Mental Hygiene and Mental Health

In this country “mental health” typically refers only to the negative end of the spectrum, in other words, neutral mental health to mental illness—we too often think of “mental health” in terms of either having mental illness or not. We tend to ignore the role of mental health in terms of strength or resilience—the positive end of the spectrum. Psychologists are thought of in terms of fixing things that have gotten broken, but not thought of in terms of preventing things from getting broken in the first place. We do preventative maintenance our cars, but do not often (enough) think about preventative maintenance on our psyches.


The opposite of negative is not zero, but rather positive. Yet the role we have relegated psychologists to is to deal with the negative to zero range. We have come to equate “happiness” with the absence of being unhappy, and they really are not equivalent. Happiness is a positive, while the absence of unhappiness is actually zero. The greater happiness (in terms of contentment, rather than momentary joy) we have in our lives, the less susceptible to mental illness we are. As long as we ignore half of the spectrum, we will find ourselves more and more in the side of the spectrum to which we do attend.

We fail to recognize that many of the skills and techniques that psychologists have developed for mental remediation and repair can also be used for mental enhancement and strengthening (e.g., communication and social skills, openness to experience, stress management). Pre-marital counseling used to be valued, but now we only go to a counselor after the relationship has become problematic (and even then usually not until the resentment has gotten out of control).

When I was deciding on a graduate program I choose a Counseling Psychology program (rather than the more popular and better known Clinical Psychology) because as a sub-field it was known to emphasize mental wellness, instead of mental illness. Counseling Psychology was (and is) known for the emphasis on optimal function, not simply adequate functioning. Counseling Psychology tends to be more focused on hope, optimism, self-efficacy, emotional intelligence, wisdom, courage, and personal strengths. We are less excited about helping a client get better than we are about helping the client become a better version of himself or herself—even if that is from a position of mental illness.

I think of Counseling Psychology as aspirational, let’s not just make you better, let’s make you the best. When Counseling Psychology was first forming as a discipline within psychology, it focused on what was called “mental hygiene.” It was focused on keeping people’s minds functioning well, not on returning people’s minds to a functional state. There is a wealth of research on the benefits of psychological enrichment, above and beyond psychological remediation. However, we continue to value psychological remediation over psychological enrichment.

I have a friend who is a psychologist who claims that the reparative work he does with clients is more valuable or meaningful than the work that I strive to do with (typically higher functioning) clients to bring them to optimal functioning. In our culture we focus on deficiency rather than enhancement; we focus on what is missing in our lives rather than how to better develop and utilize what we already have. But the research shows that nation-wide, the impact of improving the lives of people who are already functional can have more of a positive impact than bringing (the minority of) people back to base functioning. People’s productivity and pro-social helping behaviors are more affected by life improvement than remediation of a disorder. Improve the lives of many slightly and there is more of a positive impact on society than remediating the problems of the few. However, even in the presence of many studies that have shown that happier people who better manage their stress—including the cost savings of mental preventative maintenance, mental hygiene is dismissed as unimportant.

I often run into people socially who tell me about how their lives are unsatisfying, even though they are adequately functional. They will even tell me they are not unhappy, but also unfulfilled (not happy). Most of these people would never consider going to a counselor, psychotherapist, or psychologist to help them improve their lives because they do not see their lives as “broken.” Instead they spend their time acquiring objects or sex to feel more fulfilled, which will never be as effective as counseling, and more expensive in the long run.

Partial Presentation and the Hook

Have you ever met someone who seemed a little too together? I acknowledge that some people really do have their shit together—they have both a sense of accomplishment and a sense of purpose and direction. But there is perhaps no one that does not simultaneously harbor some self-doubt as well. In fact, I have found that people’s uncertainty is a big part of what makes them relatable to me.

I recently met a guy online and had some rather enjoyable chats with him. However, when we met in person for lunch he presented himself as having solved all of his problems and as being very certain about himself and his life. He relayed a situation with his boyfriend in which he had recently addressed and successfully resolved a problem. There was no regret or doubt in his telling of the story—no un-sureness that the resolution would be successful. He presented his life as on track and betrayed no fear of challenges or obstacles or dissatisfaction.

Online he had been quirky and we had shared our respective senses of not fully understanding ourselves. It was as if online he was able to be more vulnerable, but face to face he needed to present well. The self-doubt, the willingness to be not quite “normal” which appeared in the online conversations disappeared in person. Unfortunately, this persona was very distancing for me. I do not know to what degree he presented this composure because he realized I was a psychologist, but it caused me to experience him as false or at best “partial,” as if I were only getting the shiny part of the whole picture.

In counseling and psychotherapy we talk about clients’ “hooks.” The hook is the aspect of the client from which our empathy for the client grows. Typically it has to do with the internal struggle. People who appear to be trying to do life right are appealing. People who are not struggling are difficult for anyone to relate to—few (if any) of us have a sense of what it is like to not have an internal struggle of some kind. Some people’s struggles do not make sense to us personally as struggles. That they are struggling internally is what makes them relatable—not necessarily the struggle itself. Sure, the person has to be likable or someone we can care about in the first place in order for their struggle to matter, but someone who is simply likable usually feels incomplete, or false. This guy seemed likable—not offensive in any way—just not fully present (or fully presenting).

I enjoy confident people. I have frequently said that confidence is the most attractive cologne. I like people who have a sense of accomplishment and a sense of purpose and direction. However, someone who is accomplished and simultaneously is uncertain is someone I experience as a real person. I don’t think anyone wants to be friends with just a façade of a person. We may even admire a person without apparent problems, but their friendship would not actually be rewarding.

Ideally, one would present as confident, but perhaps not certain. We like to know that others are also vulnerable. Similarly, I think it is comforting to present as recognizing that you are flawed—accepting of the flawed state, but also maybe wishing not to be. Though I would caution that (especially upon initial and early contact) it is also important to exhibit that you are grounded and not just a mass of uncertainty—that can be just as partial, absent a center. In the absence of substance there is also no personality in which to hook into. Someone who seems to have it all figured out does not seem like someone who is going to grow much.

“Alcoholic”

As a therapist the word “alcoholic” is bothersome. It is not that I have a problem with alcoholics particularly, but rather I have a problem with how the term—and its associations—interfere with treating alcohol-related problems. The common use of the term, and especially the commonly held definitions or expectations of the label, create an either/or designation for alcohol problems—either one is an alcoholic or one is not, there is no in-between ground . If someone is using alcohol to his or her detriment, but does not drink to messy intoxication regularly (or always), we tend not to label that person an alcoholic and consequently there is (frequently) no attempt to address the problems that are associated with the alcohol use.

“Alcoholic” and “Alcoholism” are not clinical terms and therefore they sometimes have poor operational definitions. If someone drinks every day, but not to the point of apparent (or clinically significant—in psychologist speak) dysfunction, we do not classify that person as an alcoholic—even if his or her drinking is negatively affecting the overall quality of his/her personal life (e.g., relationships, sex life, hobbies). If the drinking causes problems, but does not appear to be an "addiction" (another term that is not clinically defined), then we tend not to label it as something to be treated. We may even talk to the person about how his/her drinking is affecting him, but we do not typically address it in terms of maybe the person should seek help—that would mean he/she was an alcoholic after all, and we do not want to give that stigmatized label to anyone inaccurately.

Furthermore, someone who is experiencing alcohol-related problems but does not experience the symptoms associated with “addiction” is not likely to benefit from Alcoholics Anonymous meetings. Maybe he/she is drinking more frequently, but not substantially more at any one time, or has cravings, but not actually withdrawal. These could, however, qualify someone for a diagnosis of Alcohol Dependence or Alcohol Abuse. But a person is not likely to see himself/herself as an “alcoholic.” “Alcoholism” and “addiction” are the common terms used to describe someone who we perceive as having as having a drinking problem, not “dependence” or “abuse,” which allow for more flexibility in identifying problematic drinking.

Another aspect that is missed with traditional thinking on alcoholism is that someone over 50 may not be drinking more, but is most likely getting more drunk on the same amount of alcohol. Around the age of 50 our bodies become less able to detoxify alcohol, so smaller amounts can actually have more major impacts. But we see a person having two to three drinks a night still—without needing a greater quantity of alcohol, yet his/her body is processing the same amount as if it was in fact more. This can disguise the tolerance a person might be developing.

If we were willing to think of drinking problems in terms other than “alcoholism” or “not alcoholism” we could better address the negative impacts that some people’s alcohol use causes.

Mimicking Depression

There are two medical conditions that frequently show up in psychologists’ office as depression. These medical disorders outwardly mimic depression (and may even cause depression), but have distinctly different causes, and, untreated, can endanger a person’s health. If you are experiencing depression symptoms, you may want to consider seeing a physician, not for antidepressant medications, but rather to be checked for other problems that may mimic depression.

When I was in graduate school we were frequently reminded to consider hypothyroidism (insufficient release of thyroid hormone) in women who presented with depression. Both cause lethargy/fatigue and hypersomnia (sleepiness), are associated with physical pain in the joints and muscles, and involve lack of motivation, anhedonia (loss of enjoyment in things which use to be enjoyable), negative mood states (e.g., sadness, regret, or anger), mood swings, and weight gain. Many of the symptoms of hypothyroidism mimic depression and it is consequently frequently under-diagnosed, or misdiagnosed as depression.

No amount of anti-depressant medication will make the symptoms of hypothyroidism go away. Thyroid hormone affects many other bodily functions and low levels can negatively affect multiple organ systems. Untreated hypothyroidism can lead to goiter and heart problems and can even cause birth defects if a pregnant woman has hypothyroidism, so proper diagnosis is very important. More women than men present with depression symptoms, so awareness of this mimicking phenomenon is drilled into psychologists in grad school. However, it is also important that women be aware of the similarity so that they know to consult a physician (perhaps in addition to a psychologist) if they experience symptoms of depression.

Perhaps because men present for depression less frequently than women, being able to distinguish medical disorders from mental disorders is less emphasized in grad school. If a man presents with difficulty attaining or maintaining an erection, lack of sex drive, irritability, mood swings, negative mood states (e.g., sadness, regret, or anger), difficulty concentrating, lethargy/fatigue, a lack of motivation, and weight gain the psychologist is likely to diagnose depression, whereas the medical doctor will probably evaluate testosterone levels. These symptoms are common to both disorders and both would be reasonable diagnoses given the respective experts’ fields.

Many of the symptoms that might allow for differential diagnosis are not likely to be mentioned by men over 35 to either a psychologist or a physician. Hair loss is normal as a man ages, but is also accelerated by low testosterone. The development of fatty tissue in the breast/chest area probably also isn’t going to have attention called to it when presenting to a health professional—either because it is embarrassing or because it won’t even be noticed with the rest of the weight gain. But these are some of the things that can be used to assess if a man is suffering depression or low testosterone. Sometimes, though increasingly less so, male clients will not tell their psychotherapist or counselor about sexual dysfunction either. Even in the absence of these symptoms I have encouraged some of my male clients to have their testosterone levels checked.

Decreased testosterone is normal for a man over 40, but sometimes there is a precipitous drop in testosterone levels and that will lead to depression-type symptoms, along with health risks. Low testosterone is associated with heart problems and even susceptibility to broken bones. And, like hypothyroidism, anti-depressant medication will not address the symptoms, not even the mood symptoms, effectively.

Along with the normal drop in testosterone, there is a natural drop in sexual function and energy, which may be perceived as the normal part of aging—and for many it is—but even many physicians are not trained to ask about the effects of lessened testosterone in a way which would indicate lower-than-normal-for-age testosterone levels. It is important that men be aware of the symptoms and question the severity of the drop (and the mood features associated with low testosterone) in order to take care of themselves.

There is some controversy whether hypothyroidism and low testosterone mimic or actually cause depression. To me the distinction might be irrelevant. If after taking the medication the depressive symptoms do not go away after a few weeks, you might want to see a therapist to address whatever depression may have followed the body chemistry problems from the physical disorder. If the depressive symptoms go away from treating the primary physical problem, then the depression has gone anyway. But the main point is that, like with so many physical disorders, it is important to know to consider with the medical or mental health professionals all of the possibilities.

Doling Out Your Crazy

When we meet someone for the first time, especially someone with whom we want to get intimate, we want to make a good impression. Part of making a good impression is being yourself with someone. People are pretty good at detecting insincerity; people do not respond well to partial presentations. But people also don’t tend to want to associate with people who present as a “mess.”

I encourage my clients to dole out their crazy a little at a time when developing a relationship. There is a pace at which it feels healthy and appropriate to share one’s uncertainties and idiosyncrasies. It is sort of like testing the waters. Trying to see how much of our own craziness the person is ready to handle. This is partially determined by how much quality is perceived in the person—in other words: “Does the person have enough good stuff to put up with the crazy?” By the way, we all have a little craziness.

The craziness may be some odd superstitious ritual or fear that is not grounded in any rationality, but is grounded in the perception of our own experiences. We all have some strange ideas about the world and frequently our own un-founded insecurities (e.g., I have a faux paranoia about ebola). No one is really quite “normal,” while they might be mentally quite healthy. These are the quirks that make us who we are—often the parts that people find endearing after they get to know us.

However, emphasis on “after they get to know us” is worth highlighting. Too much intimacy—crazy or not—too soon is usually off-putting. We enjoy the process of getting to know someone; the process of discovery is engaging. Knowing everything at once can feel overwhelming—there is no context for the details, no sense of nuance or flavor. It can feel too raw. Additionally, I think there is something to feeling special because an intimate aspect of someone was shared with us. Aspects of oneself shared too easily do not feel like intimacy.

We also take as a cue how much we will share (or are expected to) based on how much another shares, and therefore someone sharing too much too quickly may feel threatening. Most of us want to control the rate at which someone knows our quirks and insecurities—there is vulnerability in it. When someone blurts out all of his or her idiosyncrasies, we don’t feel safe sharing with him or her our personal thoughts. Furthermore, the expectation to match the pace of sharing can make us want to back away (and protect our privacy).

I do not mean to discourage sharing, of course. Exposing our true selves actually tends to open us up to greater connection and happiness. However, when trying to decide to share one’s quirkiness think about the purpose of the sharing—what are you trying to achieve by it? Are you trying to provide insight? Are you trying to explain a particular behavior or tendency? Are you trying to be funny? Or is it just coming out of you uncontrollably? That last one is the one to watch out for—it will drive people away (or to stare).

The Five Love Languages

Gary Chapman came up with the theory of the five love languages. It is an idea I use with clients frequently. It addresses the idea that demonstrations of love often go unnoticed (or unappreciated) by a partner. Chapman discovered that people engage in and recognize demonstrations of love differently. He categorized these disparate actions into the categories, or languages: words of affirmation, quality time, receiving gifts, acts of service, and physical touch.

Saying “I love you” is important and can be powerful in its own right. However, in our culture the word “love” has lost some of its strength because of how loosely it is used (“Oh, I love those shoes”). “I love you” can also feel obligatory and insincere sometimes. I encourage clients to share what about their partner(s) they love. Those are true words of affirmation. I do caution people not to use them as blackmail though, don’t turn them into “I love it when you...” in order to get someone to do something, but rather only as sincere appreciation for their having done it.

One of the most valuable and overlooked things that we can offer a partner is our time. Companionship is essential for a relationship (of any kind). Doing things together can function as a bonding experience. It is important to find shared interests and it is important to be curious about your partner(s) interests, even when it is not a shared interest. Work on enjoying your partner’s company when you do things with them that you don’t necessarily enjoy doing yourself—make enjoying their company what you get out of it rather than the joy of the activity itself. Another aspect of quality time that is frequently overlooked is that just sitting with someone who is suffering, enduring what they are going through—without an agenda of your own—is one of the greatest gifts you can give someone.

Meaningful trinkets can in fact be very meaningful. A few years ago my BF was putting in some glass doors, to open the house up to the backyard. I appreciated what he was doing (and his concern that it was temporarily inconveniencing us) so I purchased and wrapped a DVD of a movie I knew liked and stuck in conspicuous place in the jobsite one night so that he found it the next day when he went back to the project. Flowers are the gold standard of trinket gifts, but occasionally spontaneously providing something that your partner has casually mentioned wanting is a great way of saying “I care about and attend to you.”

Doing non-chore household tasks, especially without being asked can be a powerful statement of “we are in this together.” Noticing things that your partner does not like or is incapable of doing and doing those things for him or her is another way of showing you are attending and care. If you can notice something you can do to improve a process of your partner’s or can create something to facilitate the ease of his or her process, you are likely to be appreciated. Even helping out in mundane ways tends to be felt as cared for. My boyfriend cooks most of the dinners in our home and I recognize his doing so is at least partially an act of appreciation for having me in his life.

Touch can be incredibly powerful. There is research that chemicals are released in our brains by just watching another person be tenderly touched. Research has even shown that a comforting touch can be desirable than sustenance. A simple caress or reaching for a partner’s hand while watching TV says “I value you.” While sexual groping can be a great way of saying “I find you sexy,” a non-sexual touch can say “I appreciate you beyond the great sex” (and might even lead to great sex!). Even people who are not touchy-feely can appreciate an occasional touch.

But the important thing to remember is that you may be saying “I love you” all of the time, but if you are speaking a different love language than you partner, the message may not be getting through. It is important to learn the language that your partner comprehends and speak that language. It may even be a good idea to let your partner know what language you hear. An issue that I have not seen Chapman address is that some people speak and hear different love languages themselves. So you cannot always count on getting your love message heard simply by speaking the same language your partner speaks. It is also worth learning what love language your partner speaks, so that you can become better aware of when he or she is saying “I love you” in a language that you don’t hear. Ideally you won’t send messages that are not received, but nor will you miss the messages that are sent in a foreign love tongue.

Misdirected (Dis)Respect

I recently had a client tell me about a guy with whom he was maybe, sort of, kind of, possibly beginning to start a relationship. And the client shared with me that one of his hesitations about starting the relationship was that “the guy deserved better.” The statement stopped me.

The idea that someone deserves better than oneself is a notion that has never made sense to me. Unless you know that you are going to do harm to someone or are being duplicitous, then I don’t know from where anyone gets the idea that he or she has the authority to decide whether one is good enough for another. I asked my client on what basis was he making the decision for his potential love interest and my client was unable to produce a coherent, rational argument. It seemed to be more of a feeling. In this case, it was a feeling of personal inadequacy of my client’s.

It strikes me as very presumptive that someone would feel he or she was in a better position to decide what would be rewarding to a (potential) partner than the partner himself or herself. On what basis does one make such a claim? Are you thinking of dating someone with poor judgment?—if that is the case, then the person probably does not deserve better than you. The assertion strikes me as rather self-centered actually.

I think the statement is made out of respect for the (potential) partner, but is actually an act of disrespect. It is grounded on the person either not being able to make good decisions or not knowing what would be good for himself or herself or that the person cannot adequately assess others. Those aren’t very respectful claims to make about another. In fact, they pretty well disregard the other person’s ability to decide or determine what he or she would most enjoy or benefit from in a partner. It pretty much is the same as saying “I know what would be good for you better than you do.”

But the aspect that I think makes it the most self-centered is that it is really about the person making the statement’s self-image than the person about whom the statement is being made. As with my client, it is more often a statement of one’s own sense of inadequacy. It seems it would a healthier and more productive approach to acknowledge and explore how the qualities you see in yours love interest make you feel, rather than write off the compatibility. Heck, you may even want to be honest with your partner. But I would strongly encourage you to be open to what your partner might see in you of value that you do not recognize in yourself.

I really don’t think we are in a position to decide if we are worthy of or good enough for another. I think we are not the best judges of that. I think that we grant a (potential) partner more autonomy and more respect by being honest about who we are (with our concerns about compatibility and being open to his or her perspective). Respect for your (potential) partner’s ability to make a good decision as much as you respect the qualities that make you feel unworthy.