On Loneliness

There’s an emptiness that many of us feel every day. Sometimes we feel it when we’re away from someone. Sometimes we feel it when we’re surrounded by people.  It isn’t depression, per se. We have all experienced it. Unless you’re schizoid, of course.

Loneliness is a want. When we want, we create a gap between what we have, and what we don’t. That gap hurts. Commonly we try to distract ourselves so we don’t have to pay attention to that pain. We don’t want to feel it. We have this deep fear it will consume us. It is almost as if we feel a need to find another person to verify that we’re really here.

As I sit and contemplate this state, there’s even guilt over feeling this way. Why should there be guilt over feelings? You feel what you feel. Unless you start thinking about expectations (from society, on yourself), about what you’re “supposed” to feel. We’re supposed to be happy and buoyant and “perfect.” Wouldn’t that be nice.

Of course we can examine if there are things we do that perpetuate these feelings, which keep us stuck. That’s the process of psychotherapy, and becomes especially important when we start to take ownership over our own participation in our feelings. While I understand the explanation of the brain as a “chemical state,” and bad feelings as “brain chemistry,” it’s an explanatory model that lessens the idea of free will. Brain chemistry exists. When I eat something, or think something, or close my eyes, I’m changing my brain chemistry. So maybe there is a way that we perpetuate loneliness as well.

When we idealize the individual and celebrate “I,” we are celebrating the disconnect of that person, what makes them unique, what distinguishes them from everyone else. When we cherish our own uniqueness, we are isolating ourselves. Thus our American culture of rugged individuality and championing the loner, who is dependent on no one, leaves the next generation very alone when they try to embody such an ideal. The more we want to be unique and important, the more alone we feel. We want to be important, which requires other people recognizing us as unique. Paradoxically trying to be independent and important makes our self-esteem dependent on the attention of others. In our culture where narcissism is on the rise (google Narcissism america), perhaps the consequence of cultivating some amazing individuals is the emptiness of some achievements, and an epidemic of loneliness.

The alternatives to the individual have their own stigma and problems. There’s the group identity, whether that’s as part of a team or an organization. There can become camaraderie amongst members, which is a definite antidote to loneliness. Fear can set in though, fear of dependence. Really this is true for any relationship. We play with the romanticization of love as something that absorbs a whole person, ultimately. As beautiful of an image as that can be, it also leads to the risk of betrayal, co-dependence and loss of any ultimate purpose. I’m sure members of any group that went down a dark path (think of cults, nazis, etc.) at first felt a true sense of purpose when they joined. It gave them an identity, a sense of belonging, and thus lessened loneliness. Social psychologists discuss that this group mentality leads to loss of humanity and performing acts that go against the morals of the individuals (see the work of Phil Zimbardo). But that person doesn’t think about them because at that time they aren’t themselves — they’re just a member of the group.

Co-dependence isn’t any more healthy, though it has the temptation of escape, and the romanticization by our culture. As much of a fan as I am, Shakespeare didn’t help this idealization of collectively losing ourselves in love. It’s beautiful to lose ourselves in another, to need and be needed completely and wholly. Depending on your belief in the idea of a soul mate, you may have convinced yourself that this is meant to be one person. And maybe it is. But if that dynamic of needing and being needed by the world could be diffused, spread out to the world, maybe we’d realize that loneliness could be an illusion.

J Krishnamurti, an Indian philosopher, believed that we’re all inherently connected. He believed that we’re all made up of the same substance. He was probably referring to a spiritual belief within Eastern philosophies that we all come from a God, and made of God. Within that framework, we’re all connected, since we’re all part of the same network. In the belief system, loneliness is an illusion, based on the false idea that we are all separate. If you could let go of the idea of having to be separate, without losing a sense of self, and feel that we are all connected, then loneliness could fade away.

Or maybe not.

I’m online right now, looking over facebook and twitter. I feel the impulse to reach out and find connection to other people. The more I feel alone, the more I feel I have to reach out to find someone and get any validation I’m real or alive. It’s hard to be alone. There’s an emptiness to it, as if I might collapse. These “social media” sites feed an illusion of connection through technology, which can make us feel more alone.

But let’s just pretend I don’t have any internet. Let’s pretend I don’t have a phone. Let’s pretend there’s no way to distract myself. I’m stuck with just me. I could fight to find another way to distract myself. Or I could stay with the feeling. I might even feel like I’m collapsing. In the strangest way, staying with that feeling of collapsing (in Gestalt therapy called the implosive layer), can lead to a breakthrough. All the energy invested in holding back the fear [of being alone, etc] can be freed up.

Then we can see the world with new eyes. That’s a whole process (going through the Gestalt layers) that we’ll touch on in another post.

Until then, consider the possibility that you’ve never been alone.


Resetting the Bar

I’m not a fan of competition. It brings out the worst in people, while trying to bring out the best. So of course I have difficulty understanding athletes using steroids or doping just to win a contest. These drugs have possible health consequences after all. For the athlete, I’m sure they believe it’s about achievement and maximized potential, but it’s driven by trying to be better than the other guy. The bar is set by another person.

With that drive they are willing to do “whatever it takes.” Train more. Work harder. We as spectators encourage it and set up an environment that doesn’t reward holding back. Those that hold back anything that might enhance their performance don’t last too long in competitive sports. Once someone else becomes the standard to be matched or exceeded, they determine the bar for “normal.” Anything less is unacceptable.

In society we have a name for functioning below the level of “normal.” We call it impairment. As a psychiatrist I am supposed to intervene when someone has a mental impairment. Physicians usually define normal as the range of functioning of the average person in society. Not having enough energy to get regular activities done is an impairment. As society pushes people to pursue one’s “full potential,” expectations shift up for “normal.” People view normal by unnaturally high standards, and feel disappointment if they don’t meet it. Performance enhancement becomes common, normal, and expected.

When I was twenty-two years old, I did my job with five hours sleep and little to eat. That was normal then. Now in my thirties I need three cups of coffee to get the same amount of work done if I’m sleep deprived. I view it as necessary and justified since the work needs to get done. It’s normal. In medicine we’ve trained ourselves to maximize functioning without sleep, because it’s expected of us.

While it’s possible that my medical training has skewed my view of athletes, college students don’t seem to find performance-enhancing drugs in athletes acceptable either. Last year, in a study in the journal Psychology of Addictive Behaviors, authors Dodge et al., found that college students viewed such athletes as “cheaters.” These same college students, though, believed it was all right to abuse stimulant medications (not prescribed) to do better academically. They did not consider that misuse of stimulants to be cheating. The more they themselves had abused stimulants, the more judgmental they felt about athletes. Stimulant abuse is rampant in colleges, with students attempting to enhance their academic performance. If their classmates are using them and scoring better on tests, the bar is raised, and a new “normal” is set.

I routinely have patients who come to me asking if they have ADHD. More of the time they insist that they have it. They insist because they’re sure they have attention problems. Or because they tried their friend’s Adderall and were “able to focus so much better.” In their minds, improvement on a drug must indicate a diagnosis and thus an explanation for the difficulties. I even have parents of patients who presume that the lack of A’s must indicate ADHD and insist on my prescribing stimulants. Two hundred years ago people weren’t expected to sit in a chair for eight hours a day. Today we have a diagnostic construct of ADHD. Now this isn’t to say to that ADHD doesn’t exist, as we have all seen children who really struggle with this condition.  But perhaps thinking about our expectations reveals the slippery slope that leads to overdiagnosis.

As we’ve stumbled upon many ways to “enhance” functioning, to maximize what we can do with our bodies and minds, the bar shifted on normal. We expect people to perform at that new level. If they can’t, it must indicate a deficit. Such a progression leads to less and less tolerance for any impairment, distress, or problem. In the end, this is really about performance at all costs, masked in the pretense of “treatment.” In 2008 a group of eminent scientists published a commentary in the journal Nature, calling for regulation to allow “cognitive enhancers,” namely open use of stimulants to improve brain function in the average person. Implicit in their argument is a goal to “call a spade a spade.” In that argument, people use drugs to do better at tasks, so let’s call it what it is. I reserve an opinion on the matter.

It’s easy to have perspective on something we ourselves are not doing. Once we have incorporated it into our routine, we develop rationale to justify it. I can understand how the college student thinks “athletes shouldn’t use drugs to win at sports, but keep your hands off my Adderall.” Personally I believe students shouldn’t use ADHD drugs they aren’t prescribed to do better on tests. It’s wrong for them to misuse drugs just to be able to take tests.

Just don’t take away my coffee. I need my coffee.


On Balance in Relationships.

This isn’t just about balance.  Or how to stay connected.  Though it serves all of that.

I touched on this just a little bit in my post about burnout, but I want to get into Balance in Relationships.

We’re asked to care.  We’re asked to do something.  We’re asked to invest time and energy.  This is usually about a person.  Sometimes it could be a project.

John was a military vet.  He didn’t have to be.  He could have been my childhood friend, or a guy I made friends with in a coffee shop.  In this case I met him where I was his doctor, and he was my patient.  I sit down with him in clinic, and I see a long list of “problems,” from medical issues to PTSD and many notes about “personality” issues.

Two seconds after I sit down, he pulls out his own list, but these are things he wants from me.  Medication refills?  Easy enough.  Help with disability?  Let’s investigate.  Call his landlord and advocate for him to keep his apartment after causing problems?  Maybe I’ll help.  Call his parole office?  Hmm.  Prescribe him medical marijuana?  Well…

It isn’t long in this interaction before I start disconnecting emotionally.  It’s natural to want him to leave, because he is putting all the burden on me to fix his life.  To a tiny degree I understand that, as it’s supposed to be my role to “help” him with many of his problems.

So let’s say I spend a couple extra hours trying to help him with everything he asks.  At the next visit he comes back with new issues, and this time he wants me to write a letter for court saying he has PTSD and that he shouldn’t be held accountable for some things he’s done.

Now let’s pretend that John has other issues.  Maybe he’s an alcoholic, and my repeated pleas to get sober haven’t helped.  Or he’s my brother (I don’t have a brother) and asks me to loan him money for the tenth time.

All of these situations feel emotionally taxing on me, and a common response is to disconnect.  I feel tired pouring more energy into a situation that isn’t changing, and I want to just stop. Maybe at best I keep going through the motions.  For those in a role where we’re supposed to stay emotionally connected to people (such as healthcare), it’s helpful to not get apathetic.

So I happened upon two simple philosophies that have helped me to stay balanced, particularly when stressed.

1.  Don’t work harder than the other person.

As sad as it sounds, this is their problem, not yours.  If they’re bringing the issue to you, they need to be willing to meet you halfway.  Now halfway might be different for each person, but the idea of effort is what’s important.  If you find yourself over-investing, doing more or all of the work, that is a recipe for burnout.  Once you’re pouring yourself into something, if it fails, you feel jaded.  You then want to withdraw and not try again.

There’s a much longer discussion that can be had about how to get someone to invest.  Another time.  Here, though, not working harder than the other person can often feel like pulling back.  And if we pull back too much emotionally we can end up apathetic, not caring at all.  So then comes the other side of the coin –

2.  Cultivate a feeling of Detached Compassion.

I want to hammer both words in there.  DETACHED.  Meaning disconnected from the outcome.  Aim high, but don’t set up your emotional payoff on the win.  COMPASSION.  Meaning you still care about the person.  Stay connected to the person, but disconnected from the outcome.

Especially since a lot of the time people don’t want things fixed, they want someone present for them.

As you pay more and more attention to this balance of effort, investment, and connection, you’re really cultivating mindfulness.  Mindfulness (which needs its own posts), which I’ll simply define here as awareness, without reacting.


Not a Lab Rat

Minnie was forty years old, and came to see me in my office to discuss being depressed. She had felt depressed off and on for many years, but had rarely told anyone about it. It was like dragging a weight around. She could still get things done in her, just not quite as well as she’d like.

At one point she had told her family physician about this, and she was offered an antidepressant, lexapro. She took it for a few days, didn’t like how it made her feel, and stopped it. Her physician told her they could try something else, which might work better. She responded: “I don’t want to be a lab rat.”

Now of course the first thing I would tell her is that the first few days on antidepressants are not a good indication of whether it will work or not. There are potential early side effects that will go away, often within the first week. That isn’t the issue I wanted to address here, though.

I hear from people that they don’t want to be “experimented on,” or “feel like a lab rat.” As if doctors are purposely sitting in labs running experiments on their patients, for some other endgame. The only purpose of trying out different medications is to find what works for YOU. This seems to come from the expectation that the psychiatrist has to “try” different medications in an effort to find one that works.

It’s absolutely true that we do not know that a certain medication works. I tell this to people all the time. The current state of the science in medicine cannot predict if a medicine will work for you. What the research says, for example, is that in a group of a 1000 people somewhat like you, 30% got better on this. Which means 70% didn’t. We don’t have the science, quite yet, to be able to say which group you will fall into. So it comes back to trial and error. Even with a blood pressure medication, where we understand just about all the physiological changes occurring from the medication, only has the desired effect in 20% of individuals. And again, we don’t know which 20%. So meds are often combined to get the desired change in blood pressure.

“Personalized medicine” is an emerging approach, where factors like genetics can be used to predict if someone will respond to a medication. We’re juuuuust beginning to crack this area, such as with tests for the blood thinner warfarin. We can identify who might be sensitive to it, and who might not respond. We’re still some steps away from being able to reliably do this in the field of psychiatry, but it’s well on the way. Ideally, a finger-prick blood test will be able to tell us whether a medication will benefit you or not. That will still be a far distance away from understanding and treating all aspects of depression, but maybe it’ll help people stop believing their doctor is experimenting on them.


How to Not Burn Out

“I just can’t do it anymore.”

People burnout everywhere, in every field. They burn out professionally. They burn out in taking care of others. I live in Los Angeles and I can understand how just driving a car can burn someone out in this level of traffic.

No one plans to burn out. Maybe they do have a little awareness that they’re going down that road, though.

We have a level of control over where we place our attention, as well as our effort. If you’re worried you’re burning out, consider preventing it.

There’s two parts, I believe, to preventing burnout.

For the first, I’d like to borrow from a simple model I first heard from Dr. Christine Moutier (a psychiatrist and former supervisor of mine at UCSD), modified a bit here. Imagine a gas tank. It’s feeding an engine. That engine is you. If the engine shuts down, you shut down.


This gas tank has a leak in it. It’s losing gas. Gas is pouring out. Eventually if we do nothing, the tank will be empty. When it’s empty, the engine stops. It doesn’t run anymore. The engine burns out.

We don’t want the engine to stop, so we need to fill the tank. It has to be filled faster than it’s losing gas. In life we each have our strategies to fill the tank. Sleep. Food. Socializing. Rest. Sex. Yoga. Watching TV. Meditation. Talking to people.  Exercise. Make a note of your ways to fill the tank, and note what others do, since one way might not be enough. One way might not be able to fill it fast enough.  It’s for your own well-being.

On the other side, look at the size of the hole that gas is leaking out of. This is the effort we put out into the world. We can try to narrow the hole, to hold back. That may be effective, to a degree. If done too much, it leads to apathy. The hole can’t ever be completely plugged up, in a normal life.

It’s not a particularly complex model, I’ll give you. Yet really smart people neglect themselves all the time. They think their tank will never run out, as if there’s a secret reservoir somewhere. Running on empty hurts the engine. So the first step is to keep the tank filled.

The second part of not burning out is to Not Overextend. We all have projects we’re asked to be involved in, whether that be something at work or even fixing up something in the house. Or maybe it’s arranging an event for family or friends. Presuming this is not a startup business that is your idea, ask yourself – how much am I putting into this? How much are the other people putting into it?

Here’s the key: If you’ve been asked to do this project by someone else, and you decide to invest a lot of time/energy in it, make sure the other person is as invested in it as you.  The plan, the approach, and if possible, the energy/time.  If you’re thinking up a lot of aspects of it, make sure the other person agrees along the way, or has as much skin in the game.

Let’s say I’m asked by my wife to plan a party for our friends. I put a lot of time into planning and arranging it, and then my wife tells me she doesn’t like what I did. I devoted hundreds of hours into the project, she devoted none. My response to any criticism she might have is anger and wanting to quit and disconnect. I would feel burned out. Such is the way when only one party in a group does most of the work, and the other critiques or doesn’t support it.

Now in many situations the division of labor is unavoidable. One side will do more work than the other. Chances have to be taken. When they are done with open eyes, though, the disappointment may be less.We can clarify the point, then, that the other party needs to buy into the plan at least. Don’t overdo it expecting the other party to be wowed by the amount of time you’ve put into it. What if they aren’t? You may end up apathetic and withdrawn. Check in with them frequently, to get their buy-in on the approach, so they won’t be surprised, and you won’t be surprised. And finally, try to discern endeavors that might not be worth the investment.


In Brief for Those New to Therapy

If you ask ten different therapists what it is they do, you’ll get twenty answers. A therapist talks. A therapist listens. Using the term “therapy” implies only one thing, so for those who don’t know what therapy is, it’s hard to get a grasp on it. It’s even harder to understand that there’s many types of therapy.

So let me begin with a comparison to religion. Religion is similar to therapy, in that they both have belief systems. Therapy is usually based more on research and evidence, though, rather than faith. Trying to pretend that there is one “religion” doesn’t help to define what religion is, or to understand the different religions. Nor does understanding Catholicism tell you much about Buddhism. Understanding Catholicism does of course give you a frame of reference to understand other religions, but its minutiae don’t tell you about the minutiae of other religions.

I’ve studied and trained in a number of different psychotherapies. Psychodynamic, Gestalt, CBT, DBT, hypnotherapies, brief strategic therapy. Within that there are others such as supportive and insight oriented therapy. Maybe some of these are better fits for you as a patient than others. That’s fodder for a longer post, discussing what to expect from each therapy style. I’ll get to it. In the meantime I hope the idea can be seeded that no one therapy is absolute, and that change can come about in many different ways.

Let’s get to some myths and misunderstandings about therapy. Therapy isn’t simple. And it isn’t just listening or support. Or at least it shouldn’t be. It’s idealized from those outside. As if a little support is all that’s needed. As if people go to therapy to vent or complain about others, and somehow they come out “fixed.” That’s never how it works. Real therapy is more than that, and should be more than that.

Therapy is about change. This can be changing how you feel or think or function in life. It usually comes about through working with a therapist. A relationship is formed. Usually trust develops. This alone can help some people change.

Beyond this there are a number of strategies and theoretical systems. There’s simply talking about whatever comes to mind, developing a relationship with the therapist that can reflect other relationships, recognizing and changing thoughts to change feelings, changing behaviors or exercises that alter the way you feel. It can be about changing patterns in life.

Sometimes therapy feels good. Sometimes it involves a lot of effort. Both can be important.

There is not only one way to do therapy. Many therapists will become dogmatic about their approach, as if their way is the only way. I would again draw the comparison to religion. Many therapists become invested in the approach they learned first, just as many people stick with the religion in which they were raised. They may even push the belief that their approach is better proven than others. Other people wander and explore various approaches, for better or worse. The skinny on this is that different therapy styles may be a better fit for you as the patient (aka client or receiver of therapy). If you don’t feel like you’re making progress through therapy, perhaps it is a bad fit with the therapist or the style being used. Also it is possible that you’re not feeling a good fit because that which is being stirred up in therapy (bad feelings, annoyances, etc.), may be exactly what needs to be worked on in therapy.

Being told exactly what you want to hear is usually not that helpful in therapy. If that is all you want (to vent and be agreed with), then I’d suggest that therapy may not give you what you’re looking for.

Oh, don’t get me wrong. You may find someone to agree with you and allow you to vent the whole time. That alone may not lead to the change you want in your life, though.


Psychotic vs. Psychopathic

They aren’t the same. Going back to at least Hitchcock (one of my faves), who brought the muddy term “psycho” into the public psyche, conflated the definitions as if all are violent, and all “crazy” is crazy.

I’m sure there are briefer answers out there for those wondering what’s the difference between psychotic and psychopathic. And even though SRSLY made it into the OED because of its widespread use, lay inaccurate uses of the term psychotic will likely not.

Briefly in discussing how we got here, the words are interchanged because they sound alike, and are used commonly to describe someone “out of control,” often in an unpredictable or dangerous way.  In a way that is accurate for both.

Psychotic refers to someone who has detached from reality in a severe way that the common person would believe they are ill. Common examples of psychotic disorders include schizophrenia, schizoaffective (kind of schizophrenia and bipolar in one). People with psychosis can have hallucinations (hearing or seeing things that aren’t there), delusions (believing things that are known to be false or fantastical, like aliens are controlling their mind through a chip), paranoia (belief others might be following or trying to hurt them), magical thinking (believing they have special powers or could control things that they cannot), or ideas of reference (believing TV or commercials has special messages inlaid just for them personally). Now there are some mimics for any of these, so a single symptom shouldn’t be taken as proof of a condition, but instead the whole picture examined by a professional. Even then many professionals can get it wrong. We do the best with the information we have available.

People with psychotic disorders seem scary because their break from reality can make them unpredictable. Research evidence is quite mixed as to whether they are more dangerous than anyone else. Aside from some individuals who make headlines in terrible ways, on average they probably are not more dangerous than anyone else.

Psychopathic refers to someone without a conscience, who exists on a spectrum from your con man (self-involved, uses others for own benefit, not prone to violence) to the serial killer (predatory, gets aroused by hurting people physically or causing suffering). Psychopaths are scary because they seemingly have no limits to what they might do, including hurting others, just for their own benefit or enjoyment. If you want a bit more detailed discussion about psychopaths, see my posting here regarding Walter White and Breaking Bad.

Is it possible for someone to be BOTH psychotic and psychopathic? Unfortunately, it is. That raises all kinds of other topics, and I’ll leave that for my fictional writing.

Is being a psychopath a mental illness? That is an area of debate, both between mental health professionals, and between government/social services individuals and mental health professionals. Attributing it to an illness lessens the idea of culpability and choice, and directs thinking towards treatment and rehabilitation (of which there is little evidence that much works, though there are some small projects out there that might). Not attributing it to a mental illness or even acknowledging the lack of treatment options means the intervention of choice is containment (usually in prison), which raises all kinds of larger questions – should it be the crime that leads to containment? Can professionals feasibly identify psychopaths and identify those who can’t improve? A lot of controversy has arisen regarding the overuse of the PCL-R (a tool used to measure psychopathy), and that misidentified people might be incarcerated indefinitely. The UK has had an interesting experiment with all of this, with the government wanting psychiatrists to treat dangerous individuals with personality disorders. The psychiatrists didn’t want to do it, so the government forced the issue, creating their own name of DSPD (Dangerous and Severe Personality Disorder), and mandating that psychiatrists intervene. It’s an interesting social experiment, and continues to raise questions and controversy.


Portraying Mental Illness in Story

Mental illness as a term gets thrown around a lot. It’s used by politicians as a scapegoat for problems or a target for funding. It’s sought by individuals to find meaning to their experience, or sometimes a justification for their difficulties. It’s a thing, talked about like any other disease. And yet the term is a lumping of many conditions under a single term, as if all mental illnesses are the same. They are not, but we talk about them that way and “let the experts sort it out.” I get that. At the same time it maintains the mystique and stigma behind mental illness. Because that is what the average person fears – the unknown. By keeping it labeled as one thing, whether that be to ostracize, excuse, or empathize, without educating the public more, we continue to leave it as a large unknown. So the stigma continues.

Media portrayals of mental illness usually fall into one of three categories:

1. Spectacle

2. Educational

3. As a relatable factor to human struggle and suffering

"Crazy" blonde girl.

The first reason clearly stands out as the most popular use of mental illness in the media. I can’t count the number of characters nowadays in movies and TV who are given mental illnesses primarily for the purpose of making them “different” or interesting. This misses the boat though, particularly when added to secondary characters or even worse, villains. The spectacle of the mentally ill involves the “crazy person,” usually meaning dangerous or unpredictable, which can be used for plot turns or as an explanation for the odd character. “He’s just nuts, man.” No one is “just nuts.” We miss the truth when we oversimplify.

Of course spectacle is the purpose of much of film and television. It’s entertainment. It serves its purpose in our lives. Using mental illness to have the “crazy guy” in a group of friends just becomes cliché, though. It isn’t that entertaining, anymore. And in the world of political correctness, it’s offensive.

Any good writer will not hold back from offending now and then, sometime more than that, all for the purpose of telling a good story. I don’t hold back, and others shouldn’t if it truly enhances the story. Adding in a mental illness just to add a character quirk can lessen the story, though. If the intention is to make the person more interesting, but is done only as a spectacle, where it doesn’t serve the larger story, then it hurts rather than helps.

I’m watching “The Bridge” right now, an FX TV show where one of the leads, Sonya Cross, appears to have Aspergers. In examining the story, it isn’t clear at first what the purpose is to the story of her having Aspergers. It isn’t a story about Aspergers. It does contrast well with the “normal guy” of her partner, detective Ruiz, who fits a different cliché of a cop. That may enhance the story as it makes her behavior and his more noticeable (by contrast), but there has not yet been revealed how her having these particular characteristics, with difficulty in social engagement, makes the serial killer stories more powerful. It may raise some obstacles against her pursuing the killer(s) as efficiently as possible, but that more extends the story rather than enhancing it.

Robert Mckee talks about this a bit in his book Story, when he describes the difference between characterization and character. Characterization are the demographics of an individual – their height, weight, job, clothing, background. That isn’t their character, and for the most part that isn’t what makes a story good. Whether it’s an accountant or a lawyer lying to the district attorney doesn’t matter as much as we might think. Character is revealed through the choices people make, with decisions under pressure revealing their deeper nature. Mental illness as a characterization doesn’t enhance a story. If it is left as that, as window dressing, then it’s a missed opportunity.

educational blocks

The second reason, that of educational, isn’t particularly useful in stories, either. I view it as the antithesis of spectacle. In fact, it’s usually boring. Royal Pains did some groundbreaking work from a health advocacy role by portraying a depressed person, and having that person receive ECT. It was shown realistically, with the usual anesthesia and care involved. Much of the episode centered around the stigma and one character fighting to keep the other from receiving ECT. When the ECT session was finally performed, all that was spoken was – “gee, you’re right, it really is a great thing.” It felt boring and didactic. While I appreciate the writers choosing not to further the cliché and inaccurate stereotype of ECT (e.g. Cuckoo’s Nest), it didn’t work as well as it could have as it wasn’t delivered in a way that enhanced the story. It became a story about stigma, which isn’t what the show is really about. Educational approaches require an investment from the viewer, and always risks losing them if it feels like just conveying information, similar to exposition in story. Exposition slows down a story. Education slows the story, and risks losing the audience. Even documentaries have a story structure to them to keep the audience invested.

Educational portrayals follow the rationale that “if we can increase awareness, that will solve the problem.” I disagree. Creating understanding and empathy is more important, and that comes not through the conveying of information, but through feeling a personal connection to another person, even if fictional. It is here that the true benefits of portraying mental health in media lies.


The third reason is as a relatable factor to human struggle and suffering. Mental illness is not a foreign entity. It is not like cancer, or something that “someone else” gets. Well, sometimes it is. In reality it’s usually a more extreme version of issues everyone struggles with. This is the avenue not only to make a character likable to the audience, but to make the path of that character relatable relevant to the path of the audience. Many people struggle with depression at some point in the life. Even more have lesser bouts of depression that they muddle through. Telling a story about someone with a worse depression could help the viewer, while also just being a compelling story. While psychotic disorders don’t seem relatable, more people than you’d imagine have an episode in their life where they feel like they’re “losing their mind.” These conditions are interesting because they are the extremes of human experience. The keyword is human. Understanding how to take what has been traditionally spectacle, and reveal the authentic human side of it that is relevant to everyone not only makes for good story, but indirectly helps with the stigma. Just as Orange is the New Black didn’t take the approach of a political campaign saying “women are marginalized in media.” Instead they told good stories about women, that made them empathetic and broke the mold on prior clichés.

So I encourage my fellow writers (as I remind myself) to think beyond cliché, spectacle, and even educating when it comes to portraying mental illness in story. Let mental illness be a window into humans, and let that enhance the story as a whole. Otherwise, the portrayal isn’t serving anyone.


Hitting Rock Bottom

I’ve been thinking on this a lot lately, as the issue has arisen in various clinical situations.

We do many things as caregivers (clinicians, providers, physicians, friends and family members) in an effort to help another person. Sometime it seems that if only this person could get a little help, they’d do so much better. And that is absolutely true, some of the time.

On the other hand I’m meeting many people who actively sabotage their own improvement. Maybe they do this by burning bridges with family or friends. Maybe they do this via drugs or alcohol. As this happens there are inevitable consequences — loss of job, friends, health, or housing. Watching this transpire in someone we care about can be incredibly difficult. We’re pulled as we watch the tragedy, to want to intervene. It is in the nature of our role as “givers” to intervene. As if more help in all circumstances will solve the problem of someone who actively sabotages themselves.  For the simplicity of this post, I’ll illustrate these issues using drugs.  It doesn’t have to be drugs, though.  The concern is applicable with any self-destructive behavior.

Imagine having a seventeen year-old daughter. She has started drinking. I’m not talking about a beer here and there. I mean stumbling drunk on a daily basis. She gets expelled from school. As a dutiful parent, I’m sure you’d try to support her. Maybe you would try to limit her contact to friends that are a “bad influcnce.” You might stick her into rehab or send her to boarding school if you can afford it.

Flash forward three years. Your daughter is now twenty. She didn’t go to college. She didn’t finish high school or get a GED. She has never worked a job. All your other interventions didn’t work. The more she rebelled, the more you tried to discipline her, with the hope that she would somehow obey or internalize your values. Instead she just rebelled more, and fought against every rule you laid down.

She comes into your home to eat, or sometimes to sleep and shower. She then goes back out to drink, “party,” and even dabble in some heroin. This is real, even though it seems like a nightmare. You as a parent are torn up watching your little girl go down a path you would never want for her. The options at this point don’t seem appealing.

As a parent you could decide that your daughter needs to “learn a lesson,” or “grow up and start fending for herself.” So maybe you kick her out. She couch surfs with her drug buddies for a while. But she doesn’t have any money. You cut her off because you know she’ll spend any money you give her on drugs and alcohol. That would be enabling her. By cutting her off, you hope she’ll learn her lesson. You hope she’ll hit rock bottom. That she’ll come back ready to grow up and accept an adult role in the world. But she doesn’t.

Instead she stays away. She’s mad at you. She feels rejected by you when you cut her off. She doesn’t recognize the “tough love” approach to this. Even though maybe you were right. By giving her someplace to stay for years, she was shielded from the real consequences of her actions. In a way you had been enabling her use. Now, though, since she doesn’t have money, she has to find other ways to pay for her alcohol and drugs (she’s now using heroin routinely and trying out cocaine periodically). So she starts prostituting herself.

Whoa. Too far?  I’ve seen it a lot.

So you ask yourself – Since she hasn’t hit rock bottom yet, where is that bottom for her, where she reaches the point that she won’t let herself get worse? When will she go so far that I have to intervene because I can’t stand to watch the suffering anymore? Where is my rock bottom?

For some parents in this situation, as well as doctors, therapists, nurses, teachers, etc., there is no end point. Once they cut the cord and decide to stop enabling the pattern, they emotionally disconnect themselves from the outcome. They pray. They hope the person will wake up and come to their senses.

I believe that usually the cord isn’t usually cut completely. People don’t stop caring. Instead the child (or husband/wife/sister/brother/patient) pleads harder, or debases themselves enough to get some help again. They’re desperate. And they learn that if they lose themselves more, someone else will step in to take care of them. And so the pattern continues, except really becoming a pattern of exhausting the compassion of the caregiver. Every time the caregiver has tried to stop, their heartstrings are tugged on until they give in a little. It’s an exhausting process on everyone.

I’d like to think that behaviorism has the answers, and that if this intermittent reinforcement could stop then the person would come to their senses. Sometimes that must be true. Sometimes the caregiver isn’t even aware how they’re reinforcing or enabling.

My recent dilemma comes out of the alternative path, when the person doesn’t end their downward cycle. We wait for the person to hit bottom and snap out of it. We hope it’ll happen, and we feel powerless to “force” the person to change. But in that process, what if hitting bottom means death? Can we accept that? Should we accept that? In a harm reduction model, this seems like a failure. Yet the alternative of enabling didn’t seem acceptable either. Do we rationalize this away as “they did this to themselves?” Should we be contented that this is just what happens with some in their self-destruction.  I believe these rationalizations just make us feel better about not having better tools, about our feelings of failure.

Regardless of whether its acceptable, failure should be considered as the possible outcome of setting a limit. Things may get worse. If we as caregivers cease helping the person, bad things might occur. These might even be horrible things we haven’t imagined yet. If we are shocked at each drop in functioning, though, we may be more tempted to intervene. I am not sure that always helps.

I hate being caught in the process of enabling. It makes me feel like I am being manipulated. From the other side, from the person not even conscious of what they’re doing, I can also appreciate that “benign neglect” can just look like neglect. And for those who have emotionally disconnected as caregivers, it can really take the shape of apathy. Sometimes people are just misunderstood, and it is the feeling alone that can drive them to do their self-destructive behavior. Recognizing that, we’re caught in a bind. Trying to intervene in response to “acting out” reinforces, yet withdrawing resources can potentially lead to more self-destructive behavior as well.  This might not be death, and in fact isn’t in many circumstances.  But it is possible.

I understand all of the rationale behind each side. I can even understand the parent who might say “I’d rather have them alive and using drugs in my home, than outside and dead.” Who would want to give up on those they care about?  Death doesn’t seem like an acceptable outcome. Continuing to enable a process of dysfunction in the name of good intentions doesn’t seem acceptable, either.

There needs to be better ways at intervening, and there very well might be. Resources can and should be provided, but in response to positive behaviors, rather than self-destructive behaviors or even requests for support. Other therapeutic approaches should be considered. Waiting or “benign neglect” puts the responsibility on the rest of the world to induce change in the person, while we wait to accept them back. There needs to be a better way.  We have to start by understanding the worst possible outcome, but not accepting that as inevitable.


10 Life Lessons from a Psychiatrist

I run into the same issues everywhere, from patients, co-workers, and friends. People are stuck, and not sure how to “un-stuck” themselves.

I’ve noticed some basic rules on how to live a more fulfilled life, to make life easier, and make you more effective.

Consider them like guideposts if you feel off track. Some may be obvious. Others, maybe not so much.

It’s not about knowing them.  It’s about where you put your attention and effort.

1. Be Polite

I’m not suggesting to be fake or disingenuous. Instead find the way to being kind to others. And if kindness can’t be found, then at least be civil.

You may get what you want by being rude, angry, or demanding. The squeaky wheel does get the grease. In the process, though, you’ll burn the bridge with the person you’re getting it from. They won’t respect you, and given the choice they wouldn’t help you in an accident. I’ve worked with plenty of people that steamroll over others to get what they want. A lot of the time they still get what they want, but no one likes them.

If people like you, they’re more likely to want to help. Create allies, and start by being nice to people. Especially when you have no reason to be nice to them.

2. Be Flexible

I’m not talking about doing yoga backbends. This isn’t about physical health.

This is the holy grail in functioning in life, IMHO. The way to mental health is to develop flexibility, being able to function in a variety of situations, to find appreciation wherever you are, to be a leader when a leader is needed and a follower when that is needed. And to find enjoyment in every role. To be able to see multiple sides of every issue, and appreciate the opinions of everyone. Even if you disagree with it. Even if its hateful, to be able to understand what led to that person having that opinion.

See #10 for more on this.

3. Pick Your Battles

Stand up for yourself when you can, and when it will help. Assert yourself to make positive changes, but not just to exert your will on others. Don’t let yourself be trodden down by others, but be smart about it. If it’s important to finally stand up to your boss, do you have a backup plan?

People have variable lengths to their fuses. Some will let themselves be beaten down their whole life, never speaking up for what they want or believe. Others snap violently at the tiniest provocation. Neither approach works to get your needs met. Think ahead and plan the next three steps after you stand up for yourself, and plan how to weather the worst possible consequences.

4. Be Open to New Data

Medicine has few certainties. During medical school the lesson was: “Twenty years from now, 50% of what we know is fact will be wrong.” In a field of explosive egos and paternalistically telling others how to live their lives, it’s hard to be able to admit fault. It’s absolutely necessary though.

I could be wrong about everything here. I know I don’t know anything for certain. Anyone that says they do is wrong. This is more than being humble. New information could arrive at any point, and if we choose to selectively ignore that information because it’s a blow to our ego to change our minds, then we’re living in a delusional world. We’re ignoring reality.

I very rarely get all the information on someone’s background to be able to even make a definite diagnosis. I get pieces, and I put together the best picture from that information. If new information comes in, I have to revise that picture.

Think about your own philosophy on life. Any one thing you take for granted. Would you be willing to admit you’re wrong if some new information came in that didn’t fit? Most likely you’d want to discredit it, unless it came from someone you trusted.

The better stance is to be open to any credible information, and to recognize any belief or idea is only as good as the data it is based on. This is also the way of science, usually. At least when politics aren’t involved.

5. Paradox is the answer to many puzzles

I could give a thousand examples of this. You get more by giving. When in the black hole of desire and want, feel better through focusing on gratitude. Strength comes through vulnerability not hardening the walls. Fears are broken through experiencing the fear, rather than numbing it. Giving is the best way to get people interested. You have to stop chasing a dream to get it to stop running away.

We are creatures of habit. We do things because they worked in some way, at some point in the past. So we keep trying to do them, stuck in the hammer-nail paradigm all the time. We do what we do because our approach makes sense. It fits common sense.

Sometimes what we intuitively do is very effective. But sometimes it doesn’t work at all. Conventional wisdom tells us to “fight harder” and do more of it.

If you’re stuck on a problem, consider trying the thing that doesn’t make sense. Oppose your intuition. Trying to keep things from getting worse sometimes just makes the problem last longer. We do it because common sense dictates that things would be worse if we did anything else.

When desperate for love, we’re in a place of want. We desire. We feel empty, as though there’s nothing to give. We want someone else to fill us with love. Yet giving without expectation may be the very thing that results in getting what you want.

You just have to accept the worst outcome as a possibility. Some of those worst outcomes may not be acceptable, no matter what. I can’t speak to the specifics in your life. Just think of these as guideposts. There are whole schools of psychotherapy (lesser known) devoted to this approach.

6. Growth (or change) Requires a Degree of Risk, But Not Pain

There’s always risk in doing something new. Because it’s new and unfamiliar. The pain that’s expected comes from fighting change, from swimming upstream against the current, from holding onto the past. In order to change it means letting go of something, even if only as the sole way of doing something.

Weigh the risks and benefits, and make a choice to try something different.

7. Your Heart Will Keep Ticking

Even if it feels like the end of the world. Even if you feel like your soul is dying. You will probably survive. The pain will pass, like a wave. And you will survive. Don’t give up just because the wave is rising, or because it’s scary. Fear won’t kill you (unless you have a heart condition).

In that vein, I always appreciated this quote:
“I must not fear. Fear is the mind-killer. Fear is the little-death that brings total obliteration. I will face my fear. I will permit it to pass over me and through me. And when it has gone past I will turn the inner eye to see its path. Where the fear has gone there will be nothing. Only I will remain.”
― Frank Herbert, Dune

8. Balance is a Process, Not a State

No one is perfect. No one is at bliss twenty-four hours a day. Marketing (including by self-help marketers) sell you the idea of perfection. Or balance. Or happiness. Or Mindfulness. In truth that is not a maintainable state.

Stand on one foot. Even if you aren’t falling over, that’s because opposing muscles are working simultaneously. Balance isn’t about one thing only. It’s about finding the right amount of two things that might oppose each other, so you don’t fall over.

Find the balance between apathy and overinvestment. Being totally absorbed in anything is a recipe for burnout. In relationships or projects. Apathy isn’t living, but shielding yourself from any future risk, because it doesn’t seem worth it. Life is best lived in-between, in a state of mindfulness.

9. Everybody is Doing the Best They Can with the Tools They Have

Just sometimes their tools aren’t good enough. If that’s you, get more tools. Try new stuff. Shrugging your shoulders that you are the way you are doesn’t leave much of a path for your story.

If it’s someone else that is pushing your buttons, find some compassion. Whatever they’re doing, no matter how annoying, has served a purpose for them. They’re using what they believe is the best tools they have, even if it makes no sense to you.

10. Problems in Relationships Can Often Be Fixed by Trying Different Positions

Get your mind out of the gutter. I’m not talking about that.

Think about where you find yourself, in relationship to others. First, second, third positions.

First position (I) is looking at it through your own eyes. Some people literally cannot think for themselves, but are constantly caught in the needs of others.  They’re disconnected from their own needs and always put others first.

Second position (you), is about empathy and being able to imagine yourself as another person. Why they do what they do, and how they feel how they feel. Understanding that helps to understand how to deal with another person.

Third position (outside) is looking at the group from the outside, detached, and seeing the big picture. Seeing that when I push, he pushes back, which I might not be able to appreciate from the first or second positions. Each of these is like a muscle. Which of yours is underdeveloped?  Which is overdeveloped?


Now of course there’s lessons #11 – 20. But those will wait for another post.

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