If you’ve noticed yourself feeling more fatigued, sluggish, numb, or even down since the election, you’re not alone.

For some people, it might come as a surprise that a period of time they associate with feelings of relief, hope, or even joy could also be a time when depression symptoms show up. But it actually makes a lot of sense when you consider one compelling theory for why we get depressed in the first place. [1]

Most people will probably experience depression at some point in their lives. It’s pretty much the common cold of mental illnesses. But unlike the common cold, which is caused by a pathogen that enters the body, depression is something the body does to itself. Given how destructive depression can be, and how it can disrupt just about every facet of human functioning, why would our brains be able to do this shitty thing to us?

Depression exists in our neurological repertoire for a reason. At its core, depression isn’t really sadness—its numbness, apathy, fatigue, lack of motivation. It’s like the psychological version of our body’s immune response—adaptive and possibly lifesaving in many cases, but harmful or even devastating when it malfunctions and runs out of control.

One of those “natural” functions of depression is to force the body to rest and recover when needed. It often happens after a stressful event or period of time, whether that event or period was positive or negative, because the body has expended a lot of resources on managing that stress and now needs to rest. Continuing to be super active and do stuff when you need to rest can leave your body vulnerable to illness or other types of harm, so the brain flips the depression switch to “on” and forces you to just stop—stop caring, stop doing stuff, stop trying to go out and experience new things or make new connections, stop expending lots of energy on other people, stop caring about less-important things like showering or getting out of bed early. It makes you sleep more, and sleep is essential to healing.

In this way, emotional pain is a lot like physical pain—another sort of emergency brake that our bodies have. People with congenital analgesia [2], a condition that leaves them incapable of feeling physical pain, often experience permanent injury or even die early on in their lives; without pain, it’s very difficult for them to keep their bodies safe.

Of course, depression doesn’t feel good, but one of the reasons it feels as bad as it does in our modern world is because we’ve created a society that’s incompatible with these types of rhythms. We also live in a culture that expects happiness and high energy all the time. [3]

(This is by no means an argument that major depressive disorder as a mental illness is a product of industrialization. Obviously it’s not, as it’s been recorded across cultures and throughout history. However, it’s undeniable that there’s a lot going on in our culture that makes it more likely to happen, and more severe when it happens.)

Stigma and lack of understanding of mental illness also lead people to do things or think in ways that make their symptoms worse. Suppose you broke your leg and had to wear a cast and avoid putting weight on it for a while. That sucks, obviously, but aside from maybe mentally kicking yourself a bit if the broken bone was somehow your fault, you probably wouldn’t tell yourself that your leg /should not/ be broken right now, that you should “just snap out of it,” and that you’re a useless human being because your leg is in a cast for a while. You certainly wouldn’t rip off the cast and proceed to try to walk around as if your leg weren’t broken.

Yet that’s what we do with depression all the time! That’s especially true when we get depressed after something good happens, or during a time when we think we “ought” to be feeling good. A lot of people out there right now are probably telling themselves, “Why am I depressed now? Biden won. I should be happy.” Actually, neurobiologically speaking, right now is exactly when it makes sense to become depressed.

Unfortunately, I think some people are also taking this in a different direction: “Biden won, yet I feel depressed rather than happy; therefore things must actually be objectively very bad and hopeless.” A quick scroll through Twitter demonstrates how this plays out.

That’s not to say that it’s impossible to make a solid argument for things being objectively very bad and hopeless, although I disagree with that. However, there’s a difference between looking at the facts and deciding that they’re depressing, and feeling depressed and looking at everything through that lens.

There’s also another reason folks are likely to get depressed after the election, and that has to do with self-care and managing expectations. All these weeks/months/years of doomscrolling, ruminating about politics, getting into pointless arguments, et cetera probably left a lot of other areas of folks’ lives untended. Once the stimulation of election season is gone, a lot of people might realize that they’ve neglected a lot of meaningful things and now there’s a big election-shaped hole in their brain.

Some people might’ve also had an unexamined expectation that if Biden wins, they’ll finally get to relax and not worry about politics or the state of the world, or even that if Biden wins, things will get better right away. Obviously, that’s going to be a huge disappointment. For some people, a potential Biden win might’ve been one of the few things to look forward to during the pandemic, and now that it’s happened, there might not be anything else on the horizon that actually feels positive.

Of course, for a lot of folks in this situation, depression may have come up long before the election. Although the four-year adrenaline rush of this administration’s constant assaults on human rights and democratic norms may have allowed some folks to outrun their depression for a while, the crash inevitably comes, and it might come even before the body decides that it’s relatively safe.

Four years ago, I wrote about why we are not going to make it through this if we try to force our brains to be on high alert all the time. [4] I argued that refusing to incorporate Trump’s presidency into our model of the world—to accept that it is happening for now and to stop treating each new tidbit of horrible news as if it were a fire alarm—would inevitably result in burnout.

Unfortunately, that’s exactly what ended up happening to a lot of people. And even more regrettably, some of us did it to each other by reposting news articles with alarmist headlines (some of which were almost certainly false or misleading) and speculating wildly all over social media about the imminent collapse of democracy in ways that, while totally valid, also vicariously traumatized others.

There will be time enough to unpack all of that when things calm down a little bit—which I believe they will—but point is, depression is likely to strike right now for a lot of reasons.

I don’t really have any specific thoughts or advice here—if you recognize your own experience in what I’ve written, you probably know better than I do what helps you most when you’re in a depressive episode. But what I really hope folks get out of reading this is to be aware that major events can contribute to triggering a depressive episode even if those events are seen as positive.

If you’re feeling the urge to lay low and rest right now, it’s okay to do that—just try not to isolate yourself from the people you love and to set a date in your calendar to check in with yourself and evaluate whether or to you’re ready to get back out into the world a little bit more (safely), or if you might need some extra support.

THere’s already been a lot on social media about how we shouldn’t stop caring and protesting now that Biden’s won, and lots of understandable snark about people who allegedly think that their political engagement begins and ends with voting in presidential elections. Unfortunately, though, the “just keep fighting no matter what happens and never stop and rest after a major victory” take isn’t really trauma-informed or compatible with like, basic neurobiology. Your body is telling you to stop and rest. Listen to it, or it’ll force you to stop and rest later, when it’s even less convenient.

[1] https://www.psychologytoday.com/us/blog/theory-knowledge/201604/the-behavioral-shutdown-theory-depression

Note: While this is one theory of depression, it’s by no means the only theory or the only explanation for why depression occurs in humans. It’s just the one that’s most relevant to what I’m talking about here.

[2] https://en.wikipedia.org/wiki/Congenital_insensitivity_to_pain)

[3] https://bookshop.org/books/bright-sided-how-positive-thinking-is-undermining-america/9780312658854

[4] https://the-orbit.net/brutereason/2016/11/21/danger-necessity-normalizing-new-political-reality

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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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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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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:

• ADHD Survival Guide: How I Stopped Procrastinating and Got My Sh!t Together
• How I Came to Understand My Adult ADHD
• Why Adults with Undiagnosed ADHD Often Turn to Self-Medication
• 3 Symptoms of Executive Dysfunction–and How Not Recognizing Them Might Result in Ableism
• “I Thought I Was Stupid”: The Hidden Struggle for Women with ADHD
• Decades of failing to recognize ADHD in girls has led to a “lost generation” of women
• ADHD is Different in Women
• How ADHD Ignites Rejection Sensitive Dysphoria
• the rest of the ADDitude site

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

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

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

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

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

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

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

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

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

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

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

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

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

Worse than pandering to Nazis and dictators.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

1. To be seen.

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

2. To filter people out.

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

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

3. To increase awareness of mental illness.

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

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

4. To reduce the stigma of mental illness.

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

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

5. To reduce the stigma of vulnerability, period.

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

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

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

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

6. To create the kinds of friendships I value. 

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

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

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

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

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

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

Really, though, it’s more like this:

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

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

If you don’t tell the truth, or only tell little pieces of the truth, don’t try any of the therapist’s suggestions, always stay away from any topic that feels too painful or awkward, never think about therapy itself outside of sessions, and don’t have any idea of what it is you’d like to change in your life, you’re not going to get that much out of it. You’ll probably get something out of it–and some therapists are better than others at orienting clients to therapy and helping them figure out how to benefit fully from it–but the biggest change is only possible with the biggest effort.

This article is a compilation of suggestions for getting the most out of therapy. They come from my clinical experience as a therapist, my personal experience as a client, and feedback from a bunch of friends–clients and therapists both.

This article is not a list of things you must do in therapy. There could never be a list of that. Some of them will not be accessible or applicable to you, and that’s fine. As I said, these are suggestions. They’re not demands or requirements.

1. Show up. It sounds silly when put that way, but a common cause of ineffective therapy is that the client does not show up often enough. Obviously things come up and everyone will miss sessions occasionally, but I have clients who miss most of their sessions–or insist that they only want to come once a month–and I don’t think they’re getting much use out of therapy. Ideally, go to therapy weekly or biweekly at minimum. Any less often than that, and you’ll spend your entire hour just rehashing what’s happened in your life over the past month or two. (An exception is people who have already done most of the work of therapy and are now just wanting “maintenance” sessions to make sure that they’re keeping up the progress they’ve made.) If you’re having trouble fitting therapy into your schedule, communicate with your therapist. They may have lots of suggestions or ways that they can accommodate you, such as phone or Skype sessions, different times, and so on.
2. Let your therapist know how to communicate effectively with you. Do you prefer to schedule sessions by phone, email, or text message? Should your therapist use a particular nickname or set of pronouns to refer to you? If you’re going to be discussing issues of identity, how do you want your therapist to refer to your gender, sexual orientation, ethnicity, religious beliefs, etc? Do you shut down when your therapist begins a question with the word “Why”? Is it considered inappropriate in your culture to start “talking shop” before exchanging a few lines of small talk? Does direct eye contact make you uncomfortable? Do you need your therapist to speak louder, softer, or slower? These are all things you can discuss with your therapist if they’re important to you.
3. Speak up if your therapist does something that bothers you. I have a whole article about setting boundaries with therapists, so I won’t rehash all of that here. The important thing to remember is that 1) as a client, you have the right to set boundaries, expect those boundaries to be respected, and fire the therapist if they’re not; and 2) therapists are not mind-readers. When I wrote about this topic for Everyday Feminism, I got a lot of pushback to the tune of “the therapist should just know what my boundaries are; I shouldn’t have to tell them.” That’s dangerous thinking in a therapeutic relationship and in any other relationship. Yes, sometimes people can pick up on your nonverbal cues and intuit your boundaries, but this is too important and nuanced for that. Please speak up.
4. If it’s not working, find a new therapist. “Not working” doesn’t mean you’ve gone a few times and you don’t feel better yet; it means your therapist won’t respect your boundaries, is uninformed about your presenting issues, or can’t seem to establish a rapport with you. If you’ve been going regularly for weeks or months and there’s still no difference, and you’ve addressed that directly with the therapist to give them the chance to try another approach, then that’s a sign that things aren’t working, too. Some therapists are crappy therapists, but sometimes people just don’t mesh and it’s no one’s fault. Regardless, you don’t owe your therapist anything and you’re not obligated to stick around out of politeness or charity.
5. Set goals for therapy. What made you decide to go to therapy? What are you hoping to get out of it? These are probably questions that your therapist will ask early on, and it helps to have answers for them. If you don’t know right away, that’s fine–often what sends people to therapy is a vague sense that things are wrong, and at first they don’t know exactly what. In therapy, almost any answer is better than “I don’t know,” so if all you’ve got is “a vague sense that things are wrong,” tell your therapist that. If you can, though, setting specific goals increases the likelihood that you’re going to get to where you want to be. Specific goals can look like: “Stop drinking,” “Reduce drinking to two nights per week and no more than four drinks per night,” “Find a reason to keep living,” “Stop having panic attacks in public,” “Learn how to keep my job despite my ADHD symptoms.”
6. Take notes during the week about things you might want to discuss in therapy. This is especially helpful if you have mood swings, memory problems, or difficulty opening up in therapy. Folks with mood swings often find it difficult to “access” moods they’re not currently having, which makes it hard to talk about later. But mental illness isn’t always considerate enough to have a flare-up right during your therapy session so you can process it with your therapist in the moment. Taking notes when relevant things happen can help you talk about it later, when you’re no longer feeling that way or when your memory would’ve otherwise faded.
7. Plan ahead for your sessions. The previous tip can help with this. Since most of us have way more than a weekly hour’s worth of things to talk about, it can be helpful to think about what you’d like to get out of each session and what you should prioritize talking about. I wish I’d known to do this when I was in therapy in college, because I also had the mood swings issue I discussed in the previous tip and was usually in a pretty decent mood when I actually went to therapy. Since I had no plan, and my therapists were nondirective and would never ask a question like “How has your depression been this past week?”, I’d inevitably just start babbling on about whatever stressful exam or argument with a partner was currently on my mind without ever connecting anything to my overarching issues or goals for therapy. I got exactly nowhere.
8. Set aside time after sessions to do some self-care. Not possible or even necessary for everyone, but can be very important for some people. Remember that self-care doesn’t have to look like chocolate or bubble baths. I used to like going straight to work after therapy because it helped me get back into the swing of things and feel good about myself. Other people might prefer journaling, messaging a friend, taking a walk, working out, or any number of other restorative activities.
9. Don’t just vent. Many people think that therapy is venting about your problems while someone listens attentively and says “Uh huh” and “Hmm” and “That must’ve been stressful.” While this is usually part of what happens in therapy, and it can build rapport between you and the therapist, and sometimes it’s all you can do, it’s not what therapy ultimately is. Therapy is learning to understand yourself and your patterns and then learning how to change them. A skilled therapist will eventually start to show you the patterns in your venting: “I notice you’re often upset because you feel like the people in your life aren’t really listening to you.” “It seems like you feel like things ‘just happen’ to you without you having much control over them.” Sometimes the therapist will be wrong about the patterns they perceive, but often they’ll be right even if you don’t initially think so. Follow these threads where they lead. That can be the key to creating a life where you don’t have to constantly rant about your stressful whatever or your disrespectful whoever.
10. If you can’t talk about an issue in therapy, talk “around” it. Talking around an issue means exactly what it sounds like–talking about your own boundaries around that issue and why you feel like you can’t talk about it. A skilled therapist, when told “I don’t want to talk about that,” neither pushes it nor changes topics entirely, but will ask questions like, “What worries you about talking about that?” or “What would it be like to tell me about it?” That way, you can move forward on this issue in some way while giving your therapist some important information, without pushing yourself too far. Often, this also becomes a valuable opportunity to share your concerns about being judged or stigmatized by the therapist–concerns that they can then address in a way that might make it possible for you to talk about the issue after all.
11. Try suggestions even if you don’t think they will work. At some point, depending on your therapist’s theoretical approach, they may start to work with you on practical ways to deal with some of your symptoms on your own–i.e. coping skills. A common experience in therapy for people who have depressive symptoms is that the therapist will suggest things for them to try and they’ll shoot down every suggestion, saying it could never work. (I’ve been there as a client, and as a friend/family member being supported by others. Have I ever.) You might very genuinely feel that it won’t work–you’re not just being difficult for its own sake. You might even be right. However, unless there is an actual barrier to trying the thing (therapists don’t always know the limits of your physical energy, schedule, or bank account), just try it. At worst, you’ll learn what doesn’t work and is a waste of your time. At best, you’ll take a significant step forward in managing your symptoms. And because depression tends to cloud our vision of what’s possible, trying as many things as you can even if you don’t think they’ll work can be a useful check on that.
12. Don’t ask your therapist for advice. By “advice” I don’t mean “What are some ways to manage anxiety symptoms when I’m out in public” or “What are some lifestyle changes that have been proven to help with depression”; those are things therapists should work on with you (as discussed in the previous tip). I mean, “So do you think I should dump my partner?” or “Is this a wise financial investment?” or “Should I just tell my mother-in-law we’re not coming for Thanksgiving this year?” Therapists are not qualified to tell you what to do with your life. Good ones will gently steer you back towards making decisions based on your own values and priorities, but in any case, you’ll get more out of therapy if you don’t see it as a place to get life advice and therefore aren’t disappointed when your therapist doesn’t give it. Obviously, the line here can sometimes get a little blurry–while therapists aren’t qualified to tell you whether to dump your partner or punish your kid for something they did, they can tell you about best practices for strengthening relationships, communicating, and parenting. Remember that even there, though, research might be mixed and anything your therapist says is filtered through their own experiences, values, and social position. I’ve heard licensed mental health professionals insist that spanking children is not only morally acceptable but practically effective, even though the research strongly suggests otherwise.
13. Practice the skills you learn in therapy throughout the rest of your life. A therapist’s ultimate goal is to make themselves unnecessary. In order for that to happen, you have to take what you learn in therapy and apply it elsewhere. This happens on two levels. One is the more surface level: practicing the coping skills, communication strategies, and other practical knowledge outside of the therapy session. The other takes place on a deeper level. In many schools of therapy, the relationship between the client and the therapist is meant to serve as a model for other relationships (in certain ways). When you learn how to open up to your therapist, set boundaries with them, and trust that they won’t judge or reject you because of your flaws or because you disagreed with them, you’re also learning how to do that with other people. Of course, it’s not easy–those other people probably aren’t getting paid to listen to you nonjudgmentally. But the point is that just as your therapist accepts you for who you are, so can other people. Once you’ve started to believe that about your therapist, practice placing that trust in other people. With this and with the practical skills, you can ask your therapist to help you find ways to practice if you’re not sure how.
14. Try to let go of the idea of getting your therapist’s “approval.” A lot of people mess up in therapy by focusing way too much of their mental efforts on getting the therapist to like them or making sure that they don’t say anything that makes their therapist dislike them. Sometimes, this just means you’re not getting that much out of therapy; sometimes it actively causes harm, such as when my clients with substance use issues repeatedly tell me that they don’t have any cravings ever not at all nope and then weeks later it turns out that they had a massive relapse ages ago and never told me because it’s embarrassing. But if they’d told me as soon as they started getting cravings, we could’ve worked on ways to manage that and possibly prevented a relapse. I get it–facing someone’s judgment is never easy, especially not if that person is in a position of power or authority over you. But therapy can’t work if you only talk about what’s going well for you or what you’re good at. If your primary goal in therapy is to make sure the therapist likes you, you’re wasting your time and money.
15. Tell the truth. In therapy, you get to be as petty, judgmental, whiny, pessimistic, jealous, bigoted, and callous as you are on your worst days. You get to be bitter that your sister’s married and you’re still not. You get to judge your friends for their sex lives. You get to admit that you’d rather get high every day than go to work. You get to insist that everyone hates you and they’re right. That doesn’t mean you have to lay out a complete catalog of your flaws right in the first session, but it does mean that you should tell the truth. Even saying “I don’t want to talk about that” or “I can’t talk about that yet” is better than saying something you know is untrue. But even if you do lie, it’s never too late to set the record straight. As a therapist, I’d much rather hear, “Actually, when I told you I don’t drink anymore, that wasn’t true,” than to continue not helping someone who needs help with their drinking.
16. Push yourself. A lot of the suggestions on this list might have you thinking, “But I can’t do that! That’s too scary/triggering!” First of all, that’s why they’re only suggestions. But second, part of your work in therapy is learning more about yourself and your boundaries, deciding whether or not those boundaries are acceptable to you, and, if not, learning how to gently expand them. As a therapist, my job isn’t to pressure you to try things you don’t feel ready for; it’s to meet you in the middle and help you through it once you decide to try. And as a client, your job isn’t to blindly do what I suggest for you to do; it’s to choose your goals and the pace at which you’re going to move towards them, and then to push yourself to do that. Maybe being able to tell your therapist about your trauma isn’t one of your goals at all. But if it is, at some point you’ll need to turn “I don’t want to talk about that” into “Okay, I’m going to try talking about that even though it might hurt.” Only you get to decide when that moment comes.

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Although I’ve closed comments, I’d love to hear what you’ve done that’s helped you get the most out of therapy. Please tweet at me if you’d like to share, and I’ll update this post with responses.

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

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

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

This approach to friendships with chronically ill people–“keep inviting them over and over even if they say no every time!”–feels like it conflicts with another principle I generally live by, which is that if someone doesn’t seem like they want to do something but isn’t saying “no” directly, I treat that as a no. And if they keep saying “no” to my invitations without suggesting alternatives or otherwise indicating that they do want to see me and would if they could, I stop asking.

To people who give the “keep inviting them” advice, this probably reads as “being lazy”/”not caring enough about your chronically ill friends”/”taking their illness personally.” To me it’s respecting boundaries, including implicit or unstated ones. I would much rather risk hurting someone by being too distant than by being too close, i.e. crossing their boundaries.

Of course, ideally, that’s a false dichotomy. Ideally, I would say, “Hey, I’ve noticed that when I invite you to things you always say no/always end up canceling. Would you like me to stop asking?” And ideally you would say, “No, please keep asking, my depression makes it hard to keep or initiate plans but I appreciate being asked,” or “Yeah, my anxiety is too bad these days but I’ll let you know when that changes,” or “Yes, I’m sorry but I’m not interested in hanging out with you.”

That would be ideal. But practically, I am myself chronically ill (depression, anxiety, and fatigue) and don’t have infinite spoons to chase people around. (I think much of this “just keep asking them” advice presumes that these people’s friends are all healthy and neurotypical, when in fact, many of us end up being close to people with similar struggles.) And practically, at the point when communication has broken down so badly that I don’t even know if the person wants to see me or not, I don’t think I could trust them to answer that question honestly. After all, if they’ve been saying yes despite meaning no and then cancelling or not showing up, or if they’ve been saying no while silently wishing they could say yes, then I can’t exactly expect direct communication because it hasn’t been happening thus far.

If that sounds harsh, keep in mind that I’m calling out myself as much as (if not more than) anyone else, because I’ve also done all of these things. And yes, I did them because of chronic illness, and that’s valid. But I still don’t get to expect people to read my mind.

This is why advice columnists like Captain Awkward often encourage people to “use their words” and be clear with friends and partners about what they need, even–especially–if they have a mental illness. (That mental illness makes something more difficult to do doesn’t make it any less helpful.) “I would like you to keep inviting me even though I say no because it makes me feel included” is a valid request. “I want to see you but I’ll often have to cancel because of my illness” is a valid reminder.

In general, we tend to over-estimate the degree to which our internal states and motivations are obvious to people. It’s not necessarily obvious to your friends that you appreciate their efforts to reach out or that you wish you could see them, especially not if your friends struggle with depression and the self-doubt that it brings.

Somewhat similarly, many of my friends in the chronic illness community have been trying to normalize the idea of extremely asynchronous online communication, where you might initiate contact or answer messages from people very rarely even though they’re still very important to you. So I might message you and you might not answer the message for weeks or even months, but I’m still meant to know that you care about me a lot. And similarly, I get it and it’s very appealing. We’re busy. We’re sick. We’re pioneering new ways of staying connected that work for us.

But at the same time, when I see these memes about “I still care about you even though I never talk to you, see you, or otherwise give you any evidence that I even remember you exist,” I can’t help but feel incredibly invalidated. It hurts when a close friend suddenly all but drops off the face of the earth, barely answers my messages, never initiates their own. It only adds insult to that injury when I’m told that I’m supposed to just assume that they still love me and care about me despite doing nothing to show it–with the added implication that if I feel rejected or ignored, it’s my fault for not knowing how much they “obviously” care.

To be clear, it’s not the idea that someone might need to avoid people for a while that bothers me. Not at all. It’s the idea that I, a person being avoided with no explanation, should just pretend it’s not happening, keep my own behavior unchanged, and not feel bad about it.

That they probably have Valid Reasons for disappearing doesn’t make it hurt any less, and at that point, the healthiest thing for me to do to deal with my own feelings is to mentally write that person off as a close friend until they give me a reason to reassess. And they often do, and I’m always happy to have them back in my life. But in the meantime I don’t think about them much and I don’t count on their friendship or support. That’s healthier for me because it helps me manage my expectations and prevent disappointment. For all I know at that point, they don’t really care or remember me, and I learn to be okay with that.

I try to base my models of other people’s minds on what they communicate to me, not on what I wish or hope is true. If someone is not accepting my invitations, not answering my messages, and not otherwise acting like they want me to be in their life, it seems laughably naive to just assume that they do.

And sure, “friend” can mean many things and if we’re talking about a very close friend who is suddenly very distant, it might seem unfair for me to just assume that they don’t want to be friends anymore.

On the other hand, if they don’t want to end the friendship, it’s also kinda unfair for them to distance themselves without any explanation and expect me to feel like nothing’s changed. It’d be nice if we could all read minds and I could just know that they don’t have spoons for socializing right now or their anxiety’s been bad or whatever. But I don’t know that, and “Why haven’t you been answering my texts” is an awkward-as-hell question to ask. It’s not at all easy to tell someone that you need to be distant, either–I get it. But if you’re concerned about how they’re going to interpret your distance, it might ultimately put both of you more at ease.

On the outside, “I’m chronically ill and silently hoping you keep trying to include me even though I always say no” looks remarkably similar to “I really wish this pushy person would take the hint and stop trying to get me to hang out with them.” I never want to risk being that pushy person. I don’t know what’s in your head unless you tell me.

I don’t like advice that sounds like “ignore the signals people are sending you.” I also don’t like implying that struggling people shouldn’t expect any support they don’t explicitly ask for. There’s room here for unspoken understandings that develop between friends and partners over time. There’s room, too, for the acknowledgment that unspoken understandings can easily turn into misunderstandings, and sometimes you need words.

In that way, posting all these memes, as cognitively dissonant as they make me feel sometimes, is a great thing to do because it lets people know that they can keep initiating contact with you despite a lack of reciprocation. It’s a pretty low-cost way of communicating that, too.

I can proclaim the virtues of direct communication all I want, but the truth is that sometimes we don’t have the spoons for it or we don’t trust each other enough because we’ve been burned too badly in the past. So there may not always be a way to resolve the tension between supporting a friend with chronic illness who always says no or avoids you, and respecting that person’s unstated boundaries. I hope that talking about this tension more, though, will make it easier to navigate.

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These two pieces may be useful to folks working through these issues: Some Advice on Supporting Friends with Depression & Reaching Out for Support When You Have a Mental Illness.

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[Content note: depression and eating disorders]

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

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

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

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

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

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

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

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

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

A while back, I wrote about a particular strain of criticism of people (generally teenage girls) who “glorify” or “enable” mental illness symptoms by presenting them in a romantic or sexy light. The argument goes that these blogs may discourage young people from seeing their mental illnesses as treatable (or seeing them as illnesses at all) and encourage them to do harmful behaviors associated with those illnesses–self-harm, restricting, purging, etc. In that post, I concluded: “It’s easy to say, ‘Don’t romanticize depression! It encourages people to view depression as normal and healthy.’ It’s harder to say, ‘Don’t show symptoms of your depression! It encourages people to view depression as normal and healthy.'”

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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