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Mental and behavioral health week 2: Looking at stigma, the 'subjectiveness' of PHQ-9
On April 4, we're taking the topic of mental and behavioral health back on stage with our first salon of 2019: Future of Mental and Behavioral Health.
Register now so you can reserve a seat. There are 250 available. Join Aydin Senkut (Felicis), Sonia Arrison (Author, 100 Plus), Alex Morgan (Khosla Ventures), Dr. Archana Dubey (HP), Mark Goldstein (UCSF HealthHub), Eva Borden (Cigna) and more!
As our community knows, this is a space I'm very passionate about. And in keeping with our research leading up to the salon, here's my first weekly - a round-up and my thoughts on recent and/or relevant stories and studies around this particular topic.
Having covered this space quite a bit, I want to touch on the well-publicized observation that there is a "stigma" around "mental illness."
Stigma of mental health? Or stigma of flaws and inadequacy? June, 2018
Fighting the stigma of mental illness through music NYTimes, Jan. 2019
Glen Close wants to change the stigma of mental illness ABC, Feb. 2019
Mental illness stigma silences many spouses The Denver Post, Jan. 2019
Nine ways to fight mental health stigma NAMI, Feb. 2017
The stigma of mental illness is making us sicker, Psychology Today, 2014
The word stigma originated from the Greed word stigmata, which was a physical mark left on slaves or criminals. From the biblical origins, the word evolved to become inclusive of seriously sick people with outward deformations (leprosy) to those with the severest form of mental illness ("demon-possessed"). (See Mark 5:1-20).
The word has now evolved from an actual mark on one's body to a troubled mind, suffering from anxiety and stress. There's a stigma of anxiety and stress. Let's just say it loud and clear. Saying there's a stigma of mental illness just obfuscates the point because too many people have varying definitions of "mental illness".
But it is true that society has had a problem sharing their innermost insecurities and weaknesses. So I'm glad that people are raising their hands and saying, "I struggle." And society is responding with meditation apps, platforms to access therapists, cognitive behavioral therapies that help bring out focus and awareness, and so on. These are all tools to cope and self-regulate and assuage our fears and fragile emotions.
Ironically, though people with severe mental illness were stigmatized in the bible, those who were emotionally troubled were never stigmatized. In fact, the bible makes it pretty clear that people will suffer and that life is full of trials and tribulations. What the bible provides, whether you believe it or not, are remedies to cope and self-regulate in a world full of suffering -- mainly by preparing people to expect struggles, and then giving them something to hope in.
1 Peter 5:10. "The God of all grace... after you have suffered a little while, will himself restore and make you strong."
Romans 12:12 - "Rejoice in hope; be patient in tribulation, be constant in prayer."
Believing in something other than ourselves has a tremendous impact on how we hope and perceive life and reality. In a world in which God's presence has declined, it is no wonder every new behavioral therapeutic modality is trying to recreate some process to help us put things into perspective, shape our reality, and give us hope. It's no wonder we're being provided coping skills and tactics to deal with people who are struggling.
I'm a big fan of this trend. I want people who struggle to have help. We need others to show empathy and be able to steward them toward a new positive reality.
But I also know many of these modalities will fail because they're just tactics. Take this guideline on how to deal with people who have "abandonment issues." In this piece, they share "symptoms" of people who have this condition (if it's a condition) and they give you a couple things to do when interacting. 1) Leave the conversation when it turns unproductive. 2) Tell them if you're feeling trapped or manipulated.
Moreover, this article tells you. "People with abandonment issues don’t do these things on purpose. These responses are reflexes built up from being abandoned."
This is helpful? People "don't do these things on purpose"? These are "reflexes"?
Tactics and lies perpetuate the problem. Telling people they are not responsible for their actions is not teaching them accountability. That's why the modalities rooted in tactics and dimwitted lies will fail.
A simple truth is always better: Don't put your self-worth in others. Don't measure yourself in how people think of you.
In an interview with Dave Rubin, Peter Thiel said this when asked what advice he would give to people to be happy: "We're looking too much at people around us... you need a different reference point."
Now to some interesting articles on this topic for my weekly round-up.
How mental health conversations are reinforcing the stigma
In this piece, author Amy Morin says it well!
If you've never experienced a bout of depression or anxiety, it might be easy to assume that it only happens to "some" people. But here's the thing about mental illness: It doesn't discriminate. The phrase "mental illness" tends to be used in a derogatory manner. "He must be mentally ill." "She has a mental illness." But we don't talk about physical health that way. No one ever describes someone else by saying, "He's physically ill. Mental health is a continuum. And there's a good chance you aren't at the "completely mentally healthy" end of the spectrum."
Essentially, we all struggle with our mental state. We're not always at our optimal mental state, so when we move toward suboptimal, does that mean we're all mentally ill (at least on some days)? Yes. But is that bad? No. Just the term is used derogatorily as Morin points out, so we misunderstand it. Either we change the term. Or we realize we all fall into the mental illness continuum. Or as I said above, let's just realize the real problem is that we're assigning a stigma on just anxiety and stress.
How parents can help their child's mental health
Morin's piece dovetails nicely with one I recently wrote about the role of parents and teachers in attending to a child's emotional well-being or emotional intelligence, which is defined by Psychology Today as: the ability to identify and manage one’s own emotions, as well as the emotions of others.
Our mental health relies on our ability to know our own emotions and that of others, and importantly know how to regulate them. In this post I conclude that parents need to teach their kids to put life's bad days and suffering into perspective. This awareness will dictate whether a child collapses in fear and surrender in the face of struggle or embraces the courage and strength to get through. This awareness dictates where a person falls on that mental health / mental illness continuum.
Here are the three ways parents can help their children better understand their emotions and therefore care for their mental health.
Teach your children: 1) Life is full of painful experiences that are often not in our control (can't blame yourself); 2) Your response to that pain, and how you cope and handle it, is in our control (can blame yourself). Blaming oneself or taking ownership of one's actions is called accountability, a virtue that is rarely taught these days. It's often swept under the rug. 3) Your self-worth is invaluable - regardless of what you do and or how smart, beautiful or athletic you are.
Students help themselves when help is slow in coming
This is a great piece on a group of students who started an advocacy group called "We Will", to create awareness and training around youth mental health. Through their efforts, 80 kids from their school were trained in what they call youth mental health first aid. And they plan to create more awareness by producing videos and interviews with mental health experts. In their first video clip, they seem to be already espousing one guideline: Do an act of kindness, rather than bombard a troubled child with statements, such as "There's nothing wrong with you. You're just attention seeking" or "Just try and get better" or "You'll never get where you want to be" or "Cheer up."
Kudos to the kids.
Screenings for depression are subjective
The most popular screening to see if there is a presence of depression comes in the form of nine questions in a form called PHQ-9. Unlike testing someone's blood pressure to get objective results, like the pressure in one's blood vessels when the heart pumps, it's entirely subjective. Throughout someone's life, I imagine almost everyone would be able to say yes to many of the questions. Notice how the questions just address the symptoms. But not the why those symptoms appeared in the first place.
Psychology Today puts it this way: "These are subjective forms of assessment which ask you about the type and number of symptoms you have, how long you’ve had them, and how much they interfere with your ability to live a “normal” life. In a way, it is not too different from a quiz score in a popular magazine telling you, for example, how emotionally healthy your relationship is."
Read more from our "Invent Health" series
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