The Expanding Staircase

Square spiral staircase
Photo by Elena Kuchko on Unsplash

The following is a work of fiction, based on my experiences working with clients but not a reproduction of an actual session with a specific person.

My office, any given day:

— It just feels like I’m not making any progress. I mean, I know I’m making progress, but…it just doesn’t feel like it.

— Yeah. It’s hard to keep going when you can’t tell where you are.

— Yes, it’s like, I keep doing the things that are supposed to help—getting in to see you, getting in to see the psychiatrist, getting the referral for the assessment, starting the medication—but each step takes such a long time, and then that psychiatrist turned out to be unable to do the assessment, and then when I finally got the referral and scheduled it, it turned out they don’t even do those assessments either…

— Does it feel like those steps—for instance, getting in to see the psychiatrist or starting the medication—are getting you to where you want to go?

— Not really, because the psychiatrist couldn’t do the assessment, and the medication isn’t really helping so now I have to try another one.

— Right. It’s frustrating when the steps you take don’t seem to “count.”

— Exactly. Like, if the medication isn’t helping, did that step really take me anywhere?

— What does your gut tell you?

— No. Well, I don’t know. Obviously I had to try the medication that was offered first. The doctor wouldn’t have known it wouldn’t work until I tried it.

— But nevertheless, it doesn’t really feel like a productive step.

— No, it doesn’t.

— So, what if…we know that this process can take a really long time. That’s really frustrating and disempowering, but the delays are part of the process—

— But a lot of those delays are because I keep procrastinating. Like, I don’t even know why I haven’t called the next place yet. I got the referral from the doctor and it’s in my phone somewhere but I don’t even remember what it’s called right now. And if I hadn’t missed that one appointment, I would’ve seen the psychiatrist much sooner, started the medication sooner…

— That’s what I mean, though. That is part of the process. You’re struggling with executive function. So of course it’s going to take a bit longer to do some of these things than it might for some other people. And that’s not even taking into account the other part, which is the delays inherent in the system—waiting for the doctor to have availability, waiting for insurance to approve the medication, and so on.

— So…

— So, imagine you could somehow know all of the steps that this would take. And imagine that the steps are a literal staircase that you’re looking up at, and each flight of stairs is a stage of this process. At the top of the stairs is your goal—having an accurate diagnosis, having effective treatment, managing the symptoms, succeeding in school. It’s a really tall staircase—obviously, we’re not making this too fantastical of a thought experiment—but you’re already part of the way up. For instance, the first flight of stairs was realizing you needed to go to counseling. The second flight was getting in to see me. The third was telling me about your symptoms, and me figuring out that you probably have ADHD. The fourth was getting in to the psychiatrist, who could prescribe some medication that might help but couldn’t do a formal ADHD assessment. The fifth was trying the medication. The sixth was getting the referral for testing—you get the point.

— Right, so I can tell that I’ve gotten off the ground at least.

— Exactly. And you’re looking up to the top of the staircase and it still seems quite far away, but you’re also a ways off the ground now. How would that feel?

— I mean, that wouldn’t feel nearly as bad as I feel now, but that’s because I would at least know where the top was. Like I could see how far away it was.

— And instead, it’s more like the staircase keeps expanding.

— Yeah! It’s like I keep climbing the stairs but the top keeps getting further away.

— That’s where your frustration is coming from. Unfortunately, in the real world, you can’t actually know how many discrete steps some overwhelming task is going to take, especially when it involves factors you can’t control, like what doctors can prescribe, what insurance will pay for, which clinic provides which assessments…and you know which steps you have taken so far.

— But what does it matter how many steps I’ve taken if the staircase just keeps growing?

— Because in reality, it’s not actually growing. It’s more like that thing where you’re walking towards a distant landmark, like a skyscraper in a city, and you feel like you’ve walked so far but it still seems just as far away. It’s not, though—that’s just a trick of our vision and also of our frustration with how long the journey is taking. In reality, there is an actual physical distance being crossed, and that gap is closing inch by inch whether or not it appears that way in the moment. This is even harder, because while you can Google how far away the Empire State Building is from Battery Park and get some sense of how long that walk will be, there isn’t a knowable answer here. Not right now. When you reach the end, you will know exactly what steps it took, and how long you spent climbing the staircase. There is a real number. You just can’t know it yet. …How well does that fit with your experience?

— I agree with that. I do believe that there will be an end, at least, even though I often feel like there won’t be. Do I have to just accept feeling that way?

— I think you do have to accept feeling that way, but you don’t have to just accept feeling that way. You feel that way for now. Just as you’d feel frustrated on long walk that’s taking even longer than you thought, towards a landmark that doesn’t seem to be getting any closer, you will feel frustrated here, in this situation. But in the example of the long walk, you would know, rationally, that you’re making progress. You wouldn’t just quit walking, unless of course you need to—that’s a separate thing. You would tell yourself, “This is a really frustratingly long walk and I had hoped it wouldn’t take this long, but I’m going to get there.”

— That definitely sounds more reassuring than what I’ve been telling myself, which is that I’ll never get there.

— And that’s not the only tool at your disposal, either. Imagine the staircase again. We talked about what it’s like to look up. What’s it like to look down?

— Well…I definitely keep getting further up from the ground. As long as all those things you listed were actually steps, and not just like…detours.

— Do you think they were steps? Even if they didn’t propel you all the way to the top?

— Definitely.

— Does your distance from the ground ever shrink?

— I sure feel like it does…

— Do you, though? What brings you back towards the ground?

— I mean, no. I’m only feeling that way because of the thing where the stop of the staircase seems farther away.

— Exactly. And, not to bring math into this—

— Please no math.

— Okay, no math, just words: there’s a difference between absolute and relative. As you revise your estimate of the height of the staircase—unfortunately, you keep learning that there are more steps than you expected—your relative progress changes. Maybe before you hoped you were at 50%, but now you realize it’s more like 30. Hence your frustration. But your absolute progress never changes. If you’ve climbed six flights of stairs, you’re always gonna have climbed six flights of stairs, no matter how the top of the staircase is looking at this particular moment. Feeling shitty about how hard this is doesn’t just suddenly knock you back down a few flights.

— But how do I actually, like, feel that?

— When you find yourself looking up, try looking down instead.


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The Expanding Staircase
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“But You’re a Therapist!”

It can be weird being open and vulnerable with others as a person who also happens to be a therapist. People are sometimes very surprised to hear that their therapist friends also, believe it or not, struggle to understand their partners, get petty or irritated, feel abandoned, lash out at people, avoid flossing or exercising or initiating difficult conversations, or feel judgmental. For example.

I’ve been hearing the refrain “But you’re a therapist!” since—actually—before I even technically became a therapist. (Back then it was, “But you’re going to be a therapist!” Yes, and? You’re apparently going to be a millionaire or a bestselling author one day, and yet.) I even see therapists themselves throwing this at other therapists in some of the Facebook groups I’m in. That, combined with actually becoming a therapist and hearing a lot about how other people think, has given me a lot of opportunities to reflect on what causes people to say this.

People seem to be of two minds about therapists. Either we are fully self-actualized human beings who float through the world with the gravity-defying force of our own impeccable coping skills and preternatural ability to sense others’ thoughts and intentions; or we’re all “crazy” and “broken” and got into this field either to wallow in our misery along with our clients, exploit those clients, or use them to somehow fix our own unusually severe mental issues.

Obviously, I highly dislike both of these stereotypes (though the latter is of course more offensive and ableist). The reality is that most people will experience some sort of significant mental distress at some point in their lives, therapists included, and experiencing it early in one’s life can be a motivating factor when it comes to choosing a career path.

But I think there’s more going on here than just stereotypes about particular professions, and I think it reflects a common misunderstanding of how therapy works. That misunderstanding is:

  1. Go to therapy
  2. Talk about yourself
  3. Have a Sudden Realization™ or receive a powerful Insight™ from your therapist
  4. ???
  5. Profit/recover from your mental illness.

Actually, it’s more like:

  1. Go to therapy
  2. Fill out a lot of paperwork (sorry)
  3. Talk about yourself
  4. Hopefully, maybe (please) do some homework stuff outside of the session (I call them experiments!)
  5. Learn things about yourself and your mental illness, both through information and perspectives provided by your therapist and your own experience
  6. Apply that knowledge to change some of your patterns of thinking and/or behavior
  7. Have a really bad week/month and forget all of that knowledge for a while
  8. Relearn the knowledge and resume applying it
  9. Increase your tolerance of painful thoughts and feelings and your confidence that you can climb out of future mental health setbacks
  10. End therapy and continue being an awesome person.

The first model doesn’t work chiefly because 1) there’s no magical realization or insight; shit is way too complicated for that and more importantly 2) knowledge alone doesn’t automatically change people’s thoughts, behaviors, or circumstances.

(Why does anyone still think that therapy is about Receiving Insights from on high? I blame Freud.)

But if it did, then it would generally be true that therapists wouldn’t have the same problems other people do.

But since it doesn’t, it stands to reason that our knowledge about mental health and creating positive change doesn’t automatically cure our personal problems. Kind of how even the best brain surgeon in the world doesn’t operate on their own brain.

The inconvenient thing about therapy is that it is, at its core, an interpersonal process. That’s why the strongest predictor of effectiveness in therapy is the strength of the working relationship between the therapist and the client.

Although there are a lot of fascinating processes that go on in therapy (I hope someone has written a blog post about them), I would argue that the core process—the one that’s absolutely necessary for any kind of change to occur—is the one in which the therapist shows the client that they have worth, that they deserve respect, that their experiences are real, that their feelings are valid, and that their attempts to cope with their situation make sense, even if they aren’t working well for them anymore .

And that is really hard to do for yourself. I would say it’s a bit like giving yourself a hug. Can you go through the motions? Sure. Is it even anything like a hug from another person? Nope.

And this is why all good therapists have their own therapist at least some of the time. And also why we have the exact same super cool fun problems as the rest of you.


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“But You’re a Therapist!”

A Support Role Taxonomy

Close-up of a life preserver.
Photo by Jametlene Reskp on Unsplash

A universal human dilemma: you need social support, but the type of support you need isn’t the type you’re getting.

You just want to vent, but your partner jumps in with advice. A sick person gets tons of gifts, but all they really want is someone to come over and spend time with them while they’re stuck in bed. Everyone wants to come hold the newborn baby, but nobody’s offering to do the parent’s laundry or make some meals for them.

This is complicated by the fact that most people find it difficult to articulate exactly what they need in terms of support, especially when they’re already in a rough spot. Even if they do know, and could verbalize it, many people feel like they shouldn’t look a gift horse in the mouth. So, sure, you don’t need all those nauseating frozen meals while you’re dealing with chemo, but at least they were nice enough to think of you, right?

It can help to learn how to identify what it is that you do need and how to communicate that to people. On the flip side, it can also help to learn which types of support you’re best suited to providing and look for opportunities to do those things—as well as to be careful not to push those types of support onto people who don’t need or want them.

This article is a taxonomy of different types of support that people might need. There are probably many more, although just about anything I can think of fits into one or more of these types. Some are subtypes of each other–advocacy is a type of assistance; perspective could be considered a type of information.

There are three major types of social support. Emotional support involves directly creating space for the person’s feelings and helping them to express or process them. It includes validation, affirmation, comfort, and perspective.

Intellectual support requires using your knowledge and critical thinking to help the person find ways to move forward. You can offer it through information, advice, feedback, or motivation.

Practical support helps people set up their lives and environments in ways that promote coping and healing, and is an ideal way to help if you struggle with emotional labor, listening, or other interpersonal skills. You can provide practical support by giving resources or assistance, supplying distractions, or simply being physically present.

Here are the twelve support roles, broken down in detail. They’re in order (roughly) from least involved and complex, to most.


1. Presence

Presence is the gift of intentional togetherness—the simplest way of “being there.” When you’re present with someone, you are physically[1] there with them. Even if you’re both doing your own separate activities, the person you’re supporting knows that you will shift your focus to them if they need it.

You may need presence if: You just don’t want to be alone.

Ways to be present with someone: Sit with or near the person. Don’t check your phone or start doing other things until they do, and stop if they stop. If they aren’t speaking, resist the urge to fill the silence with talking.

2. Distraction

When the person who needs support isn’t ready yet to actively resolve their problem, or there isn’t a realistic way to resolve it right now, you can help them distract themselves so that they can have a few hours of relief from what’s troubling them. Your main role here is to be the one who suggests the distractions and obtains or sets them up.

You may need distraction if: Focusing on the problem at hand is doing more harm than good; you can’t keep yourself from ruminating and feeling even worse; there’s no practical or effective way to resolve the issue right now, and you just need to get through the next hour(s).

Ways to provide distraction: Take the person out to do something they enjoy. Come over and watch TV or movies together. Talk to them about your own life or tell funny stories. Play games together. Let them play with your pet.

3. Comfort

When two people have an attachment bond, they can comfort each other—a social process that actually reduces the body’s physiological stress response. [2] (Remember oxytocin from all that fear-mongering about casual sex? This [among other things] is what it’s really for.) Comfort can involve touch or words, but the words are just there to make those bodily changes happen. People don’t have to be sexual/romantic partners to be able to comfort each other this way—these types of bonds are common between family members (even adults) and close friends, as long as those relationships are healthy and consensual.

You may need comfort if: You feel unsafe or scared, and there’s someone you trust to reassure you.

Ways to comfort someone: Hug, cuddle, or hold hands with the person (with their consent). Reassure them verbally that everything will be okay, that you’re here, that they’re safe. Keep repeating any words or phrases they find soothing. It’s okay to be repetitive—this isn’t about conveying information to them, it’s about facilitating a physiological response. Give them your full attention, or it won’t work.

4. Validation

Validation is often the first and most important significant process that occurs in therapy. [3] It’s important in other types of relationships as well. When going through difficult times, almost everyone struggles on some level with feeling like their thoughts or feelings don’t make sense or aren’t reasonable or proportional to the situation. For whatever reason, humans can’t really start to heal until we start to understand that it’s completely okay to feel and think as we do. If you’re finding that your attempts to support others fall flat, it may be because they needed validation first, and you skipped over this step. [4]

You may need validation if: You’re struggling with feeling like your experience isn’t real, visible, recognized by others, or “that bad”; you have people actually telling you that it’s not “that bad”; you feel ashamed of your own thoughts or feelings; you worry that you’re being “overdramatic” or irrational.

Ways to provide validation: Listen. Verbally acknowledge what you’re heard. (“I hear you.” “I’m still listening.”) Remind the person that it’s okay to feel the way they do. Reiterate that what they’re saying makes sense to you; if it doesn’t, ask open-ended questions until it does.

5. Affirmation

Closely related to validation, affirmation is the process of helping someone feel that you like them and think well of them. Just as people typically need to feel that their internal experiences are valid, they also tend to cope and heal better when they are reassured that the people close to them still respect them and want relationship with them. It may seem irrational, but I think it has to do with how fundamental our need for social connection is.

You may need affirmation if: You feel diminished or beaten down by your experience; you worry that people think less of you because of it; you’re receiving lots of negative feedback or criticism.

Ways to affirm someone: Tell the person why you admire or respect them. Compliment them. Give them genuine positive feedback about how they’re coping with the situation.

6. Resources

Sometimes, throwing money and/or stuff at the problem really does help. The prevalence of crowdfunding campaigns online is a testament to this. If you can afford it, supporting someone with resources can make a huge difference.

You may resources if: You’re faced with a financial crisis you can’t handle alone; there are tangible things you don’t have and can’t find or afford that would help; dealing with your situation has left you without money to spend on small pleasures or self-care that would help you cope and heal.

Ways to provide resources: Donate/contribute money. Ask what they need and buy it for them.

7. Assistance

If you don’t necessarily feel up to supporting someone emotionally, don’t forget the importance of practical assistance. It’s common to offer this when someone is going through a serious physical illness or has recently had a baby or lost a loved one, but people need it in all kinds of situations. Mental illness or stress can make it difficult to do basic “adulting” tasks, and helping someone with basics like food and laundry can free up time and energy for them to resolve whatever they’re going through.

You may need assistance if: An illness or disability is making it difficult or impossible for you to do something that needs done on your own; managing your current situation is taking up so much time you can’t do other necessary things like cooking, housecleaning, etc.; you lack transportation; you’re concerned about caring for your children or pets while you deal with things.

Ways to assist someone: Ask the person (or someone closer to them) what you can do for or with them. Offer rides, household help, childcare, petsitting, or other types of practical help. Identify what your skills are when it comes to helping people: Are you handy around the house? Great with kids? Skilled at making nutritious frozen meals? Let the person know that you are available to do this thing for them, preferably in writing so they have an easier time remembering to reach out to you if they decide they need it.

7. Information

Information is an often-overlooked form of support, perhaps because it doesn’t seem like a social process. But it is—even if you get it from a book or from the internet, you’re still receiving it from someone, hopefully someone you trust. Some people are very resourceful and tend to quickly learn what they need to know. They may not even realize that information is a specific type of support someone else might need. Others struggle with resourcefulness, and may not realize that they’re missing information, or that someone trustworthy may be able to provide it. Some people have been resourceful their whole lives and flounder when a crisis they’ve never faced before makes them suddenly incapable of finding the knowledge they need.

You may need information if: You don’t understand the facts of what’s going on; you’re feeling stuck because you don’t know enough to feel confident that you’re making a good decision; you feel like there’s nothing that can be done in your situation; you have a serious medical condition that your doctor didn’t adequately explain; you’re facing a situation that involves legal issues, financial decisions, or other specialized knowledge that you don’t have.

Ways to provide information: Suggest books, articles, or other educational materials. Recommend a doctor, lawyer, accountant, therapist, or other professional that you trust. If you specialize in this issue, donate some of your time to provide some education around the issue (within the boundaries of your professional ethics, of course.)

8. Advice

Advice is without a doubt the most-given and least-wanted form of support, which is something we have to acknowledge before we can even talk about helpful advice. While it’s almost always a good idea to get consent before offering support, advice is one of the most important types of support to never give if it’s not asked for. Unsolicited advice isn’t just useless much of the time; it also tends to directly interfere with other vital support processes, such as validation and affirmation. Nevertheless, people do often want advice—they just tend to want it from specific people, and only when those people have the context they need to give advice that’s actually useful.

You may need advice if: you want to know how other people would handle the situation if they were in your shoes; you want to hear from someone else who’s been through this.

Ways to give advice: Ask first! Consider how you’d handle the situation, but take the person’s own needs and values into account. Ask what they’ve already tried or considered, and why it didn’t or wouldn’t work. Make sure you have all the information you need to give helpful advice.

9. Motivation

There are many things that can mess with our executive function—ongoing conditions like ADHD or autism, situational factors like sleep deprivation, long-term emotional states like grief or stress, or simply having way too much to do. Internal motivation is one of the main executive functions, and often one of the first to go. Thankfully, motivating each other is something we can easily learn how to do.

You may need motivation if: You have the capability to do what you need to do, but can’t seem to get started; anxiety, perfectionism, or depression are getting in the way or resolving your issue; you need someone to hold you accountable.

Ways to motivate someone: Check in with the person about the things they’ve said they’d do. Offer encouragement and positive reinforcement. Ask helpful questions (“What would be the next step?” “What’s keeping you from doing that?”).

10. Feedback

Sometimes people need a more involved version of advice or motivation—that’s feedback. Note that sometimes people want constructive criticism specifically, and other times they may only want “negative” feedback if you see something actively wrong with what they’re thinking or doing. It’s the difference between “Do you think I handled this wrong?” and “How could I handle this better?”

You may need feedback if: You’re not sure if you handled a tricky situation appropriately; you’re not sure if you’re interpreting something correctly; you want constructive criticism.

Ways to provide feedback: Point out the person’s strengths or what they’re doing well. Offer suggestions for improvement, or alternate interpretations of a situation. Ask useful questions (“What’s your goal here?” “What other options are you considering?”)

11. Advocacy

Advocacy is a very special type of assistance that involves using privilege, social skills, or knowledge that someone else doesn’t have in order to communicate on their behalf. This usually comes up when someone needs something from some sort of institution or authority figure, but it can also apply to mediating an interpersonal issue or backing someone up when they set a boundary.

You may need advocacy if: You need something from a person or institution and don’t feel empowered to try to ask for it; you feel that it might help to have someone (perhaps someone with more privilege or with skills you don’t have) in your corner.

Ways to advocate for someone: Accompany the person to appointments and help them express themselves effectively. Make sure they are being understood. Resolve an interpersonal issue on their behalf, or serve as a mediator. Obtain their consent to speak to their doctor, therapist, or insurance company to appeal a decision or provide collateral information.

12. Perspective

One of the rarest and most precious gifts you can offer to someone who is suffering is perspective. Like advice, this one is offered much more often than it’s actually available to give, and that’s because many people don’t have as much perspective, or as useful of one, as they think. Perspective isn’t “it could be worse” or “I’ve suffered worse.” Perspective never minimizes the problem; if anything, it shines a clarifying light on it. It can come from a religious or spiritual approach, but doesn’t have to. It can also be thought of as wisdom.

You may need perspective if: You feel lost or hopeless. You have no idea how anyone could get through this. You need someone’s wisdom.

Ways to provide perspective: Make sure you actually have perspective to offer on this issue. (Have you been through something similar? Are you knowledgeable in the person’s faith tradition?) Share an empowering, comforting, or personally meaningful way of looking at the issue. If appropriate, provide a religious, spiritual, or secular interpretation. Use perspective-finding tools that the person values, such as a tarot reading. Recommend a work of art, a book, or an essay that offers wisdom. Perspective is not the same as advice, and does not necessarily include any guidance on what the person should do. It’s more about providing a new lens for them to look through if they want to.


It’s a good idea to explicitly make sure you know what the person wants before providing any type of support. This is especially important with comfort, resources, assistance, information, advice, feedback, and advocacy, as these things are the most likely to cross boundaries when they’re unsolicited. But any type of support can come across as invalidating, tactless, or even violating if it’s not wanted. Nonconsensual touch that’s meant to be “comforting” can be actively harmful.

I’ll break down some of the more complex support roles in later articles. For now, I hope this taxonomy helps you give and receive support to others.


[1] Sometimes presence can be virtual, as when people hang out together via video call or have an ongoing text chat that they know they can use at any time. But it’s much harder to demonstrate presence without a face-to-face (or side-by-side) connection.

[2] https://www.sciencedirect.com/science/article/pii/S0306453013002369

[3] https://www.miriammogilevsky.me/blog/2018/8/21/what-is-therapy

[4] https://the-orbit.net/brutereason/2015/06/29/dont-tell-people-how-not-to-feel/


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A Support Role Taxonomy

Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness

This is a cross-post from my professional blog, where the most updated version of this will be.

The field of mental healthcare has its roots in medicine. The earliest mental health professionals were doctors—psychiatrists. Like medicine, psychiatry and clinical psychology are based on the process of assessing patients’ symptoms, performing some sort of test if needed, assigning a diagnosis, and creating a treatment plan based on that diagnosis.

This is a very sensible approach for most medical issues. If I appear at my primary care doctor’s office complaining of persistent headaches, she shouldn’t just treat the headache by prescribing a painkiller. She should refer me to someone who can figure out what’s causing the headache, and then treat that condition, whether it’s extreme stress, a head injury, a bacterial infection, a brain tumor, or some other problem.

Even though we’ve been treating mental health issues this way for at least a century, it’s not the best way to treat them. And many psychiatrists, therapists, and researchers are starting to realize that.

That’s why we’re finally starting to see approaches to assessment and treatment of mental illness that move away from the much-argued-about diagnoses in the DSM, and sometimes away from the concept of mental illness altogether. Psychologists such as David Barlow, Rochelle Frank, and Joan Davidson have been working on so-called transdiagnostic approaches[1]; the newest edition of the DSM includes a chapter about a proposed new way to diagnose personality disorders that’s based on specific personality traits rather than broad, stigmatized labels[2].

I’m looking forward to the day when the field as a whole has shifted to these types of approaches entirely. For now, I needed a tool I can use with clients to help them (and myself) understand what they’re dealing with and access helpful resources and support. So I created my own informal dimensional assessment.

This assessment is a list of 33 (and counting, I’m sure) ways in which our brains can get in our way. You could think of them as symptoms, but I prefer to think of them as painful patterns, or building blocks of mental distress. Everyone has at least some of these; many people have a lot of them and don’t necessarily suffer greatly for it. It’s all a matter of degree.

Most of these terms are actual mental illness symptoms that appear in the DSM or in other clinical psychology texts. Some of them I coined from existing words because they aren’t really being talked about very much yet. Each of them shows up commonly with at least one established diagnosis, and most relate to quite a few of them.

In creating this list, it was important to me to try to get at the ways in which people who aren’t therapists or scientists might actually think of these experiences. So each building block has a statement with it. The way I plan to use this clinically is to show clients a list of the statements and ask them to rate each one on how much they agree or disagree with it. That would give both of us a sense of what their psychological landscape looks like, regardless of which DSM diagnoses it might resemble.

The initial feedback I’ve gotten is that folks find this really helpful for communicating with their therapists and psychiatrists about what they’re dealing with. I think that’s a great way to use this tool. Therapists know specific interventions that target many of these things; coming to a session and saying that you’d like to address your amotivation, emotional disregulation, and tendency to ruminate is bound to be more helpful than just saying that you want to be less depressed.

  • Agitation: “I often feel so on edge that I need to be moving constantly, as if I want to crawl out of my skin.”
  • Amotivation: “I struggle with getting myself to actually do things, even when I want or need to.”
  • Anhedonia: “I don’t get any joy out of things I used to like.”
  • Attention disregulation: “I can’t seem to choose when to stop or start paying attention to something.”
  • Avoidance: “I find myself trying to avoid things that bring up painful thoughts or feelings.”
  • Cognitive inflexibility: “When things don’t go the way I wanted or planned, it’s very difficult for me to adjust my expectations or make a new plan.”
  • Compulsiveness: “Sometimes I feel like I need to do an action or ritual in order to feel okay, and I feel awful if I try to force myself not to.”
  • Depersonalization: “Sometimes I feel like I’m not really in my body, or I don’t know who I am.”
  • Disordered eating: “I have a hard time controlling what or how much I eat; or, I need to control it so carefully that it’s hurting me.”
  • Dissociation: “Sometimes I experience a memory so strongly that I’m not sure who, where, or when I am.”
  • Distress intolerance: “I don’t feel like I can handle strong emotions. I need to make them go away.”
  • Dysmorphia: “I seem to see my body differently than other people do.”
  • Emotional disregulation: “When I have strong emotions, it’s very difficult for me to manage them and calm myself down.”
  • Emotional lability: “My mood can change quickly between extremes.”
  • General anxiety: “I often think about things that could go wrong in the future.”
  • Guilt: “I feel guilty even when I didn’t do anything wrong.”
  • Helplessness: “I don’t really believe that there’s much I can do to help myself feel better or improve my life.”
  • Hopelessness: “I feel like things won’t turn out okay.”
  • Hyperactivity: “Having to sit still and not move makes me extremely uncomfortable.”
  • Hypervigilance: “I’m always on the lookout for possible danger, and often I sense danger where there isn’t any.”
  • Identity disturbance: “I don’t have a strong sense of who I am; it depends mostly on the opinions of the people around me at the time.”
  • Impulsivity: “Sometimes I say or do things without thinking about them first, and afterward I can’t always tell you why I did them. When I have an urge to do something, it’s very difficult to keep myself from doing it.”
  • Inattention: “I can’t make myself focus on things I need to do.”
  • Irritability: “Little things annoy me so much I want to yell or snap at people.”
  • Mania: “I have periods of time during which I feel extremely energetic, irritable, or ‘high,’ and during these periods I tend to sleep little, talk too fast, accomplish a lot of things, or do things I later regret.”
  • Obsessiveness: “I have intrusive thoughts that bother me and I can’t make them stop.”
  • Panic: “Sometimes, my breathing speeds up and my heart starts rushing, and I feel like I’m going to die.”
  • Psychosis: “I perceive or believe things that feel very true to me, but aren’t true according to everyone else.”
  • Rejection sensitivity: “I feel like I can’t deal with it if someone dislikes me, or says no to me. I’m constantly on the lookout for potential rejection, and I probably sometimes see it when it isn’t really there.”
  • Rumination: “When I start thinking about something negative, I tend to keep thinking about it over and over and feeling even worse.”
  • Social anxiety: “When I’m around people, I worry about how I’m coming across or what I should say or do.”
  • Splitting: “I tend to see people either as extremely good or extremely bad, and I can switch quickly from one to the other.”
  • Suicidality: “I have thoughts that I want to die, or that I wish I could just not exist.”

Although I’ll probably never be able to turn this into an Official Research-Verified Published Thing or anything like that, I do hope to keep refining it and making it useful to my clients—and to any other therapists who want to give it a try.


[1] https://www.newharbinger.com/blog/transdiagnostic-psychology-why-we-need-transdiagnostic-road-map

[2] https://www.psychologytoday.com/us/blog/fulfillment-any-age/201303/whats-new-and-old-in-the-dsm-5-personality-disorders


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Building Blocks of Mental Distress: A Dimensional Assessment of Mental Illness

Stuff I Read That You Might Like, Vol. 1

An e-reader with a cup of coffee, a notebook, a pen, and a pair of reading glasses.
Photo by Aliis Sinisalu on Unsplash

For a long time I’ve used Tumblr primarily to share quotes from my favorite articles that I read online (and sometimes books, too). Since I’m no longer using Tumblr due to their atrocious, sex-negative decision about adult content, I haven’t been able to find a better way to do this. Most so-called Tumblr “replacements” are pretty barebones and/or nonfunctional.

So, clunky as it is, I’ll be doing it here! Every so often I’ll post some quotes and links to stuff you might like.

Starting off with a very topical one:

Tumblr made sex a community experience.

—Vex Ashley, “Porn on Tumblr — a eulogy / love letter

Now that the full scope of this administration*’s political vandalism and base criminality is largely being copped to in broad daylight in various federal courthouses, a good chunk of the elite political press is moving into the Hoocoodanode? stage of political journalism. This is best exemplified byThursday’s New York Times podcast, the headline of which—“The Rise of Right-Wing Extremism, and How We Missed It”—got dragged like Hector’s corpse all over the electric Twitter machine until someone at the Times sharpened up and changed the last half of it to “…and How Law Enforcement Ignored It,” which is a little better, but not much.

To take the simplest argument first, “we,” of course, did no such thing, unless “we” is a very limited—and very white—plural pronoun. The violence on the right certainly made itself obvious in Oklahoma City, and at the Atlanta Olympics, and at various gay bars and women’s health clinics, and in Barrett Slepian’s kitchen, and in the hills of North Carolina, where Eric Rudolph stayed on the lam for five years and in which he had stashed 250 pounds of explosives for future escapades.

—Charles P. Piece, “‘We’ Did Not Miss the Rise of Right-Wing Extremism. You Did.

Inspired by online recipe sites, he’d sit down to dinner and then let me know what rating I earned. “If I give you five out of five, you’ll quit,” he joked. And I laughed because when I was in my 20s, I believed that you were supposed to laugh when someone hurt your feelings. I thought you were constantly supposed to be trying harder.

—Lyz Lenz, “Now That I’m Divorced, I’m Never Cooking for a Man Again

“As you become more acclimated to the cold, your body becomes more effective at delivering warm blood to the extremities, your core temperature goes up, and all that contributes to being more resistant to the cold,” Leonard told me.

That means the only cure for hating winter, unfortunately, is just more winter.

—Olga Kazan, “Why So Many People Hate Winter” (ugh.)

Mattis saw it up close. He bore it as long as he could, in hopes of mitigating the damage. But when Trump broke America’s promise to the Syrian Kurds, he stained Mattis’s honor, too. That, apparently, Mattis could not accept. He leaves and takes his honor with him. And now the question for Congress is: The Klaxon is sounding. The system is failing. What will you do?

—David Frum, “No More Excuses

It’s called Star Wars. Not Star Trek, not Star Peace, not Star Friends, not even Star Tales. This gargantuan fictional universe is labeled with a title that guarantees the ability to travel space… and near-constant warfare.

We can debate the relative okay-ness of this focus from a moral standpoint, sure. But in reality, I think that Star Wars is accidentally teaching us the greatest lesson of all: It’s depicting what a universe looks like when you dedicate all of your research and technological advancements to war and destruction, and unwittingly showing us what an incredibly dark place that universe is. Because the Star Wars universe is a fun fictional playground for sure, a great place to build weird and wonderful stories… but it’s not a good place. Not by a longshot.

—Emily Asher-Perrin, “Star Wars is Really a Cautionary Tale About Devoting All Technological Advancements to Death

It’s no longer socially acceptable to believe that women are somehow less than especially not during a time when feminism is wielding so much cultural power. But arguing that women are just naturally better at caretaking or domestic work has become a clever way to shirk living up to progressive values while claiming you are simply complimenting women on their stellar ironing skills.

One way to combat this line of thinking is to highlight how fully capable men are in the private sphere. It is true that American culture relishes in portraying men as dolts when it comes to parenting and cleaning, and it’s an unfair stereotype.

But for women to make real progress in and out of their homes, men must give something up: the backwards dream of holding onto their feminist bona fides while seeking out female partners willing to limit their own aspirations to the home.

—Jessica Valenti, “The ‘Woke’ Men Who Still Want Housewives

So yes, forced birthers and [Status Quo Warriors], if you’re going to play it like that, I am OK with the idea of a world into which you, personally, were never born. I am equally as OK with the idea of a world where I don’t exist, either. Neither you nor I personally matters that much in a universe so vast and a sea of human experiences so rich. You and I both are accidents in our existence, possibly unhappy ones.

I would’ve rather your mother not have been forced to carry a pregnancy she didn’t want to term. I would’ve rather your father had approached your mother respectfully in an appropriate setting, or not at all. I dare to love your mother as a fellow human being more than you do and to dream of a better world for people like her. It’s rank misogyny and not very humanist at all to think otherwise.

—Heina Dadabhoy, “Why I Don’t Care If You Wouldn’t Have Existed

It is maddening to watch adult men respond to revelations of endemic sexual harassment in the workplace by instituting a series of ludicrous personal codes, rather than by learning the relatively straightforward lesson on offer: Don’t sexually assault or harass anyone.

At best, these “rules” are reflective of employers’ woefully incomplete approach to sexual harassment. Employers have long done the absolute minimum to comply with the law, relying on trite videos focused on what you can and cannot say or do in the workplace (“don’t give back rubs” or “don’t offer promotions in exchange for sex”) and sexual harassment policies designed primarily to protect them from lawsuits. The sweeping scale of the Me Too movement makes it clear that no mere set of rules is sufficient to prevent workplace harassment, especially when those rules fail to speak to all of the various power imbalances that make the critical distinctions between genuinely consensual workplace romances and harassment.

—Tahir Duckett, “Avoiding Women At Work Is A Childish, Cowardly Response To #MeToo

When you are terribly afraid of being held responsible for the emotional well-being of others, it feels very mature and responsible to decide that you should “work on yourself.” It becomes both a way of retroactively absolving yourself (wow, can you believe all of the ways my issues manifested before I decided to work on them) and a rather elegant little trick to exonerate ongoing bad behavior (dang, those pesky issues again! I guess I must keep working on them). This is especially true for those too-clever-by-half motherfuckers who think that nobly warning someone in advance they “are working on their issues” mitigates any way in which they might disappoint or harm. And even with the best of intentions, it obviates the fact that relationships themselves are a process of being made ready, not something you come to static and fully formed.

[…] We need each other desperately, in ways none of us can be ready for.

—Brandy Jensen, “Ask A Fuck-Up: I’m still in therapy. Should I be dating?


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Stuff I Read That You Might Like, Vol. 1

How Big is Your Hard Drive?

Close-up of a hard drive.
This is relevant, I swear.

This is a cross-post from my professional blog.

Some friends and I were talking recently about the concept of “emotionally unavailable” people. Most of us have had a friend—perhaps ourselves—who has tried to date someone who seemed into them, but just wasn’t quite present. Sometimes this type of partner is upfront about their ability to commit and/or be there. Sometimes, they aren’t, and their behavior seems confusing and contradictory. These pseudo-relationships can drag on for years until we are finally able to move on, understanding that however much the person enjoys our presence, they are not interested in making things more committed or structured than they currently are.

If I knew what to do in these situations I’d probably be retiring a millionaire, but I do have an analogy that might be helpful. I thought of it on the spot to give my friend some advice. (If you’ve ever been my client, you know how much I love a good geeky analogy.)

Computers come with different hard drive capacities. If yours doesn’t have enough space for you, you can maybe buy and install a new one—but for the moment, you’re stuck with the one your computer came with. Maybe you can’t afford a new one right now.

Different hard drives also have different things stored on them, and these things take up different amounts of space. I know people whose hard drives pretty much just contain the system files, maybe a few extra apps. These people use their computers mainly to get online. Maybe computers aren’t very important to them and they don’t use them much at all.

Some people have a lot to store—photos, music, videos, complex projects they’re working on. These folks are buying hard drives in capacities I didn’t even know existed. (This year, the world’s largest solid state drive hit 100 terabytes. What are they storing on that hard drive???)

Don’t think of the hard drive as your brain. Those analogies are really reductive, and usually insulting to us humans. The hard drive is a symbol, and it represents something I call your capacity as a person. That encompasses a lot of things—time, energy, physical and mental ability, willpower (which isn’t really a thing, but that’s another article; it’s useful here as a concept), tolerance for uncertainty or negative emotion, and much more. For instance, not everyone has the capacity to be a therapist. Being a therapist requires having a lot of space to hold other people’s pain. Not everyone has enough space for that. Unfortunately, some therapists end up without enough space to hold their loved ones’ pain, or even their own.

Say I have a 1 TB hard drive that’s full of music and photos. Maybe there’s 300 GB left over. Then a friend asks, “Could I put some of my videos on your hard drive? I need somewhere to store them for a while.” I say sure, but then they come over with their external drive and I see that they have an entire terabyte of videos. That’s not going to fit on my hard drive. I could probably store some of their videos, and that might still be helpful for them. But maybe they really needed to store the entire drive’s worth. I don’t have the capacity.

This kind of thing happens in friendships and relationships all the time. You might have a good amount of your own shit to deal with, but that doesn’t mean you can’t listen to your friends vent about their own problems from time to time, or give them advice about a work situation, or treat them to a nice dinner while they’re going through a breakup.

You might not be able to be a friend’s primary source of support as they navigate a serious illness, however. First of all, the time factor would be prohibitive—you may not be able to drive them to all of their medical appointments, be at their house enough to care for them when they can’t care for themselves, and so on. The stress of being a full-time caregiver would be way too much. Holding their anguish as they face the possibility of death or disability is also, well, a lot. Your friend needs more people on their team.

Some people are carrying a lot of trauma, hardship, or personal responsibilities with them already. No matter how large their hard drives happen to be, there may not be space there for you.

Not only that, but some people have pretty small hard drives to begin with. I’ve known many people who just don’t seem to have a lot of space for others in their lives. They don’t tolerate much emotional turbulence when it comes to other people. They may be interested in sex, casual friendship, or even romance, but they don’t have the capacity to build interdependent, long-lasting relationships with others—at least not until they do some work on themselves, and get some bigger hard drives. Some people want to do that work; others are perfectly content as they are.

Here’s where this analogy really breaks down—buying a new hard drive is a million times easier than increasing your capacity for holding other people. And while you can buy a larger hard drive for your friend whose computer you’re always wanting to store your videos on for some reason (this is weird), you cannot increase others’ capacity for them. They have to choose to do it for themselves, and they may not want to. Or it may take them a long time, or they may not be able to do it at all.

If you are hoping for a deeper relationship with someone whose hard drive seems to be too small—or who has way too much data on it already—you have to ask yourself whether or not it’s likely that this person is going to have more space for you anytime soon, and whether or not they want that space to be yours.


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How Big is Your Hard Drive?

Intuitive Eating Made Me Miss My Flight

(But, in the words of the great Rebecca Bunch, the situation’s a lot more nuanced than that.)

Rebecca Bunch from Crazy Ex-Girlfriend

Last night I was supposed to be on a flight to DC. I arrived at the airport straight from work with some time to spare, checked my luggage, went through security, bought a snack, and arrived at the gate to find that the flight had been delayed by two hours. It was 7 PM. My usual dinner time. I ate some of my almonds but found my hunger worsening. With the delay I would not arrive in DC until about 11 PM, plus a half-hour ride from the airport, so it would be nearly midnight by the time I could finally have a hot, nutritionally complete meal—my first since lunch at noon. What to do?

Lately I’ve been working with a dietician[1] on intuitive eating, a radical (but not new) approach to food in which you learn to pay attention to your body’s hunger cues and eat things that feel good to you. No numbers are involved in this process at any point. It’s not a weight-loss program, or even a “health” program, really. It’s more of a “rebuild a healthy relationship with food and be more mindful” program.

Most people, even those who have a relatively healthy body image and few issues around food, have taught themselves to ignore bodily cues like hunger, satiety, and energy. That’s because bodies are inconvenient and our society demands that we run on its schedule, not on our bodies’ schedules. If lunch is at noon then you eat at noon. If you have a lot of work to do and don’t have time for eating, you keep working until you can stop. If we’re eating now then you eat now even if you’re not hungry. If dinner is meatloaf and broccoli then you clean your plate before you can leave the table because of [insert racist and classist cliche here]. If salads leave you feeling weak and tired but salads are clean and healthy and you need to eat clean and healthy, then you eat salads and feel weak and tired and tell yourself it’s because of something else. If the flight is at 7 PM and there’s no time for dinner beforehand, then you grab a snack and head to the gate, and if the flight is delayed and there’s no one with you to text you updates, then you stay at the gate in case the flight leaves suddenly and you worry about your worsening hunger later.

Recently finished chemo? Recently had a double mastectomy? Recently started hormone suppression meds that put you into early menopause, causing hot flashes, fatigue, weakness, and confusion, especially if you don’t eat properly? Don’t worry about it! Wait at the gate.

Needless to say, I didn’t do that. I went to a pizza place not far from the gate, ordered myself a small pizza with olive oil, bacon, onions, and mushrooms, listened for any flight announcements, did not hear any flight announcements, refreshed the flight info on Google, and missed the flight anyway.

“Should’ve stayed at the gate,” the gate agent said when I appeared half an hour before the flight’s rescheduled departure and inquired what the fuck.

But I was exactly where I needed to be—taking care of my body so that it takes care of ME on my trip.

Now it’s the morning after, and I’m on my rebooked flight to DC, somewhat frazzled but nevertheless feeling energized enough to enjoy my weekend. Because last night when I started to feel really hungry, I had a complete meal with carbs, fat, protein, and fiber, along with hot tea and later water.

Bodies are inconvenient. I’ve tried the thing where you replace your meals with “healthy snacks” because you can’t make time to eat meals. It doesn’t work. I’ve tried the thing where you grab greasy fast food and bring it on the plane with you because you don’t have time for anything else. It doesn’t work. I’ve tried ignoring the problem. It doesn’t work.

What works is paying attention to my body’s physical sensations and responding to them with a combination of carbs, fat, protein, fiber, water, rest, physical activity, and sleep.

In fact, that’s probably the only thing that ever would’ve worked. But until I got so sick that I HAD to stop and pay attention to it, I ignored it like almost everyone else does.

(No, ignoring my hunger did not cause my cancer, but having cancer caused me to stop ignoring my hunger.)

When you start noticing your body’s cues and responding to them appropriately, you may also start missing flights. Or turning down opportunities, or no longer eating some foods you thought you liked but turned out to actually make you feel bad, or being late to things because you realized you needed to eat first but you weren’t hungry early enough to eat early enough to not be late. You may decide that you can’t be vegan after all, or that you don’t need to eat meat after all. You may notice that you don’t get hungry at 7 AM, 12 PM, and 6 PM. You may get hungry at totally different times. You may need to adjust your work schedule to accommodate this.

You may find a way to avoid many of these potential problems by being strategic about bringing snacks with you or taking breaks from things. But sometimes you’ll forget, or it won’t be enough.

You may also find yourself feeling better, physically and mentally. You may stop sending yourself on guilt-trips over food. You may realize that stopping at Dairy Queen for an ice cream cone after work is actually a great way to boost your mood and make sure you don’t get hungry until you’ve had time to make dinner.

You may even find yourself noticing other types of bodily cues more, too—for instance, that the party is loud and you need a break from the noise, and if you take a break now, you won’t be overwhelmed and will be able to return and stay for the rest of the party and enjoy yourself. Or that these shoes are so uncomfortable that it actually impacts your mood and productivity, so wearing them just isn’t worth it anymore. Or that you always feel vaguely uncomfortable and on edge around this particular person and maybe it’s time to try to figure out why.

Yeah, it’s inconvenient. It makes me feel over-sensitive, fragile, high-maintenance, and a lot of other things we often label women with. It’s difficult that at a moment when I most need to get past my preoccupation with my body’s weakness and vulnerability, the self-care I need the most seems to just highlight those things more and more.

But every time I make the decision to honor my body’s cues rather than ignore them, I can feel that I’ve taken another small step towards well-being. Towards working as a team with my body rather than fighting it every step of the way. Towards feeling at home in myself again.

A missed flight starts to seem like a small price to pay.


[1] If you live in Ohio, you may be able to work with my dietician! Find her here: https://www.kristenmurrayrd.com/

More info about intuitive eating here: http://www.intuitiveeating.org/


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Intuitive Eating Made Me Miss My Flight

And Suddenly, Life

My tomato seedlings.

And just like that, it’s over. The surgeon said there’s no evidence of cancer remaining in my body, my hair is growing back, my new boobs are growing steadily until I decide they’re big enough, and I’m trying to grasp that thread of my life that I left dangling over half a year ago and tie it to the one I’m holding now.

As anyone who’s had cancer knows, you’re never really “done” with it. Even after successful treatment, there’s always the possibility of recurrence, the long-term consequences of chemo or radiation, and, in my case, a slew of reconstruction-related procedures and an oophorectomy in 8 years.

That said, now—when I’ve returned to work after my surgery—seems an appropriate moment for a post-mortem on the whole thing. (Sorry, poor choice of wording.)

For a brief window of time after my diagnosis I thought it would be my unraveling. I quickly realized that, instead, it would be my becoming. If a year ago I was in my intermediate Pokémon evolution, I’m now in what feels like my final one. (Don’t forget, though, that even fully evolved Pokémon continue getting stronger and learning new moves, and that eventually someone might “discover” mega-evolutions and I might change form again. I’ll leave it to you to decide which Pokémon I might be, before this analogy completely runs away from me.)

Before this I was essentially comfortable with who I was, with how I lived my life and conducted my relationships, with the career I had chosen, with the way I spent my time, and with that most fragile of things, my body. The illness transformed the way I saw all of these things, not in the sense that it made my views totally different, but in the sense that it strengthened, catalyzed, leavened, solidified them.

Any lingering doubts I had in myself or in the people who form my inner circle disappeared. Before, there was a part of me that really believed that when the time came to sit for the exam, the people around me would fail me, and more importantly, that I would fail myself, and that I would be alone in my darkest hour. But nobody failed.

Well, perhaps a few people failed. But their grades had been slipping for a long time, and some of them had really been failing already.

I no longer doubt that my friends and family will carry me forward when I can’t carry myself. But I also no longer worry that I’ll ever become completely unable to carry myself. I don’t struggle with imposter syndrome anymore, and I don’t worry that I’m not enough of an “adult.” What does that even mean for someone who has made the decision to carve up their body to save their own life? What does that mean for anyone, really?

What I keep coming back to every time I write about this strange episode of my life is simply how banal most of it was. It was so banal that I’m not sure I could even claim that I cried more, or was sadder or more scared, on average during this time than during any other period of my life. In fact, I will still say that the clinical depression I experienced from ages 19 to 22 was much worse and left me with so much fewer resources to help myself and seek support from others.

I would not repeat so much as a month of that experience for any price. The cancer, eh, fine, especially if we can do the surgery with proper pain management this time.

The point of that isn’t to pit depression and cancer against each other generally or adjudicate whether mental illness really is worse than medical illness or vice versa; it’s just to say, I already had unimaginably more strength than I thought I did. It just hadn’t been tested and proven yet.


After my surgery, which to me represented the culmination of most of my worst fears, people wanted to know if it was really “as bad” as I thought it would be. Of course, they wanted to hear that it wasn’t. Unfortunately, it was even worse than I thought it would be. It was worse than I had expected even at my most panicky moments. So this isn’t the story of how I overcame those phobias. It’s the story of how I learned that I can survive weeks of unrelenting pain, panic attacks, and suicidality and come out the other side essentially myself.

I’m comfortable saying that I’ve been traumatized by that experience. In dreams I wake up after surgery only to be told that something went wrong and it has to be done again, over and over. Most evenings, when I’m home from the life I’ve finally returned to, alone and in silence, an inexplicable sadness comes over me—so inexplicable that I know exactly what causes it.

It’s not that I “miss my old body,” though sometimes I do. What I feel goes much deeper than that. There are memories, images, that fill me with something I can only call grief—looking back at my parents as I was wheeled away to the OR; watching them cut up my food for me when I couldn’t; walking around on the deck of their house, back hunched, trying to explain to my mom a meditation exercise I was trying in which you breathe the pain in and then breathe it out; when my friends visited me at home two days after and I sat, again hunched, mostly unable to speak or even look at them; the first time I sat on the deck in good weather, no hat, and felt the sun on my skin again; and more, and more, and more.

All of this lives in me now, not compartmentalized or repressed but very much there, just beneath the surface. It ebbs and flows and sometimes retreats deeper and other times comes closer to my skin, where I can all but feel it with my fingers when I press them onto all the parts of me that no longer feel.

It hurts all the time, but it’s also, in its own way, completely normal and healthy. I now contain a lot more things than I did six months ago, and not all of them hurt.

Rather than feeling diminished by the experience, I feel expanded. Which is fortunate because it gives me enough room to contain all of the contradictions inherent to this process. My friends were probably hopelessly confused. One day I’d be crying about what an ugly scarred half-person I am; the next day I’d be marveling at how it feels to dance, to sit in the sunshine, to run my fingers over my healing incisions. One day I would say that my life has been standing still; the next I’d be talking about all I’ve learned, everyone I’ve met, everything I’ve planned.

And then there were the times, most of which I never found the words to explain to anyone, when I felt like I was experiencing something transcendent. I had feelings that felt completely outside of my normal existence and that I couldn’t have had any other way. I’m not a religious person, so I don’t think of it that way. Instead I think of them as moments when I felt the pulse of life. I felt how precious it was, how sacred. I felt overwhelming gratitude, both towards people who helped me in even the smallest ways and towards the universe itself. I felt like I could survive anything.

And then I’d go back to feeling like a broken old piece of crap nobody wants anymore.

Well, it may be confusing, but it’s also part of the experience of being ill—and, to a slightly lesser extent, of being human. I invite you to enter the contradiction with me and make yourself comfortable.


Besides work and spending time with friends, nowadays I’m often working on my garden. Last fall I decided I wanted to try growing fruits and vegetables in the spring, and I had all these ideas about buying all kinds of plants and building a structure to house the containers and starting seeds early indoors, and for obvious reasons that didn’t happen. So I started last week. It was probably slightly late to plant seeds, but it is what it is and it’ll be what it’ll be.

I’ve always loved plants, and always felt disproportionate grief when they sickened or died. Now it’s no different, except that I’m even more aware of the precariousness of life, of the journey seeds must undertake to become plants, and how perilous all of that is. Soil, water, warmth, light. And out springs something that nourishes.

I used to feel beautiful. Now I don’t, and it’s hard to fully imagine what that even felt like. But I think I’m finding my way back to it, slowly. In the meantime, I look around at my pots full of fresh soil and think, maybe I can still make something beautiful.

I understand how plants “work,” mostly, but the more fundamental part of my brain is still stunned every time a seed germinates. I’ve now planted everything I’m going to plant, and some of the seeds have sprouted–pulling themselves up through the soil, hunched over like I was right after surgery, slowly stretching themselves out to stand tall just like I did, and finally unfurling their first two leaves, just like the first time I felt well enough to bring my arms up and stretch them out from my sides as hard as I could, feeling them become a part of my body again.

I can never fully expect them to do it. Every time I’ve ever planted a seed I’ve thought, no way, there’s no way you can just stick these tiny hard things into the ground and a week later they turn into actual plants.

And yet, inevitably, they do.


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And Suddenly, Life

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

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