Bipolar 2 From Inside and Out

Posts tagged ‘public perception’

Pill-Shaming

When I first started taking Prozac, when it was just becoming ubiquitous, my mother said, “I hear it’s a ticking time bomb!”

“Oh, dear!” I thought. “Mom’s been listening to Phil Donahue again.” (She had been, but that’s not the point.)

Back in the day, Prozac was hailed as a miracle drug and condemned as a killer drug. On the one hand, it was said to be a “magic bullet” for depression. On the other, it was supposed to result in addiction and suicide.

It’s probably true that it was prescribed too often to too many people who may not really have needed it. And it may have led to suicides—not because Prozac prompted such an action, but either because it was improperly prescribed or because it activated people who were already passively suicidal and pushed them into action.

At any rate, Prozac was not an unmixed blessing.

For me, it was closer to a miracle drug. It was the first medication that had any significant effect on my depression. I noticed no side effects.

But Prozac is no longer the psychiatric drug of choice. Since that time, hundreds—maybe thousands—of psychotropic drugs have been introduced and widely prescribed. Many have proved just as controversial as Prozac. Indeed, the whole concept of psychiatric drugs is now controversial.

I belong to a lot of Facebook groups that encourage discussion on psychological matters and have a lot of Facebook friends with opinions on them, sometimes very strong ones. Some of the people with the strongest opinions are those who condemn certain classes of psychiatric drugs or that category of drugs altogether. They share horror stories of addiction, atrocious side effects, zombie-like behavior, and even death from the use of these drugs.

Benzos are the drugs that are most often condemned. And it’s true that they can be addictive if they’re misused. Whether that’s because a doctor overprescribes them or a patient takes more than prescribed I couldn’t say. But I maintain that benzos aren’t inherently harmful when prescribed appropriately and supervised professionally.

I have personal experience with benzos. They were the first psychiatric drug I ever took, meant to relieve a rather severe nervous tic that affected my neck and head during junior high school. I do remember walking off a short stepstool while shelving books in the library, but I was not injured and the misstep could be attributable to ordinary clumsiness, which was something I was known for (and still am). The benzos were discontinued when I got better. I also took benzos in college because of pain due to temporomandibular joint problems.

Now I have benzos that my psychiatrist prescribed “as needed” for anxiety and sleep disturbances. After all the years I’ve seen him and my history of compliance with prescribed medication, plus the very low doses, he had no hesitation prescribing, and I have no objection to taking them.

But some of the people I see online object to any psychiatric drugs whatsoever. Again, the most common complaints are addiction, side effects, and zombie-like behavior. Of course, I can’t—won’t—deny that they have suffered these effects. Psychotropics are known to affect different people differently. I’ve had side effects from many of the ones I’ve taken that were too unpleasant for me to continue taking the drugs. But after all the different meds I’ve tried during my journey to a combination of drugs that work for me, it would be a surprise if I objected to them altogether.

But I don’t. I’ve had cautious, responsible psychiatrists who’ve prescribed cautiously and monitored rigorously, listening to me when I reported side effects.

So, my personal experiences have been good. I know not everyone’s experiences have been, for a variety of reasons.

What I object to is the drumbeat of “all psychotropic medications are bad and ruin lives.” And the memes that show pictures of forests and puppies that say “These are antidepressants” and pictures of pills with the caption “These are shit.”

I hope those messages don’t steer people who need them away from psychotropic medications. And I hope that people who do need them find prescribers who are conscientious, cautious, and responsible in prescribing them. On balance, I think they’re a good thing.

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Stigma, Prejudice, and Discrimination

Those of us with brain illnesses such as bipolar disorder, OCD, PTSD, and schizophrenia often speak of the stigma associated with our problems. It’s no wonder—stigma affects our lives in both predictable and unpredictable ways.

For instance, say you’ve become comfortable talking about your disorder. Then one day when you’re at a reunion or some other gathering, you happen to mention it and get the glazed-eyes-fixed-smile-back-away-slowly response. Sure, a lot of people don’t know what to say to you, but that reaction just makes it clear that you are different and, to that person, potentially a source of danger. Someone to be avoided. Someone not to engage with.

That’s stigma.

Prejudice is related to stigma. It’s just a short step away. Prejudice happens when people have a preconceived idea of what brain illness looks like. (That’s what prejudice means.) This could be a person who assumes that a serial killer or mass shooter is obviously “insane.” Their assumptions are reinforced when it’s revealed that the perpetrator had a history of psychological problems or had taken medication. They’re ignorant of the facts—that most killings are prompted by motivations such as rage, gender or racial hatred, jealousy, or fear. They don’t know that the mentally ill are much more likely to be the victims of violence than to be perpetrators.

People with prejudice against people with mental illness can also assume that psychiatric diagnoses are not “real.” They think people with these conditions can—and should—just “snap out of it,” “pull themselves up by their bootstraps,” or “get over” their problems. They look down on people who seek help. They make jokes about “crazies” and “lunatics.” They believe that anyone with a “real” mental illness is in a locked ward in an “insane asylum,” or should be. They don’t know that straightjackets aren’t used anymore and feel they’re funny Halloween costumes.

In other words, people who are prejudiced lack understanding and empathy.

Discrimination takes it one step further.

When people with brain illnesses suffer from discrimination, they lose opportunities because of their condition. If they are open about their diagnosis on applications, they may never receive a callback or an interview for a job. They may start receiving bad evaluations at work if they have to leave for doctor’s appointments or be let go for not getting along with other workers, many of whom may have prejudice against them. They don’t receive the accommodations required by the Americans with Disabilities Act (ADA).

Discrimination can also be involved with decisions from Social Security Disability. It’s not supposed to be that way, but people with mental illnesses are likely to have more difficulty “proving” that they have a disability severe enough to warrant supplemental income.

So what’s to be done? Education is the solution we always advocate. But it’s a hard ask. It’s difficult to get anyone to learn about the realities of brain illnesses. They don’t learn about it in school, and the messages they get from the media do little except reinforce the stigma surrounding the various conditions. In fact, they perpetuate much of the stigma.

Pushback is another strategy. We simply cannot let it pass when someone makes a prejudiced remark or demonstrates a lack of understanding. We can speak up about inappropriate Halloween costumes or assumptions about violence and the mentally ill. We can inform others that not all homeless persons are mentally ill. In fact, most homelessness is caused by a lack of affordable housing and low wages.

When it comes to discrimination, legislation and activism are often the solutions or at least the beginnings of them. Lobbying efforts regarding policy and treatment will help. Lots more needs to be done to inform legislators about the very basics, much less the possible ways to address the problems. Reporting violations of the ADA may not lead to resolutions, but it still needs to be done.

Of course, it’s difficult for many people with brain illnesses to do these things. We are frequently isolated and doubt our own abilities. Confronting legislators, educating them, and lobbying for their attention is daunting. Neurotypical people have trouble doing it, especially without an organization that gives them leverage. But it’s work that needs to be done. I admit that I’m not at the forefront, though these blog posts and my books are intended to help educate, and the groups I belong to try to do likewise.

It’s not enough. But it’s a start.

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Positivity and Acceptance

Those who follow this blog have seen me rail against toxic positivity. When it’s not absurd, it’s insulting to those of us with mood disorders. No, we can’t just cheer up. If we could look at the bright side, we wouldn’t have depression or anxiety. You may be able to choose happiness, but I can’t. I’ve needed medication and therapy just to feel meh at times. If I could turn bipolar disorder off like a light switch, don’t you think I’d do it?

Toxic positivity can be seen nearly everywhere, in a lot of different situations: the self-help movement, of course, but also business, medicine, and even religion – as well as endless memes. American society is rife with toxic positivity. It appears in motivational business conventions and TED Talks. Salespeople are advised to think positively and envision success. Breast cancer survivors are advised to keep a positive attitude, to the extent that they are encouraged to tell how the disease has had a positive effect on their lives and relationships. (Expressions of fear, anger, and other natural emotions in response to the diagnosis are downplayed or discouraged.) Religions can exhort us to count our blessings or “manifest” our wants and needs by using positive thoughts to attract them.

Positivity becomes toxic when it is seen as the only method of coping with problems in life, even ones that have other solutions or none. Toxic positivity presents relentless cheer as the only acceptable reaction and a panacea for every difficulty. And toxic positivity leads people to demand that others take up the mindset and apply it to every situation, even devastating ones. As such, it denies the reality of human suffering and normal emotional responses. It’s a form of non-acceptance.

So, what is the alternative? What is a more natural – but still effective – technique for dealing with difficulties? How can those of us who have mood disorders or any other brain illness find ways to navigate through life without slapping on a smile and coercing our emotions to fit a certain mold?

Radical acceptance is one answer. Radical acceptance means that you accept your inner feelings and your outward circumstances as they are, especially if they are not under your control. You acknowledge reality without trying to impose a set of emotional mandates on it. Your acceptance and acknowledgment may involve pain or discomfort, but those are understandable, normal human conditions. They are natural conditions that evoke a natural response.

Rooted in Buddhist teachings and given a name by Marsha Linehan, the psychologist who developed dialectical behavior therapy (DBT), radical acceptance uses mindfulness to help people learn to face and regulate their emotions. Interestingly, one 2018 study found that accepting your negative emotions without judgment is a factor in psychological health.

With radical acceptance, when you encounter difficult situations and emotions, you note their presence without trying to suppress them. You accept them, as the name implies. This attitude can address – and reduce – feelings of shame and distress that you may feel, especially when you are not able to simply shut off those feelings and replace them with positivity. That doesn’t mean that you wallow in unpleasant feelings or allow unfortunate circumstances to stunt your responses.

Instead, you note the feelings – accept that they exist – and “hold space” for them within you. You appreciate that your emotions can lead you to new understandings of and reactions to your circumstances. For example, instead of adhering to the unattainable maxim that “Failure is not an option,” you can recognize when you have indeed failed and accept it as a natural part of life. You can then move on to a mindset of growth where you use that failure to inform your future actions. You develop a more accurate picture of the world and can begin implementing real solutions.

Of course, there are situations where radical acceptance is not appropriate. Abusive situations, for one, shouldn’t simply be accepted without being addressed. But neither will positive thinking resolve them. They require action, from seeking help from a trusted individual to leaving the situation to contacting law enforcement or an organization that can help.

But in other circumstances, radical acceptance may be an answer for some. For myself, I’ll just be satisfied if radical acceptance helps drive out toxic positivity. I don’t think it will, but a person can dream.

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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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The Question I Hate the Most

There are many things you shouldn’t say to a bipolar person: Cheer up. Smile. What have you got to worry about? We all have mood swings. Calm down. You’re overreacting. You don’t look depressed.

Each of these remarks contains a hidden assumption, from simple – you can choose your moods; to dismissive – your anxiety is not as severe (or as important) as mine; to possible gaslighting.

I’ve gotten all of those and more. Once I revealed my disorder to a coworker and she’d ask me, “How are you?” with a concerned look several times a day, taking my emotional temperature. But the question I hate most is a simple one.

Are you off your meds?

Let’s unpack this, shall we?

First, the underlying message is that, to the speaker, you are acting in a strange, inappropriate, frightening, incomprehensible, or otherwise “off” manner.

The second assumption is that you must be on medication in order to appear “normal” at times.

Third, that since you do not appear “normal” to the speaker, the only explanation is that you must not be medicated at the moment.

Fourth, that the speaker has the right to give you advice on how medicated you need to be in order to appear “normal.”

And, finally, that “meds” are the answer to all your problems. If you want to fit into society you must be on your guard at all times and medicate until you are acceptable to them.

There is a slightly less offensive version of the question: Have you taken your meds today?

This might be marginally acceptable from a loved one, who knows that you take medication for your disorder and also knows that you are sometimes forgetful.

But really. Most psychotropic medications build up in a person’s system over time and leave the body over a long time as well. Missing a single dose is not likely to have an appreciable effect on a person’s moods or actions.

There are some anti-anxiety medications that have short-term effects, and a bipolar person might have forgotten a dose or two.

But unless the speaker is the bipolar person’s caregiver, official or unofficial, it’s still rather parental and demeaning – suggesting that we aren’t competent to handle something as vital as our own medications.

Of course, sometimes it may be necessary to help a loved one remember to take medication, whether that person is bipolar or not. On a vacation, for instance, when one’s normal routine is disrupted, a gentle reminder may not be amiss. When one has just started treatment and the routine is still unfamiliar. Or if the person actually is a child.

You wouldn’t ask an adult with the flu “Have you taken your antibiotics today?” You wouldn’t say to a blind person “Now, don’t go out without your service dog.” Most people, most of the time, are deemed competent to know their needs and take care of those needs themselves.

But bipolar disorder and other psychiatric conditions, being largely “invisible illnesses,” seem to invite meddling. Everyone else knows what’s best for us, from a different drug to herbal medicine to a walk in the park to prayer.

They know a little bit about the disorders, perhaps, largely through television and celebrities. But they don’t know your particular version of the disorder (bipolar 1 or 2, rapid cycling, dysthymia, hypomania, anxiety, etc.)

So if I snap at you, or seem anxious, or don’t want to go out, don’t assume. I have regular “normal” moods too, even when I’m on medication. Sometimes I get annoyed if my husband has lost his cell phone for the third time this month. Sometimes I feel sad if my picnic is rained out. Not every mood is pathological.

So don’t assume you know what’s going on inside my head. Unless I ask for help, refrain from putting in your oar.

And don’t ask me, “Are you off your meds?” It’s an insult, not a question.

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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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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 Is Resting Sad Face?

Resting bitch face is a thing, you’ve probably heard. Some people – usually women, though I suppose some men have it too – look mean when their face is still and their muscles are slack. People who see them assume that they are grumpy at the least or maybe sulky or angry – hence the name resting bitch face.

I have resting sad face. Once when I was working at a restaurant, the manager saw me sitting while on my break and told me that I should smile. I replied that I was paid to smile at the customers, not on my break. Of course, that was a bad response, though I know that women are often told to smile more (men, not so much). I probably would have gotten along better with my coworkers if I had smiled more.

But I was suffering from depression at the time, or at least the depressive phase of bipolar disorder, and was untreated. Smiling was something I had neither the inclination nor the energy to do. Sad was my natural expression.

When I didn’t have resting sad face, I had resting worried face. (A different manager asked me, “What does a girl your age have to worry about except ‘Am I pregnant?'” As it happened, that was the one thing I knew I didn’t have to worry about.) I was also suffering – again, untreated – from an anxiety disorder.

What I haven’t had is the mask of “smiling depression.” Many people with depression pretend to be happy most of the time, at least in public. You can see it dramatized in depression medication commercials when someone holds a happy face symbol in front of their face. (In real life, I’ve noted that the depression or sorrow sometimes leaks out around the eyes, though, even past the mask.)

There are two different kinds of smile – the “Duchenne” smile (named after a 19th-century scientist whose major contributions centered on mapping the muscles that control facial expression) and the “Pan Am” smile. The Duchenne smile is the sincere smile of a truly happy person. It’s easy enough to tell when someone is giving you a Duchenne smile. The muscles at the corner of their eyes crinkle, making little crows’ feet. It happens automatically when you think of a happy memory or greet a person you like a lot.

The Pan Am smile is the one where the smile does not reach the corners of the eyes. (It got its name from airline attendants who were required by their job to smile at all times, whether they were at rest or not, happy or not.) No one has resting Pan Am smile face. It’s impossible. It takes a number of facial muscles to smile and when you’re resting, you don’t use those muscles. No, the Pan Am smile takes intention.

The Pan Am smile, however, is the one a person uses when they do have smiling depression. (I used it once when, at a different job, we were all posing for individual portraits. My results were so fake-looking that the photo was never used. They didn’t even let me see it, much less anyone else.)

I’m kind of hoping that these days, I have at least resting neutral face. That sounds like the right expression for a stable person.

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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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What’s Good About Drug Commercials?

I’ve often bitched about TV (and, I assume, magazine) ads for psychotropics. I’ve said that I despise the fact that they make the entire public their own experts on what they need and shills for “Big Pharma.” I’ve complained that they hamper doctors by encouraging consumers to “ask if drug X is right for you” and to accept no substitutes. I’ve also said that the ads present unrealistic pictures of very serious mental conditions by making depression, for example, no worse than the flu or a hangover.

Nonetheless, I’ve decided that drug commercials do have some beneficial purposes and effects. They aren’t all evil after all. They send messages to the viewing public that are actually positive. These messages contradict the prevailing public conception that people with mental illnesses are different from other people – that the entirety of their lives is taken over by their illness. People with bipolar disorder change from the depths of despair to uncontrollable, laughing lunacy within the span of hours or even minutes. People with OCD are picture-straighteners and tile-counters. People with schizophrenia are violent criminals or raving crazies, often hospitalized for life. None of these brain illnesses can be treated, according to the general wisdom.

Modern drugs have improved people’s lives and improved the general public’s conception of what mental illness is like.

First, more of the commercials now present understandable views of what some mental illnesses are like. They do this primarily when they use analogies or metaphors. Bipolar mania is like climbing a house of cards that is destined to collapse inevitably at some point. Depression is like darkness, and medications can lessen it by bringing light. They even make the symptoms and side effects more understandable: tardive dyskinesia, for example, is depicted with actual twitches, intractable movements, and mobility issues.

Also, the ads do emphasize that there are treatments, if not actual cures, for disorders that the general public views in a stereotypical way. Take schizophrenia, for example. Most people associate schizophrenia with homelessness, psychosis, and/or raving unintelligibly. Yes, those are sometimes the consequences of the disorder, but they’re far from the whole story. I’ve seen commercials for schizophrenia medications that show a man with a family playing guitar, two women with schizophrenia calmly discussing their symptoms, and a comparison of daily pills and twice-yearly injections for treatment. They humanize an illness that too many view as intractable and untreatable.

I stand by most of my criticism of ads for psych meds. They are shallow and simplistic. They do promote self-diagnosing and self-prescription and demands on doctors. They minimize the good that talk therapy can do, concentrating instead on medical and pharmaceutical interventions. At the same time, though, these ads promote more accurate, healthier views of mental illnesses, even the most severe. They portray people who have the illnesses as having alternatives, socially productive lives, and “normal” interactions with others despite their psychiatric conditions.

I have no scientific evidence to support this theory, but my guess is that after viewing these ads, often several times a day, a poll would reveal changes in attitude. That, combined with the public service announcements about depression and even ads for telemedicine therapy sessions, may indeed make it more likely that people who live with these conditions without realizing it to better understand their own possible mental problems and those of their friends and family, and to have greater empathy toward them.

And those are good things. May the trend continue.

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