Avera's Matt Stanley Offers Insight On Mental Health And Violence

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We continue our series of conversations about the prevention of mass shootings in America. Today we discuss mental health. Dr. Matt Stanley is a psychiatrist with Avera and Vice President of Avera's Behavioral Health.This conversation has been edited for web use, to listen to it in its entirety click here.

Lori Walsh:                           

Welcome to In The Moment. I'm Lori Walsh. After America's latest mass shooting, this time at a high school in Parkland, Florida, people are asking is this time any different? Will this nation do anything to solve one of its most devastating problems? Now, the news on this changes every day, and this week, throughout the week on In The Moment, we're looking at the topic from a variety of angles. Tomorrow, we discuss everything from school culture to the Sentinel Program in South Dakota. Today we discuss mental health. Dr. Matt Stanley is a psychiatrist with Avera and vice president of Avera's behavioral health. I talked with him yesterday on the phone from his office in Sioux Falls. First, Dr. Stanley, thank you so much for being here with us again today. Welcome back to In The Moment.

Matt Stanley:                      

My pleasure. Always looking for an opportunity to discuss mental health.

Lori Walsh:                           

So as we discuss that, it's a hot topic today, or maybe not a hot topic, but something that even the president is saying it's time we take a serious look at mental illness and mental health in our society. When you hear comments like that, and you hear more people asking questions about mental illness and mental health, what's the first thing that comes to your mind? How do you take those kind of comments and begin to process them from your perspective?

Matt Stanley:                      

Well, what it really drives home to me is that there's actually a fairly large difference between, I think, what the president or what maybe the general public considers a mental health illness and what I do. I think when we see someone do something so heinous, so atrocious as what happened in Florida, our first assumption is that person can't be normal. They have to be mentally ill. They have to be crazy. That has been the case in some of these shootings. That is not the case in every one of these, so I just want to make it clear that every unnatural, evil action isn't a result of someone has a mental illness. I think our natural inclination as human beings is to want to assume those people are very different or very twisted, and in a sense they are, but that's a different concept than being mentally ill.

Lori Walsh:                           

We protect ourselves in some ways by doing that. It could never be me. It could never happen. It could never be someone that I know. A person with mental illness is someone else, is an other.

Matt Stanley:                      

Therefore, that term mental illness itself becomes a pejorative statement, and yeah, it is ... You're exactly right. It's how we classify the other. We know that it couldn't be my son, or my cousin, or my brother who did that because he's not that kind of crazy. He's not that kind of mentally ill, so I think it's a natural reaction. I just think that it is not factually correct from a medical standpoint.

Lori Walsh:                           

What do we know about the connection between certain mental illnesses and violence or leaning toward violence?

Matt Stanley:                      

There are certain illnesses that can make you more unpredictable, certainly, and can contribute to violence, and I think some shooters have had a diagnosed mental illness, but I think it's oversimplifying to say that all shootings lead back to a mental illness that was not identified or not appropriately treated. If you look at it statistically, mentally ill people commit violent crimes at about the same rate as the rest of the public. If you kind of look back over what seems to be the accelerating mass shootings, but we certainly have several examples to look back over in just the last few years, as I said, as I read through those, some of these people probably did have a mental illness, but by no means did I think that even captured the majority of them. Sandy Hook, I think, was a pretty well documented that that individual had some form of psychotic disorder. In this most recent case in Florida, there's a history there that would indicate some developmental problems and some other issues that might be labeled as mental illness, but it is usually those that have some loss of touch with reality, some distance, some what we would call psychosis. Then, if you broaden it, you could say that many of these people maybe have issues with socialization. You could even argue maybe there's depression in some of these, but I think that that's a little bit like identifying the symptom as the cause. I don't think it was depression that makes somebody shoot a bunch of people from a multi-story building in Las Vegas, and I think there's an example. I don't know that that gentleman, that individual I should say, didn't, to my knowledge, have a diagnosed mental illness. In fact, I think his motivation still is vague, but ...

Lori Walsh:                           

How difficult is it to predict human behavior as you deal with people of all different walks of life and some who might come through some kind of treatment and go on to have a problem? Do we have an algorithm yet to sort of say this leads to this and, therefore, we know when it's going to happen? Not likely.

Matt Stanley:                      

One of the most difficult things to predict is human behavior. I think it's not because we haven't learned quite a bit, but I think it's because the environment people are operating in is constantly changing, new stressors, new variables are introduced all the time, and how those variables will impact somebody, very difficult to predict. I always tell our residents, tell others that I'm teaching the best predictor of future behavior is past behavior, so if you have someone who has threatened or has actually done something violent, that is a much higher risk, but beyond that, there certainly are symptoms to watch for and ... but actually having a high degree of predictability, we don't have that tool. I know that in reading about the government's attempts to try to better learn ... Several years ago I was reading articles on this, and they set out to kind of create profiles of school shooters much like they did with serial killers years ago. Essentially, the outcome of that, as I recall reading it, was that they really didn't find that there was a profile for a school shooter. There was not really a tool they could give schools and others to help them predict who might be the violent ones. What they did find, though, and it was in almost in every case, whoever the shooter was had told someone else about their plans, had given some indication about what they were planning, so the biggest outcome of them studying this and trying to create a profile was really to make the recommendation that we reach out to kids in school, to young people and say, "It's not only okay, it's right to reach out to someone in authority when you hear about this or when someone tells you about this. It will save lives. You need to do it." I think that's the biggest message we can get out there is we need to take these seriously. We need to share that information when it comes to us, and that's how we will save lives.

Lori Walsh:                           

When we talk about an increase in resources for mental health in the nation or just an increased awareness and best practices, there's benefits to that in that people are thinking about it and thinking about what matters, thinking about their own treatment, and then there's also the potential of increasing a stigma and sort of saying this is part of the, quote, problem. Do you worry as people sort of are in an emotional conversation about an event like the shooting in the Parkland or any kind of event similar to that? Do you worry that people will start to sort of stigmatize and cast too broad a net and just say, "Mentally ill people. This is a problem and ..." How do we kind of address that?

Matt Stanley:                      

I absolutely worry about it. I have seen us make progress in reducing stigma over the course of my career, but I think just how we talked earlier about the fact that, in this context, people are using mental illness in the broadest possible sense. In fact, I think they're almost using it to try to identify that the people who do this have to be in their wrong mind because no one else could do this. It's not even an accurate diagnosis of mental illness or an accurate representation, and I do worry that people who have become comfortable enough with society's acceptance of mental illness that they've reached out and received help will draw back, will be afraid that then they'll now be labeled as dangerous because they have mental illness. I think increasing resources for mental illness is an absolute win. I mean there's no way. The benefits to society are numerous. I can't tell you for sure that that would correlate to a reduction in these kinds of shootings. I think there are multiple factors at play. I think that you look at each of these shooters or these shootings, I don't even know that the expectation from the individual is the same. Some seem to be ... Columbine was more about self-glorification, for instance. This Florida, I think this was a disturbed individual, a very angry individual, but I can't claim to have studied them each individually. Some end with the person ending their own life so, clearly, their expectation was maybe something different, but I think it is complex, and I'm very afraid, though, that the boomerang effect here is that, by identifying that this is a mental illness issue, we create the wrong perception of mental illness. I am fully supporting that we improve screenings and reach out to more people and provide more services, but I just want to make sure we do it in the right context.

Lori Walsh:                           

Let's broaden a little bit and talk about ... You mentioned anger, people who are feeling isolated, and lonely, and angry, or sad, maybe not a diagnosable mental illness. Maybe it's just this feeling of being lost in a society or things are moving too fast. Mental health is ... A good counselor is for them too, right? I mean that's something that you could seek some kind of a treatment for and have benefit from.

Matt Stanley:                      

I do think counseling is exactly probably what those people need. They need someone to help, I think, put their life back in perspective, and give them hope, and give them a connection to community. I'll paraphrase Freud, but many years ago ... and I'm not Freudian by any means, but someone asked him, "Well, you're always defining pathology. What is good mental health?" He said, "To work and to love." We have to feel productive, and we need to feel connected. I think those are the things that societies ... You used the term the pace is so fast, and we're now digitally connected in a way that used to only be possible through face-to-face interaction, so isolation is even easier to achieve. Again, I don't want to oversimplify what's a very complex problem, but the pace of society, the way society has changed, it's very easy to become isolated, feel left behind and left out, and anger is kind of a natural result of that because we all need to feel some level of love, and some level of acceptance, and some level of belonging.

Lori Walsh:                           

How far have we come in treating mental illness or in addressing sort of a robust mental health in a positive way in our society?

Matt Stanley:                      

I think we've become much better from the medical perspective. We still have a long way to go, believe me, but some of our diagnostic tools, screenings and, certainly, our medications have improved over the years, but it feels like, to me, and this may be a strange way to put it, we've been playing catch-up so much. We've been trying to get on top of this problem. We have done very little to get to avoidance of development of an illness or raising healthier people or identifying people at risk earlier and trying to put them on the right path to wellness. It's we're always reacting. We're not proactive in this, and you could probably say that about other health care issues, but that is where we need to get, and the only way we'll get there is with, of course, continued development of tools, and education, and understanding of mental illness, but it's also going to take funds, and it's also going to take providers. That's one of my greatest hopes is if we, as a country, commit more to trying to kind of tip the scale on this issue of mental illness, that we will get down to identifying and preventing illness before it ever manifests. 

Lori Walsh:                           

Is there a model for that in other countries? Are we on the leading edge of it? Are we behind? Is there an overall narrative where people say, "Oh, you have to look to the mental health resiliency of this place or that place"?

Matt Stanley:                      

I don't think there's a model. Of course, we always kind of look to some of the socialized medicine areas in some of The Netherlands and things where I do think gun violence is so much less. Some of that's ... Again, I don't want to oversimplify this. They have a totally different environment, totally different outlook toward guns, but they have a public health system that screens, I think, better, and I think there's less stigma for asking for help there. I can't point out one specific country. I do think some of those Scandinavian countries would probably be an area that I would want to look for. We are improving, and I think all health system are. We are beginning to screen all our patients as they come through, whether they come for mental health or not, down to age 13. We are trying to identify issues earlier. I think the government very much supports this. It's just that we just have a very limited, I think, set of resources to go after this and because we're not socialized medicine, honestly, our kids don't come to the doctor a lot unless they're ill, so we do need a stronger strategy. Yeah, that's why we're trying to push behavioral health out into our primary care clinics more and not make it seem that you have to go see a psychiatrist or a specialist. This should be part of just a general ... a work up, kind of a just a general history. These kind of questions should be asked all throughout our stages of growth and development.

Lori Walsh:                           

You and I have had this conversation before, and I think parts of it are definitely worth repeating, this notion of going to the doctor and being asked if you're a smoker or being asked if you feel safe in your home and then adding to that the notion of indications of sort of mental health indications. This is really kind of a fascinating concept. What do you think the potential impact of that is, just the repetition of that for patients throughout a lifetime of care, of having your primary care doctor ask you some of those questions again and again?

Matt Stanley:                      

My biggest hope is there's really kind of a two-prong culture change, that the patient and his mother or whoever is there with him, as they grow up, they realize that it's normal, it's okay to talk about this, "If I have been feeling depressed, if I have had thoughts of suicide, if I have been using a substance, this is where I talk about it. This is where I get help." As they go through their life, it becomes more natural to say ... to even just recognize those symptoms, so even if you're not at the primary care, "Oh, yeah. I remember my doctor has asked me about this at every one of my physicals for the last three years, and now I'm kind of feeling it, so maybe I better go get help." When I say two-pronged, then the primary care doctor ... I mean I think our primary care clinicians, who are fantastic but are asked to do so much, but they get more comfortable with the concept that, yeah, behavioral health belongs here just as much as high blood sugar or a sprained wrist. This is just something ... it impacts 20% of our population every year. This is something I'm comfortable talking about and I'm comfortable treating.

Lori Walsh:                           

Again, I'm going to repeat what I said last time, which is I always think of taking my daughter to the pediatrician and them asking her if she feels safe and that notion that you're also planting the seed that you should feel safe in your home. Maybe some child who's never felt safe is like, "Oh, I didn't realize that wasn't normal or that there was some ... that I had to think about that at all," so I think it's a remarkable idea. What are we doing really well in South Dakota, specifically at Avera? When you look around, what do you think that you are doing really well and you're feeling good about as you kind of deal with mental health in the state or in the clinics that Avera serves, really, which is multi-state?

Matt Stanley:                     

I'm glad you asked that. I do want to lift up our primary care providers at Avera. They have really embraced the idea that they're on the front lines dealing with this, and they look to our psychiatrists and our behavioral health team to help them or work together in a team concept, but they've really embraced the screening concept, the initiating treatment, the referral when people need more help. I think we're now starting to look at the same thing with substance abuse. Again, culturally, it's been kind of a taboo to inquire too much about how much do you drink, is it a problem? That's another mental health issue that ends up in a large loss of life, multiple accidents. If you look at our children, unfortunately, up until about the age of the mid-30s, it's accidents and suicides that are our biggest loss of life, and one is related to depression, and one is probably frequently related to substance use. Our biggest issues in our most vulnerable and yet most precious demographic are mental health issues, so I'm really proud that our primary care docs are embracing this. We do a lot of inpatient behavioral health, which is kind of the most ill people, and we do that very well, but we're trying to strengthen our outpatient counseling as well. For those that aren't kind of familiar with Avera, we have a tremendous telemedicine program. It's called eCARE, and we're now reaching into emergency departments across a 14-state region, actually, to help them sort through patients that come in with behavioral health questions. All those are very ... make me feel very well about where we're heading. The other thing, I think, we talked a little bit about it, but we're really just pushing the standardized screening sets that, whether we're in the ED, or looking at post-partum depression in a mom in our OB/GYN clinic, or whether we're looking at annual physical at our primary care, we want to have standardized, validated tests so that we all start speaking the same language and so do our patients.

Lori Walsh:                           

What do you think? That could really resonate out. As you have those conversations with your primary care doctor or your pediatrician, then ... and your employees are having those conversations then more with their colleagues and with their families at home. Pretty soon, all of us are having more conversations about how we feel and our sort of senses of isolation, or joy, or what have you that relate to that.

Matt Stanley:                      

Absolutely, and I think you mentioned it. The more we talk about it, the more you start to realize not only is it okay to talk about it, but you realize, "Hey, maybe I have been feeling that, and I've never acknowledged it, or I've been afraid to seek treatment." Again, I think sometimes the biggest message we could tell people is, "You're in good company. It is 20% of Americans every year that are going to have a major depression or anxiety disorder. That makes it one of the most prevalent illnesses in your lifetime, and it happens, and there's no reason to be embarrassed, or ashamed, or avoidant of seeking treatment," but it's hard. It's still hard. I know that it is, and every day we become aware of people that were afraid to ask, and it's not just hurting others. Sometimes it's hurting ourselves. It's the terrible news we see, and we need to put an end to that.

Lori Walsh:                           

Which brings us back to where we were at the beginning. Again, not to minimize people who have an ongoing struggle where they've been diagnosed, and they've been medicated, and they've been with their provider, and they're still struggling in the sort of ... in this ongoing battle similar to a cancer patient who has to go back for yet more treatment, so by no means do we want to make it seem as if this is an easy, easy problem, but I do ... I like what you say about this idea of also getting in front of some things, other things that can be addressed sooner, some prevention and some avoidance.

Matt Stanley:                      

Yeah, we need to work upstream. I'll leave you with this thought. I'm assuming we're winding down. You sound like you're winding me down.

Lori Walsh:                           

I could talk to you all day, but I know you have other things to do too, so yeah, let's wind down.

Matt Stanley:                      

Appreciate that. Well, I did ... one thought. We focus on these mass shootings, which are horrible, and they are frightening because we're parents, we're brothers, we're sisters. We wouldn't want it to ever happen to anyone we love, but more people are killed by a firearm killing themselves than people are killed by firearms through murder. Suicide is still the biggest risk of death by firearm, so that's the other problem here that we need to address. They're both critically important and, hopefully, we'll be developing solutions to address both.

Lori Walsh:                           

Matt Stanley, thank you so much for being here with us again. We always appreciate your insight. Come back.

Matt Stanley:                      

I will absolutely. I enjoy being with you. Thank you.

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