Mental Health Awareness and Suicide Prevention with Dr. Stephen Hinshaw

Q: How is defunding the police related to suicide prevention and mental health care?

Hinshaw: 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?

Q: How do we move away from an understanding of safety as an “agreement to not hurt myself” and being forced into signing safety contracts?

Hinshaw: 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.

Q: What’s the earliest you should start speaking to children about suicide and mental health?

Hinshaw: 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.

Q: Do you think suicide prevention and mental illness should be talked more about in schools to the young kids?

Hinshaw: 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.

Q: 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?

Hinshaw: 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.

Q: What is the best and most sustainable course of action for improvement?

Hinshaw: 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.

Owlia: 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 second 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?

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

Owlia: 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"?

Hinshaw: 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.

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

Hinshaw: 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.

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