“You Aren’t Throwing Chairs At Me.”
Stereotypes within professional mental health services are surprisingly pervasive
The fields of psychology and psychiatry have, regrettably, emerged from a history of unethical experimentation and decision-making that was deeply rooted in misinformation, superstition, and inhumane treatment. The now romanticized idea of nail scratches on the wallpaper, hysterical screams in padded rooms, and the “insane” being locked far away from society seems so far behind us. Now, we bring up mental health in every context to educate each other and aggressively advertise online resources to make treatment more accessible.
All this progress within psychiatry, psychology, and society is crucial in redeeming the credibility of such sciences. Yet, we’re not actually as far from the historical prejudice and misinformation as perhaps we’d like to think — especially toward less “mainstream” disorders.
Level 1: try to get a diagnosis.
About one year ago, I finally mustered up the courage to seek help for something I knew I was struggling with for my entire life. Every clinician was quick to grant me a diagnosis of anxiety and depression. From there, it was all the very same formula. They’ve gone through it so many times they must be numb to it.
- Cognitive Behavioral Therapy for however long your insurance pays for it
- SSRI’s for everything else for possibly the rest of your life
At my first appointment, I mostly needed help with difficulty focusing in class due to profound, chronic fatigue. After three types of antidepressants, two different anxiolytics, and a full year of various types of therapy, my depression and anxiety became disabling. Most days, I couldn’t even go to class in the first place.
I always felt like there was something that wasn’t being addressed in my treatment but needed to be addressed, like, yesteryear.
Around the same time, I got my very own shiny copy of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) — a tool used by professionals in the U.S. for diagnosing mental illnesses. There was a particular chapter that stood out to me: Borderline Personality Disorder (BPD). It felt like reading my own biography, written without my knowledge. However, the DSM is infamous for being a very slippery slope for self-diagnosing. It often leads to a severe case of hypochondria in students who are continually being exposed to all types of diseases that all sound like what they have!
So, I immediately dragged my seemingly ten-thousand kilogram DSM-5 to a therapy appointment for a professional to look at it instead. Every paragraph of the BPD section was annotated with an example from my own life. Even if I didn’t fit the clinical criteria for the disorder per the actual licensed professional, at the very least, I expected this to be a conversation-starter about the things we haven’t addressed yet — which could be why I was trending downward in my recovery.
But, in this story, it’s extremely irrelevant whether or not I have the disorder. Plus, I still don’t know — courtesy of how the professionals handled this situation.
You aren’t throwing chairs at me, so I’m ninety-nine percent sure you don’t have that.
That was the only thing my therapist responded with after I merely told her that I thought I might have BPD. I hadn’t even opened the DSM yet!
I wish I were joking, but I’m pretty sure you can’t make this stuff up.
Marie Rose is a YouTuber and mental health advocate who, unlike me, was formally diagnosed with BPD at a point in time. However, even she shares difficulty in getting to that diagnosis. On admission to a psychiatric hospital, she was awaiting an assessment for personality disorders when a clinician told her,
“Oh, you don’t want one of those.”
Even after the actual assessment following the comment, she was not notified of her diagnoses during the lengthy hospital stays (as though the information needed to be protected for everyone’s sanity). Yet, admirably, she persisted.
I tried to persist, too. I attempted to bring up the topic with three more clinicians. Two of them completely glossed over me mentioning rather dangerous thoughts, and the last one said,
“If you meet the DSM criteria, you probably have it. You can just know in your mind that you have it, but just never put it in your medical record unless clinically relevant.”
None of the four asked to elaborate on why I thought I might have it, so I’m not sure how they were able to determine “clinical relevancy.” They did not want to hear any of it unless I was in acute danger. And, even in that case, they still would not listen to it as they’d immediately refer me to a psychiatric evaluation.
With that, I dragged my DSM right back to its shelf, the feelings annotated within it having been shut down by actual “professionals.” It still sits collecting dust.
Level 2: congratulations, you (maybe) have a diagnosis.
Now, good luck getting treatment.
Due to the quarantine, I briefly switched to online counseling. Through it, I matched with a counselor who claims that she was trained by the very creator of Dialectical Behavioral Therapy (DBT). She suggested that I try it. DBT is widely used across the globe for treatment of BPD and is cited as the most effective treatment for the disorder. So, naturally, I wondered if she thought I might have BPD. She told me two things, which in my mind, I categorize as the good and bad news about DBT.
The good news: DBT is intended for the reduction of certain symptoms regardless of diagnosis, as a person is so much more than their diagnosis. Great! So a diagnosis (theoretically) shouldn’t matter as much as the person’s functioning and experiences, right?
The bad news: DBT therapists are very few and far between. This is jarring in combination with another piece of advice she has given me regarding BPD.
Basically, no one wants to treat people with BPD unless they specialize in it.
The therapist who told me about the “chair throwing” also explained that she used to work in inpatient units, where most clinicians held a strong belief that people with BPD have severe anger issues. Anger is not a required criterion for the diagnosis, per the DSM. But, based on a few bad experiences of having chairs thrown by one patient one time, many therapists don’t ever want to deal with BPD clients. Correct me if I’m wrong, but there isn’t a better definition of the term stereotype: an unfounded belief purely based on a few personal anecdotes.
So, she said she would be very hesitant to diagnose me with it as it could prevent me from receiving care in the future.
Level 3: the end game
We’ll try to help you feel better . . . probably?
Seemingly, a hospital is where one goes to get better, right? Remember the whole “putting nail scratches on the wallpaper behind us” part from the intro? Well, if you spend any time listening to mental health advocates, you’ll inevitably come across some of the hundreds of thousands of people who had been traumatized by hospitalizations in one form or another.
This issue isn’t only limited to personality disorders but to a range of conditions, basically other than the widely advocated depression and anxiety (and there are so many other issues within the two, but that’s for another day).
Elyn Saks, now a renowned scholar, has done a Ted Talk on her frustrations with mechanical restraints in hospitals. She has had severe struggles with chronic schizophrenia throughout her life, resulting in hospitalizations where she would be restrained without ever having threatened anyone’s safety. She was even told by a colleague, who is also a psychiatrist (and did not know of her schizophrenia),
“Elyn, you don’t really understand: These people are psychotic. They’re different from me and you. They wouldn’t experience restraints as we would.”
In the Ted Talk, Elyn counters that with simply,
No, we’re not that different from [the psychiatrist]. We don’t like to be strapped down to a bed and left to suffer for hours any more than he would. In fact, until very recently, and I’m sure some people still hold it as a view, that restraints help psychiatric patients feel safe. I’ve never met a psychiatric patient who agreed with that view.
I can’t even begin to compare a few inconsiderate comments from my therapists to the trauma of being restrained in what sounds like a place not that far from a medieval asylum. But, looking at the big picture of how pervasive this issue is at every level of treatment, I can say this much:
Knowing this shouldn’t discourage us from seeking treatment. Instead, it should encourage us to admit that there is indeed a problem and express frustrations about our treatment. Thus far, that has been the most effective approach to bringing awareness and accelerating change within psychiatry.
