May is Mental Health Awareness Month, which makes this an excellent time to talk more about our beautiful broken brains!
(Ahem. Because I am an honest chap, I feel compelled to stress that we did not plan this in advance. We are not nearly organized enough to do that. It was purely coincidental.)
I’m an advice column junkie. My regs right now are Where Should We Begin?, Dear Prudence, Dear Sugars, Savage Love, Care and Feeding, Captain Awkward, Ask a Manager, My Brother My Brother and Me, and the collective wisdom (?) of r/relationships. Yeah… it’s a problem.
When the subject of mental health arises, I’m perennially dismayed to see a very narrow, circumscribed answer appear again and again and again. It goes something like this:
“Go see a therapist; get counseling; find a psychologist; get into therapy; go see your school’s counselor; go to a mental health clinic; you need to be in therapy; find a support group; have you talked to your therapist; have you tried group therapy; talk to your doctor; therapy, therapy, counseling, therapy…”
And this really bothers me.
It’s not that this advice is bad. It’s not bad! All things being equal, most people would probably benefit from therapy. I have no doubt that the net benefit of professional mental healthcare is incalculably vast.
But it pains me to see therapy described as a one-size-fits-all solution for every person in every situation. I’m someone who experiences intermittent depression. Like half of all mentally ill people in the United States, I’m not currently receiving medical care for it. This doesn’t mean I’m irresponsible or helpless. There are a lot of very understandable reasons why people can’t or won’t seek professional help. Let’s talk about a few of them.
Therapy is hard fucking work
For one, the unanimity of advice suggests that therapy is some kind of magic bullet—a store you can walk into crying “One mental health, please!” This isn’t the case. Therapy cannot be successful if the person getting therapy has the wrong impression about what it consists of, and what it requires of them.
Mental therapy is just like physical therapy. It requires work. No, seriously, like a lot of fucking work. It requires you to challenge yourself and change your behavior. You may be tasked to read books, follow workbooks, keep a journal, document your thoughts and behavior, change habits around exercise, sleep, and diet…
You may even be shocked at what most needs work. Maybe you go in ready to talk about job stress, but therapy leads you to revelations about your family, or your relationship. You might not want to talk about that stuff yet, but a canny therapist is like a fucking truffle pig: they’re gonna root all that delicious stuff up. And surprise: you may feel worse before you feel better.
Your therapist is a facilitator, not a magician. And knowing what your issues are doesn’t immediately, automatically unlock your best, healthiest self.
Therapy requires a sustained commitment
Some people aren’t willing to work on themselves. There are people out there who misuse therapy as a tool to curate their story and validate their current actions. (Incidentally, therapy can make sociopaths and psychopaths more powerful by teaching them better mimicry of emotions! Who knew?)
Some people are unable to work on themselves. Illnesses like depression rob you of the spoons needed to invest in mental health treatments. When I’ve been at my lowest, everyday tasks feel like wading through knee-deep mud. It’s some real Artax in the Swamps of Sadness shit. I have to ration the energy I need to shower. You want me to do a bunch of research on healthcare providers, call them to schedule an introductory visit, wait a few weeks, then leave the house to go talk to a stranger about how weak and pathetic* I am?
(*Depressed people are not weak and pathetic. Rather, I feel weak and pathetic when I am depressed. Important distinction!)
Therapy requires some existing support and stability
Finally, some people are emotionally willing and able to work on themselves, but can’t for logistical reasons.
Students, night workers, and working class people with irregular shifts may find it hard to maintain momentum (and a good relationship with their chosen healthcare provider) through frequent rescheduling and cancellations.
Therapy is of great potential help to stressed, burnt-out caregivers. But caregivers may feel compelled to spend the little time and money they have on counseling for their dependents, rather than themselves.
Women feel this pain in particular. They’re already statistically shouldering a much greater share of childcare, elder care, household chores, and emotional labor. (This cultural norm is so deeply ingrained that even same-sex couples mimic it.) They cannot afford to address their illness because all the spinning plates may come crashing down. As one practitioner puts it:
“When postpartum women say they do not have time to come to therapy or seek treatment or get help, it is more than just an excuse. It is a symptom. Asking for and accepting help is just another way of screaming ‘I’m sick’ and many women do not feel ready or able to accept that. Sometimes, it can be as simple as giving them permission to do so.”
Not all partners (or employers, or parents, or friends, or even medical professionals) validate the existence of invisible mental illnesses and the importance of their treatment.
You need the right provider with the right approach
The success of therapy often depends on finding a skilled healthcare provider with whom you click. But finding a great therapist can feel like trying to find a mate. They have to be affordable, close by, take your insurance, work with your schedule, understand your situation, have at least some overlapping values, and be scrupulously ethical. Opening up to someone is fucking draining. And it’s really easy to become discouraged if the first (or second, or third) person you try isn’t for you.
And there are lots of different kinds of therapy! Cognitive Behavioral Therapy, Cognitive Analytical Therapy, psychoanalysis, mindfulness, relationship counseling, family counseling, music therapy, art therapy, equine therapy… one or more may work for you, but it’s expensive and access can make it difficult to explore them all.
Therapy can make things worse
Anything that can heal you can also damage you. The wrong kind of therapy with the wrong kind of therapist can fuck. you. up.
The first mental healthcare provider I ever went to betrayed me in basically the worst way a mental healthcare provider can betray a patient. I was a child, and I disclosed sexual abuse. She was a mandatory reporter, and she did not report. The result was that I spent a few more months living in the same house as my rapist, and suffered a pretttttttty respectable mental breakdown in complete isolation before striking out on my own at seventeen.
Therapists are people. They have training and knowledge, but they also have weaknesses, biases, lapses, and gaps in experience. I didn’t know mine was a bad apple until she poisoned my ass. Your mileage may vary.
Access is a problem
Counseling and therapy can be really freaking hard to access in rural areas. There may only be one person or one clinic that honors your insurance—or you may have to set aside half a day to drive to the closest urban center. And if you don’t like the local option, or they don’t specialize in the kind of care you need? Tough shit.
See my wretched anecdote above. This woman was a Christian family counselor because that’s what the area had. She believed that forgiveness was the highest form of healing. I disagreed; instead, I was really jonesing for that physical and psychological safety stuff. Even though I was a kid, I knew this lady was not going to be the right person to help me. But when you live in the cornfields, you may not have any other choice.
People who aren’t white have problems finding mental healthcare providers who understand their cultural experience. The Atlantic did an amazing deep dive into this topic, read it here.
This isn’t just anecdotal, or specific to one demographic or region. There is a serious shortage of mental healthcare professionals across the United States. 89.3 million Americans live in an area designated as a mental health professional shortage area by the Health Resources and Services Administration. Fewer and fewer people are interested in pursuing the field of mental healthcare.
One of the main reasons? Check the blog, kid, it’s money! Insurance reimbursements are slow, burdensome, and incomplete, leading many therapists to only accept new clients on a cash-only basis.
That cost tho
And here we go, kids. This is the real shit right here.
If you think houses are money pits, try having a fucked-up childhood!
Healthcare is expensive. That includes mental healthcare. And it’s never a one-time expense. (Related: Bad With Money just had a great episode on medical crowdfunding. Turns out that nobody likes to chip in towards chronic conditions because they’re fucking bummers. Cool!)
If you have great insurance, you might have a copay as low as $25 per session—but if you’re seeing a counselor once a week, that’s still $1,300 for just one year.
If you want to see someone outside of your insurance, or you don’t have insurance at all, expect to pay at least $100 per session. That’s $5,200 for a year. I don’t know many people who have that kind of money jangling around in their pockets. And if you’re seeking treatment from a specialist, or an intensive therapy, or live in a high cost of living area, you could pay double. This doesn’t include the cost of medications you may be prescribed on top of therapy.
This is not to say that mental healthcare is some kind of optional or frivolous expense. For all my handwringing, there is no way to quantify the number of lives improved or outright saved by counseling, therapy, psychology, and psychiatry. It is an invaluable tool.
But if that tool isn’t universally available, affordable, and achievable, it can’t be the only tool in the box.
Cheap therapy might not be good or realistic therapy
Try Googling “I can’t afford therapy” and see what comes up. Or don’t, because I already did it and I’m about to tell you what’s out there.
- Here are ways to get shady discount therapy that are extremely situationally specific, geographically exclusionary, and wildly optimistic!
- Here is a list of 2,500 $10 mindfulness apps???
I ran this by former roommate Goosey, who’s no stranger to mental health issues.
KITTY: If you google “what to do if I can’t afford therapy” it’s like “go to a local school and let inexperienced people practice on you lol!”
GOOSEY: Okay wait this is relevant because I sent this to my therapist who LAUGHED FOR DAYS AND SAID PLZ DONT GO TO A SCHOOL…
Yeah, Goosey once looked for low-cost help after a major traumatic event. Her reward was being locked in an evaluation room against her will, One Flew Over the Cuckoo’s Nest style, by a provider who was (she found out later) actively under investigation for violation of human rights.
These kinds of lists come with the best intentions, and aspects of them are totally worth trying. But I think it’s too simplistic of a view of mental healthcare. People who are cash-strapped are almost always time- and energy-strapped as well. Are you seriously telling me to cold-calling counselors and asking for free healthcare until someone says “yes?”
You want me to run a marathon, too? If you stick a broom up my ass, I’ll sweep the streets while I’m at it!
Help is hard
For people who have mental health issues that manifest through low energy (like depression!) or low self worth (like depression!) saying “I can’t afford it” is often shorthand for “I cannot fucking fathom it.” The energy isn’t there. I don’t want to look at myself, think about myself, talk about myself, or spend money on myself. My hygiene isn’t good enough to leave the house. I don’t have the strength to try. I am too afraid to fail. It feels good to put it off because it helps me feel like I’m not at rock bottom yet.
I’ll speak from my own personal experience here: when I am depressed, I feel like I’m failing myself. (I intellectually understand that this isn’t true and that this is just my brain chemistry being off—it’s just how I feel.) And when I feel like I’m failing myself, I’m most fragile to the idea of being failed by others.
Knowing I could call someone to ask for help feels like having a safety net. I would never intentionally leap into that safety net to test it. Because what would I do if it failed? How could I survive if I thought that I knew, for certain, that no one could help me? How would I cope if a suicide hotline hung up on me?
That’s my attempt to explain the odd logic of my personal depression, and why it’s actually a comfort to hide my symptoms and not seek help. Don’t take this as an endorsement to not ask for help when you need it. I am as my life experiences have made me. But if what I’m saying sounds familiar to someone, I hope it’s a comfort. Everyone’s brain is different, so again, your mileage may vary!
Is there more?
I am thrilled to report the vacuum of practical alternative advice is slowly being recognized and filled. I’ve seen it most in the fair land of Tumblr, home of good-good children who are dedicated to validating each other’s mental health experiences.
I believe that peer support might be the greatest untapped mental health tool on the planet. And next week, I’m going to aggregate some of the best of it into a collection of mental health advice that isn’t therapy. If you don’t find therapy helpful, or you can’t access or afford it, or you just don’t have the energy to take that step yet, it should offer some practical small steps that might help you feel better.
A caveat, which I will repeat next week: if you are thinking about hurting yourself or someone else, that is where the armchair Internet advice sidewalk ends, bruh! I’m extremely lucky that my depression has never manifested serious thoughts of violence to myself or others. I don’t know what that exact experience is like, and I am utterly afraid that someone would read my well-intended words and use them as permission to give up on themselves.
If that’s your situation, you need to tell someone—anyone—and ask them to help you. It doesn’t have to be a stranger or a doctor. It just has to be someone who will listen and take you seriously and help you find the right next steps.
And all you mentally healthy, trauma-free, fifty-five-spoon-having motherfuckers readers can just fuck right off JKJKJKJK we love you too! Please read this stuff anyway! One in five Americans suffers from some kind of mental illness. You can make yourself a good ally by soaking up some of this information. You’ll need it some day, even if it’s not for yourself.
Phew… That’s the most personally uncomfortable article I’ve written yet! My ENTJ ass would rather have one (1) nail pulled out than expose my soft underbelly to the world for public consumption. And I’m probably gonna get dragged by a bunch of people who don’t read the article and want to call me irresponsible. OH BOY I CAN’T WAIT.
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