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.