1.02: Vivere Est Vincere

Hello, I'm Armon Owlia. This episode of "Shadow Gallery Seminars" deals with mature themes of suicide awareness and mental health stigmatization. These topics mean so much to not only myself and our guest panelist, but to so many others. 10.7 million Americans seriously consider suicide with about 3.3 million making a plan. Suicide is never the final solution. If you were thinking about harming yourself or attempting suicide, please contact the 24/7 National Suicide Hotline at 1-800-273-8255. Your call is toll-free and confidential. Together, we can all help prevent suicide. Thank you.

This is an LLD Production.

On this episode of "Shadow Gallery Seminars:" mental health awareness and suicide prevention with Dr. Stephen Hinshaw of UCs Berkley and San Francisco.

Recognizing suicidal behaviors, destigmatizing mental illness, and an attempt to better the health care system to help those most at risk in the age of COVID-19; these are just some of the factors that make this such a hot button issue.

What needs to be done to create this awareness and, in an age when we are all more aware and open about mental health and suicide, what more can we do to destigmatize something that happens to more people than we want to admit?

The answers to all that and more, when "Shadow Gallery Seminars" begins...now.

Hello from the SF Shadow Gallery, I'm your host, Armon Owlia.

We are all painfully aware of the over 225,000 deaths in the United States by COVID-19, which has been running rampant since the first case was identified in January.

However, there is an unfortunate side-effect of COVID that we are not as painfully aware of, one that will exacerbate an already serious problem: a morbid statistic that will increase with the same level of urgency as the COVID deaths is the number of people who attempted and committed suicide in 2020.

In the pre-COVID era, suicide was America’s second-leading cause of death in people aged 10 to 44. That’s the second-leading cause of death for almost half of the population. Overall, it is the tenth leading cause of death in the country, responsible for over 48,000 deaths in 2018.

It may not sound serious at face value, but the problem is even worse when you put this into perspective. According to the CDC, the number of people who have seriously considered suicide in a given year was 10.7 million Americans. Less than a third of them (about 3.3 million people) actively make a plan. Of that third, about 42 percent, or 1.4 million Americans, actually go through with their plan. This means that, overall, 3.5 percent of all suicide attempts are, in fact, successful.

Yes, this is a problem that directly impacts millions of Americans and a pretty serious one at that. And yet, for the second-leading cause of death amongst nearly half the population and the tenth leading cause of death overall, it is rarely spoken about. This is kind of strange when you consider that talking out the problem is actually one of the best ways to fix it.

When you factor in social distancing, lack of travel, a general fear to get outside the house, and massive amounts of screenings at the hospitals and treatment centers that have helped those mentally ill and suicidal through counseling, it’s safe to say there will be a massive uptick, and thus, an even more urgent problem to solve.

So, what needs to be done? What needs to change? How do we bring an issue that has been in the limelight for so long back into the open? And already, with the awareness and efforts already made, what more needs to be done to at least say we have somewhat of a handle on the situation?

Joining me via satellite is Dr. Stephen Hinshaw, a psychology professor at UC Berkeley and UC San Francisco, and scientist and advocate for mental health and reducing stigma. He is also the author of the award-winning book, “Another Kind of Madness: A Journey Through the Stigma and Hope of Mental Illness,” coincidentally my pick for November’s Book of the Month.

Dr. Hinshaw, welcome to the program.

Thanks for having me on.

No problem. So before we get into this, why don't you explain to the people listening in who probably, if they know you, then wonderful, if they don't, why don't you explain to us your qualifications for talking about mental health awareness and mental illness?

Well, I've really been spending my whole career on, first and foremost, child and adolescent mental health, uh, second, treatments for kids, teens, families, in which a parent or a child has mental health issues. Third, a lot of my specific research on attention deficit hyperactivity disorder, ADHD, excuse me, which exists in tandem with anxiety, depression, many other mental health conditions, and fourth, for the last 25 years. I've had a very explicit focus on reducing the stigma that attaches, and still, unfortunately, clings to depression, schizophrenia, bipolar disorder, autism spectrum, ADHD, the shame of talking about it, the fear that it's a weakness to admit having such a problem. You have one standard of healthcare for people's physical illnesses and a very different standard, uh, for people's mental afflictions. And, basically, the stigma that still attaches itself to mental health issues is worse than the mental health issues themselves, because it leaches hope out of the individual or family. It prevents the seeking of treatment and it makes what's at best, a tough situation, almost impossible. So because of narrative works like the book you just mentioned, "Another Kind of Madness," studies of high school kids in California and throughout the country in high school clubs that where we explicitly try to have them reduce mental illness, stigma, I feel that all of the work I've done sheds a light on what you so eloquently and tragically introduced this, this program with, we're in an epidemic of self-injury both non-suicidal, self-injurious behavior and frank suicide attempts, and it's time to tackle these head-on.

So it's very safe to say that from a professional standpoint, and also from a personal standpoint for, because I read the book and first of all, very well-written, very beautiful. And, I think we even talked about this, hit me in a very, very deep spot, because I can relate to some of what you, what you wrote in there. So you also have a very good personal experience with this as well.

Yeah, absolutely. So blending the best of science, the best of clinical care and the narrative, the coming out of the closet, disclosing, then we get into a situation that I want to remind everybody of. It wasn't all that long ago in the United States that, and then back in the '30s, '40s, '50s, even '60s of the last century, you never put in the obituary that your, uh, aging grandparent or uncle or aunt died of cancer because everyone knew that cancer was a very shameful illness that you essentially brought on yourself because you'd lost the will to live. It was a psychosomatically-induced illness. Today, cancer is a cause. The NFL behemoths will wear pink knee socks a couple of Sundays this fall in front of the largely empty stadiums in the COVID era to fight breast cancer. What color knee sock will they wear to raise mental health awareness? Well, it's a trick question because we're not there yet, but if we talk about the issue, the way that women have talked about breast cancer and made it a national cause, if we, by sheer prevalence alone, mental illness, isn't rare. Half of the country will experience some form, maybe in mild form in their lifetimes, and up to a quarter will experience moderate to severe forms of mental disorder throughout their lifetimes. But if we don't talk about it and don't treat, treat it, and still think it's shameful, everybody loses.

Which is, actually leads perfectly into what I wanted to begin with. So, as I mentioned, on the first episode, Mark Twain said something which I personally agree with. This is sort of the secondary motto of the show: "What gets us into trouble is not what we don't know, it's what we know for sure that just ain't so." So let's, let's establish what we know, what we don't know, and what we claim that we know that we actually is not true. So first of all, um, what exactly do we know that's proven? So for example, um, forms of suicide prevention, behaviors, the warning signs, social factors, things like that.

So, I want to emphasize what you said a few minutes ago. There are more completed suicides in the United States every year than completed homicides. Would you ever know that from the news headlines or social media? No, it's, it's all about homicide and obviously gun control is a major issue for both preventing homicide and suicide, but suicide is shameful. It's still illegal in some countries to kill yourself. So the stigma is huge. Someone in your family lost the will to live? Well, what kind of a family do you have? Didn't have sufficient spiritual or religious beliefs must not have been a strong family. And so the silence and shame around it is, is tragic because we know that losing a family member to suicide, especially if you're a kid of a parent who has ended his or her life, is above and beyond the genes that might predict the same depression or form of mental illness in the kid, the act of a family member's having killed himself or herself is a big risk factor for that individual thinking, well, I guess this is a way of coping with these behaviors. We know that suicide, especially in young people, and also among middle-aged and older people is rising rapidly. Not only in our country than in many other countries around the world. We know a number of risk factors, the feeling of hopelessness, having a mental illness like severe depression or bipolar disorder. We know that suicide rates tend to rise in times of economic downturn. Well, if COVID, isn't a time of economic downturn, probably more than any we've had since the 1930's, we're going to witness, as you so aptly put it in the introduction, a rise in depression, anxiety, post-traumatic conditions, grieving from loss of people to death, and the suicide rate will undoubtedly, there's signs already that suicidal thoughts and behavior have risen since the onset of the COVID-19 pandemic. We know that, as you put it as well, talking about it, looking for warning signs, keeping peoples' hope alive, is the great limiting factor in preventing suicide. There are many stories now of people who've made extremely serious suicide attempts. The man who jumped from the Golden Gate Bridge twenty years ago, who miraculously survived his plunge into the Bay, very few do. And in his documentary, he talks about, as he was falling, he realized he didn't want to end his life. If only we could get people whose emotional regulation capacities have dwindled and are feeling despairing and hopeless through to the next hour, the next day with social support, hope will surge back in, Suicide is not inevitable, if you have a serious depression or other form of mental disorder, but it feels inevitable when hope is gone and social support seems absent. So, the more we can talk about it, the more in primary care, in suicide prevention centers, in high school and college counseling situations, let people know it's not a sign of weakness to talk about your anxiety and depression and despair. It's actually a sign of strength, because then you can get support. Then we'll have begun to turn the corner on this battle.

I 100 percent agree with you on pretty much every word you just said, because yeah, I mean, it, it is a very difficult thing to talk about. Another thing that I think that should also be addressed is that, especially amongst people who are my age, you know, we have, um, a higher amount of stress I would like to believe than other previous generations. Do you think that would also contribute to what's going on? Do you think we're putting too much stress on people my age?

So I wrote an earlier book in 2009 called, "The Triple Bind: Saving Our Teenage Girls From Today's Pressures," in which my coauthor and I talked about, especially in the teenage years and especially for girls, but boys, aren't far behind, the unbelievable pressures to succeed, to achieve academically and for a girl to look very sexualized as you do it, puts kids in an impossible situation. And part of the impossibility, especially for girls is, you've gotta be nurturing and compassionate. You've got to rise to the floor athletically and academically, but you've got to do so effortlessly in a very "hot" way without the world, noticing that this is really impossible to do all three things at once. And this fuels internalization. "I don't feel worth it. My self-worth is plummeting. How can I meet these impossible pressures, uh, without admitting that there are these impossible pressures?" And I believe that that major forms of mental disorder have a strong genetic and biological set of risks, but also societal pressures up the ante, so to speak. They make, especially the most vulnerable teens, even more likely to despair and feel that their life isn't worth living and have to go around with this feeling of learned helplessness, that no matter how hard they try, they can't meet all these expectations. So I believe that in a time in our world, history of relative affluence, A: the economic disparities are more stark than anytime during the 1920's, and B: the pressures have mounted to the point where it's, it is possible. Many kids are quite resilient, but we're seeing in front of our eyes, now compounded by the COVID pandemic, we're seeing in front of our eyes, just how serious the consequences are.

And then also people talk about, well, "Oh, you know, we're all of us, you know, the economy is going down, everything is going down and you don't see me wanting to go and commit, there must be something wrong with you." I mean, isn't it, it's not just a biochemical thing though, isn't it?

So this is, It gets us into this concept of stigma. "Stigma" literally meant back in Ancient Greece and Rome, being branded with sharp implements, often heated, to literally burn a mark into your skin so that everyone would know, you're in Athens, you had fought for Sparta, or you're a former slave or a traitor, right? Everybody needed to know who was in the in-group and the out-group. Today in the 20th, early 21st century, we still have some branding, physical, like concentration camp members in Europe, who included not only Jewish people, but gay and lesbian people, people with mental illness and intellectual disability, Roma, gypsies were branded with a number on their wrist, many countries on our planet, literally branded HIV positive individuals in the 80's so you'd know to stay away. Most stigma today, however, is psychological: we know your flaw. We know the group you're in. We don't have to brand you. We know of that, that defect inside. And so when we stigmatize certain groups, and remember, women are still stigmatized, they're 51 percent of the population. You don't have to be a "minority group." That stigma limits life opportunities, makes people feel blame-worthy. The bottom three, the conditions or groups to which you might belong, that received more stigma than any other groups today are having a mental illness, being homeless, or using drugs, substance abuse. Because we feel well, it must be your fault. Maybe you just have a weak, personal will, moral fiber, right? You chose to put those substances in your, your mouth or your body. If you really tried hard, you could have a home, the attribution that you must be flawed. And the very behaviors you're exhibiting are threatening to us. I work pretty hard during the day. Yeah, I'm stable. Must be someone else's fault if they're not, it threatens our own sense of stability. So we know as an American society, much more than 50 years ago about the symptoms of alcoholism, schizophrenia, autism. Knowledge is up, but acceptance and stigma have not changed in that same time period, because simply knowing the facts and symptoms might just reinforce the stereotypes. "Oh, people with schizophrenia hear voices. How frightening is that? People who are seriously depressed want to end their life? Well, that's the most selfish thing I could think of." What we need is with the cancer example from a few minutes ago, everyday people to tell their stories of the daily heroicism and the daily struggles. It's great for celebrities to come out of the closet. That's, that's okay. But if it's only celebrities, I guess, in "A Beautiful Mind," if you're John Nash, you have serious schizophrenia, you win the Nobel Prize, but most everybody else with schizophrenia lives under a freeway in a tent. We don't want to heroicize or demonize. It's the everyday stories and we know mental disorders are surprisingly frequent. If we come out of the closet, everybody has to confront the issue.

And I, I mean, I can speak as someone who witnessed someone fight mental disorder. I mean, it's a battle really on two fronts on the one hand you're battling against your own mind, you're battling against basically delusions, things like that. And the other hand you're battling against, um, the public. You're basically battling gets people saying, "Oh, like, you know, you you're, you're going to be fine. Like man, up toughen up," that type of thing. It's it is a sad thing to witness.

It's, it's you're not strong enough. "Hey, I feel sad during the COVID era, what, what, I don't let myself get depressed. I fight through it. I'm tough." This kind of attitude of, the pioneer spirit almost, it's, uh, the strong ones versus them, the weak ones. And if you're weak, you succumb. We are all depending on our genetic heritage, more or less vulnerable to heart disease, coronary artery disease, or lung disease or cancer, the choices we make, lifestyle, diet, exercise, economic position we're in also influenced that risk. But with mental illness where it feels like some force has taken over your mind, which is threatening to us as observers, it feels like you're more fundamentally flawed. Again, cancer used to be viewed as a flaw, you'd given up the will to live so that the cells started growing into tumors. Today, we understand that is a biological illness also influenced by social forces and lifestyle factors, but we haven't really confronted because of the mere threat of it, the threat to our own sense of stability, that mental illnesses operate almost exactly in the same way, genetic vulnerability, for some, life stress conditions like the pandemic, push everybody into a more risky zone. But if you have the underlying vulnerabilities, a family history of depression or psychosis or whatever, you're going to be closer to going over the top of that threshold. If you will, during difficult times.

So it's safe to say, we already know so much about mental health awareness and suicide prevention, we already know a lot. So what exactly do we "know" that is really we're, we're basically lying, you know, basically they're not lies, but misconceptions that are being put out, put out there that really make it not as easy, really, to confront it.

Well, once you're mentally ill, you're always mentally ill. You're flawed forever. Well, do you ever go into remission from cancer, either naturally or through chemotherapy or radiation or surgery? You certainly can. There is probably greater risks than in other people of recurrence, but we know that with treatment and early detection, of course there's many different forms of cancer, then in many, many cases, the earlier it's detected and the better the treatment, the more years you have of healthy life. With mental illness, it's exactly the same. Whether it's depression or bipolar disorder or PTSD, the earlier we can get at it and understand it, sometimes medications are going to need to be used, often psychological forms of treatment, individual therapy, family therapy, group support are more effective than medications for many forms of mental illness. We know that for the more severe forms, combining medication with psychological treatments yields the best results. Why don't more people get access to care? Well, if society stigmatizes you or me, we're likely to know of all those stereotypes. We're likely to develop what we call "self-stigma." "I guess I don't deserve treatment. I guess I am flawed. I guess that I let that depression get the most of me. And I'm not as strong as I thought I was. I guess when I heard those voices for a period of time, I just lost control of my mind. And it must be because of the way I was raised or something fundamentally flawed about me." If we develop self-stigma, we don't feel we're deserving of treatment. And of course, it's not only that there are structural reasons. What kind of healthcare do we have in our country now, have we really attained parity, do we, it's on the books in laws. We're supposed to get equal care and insurance coverage for our mental conditions as for our physical conditions, but there's loopholes big enough to drive trucks through. So at a structural level and a policy level and at a very individual level, discriminatory laws and self-stigma prevent us from getting the care that we might need. And again, the myth is mental illness is permanent. Uh, if you're doing for the rest of your life, if you see a psychologist or psychiatrist for your mental illness, we don't really have cures in the way we don't really have cures for most forms of cancer now, but you can get a lot better. In fact, seeing a psychological therapist or psychiatrist for your mental health issues, on average, leads to bigger effects than seeing a doctor for your physical health issues. But the stereotype is it's permanent and people can't be treated. If we realize that these treatments work and will only get better if we fund more research and if people get access to them, we could move the dial. We're still generations away from curing mental illness, but we could offer hope and recovery for far more people than, than you get access now

There's also one other thing that I think is very much worth bringing up is that everyone thinks suicide was always stigmatized. Well, when I did my research, I found that for example, in the days of the Greeks and the Romans, suicide wasn't always a negative thing. In fact, during extreme situations, I think there are cases in Pompeii, when Vesuvius erupted that, instead of dying from inhaling the smoke, they actually committed suicide before the final pyroclastic surge even hit.

Right. I mean, think of, uh, the, the latter parts of World War II, the kamikaze pilots in Japan, right? This was the ultimate sacrifice for your country to dive bomb your plane into an American aircraft carrier. Suicide was revered because you had given the ultimate for your country. And so we know that different cultures have different beliefs about possession by spirits or low personal will or biology. Mental illness is stigmatized, more or less, to different cultures. However, there's no culture we've ever found that really lets mental health issues off the hook. Stigma's universal too. So, there's probably something in the way we're wired as humans, I mean, let's face it when a hundred thousand years ago, homo sapiens sapiens were on the savannas in Africa. We weren't as big or strong or fast as the predators around us. We had to be very social. We raise our kids with their big heads and brains for years at a time and bond together and social groups, the only way we survived, but at the same time, this is what the evolutionary theories of stigma are: if we were social all the time and cooperative, other humans might make us sick. We can tell if they were contagious or they might gyp us or cheat us, or those humans that looked across the river in a different tribe. So different in custom, we might have to fight them. So, we're both a very social species, but we're also wary of big differences, especially if we think those differences are threatening. That doesn't mean that we're all born to be racist or all born, to be stigmatized as against people with mental health issues. But it means that we've got to overcome some pretty fundamental tendencies to consider it us versus them. If we realize how frequently mental illnesses occur in all of our families, some more than others, of course, given the genetic patterns and that everybody loses if we exclude people from schools and jobs and relationships, culture matters in some Eastern societies, more collectivist, there's less stigma in some ways, but in some of those societies with arranged marriages, the ultimate hate against dowery and bringing, uh, a wife into the family is if she or her family has a mental illness. So stigma's not East or West, North or South, collectivist or individualistic, as a society, stigma against behavioral difference is pretty deeply ingrained in us. But, with compassion and humanization, we can overcome it.

And there's one other factor that I noticed is that, if you look at the religious component as well, like a lot of religions really do abstain from suicide. So for example, look in Christianity, Judas, who betrayed Jesus, ended up being so overwhelmed by guilt that I believe he hung himself from the branch of a tree. Um, for, for Judaism, I mean, you would be buried in a different plot of the cemetery, if you committed suicide, you would be denied certain rituals. Um, in Buddhism, he would say, oh, you wouldn't reach Nirvana. You say there is a massive component terms of religion that, I'm not saying religion causes suicide, don't, do not get me wrong there, but do you think that the religious component also plays a factor in the amount of stigma that comes with suicide and mental illness?

Well, again, I, in some primarily Catholic countries, it's, it's illegal to kill yourself. It's not just immoral, right? Because this is the ultimate right, we have the ultimate blessing we have to be alive. And for one to relinquish that right by taking one's own life is literally a mortal sin and is illegal. And so, family members are caught up in legal issues and payment issues and the taint is left for many generations. So, spirituality is a source of refuge to many people around the world and actually, organized religion can be a buffer against suicidal tendencies and many people. But many religions overtones about the sanctity of life spills over into further stigma against suicide. And I think you're exactly right.

So, before we get to commercial break, let's talk about what exactly we don't know and we need to find out, you touched upon it a little bit in terms of, you know, learning to recognize the signs, in terms of, cause it does get, it can get passed down. Like, for example, in the case of bipolar disorder, which you and I are both very much familiar with, I mean, there does come a point where we do look for signs very early on. Then when we get to our twenties, it's like, if there are no signs, like, okay, we can breathe easy and we can continue. But do you think that…

Or breathe easier? Cause are you ever out of the risk period, which I've been battling with for my whole life?

You're right, you're right. My bad. Um, but yeah, I mean, do you think that type of thing needs to be, um, more of a priority for families who know they have mental illness running through their, um, through their genetic pool?

So, I was, uh, doing, um, a national conference just the other day, the American Academy of Child and Adolescent Psychiatry, the closing plenary talk, and the president of this organization, who'd also read "Another Kind of Madness" said, "Look, what if your book had been about your family's colon cancer and it was in multiple generations? Wouldn't you be screening yourself twice as or three times more frequently than your doctor says, tells you to, but yours is about bipolar disorder and many other forms of mental illness in your family. How much did you scrutinize yourself as a teenager and in your twenties or because it was so stigmatized, did you not?" And so this is the $64 gjillion question. We're pretty good. Now, of course there's not equal access to healthcare, about if you have a big family history of death by MI, myocardial infarction, infarctions, heart attack, you're going to go to more screenings and you're going to be much more conscious of diet and exercise. But with mental health issues that we still want to push aside, why don't pediatricians, for example, seeing babies every few months and then kids every year for the checkups, why aren't behavioral and emotional signs part of those pediatricians checkups? Well, why aren't we scrutinizing behavioral and emotional development, not just physical development and vaccines and flu shots, because we think it's really under your personal control, because why would we need to check up something that if you were just stronger, you wouldn't, you wouldn't have to deal with? We're, we're, so, even in the healthcare professions, we think so differently still about the personal blame for mental illnesses, as opposed to the biological risk for physical illnesses, it makes it harder to pay good attention if you're in a family, that's at high risk, when by admitting that you're at high risk, again, it's not a sign of weakness, it's a sign of strength. You may be able to get literally prescribed or more, um, uh, figuratively prescribed, different social supports or healthier activities or ways to avoid the rumination that can often precede depression. Everybody loses if we don't take mental health screening seriously.

So what else do we not know that we need to find out in order to better understand the issue?

We don't know yet. I mean, I think we know, but maybe we don't do it well enough yet, how to get things that work, certain medications for depression and bipolar disorder and other of mental illness, especially forms of therapy, cognitive behavioral therapy, (CBT), a newer form of therapy, DBT, dialectical behavior therapy. But it's very helpful for people with chronic suicidal thinking tendencies toward self-injury, how do we get more primary care physicians, psychologists, school counselors trained in these evidence-based strategies? Right now, there are some States in which there are one or two psychiatrists in the whole state. There's others, big cities, East Coast, West Coast, where there's many psychiatrists and they have a waiting list a mile long, same for clinical psychologists. Well, we don't both know how to do effectively, but we know more than we think we know when we don't do effectively, and it's called "dissemination," training of many people to deliver mental health interventions. We know that under half of people with mental illnesses in our country don't ever get diagnosed or treated. And among those who get treated, most people who get treated, get treated by people who aren't trained in the really effective evidence-based forms of therapy that we know from research studies work. So we're fighting a losing battle right now because stigma makes it hard to get access to care on the consumer end. And we're fighting a double losing battle because we don't have sufficient training or dissemination in delivering evidence-based care from the professionals who should be learning it. So, we've got to change our training models, we've got to get more people invested in and involved in this field, and we've got to take, coming up soon, as Dr. Fauci tells us, there'll be some viable vaccines pretty soon now, but it's going to be month after month after month before they're accessible by more than a relatively few members of the population. Dissemination and outreach is the next step to get treatment to people at risk for depression, suicide, etc.

With that, we are going to take a quick advertising break. When we come back, Dr. Hinshaw will be answering the questions that you post via social media. Don't go away.

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We are back now with Dr. Stephen Hinshaw of UCs Berkeley in San Francisco. A little bit of a "Shadow Gallery Seminars" tradition, even though now we've been doing this for two months, is that when I post a social media post and saying, "we're going to do panelist's questions," you guys put some wonderful, wonderful, wonderful questions up online. We've already gone through some of that just based off the last, like, at least 30 minutes before the commercial break. So, if you want to go through that, you want to rewind, there's no shame in doing that. You can. It's completely fine. We’ll wait. Done? Wonderful. OK, so let's go through these panelist's questions, if you are ready, Doctor. So first one, how is defunding the police related to suicide prevention and mental health care?

This is where science and activism and politics are, I think, clashing right now. Clearly, police in societies are designed to protect members of society. Clearly, there are inherent biases in many police forces, in many police officers, and dovetailed with the structural differences in society and health disparities and economic inequities. So, would completely abolishing the police help the social order, health, individuals, or harm? Political question far beyond my pay grade to know. Would defunding to the extent that current police officers are much better trained in how to recognize signs and symptoms of mental health issues? A. And then B, would some of the funding that current goes into law enforcement do better to tackle some of the roots of mental health issues? Because we know that many mental health conditions may lead to criminal activities and certainly in terms of substance abuse, in terms of depression. bipolar disorder, certainly, and bipolar disorder is more florid, manic episodes, people may not be law-abiding. Do we keep funding police and enforcement at the same levels? Do we take some of the defunding efforts again to help train police officers to recognize not just law-breaking behavior, but signs and symptoms of mental illness? Or do we use some of the funding to attack more of the root causes; child maltreatment and abuse, impoverished living situations, social inequities that lead to under and unemployment, which then can lead to criminal behavior? This is a hugely political issue, but I think we really as a society have to take seriously if we're not going to fund police forces at the same levels we do, where do we put our money into preventive efforts for some of the mental health issues that may lead to criminal behavior?

All righty, next question, how do we move away from an understanding of safety as an "agreement to not hurt myself" and being forced into signing safety contracts?

So, a very important question. A lot of elements to the question here. So I'm going to go back in history a little bit further than this question directly implies in terms of safety contracts right now. For long periods of the history in our country and many other countries, if you were deemed insane, not of sound mind, a lunatic, these are all formal terms that were used to define mental illness, you could be forcibly placed into a mental facility, a hospital, a lunatic asylum against your will, with no term in prison, you have a term. In a mental hospital, you get out when the doctors say you're better. During the 60's and 70's, the Civil Rights Movement, the Civil Rights Act of '64, the Voting Rights Act of '65, women's movement, gay pride, etc., etc., civil rights began to be extended to people also with mental disorders, or for the parents of children with signs of mental disorder, so that it became from very easy legally to place someone against their will in a hospital for the last 150 years to almost impossible. Most of all states have these civil commitment laws now making it very difficult. Most states have two or three criteria, which are usually: are you a danger to others? Are you threatening to kill someone? Are you a danger to yourself or are you imminently suicidal? And in California, the third is "grave disability": Are you not able to fundamentally take care of yourself? Danger to self, danger to others, grave disability, are the three and the only three criteria that can get you placed in a mental hospital against your will. Of course, we've closed down most of the mental hospitals, they're at 93 percent reductions compared to 60, 70 years ago. But we haven't funded adequate community care, which is why homelessness and all sorts of ramifications of closing the mental hospitals, which, again, to protect human rights, but we haven't been doing a good job of community care. So what we have is a very difficult situation in which people with psychotic forms of mental illness, schizophrenia, bipolar depression, bipolar manic episodes, who may not realize that they're mentally ill at the time and don't see any need for them to be treated, can't be forced into getting treated because it would violate their civil rights under these new laws. So what do we do? And then, short of hospitalizing someone, if you're getting to the point of hopeless depressive despair, and the therapist or counselor is working with you on a safety plan, but do you have a right to what's called a rational suicide? Can, do you have a right to end your life, or is it always the sign of a psychiatric illness? And certain European countries now have suicide panels for people who have been chronically mentally ill for many, many years and who don't see any way after medications and therapies of getting better. And if you appeal to one of those panels, then in rare cases, if they deem along with you that you don't see any purpose in your life going forward, you can have an assisted suicide. Now, this is very controversial. Many people in the mental health field think that this is caving in, and if only we take the stance that with better treatment, you could get out of that hopeless space, that's what we should be working for. So, safety plans are the kinds of things that a counselor or therapist might do to monitor you closely during a very at risk period: Here's whom you call, here's our suicide hotline, here's behavioral steps you're going to take if you feel yourself sort of slipping into that despairing place. And at what point does the therapist then say, "The safety plan isn't working. For your own sake, I want to legally commit you to treatment again," even if you get someone involuntarily committed into treatment to a facility these days, in California, it's for a grand total of 72 hours. And you're released after three days unless an administrative law judge gives you another 14 days or very rarely another 30 days after that. So we're in a legal and ethical and mental health dilemma right now of how we uphold the civil rights of people with mental disorders while still protecting such people who may not be aware of how serious their condition is at a given moment.

Next question. What's the earliest you should start speaking to children about suicide and mental health?

Fantastic question and a difficult question to give a blanket answer to. Let me start off by saying what we can't have is the default position that I grew up with. My father had very severe bipolar disorder, misdiagnosed for 40 years as schizophrenia. When I was a boy growing up in the Midwest, my little sister and I would wake up one day and dad would be gone for three months, or six months, or, at one point, a year at a time, we didn't know where he was and we didn't know if he was alive or dead, and Mom was not allowed to say where he was, which was in mental hospitals, because the lead psychiatrist from my father told him and my mother that if "Stevie and Sally, the kids in the family, ever learned of their dad's mental illness and hospitalizations, it was sufficiently toxic that they would be permanently destroyed psychologically." So my mother and father were forbidden from ever mentioning the topic. When I was 18, came back from my first semester of college, second semester, my first spring break, dad pulled me in his home study. He was a professor of philosophy at Ohio State and started to tell me about his life, of severely psychotic episodes starting when he was 16, back in California, when he thought if he jumped off the roof of the family home, his arms had become wings and he could stop Hitler and the fascists back in the 30's. So this awakened me to the idea that my family had been hiding the biggest issue in their whole lives, my dad's severe mental illness, my first 18 years of my life. If we have that as the default, what do kids do when they know something's really wrong in a family? The parents are about to split up, there's violence, someone disappears, but nobody talks about it? Well, I guess you have two choices as a kid: you could think the world's a random, cruel, awful place, not a very helpful or healthy attribution, or you could think it's your fault, at least, well, of course, it's not your fault as a kid. But the belief of some control helps you from falling into the place where I guess everything is randomly bad. So I thought it must have been, because, I was a bad kid, that dad would disappear and then magically reappear. But if I raised where he was when he was back, maybe I jinx it and he would leave again. We have to talk about these issues. Kids know when something's wrong. Now, does that mean a four year old witnesses a parent's irrational, substance-abusing behavior or psychosis? No. Does it mean a three or four or five year old tries to counsel a parent out of suicide? No, that's too young. But, starting when a kid is pretty young, grade school, certainly on the pre-teen years and beyond, there are forms of family therapy that have been devised was one called "Family Talk," originated by Professor Bill Beardslee, Harvard Medical School, expressly devised for families in which one or both parents have depression or bipolar disorder. And the goal of the therapist is to get the parents to engage the kids and discussion not about the DSM symptom checklist of depression or bipolar, but about the loss of a job or dad's drinking or mom's absences, so the kids know the parents are getting treatment and are trying to help themselves without blaming themselves. If the attitude is what I grew up with, that mental illness is so shameful, you can never discuss it, again, everybody loses and the kids themselves lose a lot. If we can find sensitive ways to bring kids in on the process of family therapy and getting treatment, then kids may not internalize and it might reduce their own chances of mental illness as they grow up.

Final question. Do you think that suicide prevention and mental illness should be talked more about in schools to young kids?

So, I'm going to give an analogy back to cancer we were talking about before the commercial break. What if an oncologist told a mom and a dad or a dad and a dad or mom and mom, if your children ever learn of your cancer, it's such a shameful disease, your children will be permanently destroyed. You can never mention while you go to the hospital of the dog, your cancer is off limits, well, we probably sue that oncologist for malpractice. Kids need to know you've got cancer and kids can learn what cancer is at different ages, once they get older and older and understand more about it, and to know that the family is getting treated. But when I was growing up, it wasn't all that long ago, even though I'm an old guy, mental illness was deemed so toxic, you can never talk about it. Grade school, middle school, high school, talking about illness, there's health classes, talking about mental health concerns, we don't want to just teach kids the symptoms of depression or bipolar disorder or schizophrenia. Kids will learn and do well on the test at the end of the term. But when we do that with kids, kids actually get more stigmatizing because they learn the stereotypes and the bad symptoms. What we need to do is bring in people with lived experience. There's career day, you see a firefighter, you see a letter carrier, you see a doctor, you see people who have depression or eating disorders and talk about it as regular people who have been fighting an illness, the way people with cancer have been fighting an illness. That's the kind of education that'll take mental health issues off limits and bring them into the dialogue. As kids get older, they'll think it's fine to talk about it.

So, we are coming close to the end of the show. So, we've got a couple more things to do. So, first of all, we need to come up with an action plan. So for our audience, who wants to take action, who don't know where to start, what exactly can we do that would make that a sustainable plan that can either reduce or even potentially eliminate the issue of stigma, stigmatization of mental illness and greater awareness and prevention of suicide?

Complex social issues, climate change, police brutality, racism, stigma of mental illness, require solutions at multiple levels. If we're going to reduce stigma, we, and let's start let's go top-down, let's go policy on down, you do enforce the Americans with Disabilities Act that makes it illegal since, 30 years anniversary, just this past summer, it's illegal to discriminate in the United States against someone with a mental or physical disability in public or the workplace. Most people who bring suits under ADA, the Americans with Disabilities Act, are the relatively small group of people with physical disabilities because it's not shameful, it's, you're in a wheelchair or what have you, and, now, those accommodations are kind of expensive because you've got to build a ramp or widen the doorway. It's so shameful to admit a mental illness, that most people with mental illnesses don't bring suit under ADA. But, what would the accommodation cost? You work an extra hour so you can see your shrink at lunch. It's flex time. Doesn't cost the employer a dime. So policies go, we need to enforce the ADA, we need to enforce parity, same mental health coverage as physical health coverage. But if it's only top-down from policy, what about the media images that still promote the stereotypes that mental illnesses are the sources of aggression and incompetence? And we still don't change our own or other people's hearts by contact, bringing in people from all walks of life in schools and to dentists' offices to talk about what the experience of schizophrenia or PTSD or depression is like. By having people not afraid to disclose. Finally, so we've gone top-down policies, middle-out media, bottom-up, opening up. But the fourth pillar of reducing the stigma is dissemination of medication, treatments, and more than that, even psychological treatments, because the best way to reduce stigma is for people with mental health issues to recover and lead better lives, everybody wins. So, it's going to take multiple levels of action to really erode the stigma.

And I must admit, I mean, I've even talked about, I even brought the religion point during the commercial break. There's something that I found in my research, which I think is a step in the right direction, may not be the full giving way, but it's a good step. In '92, with John Paul II amending the Catechism to, in Roman Catholicism, so it's saying, if you commit suicide, you're mentally ill. That's completely fine. I mean, that's like 90 percent of all suicide cases basically pardoned by the Catholic Church. I mean, doesn't excuse all of them, but it's still a step in the right direction, don't you think?

It's a step in the right direction. Absolutely. Yeah.

Do you think there would be, have to be any, major religious reform, like, for example, with Pope Francis or any other major religious figure who would have to step up and say, "hey, this is a major issue, yeah, we may not condone it, but we still need to tackle it head-on"?

So, this is happening now with women in the priesthood and people of sexual minority orientation, gay and lesbian people in various churches. I think a public change in policy around mental health from religious leaders and religions, which again is a form of solace for many, many people in many parts of the world, would be a major step.

So, finally, let's talk about Book of the Month in November. Of course, I chose your book, "Another Kind of Madness." I don't need to ask you why you would choose this as well. I mean, you wrote the thing. It's such an amazing piece. What do you think the audience would get out of it? What do you want them to get out of it?

So this is a memoir. I write scientific articles on ADHD and treatment and risk factors for mental health issues. "Another Kind of Madness: A Journey Through the Stigma and Help of Mental Illness" is a memoir about my dad, my family in Columbus, many other relatives, my journey from not knowing why dad disappeared when I was a kid to now being a mental health advocate and anti-stigma advocate. It's pretty harrowing, dad stayed in some of the country's worst public mental hospitals, almost didn't make it a few times in his life yet. It's a story of resilience. How did he survive as long as he did? And, he's a grad student at Princeton. He studied with Albert Einstein and Bertrand Russell and became a really great philosopher. Loved teaching, sometimes had to be removed from the classroom, because he was misdiagnosed and maltreated from the age of 16 till his mid-50's when I finally got him diagnosed correctly with bipolar disorder. He finally got the right treatment in his life. And subtly, through the book, it's really a memoir, it's certainly not a textbook, I raised this issue of how stigma influenced my dad's life, my mom's, my sister's, many people in our community's, back in Ohio growing up, and all around the country and world now, and how our family's story shows that if we maintain stigmatizing attitudes, everybody loses. So, I wrote it as honestly and deeply as I could, thanks for your nice words about it at the beginning of the program, it is a memoir with a message and the message is if we don't take mental health issues seriously, we relinquish hope, we don't get people treatment that they need, so many people in the workforce have mental health issues, so many school kids have mental health issues, we could become a more tolerant and even productive society by being much more open about the whole issue.

Any final things that we didn't cover? Any final things you want to say?

I think we covered a lot of ground. I will take the next seven hours and the subsequent shows, no, I'm kidding, to emphasize the points even more. I'll say what I've said a couple of times during the program: it's not a sign of weakness to say "I'm depressed, I can't cope." I mean, sort of a badge of courage now to be more stressed than everybody else, even before COVID, and, now during it, and, you know, everybody's suffering. But in terms of losing hope, in terms of anxiety, that it's kind of paralyzing to you, it's not weakness to admit that it's strength, because then you get support, you boost your own morale, you get people, mental health professionals helping you, doctors helping you. You get the community around you knowing that you're strong enough to talk about it. Let's reframe. It's not weak to say I've got a mental health issue. It's a sign that you're getting help for yourself.

Dr. Stephen Hinshaw, UC Berkeley and UCSF, thank you so much for your time patience. It's really been a pleasure.

Armon, thanks a lot. And, thanks to everybody tuning in.

So, for the folks at home, quite a lot of information we went through during this broadcast, including the reform for health care, including what needs to be done in education, so much that needs to be covered, you can go through the entire episode, if you need to listen to it again.

So, just as a reminder, Dr. Hinshaw and I both picked the same book for our Book of the Month, which is, of course, his "Another Kind of Madness: A Journey Through the Stigma and Hope of Mental Illness." You already heard what Dr. Hinshaw wants you potentially to get out of this book. And, obviously, I got everything out of it that he mentioned. So how do you find it? It's very, very, very simple. You go to our website www.shadowgallsemis.com, you click on the "Book of the Month" tab and it's right there. You can just click, you can purchase them on Amazon in hardback, paperback, Kindle, and Audible.

And, while you do that, check out the rest of our beautiful website. Do not forget to subscribe to all of our social media @ShadowGallSemis. That's Shadow, G-A-L-L, S-E-M-I-S, all one word. After that, if you haven't yet, subscribe to the show via Apple Podcasts, Spotify and, Google Podcasts, and leave us a written review and maybe even five stars. Wouldn't that be amazing?

Next month, we discuss the state of nutrition in the age of COVID with Dr. Debbie Fetter of UC Davis. Folks, this is one episode, topic, and special guest you do not want to miss. But that is in December. Right now, I want to thank everyone involved in the making of the episode, including Dr. Hinshaw and, in particular, Kieren Brereton, for allowing us to use this fantastic remix of Dave Brubeck's "Take Five" as our opening.

Thank you for listening, and remember, in an age where awareness is paramount, Scientia Potentia.

We'll see you next time from the Gallery.

This has been an LLD Production.

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