Greg Thorkelson, MD with Ryan Reagan, PhD(c), LPC

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It is Mental Health Awareness month and this week the blog for mental health will be devoted to the subject of asking for help.  It may surprise you to know that this can be exceptionally difficult. Or, it may not surprise you at all because you or a loved one have seen what it is like to struggle with a mental illness.  Maybe you have asked once and had an unfortunate experience and then thought—“see I shouldn’t have bothered.”

The tough thing about having a brain is that it comes with a mind.  The human brain is not a computer although this analogy is often still frequently used outside of the field.  And before you dismiss this as obvious, think for a moment about how much of our language is still oriented this way.  When is the last time you heard someone say “hang on, I’m still processing that?” This is important because language shapes our expectations.  If we go to therapy thinking, I am doing this because I need to process emotions, when is the “processing” complete?  

These are rhetorical questions so there is no answer here, the purpose is to think deeper about what is involved in seeking help.  It is no exaggeration to say that it might be the single most important thing you do.  It is also important to dispel any notion to people outside of the mental health field that this is an easy process.  Despite the improvements in access to care and increasing awareness, despite the efforts to reduce stigma, the “asking” is sometimes not heard or understood on the receiving end.  

This “unheard asking” is not just within the mental health system. Whether public, as with Anthony Bourdain and Kate Spade a few years ago, or less public we all know the words—“I knew they struggled, but not like that.”  We all know that instance.  The problem lies in that final word—“that.”  We are human beings and none of us get through life without struggle, but, there can be a world of difference to unpack within the word “that.”  “That” is sometimes a stand in for a world of suffering.  

Why We Might Not Ask for Help.

Part of the purpose in the writing on our blog for mental health is to help educate the public and increase awareness of mental health needs and treatment.  Depression and anxiety are routine ailments that affect millions of Americans annually.  Our understanding of human cognition has improved significantly in the past two decades.  Cognitive Behavioral Therapy (CBT) is a highly effective treatment approach for depression and anxiety.  

Psychotherapy is one of the common recommendations for anxiety and depression.  It works, but we should be clear that there are any number of factors that may require it to be repeated, possibly multiple times.  If you are feeling like you have tried it and found that it was not helpful it could be due to a variety of circumstances including time and place, a poor match between client and therapist, and of course change.  The fact is that we grow, and it may well be that a second round of psychotherapy with a different therapist may reveal something new or connect to something old in a way it had not previously.  It is worth doing if you are suffering.

One of the that can contribute to not asking for help is that depression and anxiety actually make it difficult to decide if you need help.  Both depression and anxiety can contribute to difficulty concentrating and making decisions.  It is also true that one of the emotions that comes with suffering is shame.  We think of mental illness differently than we think about other medical phenomenon.  Depression is unique in that it is sometimes accompanied by feelings of worthlessness and inappropriate guilt. While receiving a medical diagnosis maybe shocking and in some cases traumatic, people generally do not report that they feel worthless in the way depression invites us to.  

With anxiety disorders, there is often nervousness, and this also contributes to feelings of shame.  People with anxiety often identify that the thoughts may be entirely irrational.  Someone suffering from OCD may say, ”I know that I do not need to wash my hands this precise number of times, but I can’t stop feeling that it is necessary.”  With anxiety disorders there is often frustration that the body just responds with panic when there is no rational reason.  This often leads the person suffering anxiety to avoid situations that provoke this response.  This avoidance tends to reinforce shame, and it is only a short step to concluding “I just can’t do this, it’s not worth it.”

We have two problems here, and as mentioned above, part of it is about how we are thinking.  One problem is that we are thinking with a brain that is probably not in its optimal state.  Remember, you have a mind, not a computer.  An unfeeling computer has the luxury of not having to deal with emotions like guilt or shame.  We on the other hand, have to make treatment decisions through the fog of guilt and shame.  Human beings, each of us, are hardwired to seek equilibrium or balance.  In a state of guilt or shame the brain will look for a compelling narrative to avoid greater discomfort.

This is the pathway to “why bother” and “it’s not worth it” reasoning.  This highlights the cruelty in mental illness.  The brain may be assisting you in rationalizing the story that you don’t need help.  Suffering from depression or anxiety are an exhausting experience, fatigue is one of the symptoms. It takes motivation to engage in treatment.  Pause for a second and think about how many steps are involved in calling, scheduling, arriving to an appointment, and continuing weekly.  These steps are purely mechanical, this scenario didn’t even ask you to ponder working through emotions.

A post at The Mighty by Emily Watts provides some helpful personal advice written from the perspective of someone who struggled with making the decision to start treatment. We have already addressed that these are common conditions affect many people annually and that it is also part of the nature of the illness to be uncomfortable seeking help.  Watts makes two excellent points.  The first—you will never really be ready.  The second—every day you wait is a day lost.

On the latter point, there is research that supports that putting off treatment can increase the duration and intensity of symptoms.  In other words, putting of treatment may worsen symptoms and increase the length of time suffering.  On the issue of readiness, the truth is that the mind will provide you an endless supply of reasons to delay.  Again, the brain’s preference is often set to status quo.  It takes motivation to make change happen, and that requires energy, and energy is in short supply during depression.  Short answer—if you are asking the question do I need help? you are ready.  As one writer has noted—“there is no wrong time to get help.”

What are some signs that I might need help?

This is a different subject from what we were addressing previously.  The previous section was about reducing stigma by increasing awareness that this is common and increasing understanding as to why it can be difficult to initiate treatment.  We have not yet answered the question when treatment should be sought.  A good assessment will almost always begin with an attempt to understand the duration and intensity of symptoms.  Put another way, how long are the symptoms lasting and what type of impact are they are having.  You can ask yourself two questions:

1. Am I feeling an unpleasant mood state (sad, angry, on edge, numb, depressed) and does this mood state feel stuck (not lifting for most of the day for the last two weeks)?

2. Are these symptoms causing a significant disruption to normal routine—unbale to go to work or school, straining relationships, unable to perform important roles like parenting?

These symptoms can be mild, moderate, or severe, and there is zero downside to assessing them and speaking with a mental health professional or your doctor.

After assessing duration and intensity, we can drill down to a deeper level.  Feelings and thoughts are the substance of the mental illness.  With depression people typically report, feelings of sadness, hopelessness, guilt, worthlessness, loneliness, and irritability.  Thoughts are negative in orientation and pessimistic: “why go on, it’s pointless; I can’t focus; I’m useless, it’s never going to get better.”  With anxiety, the feelings are generally fear driven, nervousness, feeling on edge, worried, exhausted, overwhelmed. Thoughts like “it’s too hard, I can’t cope, I’m in a daze” are common.  These symptoms also easily overlap, it is very common to feel stressed and on edge throughout the day and then slip into exhaustion and hopelessness.  

With feelings, only the individual experiencing them can say precisely what they are feeling.  For family and friends that are concerned about a loved one who may be suffering, it might be helpful to focus on behavior.  People who are suffering do not always come right out and say so, there is tendency in some to minimize the extent of symptoms.  Some of the key indicators are lack of sleep, agitation, risky or impulsive behavior, lack of motivation or energy to engage, and difficulty focusing or concentrating.

Ok, I Decided to Get Treatment, What Should I Expect?

The two most common forms of treatment are psychotherapy and medication.  Some opt for one or the other, while many people do both.  There is research to support that strong outcomes when the two work together.  The reason is that human cognition is messy, and some of the mess may be driving the symptoms.  Medication can reduce the intensity of the symptoms, and in some cases, it is essential to bringing symptoms to a manageable level.  Psychotherapy is aimed at developing deeper insight and understanding about ourselves and how we relate to problems that may be contributing to distress.  The popular idea of the patient, couch, and a therapist asking about your childhood is a relic of the past.  Modern psychotherapy is much more focused on the present and future—a growth orientation.

The decision to take medication, and what specific medication involves a conversation with the psychiatrist.  Some people are highly sensitive to medication side effects, and there might be alternative treatments like TMS that might be more appropriate. Your psychiatrist will also want to know if you have tried any medications in the past and whether they were effective.  The psychiatrist may ask you questions related to overall health, including diet, exercise, and sleep.  The body systems can easily become dysregulated, and this can have an impact the intensity of symptom.  For example, lost sleep usually increases irritability.  A decrease in the intensity of symptoms like insomnia and worry are some of the first noticeable effects of medication.

Helpful Tips and Preparing for Your Visit.

The National Institutes of Mental Health makes the following recommendations.  Prepare questions ahead of time.  The NIMH website has some data sheets available that can help with this and medication lists.  It is very important that your doctor know all of the medications that you are presently taking.  Knowing your family mental health history is helpful since certain disorders have a genetic component. It is not uncommon that close relatives will suffer from the same conditions.  It can also be helpful to a bring a relative or close friend for support.  You may feel overwhelmed by the amount of information presented and it may be difficult to concentrate if you are not feeling well.

Be honest.  The communication between you and your healthcare provider is confidential.  You do not have to feel ashamed or embarrassed. The fact that these conditions are so common makes it very unlikely that your provider has not encountered similar symptoms or scenarios.  Again, the stigma that comes with mental illness is a heavy burden.  Depression and anxiety are disorders that kick you when you are already down.  If you’ve decided to get into treatment and arrived, you are doing much better than you may realize.  

Ask questions.  You will likely receive a diagnosis, especially if you are using insurance.  This is a necessity for billing purposes and communication between providers within the field.  Feel free to ask questions about the diagnosis, symptoms, and how the physician or therapist arrived at their conclusion. Regarding medications, you should come away with an understanding of what the medication is supposed to treat, when it should be taken, what side effects should be anticipated, when the medication should be taken, dietary considerations, and how long it should take to notice effects.

Keep an open mind.  Psychotherapy can be an incredibly transformational and powerful experience.  It can also be uncomfortable at times.  This is not cause for concern, it signifies where work needs to be done.  The analogy of physical therapy can be helpful.  If you blow out your knee and the doctor sent you to physical therapy, you expect to encounter discomfort and pain as you regain your range of motion.  Emotional pain is similar.  Keep in mind that like medications, you may also benefit from repeated doses of psychotherapy, and with a different therapist.  A good relationship is foundational to all the caring professions.

Remember, asking for help was no easy feat, but you can be assured that you arrive at your appointment following the steps in a journey that thousands take daily.  You were never alone, it just felt that way until you asked.

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