Bipolar 2 From Inside and Out

Posts tagged ‘mental illness’

Advice from the NYT

On December 30, 2024, the New York Times offered an article: “10 Ways to Keep Your Mind Healthy” in 2025, by Christina Caron and Dana G. Smith. Now, I’m not saying that their advice was bad. I’m just saying it didn’t go far enough. All of their recommendations are things we already know. Someone with a simple need for better mental health may get something from the article. But for someone with a mental disorder, it’s inadequate. Here’s what they said.

1. Move your body.

“If you’ve heard it once, you’ve heard it 1,000 times: Physical activity is one of the best things you can do for your brain.” Well, we have heard it 1,000 times. The Times notes that people feel better after a workout, but that ones who have a consistent exercise routine, there’s less risk of depression (and dementia). They attribute this to better blood flow and connections in the brain. This is hardly revolutionary advice.

2. Address your anxiety.

Easier said than done. NYT says: “Many Americans are anxious.” They suggest the following solutions. Face what makes you anxious to break the pattern of fear. They say that you can do this kind of exposure therapy with or without a therapist.

They also recommend that you focus on your values rather than anxiety. I’m not sure how this is supposed to work. One suggestion they give is to volunteer in your community. Then they advise that you not catastrophize—but they don’t tell you how to do that, except for journaling about whether you had an appropriate amount of worry compared to the situation.

3. Challenge your brain.

The authors note that this is “still up for debate,” but they say that crossword puzzles, reading, and brain games “can’t hurt,” especially regarding dementia. The most definite thing they way is that such pursuits “can’t hurt.” A professor of psychology adds that “chances are that’s probably good for your brain.” But “good for your brain” is a long way from mentally healthy.

4. Get a good night’s sleep.

Lack of sleep “can affect how they experience stress and negative emotions. They might also be more likely to ruminate, be quicker to anger, have more negative thoughts or find it harder to cope with stress.” Those are serious symptoms, and for once, the NYT recommends actual therapy—Cognitive behavioral therapy for insomnia, or C.B.T.-I. They note that it is more effective than medication. At last, some useful information!

5. Get unstuck.

Good idea, but how to do it? According to the NYT, you should conduct a “friction audit.” which basically means identifying your problems and trimming them away, whatever that means. They also recommend “futurecasting,” or imagining you aren’t stuck and what steps would get you there. “Try to do at least one step each day.” Baby steps are good, of course, but doing one per day isn’t practical for most people with mental disorders. A therapist might help with this, but the NYT is silent regarding that possibility.

6. Stay cool.

At last, something that you may not already know! “Studies show that hot days impair our cognition and make us more aggressive, irritable and impulsive.” Typical ways of cooling off are recommended: stay cool and hydrated, use air conditioning or a fan, spritz yourself with cold water or take a cool shower, or go to a nearby cooling shelter. Nothing there but obvious remedies.

7. Quiet your inner critic.

If only we could! The inner critic is a real thing, and it makes you miserable. But the trick is how to do it. The authors suggest “letting go of that nagging feeling…and giving yourself credit credit for what you accomplish.” They do quote a psychology professor who suggests using “you” or your name rather than “I” when you engage in internal dialogue, which I take to mean affirmations.

8. Take care of your physical health.

This sounds good; the body and brain, of course, are interrelated. The NYT recommends taking a quiz about your physical health that analyzes common health conditions and behaviors such as blood pressure, cholesterol, and exercise. It’s said to estimate your risk for depression, as well as dementia and stroke. But most general practitioners these days use a specific depression screening quiz with more questions particular to that condition.

9. Make a new friend.

This is a great idea. People with mental disorders need a support system which can certainly include friends as well as family. One problem is gaining the courage and social skills to make overtures. The Times notes that loneliness can increase brain inflammation that damages brain cells and the connections between them. Then the article recommends reaching out to a friend or family member, joining a club, or attending a support group. Reaching out is difficult for people with depression in particular. Waiting for someone to reach in to you is sometimes all you can manage.

10. Forgive — or don’t!

Contradictory advice? Certainly. The Times article suggests that “forgiveness is an emotional process rather than an endpoint.” So, should you or shouldn’t you? Maybe. Forgiving someone who’s hurt you may lead to fewer negative feelings, the Times says, but they also recommend a book called You Don’t Need to Forgive: Trauma Recovery on Your Own Terms by Amanda Gregory.

I know what you’re going to say: This article is intended for the general public. It makes no mention of the many things such as therapy and medication that can help you achieve a healthy mind if you have a mental disorder. That the actions mentioned are meaningful adjuncts to those interventions.

But the title is misleading. I first got treatment for my mental health when I saw a sign for a mental health clinic and realized that whatever I was feeling, it wasn’t mentally healthy. At that point I received therapy, and later was prescribed medication. And they truly helped.

I would hate to think that someone like me would ready this article and think that the suggested actions, by themselves, will make a person mentally healthy. They are great adjuncts to proper treatment but won’t solve many problems that people with mental disorders have. If, like me, your only realization is that you don’t feel mentally healthy, the article may prevent or delay getting significant treatment.

So, go ahead. Try all the advice in this article. But if you still don’t feel you’re on an even keel, seek other kinds of help.

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We Don’t Talk About It

When I was first diagnosed with depression (later bipolar disorder), my family was somewhat less than understanding. My father was concerned that he might have to go to family counseling, with the implication that it would involve analyzing or blaming him. My mother informed me that Prozac, which I was prescribed, was “a ticking time bomb” and later said that she thought that if I got a better job, I wouldn’t be depressed anymore. And my sister was dismissive about paying someone a lot of money just so I could talk.

I admit that I did not handle this terribly well. I missed the opportunity to educate my family about these psychological conditions. (I did tell my sister that I was going to a community mental health service that had a sliding scale for payment.) In my defense, I was new to the concepts too, and had barely begun to educate myself about them. I did gradually learn more, but their initial reactions kept me from saying much about it to my family.

As stigma goes, this was pretty mild. They didn’t try to tell me there was nothing wrong with me. They didn’t blame or shame me for reaching out for therapy (other than my sister). But because of this, I didn’t receive much support from my family which would have made my journey easier. That only happened when I married a man who knew something about psychology and learned what would help and what wouldn’t.

Stigma can be a familial problem, but it also happens at a societal level. But mental health concerns are very low on the list of many legislators’ concerns and priorities. Some have denied that mental illness even exists or responded to it by clearing away the unhoused or creating sober houses. Mental illness is seen as a consequence of PTSD, which is talked about mostly in the context of veterans, seldom about other causes like abuse. Also, most of the fundraising for veterans seems to concentrate on limb loss and traumatic brain injury. If funds are going to specific mental disorders other than PTSD, it isn’t emphasized, despite the need.

A lot of what we hear about mental illness is about SMI or serious mental illness. And that often gets conflated with the problems of homelessness, addiction, and violence. But what about all the people with Major Depressive Disorder, Bipolar Disorder, Anxiety Disorders, Personality Disorders, and even Schizophrenia who live in homes and families, who have families of their own, and who have jobs? They’re very rarely talked about. They don’t get emergency funding. They don’t require street psychiatry, emergency housing, forced commitment, and other services that are needed for the most severely ill. They’re not high-profile.

They’re called “high-functioning” and then largely ignored, left to deal with their disorders on their own. Many of them miss out on the therapy, meds, and lifestyle changes that might help them, either because they don’t know where to go or don’t have the funds to access them. Insurance pays for quick fixes of 6-8 weeks, which are the merest band-aid on their problems. Supportive families, biological or chosen, can help them maintain their relationships, living situations, and jobs, but public attention isn’t focused on them in any meaningful way. There are ad campaigns that say “It’s okay not to be okay” and encourage friends to reach out, but they’re vague and short on what to do when you realize you need help. Hotlines focus on suicide and self-harm. They’re certainly needed, but so are resources for the day-to-day, less dramatic disorders.

Stigma, confusion, lack of education, ignorance, and even hostility keep us from the conversations that might lead to actual, useful change. Let’s open up those conversations with our families, friends, coworkers, the press, local and national government, and anyone else who’ll listen. Blogging and maintaining a Facebook group (Hope for Troubled Minds) are among my contributions to the effort.

I’ll keep trying if you will.

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How Insurance Handles SMI

Why are so many people with Serious Mental Illness (SMI) underinsured or unable to get insurance at all? As you may guess, a large part of the problem lies not with the providers but with the insurance companies.

The recent murder of an insurance company CEO has focused a spotlight on the role of insurance companies in denying health care in general. There’s been a groundswell of people angry at insurance companies coming between sick people and the doctors who prescribe them care. Ridiculous rulings such as providing anesthesia for only a limited time during surgeries have come to light. Denials of life-saving or pain-alleviating medications have been exposed as common.

One part of the problem is “ghost networks.” These involve the list of in-network providers insurance companies provide to their subscribers. Again and again, these have proved to be faulty. The lists contain doctors who are no longer practicing, ones who aren’t actually in-network, and ones who aren’t accepting new patients. There can also be incorrect phone numbers.

But the plight of people with SMI is even more serious. Insurance companies don’t want subscribers with mental disorders because they don’t make money from them. “One way to get rid of those people or not get them is to not have a great network,” according to someone involved with managing contracts with providers. Patients are pushed out-of-network for more expensive care that’s not covered or covered to a lesser extent by insurance companies. The Affordable Care Act was supposed to guarantee parity for mental health treatment, but that hasn’t always happened, and patients with mental disorders often couldn’t follow up on denials. And Obamacare as it exists now may not last under the new Republican administration.

Then, too, insurers encourage providers to change their treatment plans for clients who have SMI, even if they’re suicidal. Psychiatrists and psychologists find themselves having to tread carefully when writing care plans so that insurers will approve the care that patients need and keep approving longer-term treatment. The insurers can even pressure providers to terminate treatment altogether. Treatment plans that last over six to eight weeks are especially likely to be denied.

Even when insurers do approve treatment plans, another problem is reimbursement to providers. The money they receive is meager and insurers stall in regard to providing it. It can take three or four months to receive any reimbursement at all. This means that providers struggle to keep practicing. Some go out of business and then remain listed on the ghost networks as continuing to provide services.

Some therapists end their relationships with insurance companies because of the frustrations of getting approvals for care. One reported spending eight hours with a client and then having to spend four hours communicating with a difficult insurer while trying to get approvals and payment.

Yet another problem that providers experience is that claims servicing has often been outsourced. Customer service may be handled by representatives in other countries. They may not have access to all the information they need to process claims. Others aren’t familiar with the psychiatric terminology. When providers find it too difficult to follow up on claim denials, they may stop pursuing the matter. The insurance company then doesn’t have to pay for the treatment.

The insurance companies counter that they are following state and federal laws, that their reimbursements represent payments at current market rates, and that their policies are designed to provide access to care for patients with mental illnesses.

And that’s private insurance providers. What about Medicaid?

In four cities, researchers pretended to be Medicaid patients and called clinicians at random regarding their first available appointment. Just over a quarter reported having any available. In LA, only 15% had available appointments and the wait for them could be as much as two months. There were also Medicaid providers on ghost lists like the ones from private insurers.

All these problems certainly contribute to inadequate care for people with SMI. Between finding a provider, receiving a treatment plan, and being at the bottom of insurers’ list of patients to be served, it’s no wonder that so many people who really need care aren’t receiving it.

Will the current level of outrage have any effect on how mental patients receive care? It doesn’t seem likely. Most of the people decrying the brutal treatment by insurance companies are patients experiencing problems other than mental health-related ones. As usual, there are few who speak up for those who need psychiatric treatment, even though egregious obstacles are put in their way. As my father would have put it, mental patients are “sucking hind teat.” And the prospects for that to end look remote. Dealing with the mighty insurance companies is difficult at best and demoralizing at worst. Effective advocacy is needed but unlikely to appear. In the meantime, psychiatric patients are suffering.

Information for this post includes material from Mindsite News, ProPublica, and JAMA.

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Hello, Post-Traumatic Growth

I’ve had my share of trauma in my life. There was trauma in my childhood starting with relentless bullying, including children throwing rocks at me. I still remember crying into my mitten, my tears mixing with the blood. There was trauma in my young adulthood from self-harm to the gaslighting and implosion of my first serious relationship. There’s been trauma of various kinds since I’ve become an adult, when many of my traumas became lumped into the effects of my newly diagnosed bipolar disorder. When my psychiatrist said that I needed ECT, that was traumatic, too.

But I’ve recovered from all those traumas. (At least I think I have.) In fact, I may have experienced what’s called post-traumatic growth (PTG).

Post-traumatic growth is when you come out the other side of a trauma and experience positive changes in five spheres of your life. These are often listed as: appreciation of your life, relationships, personal strength, new possibilities, and spiritual change. PTG is usually discussed in connection with PTSD, sexual violence, and near-death experiences. By those measures, I guess what I experienced was really resilience, the ability to bounce back from hardship. Only one therapist has ever suggested that I had PTSD from the emotional abuse I suffered and, at the time, I dismissed it as unlikely. Now I wonder.

I do appreciate my life more now. My relationships are stronger and more stable. My personal strength is vastly improved. I have responded when new possibilities entered my life. My spirituality has evolved. I feel like a new person, a stronger feminist, a better person, better able to make and develop new relationships.

This is not to denigrate the experiences of anyone who has experienced PTSD, a near-death experience, or sexual violence. I understand that my experiences are nowhere near those traumas. But I’m not here to compare traumas. I’m here to talk about the aftermath.

Some people may experience PTG in the immediate aftermath of a life-altering experience, but I think that’s rare. It can take years or never happen at all. Therapy is likely to be a part of achieving PTG.

There are circumstances where PTG is assumed to be instantaneous, or nearly so. Cancer is a life-changing diagnosis that can take you through the five stages of grief. But, in the case of breast cancer, some people are expected to demonstrate PTG almost immediately. Barbara Ehrenreich has written about her own breast cancer diagnosis. She pointed out the number of people who, quite soon after their diagnosis say that it was the best thing that ever happened to them or that “cancer is a gift.” Ehrenreich noted all the pink ribbons and cheerful positivity that ensued. It was as if people with that diagnosis were not allowed to feel frightened, angry, or bitter.

But for most people, it takes time. The five stages of grief don’t occur according to anyone’s timeline. It’s personal. No one can tell a sufferer what they should feel or when they should feel it. In fact, those diagnosed aren’t even supposed to think of themselves as suffering from cancer. They call themselves survivors rather than victims. Acceptable reactions are strictly limited. How different is that from when people with psychiatric diagnoses are told to simply get over it?

Both resilience and post-traumatic growth are good things. I wonder if they’re related—if people who have resilience are more likely to experience PTG, or if people who demonstrate PTG then become more resilient. And I don’t know if we’ll ever find an answer to that.

But whether either explanation proves to be true, I’m just thankful they both exist. And I feel deeply for those who fight trauma without either one. They need help in any way they can get it, but likely through professional help. I know that whether I am resilient or have PTG, professionals have helped me. And so have non-experts who have supported me on my journey. I thank them all and wish the same for others.

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Why Can’t You Just Get Over It?

That’s a question we all get—and we all hate. It implies that we can just get over it, but haven’t, for whatever reason.

The questioner may believe that we just aren’t trying. That we can pull ourselves up by our metaphorical bootstraps or choose to be cheerful. That we aren’t doing all we can to “regain our sanity.” That we haven’t tried the right diet, the right exercise, the right supplements, or the right therapy. Everyone has an answer.

Parts of their answers may be part of our answer, sort of. Diet and exercise are important, to be sure. But one food, like apple cider vinegar or acai berries, is not a secret remedy. A healthy, balanced diet of meat, veg, fruit, and grains is ideal. But many of us are simply not able to cook like that. I’ve had days when all I could manage to eat was Cocoa Puffs straight from the box or peanut butter straight from the jar.

Exercise and fresh air are good, of course, but again many of us are simply not able to accomplish it. Some can’t leave the house except for absolutely necessary errands and appointments. Then we bustle back to the safety of home. Or, if we have someone to help, they can do the errands for us. My husband can sometimes get me out of the house for a meal, but usually not a healthful one. If a friend invites me over for dinner, it’s a very special occasion and I make sure to hoard my spoons for it. Those are times I’ll even take a shower and get dressed for. As for exercise, I just can’t. I have severely arthritic knees that need to be replaced, so I can’t even do yoga or tai chi. Plus the whole getting out of the house thing.

Another common comment is, “Get some therapy.” I have and am and most of us are. What people who say this don’t realize is that therapy doesn’t work quickly, even if you can find the type that’s right for you. Personally, I can’t handle group therapy. I’ve tried. I have problems with the idea of CBT and DBT, currently two of the most favored forms. Talk therapy is the one I choose, and that helps, but I’ve had to go to the same therapist sometimes for years. A quick fix is not what I need or can get.

Also, there’s “Have you taken your meds?” which really pisses me off. First, there’s the assumption that I’m even on meds (I am, but it’s rude to assume that), plus the idea that a layperson can tell me when I need them.

No, I can’t just “get over it,” and neither can most people with depression, anxiety, phobias, bipolar, PTSD, or schizophrenia. They’re just too complicated.

Think about it. There are three causes considered likely to be the cause of brain illnesses: genetics, psychological trauma, or brain chemistry. None of those is something that can be gotten over by choosing happiness. If the origin is genetic, pulling yourself up by your bootstraps is not even a possibility. It will likely take years of therapy and medication to achieve stability, if that’s possible. If the cause is trauma, you can’t just forget about it. Imagine all your worst nightmares hitting you suddenly, asleep or awake, as though you’re experiencing the triggering event just as you did when it happened. Think about how it would feel to have grown up with repeated abuse that you couldn’t escape because you were a child. And if your brain chemicals are out of whack, there are dozens of meds that might work and dozens more that won’t. Finding the right combination is a lot more complicated than just popping a pill.

When you get hit with the question of why you can’t just get over it, you might be able to take ideas from this discussion and try to educate the person who asked it. Or you can print out the whole post and give it to them. (I give you permission.) They probably won’t realize they’ve just insulted you. At the least, you can tell them that they have. Maybe that will stop that one person from coming at you with the same question over and over.

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Where to Go First

Most of the advice about depression that’s out there says that the first place to go for help is your primary care physician. That may seem counterintuitive. After all, doctors are notorious for being oblivious to psychiatric problems. Either they dismiss them, assuming that all their complaints (especially those of women) are “all in their head,” or they over-diagnose mental illnesses and pass out pills indiscriminately. At least, those are the stereotypes.

The reality can be far different. Family doctors can absolutely have a positive role to play in diagnosing and treating mental illness.

The last time I went to my primary care physician (for a nail fungus), the nurse practitioner, after taking my vitals, proceeded to ask me the questions collectively known as the Depression Screener. “Do you feel like a burden to your family/do you no longer enjoy things you used to All the time/Most days/Sometimes/Once in a while/All the time” and so on.

My blood pressure was high that day and I see a psychiatrist and take all kinds of psychotropics. I’m sure all that is in my file. “Can’t you just put down that I’m anxious and depressed and leave it at that?” I asked.

“Let’s go through it anyway,” she said. And so we did. No surprises. I was anxious and depressed.

The depression screener may not have been useful for me, but it is for lots of people. There are a lot of seniors, for example, who are living with depression without realizing it. Children, too. Teens. People of all ages. Finding them and getting them help when it’s in the early stages can help them avoid a life of misery and despair.

Not every person gets to find out through the screener. My mother, who was in a nursing home, made some remarks that suggested to me that she was depressed—extremely depressed, including suicidal ideation. I excused myself, found her doctor, and told him what she said, and that I believed she needed antidepressants. Rather than pushing back, he believed me and prescribed them.

Of course, it’s easy enough to beat the screener. The answers are fairly obvious. In fact, I know one person who gave all the answers that would keep him out of the psych ward. But fortunately, most people answer the questions truthfully and get the help they need.

But back to primary care physicians. They’re also helpful in cases of depression, anxiety, and other mental disorders. They know about the most common antidepressants and other psychotropics and can prescribe them to get you through until you can see a psychiatrist. They can give you a referral to a psychiatrist. And, difficult as it is for a first-timer to get a prompt appointment, they can keep monitoring your condition, prescribing as needed, until there’s finally someone who’s taking new patients. My own family doctor was willing to keep prescribing all my medications when one psychiatrist retired and I had to find a new one and wait for an appointment.

My primary care physician is part of my treatment team.

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Finding Intimacy

What do you think of when you hear the word “intimacy”? Sex, right?

That’s a part of intimacy, but it appears nowhere in the American Psychological Association’s definition. There, it says, intimacy is “an interpersonal state of extreme emotional closeness such that each party’s personal space can be entered by any of the other parties without causing discomfort to that person. Intimacy characterizes close, familiar, and usually affectionate or loving personal relationships and requires the parties to have a detailed knowledge or deep understanding of each other.”

Let’s take a look at that definition. “Extreme emotional closeness” is pretty understandable. But note the word “extreme.” It implies that intimacy is more than ordinary closeness. We have friends whom we are close to, but not intimately close to. They may be friends we can talk to about our troubles, share our stories with, be close to, but still not share that extreme emotional closeness. You’re not necessarily intimate with a best friend, though of course it’s possible.

The next part of the definition is more troubling to some. That part about “personal space” being entered by “any of the other parties.” It implies that there can be intimacy among more than two parties. To some people, that sounds like cheating or polyamory. But that’s when intimacy implies only sex.

Personally, I have a number of intimate friends, both male and female. That’s not to say that I’m promiscuous, bisexual, polygamous, or polyandrous. What I mean is that, as the APA definition states, we “have a detailed knowledge or deep understanding of each other.”

What does it take to get that detailed knowledge and deep understanding?

What are the qualities that foster intimacy?

Time. I’d say that, for non-sexual intimacy anyway, time is required. I can’t say how long that is exactly, but I do know that it isn’t instantaneous. You may feel an instant connection with someone you meet, but that’s not intimacy. I felt an instant connection with someone I helped through a public breakdown, but our intimacy had to grow over the years. Now I do count him as an intimate friend.

Sharing. You don’t have to share everything, but some sharing is essential. It may be seemingly superficial things like a love of country songs or a television show, but that’s only part of it. The intimacy kind of sharing involves actual sharing of thoughts, ideas, and experiences. You don’t have to agree on everything, though there are usually some non-negotiables. But for intimacy, you shouldn’t be afraid or embarrassed to share the truths about and inside you.

Laughter. Nothing bonds two (or more) people like laughter. Intimacy can be enhanced by laughing at the same things. A good belly laugh, the kind where you can’t stop and can’t breathe, is what I’m talking about. Or the snickers that you both have to suppress because you know you’re in a place where you can’t express it until you’re alone.

Help. For true intimacy, this is probably the most important quality of all. Someone you feel intimacy with is someone you can turn to when you’re at your lowest. Someone who understands or even if they don’t, will hold you closely in their heart or spirit. Physical help or financial help is good, but it isn’t required.

For those of us with SMI, it can be hard to feel intimacy. We may even fear intimacy because we’ve been betrayed by someone we’ve felt intimacy for. It’s difficult—or sometimes impossible—to get past that, but if you can, and you can open yourself to that extreme emotional closeness once again, intimacy with someone new is possible. Looking for someone to share intimacy with may not work. Sometimes intimacy has to find you.

Be open to it if it does.

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It’s Not That Simple

I’ve bitched before about the ads on TV for psychotropic drugs, and I’m about to do it again. The first ones that caught my eye were the ones that compared depression to holding up a smiley face mask in front of their face, while the person’s actual face exhibited sadness.

But it’s not that simple. Smiling depression is a thing, of course, but treating it is not as simple as taking away the mask and replacing it with a real smile. Psychotropics don’t work that way. Of course, since the ads are for psychotropics that are supposed to work quickly (though not as quickly as the ads imply), we can’t expect them to mention the years of struggle and therapy that go into improving the condition.

The next kind of commercials are a tiny bit better. They mention actual symptoms of depression: sadness, loss of focus, lack of interest in fun things, or an inability to do chores.

But it’s not that simple. Personally, I don’t think it’s a tragedy if the barista has to wait two seconds while I remember whether I want oat milk or if the family has to put away the laundry. These are obvious but probably not major symptoms of depression or symptoms of major depression. What about not getting out of bed for three days or not showering for a week or more? Crying all day about nothing or everything? Thoughts of self-harm or suicide? They just don’t make for good 60-second television. The long, lingering effects of depression are glossed over or ignored.

There are also ads for treatments for bipolar disorder, both types I and II. Most of them concentrate on the mania or hypomania side of the problem. Most of the ads use metaphors—climbing a tower of cards or going from darkness to light. Overspending is the issue most illustrated in regard to bipolar if you don’t count all the depression ads. I recall one that showed a woman who had bought a lot of expensive cameras and came to realize that she had overdone it.

But it’s not that simple. Bipolar disorder is a complex disorder that metaphors just can’t capture. Like depression, the ads concentrate on only one symptom, and don’t do a good job of creating those metaphors. (I’m just glad they don’t use a metaphor of someone on a swing.) I realize that it’s not likely that ads on TV will address hypersexuality, but what about the pressured speech, euphoria, irritability, bad decisions, and reckless behavior that go with mania?

Schizophrenia is probably the worst. The ads show not the disorder, but the lack of it—women saying, “I’m glad I don’t hear voices anymore” and “I’m glad I don’t still think everyone is looking at me” or men playing guitar to illustrate how “normal” the drugs make them.

But it’s not as simple as that. I admit that it’s not possible to portray some of the more frightening aspects of schizophrenia, which would probably only add to the stigma surrounding schizophrenia. But making it seem like one pill will cure it isn’t reasonable or accurate.

Then there’s tardive dyskinesia, also called TD. The ads do a competent job of giving examples of uncontrolled movements and how they interfere with a person’s life. The drug being advertised may indeed help with those.

But it’s not that simple. If you read the fine print at the bottom of the screen or listen to the rapid-paced list of possible side effects, you’ll notice that one of them is uncontrolled movements. WTAF? It gets rid of uncontrolled movements but may cause uncontrolled movements? Why take it and take the chance?

The ads I may hate the most are the ones that emphasize family. We see a woman folding the family’s laundry, grandparents romping with the kids at a park, and other idyllic scenes.

But it’s not that simple. Treating a mental illness is not something you do for the benefit of other people. It’s something you do for yourself, even if you don’t have a nuclear family or grandchildren or a large circle of friends. Granted, the people around you may be happy that you’ve found a therapy that works (and the ads almost never show a combination of drug therapy and talk therapy). That’s a side effect—a good one, but still not the intended effect of the psychotropic drug.

I attribute this primarily to the lack of inventiveness and understanding shown by people at the advertising agencies, as well as the tiptoeing around the whole subject of SMI. But what happens is that the viewers get an unrealistic view of both the disorders themselves and what the drugs can do to relieve them. It’s not simple, and the ads simply don’t reflect that.

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Dual Diagnosis and AA

Dual diagnosis, also called co-occurring disorders or co-morbidity, is one of the most complicated conditions that affect people with mental illness. The heart of dual diagnosis is that the person has both a brain illness and a substance use disorder (SUD). Estimates differ wildly as to how common dual diagnoses are, depending on differing definitions of dual diagnosis, for example. According to SAMHSA, 21.5 million Americans experience both SMI and SUD.

Alcoholics Anonymous, of course, is the best-known support group for alcohol abuse disorders. Narcotics Anonymous focuses on illegal drugs rather than alcohol. But there are fewer opportunities for people with dual diagnoses to find similar kinds of support. There is a group called Dual Diagnosis Anonymous (DDA), but it doesn’t have nearly the reach of the older, more familiar organizations.

So, how do dual diagnoses and substance use disorders share the support group space? Is the standard AA model open to or beneficial for people with dual diagnoses?

I recently spoke with Tony, a friend who has bipolar disorder and alcohol addiction. He’s currently in recovery in a treatment program that addresses both problems. Tony, who has been in the program for around six weeks, has started out in a sober house and with AA meetings. While he discusses his SMI, for now the primary focus of his treatment is substance abuse.

According to Tony, the relationship between AA and SMI support is sometimes fraught with contention. The history of AA doesn’t prohibit people with co-occurring disorders, but in practice, the situation can be different. Tony, in his early years of association with the organization, was dropped by his sponsor when he revealed his dual diagnosis.

Part of the problem Tony has found is that many people involved in AA are biased against the use of psychotropic drugs, even those properly prescribed by a psychiatrist and taken as prescribed. To them, drugs are drugs, and they are universally thought to be addictive. This is, according to Tony, an old-school and literalist interpretation of AA’s principles.

But if a person with a dual diagnosis goes off their psych meds, their condition can deteriorate. And untreated SMI can cause a person to self-medicate with alcohol, creating a vicious cycle. AA literature says that group members should not stop taking doctor-prescribed meds, but the problem persists. People with dual diagnosis may therefore avoid AA.

Of course, people can be addicted to prescription medications (whether they get them from their doctors or not). AA and NA can be extremely beneficial for them. Still, according to DDA, people with dual diagnoses can experience “a sense of ‘symptomatic difference’ between addicts and alcoholics and dually diagnosed persons. Some symptoms may result in disruptive behaviors during meetings, further alienating the dually diagnosed. Many dually diagnosed people experience increased levels of fear, anxiety and/or paranoia in group settings. Additionally, there is a common perception among some more traditional 12 Step members that medical management represents the ‘easy way,’ and do not consider those individuals who take prescribed medications to be ‘clean and sober.’ For these reasons, the feeling of ‘not fitting in’ at traditional 12 Step meetings is common for many individuals with dual diagnosis.”

A report published by the Veterans Administration of Virginia focuses specifically on the combination of PTSD and SUD. It notes, “Substance abuse co-occurring with PTSD is often a chronic disorder that
requires long-term help, which AA may provide” and that “aspects of 12-step activities may address core issues of trauma-related symptoms and enhance treatment outcomes.” However, it also discusses how the faith component of AA can be problematic: “Trauma, and PTSD-specific symptoms of loss of faith and hope for the future, may deter individuals from embracing the concept of a higher power and the directive to surrender…. Trust is shattered such that a benevolent spiritual force is hard to imagine, and so surrender to a higher power may be seen as impossible. Further, hypervigilance and the need to
maintain control are integral parts of a traumatic stress reaction, creating hardships in turning
over one’s will and life to God.”

DDA has developed 5 steps that coordinate with AA’s 12:

1. We admitted that we had a mental illness, in addition to our substance abuse, and we accepted our dual diagnosis.

2. We became willing to accept help for both of these diseases.

3. We have understood the importance of medication, clinical interventions, and therapies, and we have accepted the need for sobriety from alcohol and abstinence from all non-prescribed drugs in our program.

4. We came to believe that when our own efforts were combined with the help of others in the fellowship of DDA, and God, as we understood Him, we would develop healthy drug- and alcohol-free lifestyles.

5. We continued to follow the DDA Recovery Program of the Twelve Steps plus Five and we maintained healthy drug- and alcohol-free lifestyles and helped others.

Tony’s treatment program is focusing first on substance abuse programs, specifically achieving one year of sobriety, though in his shares at group, he does discuss his dual diagnosis. And he finds the spiritual component of his recovery to be essential. After his formal treatment ends in mid-January, Tony wants to continue working in faith-informed service to workers in the field—perhaps in a virtual capacity with the intention of helping prevent burnout.

I’m not in AA or DDA, but it seems to me that some discussion and communication between the two organizations would help matters.

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Mental Health

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Say It With Casseroles

In the South, casseroles are known as “funeral food.” After a funeral, people gather at the home of the bereaved and bring casseroles for a kind of potluck. The idea is that the family shouldn’t have to entertain the mourners and shouldn’t have to cook for basically the rest of the week. Some people even bring frozen casseroles to extend the usefulness of the food offerings. Tuna noodle casseroles are popular. Chicken rice casseroles. Green bean casseroles. Shepherd’s pies. Eggplant parm. Tater tot casseroles. Frito pies. Lasagna. Sweet potato casseroles. Ham and potato casseroles. Broccoli cauliflower casseroles. Moussaka. Even one that’s simply called “Funeral potatoes.” There are plenty of cakes and pies, too.

Food is an essential when there’s a new baby as well. It’s assumed that the new parent or parents won’t have time to cook substantial meals, so plenty of frozen casseroles are supplied. Visitors don’t arrive en masse and don’t expect to be entertained. They often bring useful items like diapers and wipes. They expect a few minutes of conversation, a look at the infant if they’re asleep, or a chance to hold them for a minute. What they mostly offer is help. Cleaning. Babysitting for older children. Running errands. Preparing bottles if needed. Emotional support is a big form of support as well. Helping the new parent with self-care. Comfort items. Listening. Offering encouragement.

Even an illness or operation generates plenty of contact. People visit in the hospital, bringing flowers, treats, plushies, prayer circles, and more. They stay as long as you want or leave when you’re feeling tired. They ask if there’s anything they can bring you, and then they do. They ask if your plants need watering. When you come home, there may again be casseroles, especially if it’s been a major operation like knee replacement. There are offers of picking up groceries or medication. They ask what you need and, nine times out of ten, they follow through. They call to check up on you or just to talk.

It’s all different if you have SMI, however. SMI is just not a “casserole illness.”

If you have a public meltdown, no visitors, no encouragement. No casseroles.

If you spend time on a psych ward, no visitors, no flowers. No casseroles.

If you aren’t able to go to an event or meet for coffee, no sympathy, no prayer circle. No casseroles.

If you’re not able to get out of bed all week, no housekeeping, no errands run. No casseroles.

And if you survive a suicide attempt, no understanding, no acknowledgment. No casseroles.

I get it. I do. People don’t know what to say, so they don’t. They don’t know what you need, so they don’t offer it. They don’t know how to cheer you up (and they can’t), so they stay away. They’re afraid of psych wards, so they don’t visit.

Casseroles can’t hurt and might help.

What it all comes down to is stigma and ignorance. There are no social conventions that apply to those with SMI. Except for the most fortunate among us, we’re on our own.

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Mental Health

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