91. Destigmatizing Mental Health

Mireille: Hello, hello. Yes, my name is Dr. Mireille Reece. Like Chris said, I'm a psychologist. I operate out of the fabulous Pacific Northwest. I've been working in clinical practice for over 10 years, but prior to that, I spent a number of years specializing in brain injury, both the treatment and rehabilitation of individuals with developmental disorders, disabilities, as well as people who had different brain injuries, so be it stroke, or traumatic brain injury, and really helping people get back to work.

Mireille: So I loved that exposure and experience clinically, because it really enhanced all of the other foundational knowledge and skills I had from graduate school, and gave me so much more of a repertoire and curiosity about what drives some of the challenges that people struggle with, and also recognizing the difference between what testing might say people are capable of, and then functionally, what that looked like. Because, just because somebody might have a certain degree of memory impairment, or their brain wasn't working, language skills, et cetera, there was ways that we could help them learn how to compensate for that.

Mireille: I think that's what all of us are looking for, relative to mental health as a broad stroke, to say, there's skills and strategies we can all learn, and we don't have to be subjected to feeling a way in which we don't want to feel. Like we actually have some degree of agency around doing things that help move us in one direction or another.

Chris: Yeah. Compensate for something and agency, two things I'd love to chat about more, but I want to let Adam introduce himself first.

Adam: Well, that's exactly what why do this show, Chris, is to employ those things because we feel that, as you had said in the intro, that mental health has this stigma, and part of the reason why we do this show ... Because I'm just somebody who's curious. I don't have a doctorate. I've never really studied this in an academic way, but I am the founder and editor in chief of Changelog, and we have awesome podcasts, primarily focused around software development, dev culture, open source, artificial intelligence, the web, front end.

Adam: So having a show called Brain Science is kind of an outlier for us. But that's the problem, right, is that we need to have a show like this that helps people to understand these different aspects of mental health, being a better human, like we like to say a lot, things like habit formation, being a better team member, playing a better role on a team.

Adam: All these different things play into our lives, both professionally and personally, and we felt that there was a lot to talk about around mental health, and particularly how we can take what we know about the brain and apply it to bettering our lives. That's the crux of our show, and absolutely why we produce it. So I'm just somebody who's curious, who happened to know Mireille through other connections, and I was like, "Hey, we really should do a podcast talking about brain science and all these fun things, and just geek out."

Chris: Yeah, we'll link to that, the Brain Science podcast, in the show notes. I think, for me, discussing something that's difficult helps me get by it, or helps me resolve it, instead of going at something, being like, "Okay, how do I fix this problem?" I'm a software engineer, kind of have a science and math background, and so I'm always very objectively like, "How do I fix this problem?" and try to go head-on at it.

Chris: But in my older years, maybe, I've figured out that, or learned that, it's sometimes more helpful just to step back and discuss it, and to kind of force it, in that you have to have a discussion about it, or even writing about it in your journal or whatever, but not force it in that, like, I must solve it within the next hour, or in the next day, or something like that.

Mireille: You know, we all encounter challenges throughout our lives. I think that was in one of our primary episodes. We all struggle. Our struggles aren't going to look the same, but we struggle nonetheless. So if we approach things with wanting to just throw that away like trash, I don't want to struggle and I just want to fix it, it's very much like differentiating between trash, throwing something in the trash, versus composting, right.

Mireille: I can't throw my trash away and expect it to become fertilizer. It actually has to be exposed to other chemical processes in order to allow a transformation to occur, that then allows for other things to grow from that fertilizer. That's what you're getting at, Chris, of going, when I talk about it, it gives me an opportunity to categorize it, make sense of it, expose it to oxygen, so I'm not holding it or containing it all within myself, but actually exchanging and upsetting that homeostasis internally to prompt to some other changes.

Chris: Yeah. Why does this stigma exist? Why do you think people are hesitant to talk about mental health, whether it's their own personal mental health or generally, as something that's maybe more important, or important in society? Why are we hesitant and why have we always been hesitant, we being society, to talk about mental health?

Mireille: Well, I think in general, people have long-time seen it as a weakness, right? Like if my brain isn't working the way that I think it ought to, then that shows that, one, there might be something wrong with me, and then if I think that there's something wrong, why in the world would I tell somebody else there's something wrong with me? Right? It's like exposing my dirty laundry, so to speak.

Mireille: Brené Brown, who's a social worker, or once upon a time was a social worker at the University of Houston, talks about aspects of vulnerability and connection. I would say that that also is a significant component of that stigma of going, if I attest to having challenges mentally, maybe I really feel like it's putting myself out there and being vulnerable, exposing myself, literally, to judgment, criticism, or, God forbid, condemnation.

Adam: It's also very personal too, right? Having something wrong with you mentally is not something that you can go in and fix. Unlike, say, a broken bone or maybe a skill you can learn, it's something that's sort of out of your control and very personal. So it's sort of inherent that you would take it very personally, and then as Mireille said, putting yourself out there and being vulnerable, that's leading to disconnection, which we will talk about and have talked about in our show, is that connection is really the resolve of many things that can go wrong.

Adam: So if you are isolated, you're less connected with other people, so you're less open to opportunity, change, free mind et cetera, and you essentially begin to detract and retract, rather than, I suppose, puff up, get bigger, take up more space and connect with more people-

Chris: Yeah, flourish.

Adam: ... because we are social beings, and being antisocial leads to a lot of these things, essentially. It's a stigma because it's very personal and leads to, potentially, rejection, and nobody wants that.

Mireille: Yeah. Adam, I'm glad you brought that up, because the rejection is a significant part. Here's a little nugget that I think is so fascinating, but when we're rejected socially, the actual physical pain centers of our brain are the first things to light up when they look at things under MRIs. So it legit hurts, and so it's a really big deal, and I would say especially nowadays, with the pandemic, when we are more isolated socially, and then you add any sort of rejection or struggle on top of it, it's just automatic deflation to some degree.

Adam: The pain is real, essentially.

Mireille: Yeah. Yeah.

Chris: That's interesting. I never thought about it that way, or I don't think about it that way. I think of, like you were saying, Adam. Let's say I break a finger, right. That doesn't define me. It's not this inherent thing that's part of me, and I know that, oh, I can put a splint on it, or I can go to the doctor, they pull on it, they realign it or whatever, and it will heal over time.

Chris: But mental health is different, right? It's like it defines my personality or my character if there's something wrong in there, or if something's broken in there, like I have a broken bone in my head. But then it also doesn't just heal automatically. It doesn't heal in the same way that the broken finger does.

Mireille: Yeah, so Chris, you're getting at how it isn't a quick fix, right? Like you can't step in and have a doctor be like, "It's casted, come back six weeks, we'll take it off, and then you'll do rehab and you're good to go."

Chris: Yeah.

Mireille: Right?

Chris: Yeah.

Mireille: But there's actually insight as part of what's required to be able to change, and if I don't know, which is where a lot of people get to, right, I don't know why I'm depressed. Like a lot of people, anxiety, there isn't anything that I should be anxious about, and yet physiologically my body and my brain are amped and always ready to go, as if there's some active threat in front of me.

Adam: What you're saying though, Chris, about defining though, and describing, I think is pretty important. I think the reason the stigma exists is because people feel as though their mental health, or the things they feel are wrong with them, or maybe really are wrong with them, define them and not describe them.

Adam: So I would say the stigma is that it describes something that may be challenging for you, or different than you than, say, common human beings, or the default design of human beings, or whatever, however you want to describe it. But it doesn't define you because human beings are very capable and very resilient despite challenges.

Adam: So while it may be a mental health issue, it shouldn't define you. There's obvious cases where that, Mireille may push back, and that that's really true, because there are true mental health challenges that will define you, but my encouragement is that, and this is from the curious person, not the one with the doctorate, that it describes you, not to defines you.

Mireille: So with that, tagging on, it's sort of differentiating between who you are versus what you do. So if you confuse the who and the do, it makes it all the more challenging, right. Because I don't think I interpret that there's something necessarily defective with me if I broke my finger. I mean, maybe if I did something silly or foolish, but it's not going to likely prompt feelings of shame like something with my mental health, which is like, that's me, it's my brain, and if there wasn't some externally imposed injury, then who else do I have to look at, but me?

Chris: Yeah. I guess, yeah, one thing, I think, associated with that stigma, is that it sometimes seems like I don't know how to fix this thing. There's maybe the first step of, is there something there that I'm ignoring? Is there a problem, anxiety, depression, whatever, that I'm kind of ignoring or just sweeping under the rug? And then second, there's like, okay, I kind of think there's something there, but I don't know what to do. I don't know how to find a therapist or talk to a therapist.

Chris: It just seems like an insurmountable problem, or there's not enough common knowledge, maybe, out there, that's taught in schools or whatever it is, to give people the skills to understand that, hey, there are steps you can do here, and hey, you are are not unique, other people experience very similar things.

Mireille: Well, right? I mean, I think it's normalized if it's a medical doctor, right?

Chris: Yes.

Mireille: If you're having physical issues, you're like what? And in general conversation, you go, "Well, I was having this trouble, and I called my doctor, and I saw my doctor." Nobody's going to think anything of that. However, if I were to say, "Well, I've been having these trouble with my thoughts. I keep telling myself really wretched, horrible things," those aren't usual conversations, and then it's not followed up by, "And so I'm going to go see my head doctor," or think of all of the names people use to reference my profession.

Chris: Yeah, totally, very derogatory or kind of diminishing names, maybe.

Adam: Yeah. The pathway to define that therapist is difficult, and then attach that stigma also to having to be vulnerable with another human being. So the processing of whatever it is you're thinking, that process, to actually process those thoughts and to examine them, requires connection with another human, that does require some vulnerability. It takes effort and intention. Like, I've got to find some resource that has a phone number or some credential that I have no idea. What's a PsyD? I don't know what a PsyD is. I don't know what these things are. I'm just intimidated, and now I'm just going to ... okay, I'm going to skip it. I'm done. I'm not going to do it.

Mireille: Well, sure. Because, too, at some point you have to admit, I don't have the tools, or skills, or repertoire of knowledge in order to resolve it on my own. I mean, so people will read self-help books, or investigate on their own, which is good, but one of the challenges when people get to the point of looking for therapy or help is access.

Mireille: One, I don't know these different degrees, which, there are a number of different ones, and that just really indicates level of education or specialty of focus. For example, a licensed marriage and family therapist, their framework for education is around families and marriages, so that sort of, for lack of a better way to say it, a bias or the sort of mental construct that they approach the people that they're working with. Whereas, a clinical psychologist, so someone with a PhD or a PsyD, has done five or more years of school and just has a broader sense of clinical skill and experiences because they've spent more time and been exposed to more things.

Mireille: That being said, if you don't have either the funds to cover the cost or insurance to assist with that, it's going, how do I find that person, and who's going to be the most helpful to me? The beautiful thing that research has found is that none of the degrees actually matter. Woo-hoo.

Chris: Really? Okay.

Mireille: Yeah, it really isn't about that, that what contributes to the effect is the relationship. Because, fundamentally, are you going to listen to somebody you don't like?

Adam: True.

Mireille: Probably not.

Chris: Yeah. So there's another layer there, I think below that, where I've ... when I did some find a therapist research, where there was CBT, cognitive behavioral therapy, there was existential therapy, humanistic therapy. I can't even remember all these different types, and I was like, what is this huge world and how do I choose one of these?

Mireille: Again, all of those things are great. They're different styles or tools in clinicians' toolkit, but at the end of the day, they aren't really what contributes to the change that happens in therapy. That it's about the relationship that you have with the therapist. So there are certain ones, like, yeah, CBT or cognitive behavioral therapy is short-term focused. It's teaching and training you a skill around challenging your thoughts and recognizing events or internal triggers, that you can then navigate differently with just an alternative thought pattern or different behavioral skills. Opposed to EMDR, which stands for eye movement desensitization and reprocessing-

Chris: Wow. Okay.

Mireille: ... because everyone like to say that often, right? But EMDR is a fantastic therapeutic orientation, in that it really helps people with trauma, and has been well verified through research that people can have significant improvement in their symptoms quickly, which is the allure of that sort of thing.

Mireille: But this is also why I'd like to have the conversations on the podcast, because if people don't know and they don't learn that there's routes or avenues that they can get the help, it's just one more barrier, which further enhances the stigma. So if I'm struggling, I don't know where to go, and then I do try to go, and then it implodes in my face, and that ... I mean, none of that is reinforcing to continue to seek help.

Adam: There's a lack of a map, so to speak.

Chris: Yeah, totally. I want a flow chart, right, a decision tree of, do this, do you feel this thing? Okay, maybe think about this. But then, maybe to your point, Mireille, maybe ultimately a lot of those things don't matter. I mean, there probably is something worth, like CBT, you said, was more near-term or short-term focused, and then there's EMDR, is maybe better if you have past traumas that you're trying to work through.

Mireille: Yeah, but so, flow chart of, how do I do, or what do I do? I always encourage people in looking at the resources they do have. For example, most insurance companies, if you're here in the U.S. at least, this is true, that you can call them up and they keep a list of credentialed providers, who you can say, "Hey, I'm struggling with anxiety, or I'm struggling with depression." Anyone who's paneled with that insurance company has a list of what people in their area actually do.

Mireille: So there's one step, and then that famous thing called the internet, go cross reference. See if they're out there, if you can find any other information, because, again, do you feel like they're relatable? If you're struggling with an issue, do you feel like this person has a sense of understanding? You can try more than one and say, "Hey, I want to show up. I want to see what this is like," and go, do I feel like I'm getting the benefit that I want?

Mireille: Some people have experiences in reaching out, and you know that infamous statement that many people in the mental health field say, "How does that make you feel?" While that's significant, that isn't the entirety of what the therapeutic process should look like, and going, are you building skills or changing behavior in the direction that you want to go? Ideally, they're just like crutches for the broken leg. You would use them for a time, for additional support while healing can transpire, so that you don't need them in the same way in the future.

Chris: Yeah.

Adam: I'm glad you said that Mireille, because that's applicable. I was going to ask about bias confirmation, because sometimes you had said, "Did you get what you wanted out of the therapy?" Sometimes that might be not what you really needed. Wanted and needed may be different things. So how do you prevent or maybe avoid bias confirmation?

Adam: I mean, would it be going too deep to talk about what, I guess, maybe a first few visits might be like? Or, not so much what you'd go through, but how many visits should you see of a therapist before you sort of say, "I want to keep continuing, whether it's momentary or not," or if it's like getting that kind of resolve back from that person, that connection? How they know?

Mireille: Well, I think it's not a set number, but usually, you show up, an initial appointment is sort of throwing up everything, so that the person has a sense of who you are, where you've come from, and what exactly you're struggling with. A key part is going, does it feel collaborative? I always say that I might have expertise, but you're the expert on you, and so unless we can work together, this isn't going to really be fruitful in the same sort of way. So you should be participating and going, does it resonate with me when my therapist responds? Does it feel like it fits? Or they just keep saying, "Wow, that must make you feel sad."

Chris: Right. Yeah. I don't know if this is true with other people, but I have ... I tend to be reserved in my emotions, but at some point, this dam will break or this trigger will happen, and I'll just start ... Five minutes later, I'm like, oh, wait, I just accessed all these things that I didn't know were in there, but also shared them with you. It kind of feels good, but I think that's the vulnerability that maybe we were talking about earlier. It's like I hold back from it, and so I need someone who somehow breaks that dam, or tricks me into throwing up on you, right?

Adam: Well, here's the encouragement. Those listening, and even you, Chris, there's a bunch of Mireilles out there. I think the hard part is that the other side of what you need, if you need therapy or you want to seek therapy like this, is that they're a person, too, and as Merrill said, it's about a relationship.

Adam: There's another side of that, too, where Mireille can talk about, from her perspective, on the fact of collaboration, that she wants to work with people that want to change, right, that collaboration. If you can't share your story or what you're dealing with, then she can't help you, and she wants to help people, and there's other Mireilles out there. Why I say that is to give people hope. So when you challenge yourself or encounter this stigma, know that there's people like her out there that do want to help you and are invested.

Mireille: Yeah, and it is hard, I mean, because it's very much ... and I think this is a really significant point in going, what keeps people from pursuing the change, is pain. I mean, it's painful to be depressed, or struggle with anxiety, or trauma, or any of these things, but it's also painful to try to walk through it.

Mireille: One of the things that is so important when you look at going, what does feeling better, getting better look like, is differentiating pain. I don't want a blanket file for pain. I mean, even, I think about this a lot, just in terms of my background in being in athletics as a kid, and to be able to talk through with my coaches or my parents about, is it a sharp shooting pain, is it a dull ache, what is your experience?

Mireille: But I think about it, going, now, when I exercise, if I'm having trouble breathing, I don't call my doctor because I think I'm having a heart attack, unless maybe I have tightness in my chest and my left arm is going numb, or shooting pains down it. But, so I have to learn how to talk back to my brain and sort of go, "I know this is aversive, I know this doesn't feel good, but this will produce a harvest if you can endure or tolerate some of the pain that comes along with it."

Mireille: That's critical, and so within even the therapeutic context, there should be skills taught in terms of, how do I manage it when I get upset, or activated, or anxious? You mean there's things I can actually do, I don't have to just keep having panic attacks? Uh-huh (affirmative), yeah.

Chris: Yeah. So that's something else I wanted to talk about, the harvest, I guess, is, when you break a finger, you're like, "Oh, that hurts. I want that to get better. I can see the problem, it's pointing the wrong way or something." But I think very often, from personal experience, in mental health, sometimes you can't see the brighter side, you can't see the, what would it be like if I actually did work on this thing, or did talk to someone, or did, I don't know, my daily mindfulness practice or something like that, how would it help my life, my relationships, my whatever? Do either of you have anything to share for, either that you've experienced personally, what are those benefits, or you've seen in your work, Mireille?

Mireille: I think one of the key things, and Adam and I have talked about this relative to even habit formation, and going, there has to be some immediate sort of payout. I think, repetition with the payout. I mean, why do we continue to exercise when we can't breathe, and our muscles burn and want to give out? It's because we have some other goal that we're trying to achieve.

Mireille: I think when people are really struggling with managing their mental health, it's really hard for them to hold onto a hope of anything other than how they feel at that moment. That's why having a therapist, and this is why, too, I actually encourage, when I give resources to patients, a lot of times I'll encourage them to listen to books via audio, so that they don't hear it in their voice, but rather another voice-

Chris: Interesting. Yeah.

Mireille: ... so that they're practicing reframing and getting hope in a different sort of way. I mean, one of the best ways I heard it said with someone who is really struggling, was going, "You know what? I know this is so hard, and it's so hard for you to imagine anything other than what you're feeling right now. But I do know that it can be different, and so if you can borrow my hope to take you to the next step ... "

Mireille: It's part of facilitating that trust in the relationship, that, I know that this is a marathon and you feel like you're on mile one, and I'm like, "Just run 25 more miles, come on," which is the feedback you might get from other people. But going, "You know what? You're not going to do it by yourself, and I'm going to help you along, and cheerlead you, and go 'That sucked, that was so painful, and you know what? Good for you? You hung in there amidst the suck. Good on you.'" So then that becomes the reinforcement, which leads to the harvest.

Adam: What about the future you, though? If you can sort of future cast this, and in my experience this is the case, whenever I'm in those scenarios where I don't get that help, or I'm in that pain that you are talking about, and I just stay there versus get the help or resolve the problem, the future me is like, "This problem's solved," and now you're moving onto it, but thinking more so that, that feeling like you wish you had done it sooner.

Adam: Imagine the future. This is no longer an issue. I've busted through the boundary. I've resolved this issue or I've got a relationship helping me process these thoughts, feelings, et cetera, and that it can be better. But future you is like, "Just get here because you'll wish you had done it sooner."

Adam: That's how I've been, in different scenarios where I've procrastinated with dealing with certain things, is when I get to the moment I desired to get to, I tell myself, "Man, I really wish you had done this sooner." Because this is the joy and the feeling you get there. When you get there, you feel this. But that old person, the person that's stuck in it, can't see it.

Adam: So I like your aspect, Mireille, where you say, borrow that hope, because that's what a lot of us need, is we need to borrow somebody else's hope. That's the whole point of ... that is empathy and compassion, is like, that's what it is. Right? You've got somebody else who cares and helps you walk through it.

Mireille: I think with that, Adam, it pulls us right back to, what is the actual stigma? It's the fear that if I reach out, I'm not going to be met with empathy and compassion, but I'm going to be met with judgment and criticism, that goes, "Yeah. You know those horrible thoughts you think about you, and that you're not enough? Guess what? They're true." Because you have Joe Schmoe and Betty Sue telling you and confirming your own bias internally, and then it's defeated.

Chris: What about, there was this quirky, I think it was a comedy-drama TV show called Limitless. Have you heard of this?

Adam: I've seen the movie, if I'm referencing the same one that's-

Chris: It's the same as the movie. The idea is, there's this pill that you take, and it's this mentally enhancing pill that lets you be better at work, focus on things better, do math in your head, understand, see everything around you, have perfect situational awareness.

Chris: I'm just using that as an example of, I know that when I have continued with or been consistent with my mental health habits, whether that's speaking with someone about stuff, or exercise, or meditation, whatever it is, I feel, not 1,000% amazing like that pill that show talks about, but I feel like I'm a better employee, like I can do better at my job, I'm a better partner in a relationship.

Adam: Well, that's the key there. The magic pill, then, is connection.

Chris: Yeah.

Adam: Because, usually, when you're isolated is when you're probably feeling this. Maybe go back through your own journal, or share here, even, I would imagine, and just by assumption, that when you're feeling that, you're less connected with others that care about you and you care about them.

Mireille: Yeah. I mean, connection is one part, but to some degree, we're all a little dense. When it comes to emotion and memory, it's all part of the same system, so if you can think of emotion hijacking your ability to retrieve data from your memory bank, that's part of what happens. So our feelings in general can run interference with just our overall processing.

Mireille: So imagine I'm just stuck seeing really far and narrow, as opposed to panoramic view, that changes what I believe there's access to or around so that I think I could move or maneuver. With that, we want to practice doing things. I mean, because of straight conditioning, I'm better able to recall when I've done it so often that I'm like, I know this pays. I know that every time I exercise, I don't feel better before I do it, I feel better after, and I'm always glad I did.

Mireille: So when you're really struggling and it just feels hard, just move one degree in the direction you want to go. If exercise is hard, 90 seconds. Can you jump? Do something. Walk 90 seconds. Make it so easy that you're like, I could do that in my sleep. Because that's how you span the chasm that feels so overwhelming, because usually there's a degree of self-imposition of expectations that say, if you're really going to do it, it only counts if you do it like this.

Chris: Yeah, that resonates with me, or maybe the perfectionist tendencies that I have, I'm like, perfection is like spanning this chasm and getting to the other side. But what I need to actually do to get there is take one step, right? You said compensate earlier, which I thought was an interesting word in your intro, and I like that word because it's like compensate doesn't imply a perfect fix for whatever the thing is. It's like, I'm just trying to mitigate the effects. I'm trying to get a little bit better.

Mireille: Yeah, and then it's reinforcing because it instills confidence. Like, it was hard and I did it anyway. So in the same way, if you're lifting weights and going, "It's too heavy, I'm going to drop the weight and then I can keep going," as opposed to, "Forget it. I'm just not meant to work out." We just roll down this snowball hill of ways in which we fall short of the expectation, which in no way is motivating for any of us to be like, "Oh, yeah, let's go do that again."

Chris: Well that’s it for part one of two of our mini-series on mental health. Join us next week for part two during which we’ll get a little more hands-on and practical on this fascinating topic.