Get my Free E-Book Staying Well with Bipolar Disorder

It’s hot off the press. Just go here to get yours. And, while you are at it, sign-up for a dose of sanity with my e-newsletter. Thx again. I look forward to giving you more content on mental health soon. I’m working on an article on bullying and mental health and programming for children and teen mental health. Those will be coming soon by the end of the summer.

988 is the New Suicide Hotline, but be careful what you say

This past week the National Suicide Prevention Line became easier to use. All you need to do is dial 988 or text 988 and you can be connected to a trained listener. 

However, be careful what you say to them. They are mandatory reporters which means they have to report abuse, violence or self-harm. If you say the wrong thing, they might call 911 on you. Before you say, post, or text anything, think twice. How is the other end going to respond? If you do not want emergency first responders at your door, please think twice about how you phrase things. 

Talking to someone when you feel at your lowest helps. They can point you to resources in your community. 988 is an important resource for everyone who wants better mental health to know. You can talk about bullying at your school or your insensitive boss. You can talk about a family member in crisis and how to deal with them. You can talk about how hard it is to live in your violent neighborhood and you can talk about how hard unemployment or under employment is. 

Mental Health Q & A: Dear Lex

Dear Lex,

I’m compelled to trace certain numbers in the air, twirl my pen and touch the corners of paper. This is all to cope with my generalized anxiety disorder (GAD). The bad thoughts start coming and I am compelled to get relief by doing these things. The thoughts never stop. The compulsions happen in infinitum. I just cannot stop. I’ve tried listening to music to interrupt my thoughts, meditating, running, strength training. All this works for a minute. But when I am working or idle, I am back at it. OCD is driving me crazy. I also repeat myself over and over to reassure myself that everything will get done today. I need to try freewriting more like I am doing now to occupy my fingers and thoughts. Whether typing or through a journal this serves to stop the thoughts and give me something else to focus on. I also love to play with pens and pencils twisting them in the air, making shapes with them. 


Dear Compelled,

You need to find out exactly why these thoughts occur. Next time, one occurs, start freewriting about why you think you are having the thought. If you can pinpoint the why of the thought, you can self-talk next time it happens. You can say to the thought “I know this is distressing but it is not what I want to focus on right now. Please go.” Or “Everything will be fine. I don’t need to do this now.” Or you can allot time to do the compulsion as a reward for doing actual work. Though, the latter is not recommended. You don’t want to reinforce negative behavior. Exercise, writing, meditating and listening to music all will help. It sounds like you have started to develop some coping mechanisms naturally. 


If you have questions for Lex, please email me on the contact form on this blog. 

Swiss photographer Captures Manic Depression on Film

Courtesy of Matthieu Zellweger, a photograph in the “Worlds Beyond” collection

Matthieu Zellweger

Matthieu Zellweger, Ph.D., a Swiss scientist and photographer, shoots haunting, surreal and journalistic pictures of manic depression that make it seem like the subjects are experiencing unreality in real time. The pictures in “Worlds Beyond” featured in the scientific journal the Lancet are staged but give one the feeling of experiencing the states in which the subject has experienced. His journalistic work on the subject were documented in “Invisible Handicap,” which can also be viewed on his web site. The pictures have a haunting beauty of this otherwise mysterious, sometimes frightening illness. The surreal-like quality of “Worlds Beyond” helps bring one immediately into the mind of the subject. I interviewed Matthieu about “Worlds Beyond” after reading his essay in Navigating Bipolar Country by Merryl Hammond. His work has been featured around the world in many publications such as the New York Times. Here is a transcript of our chat. 

AZ: Where in Switzerland are you?

MZ: In Rolle, near Geneva, in the French-speaking part of Switzerland

AZ: What type of cameras do you use? digital, print or both? 

MZ: Both, depending on the specific project. The project “Worlds Beyond”, and the eponymous book was shot only digitally, however.

AZ: Where did you do your education for photography and health science?

MZ: I am an autodidact photographer. As an adult, I participated in a few carefully selected Masterclasses. For the health science part, I was educated and trained in Switzerland (Ph.D) and Japan (Post-doc).

AZ: What is your process for creating the dreamy effect in your work?

MZ: Slow speed, mainly, and the right amount of movement, lighting and instinct.

AZ: How do you capture people going through manic episodes? 

MZ: I met only few people during manic episodes. All people featured in the book were in a stable period of their life and/ or disease. For people during manic episodes, I asked for permission, then usually secured a second and a third level of consent by, for instance, contacting the person again at a later stage or asking the doctor looking after that person if the consent was acceptable or not. Some pictures that I have shot around people unable to give a suitable agreement were simply never published or used.

AZ: What was your interview process like? 

MZ: For the pictures in the book, I only selected people whom I had already met and interviewed for the first, journalistic part of the project. They were all in a stable period of their life and/ or disease. I recontacted them and asked if they would be willing to share with me some details of their choosing on their own manic phases. Then I reconstructed images based on these details and, with their agreement, staged them. All the pictures in the book are thus deeply personal to the subject on the pictures because they are reconstructed using elements specific to that one person and nobody else. The images are also staged, posed and later validated by the people who participated. In that sense, they are not journalistic, but artistic. The journalistic images of this project are kept separate in a project titled “Invisible Handicap”.

AZ: What is it like to play the voyeur in someone experiencing unreality?

MZ: I do not know. The role of a photographer is to uncover realities that society prefers to ignore, to show the invisible. My work ethics is such, however, that I am extremely careful to secure the agreement of all parties before I start shooting. This is even more the case for staged pictures, such as the ones in “Worlds Beyond” inasmuch as the protagonists in the pictures took an active role in giving me details about their manic phases, agreed to the project and the pre-arranged shootings, etc. This was very much a collaborative effort. 

AZ: How is photographing mental illness unlike documenting your other work?

MZ: Mental illness is, as one protagonist put it, an invisible handicap. It is more delicate to show something invisible.

AZ: What countries did “Worlds Beyond” take place in?

MZ: Switzerland, UK, USA

AZ:Was it exhibited in any place besides the Lancet? like a gallery?

MZ: It was not, but it was widely featured in newspapers, magazines, television. It still may be exhibited at a later stage. In addition, the third part of the project, “His Name Was Alban” was exhibited in Switzerland and printed as a portfolio of conceptual, fine art photographs.

AZ: What was your thinking about capturing manic depression using the blurry effect?

MZ: I did capture it in many different ways, since the entire project had three chapters: “Invisible Handicap”, “Worlds Beyond” and “His Name Was Alban”. Only the latter two use the blurry effect. Initially, I saw it as a suitable way to distinguish the journalistic images from the staged ones. Later on, it became clear that it was rather adequate to describe the inner mental space of someone who had, literally, taken me into their mind.

AZ: What is your favorite photograph in “Worlds Beyond”?

MZ: Not sure I have a favourite one. They all tell a story, perhaps several stories, to the extent that they talk about one person and about the connection that I established with that one person, the trust they placed in me and, sometimes, the friendship that resulted. 

AZ: You have a scientific background. How does it interplay with your art?

MZ: It helps me start a new project by exploring quickly the state-of-the-art knowledge on a question I might ignore all about. It also guides my choice of topics to photograph.

AZ: Have you documented other health related stories in photography?

MZ: Yes, several: stillborn children; domestic violence inflicted upon men; depression; suicide survival.

AZ: Who are your photographic inspirations?

MZ: Anyone able to tell a story, stir emotions and surprise me by taking me on a journey with a photo essay.

To view his “Worlds Beyond” series please visit To view his other work, visit Matthieu Zellweger is represented and distributed by Haytham-REA, Paris.

Boundaries Strategist and Psychological Safety Consultant Talks about Struggle with Mental Health System

Katrina Strohl

“Because Black people are less likely to be diagnosed with ADHD at younger ages they are more likely to develop a substance use disorder,” Strohl said. “It is systemic to associate certain groups of people with certain substances such as marijuana. We need to have a better conversation about substance use.”

Katrina Strohl

Katrina Strohl (They/She/He) is the creator of the podcast Absolutely Not! About setting boundaries in the workplace and emphasizing the vocabulary needed to name harm in those spaces. Katrina is a psychological safety consultant, boundaries strategist, and mental health advocate who identifies as Black and Samoan and Queer. In 2018, she tried to end her life and while in the hospital was diagnosed with Post-Traumatic Stress Disorder PTSD, Major Depression Disorder, and substance use disorder. But more recently, she was diagnosed with Attention Deficit Disorder and Hyperactivity ADHD. Katrina is a veteran who served as an aviation structural mechanic in the US Navy. 

During Katrina’s first hospitalization, she was one of two Black women and was constantly called the other woman’s name. 

“We are at the lowest point in our lives and constantly dehumanized,” Strohl said.

Most of the time during the hospitalization Katrina spent going to sessions and lying their way out of the hospital. Katrina was a single mother of a three-month old son and they needed to get back with their son. The hospital let her go in four days.

Two months later Katrina took their own life again. Katrina had no support as a single mother and when they had to breast pump or take their son somewhere Katrina’s employer in the office she worked as an administrative assistant didn’t understand. They brought Katrina into a room and criticized and berated Katrina. 

“I felt like I didn’t have a place on the planet anymore,” said Strohl.

During her second hospitalization, Child Protective Services got involved and made Katrina prove that their son lived in a happy, safe family or he would be taken away. 

“This is when I decided I needed to move forward and figure out what we needed to be safe,” Strohl said. 

“I left the practitioners who diagnosed me with PTSD, MDD, and substance use disorder because they weren’t helping me,” Strohl said. “They didn’t give me resources I needed to feel better.”

Katrina then went to a few white, women therapists who acted dismissive whenever she brought race into the picture. 

“A Black woman therapist was the first person who taught me about boundaries that most people learn in their first therapy session,” Strohl said.

Katrina doesn’t take medication anymore and has a new Black woman therapist; the old one turned out to be homo/transphobic. This therapist correctly diagnosed her with ADHD. This was shocking to Katrina but she felt it rang true when her therapist asked her during her evaluation if she felt like she had a motor inside her that never stopped. Katrina cited an article that said Black children are less likely to be diagnosed with ADHD and it often leads to suicide. 

“I’m still processing the diagnosis and I cried a lot in the final assessment because it rang true,” Strohl said.

“Growing up there was an ugly stigma toward ADHD in the black community,” Strohl said. 

“Because Black people are less likely to be diagnosed with ADHD at younger ages they are more likely to develop a substance use disorder,” Strohl said. “It is systemic to associate certain groups of people with certain substances such as marijuana. We need to have a better conversation about substance use.”

Today Katrina is self-employed and works with organizations to make them aware of what psychological safety looks like and how to create boundaries for employees. 

“I create boundaries in everything I do. Every facet of my business helps me hone into who I am.”

“I have to figure out new boundaries because I live with ADHD.”

“With the PTSD, I cannot be in emotionally activating conversations for longer than 45 minutes and I cannot be interrupted or my thoughts will derail.”

“Sometimes my work makes me sad and the responses I get from my posts on social media is eye-opening as people with my shared identities and lived experience have been through the same things.”

Katrina knows their work is creating a safer world for their son to grow up in. Katrina can be found at  

An Interesting Article on PTSD in Survivors of War in light of the war in Ukraine previously published on Medium and Psychology

Grant H Brenner

Grant H Brenner

Mar 14

How PTSD Becomes Self-Sustaining in Civilian Survivors of War

Research maps out how trauma takes on a life of its own

Photo Credit: Grant H Brenner

New research on Balkan war survivors sheds light on the persistence of PTSD.

As the war in Ukraine wages, and the world watches millions of refugees flee for their lives, we are reminded of countless prior wars. While media attention mobilizes our outrage and the outpouring of immediate help to affected civilian populations, what happens after the wars end?

We know that war takes a massive toll on the people, but our understanding of how the effects unfold for years after is still evolving. Do we forget to pay attention after the cameras stop rolling? What can we learn from past wars about post- traumatic stress?


Researchers Schlechter, Hellmann, McNally and Morina conducted a study of civilian survivors of 1990s Balkan wars, including those who had stayed in their countries of origin (including Bosnia-Herzegovina, Croatia, Kosovo, Macedonia and Serbia) and those who had settled in Germany, Italy and the UK. The results wee recently published in the Journal of Traumatic Stress (2022).

Study authors focused on PTSD among war survivors to understand how symptoms emerge and change over time, and specifically how earlier symptoms predict and maintain later symptoms. Common symptoms of PTSD, including avoidance of trauma and emotional numbing, get in the way of people getting treatment, as do systemic issues like stigma and lack of resources, including paucity of qualified clinicians and lack of screening in at-risk groups in primary care settings.

Up to 227 million adult war survivors are estimated to have PTSD. A systemic review of PTSD and Major Depressive Disorder (MDD) (2021) in countries affected by war in the last three decades suggests that 316 million people suffer from war-related PTSD and/or MDD. Half of the people in that study had both PTSD and depression, with about a quarter of people having one or the other, but not both.

PTSD can take on a life of its own, especially if left unchecked. Once trauma sets the brain off on a dysregulated pathway, it can become a self-regenerating system. Brain network activity is altered by trauma; for example, we may miss what’s right in front of us-problems in a relationship, a health issue-because we are so busy guarding against the return of past threats. Intrusive memories of past trauma may trigger further hyperactivation, leading to a cascade of symptoms.

Avoidance, akin to procrastination, may reduce short-term distress at the expense of preventing long-term restoration because we cannot become desensitized to traumatic memories. Understanding the specific pathways by which PTSD is sustained is key for successful intervention.

Survivors of War

Schlechter and colleagues recruited several hundred civilian war survivors to arrive at a final group of 698 participants, who were assessed for symptoms eight years post-war and then again one year later. Participants completed the Life Stressor Checklist-Revised to appraise stressful (potentially traumatic) experiences before, during and after conflict. PTSD was assessed using the Mini-International Neuropsychiatric Interview and the Impact of Events Scale-Revised.

PTSD symptoms of re-experiencing/intrusion (memories, intrusive thoughts, nightmares), avoidance/emotional numbing, and hyperarousal ( fear/ panic, being easily startled, rage, etc.) were analyzed using network theory to determine first the correlations among symptoms at each time point and, second, the relationship between earlier and later symptoms, to show which symptoms in the present cause which future symptoms ( causation).

The Anatomy of PTSD

Eight- and Nine-Year Time Points

Overall, there were moderate to high levels of trauma, with average IES-R PTSD scores of 2.45 at 8 years and 1.98 at 9 years (with 4 being most severe). The most frequent traumatic experiences reported were lack of food, lack of shelter, shelling, siege, and finding out a loved one had died violently.

At each time point (cross-sectional analysis)-eight years and nine years post-war-findings were similar for PTSD . The symptoms most strongly connected to PTSD were trouble staying asleep, trouble falling asleep, feeling as if trauma weren’t real or hadn’t happened, feeling numb emotionally, trying not to think about trauma, and trying to remove trauma from one’s memory.

Post-Traumatic Stress Disorder Essential Reads

There was a moderately strong correlation between thinking about trauma when one did not want to and avoiding getting upset if thinking about trauma (suppressing emotion).

Symptoms with the strongest impact (“expected influence centralities”) were having strong feelings about traumatic experiences, being jumpy and easily startled, and trying not to think about traumatic experiences. Network patterns were equivalent at eight and nine years post-war, but overall symptom severity decreased somewhat over time.

Which Symptoms Cause Future PTSD to Persist?

Looking at how earlier symptoms lead to later ones, network analysis (“cross-lagged panel network”) found five key relationships, in order of descending strength, as shown in the graph above by arrows connecting one symptom to the next. Thicker arrows indicate stronger causality:

  1. Difficulty concentrating led to trying to remove trauma from one’s memory.
  2. Difficulty concentrating led to trouble staying asleep.
  3. Trouble staying asleep led to pictures about trauma popping into one’s mind.
  4. Trying not to talk about trauma led to trying to remove trauma from memory.
  5. Reminders of trauma causing physical reactions led to difficulty concentrating.

The biggest predictors of future PTSD symptoms were:

  1. Getting physical reactions from traumatic reminders.
  2. Difficulty concentrating.
  3. Trouble staying asleep.

The symptoms most caused by prior symptoms were:

  1. Avoiding letting oneself get upset.
  2. Trying to remove trauma from memory.
  3. Acting like one was back at the time of the trauma.
  4. Dreaming about trauma.

Unpacking the Persistence of PTSD

Participants in this sample had a significant burden of post-traumatic symptoms, reflecting the findings from earlier studies on war trauma. Eight years later, they continued to report a high level of symptoms, which were lower the next year. It’s tempting to wonder whether participation in the study itself had a therapeutic benefit, by combating avoidance and raising awareness of problematic symptoms.

Only 38.4 percent of the participants had received mental health services, and yet almost 90 percent had seen a primary care practitioner, highlighting the critical importance of screening in primary care settings.

Addressing the identified pain points may be useful in hastening the resolution of PTSD, a subject that future research can clarify. Reducing avoidance-gently increasing engagement with trauma-is important for treatment to be effective and key to recovery for many PTSD sufferers. Improving concentration may help improve sleep quality, which in turn could reduce the frequency with which traumatic memories spontaneously arise. Reducing traumatic memories reduces reminders of trauma, which would then be expected to reduce physical symptoms interfering with concentration. Body work can address physical symptoms of trauma, which increase traumatic reactions, and so on.

I Am Not My PTSD

Traumatic dynamics can end up taking over how our brains process information, experience, and relationships. Trauma can overshadow regular day-to-day experience long after the threat has passed, creating an all-present context that may be significantly disconnected from what is actually happening and leading to frequent distorted perceptions, misunderstanding, functional disturbances, and maladaptive coping.

In the extreme, PTSD may be mistaken for one’s personality, especially with early or pervasive trauma, making it difficult for people to get in touch with their authentic sense of self and shaping life choices in regrettable ways. Recognizing PTSD and addressing key therapeutic levers is a potential game-changer: The often difficult work of recovery pays off with less future regret and greater self-regard, security, and life satisfaction. We have a clearer understanding of how war causes PTSD on a collective level, and left wondering how PTSD contributes to future outbreaks of war through triggering, avoidance and excessive aggressive reactions to perceived threat.

Graph Abbreviations

In1 = Any reminder brought back feelings about it; In2 = Other things kept making me think about it; In3 = I thought about it even when I didn’t mean to; In4 = Pictures about it popped into my mind; In5 = I found myself acting like I was back at that time; In6 = I had waves of strong feelings about it.

Av1 = Avoided letting myself get upset when I thought about; Av2 = I stayed away from reminders of it; Av3 = I tried not to think about it; Av4 = Lot of feelings about it; but didn’t deal with them; Av5 = I tried to remove it from my memory; Av6 = I tried not to talk about it.

Ha1 = I felt irritable and angry; Ha2 = I was jumpy and easily startled; Ha3 = I had trouble concentrating; Ha4 = Reminders of it caused me to have physical reactions; Ha5 = I felt watchful and on guard.

Nb1 = I felt as if it hadn’t happened or it wasn’t real; Nb2 = My feelings about it were kind of numb.

Sd1 = I had trouble staying asleep; Sd2 = I had trouble falling asleep; Sd3 = I had dreams about it


Hoppen TH, Priebe S, Vetter I, et al. Global burden of post- traumatic stress disorder and major depression in countries affected by war between 1989 and 2019: a systematic review and meta- analysis. BMJ Global Health 2021;6:e006303. doi:10.1136/ bmjgh-2021–006303

Schlechter, P., Hellmann, J. H., McNally, R. J., & Morina, N. (2022). The longitudinal course of posttraumatic stress disorder symptoms in war survivors: Insights from cross-lagged panel network analyses. Journal of Traumatic Stress, 1–12.

Note: This Blog Post (“Our Blog Post”) is not intended to be a substitute for professional advice. We will not be liable for any loss or damage caused by your reliance on information obtained through Our Blog Post. Please seek the advice of professionals, as appropriate, regarding the evaluation of any specific information, opinion, advice, or other content. We are not responsible and will not be held liable for third party comments on Our Blog Post. Any user comment on Our Blog Post that in our sole discretion restricts or inhibits any other user from using or enjoying Our Blog Post is prohibited and may be reported to Medium. Grant H. Brenner. All rights reserved.

Originally published at