Sane Thinking About Mental Problems

Epistemic status: exhortatory and personal, but pretty confidently my true belief

CW: suicide mention

When I was a teenager, I was depressed.  And the way I thought mental illness worked, the way I had learned from novels and from some of the adults around me, was as follows.

You are in pain. You try as hard as you can to hide this from others, keep up with all your responsibilities, be a “good girl.” But you are in pain, and eventually something’s gotta give. At some point, you “hit rock bottom” — you express your emotional pain through some act of self-destruction that is impossible to hide. At that point, people around you will be horrified, and will send you off to an inpatient clinic, where you will rest, recuperate, and be healed by wise and sympathetic doctors and therapists.

This is really not how it works, and it is a destructive myth that I think is actively wrong to teach children.

The reality is that mental health care is hard to get. For various economic reasons, there is a shortage of therapists, a shortage of beds in hospitals, and so on. A lot of people really struggle to get mental health care.

And mental health professionals are not magic. There is no guarantee that going to therapy, or taking medications, will solve your problems. It’s still often worth doing, but it’s not a “happily ever after,” and in some cases will be useless or harmful.

Moreover, there is a lot of discrimination against the mentally ill today. The stigma of mental illness can impair your ability to get an education, or keep a job.

All of which means that people with mental health issues are constantly in the position of making practical tradeoffs, sometimes quite painful ones, sometimes ordinary uneventful ones, between taking time to focus on getting well and just keeping the business of daily life running. The myth that, as soon as you acknowledge that you have a problem, that your life will be swept away into a therapeutic cocoon, is laughably unrealistic for pretty much everybody.  Life goes on, even when you’re crazy.  You go on.

And everybody, from people who just struggle with the odd neurosis to people who are severely disabled, has to more or less muddle through with the good humor, determination, and common sense they already have, and without any absolute answers from on high.  Even if you wind up needing help — and needing help is normal — you’re still driving your life.  You can’t pass the steering wheel to anybody else, and even if you could, that would be incredibly dangerous and you really don’t want to do that.

This is nothing new to people who have already been around the block.  But it would have been news to a younger version of me, and I’m writing this for her, and for anyone like her who might be reading.

Letter to a Young Depressive

You’re wondering if this is real.

It seems like life shouldn’t be like this. Surely not everyone spends long nights at the lab wondering whether acrylamide or ethanol or the strong bases are the best way to go.

But you’re fine, your grades are still good, god knows you’re managing, you don’t want to wreck your chance at college by going to the school counselor, and anyhow it’s not clear whether your problems are real or fake, so for now, you do your best to keep your head above water.

It has not occurred to you that one could try to stop wanting to die.

So: yes, it’s real.

If you looked up the DSM definition of depression, you would very definitely meet criteria. But that’s not the point.

The point is that you are unhappy, and that in itself matters. It turns out you are allowed (actually, required, but that’s a long story) to care about your own life and achieve your own happiness.  It also turns out that’s possible even for people who have made bad choices. It turns out you always have the right to live.  It turns out you are good.

That’s a lot of impossible concepts, I know, and it’ll take you a long time to work them out, and that’s also fine.

The accessible part is this: you can start trying to be happier, now.  You don’t have to take big risky steps like therapy or meds if you’re not ready for that. You can write in your diary, you can read the odd self-help or psychology or philosophy book, you can talk to a friend.  You can do more things that make you happy and fewer things that make you unhappy.  The incremental, DIY, trial-and-error forms of self-care that you work out on your own are not futile.  In fact, there’s a chance they’ll be the only things that work.  And even if you do get professional help eventually, you’ll be doing the “homebrew” stuff anyway.  That part never goes away.  Recovery just means getting good at it.

It is a bad idea, if you can avoid it, to “hit rock bottom”, but if you do crash spectacularly, the reality is that it’s just more life, with some added inconveniences.  Actually going to a mental hospital is not very much like it’s depicted in YA novels.  It is a liminal space that gives you time to recuperate, but it’s often mundane, sometimes shitty, and quite short-term, and afterwards you still have to go on with life.  If you’ve damaged yourself physically, or damaged your relationships, or whatever, now you have to go on with life while damaged, which is why it’s generally a bad idea.  Regardless of your degree of involvement with mental health professionals or the psych system, you’re going to be making tradeoffs and practical choices.  That part also never goes away.

The Big Lie

The mantra taught to young people today is “If you’re having trouble, get professional help.”  And also, “If you see someone in trouble, don’t try to help them yourself, get them professional help.”

In college, I had a barrage of orientation sessions where we were told that if a classmate or friend was struggling with an emotional or psychological problem, that we should not attempt to handle the situation on our own, but should refer them to the school’s mental health facilities.

Think, for a moment, about how wrong this is.

They are teaching kids not to be kind to sad friends, but to report them to the authorities instead.

So I watched my roommate, who had life-threatening mental health problems, as she was  abandoned by all her friends at the first sign of weakness. I saw our little quad talking around the problem, trying to “get her help” that never actually came, passive-aggressively blaming her for being ill.  I watched the laughable incompetence of the mental health people as they did precisely the wrong things for her. I was too socially awkward to do much more than clumsily ask her to stop hurting herself.  She became an evangelical Christian because those were the only people on campus who were actually nice to her.

Even at the time, I knew something was wrong with the culture — it drove me into a despair of my own — but I wasn’t sure it wasn’t just me who was out of step.  It wasn’t until later, until I read Allen Ginsberg, that I got external confirmation that it was normal to suffer along with a mentally ill friend, that it was normal to give a damn.

ah, Carl, while you are not safe I am not safe, and now you’re really in the total animal soup of Time —

The irony was that I was taking a course that semester called “The Politics of Friendship.”  We read De Amicitia and the Nicomachean Ethics and The Four Loves.  And meanwhile, in the real life I saw around me, there was nothing like that, nothing at all, only callousness and falseness and denial.

Ivy League schools in particular deceive students into believing that they can treat mental illness, when in fact they do not have the resources to do so. Colleges tend to encourage mentally ill students to go on leave — and not come back.  A few years ago, an anonymous op-ed from a schizophrenic Harvard student made the news:

Harvard should abolish the present oft-coerced leave of absence imposed on students who admit themselves to the infirmary. Students who decide to go on leave are often unaware that in order to return, they must prove that they have held a job or internship and that they have been seeking treatment. The burden of this policy falls brutally on students from poor backgrounds, students lacking robust health insurance, and students with unstable family situations. Ironically, these are the very students who are more likely to have experienced trauma.

Another Yale undergrad who struggled with mental illness writes of being expelled after going to “Mental Hygiene.”  Another Yalie reports that her psychiatrist said, “Well, the truth is, we don’t necessarily think you’ll be safer at home. But we just can’t have you here.”  As with most colleges, Yale’s mental health services vastly undershoot the demand, and Yale is not entirely candid about this fact, not telling students about the (limited) number of therapy slots available, the long wait times, and the risk of being asked to “voluntarily” withdraw — which still requires paying tuition for the classes you don’t take.  Recently a Princeton student sued the university for violating his medical confidentiality by requiring him to “voluntarily” withdraw after a suicide attempt.  The issue seems to be pervasive.

My closest friend in college was threatened with expulsion, unless he went to therapy, because he wrote a short story for a creative-writing class that involved violence.  Specifically, it was a science-fiction short story about a slave rebellion.  He said that other short stories in the class contained violence too, sometimes much more gruesome; the problem was that he depicted justified, good-guys-fighting-bad-guys, violence.

Not only does this mean that a student’s education can be suspended on highly subjective criteria, but in practice those criteria are profoundly opposed to justice.

The problem isn’t necessarily that schools aren’t equipped to serve the needs of mentally ill students. No school can be all things to all people, health care is scarce and expensive, and a school’s main mission is education, not treatment.  The problem is that schools promise that students will be taken care of.  The message is “don’t worry about solving your problems on your own — we have lots of wonderful professionals to solve them for you!” Which is absolutely the opposite of the truth.

There’s a human cost to not being honest about the limits of mental health care at colleges.

I remember scrolling through Facebook once, while hanging out with a friend who was a student at Yale Law, when suddenly my face fell and she asked “What’s wrong?”  Well, another friend of mine had lost his job, and I was worried about him.

My Yale friend was very impressed and made a big deal about how compassionate I was.

And that struck me as weird. Surely anyone would be sad about a friend who lost his job. A good friend would try to help him get back on his feet, or do some other concrete act of service.

But there are actually a lot of Ivy League types for whom common sympathy is unusual, to whom it doesn’t occur to pause for a moment and be sad for someone else.  We’re taught not to. We’re taught that other people’s troubles are not our problem, unless we can get public credit for some kind of conspicuous charitable work.  The right thing to do is to keep reaching for the brass ring and to resist the temptations of sympathy.

Sad friend? There are professionals to handle that.

A ragged urchin, aimless and alone,
  Loitered about that vacancy; a bird
Flew up to safety from his well-aimed stone:
  That girls are raped, that two boys knife a third,
  Were axioms to him, who’d never heard
Of any world where promises were kept,
Or one could weep because another wept.

Auden’s world is real today, except that it’s not among ragged urchins, but among privileged and intelligent young people, that integrity and compassion are out of the ordinary.

Frames and Fluidity

There are multiple ways of looking at problems with the mind.  I don’t think that there’s a best one, but that it’s practical to switch between them pragmatically and to be mindful of the local advantages and disadvantages of each frame.

The medical model speaks of mental illness as a type of disease, which can be treated medically.  The mentally ill are sick, and they can get well.  They are patients.

The advantage of the medical paradigm is that it’s largely the only one that engages with the awesome power of psychopharmacology. It’s not an exact science, but there is no doubt that brain drugs affect the brain and can be studied experimentally, which is more than you can say for a lot of other approaches to the mind.  Some medications work spectacularly, some less so, but either way, there’s a tangible concreteness to thinking of mental illness as a physical problem, an engineering problem.  You can get some purchase that way.

One downside of the medical paradigm is that it’s demoralizing to view your situation as a catastrophic aberration, as something that should not be, especially if it’s not going to be swiftly fixed.  This problem also affects the physically disabled and chronically ill.  If you’re living with an issue indefinitely, it has to become ordinary to you, it has to become your new normal. And it usually will, by default. People get used to using wheelchairs and hearing aids. But if you’re constantly rehearsing the thought that you’re broken, or spiraling out of control, and in need of someone to “fix” you — then you’re going to be more miserable than your condition strictly requires, and more passively accepting of medical authority than is safe or useful.

The social model of disability frames mental issues as disabilities, in the sense that they are socially discriminated against by a “one-size-fits-all” society.  It emphasizes the right to access, to be treated decently, to have a normal life, even if you’re not neurotypical.

A major advantage of the social model and the disability community is frank talk between disabled people.  The questions become “how do I make my life work while disabled?” and “how do I keep from being jerked around by an unfriendly system?”  And, from the people thinking in this vein, you can get bonding, advice, practical problem-solving, camaraderie, validation, and courage.

A major disadvantage, though, is that the disability paradigm takes permanence for granted, and frequently mental illness involves the possibility of getting well.  If your identity and community are based around disability, then healing can subconsciously seem disloyal.

What I’d call the “skill model” is a family of viewpoints which say that problems of the mind are fundamentally about being weak at a skill, and recovery is about gaining that skill.

Some forms of therapy are straightforwardly skill-based. Cognitive remediation therapy is just memory and concentration practice.  Dialectical Behavioral Therapy is largely about teaching the skill of managing emotions.  Behavioral activation is a concept from cognitive-behavioral therapy that says “if you practice doing stuff, you’ll be able to do more stuff.”   Exposure therapy is literally just practice doing the thing you’re scared of.

Some types of self-help outside the world of formally trained psychology are also skill-based. Some people approach meditation this way, or Stoicism, or a regular exercise practice, as a way of training yourself to be saner. Unfuck Your Habitat is about gaining the skill of keeping your house clean.  Ureshiku Naritai is a very nice, straightforward essay that epitomizes a skill-based way of overcoming depression: the author trained herself to notice which things improved and worsened her mood, and did more of the former and less of the latter.

The advantage of the skill-based approach is that it incorporates the human capacities of learning and trying.  Once you have the lightbulb moment of “wow, I can try to get better on purpose?”, once you start working directly on things rather than waiting for someone to “treat” you, your progress can accelerate quite suddenly. The skill model takes you, meaning your “wise mind” or the part of you that wants to be sane, seriously as an agent, and enlists your effort and intelligence.

The downside of the skill-based approach is that some mental illnesses don’t respond well to it, and if you don’t find a way to engage the gears that bring you to “wow, I can do this!”, it can sound quite condescending. The negative stereotype of the skill model is “I fixed my depression with yoga and you can too!” which gets a bitter chuckle from old pros at the badbrains game.

What I’d call the “spiritual model” is a final family of viewpoints, which are related in that they take the denotational content of mental problems seriously, especially mood problems.

In this model, if you are having a crisis of faith, then your depression is fundamentally about religion, and you’re going to need to figure out your answers to religious questions.  If your problems take the form of extreme guilt, then you’re going to have to engage with ethical philosophy and figure out a form of ethics that is compatible with life.  If you’re experiencing nihilistic despair, then you’re going to have to find a source of meaning.  If you’re having delusions, you might need to build up a stable epistemology.

The spiritual model takes unhappiness as a normal or even universal part of the human condition, not something exclusive to “abnormal psychology.” People get profoundly unhappy; people have to find a way to overcome despair; the way to overcome your despair is to figure out where you have a misunderstanding and gain the insight that will resolve it.

The advantage of this approach is that it is much more individual and fine-grained than the other approaches.  It deals with your mind, not the generic mind that has similar problems to yours. And it engages with your mind, including your mental illness, as a peer — not as something to fix or to accept, but as someone to talk to and listen to. It allows for the possibility that your strange thoughts while depressed or manic or whatever might in fact be true, at least in some facets.  There’s a sense in which resolving inner conflicts is “getting to the root of the problem”, actually untangling the knots in your mind, rather than “merely” palliating symptoms.  The work of life, from the spiritual point of view, is building a valid and life-sustaining personal philosophy, and almost incidentally, this will resolve many “psychological problems.”

The downside of this approach is that sometimes your problems aren’t really about anything discernible, and it’s counterproductive to try to seek meaning in them, rather than just trying to manage or treat or accommodate them.  Sometimes trying a spiritual approach just means getting trapped in ruminating or becoming an “insight junkie”, with no productive effect on your actual problems.

It’s very rare to see discussions of mental illness that treat multiple possible frames as valid and usable.  I’ve seen personal narratives where people shifted from one frame to another and present it as “seeing the light,” but I think that’s not the whole story. I suspect that successfully living with, or recovering from, mental problems involves being somewhat eclectic about frames.

I switch between frames a lot myself. To wit:

My tendency towards anxiety is probably best framed medically — my whole family is tight-wound, I have genetic mutations that mean my adrenaline level is going to be higher than normal, and my anxiety responds really well to medication.

I view a lot of things, like Uber and text-based communication and to-do lists and calendars, as basically assistive tech for my poor spatial awareness and executive function, which is a very social-model perspective.  I use a bunch of hacks like weighted blankets to make myself physically comfortable when it’s practical, without viewing my unusual needs as shameful “symptoms”, which is also a very social-model way of looking at things.

I think about building resilience and fortitude to emotional shocks from a skill-based perspective.  There’s a lot of value in practicing toughness or patience or self-restraint.  Like Ben Franklin, I think you can sometimes reinforcement-learn your way to virtue.

I largely deal with my guilt and shame issues through the spiritual approach. Learning that the things that torment me are illusory and based on bad philosophy has been extraordinarily helpful. Reading and friendship — and I’ve had truly wonderful and wise friends — have allowed me to work towards a perspective on life that promotes my survival and flourishing.

“Shit Happens”: The Value of Normalizing

The one frame I don’t find helpful for thinking about mental problems is the frame of horror.  “How could this happen? This shouldn’t happen!  This is the worst and everything is falling apart!” is unproductive and often cruel.

Here’s the issue:

I’ve had the cops called on me for crying in public.

A friend of mine, who has dyspraxia, has had the cops called on her for walking funny.

We’re mild-mannered white women, so we got off easy. If we weren’t, those encounters could have been deadly.  When somebody has a panicked overreaction to seeing someone behaving weirdly, the consequences can be quite serious.

The reality is that about one-fifth of Americans experience mental illness in a given year.  This is a medical-paradigm statistic so obviously there are reasons to be skeptical of it; but the point remains that having problems with your mind is common. It is so common that it does not make sense to freak out about it.  It has to be acknowledged as part of the landscape of life.

When a person with mental problems freaks out about them, it’s usually self-destructive.  Self-pity or internalized ableism or a victim mentality are not conducive to getting better.  Feeling like “OMG this is terrible!” is understandable, but it’s not an aid to recovery.

When people freak out about others’ mental problems, they can range from callous (abandoning friends because they’re “crazy”) to frankly evil (violating people’s rights and committing violence against them because they’re “crazy”).

The antidote to freaking out is the acknowledgement that “shit happens.”

You have to expect that misfortune is pretty common, you have to account for the fact that most people you meet will experience misfortune at some point in their lives, and you have to learn a sort of reasonable tolerance about that.  Otherwise you’ll be in denial about reality, and that’s inevitably going to hurt someone.

Denial-followed-by-freakout is how we got into the mess that is campus mental health policy, and probably a lot of other systemic problems as well.

If we take a pragmatic, balanced, trial-and-error, “shit happens”, kind of perspective on the problems of the mind — if we accept that they’re very common and we have to make the best of them, both individually and communally — we’ll be a lot more prepared to deal with life as it is.


45 thoughts on “Sane Thinking About Mental Problems

  1. Your description of Ivy League student culture reminds me of a bit (possibly from This American Life) about a police (FBI?) agent who was embedded in a motorcycle gang or somesuch. He was seriously tempted to just go over to the criminals because they were kinder to him than his co-workers.

  2. It seems important to understand how widespread the “refer your friend to the proper authorities” problem is. It might help if people shared where they’ve experienced this, and where there experience differs from yours, and where they went to school. I’ll share mine as a reply to this comment and I encourage you to do the same.

    • I went to St. John’s College in Annapolis, which has some very smart people but is very much not a generically elite school like the Ivy League. So it makes sense that my experience differed. St. John’s made no pretense of offering mental health services, and being deeply troubled by the Program (and in general the spiritual frame) was normal. For reasons not directly related to my college environment, I wasn’t good at connecting deeply with many people until later, but mostly we took care of each other without referring the matter to the authorities unless someone was physically injured.

    • A friend asked me to post this on their behalf to preserve anonymity:

      >My experience at a top 10 private school was the same as Sarah describes, in terms of the institutional response. There greatest concern was clearly liability that someone might kill themselves at school. To that extent, anyone who saw a doctor there and reported suicidal feelings was at risk of being forced to take a medical leave of at minimum the semester they were on, more practically the entire year. Clearance to return was only allowed with the positive opinion of a psychiatrist who had been treated the student a number of times. The school would not allow you back into the system in order to see one of *their* mental health workers for this purpose, so it required outside payment to an independent practitioner. All fees and costs related to the semester were forfeit. Scholarships were lost. Students on leave were even technically banned from coming on campus, meaning they were effectively separated from their support networks of friends, and sent back home to sometimes severely disapproving parents (who had paid for such an expensive private college, “all for this?”). Rentry to school offered no additional support or help, other than mandatory follow ups with a dean.

      >Fortunately, the part of my experience that differed was in the response of the other students, friends, though this was more a function of an especially lucky and close knit, caring friend group. None of us knew what were doing, we made mistakes that got each other hurt. One friend was banned from campus permanently after being caught trying to stay with friends, another lost his funding to return. We all knew people who developed unhealthy, chronic problems such as stimulant and alcohol abuse, eating disorders, and unhealthy relationships as a result of school pressures. We did the best we could. Most of us still managed to graduate, for all the good it did us. I shudder to think of my future children enduring a similar environment and its damage.

    • I would blame it not on lack of compassion, but lack of bandwidth. Elite schools (esp law schools) are full of stressed, overwhelmed people in direct competition with each other–and rates of mental illness are quite high. That is not a time in life when you’ll have a lot of leisure to worry about a sad friend. And not a time when everyone has developed the habit of taking responsibility for your own life, let alone a friend’s.

      • Seriously! I feel like this is being so wildly overlooked. What happens if you friends don’t have the bandwidth of their own to support you? Clearly in these scenarios you don’t have the bandwidth to support them.

    • I went to a small private school, mostly because I could graduate much faster there than other options. I had been disrespected by authority in the past, so wasn’t particularly interested in attempting to get any of my needs met through any of the authorities at my school. They were just there for me to get good grades from.

      I prefer to avoid filter bubbles and to maintain a high level of cultural versatility, so I’ve met a large range of people in both social classes and multiple financial classes. It’s very rare to meet anyone you can talk about an actual life problem with who doesn’t immediately insist that you get a counsellor. Please notice that I did not say “mental problem”. I said “actual life problem”.

      For instance, if someone commits an act of sexual violence against me and I’m trying to work out what to do with the sticky political situation it created in my social network, my actual goal will be ignored. “Get a counsellor!!!!” is the answer. *shrug*

      To many, every problem is a mental problem. It all goes to the counsellor.

      This applies to both income brackets and classes. The majority of people in both will do this.

      Some people have woken up to how limited professional help is. These tend to be the people who have tried it for themselves and have been disappointed with it. That’s a minority in both groups.

      There seem to be be a larger number of disadvantaged / poor people who have woken up about the mental health industry being a wreck in this manner but that might be because prejudice forces them down. It might also be because disadvantage forces them into the system which triggers prejudice… The more privileged people I know more or less universally recognize that psychology research quality is bad to the point of being ridiculous, but for some reason, they also behave as if counselling is a silver bullet. If you experience significant stress from any cause, “Why didn’t you see a counsellor!?” they ask. They ask this *before* asking *whether* you saw a counsellor as if counsellors always fix it.

      A lot of my friends over 30 have had enough bad experiences with doctors to have woken up out of silver bullet thinking, regardless of privileges/disadvantages. I’m not sure if there’s a pattern with their views on counsellors, but it shouldn’t be too hard to get through to them if you start with medicine as a metaphor.

      The key difference I see between privileged and disadvantaged people is that disadvantaged people are far more tolerant of differences of all kinds. This includes differences associated with stress, mental disorders, and life problems. Even tiny expressions of stress can result in rejection in environments full of privileged people. If they discover that you don’t share the nirvana fallacy type views they hold, and you don’t know how to present this in their particular way, they will ostracize you as fast as possible. This was one of the most challenging forms of prejudice I faced while working on breaking into effective altruism. Older people, and/or those in leadership positions, often seem to have abandoned such thinking in favor of something more practical. The rest are often very keen to police anything that doesn’t match their overly idealistic world views.

      It’s significantly harder to prevent privileged people from ostracizing you for having differences caused by an imperfect life than it is to prevent disadvantaged people from ostracizing you for the same things. Even if the differences are harmless. It’s as if they can’t emotionally tolerate being reminded that bad experiences exist. I don’t know if this is because they fear being ostracized for losing their “religion” of idealism, because they haven’t had the opportunity to grow a thick skin, or something else.

    • I went to a highly-ranked small liberal arts college. During freshman orientation there was a lot of emphasis on the available mental health resources, but nothing like “don’t try to help your friends yourself”. My friends and I were fairly isolated from the mainstream of social life, so I don’t know how it was for most people, but in my social group abandoning a friend for weakness was outside the Overton Window, and something like showing compassion towards a friend who lost their job would’ve been completely normal.

      I briefly tried therapy at the student health center. The first person was rather bad, didn’t seem to understand the issue, and snapped at me when I asked if she had any suggestions for me. I tried someone else the next time, who was nicer, but still unhelpful. But I’ve heard others say they had better experiences.

    • I’m currently an undergrad at an Ivy League school, and like some other commenters, my experience of the administration is in line with what this post describes, but my experience of the students is not. Yeah, the message “if your friend is having problems encourage them to seek help from [list of campus resources]; don’t try to fix everything yourself” is definitely out there, but my impression is that students don’t really believe or abide by it. (That’s why the administration keeps pushing the message!) Everyone knows that psych services can be completely unhelpful, and people definitely try to help their friends, not abandon them at the first sign of weakness (?!).

      To be honest, if anything, I wish I had listened to that messaging more than I did. Not that I should have placed more trust in authorities, just that I wish I had seriously considered the “don’t take on all your friends’ mental health issues” path. Supporting a roommate with depression/anxiety/etc, especially leading up to and in the aftermath of their suicide attempt, is what I usually point to as the beginning of the depression that I have had for the past two years.

  3. I went to the ivy that officially cares the least about its undergrads, and your description of of the administration rang true, but my friends and I were appropriately supportive of each other. But I also thought we were the ivy without any blue blood dipshits, and that turns out to be an artifact of my major.

  4. Everyone: Colleges are groups of humans following incentives. Most schools, and especially Ivy League schools, are not well-described as actors looking out for the best interests of their undergraduates. You can try to shame them into adopting new policies, but if you’re *shocked* that they don’t really truly care about you, then you’ve got a bad mental model. Likewise if you think there’s a fundamental difference between them and typical for-profit employers.

    • At 18, if you’ve previously been surrounded by people who actually care about you, it might be understandable to have that kind of bad mental model. But you’re basically right.

      • Ben, I think it’s a good question. People tend to shoot you down in droves for saying anything bad about school. To many, school is good. Why? One option: school is the place where people learn, and the place where people learn taught them that school was good. :/ Also, there is choice supportive bias, the tendency to throw good money after bad, and the tendency to see things as more valuable if they cost more. Going up against that much bias and legitimacy would be pretty hard to do successfully. Extra love to Sarah and Ben for doing this! 😀 ❤ ❤ ❤

    • Yea, I’m not trying to cast blame, and in any case the fact that lots of undergrads make this mistake is a mitigating circumstance for any epistemic culpability. But I do think it’s more productive to advise students to be wary (which is indeed done in this post) than to express outrage at an institution.

    • I think it’s pretty important to avoid framing this as (yet another) instance of college students expecting schools to provide an infinite array of services outside of their core missions. Full-time students, who are excluded from the U.S.’s employer-centered healthcare system unless covered by their parents, pay good money for university health plans which have a lot of monopoly power.

      If universities are providing subpar mental health services (which, in my experience, they do) students, as consumers, ought to be outraged. Healthcare in the U.S. comes in a bundle so students essentially have no exit option if they feel they’d benefit from professional mental healthcare and a university falls down on the job. This seems like the classic scenario where exercising “voice” is worthwhile.

  5. When we’re thinking about mental illness, we should remember that mental illnesses fall on a spectrum in terms of “does it hurt.” Some things are almost or always painful to the person who “has” the “illness” (depression, OCD, anxiety). Other things are not, but are defined as illnesses because they inconvenience third parties (personality disorders, sexual fetishes, random shit obviously made up for the purpose of social control like ODD). Lots of things are in the middle, where they might or might not be painful depending on how the person experiences their “illness” and how the society around them reacts. This is where I would put autism, schizophrenia, substance abuse, eating disorders, and bipolar disorder.

    One of the causes of disagreement about mental illness is when a person for whom the paradigm mental illness is at one end of the scale doesn’t consider the other end of the scale. Imagine Szasz or Laing, for whom the paradigmatic case was schizophrenia, talking to the author of Talking About Prozac. It’s a lot easier to advocate aggressive treatment and institutionalization when your paradigmatic case is depression, something that demonstrably causes people to suffer and sometimes die, and something that many people believe is curable. If your paradigmatic case is autism, it’s a whole different conversation, where the answer might be “just leave this person alone, they are fine.” And if your paradigmatic case is psychopathy or pedophilia, well then the best we generally do is the criminal model. So–another thing to consider when deciding which model is most useful at any given time.

    • In this post I was primarily talking about painful/harmful mental problems. Even if you don’t wish to be neurotypical, your condition can cause harm, and recovering or managing the harm is relevant.

      Autism isn’t a mental illness, it’s a developmental disorder, though I’m not confident that’s a principled distinction. It definitely causes problems for the majority of autistics. Medical paradigms make less sense for developmental disorders because medicine will not treat cognitive disability. (Medication can treat other things that show up frequently in autism, like epilepsy.) I also have the (not-too-confident) intuition that spiritual paradigms make less sense for autistics — you’re not really “autistic about” anything, you were just born that way. But skill models and disability models work just fine.

      Personally, I think the morally right answer is *always* “just leave this person alone unless they threaten others” when it comes to involuntary treatment. That’s a radical position, but in my book, a rights violation is a rights violation, and it doesn’t matter whether the person is sane or what their IQ is.

      But, do people with schizophrenia, BPD, autism, eating disorders, and substance abuse often suffer from their conditions, and try to get better and improve their quality of life? YES, unquestionably. Recovery-focused advice is absolutely applicable to more things than mood disorders.

  6. Thank you for writing this post. The intense despair at the sudden heel turn of Ra that some can experience is ameliorated by knowing that it is not some isolated event and they are not being uniquely shunned by the system.

    • “Sudden heel turn of Ra” is a pretty good phrase for this, and points to something pretty important – Ra says that it wants to help and you should trust it because this is the respectable generic thing to say, not out of any intent to do anything in particular. If you take its words literally as a commitment to help in any concrete way, you’re going to be disappointed.

  7. And please please can we spread more knowledge about the existence of tianeptine, which has fewer sides, is just as effective as SSRIs and importantly can just be mail ordered.

  8. You nailed it again, Sarah. You are an inspiration. I will be your real friend. My heart is yours. I wrote a post about your article on Facebook and asked friends to heart the post if they are ready to love and be loved as real friends. If people do that, then like minded people will be able to find each other. It’s public, so the results are visible to you as well.

  9. Thank you so much for writing this — this is an amazing post and I too would send this back through a time machine to my younger self. Your description of the different lenses and the pros and cons of each is dead-on. They should seriously print this out and distribute it to all incoming college freshmen.

  10. I really liked this post but did want to mention that my experience at Yale Law was fairly different from this. The Yale Administration’s attitude toward mental health was atrocious and dishonest. Wait times and the quality of care were very bad. But on the whole the Yale Law student community, and several professors, offered incredible support to me and several of my friends while we were dealing with mental illness. I was particularly impressed by support for students who publicly discussed mental illness in order to reduce stigma or push the administration for change.

  11. You said “The right thing to do is to keep reaching for the brass ring and to resist the temptations of sympathy.” and I can totally see them doing that. In their scramble to live life to the fullest, they miss a lot of the experiences I cherish most. To me, it seems strange that they do this. Perhaps one has to adjust a bit in order to enjoy sympathy. Like your very first sip of coffee or wine, you may notice only bitterness. After it has sunk in on an instinctive level that this flavor isn’t likely to kill you, (poison is a matter of dosage), you can easily drink enough to experience the benefits. In the case of sympathy, I experience a sensation of being lit aglow with warmth. Like a connoisseur, I am also able to appreciate many different subtleties in “flavors” of empathy on the way. It is not just the high that I enjoy but the journey there. The bitterness is gone for me. There is only joy. Perhaps sympathy is an acquired taste.

  12. Regarding being kind to sad friends, I once thought that the kindest course of action would be to tactfully ignore it and act like nothing was wrong. To try to help them would almost necessarily involve talking to them about it, which felt intrusive – they don’t want their weakness pointed out and emphasized. If one were socially adept and/or saw a good opportunity to quietly support them without coming close to mentioning the issue, it would’ve been good to do so, but to actually initiate conversation about it would’ve been seen as either social ineptitude or the prelude to intentionally hurting them. Casually mentioning professional help without aiming it at the friend’s problem directly would’ve fit with this strategy.

    I no longer endorse this approach, but if there are others who think as I thought, maybe there are some people of good will out there who think they’re being kind by not intervening.

  13. In my first year at Oxford, my friend got depressed, went to the nurse, and went to counselling soon after, and has had no repercussions.

    The friend later tried SSRIs. My general impression is that Oxford has good mental health support, although to be clear this is what they advertise themselves as having.

    • This is remarkable to me; a friend of a friend in London has refused medical care for his depression (which I’m led to believe is rather serious), apparently for many years, because he claims that the Britain does not protect people’s medical records from employers well enough and he is afraid of losing out on employment in the future as a result. I have never known how seriously to take him, not being from Britain myself.

  14. One thing worth mentioning is the risks of seeking treatment for a nervous system disorder like major depression. Very often the only response available to someone, due to either lack of skill or fears of liability, is to impose treatment involuntarily on the patient. This can take the form of your employer requiring proof of counseling to return to work after a co-worker or manager reports a “safety issue”, to an involuntary committal by a health care professional able to do so. Both are done out of not compassion or concern, but of fear of liability. The result is that you must be *very careful* about what you say to whom, or you’ll say one of the “magic words” and find yourself in a locked unit without your shoelaces. So, people do not seek support or treatment, because they value their freedom. (Both of the above have happened to me personally).

  15. I don’t see how the medical viewpoint in any way requires viewing your situation as a catastrophic aberration. One would be hard pressed to find anyone over 40 in the developed world not regularly taking some kind of medication and if not medication than vitamins.

    If I don’t eat food and eat food with the appropriate nutritional balance I get sick, feel worse etc.. The fact that I know to eat fresh fruit (or other sources of vitamin C) so I don’t get ricketts is medical knowledge that causes me to take a regular dose of a chemical to feel well. I fail to see in what way taking antidepressants regularly is any different.

    The real problem with the medical view is lack of efficacious solutions. Yes, it does seem that on net SSRIs are slightly beneficial in treating depression and other antidepressants may be slightly better but they are still pretty crappy at it…so crappy that I wonder if they aren’t merely a random alteration (regression to the mean) plus caffeine style stimulation (from things like wellbutrin).

    The problem, IMO, is that the medical establishment is fixated on the idea that there should be a drug that makes the depressed people normal but leaves the rest of us alone. That seems implausible. Just as we treat growth deficiencies with the same hormones that one would use to cheat at sports I would expect that a good antidepressant would probably make everyone feel better. Unfortunately, I think there is too little research into such drugs (i.e. drugs that make everyone happier but without the problems of existing narcotics/stimulants/etc..) because people find the idea of human enhancement troubling but that is a bigger issue.

    On another point I wonder if you actually have any good reason to conclude these various approaches are actually beneficial. The history of psychology is littered with apparently useful (psychoanalysis) approaches that turned out to be BS in the light of day. That doesn’t mean that anyone who has found something that works should abandon it (even BS can work) but it does urge some degree of caution in passing on advice.

    • Ohh and sending people to professional help would actually be a great fix if it really worked effectively. The problem is that, as a society, we don’t want to admit that there isn’t always much we can do so we pretend professionals are a magic bullet when they aren’t.

    • The medical view point doesn’t require viewing your situation as a “catastrophic aberration.” But there’s at least some empirical evidence suggesting that in practice the medical viewpoint leads people to view the mentally ill as less”blameworthy” but more abnormal and less likely to recover. Citations below but note that: 1) I haven’t read the studies closely and don’t know how compelling their conclusions are; 2) I don’t know if there are studies coming to the opposite conclusion; 3) I’m biased because the researcher on these studies was a high school friend/acquaintance of mine.

      Biological Conceptualizations of Mental Disorders Among Affected Individuals: A Review of Correlates and Consequences.

      Biological Explanations of Generalized Anxiety Disorder: Effects on Beliefs About Prognosis and Responsibility. Experimental evidence that patients provided w/ a biological explanation for their anxiety disorder experience ” decreased ascriptions of personal responsibility for anxiety (p=.02) and expectations of increased duration of symptoms of generalized anxiety disorder (p=.01)” relative to a control group.

      Fixable or fate? Perceptions of the biology of depression. Patients who believed in biochemical and genetic causes of their depression had more pessimism about their prognosis. Giving them info about the malleability of genetic effects and neurochemistry made them less pessimistic.

      Effects of biological explanations for mental disorders on clinicians’ empathy. “In a series of studies, US clinicians read descriptions of potential patients whose symptoms were explained using either biological or psychosocial information.” Biological explanations evoked less empathy from the clinicians.

      Sometimes more competent, but always less warm: Perceptions of biologically oriented mental-health clinicians.

  16. Interesting article though it is much more personal and less empirical than your other stuff. Ultimately health insurance doesn’t cover psychological services in large part because they’re relatively new developments and because there aren’t that many consensuses in psychology about how to effectively treat patients. (There’s some evidence that many forms of therapy are completely ineffective.)

    I wrote this about a friend of mine who killed himself:

    I didn’t write in the article, but the friend was seeing a psychiatrist during his lifetime, I believe the psychiatrist was ineffective for cultural reasons (nearly everybody in the college and the surrounding town was relatively ignorant about non-European cultures). For what it’s worth, I considered going into some sort of grief counseling as those services were freely available at my college, but I decided against it. I don’t regret that decision because I think I would have had to spend way too much time educated whomever I talked to about all the things they don’t know about other cultures.

  17. One approach to handling mental issues that I like is the Buddhist practice of dharma sharing. You and your fellow practitioners sit in a circle, and take turns sharing something personal, often something very troubling, and everyone just promises to listen without judgment, as well as they can. There is no discussion, no back and forth, just one person speaking at a time. Just being able to get some things off my chest, and not seeing the world crash around me, was very uplifting for me. I think many people don’t have or want knots to be untangled, they just want to be heard by their peers, rather than a paid clinician, without being abandoned.

  18. Nice post. You probably know about it (since you know DBT), but if not you might like contextual behavioral science, for example Acceptance and Commitment Therapy seems to combine the stuff you (and most of us) like: taking into account multiple points of view(biopsychosocially), evidence based based on a nerdy theory (Relational Frame Theory), and still ending up with a spiritual normalising approach to psychopathology.

  19. We’ve only met twice, but I shared this on Facebook and my mother in law (a nurse) wanted to thank you for writing this.

  20. > The downside of the skill-based approach is that some mental illnesses don’t respond well to it, and if you don’t find a way to engage the gears that bring you to “wow, I can do this!”, it can sound quite condescending.

    Where I come from, people are particularly anti-authoritarian, and have a strong distrust of the medical establishment, so it looks really good to treat it yourself by your own labor. (Maybe this is common; I don’t know.) A bigger downside to the skill-based approach in my experience is that it’s so easy to accidentally train the skill of convincing everyone that you’re doing well rather than to train the skills needed to do well, which not only prevents getting help if you do need it but also incentivizes you to be less aware of warning signs. I have a friend, for instance, who managed to convince many people that their DIY solutions have cured their anxiety disorder, but from the friend’s body language I am convinced that the friend still suffers from it but has convinced themself that they are fine now and has learned the words to say that make people respond “That’s great, congratulations!” If this is what the friend wants to do to cope and it’s working well enough for them, that’s great, but I worry that the friend was pressured into this by not wanting to be seen as weak for trying medication or other more traditional approaches which they might benefit greatly from, and that now they will fear looking foolish if they go back on their preaching and try these approaches if the coping mechanism fails them eventually.

    (I was also going to give an example of a friend who convinced people they had managed to self-treat what turned out to be paranoid schizophrenia, but realized that’s covered by the “some mental illnesses don’t respond well to it” clause.)

  21. Reading some more articles of yours has been worth it, and I can greatly empathize with this one, or the (luckily) few sections I’ve come in contact with myself:

    > If your problems take the form of extreme guilt, then you’re going to have to engage with ethical philosophy and figure out a form of ethics that is compatible with life. If you’re experiencing nihilistic despair, then you’re going to have to find a source of meaning. If you’re having delusions, you might need to build up a stable epistemology.

    A background in epistemology can be valuable also without delusions. As a child I realized at some point that everything I perceived was filtered through my senses, so that I couldn’t infer that just because I saw the world a certain way, that was really what the world was like objectively. I wondered what makes the reality of the sober person more real than that of a drug addict. The reality that had always seemed so stable, reliable, predictable to me, was suddenly very doubtful. Luckily I found out about radical constructivist epistemology and abandoned the idea of a dual true–false categorization of mental models in favor of one on a scale of viability. It didn’t matter anymore whether there was a “Ding an sich,” because in either case I could hone my models of the world according to their usefulness for making prediction. Yay!

    But guilt is still tricky. One solution to the prisoner’s dilemma is to penalize defection from outside the system. If defection causes guilt, guilt has the function of this penalty. But if your partner is a person who is so empathetic that they will not defect against you if they can help it directly in order not to hurt you, can it then still be held against them if they don’t know guilt, or is guilt in that case rather some old proxy, now obsolete?

    > The antidote to freaking out is the acknowledgement that “shit happens.”

    I think stoicism goes even further in that it also wonders what unique opportunities this supposed “shit” may have to offer. It’s kind of hard to stay in that frame of mind, but it’s something that I’m trying to achieve.

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