Teaching About Mental Health through Music

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

**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.

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  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

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

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. Because my husband was kind enough to drive the whole way on a long road trip last weekend, I had the opportunity to read it in its entirety. 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

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.

If you or someone you know needs help, please visit our links page for resources.

lifeline

*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.