I need to get myself back into treatment, but it’s so overwhelming and intimidating. Often, people who don’t have mental illness do not understand why so many of us are resistant. They think it’s like going to the doctor for the flu. It’s nothing like that. I know it can help, but only if I’m lucky enough to find the right people.
If it’s your first time seeking help I don't want to discourage you. However, I think it’s important to know that mental health really is still in the dark ages. There are some great things, but the road is covered in mines. Today I want to explore some of these problems, because if we can go searching for help knowing how to spot signs of less-than-stellar care, hopefully we can get ourselves out of bad situations.
1. People or clinics promising to cure you
Anyone who promises they can fix you should not be trusted. Our goal is improvement and management. Some depression will fade over time, but there’s no way to tell who has chronic depression and who doesn’t. We all need to treat this like a chronic, degenerative disease. If it disappears, you are one of the lucky ones. Go live your life, baby!
The rest of us (including bipolar and schizophrenic people) have to understand that we need to gain the skills and assistance to live the rest of our lives plagued by psychic distress. With management it may go into remission, but even then, it can come roaring back if we act like it’s “cured.”
I was first diagnosed with bipolar disorder when I was 19, and the therapist told me I’d probably grow out of it by the time I was 30. For 11 years, I figured if I white-knuckled it I could outlast it. I first took neuroscience around age 29, and discovered that bipolar disorder doesn’t go away; in fact, it gets worse. If they had told me I needed to take this seriously back then, I could have done something different. I might not be in the kind of pain I’m in now. I might have made different decisions about my future.
Mental illness almost never goes away on its own. Your immune system doesn’t work on cognition or emotion. We say people are “sick” but it’s not the kind of diseases we’re used to dealing with. We must be actively and mentally engaged in our own treatment, even if you take medication.
You need to be ready to show up, be honest, and demand to be taken seriously. You need to be prepared to do hard work, which is extremely difficult when you have a disease that saps your energy and hope. If you are willing to put in that much effort, you deserve a therapist or psychiatrist who is going to be honest with you, and who will stick with you past the current crisis.
2. Some psychiatrists and doctors are pill pushers
First of all, no one should ever judge you for taking medication or not taking medication. As far as I’m concerned, this is a “my body, my choice” situation. I think programs that require clients take medication in order to access social security or disability (yes, they exist) are unconstitutional and immoral.
That said, medication can be an excellent tool for people struggling with organic mental illnesses. Medication alone won’t fix you. However, it should help you work through the other stuff more easily.
Unfortunately, pharmaceutical companies are notoriously unethical and lots of doctors are extremely money-driven. We’re seeing this with opiates. Some doctors were told that opiates aren’t addictive by the drug companies. Other simply didn’t care and loved getting the bribes the pharmaceutical companies offer. Now thousands of people are dying for no good reason. When it comes to mental health, it’s even easier to push certain drugs.
I think I was 20 when I first screwed my courage to the sticking place and visited a psychiatrist. I was terrified. I had received a diagnosis of bipolar disorder a year before, but that guy only talked to me for like 15 minutes and didn’t explain anything about it. I decided he didn’t know what he was talking about.
Bipolar people, on average, take 10 years from onset of symptoms to treatment. It’s a very serious but poorly understood disorder, and in the US it’s shorthand for “batshit crazy.” That’s a terrifying thing to hear as a teenager (or at any age) and it’s extremely common to reject it.
Anyway, this psychiatrist only scheduled me for 15 minutes. That’s pretty normal. Psychiatrists often run their offices like any other doctor, stacking patients and only briefly checking in. This is bad for physical health, but catastrophic for mental health. I told the doctor about my depression symptoms, but I didn’t mention the previous bipolar diagnosis. She barely asked me anything. Instead, she asked me “What medication do you want?”
I was floored. I knew nothing about mental health treatment or medication. I had no idea what I needed. I remember, in that moment, realizing that everything in her office was branded by some drug or another. I ended up with Zoloft, the brand of drug sponsoring her prescription pad.
Medicating someone with bipolar disorder for depression is a very dangerous thing to do. Bipolar disorder is characterized by extreme highs and lows; the highs are the most dangerous. If you only prescribe antidepressants, bipolar people get thrown into mania.
Every month, I came back for my 15-minute session, and I was completely honest about what was going on in my life (except about the escalating suicidality). I was experiencing rage like never before, I couldn’t sleep, and I couldn’t stop moving. A good psychiatrist would have realized what was wrong, but not Dr. Wu. Every time things got worse she’d increase my dosage of antidepressants, so every time I went back it got worse. I was part of this terrible cycle until my health insurance ran out and I couldn’t afford the $700 per month for the drugs anymore.
I believe she is probably responsible for the deaths of several people, because if I hadn’t gotten off those, I don’t think I would have survived much longer.
If you are seeing a psychiatrist or other doctor who seems to think the only answer is medication (or more medication) you may want to consider a second opinion. If someone simply asks, “What medication do you want?” call them a drug dealer, walk out, and refuse to pay for the session. It’s not OK. It’s not even healthcare.
3. Most primary care physicians know very little about mental health medication
I don’t want to shit all over psychiatrists, because I do think that they are a better option for psychiatric medication than other doctors. Currently, close to 70% of Americans receiving psychiatric medication got that prescription from a primary care physician. Some PCPs are knowledgeable about neuropsychopharmacology, but most are not. I have taken neuropsychopharmacology, and as an ally and friend I have done drug counseling with many people who received antidepressants from PCPs who didn’t tell them anything.
There are at least 4 biological routes to depression, one of which was only discovered recently, and for which there is no medication available. There are good drugs designed to treat the other three, but your doctor doesn’t know which one you have (or if there more than one is present). We don’t yet have that test. There is a lot of trial and error in psychiatric care.
There are three main types of medication, and each one works in about 30-40% of cases. I find most people don’t understand that if one doesn’t work, there are other options. Furthermore, it takes a month to even tell if it’s having any effect. These drugs build and act slowly, and people get so frustrated after a week or two that they give up. Going on antidepressants (or antipsychotics, mood stabilizers, or antianxiety medication) is extremely complicated, especially if you need more than one type. PCPs are usually not equipped for this.
If you really need to get these drugs form the PCP (like, for financial reasons), ask about how knowledgeable they are. Ask about the things I wrote above. You should be checking in once a month, at least at first. Is your PCP willing to invest that time in you? These drugs can make you worse if they aren’t right; can your PCP see you on short notice if you have a crisis?
If you have good insurance and/or the financial means to do so, I strongly recommend seeing a psychiatrist when you start treatment. Once you and your psychiatrist agree that you’re at a good place, you can ask your PCP to do the monitoring moving forward, as long as you agree that any changes will be made by the psychiatrist.
Actually, a PCP is a great person to do monitoring because while you’re there you can check in with any physical ailments you’re experiencing, too. I wouldn’t rely on them to find the right thing for your brain chemistry, though. There are way too many specialized variables.
4. Some therapists have poor boundaries
Therapists typically are not involved in medication. Instead, they use talk therapy and other cognitive tools to help you work through difficult emotions, learn new coping skills, and generally live a better life. It’s usually much less medicalized than psychiatry. However, since it involves a deep and continued personal relationship between client and counselor, things can get inappropriate if they have poor boundaries.
Obviously, if your therapist tries to have an outside relationship with you, that is not OK. Dr. Phil lost his license by having sex with a client. It’s not uncommon.
Other things are more subtle. I have had several therapists who I loved. They were like having a friend I could tell (almost) anything to, and I didn’t need to freak out my friends and family by dumping this stuff on them. Then there was Mary.
I was at the end of a long-term relationship with a man who was manipulative, controlling, and a liar. I tried to break it off, but he threatened suicide, so I agreed to go to couples counseling (you better believe we’ll talk more about manipulative suicide threats later). Couples counseling rarely works when one party has already decided the relationship isn’t worth saving, but I threw myself into learning how to fight fair and how to listen well. No matter what those were good skills to have.
After maybe a month of sessions, Mary waited until my ex left the room then told me, “I see myself in you. You want someone to understand you, but no one ever will. This man wants to make a life with you, and you’re never going to find better.”
That’s the moment I knew I was getting out of that relationship, and fast. Of course, I refused to ever go back. That’s not the role of a therapist. A therapist is there to help you figure out what your best life looks like and to help you work towards it. They aren’t there to put you in your place. You do not have go to someone who makes you feel worse about yourself, or who asks you to just give up.
Therapists are licensed by the state, and what constitutes a violation of ethics is public record. If you suspect your therapist has stepped over the line, do not hesitate to report them to the board. If they’ve done it to you, they have certainly done it to other people who didn’t realize it was wrong.
5. Mental health providers are also affected by stigma, and they may not listen to you
Unfortunately, we all live in a world steeped in mental health stigma. All of us are guilty of it, including mental health professionals. Sometimes, some people who should know better will ignore you because they think you’re being crazy.
A few years ago, I had the resources to go back to a psychiatrist. This time, she threw the kitchen sink at me. I went from completely unmedicated to having mood stabilizers, antidepressants, antipsychotics, and antianxiety medication. That’s probably not the best way to go about medicating someone, but I was in a bit of a crisis, so OK.
The problem was, after a couple of months, the crisis was over but these medicines were messing me up. I lost all motivation. This isn’t like “I only want to watch South Park and sleep” kind of motivation-that’s every day of my life. I didn’t get hungry anymore, just sick if I didn’t eat for a long time. I didn’t get thirsty, just dehydrated. I didn’t get sleepy. Time didn't seem to flow in any logical fashion. I couldn’t get sexually aroused if I wanted to. None of my systems were working right, and I knew it was related to the meds.
When I went to the psychiatrist and told her about this she told me, “Well it’s summer. Lots of people don’t want to eat in the summer. We’ll see if it’s still like this when it cools down.”
This meeting was in May. Here in Texas, summer ends sometime in October. It didn’t get better. When October came she made some other excuse. I kept getting worse. For nearly two years I lived in a gray nothingness, it was like being lobotomized. I didn’t go to class, but I didn’t even feel bad about it anymore. I didn’t feel anything. She told me what I was feeling was what normal people felt, but I’m not stupid. Once again, I had to stop the drugs on my own. Once again, I think it saved my life. It definitely saved my PhD.
Bipolar people, especially, have a reputation for not taking their medicine. When I ask counselors and psychiatrists why this is, most of them blame the symptoms of bipolar disorder. To me, it’s just as easy to see it as the drugs we’re using or the quantities we prescribe don’t work the way we want them to. For me, I finally realized the drugs were interfering with my life more than my actual mental illness.
I’m willing to try again, but I’m never going to accept that gray, empty space. If I have a psychiatrist who wants to convince me that that’s OK, I’m moving on. No way.
6. Racism, sexism, and classism may affect your client-provider relationship
It’s a sad truth that we act differently towards people in our in-group compared to people in out-groups. Study after study has shown that women and people of color receive less time and information in doctor’s appointments than white men. When we talk about emotions and trauma, so much of it is culturally rooted that it may be difficult to overcome that boundary.
Good therapists recognize this in themselves and work to overcome it. However, if you suspect your health provider is treating you poorly because of your color, gender, sexual orientation, place of birth, or social class you shouldn’t ignore that.
As a white woman who has always seen female practitioners, I haven’t had to deal with much of this. However, I did have a psychiatrist diminish the severity of my manic episode by saying, “Well, you haven’t flown off to Europe or anything.” I had $40 to my name at the time. The idea that I wasn’t suffering as much as a rich manic person on vacation made me furious.
It’s important to find a therapist that you feel comfortable with. For many minority groups this is difficult, because we have a major shortage of diverse options. However, it is slowly getting better. Someone who is from the same culture as you might be great, or they may reinforce culturally-bound stigmas that are harmful.
If the first person you see is dismissive or rude, you can find someone else. If they are outright hostile, racist, or insulting, you can report them.
7. Money rules the world
Finally, it’s critical to understand that mental healthcare is criminally expensive. Americans with mental illness spend more out-of-pocket on healthcare than people managing other chronic diseases. Insurance acts like mental health services are an extravagance, as opposed to a necessary specialty service, like a cardiologist or physical therapist. If someone can’t afford it, telling them to “get help” is worse than nothing. It’s double shaming.
A good inpatient program could be easily $30,000. Without insurance, bipolar medication can run about $50 a day. Therapists typically cost $60-100 an hour, psychiatrists even more. Even with insurance, it was going to cost me $60 per psychiatrist visit. It’s a ridiculous racket and a terrible obstacle that no one talks about when they say, “get help.”
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| Have you tried bribing a child? |
There are some options. Some clinics offer sliding scales based on income. If you have a United Way help line (311) or service in your area, that’s a good place to start. Medicare and Medicaid cover some mental health stuff, but obviously you have less control over who you see than if you had other options. Students may have resources available through school. Some drug companies offer vouchers to low-income people who need medication. Try to stay out of the emergency room if you can. They are the worst at putting people on inappropriate drugs with no follow-up.
You’ll notice that low-income people must work 5 times harder to access care with a disease that makes it hard to do anything or ask for help. Its an absolute disgrace, but there are some options. Obviously, we need to push for better.
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I know some people would critique the framing of this article. “Can’t you make it more positive? Don’t you think this will deter people from seeking help?”
One thing I hate is how most suicide resources bend over backwards with positive framing. First, people don’t remember the positive as much as the negative. I’ve tried to present the problems, so you can more quickly recognize them if they happen to you or someone you care about. “Do’s” are lost in the noise. That’s basic learning theory.
Second, these things seriously hurt me, and they’ve hurt a lot of people. My entire life people have told me not to talk about it, and I’m done with that. Millions of us have no voice because we’re constantly told to “be positive” when that’s not our truth.
I had three audiences in mind when I wrote this. The first is other people like me, people who need help but have been traumatized and fear trying again. We need to find the strength to demand respectful, cutting-edge treatment. I want you to know that it’s OK to keep trying, and just because one person screwed you over doesn’t mean everyone is like that.
Second, I want allies to understand that getting someone into treatment isn’t a resolution, it’s the beginning of a different kind of struggle, one that could get worse before it gets better. I want them to understand that it’s not going to be fast or easy, and that their loved one may be mistreated. They should listen openly to their friend’s concerns about their therapist or medication or whatever.
Third, I am thinking about people who have never been in treatment and are embarrassed or afraid to try. It’s OK to be afraid. It is one of the scariest things I’ve ever done, and I get around. However, it isn’t as bad as horror movies would lead you to believe. There is the potential for transformative, supporting relationships. It can help you get out of your hole. Just the act of investing in yourself by visiting someone will make you stronger and help put you on the path towards remission. I also want you to know that there is recourse if you are mistreated.
Breakthroughs are being made every day, but mental health is about people, not bacteria or viruses. Most will try their best to help you, and there is hope. However, you can and should remain in the driver’s seat. Stay alert, traveler. You, and you alone, know what it’s like to be inside your mind.
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