later.) But that’s the feeling that results when your executive functioning doesn’t match what your lifestyle demands.

What about hyperactivity?

Hyperactivity is kind of the red-headed stepchild of ADHD symptoms. Many people with the disorder don’t have it at all (though you wouldn’t know it from stereotypes and media representations), and it’s not necessary for the diagnosis. The DSM deals with this by dividing ADHD into “types”: inattentive type, hyperactive-impulsive type, and combined type. You can still have symptoms from the other category to be one of the “types,” you just have to be predominantly that “type.” It’s kind of confusing (and in my opinion, unnecessary).

Hyperactivity doesn’t initially seem to have anything to do with executive dysfunction, except perhaps in the case of impulsive behaviors. What about executive dysfunction would cause a person to need to fidget, or to talk very quickly or feel restless all the time?

I’m not convinced that ADHD as we currently think of it is all one disorder. I think it’s two that often go together: one that I’d call executive dysfunction syndrome, and another that some researchers already call reward deficiency syndrome.

(Unfortunately, one of these researchers is using the term to promote some dubious claims about genetics and substance addiction[3], but I’ll be using it more generally.)

I don’t want to get too derailed by talking about dopamine, but in a nutshell: when we do or experience things we enjoy, certain brain regions release the neurotransmitter dopamine–especially if the reward was unexpected in some way. The chemical is a sort of a signal to the body to seek out more of the thing.

We know that people vary in how much and under what circumstances their brains produce dopamine, as it’s linked to all kinds of neurological/mental conditions. But it’s possible, too, that there’s a sort of spectrum–for some people, a relatively small reward is enough to trigger a noticeable burst of dopamine, while others need much more.

Maybe people with hyperactive traits are those who need much more–so they’re always on the go, always moving, just to feel as engaged and interested as others may feel just from petting a cat or listening to the rain. And it would make sense, because dopaminergic pathways[4] are involved in executive function, too.

Anyway, that’s mostly (somewhat scientifically-based) speculation, and it doesn’t really matter. The point is, some people with ADHD struggle with hyperactivity, and some don’t. Executive dysfunction is really the core of the disorder.

And what about depression and anxiety?

If you have ADHD, you almost certainly have lots of symptoms of depression and anxiety, too. You may even qualify for the formal diagnoses of those disorders. Think about it: for your entire life, you’ve struggled to accomplish what others see as basic functions. You may have failed classes, dropped out of educational programs, gotten fired (or quit to avoid getting fired) from jobs, lost friends and partners due to executive dysfunction, and generally failed to accomplish what you want to accomplish. Worse, if you’ve been undiagnosed, you haven’t even had the language to explain to yourself (much less to others) why you failed at those things. You’ve probably internalized others’ opinions that you’re lazy, “stupid,” unmotivated, and unlikely to amount to much. Unless you come from a very privileged background, you’re probably terrified about your future and have no idea how you’re going to pay the rent given that you can’t “adult” well enough to get things together.

The thoughts that therapists consider indicative of depression and anxiety–“I’m a failure,” “Nothing’s ever going to work out,” “What if I lose this job/relationship/apartment,” “There’s no point in even trying anymore”–might actually be very “realistic” thoughts for a person with undiagnosed, untreated ADHD to have. Cognitive behavioral therapy teaches people with depression and anxiety to question their automatic thoughts and see how “irrational” those thoughts are. But what if you have very good evidence that you’re probably going to lose your job and alienate your partner, because that’s how it’s been for your whole life?

That’s why it’s very important for people who think they might have ADHD to dig beneath these thoughts and urge their mental health providers to do the same. Antidepressants, anti-anxiety meds, and therapy that’s focused on these symptoms can provide a bit of relief to someone with ADHD, but it won’t do much, and it won’t help with the ADHD symptoms. And that’ll only reinforce the belief that nothing will ever get better.

The good news is that medication, therapy, and lifestyle interventions that are targeted specifically at ADHD are very effective. Even knowing (or suspecting) that you have ADHD can immediately make things better, because it lets you stop blaming yourself and helps you access advice and support that’s helpful. So while your negative thoughts might be “accurate” in a sense–maybe you really have failed at basically everything you’ve tried, and maybe right now you’re failing too–with the correct diagnosis, all of that can change, and it can change quickly.

What should you do if you think you might have ADHD?

For starters, don’t invalidate your suspicions just because a professional hasn’t diagnosed you (yet). Most diagnoses happen because the patient noticed something first.

Unfortunately, when it comes to ADHD, a lot of medical professionals have their own biases which aren’t helpful to anyone in this situation. Be prepared to advocate for yourself a bit. The good news is that once you’re referred to the right professional, you shouldn’t have to keep advocating for yourself. They will advocate with you.

If you have a primary care doctor, tell that doctor about your concerns and ask to be referred for a neuropsychiatric evaluation.[5] These tests are performed by doctors with MDs or PhDs in clinical psychology, and they’re the primary way to diagnose ADHD. They’re also quite accurate because they measure neurological processes that can’t be faked or altered intentionally. So while some people feel nervous about not being believed when they say they have ADHD symptoms, these evaluations are a great way to put that concern to rest. You can’t fake these results just because you want stimulants.

If you don’t have a primary care doctor, but you have a therapist or psychiatrist, same thing. But if you’re not seeing any medical professionals, I’d actually suggest taking the counterintuitive route and setting up a primary care doctor first. They’re sometimes more likely to have a quick referral for a neuropsych eval available.

If you are uninsured, keep in mind that large medical systems and university hospitals often have substantial financial aid available. For instance, Ohio State’s Wexner Medical Center, where I get everything from my annual flu shot to my cancer surgery, provides assistance to anyone whose income is under 400% of the federal poverty line. Some people end up getting their care almost, or nearly, for free.

Most counties also have free or sliding-scale mental health services for uninsured residents. I’m employed by one of those. Our clients get counseling, case management, vocational assistance, psychiatry appointments, and other services mostly for free, and their medication is free, too, through a charitable pharmacy. The only issue with that is that charitable pharmacies won’t stock all psychiatric medications because some are very expensive. Stimulants tend not to be available, but that may not be true for every county.

(Also, here’s my regular reminder that until they have repealed the ACA, they have not repealed the ACA. If you can, apply for insurance this fall.)

Getting diagnosed can be helpful even if you don’t want medication. But even if you don’t get diagnosed, there are lots of ways to cope with your symptoms, whatever they’re technically called. If you have a therapist, explain to them that you’re struggling with executive function and ask them to work with you on that. If you can afford it, you can also work with an ADHD coach[6]. It’s an emerging off-shoot of life coaching that specifically focuses on the challenges faced by people with ADHD. (I actually hope to get trained as an ADHD coach someday when I can afford it.)

Besides that, two books I recommend to everyone who has or might have ADHD are:

  • More Attention, Less Deficit by Ari Tuckman [7]
  • ADD-Friendly Ways to Organize Your Life by Judith Kolberg and Kathleen Nadeau [8]

Here are some articles that people I know have found helpful:

Many people also find the ADHD subreddit helpful.

This article is already getting super long, so I’ll save all my other thoughts for part 2. (A preview: why prevalence of ADHD is increasing, what connection (if any) there is between ADHD and autism, how ADHD affects relationships and emotional processing, and why people with ADHD are sometimes very good at getting certain things done!


[1] https://en.wikipedia.org/wiki/Neural_substrate

[2] https://images.pearsonclinical.com/images/assets/basc-3/basc3resources/DSM5_DiagnosticCriteria_ADHD.pdf

[3] http://blogs.discovermagazine.com/neuroskeptic/2015/06/10/strange-world-reward-deficiency-syndrome-part-1/#.WrphwP0lExF

[4] https://en.wikipedia.org/wiki/Dopaminergic_pathways

[5] https://www.med.unc.edu/neurology/divisions/movement-disorders/npsycheval

[6] https://www.adhdcoaches.org

[7] https://www.amazon.com/More-Attention-Less-Deficit-Strategies/dp/1886941742

[8] https://www.amazon.com/ADD-Friendly-Ways-Organize-Your-Life/dp/1138190748/ref=dp_ob_title_bk


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What ADHD Actually Is

Trump’s Mental Health Diagnosis is Irrelevant

Donald Trump’s mental health diagnosis, if he even has one, is almost entirely irrelevant to any of the questions we are trying to answer about our future and is a pointless and dangerous distraction that we cannot afford.

I regularly diagnose people with mental illnesses. I am myself diagnosed with a mental illness. As far as I can tell, these diagnoses have a few main functions:

  1. Insurance billing. Your insurance company needs to see something from the doctor justifying the money they’re spending on you.
  2. Research. Participants in studies have to be systematically categorized somehow, because a treatment for depression symptoms may not work for eating disorder symptoms and we need to know which it works for.
  3. Treatment. You and your therapist or doctor can use diagnoses to figure out a course of treatment that’s most likely to be effective, and to know what to try next if that doesn’t work. You can also use it on your own to find books and other resources that might help you or a loved one with coping skills and self-acceptance.
  4. Community. When people know what their diagnoses are, they can use those labels to find others who have very similar issues and build solidarity with them.

Notice what’s not anywhere on that list? Predicting a stranger’s future behavior.

Suppose you know that Donald Trump qualifies for the DSM criteria for narcissistic personality disorder. What exactly does this knowledge change? How does it impact your predictions of Trump’s future behavior or your decisions about your own behavior? How is a world in which Trump technically fits those criteria different than a world in which he doesn’t technically fit those criteria?

The only halfway-reasonable answer I’ve ever seen anyone give to any of these questions is that maybe if a fancy doctor examines Trump and concludes that he fits the criteria for some or other mental disorder, then people will finally realize that he’s unfit to be president.

First of all, that’s just false. Trump has been accused of sexual violence by numerous women, saluted by actual Nazis, and implicated in numerous cases of fraud. A bunch of clinical jargon isn’t going to change anyone’s opinion on anything if none of those things have. And given what I’ve gathered from Trump supporters by actually listening to them, many of them don’t recognize the validity of psychiatry, the DSM, or mental healthcare in general.

Second, Donald Trump is going to become president on January 20, 2017. Do whatever you need to do to cope with that knowledge, but it’s going to happen no matter which billing codes his doctors send to his insurance company.

Third, if–after the sexual violence and the fraud and the nepotism and the tax evasion and the naked racism and the probable interference of Russia in the election–it’s mental illness that makes people finally see Trump as unfit for office, that is horrifying.

What that says is that our unjustified, irrational fear of people with mental illnesses is more powerful than the collective evidence of someone’s past behavior.

That being a person with a mental illness is worse than being a rapist.

Worse than stealing the labor of working class people who need that income to put food on the table.

Worse than threatening to imprison and deport innocent people, and having the power to actually do it.

Worse than pandering to Nazis and dictators.

What does that say about the millions of people who share Trump’s supposed diagnosis?

And as awkward as I find it to disagree with a bunch of Harvard psychiatrists with much more experience than I have, we don’t need an expert neuropsychiatric evaluation to tell us that Trump is unfit for office. We already know because he provides evidence of this daily and has been doing so since he first emerged in the public spotlight. We elected him anyway.

And there’s both the bad news and the good news. The bad news is that you can never predict with anywhere near-certainty what someone will do in the future, especially if it’s not someone you know personally. People surprise us every day. It would be nice if we could magically divine a complete catalog of the disasters that Trump will cause while in office, but we can’t. Knowing which DSM criteria he fits will not help with that, and it may even obfuscate it even further.

The good news is that there is one fairly effective way of predicting someone’s behavior, and that is by observing their current behavior and reflecting on their past behavior. Trump has a long and clearly-evident record of dishonesty, boundary violations, fraud, discrimination, nepotism, harassment of journalists and other critics, conservative politics, and other things that most of us generally dislike. It’s a safe assumption that he will continue to do these things in the future.

Mental health diagnoses, on the other hand, are very poor predictors of behavior because the causative link between mental illness symptoms and outward behaviors is much more complicated than simple cause-and-effect. Diagnoses mostly describe internal processes, such as feeling hopeless or thinking everyone’s out to get you, and not outward behavior (although outward behavior can help identify internal processes). Someone who really wishes they were dead may or may not ever attempt suicide or even self-harm. Someone who is scared of elevators may or may not choose to use them anyway for any number of reasons. Plenty of people with depression hide it perfectly even from people who know them well. Someone experiencing hallucinations that tell them to jump out a window may or may not realize that the voices are a symptom of psychosis, and may or may not be able to ignore them and stay away from windows.

Personality disorders, which is what people typically associate Trump with, are an even more complicated thing. For starters, many professionals are skeptical of their validity as diagnoses in the first place because they’re extremely subjective and based much more on local norms of social behavior than on what is actually harmful or distressing for the patient. Regardless, we typically do not diagnose something as a personality disorder unless it’s maladaptive for the individual being diagnosed or they’re unhappy with the way they are. That others are unhappy with the person’s behavior doesn’t count. Trump does not seem to be unhappy with his behavior and you could hardly argue with a straight face that it’s been maladaptive for him.

In any case, I work with individuals with personality disorders on a regular basis and while knowing their diagnosis certainly predicts some of their symptoms–that’s literally the point of a diagnosis–it doesn’t necessarily predict their outward behavior, especially not when it comes to complex roles like running a government. That’s because, as I wrote above, diagnoses mainly describe internal processes.

Having a few random experts declare that Trump officially has a mental illness will not remove him from office or undo any of the harms he has already done or will do by that time. If it could, then we’d have to have a difficult conversation to have about just how badly we want to fuck over ordinary people with mental illnesses for the sake of removing from office someone that we elected in the first place, because that would mean that nobody with a history of mental health treatment will ever be able to hold elected office in this country again.

But it won’t, so the conversation we should be having instead is whether or not we will continue to attribute everything we don’t like in ourselves to mental illness, or whether we will stop demonizing those of us who suffer from it and instead aim our arrows at the proper targets.


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Trump’s Mental Health Diagnosis is Irrelevant

Social Media, Mental Illness, and Vulnerability

“Wow, uh…you’re very open online.” I still hear this from people every so often.

“Yup,” I say, because I don’t assume it was meant to be a compliment.

And it’s true. On my Facebook–which, by the way, is not public–I’ve posted regularly about depression, anxiety, sexuality, sexual harassment and assault, body image issues, interpersonal problems, and other various struggles, big and small, that make up life. Don’t get me wrong–I also post plenty about food, cute animals, books, and other “appropriate” topics for online discussion, although I’ve noted before that there really is no way to win at social media (including refusing to play at all).

People who don’t know me well probably assume I do it “for attention” (as if there’s anything humans don’t do for some sort of attention, one way or another), or because I’m unaware of social norms (they’re not that different where I come from, trust me), or simply because I have poor impulse control. Actually, I have excellent impulse control. I’m not sure I’ve ever acted on impulse in my entire life, with perhaps the sole exception of snapping at my family members when they get under my skin. I know plenty of people who have destroyed relationships, lost jobs, or gotten hospitalized as a result of their impulses. I get…speaking rudely to someone for badgering me about my weight.

Being open about myself and my life online (and to a certain extent in person) is something I do strategically and intentionally. I have a number of goals that I can accomplish with openness (or, as I’ll shortly reframe it, vulnerability), and so far I think it’s worked out well for me.

A lot of the good things about my life right now–and, yes, some of the bad–can be traced back to a decision I made about five and a half years ago, when I was a sophomore in college. I had recently been diagnosed with depression and started medication, which was working out great and had me feeling like myself for the first time in years. (Yeah, there were some horrible relapses up ahead, but all the same.)

I wrote a very candid note on Facebook–later a blog post–about my experience and how diagnosis and treatment had helped me. At the time, I did not know anyone else who was diagnosed with a mental illness–not because nobody was, but because nobody had told me so, let alone posted about it publicly online. While I obviously knew on some level that I wasn’t “the only one,” it felt that way. I certainly didn’t think it would be a relevant topic for my friends. Mental illness was something experienced by Other People and by weird, alien me, not by any of the happy, normal people I knew.

I couldn’t have been more wrong. In response to my post, tons of friends started coming out of the woodwork–both in private messages and in the comments of my post–and talking about their own experiences with mental illness. An ex-boyfriend texted me and apologized for dumping me years prior for what he now knew was an untreated mental illness. Acquaintances and classmates turned into close friends. Circles of support were formed. I started speaking out more and gradually became recognized as an advocate for mental health on campus, and eventually started a peer counseling service that is still active on campus today, three years after I left. These experiences pushed me away from the clinical psychology path and towards mental health services, leading me to pursue internships, my masters in social work program, and now, what looks to be a promising career as a therapist.

All because of a Facebook post that many would consider “TMI” or “oversharing.”

Well, not all because. I don’t know what path my life would’ve taken if I’d made different choices, not just with coming out as a person with depression but with all kinds of things. Maybe I’d still be here, or somewhere similar. But I can’t possibly know that–what I do know is that the decision to make that Facebook post had very far-reaching and mostly positive effects on my life.

This isn’t a “you should come out” post; I don’t do those. I’m writing about myself and why I’m so open. This experience, and others that followed, shaped my perspective about this. So, here’s why.

1. To be seen.

That’s my most basic reason and the one that comes closest to being impulsive. But basically, I don’t like being seen as someone I’m not. I don’t like it when people think my life is perfect because I only post the good things. It hurts when people assume I have privileges I don’t, and when people think I couldn’t possibly need support or sympathy because everything is fine. If I didn’t post about so-called “personal” things,  people would assume that I’m straight, neurotypical, and monogamous, and the thought of that is just painful.

2. To filter people out.

I don’t expect everyone in my life to support me through hard times or care about my problems. Some people are just here for when I’m being fun and interesting, and that’s only natural. However, posting about personal things on Facebook is a great way to filter out people who not only aren’t interested in supporting me, but who are actually uncomfortable with people being honest about themselves and their lives. Otherwise, it’s going to be really awkward when we meet in person and you ask me how I’m doing and I say, “Eh, been having a rough time lately. How about you?” Because I do say that. Not with any more detail than that if you don’t ask for it, but that’s enough to make some people very twitchy because I didn’t perform my role properly.

I don’t want anyone in my life who thinks it’s wrong, weak, or pathetic to be open about your struggles. Because of the way I use Facebook, they don’t tend to stay on my friends list for long, and that’s exactly how I want it.

3. To increase awareness of mental illness.

When I post about my experiences with depression, anxiety, and eating disorders, it’s not just because I want people to know what’s going on with me personally. I also want them to know what mental illness is. When I published that post about depression I mentioned earlier, I didn’t just get “me too” responses–I also got comments from people who said that they’d never had depression and struggled to understand what it’s like, but that my piece helped. Some people took that knowledge and applied it to their relationships with depressed friends, partners, and family members, which I think is great.

It seems weird to write this section now, because so many people in my life have themselves been diagnosed with mental illness or are very knowledgeable about it through supporting others with it. But when I first started being open online about depression, that definitely didn’t describe my social circle, and I’d like to think that my openness is at least part of the reason for the difference.

4. To reduce the stigma of mental illness.

I don’t just want to make people aware of what mental illness is like–I want them to stop thinking of it is a shameful thing that ought to be kept secret. Since I’m fortunate enough to feel safe coming out, I think that’s a powerful action I can take to reduce that stigma. The more people see my posts about depression and anxiety as normal, just like posting about having the flu or going to the doctor, the less they’ll stigmatize mental illness.

Of course, stigma–and the ableism that fuels it–is a broad and systemic problem with intersectional implications that I don’t even pretend to be able to fix with some Facebook posts. But I do what I can.

5. To reduce the stigma of vulnerability, period.

Not everything “personal” that I put online deals with mental illness specifically (although, when you have lifelong depression, everything does tend to come back to that). I write a lot about homesickness, my love for New York (and the pain of leaving it), issues with my family, relationships, daily frustrations and challenges, and so on.

Not everyone wants to share these things with their friends (online or off), but many people do–they’re just afraid that nobody cares, that they’ll be seen as weak, or that there’s no room for this kind of vulnerability within the social norms that we’ve created. That last one may be true, but there’s no reason it has to stay that way.

As Brené Brown notes in her book that I recently read, vulnerability isn’t the same thing as recklessly dumping your personal problems on people. I’ve also written about guidelines for appropriate sharing, and how to deal when someone’s sharing makes you uncomfortable.

The point isn’t to completely disregard all social norms; some of them are there to help interactions go smoothly and make sure people’s implicit boundaries are respected. The point is to design social norms that encourage healthier interactions, and while I’m sure there are some people who can healthily avoid divulging anything personal to their friends, I’m not one of them and my friends aren’t either. So for us, reducing the stigma of vulnerability and encouraging openness about how we feel is healthy.

6. To create the kinds of friendships I value. 

Being open online doesn’t just filter people out–it also filters people in. Folks who appreciate vulnerability read my posts, get to know me better, and share more with me in turn. I’ve developed lots of close friendships through social media, and not all of them are long-distance. In fact, a common pattern for me is that I meet someone at a local event and chat casually and then we add each other on Facebook, at which point we learn things about each other that are way more personal than we ever would’ve shared at a loud bar or party. Then the friendship can actually develop.

I’ve been very lucky to find lots of people who appreciate this type of connection. People who don’t always answer “how are you?” with “good!”, who engage with “negative” social media posts in a supportive and productive way rather than just ignoring them or peppering them with condescending advice or demands to “cheer up!” People who understand that having emotions, even about “silly” things, doesn’t make you weak or immature. People who understand that working through your negative/counterproductive emotions requires first validating and accepting them, not beating yourself up for them or ignoring them.

So, that’s why I’m so open online. If you don’t like it, you don’t have to read it. But I’m not alone in it, and it’s becoming less and less weird. It’s hard to believe that just a few years ago, I was the only person I knew with depression. Not only do I now know many, but I’m also so much more aware of all sorts of joys and sorrows I haven’t personally experienced–all thanks to my friends’ openness online. For a therapist–hell, for a human being–that’s an invaluable education.


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Social Media, Mental Illness, and Vulnerability

How to Get the Most Out of Therapy

Drawing of a therapy session in progress.
Credit: Guy Shennan

When you spend a lot of money on things, they usually come with an instruction manual to help you use them in the most effective possible way. Unfortunately, therapy doesn’t.

A common misconception about therapy held by many laypeople (and, unfortunately, some therapists) is that all you have to do as a client is show up and then…some vague hand-wavey magic stuff happens, and then the client gets better. Many people think of therapy like this:

  1. Go to therapy
  2. ???
  3. PROFIT

Really, though, it’s more like this:

  1. Go to therapy
  2. Establish some rapport with the therapist before you can delve into the serious stuff
  3. Sometimes be really uncomfortable
  4. Have a lot of meta-conversations with your therapist–that is, talk to the therapist about the process of talking to the therapist
  5. Do homework (in some types of therapy)
  6. Get called on your shit by the therapist
  7. Be uncomfortable again
  8. Make changes in your life outside of therapy
  9. PROFIT

As a therapist, it’s tempting to say that you should just show up and let the therapist do their job and you’ll feel better. Sometimes that’s exactly how it works. But ultimately, you can only get as much out of therapy as you put into it.

Continue reading “How to Get the Most Out of Therapy”

How to Get the Most Out of Therapy

When Including Friends with Chronic Illness Feels Like Ignoring Boundaries

Text reads, "Plans? Yeah, I know...I cancel, I postpone, I reschedule, I delay committing. Illness sometimes controls my schedule, but I am determined it won't control me! Please keep inviting me."
I’ve been seeing a bunch of memes lately to the effect of, “keep inviting your chronically ill friends to things, even if they always say no/flake out/don’t respond at all/etc.”

(Chronic illness here refers both to mental illness and to chronic physical conditions like fibromyalgia and fatigue.)

That’s a bit of advice that I’ve endorsed and given myself, especially having so often been that exact chronically ill person. I do think that those who are close to someone with a chronic illness and want to be supportive should, if they can, make that extra effort and try to get past their own feelings of rejection to try to include that person, because even if they always say no, the invitations may be a heartening reminder that they’re still wanted and missed. That’s easy to forget when you’re in the throes of a chronic illness flareup, especially if it’s depression.

Lately, though, this advice has been giving me cognitive dissonance and I think I’ve figured out why.

Continue reading “When Including Friends with Chronic Illness Feels Like Ignoring Boundaries”

When Including Friends with Chronic Illness Feels Like Ignoring Boundaries

The Mental Health Advocate Pedestal

[Content note: depression and eating disorders]

I recently read Olivia’s excellent blog post, “I’m Tired Of Curating.” In it she describes her experiences as a mental health advocate and a person with mental illness(es), and it resonated a lot with me:

I’m not allowed to share these thoughts because they glorify an eating disorder, because I’m not actively telling people how awful it is to be sick, because I’m remembering how intertwined I am with the disease, the way it really is part of the way my mind works rather than something that needs to be kicked out of my life.

[…] I’m sick of trying to spin these thoughts into something useful or meaningful. Since I’ve started to write openly about treatment and recovery and mental illness, I feel as if I need to be a role model or someone that others can look to to see that mental illness does not destroy your life. And yet it’s consumed all of mine and I feel as if I’ve gained nothing except 50 pounds.

I don’t want to curate my words today. I don’t want to be careful not to trigger anyone or to mistakenly portray the ways I behave in a positive light. I want to be allowed the space to honestly portray my mental illness, including the way that it looks seductive when I’m anxious and overwhelmed. Right now restriction is the only thing that makes sense to me. I hate having to hedge that with the caveat that I know it’s not healthy and no other people shouldn’t do it and yes it will fuck up my life.

[…] As someone who has a mental illness and advocates for people with mental illnesses, sometimes I feel like I’m not actually allowed to have my mental illness. Sure, I get to talk about the experience and share inspiring stories or even stories about how nastybad it is and tips and tricks that I’ve picked up, but I don’t get to publicly have the thoughts and feelings that come with a jerkbrain. I don’t get to type “I think I’m a shitstain on the world” without people disregarding everything else I say. I don’t get to type “I truly would like to skip all upcoming meals indefinitely” without being accused of promoting unhealthy behaviors. Newsflash world: I have depression and an eating disorder. These are things that I think on the regular. If it’s too ugly to see it and you have to look away when I can’t be polished, then I don’t understand the point of my activism and advocacy. I don’t understand why I write anymore.

When I read this, it suddenly put my experiences into a context that made sense. Because I’ve been there.

Not only have I felt like I couldn’t share my negative experiences with mental illness, but I was also made to feel like I couldn’t share my victories, either. I once posted on my personal Facebook that I was proud of myself for having been (safely) off of medication for a year, and someone messaged me letting me know that I shouldn’t post things like that because it’ll make people who still need to be on medication feel bad, and that this might be helpful for me to know “considering [my] future career.” Except my personal Facebook page isn’t the same as my professional counseling website, and it’s not even the same as my blog. It’s my space to share my life with my friends. The purpose of my Facebook is to connect with my friends, not to affirm other people. Of course, I like to affirm other people and often try to, but that shouldn’t be an expectation placed on me. It shouldn’t have to be the primary goal of my self-expression.

So that’s a weird, narrow line we mental health advocates have to walk. We’re criticized for being honest about the ugly sides of mental illness (either because it means we’re “glorifying” mental illness or because we’re “confirming negative stereotypes” or [insert accusation here), and we’re criticized for “making others feel bad” when we’re honest about successful recovery. (And, yes, I get to simultaneously believe that there is nothing wrong with taking psychiatric medication and to be proud of myself for getting to a place where I am able to stop taking it. You can accept medical treatment as necessary and morally acceptable and you can be glad when you don’t need medical treatment anymore!)

As a result, we end up presenting a sanitized version of our actual struggles that’s neither overly negative nor inappropriately jealousy-inducing. “Jerkbrain’s really getting me down today, please send cute animal photos.” “Today sucked so I’m going to do some much-needed self-care.” And so on and so forth. Obviously, those can be completely valid and genuine expressions, but as Olivia pointed out, sometimes it’s a lot less pretty.

A while back, I wrote about a particular strain of criticism of people (generally teenage girls) who “glorify” or “enable” mental illness symptoms by presenting them in a romantic or sexy light. The argument goes that these blogs may discourage young people from seeing their mental illnesses as treatable (or seeing them as illnesses at all) and encourage them to do harmful behaviors associated with those illnesses–self-harm, restricting, purging, etc. In that post, I concluded: “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.'”

Unfortunately, as I’m learning, it’s not actually particularly difficult to say that at all; you just have to be a little more subtle. Certainly nobody in our communities would ever come right out and say that people with mental illnesses should hide all of their symptoms; heavens no, that would be ableist. Instead, they fill our Facebook threads with condescending reminders to “take better care of yourself” and “that’s just jerkbrain talking.” We can discuss our symptoms as long as we make it absolutely clear that we hate the symptoms and the illness and are completely dedicated to the project of making a full recovery. To admit that sometimes we don’t want to recover is to “glorify” mental illness and “enable” others. It’s to “confirm stereotypes” about people with mental illness, as if the problem is overlapping with a stereotype and not stereotyping people to begin with.

The Mental Health Advocate Pedestal is real and it’s a narrow ledge to squeeze yourself onto. Be honest, but don’t freak us out. Motivate those who are still struggling, but don’t give a rosy and unrealistic perspective. Hate your illness because it’s unhealthy and bad for you, but don’t hate your illness because that’s ableist and implies that there’s something wrong with having a mental illness. Recover, but not so much or so visibly that you make others feel bad. Accomplish because it’s inspirational for others and because people with mental illnesses can do anything neurotypical people can, but don’t accomplish too much, or else are you sure you’re really all that mentally ill? Maybe you just want attention.

I used to blame myself a lot for doing what Olivia calls “curating”–for only portraying my depression in a particular way, not too negative and not too positive. Now I’ve come to see it as a double-bind that everyone who discloses mental illness is placed in, one way or another. Why is it that we’re the ones constantly accused of “encouraging” mental illness when everything about the way our society is set up encourages it? Why is a teenage girl who posts a selfie of herself with mascara tears running down her face any more responsible for someone else’s mental illness than the neurotypical adults who tell each other to “calm down” and “just get over it,” or the boss who creates a stressful and anxiety-provoking work environment, or the primary care doctor who fails to spot the warning signs of depression and refer their patient to a therapist, or the parent who tells their teenager that they’ll “grow out of it”?

We all contribute to ableism and mental illness stigma in various ways, and those of us who actually have mental illness tend to be more aware of that than anyone.

As usual, I’ve got no solution to this except to pay attention to your automatic responses to folks with mental illnesses discussing their experiences. Watch what makes you go “Wow, that is So Real, that is So Brave of you to share” and what makes you go “Uh, are you sure you want to post that so publicly?” The answer might be instructive.

~~~

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The Mental Health Advocate Pedestal

"How can I support you?"

When people share mental health struggles online, well-meaning friends and followers often rush in to give them unsolicited advice. That’s something many of us find irritating and push back on. One of the responses we get often goes something like this: “But I give advice because I need to say something. How am I supposed to know exactly what they need?”

These days my response is usually the same: “Have you tried asking them?”

It’s both surprising and unsurprising how often the response is: “Oh. I didn’t think of that.”

It’s surprising because, rationally, that seems like the obvious thing to do when someone is struggling and you have no idea how to help them. It doesn’t make sense to waste your time and energy and risk upsetting or pissing them off by guessing what they might want and offering that. When you need information to make a good decision, and the information is readily available by asking someone who is as close as it gets to being an authority on the subject, it makes sense to just ask them.

At the same time, it’s also utterly unsurprising that people so rarely do this.

For one thing, we have all these cultural scripts about how this stuff is supposed to go, and one of them is that if you’re really a good friend/partner/family member to the person who’s struggling, you will “just know” what they need and be able to offer it without needing to be told. On the flip side, you might believe that if someone is really a good friend/partner/family member to you, they shouldn’t have to ask you what you need; they should just know. If they do ask, and you tell them, and they do that thing, then that might be nice and all, but it’s not as special as it would’ve been if they’d just known.

You’re probably familiar with these dynamics from discussions of sexual communication and the importance of asking/telling partners what they’re/you’re into, but this applies to so many other interpersonal situations.

That second part is talked about a little less often than the first, because the first seems on the surface to do more immediate harm. But they’re two sides of a coin. We need to get rid of that sort of thinking in order to be able to intentionally create strong, communicative relationships of all kinds.

In fact, I suspect that a small part* of the reason many people are vague about what they need when they let close ones know about their struggles is because they hope that those close ones will be able to help them without being explicitly told how. When you’re neck-deep in some sort of life shit, that sort of effortlessness can be so incredibly affirming. It satisfies a need many people have to feel taken care of.

(*Note I specifically said “small part”; there are many other, probably more significant reasons people do this, such as not knowing what they want, not having the emotional energy to communicate extensively/clearly, fearing criticism or pushback for stating what they really want, etc)

Besides cultural scripts about Just Knowing what someone wants, another reason people might not ask “How can I help?” is that they worry about annoying the person or putting an additional burden on them (that is, making them explain what it is they need). While that’s definitely a risk, especially with someone who expects you to Just Know, it’s significantly less annoying than shoving useless (or even harmful) advice or assistance at someone.

In her article about unsolicited advice online, Katie Klabusich lays all this out in a great way:

“How can I support you?” is a question that works in almost every situation imaginable. It preempts judgement and assumptions while oozing humility. Often the person won’t have an immediate answer—likely because they aren’t used to being asked a question that’s about what they actually need as a unique human being. If they look stunned, I suggest something like: “It’s OK if you don’t have an answer or don’t need anything right now; the offer’s open for whenever. Just let me know.” And then use an emoji of some sort or make a face that conveys warmth so they know you mean it. (This could be a unicorn, the two señoritas dancing, or the smiling poo. Up to you.)

*Here’s the fine print: you have to believe their answer, whatever it is. If they tell you they don’t need anything, you don’t get to push or pressure or demand they give you something to do so you feel less helpless. Remember, this isn’t about you.

Following up a few weeks or months later (whatever equals “a while from now” with the two of you) is totally fine. Asking clarifying questions about what they need if they need something is also totally fine. Being unsure and having to ask along the way if the thing they asked for that you’re trying to provide is helping or being provided in a helpful way is also totally fine.

Telling the person you don’t know if the thing they need is something you can do is also totally fine; no one expects you to be everything they need, and we’d all rather you not promise than drop the ball. These are all honest, humble, supportive responses and, frankly, just being asked “How can I support you?” will make the person feel less alone and more cared for.

 

As Katie notes, the fact that many people won’t have an answer right away doesn’t mean that the question was wrong. It could mean that they’re surprised at actually being asked, and it could also mean that they’re not used to thinking of some of their needs as needs. For instance, we might ask someone for advice or for practical assistance, but it feels a little weirder for most people to ask someone to just listen or to tell them something affirming. Being asked “How can I support you?” can help shift them into that way of thinking about it: “Hm, what would feel supportive for me right now?”

Feeling supported is not always the same as Making The Right Decision or Growing As A Person or whatever, which is another reason people are sometimes hesitant to ask others what they need to feel supported. “But what if they’re making the wrong decision!” they might protest. “I need to tell them they’re Doing It Wrong!”

Yes, there are some cases in which it’s probably a good idea to speak up and rain on someone’s parade because you’re seriously concerned about their safety or wellbeing. But most cases are not that and most people are not the kinds of people you have that relationship with (i.e. children, little siblings, partners with whom you have that sort of understanding, etc). I have watched friends and partners make decisions that I personally thought were bad decisions, but because they were clear with me that they wanted support/affirmation and not constructive criticism, I kept my concerns to myself. For the most part, those people turned out okay, because they are adults and they have the right to make their own decisions.

I’ve written before that self-awareness is really important when you’re trying to help people, because you need to make sure you’re not just doing it to try to relieve your own feelings of helplessness. Even if you are doing it to relieve your own feelings of helplessness, you can still go ahead and try to help, as long as you acknowledge those feelings and understand that they are your responsibility and not that of the person you’re trying to help. Only then can you focus on helping them in the way they need rather than in the way you need.

Asking what they need is a big part of that. Don’t try to show off how amazing you are at magically intuiting what they need. You’re likely to mess up and cause more trouble than you solve. Just ask.

“How can I support you?” is not a magic question. It will not necessarily get you the answers you need or them the help they need. Maybe that phrasing sounds weird and stilted to you; try not to get too caught up in that and find other ways to ask the same essential thing. The point isn’t the exact words, but rather the idea that you should figure out how best to help someone before trying to help them. They might not always know, but they certainly know better than you do, even if it takes them some time to be able to access that knowledge. They are the expert on what they need, or as close to an expert as anyone is going to get.

Be prepared, too, for the answer, “Nothing.” Sometimes people share their struggles not to get help or support but to be heard and witnessed. Sometimes they don’t know why they’re sharing at all. Sometimes they will tell you that the best way you can support them is to hear what they have to say; sometimes they will tell you, “Nothing.” Thank them for their honesty and move along. “Nothing” is a difficult thing to hear, but it is also a difficult thing to say.

~~~

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"How can I support you?"

How Mental Illness Labels Help

I wrote this piece for Everyday Feminism. Please note that it’s based on my own experience and I include a section about how it doesn’t apply to everyone, so please read all the way through before commenting.

When I was first diagnosed with depression as a nineteen-year-old college freshman, I felt an emotion you might not associate with getting diagnosed with a mental illness: relief.

I was relieved that it was actually a real illness and not just a personal fault. I was relieved that there was treatment available for something I thought was just my burden to carry for life. I was relieved to have the language for the background noise of hopelessness, sadness, and pessimism that I had experienced for as long as I could remember.

Not everyone agreed.

Concerned loved ones questioned my decision to accept the diagnosis and use it as a personal identifier when relevant. They worried that thinking of myself as a person who has depression would prevent me from taking responsibility for recovery, or that telling others about it would cause them to judge me and abandon me.

Many people wondered why I needed to concern myself with labels at all. Couldn’t I just go to therapy, take my medication, and leave the technical words out of it?

Actually, I don’t think I could.

Identifying with the label “depression” has helped me in a number of ways, both with recovery and with coping with the symptoms that I still have.

Here’s how.

1. Finding Helpful Information About Mental Illness

The most basic way that mental illness labels have helped me is that they’re a great way to find information about mental illness.

Sounds obvious, right?

But many people who disparage labels don’t realize that you’ll probably find a lot more useful stuff if you Google “how to cope with depression” than “how to stop feeling sad” or “what to do when you feel numb.”

When I was first learning about mental health – both in general and mine specifically – I looked up a lot of things online and read a lot of books.

My searches led me to life-changing perspectives like Andrew Solomon’s The Noonday Demon, which helped me understand different ways in which depression can manifest itself, and Peter D. Kramer’s Listening to Prozac, which helped me feel much less ashamed about needing to take medication.

These books have “depression” and “antidepressants” in their subtitles, and I wouldn’t have found them without knowing what to look for.

Many people first realize they might have a mental illness by looking at simple, nonjudgmental websites like WebMD, Mayo Clinic, or even Wikipedia.

Unlike some of the people in our lives, these websites won’t tell you that “it’s all in your head” or “other people have it worse.” They present scientific information in a way that’s easy to understand and relate to.

But in order to end up on one of these pages, you generally need to have a diagnosis in mind.

Even if you’ve already been diagnosed and started treatment, knowing your diagnosis can help you find information that’ll help your treatment.

For instance, if you’re looking up information about borderline personality disorder, you might learn that dialectical behavior therapy is one of the best treatments for it. This can help you find therapists who specialize in DBT, join groups that use it, and learn some techniques on your own.

Read the rest here.

How Mental Illness Labels Help

A Good Critique of the Medical Model is Hard to Find

I was optimistic about reading this critique of the medical model of mental illness by professor of clinical psychology Peter Kinderman, in part because it is written by someone with experience in the field and in part because it is published on Scientific American, which I trust.

However, while the article makes a number of good points that I will discuss later, it starts off immediately with such a tired and oft-debunked misconception that I almost quit reading after that:

The idea that our more distressing emotions such as grief and anger can best be understood as symptoms of physical illnesses is pervasive and seductive. But in my view it is also a myth, and a harmful one.

I’ll say it again for the folks in the back: nobody* is trying to medicalize “distressing emotions such as grief and anger.” They are medicalizing mental patterns (which can include cognitions, emotions, and behaviors) that are not only very distressing, but also interfere with the person’s daily functioning. It’s kind of like how some stomachaches are minor annoyances that you wait out (or take a Tums), and some land you in the ER with appendicitis. Therapists and psychologists are not concerned with the mental equivalent of a mild cramp.

In general, people don’t end up in my office because they get pissed off when someone cuts them off in traffic; they end up in my office because they are so angry so often that they can’t stop physically attacking people. They don’t end up seeing the psychiatrist down the hall because they get jittery and uncomfortable before a job interview; they see the psychiatrist because they feel jittery and uncomfortable all the damn time, and they can’t stop, and they can’t sleep, even though they rationally know that they are safe and everything’s okay.

I understand that it’s more difficult to grok differences in degree as opposed to differences in kind, because Where Do You Draw The Line. Yes, it would be easier if mentally ill people had completely different emotions that had completely different names and that’s how we knew that they were Really Mentally Ill, as opposed to having emotions that look like more extreme or less bearable versions of everyone else’s. (Sometimes, from the outside, they even look the same. “But sometimes I don’t want to get out of bed either!” “But sometimes I feel sad for no reason either!” Okay, well, you might be depressed too. Or you might find that those things have no significant impact on your day-to-day life, whereas for a person with depression, they do.)

But it really doesn’t help when you’ve got mental health professionals obfuscating the issue in this manner.

As I said, Kinderman does go on to make some really good arguments, such as the fact that psychiatric diagnoses have poor validity and reliability. This means that they don’t seem to correspond that well with how symptoms actually look “on the ground,” and that different diagnosticians tend to give different diagnoses to the same cases. However, these are criticisms of the DSM, not of the medical model. I’ve felt for a while that we should move away from diagnostic labels and towards identifying specific symptoms and developing treatment plans for those symptoms, not for some amorphous “disorder.”

For instance, suppose I’m seeing a client, Bob. After getting to know each other for a few weeks, Bob and I determine together that there are a few issues he’s particularly struggling with: self-hatred and feelings of worthlessness, guilt, difficulty sleeping, lack of motivation to do anything, loss of interest in things he used to enjoy, and frequent, unbearable sadness. Traditionally, I’d diagnose Bob with major depression (pending a few other considerations/differential diagnosis stuff) and move on with treatment. But without these often-invalid and unreliable diagnostic labels, I just skip that step (although I might let Bob know that “depression” might be a useful word to Google if he’s looking for support and resources). Instead, Bob and I look at his actual symptoms and decide on treatments that might be helpful for those particular symptoms. Cognitive-behavioral therapy might help with Bob’s self-hatred, feelings of worthlessness, and guilt. Behavioral activation might help with his lack of motivation and interest. Certain dialectical behavior therapy modules, such as distress tolerance, might help him cope with sadness in the meantime. Antidepressants might very well help with all of them!

Because mental healthcare doesn’t treat disorders; it treats symptoms. Whether that mental healthcare is medication, therapy, or some combination, the ultimate goal is a reduction in symptoms.

I can see how the medical model makes this seem bad when it isn’t. In traditional healthcare, treating symptoms rather than getting to the root of the problem is downright dangerous. If someone has headaches and you give them painkillers without diagnosing their brain tumor, they’re in serious trouble.

However, we haven’t yet developed great ways of figuring out what “the root of the problem” is when it comes to mental symptoms, especially since there often isn’t one. It’s almost always some complicated tangle of genetics, early childhood stressors, interpersonal patterns learned from family, sociocultural factors, and so on. All of this affects the brain in fundamental biological ways, which further drives the symptoms.

Thankfully, that’s not as much of a problem as it would be with a physical health condition. If you only focus on symptoms and don’t treat the underlying cancer or diabetes or whatever, it will slowly kill you. But if you successfully treat the symptoms of mental illness, you will make the person’s life much better no matter what originally caused the symptoms. There won’t be anything silently killing them in the background, and good therapy teaches people the skills to avoid future relapses of their symptoms.

Sometimes the root cause of mental illness is, as Kinderman points out, a social problem. Poverty, social inequality, and other issues contribute heavily to mental illness. But since you can’t solve those issues from the inside of a counseling office, all you can do is help your client as much as possible. I do this every day, and believe me, it feels weird and gross at times. But what else can I do? Until our fucked-up society decides to come in and take a seat in my office, I can only work with my clients as individuals. (Otherwise I would have a very different job and it would not be therapy.)

Kinderman argues that treating mental illnesses as diseases is wrong because of these social factors that contribute to them. I understand his concern, because he (and many other people) treat “disease” as synonymous with “thing that is entirely biologically based.” So, the medical model feels like an erasure of the complex and valid social dynamics that contribute to what we call mental illness.

But I don’t think of disease that way at all, and I’m betting most doctors don’t either. Social factors contribute heavily to physical illnesses, too. People who are living in poverty or who are marginalized by the healthcare system in other ways are much more likely to have all sorts of physical health problems, and the results tend to be more severe for them. Stress, which includes the stress of poverty, racism, and other social problems, makes everyone more vulnerable to illness. Eating well and exercising enough, two very important factors when it comes to physical (and mental) health, are not equally accessible to everyone. Heart disease and diabetes may have biological origins, but they do not happen in isolation from societal factors, either. Just like mental illness.

You might argue that physical illnesses and mental illnesses differ in that physical illnesses are more heavily caused by biological factors and mental illnesses are more heavily caused by social factors, and I might agree. But again, that’s a difference in degree, not kind. Both types of illnesses affect us physically and mentally.

Another good argument that Kinderman presents is that the medical model may not help reduce stigma, and there’s research to back this up. Kinderman writes:

Traditionally, the idea that mental health problems are illnesses like any other and that therefore people should not be blamed or held responsible for their difficulties has been seen as a powerful tool to reduce stigma and discrimination.

Unfortunately, the emphasis on biological explanations for mental health problems may not help matters because it presents problems as a fundamental, heritable and immutable part of the individual. In contrast, a more genuinely empathic approach would be to understand how we all respond emotionally to life’s challenges.

So, that’s important and deserves highlighting.

However, I think the issue of how best to reduce stigma against mental illness is slightly separate from the issue of how best to help people with mental illnesses feel better. (There’s a school of thought in the disability community that disabilities [including mental illnesses)] “hurt” only because of the stigma and prejudice against people who have them, and I’m not particularly equipped to engage with that here except to say that it makes me angry in a way I can’t possibly explain. It completely invalidates how awful and wretched I felt because my symptoms hurt unbearably and not because of anything anyone else said or did to me as a result.)

When it comes to what people with mental illnesses actually find helpful, for some it’s the medical model and for some it isn’t. In her piece on mental “sick days,” Katie Klabusich writes about how freeing it actually was to see herself as “sick” when she needed to take a day off due to her mental illness:

I’d realized that not only is it alright for me to think of the dysthymia as the illness that it is, it’s necessary. If it were a south-of-the-neck illness, I wouldn’t have had the conflict about it. Yes, I’ve worked when I had a virus and shouldn’t have. (See the stats on service industry staff who work when they’re sick; we’ve all done it.) But my thought process would have been totally different. I certainly wouldn’t have needed the Ah ha! moment to know I had the flu. So why didn’t I realize I was sick?

Our culture impresses upon us that we SUCK IT UP and GIT ER DONE when our “issue” is “just mental.” Except . . .

MY BRAIN IS PART OF MY BODY.

It turns out that what happens in my head has a real—not imagined or exaggerated—physical affect on my other bodily functions. That list of symptoms from a dysthymia flare? They’re worse than the flu. Full-blown body aches and exhaustion alone are enough to make just sitting up nearly impossible. What work Idid do last week was all done from bed. Including writing this.

Others may not find that way of thinking helpful, in which case, they should absolutely abandon it in favor of whatever does help.

I want to end on a cautionary note about this whole idea of the medical model “pathologizing” “normal” emotions, because the alternatives I sometimes see offered to the medical model seem far, far worse about this. While Kinderman seems to argue sensibly for a more “psychosocial” approach to mental healthcare and a reduction in the use of medication (which I disagree with, but at least it’s sensible), others turn entirely away from scientifically validated treatments into “holistic” or “alternative” treatment. In many of these communities, “positive thinking” is seen as the only treatment you need, and anything that strays from the “positive” (like, you know, the negative emotions that are a normal part of almost any mental illness) is actively preventing you from recovering. There’s a very victim-blamey aspect to all of this: if you’re unhappy or sick,” it’s your own fault for not thinking positively enough.

I’ve had clients from these communities in counseling, and it’s very difficult to get any work done with them because they only ever want to share “positive” thoughts and feelings with me. As it turns out, medical model or no, they have completely pathologized any sort of negative emotion–including, in fact, the totally normal negative emotions that all of us experience all the time.

Yet it’s those evil psychiatrists who don’t want anybody to be sad or angry ever. Okay.

Some critiques of the medical model are quite valid and very useful. Others seem to rest less on evidence and more on a general sense of unease about the idea of thinking of mental symptoms as, well, symptoms. Kinderman even implies that it’s unethical. But “makes me uncomfortable” isn’t the same as “unethical,” as we all know. Unless I see evidence that this conceptualization is harmful overall, I see no reason to throw it out.

That said, if you’re a mental health provider and you have clients who are clearly uncomfortable with this model, maybe don’t use it to explain their conditions to them, since it’s unlikely to be helpful. All of these labels and diagnoses and explanations should serve the client, not the other way around.

And if you’re a person who experiences some significant amount of mental distress and you can’t stand thinking of it as an illness, then don’t! You don’t have to think of it in any way you don’t like. I hope you’re getting treatment of some sort that works for you, but at the end of the day, it’s actually none of my business.

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*Yes, there are probably some bad psychiatrists out there who think that grieving at the loss of a loved one is literally a mental illness. There are also surgeons who leave crap inside of people’s bodies or amputate the wrong limb. I see these as roughly analogous.

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A Good Critique of the Medical Model is Hard to Find