“But I’m not crazy, right?”
I get asked this question at least weekly. There’s a person, let’s say twenty years old. Or forty. Or eighty. Or fifteen. Doesn’t really matter the age. And they’ve reached some point where they’re actually starting to question their own sanity, wondering if they’re about to “lose it.” So they come to someone for help. Are they really at risk? Maybe. If so, it’s probably being driven by the fear itself.
Of course there’s that old colloquialism that if you think you’re crazy, you’re not crazy. That has a grain of truth. One of the biggest issues in actually helping someone change their life or address a problem is getting them to admit that they have a problem. They need insight. Once they have it, the first step has been taken. There’s so many other important steps, though. And that’s really about crossing the threshold to try something different. We each have our normal ways to stay functional. It takes a lot to push us to realize that these normal strategies aren’t working.
The word “crazy” in the question raises a deeper issue of stigma. It’s the fear of “losing it” that may keep someone for far too long from actually seeking any help. And in help I’m not necessarily talking about professional help. That’ll be a distinction I make throughout this blog. People learn through many different paths (hence the blog title), and professional help (with a psychiatrist or other therapist) is one established path. It is not the only one, though. Let me illustrate on a brief tangent.
Borderline Personality Disorder (which will certainly be a topic for many future postings) is a kind of dysfunctional personality that causes a lot of impairment in the individual, but usually prompts treatment because it’s distressing to others. In fact people with borderline PD often get treated because they provoke reactions in others. This might take the form, for example, of a person cutting superficially on their arms, which can be distressing to others to observe. The person watching this happen feels like they can’t watch it any longer, and decided to get them help. Now we have many Evidence Based Treatments for this problem, which are proven to reduce certain symptoms, like cutting (“self-mutilating behavior,” AKA “Non-suicidal Self Injury”). Dialectical Behavioral Therapy, for example, is one of the most popular these days. But this is not the only path to improvement. In older teachings, personality disorders weren’t very treatable. Meds didn’t work. Maybe psychotherapy worked, kinda. Research now shows that when you check in with borderline PD patients later, they got better, maybe even without professional help. More specifically, they had symptom remission, even without having to have aggressive treatment the whole time. Now of course many were in regular outpatient treatment, but it raises a possibility (supported by other research) that even those with severe personality disorders can improve eventually, without aggressive treatment. So maybe these individuals are learning in other ways, from people around them, and it just takes longer for those changes to occur.
So maybe it’s all just a waiting game. For someone feeling out of control, though, part of the fear is it’ll go on forever, or pass the point of no return. Waiting means letting things get worse, or who knows? That’s scary. It’s unknown. There’s a message behind the fear of going crazy, which is really a worry of losing control, in a way that is irreversible. As if once you’re “crazy,” there’s no turning back. It’s a fear of losing a sense of self.
I had a patient a number of years ago, we’ll call him AJ, a young man without anything really unique about his life, who got brought into a psychiatric hospital out of “fear he might do something.” AJ was afraid that he would lose control of himself and do some horrible act that could never be taken back. It’s actually a common fear.
“I think I might lose it and hurt someone in my family.”
He was as normal appearing as anyone, dressed in a button-down and khakis, educated with a college degree, and had been working a regular job as a bank teller. He didn’t have any risk factors that we consider red flags, like a history of violence, drug use, etc. But job stresses being what they were, he started worrying about his job, and if he might get fired. And he had a scary thought about “what if I did something bad.” And that thought led to the concern “what kind of person am I that could have such a momentary terrible thought to hurt my family.” And that led to this snowball effect. The fear of going crazy made him anxious, and being anxious made him feel all the more out of control. Until this all built up to the point that he went to an emergency room. It had taken a long time before he actually sought out any help, avoiding talking to someone out of fear he might be “crazy.” And his avoidance fed the anxiety, until he ended up in an ER. And by that point he had fought it so long he actually was having problems at work. How much easier it would have been to admit that what he was doing wasn’t working. That’s the second hardest step.
Now I’ve seen patients like this quite often, and half the time they’ll get hospitalized by someone to give a level of containment. No one wants to be the psychiatrist that says “OK, this is anxiety, just go home.” Because IF that person (heaven forbid) does something bad (like out of desperation lashes out and hurts someone), we don’t want to be responsible for sending them out of the ER. Sometimes the anxiety is so out of control they might even get misdiagnosed with a psychotic disorder, and end up carrying that diagnosis for a long time. If there was less stigma around mental health, people might seek help sooner. The unknown and idea of losing self to an illness like schizophrenia is scary. I’ll touch on that in future posts. Uncommonly is this anxiety-ridden fear of loss of control driven by legitimate psychosis. Again, the colloquialism has some truth to it, as most who are legitimately psychotic don’t realize it, at least not in the beginning.
The fear of loss of control fed the anxiety, and the stigma fed that fear. I don’t really like the word crazy. Or “nuts,” or “whackjob.” Or any of that crappy colloquial jargon that perpetuates stigma. I’m not even particularly a fan of “mentally ill.” For some people labels give them a sense of meaning behind their experience, which I think is fine, but it can come at the expense of labeling without explanation, or even externalizing all blame. “I do this X because I have Y.”
After I’d spent some time with him, determined this was severe anxiety (with panic attacks), and explained it to him, AJ was able to calm down substantially. I started him on medication, taught him some relaxation exercises, and connected him with some therapy options. He had someone outside of himself to normalize things, and give him a way to feel better, quickly. It had a happy outcome. And yet after he had heard the explanation and the options for treatment and normalizing and all that, he still asked the question – “But I’m not crazy, right?”
Most people will tell you we should decrease the stigma behind mental illness. Aside from awareness and increasing services (I.e. giving more services), few ideas float around. I am equally as concerned though about the increasing prevalence of mental illness (more people being diagnosed as having them). Maybe that’s an artifact of increased awareness, and decreasing stigma, leading to more seeking help. Simultaneously, though, is the very real concern that just more and more is being considered pathological or ill. Indiscriminate diagnosing and ignoring the context of a life may help some people, but in the larger picture causes a whole set of new problems, which now have a life of their own. #Psychiatricmemes that cause new problems, in an attempt to solve others.
“No, you’re not crazy. You’re struggling and feeling out of control. Good thing we can help with that.”
[I’m aware I have many soapboxes, and will make attempts to limit the number of tangents per post.]
Coming up next week:
Well am I Bipolar, or not?