Wednesday, November 22, 2023

Diagnosing Mental Illness During Difficult Times

A guest essay in the NY Times makes some excellent points about the way we're framing mental health issues in kids. 

Psychologist Darby Saxbe discusses the well-intentioned but problematic way many schools have added mental health resources, like those focusing on emotional regulation or mindfulness:

"Recent studies have found that several of these programs not only failed to help young people; they also made their mental-health problems worse. . . . Researchers suggest, convincingly, that the teenagers weren't engaged enough in the program and might have felt overwhelmed by having too many tools and skills presented to them without enough time to master them. . . . I would venture three additional explanations for the backfiring. . . . First, by focusing teenagers' attention on mental health issues, these interventions may have unwittingly exacerbated their problems. Lucy Foulkes, an Oxford psychologist, calls this phenomenon 'prevalence inflation'--when greater awareness of mental illness leads people to talk of normal life struggles in terms of 'symptoms' and 'diagnoses.' These sorts of labels begin to dictate how people view themselves, in ways that can become self-fulfilling. . . . Greater awareness of mental health problems risks encouraging self-diagnosis and the pathologizing of commonplace emotions--what Dr. Foulkes calls 'problems of living'."

I agree that framing every negative emotion as depression or anxiety can be self-sabotaging for people. On top of that we're also forcefully ignoring how withdrawn and exhausted people can become from chronic illness from repeated exposure to viruses and from watching friends and family members suffer, not to mention seeing catastrophic news about climate change and the many conflicts around the world and the burgeoning rise of authoritarian governments. Nothing feels stable anymore. Many of us in my part of the world have lived relatively comfortable lives for a few generations, long enough to forget what it might look like and feel like to struggle profoundly and to watch the suffering around you. Our problems of living have changed dramatically in the last few years, and it can be hard to come to terms with that change, so we might end up thinking something's horribly wrong with us instead of the world at large.

It's amazing any of us are able to keep our heads on straight during all of this. Saxbe's other two explanations:

"A second possible explanation for why these programs backfired is that they were provided in the wrong place and to the wrong people. The structure of school, which emphasizes evaluation and achievement, may clash with practicing 'slow' contemplative skills like mindfulness. . . . A third possible explanation is that these interventions offered enough information to highlight a problem, but not enough to fix it. As research has repeatedly shown, the most effective therapies involve not just learning skills but also developing meaningful relationships. . . . In school settings, creating more opportunities for young people to build relationships with adults through smaller class sizes and greater access to traditional guidance counselors might move the needle more than specialized mental-health curriculums can. Other, more prosaic-seeming changes like starting school later to encourage sleep, decreasing the homework burden and creating more opportunities for play, exercise, music, arts and community engagement are all empirically supported strategies for improving mental health. In the meantime, those serving up mental health guidance, both online and at school, should be cautious. It's critical to keep pace with the evidence and attend to the first principle of all health care providers: First, do no harm."

The one-size-fits-all type of wellness initiatives delivered to entire schools backfire because the strategies can't replace the connections. Someone coming for an assembly or a few weeks for a workshop en masse can't make the necessary links to individuals - particularly when people need to feel heard. I also wonder about the top-down delivery method with skeptical, research-savvy teens. 

Back to that first bit about diagnosis. There are many, many nuances to the issue, like not trivializing a very real condition by, for instance, self-diagnosing OCD because you like things tidy, but also not stepping on people's self-diagnosis because they don't have the ability to get a "real" one. It's very complex. I'm particularly interested in why people might want the label. 

So many feel relief when they get some kind of label to put on their troubles, some categorization. I can understand that desire for the right answer to it all. Part of it might be that it can provide a better way of understanding behaviours, like an inability to get work done. People may find it less painful to think of themselves as having a disorder (depression, executive functioning issues...) instead of believing that they're lazy. But really, it's just plain hard to get things done when the world is so topsy-turvy. It's really not your fault. It helps that there's less stigma around mental health issues for sure, but we still need less stigma about our personal limitations, what we might call our shortcomings. Our expectations for what we should be able to do are through the roof as part and parcel of a push for extreme independence. We can't do it alone. Those that think they have are likely failing to notice all the people who have supported them through their achievements.

The other part of this is that we think once we can put a name to it, then we can fix it. Our hubris around mental health solutions has oversold our actual ability to fix anything. Many techniques are re-worked applications of ancient philosophies. They can definitely help, as can some medications, but they're not the quick fix we think they are. The diagnosis isn't the beginning of the solution as much as it's just a slightly different path. But having that label can help to find others in the same boat who can talk through a similar set of struggles, which is invaluable. Like Dr. Saxbe says, it's this connection that's key. If having a name for what ails them provides the means for connecting, then it might be worth the effort. 

Formal assessment can be costly, though - in time, money, or both. There are lengthy waitlists for psychiatrists who can formally diagnosis. Where I live, if you go private, then expect a price-tag of $1500 to $3000. The alternative is a family doctor diagnosis, which is official despite it often entailing just a few questions asked in a 10 or 20-minute appointment. The middle ground that some take is to get assessments done by a therapist who can't officially diagnose, but can administer assessments and write a summary of them, for about $150, then that summary can be taken to the doctor to be rubber stamped. When you look at the effort necessary to get any kind of official diagnosis it's amazing so many kids have one, and it's perfectly understandable when people self-diagnose.

I often found it frustrating that many teachers with a basic education in disorders can spot who has which issues by the second week of classes before checking their file because they have to be able to accommodate each student's needs to bring out the best in them. Well, at least they should be trying everything they can if they're worth their salt. But even after spending several hours each week for five months with a teenager, and having the unique ability to see how they relate to peers and how they handle a wide variety of tasks, teacher assessment counts for very little beyond the occasional questionaire, which is a lost opportunity.  

Learning disabilities are a different kettle of fish, and the most frustrating phenomenon I've observed several times is when parents insist their teen has a drug problem that appears to be a cover for an undiagnosed learning disability since a quick look at their file shows these same problems have stymied them from grade one. When I ever-so-carefully broach the subject of spending the time and money to have some testing done, it's met with the assurance that, if they could just stop smoking pot, then they'll start to do really well in school. Parents would rather believe their kids are addicts, which is possible to affect, than that they struggle with learning, which can sometimes be a lifelong barrier to academic success. Some parents don't even want to dip their toe into assessment or even try different learning strategies, which ends up adding to the barriers their kid is facing. We've come a long way to get rid of the stigma around mental illness, but not nearly far enough around disabilities.


Saxbe is rightly concerned about over-diagnosing, but the upshot of our crazy-making system is that many go undiagnosed and many others get a dubious diagnosis. I took the most expensive option for one of my kids, and I felt like, even there, with all their degrees on the wall, they swayed me into an inaccurate autism diagnosis, badgering me over and over about a singular obsession that didn't exist until I coughed up, "Well, she really likes animals," as if that's in any way unusual for a kid. It's curious that the DSM has over 300 discrete disorders, yet the choices of diagnosis at some establishments seem limited to be anxiety, depression, ASD, or ADHD.  How different is it from differentiating people as, respectively, choleric, melancholic, phlegmatic, or sanguine? We're still focusing on bodily fluids, but now we're less focused on mucus and bile and more on the neurotransmitters swimming in the synaptic gaps in our brain. 

I'm not sure we've come quite as far as we think we have in diagnosis. Knowing all we do about the neuroscience now, at the very least, helps us to be less judgmental about people who have different behaviours. We can spend more time helping people function within this world instead of shaming them for not acting the way we would prefer. But it's all still a guessing game when someone needs help. 

We have some meds that offer questionable results for various people, and then we offer conversations about what they're thinking when they experience negative feelings and how to change that line of thinking, or we try to trace back the negative experience to the first time they had the feeling to try to resolve a troubling pattern that's developed over the years. We no longer lock people up in asylums; instead we give them less than they need to survive, and they end up living in tents that randomly get bulldozed into the trash by government officials. We're back to the pre-asylum days where people who couldn't work because of a mental condition had to resort to begging in the streets. In just a few months, they'll be eligible for MAiD. 

We need kinder, more accessible and accepting interdependent societies to take us through these very difficult times. And we need a wide variety of connections to help our kids. 

ETA from Mound of Sound: You might find some helpful information at the websites of the Climate Psychology Alliance and its companion Climate Psychiatry Alliance. In Canada there is also the Mental Health and Climate Change Alliance. Additional useful material can be found at the journal, Lancet Climate Change. The scope of this threat to our children is enormous and it beggars belief that our leaders ignore it. 


Marie Snyder said...

Thanks, Mound. I added the very useful links to the post because your comments often disappear (by accident or design?).

MoS said...

I was discussing this with a psychiatrist who has 5 children, 3 still in the elementary school system. In terms of the mental health of today's younger generations we're doing next to nothing. He doubts that parents would support classes teaching their kids about looming perils and coping strategies especially when the adults - parents, educators and political leaders - do so much to ignore the problem.

Marie Snyder said...

I think if I had any say in the situation, I'd assume many kids have heard bits and pieces of things and suggest teaching kids helping behaviours, which can makes us feel less powerless in the grand scheme of things: like composting, using less paper, buying fewer things, encouraging parents to walk/bike/bus instead of driving -- make it an adventure! As a kid, we were inundated with anti-littering campaigns, and kids influenced parents around clean-ups. A whole anti-consumerist agenda might not sit well with the most powerful in the board (or some parents), but it can help kids feel like they're doing something useful for the cause.

Instead of having them sit through boring workshops that have them rolling their eyes, I'd want to implement some kind of peer chat clubs -- just spitballing here, but some time and place and space where kids could take with each other about things that they're worried about, with a teacher nearby to field questions and guide things if they get too dark. Something like that. I've had philosophy clubs (and classes) turn into support networks where kids start sharing their worries about the world and feel heard by others, and that can help them unload some anxiety.

Marie Snyder said...

*talk with each other, not take