Are u ok?

chapter 1

What Is Mental Health?

What You Should Know and Where to Start

What’s the difference between mental health and mental illness? We all have mental health. The term mental health is often thought to be synonymous with mental illness, but that is simply not true. Our mental health is how we are doing psychologically and emotionally. In other words, how are you feeling today? And I don’t want the thoughtless “I’m fine” answer, but honestly, how are you doing? Are you able to keep up with work or school? How are your relationships? How is your home life? If you’re doing pretty well in life, keeping up with your responsibilities, making time for meaningful relationships, and are able to manage any small upset that occurs, I would say your mental health is in good shape.

On the other hand, if you are feeling more tired than usual, not enjoying the things you used to, and a minor upset ruins your entire day, then you may need to put more effort into your mental health. When I am tearful for no reason, I know that I need to take better care of myself. I could cry watching a commercial or get easily upset by a small conflict. Whatever minor issue comes up, I feel so emotionally taxed that I simply can’t handle it. When I find myself feeling this way, I know I need to carve out some self-care time as well as call my therapist for a session.

Since we can’t see our mental health in the same manner we can often see our physical health, it’s an easy thing to ignore. Many people find themselves feeling tearful, easily upset, and emotionally exhausted for years before reaching out to a professional. I constantly hear how people put it off because they think, “It isn’t really that bad” or “I can still get up and get to work, so I’m all right.” Know that we don’t have to wait until we cannot function at all to get help. In fact, our prognosis is better if we get help early on.

Mental illness, on the other hand, occurs when our mental health is compromised or neglected for so long that it affects our ability to function in our everyday life. Meaning that we can’t do the things we used to, enjoy what we used to, or even see the world around us as we used to. Mental illness covers a wide range of conditions such as depression, anxiety, eating disorders, and borderline personality disorder. How affected we are by our mental illness depends on how severe our case is, how much support and help we are getting, and how quickly we sought out help.

Mental illness can feel like our mind is actually fighting against us, keeping us from the things we love, and making everyday tasks much harder. Just as we would talk about a cold or flu in our body, our brain is sick and needs professional attention. That’s why I constantly remind people to think of mental illness just as they would a physical illness. Would you tell someone who had pneumonia to get up and finish their workday? Or would we expect someone with a broken leg to go about their day in the same way they did before the break? Of course not! So why is it that we often don’t take mental illnesses as seriously as we do physical ones?

I had a patient many years ago who suffered from flu-like symptoms for months. She felt achy, tired, and nauseous and would vomit sometimes. Her husband took her to doctors, specialists, and even a neurologist to figure out what was going on. They found nothing. All her blood tests and scans came back normal. My patient was upset, felt lost, hopeless, and her husband started to wonder if she was making it all up. So they came to see me.

I vividly remember my patient’s husband asking me, “Kati, do you think it’s just all in her head?” I struggled with how to manage an answer to this while being respectful of both him and his wife, but what I really wanted to blurt out was “Why would that matter?” If her problems were psychosomatic (meaning her physical symptoms were caused by mental illness), did that make her symptoms less important? Doesn’t our brain run everything in our body and ensure that we can do all we need to do each day? If we have that understanding, why do we still struggle to take our mental health as seriously as we do our physical health?

I did end up saying something like “Well, in truth I don’t think the origin matters. What is important is how we are going to get her feeling better.” In the end, it turned out that her intense anxiety and bouts of depression were making her ill. Once she started taking an antidepressant and learned some helpful behavioral techniques, the symptoms went away—but I don’t really see how that’s different from her actually having the flu. Either way, she was sick and needed professional help to feel better, right?

Just How Common Are Mental Illnesses?

If you worry that having a mental illness is odd or a rarity, just consider that worldwide one person in five is affected by mental illness.¹ What that means to me is that everyone has been impacted in some way, whether we know someone close to us who struggles with mental illness, or we have experienced it ourselves. I would even argue that the number can’t be entirely representative because so many people are suffering in silence, too scared to get the help they desperately need.

It’s also important to know that a mental illness isn’t always something that follows us for our entire lives. If we get the proper help and follow through with what our treatment team (meaning our therapist, psychiatrist, doctor, etc.) says, we can limit the amount of time we are affected by our mental illness. I compare having a mental illness to my body’s propensity for strep throat. I used to get it at least three times each winter, and even though I got my tonsils removed at the ripe age of twenty-three, it still comes back from time to time.

Now I have a plan to stop it before it starts, and know what to do if I feel it coming on. First, I start drinking tea with honey and take oregano oil and vitamin C each morning. If I start to feel soreness in my throat, I call my doctor and get in to see him immediately. He runs the tests quickly and either gives me an oral antibiotic, or if it’s bad, I get a steroid shot. Either way, it only lasts for a week at most. The same goes for our mental health. There are things we are going to have to do each and every day to keep our illness at bay, but if it starts getting worse we will need to see a professional. The more we practice these preventative measures, the less likely it will be that we will continue to need professional help.

Anxiety is the most common mental illness in the United States, affecting more than forty million adults (that’s roughly 18 percent of the population).² Anxiety is something we naturally feel when we are in a scary, dangerous, or unfamiliar situation. It is what keeps us safe and tells us when something is off, just like our fight-or-flight response. It only becomes a problem when the level of anxiety we feel is irrational or disproportionate to the situation, meaning that we may feel extreme anxiety about being outside of our home, or meeting new people. It can stop us from eating, sleeping, and concentrating. Anxiety symptoms can vary from person to person, even expressing themselves physically like they do for Alice:

The truth is, yes, all those symptoms can be part of our anxiety, but since many of these symptoms mimic those of a physical illness, people with anxiety are three to five times more likely to wind up at their doctor’s office or hospital.³ I only mention this so you can be open to the idea that what you physically feel may come from something going on psychologically. I am not saying it’s all in your head and you are not in need of care or understanding; but rather that no matter where it comes from, you feel that way, it’s warranted, and knowing its origin can help us find you the proper care.

Lastly, remember that anxiety is not stress. Many people misunderstand and think that when we are stressed out because of a big presentation or test that what we are experiencing is anxiety, but that couldn’t be more wrong. Stress has a trigger, a reason for its existence in your life, while anxiety doesn’t. Many of my patients with anxiety didn’t even know that what they were feeling was anxiety until their doctors referred them to me. More often than not, they don’t know what triggers it. It can feel like it comes out of nowhere, bothers them for a long time, and no matter what they try to do it won’t go away.

While depression is less common than anxiety, affecting 15.7 million adults in the United States, the thing to consider as we briefly talk about depression is that 3 to 5 percent of adults will suffer from a depressive episode in their lifetime.⁴ I honestly think the number is much higher, but if we don’t reach out for help, how can anyone know we are suffering? Also, something to remember about depression (as well as other mental illnesses) is that it’s episodic, meaning it comes and goes. We can have episodes of depression that last for a few weeks up to months, and then they go away like they were never there. I believe it’s because of these episodes that people don’t reach out for help. All of those terrible “I can’t get out of bed” feelings go away and we think maybe we were making it all up, or it’s really not that bad and we can work through it on our own. Then they come back, and we go through the same cycle all over again, possibly not getting help for years.

I blame myself and people like me for why depression so often goes undiagnosed and treated. I think it’s because our teachers drill lists of symptoms into our heads about what depression is supposed to look and feel like to those who suffer from it. The truth is that depression doesn’t always show itself in the way we expect. It can be quiet, sneaky, and shift over time. Some of the most common symptoms I have seen, which are not listed on any diagnostic criteria, are:

I know these symptoms may seem too vague or as if they can be applied to many illnesses, but it’s important to highlight just how varied depression can feel. It’s not always about feeling sad or struggling to sleep; it can look and feel very different person to person. Just remember that however you feel, if you don’t feel like yourself and find that you are less and less interested in things you used to like, please get help.

The lack of energy that comes along with depression is always my largest concern. Many people who come into my office or reach out online tell me they just couldn’t muster up the energy to reach out any sooner. Or if they did try to reach out, their therapist or doctor didn’t call them back and they gave up. When simply showering and getting out of bed become huge successes, then calling and making an appointment for therapy, checking your insurance to make sure it’s covered, getting to the office on time, and expressing what you are feeling is just not feasible.

That’s why depression can hold people hostage for so long. When we have the energy to get up and out of the house, we don’t think we feel bad enough to need any help or treatment.

By the time we actually do feel bad enough and believe we need to get some help, we physically and mentally can’t. This is why we need not only to do our best to check in on our own mental health, but also to have supportive people in our lives who can help us when we can’t help ourselves. This could be having that friend make the call to see a therapist, or driving us to our appointment and waiting with us. However we can make it happen, it’s important that we have a plan to get back up and keep fighting.

Many years ago, I was at a women’s convention and heard one of the most motivational speeches of my life. There was much to digest in this speech, but my key takeaway was this question:

The reason I like this question so much is that it’s brutally accurate. If I trip and fall in real life, I bounce back up, look around (hope nobody saw), brush myself off, and go on my way. Emotionally, on the other hand, I can replay a bad or hurtful thing that happened over and over, essentially holding myself pinned to the ground where the incident took place. It baffles me why I do this, and I am still working to more quickly process hurts and changes so I can get up, dust myself off, and move on.

Take some time to consider this. Would you allow yourself to trip and fall only to lie on the sidewalk while others walked past? Of course not! Then why when we trip up emotionally do we allow that to happen? For many it’s because it’s embarrassing to admit and harder to face than just pretending it never happened. Others share how they didn’t even realize they were on the ground in the first place! Whatever the reason, I think this question is something we should all consider. Especially as we talk about the stigma associated with mental illness and how we all play a role in fostering it.

Why Is Mental Illness So Stigmatized?

We all add to the stigma surrounding mental illness. I am not trying to call anyone out or make anyone feel bad, but in our own way we each contribute to the stigma. It could be the way we think about other people with mental illness, or even the way we talk to ourselves about our own struggles. As an example, we could (without realizing it) assume that all people with schizophrenia live on the streets and talk to themselves, or that every depressed person should just get up and shower; that will make them feel so much better. I know these are varied examples, but whether we like to admit it or not, we all have biases and live our lives based on our beliefs and experiences. We should all take some time to think about the mental illnesses we know of and what our thoughts or beliefs are about them. Be honest, because we have to truly recognize our own prejudices before we can work to change them.

Some of our assumptions or prejudices about mental illness can actually be helpful; when confronted with a mentally ill person they may make us more patient or encourage us to communicate more clearly, so there isn’t a misunderstanding. Other assumptions can be hurtful and isolate us. I believe the best way to manage our thoughts is to first educate ourselves. We need to fully understand how a mental illness can feel to someone before we can thoughtfully talk about it. Second, for a moment, try to put yourself in their position. How would that affect you and your life? Could you do all you do each day with that illness? I find this to be the part where people who may have judged others prematurely have that ah-ha! moment. It can be powerful to consider what you could and couldn’t do as a result of your mental health. Consider this concept as we move through the next two mental illnesses.

I saved these for last because they are by far the most stigmatized and misunderstood, each for very different reasons. But let’s start by talking about eating disorders (EDs), since they are my specialty. EDs are an interesting mix of physical and mental health, and why I have always believed the two are inextricably linked, whether we want to admit it or not (“healthy mind, healthy body” is my motto for a reason). When we overeat, starve ourselves, binge and purge, exercise too much, or whatever our eating disorder tells us to do, we are affecting our physical health because of our mental illness. It is because our mind and body are so linked with this illness that eating disorders have the highest mortality rate of any mental illness.

The biggest misunderstanding about eating disorders is that they are all about the food. In truth, they have nothing to do with food. It’s all about why we decided that controlling our food intake was necessary and what we get out of doing so. Do we do it because if we eat until we are uncomfortably full, we can’t possibly think about anything else? Do we feel so sick and sad inside that we want our outsides to mirror those feelings? The reasons people have eating disorders are endless and very personal to those who struggle.

Another misconception is that eating disorders only cause people to be underweight. I know that’s what the media emphasizes and what we see on most shows or movies about EDs, but the truth is that eating disorders come in all shapes and sizes. I vividly remember walking through the parking lot of a Walgreens and seeing a van rocking back and forth. I figured kids were in there messing around, or possibly adults, but what I saw forever changed the way I view eating disorders.

The woman in the van had just come through a Carl’s Jr. drive-through and was moving around quickly to get all her food set out on the dashboard. Her fast movements were causing the van to rock as she hastily ate through her stack of binge food. I know this image isn’t as shocking as the underweight version we are used to, but it’s just as serious and dangerous, and the stigma even more intense. There was a reason she was doing this at night in a pretty empty parking lot, alone. Many who suffer from binge eating disorder (BED) do so in silence, never reaching out for help, wondering why they can’t stop eating after they are full.

When you combine the stigma people attach to EDs with society’s judgment of those who are overweight, it’s no wonder most sufferers don’t reach out for help. I have worked at many eating disorder treatment centers over the years, yet never treated someone with BED. This isn’t because the treatment centers wouldn’t take them, but because insurance companies wouldn’t pay for their care. If they were not underweight, companies would deny our plea for coverage, and unless the patient could afford the $35,000 cost, or more, each month, they wouldn’t be admitted to the program. The way our society views what “sick enough” looks like makes the illnesses themselves so much more severe and shame filled.

I don’t say all this to deter anyone from getting help or to make you feel bad for those who are struggling. I only say this to make you aware and start a conversation. I find that by simply talking about the things I find upsetting, and shedding light on something that often goes unnoticed, we can enact change. Eating disorders (like all mental illnesses) thrive in the dark, in the shame and embarrassment. So let’s shed a little light, offer a little understanding, and (fingers crossed) spark some hope.

The final mental illness I want to discuss is borderline personality disorder (BPD), which I believe is possibly the most stigmatized and misunderstood mental illness out there. If you don’t know what BPD is, it is a personality disorder marked by fear of abandonment, emotion disregulation, and difficulty in relationships. The best phrase I have ever heard to describe BPD is “they are emotional burn victims.” Meaning that those with BPD feel everything so intensely and painfully that it makes it hard for them to manage any emotion.

What pains me most about BPD is not just that the illness is usually misunderstood, but that it’s often born out of abuse. Many who have BPD will share stories of emotional neglect and physical or sexual abuse. Not having any real way to cope, they turn inward and tell themselves terrible and hurtful things. Over time they believe these things to be fact and act out of that supposition. Many of these “facts” are things like “I deserve to be alone, and always will be,” “I am not worthy of real love,” and “everyone will always end up leaving me.” It is because of these false beliefs that those with BPD lash out at others; it’s not because they are mean. They just hurt so much all the time.

The stigma associated with BPD doesn’t only occur in normal everyday life; it also exists within the mental health community. Many therapists, counselors, and psychiatrists will not treat patients with borderline personality disorder, stating that they are too difficult and require more time than an outpatient (meaning you see them once a week or so and then go about your life) professional can offer. I find this to be the most harmful kind of stigma. This means that when we are struggling and we reach out, we may be referred to someone else and seen for a bit, only to be told we need different or more extensive care; we may be passed around from therapist to therapist only to be left without any care at all.

I fully believe the reason many professionals won’t treat someone with BPD is that they don’t fully understand it. If we can work together to increase knowledge of BPD, where it comes from, and what treatments work best, then I really think we can start offering real help to those who need it.