Who Am I to Tell You?

 I recently saw a series of tweets by Allison Raskin, a mental health advocate that I respect and admire, and I've been thinking about her tweets ever since. In these tweets, she talks about how she used to "gate-keep" OCD diagnoses. She said that she used to be someone who didn't want people to say they had OCD unless that person had been diagnosed by a mental health professional. She went on to say that she felt differently now because she realized that, basically, she didn't have the right to say whether another person had "OCD tendencies or enough symptoms for it to significantly impact their life."

I hadn't realized it until I read the words of Allison Raskin that I'm also guilty of gatekeeping mental health diagnoses, especially OCD diagnoses. I've had a few people in the past earnestly tell me that they believed they had OCD. A dear friend once told me that he believed he had "a touch of OCD" after I disclosed my diagnosis to him. My response was usually to tell the person something like, "Well, unless you see a mental health professional and get a diagnosis, you can't really just go around saying that." After my dear friend said he thought he had a touch of OCD, I remember telling him, "You can't have a touch of OCD, really. You either just have it or you don't, and you need to see a professional to find out for sure." I have to admit that I was also a bit offended when people would say they had OCD if they hadn't been clinically diagnosed. 

My reasons for gatekeeping are similar to the reasons Allison Raskin laid out in her tweets. Like her, I also felt like people self-diagnosing OCD (or any mental health condition, really) would minimize the condition and the struggle of living with it. My other reason for gatekeeping was well-intentioned, but it was still gatekeeping. I didn't want people to self-diagnose mental illness because they might be wrong. I was worried they would self-diagnose a mental health condition and get the condition wrong and then apply the wrong at-home treatment approach or that what they thought was a mental health condition could actually be a neurological condition or some other physical health problem that needed timely medical intervention.

Thinking about it now, of course, Allison Raskin is absolutely right. Who am I to say whether or not someone has a mental health condition? I don't live in their body with their brain. I don't live their life with them every day. Who am I to say whether or not and to what degree something impacts somebody else's life? I don't have the right to tell them that they can't say or think they live with a certain mental health condition because they haven't been given a clinical diagnosis from a mental health professional. Not everyone has access to a mental health professional to even get the clinical diagnosis. 

My job isn't to police whether or not someone has a mental health condition based on whether or not they have seen a mental health professional to tell them they have the condition. My job isn't even to observe them to see if they actually have symptoms of the mental health condition so I can disprove or approve their self-diagnosis. My only job is to ask, "How can I help?" and then listen to them when they tell me what they need from me, whether that's helping them find information about the disorder they're concerned about, helping them navigate finding mental health services, sharing what I've learned in therapy, just listening to them as they think out loud about it, or just checking on them every so often.

I'll end with this: Recently, thanks to Allison Raskin, I realized I had been gatekeeping mental health diagnoses and that I shouldn't have been. I don't have the right or the knowledge and insight to tell someone whether or not they have a mental health condition or to what degree it affects their daily life. I don't live in someone else's body to experience the way they think and feel, and I'm not a mental health professional qualified to observe and diagnose them. In situations in which someone believes they have a mental health condition, my only job is ask how I can help and then actually listen to what they need from me.

My OCD Didn't Make Me a Better Person

I get varied reactions when I mention that I live with a subtype of OCD called primarily obsessional OCD and that my obsessions tend to be religiously and morally based. Some people are confused but curious because they never knew OCD could be more than the stereotypical contamination or checking type of OCD. Some people think I'm joking when I tell them that I can't lie. Some people are dismissive because the particular type of OCD I live with doesn't seem like a "real" mental illness. Then some people say things like, "Well, at least your mental illness makes you a better person."

I know, or at least I hope, the person is saying that statement from a place of kindness. I try to remind myself that the person is probably trying to find the silver lining in a situation that they don't really understand. However, statements like the above really hit a nerve with me. 

On the surface, the statement feels dismissive of my mental health struggle. On a deeper level, it feels uncomfortably close to the "transformed by suffering" trope we see over and over again in movies and books in which something tragic happens to a person who consistently lives in a moral shade of gray, and then they suddenly realize they need to be a better person after the tragic thing happens to them. It feels, to me, like the person is softly implying that my OCD is the tragic thing that turned me into a better person, which isn't really how OCD works.

The thing about OCD, according to my therapist, is that it tends to attach to the areas of a person's life that are most important to them, and then it tortures them with it. For people with morally based OCD, sometimes called Scrupulosity, those people are already morally upstanding people that are doing their best to be honest, kind, and helpful, but OCD makes them doubt that and then tortures them with intrusive thoughts related to falling short of their version of moral perfection. For people with religiously based OCD, they're already walking in a path of faith and doing their best to live their lives according to that faith, but the OCD torments them with thoughts related to their sins, their higher power's anger at them for falling short of perfection in their religious practice, and terrifying blasphemous thoughts. This aspect of life that the OCD is attached to is so important that the person often feels a crushing amount of guilt and shame. With OCD there is no such thing as "good enough"; it has to be complete perfection or we're complete garbage. 

I was already doing my best to be a good person. I was already doing my best to walk thoughtfully down my faith path. My OCD didn't make me a better person or a more devout Christian. All it actually did was give me an unhealthy dose of moral perfectionism, and it made me hate myself so much that I thought it would be a blessing if I didn't exist anymore. I didn't need all the mental anguish that comes with living with a mental illness to grow as a person or to push me to strive to be the best version of myself. What I needed was to be able to love myself while allowing myself to be as human as possible so that I could learn from my mistakes and grow as a mentally healthy person without the rigid black and white thinking and self-loathing that comes with OCD. 

I'll end with this: Some people think that certain mental illnesses like morally themed OCD and religiously themed OCD make the people that live with them better people. On the surface, sure, it might look like that because the person is really honest and kind or really devout. But...that's not actually how OCD works. OCD actually attaches to an area that is really important to someone and then basically tortures them with it. Since that area was already super important, the person was actually already trying their best to be morally upstanding or trying their best to walk thoughtfully down their faith path. They didn't need to be made into an even better or more devout person by irrational fear, mental anguish, and self-loathing. 

The Balance of Moments

     A lot of the time, living with a mental illness can feel like living with a bully inside our heads. It can feel like OCD and other anxiety disorders hoard our worst fears or our most embarrassing and most shameful memories to use against us when we start to feel the least bit secure or confident. Another way that our mental illness can be a bit of a bully, too, is by making us feel like we're difficult to deal with or a burden to our family and friends. 
    Life with anxiety comes with its fair share of panic attacks and stress crying. Sometimes, I end up catastrophizing in a situation, and all I can see are bad, worse, and end-of-the-world types of outcomes, which, of course leads to panic, hopelessness, and crying. Then loved ones have to deal with me after the crying or sometimes even during the crying. I'm frustrated that I've catastrophized myself into a panicked meltdown when I can logically see that I have catastrophized AGAIN, but I can't stop it once that ball starts rolling. They're frustrated because they may not even know why I'm crying or how to talk me down from that panicked ledge that looks right down at the end of the world.
    After it's all over, I'm left feeling, at best, like I was difficult in a situation that didn't even need to be made difficult by me or, at worst, like I'm a burden that my loved ones probably wish they didn't have to deal with at all. After every panicked meltdown I have that my mother has to witness, I'm so sure she's just going to be so tired of having to deal with me that she kicks me out of the house. In reality, she would never do that, but my anxiety often is not based in reality. My anxiety makes me feel like I'm such a difficult person, that I'm so hard to live with most of the time, that the only logical option is that people must not want to have to deal with me at all. I mean, some days I don't want to deal with myself either, so I get it.
    When I talked to my therapist about these feelings, she told me that just because we have moments that are difficult doesn't mean that we, as people, are difficult or a burden. She asked me if I had a friend who was experiencing something and catastrophizing until they cried if I would think they were difficult or a burden. Of course, I wouldn't. So, she asked me, "What makes you different from your friend? What makes you feel like you're more difficult and that people don't want to deal with you?" I didn't have a logical answer that didn't have to do with my mental illness. 
    My therapist also asked me to think about the balance of the moments. Sure, there are difficult moments. Sure, there are moments when I'm a difficult person to deal with and people get frustrated with me. However, there are also good moments in my relationships with people...moments in which I'm funny, moments in which I'm caring, moments in which I'm the one listening to loved ones and offering helpful advice, and moments in which I make people's lives a little bit better because I'm part of their lives. She also reminded me that it's likely that the difficult moments don't actually outnumber the good moments and that the difficult moments don't take away from the good moments. 
    It's also important to remember that all humans have moments when they're difficult to deal with, whether or not they live with a mental health condition. Nobody is pleasant and agreeable all the time because we all have changing moods, unpleasant thoughts, and days that feel like they're terrible for lots of internal and external reasons. What's important is to view the bad days in the whole balance of good and bad moments and to try to remember not to believe everything you think.
    I'll end with this: Life with mental illness comes with its fair share of moments that are difficult for us and of moments in which we're difficult to deal with. The moments in which we feel like we're being difficult or making a situation difficult can often lead us to feel like we're too difficult so that our loved ones wish they didn't have to put up with us or like we're a burden. Instead of letting that feeling take hold it's important to take the time to view the difficult moments in the whole balance of moments in our lives. Sure, you were difficult in that one moment, but that doesn't mean there weren't moments before and won't be moments after the difficult moment in which you did or can improve the lives of your loved ones by being yourself and being the kind, understanding, funny, and/or helpful person that you usually are.

Therapy Doesn't Work?

    Sometimes when I bring up therapy, people tell me that it doesn't work. I hear this from people who have never tried therapy at all, sure. However, I also hear this from people who have gone to therapy for a mental health condition who feel like therapy didn't help them, or worst-case scenario, that therapy made their mental illness and/or trauma worse than it was before. 
    I get it. I've been there. Through no fault of her own, my first therapist felt like she made my OCD and panic disorder worse. While I was in therapy with her, I probably would have been a person that was extremely hesitant to recommend therapy to other people because, at the time, I felt like therapy didn't work. Then I met my current therapist, and I finally started to manage my mental health conditions well enough to truly improve and begin a real wellness journey with the things she was teaching me.
    A lot of people think that just starting therapy sessions with any licensed mental health professional is the most important thing about therapy. It isn't actually. The most important part of starting therapy is actually finding the right therapist for you. This means finding a therapist that matches you in certain areas like their area(s) of expertise, the therapeutic techniques they use to treat clients, their treatment plan for you as a client, their ability and willingness to be available when you need them for regular sessions as well as emergencies, and their goals for your treatment. If you don't match with your therapist on these key elements, then, of course, you're not going to get what you need to improve from that therapist, and you're going to have the idea that therapy doesn't work because you're not improving. 
    My first therapist, although I was attached to her because she was the first professional that ever told me there was a name for the thing that made me hate myself and that it was a treatable condition, was not the right therapist for me. I needed more frequent sessions that she was able to offer me. She also didn't have the experience she needed to be able to adequately treat my subtype of OCD. So, of course, if I wasn't getting the treatment I needed from her, my mental health was going to continue to get worse. 
    It also seems like a lot of people expect therapy to work faster than it possibly can, and then they start to think therapy doesn't work because they aren't getting "better" fast enough. Therapy is a slow process. It's literally rewiring your brain and forming new neural pathways to make your brain healthier. You can't go to a month's worth, or even three months' worth, of therapy sessions and expect your mental health condition to magically disappear. If that's your expectation, of course it's going to seem like therapy doesn't work, and you'll be more likely to stop going to therapy before it has the chance to truly work. (Medication can generally help chemically rewire a brain faster than therapy alone for some conditions, but that's an option that people need to discuss with their treatment team.)
    I should also point out that some mental health conditions can be medication-resistant in some people. This naturally means that treating mental health conditions in those clients will be more difficult and will take longer. This doesn't mean that therapy doesn't work for them. It just means that it doesn't work as quickly as it does for clients that have medication as part of their treatment plan. 
    I remember when I first started therapy with my current therapist. I cried every week in my sessions for at least the first two months, and I cried more at home as I was learning to process and manage my anxiety and my other emotions in healthier ways. Even after I stopped crying in my sessions, it took a few more months to notice myself feeling, thinking about, and interacting with my OCD and panic disorder in a healthier way. I had to learn to let go of my expectations about how quickly I would get better and actually give the things I was working on in therapy time to change my brain. That's when I was able to let therapy do its job without judgment and impatience, and that's when I was sure therapy was working for me. But, before I saw that progress, man, did I want to give up a few times. (I'm really glad I didn't.)
    I'll end with this: Some people think that therapy doesn't work. They're not completely wrong, but they're not completely right in thinking that either. Therapy with the wrong therapist, the wrong treatment plan, the wrong treatment goals or expectations, and/or the wrong medication(s) will be therapy that doesn't work. When one of those things isn't right for someone, it can be discouraging, and it can make anyone want to give up on therapy altogether. It can even make us feel like it's our fault that therapy isn't working for us even though we desperately want it to work. However, therapy DOES actually work when you find the right therapist for you, and you actually give the therapy the time it needs to start working on your brain. If therapy hasn't worked for you before, or it currently isn't working, it may not be that therapy doesn't work at all; it could mean that one of the key elements doesn't match for you and something needs to be changed in order for you to get the help you need.

Your Friends are Not Your Therapist

    A lot of people think that therapy is just an un-interrupted hour in which people talk about their feelings, vent about their problems, and/or get advice from their therapist. Because that's the way so many people think of therapy, they also think that talking to their friends and going to therapy with a licensed mental health professional are the same thing. Those same people are also quick to point out, "Therapy costs money, and I can talk to my friends about the same stuff FOR FREE."

    Yes, it's always good to be able to talk to your friends about your life, including your mental health. Yes, your friends can be great at listening to you and helping you sort through some life-related issues.  But...YOUR FRIENDS ARE NOT YOUR THERAPIST and expecting them to be is unfair. I also feel like this needs to be said: talking to your friends about your mental health, although it can feel wonderful to unburden yourself to someone when you're dealing with a mental illness, is not the same thing as actually treating your mental illness so you can recover and heal your brain.

    On the most basic level, your friends are not qualified or trained to be able to SAFELY help you with your mental illness. Psychology (and counseling since it's part of psychology) is an actual science that takes years to study, understand, and use properly. Therapy is the actual scientific treatment plan that a licensed mental health professional uses with their client to be able to treat and manage the mental illness and the other ways that our brains can become unwell. Expecting your friends to take on the responsibility of being your (unofficial, untrained) therapist isn't only dangerous for them because they may take on your trauma as their own trauma since they aren't trained to properly set up boundaries like a therapist; it's also dangerous for you as well because your friend doesn't really understand how your brain is unwell in order to help you, which could actually create new ways for your unwell brain to become even more unwell when your friend says or does the wrong things.

    On a deeper level, treating your friends like your therapist will ruin your relationships. When you treat your friends like your therapist it can make you and your friends feel like they're responsible for your healing. That's a lot of weight to put on someone else's shoulders, especially when they weren't meant to pick it up in the first place. It's impossible to maintain a friendship when you expect things from the other person that are literally impossible things for them to give you. Your friends can't heal you from your traumas, especially when you're dealing with a mental illness that you're refusing to get actual treatment for, because your healing is your responsibility, not theirs. 

    I'll end with this: Talking about your mental health with your friends is generally a good thing. Expecting your friends to be your therapist instead of getting the real therapy that you actually need, however, is never a good thing. Your friends are not your therapist and expecting them to be is unfair and dangerous for you, your friends, and your relationship with them. 

It Takes a Team

    Friends and family will often say things to me like, "I'm going to ask my doctor for some Prozac or Paxil or Zoloft. I've been feeling depressed/anxious, and I just hate feeling that way." Then they'll go to their general practitioner family doctor, and they come back with a bottle of the psychotropic medication because the doctor wrote them a prescription for it, pretty much because they told the doctor they wanted it. When I ask them about a therapist and a psychiatrist or mention the words "mental healthcare team" they incredulously reply, "I don't need any of that stuff. I just need these pills from my doctor, and I'll be fine." (Spoiler: Most of the time, they're not fine with whatever they asked to be prescribed, and then they're angry that the medication didn't make them feel "fine". Sometimes the medication even makes them feel worse.)

    It's common practice in my state for general practice family doctors to prescribe psychotropic medications to their patients without consulting or referring to a psychiatrist or a licensed therapist for counseling. Family doctors here hand out anti-depressants, anti-anxiety medications, and some mood stabilizers like they're Advil or Tylenol. Pediatricians even prescribe ADHD medications for small children and anti-depressants and anti-anxiety medications to their teenage patients. Here, a person's general practice family doctor is usually the first and last stop for mental healthcare.

    Did you know that your general practice family doctor isn't supposed to prescribe medications to treat mental health conditions? I did not know this until I was majoring in psychology in college, and most people in my area do not know this. Let me put it like this: Getting psychotropic medications from your general practice family doctor is a bit like asking your cardiologist to prescribe the right eye drops to treat your eye infection.

    A general practice family doctor doesn't have the specialized training that is required to know how medications for mental illness (AKA psychotropic medications) work with the brain to treat the mental illness. Sure, they know what the pharmaceutical sales rep told them, what's on the package insert, and they know what the medication is prescribed for...but that's not enough to SAFELY prescribe them. They don't understand what these medications do as they work with a person's brain chemicals to make them feel differently or how they interact with each other if more than one medication is needed. The only medical professional that is specifically trained to understand how psychotropic medications work in the brain, with the mental illness that lives there, and what combinations of medications work well with or against each other is a psychiatrist. A psychiatrist is actually a medical doctor who specialized specifically in the study of the brain, mental health conditions, and the medications meant to treat them.

    Your general practice family doctor should definitely be involved in your mental health treatment, but your general practice family doctor should NEVER be the only person treating your mental health condition. Treating mental illness should ALWAYS involve a team of professionals. That team should include a therapist for counseling, a psychiatrist for prescribing any needed medications if medications are part of the treatment plan, and then your family doctor to help monitor the medication in your body and to consult with the psychiatrist about side effects and medication levels and your overall health.

    I'll end with this: Treatment for mental illness isn't a thing that can be accomplished by one single medical professional. Mental health treatment requires a team that includes a licensed mental health counselor for therapy sessions, a psychiatrist to prescribe medications, and your family doctor for things like monitoring the medications and side effects. Your general practice family doctor should NEVER be the only member of your mental healthcare team, and your family doctor should NEVER be the person prescribing your psychotropic medications. The only person with the proper training and knowledge to SAFELY prescribe psychotropic medications is a psychiatrist. 

Focusing on the Good

    Sometimes, feeling hopeful is hard. I feel like we've all had a period in our lives in which we hope for things, and then it feels like one gut punch after another when most or all of those things don't work out the way we had hoped or needed them to. After each gut punch, it gets a little bit harder and a little bit scarier to hope. It can feel like the next logical step is just to stop hoping and accept that things won't work out because that seems to be the pattern we're stuck in.

    Feeling hopeful has been particularly difficult for me for the last few years. More and more often over the last few years I've found myself thinking, "Yeah. There's no point in even hoping for that because I know it won't happen." Recently, I got a little worried about myself when I realized that hope-squashing thought had pretty much become my life motto.

    I addressed this concern with my therapist in my session. She told me that instead of only thinking about the times that I hoped for something that didn't work out, that I should think about the things that I had hoped for that did work out. She also told me that instead of focusing on the things that I felt like I wanted but didn't have in my life yet, to focus on the good things that I already had in my life while I wait.

    It's sort of like that saying, if you're always on the lookout for a spider, you're more likely to find a spider. If you're on the look-out for something, your brain is more likely to find it or, sometimes, even generate it for you. By thinking, "X happening is the pattern," you're programming your brain to pick out the examples that support that thought and disregard examples that don't support that thought.  Of course, if I'm thinking there's no point in hoping for something, I'm going to find more examples of when I hoped for something that ended up not working out. If I'm thinking that it might be okay to have some hope, I'm more likely to find examples of when I hoped for things that ended up working out. 

    Whenever I feel that hopelessness creeping back in, and whenever I catch myself thinking that I shouldn't hope for something because it won't work out, I try to think of a list of times when I hoped for something that did work out. Then I can shift my thinking to, "Yeah, things feel impossible right now, but X, Y, and Z also felt impossible at the time, and those things worked out. So, something has to work out eventually. The waiting is really hard, and I hate it...but right now I have X, Y, and Z that I hoped for in the past."

    My default is still to tell myself not to hope, but I made a New Year's resolution to try to be more hopeful in 2022 so I'm working on it. Some days, I literally have to list off everything over the last year or so that I hoped for that I have now so I don't get completely lost in the land of hopelessness. It's still a work in progress, but I can feel it making a small difference. 

    I'll end with this: The way we think about certain things programs our brains to cherry pick evidence from our lives that supports the way we already think and to disregard the things that don't support the way we think. So, if we think we shouldn't hope for things because it won't happen, of course, our brains are going to only pick out the instances that support that thought, which is going to feed that feeling of hopelessness. The only way we can actually fight that feeling of hopelessness so we can start feeling hopeful again is by focusing on the good instead and thinking about all the times we hoped for something that worked out.