therapy

A Case for Strengths-Based Diagnosis

Miri, , , , , , 13 Comments

[Obligatory disclaimer that I am not (yet) a licensed therapist and that the following is my personal opinion, informed by practice and academic study.]

Recently in a class on adult psychopathology, my professor was discussing the strengths and weaknesses of the DSM (Diagnostic and Statistical Manual of Mental Disorders), the text used to diagnose mental illnesses and categorize them for the purposes such as research, insurance billing, and sharing information among professionals.

One of the weaknesses he mentioned was one I’d actually never heard before: that the way the DSM diagnosis is written and shared does not include any space for also “diagnosing” the client’s strengths.

At first, this seemed irrelevant to me, not in the sense that thinking about your client’s strengths is not important, but in the sense that I didn’t see how it matters for a diagnosis. It almost seemed a little patronizing: “Yes, you have major depressive disorder and social phobia, but hey, at least you seem like you’re pretty resourceful and good at expressing yourself!”

But then I rethought that.

Here’s an example of a DSM-V diagnosis:

296.35 (F33.41) Major depressive disorder, early onset, recurrent episode, in partial remission, with atypical features

300.4 (F34.1) Persistent depressive disorder, early onset, with atypical features, with intermittent major depressive episodes, without current episode, moderate

V62.89 (Z60.0) Phase of life problem

It’s honestly difficult for me to imagine looking at this information with anything other than relief. For me, diagnosis has always meant one thing first and foremost: You’re not a terrible person; you just have an illness.

But to other people, seeing something like this can communicate a whole lot else. You’re sick. You’re fucked up. There is nothing redeeming about you. You can’t do something as simple as not being so sad. This is especially true when someone is already predisposed to interpret information about themselves in a negative light, because, well, that’s what mental illness always does.

In that moment, it can be really helpful to have confirmation–not just from a friend or loved one, but from a professional whose job it is to assess you–that you do have strengths and positive qualities.

So, here are some reasons incorporating strengths into diagnoses might be a really good thing.

  1. Giving hope and affirmation to the client.

Just like it can be nice to go get a dental checkup and hear, “You’ve been doing a great job at preventing cavities, but you need to floss more consistently in order to keep your gums from getting irritated,” it can be nice to hear, “Based on what you’ve told me, I believe that you’ve had a major depressive episode for the past few months. However, you’ve clearly been very good at reaching out to friends and family for support, and it sounds like you have a lot of people rooting for you to get better.”

Therapists and psychiatrists say “nice” things like this all the time, but writing it down as part of a diagnosis might be symbolically meaningful. To the client, that communicates the fact that their strengths are just as important as their diagnosis–important enough to be written on the form or in the chart. It shows that their mental healthcare provider, whom they might feel shy around or even judged by, does see them as a whole human being with strengths as well as a diagnosable illness.

  1. Providing possible avenues for treatment.

A psychiatrist may diagnose a client and then refer them to a therapist (therapy combined with medication tends to be more effective than either in isolation). Now what? The therapist can look at the diagnosis, or ask the client what it is, and proceed from there.

What if the diagnosis included something like, “Client reports that volunteer work helps them distract themselves from symptoms, and that writing in a journal has occasionally been helpful”? The therapist now has some potential ways to help the client. Or the diagnosis might include, “Despite severe symptoms, client shows a high level of insight about the possible origins of their depression.” The therapist now knows that lack of self-awareness isn’t the problem–symptom management might be.

I continue to be amazed that none of my therapists ever asked me if there’s any way I could incorporate writing into my depression recovery, or if there are any ways I’ve been incorporating it already. Writing is my life. Usually I’ve either said as much in therapy, or I haven’t because nobody ever asked me what I like to do or what makes me feel good. Why not?

  1. Reducing negative bias from providers.

I can’t make definitive statements without more research, but based on what I understand about bias, I can imagine that consistently viewing a client as “major depressive disorder with atypical features and moderate persistent depressive disorder” does things to one’s perception of that person. Not positive things.

It is difficult (if not impossible) to effectively help someone you view as deficient or weak. First of all, your likely pessimism about the person’s recovery will almost certainly be perceived (and possibly internalized) by them. Second, any roadblocks that come up in treatment will likely be interpreted as “resistance” or “not really wanting to get better” or “not being ready to do the work of therapy.” In fact, maybe it’s that your approach isn’t actually helpful to them. Third, without a conscious awareness of the person’s strengths and assets, what exactly are you using to help them recover? Therapy isn’t about “healing” people so much as helping them discover their own resources and help themselves. If you don’t even know what those might be, how could you possibly help the client see them?

Many therapists try to think of their clients’ positive traits in addition to their “negative” ones. However, formalizing and structuring this process as part of a diagnosis might make it sink in better, and become more embedded in one’s general impression of a person. The questions we generally have to ask while diagnosing someone are fairly negatively oriented–”Do you ever have trouble falling asleep? How often? To what extent does this impact your daily life?”. What if we also asked, “What helps you sleep better? How do you cope with being tired after a night of insomnia?” Maybe that can help shift a therapist’s perspective of this person from “insomniac” to “person with difficulty sleeping, who has reached out to friends for help with daily tasks.”

  1. Preventing provider burnout.

I dislike talking about my work because people are consistently amazed at it in a way that annoys me. “How could you deal with hearing these awful things?” they ask. “Isn’t it really depressing to work with all these people?” It isn’t, because thanks to my training, I’ve internalized a strengths-based perspective. When I think about the people I’ve worked with, I don’t see poor suffering depressives and trauma victims. I see resilient, determined individuals who are working to overcome their challenges in the best ways they can.

I think that some people in this field burn out because they can only see the suffering and the oppression and the unfairness of it. I also see those things, obviously, because they’re sort of a big deal. But if that’s all you see when you sit with a client, not only will that be reflected in your treatment of them, but it’ll also impact your own ability to persevere.

If every time a therapist made a diagnosis, they had to intentionally remind themselves of the client’s strengths, that might go a far way in helping them remember that there is hope and everything is not absolutely bad.

As I’ve mentioned, plenty of mental health professionals already incorporate a strengths-based perspective into their work. But this is more common in areas like social work, where diagnosis is rarely used and actually often criticized, anyway. I certainly don’t remember any of my psychiatrists or PhD-level therapists spending any time asking me about my strengths or coping strategies. They gave me my diagnosis, and that was mainly it as far as assessment goes.

One might argue that strengths assessment has no place in the DSM because it needs to be standardized and reliable. However, reliability may be a problem for the DSM regardless, meaning that different professionals assessing the same client may disagree in their DSM-based diagnosis.

One might also argue that the DSM is “about” mental disorders, not “about” a client’s overall set of traits or strengths. I’ll grant that. Regardless, I think that formally incorporating individual strengths into clinical assessments in therapy and psychiatry may be helpful. May be.

A Case for Strengths-Based Diagnosis
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Feminist Bloggers Cannot Be Your Therapists

Miri, , , , , , , , 119 Comments

[Content note: mentions of sexual assault and suicide]

I’ve been thinking more about Scott Aaronson. Specifically, I’ve been thinking about what he struggled with during adolescence, and about the (in my opinion, misguided) notion that feminism could have possibly been of any help to him.

The battle cry I’ve heard from men since Aaronson’s now-infamous Comment 171 was published is that feminist writers and activists need to be more mindful of situations like Aaronson’s when we choose our language and strategies. There seems to be a collective yearning for acknowledgement that the usual feminist rhetoric is not only unhelpful for people in the teenage Aaronson’s frame of mind, but actively harmful to them. There is one piece of this that I fully agree with, that I will get to later. But for the most part, I continue to feel a sort of frustration and exhaustion, and I think I’ve finally figured out why.

I wrote in my previous post on the subject that I feel that we (women) are being given all these male traumas and struggles and feelings to soothe and fix, as we always are. But now I understand why exactly I feel like we’re such an inadequate receptacle for these things.

Let’s look at some of the most salient parts of Comment 171:

I spent my formative years—basically, from the age of 12 until my mid-20s—feeling not “entitled,” not “privileged,” but terrified. I was terrified that one of my female classmates would somehow find out that I sexually desired her, and that the instant she did, I would be scorned, laughed at, called a creep and a weirdo, maybe even expelled from school or sent to prison. And furthermore, that the people who did these things to me would somehow be morally right to do them—even if I couldn’t understand how.

You can call that my personal psychological problem if you want, but it was strongly reinforced by everything I picked up from my environment: to take one example, the sexual-assault prevention workshops we had to attend regularly as undergrads, with their endless lists of all the forms of human interaction that “might be” sexual harassment or assault, and their refusal, ever, to specify anything that definitely wouldn’t be sexual harassment or assault. I left each of those workshops with enough fresh paranoia and self-hatred to last me through another year.

[…] Of course, I was smart enough to realize that maybe this was silly, maybe I was overanalyzing things. So I scoured the feminist literature for any statement to the effect that my fearswere as silly as I hoped they were. But I didn’t find any. On the contrary: I found reams of text about how even the most ordinary male/female interactions are filled with “microaggressions,” and how even the most “enlightened” males—especially the most “enlightened” males, in fact—are filled with hidden entitlement and privilege and a propensity to sexual violence that could burst forth at any moment.

Because of my fears—my fears of being “outed” as a nerdy heterosexual male, and therefore as a potential creep or sex criminal—I had constant suicidal thoughts. As Bertrand Russell wrote of his own adolescence: “I was put off from suicide only by the desire to learn more mathematics.”

At one point, I actually begged a psychiatrist to prescribe drugs that would chemically castrate me (I had researched which ones), because a life of mathematical asceticism was the only future that I could imagine for myself. The psychiatrist refused to prescribe them, but he also couldn’t suggest any alternative: my case genuinely stumped him. As well it might—for in some sense, there was nothing “wrong” with me.

[…]And no, I’m not even suggesting to equate the ~15 years of crippling, life-destroying anxiety I went through with the trauma of a sexual assault victim. The two are incomparable; they’re horrible in different ways. But let me draw your attention to one difference: the number of academics who study problems like the one I had is approximately zero. There are no task forces devoted to it, no campus rallies in support of the sufferers, no therapists or activists to tell you that you’re not alone or it isn’t your fault. There are only therapists and activists to deliver the opposite message: that you are alone and it is your privileged, entitled, male fault.

It’s worth reading the entire thing, and reading it carefully. (Aaronson’s defenders are correct that some people have been making accusations of Aaronson that are directly refuted by things that he said in the very same comment. Let’s not do that.)

Here’s what I thought. If someone came to me and said that he earnestly believes that he will be “expelled from school or sent to prison” if a woman finds out that he finds her attractive, and that he has “constant suicidal thoughts,” and that his daily existence is characterized by “crippling, life-destroying anxiety,” I would not recommend that he read Andrea Dworkin or attend a sexual assault prevention workshop. I would recommend, gently and tactfully, that he go see a therapist.

I would do that because these are very serious issues. They are serious enough that, when a client tells me that they have “constant suicidal thoughts,” there is an entire protocol I’m required to follow in order to ensure that they are safe and receive appropriate care if they accept it.

I will not speculate about what mental illness Aaronson could have theoretically been diagnosed with in his adolescence; I oppose such speculation and it’s actually irrelevant. I don’t need to diagnose him to say that he had serious issues and could have really benefited from treatment. (However, I may reference some diagnoses in what follows, not to suggest that Aaronson had them but to show how mental illness can interact with other life circumstances.)

Maybe Aaronson didn’t think to seek therapy as an adolescent, because therapy and mental illness are still quite stigmatized and would have been even more so when he was younger. Maybe nobody close to him noticed or cared what was going on, and therefore did not encourage him to seek therapy. Maybe the psychiatrist he asked to prescribe castration drugs did not pause to consider that a teenager seeking castration is a red flag, and that maybe he should refer him to a colleague who practices therapy. Maybe, maybe, maybe.

But why aren’t we talking about it now? Why are people blaming feminism–the feminism of the 1970s or 80s, no less–for failing to cure what appeared to be a serious psychological issue? Why are people claiming that the solution now is simply for feminist writers and activists to be more compassionate and considerate towards male nerds like Aaronson, as though any compassion or consideration could have magically fixed such a deeply layered set of deeply irrational beliefs?

This troubles me. If I ever start claiming that, for instance, I’m a terrible person and deserve to literally die because I’m queer, or that I cannot be in the same room with a man without literally having a panic attack, I sincerely hope that people advise me to seek mental healthcare, not to read feminist literature.

Lots of helpful things can harm a small subset of people because of that subset’s individual traits. For instance, there are a lot of PSAs about washing your hands to prevent the spread of disease and things like that. But some people have OCD and wash their hands compulsively, to the point that they’re hurting themselves physically and having trouble accomplishing daily life tasks because they have to wash their hands so much. I can imagine these PSAs being extraordinarily unhelpful to them.

We also often hear about the importance of donating to charity. Most people could probably donate more to charity if they wanted to. However, some people compulsively donate so much to charity that they harm themselves or their families. I can imagine this being exacerbated by someone telling them how important it is to donate to charity. Perhaps they feel they are never good enough.

I can see how feminist literature might have functioned in a similar way for Aaronson. The truth is that most men are about as far away from his mindset as you can get. Some are even the opposite extreme. Most men spend very little time thinking about how their behavior impacts women. Most men need to spend more time thinking about it. But how could he have known that these feminist books were not for him? If they were to put on the cover, “If you’re a great guy who does not hurt women, you don’t need to read this,” well, no man would ever read it. They all think they’re great guys who do not hurt women, even though some of them rape women.

Neurodiversity is an axis of privilege/oppression. People who suffer from mental illness or whose brains are set up differently from what is considered the “norm” (such as people with autism) lack privilege along this axis. They have difficulties because our society is not made to accommodate them. However, if these people are white, or male, or straight, or cisgender, or so on, they still benefit from the privileges afforded to people in those categories.

For instance, despite all his other fears and anxieties, Aaronson did not have to live in constant fear of being sexually assaulted, because he is male. He did not have to live with a significant risk of being harassed or brutalized by the police, because he is white. He did not have to deal with having people constantly refuse to identify him as the gender he identifies as, because he is cisgender. He did not have to struggle to physically access places he needs or wants to go, because he is able-bodied. Of course, he still faces some risk (in some cases fairly negligible) of all of these things, because having privilege doesn’t shield you from everything.

However, as a person who was (apparently) neuroatypical, Aaronson did have to live with “crippling, life-destroying anxiety.” He did not appear to have access (even if it’s just because he didn’t know to ask for it) to mental healthcare that could have helped him. He was forced to spend years feeling horrible. If he told people how they felt, they may have blamed him for it, because victim-blaming is a key component of our society’s oppression of neuroatypical people. Had he lacked some of the other privileges that he had, such as race and class, he may not have been able to access the apparently-useless psychiatrist that he did access.

Aaronson claims that he did not have “male privilege” because he did not feel that he had it. I’ve addressed arguments like these before. He presumably did not feel privileged because on one very salient and relevant axis, he certainly was not.

But otherwise, having or not having privilege isn’t actually dependent at all on how you feel. You have it or not. Men on the street hurl sexual obscenities at you or they do not. Cops stop you and slam you to the ground for no reason or they do not. You are allowed to marry someone of the gender(s) you’re attracted to or you are not.

Aaronson might be interested (or not) to know that many feminists are busy fighting to ensure access to mental healthcare for everyone, and an end to the stigma that prevents people from seeking help. But maybe that’s irrelevant now.

As I mentioned earlier, I am taking one piece of Aaronson’s (and the many others who have echoed him) criticism to heart. Namely, feminist materials need to be better at specifying what to do rather than just what not to do. Now is a good time for a reminder that I offer a workshop on this exactly, with a light-hearted tone and lots of audience participation and definitely no yelling at men that they are horrible awful creeps no matter what they do. I am far from the only person who offers such materials, but it would be cool if there were more. That said, anyone claiming that feminism does not offer this at all has quite clearly not done their research. Andrea Dworkin and some random shitty college sexual harassment training are not the only resources feminism has to offer.

(Some things that I have read along these lines [“these lines” meaning, roughly, “affirmative resources that help men and others conduct their sexual/romantic lives ethically without shaming them]: Charlie Glickman, Doctor Nerdlove, Yes Means Yes (the book and the associated blog by Thomas Macaulay Millar), Pervocracy, Franklin Veaux. If you don’t like any of these, create your own!)

But even then, your average casual feminist blogger or columnist cannot take responsibility for fixing the problems of someone who apparently sincerely believes that speaking to a woman will get him sent to prison. Or someone who is literally unable to talk to a woman because they have so much social anxiety. These are issues for professionals to deal with. Professionals can affirm. They are there to hold your feelings and make you feel comfortable and supported. They can teach social skills. They can help you examine maladaptive and irrational thoughts. They can help you learn how to cope with anxiety. That is what therapists are for. They are imperfect, but they are trained for this. I worry about placing this responsibility on every feminist with a blog.

Aaronson claims in his comment that “there are only therapists and activists to deliver the opposite message: that you are alone and it is your privileged, entitled, male fault.” I’m not sure if this comes from experience or is purely the creation of his mind with the biases that it had at the time. If Aaronson went to see a therapist and that therapist shamed him, then that therapist is wrong and does not deserve the title. (I’m not trying to do a No True Therapist fallacy here; I’m just pointing out that shaming people is against our ethics and if you cannot not shame people then you should not be a therapist.)

If Aaronson did not see a therapist, perhaps because he was afraid that they would shame him, then that’s unfortunate. And I don’t blame him. But I still think that we should be encouraging people with such pronounced irrational beliefs to seek therapy, not feminist literature.

No wonder I was so frustrated when I wrote that earlier post. I felt like feminist writers are being asked to do the job of a mental healthcare professional.

~~~

A few relevant points that I did not have time to expand on here, but may in the future:

  • Part of the reason that a lot of what Aaronson read/watched was so shaming towards men was probably because it was shaming towards sex and sexuality in general. Especially those college sexual harassment trainings, some of which are woefully retrograde. It’s important to remember that stigma/shaming around sex is something that is so entrenched in our culture that it’s bound to show up all over the place, even, yes, in feminist literature.
  • Aaronson claims that all the feminist literature he read confirmed his belief that straight men are awful and violent. While this may be so–I haven’t read Dworkin and don’t intend to–I have also personally watched men respond to materials that were not at all whatsoever shaming of men by claiming that they were being shamed by those materials. This seems to be a very common bias. They expect to be shamed by feminist materials, so they feel shamed by them.
  • I have seen dreadfully few discussions about how everyone–especially non-/anti-feminist men and women–perpetuate toxic ideals about masculinity. It’s usually not feminist teenage girls slamming shy nerdy boys into lockers and publicly humiliating them, is it? We should talk more about that. Unfortunately, most men dislike talking about toxic masculinity, because they think that “masculinity” is synonymous with “men,” and perhaps also because they have bought extensively into this ideal and appreciate the privileges it affords them.
  • There needs to be a space where we can say, “Wow, that is really awful, I’m sorry you felt that way and had to live with that, but I need to point out that your interpretation of things was inaccurate.” Because right now, it’s looking to me like anyone who includes the latter part of that sentence is accused of hating men or lacking compassion. If I read a Richard Dawkins book, came away with the idea that Dawkins believes that all religious people should be put to death, and therefore started to fear for the lives of my religious relatives, I would want someone to try to explain to me that I had misinterpreted the book. It would not be compassionate at all to allow me to continue believing that Dawkins was calling for my relatives’ deaths. It is not compassionate to allow Aaronson to believe that feminists want him to never, ever so much as kiss a girl. (A moot point now, but it wouldn’t have been earlier.)
  • It is also entirely possible that all the feminist literature that Aaronson read was woefully inadequate. (I disagree, and wish he had picked up bell hooks, but let’s grant it.) Feminism is, like every other field of study, constantly advancing and finding new ways to analyze and advocate. The feminist literature of the past decade or so focuses a lot more on helping men than the feminist literature of the 1970s and 80s. But feminist activism still consists mostly of women, and when men join in, they often try to speak to us about our own issues than to other men about men’s issues. And women, naturally, will focus first on issues we primarily face, some of which are life-threatening. Men, please, don’t stand around and lament the fact that feminists are not addressing your problems. Familiarize yourself with feminist principles and join in.
Feminist Bloggers Cannot Be Your Therapists

Why We Should Ban Conversion Therapy

Miri, , , , , , , , , , , , 6 Comments

[Content note: suicide, transphobia, abuse]

I wrote this article for the Daily Dot about conversion therapy. Please note that I did not write and do not endorse its headline as it appears at the Daily Dot.

At the close of a year that saw both incredible gains for transgender people and a number of tragic acts of transphobic violence, 17-year-old Leelah Alcorn, a trans teen from Ohio,committed suicide on Sunday. In a note that she had preemptively scheduled to post on her Tumblr, she described the bigotry she had faced from her parents, who tried to isolate her from her friends and the Internet as punishment. They also sent her to Christian therapists who shamed her for her gender identity.

In response, the Transgender Human Rights Institute created a Change.org petition on December 31. The petition asksPresident Obama, Senator Harry Reid, and Representative Nancy Pelosi to enact Leelah’s Law to ban transgender conversion therapy. Less than two days later, the petition has already gained 160,000 signatures and made the rounds online. It may be the most attention that conversion therapy has gotten outside of activist circles for some time.

Aside from LGBTQ activists, secular activists, and mental healthcare professionals seeking to promote evidence-based practice, not many people seem to speak up about conversion therapy, or understand much about it. Most discussions of it that I come across deal with therapies that attempt to “reverse” sexual orientation from gay to straight or to eradicate same-sex attraction. However, conversion therapy also includes practices aimed at transgender people with the goal of forcing them to identify as the gender they were assigned at birth.

In her suicide note, Alcorn wrote, “My mom started taking me to a therapist, but would only take me to Christian therapists (who were all very biased), so I never actually got the therapy I needed to cure me of my depression. I only got more Christians telling me that I was selfish and wrong and that I should look to God for help.” Although she did not elaborate further about her experience in therapy, it’s clear that the treatment goal was not to help Alcorn reduce her risk of suicide, accept herself, recover from depression, or develop healthy coping skills that would help her stay safe in such an oppressive environment. The treatment goal was to force Leelah Alcorn to identify as a boy and to fulfill her parents’ and therapists’ ideas about what being a Christian means.

This is not mental healthcare. This is abuse.

Read the rest here.

Why We Should Ban Conversion Therapy

Therapists Can Be Wrong

Miri, , , , , , , , 20 Comments

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

The client is the expert on their experience.

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

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

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

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

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

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

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

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

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

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

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

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

I trust people more when they admit their mistakes.

 

Therapists Can Be Wrong

A Flare-up of a Chronic Illness

Miri, , , , , 12 Comments

[Content note: depression]

This is a personal post, not an advice post or a big societal problems post. But past experience has shown that some people appreciate and benefit from it when I describe how I try to think about things.

“Reframing” is a term we sometimes use in mental healthcare (and elsewhere) to basically refer to changing the way you think about something. While therapists sometimes suggest ways to reframe things to clients, it’s ultimately up to the individual to decide whether or not they want to reframe, and if so, how.

For some people this concept can hit a nerve because it can sound a lot like the well-meaning but ultimately useless (and even hurtful) advice we get to “look on the bright side” and “think about the positives.” But that’s not what reframing means to me. Here’s an example.

In one of my classes, we are required to meet in pairs for ten weeks to administer and receive counseling. Not as a roleplay exercise, but as an actual attempt to disclose one’s struggles or work with someone else on those struggles. Many students in the class expressed strong discomfort with being one of the “clients” in this exercise, but I’m already accustomed to sharing very personal and intimate details with thousands of strangers online, so I had no qualms about signing up to be counseled.

During our first session, my student-counselor asked me a question: “What, to you, would be an ideal or perfect day?”

It didn’t take me long to think about my answer, which turned out to be sort of a non-answer.

“There isn’t one,” I said. I explained that after eleven years of depression, there is no longer such a thing as an ideal or perfect day and it feels like there never was. That sort of thing is so far out of the realm of possibility for me that, in my view, there’s no point in sitting around hypothesizing about it*.

The reason is that hypothesizing won’t bring me any closer to experiencing it. The things that stop me from being able to have perfect days, those days you spend the rest of your life wishing you could relive, are not surmountable things.

As an example, I told them about the previous weekend, when my roommate and I had gone to visit friends in the suburbs of Philly and then went to a steampunk-themed dance in the city proper. I’d been looking forward to it for a while. It was supposed to be one of those awesome nights. We got all dressed up, and I was wearing my friend’s spectacular dress that I felt amazing and sexy in, and I was with my friends, and it was going to be awesome.

Until, of course, it wasn’t. Not long after we got there, I experienced one of the things I refer to as a depressive trigger, for lack of a better term. It’s whatever the depression version of getting triggered is–specifically, it brings on acute depression symptoms–and it happens to me periodically. I heard it and I felt every metaphorical gear that keeps my brain working properly grind to a halt. It was like driving down a beautiful country road in the sunshine and suddenly finding yourself in a thunderstorm.

After that I couldn’t make myself function. I felt an uncomfortable combination of numb and sad in a very “deep” sort of way. I was constantly on the verge of crying, and knew I would if I let myself think about the thing that had triggered me. I couldn’t talk to anyone, at least not in any socially appropriate way, and I couldn’t dance or pretend to be happy or do much of anything else.

So I left my friends, sat in a corner, and spent most of the rest of the night writing in my notebook (good thing I carry it everywhere) and messaging with one of my partners on my phone. (Situations like this, by the way, are one of the reasons I’m so adamant that it should be socially acceptable to be on your phone at social events. Because my options at this point were: cry in front of my friends, be on my phone, or leave and somehow find my own ride back from Philadelphia to New York at 10 PM on a Saturday night.) I was eventually more or less okay, but it took a long time, and I spent most of the night on the effort to make myself feel more or less okay.

This is not atypical for me; it’s been happening for almost as long as I can remember, and while the triggers have changed a little over the years–as has my ability to manage them–the fact that they happen in the first place has not.

I used to hate myself for it. I’d berate myself endlessly for “ruining” everything or “wasting” good times away, especially since the triggers were as predictable as they were unavoidable. Surely I could learn to stop doing this? (But I see nothing about “acute depression triggers” in any of the scholarly material I read and I don’t even know if this is a typical aspect of the experience of depression or if anyone has ever reported it at all. I just know that that’s how depression works for me.)

Now, I told my student-counselor, I think about it differently. Of this specific incident, I think: I had a flare-up of a chronic illness, but I was able to manage it.

And because I’ve learned to think about it that way, a lot of other things start standing out–the things that went right. I had a great, relaxing day with my friends before it happened. I got dressed up and felt good about how I looked. At the event itself, during the times when I was feeling more or less okay, I met some interesting new people and took some great photos that I’ll have to look at and reminisce. While I was feeling triggery, my friends noticed and checked in on me in ways that demonstrated their concern and care but did not step over any of my emotional or physical boundaries. (Most significantly, I don’t like to talk about the things that cause me to feel bad, and nobody asked or expected me to.) While I was feeling triggery, I managed to disclose a little bit of it to my partner online–not something I am often able to do–and my partner was supportive. I was able to stop it from getting any worse.

Reframing is not the same as its distant cousins, “looking on the bright side” and “finding the silver lining.” I didn’t choose to look on the bright side or find the silver lining. The silver lining found me, after I had reframed the situation in a way that didn’t make me look like a horrible wretched failure of a person. And when I reframe, I don’t attempt to dilute or ignore the reality of the situation. It is not preferable that things like this happen when I’m trying to have a good time with my friends. There is no “silver lining” to getting triggered. I’m not going to wax poetic about what this teaches me about myself or about the human condition. I’m not going to gush about how situations like this really bring out the wonderfulness of my friends and partners, because my friends and partners are wonderful a lot of the time, whether or not I’m currently feeling like crap.

When I think back to that night now, I don’t feel sad, because I’m remembering the good things along with the bad. Previously, the distortion that my brain engages in would’ve made that impossible. I’ve tried to somehow force myself to think about the good things before and failed. It could only happen once I found a way to look at the situation realistically.

I didn’t fail. I didn’t ruin anything. I didn’t choose for this to happen. I had a flare-up of a chronic illness, but I was able to manage it–with the help of some of my friends, but also by drawing on my own strengths and resources.

~~~

*That said, the question the student-counselor asked is typically a pretty good one to ask, as it helps the therapist understand what their client hopes to change about their life. But I already know that I want something impossible. I want to be cured. I won’t be, and that’s okay.

A Flare-up of a Chronic Illness

Venting About Your Problems Is Therapy's Failure Mode

Miri, , , 22 Comments

At least, it was for me.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Venting About Your Problems Is Therapy's Failure Mode

A Primer On Atypical Depression

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

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

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

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

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

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

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

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

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

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

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

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

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

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

A Primer On Atypical Depression

Depression Is Not Sadness (Again)

Miri, , , , , , , , , , 26 Comments

[Content note: mental illness, depression, anxiety, suicide]

When I think about the frequent charge that therapists and psychiatrists and those who work with them are trying to “medicalize” “normal” emotions like sadness and fear, I think that people don’t really understand how emotions like sadness and fear can be distinguished from mental illnesses like depression and anxiety.

I’ve tried to explain this to many people multiple times, in person and through writing, and so have many other people with mental illnesses as well as professionals in the field. Yet people continue to conflate emotions and illnesses, or rather to assume that mental healthcare advocates are conflating them. It’s often difficult to continue engaging patiently with this claim.

Even those who are knowledgeable about illness and disability make this error. In an otherwise-fantastic blog post about the medical model of disability, Valéria M. Souza uncritically cites this very inaccurate view of antidepressants:

In The End of Normal: Identity in a Biocultural Era, Lennard Davis affirms: “A drug would be a prosthesis if it restored or imitated some primary state that appears to be natural and useful” (64). Davis makes this statement in the context of his argument that SSRIs are not “chemical prostheses” for depression, since happiness is not a “primary state” of being and since there is compelling evidence to suggest that SSRIs do not actually work (Davis 55-60).

I’ll address the SSRIs-not-working thing first since I have less to say about that and it’s not as relevant to this post. The reality seems to be more that SSRIs work well for some people but not at all for many other people and we haven’t really figured out why they work for some people but not others, or more specifically, which types of people they work for and which they don’t. And on a personal note, I’m a little tired of being told that SSRIs “don’t work” when they’re part of the reason I didn’t try to off myself four years ago. There is compelling evidence to suggest they do not actually work and there is compelling evidence to suggest that they do actually work, so I’m comfortable saying that the jury’s still out on this one.

More to the point: antidepressants are not meant to cause “happiness” because depression, the illness they are meant to treat, is not defined by a lack of “happiness.” Depression involves a constellation of physical, emotional, and behavioral symptoms that make happiness very difficult or even impossible. These symptoms have a number of other deleterious effects which vary for different people. There are many ways depression can ultimately “look,” such as being unable to get out of bed, being unable to hold down a job, bursting into tears several times a day over tiny inconveniences or in response to nothing at all, losing your sex drive, being unable to sleep, having to sleep over 12 hours a day, having severe memory loss, losing the ability to enjoy any previously enjoyable activity, experiencing complete emotional numbness, obsessing over death and suicide, physically hurting yourself, or attempting suicide.

Maybe being “happy,” whatever that even means, isn’t a “primary state,” but I would argue that being able to live a relatively normal life in which you can go to school or have a job, have relationships with people, and not want to kill yourself is a “primary state.”

Being treated for (and, hopefully, recovering from) depression does not give you extra things that other people don’t have, such as constant happiness and optimism. It gives you what everyone else has had all along, which is a reasonable and age-appropriate amount of control over your emotional state and the ability to create your own happiness if you want to and make the effort.

By the way, you can definitely be miserable and unhappy without having a diagnosable mental illness, but it’s rare to find a person whose unhappiness is truly caused entirely by their own voluntary actions. Depression can also develop as a result of voluntary actions; for instance, if you have a number of career options available to you but you choose an extremely stressful and mind-numbing (but perhaps lucrative?) option, you might end up becoming depressed because of it. At that point, your best bet might be to find a way to make a career change, but it’s likely that you’ll also need therapy to help undo the maladaptive mental habits that the situation has created. (Medication might help too, but in a case like this I’d personally recommend therapy first.)

I think a better way to explain the difference has been that, at least in my experience of mental illness versus mental health, there are things that mentally healthy people can do to significantly increase their level of happiness, whereas people who are going through a bout of mental illness can rarely make a huge difference just by stopping and smelling the roses or making more time to play with their kids or enrolling in a cooking class or whatever. They can maybe make a small difference, but it’s unlikely to reduce the mental illness symptoms themselves. I used to get so frustrated at things like The Happiness Project and other initiatives of that sort, until I finally realized that they weren’t aimed at me because happiness would literally not even be a possibility for me until I treated my damn mental illness.

(That said, things like that can be very useful for someone whose mental illness is in remission or otherwise low-grade. Right now, I’m not fully symptomatic for depression but I’m aware that it can probably come back at any time, so I do a lot of things to keep my mental health strong to try to avoid it coming back.)

It’s difficult to tease out all the complicated interactions between mental illness, mental health, and happiness, and of course it varies for different people. In my experience–which includes my personal experience, my interactions with friends and partners, and my studies and clinical experience, here it is in a nutshell: untreated/unmanaged mental illness makes happiness virtually impossible to achieve. Treating or managing your mental illness, whether through medication, talk therapy, or personal lifehacking, helps make happiness possible to achieve. But the work of achieving it is still yours to do. No drug or therapist can just give you happiness.

And most people with mental illnesses realize this. I haven’t met anyone who was just like “I wanna go to the psychiatrist and get a pill and just be happy always forever.” Most of us just want to stop crying all the time, or stop having panic attacks whenever we need to interact with new people, or stop having intrusive and scary thoughts of killing ourselves, or stop lying awake for hours each night because we can’t stop imagining all the bad things that could happen to us.

“Happiness” is the cherry on the sundae of mental health. You need to put the ice cream and the syrup and the whipped cream in the cup first.

(I’m not sure what it says about me that in reality I actually despise maraschino cherries and always ask for them to be left off my sundae. This is an analogy that was definitely intended for the presumably more normal people who will read this.)

If you still think that what we call “depression” is just an attempt to medicalize “sadness,” then you don’t know what one or either of those things are. So I’ll illustrate with an example of an internal monologue I have had when I was sad, and one I have had when I was depressed. The subject is the same, but the emotional response isn’t. See if you can figure out which is which!

I really wish I had a partner. It’s lonely not having anyone to come home to and it feels crappy seeing all my friends with their partners even though I know I should be happy for them. Sometimes I wonder if I’m just not that attractive or likable as a person. It seems like I’m the only person not dating anyone. I hope I meet someone soon, but I don’t know when or how that will happen and I’m not that optimistic about it right now. 

I really wish I had a partner. I feel like a complete worthless failure because literally everyone else I know is seeing someone and I’m not. I’ll probably never find anyone and I’ll just be lonely for the rest of my life and there won’t be anyone to call 911 if something happens to me and they’ll find my body in my apartment days later because nobody gave enough of a fuck to check on me. Not like I blame them. I’m so ugly and stupid that I don’t know why anyone would even want to hang out with me, let alone go out with me. Everyone’s probably pitying me because I don’t have anyone and everyone can tell that it’s because I’m completely pathetic. I feel like I might as well not even exist because what’s the point of going through life alone and unloved?

One of those is a sensical reaction to lacking something in your life that’s important to you (a romantic relationship); the other is over-the-top. The emotional response in the second example is disproportionate; it doesn’t make sense to leap all the way from “I’m sad because I wish I had a partner” to “I’m a worthless failure and will die alone.”

That second monologue contains a number of characteristic cognitive distortions associated with depression, such as all-or-nothing thinking (I have to have a partner or there’s no point in even living), disqualifying the positive (the good aspects of my life are irrelevant; it’s all bad because I’m single), mind-reading (everyone must be pitying me), fortune telling (because I don’t have a partner now, I will never have one), catastrophizing (something bad will happen to me and I’ll die alone in my home because nobody will help), personalization (it’s completely my fault that I don’t have a partner; none of it comes down to chance or being in the wrong environment or anything else), and emotional reasoning (I feel like a failure because I’m single; therefore I definitely am a failure).

While mentally healthy people do make cognitive distortions too, mental health is a spectrum: the more you’re able to refrain from thinking in these harmful ways, the more mentally healthy you’ll (generally) be. If you look at the first monologue, you’ll see some slight distortions, like the fear that you’re unlikeable or unattractive just because you happen to be single, or the perception that you’re the only person not dating when that’s obviously not true. But only in the second example do these irrational thoughts become all-encompassing. And, importantly, only the second example involves thoughts of death and suicidal ideation.

Note also that in the first example, being single is causing sad feelings, whereas in the second example, the emotional responses are not primarily caused by the singleness. Perhaps being single is the immediate trigger of the extreme sadness and negativity, but what’s really causing it is depression. A depressed person who is miserable about being single will not stop being miserable if they stop being single; they will usually be miserable about other things. That’s exactly what happened to me back when I was having that monologue. I’d inevitably get into a relationship and then be miserable because I didn’t think my partner liked me enough, or because I was worried about school, or because I felt like all my friends hated me, or because I hated myself, or just because.

Depression can trick you into thinking that you’re depressed “about” something. You’re probably not. You’re depressed because you have depression, and luckily, you can treat it.

Sadness, on the other hand, is about things. You can be sad because you’re single or because you got a bad grade or because you hate your job. Sadness is a normal, healthy reaction to experiencing things that you don’t like. It’s a useful and important emotion because it tips us off to situations that we should try to change if we can. Sadness can prompt us to take a step back and think about things and how we would like them to be better.

Medicalizing sadness and medicating it away would probably harm individuals and also our society as a whole. It would make things pretty boring. Isn’t it great that antidepressants and therapy are not actually trying to do that? Isn’t it great that we can help people avoid catastrophic, paralyzing, life-ruining sadness and fear like the ones associated with mental illnesses, while helping them get in touch with healthy and situationally appropriate sadness and fear? That we can help them understand their emotions and use them to change themselves, their lives, or the world, without having their lives completely governed by them?

Indeed. Depression is not sadness. Anxiety is not fear. Nobody is actually trying to eradicate sadness and fear.

~~~

At Skepchick, Olivia has a great take on this, concluding that:

I do think that it’s important to address our societal phobia of sadness, grief, and pain. But the way to do that is not to throw the mentally ill under the bus by implying they are running from their negative emotions when they seek out treatment. It also doesn’t mean casting shade on the few tools for treatment of mental illness that we actually have evidence are effective. A diagnosis of depression does not say “this person is too sad”. It says “this person can’t function the way they would like to because their emotions are consistently out of control”. There is a world of difference between those two statements.

Depression Is Not Sadness (Again)

Are Celebrities Responsible for Modeling Good Mental Health?

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[Content note: depression, mental illness, suicide]

My newest piece at the Daily Dot is about Lana Del Rey, mental illness, and what we expect from artists and celebrities.

Singer Lana Del Rey has recently reignited an age-old discussion about the glamorization of depression and suicide among (and in) young musicians. In a Guardian interview she has since tried to distance herself from, Del Rey focused on death:

‘I wish I was dead already,’ Lana Del Rey says, catching me off guard. She has been talking about the heroes she and her boyfriend share—Amy Winehouse and Kurt Cobain among them—when I point out that what links them is death and ask if she sees an early death as glamorous. ‘I don’t know. Ummm, yeah.’

[…] It’s unlikely that statements like Del Rey’s actually make anyone go, “Huh, maybe I should try killing myself.” However, they can be harmful because they perpetuate norms that discourage seeking help and prioritizing mental health. Del Rey certainly isn’t single-handedly responsible for this, by the way—mental illness has long been associated with artistic brilliance, glamour, and even sometimes sexual desirability. Some believe that you can’t really be a great artist unless there’s something very wrong with your brain, but I think that’s largely confirmation bias. If you think that artists must be crazy, you’ll pay extra attention to the ones that are and little attention to the ones that aren’t.

We tend to expect that when artists go through difficult times, their way of coping is to make art about it. (Neil Gaiman gave a beautiful speech about this.) Making art can indeed help people deal with all sorts of adverse circumstances, including mental illness, but sometimes it’s not enough. Luckily, some artists, musicians included, have spoken out about seeing therapy and medication when they needed it—not an easy thing to do in a society where mental illness is still stigmatized and being a celebrity means having your private life constantly scrutinized and sold as entertainment.

On the other hand, I’m also leery when celebrities are expected to be “role models” and to demonstrate positive, healthy behavior to the children and teens who look up to them. It would certainly be nice if, when interviewed about her moods, Del Rey said something like, “I’ve been going through a hard time and dealing with lots of sadness, but I’m seeing a great therapist and taking good care of myself.”

But holding her responsible for the mental health of hundreds of thousands of young people is unfair and hypocritical. Del Rey’s young fans would benefit a lot more from seeing their own parents model good self-care, but we don’t encourage that in parents any more than we do in glamorous singers. Instead, we shame people who take poor care of themselves, and we shame people who are open about seeking therapy.

Read the rest here.

Are Celebrities Responsible for Modeling Good Mental Health?

Against Role Models

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Whenever a famous person does something of which the general public disapproves, much is often made of that person’s status as a “role model” and how it influences the public’s judgment of their behavior, and whether or not it is time to revoke that status.

It seems that celebrities cannot escape being seen as “role models” no matter what made them famous. We expect an athlete or a singer or an actor to be good at not just sports or singing or acting, but at upstanding, ethical behavior, too. The assumption is that children should look up to these figures not just because they represent talent and achievement that (supposedly) comes from lots of hard work and sacrifice, but because their behavior in the rest of their lives is something to emulate, too.

This makes sense to an extent. We know that children learn by modeling the behavior of adults, and we want them to have adults whose behavior they can model. While a parent is normally the one expected to serve that function, most parents hope for their children to achieve more than they (the parents) have been able to in their own lives. Choosing and fixating upon a random successful but unknown doctor or lawyer or scientist or writer seems odd, but famous people already serve the role of entertaining the public simply by existing. So, perhaps some parents hope that celebrities can be good role models for their children and inspire them to both professional and personal success.

In fact, there is absolutely no reason why someone’s success at sports or music should be taken to mean that that person’s treatment of others is just as admirable. There’s no reason why being a great actor means you keep your promises to your partners and respect the law. There’s no reason why being in a famous band means you are very careful about your health and avoid dangerous drugs. Expecting celebrities to be able to model these types of “good behavior” makes no sense.

And even when we try to see someone as a role model in a specific domain only, it never seems to quite work. We fall victim to black-and-white thinking–people are either “good” or “bad,” and if a talented, successful athlete cheats on his wife, he goes from “good” to “bad” very quickly. Even though many people cheat, and even though occasional bad behavior doesn’t necessarily mean someone is a “bad person.”

The expectation of being a role model places undue pressures on celebrities, especially women. Tracy Moore writes:

Critiquing famous (or any) women’s behavior in terms of whether what they do is good for the girls or not is a sticky trap. It prevents them from being complicated, actual people working themselves out — you know, individuals? The thing we want women to be seen as? It keeps us in an endless loop of chasing after this One Correct Way for Women to Conduct Themselves. It’s exhausting, and I refuse to buy into it, and I don’t want to help christen it.

I also think it insults girls, who are more individual, and already far more developed as people than we give them credit for by treating them like blank slates who will copy and absorb every thing they ever see on command. That may be true for fashion, and I’m not disputing that teens copy famous people’s behavior too (and yes I’m staring down a princess phase with a toddler), but that doesn’t mean they instantly absorb the values and ideology of everyone they admire.

What I want is for women to be seen as human, which means, flawed, misguided, shitty, awesome, talented, cool, all of the above. In order to be treated like equal people, we have to have the latitude to have the same range of profound greatness and disturbing awfulness as men. We have to be ordinary, boring, fascinating, idiotic and brilliant.

Moore notes that female celebrities seem to bear a greater burden for Making Sure Our Children Turn Out Okay than male ones do, and male celebrities do seem to have an easier time recovering from Scandals with their popularity mostly intact (see: Bill Clinton, Charlie Sheen, Chris Brown, R. Kelly).

And what about non-celebrities? What happens when they’re expected to be role models?

I don’t know how this plays out in other professions or contexts, but within social work and mental healthcare, there is an immense amount of pressure put on professionals to be role models. We’ve talked about this in my social work classes.

People look to social workers and mental health professionals for more than just “help me fix my brain bugs.” They also look to them as examples of how to live well, and they often expect them to be wearing the same professional “face” even if they encounter them randomly outside of the office.

Our professors ask us what we would do if we encountered a client, say, at a bar or on public transit or even at a party. How would we manage their expectations of us with our desire to behave as we usually would at a bar or on the subway or at a party? Would it harm our relationships with our clients if they saw us acting like, well, normal people?

It’s true that if our clients think that we’re always the way we are in a session–calm, empathic, curious, mature, “wise”–it might disturb them to see us drinking at a bar or kissing a significant other in public or dancing at a party. They might wonder if we’re “faking” when we’re in a session with them. They might wonder who we “really” are.

For some professionals, this seems to be enough of a reason to significantly alter their behavior if they see a client out in public, or leave a bar or party where a client happens to be. They might even consider whether or not doing things like going to bars and parties after hours is even compatible with who they are as professionals.

When we discussed this in class, I was glad that most of my classmates reacted with minor indignation. Why should we be expected to be professional 24/7? Why does everyone else get to take off their work persona when they leave the office, but we don’t? Why is it our fault if our clients judge us as immature or irresponsible just because we go to bars on the weekends?

I think there are two reasons why expecting therapists to act like therapists 24/7 is harmful. One is that, on the individual level, it’s stressful and takes a toll on one’s mental health and freedom to live life the way they want to. Deciding to be a therapist should not be a life sentence to never behave like a normal person outside of work again. That’s too much of a burden for someone whose work is already very stressful and difficult.

Second, part of our role as mental health professionals is encouraging clients to think rationally, accurately, and adaptively about other people and their relationships with them. “This person is drinking at a bar therefore they are immature and I can’t trust them as my therapist” is not a rational, accurate, or adaptive thought. (Well, it could be accurate, but you’d need more evidence to come to that conclusion.) Neither is, “This person is behaving differently after hours than they are at work, and therefore the way they behave at work is totally fake and they’re just lying to me.”

But speaking as someone who’s been on both sides of that relationship, I have to say that we are really, really patronizing our clients if we think that they are incapable of realizing that we have selves outside of the office. We are treating them like children if we presume that they need to be carefully prevented from seeing any part of our non-therapist persona, including kissing a partner in public or getting tipsy at a bar.

But it’s possible that some clients might be confused or bothered by seeing a therapist acting non-therapisty out in public. I think that the best course of action then is to discuss that in therapy, not laboriously alter one’s public behavior so that such an issue never comes up to begin with.

Because our classes are mostly discussion-based and there’s little in the social work code of ethics about situations like this (dual relationships, though, are a different matter), my professor never gave a definitive answer on whether or not we should endeavor to be role models to our clients no matter where we encounter them. His intent, I think, was mostly to spark discussion and let us know that this is something to consider.

The examples of celebrities and mental health professionals are two very different examples, but my conclusion is largely the same for each: being expected to be a “role model” in every context, at work and outside of it, in one’s chosen domain (be it sports or entertaining or counseling) and in every other domain in which it’s possible to judge a person’s behavior, is too much.

A final reason holding people up as “role models” is harmful: the criteria by which we judge them are largely based on social norms, which can be a very poor barometer for determining how ethical an action is. That’s why, when Miley Cyrus was vilified for her performance at the VMAs and reprimanded by many commentators for not being a good enough “role model,” the focus of most of the criticism was not the racism inherent in her performance, but the fact that she dressed revealingly and shook her ass. And she shook it…at a married man! How dare she. The married man, by the way, made a clear show of enjoying it, and he’s the one who’s married. And the one who sings a song about “blurred lines.”

It’s also why, when Kristen Stewart cheated on Robert Pattinson (to whom she was not married) with Rupert Sanders (who is married), it was Stewart on whom the majority of the public opprobrium fell, and who was finally compelled to publicly apologize. (A hopefully unnecessary disclaimer: I think breaking a promise to a partner is wrong, but I also wish people didn’t make promises they couldn’t keep in the first place, and I don’t think cheating is the worst thing a person could do and I don’t think a person who cheats owes an apology to anyone but the person they cheated on.)

And women of color in particular are held to impossibly high standards as “role models,” as public reactions to Beyonce and Rihanna attest.

Sometimes the intersections between the expectation of role model behavior and various types of prejudice affect people’s livelihoods in really crappy ways. To return to the example of therapists, I’ve been reading this blog by a woman who is studying to be a therapist and also works as a stripper. The faculty of her program are pressuring her to either quit sex work or leave the program, because doing both is necessarily an ethical violation. They also told her that being a stripper “contributes to further injustice in the world,”  and is therefore incompatible with her other role as a therapist.

That’s a slightly different type of role model that she’s being expected to perform, but that demand that therapists be perfect in every aspect of their lives is still there. The role of therapist is supposed to take precedence over everything else she may want to do in her life, including making enough money to get by and finish her education. And in this case, these expectations are intersecting with stigma and prejudice against sex workers.

So, whether you’re a celebrity or just a regular person trying to make the world better, it’s rarely a neutral expectation that one be a “role model.” Like all social expectations do, it comes along with lots of baggage. And it’s incredible how often, for women, being a “role model” means having no sexuality.

Children may need adults to look up to and clients may need therapists to learn from, but that’s not a good enough reason, in my opinion, to expect or demand perfection from people.

I think a more realistic view is that almost everyone can teach us something, and almost everyone has done things we probably shouldn’t emulate*.

~~~

*And to be clear, wearing revealing clothing and/or being a sex worker are not the sorts of things I’m particularly desperate to discourage.

Against Role Models