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Mental Health Stigma: From NYC to the Workplace
202 Plays2 years ago
In this episode, Fara and Grant discuss recent mental health initiatives in NYC for hospitalizing unhoused people, school policies that may be harmful or stigmatizing to students, and the foundations of stigma and the implications for individuals and society.
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Transcript
Introduction to the Hosts and Podcast Origin
00:00:01
Speaker
Hello, I'm Dr. Farah White. And I'm Dr. Grant Brenner. We're psychiatrists and therapists in private practice in New York. We started this podcast in 2019 to draw attention to a phenomenon called the doorknob comment. Doorknob comments are important things we all say from time to time, just as we're leaving the office, sometimes literally hand on the doorknob.
00:00:23
Speaker
Doorknob comments happen not only during therapy, but also in everyday life. The point is that sometimes we aren't sure how to express the deeply meaningful things we're feeling, thinking, and experiencing. Maybe we're afraid to bring certain things out into the open or are on the fence about wanting to discuss them. Sometimes we know we've got something we're unsure about sharing and are keeping it to ourselves. And sometimes we surprise ourselves by what comes out.
Impact of Mental Health Stigma
00:00:52
Speaker
Today, Grant and I discussed the terrible toll that mental health stigma takes on not only those in direct need, but all of us as a society. Spurred by current events, we cover a lot of territory in looking at how we make sense of and respond to those in need. We hope you enjoy it as much as we did.
00:01:10
Speaker
So Grant, how are you today? I can't complain. How are you today? I'm
NYC's Mental Health Plan for the Homeless
00:01:16
Speaker
doing okay. I wanted to just take a few minutes to talk about, you know, a lot of the mental health stuff that's been going on in the news and sort of how, you know, we've all kind of come through the crisis.
00:01:30
Speaker
of the pandemic and it really feels like we're almost in a different world or it feels that way to me. But there have been some big changes around the city and like most recently the mayor's office put out some information about how they're going to treat the problem of
00:01:52
Speaker
the homeless and mentally ill on the streets. And there's been like a very swift and intense reaction from people. We're talking about New York City, right? New York City, yeah.
00:02:07
Speaker
they're basically going to try to bring people that appear to be mentally ill into hospitals for treatment. And it's nothing that has been, that's really new to me, except that I think for whatever reason this got a lot of press and it seems to have like touched a nerve in the city's like main communities.
00:02:36
Speaker
Yeah, we're talking about New York City where we're based and we're talking about Mayor Eric Adams, who is also a former police officer with a lot of subway experience. And if you've been to New York or if you live in New York, you know that among other areas, the subway has a lot of people who are unhoused and also who appear that they may be suffering from mental illness.
History and Ethics of Mental Health Care
00:03:04
Speaker
Or and or addictions and other problems and so this is something you know we live with everywhere really everywhere in the world my traveled in other countries. Where the level of mental illness poverty disease that is unaddressed is it's so massive.
00:03:25
Speaker
that absent charity groups or social justice or social responsibility oriented or governmental groups that are working on it, by and large, we learn to stop paying attention, even if it's really right in front of us.
00:03:44
Speaker
Or if we do, a lot of times, for me anyway, there's a feeling of, gee, I wish there was something I could do. I do not-for-profit work, but when you pass another human being, they're asking you for help, and there's no sort of obvious thing to do. You can give them some money. You could buy them some food. But it's evident that there's a problem that isn't being addressed.
00:04:09
Speaker
And I think though it hasn't been a big part of the dialogue coming from the mayor's office, it is part of the reaction that part of the root cause here is that there is not adequate mental health treatment.
Psychiatric Ethics: Autonomy and Human Rights
00:04:23
Speaker
And a couple of decades ago, there was something called deinstitutionalization.
00:04:28
Speaker
where a lot of people who essentially lived within mental health institutions, hospitals, were released onto the street without adequate services available. And in the decades since that time, we still don't have adequate mental health services. The frightening part, though, is that
00:04:51
Speaker
If there's kind of carte blanche to just take people and put them in the psych ER or hospitalize them, there's a risk that people who don't need those types of services will be mandated against their will. There's a concern about human rights violation. And then how do you know who needs mental health treatment just from looking at them?
Challenges in Psychiatric Resources and Economics
00:05:14
Speaker
Right. Well, I know you're sort of asking rhetorically, but I think there are some hallmarks of poor mental health that you can see in people who are undamaciled and even people who might have more financial resources. I think we should talk a little bit about the history of
00:05:40
Speaker
You know, when you said deinstitutionalization, you know, psychiatry has kind of a dark past where we used to sort of strip patients of their rights, keep them in the hospital much longer than they needed to be there, force them to take medications that maybe they didn't want to take.
00:06:00
Speaker
And so overall, I think patients having the right to refuse medicine or if they're generally harmless, they don't need to be in the hospital. I think that's a good thing.
00:06:14
Speaker
overall, but I think how it plays out is, and maybe people don't realize this, I know that you and I probably do, but there are a lot of people that want to be in the hospital to get treatment and really need to be in the hospital for their own safety, who have no place to be. So a lot of the beds, the psychiatric units were converted over to medical beds during COVID.
00:06:43
Speaker
And for a city of however many million, what is it, seven, eight million people, there are not a lot of beds for the psychiatrically ill.
00:06:54
Speaker
And it's a problem because it means that people come in and out of the hospital more and they get discharged before they're maybe fully ready to be discharged in many cases. But there are people that end up in the hospital that on the other hand, you know, advocate for their own release, right? And they call their mental hygiene lawyer and try to negotiate getting out because they don't want to be there.
Fairness in Psychiatric Evaluations
00:07:22
Speaker
Right, so just to give some background, there's different ethical principles at play. And it's true that sometimes people who aren't able to make their own decisions, as determined by properly trained psychiatrists, often a forensic psychiatrist, often in a mental health court,
00:07:40
Speaker
can be mandated to treatment both inpatient and outpatient if they meet criteria which are fairly stringent of not being able to take care of themselves or if there are risks to themselves or others and that's not taken lightly. It's also true that physicians can temporarily commit someone to the hospital for three days if it's a one physician or up to two weeks if it's two physicians based on mental health examination.
00:08:09
Speaker
But the ethical principles here, let's see if I can remember them are autonomy, like respecting the individual's rights and abilities to make decisions if they have the competence and capacity to do that. Beneficence, the idea that we're gonna try to help people can and should help people in need. And paternalism, which is taking over people's autonomy when they're not able to make decisions for themselves.
00:08:38
Speaker
I was reading up on this a little bit. And it's interesting if you think about Mayor Adams' background as a transit police officer, and if you've been in the New York subway, like we said, what is the story here? And you're saying there's not that many beds. So if everyone who looks mentally ill is taken to a hospital and evaluated for psychiatric treatment inpatient,
00:09:03
Speaker
There's definitely not going to be resources for that. And you're saying there are some folks who don't want to be in the hospital at all for psychiatry. There are other people who want to stay in the hospital because that's a preferable place for them to live, even if they don't need inpatient services.
00:09:22
Speaker
because of the shortage of beds, the length of stay has gone down and down and down. So generally hospitals, if they admit people,
College Mental Health Crisis Management
00:09:31
Speaker
they try to get them stabilized on medications and discharge them very quickly. In the old days, in the good old days, or in certain types of higher end expensive facilities that often aren't covered by insurance, you can actually get intensive evaluation and psychotherapeutic services
00:09:51
Speaker
But that is less the case in city hospitals. It tends to be more kind of like battlefield psychiatry, you know, in the sense in traditional military psychiatry, the goal would be to get people back into the action. And so the idea is to get people stabilized and discharge them. But then when you discharge them, it's very hard to find services.
00:10:14
Speaker
And within the first week, it's very common for people to get re hospitalized. And the risk of suicide goes up in the first week after discharge as well. And so it's you know, it's a serious problem without any kind of quick fix. And that's part of why the reaction to this kind of mandate has been so vigorous. Basically, anyone who knows mental health immediately said that's not going to work. What are you doing? Like, what's the story? Why are you doing this?
00:10:45
Speaker
It sounds good, but it's like everyone should have the medical care they need and I'm passing a law. But if the resources aren't there, you're not addressing the root cause. And I think you're saying part of the root cause may be stigma.
00:11:01
Speaker
Yeah, I think that the stigma around the mentally ill goes back many, many centuries. And when we had more like either spiritual or, I don't know, in like a religious society before people.
00:11:20
Speaker
thought, okay, there are biological causes for, let's say, illnesses like schizophrenia, right? People were thought to be either dangerous or possessed by demons. And I think it's a very, very scary thing that someone can appear physically healthy, but is just not there intellectually or emotionally.
00:11:45
Speaker
their ability to take care of themselves, to deal with reality, to have normal relationships.
Historical Roots of Mental Health Stigma
00:11:49
Speaker
Though I think there's a flip side to what you're saying historically, which is where before we had psychiatry and mental illness diagnosed as readily, people who had problems like that, whether it was psychiatric illness or developmental problems,
00:12:04
Speaker
would have a place in society quite often. And so the flip side of the kind of religious and spiritual explanations is the idea of kind of the wise fool or the kind of holy fool where there wasn't stigma because of course, you know, there's all different kinds of people in society.
00:12:27
Speaker
By having a diagnostic system, the benefit is that we can understand illness and treat people. The risk is that there's too much pathologizing and that stigma can come into play around diagnosis. And stigma can be internalized as well. There's social stigma, but there's also one's own stigma, which often leads people essentially out of shame and fear to hide it when they have a problem.
00:12:57
Speaker
Though a lot of times while mental illness is invisible, you can see that there's a problem. And that's where the ambiguity comes in. Not all unusual behavior is mental illness as I can personally attest. I think you brought up an important point, you know, that sometimes people are struggling in ways that are not visible.
00:13:24
Speaker
But there might be consequences for getting some treatment or some help, even for disclosing what people are going through. And it reminds me of some of the other stuff that's happened to the news recently, which is how college campuses and administrations respond to students who are struggling.
00:13:50
Speaker
I think you're talking about, you know, very prestigious Yale University was in the news recently. And what was reported is that when when students have depression or particularly suicidal, perhaps allegedly, that they are essentially forced to go on academically or actually not even academically, right? They're they're forced to dematriculate medical leave.
00:14:18
Speaker
If I remember correctly, I think it's not actually leave. They actually withdraw from being a student there. And then they can reapply if they can sort of demonstrate that they're stable and able to reapply. And by and large, I think they get readmitted. But I think there was a very, very tragic case in the news of sort of a wonderful, promising young person who ended up dying by suicide during that period of time.
00:14:48
Speaker
And I think you're talking about the consequences in schools, but also in the workplace. Is there discrimination against people with mental illness, which often like physical illness can interfere with productivity?
00:15:02
Speaker
for sure, for sure. But I also think, you know, for college students, it's very complicated. The help that
Critique of NYC's Mental Health Crisis Approach
00:15:11
Speaker
they want or need is not always there. Even at, you know, schools that have these massive endowments, usually
00:15:20
Speaker
the health centers and offices of accessible education and all of that still struggle to meet the demand. And for someone who's already depressed, who may be very far from home, who may end up having to go back to an environment that's not supportive, it can be really awful to be sort of forced away from whatever might be a stabilizing force.
00:15:48
Speaker
for them. And then the fact that they have to sort of reapply in this way and what they have to demonstrate. And I think it's always very, very difficult. What people don't understand about psychiatric evaluations is that, yeah, you can get a history.
00:16:09
Speaker
And you can sort of prognosticate. But what we see is that people are always changing, and their mood might be changing, and people might feel suicidal one moment and then feel very future-oriented the next. So it's almost unfair for people who have been struggling with depression, which is a massive subset of our population, to say, well, we need some sort of guarantee.
00:16:39
Speaker
Right, there's like 20 million people. Yeah, I'm not sure what the evaluation process is from what I've read, but in general, it can feel very shaming and further ostracizing and being ostracized, being expelled from your social group activates pain circuits in the brain.
00:17:02
Speaker
And if you think about it from an evolutionary point of view, if you get thrown out of the community, if you get thrown out of your tribe, you are on your own, which in a natural environment can be a threat to survival for sure. And so we're like so strongly wired to get worse when we're kicked out of our group. And there certainly are universities that respond to students in such need very differently.
00:17:29
Speaker
And I think one of the concerns here is, I don't know about this particular school is just our society, Western society, American society is so performance oriented. So if you have ADHD, then you're likely to get a lot of support to get treatment so you can do well academically. But what is it about students with depression and elevated risk for suicide that would lead our society to
00:17:58
Speaker
push them further away, you know, maybe into greater peril. What is it about the stigma? And is there something about the internalized stigma? You know, for example, maybe I have depression and I don't want to acknowledge it. And so when, you know, I'm imagining maybe I'm a school administrator and I see a student in a similar situation,
00:18:26
Speaker
Because I'm denying my own needs, maybe I can't imagine that the other person also has needs. And so that interferes with my capacity for empathy.
Resource Comparison: Mental Health vs. Refugee Support
00:18:37
Speaker
And in the absence of empathy, which is like your first tool for understanding where the other person is, you're more likely to make the wrong move.
00:18:46
Speaker
That makes me think about what's happening in new york like how can we. Sort of reasonably and usefully respond to this crisis cnn did a survey a month ago or so and ninety percent of americans said that they thought america was facing a mental health crisis.
00:19:06
Speaker
And I was reading up a little bit on the New York City situation, and there was an op-ed in the New York Times on December 7th by Anthony Almohara, a lieutenant paramedic with the Fire Department Emergency Medical Services, EMS. He's been through the ringer. He's seen everything. He described, quote unquote, a dystopian streetscape where his colleagues have been assaulted and even murdered by emotionally disturbed individuals.
00:19:32
Speaker
that are also homeless. You may or may not know, I know you know this, but listeners may or may not know the term that police and EMS use is EDP, an Emotionally Disturbed Person. And so, you know, we all worked in the psychiatric emergency room, some of us still do or work in the community to say we have an EDP, you know, doctors love acronyms, because it saves a couple of seconds, but those seconds add up to days and hours over the course of the year. And this is what he wrote.
00:20:01
Speaker
I'm not opposed to taking mentally ill people in distress to the hospital. Our ambulances do this all the time, but I know it's unlikely to solve their problems. Hospitals are overwhelmed, so they sometimes try to shuffle patients to other facilities. Governor Kathy Hochul has promised 50 extra beds for New York City's psychiatric patients, 5-0.
00:20:21
Speaker
We need far more to manage these patients who would qualify for involuntary hospitalization under Mr. Adams' vague criteria. Mr. Adams says that under the new directive, this patient won't be discharged until a plan is in place to connect the person with ongoing care. But the systems responsible for this care, sheltered housing, access to outpatient psychiatric care, social workers, a path to reintegration into society are horribly inadequate.
00:20:47
Speaker
There aren't enough shelters. There aren't enough social workers. There aren't enough outpatient facilities. So people who no longer know how to care for themselves need their hands held through a complex process are alone on the street. Once again, you know, it reminds me of working with refugees. I served in volunteer work in an Afghan refugee village last year.
00:21:09
Speaker
And the process through which someone can enter the country is incredibly complex. There's multiple organizations involved. The level of resources, the level of thoughtfulness, the level of collaboration is unfathomable unless you actually see it yourself. Yeah, but I think making unilateral decisions that may put people at risk or may redistribute resources in a way. And I just think about what it's like
00:21:39
Speaker
I remember when I was in residency and it dropped below a certain temperature. I don't remember exactly what it was, but it's like then the city issues an emergency. When you were training? Yeah. Yeah, there's a certain temperature where people start to die.
00:21:56
Speaker
where people start to die and if they're sleeping on the street, the police or the paramedics, you know, they are brought into the hospital for their own safety. And sometimes they would have to be on these bear huggers to kind of warm them back up. A bear hugger is like an inflatable thing. It kind of looks like bubble wrap and it gets hooked up to like a heating tube and it blows warm air, right? They use it in surgery usually because people have trouble maintaining their body temperature with anesthesia.
00:22:24
Speaker
and also when they're opened up. And sometimes if you're called as a trainee, you'll kind of swipe a bear hugger and it's quite nice actually. I never did that for the record.
00:22:37
Speaker
Yeah, well, I did surgery for two years and I don't think psychiatry had access to bear huggers, but I did general surgery for a couple of years and we would see people who came in off the street with terrible physical injuries, you know, no question. And sometimes they got treated because they were in a psychiatric hospital. Sometimes it wasn't very good, but quite often when they were in for psychiatry, you could get a lot of their basic needs treated, you know, from serious medical problems to maintenance like dental care. Yeah.
00:23:07
Speaker
Absolutely, I think people who have chronic illnesses like let's say diabetes and a lot of psychiatric patients have been on medicines lifelong that may have caused metabolic syndrome or a whole host of other issues, right? Just to be clear, some of the most effective medications for severe and persistent mental illness and even depression very commonly are antipsychotic medications which
Political Motives in Mental Health Policies
00:23:36
Speaker
are the most effective medication to add for severe depression, and they can cause essentially diabetes, weight gain, increased lipids and cholesterol, and a host of other problems which, if they're not properly managed, and sometimes even if they are properly managed, lead in the future to increase diabetes, heart disease, cerebrovascular disease, et cetera.
00:23:59
Speaker
Right, and I think there are other complicating issues. I think smoking cigarettes is a big one. Yeah, nicotine helps with cognition. I was having this conversation with someone who has a relative who has schizophrenia
00:24:16
Speaker
And there's evidence, if I remember correctly, that even the relatives of people with schizophrenia can have some impairments in working memory. And a lot of patients with schizophrenia will smoke because it may actually improve their cognitive function.
00:24:30
Speaker
Right. And so they have all the associated screening and management that goes along with that, I think is just exceptionally difficult. So yeah, sometimes being in the hospital means they can get there.
00:24:49
Speaker
the medical treatment they need, their blood sugar is well controlled, it is safer. And I think what a lot of people forget is that people with severe mental illness are far more likely to be harmed by others than they are to be aggressive. So they are really the most vulnerable population, in my opinion.
00:25:11
Speaker
Right, there's some concern that this is kind of politically motivated because of increasing violence and it is perpetuating the part of the stigma against people with mental illness that if we get them off the street, you'll be safer on the subway. I think if there's a bright side, even if it's premature and ill-fated,
00:25:32
Speaker
an announcement like this draws attention to the problem and motivates people to kind of go, all right, we actually do need to do something about this.
Insurance Barriers in Mental Health Treatment
00:25:42
Speaker
This isn't going to work, but what would work? Yeah.
00:25:45
Speaker
And then, of course, a lot of people in practice don't work with people with these more severe problems. Private therapists and psychiatrists don't typically work with people who live on the street. There's community psychiatry and outreach programs. And even some of the mental health companies that are coming up
00:26:09
Speaker
that treat people, actually take insurance, can scale up and treat a lot of people. They also don't typically work with patients with severe and persistent mental illness, though there are a couple of exceptions. In significant part, there are two big reasons. One is the care is much more complex. And as we were saying, needs the medical coordination. And number two is the insurance is typically Medicaid if there is insurance. And the reimbursement is so low
00:26:38
Speaker
that it's very difficult to build an effective and efficient healthcare system. And so I know we're wrapping up. I'll say, you know, if you're voting, then vote for representatives who really understand the issues because a big part of the fight and it's been going on for years is at the level of the legislature. Until state and federal Congress allocates funding for this, it can't even get off the ground.
Role of Public Figures in Reducing Stigma
00:27:04
Speaker
And I think thankfully the federal government
00:27:07
Speaker
now is actually trying to look at what are the drivers to start to understand the complexity and set up resources so that groups can actually do something. It's pretty early on.
00:27:24
Speaker
Yeah, I think you make a good point, which is that this has opened up a conversation and it's a really important conversation that we should be having and how we can sort of take care of ourselves and take care of each other in society and with regards to mental health.
00:27:46
Speaker
Yeah, it's important for leaders and people with visibility who are doing really well to be open. So we see much more musicians, leaders in the government, military, Hollywood coming out and saying, I'm depressed or I have bipolar disorder. Even the royal family in England has talked about it much more openly.
00:28:11
Speaker
And there's actually evidence, I love data, right? That when people talk openly and tell their stories, it helps. So my own story, I've been quite public about that involves early parental loss, meaning my mother died when I was quite young and it wasn't that good for me.
Personal Story: Dr. Brenner's Experience with Stigma
00:28:31
Speaker
And I've written about it quite a bit. And I do that in number one, because I think
00:28:36
Speaker
I find it helpful personally to share, but also this particular thing about one in 20 people lose a parent when they're children before the age of 18, and it's highly stigmatized. And I'll tell you from personal experience, and of course, everyone has their own experience, I can't fully empathize, but to be a kid whose parent passed away,
00:29:01
Speaker
makes it really tough to fit in school in a lot of ways not not the least of which aside from any personal impact is how other people see you and so this gets to this idea of the stigma is how other people see you and one of the points that al mojera said is if you see a guy shadow boxing in time square.
00:29:20
Speaker
Is he, you know, quote unquote crazy and they're going to pick him up and take him to the hospital or is he kind of just, you know, a little bit idiosyncratic, right? And if you live in New York, I'm sure every day we see people where, you know, who's to say, right? The other thing I want to mention is
00:29:41
Speaker
This is sort of, I'll say hopeful, the Pentagon recently announced within the last couple of weeks that they're removing all of the stigmatizing language from their from their mental health policies. I think that's that's pretty important. And it's a start, you know, that to look at the words we use and the effects that, you know, they have on others. So.
Conclusion and Listener Engagement
00:30:08
Speaker
Anyway, thanks for sharing a bit about your experience and thanks for talking today. Yeah. Likewise. Um, I hope you, um, are able to catch up a little bit on some rest. I know you had a, uh, a tough night with a, the more prosaic problem of raising little humans so you can get some Z's. Um, yeah, it's been, been a pleasure speaking as always, almost always.
00:30:35
Speaker
Okay. All right. Thanks for listening. Thank you for listening to the Doorknob Comments podcast. We appreciate your time and hope you've gained something from joining us today. Please let us know what you think. You can email us at hello at doorknobcomments.com, find us on Instagram at doorknobcomments on iTunes, and on our website doorknobcomments.com.
00:30:57
Speaker
Let us know if there are any particular topics you'd like us to address. We'd love to hear from you. Remember, the Doorknob Comments podcast is not medical advice. If you may be in need of professional assistance, please seek consultation without delay.