Bipolar 2 From Inside and Out

Posts tagged ‘mental illness’

Bipolars, Rollercoasters, and Sex

Wooden RollercoasterThe rollercoaster is the most common metaphor for bipolar disorder. But is it really the best one?

After all, a rollercoaster has long, abrupt downward swoops, and anticipatory highs. (At least the ones I’m familiar with. I won’t go on the ones that turn you completely upside-down. I understand the physics, but no. Just no.) Rollercoaster highs crank slowly, grindingly up. Mania isn’t like that. Boom! You’re suddenly at the top.

Nor are rollercoaster lows like the lows of depression. If they were, the downward slide would not be the exhilarating, thrilling part of the ride, and would not immediately be followed by another high. Instead, the rollercoaster would plod along through a lengthy trough, or maybe a tunnel (though not of love), with no idea of when the next up would come.

Perhaps a seesaw is a better metaphor. Its ups and downs are quick, and you can stay stuck in either position for an undetermined length of time. And a seesaw is all about balance.

But no. A seesaw requires a second person to operate correctly, and that is certainly not the experience of a bipolar person. Our brain chemistry or genetics or trauma alone is enough to get us going up and down.

A pogo stick? The spring gets squashed and then rebounds. But it’s a rhythmic bounce, not one that you don’t see coming until you’re in it. (If then.)

The basic problem with most of the usual metaphors is that they involve fun at some level. Bipolar is not fun. Oh, the mania may be enjoyable – for a time. But the gut-wrenching drop does not make you go whee!

So how about a soufflé? It can rise or fall, and you never quite know which it’s going to do.

Or a computer? It can open up the world, but is going to crash sometime, inevitably when you most need it to work.

I suppose we could split it up. Mania is a fountain and depression is a ditch. Depression is a b&w rabbit-ear TV and mania is streaming with 1000 services. Mania is a battery and depression is a dead battery.

The root of the problem is that no metaphor can adequately explain bipolar disorder. Even Spoon Theory, useful as it is, explains only the effects, not how the disorder itself works. A metaphor may capture one half of the experience – the ups or the downs – but not the reality of both.

If it’s not possible to explain bipolar disorder with a metaphor, why do we so often try to? Because, really, only people with bipolar know what it is like, and the experience even differs from person to person. A psychologist or psychiatrist may understand the mechanisms and the causes and the complications and the medications. But she or he is essentially watching from the outside.

My husband didn’t really “get” depression until he fell into depression himself which lasted a couple of weeks. “Now,” I said, “try to imagine that feeling lasting for months.” He couldn’t, but at least he was closer to understanding.

My mother-in-law, who doesn’t “believe in” mental illness, now has a clue too, since she experienced a profound reactive depression.

Neither of them really “gets” mania.

Maybe the best metaphor is that bipolar disorder is like sex. You can’t adequately explain it to someone who’s never had it. And even when you’ve had either sex or bipolar disorder, you only know what it’s like for you. You can generalize your experience and share commonalities, but basically, every case of bipolar is something a person goes through alone, or maybe alone together, as Jenny Lawson says.

Bipolar disorder.

It is what it is.

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The Fire and the Window

fire orange emergency burning

When Anthony Bourdain died by suicide and I told someone the news, he asked me, “Why?”

I was taken aback. “What do you mean, ‘why’?” I replied.

“You know,” he said. “Did he have money trouble? Break up with his girlfriend? Have some disease?”

That’s a common reaction to suicide and it’s uninformed. Real-life stressors can contribute to suicide, but they are almost never the whole story. People die by suicide when the pain of living seems greater than the pain of dying.

Gregory House, the misanthropic, genius title character of House, M.D., once said, “Living in misery sucks marginally less than dying in it.” People who kill themselves don’t believe that. They believe the opposite.

The best metaphor I ever heard for suicide was the plight of people in the World Trade Center’s upper floors on 9/11. There were the flames. There was the window. And that was the choice. Suicide happens when a person sees only two alternatives and both are equally horrible, or nearly so.

The bullied child does not take her own life because she was bullied. She was in pain, for a variety of reasons that included bullying. It was a factor, but it wasn’t the reason. She was hurt. She was isolated. She was depressed. She didn’t believe that things would improve. She wanted the pain to stop. She believed she faced the choice between the fire and the window.

The politician who dies by suicide in the face of a major scandal does not kill himself because of the potential scandal. He dies because he sees his choices limited to shame, humiliation, despair, and ridicule. He believes that what happens to him will be as bad as dying. He is caught between what he sees as the fire and the window.

Mental illness can make it difficult to see that there are other choices. The distortions of thinking associated with serious mental illness can make us see only the fire and the window.

The one time that suicidal ideation got the better of me and I was close to making the choice, my thinking was just that twisted. I was faced with a choice that seemed to me would ruin someone I loved. I thought that I could not live with either choice – to ignore the behavior or to turn him in. One was the fire and the other, the window.

My thinking, of course, was severely distorted by my mental disorder. The thing that I thought might rain destruction on the other person was much smaller than I believed. There were ways out of the dilemma other than dropping a dime or killing myself. If we continue the metaphor, the fire was not that big, or that implacable, or that inevitable, but I couldn’t see that. In the end, I hung on long enough for my thinking to clear and for me to see other options.

I don’t actually know what was going on in the minds of the souls who were trapped in the Twin Towers. I don’t mean to lessen the horror of their deaths or wound their families by speaking of suicide this way. The reality of their choice is so far distant from the choices that other people who consider suicide face.

But that’s kind of the point. People who die by suicide don’t see any other way out. If they seem to be responding to what most people see as survivable hurts or solvable problems, people say they can’t understand how someone that rich, that successful, that beloved, that full of potential could have not seen that help was only a reach away.

The person who dies by suicide doesn’t see the hand reaching out. Only the fire and the window.

If you are considering suicide, call the Suicide and Crisis Lifeline: 988.

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Brain vs. Brain

Having bipolar disorder is like having cognitive dissonance all the time.

What is cognitive dissonance? When people ask, I usually describe it as when the two halves of your brain slam forcefully into each other and give you a brain-ache. It’s also known as “brain go ‘splodey.”

Take, for instance, the time when I saw excerpts from the musical Cabaret, with the dancers portrayed by women of at least 65. As I reeled out of the theater, my mother saw the dazed look on my face and said, “Don’t you like Cabaret?”

“I love Cabaret!” I replied. Meanwhile, the other side of my brain was saying, ”Oh my God, if they had tried to do the Bob Fosse choreography, someone would have broken a hip for sure!” Slam! Pow! ‘Splodey! Cognitive dissonance.

You can probably see how this relates to bipolar. One half of your brain says, “If you just take a shower, you can go out to lunch.” The other half says, “A shower?!? First I have to find a clean towel and a bar of soap, get undressed without seeing myself in the mirror, fiddle with the water temperature, wash and shampoo, dry off, find clean underwear, and that’s not even thinking about drying my hair and figuring out what I can wear! Oh, my God, I’ve used up all my spoons just thinking about it! I should just eat Cocoa Puffs and go back to bed.”

Instant cognitive dissonance.

Or try this scenario: You see on your newsfeed that the government is considering a new law with a feel-good title regarding mental health issues. “Hooray!” one side of your brain says. “At last! Everyone should support this fabulous bill!” Then you look at the whole article and find that one provision in the bill allows violating the privacy protections of HIPAA, as an example.

“Oh no!” the other half of your brain says. “Any person, even one who’s mentally ill, has the right to medical privacy. What if an abuser gets information about his victim? I’ve got to write a letter protesting this bill. Where are my spoons? Did someone steal my spoons?”

There are lots of these situations, hence the near-permanent state of cognitive dissonance.

I want to be around people but I don’t want to talk to anyone.

I want to be left alone but then I’m lonely.

I really want to make love to my partner but I can’t get aroused.

I want to be cured but I hate the idea of being “normal.”

That degree of cognitive dissonance is positively exhausting. No wonder we never want to do anything but lie in bed, not read, not interact, not reach out, not try to do anything but survive another day.

If we think too hard about anything, our brains may go ‘splodey.

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Teens and Social Media: A Contrary Opinion

Vivek Murthy, the US Surgeon General, just released an advisory on the dangers to teen mental health that social media poses.

CNN reports, “While noting some benefits of the online platforms, the report warns of increasing concern and ‘ample indicators’ that social media can have ‘a profound risk of harm to the mental health and well-being of children and adolescents.’ The 19-page report acknowledges that further research is needed and that online youth well-being is shaped by many complex factors, including screen time, content, and countless strengths and vulnerabilities of individual users.'”

There have been warnings about this crisis for over a decade. According to NPR, psychologist Jean Twenge looked at mental health metrics around 2012 and was shocked: “Rates of depression, anxiety, and loneliness were rising. And [Twenge] had a hypothesis for the cause: smartphones and all the social media that comes along with them. ‘Smartphones were used by the majority of Americans around 2012, and that’s the same time loneliness increases. That’s very suspicious,’ she wrote in The Atlantic in 2017.”

Well, I’m not so sure. Twenge also said that “22% of 10th-grade girls spend seven or more hours a day on social media.” That does sound like an alarming statistic, but it also means that over three-quarters of 10th-grade girls didn’t.

Other stats are similarly suspect. For example, “Teen social media use has skyrocketed in recent years. The rise in tech use coincides with rising rates of anxiety, depression, and loneliness.” This may be true, but it’s a far cry from saying that the rise in social media use causes the rising rates of mental distress. Throughout the years, everything from comic books to rock and roll to video games has been said to cause ills from teen violence to drug use to sexual deviancy. But correlation – the fact that two things happened around the same time – does not equal causation – that the one circumstance causes the other.

Similarly, “A study — considered one of the best to date on the subject — found an uptick in mental health issues after Facebook arrived on college campuses.” Even though it was thought to be one of the best, there were flaws in it (only lasting four weeks, for example), and once again, it suffers from the correlation-causation problem.

Now, I’m not arguing that social media isn’t at all related to adverse psychological outcomes. I’m just saying that the talk about them may not be incontrovertible evidence.

Certainly, social media has bad effects on teens – in particular, in cases of cyberstalking and cyberbullying. Cyberbullying has even been blamed in cases of teen suicide, though it seems likely that mental issues of existing depression, isolation, and low self-esteem are involved as well. I’m not going to say there’s anything even remotely questionable there. A lonely, isolated, depressed teen can be preyed upon by a bully, either same-age or older, taking advantage of their insecurities and desire for connection. The fact that this can end in tragedy is no surprise.

The technology of social media makes it easier for bullies to spread their messages further and more quickly than was possible in previous days. The potentially worldwide audience for hate and degradation makes the behavior even more devastating. But, while the technology makes the problem worse, the underlying cause is still bullying. Current efforts at reducing bullying have been largely ineffective. I don’t see how reducing cyberbullying will be any more successful.

Still, most of the objections to social media seem to focus on time spent and “inappropriate content.” And when they say “time spent,” they aren’t talking about the positive aspect of social media on education and homework. We learned during the COVID-19 pandemic about how social media can be used to further education. Zoom meetings for project work, Google searches for research topics, YouTube for instructional videos, and more are appropriate uses of social media.

As to “inappropriate content,” that’s always been available, from magazines to movies. True, there is a greater variety of content with greater disgustingness available. But just as it was never possible to shelter teens from magazines and movies, shutting off inappropriate content is not feasible. Nor can parents reliably monitor their teens’ social media use and the content they interact with. Adults are attached to their own screens, whether for business, shopping, entertainment, or accessing adult content themselves – not to mention all the other tasks they perform. They can’t be looking over teens’ shoulders all the time. Maybe it’s possible to take away a younger child’s smartphone at bedtime, but not teens’.

Some of the objectionable content doesn’t relate to sex, either – or at least not directly. Teen girls are hammered with content that encourages them to be thinner, more compliant with unrealistic adult standards of beauty, and ways of molding themselves into those images. This does promote negative self-images of teen girls’ reality and expectations, leading to lower self-esteem and, potentially, depression. Again, though, short of parents monitoring teen social media use, there’s virtually no way to stop this. Parents have no control over the messages that are coming in and little over how much gets through to teens.

And while the Surgeon General’s report makes some mention of the good aspects of social media, the potential for social media to foster beneficial connections is undeniable – another lesson we should have learned from the pandemic. Teens can keep in touch with friends from around the world, interact with relatives in other states, and attend virtual meetings and events. And if they use that personal connection time to engage in teen talk and trivia with their friends, that’s been true of teens since time immemorial. Think back on how many current adults spent hours talking on their low-tech phones after school with their friends.

So what are the solutions? There aren’t very many, and they aren’t very likely. Some potential (partial) remedies can be tried in schools – more anti-bullying education, and more tech education that focuses on ethics and responsibility. But, of course, those would take time away from the many other educational imperatives that schools have been made responsible for.

The other potential solutions are even less likely. There’s no way to stop content producers from producing objectionable content – not just porn and shady dating sites, but the many messages that teens get about their appearance, dangerous behavior, and other matters of questionable good and benefit.

So, are the warnings justified? Probably, yes. Teens are not just impressionable. Their brains are still pliable and forming. The content they see and hear through the internet does not take that into account. Parents can’t effectively monitor teens’ online behavior, and content producers won’t change what they put out – it’s too profitable.

Alerting parents to the dangers is all well and wonderful, but pointing out a problem with no solutions isn’t all that helpful, really. Here’s one story for parents about what might help: https://www.npr.org/sections/health-shots/2023/05/17/1176452284/teens-social-media-phone-habit?utm_source=npr_newsletter&utm_medium=email&utm_content=20230528&utm_term=8496137&utm_campaign=news&utm_id=57068906&orgid=726&utm_att1=

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Questions (And Some Answers)

They say there’s no such thing as a silly question. But I’ve heard a few that come darn close. I understand that some of the people who ask them are genuinely confused about brain illnesses in all their variety. But some of them – I just don’t know. Here’s a look at some of the questions I’ve encountered.

Some people are concerned that various practices can affect mental illness or its treatment. I’ll tackle a few of these.

Can chanting a mantra harm someone who is mentally ill or has schizophrenia?

Can people with mental illness practice mindfulness meditation without hindering their treatment plan or making symptoms worse?

To these questions, I would say that chanting a mantra or practicing mindfulness meditation poses no threat. In fact, these practices are often encouraged as ways to reduce harmful stress.

Does astrology have any cure or remedies for mental illnesses like schizophrenia and bipolar disorder, etc.?

As to astrology, I’d have to say no. It has no place in the treatment of brain illness. It’s not science and has nothing to say about the inner workings of the human mind.

Can mental illness be caused by external factors such as mind control or manipulation?

While manipulation exists, mind control doesn’t, unless you’re talking about cult indoctrination. Manipulation in the context of gaslighting can cause stress-related disorders or possibly trauma.

Can too much intellectual curiosity cause mental illness or psychological problems later in life?

Intellectual curiosity is a good thing. Honestly, I don’t see how anyone can have too much. At any rate, it has no relation to mental problems.

Some questions come with relatively simple answers.

How can you find out if a doctor has diagnosed you with a mental disorder?

Your doctor will tell you what the diagnosis is. They won’t keep it a secret.

Can someone with bipolar disorder join Alcoholics Anonymous (AA)?

Sure, they can join. But not all AA groups are comfortable working with people who have psychiatric diagnoses. They concentrate on alcoholism and not mental disorders, so the bipolar disorder likely won’t be addressed in many meetings.

Can covert bullying and gossip harm a person? Would the said person seem mentally unstable or unwell?

Absolutely, bullying and gossip can harm someone. Some people even see bullying as a contributor to teen suicide. The victim is likely to show symptoms of depression and anxiety.

There are questions that ask about specific populations.

What can be done to help teachers that have mental disorders?

The same treatments that work for other people will work for teachers, too. The teacher may need to take a sabbatical to work on their issues without the pressures of their job.

How do the constant pressures of fame and scrutiny affect the mental health and overall well-being of celebrities, and what steps can be taken to better support their mental health and prevent the negative effects of celebrity culture?

While I’m sure there are special pressures on celebrities and they certainly can have mental illnesses, there really isn’t much chance of changing celebrity culture. Supporting their mental health might involve not penalizing celebrities for taking time off from their careers to seek treatment.

What are the most common mental problems among thru-hikers?

I’ll be honest. I had to Google “thru-hikers.” They’re people who hike a long, multi-state trail like the Appalachian Trail from end to end. That said, their most common mental problems are the same as the most common problems of the general population. There’s nothing about being a thru-hiker that poses a special risk.

Then there are questions about family matters.

Does being raised by a single mother cause mental illness or personality disorders?

Just being raised by a single mother doesn’t cause any mental illness. Single mothers are perfectly capable of raising happy, healthy, well-adjusted children. That said, any parent – single, married, mother, father – can have a child with mental problems.

Can tough love from parents prevent mental illness in children?

No. There is no one technique to ensure that children do not develop mental illness. Tough love may not be the best approach for a child who already shows signs of mental difficulties. Tough love can be traumatic, which can make a mental illness worse.

There are the questions that simply perplex me.

What are the effects of watching cute animal videos on mental health?

Aside from saying “Awww” a lot, none that I can see.

What are the effects of reading creepy pastas on mental health?

WTF? Is this about alphabet soup controlled by a Ouija board? A reference to the Flying Spaghetti Monster?

What is the worst diagnosis made by a fictional doctor?

Fictional doctors can’t diagnose fictional characters. They’re fictional.

Did Fred Flintstone ever experience mental illness? If so, what was the reason for it?

See previous answer.

Then there’s the ultimate question.

How can we address the mental health crisis in our society?

A simple blog can’t answer this question. No one person can. It will take the work of thousands of people (or more) to convince the rest of the people to take appropriate action. It won’t be easy and it won’t be quick. We need to convince the general public that, first, there is a problem, and then, that there are things we can indeed do to address it. Even making a dent in the problem is a long-term project. So we’d better get busy. The problems aren’t going away on their own.

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Emotional Numbers

What’s the relationship between mood and emotions? How is the mind involved? Is it even possible to sort them out?

These days, people talk a lot about one’s Emotional Quotient, or EQ, also known as emotional intelligence, or EI. EQ is defined as “the capacity to be aware of, control, and express one’s emotions, and to handle interpersonal relationships judiciously and empathetically.” Emotions are “a natural instinctive state of mind deriving from one’s circumstances, mood, or relationships with others.” Mood is “a temporary state of mind or feeling.” Obviously, the definitions overlap somewhat.

All of these terms are used by the general public. EQ is the currently popular term. You can find any number of “tests” online that claim to determine your EQ. Often these are phrased in terms of your “personality” and may refer to enneagrams or other psychological theories. Other searches revert back to showing you your IQ, even if you were looking for EQ tests. Many of them charge money to show you the results. I’m not interested enough in my EQ to spend the money, though I took one of the tests. I might ask my therapist if she has a handle on what my EQ might be. I’d be happy with a subjective evaluation such as Excellent, Good, Average, Poor, or Terrible. Anything more, like a circular chart with bright-colored segments, I believe I’ll pass.

How do EQ and IQ tests compare? Healthline says, “IQ tests measure your ability to solve problems, use logic, and grasp or communicate complex ideas. EQ tests measure your ability to recognize emotion in yourself and others, and to use that awareness to guide your decisions.” So, completely different things. A person with a high IQ could have a low EQ and vice versa.

So, what else do the experts say about the difference between moods and emotions? “Moods can last for hours while emotions last anywhere from seconds to minutes, at most.”

There I would disagree.

At least, I have an opinion. An emotion is something I feel for a defined amount of time, usually a short one. My husband and I disagree and I feel an emotion of annoyance. But it seldom lasts for mere seconds. It can dissipate within a minute or last for several hours, depending on when we talk it out.

A mood lasts longer than that. Now that I’m relatively stable, my moods may last longer than a week, but less than years. Right now, I’m having a mood of anxiety, which has lasted for nearly a month, which doesn’t show much sign of pulling back, and which I’ve had to discuss with my therapist and my psychiatrist.

Moods certainly can last for more than seconds or minutes – hours, days, weeks, or longer – but emotions can last a long time too. Have you ever held a grudge? It’s not a fleeting emotion. It’s not a mood, but it can last for potentially years – even the rest of your life. What’s left? A state of mind? A personality trait? A decision?

In my research, I did come across a piece about EQ and various disorders. It was on a site that promotes a treatment center for drug abuse, so I don’t know how accurate it is. But it said that empathy, being a major component of EQ, will change in a person with depression. They may feel more empathy for a person who is also suffering, but less for a person who isn’t. This leads to numbness, they say, which may further impair one’s mental health.

In cases of ADHD, the center says, people may have trouble reacting to emotional stimuli and engage in “inappropriate behavior” for a situation. Without treatment and EQ, they may still feel internal restlessness.

Anxiety and EQ, they say, are complicated. Low EQ may mean detachment from things that threaten safety and self-esteem. On the other hand, people with anxiety and high EQ may have a tendency to be so empathetic that they overthink and lack the ability to self-regulate.

The treatment center says it can improve EQ and thereby improve self-awareness, self-regulation, motivation, empathy, and social skills, all in the context of addiction recovery. Whether this is true – whether raising EQ is possible and promotes benefits in understanding and behavior – is, as far as I can see, far from settled. It’s also unclear to me in which order this would happen. Would treating the mental condition raise the EQ, or would raising the EQ help treat the mental condition?

I also encountered a study that said high EQ is positively associated with good general physical health. Yet another investigated the correlation among EQ, a sense of belonging, and mental health among college students. Rejection in particular was associated with poor mental health outcomes.

I’d like to see more on the subject.

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Does It Matter What We Say?

Words matter. I preach that all the time. Language is what gives our thoughts reality and how we make essential connections. Ideas become more concrete when they have words attached to them. It’s hard – perhaps impossible – to convey a thought without language of some kind. And how we use words is dependent on how and what we think.

Words matter. Think about how the terms “rioters” and “protesters” reveal a person’s opinions about the motivations of the people in the “mob” or “crowd.”

Words matter. Our community has been pushing back against words such as “psycho” and “crazy” when it comes to referring to people who need psychiatric help. Many people are gradually realizing that such words are equivalent to slurs and are no longer acceptable. (Except in the aftermath of violence, of course. Then, those terms are tossed around indiscriminately.)

Words matter. But how do we in the community refer to ourselves? What words are advocates using? And how do we want the general public to refer to psychiatric problems?

I’ve written before about the terms “behavioral health” (bad) and “mental illness” (better). But what’s best? Increasingly, the words du jour are “brain illness” and “brain disease.” We’re watching linguistic change in action.

But linguistic change happens at a glacial pace. Words that were used in Elizabethan England are still used today. Think about all the words and phrases that Shakespeare invented that are still used today, and with the same meanings – unreal, lonely, and green-eyed (as in jealousy), for example.

Linguistic change, on the other hand, also happens blindingly fast. Slang, tech terms, and jargon in particular appear and disappear in the blink of an eye (as it were). Think about the terms that refer to female beauty. There were times when “phat,” “fresh,” and “fly” were all applied to women. (Yes, I’m dating myself. I don’t even know what the current term is, but I bet it’ll be gone next month. At least I know that “fire” has replaced “awesome,” “boss,” and “da bomb.”)

So, where are we in the (something) community now that we’ve left “behavioral health” behind? “Mental health” was the clear frontrunner for a time. Then it was “mental illness,” then “serious mental illness.” Now the term being put forward is “brain illness” – or even “brain disease.”

I’ve talked about the implications that various words have. What are the connotations of the new terminology? “Mental illness,” as opposed to “mental health,” drives home the point that “mental health” is a euphemism. It’s not health that’s the problem – it’s the opposite of health. “Brain illness,” as opposed to “mental illness” says that the problem is not in the mind, it’s in the brain.

I think that’s a tough concept for the general public to take in. To most, the mind and the brain are synonymous. Whether that’s accurate or not is hard to say. It’s true that the brain is the physical embodiment of thought, emotion, and cognition. These things can’t exist separate from the brain. They are so intertwined that it’s hard to think of one without the other – especially for laypeople.

But “mental illness” implies that the mind – the thinking – is what is disordered. “Brain illness,” on the other hand, says that the problems lie in the functioning – the physical structure – of the brain. In my opinion, it’ll be tough sledding to make the public understand the sometimes subtle difference between the two.

Recently I saw an online post that decried the fact that advocates and professionals aren’t yet using the terms “brain illness” and “brain disease.” And there’s some truth in that. My own therapist doesn’t. But practitioners are engaged in dealing with the general public as well as those in the community. There’s something to be said for addressing those people in language they understand better. There’s the possibility that when hearing “brain disease,” most people will think “brain tumor” rather than what we are really talking about. And there’s the problem with the slowness of linguistic change.

Words matter. But so does the speed of change. Of course, if we want to change the dialogue, we need to use more accurate terms to promote our message. But it’s probably too soon to expect everyone to be on board. I’m not saying that we should give up on the process of fostering change. I am saying that we shouldn’t be beating each other up for not yet having made that progress, even among ourselves. It’s a process, and not everyone progresses at the same rate.

Incremental change is better than none. Indeed, unless you’re talking about a fad, it’s the only way change happens. And we’re not talking about a fad here. We’re talking about a fundamentally new understanding of what it means to have schizophrenia, bipolar disorder, major depressive disorder, and other illnesses.

That’s going to take serious time.

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What Does PMHNP Mean?

What the initials mean is Psychiatric-Mental Health Nurse Practitioner (also known as Psychiatric Nurse Practioner or PNP). What that may mean for mental healthcare is the potential for more treatment and access to therapy. Increasingly, nurse practitioners are taking over some of the duties of psychiatrists and providing services to people who have mental disorders, or even serious mental illness (SMI).

What qualifications do nurse practitioners have? They must have a master’s or doctorate in nursing with a psychiatric nurse practitioner concentration, plus two years of work experience. Unlike psychiatrists, they aren’t MDs.

Psychiatric nurse practitioners perform many of the same functions that psychiatrists do. They work in hospitals, rehab facilities, outpatient mental health centers, and even in private practice in many states. (Other states require that they work under the supervision of a physician.) In addition to providing psychotherapy, PNPs can write prescriptions – including for controlled substances – regulated by state boards of nursing. They work with other professionals and with families to meet patients’ needs and create a holistic care plan that typically includes therapy, counseling, and medication.

There’s a crying need for PNPs. It’s no secret that it’s difficult to find psychiatrists and psychotherapists and that the waiting list is long for a new patient seeking treatment. Last year, 151 million Americans lived in mental health professional shortage areas, according to the U.S. Health Resources and Services Administration (HRSA). They reported that those areas need 7,584 mental health care practitioners to fill the gap.

It’s a good field to go into, too. Salaries are reported as ranging from $81,000 up to $140,000 per year. And in 2021, the unemployment rate was less than 1%. Currently, there are over 10,000 PNPs in the US, of which 80% are women. The U.S. Bureau of Labor Statistics (BLS) projects that the employment of all nurse practitioners will grow by 52% between 2020 and 2030! They anticipate 29,400 new job openings across the U.S. every year between 2020 and 2030. 

Minority Nurse magazine reported in 2020 on why there’s such a strong demand and positive job outlook for PNPs. They cited expanded insurance coverage for mental healthcare under the ACA, increased awareness of the importance of mental health, and the mental healthcare needs of veterans who served in Iraq and Afghanistan. The aging population of Americans may be another factor, as more and more people require services for disorders such as Alzheimer’s and dementia.

How good are PNPs? Psychiatric Times says that “patients report favorable experiences working with nurse practitioners.” Findings from one study determined that patients had “greater satisfaction with their care provided by nurse practitioners when compared with their MD colleagues….Investigators found that patient outcomes from nurse practitioners working independently or with MD collaboration had similar outcomes, when compared with the patients working with MDs alone.”

Although it seems that psychiatrists and PNPs ought to be natural allies, Psychiatric Times also notes that “national initiatives and some agencies have encouraged an us vs. them mentality, pitting psychiatrists against nurse practitioners and other advanced care providers.” That’s unfortunate for so many reasons.

I’ve never used the services of a psychiatric nurse practitioner, though there are several near me. If I had known about them when I was between psychiatrists, I certainly would have investigated the option. There’s something appealing about getting my therapy and my meds all from one person, a situation that hasn’t occurred since my previous psychiatrist retired. (I had to spend six months on a waiting list before I found another.)

For anyone in the same situation, I would suggest looking into it. I am convinced that PNPs have an important role to play in mental healthcare. If their presence reduces the problem of scarcity of mental health professionals, they should be welcomed, and awareness of their availability should be publicized. If more people knew about PMHNPs, it would expand the choices that mentally ill persons have. It would also benefit organizations, inpatient and outpatient facilities, and community-based care.

Is there a downside? I don’t see one.

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The School Shooter Problem and the Mental Healthcare System

It’s been reported lately that there is a mental health crisis among young people in the US. Depression and anxiety are on the rise. Some claim they know what causes it, and some don’t. The usual suspects include social media, bullying (especially bullying on social media), academic pressure, the COVID-19 pandemic, isolation, and uncertainty about the future. Fear of and reactions to school shootings are in the mix, too. The problem has garnered interest among the people who have the capacity to address, if not actually solve, the problems.

President Joe Biden announced in his 2023 State of the Union address that the Department of Education will divvy up $240 million in grants to help schools tackle the crisis. If you average that by 50 states, it comes to around $50 million per state. A more accurate estimation considers that, since there are 16,800 school districts in the US, that, on average, each district would get roughly $141,000 for youth mental health to be spread around all the schools in each district – not really very much. That money, plus the billion dollars invested last year, is earmarked for more mental health counselors and mental health professionals in the schools.

All that is well and wonderful, but what are the problems that lawmakers want those funds to solve? Apparently, many lawmakers and public policy boffins think that preventing school shooters should be the primary goal. Identifying the kids that are likely to resort to weapons to settle their differences with schoolmates and teachers seems to them to be the most effective use of the funds. The basic debate is whether those funds should be used to identify and treat potential school shooters or help the students who are traumatized by the incidents and by the looming threat of more – prevention of violence versus reaction to the threat itself. In general, Republicans want to address finding and preventing the shooters, while Democrats seem to prefer ministering to those affected by the shootings – and enacting gun control. (I’m not getting into the gun control debate right now.)

Democratic senator Chris Murphy raised the issue in the wake of the school shooting deaths in Uvalde, Texas. “Spare me the bullshit about mental illness,” Murphy said. “We don’t have any more mental illness than any other country in the world. You cannot explain this through a prism of mental illness because we’re not an outlier on mental illness.” Biden also played up the necessity of dealing with the repercussions of the school shootings: “Address the mental health crisis deepening the trauma of gun violence and as a consequence of that violence.”

When it comes to getting shooters into treatment, though, there are problems. Differences in opinion are rampant on whether psychological treatment can prevent school shootings. Partly, it’s a problem of anosognosia. The potential and actual school shooters do not think they have a problem – and the same can be said for many of their parents – so they’re not very likely to make it into the mental healthcare system or gain any benefit from it if they do.

Another reason is that CBT, the currently favored treatment option, really doesn’t have anything that would address the incipient violence of students who are so troubled that they think it would solve their problems of anger, isolation, revenge, desire for fame, bullying, or whatever other factors may be implicated. It’s also worth noting that many, many students are bullied, mocked, ostracized, or otherwise demeaned. The vast majority of them do not go on to become school shooters, or the problem would be worse than it already is. (Personally, I was subject to some extreme bullying in school – and had access to guns and no access to mental healthcare at the time. I never shot anyone or ever thought about it.)

Perhaps the best that can be expected of mental healthcare right now is ministering to the bereaved and the traumatized. Until or unless we come up with some way of more reliably identifying and treating potential shooters before they become actual shooters – something that has yet to be accomplished – we’ll be more adept at cleaning up the aftermath.

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Live for Today

I see a lot of memes exhorting us to “live for today.” Sometimes these are in the context of life being uncertain and needing to live each day as if we’re going to die tomorrow. And it’s true that the future isn’t guaranteed to any of us.

This has evolved into the “YOLO” (or “You Only Live Once”) philosophy. It’s not clear what YOLO really means. To some, it’s a challenge and defiance – the idea that you should try something even if it’s dangerous because you may never again get the opportunity to do it. If you look at it this way, it’s the opposite of the previous understanding of “live for today,” in that one can actually hasten the absence of tomorrows based on what potentially terminally stupid thing one decides to try or is goaded or shamed into trying. I followed this philosophy one time when I decided to go for a ride on a zipline. Stepping off the platform frightened me, but I did it. Now I’m too old and decrepit to do it again, so I’m glad I did it then.

On the other hand, “You only live once” could also mean that you should take care of yourself. You only live once, after all, so why not live as long as possible? Nutrition; sleep; exercise; avoiding drugs, smoking, alcohol, and unhealthy foods; and relaxation techniques are all considered factors that will lead to long life – as long as you don’t consider factors such as genetic disorders, cancer, and tragic accidents you can’t control.

If those behaviors sound an awful lot like self-care, well, they are. And for those of us with brain disorders, self-care is perhaps the most often recommended thing we can do to keep ourselves functioning as well as possible. Of course, if I were a cynic, I would say that self-care might be recommended so often because it’s an easy thing for businesses and insurance companies to recommend rather than actually helpful, but more extensive or expensive, interventions.

Living with a brain disorder is in many ways a day-by-day challenge. Every day, we must do the things that will lead to stability (we hope), including taking our meds if they’re prescribed, going to therapy, building a support system, and performing self-care. It’s true that we only live once, but that once proves to have its own unique challenges.

At times, it feels like we have been cheated by life by having our once around be so difficult. And I’m not going to say that isn’t true. I don’t think that having a brain illness makes us more sensitive or understanding or creative – except that we may be more sensitive to the needs of others who also have brain disorders. Mostly, it just makes life more – challenging is about the best spin I can put on it. And everyone in this life has their own challenges. There’s no use comparing whose life is worse.

Still, it’s a worthy goal to try to live the best life we possibly can within the limitations that our disorders impose on us. The fact that we only live once – and that our lifespan may be reduced by our illnesses – makes it all the more important that we make the most of what we are given.

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