Crisis Chat Observations: “You’re Very Aware”

One of the frustrating things about depression (and other mental illnesses, but I spend the most time talking to depressives) is that… well, actually there’s a lot of frustrating things.  One is that finding good medical professionals is hard, finding good mental health professionals is harder because personality fit is more important, and depression takes out exactly the systems you would use to seek and evaluate treatment.   Even if you have no other obstacles (financial, social, transportation…), it is still really hard to find a medic taking new patients, make an appointment, keep an appointment, and follow up on what the provider tells you to do.

But the frustrating thing about depression I was thinking of when I started this post is that even when you do all of those things, treatment can take a while to work.  Typical protocol is to give an anti-depressant six weeks to work, and the first one may do nothing, or have intolerable side effects.  The STAR*D protocol study, which tested an algorithm for finding anti-depressants that worked for individual patients, found a 70% success rate over four months- excluding the 42% who dropped out.  Therapy can take years, and there’s often a painful period before it starts to help.*  Some people I talk to at crisis chat need help getting into treatment.  Others are doing everything I could possibly recommend to them- psychiatrist, therapy, social support, a list of self-care activities of which crisis chat is neither the first or last on the list- and are still miserable.

At least for the teenagers**, the most helpful thing I have found to say in this situation is the truth: you are doing everything right, and it is deeply unfair that it takes so much time to bear fruit.  Crisis chat is deliberately not an affirmation on demand service because generic cheerleading is emotionally draining for volunteers and even if they specifically request it, visitors tend to reject it as insincere- but if I see something someone is doing that will be long term helpful to them, or that they are especially good at, I will tell them.  I don’t give the same ones every time and I don’t make up things to make people feel better, I only say something if I see a genuine skill. This isn’t cheerleading or attempting to logic them out of depression so much as it is giving an objective, informed eye to people who know their brain is unreliable reporters but don’t know what specifically it is lying about.

I thought of this while reading Brute Reason’s Case for Strength Based Diagnosis.  Mental health treatment right now is all about the things you are bad at.  The strongest counter force is the pop culture romanticization of depression and bipolar disorder, which is not helping. But I could see it as very helpful to hear “the same gene that contributes to your depression also contributes to your high intelligence, and you can use that intelligence to fight depression”.  This seems like another problem caused by trying to use the same system for “accurately describe patient state to patient”, “accurately describe patient state to another practitioner” and “tell insurance why they should give you money.”

*When I’m detailing treatment options to crisis chat visitors I often make a point of mentioning CBT as something that isn’t a drug, works fairly quickly and doesn’t involve dwelling on pain.

**Adults tend to be more pessimistic, and I have no way of knowing if it’s because they’ve actually been depressed for 20 years straight or because their liar brain is telling them so.