S1E5 – High functioning mental health problems, with Karen Lowinger

W: Before we begin this week’s show, my cat Nala, who helps me with the editing, and I, have

a small favour to ask. Would you be able to share your favourite episode of Lively Minds

so far on social media?  Probably the easiest way to do this is via our website, anyamedia.net/livelyminds.

That’s Anya A.N.Y.A media.net/LivelyMinds. Go to your favourite episode and then you’ve

got the share links at the bottom of the page. Or if you’d prefer a more low-fi approach,

maybe you could just tell a couple of friends about our show. It really helps to spread

the word.

 

 

E: Hello, my name is Ellie.

 

 

W: And my name is Will.

 

 

E: Lively Minds is a UK-based podcast about mental health challenges that go beyond the ebb and flow of the everyday.

 

 

W: Led by people with lived experience, this podcast is less about how we deal with our mental

health problems and more about how we understand them in the first place.

 

 

E: If anything comes up in this show that you need support with right away, for signposting

to services, including those outside the UK and Ireland, please visit our website, annyamedia.net/LivelyMinds.

 

 

W: In today’s episode, we will be talking to Panama based psychologist Karen Lowinger. I

I came across Karen when I stumbled across an article she wrote called “When you are

too functional to have your mental illness taken seriously.”

 

 

E: Karen begins by telling us about her efforts to raise awareness about high functioning

mental health problems.

 

 

W: Then our conversation moves onto the question of whether or not labeling a mental health

problem is helpful for people who are high functioning. Does it mean that they and those around them will be more likely to give the issue the attention it deserves?

 

 

E: Before we go any further, in this episode we will be discussing aspects of mental distress

including suicidal thoughts and panic attacks. If anything comes up that you need help with

right away, you can find signposting to support on our website, www.anyamedia.net/LivelyMinds.

If you are listening to us from Panama, then help is available at Tezcuccha Panama on 831-7600.

 

 

W: We began by asking Karen how she would define mental ill health.

 

 

K: I think that to define ill mental health, we need to first define mental health.

And for that, we need to understand that somebody that has or enjoys a good mental health is somebody that is conscious of their own limitations and their own strengths as a person that can deal with the normal stresses of life. And that is precisely the definition that the World Health Organization uses to define mental health, also including that the person can work productively and fruitfully and is able to make a contribution to his or her community. Okay, that is how the World Health Organization defines mental health.

 

 

Something that I think is really interesting is that lack of functionality would definitely raise a flag in relation to the person’s mental health. Er, However, the opposite would not entirely be true.

Somebody that is functional should not be taken as an indicator that everything is okay.

 

 

W: When I was kind of trying to work out how I defined mental ill health for myself, the article I found of yours in The Mighty really helped me to crystallize that. Before I go into any more detail about that, would you mind just introducing to us why you wrote that article and what it’s about?

 

 

K: When I was studying psychology, and this was, this was a couple of years ago, many years ago actually, when I wrote this, I remember being in, in one of these events in which there was somebody talking precisely about mental health. This was a psychiatrist. And he was explaining to all of us, he was teaching us about this type of therapy. So he started the introduction regarding mental health and people started, he asked people what is mental health and people started answering and between those answers, people started saying that a person who has, doesn’t have a good mental health is somebody that is not functional. And that really got to me because I myself have had my own difficulties and I have been very, very, very functional.

I have been inside the mental health closet. I had actually, I am not anymore, but I had been inside the mental health closet at that point for so many years, and I was incredibly functional, but by then I had one suicide attempt that nobody knew about. And by then I was struggling every single day and surviving and trying to be where I had to be because the panic and the anxiety was so strong that I couldn’t deal, I couldn’t function. I could function outwards,

But inside, I was just a robot. I just kept myself, kept telling myself, just keep walking, keep walking.

 

 

And so I started thinking when this presenter told us, it talked about this, I started thinking, what about people like me? They would go completely undetected, you know. And then when I started working with people in the clinic, I started seeing this more and more often.

And suddenly it didnt, it wasn’t such a surprise when people started being amazed when somebody died by suicide and they just didn’t know that the person was going through something difficult. They just had no idea. So because they were functional, because they were working, because they were going to school, because they were hanging out with their friends, because they were cooking or eating or doing whatever they needed to do. So it just made no sense to me and that’s why I started to write about this, not just that article, but in different platforms, trying for people, trying to help people understand not just the patients, not just the people that suffer themselves, but also the mental health professionals that we need to open our eyes.

 

 

E: I’d forgotten until you mentioned it in the World Health Organization definition that you

mentioned, you know, and it says that a marker of good mental health is, there’s a, I can’t

remember how they phrased it, but providing

 

 

K: A contribution to his or her community,

 

 

E: A contribution to his or her community. Because then I was thinking, well, what’s the definition of functioning then in this context? And that’s it, isn’t it? They’ve decided, the World Health Organization has decided that functioning is contributing to your community. But that

is, quite a, philosophical judgment on what one’s purpose is in the world. I’m sure there are lots of people who would consider themselves to experience very good mental health, but who don’t particularly contribute to the communities around them. And then is that suggesting to people who currently consider themselves to have poor mental health that they can only have good mental health once they’re providing a service again to the community around them?

 

 

K: I think one of the most important things we base ourselves in in psychology, psychiatry and other mental health professions is that the human being is biopsychosocial. That means there’s a biological part, a psychological part, but also a social part. So when we talk about making a contribution to the community, perhaps it doesn’t necessarily mean the extended community, but perhaps the ability to even be able to socialize within one or two people, friends, family members, anybody. Because I think the opposite, if you weren’t able even to be able to have

an OK relationship in which you would normally be able to contribute, because that’s how relationships go, then probably you wouldn’t be able to have a social part, meaning that that bio-cycle social part wouldn’t be complete.

 

 

E: So it’s sort of more like, yeah, engaging with your community, as in just like having conversations and relationships with the people around you.

 

 

K: I would think it wouldn’t mean, it would go more to the social part, whether it’s a contribution to the community as a large, or to your close community, or maybe your close friends, or the people that are nearby.

 

 

E: Yeah, that makes more sense, yeah.

 

 

W: It just goes to show how, when trying to define mental health and mental ill health, just how

important yet also restrictive language can be, because we have to find words to be able to

explain this stuff. And I I think sometimes, as is shown through controversies surrounding stuff like, for example, the DSM, the Diagnostic Statistical Manual in the USA, when people try to define stuff too much, then it starts to get into troubled waters, doesn’t it? It starts people – because people have very different ideas about what different things mean, I guess.

 

 

K: That’s a very interesting subject to talk about because the DSM, the Diagnostic Statistical

Manual, it talks about diagnostic criteria. The way I work in the clinic is not precisely towards diagnosis per se, but more about what the person is feeling, experiencing, and how we can work through that.

 

 

I think it definitely works to be able to have an idea as to what the person might be dealing with, but at the same time, it’s not, it’s not as black and white. Definitely we’ve seen that people have a lot of different ways of expressing, of even feeling, things that come from the same root, but don’t necessarily express themselves in the same way. For example, even for example, a panic attack. Some people experience a panic attack one way, and some people experience a panic attack with the other symptoms being most prevalent. So we can’t really compare one situation with the other, but it’s good to have a base. It’s good to understand a little bit where it comes from. Most importantly, I think it’s important to understand the root, you know, what is causing

the situation and how it’s manifesting itself, itself in the person. Whether it’s, whether the person can verbalize it or whether you can see it in symptoms such as a person not being able to sleep well or not being able to eat well or even in behavioral symptoms, such as, for example, the person cannot concentrate. So that’s why we need to really understand the person as a whole, okay, and one of the things that I really advise that people do is that when they’re feeling bad, when they’re going through a crisis in which, by crisis, I mean that they’re having a situation which is difficult to cope with and their mental health is not in balance, OK, like their floor has moved a little bit, okay, that’s a crisis. When somebody is going through one of these moments, I would really advise a person to be able to write or to be able to express in any way that is good for them and to take that then to the mental health professional. Because sometimes when we, when we leave that state, okay, when we become a little bit more rational and less emotional, we don’t understand ourselves.

We’re like, “Why?

Why was I feeling that?

What was I feeling?

That’s so weird.”

But it made all the sense in the world when we were feeling it. So it’s a good idea to try to record it in any way, whether again it’s writing, whether it’s talking to a recorder, whether it’s identifying songs that you identify with or writings or anything, you know, to be able to express it in that moment.

 

 

E: That’s probably particularly good advice to people who are kind of high functioning and

struggling with their mental health, because I know that as a tendency, we tend to, especially

once you’re not in that um, particular state, because the drive that is to just keep going and function as highly as possible and keep things going, you’re more likely, even more unlikely to

not really understand what was going on then and also think,

“Oh, well, it doesn’t matter. It’s done. It’s dealt with. I’ll just move on.”

So it’s probably even more helpful for those people.

 

 

K: Exactly. And I don’t know if you have experienced this, I’m sure you have, that sometimes you actually question yourself.

 

 

E: Yeah.

 

 

K: You know, you start wondering what happened. What’s what’s going on? Am I actually trying to prove something? And am I trying to call for somebody’s attention or mine or what’s going on? It confuses us, because there’s such a, such a big space, big space between those moments and our functional moments. It’s like two different people.

 

 

E: If you’re enjoying the show, please consider supporting the next series of The Lively Minds

podcast. We are recording the next season right now, but we can’t finish it without your help. To make a donation, no matter how small, head over to buymeacoffee.com/livelyminds. That’s buymeacoffee.com/livelyminds. Now back to the show.

 

 

W: I heard about this thing called high-functioning mental health problems or high-functioning mental illness. Only a few hours before I read your article, I was out in the pub with a friend

and we were talking about mental health stuff. I was saying something and she, she responded, “Oh, you mean like, high functioning mental illness? And I was like, what? What’s that? And I got back home. I web searched it and lo and behold, your article was one of the first that came up. And having read the article, I think I was able to start transitioning from a place where what was happening to me was that I was being weak and I was being, you know, just unable to cope with other stuff that everybody else can cope with perfectly well, um, I went from a place of, um, feeling that because I was functioning okay, I was, I was fine really. To actually going, hang on a second no, I do have a problem! uh, this is something which I should call out, something that I should recognize and something that’s actually probably far more serious than I’m giving it, giving it credit for, for want of a better word. And so I think that for me, it was all about starting to take my mental illness seriously. And I do call it my mental illness. I know that there’s some really interesting con, conversations to have around language and about how we describe mental illness or mental wellness. But I think that actually calling it that meant that it, it kind of, yeah, it sort of made me think that I should really start doing something about it. I had been, I had been doing bits and pieces up until that point, but I think that attitudinally, I think that I changed my, my attitude quite fundamentally changed from that point onwards. And that’s why I think it was so, so helpful. I want to just read an extract from the article, actually, something that really spoke to me. You say,

 

 

“Acting fine is a cognitive process. You can probably mention right now how an emotionally stable or ‘mentally sane’ person is supposed to act. It really is simple. A generally accepted lifestyle is one where a person wakes up every day, looks presentable, takes care of stuff that needs to be taken care of, eats and goes to sleep. This can sometimes be done regardless of how you feel inside. To say it’s difficult is an understatement, but it’s not impossible.”

 

 

I think for me that really kind of sums up, I think, what my experience has been in terms of how my daily routine and how my, how my behaviors actually connect, interconnect with what’s going on inside, as it were.

 

 

K: I think what do you bring is something that I think a lot of people have expressed in the clinic when they have been sitting in front of me, patients. And one of the things that, that comes out, that is very notable is how a lot of people express what we call an imposter syndrome. Okay, when the way you feel inside and what happens when you’re at home or at nighttime, or when you have a couple of minutes with yourself, it’s completely different with the person that you present yourself on the outside. And what you describe, Will, I think is very much in tune with that, because when you are outside and you are doing what needs to be taken care of, and you’re doing all these cognitive processes, you’re okay. You know that’s how people see you.

But in reality, there’s a lot of things that are down the surface, that are below the surface. And people are not seeing it. And I think that’s one of the biggest issues with mental health illnesses or mental disorders, that they’re invisible. They’re mostly invisible to other people. And so it’s really difficult to have a skill to measure, you know, what’s going on.

 

 

Is it, is it me being weak? Is it me just being, I don’t know, not being perseverant enough or strong enough or focused enough or maybe I’m just whining too much or not thankful enough?

 

 

All of these questions constantly come to our mind and then we don’t understand how, how

is it possible that we’re actually out there and people praise us and people say, “Hey,

you know you’re doing a good job,” or “Hey, you know you’re doing what you need to do”, but then on the inside, it’s something completely different.

 

 

One of the most impactful situations that I’ve had in my office is seeing people that are CEOs of companies or that are very successful in their businesses and they come in their dresses and their makeup or in their suits and ties and, you know, they’re very successful people. But they sit down and they break down. And they and they say, I don’t know what I’m doing. You know, I’m scared of every choice I have to make. And that’s not how people see them at all. So it’s a good thing that they’re there, obviously. But the struggle is real, you know, the struggle of not being,  not knowing if you have to take yourself seriously. And then when a professional doesn’t take you seriously, when you’re actually able to raise your voice, that’s so difficult. So it’s a good thing to be able to advocate for oneself.

 

 

E: The instance you gave is that conference you were at where you were irritated by that idea

about functioning and things. I just wondered when you were talking to other mental health practitioners, either in practice or other academics, what’s their kind of reception been, of you talking about this sort of high functioning mental illness?

 

 

K: I wouldn’t say that I am in touch with all of the psychological population in Panama, but the, the few mental health professionals that I am close with, I think they actually do agree. Um, at least when they are in practice, they are, they go a little bit more further into into what is seen and they actually try to see the patient for also what they bring. Okay, not just what they see. And that also has a lot to do with the kind of therapy that I, I practice and the kind of people that I frequent, in which we actually aim to go deep. We try to go deep. Other than that, I do believe that one of the biggest faults that some mental health professionals have is not seeing the person that they have in front of them as actually a person. And you mentioned before the DSM.

Okay, and when the person comes with a diagnosis and the person says, “Okay, I’ve been diagnosed as a depressive. I’ve been diagnosed as BPD. I’ve been diagnosed as, a panic, with having panic disorder”, whatever, then it’s so easy to get lost in the labels. Then what you have is this and this and this because that’s what the literature says. Hold on. Who is a person in front of you? who is a person in front of you?

 

 

W: What you’re saying intersects really interestingly with this idea of validation. This sort of idea that we on one level kind of need, some of us need to call our mental health problem something in order to feel validated, in order to feel like we should get the help that we need. And that’s, you know, super important. On, on the other hand, and somewhat paradoxically, I think, there are others for who validation is almost the opposite. Are actually trying to get rid of labels that they have been given by somebody else. And I think those two things are really interesting how they seem on one level, quite opposite, but on another level, they’re both about people who want to be able to understand themselves better.

 

 

K: I also say that we people, not not just the mental care system or the government or, you know, us people, we tend to take more seriously when somebody comes to us and tells us they

have a diagnosis in difference as to when they come and tell us that they have or they’re

feeling something. For instance, if a friend comes and say, you know, I haven’t been feeling

well, I’ve been feeling hopeless, you know, I feel sad, I feel I don’t have any energy, they’re describing depression, they’re not saying they’re depressed, or they have a diagnosis, but they describe it and we don’t take it as seriously as when our friend comes and say, “you know, I went to the psychiatrist or the psychologist and they told me I have depression”. It makes an impact in ourselves too. It’s how we as a society are, have been developed, I guess.

 

 

W: I think there’s a real human need to categorize, in that sense, I do sometimes wonder whether my own personal need for validation of what what I go through to call my anxiety anxiety to maybe even call it clinical anxiety to give it that kind of grander sounding label. To what extent is that me, to what extent is that a good thing because I’m taking it seriously as a result or taking it more seriously as a result? And to what extent am I just trying to fit into this idea of having to categorize that kind of human need almost to categorize things?

 

 

K: I think that also, also humans, we have the need to be able to identify or name something in order to be able to make sense of it or accept it because things that are unknown for us or things that scare us or things that we don’t we don’t understand, they have the potential to scare us a lot more. And and see, I was thinking a bit about my own mental health journey. I started having panic attacks when I was 14 years old, but I did not know they were panic attacks until I was 17 or 18 years old, okay, nobody, no, no, no doctor was able to identify it. And I myself did not know any information to be able to know what was happening. So what was going on in these three, four years was I was feeling that I was weak all the time. I felt that I was dizzy. I felt that I was going to faint. I felt that I was going to throw up all the time because my heart was racing all the time. I felt like I couldn’t breathe well, which are all the symptoms of panic attacks. But for me, it had no name. Okay. And for those years, it was horrible because I didn’t know what it was. And people said that maybe I was a hypochondriac. Maybe it was all in my mind. Maybe it was all of this. And I said, no, I’m, it’s happening, you know, I’m feeling it. And after that, when I was able to put a label on it, when I was able to find,

“Hey, you know what? These are panic attacks and I’m not so alone. Maybe I’m not that

weird or broken, you know because people actually go through this.”

That for me was an instant revelation, probably, Will, the same way that it was for you when you were able to know that there were high functioning people like you, you know, that it had a label as well. And I think it’s really important for us to be able to identify with a label sometimes to be able to know that we’re not alone. However, it’s important also to know that the label doesn’t define us.

 

 

E: This has been a real learning curve for me in terms of my experience because I come from quite a, I’m very sort of, overall very against the biomedical model and sometimes alongside that is being very anti-diagnostic labels and that kind of thing. And it’s funny because sometimes it seems that Will and I have opposite views about some of this so the things that we’re validating for Will, I’m like but I find that so un-validating, it’s more validating to me if someone will listen to me and treat me regardless of what label a clinical psychiatrist put on me ten years ago kind of thing. And this has just been really interesting because yeah, I totally understand it and you’re right and it’s it’s so different for individuals crucially, isn’t it? And I think with my labels I was,

I sort of treat it more as like a pick and mix. So there are a couple of them that I’ve agreed with

various psychiatrists over the years when like, I don’t have that and they’re like, yeah, no, no, you don’t. We’ll take that one off. It’s like, oh, but I do find this one quite helpful because it does actually help me to frame some of my experiences and I find it helpful to be able to kind of have a direction of where to read more and how to think about things because I have that label.

 

 

W: In terms of looking to the future, if you could sort of have just one big change in the way that like the psychiatric profession thought about how we define mental illness or mental health problems in somebody, what would that change be? What would be the sort of first step along the way to changing things for the better? I would like, for this I would like to quote what mental illness is according to the the American Psychiatry Association. Okay, according to them, a mental illness is a health condition involving changes in emotion, thinking or behavior, or a combination of these. And mental illnesses are associated with distress and/or problems functioning in social work or family activities. Okay, I think here, once again, same as the World Health Organization and their mental health definition, they also bring in functionality. And again, I think, I really do believe that when a person is not being able to function, we should look into their physical or mental health to be able to understand why that person is not being able to function or maybe doesn’t want to function, to be able to understand, okay, that’s a red flag.

But again, as, as we started, as I said in the beginning, I think that it’s important to note that the opposite is not true. Okay. While lack of functionality might mean that there is something we have to look into, functionality does not mean that people are okay. I think that we should stop using that as an indicator.

 

 

W: So a huge thank you to Karen Lowinger for joining us on the podcast. A really fascinating conversation. I think my key takeaway from that, Ellie, was when we were talking about how, for some people it seems that validation is about being able to give one’s condition and an inverted commas a name, and I think that, you know, I was obviously saying that for me that was quite important, but then for you, you were saying that actually the opposite of that, the validation is actually about discarding labels that have been put on you that you don’t connect with.

 

 

E: I don’t think that validation is always about discarding the labels. I think it’s about having agency over what labels are applied to you and understanding, you know, who’s applied them and why and whether or not, you know, you have any say in the matter. And I guess the point is

in most of these situations you don’t, they’re given to you. Because yeah, I’m quite happy with

my labels.

 

 

W: Yeah

 

 

E: Even though I do hold that view that labels are not the be-all and end-all.

 

 

W: And I guess where this kind of connects in with the the overarching topic of the the podcast i.e. high functioning mental health problems is that one could say that potentially it’s in people who have so-called high functioning mental disorders where they’re less likely to be labelled by other professions precisely because they are high functioning.

 

 

E: Yeah

 

 

W: They’re not necessarily giving any outward signs of any kind of problem, which I guess might explain why, as somebody like myself, who considers myself to have a high functioning mental health problem, kind of quite likes the labels. But what I think is really important and links into what you just said is, that because the medical profession hasn’t ever really ever labelled me, I might actually take, I have from the very outset, I’ve got control over those labels that I’m giving myself. And so in that sense, I’ve been in quite a, I’ve got a position of privilege there in being able to have that agency from the very outset.

 

 

E: There’s like a kind of duality there because in this conversation we have been talking

about high functioning in like, a capitalist sense. That’s kind of the type of high functioning that we’ve been talking about, people in careers or jobs and productivity. But within that, those people are potentially more likely to be concerned with or have to stay in the closet, the mental health closet, in order to maintain those positions and the luxuries that you’re afforded by being someone who is highly functioning and doing this, that and the other, you’re therefore more likely to be in scenarios, including your workplace, where there’s very little understanding of more complex mental health experiences, and so you’re more likely to have to sort of shuffle your diagnostic labels like under the rug. I also definitely am high functioning with mental health difficulties and things and it really resonated what Karen said about having like been in periods of crisis that then like no one around me knows about and I go back into robot mode and carry on as though you know you’ve just had the most normal Monday evening and not sort of ended up in a complete crisis meltdown point. Because the flip side is also that with those certain labels comes a lot of stigma, misunderstanding about what certain conditions are. There’s a lot of like myths that need to be busted but sort of aren’t really. That pressures you to remain inside your mental health closet but how much worse is that for your, you know, it’s like a cycle that feeds into you then forcing yourself to be so highly functioning and appearing as though everything’s fine when actually things are not fine and you need to probably take some time out and process or share it or seek help.

 

 

W: A great point to finish this episode on as well thank you so much Ellie. So thank you so much for listening everybody, we hope to see you next time and also Ellie just a reminder to our listeners if they want to support this podcast and help raise money for the next season for season 2 of this podcast that they should check out

 

 

E: buymeacoffee.com/livelyminds

 

 

W: In next week’s show, Professor William Tov will talk to us about the definition of happiness.

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