Well, welcome guys. You guys are like a half a dozen more people than I expected at this time. So since it's only like half a dozen of us, for one thing, I have multiple digression disorder and feel free to encourage my relapses. At least then I'll know that I'm saying something you're interested in if you brought it up, so feel free to interrupt. But we might as well do a quick go-around so I can get where you're from because there's basically two parts of this presentation. One's about recovery and one's about college, and if the whole audience knows a lot about one or the other, I can shortchange one and do the other and see how it is. So let's start over there. Who are you and where are you from? Okay. Okay, so you come like me from the world of more adult psychiatry into the college group. Mark, hold on. No, I'm not gonna make them stand at the thing to do this. No, but you. Oh, I should repeat? You have to summarize and say. All right. Something from her mind, blah, blah, blah. Sorry, I'm from the SBC. It's almost like I brought my wife along if I'm gonna get this much instruction. I mean, assistants, she would put it. So the first person, I forgot what your name was, but she said she was from Vermont, from VA stuff, and was working with medical students, not a sorority, and was looking to see how to help college students. So she's from Israel with a student, did a lot of research on COVID things, and the students there pipe in along the way. You have expertise in things that I don't. Hi, I'm a psychiatrist at Student Health at University of Central Florida in Orlando, Florida. That's a psychiatrist from college mental health at UCF. We have a 39-year veteran of college mental health and psychiatry from Lawrence, Kansas. I went to Topeka once for six weeks. Way back in the corner. Hi again. I'm an undergraduate right now. I'm applying for doctorate school in the fall. Welcome. This is an undergraduate applying for graduate school. So Mary Kay is from Toledo, Ohio, long experience in recovery things, and less in the college side. And last but not least. I want to hear what you would say about me. You better watch out with that. I'm from Birmingham, now in rural Missouri. I do feel like I know a lot about recovery, but absolutely nothing about a student of my mom. So Jackie's from UAB, long time, recovery stuff, and a bunch of other stuff she didn't mention of substantial note, but not much in college mental health at all. So actually we have a good combination of stuff, so I'll do some of these. So to give you guys a little background on myself, I'm Mark Reagans. I had a long career, about 30 years working in recovery things at a place called The Village, which became the APA Gold Medal Award winner, and I got the Van American APA Award for Rehabilitation for leading stuff in recovery, written textbooks, and actually a book over here about psychosis along the way, and working with people on the streets, in and out of jail, and homelessness, and hospitals, and stuff like that for many years. And then I left to sort of take it easy to go to a college near me at Cal State Long Beach, only to find that this was not particularly taking it easy, but it was immensely a rewarding work, and I'd really recommend it almost anyways. And actually, let me start with just a few stories, especially for guys who haven't done this kind of work. So I go, and it's like the first month or two, and I'm working with this lady, and I'm working with this lady, and she comes in, she's got a boyfriend, she's going to school, and she's doing pretty well, but she also has a job on the side, and a terrible affair with this married guy, who's like, he treats her badly, and hides her, and all this stuff, and she's feeling bad, and she's just getting worse and worse, more and more anxious, and then obsessions, and panic attacks, and getting worse, she can hardly function at all. So she comes to see me, and I give her, if I remember right, an SSRI for helping with all these kind of anxious symptoms going on, and I said, you know, you don't really seem cut out for having an affair to me, you're not enjoying it very much, and it's like eating you up, and it's tearing up, you know, maybe you should just get rid of that, and go back to your regular life instead. A month later, she does. Another month later, the symptoms have all gone away, another month later, I got rid of all the pills. If that was a 50-year-old, they'd still be with me five years later, complaining the guy hasn't left his wife, and asking, can I have some Xanax on top of this? The college kids actually make big changes in their lives, and use the pills amazingly, and often can use it just temporarily or episodically to get their growth back on track in really amazing ways to get things going for them. So our idea that you have like this permanent, lifelong condition you have to take pills for doesn't really fit nearly as well with them, because they do make these changes, and start missing things in different ways, including people with psychosis, not just these other disorders. So I came to the college side with this recovery background, and I see this giant issues going on everywhere, and they want to do more and more medical model things. Let's do an integrated wellness center, let's do integrated health and mental health, let's make more diagnosis, let's put more people in hospitals, and it's like, wait a minute, that doesn't even work in the community. Maybe the stuff that I learned in recovery could be applied instead. Didn't get too far, but this is, I want to share the efforts of things I did apply to it in ways I think it can be applied. We did some, we didn't some. I did this presentation, I think it's about a year and a half ago, to a group of college medical workers and mental health workers and stuff at one of their conferences, and I had along with me a guy from Florida who was what we in the community would call a peer, and college peers are other students. And for us peers, someone who has other lived experience. So this guy, when he was in college, he had, he tried to kill himself and had psychosis and stuff, and he recovered from the whole thing, became a college counselor, so he was coming from that point of view in the college. So we did this presentation together. So a little of this stuff is his that I'll barely give him credit for along the way, but you'll see the language there. But that's a rarity in college to use people with the experience and having their shared experience, and it's kind of common over in the community side. Even the word peer doesn't mean the same thing on the two sides. So he was part of this presentation. Even though it says that I'm still working over at Cal State Long Beach, last September I left and I'm now back to my community roots. I'm a street psychiatrist working for the Department of Health Services, wandering and seeing homeless people scattered all over Los Angeles because working in college was too rewarding. All right, so I want you to look at this first slide, and I want you to enjoy it because it took me an hour and three YouTube videos to do this animation. Do not expect any of the rest to look like this. It's the only one that looks like this. Do I have to click again to make it work? You better. Oh, here we go. What do you think? Isn't that amazing? That's very good. So in case you can't read it here, oops, here's the slide. So the premise here is instead of we're looking at this desperation in colleges and this huge problem, instead of looking to the medical model, maybe we should look to this outsider recovery model for solutions instead. That's my premise. It isn't well-publicized, the recovery thing is even less. So little review of what recovery is overall and how it's impacted the community mental health. So the idea of recovery is that it's not so much about treating illnesses. This is SAMHSA definition. It's about helping someone in their process of growing and improving in their lives and wellness so that they can direct their lives and they can get their full potential. And usually they talk about it in terms of your health, your home, your purpose, and community connecting. And you can see already that a college student, let's make a wellness center, a wellness approach. Well, when I was in college, I wasn't very interested in wellness. Not until I was like 50-something did I care about wellness when I wasn't well anymore. We're interested in passing enough classes and getting laid and finding a career and getting more independent from my parents. I was interested in growing and developing. So from the very beginning, this saying, this is going to be about you growing and developing and leading your life and moving on, adulting in their words, is already a better meeting them where they're at than the wellness model is. They're not that concerned about being well. And we don't eat right. You don't do anything right when you're a college student. The recovery model is not totally fringe. It did have some substantial converse and credibility. There's two. One is the President's New Freedom Commission. This is going back 20 years now. Went all over the country and said, you know, mental health system is a mess. What do we need to do and how can we fix it? And their conclusion was it needed to be remade entirely as a recovery-based system. And they pushed for that in states all over. And it's been working in some ways and up and down. Tom Insull was running NIMH for years. He recently wrote a book. He says, oh, my God, I spent a billion dollars researching brain chemicals. And I realize now that mental illnesses are not the same as diabetes or physical illnesses. That you have to pay attention to the whole person and you have to pay attention to recovery. And purpose, place, and people is an important part of it. And so how do we do this more? So it's not I'm not being, you know, totally outsider there. There is a substantial movement for this. Recovery is used in a lot of different ways. But I want to emphasize three shifts that I think define the movement. For those of you who are new to this movement, I think are crucial. So it says, I'm doing recovery. I believe in recovery. The question is, are you doing these three things? Did you shift from focusing on treating the illness to helping the person? Is the goal to help you be less depressed and anxious and calm? Less depressed and anxious and panicky? Or the goal to get you away from the bad affair and get your life back on track? Is the goal to help you get less depressed or be able to come out as gay with your parents, even if they reject you so you take control of your own narrative to move on in life? Is the goal to get rid of the psychosis or to be able to be a good musician? Because you can focus on the music when it's not quite as intense and flowing through you and you can actually hear the conductor. Are the goals about the person or about the illness itself? The second one is, is this professionally driven or is it client-driven and collaborative? Are you coming to me because I'm an expert and I'll tell you what to do as a doctor? You're supposed to do. I'm the expert. You're just a kid. I'll tell you what to do for all these things and you'll get a lot better and things will go well. You know, leave the guy just like I told you. That wasn't actually a very collaborative example. Or is it me meeting you where you're at, your goals, me helping with what you want in your life and making choices along with you, helping guide you to make your choices work out as best they can? So it's a collaborative process instead of a compliance process. I'm not taking responsibility for your life. I'm just here for a while in your life. It's your life. I'm here to be like a mentor, help it go better, more like a guide. And the third one, and in some ways this is the least intuitive one, is it's strengths-based instead of deficit-based. I'm not trying to fix what's wrong with you. I'm trying to build up what's right in you. And you're going to see that as a huge shift down the way when we get to college things. So keep in mind those three things are, I think, a brief core of what recovery is really about, making those shifts. And you see none of them are normal in the usual medical model, normal psychiatric processes. And some places do more or less than these. And a good deal of medicine is drifting this way. And there's even parts of medicine like hospice or like AA that do these things more than the rest of medicine in the first place. Anywhere where it's a person's going through some big experience and not just a condition. So some examples from community mental health is instead of hospitalizing people who are on the streets all around us, you've got someone like me wandering around the streets, talking to them on the streets, hoping to get connected to stuff to try to rebuild them, meeting them where they're at. Instead of them coming to a clinic or a hospital to get treated, they come to a clubhouse where they can have a job, where they can have a role, where they're running it for themselves. Where they're running it for themselves and then I sneak in the back and hand out some bills and connect in while they're leading their lives, rather than making them come into a clinical environment. Or instead of focusing on, I'm going to get you really well and no symptoms, what will rebuild your life? So things like supportive employment, education, housing, housing first things, healthcare. And especially things like finding meaning. We're not big in general in the medical model. Let's find the meaning of your depression. Let's find the meaning of your panic. Let's find the meaning of your voices. Let's just get rid of them because they're an illness or something bad. This is more about, can we help you find meaning in this suffering so you can overcome it? Soteria was back in the 70s, was these crisis houses with a bunch of people, staff who used to be really good at LSD, who said maybe we could help this with psychosis too and help you through the process. And people got over their psychosis after a while in crisis residential, being guided through the process to come more to terms with it. Voice here is like a group that you'd say, no, my voices are real and I have to learn how to live with them and what they mean to me and how to come to terms with them rather than they're just something bad to get rid of, waiting for the doctor to get rid of. And that relationships are the basis of what's going on. Any traditional psychotherapist wouldn't think that was weird in the first place, but it has become weird in let's just give you every three month maintenance medicines or something, or let's do it online or something like this. And so they're big on relationships, both of the person, so peer support with someone who's been through the same thing as a key piece. And open dialogue is a system from, of all places, rural Finland, where when someone has their first breakdown, they send people who are really good at family dynamics and family therapy out there to meet with the people and say, how can we keep it going out here? How can we all help him go through this or her go through this process? So that they ended up out for six months, 80% of people with psychotic breaks, never need any medicine and get over it in six months. Because they're so big on keeping you in your relationships and your roles. By the way, think of this one for college, when someone has a psychotic breaks in college, do we tell them, oh, I think you better, it's too much stress to be in class. Let me help you get a leave. And then you got to do this paperwork and then go home and get better. When you get your psychosis taken care of, then you can come on back and we'll have you fill your papers. And if you're doing it, then you can come back. But by then you've lost all your friends. You're behind and you've lost your identity. It's a big mess. Or do we say, keep hanging out here. Keep as much as you can going. All right, you're kind of acting weird. And maybe you're going to flunk these. Maybe I have to do a medical leave at the end of this or something or an incomplete or something. But keep hanging out with your friends. Don't leave your dorm room. Don't leave this stuff if you can't. Let me talk to the RA on the dorm so you can stay where you're at. Let's keep it going. And here's some meds to get it down. And here's some what's going on with you. So get it down. So by the time you're well, all right, maybe you lost that semester. But you didn't lose your identity. You have to regain it. You're still there to carry on with the next semester. The friends and going on. And maybe you acted a little weird in the meantime. You can see how that would apply to college. Would apply differently than our standard way of doing things. So these are examples of things in the community that recovery does. But you go, well, why couldn't the medical model do those things? Those are all reasonable things. You didn't like, well, that thing from Finland was a little weird. But the rest of that, why couldn't we just have those? Can't we have outreach workers and crisis houses and peers and stuff in the medical model? Not very easily. It's been a huge struggle. It's been a huge struggle for a number of reasons. One is the medical model tends to only fund illness-centered things, not person-centered things. They, the medical culture requires people to act like patients. Doctors don't go sneaking into the back of clubhouses and ordering food from them as a restaurant or being on part of the art show with them or sweeping the streets with them while handing out pills. You say, no, I'll act like a doctor. You act like a patient. Our ethics require these huge boundaries. Those like 27 boundary violations you just said in there. And I got to keep my emotional distance and my professionalism. I got to keep the relationship limited and structured away from things. My liability says, no, no, you're not responsible for your own life. I am. If you kill yourself as my responsibility, I'm going to lose my license. I better hospitalize you so I don't get in trouble. And we're held accountable, when we're held accountable for any outcomes at all, we're held accountable for symptom relief, not for quality of life. We say, it's not my fault they don't have a house or didn't get employed. What does that do to me? And we usually require services that are professionally provided in private settings, highly professionals responsible, highly secretive for confidential settings, not things that are out there in the community and connected and public and socially responsible. When we close the state hospitals, we retain the same staffing patterns, roles, goals, culture, paperwork, everything. We kept the same medical model and it isn't working. And we haven't even adapted it. We keep yearning. It's not before any of us were even practicing. We now keep yearning for, can you rebuild us hospital beds? Rather than adapting, we've really failed to adapt for years. 60, 50 years now. And college mental health wants to follow the same pathway. Here's another huge set of stuff that have been developed in the last 30 years and aren't being funded or used much anywhere within community mental health. And by now you can get my shtick that says, all these services are person-centered, client-driven and strengths-based, and therefore they're not part of the medical model system and aren't paid for by the state. And every community should have all of those things and they should be part of what our system pays for. And most of them are way cheaper than our normal services and more effective. All right. So that's the quick background of recovery. For the guys who don't know about recovery or came to college stuff, questions about that piece that says, hey, wait a minute, you just rushed through that. It says, do you get what I mean by recovery here? Any questions or comments? Ready for me to go on? Okay. So I show up at college and I am greeted with slides that look like this. It's neither an exaggeration as long as they're a mental health crisis today facing America's cause. Look at the year this is written, by the way. Things were 10 times better in 2014 than they are today. And they've got these graphs. Look how everything is getting terrible. It's going up and up and up. It's going on in every illness in young people. Here's one for, what do I got here? Some bipolar, some ADHD, some, what is this one? Depression. They're all zooming. I mean, look at the young people, how crappy they're doing compared to everyone else's, you know. So what do we got? We have an, in the 21st century, we have 17 simultaneous deaths. Simultaneous medical epidemics happening within young people. This would be an illness-centered way of looking at this. How can that possibly be true that we've got seven, everything is an epidemic? Here's another one. Look how they all zoom over these years. By the way, there's self-interest in these stats. This particular graph, which is fancier than most of the rest of them, was produced by the people who run college mental health services and say we need more services. They say we need more and more of them. They do these surveys. I don't think they're slanting things, that's the experience. There's more and more people out there that are overall, but they're the ones collecting it. But since I'm a contrarian heart, let me show you another graph. Look at this one. Why is this graph different? This says college student, or this is just young people, are you happy, teenagers, are you happy, pretty happy, or very happy, pretty happy, or not happy? And it's just about flat. Now, for those of you researchers, you can see that's a really bad Likert scale with only three of them there, because most people are going to take the middle one of three choices no matter how they're doing. You really need more points of interest. You really need more points to get the graph. You can say that's just crappy research, which may be. But it may be that when you ask the question from a strengths point of view instead of a deficits point of view, instead of asking, do you have a depression? Do you have an anxiety? Do you have ADHD? If you say, are you happy? You get, yeah, I'm about as happy as the teenagers were last decade. If there really were 18 epidemics, shouldn't that curve be going down? Is there some artifact in the way we've medicalized it that's creating some of these increases? But it isn't just like we're over-diagnosing or more diagnosing, like autism went up and we changed the diagnosis, because the suicide rates have gone up too. So either we're creating the more illnesses and we're actually creating suicide too, or we're noticing something going up. And I'm going to have opinions about that along the way that says the lens we're using, this medical model lens, may be part of the reason we're seeing a giant epidemic and perhaps even co-creating a giant epidemic. Even in colleges, and most colleges don't actually do a lot of medical billing for things. You don't have to have diagnoses to come in. You don't have to say it's a serious persistent mental illness and you don't have all this other stuff. Even there, you must medicalize your suffering to get services of a variety of kinds. You can't get accommodations or support for being shy. You have to have a social anxiety disorder. So let me give you an example. I got a lady who, she is super insecure and anxious. She doesn't think she's worth too much, and she's always thinking about what other people are thinking about her and think they don't like her, and she stays quiet in the back of the room and doesn't say anything. And strange enough, she wants to be a film director. Spielberg spent a year at Cal State Long Beach, so we have a lot of students who want to be film directors. So she wants to be a film director. But she never speaks up at all. I give her some, I think it was Zoloft, lower that negative thinking around, and she's no longer obsessing about what everyone's thinking about her, and she speaks up in class. And the teacher says, there we go. There's the talent I always thought was there. I got this opportunity this summer for this theater directing thing for you to do. Where are you interested in going? Did I give her medications for being shy that changed her life, or did she have an illness of social anxiety disorder that she should take medication for the rest of her life for, or chemical imbalance? One of my friends said, what are you doing, treating shyness with SSRIs? Well, it was disabling shyness that ruined her life, and her life went on a whole different course with some. Do we have to label everything as an illness to justify treatment? You can't have a dog as your best friend in a lonely apartment or dorm room. The dog has to be medicalized as an emotional support animal, which you're not too late to leave the room and go here to how to fill out this form, because one of the things this medicalizing does is doctors have to fill out a pile of forms to medicalize all these things. It can't be hard for you to study and take classes and focus because you're daydreaming or restless or distractible. You have to have an attention deficit disorder in order to be able to get tested or timed or in a different office or by yourself with no distractions. Sometimes this goes to the rest of society. They didn't believe there was something wrong with me. It was all in my head until I got a diagnosis. Now I know there's something wrong with me and I can tell them. Even in the college setting, we're forcing everything to be medicalized to get a variety of ... to get patched or extra time or a bunch of things. What's wrong with just supporting students because they need help without forcing to be medicalized? Even the pandemic. Notice these, how they write these. Pandemic causes a spike in anxiety and depression is the headline. Then the graph says these are symptoms of an anxiety disorder. Are you sure they're not just anxiety? How do we know they're symptoms of the disorder or it's in a depressive disorder? Notice by the way on the far graph on the right side that young adults will be more likely to describe themselves this way. Did the young adults really get more messed up in the 65 years old or they were willing to answer a survey that say I have symptoms of an anxiety or depressive disorder than the older people? Are they more buying into the model? Which we usually think is a good thing. Look there's less stigma. They're willing to come for help. But since we said the only way to come for help is to medicalize, we're forcing them to medicalize their experiences and they're doing it. My dad lives in an assisted living thing and they were way more messed up than the college students at that place and they wouldn't have said they had a depressive or anxiety illness to save their lives. They wouldn't see themselves that way. And one of the shames of this is people come in saying I'm anxious and depressed and that becomes the extent of their emotional vocabulary. The way they're experiencing all these wonderful and tragic and heartbreaking and disastrous experiences that we went through in college get reduced to I'm anxious and depressed. All the emotional growth by going through all these heartbreaks and sufferings and all this stuff gets reduced to I learned how to handle my depression and anxiety. All the helping late at night, your roommate down the hall or whatever going through this got to I know how to help people deal with their depressions and anxiety. All the rest of this marvelous emotional world becomes unexplored and the more we do that, the worse your mental health gets because materialism itself, I mean we already got rid of the spiritual part of our world for the most part 100 years ago or so, 150. Now we're in the process of getting rid of the emotional parts of our world. If all we leave it with is the technology and materialism, we're going to be really, really mentally messed up. So here's something I learned in college. You guys don't know about this. In college, things decolonizing is a real important thing. So the guys from the college know this one, but I'll explain it to you all. So I did a trip. This is in the 80s. I went to China for a couple months. Back it was when it was barely first opening, they're still wearing Mao suits and stuff and I went and learned about Chinese mental health and I learned about the Chinese medicine and regular medicine and stuff. I traveled all over the country. It was really, really cool. Somebody else paid for it. And what they told me was when they go to the rural countryside, they had barefoot doctors then because they just give you like a couple week training program and stuff. And they give you a little decent. It looks a little like I went to a program the other day where we were teaching primary care doctors how to do psychiatry. That's how they taught the barefoot doctors. Kind of like here, they have this two weeks to learn how to give some antidepressants and stuff. And they taught them DSM-5 and they go to these rural areas. And the people in the rural areas did not say they're depressed and anxious. They said there's stuff with their ancestors and I've got weak nerves and this spirit is getting me and I've got this weird thing that my testicles are crawling back up into my body and all this stuff. But they stuck to it and they taught them that this is somaticizing, that you really have a depression, an anxiety, a psychosis, a bipolar, and it's just expressing itself physically because you're like too ignorant, not psychologically minded enough and not American enough to do it this way. But I got this book that proves that this is how it is. And after a while, people started coming for the help because the pills actually are pretty helpful. The pills would say, I'm depressed and anxious. After a while, not only did they say that, they started literally experiencing it that way. Their distress started being major depressive symptoms, so I'm hopeless, I'm having all these things going on. Instead of my ancestors are bothering, I can feel my grandfather. The old things literally drifted away as the professionals colonized them with our way of understanding distress. We're doing that to our country overall. We are colonizing it with our way of doing it. Those quotes came from the peer who was even more pissed at this stuff than I am. One of the things our colonizing efforts, our medical model efforts, our DSM efforts, have not been willing to include or input in our vocabulary is childhood trauma. Poor Dr. Van Der Kolk. How many of you guys know Dr. Van Der Kolk's work in The Body Keeps Its Score? All right, for you students in the back there. You're nodding. You know this one too? The undergrad? I started reading this book, but yeah, I've seen a lot of people talk about it. Good for you. He's tried his hardest to turn child trauma into a regular diagnosis and make it look like a Chinese menu like the rest of them and do the studies and the validation, and they keep throwing it out. And look at the quotes of why they throw it out. Because no new diagnosis was required to fill a missing diagnostic niche, and the notion that early childhood adverse experiences lead to substantial development disruption is more clinical intuition than a research-based fact. These are the people writing our Bible. By the way, all right, how about a little piece of research? How about the ACEs study? How many guys already know the ACEs study? Everybody already know it? The ACEs study demonstrates that the more childhood trauma things go through, and these are things like physical and emotional abuse and parental violence and domestic violence and someone getting arrested and stuff like this. They correlate not just with medical things. They correlate with the whole rest of your damn life and all kinds of things. This isn't a clinical intuition that childhood trauma makes a big difference. Hang out with me for like a week on the streets and talk to homeless people and stuff. It's a clinical intuition that it's just coincidental all these people have the absurdest childhood trauma. Dr. Carl Bell, I know a couple of you knew, died a few years ago, or maybe one or two years ago. I don't know. I lost track of time through the pandemic. For those of you who don't know him, he was an extremely brilliant black guy. He was a doctor. I think he became a doctor. He was like 19 or something. He was South Side of Chicago. He wore a cowboy hat and was really outspoken, and he ran this giant program for kids in South Side of Chicago. He was friends with like Oprah and Obama and stuff. His whole thing was about prevention and protective factors. I'm in a lecture with him one day, and he shows this graph, which I cannot for the life of me find his graph, so I've made my own that isn't nearly as good as his. Those aren't real numbers. This is just copying Carl's real graph. The first line, the blue one, says, the more bad things happen to a kid, the more mental symptoms they're going to have. Unless you work for DSM-5 board, this is not news to you. Everybody believes this. But he says, that's in the absence of protective factors. If you have protective factors, it mitigates the risk, the damage from your risk factors. So the line is almost flat. Now I'm paying attention. What are protective factors, Carl? Enough money to make it through the month and a little more for emergencies. A reasonably secure place to live. Some family support. It doesn't have to be a perfect family. It can be a dysfunctional family, but some family support. Some other caring adults that are there, he would call that a protective shield. That could be like teachers, neighbors, ministers, professionals, stuff like this. Some role in life besides mentally ill or bad kid. All right, I have to do digression here for a minute. The college I was at, Cal State Long Beach, is the lower rung below the UCs than there's Cal State Universities, and they cost a fair bit less than the UCs, but it's a full four-year university. So it collects up people who have tons of talent and no privilege. All these kids were at the bottom. They had the same tragic childhoods as my homeless population that I was dealing with before. The first year, I was, what is different between these kids and my homeless kids? They even sometimes came from the same family. They identified themselves as something besides a messed up kid from the beginning. I'm the smart one. I'm going to be the artist. I'm a filmmaker, and you saw Spielberg's movie about himself. I'm the filmmaker from the very beginning, so he goes through all that stuff. He had a lot of protective factors, too, when you get right down to it. They had an identity as something else that got them through, and that was one thing. Two was, they weren't heavily into heavy drugs, and I lost what three was. Oh, hopefully it'll come back to me. Oh, they hadn't gotten involved in the system. They weren't in child welfare, and they weren't in child juvenile justice. They weren't in these things, so they hadn't been labeled and diagnosed and identified and given these roles by us as a system. That's that protective factor. You have roles in life besides mentally ill, bad kid. Carl doesn't have these next two, but I think they're sensible. If you have some spiritual connections and sustenance, that seems to help out a fair bit, too. If you're in a church of your own, however you do this, your family or something. We can go back to the psychoanalysts. If you've got a better psychological or emotional strength and you've got better defense structures, that's better, too. That protects you from bad things making you fall apart, too. Most college students, even the ones with lots of childhood adversity, have significant protective factors. The street people have none of those. If you're going to do a strengths-based intervention, maybe it's about building up protective factors instead of treating risk factors. I think Carl would have approved. He said, you got the message, Mark. If I'm going to bash illness ways of looking at things so much, and that's why we were all taught to do things, what's my alternative here? I don't believe we're all loaded with huge piles of underlying neurochemical imbalances that have been suddenly triggered and need to be rebalanced. I don't even believe illnesses are the cause of our distress. I think they're the result of our distress. Illnesses are common form clusters of human suffering. Common clusters of suppressed development. What I told the college kids, I said, you know what? We live in an era where we medicalize everything, where we talk about diagnosis and chemical imbalances and pills to stabilize your chemicals and genetic predispositions, and there's some usefulness in all that, don't get me wrong. Here with you guys, especially, I take a more developmental approach. You're born with whoever you are. You've got your strengths, your weaknesses, your talents, your temperaments. You even got a blueprint for your growth and development, comes in the factory packaging, and then life happens. Sometimes it's warm and supportive, and you blossom and grow. Sometimes it's abusive and cruel, and you get all twisted and bent and growing in ways you never expected to. By the way, I put it that way, in growing in ways you never expected to, rather than being destroyed or killed in ways, because I'm going to point out how having an alcoholic father doesn't just make you weird, it also makes you more sensitive. What are the strengths you got out of this altered development? Some people have grew in ways they never expected to, and a lot of people have both. Some supportive things and some abusive things along the way. You've been going along like this, and now you've gotten stuck, and you can't grow and develop anymore. You've gotten stuck. Maybe you've got no energy left, and you can't get anything done. Maybe you're stuck on your phone looking at social media all day. You're stuck with these negative things, what's everyone thinking about me all day. You're stuck in your fantasy world with these voices talking. You're stuck with these panic attacks. You're stuck with anxiety. You're stuck being on pot all the time. You're just stuck. The main thing I want to work with you on is not to treat an illness, but to figure out if you're stuck, how it can help you get unstuck, including meds might help you get unstuck, because sometimes part of the reason for being stuck is that your chemicals have gotten messed up, and maybe I can help you get unstuck. The hard goal here is for you to get stuck, and then you can go back to growing and developing with the person you were meant to be, until you know something else happens 10 years down the road, and you end up messed up by your husband, and your kids are a wreck, and something happened to your boss at work, and you get all stuck again, and then you've got to come back and get treated again, but at least you'll know what is going on that time. They like that so much better than, here's your diagnosis. Take these pills forever. You've got a chemical imbalance. They say, yeah, I feel stuck. That's why I came here, and they are good when you give them a little chance to get unstuck, actually. From this point of view, suffering isn't meant to be diagnosed and eliminated as a distasteful, strange experience. It's meant to be learned from, and you're only going to grow to be a more full human being by learning from your struggles. You're going to do the same damn thing over and over again. What can you get out of this one? How can you grow? This is a growth-oriented model. That's why I tell them, instead of, here's your diagnosis. Why are they having so much difficulty, if we assume there isn't a bunch of epidemics happening, and this is before COVID that I wrote this, but still true, is that for the first time in history, as far as I know, in the last 50 or so years, and mostly in this country and a few others, we've decided that you should be able to do whatever you want with your life and grow to meet your potentials and your passions and do what you want. Up until this point, you didn't get choices. My father thought it was absurd that we gave our kids so many choices. You became the same religion your parents are. You believed in gender the same way. You had the same racial biases your parents did. You lived in the same part of the country your parents did. You spoke the same language they did. You married someone with the same beliefs as your parents. They had to even approve, or maybe they picked them out for you. You didn't have all these choices. Now we have people have their own choices. On the good side, this has unleashed an amazing amount of creativity and individuality, and people have been stuck and repressed. We don't have movies anymore about, my father wants to make me work in his factory, and I don't want to be making shoes for the rest of my life. We don't have movies that look like that anymore. It's almost like the most popular plot in the 40s. Or they're making me marry someone because it's suited to my station, and I'm really in love with the maid instead. We don't have stories like that anymore, because we go ahead and do some other job or marry the maid. The downside, though, is, you know, right now, my headline there is about we start writing our own marriage vows. You don't just take what the minister doesn't get to tell you what being married means. You get to make it up yourself. I don't necessarily agree to obey and whatever to you until, no, no, I'll tell you what I agree to. We'll just make it up on the spot, or at three in the morning the night before. Never mind. That's my part of the story. Making up everything as you go along is really hard. Add to that the financial problems of the old people took all the money and it takes to about 30 until you figure this stuff out. But you're going to be struggling. And even if your parents say, I want you to be happy and do whatever you want, they really mean, as long as it's kind of like what I believe in, I didn't really mean you were supposed to like turn into a girl or marry a black woman. And you get these conflicts where then you start acting one way with your family and another way with your friends. And as you start growing more and more, you get torn apart and feel tons of guilt. And you've got two sets of clothes and sets of lies and it's hard to keep track of these things going apart. And lots and lots of college kids are in the process of tearing themselves in two. It causes a huge amount of distress in today's world. And it's a necessary outcome of this freedom and individualization we do things. This plays out even harder for East Asian and other traditional cultures that come with all this family stuff and this collectivism that they're supposed to be loyal to their family and doing all these things. And you're not just telling them to find their own path, you're telling them finding your own path instead of a collective path. From the very beginning, you took them on something else. And you have therapists that are just enraged in college places. What do you mean you're taking care of your mom and this and she's holding you back and she's letting you do this and you're making you miserable in all these ways? You should just do your own thing. Almost always when the person comes from a culture different than the therapist. Because you don't get why Moroccan men have to act like that. How would I know how Moroccan men are supposed to act? This guy goes like, no. Notice how this formulation you're never going to come to with a medical model. Only if you think developmentally will this be something you can point out to students and many of them say this. So, your depression isn't because you have a depression. The most common causes of these things when you look at them in college settings. Number one is relationship breakups. Always has been and always will be. I'm almost not a doctor because, well, it wasn't even a relationship she didn't like, but that's not the point. These sorts of things mess you up for long enough to ruin your grades and send your life in a different way. Broken, these are my diagnoses in the college system. Relationship dreams. We tell people you can be whatever you want to be if you just want it hard enough. Except that everywhere there's a competition in our school or someplace, there are losers. Not everyone gets to be the starter on the basketball team or on the touring band. Not everyone gets to be in the special research program for physicists. Not everyone gets into nursing school from the pre-nursing. That's the number one thing to get messed up in our school. Not everybody gets to pass or get an A or a B in organic chemistry to keep on their pre-med going together. Not everyone gets into the director track or the MFA, the fine arts, BFA, fine arts track. Everywhere we've got some selection built into it, everywhere there's a competition, there are people who have broken dreams on the other side. Our school structures are always big on supporting the people who got in and not checking out the damage you did to the people who didn't get in. I talked about the next one. Your dreams are moving further away from your family's dreams. This can be real cultural too. I'm Filipino, I'm supposed to be a nurse and I want to be a filmmaker. I'm Cambodian, I'm supposed to be in business. I'm supposed to be computer things. These generalizations, these stereotypes actually have a lot of family pressure behind them. Breaking through can really disappoint things. To a Hispanic girl, why are you going back to school? When are you going to have grandchildren for me? Your comfort zone isn't big enough for your dreams. That shy person, if she wasn't trying to be a film director, she wasn't too shy to be kind of shyly going around. If you put her in the same place where she'd just go into whatever family and marry her high school sweetheart and stuff and hang out in the small town, it wouldn't have been a big problem being shy. It's a problem because her dreams are bigger. I tell them, you've got a choice. You can lower your dreams to fit into your comfort zone or you can do some hard work of increasing your comfort zone. Maybe some pills, maybe some way to deal with anxiety, maybe dealing with your folks, maybe coming out. Things to make your comfort zone bigger but right now your dreams are bigger than your comfort zone. Notice how that's a strengths-based not illness-based person generally looking at it. A huge amount of sexual assault and relationship based abuse, it's just absurdly common and really devastating, especially when it's not just that you were sexually assaulted but you really believed all this stuff that we tell, especially the girls, that if you do this and you say no, he'll have to stop and you'll be protected and do those things. And then when he doesn't, not only were you assaulted but your belief about how the world is, your trust in the world and all those people told you got shattered too. Your whole world concept got shattered and it's going to take a long time to pull that back together. My favorite one is people showed up like a month before graduation. I remember the guy the first year, I've gotten to the end here and I haven't kissed anybody. I was like I don't have any medicine to fix that. And you're right, you had a better chance of kissing someone in college than when you're done. You're not ready to grow up, what am I supposed to do now? Especially I don't have enough money to buy my own apartment to stay moved out anymore. These are person-centered developmental strength-based conditions and diagnoses that they can relate to meeting them where they're at in a developmental adulting point of view rather than in a wellness center point of view. So I'll go through a list of specific things we can do in the college that can make a, that will be recovery-based, a whole bunch of technique things. This one, so our traditional clinical approach, you guys, how many guys know mental health first aid in your colleges? You got that one? And QPR for the suicide prevention? Both these approaches say don't feel bad that you have an illness, it's sort of normal, go see a professional and then you'll get treated from your illness. They're both illness-centered approaches. Emotional CPR was invented by Dan Fisher who is a man who has an MD-PhD, got psychotic, got schizophrenia while he was in school in the labs. He was hospitalized for a long time, recovered from it entirely. He's off meds and is a psychiatrist designing all kinds of programs and cool stuff who recovered from schizophrenia. And he's actually saner than I am which isn't that high of a bar. And emotional CPR says don't turn all these things into illnesses. What can I do to be a good friend to create the relationship that you can get out of your own little world? See the picture, he's out getting out of one world to connect so you're feeling with other people, you're talking to other people, you're connecting with other people. Built on peer things, built on trauma support things. Instead of teaching people, don't feel bad you have an illness, go to a professional, get them to treat you. We could be teaching emotional CPR instead of mental health first aid. It's a person-centered, strengths-based, collaborative approach. So active minds is a thing on college campuses. As many things on college campuses this comes from some tragedy. This is a girl whose brother was I think at Princeton and he ended up with a depression, a suicide attempt. They took him out of school, he wandered around for a couple years trying to get better and various treatments up and back. Tried to come back, couldn't really, and then killed himself. And his sister was, what? How did that happen to my wonderful brother? And she thinks secrecy is a huge piece of things. We need to open up things and so this is one example of the kind of thing they do. This is send silence packing all the backpacks of your secrets put out there. Or you put out, you sign to your secrets going on to try to be more open about it. No, I'm doing a presentation. And if you have a disabled 88-year-old father, the, that shouldn't be on tape. Notice though the chapter of Cal State Long Beach. Look at what their meeting agenda is. They're going through eight different illnesses with, and the description of the illness is. There isn't one there about helping people be less secret. There isn't one about sharing emotions. There isn't one about accepting parts of yourself. They too got entirely medical modelized even though that's not what it's about. They've gotten co-opted by the same thing. All right, Winnie the Pooh. Many, many of you have seen this thing before. With all the Winnie the Pooh characters given diagnoses of various things. I looked to see where this came from in the first place because I was doing a presentation. It comes from the Canadian Medical Association Journal, which suggests that the characters are better off with psychoactive drugs and more parental guidance. We cannot but wonder how much richer Pooh's life would have been were to have a trial of low-dose stimulant medication. Why low-dose, by the way? But that's not the point. Now, let's think about Winnie the Pooh for a minute. This is not a messed up pathological kid until he becomes famous because of the book. He's just fine. Well, he's not exactly fine. He's out in this countryside manor and he's playing with these animals. His father is like this English professor. He's like hoity-toity and he's really upset that Winnie the Pooh books got famous instead of his academic stuff. I think there's a mom around to help guide this stuff. He's playing with his toys. He's working out his own emotions in some creative way, the various parts of him. The two things that keep Winnie the Pooh alive to this day is that every character gets to come on every adventure without having to change. Nobody says, Tigger, stop bouncing up and down, being so hyperactive. Nobody says, Eeyore, stop being so sad. You get to come exactly as you are and every character makes a contribution to every adventure. These are not parts of you to be medicalized and coped with and gotten rid of and medicated away. They're parts of your personality you're going to be empty in a hole with if you don't got them anymore. And now for the bizarre question. These people weren't psychiatrists in 1930 or whenever Winnie the Pooh came out. How did they so cleverly come up better than DSM descriptions, come up with characters that impersonate our illnesses so well? These must, the things we're calling illnesses must be natural parts of kids and people in all of us that have gotten hyperdeveloped or stuck in or taking over for some reason, but they're in all of us. Looking for a genetic basis, Christopher Robin, a genetic basis for all of them to look at all the characters he made. And probably so to all of us. These illnesses aren't some weird thing. They're pieces that need to be integrated for all of us to be whole. The picture there in the bottom is from the movie Inside Out was making the same point. The kids have seen it more often. Although Winnie the Pooh for a hundred something years old, people still don't. And maybe every time something terrible happens at your campus, like someone kills themselves or someone gets shot or there's a shooting or some weird thing happens, instead of bringing out an army of your psychologists out of your counseling center to try to process this, we should bring out an army of peers and teachers and artists and elders and make a giant quilt and a drama thing and do something that helps us all work in all these feelings rather than, oh, yes, I'll make you an appointment at two. You can have an appointment at four. You can see me next to you at two. Because you have serious issues that need to work through. Not that nobody should come to counseling. But are we neglecting the huge strength that we've got laying around in all the rest of the campus? All right. To make it up to date, Toy Story. It's got the same characters again, by the way, doesn't it, when you think about it? We've diagnosed all those characters. With one big exception. This time, the creators are these male animators at Pixar who like playing with shit. So they're down there playing with their kids, unlike the English professor E.E. Milne. So they write themselves into the story. Woody is a father. Right? He takes care of him, comforts everybody, keeps him going and so forth. But we've got the same thing going. Fast forward to Toy Story 4. How many of you saw Toy Story 4? Just two of you. All right. So two is quite good. Three is a mess. Four is quite good. So you get to four. And I will give away a little plot of four if you don't know this. That character at the bottom is called Forky. So by this point, all these toys are with another little girl and she goes off to kindergarten. And the first day of kindergarten, she's supposed to make something out of a craft thing and they give her a box of stuff. And this other bully kindergartener comes and pushes it down and makes her cry. And I forget actually how he does it, but Woody like cheers her up and puts it and gets her back to doing it a little bit. So she puts it together and she's struggling and crying and putting it together. And she finally puts together that thing there, Forky. And because of her great love and her energy she put into it, Forky comes alive. And Forky thinks he's garbage. So Forky jumps into the trash can. And the father figure, Woody, pulls him out of the trash. No, you're not trash. He loves you. You're alive. You're precious. This goes on 187 times in the movie as they go through and through. He keeps jumping in the trash can and Woody keeps taking him out over and they go through a whole pile of adventures with that going on in every scene. By the way, finally in the last scene, she's now in first grade. Starts in the same way. They're making some project. She makes a little girl character called Spoonie. Spoonie comes to life and jumps in the trash can. And Forky says, you're not trash. Come on. I don't get how I'm alive. I don't know how either. It's magic, but you are. Peer support has moved on to Forky helping Spoonie do this. In our current world, remember the slide about making your own vows. We make young people create their own everythings. And if by some miracle manage to put together some job thing that works in their life, they think they are trash and they jump in the trash can. And we as the elders are not doing very well at pulling out of the trash can and saying, no, no. That's magical what you just made. That's so cool. It's different than anything I've ever seen. It's an individual. You go for it. That's strength-based. Suicide. The most common paradigm in suicide prevention today is thinking about suicide as abnormal. There's got to be something wrong with you. That something wrong is probably a biochemical mental illness. You should overcome your fears and stigma and get some treatment so you won't be ill and you won't think about suicide anymore. This is a QPR thing, question, persuasion, referral. Normal people don't think about suicide. Except that when the CDC did a study, they came up with this really weird controversial thing that said 54% of people who kill themselves don't have a known mental illness. Which most people then wanted to explain away, well, that's because they didn't see, they were undiagnosed, probably most of them are this or that or suppressed or something. They probably all do, we just don't know it. Or does 54% not? So they went on and said, well, why did they kill themselves? There's a set of reasons that look surprisingly like quality of life problems and growing up and adulting and the things that go wrong with all of us. The factors that contribute to suicide are the same whether you have a mental illness or not. We can only help it if we do person-centered. If you just get their illness away, if they happen to have an illness, without doing anything about all seven of those things, you're still in trouble. But the hardest thing is to have a normal conversation about suicide with somebody. Even if you've been a therapist for a long time, how many guys have had more than four people kill themselves that you've worked with? How many got more than two? How many got more than one? How many got zero? How many of you guys got it? Nobody ever killed themselves that you guys? Yeah? I'm a therapist, I'm a researcher. A researcher? Oh, so they work with medical students, they kill themselves regularly. My point is, even for people who are experienced therapists, we don't have that much experience with completed suicide. It's beyond most of our normal experiences. I happen to have seen a lot, it's like six or seven, but half those are in my family or friends or classmates and scattered around. All of us are inexperienced, really. All of us are frightened of suicide where someone kills themselves and there is liability. You can get sued for someone killing themselves. It's also just inconceivable. Why would this person have killed themselves? They're such a wonderful young person. It's incredibly hard to accept that we're powerless. This is important because our most common ways of talking about suicide are not talking about it, are either minimizing it or saying, let me do an assessment and see if you need to be in a hospital. We don't approach this with the same respectful curiosity we approach everything else. So tell me about those feelings. What's it like to have them? What's going on with that? When do they start? All these things. This is in a whole world by itself. But it isn't in a whole world by itself. Here's stats, I forget from what year, I think 2018 or something like that. What I want to point out here is that 99.6% of people who have suicidal thoughts aren't going to kill themselves. Which means if your conversation was just about the risk one and should they be in the hospital or hospitalizing them, you gave the wrong treatment to 99.6% of people. And when you did that, you made sure they'll never come back and talk to you again about it. Not to say that there wasn't .4 that didn't, that's tragic and hopefully you can find those. But we need to have an approach that actually supports everybody who's thinking about suicide because there's 9.8 million people who are thinking about it. And it's tons of college kids. It's amazing to me the difference. College kids, I tell you, half or two-thirds of everybody I have thought about suicide. Homeless people, almost nobody. I don't know. This is a slide that comes from the peer guy who says, if you've been through suicide yourself, you're much more likely to be able to have a normalizing conversation about suicide. You need to have somebody in your clinic, probably a peer, who they can talk about suicide who isn't going to jump to hospitalize you, isn't going to get all freaked out, isn't going to do some stuff who can actually say, I've been there, let's talk about it. If we've got all these suicidal kids, it's an essential component of college health and mental health to have somebody who can have a conversation about suicide with all kinds of people. By the way, for those of you who don't know motivational interviewing, you can use motivational interviewing stages and think about suicide as another ambivalent decision. Some people are in pre-contemplative, you never thought about it, they're in contemplative suicidal thoughts. They've got suicidal intent, they're in the planning stages, they're in the action stage, and then there's people in the sustaining stage that they survived afterwards. The same way you have a different approach in motivational interviewing, meet people where they're at, you can do for suicide. It can be normalized. This is a website in 2010, it says the vast majority of people who try to kill themselves end up dying from something else, like 90% or something. But they go around with the knowledge, there's somebody who once did try to kill themselves, look how weird I am, I'm beyond the pale, I'm so strange, I'm so weird, I can't be trusted, I got that in my history forever. They've got this scar and this weird shame to it. That needs help with the sustaining, staying away from suicide, talking about that, connecting other people, normalizing. This is a website of a bunch of people talking about why they tried to kill themselves. It's not suicide prevention. This is about, after you've tried, living with the fact that you tried. This was at a high school. My wife drags me to 100 different things in the community. She dragged me once to a walk for suicide. That in itself is amazing, a walk for suicide, really. I went to a breast cancer, I got lots of them, for suicide. And we were at the high school. It happened because a couple of kids in that high school killed themselves and the counselors arranged this, normalizing it as a campaign. They came with this national campaign, which has all these beads, and they asked which category you fit in, and you would wear the necklace for the one you fit into. Almost everybody had at least one necklace and maybe some more. It was the most touching moment, got back from walking. All the people who have lost a spouse or a partner, raise your hand, and you can look around how many there were. All the people who have lost a parent, have lost a sibling. People keep raising and lowering, raising and lowering. We're going to have to have a society soon where lots of people have experienced someone close to them killing themselves, and we're not ready to deal with that secondary response. All right, how about meds? All right, I did this actually already. So this is the business, remember the business about your gut stuck along the way. So how am I going to ... Meds are going to help you with being unstuck, not help you with an illness. So I want to prescribe, and I use for them the word sustainable. Like I'll say, antidepressants aren't, they're not, they don't do anything much in an hour, and they don't make you feel good. And they go, so what kind of stupid name is antidepressants for that pill then? Well, what's good about them is that they keep where they're sustainable. I'll start with they're not addictive, but more important of the cost, they will keep working. It won't wear out like your pot is worn out. You already learned you can't sustain pot. You can't sustain caffeine. You can't sustain alcohol as a way of coping with it. These things you can take as long or as short as you want. Maybe for a year, maybe longer. I don't say you have to take it forever. As long as you want until you're unstuck and have moved forward. It's now grown this. It's linked to getting unstuck with the goals. You have them trying to get closer to, shared decision making. You're using the pills, not just taking them, and how to get off of them. The questions I'm asking from a recovery point of view is not, am I effectively treating their illness? It's, are you less distressed? Are you suffering less? Are you less dysfunctional? Can you now sit in the class and do things? Can you talk to a girl in a bar? When are you now growing again that's being stuck in your development as you move forward? If you're moving forward, that's good. I didn't promise you you'd be happy. So example, lady comes in, got all kinds of negative thoughts about her and stuff. And she comes in, she keeps rounding her head, round and round, circles, negative stuff. And I give her a little Prozac to help with that and to lower her sound. She says, a few weeks later, she walks by a mirror and she says, is that what I really look like? I thought I looked like Shrek or an ogre or something. And I said, well, you're not J-Lo, but you're not bad. What do you think? Can you live with this? All right, I'm old, so I picked J-Lo, but maybe, never mind. Can you imagine the difference it'll make in her distress, her function, her development to look at herself more realistically, how she looks like instead of an ogre? Who is she going to date if she's an ogre? What's she going to put up with from her boyfriend if she's an ogre? What's she going to try to do as opposed to, she's fine. Instead of diagnosis, you've got a depressant or bipolar, what are the symptoms of being stuck? And I've got meds for almost all those things. Basically Wellbutrin and Prozac, and occasionally Abilify. So for example, I say, so let me tell you about antidepressants. So give an example, this plays out. Let me tell you about antidepressants. I've got four different kinds of antidepressants. What they have in common is they don't do anything in an hour, but they're all sustainable. The first one, you know that thing about, you know the word ruminating, which they never do, but it gets stuck in the head when I ask that question. That word ruminating, it's like a cow is a ruminant, it chews on its cud like you're chewing on your thoughts over and over. Oh, yeah. Believe it or not, they invented a med that helps with that. And you already know that going around in your head makes it hard to sleep, makes you anxious, makes you depressed, makes you have trouble with social things, can make you panicky, worry about your weight, get obsessive, it can do, so they market it for like eight different things. It doesn't do like eight different things. It does one thing. It makes you spin less around in your head going round and round and round. I got a pill that can help with that, which might help you. Second one I got is, you know, this one is more about your body. You know how you keep your emotions in your body and it's all felt kind of sluggish and weighed down like the weight of your shoulders will roll on you like you're in mud and like you can't hardly move and you can't go and nothing is fun. There's this black cloud over you. I got these pills that kind of help with that. It's more, it's as much your body as your mind. We used to call this vegetative depression, kind of get you feeling more alive to do things. Athletes choose this. People with no psychological mindedness choose this. And they get... Third one, this one's in a class by itself, but it's a stimulating antidepressant. If you like caffeine, if you smoke cigarettes rapidly, if you like to use some Adderall from time to time for things, you like sativa instead of indica, just some energy, it might help you feel more together, might be more in control of things. Students who are moms choose this all the time. You might be more in control of things. This might help. And at high enough dosages, it can... Not as good as Adderall or Ritalin, but it can be a sustainable stimulant that can help you get off the Adderall and Ritalin and just make a mess or not have to use it if you didn't like it in the first place because Adderall and Ritalin aren't sustainable and this is. And the fourth one I got, which college students never choose, is I got ones mostly about sleep, Remeron and Trazodone. If you've promised to sleep like eight or nine hours and you just got terrible dreams and night terrors and stuff, I can just give you a good night's sleep, I'll be okay. Of course, no college student has ever wanted to have a good night's sleep, so they never choose this one. Notice though, I'm not... And they say, what are the side effects? I say, you know what? If we do it carefully together and start with low doses, you've got an 80 or 90% chance of having no side effects on any of these. But you might be one of the unlucky 10 or 20%. If you are, it's good to have a second try so we can switch to a different one. But let's not assume you're going to be unlucky from the beginning and choose from side effects. Pick the one you think has the best chance of working for you. And if we run a side effect, we'll choose a different one. But choose the one you think is going to get you unstuck. And then more choices. We want to start with a low dose or a high dose. You want to go fast, you want to have control, you want the one that comes in little teeny ones to build your way up or the one that's trying to... One, the Prozac, you just take it and if you forget it for a day, it doesn't matter because it's got a half-life of like two and a half days. Keep them in the driver's seat. When I write a note, I read them all back to them. Here's your initial assessment. I read it back. Forced me to write in their language, person-centered. All right. One story, a couple of you know, but a story from this. Guy walks in my office late one afternoon. He holds up his hand like this. He says, what do you see? I said, I see your hand. He says, no, no. Be more specific. All right. It's late, but I can do this. I can see the swirls of your fingerprints. Everyone is different. I can see the creases between your knuckles and I can see your love line and your life line. I don't actually know which one's which, but I can see them. He says, when you can see nails and knuckles and hair, then you'll be able to start helping me because you'll be seeing the world from my side instead of from yours. I read back. I write the note in their words from their side and say, did I get it? If I didn't, let's change some words. I'm going to put it on each note so that each one, because I'm not going to be seeing them for the rest of their lives. Each one. So what we were talking about last time, and I'll write down what was together and what you thought about it. Now, what did we say we were going to work on? I read the note, read the note, read the note. I wrote a lot to them, each one as they go along. And then we get to the end. It says, can I have my record or something? You already know what these records say because I've read you every note along the way. It's not a secret of anything. They can stay there secretly. You can sign this paper. I'll just hand you them written out, or if you want them sent to someplace, you can do this form. I'll just stay here. It's no bizarre, weird thing, these records. They've read them all. I pay attention a lot to culture and identity. Their goals, not mine. It's their decision-making. Lots of choices. And we've got them putting together the prescribing. The normal prescribing pattern is you take a history, you make a diagnosis, you give some treatment for the diagnosis, you give some education about it. You check how it worked. You check their compliance. You make adjustments. If they're doing well, you add some rehab or some therapy on top of it. That's a normal pattern. I'm not being weird here, that's normal. This pattern says the first thing you do is get them to like you and trust you. My first comment with them in the college was, so I'm stuck here in this little room, and I'm afraid the whole world's going by me out my window. So every person comes by, can I pick your mind for a minute? I want you to tell me anything, teach me anything about anything in this college. I don't care what it is, a major, a club, or a class, or anything in the whole college. For one thing, by the way, after a few years, I knew more than anybody about all kinds of things in all this college. But for the other thing, I flipped the power dynamic, they're explaining something to me, I finished about half my mental status by the time they finished telling me whatever the story is, and half the time, more than half the time, they told me the giant dynamic of what was wrong with them in that story. So I was doing this with a student next to me, and he said, you said they were going to tell me in the beginning what was wrong with them. I didn't hear it. I said, all right, let's go back. What did he say in the beginning? Oh, I don't know. He was talking about the economics department, and he wants to be in macroeconomics to predict economic changes and when recessions, I don't know, something like this. I said, and yes, and what was wrong with him? When the depression came, his dad lost his job, his mom fell back into alcoholism and left and ended up in Hawaii, and their family broke down, and his whole life broke down. So he wants to have a career of predicting recessions so he'll never have his family broken down. He said, you're right, he did tell us from the beginning. I didn't notice that. You know, because lots of times, their ambitions are connected to their wounds. Second thing is their goals. What do they want? Then what's the shared story you build together, a formulation instead of a diagnosis? You go to your stud, then you work together decisions, or you close, or occasionally get someone, you know, we tried these four, say, you know, I tried those four different meds, different things. You know, I decided that I actually like the way, I know my mind now, I understand a lot more that it works differently than anybody else's in this weird way, because I was raised in this weird commune by these hippies and all this shit, but you know, I kind of like the way it is. Thank you for wasting four months of trying all these meds that made all these problems, but I actually appreciate the uniqueness of my mind the way it is now. That was a successful outcome, I thought. Change the adaptations. You don't look like Shrek. I am not an anxious, I'm not actually an introverted person. I'm an extroverted person who is too anxious to be extroverted. I actually enjoy meeting people in a bar once I'm not thinking all the time what she's thinking about me. ADHD I'll do really fast. I'm really confused about stimulants, because with little kids, we give it to tons and tons of little kids, it's come over things like 40% of all the little kids in foster care and stuff are on stimulants, we think it's really good. When you get to college, we make this rule that says it's only good if you had problems when you were a kid and not just problems now, and it's only good if you take it every day rather than just when you need it or want it. Why this is a good way to use an addictive substance, I'm not sure, but this is what we'd say. When we get to homelessness, and 90% are using meth in LA, we say it's bad for all of them. It couldn't possibly be helping them all or any of them. This is really strange. I would love to see a study, and I'll never see it, that says if I gave a college freshman who was having trouble focusing Adderall, what are the odds that that's sustainable by the time they're a senior, it's still going okay, and they didn't end up in some mess? I know it's not zero, but I don't know, is it two, is it five, is it 20, I have no idea. How can we reasonably give people advice about this when we have no idea? I'm really worried that stimulants are going to become the next epidemic, because the prescription levels are going up like crazy, just like the opiates did, and eventually they're going to drift, when they don't have money, they're going to go to the street once more. A lot of my people on the streets, we're using them, we're giving them first as kids. Last one is pandemic. Instead of diagnosing more and more mental illness and referring people to more and more professional treatment, because now they've got 40, remember they'll say 45% of depression or something, ask questions that are person-centered, growth-oriented. How did the pandemic affect your growth and development? When I got stuck going back home where they don't let me be gay, what happened to you? Did you lose energy and experience because you lost your face-to-face relationships and emotional connectedness? I knew I was kind of introverted, but this made me really stuck, and I just can't do anything, I can't focus, I can't do anything anymore. Did returning to the parents hinder your ability to find and become the person you're meant to be? You got stuck going backwards and it's torn apart. Did you suffer a lot of losses? I went to the mall with my friend, just for fun, we came back and I gave COVID to my dad and he died. How are you doing with that? Did you miss opportunities to express yourself? We didn't have any theater productions for two years. There were no concerts, there were no art things, there were no debate things, you lost a lot along the way, what do you have to express yourself? Did you get stuck in really isolated habitual behaviors, especially with your phone? I quote what your name it says, if it's over four hours a day, it's probably damaging your ability to have other things going on in your life. Did you get too much substances? Did you start self-harming on your own or a lot on healthy eating going, did you get bad things going on? Did this pandemic get you stuck? Is it going to take something extra to get you unstuck and growing and developing in the person you're meant to be? So it seems to me that we can use these recovery-based things instead of the medical model things to be able to create a system that will meet them where they're at, the developmental tasks that they want to be doing, that'll fit with this new generation of wanting to be in control of things and actually be able to get to their actual problems about development, about adulting, about the social anxiety of climbing various things, about all these cultural and ethnic things that are struggling, about suffering for your family things, about the pandemic harming your life that we're never going to get to by saying, let's see, your PDQ-9 is 15 or whatever it is. All right. Thank you very much for coming on to my presentation. Comments. I used to have a conference where I would say, comments, criticisms, miscellaneous personal abuse, thoughts from you all, and I guess you have to stand up at the mic to say something if you want to. Thank you. Are there any questions on the live stream? No. If you could encourage them, tell them they have the opportunity. People on the live stream have the opportunity to ask questions at this point. Anything from... Thank you so much for sticking out to the bitter end at this time. One last small... One last shameless plug. It does have a positive. I wrote this guidebook to psychosis, it uses the same principles for psychosis, both perfect along the way. Thank you all. Thank you.

recovery model

medical model

Mark Reagans

community mental health

strengths-based approach

cultural narratives

personal development

college mental health

identity growth

medicalization of distress

resilience

personal challenges