Normative Narratives

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Entering the First Post-COVID Mental Health Awareness Month, a Timely Reminder: It’s (Still) OK Not to Be OK

“It’s OK not to be OK

…was a common refrain at the beginning of the pandemic, with many people experiencing mental health issues for the first time. As the world ground to a halt, with more isolation and fewer distractions, people were forced to reconcile with negative feelings they may have otherwise been able to ignore. There was a sense of “we’re all in this together”, and I do believe a more understanding society with respect to mental health will be an enduring legacy of the pandemic.

But naturally, as vaccines have taken us out of the most dangerous phases of the pandemic for both physical and mental health, that sentiment has receded from the headlines a bit. Life has largely returned to normal for all but the highest-risk people, as COVID shifts from “pandemic” to “endemic”. Unfortunately, part of that normal has historically been a negative stigma surrounding mental health issues; the pandemic helped reduce the stigma, it did not erase it. For some people, that might have been a temporary reduction tied to the pandemic itself.

Unlike the relatively strong economic recovery, the mental health effects of the pandemic may prove more persistent. People who lost loved ones are still learning to live with those losses. People who have experienced depression once are much more likely to experience recurrences. Younger people, our future, experienced anxiety and depression at particularly high rates.

I am not trying to be pessimistic or alarmist, but a clear-eyed assessment of the situation (as well as self-reported survey results) suggests that our mental health crisis isn’t going away; if anything, it seems to have plateaued at an elevated level. So, as we enter May 2022, the first “post-COVID” Mental Health Awareness Month, a reminder—it’s still OK not to be OK; it always was, and it always will be.

There was no shortage of sources of distress before the pandemic, the pandemic introduced others, and there will be new ones in the future—that’s life even during “normal times”. Just reintegrating into society while dealing with the “social rust” of the pandemic could be a new source of self-criticism for people who tend to be too hard on themselves (as I have been, and can only assume is a common characteristic among those with a history of mental health issues.)

Shared Sources of Distress

In considering how larger shared experiences can impact our collective psyche, let’s first look inside America’s borders. The “blue wave” of 2020 appears to have been a mirage, as Biden’s agenda, which encompassed many long-sought progressive goals, has largely stalled. Structural inequalities in our electoral system, combined with a lack of progress on voting rights legislation (if anything, we’ve regressed on that front), make it seem unlikely this opportunity will present itself again anytime soon. Inflation is too high, and while as an economist I still don’t think it presents a long-term threat to the economy or American’s standard of living, it’s certainly a source of material hardship, uncertainty, and anxiety right now. Needless to say, the leadup to the midterm elections will not be a harmonious experience.

Looking abroad, while the bravery and commitment to democratic values exhibited by the Ukrainian people has been heartening, that is a small silver lining to what is an extremely traumatic manufactured crisis. Taking a broader view, universal values such as freedom, accountability, transparency and self-determination will continue to be attacked, as authoritarians wage their existential wars against them. The institutions tasked with preserving the “liberal world order” established after WWII simply don’t seem to be up to the challenge.

So, if you have a more liberal worldview, it has been a frustrating couple of years. Early in 2021, with vaccines on the way and the “blue wave” rolling into Washington, it felt like the tumultuous Trump era was about to come to an end with a New Deal-type inflection point in American history. That has failed to materialize, and instead the Democratic platform and democracy in general seem to be on the ropes.

If, on the other hand, you have a more conservative worldview, you’ve probably been either directly or indirectly exposed to the far right “rage machine”, where everyone who is different from you represents a threat to your way of life. This reality, fueled by anger, division, and an intentional blurring of fact and fiction, is also a very poor environment for one’s mental health.

Regardless of your worldview it has been a tough couple of years. But we should not despair, despair is self-fulfilling. Things may not look good now, but change often comes from unexpected places. Demographic trends and youth sentiments still point toward future interrelated victories in social, racial, environmental and economic justice. Remember, “the arc of history is long, but it bends toward justice.”

Nor should we be ignorant in the name of self-care. It is up to each person to find their own balance, one that allows them to be informed without being overwhelmed by the deluge of negative or false information out there. You can’t help others if you don’t first take care of yourself.

“Toxic Masculinity” and Mental Health

Men don’t experience anxiety and depression at lower rates than women, despite what the survey results above may suggest. Rather, men are generally less willing or able to communicate their needs and get help. The proof is in the most extreme manifestation of unaddressed distress— “deaths of despair”. Whether looking at suicides specifically, or the broader category including overdose deaths, men are about 3.5 to 4 times more likely to die this way than women are. You don’t just jump from being “OK” to a death of despair; in this case where there is fire (death), there is a lot of smoke (unaddressed mental health issues.)

Men being less likely to seek help is one of the negative manifestations of a very politically charged term, “toxic masculinity”. Before going any further I think it is important to define a term like this, which is so open to interpretation. In my opinion someone can be as stereotypically “manly” as you can imagine, and that isn’t necessarily “toxic” if they are living their truth and aren’t hurting anyone else. That toxic masculinity exists doesn’t mean masculinity is inherently toxic, or that men are inherently bad. Masculinity only becomes toxic either when someone either rejects parts of themselves to live up to gender norms, or dehumanizes others for not living up to them.

Toxic masculinity, almost by definition, precludes mental health treatment; it essentially acts as an additional, internal stigma against mental health issues. This is a shame because, in addition to all the personal benefits, talk therapy can also lead to greater tolerance towards others. The alternative, ignoring problems and letting them fester, typically results in people turning their anger towards themselves and/or other people.

For example, violent and sexual crimes are disproportionately carried out by men. I am not trying to excuse anything by pointing out one of the root causes, perpetrators of serious crimes should be held accountable. LGBTQ people deserve to live a life free of discrimination and full of dignity just like anyone else. To that end, the likes and proclivities of heterosexual people shouldn’t be defined by their genders either!

I chose to focus on the intersection of toxic masculinity and mental health because I have lived it. Even without many common impediments to care (I was lucky to have financial resources, supportive family and friends, and an employer I could be honest with), I still made things much harder on myself than they had to be. Not everyone is as lucky to have the, let’s call it “margin for error”, that I did when it came to mental health issues. Even so, it is still easy for me to imagine a world where I never made it to the point of acceptance so that I could start healing, or even one where I just didn’t make it at all.

So, as a man on his own mental health journey, a yogi and a “sports bro”, I feel compelled to state what should be obvious: even for men, it’s still OK not to be OK. There is room for toughness and vulnerability in everyone, people contain multitudes. Open yourself up to that, and to getting the care you need, and you will find the confidence to face your fears and stand up for what you believe in even when it’s unpopular—real courage. Not only will you be better for it in the long run, but you also won’t need to hide behind the shield of toxic masculinity that harms both its adherents and their victims alike.


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Transparency Report: The Supply Of and Demand For Mental Healthcare

Original article:

Shootings in places like Isla Vista, Calif., and Newtown, Conn., have turned a spotlight on the mental health system, and particularly how it handles young, troubled males with an aggressive streak. About one in 100 teenagers fits this category, according to E. Jane Costello, a psychiatric epidemiologist at Duke University School of Medicine, and they often have multiple diagnoses and are resistant to treatment.

Most of these young men will never commit a violent crime, much less an atrocity. But the questions of how best to help them and how to pay for it are among the most intractable problems hanging over the system.

Thousands of families know this experience too well: No single diagnosis fits, no drug brings real relief, and if the teenager rejects the very idea of psychotherapy, there is little chance of lasting improvement.

Congress has taken steps to bring about so-called parity for mental health, requiring insurers to cover treatments for mental illnesses as they do those for diseases like cancer and diabetes. But parents like the Serpicos have found that, even with good insurance, they often cannot get the expensive, long-term residential treatment they believe their child needs.

And it is not clear how effective intensive residential treatment is for teenagers. Some improve, experts say, but they are usually discharged to the same environment in which they got into trouble, and precious few studies follow them for longer than several months.

“The problem is that, while some kids may benefit from these extremely costly services, we don’t know which ones they are, and we don’t have a good model for distributing those services, no matter who’s paying,” said Sherry A. Glied, dean of the Wagner Graduate School of Public Service at New York University.

Lena and Robert Serpico knew something was not right before their son was in kindergarten. They had taken him and his younger brother in as foster children from a mother who used drugs, and they later adopted both.

As the teenager became increasingly indifferent to school and defiant, the family got him into a highly recommended day therapy program. He was thrown out for bringing a razor blade to a session. The family tried again, at another day program, and this time the program kicked him out for refusing to participate.

It’s useless, all this stuff,” he said in a brief interview. “It’s a waste of my time.”

He entered an alternative school last fall, and his parents, who both work outside the house, decided they had only one option left, recommended by their son’s doctor and therapist: long-term residential care. Costs ranged from $10,000 to $60,000 a month.

“No way we could afford that,” Ms. Serpico said.

Out of options, the Serpicos did what many affluent families do: They hired a lawyer. In January, they petitioned the school district to pay for their son’s education at a therapeutic school. A consulting psychologist hired by the district concluded that their son needed “a 24-hour-a-day therapeutic milieu over an extended period of time, i.e., longer than two months, in order to keep him safe and gain the skills necessary to function post-high-school.”

Last month, they learned that the suit had been successful. The Geneva School District will pay for the young man to attend a therapeutic school in Montana for one academic year. There will be horses, physical labor, and group and one-on-one talk therapy. Ms. Serpico and her husband broke the news to their son this month.

When asked about going to the new school, he shrugged and looked away.

“I don’t know,” he said. “Probably useless, too.”

Economics traditionally treats people as rational actors seeking to maximize their “utility”. While this idea is contentious even in “normal cases”, when considering those suffering from mental illnesses, the rational maximizer model becomes almost completely irrelevant. Despite the obvious benefits for those who need mental healthcare, potential patients (particularly young men) often reject the idea of therapy because of the stigma of “weakness” or embarrassment associated with it–I know this because I was once one of these young men.

Health care reform–so called insurance “parity” for mental healthcare–has gone a long way in making treatment affordable to those who need it. This was a fix to the “supply side” of the equation. However, it is very clear that there are “demand side” issues related to mental healthcare that are leading to under-treatment.

Demand traditionally focuses on the willingness of a person to pay for a particular good or service. However, young people are almost never expected to pay the cost of their own mental healthcare–those who need treatment the most often reject it even if it is being paid for by their parents or the state (or some combination of the two). To get these people the help they need, we must address the non-monetary concerns–the stigma–associated with mental healthcare.

This is a difficult task, but it can be aided by cultural and technological progress. Culturally, those in the public spotlight (movie stars, musicians, athletes, etc.) who are comfortable with their mental health issues should open up about them. It is amazing how someone who is perceived as “cool” can get through to people and change public perceptions. To this end I would like to commend All-Pro Wide Receiver Brandon Marshall, who has become a poster-boy for mental health awareness, to the benefit of both the general public and, according to him, himself; we need more role models like Mr. Marshall. Of course, these public figures can always utilize social media to amplify the effect of their message.

Another cultural shift which makes sense would be changing how we educate kids about mental healthcare. My first semester in college, we had something called “University 101”, where students where prepped and talked about the challenges and opportunities present during college life. It seems to me like there should be a similar class required during ones first semester in high school–a common time for mental health issues to arise–with a greater focus on mental health awareness. I also took a a health class in high school, but it focused much more on drug use and safe sex, and not nearly enough about mental health issues.

Often times young people are not comfortable talking to their problems with peers, for fear that news of their issues will become public knowledge before they are ready to be open about them, or used against them by bullies. In such an instance, virtually connecting with groups dedicated to peer-to-peer dialogue via social media (Facebook, Skype, etc.) could offer a way for children to start opening up about their issues to people they can relate too (other kids), without having to worry about those issues coming out in their immediate social circles.

As someone who went from rejecting the very idea of therapy to realizing its incredible benefits, this issue is deeply personal to me. I can say one thing–seeking mental healthcare is by no means a sign of weakness, or something one should be embarrassed about. The open, self-reflecting, honest approach needed for therapy to be effective requires incredible strength of character. This is the lesson we should be teaching our kids–pursuing mental healthcare is a sign of strength, not weakness.

For those who think Mental health issues are only a “rich country problem”, think again. According to a recently release United Nations report, depression is the number one cause of illness and disability globally among adolescents (10-19 yrs old).

In an increasingly complex and global world, it is only natural for new sources of anxiety to affect current and future generations of children. These new sources of anxiety will be reinforced by old social and cultural stigmas related to mental illness / healthcare. In the coming decades youth populations are expected to grow in developing countries, where youth unemployment tends to be highest and (relatedly) conditions are very conducive to mental health problems. The problem will only become more pronounced, unless we use all the tools we have to address adolescent mental health issues in a holistic and inclusive manner.

In a political / media landscape dominated by debates over fiscal responsibility and climate change, the potential of looming global mental health epidemic is not discussed. You want to talk about a “Great Depression”? Aggregate all the lost output that will systematically come out of the global economy if the proper resources are not dedicated to youth employment, mental healthcare and awareness programs. And then there are the linkages to poverty, insecurity, human suffering…