You’re the Worst: The other show therapists should be watching

Petr Kratochvil / / Licensed under Creative Commons ZeroMental health groups have been paying a lot of attention to Netflix’s 13 Reasons Why. The show depicts a teenager’s suicide and the tapes she left explaining her actions. Counselors and therapists have expressed concern that it will inspire copycats. But there’s another show that mental health professionals should be attending to, not out of concern but because it depicts mental illness and therapy so well: You’re the Worst.

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The upside of overdiagnosis

Yes, we’re pathologizing everyday life. But that also makes it easier to ask for — and get — help.                                                                                                                                                                                                                                                                                                            

DepressionThere’s a nice column on PsychCentral today asking the question, “Are we over-diagnosed and over-medicated?” Author Linda Sapadin isn’t asking whether we are diagnosing people who fail to actually meet diagnostic criteria; that’s also worth debating, but not the point here. She’s challenging the diagnostic criteria themselves. Her voice adds to the chorus of those concerned about changes coming in the DSM-5 this May, particularly those that will make it easier to diagnose a grieving person as having major depressive disorder.

There are clear downsides to broadening the diagnostic criteria for any mental health disorder. Such a shift means that more people who are functioning within normal ranges (which is not to say they are functioning well, mind you; we’re talking about people who are still suffering, it is just that the suffering is common) will qualify for a diagnosis and then receive treatment. This adds to our growing healthcare costs. It arouses skepticism of the overall legitimacy of mental health care, leading some to wonder whether these changes are driven (at least in part) by pharmaceutical companies looking for new people to sell drugs to. It also risks sending the message to more people that they are mentally ill, that there is something wrong with them, when in actuality their functioning is quite normal and their suffering would possibly resolve on its own without treatment.

But such discussion is incomplete unless we also look at the upside of broadening diagnostic criteria. Just because a person’s suffering is within normal ranges does not mean we should refuse, as a mental health field, to make help available. Bereavement is a prime example. Not everyone who is grieving the loss of a loved one needs medication. But for those who cannot seem to resolve their grief, those who feel genuine struggle and suffering, those who want treatment to help them function better — broader diagnostic criteria makes it more likely that they will be able to get treatment and have it paid for through their insurance.

It’s also possible that having broader diagnostic criteria can help reduce the stigma of a mental health diagnosis. If we looked at these diagnoses as more like colds (almost everyone gets them sometimes) and less like the plague (rare and frightening), it would be easier to publicly discuss one’s mental health struggles without shame.

I realize there is more to this, and I’ll confess I’m not yet sure where I land on many of the DSM-5 changes. There are reasonable questions to be asked about whether someone should be able to receive mental health treatment (particularly on someone else’s dime, whether that someone else is the taxpayer or other members of their health plan) simply because they feel they need it. Widespread use of psychotropic medications has serious public health and environmental consequences. And the national shortage of well-trained mental health workers means our system is already strained by current diagnostic criteria. But anyone who presumes that broader diagnostic criteria are automatically bad is failing to consider the whole picture. There are some potential benefits of allowing more people who at the edges of normal functioning to qualify for diagnoses.

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The DSM-5 comes out in May; you can learn more about it here. Your comments are welcome. You can email me at ben[at]bencaldwell[dot]com, post a comment below, or find me on Twitter @benjamincaldwel.

To ease stress, and maybe save your marriage, try doing nothing

When it comes to making a healthier self and a happier family, doing nothing may be the next big thing.                                                                                                                                                                                     

TratakaOne of the hardest things for many of us (myself included) to fathom when we dedicate our careers to solving problems is that sometimes the best solution is no solution at all — just do nothing. Refraining from action can be just as vital a problem-solving strategy as taking action.

Michele Weiner-Davis, the author of Divorce Busting, offers a touching blog entry about how doing nothing helped her own marriage. And there’s the website that challenges you to do nothing for two minutes, which is harder than it sounds if you’re used to moving at a fast pace.

Best of all: Doing nothing can be surprisingly effective.

“Taking a moment to do nothing can be very centering and calming. It allows you to slow the entire experience down and get back to a place of rational thought,” says my good friend and Caldwell-Clark cofounder Aimee Zakrewski Clark, who also runs the No Stress Foundation (full disclosure: I’m on the Board of Directors at No Stress). Indeed, doing nothing can be a surprisingly useful treatment for depression, which fairly quickly improves on its own in as many as 1 in 5 untreated cases. (Naturally, if you’re experiencing depression, talk it over with a doctor or mental health professional — just keep “no treatment” on the table as an option.) And doing nothing can improve family life; the tendency for kids to be over-scheduled has been widely covered. The impact of that hyperscheduling may actually be good for kids, but at the same time, studies routinely show that families do better when they simply spend time together… even if they aren’t actually doing anything in that time.

How does one go from doing a lot to doing nothing, even if for just a few minutes a day?

“Commit to one 5-minute practice per day that invokes the nothingness. You can do a simple exercise I call Choosing Your Thoughts, which engages the breath and mind to help you do just that. As you inhale and exhale through your nose, say to yourself, ‘I am aware that I’m doing nothing,'” says Clark. “You can even add a smile, which will help you to enjoy the exercise.”

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Adding a smile will help us both enjoy your emails to me at ben[at], your posted comments, or your messages to my Twitter feed.

From the AAMFT Research Conference: The one question that can improve depression treatment outcomes

A large number of clients who seek treatment for depression also are having difficulty in their marriages. New data suggests that one question can dramatically improve patient outcomes on both problems: Which came first?

That’s the finding Steven Beach, a professor at the University of Georgia, discussed at this weekend’s AAMFT Research Conference in Alexandria, VA. Research has shown for many years (1, 2) that marital satisfaction and depression can be greatly improved at the same time through couples treatment, regardless of which problem came first. However, new data from Beach and his colleagues suggests that when women are struggling with both depression and marital problems, individual therapy for depression will have negative effects on the relationship if the marital discord came first — suggesting worse outcomes for the depression as well.

Why should this matter to MFTs, who are eminently qualified to identify and treat both issues? Because most depressed people don’t start by seeking treatment from a family therapist. According to a 2009 NAMI survey on depression, people with depression usually receive treatment from their primary care physicians. Just 38% receive their primary depression treatment through a mental health professional of any kind. Physicians tend to treat depression with medication and/or referral for individual therapy. They rarely refer for couples therapy, in spite of the research supporting such referrals. The list of possible reasons for this disconnect is long, but some reasonable guesses include that physicians may not know the research, may not have a trusted marriage therapist to whom they can send clients, or simply may not think to ask depressed patients about relationship difficulties (an area of struggle patients may not bring up on their own).

Beach and his colleagues believe that the link between depression and relationship difficulty is so strong that physicians ought to screen for relationship problems whenever they are diagnosing a patient with depression and considering treatment options. They developed a simple 10-item screening measure for relationship problems, with an 11th question for those who show relationship difficulty: Which came first?

Notes: Two quick things about the research base here: 1, the studies of marital therapy to treat depression have universally, as best as I can tell, looked at depressed women. Whether the suggested treatment course and likely outcomes would be the same with depressed men is open to question. 2, while studies have looked at marital therapy and marital satisfaction, there is no reason to believe that non-married people in committed relationships have a different kind of link between depression and relationship difficulty. The screening instrument can be used for married and nonmarried couples alike.