CHAPTER 9
Mental Health: Dealing with Tough Times
Inside of a ring or out, ain’t nothing wrong with going down. It’s staying down that’s wrong.
—Muhammad Ali
If you had to wager that one of the three people below would become a multimillionaire, who would it be?
a. A single mother living on welfare, battling depression
b. A young woman with crippling obsessive-compulsive disorder
c. A man who has already destroyed his promising career and is so badly addicted to drugs he ends up in prison
The odds seem against all of them, right? We would understand if you chose not to make the bet.
And yet all three of these people are among the most successful in their fields. We’ve just described: (a) J. K. Rowling (author of the Harry Potter series), (b) Lena Dunham (actress, writer, producer, and director of Girls), and (c) Robert Downey Jr. (the highest-grossing actor of 2015 and number five on the all-time list).
The chances of becoming that successful are microscopically small in the first place, even before adding serious adversity to the mix. So how did each of these people overcome the barriers and setbacks to realize their dreams? They knew how to bounce back—and then bounce higher. The ability to shrug off adversity and succeed in the face of tremendous challenge is called resilience.
Resilience can come from within, but it is also strengthened by the people around us. A support network of friends and family certainly helps, but often, help from a mental health professional proves indispensable. Rowling, Dunham, and Downey had friends and family who bolstered their ability to rebound from their challenges in life, but all three also credit therapy for helping them when they were overwhelmed by depression, obsessions, and drug addiction.
Rowling says her nine months undergoing cognitive behavioral therapy saved her life, and she speaks openly about the challenges she faced. “I have never been remotely ashamed of having been depressed,” she said in an interview. “Never. What’s there to be ashamed of? I went through a really tough time and I am quite proud that I got out of that.”
Dunham has written about the indispensable support of the teachers who helped her cope with obsessional thoughts by allowing her the freedom to ask any and all questions that were crowding her mind. But it took professional help to get her to a mental state where she could succeed.
Downey credits the love and support he received from his wife for finally getting him to find therapy and stick to it. If he wanted to marry her, she told him, he had to be sober. Her uncompromising requirement and her support were what Downey needed to truly invest in his mental health and treatment. Downey found a therapist, started a twelve-step program, and began to study meditation, yoga, and wing chun martial arts.
None of these amazing individuals had an easy road to recovering their mental health, but with the power of therapy, each of them managed to muster the resilience necessary to let their talents shine through.
Going to therapy may be one of the most resilient acts any of us can engage in. It’s tempting to think mental health issues are relatively uncommon, but 50 percent of people will encounter challenges to their mental health during their lifetime: that’s every other person at the football game you’re attending, the airport you’re passing through, the lecture hall you’re sitting in. If it’s not you, it’s your roommate, classmate, or teammate. Seventy-five percent of all those affected will need professional help before their senior year of college. The peak age for the onset of mental illness? Eighteen to twenty-five. This isn’t meant to alarm, but rather the opposite. Mental illness is a part of life. What is alarming is how few of us have been given the knowledge and tools to overcome it.
People are designed to bounce back from hard times—the will to survive, adapt, and thrive is in our biology—but when emotional overload leaves you feeling like you’ve lost your mind, a therapist can help you find it again.
In this chapter we will prepare you to become your own agent of change when times are tough. To take advantage of all the qualities we’ve covered so far—from optimism, to willpower, to stress management—many of us will first need to overcome the challenges that are created by our own minds. Just as you need an academic education, a physical education, and a sex education, we believe you need a mental health education. If half of all people are going to encounter mental illness in life, we all need to become experts in how to recognize problems early and put ourselves back on the path to mental health.
A Lot of Us Have Been There
When I (Alan) talk about the challenges of mental illness, I’m not only speaking about the rich and famous, I’m talking about me. My junior year of college began with my grandfather’s death, and I missed the first week of classes. Campus felt like a lonely place when I returned. My friends didn’t know my grandfather and preferred to avoid the issue. I’d have encounters like:
“Hey, Alan, long time! Where have you been, how was your summer?”
“Hey, I got back late because my grandfather died.”
“Oh, man, I’m so sorry, that sucks. It’s good you’re back, let’s get pizza later!”
The semester moved on and I wasn’t a happy camper, and even though my grandfather had died, I didn’t connect his loss with my mood. I went about my life. I took classes. As in every semester before, I developed a crush on a woman. We’ll call her Satan (my memory is rusty, but I’m pretty sure that was her name). I was pretty sure she wasn’t interested in me, but that didn’t stop me from pursuing her. I really liked Satan, and my good friend and housemate—we’ll call him Esswipe—encouraged me to go after her. After I spent two months chasing her unsuccessfully, Esswipe and Satan ended up making out on a dance floor. The next day when I confronted him, he was hoping I would be “cool” with it.
I wasn’t.
My anxiety went through the roof over the weeks that followed. I couldn’t sleep and it was hard to keep food down. At first I couldn’t concentrate in class, and then I just stopped going. I finally went to the health center, thinking I had the flu, and was indignant when they suggested I might need to talk to someone about my mental health. “What idiots!” I thought. Still, I was barely sleeping, accomplishing no work, and even I realized it was time to go home. I missed two days of classes, but enough family and friends remarked on how unhappy I seemed that when I returned to campus, I found myself in front of the office of Dr. Janet Madigan. Pressing the buzzer to be let in, I felt nothing but doom, gloom, and an enormous amount of anxiety, but the stairs to her office proved to be quite literally the first steps I would take toward finding my mental health.
When Should You Seek Help?
Mental illness is a product of our genetics, our environment, and our behaviors. My issues in college checked all those boxes: I was always an anxious kid, which was genetically programmed into me by coming from a long line of worriers. Had my environment that semester been different, I might very well have developed significant anxiety anyway, but there’s no doubt that my downward spiral was spurred by my grandfather’s death and compounded by the situation with Satan and my roommate. Instead of trying to change my behavior to pull myself out of an emotional nose dive, I didn’t acknowledge that I was suffering. After my grandfather died, I didn’t talk about feeling upset with anyone, allowing the negative emotions to grow, and I didn’t initially seek help after the incident with my roommate, either. Believing that we are resilient can be a double-edged sword, fooling us into suffering longer than we need to.
Because it’s absolutely true that everyone has ups and downs, it can be hard to tell when it’s time to send up the flares. So how do you know when enough is enough and it’s time to seek professional help? Mental anguish isn’t as easy to see and evaluate as physical distress, but there are signs you can look for in yourself. Let’s take the two most common mental diagnoses on campus: depression and anxiety. One of the classic symptoms of being depressed is that you stop finding pleasure in the things you enjoy. If you are no longer having fun when you play a sport or an instrument you have always loved, that is an indication that you are more than just a little blue. If you feel so anxious that you stop going out or if you can’t concentrate enough to get your work done, it’s time to get some help. If your mood is consistently down for more than two weeks, this should definitely be a warning sign.
It’s okay for life to be hard, but it’s not okay for it to be miserable (for too long). When you find yourself incapable of accomplishing tasks or isolating yourself from your friends—the very people who could help you bounce back—this is a strong indication that it is time for outside support.
Most importantly, if negative feelings progress to the point where you are considering harming yourself, it’s time to go to the emergency room. More than 50 percent of college students report having thoughts at some point of not wanting to live. The moment you can even conceive of acting on those kinds of thoughts, you need to seek help. Seriously considering self-harm is the mental health equivalent of throwing up blood. That’s a graphic comparison, but it should be. You wouldn’t hesitate to go to the ER if you were vomiting blood, and if you are contemplating not living, that’s just as serious. If you get to this point, it’s time to get to a mental health clinician as soon as possible.
To Go or Not to Go?
Don’t get stuck on this question. People usually cite stigma, or shame, as being a top reason to avoid therapy, but that is changing. In a 2014 survey, over 30 percent of college students sought out services at the counseling center. More students are seeking care than ever before, possibly because of anti-stigma campaigns and growing awareness that anything divulged to the therapist will remain confidential under the Family Educational Rights and Privacy Act (FERPA: the law that maintains the privacy of mental health records for college students from all people, including their parents).
Many people mistakenly doubt the value of therapy. When the American Psychological Association asked a thousand people why they wouldn’t get therapy, 77 percent responded that it just doesn’t work. But research tells us the opposite. Fifty-three percent of people in treatment feel significantly better after just one to eight visits. Researchers who evaluate the effectiveness of various mental health treatments have found that the statistical “effect size” of therapy (a measure of how effective it is) is truly huge, and that it grows over time. In one study, people who had received up to forty hours of therapy found that the benefits continued to grow even after the therapy had ended. In another, the benefits of therapy increased by 50 percent in the nine months after therapy was completed.
For those of you who are thinking the cost of therapy will be too high or it will be a waste of your time (and time is money, after all), another large study found that getting therapy can be thirty-two times more efficient at increasing your well-being than making more money: to create the same amount of change as four months of therapy (for a cost of about $800), you’d need a raise of about $25,000.
Alan Goes to Therapy
Walking up the staircase to Dr. Madigan’s office, I was filled with doubt, the feeling that I was not normal, and a certain degree of shame. It was a calm room and I knew she was there to help, but I still sat in that chair feeling like I was facing my nemesis. The hardest part of the session turned out to be fighting the desire to like her. She asked me broad questions about who I was and how I had ended up in her office. I told her the story about Satan and Esswipe, and she wondered if that was really at the heart of everything. For the first time, I realized that I hadn’t mentioned the loss of my grandfather. It was a lightbulb moment.
Dr. Madigan helped me feel totally comfortable, and over the course of our first three sessions, I started to feel better. She helped me realize that I had to stop worrying about what was “normal” (I now think that “normal” is a useless word that should be banned). She encouraged me to pursue health both mentally and physically. During our conversations, I came to realize that I had stopped exercising, for reasons I couldn’t recall. She helped me realize that my lifelong anxiety had made me spend much of my time keeping people at a distance, afraid they would see what a wreck I really was. I felt open enough to talk about why I had never had a girlfriend and how I might do things differently in the future.
When I first went to the campus health center, I saw anxiety the way I did the flu—something to get rid of, something that needed to be cured. But with Dr. Madigan’s help, I developed a different relationship with myself, with the people I cared for, and with the world around me. I came to understand that my anxiety hadn’t been caused by a single thing, but by everything: years of being anxious, the loss of my grandfather, feeling lonely, feeling hurt. Most importantly, therapy helped me realize that if I was going to thrive in college, I was going to have to change my mental approach.
I began to resume my life, somewhat shaken but also feeling a new confidence. I had been through the worst but had gained new strategies for handling the world. I went back to the gym. I started to reach out to friends with whom I’d lost touch. Perhaps most importantly, my desire and capacity to create change had taken center stage in my life; in making this my priority, I was learning how to truly care for myself.
You Make Change Happen
Your desire to create change counts for a lot. Michael Lambert and his colleagues at Brigham Young University looked at hundreds of studies to see what factors make therapy effective. The most important variable? You. Lambert estimates that up to 40 percent of your potential for success in therapy is determined by your belief that you have the strengths and skills to create change.
If you want a guideline for how people change, check out this model developed by James Prochaska and Carlo DiClemente. This is a general path toward trying to break habits, whether that means cutting down on drinking, quitting smoking, or just keeping your room clean. Think of something you want to change, and try to imagine making that change in these steps:
Precontemplation—you are not intending to take action in the foreseeable future.
Contemplation—you are intending to change in the next six months.
Preparation—you are going to take action in the immediate future, in at least the next month.
Action—you have made specific overt modifications in your life.
Maintenance—you’ve made your change and now are working to prevent slipping back into your old habit. This stage can last from six months to five years.
Termination—you have zero temptation to return to your old unhealthy habit. Your room is spotless, there are no liquor bottles in your recycling bin, and the smell of nicotine makes your stomach roll.
Keep in mind that the process of change is not necessarily linear and you may find yourself between two stages. At any step along the way, you might relapse and slide back to an earlier stage of change. That’s natural. It takes most smokers four attempts to quit cigarettes, and at first glance this might seem discouraging. But if you have this knowledge while attempting to quit for the first time, a relapse is a setback rather than a total failure. That kind of understanding about the difficulty of change can be essential in getting yourself from maintenance to termination.
If you show up at a therapist’s office and believe you are still in precontemplation, that is the first thing worth talking about. If you seek therapy and are ready for action, you are 40 percent of the way home.
While your desire to create change is essential, it is not enough on its own to guarantee success. Your relationship with the therapist determines up to 30 percent of the success of your treatment. Lambert asserts that therapist skill accounts for another 15 percent when it comes to predicting a good outcome in treatment. Finally, if you have confidence that you are going to get better, this optimism acts like a powerful placebo: Lambert believes it accounts for the final 15 percent toward your successful treatment. All of the factors leave us with a nice chart that helps us visualize what is contributing to a person’s improvement during therapy. Every piece plays its part, but none more so than you.
The Common Questions
When a person starts therapy, a series of common questions, answered in advance, might reduce the tension and keep them on the right path.
I’m smarter than my therapist, so how can they help me?
It’s okay if you believe you are smarter than the therapist! We might be smarter than our mechanic in certain realms, but most of us still prefer to have a mechanic fixing our car. The important thing is that your therapist has the skills to organize your session in a productive way, much like a trainer in a gym. Their role is to guide you in looking at your thoughts, so that you can challenge yourself and come to a greater understanding but not feel overwhelmed.
Why can’t I just talk about my problems with a friend?
Friends and family can give great advice, but there are situations where using them as a therapist is not fair to either of you. Helping family with mental health issues can be like trying to read a map that is so close to your face, it’s touching your nose. Proper perspective can only be gained by standing back. You are also more likely to say everything on your mind to someone who has been trained to help others navigate their thoughts and who, by law, must maintain confidentiality.
How do I know if I’ve found the right therapist?
If you see change after three sessions, you are on the right track. If you aren’t seeing the change, let your therapist know. A good therapist should make an effort to mold their approach to your needs. If you start to feel change, keep track of it and keep your therapist in the loop. In one study, people who observed their change and gave their therapists feedback did 75 percent better than peers who didn’t take the time to monitor their progress.
If you don’t see significant change after five sessions, it’s time to find someone else. However, if you go to the next person and the next and there is still no change, consider that—just maybe—it could have something to do with your approach. Some people go to therapy determined to get better, just so long as it doesn’t involve changing something about themselves. Therapy won’t help people who don’t believe change is possible or who think it’s the world that needs to change. You need motivation to succeed in therapy, or at the least a desire to develop some of that motivation.
Going to therapy is an act of bravery. It is the opposite of being weak and, like going to a mental gym, gives you the opportunity to strengthen your mind. Therapy requires that you confront the thing you are most scared of, or the things that make you sad. You may confront fear itself. When the therapist says something you don’t like, you need the courage to stay in the session, respond to it, and return! The therapist should make you feel safe, but may need to push you into uncomfortable waters.
“It’s Staying Down That’s Wrong”
When I (Alan) graduated from college, I had to leave Dr. Madigan behind, but the skills she helped me discover stick with me to this day. Just days after graduating, I finally found a wonderful girlfriend, Agnes, and for that alone, Dr. Madigan was worth her weight in gold (as was Agnes!). I had started to live an examined life, really trying to understand myself. When graduation rolled around, part of me was hoping that I was leaving my anxiety behind as well. I went off to medical school, which, as you may have heard, is not known for being a low-stress environment. Surprise, surprise, I started getting anxious again. But there was a difference this time. After the very first night of not being able to fall asleep, I went in search of a therapist. I made the decision to do whatever it would take to feel good: therapy, meditation, exercise, you name it, I’d try it.
College provides a lot of opportunities to be resilient. That’s true for everyone, so remember that your peers are very likely to be experiencing struggles of their own. Don’t hesitate to seek out support and camaraderie when you get back a test with a surprisingly low score or put on a show of your artwork and receive challenging critical feedback. But beyond your resilience and the support of your peers, there might come a time when it feels like you’ve been knocked down and just want to stay there. Some of you will successfully manage on your own, but some of you will not. Remember that you deserve to be healthy, and that suffering in silence is not a badge of honor. The most resilient people understand that seeking help is a way to develop their strength. If you feel like your mental health needs an assist, or perhaps you just feel off, don’t wait for it to get better—simply having the desire to change and seek help means you’re almost halfway there.
Opportunities for Action
Exercise: It’s Time to Go
Even given the extraordinary benefits that therapy can bring, it can sometimes be difficult to resolve to seek help even if you think you might need it. If you are on the fence about seeing a therapist, here are two simple questions to ask yourself:
What is the risk of going to therapy?
What are the benefits of going to therapy?
Write down the answers to these questions. We’ve tried to answer them in this chapter, but we cannot possibly answer them fully for all of you. When it comes to the risks of therapy, it is possible you won’t connect with your therapist, you may feel misunderstood, and it will almost definitely be uncomfortable at first. As for the benefits, it could be anything from “this will help me develop a relationship” to “I won’t be anxious all the time.” When we are really down, we are not thinking with our best mind. We often feel like our worries and anguish are under a microscope and we can see little else, including the things that will help us. Completing this exercise may provide you with some needed objectivity.
Exercise: Making Change Happen in the Session
A good relationship between you and your therapist exists when the two of you agree on what your challenges are and how best to work together to solve them. To find out if you and your therapist are in agreement, we have an assessment created by Dr. Scott Miller, the cofounder of the International Center for Clinical Excellence, to measure the outcome of therapy and the quality of your alliance with the clinician. Before entering the session, look back over the past week, including today, and on a scale of 1 to 5, with 5 being the best, assess how you are doing:
1. With your personal well-being.
2. With your close relationships.
3. With your relationships at work and school.
4. Overall in your life (including work, school, etc.).
Write these down so that you can refer to them in the future. Over time, the scores may come in very handy, giving you an objective measure of whether or not you are improving.
At the end of every session, using the same scale, 1 to 5, answer these three questions to assess the quality of your relationship with the therapist:
1. Did I feel understood and respected?
2. Did we work on and talk about what I wanted to work on and talk about?
3. Is the therapist’s approach a good fit for me?
4. Overall, was today’s session right for me?
If any of these answers are scoring low, it’s a signal of what needs to be discussed with the therapist (for the full scale, check out the link at uthrive.com). Therapists are trained to ask and tolerate challenging questions, but if it is too uncomfortable for either of you, it’s time to find a new therapist.
The Takeaway
The Big Idea
Many of us have been challenged by mental illness, but with the right awareness and tools, we can find our resilience as well.
Be Sure to Remember
50 percent of people experience mental illness in their lifetimes, 75 percent of those by the time they are a senior in college.
Your belief that you can change is the number one factor that predicts that you will overcome mental illness.
Your relationship with your therapist is the number two factor that will help you overcome mental health challenges.
Making It Happen
When we are confronted with mental illness, we are often not using our best mind. If you are reluctant to seek therapy, make a list of the pros and cons of reaching out for help to give yourself some objectivity.
Before your first session, on a scale of 1 to 5, with 5 as the best, rank how you think you’re doing with your personal well-being, with your close relationships, and at handling life in general. Keep the scorecard with you so you can look back and gauge progress as your therapy continues.
If you are feeling better after three sessions, you have found the right therapist, but by the fifth session, if there’s no improvement in sight, time to find a new one.