Mental Health 101

How common are mental health issues?

Studies have shown that 1 in 4 individuals globally struggle with a mental health issue at any given time. If you expand that to the course of a lifetime, the number increases to 1 in 2. That means if it’s not you who is struggling, it’s someone you know or love.

Why is it important to talk about stigma?

When discussing mental health, two main types of stigma exist. One type is external stigma, which refers to the attitudes held by society that people with mental health issues are somehow lacking, incapable, incompetent, or not worthy of dignified and equitable treatment. The other type is internal stigma, which is the attitude held by the person with mental health challenges that they are unworthy, unlovable, and unvalued.

Stigma does a lot of harm to our society. For the people struggling with a mental health challenge, they often lack hope in recovery and don’t pursue treatment because they either don’t believe they can get better or fear discrimination from others. For those who don’t struggle but hold positions of power (such as law enforcement, educators, landlords, community leaders, etc.), stigma can lead to discrimination, which is the unfair treatment of those with mental health challenges.

Having honest conversations about stigma and sharing our personal stories of recovery are small steps we each can take to making our society more equitable and inclusive.

Is recovery actually possible?

Absolutely! One of the biggest misperceptions in society is that mental health issues are a life sentence.

Recovery means many things to many people and is personal in nature. For some, recovery is the complete absence of symptoms. For others, recovery means successfully managing symptoms as a normal part of life with no disruption to daily activities. Research has shown that even for those with the most serious mental illnesses, the right treatment can have someone living an independent, fulfilling, and successful life.

Does everyone with a mental health diagnosis need medication? What alternatives to medication exist?

It’s a common thought that the only cure to a mental health diagnosis is medication and if one stops taking his or her pills, it’s all downhill from there. While medication works for some people, it is hardly a cure-all. In fact, some medications can have side effects that are more harmful than the symptoms of the mental health challenge!

Deciding to try medication is a personal decision. The good news is that it is not the only option. Research has shown that other types of therapies can be extremely effective in maintaing a person’s level of wellness, including mindfulness, talk therapy, peer support, physical activity, and visual and performing arts, to name a few.

So, do I have to share my mental health issue with the world?

Not unless you want to! Some people are very open about their mental health issues because they value transparency and/or want to be an example of recovery. Others may not feel comfortable because they fear stigma, or simply don’t want the world knowing their personal business. Some may choose to tell family and close friends, but not coworkers or acquaintances. There is no right or wrong answer. You should do what makes you comfortable. If you want to start dialogue around mental health but aren’t quite sure if you’re ready to share your experiences, you can always frame the conversation around wellness, which applies to everyone, diagnosis or not.

What should I do if someone discloses their challenge to me?

Just listen. Providing a supportive ear is the best thing you can do for someone who chooses to open up. It’s not always easy to share something so personal with another human being, so taking a genuine interest and being free of judgment can go a long way and do a lot of good.

Focusing on Mental Health Policy Issues

The recent spate of high-profile mass shootings has inspired yet another “national conversation” about mental illness, with everyone agreeing that the country has a problem. Unfortunately, isolated instances of violence are how the subject typically ends up in the news cycle. But the more mundane social repercussions of mental illness, while perhaps not as headline-worthy, are pervasive and acutely felt nonetheless.

On any given day, one in five people in jail or prison has a severe mental illness. This means that people with serious mental illness are ten times more likely to inhabit a jail cell than a hospital bed. Besides contributing to jail and prison over-crowding, mentally ill people are especially vulnerable to victimization by fellow prisoners, spend more time in solitary confinement, and become suicidal behind bars at higher rates than non-mentally ill inmates. They also cost the correctional system considerably more than otherwise healthy prisoners.

The challenge facing prisons is just one consequence of decades of de-institutionalization policies. From a nationwide peak of around 560,000 psychiatric beds in 1955, the census has been whittled down to about 35,000 today — about half of what experts estimate is actually needed. In the absence of such beds, patients will continue to be warehoused behind bars, lie on emergency-room gurneys for days, and languish in nursing homes. One-third of the nations homeless will still be comprised of the untreated mentally ill, who are at far greater risk of being preyed upon than of harming someone else.

The lesson of downsizing state psychiatric facilities — no less powerful for being familiar — is that good intentions are not enough. Too many sick people are now caught in a pernicious cycle, rotating in and out of emergency rooms, crisis hospitalization, incarceration, homelessness, and back again. Its no wonder some of the strongest supporters of mental-health reform are police, district attorneys, corrections officials, and emergency-room physicians.

These problems afflict roughly 10 million Americans, or just over 4% of the population. Mainly diagnosed with schizophrenia, bipolar (manic-depressive illness), or major depression, such individuals are chronically or periodically unable to care for themselves or are suicidal. At times, they may be dangerous to the public. Relative to other psychiatric patients, those with severe mental illness are far more likely to need medication, intensive supervision, and even involuntary treatment at some point in their lives. But they arent getting the help they need, and the governments good intentions are often the very thing preventing their getting appropriate treatment.

To understand a key source of the problem, we should compare severe mental illness to “mental health.” The Centers for Disease Control describes mental health as a composite of “emotional well-being,” “psychological well-being,” and “social well-being.” According to government statistics, only about 17% of adults are considered to be in a state of optimal mental health — the rest, apparently, need some kind of professional assistance to achieve optimal “wellness.”

Sandwiched between mental health and severe mental illness is a clinical category called mental illness. One recent national survey estimates that nearly 18% of those individuals older than 18, or about 43.7 million people annually, are mentally ill — meaning they fulfill diagnostic criteria for any condition listed in psychiatrys official diagnostic handbook, ranging from attention deficit disorder to panic attacks to anorexia. The severity and chronicity of these conditions varies dramatically, with most conditions resolving on their own, while others are best served with time-limited psychiatric care; some may require hospitalization and long-term medication and therapy.

The distinction between mental health, mental illness, and severe mental illness is crucial, because it leads us to different clinical and policy prescriptions. The vague boundaries of “mental health” enabled a variety of advocates whose true agenda is grievance and social reform to claim that their concerns fell under its rubric, as historian of psychiatry Gerald Grob has observed. As a result, he writes, “persons with serious and persistent mental illnesses…[are] forced to compete, often unsuccessfully, with other groups that now [define] their needs in terms of mental health.”

The problem we have today is that the system is geared more toward mental health than severe mental illness. In fact, the federal governments lead agency on mental health, the Substance Abuse and Mental Health Services Administration, part of the Department of Health and Human Services, has explicitly stated this as its goal. Rather than focusing on reducing homelessness, hospitalization, or incarceration among people with serious mental illness, it concentrates federal and state efforts on delivering amorphous “behavioral health” to everyone else.

This is profoundly misguided. But it may not be surprising after a half-century of inept leadership, Medicaids financial incentives gone awry, and clashing ideas about the nature of the forces (psychological, biological, and social) that lead to psychopathology — and that, in turn, point toward the best possible therapeutic strategies. Ours is a problem-ridden system that could be markedly improved with strong political leadership.

We need a mental-illness system in which care for the sickest of the sick is a priority. If the federal government intends to take mental illness seriously, Congress and the next administration must be keenly responsive to the most vulnerable patients.

a troubled legacy

To understand what should be done, a review of the dynamics that led to the current state of disarray is in order. Four key elements are to blame.

The first emerged in the late 1950s, as officials emptied state hospitals of even the most debilitated patients without adequately planning for their continued treatment. The second contributing factor came with the creation of Medicare and Medicaid in 1965, as new policies limited access to community hospital beds. The third factor is the growing complexity of competing ideas about the causal and remedial factors involved in mental illness, and the resulting complications in policymaking. And fourth is the disproportionate leverage wielded by anti-psychiatry forces in an era of victim politics. This last influence builds upon a longstanding debate regarding the civil liberties of individuals whose capacity to manage their freedom is badly compromised by dysfunction in their brains.

Until half a century ago, the care of people with mental illness had been the responsibility of the states. This changed in 1963 when President John Kennedy ushered in the era of federal support by championing the Mental Retardation Facilities and Community Mental Health Centers Construction Act. The new law mandated the creation of a user-friendly archipelago of 1,500 federally funded community clinics nationwide to supplant the large state asylums and to allow patients to live in their communities while receiving treatment. “When carried out,” Kennedy said of the act, “reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability.” The presidents interest was personal, stemming from the tragic experience of his sister Rosemary, who was born with mild mental retardation and eventually underwent a frontal lobotomy for schizophrenia.

The nation was primed for the change the president sought. Two decades earlier, Life magazine had run “Bedlam 1946,” a searing photo-journalistic exposé of Pennsylvanias Philadelphia State Hospital at Byberry and Ohios Cleveland State Hospital. Books like Albert Deutschs The Shame of the States and popular entertainments like the movie The Snake Pit, both of which appeared in 1948, exposed shocking conditions of filth and abuse in state facilities.

State-initiated efforts improved the conditions at state hospitals in the mid-1950s, and, thanks to the availability of Thorazine, an anti-psychotic medication introduced in 1954, some patients were successfully moved into the community. But with Kennedys community centers under construction in the mid-60s, the campaign to empty out state facilities took on new urgency. Some patients did well upon discharge, but the sickest were caught in a revolving door: Without closely supervised treatment, many failed in the community and went back to whatever institutions were left. Others ended up in a kind of limbo, neither institutionalized nor embedded in a community.

The state-hospital population was further eroded by legal decisions issued in the 1960s and 70s that made it hard for judges to order necessary treatments for patients who were wildly psychotic or immobilized by depression but were refusing care. A convergence of strange bedfellows — fiscally conservative state officials, progressive reformers, former patients, and politically liberal civil-rights lawyers — formed a strong advocacy coalition for deinstitutionalization policies.

In 1965, as the exodus from state hospitals was well underway, Congress passed legislation establishing Medicare and Medicaid. The new law included a provision that unwittingly planted the seeds of the current shortage of public hospital beds. It did so by prohibiting Medicaid from paying for care delivered to patients between the ages of 22 and 64 if that care was provided in an “institution for the treatment of mental diseases,” or IMD. An IMD is defined as a treatment facility with more than 16 beds of which at least half are dedicated to mentally ill patients. The so-called “IMD exclusion” was intended to spur momentum for community treatment by barring the doors to the asylum, which Congress saw more as a warehouse than a treatment facility anyway.

The IMD exclusion did not affect general hospitals and nursing homes. They remained eligible for Medicaid reimbursement. Thus, states had a strong incentive to shift patients from state psychiatric hospitals to Medicaid-eligible institutions, even if those venues were more costly or less effective. With fewer and fewer psychiatric beds available, emergency rooms became holding areas for those who needed inpatient treatment; others spilled out onto the streets and into run-down, questionable boarding houses and jails.

It did not have to be this way, which is clear given how well Medicaid has worked for people with intellectual and developmental disabilities. They, too, could be found living in state hospitals in the mid-20th century, but Medicaid treated them differently. If they still needed residential or intermediate care, Medicaid reimbursed the state for their stay. Then when these patients were discharged into the community, Medicaid covered wraparound services such as vocational assessments, family counseling, medication management, and transportation. Today, these services are provided under a “community options” waiver that “swaps” a Medicaid-covered inpatient bed for a similarly covered, community-based slot.

Unfortunately, no such waiver exists for individuals with serious mental illness, because the IMD exclusion prohibits federal coverage for adults. The ensuing problem of fragmented services is formidable. Between orchestrating disability entitlements, housing, and treatment of medical problems, case management can require organizational skills that are beyond most of us, let alone people who are also overwhelmed by depression, difficulty concentrating, or jumbled thoughts. Even when there are quality services covered by Medicaid, such as nursing-home placement, funds are not always tailored to young or middle-aged able-bodied psychiatric patients. Meanwhile, entire subpopulations of poor, young men are not covered at all in many states.

Thus, as Harold Pollack of the School of Social Service Administration at the University of Chicago explains, “Deinstitutionalization has, on the whole, worked well for the intellectually disabled because they and their supporters could crank the political valves required to make it work. Equally worthy claimants who lacked the same political muscle or public embrace fared much worse. Thats one key lesson of the deinstitutionalization fight.”

The next major step toward our current dysfunctional approach to treating mental illness seems at first glance to have begun with a semantic, rather than a policy, decision. When Jimmy and Rosalynn Carter entered the White House in 1977, they already had an interest in mental illness. President Carter wasted no time in establishing the Commission on Mental Health. According to historian of psychiatry Gerald Grob, “the [commissions] decision in 1977 to use mental health rather than mental illness…was based on the application of a public health model that emphasized the role of the environment, social services, and prevention rather than the traditional psychiatric focus on the diagnosis and treatment of severe and persistent mental disorders.”

The dubious notion that external influences, such as stress, social problems, traumatic experiences, and even coercive psychiatric care itself are the primary causes of severe mental illness still thrives today in influential quarters, as we will see.

the recovery model

A quarter-century after the Carter commission, in 2002, President George W. Bush revisited the problem of public mental-health care by appointing a commission of his own, called the New Freedom Commission on Mental Health. The commission was charged with conducting a “comprehensive study” of the existing system and advising President Bush on improvements. The 2003 report issued some positive suggestions regarding, for example, the need for an increased number of psychiatric beds and better programs to help disabled patients participate in the workforce. But the Bush commission, like Carters before it, elided the distinction between mental health and mental illness and failed to grapple with approaches to patients with severe mental illness who refused to take medication and had a potential for violence.

Instead, the Bush commission promoted an overly optimistic treatment philosophy that came to be called the “recovery model.” It held that with sufficient therapy, housing options, and employment programs, patients with schizophrenia or manic-depressive illness would be able to take charge of their lives. To be sure, a lot of patients are indeed able to do this, especially young people with recent onset of illness. But the recovery models unrealistic one-size-fits-all approach ignored the toughest cases, which often require heavy doses of paternalism because the patients dont acknowledge their own illness — a symptom of being psychotic in and of itself, in many instances. In an un-medicated state, an individuals symptoms remain unabated, behavior remains menacing or erratic, and the risk of violence, particularly if alcohol or cocaine is involved, is increased.

The recovery agenda was inspired by the patients rights movement of the 1960s. This campaign for enlightened care, which included better quality of treatment, collaboration with physicians, and assurance of privacy of health information, was a sensible reaction to the heavy strain of paternalism that marked the medical field at one time. Psychiatry, in particular, attracted the animus of patients rights activists; after all, it is a field whose very nature requires professionals to make fraught judgments about the normal or abnormal thoughts, behaviors, and identities of their patients. Whats more, for better or worse, psychiatrists may impose tacit or actual control over their patients.

Consequently, the psychiatric patients rights movement took on a radical tenor. Spurred by a 1960s ethos of social justice, activists saw themselves as a class of social dissidents and psychiatry as an agent of social control. The Insane Liberation Front was founded in 1970 in Portland, Oregon. In 1971, the Mental Patients Liberation Project and the Mental Patients Liberation Front appeared in New York and Boston, respectively. The next year, former patients in San Francisco organized the Network Against Psychiatric Assault and the Madness News Network. They have championed the rights of severely ill patients to refuse treatment, representing the expressed wishes of their clients (patients) even when they are delusional, and they have campaigned against involuntary commitment, as well as electroshock therapy, which is one of the safest and most effective treatments for severe depression. So what do these activists prescribe as an alternative? Political empowerment.

By the 1980s, the movement had spawned a new identity known as the “consumer-survivor,” which persists to this day. In this iteration of the psychiatric patients rights movement, dynamics such as identity politics (with the mentally ill playing the role of minority population), disability status, and a sense of entitlement to public services play a larger role than they did in the 60s and 70s. Compared to their earlier counterparts who saw themselves as dissenters, not patients, these consumer-survivors actually do see themselves as ill. “Consumer” is the politically correct word for patient, and “survivor” refers to one who has survived psychiatric care. The most vocal anti-psychiatry consumer-survivor groups are the National Empowerment Center near Boston and the Nation Mental Health Consumers Self-Help Clearinghouse in southeastern Pennsylvania. Funded in part by the federal government and state mental-health agencies, these groups lobby against involuntary treatment and electroconvulsive therapy, and they discourage patients from taking medication.

As with the anti-vaccine movement, such trends always have the capacity to be damaging, but vocal, misguided fringe groups are not a rare occurrence in the United States, especially when it comes to health care. The difference is that these groups have the financial support of the U.S. government; thus, taxpayer money is being used to make things worse.

failing the most vulnerable

The Substance Abuse and Mental Health Services Administration, an agency within the Department of Health and Human Services known by its acronym, SAMHSA, bolsters the consumer-survivor agenda ideologically, programmatically, and financially. It is a striking example of government working at cross-purposes to the best interests of its most desperate constituents.

The agencys entire budget for mental health is around $1.1 billion. (The remainder of its full budget of $3.6 billion is earmarked for prevention and treatment of substance abuse.) Of the $1.1 billion mental-health budget, $482 million goes into block grants to the states for mental-health services, and the remainder goes to other programs for adults and children, the homeless, and Protection and Advocacy (described further below). Given that federal mental-health expenditures total $130 billion annually, mostly in the form of Medicaid, the SAMHSA budget seems modest. But the agency manages to leverage its funds in ways that not only shortchange but actively undermine the welfare of the sickest patients.

For one thing, SAMHSA claims to receive much of its policy input from groups of consumers that it occasionally convenes. These people may have psychiatric problems but generally need only low-levels of support, and many do not take medication. They do not represent the most impaired patients — the ones who are languishing in jails, in emergency rooms, or on the streets. Such people are too lost in their psychosis to show up for a focus group or to embrace the “recovery agenda.” Indeed, approximately half of all untreated people with a psychotic disorder do not acknowledge they are ill, which is itself a neurological condition called anosognosia.

There is a vital role for benign paternalism toward this highly vulnerable set of patients, but the culture of mental health as practiced by SAMHSA effectively denies their existence, let alone their needs. To be sure, the psychiatric profession was once dismissive and too pessimistic about many people who were indeed capable of greater independence, but there is no denying that now a subset of the mentally ill needs much more oversight and, at times, even benign coercion.

SAMHSAs worldview is reflected in the nature of its discretionary grants and programs, some of which completely undermine the best interests of patients with severe mental illness. For example, the agency is a major funder of groups that are overtly opposed to medically accepted psychiatric care. The National Empowerment Center, based in Lawrence, Massachusetts, is one beneficiary of SAMHSA funds. Its mission is “to carry a message of recovery, empowerment, hope and healing to people with lived experience with mental health issues, trauma, and/or extreme states.” The NECs Chief Operating Officer has been a long-time critic of the use of psychiatric medications.

The Washington, D.C.-based National Coalition for Mental Health Recovery is a trade group for recipients of agency largesse. Its mission is to ensure “consumer/survivors have a major voice in…policies at the state and national levels.” The coalition and its smaller, composite organizations oppose the type of services — civil commitment, increased hospital capacity — that target the most impaired. Another example is the Alternatives Conference, which is funded by SAMHSA each year. Among other things, attendees with mental illness are taught how to go off their psychiatric medications. In 2011, SAMHSA gave one of its annual “Voice Awards” to an activist who believes that “[p]sychiatry is not medical because it is not scientific. It does not diagnose or treat actual conditions. It is complete fiction. Voodoo witch doctors have a better cure rate.”

Apart from awarding grants, SAMHSA runs its own programs, perhaps the most painfully misguided of which is the Protection and Advocacy program. Established by Congress, the original, benign intent of the Protection and Advocacy for Individuals with Mental Illness Act of 1986, or P&A, was to investigate allegations of patient abuse, neglect, and rights violations in hospital wards or in residential facilities. Mission creep soon set in, however. As Rael Jean Isaac and Virginia Armat documented in their 1990 book Madness in the Streets, P&A quickly devolved into “playgrounds for anti-psychiatric activists.”

The P&A program operates with $39 million, distributed among the states. The local P&A agencies routinely flout congressional intent by lobbying state legislatures against adopting sensible treatment policies and against strengthening their civil-commitment laws. Making matters worse, they do so at the expense of conducting investigations into the mistreatment of patients. Amanda Peters of South Texas College of Law has closely examined P&A programs, and has found that their lawyers and personnel are so preoccupied with fighting civil-commitment policies and trying to liberate undeniably psychotic patients from hospitals that glaring violations of abuse and neglect go unchecked.

Many P&A lawyers are against hospitalization at any cost, to sometimes tragic result. Consider the story of Joe Bruce of Caratunk, Maine, whose psychotic son is now a murderer because of Maines P&A agency. In 2006, 24-year-old William Bruce was a patient at Riverview Psychiatric Center, where he had been committed after assaulting his father. His parents were afraid of their son and begged the hospital to medicate him with the antipsychotic that had previously quelled his paranoia and aggression. Williams psychiatrists, who had observed him for weeks as an inpatient, fought against Williams pleas for release because he remained paranoid and agitated. Nonetheless, the P&A legal advocates insisted that William was “competent” for discharge and openly coached him — as any lawyer would his client — on how to placate the doctors so theyd let him go. William and his lawyers somehow prevailed over his doctors and parents objections, and Riverview discharged him. Two months later, he killed his mother with a hatchet. The Bruce familys story is one of the most dramatic, but by no means one of the only, examples of the reckless “liberation” of dangerous or debilitated patients at the hands of a P&A agency.

For decades, HHS and SAMHSA have mismanaged the mental-illness resources of the federal government, focusing increasingly on “recovery agendas” instead of on the severely mentally ill. Our most vulnerable citizens are slipping through the cracks. It is long past time for a better, more serious mental-illness agenda.

prescriptions for mental health

Like Presidents Kennedy, Carter, and Bush, the next president could do a great deal to improve the nations mental-health system. The most radical, most effective approach might be to propose legislation to abolish SAMHSA altogether, holding on to those pieces worth saving, such as the collection of statistics, by assigning them to the Centers for Disease Control and Prevention, the National Institutes of Mental Health, or other appropriate government agencies. Charges of abuse (such as excessive use of physical restraints) and neglect could be handled by the Department of Justice. The block grants could be distributed by the Human Resources and Services Administration.

Whether or not SAMHSA is shut down, it is imperative that the next director of federal mental-health initiatives, perhaps working directly out of HHS, be a psychiatrist or psychologist with extensive experience treating and managing systems that target severely and persistently ill patients. (Currently, SAMHSA does not employ a single psychiatrist among its staff of 570, let alone in a leadership or key advisory position.) In 2013, an experienced psychiatrist joined as medical director, but she quit two years later because of what she described as “an open hostility toward psychiatric medicine by those at the helm of the agency. The concept of mental disorders as diseases was rejected.”

A SAMHSA leader who understands the clinical needs of the sickest patients and prioritizes these demands — and who is backed by the secretary of HHS — would instinctively make profound changes. He would cease grant-making to advocacy organizations whose members deliberately undermine the validity of professional help and medications and those who lobby against commitment policies at the state and federal levels. The medical-director slot would be filled by a psychiatrist who endorses mainstream views on the value of medication, the importance of promoting tested programs over a feel-good “wellness” and “empowerment” agenda, and the need for inpatient services. An enlightened agency leader would invest in research aimed at the sickest patients and accept the notion that paternalistic strategies are legitimate and necessary for some of them. Finally, such a leader would contain P&As mission creep and ensure that program funds go solely to the investigation of abuse and neglect, as was the programs original congressional mandate.

Medicaid needs improvements, too. To address the bed shortage, for example, Congress could base eligibility for Medicaid reimbursement solely upon an individuals need for care, rather than upon the location in which it is delivered. Another option is raising the limit on the number of psychiatric beds for which Medicaid will pay, to allow larger facilities already specializing in mental illness to fall outside of the scope of the IMD exclusion. Alternatively, more states could be allowed to use Medicaid Section 1115 waivers — as some already are — to draw down reimbursement for services provided in IMDs. Not surprisingly, some advocates argue against these ideas, concerned that they will re-open the door to institutionalization.

Some policymakers suggest simply expanding the number of psychiatric beds in general hospitals, but economies of scale (a benefit of larger psychiatric institutions) would be lost. Nor would general hospital units be able to reproduce the therapeutic milieu that characterizes a quality inpatient unit. Whats more, general hospitals are reluctant to admit the sickest psychiatric patients, who are often disruptive, sometimes violent, and difficult to treat and require additional nursing.

To inform lawmakers debating this complicated issue, the federal Centers for Medicare & Medicaid Services is funding the Medicaid Emergency Psychiatric Demonstration, mandated by the Affordable Care Act. Eleven states and the District of Columbia are using Medicaid funds to pay for inpatient emergency psychiatric care in psychiatric hospitals for patients aged 21 to 65 without the 16-bed restriction. By focusing on psychiatric emergencies, the three-year demonstration, which began in 2012, also attempts to explore a potential remedy to alleviate burdens placed on general-hospital emergency rooms by psychiatric patients for whom no bed is available.

Medicaid administrators also need more flexibility to cover the unique kinds of help, beyond standard fee-for-service visits for medication and therapy, which enable mentally ill individuals to thrive in the community. These may include Fountain House-type clubhouses (private, non-profit community centers that provide job training, socialization opportunities, and computer access) and various other types of assistance with staying in school or holding down a job. Assertive Community Treatment teams — intensive 24-hour outpatient supervision by clinical teams linking patients to needed medical and social services — would save money and reduce days in the hospital, but they currently have no reliable source of public funding. The same is true of Forensic Assertive Community Treatment, an adaptation of the ACT model that has been shown to reduce criminal recidivism through criminal-justice collaborations.

The good news is that there is active experimentation. In addition to emergency-room demonstrations now underway, Congress authorized a $1.1 billion, eight-state demonstration program in 2014 for a new type of community-based clinic focused on behavioral health. The Excellence in Mental Health Act, spearheaded by Democratic senator Debbie Stabenow of Michigan and signed into law in April 2014, created criteria for facilities to become “certified community behavioral health clinics.” (In 2016, Stabenow and Republican senator Roy Blunt of Missouri introduced a bill expanding the law to provide additional funding for 24 states to launch a demonstration program to tackle payment reform in behavioral health.)

These clinics are required to provide a wide range of services, such as the kinds provided by ACT teams. States will apply to develop a prospective-payment arrangement with clinics to cover all necessary treatment, a so-called flexible funding stream that supplants service-by-service reimbursement. After two years, these pilot programs may be replicated nationwide. Ultimately, certified clinics will be eligible for Medicaid reimbursement as the sole source of payment for patients.

Flexible funding streams will figure prominently in approaches to treating young people, generally in their late teens and early 20s, who are in the early stages of schizophrenia. Psychiatrists now know that the amount of time between the onset of psychotic symptoms and the beginning of treatment is very important in determining response to care. An especially promising study, Recovery After an Initial Schizophrenia Episode, just completed its first wave of trials in the fall of 2015 and attests to the value of aggressive intervention for first-episode psychosis. These data, derived from research funded by the National Institutes of Mental Health, show that a tightly coordinated team approach, including the patient, professionals, and family members, led to greater symptom control and more involvement in work and school than experienced by patients receiving treatment as usual. The team provides medication (at the lowest dose necessary), therapy for coping with stress, education for loved ones about the disease, supported employment or education for the patient once symptoms are under control, and personalized case management. Currently, these teams are in the research stage, but when they become standard practice, payment systems will need to accommodate wrap-around services en bloc instead of traditional fee-for-service arrangements.

Some additional relief has come with the Affordable Care Act of 2010, which included a provision to expand Medicaid. Currently, 31 states plus the District of Columbia have opted in to the Medicaid expansion, which means the federal government — rather than those states — will pay for the great bulk of the outpatient and hospital treatment of newly qualified low-income people. This has the potential to help individuals who are mentally ill or in the early stages of serious illness, especially young men, who are not yet designated disabled. (The IMD exclusion remains in place.) The laws requirement that young adults up to age 26 be able to stay on their parents insurance plans is also helpful in this regard, as it preserves access to psychiatric care right at the moment some will first be developing psychosis.

These encouraging developments are tempered, unfortunately, by a looming crisis in public-sector psychiatry, especially in inner-city and rural areas and especially for patients on Medicaid. While the number of all physicians in the United States rose by 45% from 1995 to today, the number of psychiatrists increased by only 12% — and over half are aged 55 or older and will soon retire. Medical students choosing the field of psychiatry are fewer in number than in decades past, in part because many graduates face huge debt burdens, and psychiatry is among the lowest-paid of the medical specialties — especially in clinics and public hospitals where psychiatrists are needed the most.

benign paternalism versus jail time

Even if these reforms were successfully undertaken and the mentally ill were granted broader access to care, however, it would not be enough to ensure that the sickest individuals received the care they needed. One of the hallmarks of severe mental illness is that patients often deny that anything is wrong with them. So for many patients with severe mental illness, a strong dose of paternalism is often required to keep them from descending further into psychosis, self-neglect, and disruptive behavior, which can range from public disturbance or destruction of property to outright violence.

Assisted outpatient treatment, or AOT, a cost-saving and effective form of civil-court-ordered community treatment, is aimed at individuals who have a well-established pattern of falling into a spiral of self-neglect, self-harm, or dangerousness when off medication. AOT allows judges to order these individuals into mandated and monitored treatment while they continue to live in the community. In some states, violation of the court-ordered conditions can result in the individual being hospitalized for further treatment. According to a review of studies by the Virginia-based Treatment Advocacy Center, AOT has reliably reduced homelessness, re-arrest, incarceration, hospitalization, and suicide by half to 74%, thereby cutting long-term health-care costs in half.

The main problem with AOT is that it is too rarely used. Forty-five states permit the use of AOT, also called “outpatient commitment,” but, due to a lack of funding and unfamiliarity with the AOT process or philosophy (which is constantly denounced by activist “consumers” in state houses), it is not applied as robustly as it should be.

In addition to AOT, which is a civil remedy, entities known as Mental Health Courts exist for those charged with criminal offenses. These courts embrace a therapeutic rather than a punitive approach, but use the power of the court to enforce ordered treatment. Defendants who agree to participate receive a treatment plan and other community-supervision conditions. Those who adhere to their treatment plan for the agreed-upon period of time see either their cases dismissed or their sentences greatly reduced. If the defendant does not comply with the conditions of the court, or decides to leave the program, his case returns to the original criminal calendar where prosecution proceeds as normal.

As a rule, most Mental Health Courts use a variety of intermediate sanctions in response to non-compliance before ending a defendants participation. At present, there is only a modest number of courts, but a 2012 Urban Institute evaluation yielded promising results: Participants in two New York City Mental Health Courts were significantly less likely to re-offend than similar offenders whose cases were handled in the traditional court system.

Law enforcement has a large role to play as well. Increasingly, emergency 911 calls for “mental disturbance” are being met by law-enforcement officials who have received crisis intervention training, or CIT. Not only do they learn how to defuse tense, potentially violent situations, but police are also taught to distinguish criminal acts from erratic behaviors due to psychosis. The first CIT program was established in Memphis in 1988, after a police officer shot a man with a serious mental illness. The program came to be known as the “Memphis Model,” and it is now a popular, 40-hour curriculum, developed in collaboration with local academics, family members of ill individuals, and the Memphis police department. It teaches police how to respond safely to a person in crisis, and includes information about the local mental-health system and laws, and about how to recognize mental illness and link people with appropriate treatment, as well as guidelines for interacting with disturbed people who are extremely agitated or aggressive. CIT can reduce arrests, injuries to police, and the need for SWAT intervention. Unfortunately, however, fewer than 20% of law-enforcement agencies train their officers, according to the National Alliance for the Mentally Ill, an advocacy group representing concerned family members.

Finally, individuals who are dangerous to others, suicidal, or unable to care for themselves may need to be hospitalized, regardless of their cooperation. Coerced care has long been a fraught issue. It pits an individuals liberty against societys safety. It also creates a tension between an ill persons “freedom” to act afoul of his own best interests and his potential to benefit from therapeutic intervention. Each case requires courts and lawyers to balance these interests as fairly and delicately as possible. The majority of states have a “grave disability” standard, an explicit and broad designation that focuses on a persons ability to feed, clothe, and protect himself. But the freedom to be psychotic and endangered is not a meaningful freedom at all. More states should adopt the “need for treatment” standard. This approach, which is in effect in about half the states, allows a court to intervene in a crisis. These standards are particularly relevant for individuals who lack insight into their illnesses.

These approaches — AOT, Mental Health Courts, crisis-trained law enforcement, and sensible commitment laws — can help divert mentally ill people from the correctional system. Though states determine their own investments in these options, the federal government could incentivize their use through extra resources or tie block-grant funding to the existence and smooth operation of AOT laws, Mental Health Courts, and need-for-treatment statutes.

the politics of mental-illness reform

Some of these solutions are currently under consideration on Capitol Hill, and constructive changes may be afoot. The furthest-reaching of the proposed mental-health bills introduced in the 114th Congress is the bipartisan Helping Families in Mental Health Crisis Act of 2015, championed by Pennsylvania congressman Tim Murphy, a child psychologist, and Texas congresswoman Eddie Bernice Johnson, a former psychiatric nurse. The cornerstone of the bill is new executive leadership in the form of an assistant secretary for Mental Health and Substance Abuse; this individual would be appointed by the secretary of HHS and subject to Senate confirmation. Funding and authority over SAMHSA would be brought under the assistant secretary who would be required to focus on both severe mental illness — thereby ensuring that adequate resources are targeted at reducing homelessness, arrest, incarceration, hospitalization, suicide, and violence among people with untreated illness — and coordinating the federal governments larger response.

The Murphy-Johnson bill would also rein in the Protection and Advocacy program, mandating an exclusive focus on safeguarding patients rights to be free from abuse and neglect. It also forbids P&A offices from lobbying federal, state, or local governmental entities and prohibits their efforts to secure discharge of patients “with a serious mental illness who [lack] insight into their condition on refusing medical treatment.” In addition, the bill encourages states to develop assisted outpatient treatment capacity and provides a financial bonus when they set up such programs. Murphy-Johnson also clarifies mental-health information privacy standards under the long-contested Health Insurance Portability and Accountability Act, known as “HIPAA,” so that medical personnel can communicate in detail with patients families in emergency situations.

Further, the legislation mandates that Medicaid cover inpatient care, no matter a facilitys bed count, as long as that facility or hospital has an average length of stay of fewer than 30 days. It also allows a Medicaid patient to visit more than one health-care provider in a given day, a boon for coordinated care. Notably, Murphy-Johnson increases the demonstration authority regarding “certified community behavioral health clinics” from eight states to 10 states and lengthens the time frame from two years to four years. The legislation also expands training and educational opportunities to ensure a sufficient number of providers.

The Murphy-Johnson bill has garnered considerable bipartisan support, and a similar companion bill has been introduced in the Senate, co-sponsored by Senators Chris Murphy and Bill Cassidy. But the legislation has met resistance on several fronts. The first stumbling blocks are basic legislative barriers such as the anticipated cost of the bill, crowded committee and floor schedules, and the fact that the bill falls into several different committee jurisdictions. As of mid-February, the Murphy-Johnson bill was wending its way through the House, having been marked up by the Health Subcommittee of the Energy and Commerce Committee.

Second, advocacy groups that receive funding from SAMHSA are protesting because their financial lifeblood is being threatened. More broadly, the mental-health consumer lobby fears that the bills provisions to increase bed space, strengthen commitment laws, and restrict the advocacy system will effectively send patients back to the asylum. According to the National Coalition for Mental Health Recovery — the trade organization representing SAMHSA-funded anti-psychiatry groups — the Murphy-Johnson bill “will set back community mental health care and undermine much of what our movement has worked so hard to achieve.”

Third, despite broad bipartisan support — 185 co-sponsors as of this writing — a cohort of Democrats has lined up against Murphy-Johnson. In a letter to the chairmen of the House Energy and Commerce Committee, the lawmakers expressed their “strong” opposition to elements of the bill that, they claim, “would restrict patients civil rights.” They refer specifically to the privacy-rule clarification (which supposedly “discriminates” against people with mental illness because no other medical conditions are singled out for special privacy considerations). The opponents decry AOT as being too restrictive because it targets patients who are not in immediate danger — the strict commitment standard they endorse — rather than merely at great risk of harm to self or others when untreated. They also reject the proposed limits on the activities of the Protection and Advocacy agencies.

Fourth, the recent, high-profile shootings in Roanoke, Virginia, and Roseburg, Oregon, have jeopardized prospects for mental-health reform. The incidents re-ignited the simmering tension between political parties as to whether such violence is more aptly attributable to the availability of high-powered guns or to the broken mental-health system, whose many fault lines allow ill people who are armed to slip into classrooms, movie theaters, and college campuses. This has resulted in a stalemate: Democrats refuse to move on mental-health legislation because Republicans refuse to pass gun-control legislation.

Some have tried to find common ground, though. Last fall, Republican senator John Cornyn promoted his NRA-endorsed Mental Health and Safe Communities Act of 2015, which tried to achieve consensus by revising the background-check system to help keep guns out of the hands of the mentally ill. But the measure falls far short of what Democrats have labeled “common-sense gun-control policies,” and so the legislation is likely to go nowhere. More encouraging, Democratic senator Al Franken’s measure that provides crisis-intervention training, funding for mental-health courts, veterans-treatment courts, and training for state and federal law-enforcement officers was approved by the Senate. And the omnibus bill passed last December provides funding for assisted outpatient treatment programs, the first time Congress has fully funded these programs. (Notably, separate grants for the same kind of AOT programs remain a major stumbling block in the debate over Representative Tim Murphys mental-health legislation in the House.) Finally, in early January, President Obama announced $500 million for expanding access to mental-health treatment as part of a series of executive actions aimed at curbing gun violence, but did not elaborate on how it would be spent.

treating the american psychosis

The right reforms can reduce the suffering of people with serious mental illness — and can protect them and improve their quality of life. That prescription entails forging better connections between institutions, and providing more quality care and community support and more psychiatric beds. We should not be afraid of creating benign asylums, especially residential psychiatric entities — ideally situated in rural areas so that patients can tend to animals and farms — that are true to the spirit of asylum: places of respite and safety. We should practice humane paternalism when needed.

This last point poses the greatest challenge to creating a system that is fully responsive to the needs of the sickest patients — that small fraction of people with severe mental illness who often require containment or intensive supervision against their will for brief periods of time and sometimes for long stretches. Some cast such intervention as an inexcusable encroachment on personal freedom. But when a persons thinking is warped by hallucination or delusion, he is not able to exercise meaningful freedom and might even endanger himself or others. The very point of involuntary intervention is to improve or restore the patients power of self-determination. Failure to recognize the need for this kind of action amounts to a refusal to face clinical reality.

What is the treatment for this American Psychosis, as it has been called? In the short term, we need more evidence that paternalistic strategies can be used humanely to produce positive results. The more effective they are, the more receptive localities will become to their use. Creating tighter community safety nets and opening up more beds will make these intrusive tactics less necessary in the first place, but the need will probably never disappear — precisely because a common feature of chronic psychosis is a lack of insight into one’s own impairment. Hopefully, over the long term, we might be able to narrow the pipeline of pathology by intervening when early signs of illness appear.

We must get rid of the distractions. We should not use government largesse to bolster opponents of benign paternalism. And we must not pit guns against patients. These are separate issues, each worthy of serious attention. Mental-health reform needs all the champions it can get. Strong political leadership could make a world of difference.

Sally Satel is a psychiatrist and a resident scholar at the American Enterprise Institute.

E. Fuller Torrey is a psychiatrist and founder of the Treatment Advocacy Center, a non-profit working to eliminate barriers to treatment for people with severe mental illnesses.

12 Ways to Be a White Ally to Black People

Michael Brown, an African-American teenager, was shot six times and killed by Darren Wilson, a white police officer, during a stop for jaywalking in Ferguson, Mo. Some facts are uncontroverted: Brown was unarmed when he was shot about 35 feet away from Wilson, who didn’t know that Brown was a suspect in an alleged shoplifting incident that occurred a short time before the shooting. Other facts are disputed: Some people claim that Brown attacked Wilson, and others claim that Brown was running away from Wilson with his hands in the air. Either way, another young black man is dead because of use of excessive force by the police in a situation that did not justify shooting to kill.

Most of us have watched as Ferguson’s black community rose up in outrage against the almost all-white police department, demanding justice and accountability. Our disbelief and heartache turned to collective anger and fear as the response to the protests became more militarized, with the deployment of police dogs, riot gear, tear gas and rubber bullets. And we’ve started speaking out in opposition to these developments, all of which have the hallmarks of being rooted in systemic, institutionalized racism.

Yet some people, especially some white people, have not yet become engaged. Perhaps they don’t know what to say or how to say it or are concerned about backlash from other white people. This is understandable but not acceptable when the continuation of white silence and inaction means the oppression and death of black people.

So let’s talk about an active role for white people in the fight against racism, because racism burdens all of us and is destroying our communities. White people have a role in undoing racism because white people created and, for the most part, currently maintain (whether they want to or not) the racist system that benefits white people to the detriment of people of color.

White people who hate racism should work hard to become white allies. Here are some ways for a white person to become engaged, thoughtfully and critically, in examining the crisis in Ferguson and systemic racism in America.


1. Learn about the racialized history of Ferguson and how it reflects the racialized history of America. Brown’s killing is not an anomaly or a statistical outlier. It is the direct product of deadly tensions born from decades of housing discrimination, white flight, intergenerational poverty and racial profiling.

2. Reject the “He was a good kid” or “He was a criminal” narrative and lift up the “Black lives matter” narrative. Those who knew him say Brown was a good kid. But that’s not why his death is tragic. His death isn’t tragic because he was on his way to college the following week. His death is tragic because he was a human being and his life mattered. The good-kid narrative might provoke some sympathy, but what it really does is support the lie that as a rule black people, black men in particular, have a norm of violence or criminal behavior. The good-kid narrative says that this kid didn’t deserve to die because his goodness was an exception to the rule. This is wrong. This kid didn’t deserve to die, period. Similarly, reject the “He was a criminal” narrative surrounding the convenience store robbery because even if Brown did steal some cigars and have a scuffle with the shopkeeper, that is still not a justification for his killing. All black lives matter, not just the ones we deem to be “good.”

3. Use words that speak the truth about the disempowerment, oppression, disinvestment and racism that are rampant in our communities. Be mindful, and politically and socially aware with your language. Notice how the mainstream news outlets are using words like “riot” and “looting” to describe the uprising in Ferguson. What’s happening is not a riot. The people are protesting with a righteous anger. This is a justified rebellion.

4. Understand the modern forms of race oppression and slavery and how they are intertwined with policing, the courts and the prison-industrial complex.Black people aren’t enslaved on the plantation anymore. Now African Americans are locked up in for-profit prisons at disproportionate rates and for longer sentences for the same crimes committed by white people. And when we’re released we’re second-class citizens, stripped of voting rights in some states and denied access to housing, employment and education. Mass incarceration is the new Jim Crow.

5. Examine the interplay between poverty and racial equity. The twin pillar of racism is economic injustice, but don’t use class issues to trump race issues and avoid the racism conversation. Although racism and class oppression are tangled together in this country, the fact remains that the No. 1 predictor of prosperity and access to opportunity is race.

6. Diversify your media. Be intentional about looking for and paying close attention to diverse voices of color on television, on radio, online and in print to help shape your awareness, understanding and thinking about political, economic and social issues.

7. Adhere to the philosophy of nonviolence as you resist racism and oppression. Martin Luther King Jr. advocated for nonviolent conflict reconciliation as the primary strategy of the civil rights movement and the charge of his “final marching orders.” East Point Peace Academy offers online resources and in-person training on nonviolence that is accessible to all people, regardless of ability to pay.

8. Find support from fellow white allies. Challenge and encourage one another to dig deeper, even when it hurts and especially when you feel confused, angry and hopeless, so that you can be more authentic in your shared journey with people of color to protect principles of anti-racism and equity. Go to workshops like Training for Change’s Whites Confronting Racism or the People’s Institute’s European Dissent. Attend the White Privilege Conference or the Facing Raceconference. Some organizations offer scholarships or reduced fees to help people attend.

9. If you are a person of faith, look to your Scriptures or other holy texts for guidance. Seek out faith-based organizations like Sojourners, and follow faith leaders who incorporate social justice into their ministry. Ask your clergyperson to address anti-racism in sermons and teachings. If you are not a person of faith, learn how the world’s religions view social-justice issues so that when you have an opportunity to invite people of faith to also become white allies, you can talk with them meaningfully about why being a white ally is supported by their spiritual beliefs.

10. Don’t be afraid to be unpopular. If you start calling out all the racism you witness (and it will be a lot, once you know what you’re seeing), some people might not want to hang out with you as much. But think about it like this: Staying silent when you witness oppression is the same as supporting oppression. So you can be the popular person who stands with oppression, or you can be the (maybe) unpopular person who stands for equality and dignity for all people. Which person would you prefer to be?

11. Be proactive in your own community. As a white ally, you are not limited to reacting only when black people are subjected to violence very visibly and publicly. Moments of crisis do not need to be the catalyst. Taking action against systemic racism is always appropriate because systemic racism permeates this country. Some ideas for action: Organize a community conversation about the state of police-community relations in your neighborhood; support leaders of color by donating your time or money to their campaigns or causes; ask the local library to host a showing of, and discussion group about, the documentary Race—the Power of an Illusionattend workshops to learn how to transform conflict into opportunity for dialogue. Gather together white allies who represent the diversity of backgrounds in your community. Anti-racism is not a liberals-only cause. Anti-racism is a movement for all people, whether they are conservative, progressive, rich, poor, urban or rural.

12. Don’t give up. We’re 400 years into this racist system, and it’s going to take decades—centuries, probably—to dismantle. The anti-racism movement is a struggle for generations, not simply the hot-button issue of the moment. Transformation of a broken system doesn’t happen quickly or easily. You may not see or feel the positive impact of your white allyship during the next month, the next year, the next decade or even your lifetime. But don’t ever stop. Being a white ally matters because you will be part of what turns the tide someday. Change starts with the individual.

People of color cannot and should not shoulder the burden for dismantling the racist, white-supremacist system that devalues and criminalizes black life without the all-in support, blood, sweat and tears of white people. If you are not already a white ally, now is the time to become one.

Editor’s note: A version of this article was previously published at What Matters.

101 Fantastic Ideas for Students when Feeling College is TOO MUCH

I think that, for most of us, there are times in life when it all just feels like Too Much. Can you say #SelfCare?

There may be some days, weeks, months, maybe even years when — for whatever reason — just getting through the day or going to work or putting one foot in front of the other feels hard. Really, really hard.


Maybe it’s because you’re wrestling with anxiety, depression, or some other mental illness.

Maybe it’s because you’ve had your heart broken. Maybe you’ve gone through a physical or emotional trauma. Maybe you’re deeply grieving. Or maybe there’s no easily understood reason for why you’re feeling bad.

Whatever the case, I want you to know that it’s OK if you’re going through a tough time.

This doesn’t make you any less lovable, worthy, or capable. This just means you’re human. Being a human can be a messy, hard, confusing, painful experience sometimes.

So if you or someone you love is going through one of these tough times right now, a time where it all just feels like too much, I want to offer up 101 suggestions for self-care to help you or your loved one get through this time.

Photo via iStock.

1. Have a good, long, body-shaking cry.

2. Call a trusted friend or family member and talk it out.

3. Call in sick. Take comp time if you can. Take a mental health day.

4. Say no to extra obligations, chores, or anything that pulls on your precious self-care time.

5. Book a session (or more!) with your therapist.

6. Dial down your expectations of yourself at this time. When you’re going through life’s tough times, I invite you to soften your expectations of yourself and others.

7. Tuck yourself into bed early with a good book and clean sheets.

8. Watch a comforting/silly/funny/lighthearted TV show or movie. (“Parks and Recreation,” anyone?)

9. Reread your favorite picture and chapter books from childhood.

10. Ask for some love and tenderness from your friends on social media. Let them comment on your post and remind you that you’re loved.

11. Look at some some really gorgeous pieces of art.

12. Watch YouTube videos of Ellen DeGeneres and the adorable kids she has on her show.

13. Look at faith-in-humanity-restoring lists from around the internet.

14. Ask for help. From whomever you need it — your boss, your doctor, your partner, your therapist, your mom. Let people know you need some help.

15. Wrap yourself up in a cozy fleece blanket and sip a cup of hot tea.

16. Breathe. Deeply. Slowly. Four counts in. Six counts out.

17. Hydrate. Have you had enough water today?

18. Eat. Have you eaten something healthy and nourishing today?

19. Sleep. Have you slept seven to nine hours? Is it time for some rest?

20. Shower. Then dry your hair and put on clothes that make you feel good.

21. Go outside and be in the sunshine.

22. Move your body gently in ways that feel good. Maybe aim for 30 minutes. Or 10 minutes if 30 feels like too much.

23. Read a story (or stories) of people who overcame adversity or maybe dealt with mental illness, too. (I personally admire J.K. Rowling’s story.)

24. Go to a 12-step meeting. Or any group meeting where support is offered. Check out church listings, hospital listings, or school listings, for example.

25. If you suspect something may be physiologically off with you, go see your doctor and/or psychiatrist and talk to them. Medication might help you at this time, and professionals can assist you in assessing this.

26. Take a long, hot bath. Light a candle and pamper yourself.

27. Read inspirational quotes.

28. Cuddle someone or something. Your partner. A pillow. Your friend’s dog.

29. Read previous emails, postcards, letters, etc. from friends and family reminding you of happier times.

30. Knit. Sculpt. Bake. Engage your hands.

31. Exhaust yourself physically — running, yoga, swimming, whatever helps you feel fatigued.

32. Write it out. Go free-form in a journal or on a computer. Get it all out and vent.

33. Create a plan if you’re feeling overwhelmed. List out what you need to do next to tackle and address whatever you’re facing. Chunk it down into manageable and understandable pieces.

34. Remind yourself you only have to get through the next five minutes. Then the next five. And so on.

35. Take five minutes to meditate.

36. Write out a list of 25 reasons you’ll be OK.

37. Write out a list of 25 examples of things you’ve overcome or accomplished.

38. Write out a list of 25 reasons you’re a good, lovable person.

39. Write out a list of 25 things that make your life beautiful.

40. Sniff some scents that bring you joy or remind you of happier times.

41. Ask for support from friends and family via text if voice-to-voice contact feels like too much. Ask them to check in with you via text daily or weekly, whatever you need.

42. Lay down on the ground. Let the Earth or floor hold you. You don’t have to hold it all on your own.

43. Clean up a corner of a room of your house. Sometimes tidying up can help calm our minds.

44. Ask yourself: What’s my next most immediate priority? Do that that. Then ask the question again.

45. Read some poetry. RumiHafiz, and Mary Oliver are all excellent.

46. Take a tech break. Delete or deactivate social media if it feels too triggering right now.

47. Or maybe get on tech. If you’ve been isolating, maybe interacting with friends and family online might feel good.

48. Go out in public and be around others. You don’t have to engage, but maybe sit in a coffee shop or on a bench at a museum and soak up the humanity around you.

49. Or if you’re feeling too saturated with contact, go home. Cancel plans and tend to the introverted parts of yourself.

50. Ask friends and family to remind you that things will be OK and that what you’re feeling is temporary.

51. Put up some Christmas lights in your bedroom. They often make things more magical.

52. Spend a little money and treat yourself to some self-care and comfort. Maybe take a taxi versus the bus. Buy your lunch instead of forcing yourself to pack it. Buy some flowers that delight you.

53. Make art. Scribble with crayons. Splash some watercolors. Paint a rock. Whatever. Just create something.

54. Go wander around outside in your neighborhood and take a look at all the lovely houses and the way people decorate their gardens. Delight in the diversity of design.

55. Go visit or volunteer at your local animal rescue. Pet some animals.

56. Look at photos of people you love. Set them as the wallpaper of your phone or laptop.

57. Create and listen to a playlist of songs that remind you of happier times.

58. Read some spiritual literature.

59. Scream, pound pillows, tear up paper, shake your body to move the energy out.

60. Eat your favorite, most comforting foods.

61. Watch old “Mister Rogers’ Neighborhood” videos online.

62. Turn off the lights, sit down, stare into space, and do absolutely nothing.

63. Pick one or two things that feel like progress and do them. Make your bed. Put away the dishes. Return an email.

64. Go to a church or spiritual community service. Sit among others and absorb any guidance or grace that feels good to you.

65. Allow yourself to fantasize about what you’re hoping or longing for. There are clues and energy in your reveries and daydreams that are worth paying attention to.

66. Watch autonomous sensory meridian response videos to help you calm down and fall asleep at night.

67. Listen to monks chantingsinging Tibetan bowls, or nature sounds to help soothe you.

68. Color in some coloring books.

69. Revisit an old hobby. Even if it feels a little forced, try your hand at things you used to enjoy and see what comes up for you.

70. Go to the ocean. Soak up the negative ions.

71. Go to the mountains. Absorb the strength and security of them.

72. Go to the forest. Drink in the shelter, life, and sacredness of the trees.

73. Put down the personal help books and pick up some good old-fashioned fiction.

74. Remember: Your only job right now is to put one foot in front of the other.

75. Allow and feel and express your feelings — all of them! — safely and appropriately. Seek out help if you need support in this.

76. Listen to sad songs or watch sad movies if you need a good cry. (“Steel Magnolias,” anyone?)

77. Dance around wildly to your favorite, most cheesy songs from your high school years.

78. Put your hands in dirt. If you have a garden, go garden. If you have some indoor plants, tend to them. If you don’t have plants or a garden, go outside. Go to a local nursery and touch and smell all the gorgeous plants.

79. If you want to stay in bed all day watching Netflix, do it. Indulge.

80. Watch or listen to some comedy shows or goofy podcasts.

81. Look up examples of people who have gone through and made it through what you’re currently facing. Seek out models of inspiration.

82. Get expert help with whatever you need. Whether that’s through therapy, psychiatry, a lawyer, clergy, or something else, let those trained to support you do it.

83. Educate yourself about what you’re going through. Learn about what you’re facing, what you can expect to feel, and how you can support yourself in this place.

84. Establish a routine and stick to it. Routines can bring so much comfort and grounding in times of life that feel chaotic or out of control.

85. Do some hardcore nesting and make your home or bedroom as cozy and beautiful and comforting as possible.

86. Get up early and watch a sunrise.

87. Go outside, set up a chair, and watch the sunset.

88. Make your own list of self-soothing activities that engage all five of your senses.

89. Develop a supportive morning ritual for yourself.

90. Develop a relaxing evening ritual for yourself.

91. Join a support group for people who are going through what you’re going through. Check out the listings at local hospitals, libraries, churches, and universities to see what’s out there.

92. Volunteer at a local shelter or hospital or nursing home. Practice being of service to others who may also be going through a tough time.

93. Accompany a friend or family member to something. Even if it’s just keeping them company while they run errands, sometimes this kind of contact can feel like good self-care.

94. Take your dog for a walk. Or borrow a friend’s dog and take them for a walk.


This kangaroo dog loves walks.

95. Challenge your negative thinking.

96. Practice grounding, relaxation techniques.

97. Do something spontaneous. Walk or drive a different way to work. Order something new off the menu. Listen to a playlist of new songs.

98. Work with your doctor, naturopath, or nutritionist to develop a physical exercise plan and food plan that will be supportive to whatever you’re facing right now.

99. Pray. Meditate. Write a letter to God, the universe, the Source, your higher self — whatever you believe in.

100. As much as you can, try and trust the process.

101. Finally, remember, what you’re going through right now is temporary. It may not feel like that from inside the tough time you’re in, but this too shall pass and you will feel different again someday. If you can’t have faith in that, let me hold the hope for you.

This list is really just a starting point meant to catalyze your own thinking about how you can best take care of yourself during life’s tough times and to spark your curiosity and interest in strengthening your self-care now and ongoing.

It’s not meant to be prescriptive nor do I mean to imply you need to do all or any of these things to take good care of yourself. You are the expert of your own experience, and I trust that you know what’s best for you.

Also, my hope is that in reading this, you’re hearing me say how normal and natural it is to struggle and to have these tough, hard times. It’s part of being human.

You’re not alone in this.

The suggestions and ideas mentioned herein— in no way are a substitute for care or advice from a licensed mental health care clinician, doctor, or other accredited professional. These are self-care coaching suggestions, not therapeutic advice. Moreover, if you feel suicidal or find yourself having suicidal ideations, call the 24/7 National Suicide Prevention Lifeline at 800-273-8255.

Racism’s Emotional Toll on Student Minds

Our screens and feeds are filled with news and images of black Americans dying or being brutalized. A brief and yet still-too-long list: Trayvon MartinTamir RiceWalter ScottEric GarnerRenisha McBride. The image of a white police officer straddling a black teenager on a lawn in McKinney, Tex., had barely faded before we were forced to grapple with the racially motivated shooting in Charleston, S.C.

I’ve had numerous conversations with friends and colleagues who are stressed out by the recent string of events; our anxiety and fear is palpable. A few days ago, a friend sent a text message that read, “I’m honestly terrified this will happen to us or someone we know.” Twitter and Facebook are teeming with anguish, and within my own social network (which admittedly consists largely of writers, academics and activists), I’ve seen several ad hoc databases of clinics and counselors crop up to help those struggling to cope. Instagram and Twitter have become a means to circulate information about yoga, meditation and holistic treatment services for African-Americans worn down by the barrage of reports about black deaths and police brutality, and I’ve been invited to several small gatherings dedicated to discussing these events. A handful of friends recently took off for Morocco for a few months with the explicit goal of escaping the psychic weight of life in America.

It was against this backdrop that I first encountered the research of Monnica Williams, a psychologist, professor and the director of the University of Louisville’s Center for Mental Health Disparities. Several years ago, Williams treated a “high-functioning patient, with two master’s degrees and a job at a company that anyone would recognize.” The woman, who was African-American, had been devastated by racial harassment by a director within her company. Williams recalls being stunned by how drastically her patient’s condition deteriorated as a result of the treatment. “She completely withdrew and was suffering from extreme emotional anxiety,” she told me. “And that’s what made me say, ‘Wow, we have to focus on this.’ ”

In a 2013 Psychology Today article, Williams wrote that “much research has been conducted on the social, economic and political effects of racism, but little research recognizes the psychological effects of racism on people of color.” Williams now studies the link between racism and post-traumatic stress disorder, which is known as race-based traumatic stress injury, or the emotional distress a person may feel after encountering racial harassment or hostility. Although much of Williams’s work focuses on individuals who have been directly targeted by racial discrimination or aggression, she says race-based stress reactions can be triggered by events that are experienced vicariously, or externally, through a third party — like social media or national news events. She argues that racism should be included as a cause of PTSD in the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (D.S.M.).

Williams is in the process of opening a clinical program that will exclusively treat race-based stress and trauma, in a predominantly black neighborhood in Louisville. Shortly after the Charleston shooting, I called Williams to discuss her work; what follows is a lightly edited and condensed transcript of our conversation.

What is race-based stress and trauma?

It’s a natural byproduct of the types of experiences that minorities have to deal with on a regular basis. I would argue that it is pathological, which means it is a disorder that we can assess and treat. To me, that means these are symptoms that are a diagnosable disorder that require a clinical intervention. It goes largely unrecognized in most people, and that’s based on my experience as a clinician.

What are the symptoms?

Depression, intrusion (the inability to get the thoughts about what happened out of one’s mind), vigilance (an inability to sleep, out of fear of danger), anger, loss of appetite, apathy and avoidance symptoms and emotional numbing. My training and study has been on post-traumatic stress disorder for a long time, and the two look very much alike.

Over the weekend, I received several distressing emails and texts from friends who were suffering from feelings of anxiety and depression. Do you think we should all be in treatment?

I think everyone could benefit from psychotherapy, but I think just talking to someone and processing the feelings can be very effective. It doesn’t have to be with a therapist; it could be with a pastor, family, friends and people who understand it and aren’t going to make it worse by telling you to stop complaining.

What do you think about the #selfcare hashtags on social media and the role of “Black Twitter” as resources for people who may not have the resources they need to help process this? Are online interactions like that more meaningful than they initially might seem?

Online communities such as VitalStudentMinds.com — can be a great source of support, of course — with the caveat that even just one hater can be stressful for everyone, and that’s the danger of it. But if you don’t have a friend or a family member, just find someone who is sensitive and understanding and can deal with racial issues.

In our initial email about the ripple effects of the murders in Charleston, you used the phrase “vicarious trauma.” What does that mean?

Because the African-American community has such a long history of pervasive discrimination, something that impacts someone many miles away can sometimes impact all of us. That’s what I mean by vicarious traumatization.

Is racial trauma widely recognized as a legitimate disorder?

The trauma of events like this is not formally recognized in the D.S.M. It talks about different types of trauma and stress-related ailments, but it doesn’t say that race trauma can be a factor or a trigger for these problems. Psychiatrists, unless they’ve had some training or personal experience with this, are not going to know to look for it and aren’t going to understand it when they see it. In order for it to be recognized, we have to get a good body of scientific research, a lot of publications in reputable peer-reviewed journals. Right now, there’s only been a few. And we need to produce more.

On your blog, you chronicled the experience of a woman who encounters a therapist who dismisses her fears about racism. Is one barrier to treatment getting the medical community to acknowledge that racism exists?

Yes. A lot of people in the medical community live very privileged lives, so racism isn’t a reality to them. When someone comes in and talks to them, it might sound like a fairy tale, rather than a real daily struggle that people are dealing with. Research shows that African-Americans, for example, are optimistic when they start therapy, but within a few sessions feel less optimistic and have high early dropout rates. It could be that clinicians don’t know how to address their problems, or they may even be saying things that are subtly racist that may drive their clients away. If the patient feels misunderstood or even insulted by the therapist and they don’t go back and get help, they end up suffering for years or even the rest of their lives for something that is very treatable.

Is there a recommended model for treatment?

We have great treatments that are empirically supported for trauma, but the racial piece hasn’t really been studied very well. That’s no easy task, because when we write these articles, they go to journals, where an editor looks at it and decides if it’s worthy and applicable to go in the journal. And then it goes to reviewers who decide if it’s a worthy and applicable topic.

Why has it taken so long to get momentum?

If you think about it, they weren’t even letting black people get Ph.D.s 30 years ago in a lot of places. Ethnic minority researchers are the ones who are carrying the torch, by and large. We’re only to the place now where we have enough researchers to do the work. And there’s so much work that needs to be done.

Checkout our handout for more information on coping with trauma. 

Record Gifts for NonProfits last year

I don’t usually wait with bated breath for annual giving trends and studies. But this year was different. Many fundraisers (including me) were eager to understand how the emergence of the Trump Presidency last year may be affecting the giving landscape, particularly at the individual giving level.

Like many people, I was intrigued and delighted at the news of big giving surges that occurred in the wake of Trump’s victory. Planned Parenthood reported receiving over 80,000 donations within days of the election. The American Civil Liberties Union received $24 million in online donations in the weekend that followed the news of Trump’s proposed Muslim travel ban.

The nonprofit Meals on Wheels, which delivers food to families in need across the country, took in more than $100,000 in donations after Trump proposed federal budget cuts. Were these giving surges one-time events or a presage of an enduring phenomenon with lasting impact?

The Giving USA Report: Documenting Increases in Gifts to Nonprofits

The annual Giving USA report is the longest-running report of charitable giving in the United States. The latest report, covering the year 2016, sheds some interesting light on philanthropy trends that may continue to affect nonprofits during the Trump era.

The Giving USA study reports that for 2016, all giving rose to $390.1 billion, which is a 1.4 percent growth over 2015 (adjusted for inflation). Individual donors really helped drive giving in 2016, and continue to represent the biggest piece of the charitable giving pie (72 percent). Individual giving alone had a 3.9 percent increase over the previous year!

Meanwhile, charitable giving from foundations and corporations also increased in 2016. However, gifts by estates decreased sharply (-10 percent).

In the individual donor category, it appears that all categories of recipient organizations saw an increase in giving in 2016, meaning that giving wasn’t isolated to so-called “resistance-oriented” groups. The greatest year-over-year increases were seen in environment and animals (7.2 percent); arts, culture, and humanities (6.4 percent); and international affairs (5.8 percent). Even religious groups saw a 3 percent increase.

Towards the Democratization of Philanthropy

Numerous commentators in the nonprofit philanthropy community seized upon this growth in the individual donor category as an important bellwether of changing giving trends in the Trump era.

Ruth McCambridge writes in The Nonprofit Quarterly: “Amid great political uncertainty, and probably even because of it, people without enormous wealth gave in larger numbers than they have in the recent past. The highest increases among recipient groups were […] front and center in public and political discourse toward the end of 2016 as areas that might be targeted for policy changes and defunding by the new administration.”

McCambridge continues: “All of this should come as little surprise to nonprofits, since we already knew that volunteering and giving are relatively closely linked behaviors. Thus, the massive number of people who volunteered to show up for protests on climate policy, immigration, science, and women’s rights over the past six or seven months should have been something of a predictor of what we could expect in giving trends. That makes this an exciting moment for fundraisers and organizers […] and you get a sense of the potential of this moment.”

Quoted in that same article is Patrick M. Rooney, Ph.D., associate dean for academic affairs and research at the Lilly Family School of Philanthropy, which researched the Giving USA report.

He suggests that “we saw something of a democratization of philanthropy. The strong growth in individual giving may be less attributable to the largest of the large gifts, which were not as robust as we have seen in some prior years, suggesting that more of that growth in 2016 may have come from giving by donors among the general population compared to recent years.”

Making the Most of This New Era of Civic Engagement

Let’s return for a moment to our initial mention of Planned Parenthood, ACLU, and Meals on Wheels, who saw a literal deluge of donations from existing and new donors. Can these — and many other organizations who aren’t mentioned here — take full advantage of this opportunity to cultivate and deepen relationships with donors, volunteers, and subscribers, eager for action?

If current trends and news reports are to be believed, we are well on our way to a new era of civic engagement. Says McCambridge: “It may be time to concentrate on making the most of this period of multi-faceted activism and our very rich landscape of mobilizable human and cash capital.”

Jay Love, writing in the Bloomerang blog, concurs. He believes that “if a strong base of individual supporters can be built via top-notch relationship building, which takes time, they can be retained at well above average retention levels.” He calls for a resurgence in individual donor cultivation.

As Steve MacLaughlin notes in Huffington Post: “Nonprofits are taking more risks, engaging supporters in new ways, and using more science to aid the art of fundraising. The future of fundraising will require risk, innovation, and a drive to move beyond the status quo.”

I, for one, will be watching nonprofit innovation blossom in the Trump era as a sign that we are embracing new strategies and tactics to engage and cultivate supporters. Will you join us in support of changing the support services for college students needing mental and psychological symptoms.

Exemplar: Mental Health Day at the Office

We’ve all heard that we should take a mental health day from time to time, but how many of us are brave enough to actually take one—and let our coworkers and boss know that mental health issues may be the reason for being out of office?

empty desksEFLON/FLICKR – FLIC.KR

Well, Madalyn Parker, a web developer, did exactly that in an email.

She sent an email to her team letting them know she was taking two days off “to focus on my mental health”—and was shocked by the CEO’s response.

She tweeted the email exchange, where it has over 30,000 likes and 8,400 retweets.

MADALYN PARKER/TWITTER – TWITTER.COM

Ben Congleton, the CEO who replied, was so stunned by the outpouring of support that he wrote about it on Medium.

“I wasn’t expecting the exposure, but I am so glad I was able to have such a positive impact on so many people,” he wrote on July 6.

“There were so many stories of people wishing they worked at a place where their CEO cared about their health, and so many people congratulating me on doing such a good thing,” he continues, adding:

It’s 2017. I cannot believe that it is still controversial to speak about mental health in the workplace when 1 in 6 americans are medicated for mental health.

Congleton is sourcing a Scientific American article from December 2016, which goes on to report that “just over one in 10 adults reported taking prescription drugs for ‘problems with emotions, nerves or mental health,'” sourcing statistics from a piece published in JAMA Internal Medicine earlier that month.

A top highlighted quote from Congleton’s Medium piece is “It’s 2017. We are in a knowledge economy. Our jobs require us to execute at peak mental performance. When an athlete is injured they sit on the bench and recover. Let’s get rid of the idea that somehow the brain is different.”

It’s even more difficult for people of color to not only receive mental health care, but to even discuss it.

HuffPost reported in October 2016, “according to the U.S. Department of Health and Human Services of Minority Health, black people are 10 percent more likely to report having serious psychological distress than white people. There’s a stigma when it comes to black men talking about their mental health.”

And it isn’t just about stigma. They continue: “Despite being disproportionately affected by mental health conditions, black men in America have to deal with a lack of health care resources, a higher exposure to factors that can lead to developing a mental health condition, a lack of education about mental health and other factors that serve as barriers to getting proper help.”

It’s also more difficult for people of color to feel as though others—even medical professionals—can relate to their mental health care; “African-Americans make up less than 2 percent of American Psychological Association members, according to a 2014 survey,” Mic reports. Even more, “Latinos are less likely to report mental illness,” with very few Latinos actually seeking help, according to Latina.

Which is why it’s so helpful and important for people like Congleton and Parker to speak openly about the need to take care of mental health.

“What if we talked about physical health the absurd way we talk about mental health?” ATTN: asked in a video posted on May 26.

Parker wrote about her previous hurdles in navigating a job while handling anxiety and depression, noting, “I struggle with illness. Just as the flu would prevent me from completing my work, so do my depression and anxiety.”

Her point is valid, mental and physical health are treated differently. As the video shows, you wouldn’t tell someone with a broken leg, “it’s like you’re not even trying to walk.” Why do we do the same thing to people suffering from mental conditions?

10 Things your OCD will lead you to believe

Staff report—

While working on my obsessive compulsive disorder (OCD) in therapy for a little over a year now, one of the biggest lessons I’ve learned is that OCD loves to lie. Through these sneaky lies, OCD pretends to be a helpful friend who wants to keep us safe. But really, it only manipulates us into doing more and more rituals. When stressed and struggling with an obsession, I’ve found it’s helpful to identify when OCD is trying to tell a lie. Then, I’m more likely to resist doing a ritual or to fight through the discomfort of an exposure.

—> Here are 10 common lies OCD tries to tell…and why you shouldn’t believe them!

1. I have to do rituals to feel safe or keep others safe.

While most people with OCD know their fears are irrational, sometimes in a stressful moment those fears can feel true. At times like this, I try to remember the relief and feelings of safety you feel after doing a compulsion will only be temporary. Doing rituals never makes me feel safe in the long run. Delaying a ritual and sitting with the anxiety is actually what gives me feelings of safety and control.

2. I have to do rituals if I want to feel less anxious.

Because of its cyclical nature, one of the main pitfalls of OCD is that it can grow quickly. Doing a ritual decreases anxiety, which feels really good in the moment, but the relief is only temporary. When the obsession pops up again, we have to do the ritual more and more for our anxiety to go away. With every ritual we do, we continue to learn that ritual equals less anxiety, even though it doesn’t work very well. Exposure and response prevention therapy (ERP) reteaches our brain that if we don’t do a ritual, eventually our anxiety will come down on its own. With every exposure we do, our anxiety comes down faster.

3. This anxiety will last forever.

This lie can feel especially true during an exposure or panic attack, but it’s not only false — it’s impossible. All anxiety will come down eventually. It might soon go back up again, then down, then up, etc., but it will come down. I pinky promise.

4. Just do the ritual one more time. It’s better than trying to resist.

This is one of the lies OCD tells me most often: “One more time!” It’s the same lie music directors and dance teachers always told us in practice, and it’s never true. Giving into the ritual only makes the obsession grow more, which means you’ll have to do the ritual even more times.

5. My thoughts make me dangerous.
Something my therapist told me this week is, “We can’t choose what thoughts we have, but we can choose what we do.” What many people don’t realize is everyone has weird, intrusive thoughts. While most people shrug them off and go about their day, the difference is people with OCD tend to overreact to these thoughts. We feel responsible for our weird thoughts and feel like dangerous people. Because of this, we obsess about the thoughts and engage in rituals to reduce our anxiety, which accidentally makes the thoughts come more often. This lie is simply not true; thoughts are just thoughts.

6. I shouldn’t tell people about my thoughts.

When my OCD tells me my thoughts are dangerous, it also tells me to keep them a secret. We don’t want people to know all the weird thoughts we have. This only makes the thoughts stronger; we fall deeper into the obsession. It also makes it harder to get help. It’s like saying “Voldemort” — you can take some of the power away just by saying it out loud.

7. I should be able to control my thoughts.

Wouldn’t it be nice if we could try really hard and just stop having intrusive thoughts? Yes, that would be nice, but I’m sorry to say that’s not the reality. Go ahead and try, I’ll wait. Tired yet? As nice as it would be to have control over our thoughts, I repeat, “We cannot choose what thoughts we have, but we can choose how we react to them.” The more we react to the thought and try to stop thinking about it, the more we think about it. The less we react to a thought and treat it as just a thought, the sooner it passes.

A common way to demonstrate this phenomenon is the pink elephant experiment. Try it yourself here!

8. There is a high probability that something bad will happen.

This is a common lie all anxiety disorders try to tell, but one I’ve tried especially hard to fight back against and test out many times. What I’ve found is usually, it’s not as bad as I expect it to be, or the bad thing doesn’t even happen at all. Quite often when I do an exposure, the anticipatory anxiety is worse than the anxiety I feel when I’m actually doing the exposure. Our brains really like to keep us safe, which means our brains really like to tell us something bad will happen, even when most of the time it doesn’t happen.

9. If something bad does happen, then I won’t be able to cope.

What about when you take the risk or do an exposure, and the bad thing does happen? I also underestimate my ability to cope with something bad. We are far more capable of coping than we usually believe.

10. I need certainty.

OCD related fears come in all shapes and sizes, but one aspect that ties them all together is an intolerance of uncertainty. Whether you check a lock multiple times or reread a page over and over, the goal is to feel certain that the feared outcome won’t happen. The only way to feel free then is to embrace uncertainty. Instead of responding to a “What if?” by ritualizing and desperately trying to achieve certainty, it’s better to respond with “Maybe…” and work on accepting the uncertainty.

~Morgan

“Smiley” Depression

Staff Reports—

 

When many people think of depression, they often think of sadness — and not much else. This generalization can be harmful to people who experience depression, but may not “look” depressed. For some, depression may look like sadness or exhaustion. For others, depression might look like a smiling face, or a person who “has it all together” — something we think of as “smiling depression.”

It’s important to remember every person’s experience of depression needs to be taken seriously, no matter what it looks like on the outside.2 We wanted to know things only people with “smiling depression” understand, so we asked members of our mental health community to weigh in.

Here’s what they shared with us:

  1. “It’s easier to cheer people up but not myself. I can make them feel great when they’re going through the worst [times], but I cannot get myself happy, really happy. That happiness you see is just a way of not letting people [see] my problems.” — Sofia V.
  2. “I am so tired. So, so tired, all of the time. It doesn’t matter if I’m sitting and pouting or smiling and engaging. [It doesn’t matter if I’m] dancing, running, swimming, eating, brushing my teeth, by myself or in a room full of people or sleeping. I. Am. Exhausted.” — Rinna M.
“Other people don’t get it. What it’s like to feel so trapped and in darkness, because I appear ‘happy’ and strong — even though [it feels like] I’m slowly dying.”
— Nicole G.
  1. “[I] fake it because [I believe] no one wants to hear about [my] depression. [I] fake it because [I am] tired of hearing all the ‘expert’ advice insinuating that [I’m] just [not] trying hard enough.” — Lisa C.
  2. “[I] don’t always wear the mask for other people. Sometimes [I] wear it because [I] don’t want to believe [I] feel as miserable as [I do]. [For me], it isn’t always about making other people with [me feel] OK. Sometimes it’s wearing the mask so [I] don’t lose [my] job or so [I] can just get takeout without being asked what’s wrong.” — Melinda A.
  3. “I can still laugh and give a big belly laugh about things, but on the inside, I feel empty. It’s a weird feeling being happy as much as you can, but your mind won’t follow suit. [I] just feel empty and the happiness isn’t genuine. It’s fake but [I] can’t change that no matter how hard [I] try for it to be a real feeling. Depression drains everything out of me. It takes an enormous amount of strength to appear ‘normal,’ it exhausts me… [My] smile doesn’t reach [my] eyes.” — Rebecca R.
  4. “The problem lies in the fact that no one truly and honestly knows me. I feel like I’m alone every day — even when I’m surrounded by people.” — Jen W.
  5. “[I] constantly doubt whether [my] struggles are real. When [I] finally get the courage and strength to open up about [my] depression, [I] always hear, ‘But you don’t act like you have depression.’ It took me years to come to terms and believe my own struggles.” — Adrianna R.
  6. “Most days, I feel like I’m just barely surviving. Once I’m alone at the end of the day, all I have the energy for is crying. Crying because I’m just so exhausted with life and I’ll convince myself I can’t handle tomorrow and I need to call in sick. But when the next day actually comes, I’m too afraid to not show up. Eventually, after debating with myself for far longer than I should, I drag myself out of bed. The cycle [feels] never-ending. It’s like, if I choose one day to just stay in bed instead of getting up, it would be the most horrible thing in the world, so I eventually always get up, no matter how exhausted I am. It’s inevitable.” — Keira H.
  7. “I try to keep up appearances to protect my family because my depression upsets them. I’m not very outwardly emotional, so everything gets to me more than I show it. I can’t open up to them, because I just get told, ‘Change your thoughts,’ ‘You seem fine, why do you want to go to a therapist?’ It makes those times when I can’t control my emotions even worse. I feel alone, tired and lost.” — Jessica C.
  8. “Sometimes I really, like really want to show people how I’m really feeling, but I just physically cannot take the mask off. It’s like the walls just grow stronger the more I try to tear them down.” — Kira H.
  9. “[I thought] if I faked being happy enough, then maybe I could get a glimpse of what it’s like to be ‘normal.’ I always feel like such a burden on the people [who] love me. [I feel] I have no choice but to pretend.” — Bree N
  10. “The time I’m most encouraging to myself is when I’m telling myself, I can make them laugh so they never suspect anything! I’m funny, right?” — Shelby S
  11. “The physical pain as well as the emotional pain. It hurts to walk, get up, move, force [myself] to smile, try to look ‘normal,’ happy.” — Keara M.
  12. “[ I believe] we are the best actors in the world. Because if I have to explain depression one more time… it’s just easier to fake it until I get home.” — Lisa K.

 

If you or someone you know needs help, visit our suicide prevention resources page.

If you need support right now, call the National Suicide Prevention Lifeline at 1-800-273-8255 or text “START” to 741-741.

 

Unique Hurdles to Managing Stress in College

Managing Stress

College requires significantly more effort from students than high school.  Once you enter college, you will probably find that your fellow students are more motivated, your instructors are more demanding, the work is more difficult, and you are expected to be more independent. These higher academic standards and expectations are even more evident in graduate school. As a result of these new demands, it is common for college students to experience greater levels of stress related to academics.

Many students find that they need to develop new skills in order to balance academic demands with a healthy lifestyle.  Fortunately, the University of Michigan offers many resources to help students develop these skills.  Many students find that they can reduce their level of academic stress by improving skills such as time management, stress management, and relaxation.

The Pros and Cons of Stress

Stress is anything that alters your natural balance. When stress is present, your body and your mind must attend to it in order to return you to balance. Your body reacts to stress by releasing hormones that help you cope with the situation.  That in turn takes energy away from the other functions of your brain, like concentrating, or taking action.  There are two different sources of stress: external triggers, like getting a poor grade or breaking up with your girlfriend/boyfriend, and internal triggers, like placing high expectations on yourself.

La Di Da by Asher Roth:
“How are you dealing?”

Watch this music video which shows how six college students deal with stress.
From halfofus.com

Stress is a part of everyday life. There are many instances when stress can be helpful. A fire alarm is intended to cause the stress that alerts you to avoid danger. The stress created by a deadline to finish a paper can motivate you to finish the assignment on time. But when experienced in excess, stress has the opposite effect. It can harm our emotional and physical health, and limit our ability to function at home, in school, and within our relationships. But the good news is that, since we are responsible for bringing about much of our own stress, we can also do much to manage stress by learning and practicing specific stress-reduction strategies.

Click here to learn more about academic stress.  This link will take you to information and helpful tips including a study skills checklist.

Are you experiencing too much stress?

Here are a few common indicators:

  • Difficulty concentrating
  • Increased worrying
  • Trouble completing assignments on time
  • Not going to class
  • Short temper or increased agitation
  • Tension
  • Headaches
  • Tight muscles
  • Changes in eating habits (e.g., “stress eating”)
  • Changes in sleeping habits

People with mental health disorders are more likely to notice that their specific symptoms reemerge or grow worse during stressful times. In many cases, stress can act as the “spark” that ignites a mental health episode. But this does not mean that every time you are busy or face a difficult challenge you will have a mental health episode. Not everyone responds the same way to potentially stressful circumstances. For example, during final exams many students feel very overwhelmed and anxious, while others are able to keep their stress under control. If you are one of the many people who have difficulty managing stress during difficult times, look for some helpful tips below.

Ways of reducing and managing stress

  • A feeling of control and a healthy balance in your schedule is a necessary part of managing stress. Learning how to manage your responsibilities, accomplish your goals and still have time for rest and relaxation requires that you practice time management skills.
  • Try setting a specific goal for yourself that will improve your mood and help you reduce stress. Start by filling out a goal-setting worksheet.
  • Avoid procrastination. Putting off assignments or responsibilities until the last minute can create more mental and physical stress than staying on top of them.  Procrastination can affect many aspects of daily life, such as the quality of your work, the quality of your sleep, and your mood.
  • Exercise regularly. Physical activity can help you burn off the energy generated by stress.
  • Practice good sleep habits to ensure that you are well-rested. Sleep deprivation can cause many physical and mental problems and can increase stress.
  • Try mindfulness meditation.
  • Limit (or eliminate) the use of stimulants like caffeine, which can elevate the stress response in your body.
  • Pace yourself throughout the day, taking regular breaks from work or other structured activities. During breaks from class, studying, or work, spend time walking outdoors, listen to music or just sit quietly, to clear and calm your mind.
  • Start a journal. Many people find journaling to be helpful for managing stress, understanding
    emotions, and making decisions and changes in their lives.
  • Realize that we all have limits. Learn to work within your limits and set realistic expectations for yourself and others.
  • Plan leisure activities to break up your schedule.
  • Recognize the role your own thoughts can play in causing you distress. Challenge beliefs you may hold about yourself and your situation that may not be accurate. For example, do you continuously fall short of what you think you “should” accomplish? When our minds continuously feed us messages about what we “should” achieve, “ought” to be, or “mustn’t” do, we are setting ourselves up to fall short of goals that may be unrealistic, and to experience stress along the way. Learn techniques for replacing unrealistic thoughts with more realistic ones.
  • Find humor in your life. Laughter can be a great tension-reducer.
  • Seek the support of friends and family when you need to “vent” about situations that bring on stressful feelings. But make sure that you don’t focus exclusively on negative experiences; try to also think of at least three things that are going well for you, and share those experiences.
  • Try setting a specific goal for yourself that will improve your mood and help you reduce stress. Start by filling out a goal-setting worksheet then help yourself stay on track.