What the F*** Is Mental Health


What the F*** Is Mental Health?

A Q&A with one of the field's leading experts.

By Genevieve Fish

The Know is here to strip guilt from your self-care, to put mental health in a different context than mental illness, and to shed some light on how to keep your mind in fighting form. Our first installation of mental health knowledge comes courtesy of Dr. Stephen Hinshaw. When he’s not teaching, performing research, leading programs in psychology and psychiatry at UC Berkeley and UC San Francisco, writing best-selling books, or acting as an advisor for Glenn Close’s organization Bring Change to Mind, Dr. H is often found playing full-court basketball, with guys half his age, at Cal.  He’s especially appreciative of the 3-point line!   We’re grateful that he spared the time to give us the 411.

The Know: So Dr. H, can you break it down for us? What actually is mental health?

Dr. Hinshaw: Well, this is something humans have been asking themselves since, or even before, recorded history. Now we have a lot more openness about anxiety and depression—as well as bipolar Disorder, PTSD, and child conditions like autism and ADHD—than ever before. But despite greater openness and greater knowledge, shame and stigma still remain.

Let’s flip the narrative.  Rather than taking on a disease perspective, we might examine the broader context of positive mental health—what people can do to keep their minds and emotions sharp and supple.  Simplified, mental health is how you manage hassles and promote thriving in a very (often extremely) stressful world.

TK: When you put it like that, mental health sounds so positive. That's generally not the case when it's portrayed in mainstream media. 

Dr. H: Mental health doesn’t get as much air time as mental illness because the orientation of the clinical fields is to deal with disorder rather than adaptation and healthy functioning. Mental health, I think, should be defined as having the resources in your mind and your body, plus those external resources like social support, access to the web, getting the right information amidst a wealth of wrong information these days, to keep your life in balance.

Remember, the goal is not to lead a stress-free existence. If you’re perfectly calm and content all the time it probably means you’re not paying attention to the world or you’re not taking on many challenges. The goal is to manage stress and to thrive.

In other words, mental health doesn’t mean the absence of stress or a perfectly flat line of emotional stability day-to-day. It means making your way through the inevitable ups and downs of life—with loss and disappointment and success and achievement—and examining your family’s, your community’s, and even the world situation with enough resources to keep you seeking your goals, with  moderation. Don’t get too high, don’t get too low. Have the emotional equipment to deal with what everyone today is dealing with--a far more stressful world.

TK: “Anxious,” “depressed,” and “stressed” have become buzz words for our generation. So what’s the difference between feeling anxious or depressed and actually having clinical anxiety or depression?

Dr. H: Depression is a tricky word. Unless you’re a very rare human being, you sometimes experience small “d” depression, encompassing sadness and low energy. It’s universal. We’re wired to deal with loss by shutting down to conserve our resources. It’s part of the human experience.

But in some people with vulnerabilities—sometimes genetic vulnerability, sometimes early trauma, sometimes just too many losses—things can slip from small “d” depression to capital “D” Depression or what’s clinically called Major Depression. It’s no longer just sad mood, it’s very low motivation…the things that usually give you pleasure you just don’t give a damn about any more….your appetite is off…your sleep is disrupted….you’re irritable…and things seem hopeless.  In really severe depressions, you’re not sad any more, you’re just flat and blank. Inevitably and tragically, people start to wonder about their sense of self-worth, and suicidal thoughts—along with specific plans and attempts—can become part of the picture.

It’s similar with anxiety. If you go through life every day and you’re not a little bit scared of what goes on in the news or what’s lurking behind that dark corner, you’re rare. . We’re wired as human beings to be wary of an uncertain environment. That’s the kind of small “a” anxiety that helps us get through a day and get cortisol flowing and get us activated in the fact of a  threat. But what if you’re really afraid of certain things like speaking in public? What if your anxiety is so pervasive that you can’t stop worrying all the time?  After the impairment builds, we’d say there is an anxiety disorder.  And, chronic worry and stress can wear you down, psychologically and physically.  It’s a vicious cycle.

For anxiety disorders, psychological forms of treatment are actually more effective than medication treatments, though for severe anxiety disorders like Obsessive-Compulsive Disorder (OCD), combinations of therapy and meds are optimal.  The same is true for serious depressions: Evidence shows that putting SSRIs or other antidepressants together with therapy usually leads to the best outcomes.

Both anxiety and depression exist on a spectrum. When small “d” depression and small “a” anxiety merge over to capital “D” depression and capital “A” anxiety, that’s when clinical help is really needed.

In mental health, just like in most medicine, everything is on a spectrum. We used to think that you either had ADHD or you didn’t; you had OCD or you didn’t; you had bipolar disorder or you didn’t.  Same for autism. And these are all now defined as spectrum disorders, which makes getting a good assessment really important.

TK: And is getting a good assessment really based on the doctor or is there an exact science to it?

Dr. H: So, one of the reasons that mental health issues still receive so much stigma is that the brain is the most complex  entity in the known universe, with 100 billion neurons, and 100 trillion or even a quadrillion synapses among those neurons. It’s utterly complex. Doctors are getting better at localizing different brain regions and brain pathways that differ between people in the normative range and people with key forms of mental disorder . But none of those brain scans yet is a definitive test.

If you go in and get a biopsy, your doctor is pretty certain whether you have cancer or you don’t. You’ve crossed that line. For mental health, it is still subjective, because we rely on symptoms and signs. We don’t have unequivocal tests. Even though diagnosis is really reliable if done well, for some people that’s fuel to say Ok, well then, it’s “made up” because we don’t have blood tests or a brain scan.

Just because we don’t know enough scientifically. It doesn’t mean that mental disorders aren’t real conditions. They clearly are. The science is working hard to find out what is going on biologically. Even so, any biological process that might make you vulnerable to mental disorder is played out by how you feel about yourself, how you relate to other people (and the supports you have), and how you cope with school or work. So, it’s always going to be a combination of biology and context, genetics and culture, to make the connection between what’s mentally healthy and what’s mentally ill. And that’s the grey zone we live in.  Still, mental illness is completely real.  And the doctor in charge needs time to make a careful assessment.

TK: Let’s talk about stress, a seeming badge of honor for millennials. Can you shed some light on stress?

Dr. H: Being “stressed out” is distinct from depression or clinical anxiety. Everybody knows what stress is—it’s that feeling of near panic you get when the world has too many demands on you.

But let’s look more closely.  Is the exam or the relationship crisis “stress”?  We should call such events stressors,  but stress is the imbalance between what’s going on outside (demands), and what’s going on inside (your own internal resources). Your ‘challenge’ may be my ‘threat,’ depending on our different histories and the different resources we each have in place.  If the seesaw tips in the wrong direction so that the threats outweigh your resources, that’s true stress.

“Stressed out” might be a good term to use for beginnings of this imbalance, to make sure that we aren’t overusing the term ‘depression,’ which can trivialize major, capital “D” depression and even capital “A” anxiety.

TK: Why are women twice as likely to be diagnosed with a stress related disorder than men?

Dr. H: This is one of the hottest topics in the field that I am in, clinical psychology and developmental psychopathology. These areas of science suggest strongly that you don’t wake up one day with an anxiety disorder, major depression, or PTSD. Rather, there has been a long process of development that led you to that point.

Let’s detour for a minute to early life. The first 10 years of life are the risk period for boys for just about every type of developmental and mental disorder we know of. Boys’ brains develop a little bit slower than girls’. At the ripe old age of two or three, boys are half a year behind girls in terms of language and emotional development. No wonder boys have five times the rates of autism as do girls, three times the rates of ADHD, five or six times the rates of Tourette Disorder (where you’ve got uncontrolled motor outbursts, etc.). Boys are more susceptible to early stressors and to developing nearly all neurodevelopmental disorders.

But the second 10 years of life are different. Somewhere around 11, which is now the average age of puberty for girls (because of nutritional changes, etc., over the past century), the period of vulnerability emerges.  In fact, girls and young women skyrocket ahead of boys in terms of developing major depression.  Clearly involved is the hormone surge of puberty.  But our culture, and the impossible expectations our society has for girls and developing women, adds to the risk.  Girls’ rates of depression, anxiety, self-harm, and many eating related symptoms are growing in the past several decades.

I wrote about all this a few years ago in a book called The Triple Bind: Saving Our Girls from Today’s Pressures. What’s “triple” in terms of risk for girls?  First, in every culture, girls are expected to be the nurturers. Well, that hasn’t changed much. Second, in the last few decades girls are outnumbering guys at college admissions, and women have caught up or surpassed men for law school and medical school admissions. Title 9 gives equal funding for sports. So now, if you’re a girl you’re expected to be athletically and academically super-competitive.  Well, that’s a double bind: How can you be the caregiver and number one at the same time? But the third aspect is the worst. If you’re a female, you’ve got to do all this effortlessly—nobody can see you sweat—and you’ve got to look really “hot” while you’re doing it.  Doing these three things at the same time is physically and psychologically impossible: to be the caregiver, to be competitive, and to have an effortless, sexualized look.

It’s hard for guys out there too, don’t get me wrong. But if a teenage guy is a good athlete, good at school, and is super nice, he’s a super guy. Who is this kid!? For a girl, it’s expected that you do all three things effortlessly.  But trying to do so cuts down on sleep, which is a big risk factor for negativity and even depression.  And when girls inevitably realize that they can’t do all three, they blame themselves, fueling low self-regard—and even self-hatred.  The result is that anxiety and depression, binge eating, self-harm, and depression are growing fast in girls and young women.  Some people are more vulnerable than others, because of genetic vulnerability or early-life trauma.  But the triple bind pressures will affect them even more than everyone else.  The gap between men and women in term of developing these conditions, after puberty, has always been there, but it’s widening because of these unrealistic pressures.

It‘s possible, as well, that #MeToo is another stressor. Of course, it’s about time that women are standing up to predatory sexual behavior.  But questions of loyalty, of how to interpret comments and actions, and responsibility may add a fourth “prong” to the triple bind.

TK: Do you think the disorders of women have been exacerbated by burn-out? The word “burn-out” keeps popping up. Do you think those are the biggest things for that third decade for women?

Dr. H: My colleague at Berkeley, Professor Christina Maslach, is a world expert on burnout.  This work focuses a lot on burnout on the job.  But I believe that the pressures of the triple (or even quadruple) bind, along with social media, may be leading to early-life ‘burnout,’ especially for girls and women.  The statistics are really troubling: suicide rates are rising quickly in girls and young women.  

First, a digression.  If you go back to the early to mid 20th century, there was major concern among adults, psychologists, therapists, and parents about comic books and how they were ruining kids’ behavior and morals.  All this now seems quaint. Every generation comes forth with new modes of communication and media that probably outstrip our brains’ capacity to handle it at that moment in time. But the curve has really shot upward in the last few years. First the internet, then Facebook, and now the seemingly infinite arms of social media. The means of distraction are stronger. The means of both expanded social contact—but also fake or harmful social contact—are everywhere via online interactions.

In earlier times, something might go wrong at school, and there would be teasing and attempts to ruin someone’s reputation.  But there was no permanent record.  Today, any interaction is etched into texts, Instagram posts, tweets, and more.

One of the risk factors for Major Depression is rumination, the endless rehashing of negative events or things that you’ve done.  It’s a little bit of chicken and egg. When you get depressed or anxious, you start to worry and go over and over that stupid thing you said in class or in a meeting.  

How is rumination fostered and made permanent these days? Through social media. Social media is literally reshaping the ways our brains and minds are sculpted from an early age. Let’s not forget positive benefits, with chances for quick spread of information, for creating bonds across oppressed people, and for extending social networks.  In fact, one of the big hopes I have for the future in terms of reducing mental illness stigma is that social media gives young people a lot of role models and a major platform to share their stories of coming out, of overcoming adversity, etc. But it also gives a platform for false information, as well as ‘how to do it” manuals for unhealthy dieting and cutting behavior.  And, as noted above, it may spur endless rumination and self-recrimination.

TK: So what’s a healthy way to use social media?

Dr. H: If the goal of social media is to seek a connection just to squelch the loneliness, studies suggest strongly that people get even lonelier. You feel like you are lost in a sea of humanity, but who are you in it? If social media is the panacea sought to end loneliness, I think it goes in the opposite direction. On the other hand, more selective and intentional use of social media to make and forge connections can be a benefit.

It’s all about moderation and being able to shut it off when you want.  But let’s face it, the designers have been quite good at fostering just the opposite, creating reinforcement for a 24/7 social media world.  

TK: Change is another big thing that has been around forever, but is always difficult to process. What is a good strategy to help cope with change?

Dr. H: We all get into our routines, and we like the world to be expectable.  But the world, including the work world, the world of social media, and the political landscape, is as we all know changing fast.

Change is one of those stressors we talked about before that for some people is a threat— I’m going to lose my grip and my balance—but for others is a challenge.  That is, maybe I’m going to find out a lot about myself through this change, and the change will be better in the long run.

It’s not just the “power of positive thinking”—that’s too simplistic. You can’t just pave over problems to optimize your way through life. But if you can foster a mindset of the following: as hard as this move is, as hard as this break-up is, as hard as this new job is, as hard as sticking with an exercise regimen is, I’m going to do it.  Along the way, I can notice what helps me to cope with the change.

For me, I’m in the gym as much as I can be, both basketball and weights. I need to stay strong! That first set of weights each time is hard. Oh man, I feel too tired today. But once I get launched, I start to feel slightly better. Exercise gives you that charge, but you’ve got to work through it. For me it’s anticipating how I’m going to feel in 15 minutes once I get going.

Much harder is think how you might feel down the road if you leave a dysfunctional relationship.  Wasn’t this going to be the love of my life? Change is lonely; routines will be broken.  But in the middle of that indecision and stress, you’ve got to keep a close eye on what you want, long-term.

Day-to-day, what do you do for yourself? Is it exercising? Is it meditation? Is it taking walks? Is it the social support you have from individuals or groups?  Relying on what makes you thrive is really important during times of change.  Remember, change can be a threat or a challenge—and keeping the ‘challenge’ mentality in mind is important (but hard).  

How to prevent an attitude of ‘woe is me;—I can’t live without that relationship, I can’t function unless I have that job?  Positive change and adaptation come slowly; don’t expect immediate happiness.  And there will be relapses a day, a week, or a month later.  But if you can start to feel that energy surge coming back, it’s a powerful reward.

TK: And if you don’t notice that energy surge coming back and you feel yourself sliding into the big D, what do you do?

Dr. H: If you’re sliding into the big D, the first thing is to fight the tendency to isolate. Instead, get help.  Therapy for depression can and does really work, but you’ve got to get into treatment to make it happen.

Short of the really big D, try journaling.  This doesn’t mean simply ruminating on paper that you feel more awful today than yesterday (though you may need to admit how bad you’re feeling).

Professor James Pennebaker of Texas made real breakthroughs here in his longstanding research program, finding that encouraging people to write about deep emotions has essential physical and psychological benefits.  Here’s his ‘prompt’:

In your writing, I would like you to really let go and explore your very deepest emotions and thoughts about the most traumatic experience in your entire life. You might tie this trauma to other parts of your life: your childhood, your relationships with others, including parents, lovers, friends, relatives, or other people important to you. You might link your writing to your future and who you would like to become your future, or to who you have been, who you would like to be, or who you are now. Not everyone has had a single trauma, but all of us have had major conflicts or stressors, and you can write about these as well. All your writing is confidential. There will be no sharing of content. Do not worry about form or style, spelling, punctuation, sentence structure, or grammar.

There’s another strategy, following Socrates: “Know thyself.”  If you know yourself well, including your strengths and weaknesses, you can start to devise a plan to get out of ruts. It’s hard to push yourself, to change yourself.  I do the things I’m good at each day, because it’s hard to feel stupid and learn new things.  Keeping the negative self-talk from overwhelming yourself—and finding the sweet spot of self-support and social support—is a life’s work.

Finally, small changes every day can make a difference a month from now. The problem is when you’re anxious or depressed, a month from now can seem like an eternity.  In sports, a quarter- inch change in your stride can take minutes off you’re finishing time; a slight adjustment to your jump shot can really up your percentage.  But it takes practice, practice, and more practice to make it happen!

TK: Final question: what’s your favorite pump-up song to get through those first 15 minutes at the gym?

 Dr. H: Well, that’s a real individual difference.  Some people want no music at all, others need a strong beat, and still others want something calmer and more meditative.  I tend to like it quiet, but be your own judge!