mental health

The Suicidal Thoughts Workbook is Now Available!

/ kgordonlab / Leave a comment

**You can listen to an audio version of this post here.**

I’m excited to share that my book, The Suicidal Thoughts Workbook: Cognitive-Behavioral Therapy Skills to Reduce Emotional Pain, Increase Hope, and Prevent Suicide, was officially published on July 1, 2021! I’m honored that my former graduate school mentor, Dr. Thomas Joiner, wrote the foreword.

One of my driving passions is sharing science-guided, helpful mental health information directly with the people who most need it. I took what I learned from years of research, therapy, and other life experiences and channeled all of that into the creation of The Suicidal Thoughts Workbook. My deepest hope is that readers will feel supported and empowered with strategies for coping with suicidal thoughts. I also hope that the workbook will help people to better understand how to support loved ones who struggle with suicidal thoughts. For therapists and crisis workers, I hope that the workbook will strengthen your confidence and expand your tools for helping people with suicidal thoughts. The book chapters were structured around a leading theory of suicide that was developed by Dr. David Klonsky (the Three-Step Theory). To give you an idea about the scope of the book, here is the table of contents:

I was also thrilled to collaborate with a brilliant artist, Alyse Ruriani, MAATC, to create two illustrations for the book (stickers and other items with these illustrations are available here).

I’m grateful for the positive reviews from people who read advanced copies:

“Kathryn Gordon’s workbook helped me self-reflect when I didn’t feel like I could handle my thoughts. When all feels lost, resources like this are exactly what we need: hopeful, analytical, educational, and practical. I will absolutely be recommending the book to others who might be feeling the same pain of suicidal ideation or hopelessness as well as those who are looking to better understand and help their loved ones.” 
—Marie Shanley aka Mxiety, mental health advocate and live talk show host, author of Well That Explains It

“Kathryn Gordon has translated our best theoretical and scientific understandings about why people are suicidal into an elegant, accessible, and easy-to-use workbook. Short chapters are full of practical and reproducible worksheets that walk the reader through hope and healing. She pairs her deep knowledge of the suicidal person with her expertise in cognitive behavioral therapy to create an invaluable resource for clients, their family and friends, and mental health professionals.”
—Jonathan B. Singer, PhD, LCSW, president of The American Association of Suicidology, and coauthor of Suicide in Schools

“Immediately helpful, this outstanding workbook offers wisdom and big-impact strategies to give you hope—that you can cope with setbacks, work through painful thoughts and feelings, find greater meaning in life, address obstacles to success, and live with purpose. Written with a supportive, encouraging tone, Kathryn Gordon guides you through the challenge of addressing suicidal thoughts, feelings, and behaviors with insight, self-compassion, and action. For anyone overwhelmed by pain and hopelessness, this essential resource will help you take the necessary steps to get your life back.”
—Joel Minden, PhD, licensed clinical psychologist and author of Show Your Anxiety Who’s Boss

“The Suicidal Thoughts Workbook has my highest recommendation. The content is informed by Kathryn Gordon’s extensive clinical expertise and deep knowledge of the research literature. The writing is beautiful, clear, and accessible. Gordon has a gift for communicating with her readers and making suicide risk understandable and surmountable.”
—E. David Klonsky, PhD, professor of psychology at the University of British Columbia, developer of the Three-Step Theory of Suicide

“For anyone who’s ever struggled with thoughts of suicide or who has a loved one who does, this workbook is a must-have. Kathryn Gordon is kind and practical in her approaches to managing suicidal thoughts, and in helping us find what we might have lost during the many years of struggle – hope.”
—Janina Scarlet, PhD, award-winning author of Superhero Therapy

“This book is outstanding—compassionate, packed with practical exercises, and based on research, theory, and clinical practice. It can help readers to suffer less, to stay safe, and to want to live. The Suicidal Thoughts Workbook stands alone just fine as a self-help book, and it also will be a good complement to psychotherapy.”
—Stacey Freedenthal, PhD, LCSW, psychotherapist, University of Denver associate professor of social work, and author of Helping the Suicidal Person: Tips and Techniques for Professionals

“I am tremendously grateful for the opportunity to endorse this helpful tool. Having survived suicide attempts, I can honestly say that I wish I had something like this that could have helped me better understand everything that I was dealing with on the inside. Kathryn Gordon, thank you for thinking about those of us who struggle everyday with this invisible illness—we are forever grateful.”
—Kevin Berthia, Suicide survivor/advocate/speaker, founder of The Kevin Berthia Foundation 

“Suicidal thoughts and feelings can sometimes end in death. And even if people don’t act on them, suicidal thoughts are incredibly painful in the moment. The good news is that for many people, using the skills in this book can help a person cope with suicidal thoughts and intensely painful emotions. Studies show that most people who use skills like the ones in this book can significantly reduce their suffering and help them build a life worth living. It is possible to recover, and this book is a good place to start.”
—April C. Foreman, PhD, L.P., executive board member of the American Association of Suicidology 

“The Suicidal Thoughts Workbook is a true gem in a world where suicide vulnerability exists in the shadows of shame and fear. Kathryn Gordon brilliantly weaves her professional expertise as a therapist and researcher to deliver a comprehensive workbook that breaks down each layer of suicide complexity, from why suicidal thoughts occur to specific strategies for developing personalized solutions. Most impressively, the workbook is genuinely empowering, offering hope to those who might otherwise feel hopeless.”

—Rheeda Walker, PhD, University of Houston professor of psychology and author of The Unapologetic Guide to Black Mental Health

You can order The Suicidal Thoughts Workbook wherever books are sold (e.g., Amazon, BookShop, and Book Depository for free international shipping), and the first chapter is previewed on Amazon. If you’re thinking about ordering my book or already have, thank you so much for the support! If you find my book useful, please consider leaving a review on Amazon or Goodreads and telling your friends about it. For books like this, word-of-mouth recommendations and social media posts about the book make a big impact!

With gratitude and wishes for good mental health,

Katie

Ask Me Anything about Eating Disorders

/ kgordonlab / 1 Comment

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For National Eating Disorders Awareness Week, I tweeted that people could ask me anything about eating disorders. Thank you to everyone who submitted questions – they were very interesting and thoughtful! I aimed to be as concise as possible, while providing links for more in-depth information. If I didn’t fully answer a question, made an error, or was unclear, please e-mail me at kathrynhgordon@gmail.com to let me know. Thanks for reading!

1) @KCapo45 asked:

Is bullying by everyone on social media making it harder for people to be honest in therapy about their true feelings about their body because they are being shouted down by groupthink for not loving their body and being afraid of gaining weight*?

*For extra context, listen to this interview I did with Ken about his recovery from anorexia nervosa. We talked about whether there were any possible negative effects of body positivity movements.

Because Ken specifically asked about people being honest about their feelings toward their bodies in therapy, and I couldn’t find any data on the topic, I’ll share my clinical observations as a therapist:

  • It’s striking to me that many of the patients I see — across a broad range of sizes, mental health issues, and ages — struggle with body image issues.
  • Many don’t hold back and will openly say that they feel bad about their bodies, even when changes are linked to having babies, medical conditions, or menopause.
  • A subset have tried to follow body positivity social media accounts and question beauty norms, so that they can love their bodies more. Still, many have body dissatisfaction and then feel like failures for not 100% loving their bodies. This is the group that will say things like, “And I know I shouldn’t care…” or “And I know I shouldn’t feel this way…” or “I know this sounds superficial, but…” and who end up in an even deeper state of shame and self-criticism.

For these patients, I recommend aiming for body neutrality over body positivity. That means that they accept their body as it is (not reject it or love it, but accept it) and accept their feelings about their body (good, bad, and all else). If they want to make changes in their body and/or their feelings about their body, we can collaboratively discuss those longer-term goals. However, in the short-term, what I’d like is for them to be okay enough with their bodies that they engage in their lives, rather than avoiding valued activities (e.g., socializing, exercising, sex, going out) due to feeling self-conscious or waiting until a time when their body is different. Here are some suggestions for ways to feel more okay about your body.

I think I’m already missing my goal of being concise, but in short, I’ll link to some other approaches I use to work toward this point of acceptance: cognitive-behavioral therapy for body image, I Am Me by Virginia Satir, self-compassion exercises, and opposite action.

Below are some interesting articles on this topic that provide history, context, and more nuance than the headlines suggest.

‘Body Positivity’ Has Had Its Day. Let’s Find Peace with Ourselves.

Body Positivity is a Scam (the author discussed the article on this podcast)

The Problem with Body Positivity

An Evidence-Based Rationale for Adopting Weight-Inclusive Health Policy

Self-Care Has to be Rooted in Self-Preservation, Not Just Mimosas and Spa Days by Lizzo

What Jillian Michaels Got Wrong about Lizzo and Body Positivity

2) @on_perspectives asked:

ED is extremely complex and certain treatments can backfire. Does the timing of treatment, in regard to what is going on in a patient’s life, play a role in recovery? When would immediate treatment of ED not be recommended because it would mean a lesser chance of success?

In the vast majority of cases, earlier treatment is associated with better treatment outcomes. The general rule is that a person with an eating disorder should get treatment as quickly as possible. If a person gets worse while in treatment, it’s extremely important to identify the factors that are responsible and adjust the treatment approach accordingly. With regard to what is going on in the patient’s life at the time of treatment, we appear to generally have more effective treatments for anorexia nervosa in youth than adulthood. I think this is due to younger patients being treated within the context of family-based care, though there are treatments aimed toward bringing in a support system for adults as well. Other factors that are likely to play a role in recovery: comorbid psychological problems (e.g., depression, PTSD, substance abuse), social support, access to empirically-supported interventions, readiness to change, other general life stressors (e.g., divorce, moving, bereavement, financial stability), functioning in other areas (e.g., academics, romantic relationships, at work), etc. On average, people who have good social connections and fewer additional stressors in their life tend to do better. This is why it’s important for therapists to look at the whole person and the environment they exist in when planning treatment.

I was trying to think about a time when you wouldn’t want someone to get immediate treatment for an eating disorder. It would be dependent on an individual’s particular circumstances, but some possibilities that came to mind would be if the person has some other more dangerous issue that needs to be immediately addressed and can’t be treated at the same time as the eating disorder (e.g., imminent threat of harm to others, imminent suicidal risk, drug dependence with a high level of associated, immediate dangerousness).

3) @mwebb22752561 asked: 

Re: goal setting in therapy, should target weights be set by the client, collaboratively or prescriptively on the basis of a healthy weight determined by BMI or similar measurement tool?

Whenever possible, all therapy goals should be set collaboratively with clients. This guideline is the same for people with eating disorders, except that sometimes eating disorders (especially anorexia nervosa) can interfere with the person’s ability to set a healthy target weight. The eating disorder can influence the person such that setting a healthy body weight does not feel like a goal they can agree to. When I have treated people with eating disorders, I find the most effective approach is to work with a team that includes a physician that can speak to medical factors relevant for setting the target weight (e.g., lab results, weight/growth history, menstrual status, etc.). I have seen therapists set a prescriptive target weight (in collaboration with a physician) only when the individual with the eating disorder cannot (due to interference from their eating disorder) and is in a state of medical risk.

4) @lluaces said (and @BianchiKristin said she was curious about this too):

Disorders that don’t have to do with body image like ARFID a lot of people get curious about

Anorexia nervosa and bulimia nervosa are eating disorders with DSM-5 diagnostic criteria that specifically mention an excessive concern with body shape and weight that leads to distress and unhealthy behaviors. Binge eating disorder has also been found to be linked to body image issues. In contrast, avoidant/restrictive food intake disorder (ARFID) is characterized by a disturbance in eating, but specifically excludes people whose behavior is driven by a fear of weight gain or disturbance in body image. ARFID often presents as an avoidance, pickiness (e.g., with textures, types) or low/lack of interest in food associated with at least 1 of the following: 1) significant weight loss or failure to achieve expected weight gain in children, 2) nutritional deficiency, 3) dependence on nutritional supplements, 4) interference with social functioning. For a fuller description, please visit this link. ARFID is typically treated with cognitive-behavioral therapy, and I have included links on the model and its treatment below. The purpose of the therapy is to identify and modify the factors that maintain ARFID (e.g., sensory sensitivity, fear of aversive consequences, lack of interest in eating or food).

Avoidant/Restrictive Food Intake Disorder: A Three-Dimensional Model of Neurobiology with Implications for Etiology and Treatment

Cognitive-Behavioral Therapy for Avoidant/Restrictive Food Intake Disorder: Children, Adolescents, and Adults by Jennifer Thomas and Kamryn Eddy

Should Non-Fat-Phobic Anorexia Nervosa Be Included in DSM-V?

5) @ThisIsSpecious asked:

Is it possible to have an eating disorder and not realise it?

Yes, these are the most common scenarios I have observed:

  • people with anorexia nervosa who are severely underweight or who have medical problems, but believe that they are overweight or in good health (this is a particularly painful part of the eating disorder that can make it hard to seek help)
  • people who have binge eating disorder, but think that their problem is “weak willpower” or “no self-control” because they don’t know about the disorder or know about it, but blame themselves anyway
  • people who are dieting, exercising, or fasting to an extent that it is causing significant problems for their health, distress, and/or functioning but who don’t attribute it to an eating disorder (e.g., they think they have an unrelated medical issue causing it)

In these types of scenarios, it often takes a friend, family member, or physician stepping in to suggest that they seek help.

Here are some useful tips for talking to a loved one about an eating disorder, and here is a post about how psychologists determine if someone has an eating disorder.

If you were to go and advise anyone who might have an ED how would you advise them to seek help? Particularly if there is a stigma around that person’s preconceived conditions? (i.e. being overweight etc)

I am most familiar with the U.S. health care system, but I recommend starting with telling your general practitioner/physician about your concerns and asking for a referral/recommendations for local eating disorders treatment. Alternatively, the Academy for Eating Disorders is an excellent organization that has an expert directory search to help you identify an eating disorder practitioner near you (the directory is international). Unfortunately,  people, including health professionals, may have weight stigma or bias that interferes with their ability to recognize an eating disorder in an person who is overweight. If a physician or other health professional is dismissive of eating disorder concerns, please seek care from someone who specializes in eating disorders. Professionals with expertise in eating disorders should be aware that people of all different body sizes are affected by eating disorders.

6) @ahlandreth asked:

Would love to know more about body dysmorphia and the way trauma (injury, illness etc) can play into that

Body dysmorphia is currently classified with obsessive-compulsive and related disorders rather than with eating disorders, but there are definitely overlapping features. Body dysmorphic disorder is diagnosed when someone is overfocused on an aspect of their physical appearance (thinking about it at least 1 hour per day), such that it is causing them distress and impacting their functioning (e.g., in their relationships, in their ability to work). While eating disorders are often related to disturbances in perceptions of body shape and weight, body dysmorphia tends to focus on particular body parts or features (e.g., perceived inadequate muscularity, skin, nose). People with body dysmorphia range from relatively high levels of insight about their misperceptions of their body to relatively low levels and engage in repetitive behaviors related to their concerns (e.g., reassurance seeking, mirror checking, skin picking, extensive grooming routines). For more detailed information, this is an excellent resource.

I did not find much research on the role of trauma, illness, and injury in body dysmorphia, and I have not treated many people who have it. However, people with body dysmorphic disorder do report higher rates of abuse and neglect compared to people without the disorder (e.g., 1, 2, 3). Research suggests that body dysmorphic disorder is caused by both genetic and environmental factors. If someone has a genetic risk for body dysmorphia and then experiences a significant stressor (e.g., illness, injury, abuse), it may increase their risk for developing body dysmorphic disorder through a number of pathways. Their self-esteem, emotional coping, anxiety, negative mood, attitudes toward their body, social support, and other life factors may worsen under conditions of the stressor(s), leaving them more prone to developing the disorder. Importantly, there are treatments available for body dysmorphic disorder, including cognitive-behavioral therapy.

7) @Ivuoma asked:

Can you talk about racial disparities in these disorders and/or disorders that manifest mainly in certain groups?

Udo and Grilo (2018) examined prevalence rates of eating disorders in a nationally representative sample of U.S. adults (n = 36,306) and found:

*Lifetime anorexia nervosa rates were significantly higher among White participants as compared to non-Hispanic Black and Hispanic participants.

*Lifetime and 12-month rates of bulimia nervosa did not significantly differ by race/ethnicity.

*Lifetime binge eating disorder rates were significantly higher among non-Hispanic White participants than among non-Hispanic Black participants, with no significant differences between non-Hispanic White and Hispanic participants.

Due to small ns, the authors combined Asian, Native Hawaiian, Pacific Islander, and Native American participants into one group. Here is the table of lifetime rates:

lifetime prevalence

Here is the table of past 12-month prevalence rates:

12-month prevalence

For more information, I recommend:

America is Utterly Failing People of Color with Eating Disorders

National Eating Disorders Association – People of Color and Eating Disorders 

I’ve done some research examining acculturative stress, perceived discrimination, and body shape ideals and how they’re potentially related to differing prevalence rates:

Cultural Body Shape Ideals and Eating Disorder Symptoms among White, Latina, and Black College Women

An Examination of the Relationships between Acculturative Stress, Perceived Discrimination, and Eating Disorder Symptoms among Ethnic Minority College Students

We need a lot more research in this area! I’m glad to see that it is has picked up quite a bit in recent years.

8) @jonathanstea said:

Brief overview of evidence-based treatments might be helpful. In my clinical experience, our teams find these disorders particularly difficult to treat, especially when concurrent with addictive disorders—and especially when addictive sxs in remission/eating sxs increase.

I completely agree that eating disorders are challenging to treat and that we need to keep improving on existing treatments. I also agree that one of the difficult aspects of the treatment is that many people with eating disorders suffer from multiple mental health issues. I have observed what you are describing too – that some patients were using substances to cope with emotional pain and other stressors. When that strategy is no longer being used (i.e., when they are in remission), you can see an increase in eating disorder symptoms. I find it beneficial to treat the complexities of eating disorders within a team context to best conceptualize and individualize each person’s care with multidisciplinary expertise (e.g., physicians, psychiatrists, dietitians).

The major evidence-based treatments that we currently have include:

  • Family-based treatment (AKA Maudsley) for children and adolescents with anorexia nervosa or bulimia nervosa. This treatment involves empowering caregivers (typically a parent) to warmly and firmly help their child to eat in a healthy, non-disordered way (e.g., meet their nutritional needs, prevent purging and excessive exercise). This is a great article written by a parent and child who received this treatment. More information on the scientific backing for it is available here and here.
  • Cognitive-Behavioral Therapy is used in a transdiagnostic protocol for different eating disorder presentations. It targets maintenance factors for the disorder (e.g., negative mood intolerance, all-or-nothing thinking, body dissatisfaction, perfectionism, fasting/restriction). More information on the empirical evidence is available here and here.
  • Interpersonal Psychotherapy for eating disorders helps the patient recover by identifying and targeting a particular interpersonal domain that is maintaining the disorder: 1) lack of intimacy and interpersonal deficits, 2) interpersonal role disputes, 3) role transitions, 4) complicated grief, or 5) life goals. There is a good review of available evidence here.
  • Integrative Cognitive-Affective Therapy is a relatively newer therapy that appears to be as effective as cognitive-behavioral therapy for bulimia nervosa. It has also been tested in binge eating disorder, but those results are not yet published. It focuses on helping the patient to regulate their eating patterns and then identify an area for skill-building (e.g., assertiveness, healthy ways of relating to one’s self, coping with emotions).
  • Dialectical Behavior Therapy has been used to treat both bulimia nervosa and binge eating disorder. It focuses on increasing skills in mindfulness, distress tolerance, emotion regulation, and interpersonal effectiveness. More research is needed on the effectiveness of the approach, but here is a useful article on its application.

9) @DrSamanthaMyhre asked:

A general discussion on the overlap of BDD and EDs and how to differentiate (I typically revert to clinical interview + BDD Y-BOCS and EDE-Q to help, but definitely interested in learning other strategies).

Using the Yale-Brown Obsessive-Compulsive Scale (Y-BOCS) and Eating Disorder Examination-Questionnaire (EDE-Q) is an excellent way to approach this differential diagnosis. The only other approach I’ve used is the Structured Clinical Interview for DSM-5 (SCID). I think that the distinction is tricky, but body dysmorphic disorder (BDD) often focuses on a particular feature (e.g., skin, nose, ears), while eating disorders tend to focus on body shape and weight. That being said, you can definitely see overlap in checking behaviors, self-esteem issues, and appearance anxiety — especially with muscle dysmorphia (MD). The International OCD Foundation website makes this distinction, “While individuals with MD often follow very precise, time-consuming, and painstakingly picky diets, their eating habits are driven by an all-consuming concern with improving the mass and leanness of their muscles, as opposed to issues relating to their weight or body fat percentage, as seen in individuals with eating disorders.”

I liked the way that the website discussed differential diagnosis:

distinction

I also like their short version as a rule of thumb:

distinction

I could not find a large study with very clear statistics on rates of comorbidity between BDD and eating disorders, but one study found that approximately 1/3 of people with a BDD diagnosis had a lifetime eating disorder diagnosis and another study  found that ~1/2 of people seeking treatment for an eating disorder screened positive for BDD. Therefore, it is certainly appropriate to diagnose both if you see symptoms that are not fully captured by one diagnosis. Our diagnostic system is far from perfect, and I think it makes sense to choose the diagnosis(es) that seems like the best description and guide for treatment for the patient. If you are gathering data from the measures that you mentioned, your clinical judgment and decision-making will be very well-informed.

For more information:

Clinical Assessment of BDD

Male Eating Disorders (discusses muscle dysmorphia)

Thank you so much to everyone who sent questions! I hope that I provided the information you were looking for – but please reach out if you’d like to know more.

For more information, check out my Short Guide to Everything You Need to Know About Eating Disorders.

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Suicide Prevention Information & Resources

/ kgordonlab / 7 Comments

If you want to learn and do more to prevent suicide, I want to help you out by linking to some resources. I hope you find them useful.

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If you need help:

National Suicide Prevention Lifeline

Trans Lifeline

The Trevor Project (for LGTBQ+ youth)

Veterans Crisis Line

Crisis Text Line

Find a Therapist

Find a Support Group for People Who Have Lost Someone to Suicide

Research-Supported Treatments for Adults

Research-Supported Treatments for Children

How to help others:

Warning Signs

How to Help Someone Who is Suicidal

Take a Mental Health First Aid Training Course

Get involved:

Call Your Representatives and Tell Them to Prioritize Policies linked to Suicide Prevention (e.g., access to quality healthcare, funding for research)

Participate in an Out of Darkness Community Walk

For information:

When It Is Darkest: Why People Die By Suicide And What We Can Do To Prevent It

Suicide in Schools: A Practioner’s Guide to Multi-level Prevention, Assessment, Intervention, and Postvention

The Suicidal Thoughts Workbook

Live Through This Photo Project

Rudy Caseres, Mental Health Advocate

Robert Vore, Mental Health Advocate

It Gets Better Project

Why People Die by Suicide by Thomas Joiner

Cracked Not Broken by Kevin Hines

Speaking of Suicide by Stacey Freedenthal

How Can Professors Help Students with Mental Health Concerns?

/ kgordonlab / 1 Comment

This post was co-written with clinical psychology graduate student and Jedi Counsel podcast co-host, Brandon Saxton.

Disclaimer: Policies, procedures, and resources vary by university, so it’s important to check with your own university and to defer to those over our recommendations.mental-2470926_960_720

In the early 1900s, faculty and staff at Princeton University noticed that several students were dropping out of school due to mental health problems. They sought to prevent this by creating the first campus mental health program in 1910. Since then, it has become standard practice to offer counseling along with physical health services on college campuses. For a fascinating overview of this history, we recommend reading this Kraft (2011) article. Here’s a sample excerpt:

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Professors often serve as an initial contact for students with mental health concerns. Some students are unaware of the available resources and reach out to professors to point them in the right direction, while others feel more comfortable checking in with a professor before seeking help from someone they don’t know.

We’ll start with some general guidelines for assisting students when they approach you for help:

  1. Listen to and assess the nature of the problem in a nonjudgmental fashion. Asking about mental health is typically beneficial for people experiencing problems and does not generally have a detrimental effect on people who aren’t experiencing them (e.g., 1, 2, 3, 4, 5, 6, 7).
  2. Respond with compassion and acknowledge their concerns. This can provide a sense of hope and validation.
  3. Refer them to appropriate services for their needs (more on this below). When in doubt, choose the services that seem most fitting. If it turns out that the student doesn’t need services or requires a different resource, the specialists at the initial referral source will know how to best proceed.

To expand on step #3, we have listed some of the most common scenarios below:

Worry about mental health symptoms: We usually start with recommending the on-campus counseling services for students. Depending on a variety of factors (e.g., the severity of the problem, their insurance coverage), they may also be interested in off-campus recommendations. We typically give them the link for the Association for Behavioral and Cognitive Therapies website to find therapists who use scientifically-informed practices. If you or the student are unsure about whether the student’s issues warrant intervention, you can assure them that the first step in mental health care is to undergo an evaluation to answer that question and then formulate a plan based on the findings. If they are reluctant to go to the counseling center, we will sometimes offer to walk over there with them or tell them that we understand and that those services will be available when they are ready. If appropriate, we also provide students with information for the National Suicide Prevention Lifeline.

Displaying unusual/worrisome behavior: If a student is exhibiting odd or potentially harmful behavior (e.g., their assignments have violent or suicidal content, they are showing up to class intoxicated, they seem disoriented), then you can typically contact a Behavioral Intervention Team on your campus for guidance. Behavioral Intervention Teams are composed of individuals who represent different components of the campus community (e.g., residence life, student affairs, faculty, law enforcement, counseling center, etc.) and provide consultation, advice, and follow-up with students who need it.

Class accommodations request: Sometimes, students will ask for accommodations without the required formal paperwork. In these cases, it’s important to refer the student to the campus counseling center or the disabilities office, so that they can go through a formal assessment process rather than leaving it up to your own discretion. If students tell us about a life circumstance that affected their ability to complete an assignment, and it’s a one- or two-time incident, we’ll typically allow them to make up the work. However, when the request is more long-term in nature or requiring special accommodations that may be unfair to other students, it’s important to defer to the experts in the disabilities office to make the decisions.

Harassment/discrimination: If a student tells you that they have experienced harassment or discrimination, you should take time to listen attentively, sympathize, and then refer them to the office that handles Title IX issues. We strongly recommend visiting your university website for that office, so that you are familiar with the most up-to-date mandated reporting guidelines and the processes for filing complaints. Here again, if you are unsure whether something rises to the level of harassment or discrimination, it’s important (and sometimes mandated) that you report it to the appropriate office so that they can use their specialized training to make a determination (rather than your own judgment).

In summary, we recommend expressing that you care while also recognizing your boundaries as a professor. You should not act as their therapist, but you can help by connecting them with one. Professors have the power to create an educational environment that reduces mental health stigma and increases students’ willingness to seek help when they need it. We try to communicate this to students by showing that we welcome their questions, providing them with mental health resource information in class, announcing mental health-related community events, and treating such topics with care. As a testament to the positive influence a professor can have through these strategies, look at this letter that Dr. Jeffrey Cohen received from one of his students (thanks to Rob Gordon for sharing it).

Please feel free to contact us if you have any questions, concerns, or corrections. We’ll conclude by linking to two informative articles and our podcast episode on the topic, which goes into more detail. Thank you for reading!

  1. Graduate Students Need More Mental Health Support, New Study Highlights by Elisabeth Pain
  2. The Myth of the Ever-More Fragile College Student by Jesse Singal
  3. Graduate Student Mental Health: Lessons from American Economics Departments by Paul Barreira, Matthew Basilico, and Valentin Bolotonyy

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Teaching About Mental Health through Music

/ kgordonlab / Leave a comment

Clinical psychology graduate student, Samantha Myhre, and I bonded a few years ago over our love of music. We both like to see live shows and get super-close to the stage. For example, here are some pictures Samantha has taken:

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Eddie Vedder on the left; Chris Cornell on the right

And a few I have taken:

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Aesop Rock on the left; Against Me! on the right

 

 

The connections we each have personally with music (discussed in more detail in this podcast episode) carried over to our Abnormal Psychology classes. We both found that adding class activities with music components engaged undergraduate students. Anecdotally, they enjoyed looking more deeply into lyrics than they had in the past. Some also said they experienced increased compassion and comprehension for mental disorder symptoms through the connection to music.

I posted our combined list of mental health-related songs below in case it’s helpful for people teaching these topics. If you have any that you think should be added, please let us know!

Anxiety:

  • 19th Nervous Breakdown (by The Rolling Stones)
  • If I Ever Feel Better (by Phoenix)
  • Breathe (by U2)
  • Flagpole Sitta (by Harvey Danger)
  • Intro to Anxiety (by Hoodie Allen)

Attention-Deficit/Hyperactivity Disorder:

  • Wrong (by Depeche Mode)
  • A.D.H.D. (by Kendrick Lamar)
  • Epiphany (by Staind)
  • Bouncing Around the Room (by Phish)

Autism Spectrum:

  • We’ll Get By (The Autism Song) (by Johnny Orr Band)
  • So It Goes (by various artists and parents)
  • Missing Pieces (by Mark Leland/Tim Calhoun)
  • I’m In Here (the anthem for autism – written from perspective of child with autism

Bipolar Disorder:

  • Manic (by Plumb)
  • Bi-Polar Bear (by Stone Temple Pilots)
  • Manic Depression (by Jimi Hendrix)
  • Lithium (by Nirvana)
  • Secrets (by Mary Lambert)
  • Down In It (by Nine Inch Nails)
  • Given to Fly (by Pearl Jam)
  • Everybody Cares, Everybody Understands (by Elliot Smith)
  • I Go To Extremes (by Billy Joel)
  • One Step Up (by Bruce Springsteen)

Depression:

  • Fell on Black Days (by Soundgarden)
  • Cleaning my Gun (by Chris Cornell)
  • Hurt (by Nine Inch Nails)
  • Lithium (by Nirvana)
  • Save Me (by Ryan Adams)
  • Today (by The Smashing Pumpkins)
  • Sway (by The Rolling Stones)
  • Turn Blue (by The Black Keys)
  • Twilight (by Vanessa Carlton)
  • Come Around (by Counting Crows)
  • Lost Cause (by Beck)
  • You Know You’re Right (by Nirvana)
  • Oh My Sweet Carolina (by Ryan Adams & Emmylou Harris)
  • Philadelphia (by Bruce Springsteen)
  • Someone Saved My Life Tonight (by Elton John)
  • Spaceman (by The Killers)
  • Go Tell Everybody (by The Horrible Crowes)
  • Danko/Manuel (by Drive-By Truckers/Jason Isbell)
  • Fade to Black (by Metallica)
  • Nutshell (by Alice in Chains)
  • Keep Steppin’ (by Atmosphere)
  • Adam’s Song (by Blink 182)
  • Whiskey Lullaby (by Brad Paisley & Allison Krauss)
  • Screaming Infidelities (by Dashboard Confessional)
  • Rhyme & Reason (by Dave Matthews Band)
  • Gotta Find Peace of Mind (by Lauryn Hill)
  • Creep (by Radiohead)
  • Everybody Hurts (by R.E.M.)
  • So Many Tears (by Tupac Shakur)
  • Dark Times (by The Weeknd)
  • Electro-Shock Blues (by Eels)
  • Quiet Times (by Dido)
  • Comfortably Numb (by Pink Floyd)
  • Hate Me (by Blue October)
  • Girl With Broken Wings (by Manchester Orchestra)
  • Jumper (by Third Eye Blind)
  • Miss Misery (by Elliott Smith)
  • Best I Ever Had (by Gary Allan)
  • A Picture of Me (Without You) (by George Jones)
  • Behind Blue Eyes (by The Who)
  • One of Four (hidden track, end of Maintenance by Aesop Rock)
  • Down in a Hole (by Alice in Chains)
  • Keep Steppin’ (by Atmosphere)
  • Picket Fence (by Brother Ali)
  • Rain Water (by Brother Ali)
  • Sullen Girl (by Fiona Apple)
  • That Hump (by Erykah Badu)
  • Rock Bottom (by Eminem)
  • Boulevard of Broken Dreams (by Green Day)
  • Moonshine (by the Gift of Gab)
  • Mad World (by Tears for Fears)
  • Black Clouds (by Papa Roach)
  • Trouble in Mind (by Nina Simone)
  • Much Finer (by Le Tigre)

Eating Disorders:

  • Ana’s Song (Open Fire; by Silverchair)
  • Demons (by Imagine Dragons)

Intellectual Disabilities:

  • This Isn’t Disneyland (by The Sisters of Intervention)
  • I Am (by Liz Longley)
  • We’re Just the Same (by Terry Vital)

Obsessive-Compulsive Disorder:

  • Monster (by Paul Walters) is a song by Paul Walters who was on A&Es Obsessed. This song was created after his decade long battle with OCD
  • Ana’s Song (by Silverchair) does a nice job of highlighting compulsions)
  • Obsessions (by Marina and the Diamonds)

Panic Disorder/Panic:

  • Be Calm (by fun.)
  • If the Brakeman Turns My Way (by Bright Eyes)
  • Circus Galop (by Marc-André Hamelin)

Positive Body Image:

  • Nobody’s Perfect (by Hannah Montana – nice Disney Channel throwback)
  • Stay Beautiful (by Taylor Swift)
  • All About That Bass (by Meghan Trainor)
  • Dumb Blonde (by Dolly Parton)
  • Just the Way You Are (by Bruno Mars)
  • What Makes You Beautiful (by One Direction)
  • Try (by Colbie Caillat)
  • Fat Bottomed Girls (by Queen)
  • Born This Way (by Lady Gaga)
  • Beautiful (by Christina Aguilera)
  • Flawless (by Beyonce)
  • You’re Beautiful (by James Blunt)
  • F**kin’ Perfect (by P!nk)
  • Beautiful (by John Mayer)
  • Hips Don’t Lie (by Shakira)
  • Fight Song (by Rachel Platten)
  • Love Me (by Katy Perry)
  • On My Own (by Miley Cyrus)
  • Unpretty (by TLC)
  • Feelin’ Myself (by Nicki Minaj ft. Beyonce)
  • My Kind of Woman (by Justin Moore)
  • I’d Want It to Be Yours (by Justin Moore)
  • The Perfect Woman (by Bo Burnham)

Here‘s a playlist my class made with positive body image songs.

Post-Traumatic Stress Disorder/Trauma:

  • Wrong Side of Heaven (by Five Finger Death Punch)
  • Hidden Wounds (by dEUS)
  • Drum + Fife (by Smashing Pumpkins)

Schizophrenia/Psychotic Symptoms:

  • Jump They Say (by the late and great David Bowie) was a song written about Bowie’s brother who had schizophrenia and died by suicide while experiencing auditory hallucinations
  • Basket Case (by Green Day)
  • Is There a Ghost (by Band of Horses) is about Band of Horses member Ben Bridwell’s experiences with paranoia
  • Annabelle (by Dessa)
  • Shine On You Crazy Diamond (by Pink Floyd)
  • Going Crazy (by Jean Grae)

Social Anxiety:

  • Social Anxiety (by Nicola Elias)
  • The Quiet One (by The Who)
  • Things the Grandchildren Should Know (by Eels)

Substance Use:

  • Everyone’s At It (by Lily Allen)
  • Never Did (by Perfume Genius)
  • Sober (by P!nk)
  • Not If You Were The Last Junkie On Earth (by The Dandy Warhols):
  • Needle and the Damage Done (by Neil Young)
  • Under the Bridge (by Red Hot Chili Peppers)
  • Rehab (by the late Amy Winehouse)
  • Detox Mansion (by Warren Zevon)
  • Cover Me Up (by Jason Isbell)
  • Super 8 (by Jason Isbell)
  • Choices (by George Jones)
  • Stockholm (by Jason Isbell)
  • Starting Over (by Macklemore & Ryan Lewis)
  • Amazing (by Aerosmith)
  • That Smell (by Lynyrd Skynyrd)
  • Gravity (by A Perfect Circle)
  • Numb (by Alanis Morissette)
  • Save You (by Pearl Jam)
  • You’re Gone (by Diamond Rio)
  • Sunloathe (by Wilco)
  • Unforgiven (by Hal Ketchum)
  • Uncle Johnny (by The Killers)
  • Drug Ballad (by Eminem)
  • The Man I Knew (by Dessa)
  • Habits (Stay High, by Tove Lo)

Suicide/Self-Harm

  • Asleep (by The Smiths)
  • The Ledge (by The Replacements)
  • Vincent (by Don McClean)
  • King’s Crossing (by Elliott Smith)
  • Suicidal Thoughts (by Notorious B.I.G.)
  • Last Resort (by Papa Roach)
  • Like Suicide (by Soundgarden)
  • The Great Escape (by P!nk)
  • Hold On (by Good Charlotte)
  • Don’t Try Suicide (by Queen)
  • 1-800-273-8255 (by Logic)
  • Out of Here (by Brother Ali)
  • Moment of Truth (by Gang Starr)
  • Jeremy (by Pearl Jam)
  • Coming Apart (by Friends of Emmet)
  • The Pretender (by Jackson Browne)
  • Keep Livin’ (by Jean Grae)
  • Keep on Livin’ (by Le Tigre)

Here‘s a playlist my class made with songs that give them hope when they’re feeling down.

While I have you here thinking about mental health and music, I recommend checking out Dessa:

 

13 Thoughts on 13 Reasons Why

/ kgordonlab / 2 Comments

**WARNING: SPOILERS APPEAR IN THIS POST.**

I watched the new Netflix series 13 Reasons Why (based on a book with the same title). This post sums up my reactions, and I am also in the process of recording detailed Jedi Counsel podcast episodes on the series with my co-host. Some people say this is art and entertainment, and therefore, exempt from social responsibility. Nonetheless, many people will watch this series, and that makes it important to view it critically and to consider its implications. My thoughts aren’t fully formed yet, but I wanted to post something as the series came out without waiting until I had it all sorted out. My feelings and opinions may develop more as I process the material for a longer period of time. I’m open and curious about other perspectives.

rainbow

  1. The series is set up as a mystery that quickly pulled me into the story. I finished the whole series within a few days. The framework for the series is that an adolescent, Hannah Baker, has died by suicide and left behind audio tapes detailing every component that she believes led up to her death. In addition, she has a methodical plan for the specific people who should listen to the tapes, how they should be listened to, and the order in which people hear them. While this is a compelling way to reveal a mystery, I believe that it contributes to stigma by painting the picture of a woman who ended her life for the purposes of getting attention from the individuals she believed ruined her life. The tone of her delivery is blaming and feels vengeful. I worry this perpetuates the myth that suicide is typically driven by desire for attention, selfishness, or revenge…which it most certainly is not.
  2. There is a scene that is explicitly blaming of one of the few kind (though not perfect) people in the series (Hannah’s friend and love interest, Clay). Hannah’s friend, Tony, tells Clay that Hannah would have been alive if he had acted differently. He later softens his tone, saying it is not Clay’s fault and Hannah is responsible for the choice that she made. Still, the blame message is there in a scene where Hannah tells Clay repeatedly to leave her alone. He reluctantly leaves the room. The show then depicts a parallel universe where the “right” things happened: Clay insists on staying despite Hannah clearly asking him to leave her alone, he turns the conversation around through persistence, Hannah feels loved, and suicide is prevented. In light of the violations of consent elsewhere in the series (including two rape scenes), I was bothered by Clay being painted as having done the wrong thing when he honored Hannah’s wishes to leave her alone.
  3.  Hannah decides, as her last attempt at help-seeking, to reach out to her school counselor about her suicidal thoughts and being the victim of rape. The counselor, insensitively and against best practice guidelines, implies she may be partially to blame (e.g., asking if she verbally said no to the perpetrator, asking if she had been drinking) and jumps right into telling her that her only choices are to: 1) report the assault or 2) to move on. She leaves the office, and he doesn’t follow-up with her in any way. He doesn’t ask for more details or conduct a suicide risk assessment, and he does not try to reach out to her parents to prevent her from harming herself. Of course, there are some counselors out there who might act in this irresponsible way. However, the vast majority would not. In a show that is viewed by a lot of young people, the depiction of the counselor matters a lot. People are already reluctant to reach out to mental health professionals. I worry people would feel even more discouraged from seeking help after seeing this terrible, judgmental, unethical interaction.
  4. The series accurately portrays some of the risk factors for suicide: social isolation, loneliness, and disconnection from others (including in the painful forms of bullying), perceiving herself as a burden (e.g., she describes herself as a “problem” for her parents and especially feels burdensome after accidentally losing some of their money), family conflict (her parents argue about issues including finances), witnessing and then being a victim of sexual assault, and hopelessness about her future (e.g., with regard to college and other plans).
  5. I appreciated the series emphasizing how crucial social connections are for health and talking about different types of loneliness – including individuals truly isolated and those who feel “lonely in a crowd.” It seemed to make the point that even apparently popular people (like Zack) can feel lonely. I believe this sends the message that anyone is vulnerable to loneliness, and we shouldn’t assume people are doing well just because they appear that way on the outside.
  6. One of the themes of the series is that – at any point – one person listening, reaching out, or doing something differently could have prevented Hannah’s suicide. Ultimately, this is a positive message. Unfortunately, I think it’s lost and distorted because it is used to blame people for their failures to save Hannah rather than demonstrating that one person could have made a difference and changed the story to a hopeful one. If the counselor or one of her parents had connected with Hannah and supported her in seeking help for her struggles, this point would have been much more persuasive. Instead, the story feels more demoralizing than inspiring to me.
  7. Hannah’s death scene is a graphic depiction of her cutting her wrists with razorblades in a bathtub. In a documentary-type episode made about the series, they said that it was to show the painful and hard-to-look-at nature of suicide. To me, it feels like a choice to make a dramatic, visually startling conclusion to the story rather than to deliver a lesson. It makes sense – this is a series meant to be watched and to get people glued to their screens- not a PSA. It’s possible that an individual who feels suicidal might see that and be afraid; however, it’s also quite plausible that an individual feeling suicidal might mistakenly view it as an end to all of Hannah’s emotional pain and problems. Anecdotally, there are cases of suicidal individuals watching scenes of suicide building up to taking their own life.
  8. There are warnings in the beginnings of episodes where there are graphic scenes (e.g., sexual assault, suicidal behavior). It would have been helpful if the episodes had information about resources, such as the National Suicide Prevention Lifeline and the American Foundation for Suicide Prevention, embedded in them too. It would be a simple way to reach a lot of people. Again, the series created a separate short documentary-like episode with mental health professionals and resources in it. However, it appears completely separately from the series (rather than as the 14th episode, for example). It would reach more people if it was connected to the full series.
  9. The pain Hannah’s parents experience after her death is excruciating. I feel this is one of the most realistic aspects of the series. It shows their horror, their confusion, their regret, and their desire to prevent other suicides from occurring. In the documentary afterwards, they suggest that this might show individuals who feel suicidal about the pain that others would experience if they died. I think this may be the case for some, but for certain individuals, tragically, they might imagine that people wouldn’t feel the same way about their death. That’s the cruelty of perceiving oneself as a burden – people struggling with mental health problems may not see how the world is better with them in it.
  10. Related to the second point, several characters clearly violate Hannah. Marcus and Bruce grab her, Tyler and Justin take and share revealing pictures without permission, and Bryce rapes her. When Hannah and Clay are starting to kiss, Clay asks, “Is this okay?” I really liked this scene because it shows how asking about consent is natural and enhances, rather than ruins, the moment. It also shows a welcome contrast in that Clay genuinely respects and cares about her feelings and perspective. Sadly, this positive point gets diminished when the scene turns into Hannah yelling for him to “get the hell out” and the suggestion that if he had only ignored her wishes, he would have saved her life (as described above).
  11. From one perspective, it seems like a point of the series is to teach bullies that their actions can lead to someone dying by suicide. However, most people who are bullied do not die by suicide – people are often remarkably resilent in the face of great adversity. It’s important that people who are on the receiving end of bullying know that. Secondly, most of the people on Hannah’s tapes are more concerned about protecting their own secrets (e.g., that Courtney is attracted to women, that Justin allowed Bryce to rape Jessica, that Ryan published Hannah’s poem without her permission) than how they hurt Hannah. If the message is supposed to be an anti-bullying one, I don’t think it really connects with bullying people in the audience. I guess that it would resonate more with people on the receiving end of bullying who feel a sense of hopelessness about the bullies having any potential for empathy and a sense that there is no help available to them.
  12. On two occasions, two adults (the counselor and the communications teacher) state that the warning signs for suicide include withdrawing from friends and family, changes in appearance, and trouble in group projects. This was a great opportunity to share the real warning signs for suicide, but unfortunately, only the first one really maps onto the list.
  13. A lighthearted, sweet aspect of the series is that Clay is different from his peers in that he cares relatively less about what other people think of him. He still cares what people, including Hannah, think of him to some extent, but he doesn’t try as hard as his peers to be something he’s not. He feels nervous around Hannah, but doesn’t ever really pretend to be someone else. He doesn’t let other people’s opinions make him feel bad about himself. Again, Clay’s not perfect (he says some mean things to Hannah and looks at a revealing picture that Tyler took without consent). But, overall, he’s smart, sensitive, caring, a good student, interested in the world beyond the walls of his school, helps others, takes reasonable caution in his decision-making, and likes geek stuff like Lord of the Rings and Star Wars. During one exchange, Hannah says to Clay, “Wow. You’re an actual nerd. There’s courage in that.” Most of the other characters in the series view themselves and their worth in terms of what their peers think of them. This generally rings true with regard to this developmental period in adolescence. It’s refreshing to see someone who has some self-acceptance and a sense of what’s right in the midst of all of the tragedy.

You can check out our first podcast episode on this series here and our second episode here.

If you or someone you know needs help, please reach out. There is hope and help is available here.

10 Hamilton Quotes for Therapists

/ kgordonlab / 2 Comments

Hamilton

Like many people, I am enamored with the music from Hamilton. There are so many things to like – all the hip-hop (e.g., Cabinet Battle #1!), the psychologically complex and nuanced development of the characters, the diversity of the creators, cast, and crew, and the powerful storytelling of US history. Because I like to explore mental health in fictional characters, I was tempted to with Hamilton as well (i.e., why did Burr and Hamilton end up on such different trajectories?). However, they are based on real people and real lives, so I don’t want to speculate about them (at least not in a blog post). So, similar to what I did with Star Wars, I decided to make a list of 10 quotes from Hamilton, that in my opinion, may be useful for therapists working with Hamilton fans (who are numerous these days).

1)  On mindfulness and gratitude:

Look around, look around at how/Lucky we are to be alive right now!

2) On taking healthy risks and decreasing unhealthy avoidance:

Rise up! Time to take a shot!

3) On acceptance, patience, resilience, and meaning-making:

Love doesn’t discriminate
Between the sinners
And the saints
It takes and it takes and it takes
And we keep loving anyway
We laugh and we cry
And we break
And we make our mistakes
—
Death doesn’t discriminate
Between the sinners
And the saints
It takes and it takes and it takes
And we keep living anyway
We rise and we fall
And we break
And we make our mistakes
And if there’s a reason I’m still alive
When everyone who loves me has died
I’m willing to wait for it
I’m willing to wait for it

4) On self-empowerment/accepting that one cannot change other peoples’ behavior:

I am the one thing in life I can control

5-6) On understanding historical context for clients who may belong to marginalized groups:

You want a revolution? I want a revelation
So listen to my declaration:

“We hold these truths to be self-evident
That all men are created equal”

And when I meet Thomas Jefferson

I’m ‘a compel him to include women in the sequel!

—

A civics lesson from a slaver. Hey neighbor
Your debts are paid cuz you don’t pay for labor

7) On not equating self-worth with work achievements

I don’t pretend to know
The challenges you’re facing
The worlds you keep erasing and creating in your mind
…
So long as you come home at the end of the day
That would be enough

We don’t need a legacy

8) On self-compassion:

Look at where you are
Look at where you started
The fact that you’re alive is a miracle

9) On not letting perfectionism interfere with productivity:

Burr (on the U.S. Constitution): And if it fails?
Hamilton: Burr, that’s why we need it
Burr: The constitution’s a mess
Hamilton: So it needs amendments
Burr: It’s full of contradictions
Hamilton: So is independence/We have to start somewhere

10)  On prioritizing health and balance:

Take a break

Cracked, Not Broken: Surviving and Thriving After a Suicide Attempt by Kevin Hines

/ kgordonlab / 2 Comments

I have known some aspects of Kevin Hines’ incredible story of surviving a jump from the Golden Gate bridge since I saw the documentary The Bridge in 2006. He has since become a powerful mental health advocate and well-known speaker. When I heard that the North Dakota Chapter of the American Foundation for Suicide Prevention had invited him out to speak in Fargo this year, I was absolutely thrilled.

When I saw his talk last week, I was moved by Kevin’s honesty, depth of knowledge, compelling storytelling, compassion, humor, and message of hope. Eager to learn more about his story, I bought his book, Cracked, Not Broken. The book impacted me on many levels, both personally and professionally. Here are four of my favorite aspects of the book:

  1. Kevin’s story is honest about what it’s like for him to live with a chronic mental illness (bipolar disorder). I feel that people who misunderstand the nature of mental illness might believe that once something as dramatic and miraculous as being a rare survivor of a Golden Gate bridge jump occurs, a person has restored hope, and all is well. Kevin makes it clear that the struggle did not end there. At times, he continued to experience suicidal ideation and other symptoms to the point of needing hospitalization in the years following. His perseverance and ability to thrive through continued struggles is inspirational.
  2. His description of a mental disorder as something that a person has rather than something that a person is is very effective and will certainly help me in communicating this message to students and clients in the future. For example, Kevin talks about how he did not want to die by suicide, but his mental illness took over and led him to think and believe things that were untrue.
  3. Societal stigma contributes to the desire to deny that we ourselves or people we care about are afflicted by mental illness, which creates obstacles to wellness. When courageous people like Kevin share their experiences, it makes others more comfortable with speaking openly and asking for help. In his book, Kevin says that it is likely that he would have been functioning better sooner if he followed the mental health treatment plan given to him after first being diagnosed. There were many factors that most of us can relate to that contributed to his denial (as he refers to it), and I think this is helpful for generating compassion for loved ones and clients who struggle with acceptance too.
  4. Expanding on my first point, stories of change and success are often oversimplified. They are boiled down to one key magical element that forever changed a person and the course of their life. Kevin tells his story in a manner that accurately reflects the complexity of living with mental illness. He highlights the many factors that maximize his chances of thriving (e.g., medication, therapy, adequate sleep, healthy eating, regular exercise, not using alcohol or nonprescribed drugs, social support, his faith). Kevin talks about how much work it is for him to stay well and that despite his commitment to wellness, outside factors sometimes interfere (e.g., a medication stops working). He has plans for dealing with those situations too (e.g., reaching out to a trusted love one, going to the hospital). I wish it wasn’t so hard to stay well for people afflicted by mental illness, but I appreciate Kevin’s honesty about the numerous factors involved.

If you get a chance to see Kevin talk, I highly recommend it. You can also see some of his presentations by searching his name on youtube. His book is available on Amazon. I’ll close with a music video for a song that I learned about from his book. It’s based on his life, and he is featured in the video:

lifeline

We Should Talk About Mental Health Out Loud

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A graduate of our lab, Betsy Sand, recently sent me a thoughtful e-mail about an obituary that is being shared widely through social media. What struck Betsy (and then me) was that the obituary explains that a 22-year-old man, Clay Shephard, tragically died a week and a half ago due to a drug overdose. This is unusual, in that many times when an individual’s cause of death is related to a mental disorder, the cause of death is not listed at all or only acknowledged in a vague way (e.g., s/he died at home). Not only does this obituary include the cause of Shephard’s death, but it also details the struggles that his family experienced as they tried to help him. Like most obituaries, they describe his strengths, accomplishments, and what they’ll miss most about him. They conclude, “To all children, this note is a simple reminder that there are people who love you, with everything they have and no matter what you do – don’t be too afraid/ashamed/scared, too anything, to ask for help. To all parents, pay attention to your children and the world that revolves around them – even when the surface is calm, the water may be turbulent just beneath.” The full obituary is online here.

People are responding in a variety of ways to the openness of Shephard’s family. Personally, I am moved by their honesty. I admire their courage and efforts to decrease stigma about mental disorders even as they grieve and make themselves vulnerable to public criticism (and, fortunately, also open to public support).

The title of this blog post is derived from a statement that one of my sisters told me about earlier this year. Dana Perry, Oscar-winning filmmaker of the documentary “Crisis Hotline: Veterans Press 1” said, “We should talk about suicide out loud,” during her acceptance speech. She dedicated the film to her son, who died by suicide. The film and acceptance speech make a compelling case that raising awareness through open dialogue is crucial to suicide prevention. If you’d like to see the speech yourself, she begins speaking at 1:37:

What gets in the way of talking about suicide and other mental health issues out loud?* Many people fear social disapproval and withdrawal of support from others. This is understandable. The prospect of criticism, backlash, and lack of support following the loss of a loved one must be incredibly painful. It doesn’t help that there are public incidents of this happening, such as the hateful messages that Zelda Williams received on Twitter after her father, Robin Williams, died by suicide.

Our lab (led by the thoughtful student that I mentioned at the beginning of this post) wanted to scientifically examine the impact of including mental disorder-related causes of death in an obituary. Participants in our study** were randomly assigned to read one of three fictional obituaries, which were identical except for the stated cause of death (i.e., cancer, drug overdose, or suicide). They were then asked to make some ratings about the deceased person. Here’s what we found: participants who read obituaries stating that suicide or drug overdose was the cause of death rated the deceased person as significantly more blameworthy, weak, cowardly, selfish, and sinful than participants who read the obituary that stated cancer was the cause of death. Keep in mind that the obituaries were identical except for the cause of death.***

The stigma is real. The fear of rebuke is supported by people’s experiences and backed by data (ours and others). I believe, as Perry said, that we need to talk about mental health out loud to reduce stigma. And I’ll slightly modify it to say that we need to talk about mental disorders out loud and accurately. One observation I’ve had with regards to perceptions of mental disorders is that when people are thinking about someone who is struggling, they often use themselves as a reference point. “I felt really bad in the past too, but I would never do that.”  The that can be drug use, binge eating, obsessions and compulsions, suicidal behavior, panic attacks, or a number of other things. Using ourselves as a foundation to understand others is not always the most helpful approach. In this case, while many people have experienced depression, most people have thankfully not been in a severely suicidal place or directly observed it in another person. As I’ve learned and interacted with more people with mental disorders through my work, I have no doubt that their mind and body are not functioning in a way that most mentally healthy (or even people with relatively less severe mental disorders) could even imagine. Mental disorders have an incredibly powerful influence on the mind and body (e.g., intense physical agitation in the case of acute suicide risk), especially when the disorder is very severe.

One objection I hear to this notion is that I, and others like me, are arguing that people don’t have any will, responsibility, or choice in their decisions. Yes, people with mental disorders still have choices about their actions and those choices are strongly emphasized in evidence-based treatments (e.g., motivational interviewing). However, the science is clear that not all choices are equally easy to make for all people in all situations. One of several possible examples includes the fact that drug craving continues to occur in one’s brain even after the cessation of drug use, and that genetics affect how likely an individual is to try and enjoy drug use, physically making drug abstinence more difficult for some individuals as compared to others. If we understand the crucial truth about how mental disorders strongly influence behavior rather than misattributing it to character flaws of the afflicted person, then treatment can be more precise and effective. Just as many of us consider how medical conditions (e.g., traumatic brain injury) and certain mental disorders (e.g., schizophrenia) have the potential to significantly interfere with decision-making, I hope that increased awareness can lead to understanding the powerful influence of other mental health conditions.

The humility needed to acknowledge that we don’t truly know what we would do if we were in another person’s situation doesn’t come easy. It involves uncertainty and vulnerability. Death, perhaps especially by suicide or a drug overdose, is scary to most of us. Our natural reaction is to want to distance ourselves and our loved ones from being at risk for those similar situations. My desire for this as strong as it is for others, “Well, that could never happen to our family, because…,” but humility opens us up to looking beyond blaming mental disorders on a person’s character. This actually empowers us to see true risk factors and do our best to reduce the chances of similar fates in our loved ones to the extent that we can control. It allows us to listen to our friends and family in a more nuanced way, to more fully understand their suffering, and to understand what will actually help them.

Another major objection that comes up when someone calls for reducing stigma is the notion that we are arguing to deny the dangerous consequences of medical and physical conditions by telling people it is “okay” to be that way. That would be a complete paradox of my intent to improve people’s health with my work. The goal in removing stigma is to prevent additional suffering by tearing down obstacles to treatment. Those obstacles may be removed by basing judgments and actions on science rather than stereotypes. Research suggests that education helps to reduce stigma, but that in-person contact is even more effective. We can educate ourselves about mental disorders before making judgments, and I, like others in my field, believe that mental health professionals are responsible for making it practical for people outside of the field to learn accurate information about mental disorders. With regards to in-person contact, we all already interact with people who have or have had mental disorders, but often do not know it. If people speak out loud about mental disorders, then stigma would likely be reduced by virtue of the fact that we each know people with mental disorders who defy negative stereotypes.

As Thomas Joiner has pointed out, it is possible to retain the useful fear of suicide (e.g., death often involves physical pain, loved ones experience great emotional pain when they lose someone to suicide) while simultaneously diminishing the stigma that leads to being disgusted, repelled, or otherwise afraid of the person who has the suicidal thoughts. I believe this principle applies to other mental health conditions as well (leave the fear of the dangerous behavior intact but reduce the blame on the person for having a mental disorder). I have hope that we’re moving in a positive direction with decreasing stigma surrounding mental health. I hear my undergraduate students talking more openly about mental health than I remember from when I was in college, and there is some research that reflects this change too. I believe that more honest obituaries, such as the one that Clay Shephard’s family wrote, contribute to this effort by spreading truth about mental disorders.

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*I am talking about this in the context of seeking help and acknowledging the cause of death when it is related to a mental disorder. Some treatments for suicidal behavior (e.g., dialectical behavior therapy) recommend against talking about details of suicidal behavior in group treatment, and there are media reporting guidelines with the same intention of preventing triggers for individuals who are already suicidal. They emphasize not romanticizing suicide or discussing details about the method of the person’s death. They are available to read in full here. (Update: Recent research on media reporting guidelines challenges the notion that discussing specifics about suicidal behavior leads to increased risk. You can see the article here.)

**In an effort to make the post smoother to read, I have not included citations in APA format. However, my scientific claims are linked to articles that support them. Readers who are interested can click on them, or contact me for more information.

***Examples of some resources that dispel these myths about substance dependence, suicide, and psychology in general are available.