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.

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