America's diseases: Depression, Addiction, and Suicide" July 14, 2019
Dr. Roger Ray & Dr. Paul Thomlinson
Johann Hari’s Lost Connections pp 74-75
Feeling lonely, it turned out, caused your cortisol levels to absolutely soar - as much as some of the most disturbing things that can ever happen to you. Becoming acutely lonely, the experiment found, was as stressful as experiencing a physical attack. . . . It turned out that [isolated people] were three times more likely to catch the cold than people who had lots of close connections to other people. . . . Loneliness itself, . . . seemed to be deadly.
I was so sure of this that in the interviews that I conducted, I very literally looked for confirmation of my bias. But it wasn’t there. What Paul and I and the six or seven other people involved in interviewing addicts learned is that there was almost never a conscious reason for their first use of meth. They all reported that they were introduced to meth in a social setting in which it was given to them and they used it to fit into the social setting they were in.
To ask someone to “just say ‘no’” is a tall order when what most people in our era suffer from the most is loneliness. The desire to fit in, to have a peer group, a circle of friends, reliable if not meaningful connection . . . in the absence of the confidence that comes from strong family ties, a meaningful love connection, a really positive and reliable connection to friends, neighbors, co-workers, people are terribly vulnerable to almost any suggestion . . . even a suggestion as colossally stupid as, “Here, take this.” Paul will be speaking here in a few minutes and he will speak most directly to the best practices in suicide prevention, preventing and treating drug addiction, and in treating or avoiding serious episodes of depression.
Adderall is the name Shire Pharmaceuticals gave to their prescription form of meth. Yes, the drug given to Nazi soldiers to keep them awake and make them dive into battle, the drug used for orgies and in the sex trade, is the drug we are giving to kids and lots of adults to help with ADD. Now, I am not a medical professional and I realize that ADD is serious and people need help but there are more than 5 million people in America taking legal meth. Do 5 million people need prescription meth? And is Adderall any less addictive than the meth people buy on the street corner? Well, what do you think? And if you doubt me, check the “google machine” and you will find countless articles in major newspapers about Adderall addiction. I have lost patience with the protections our government gives to the pharmaceutical industry. They are killing us, and turning our kids into a generation of tweakers. I would love to ask the experts on ADD, is meth really the best idea you’ve got?
But I must turn the page . . .
Whenever Paul and I talk about suicide causes and prevention, I always return to examples like Robin Williams and Anthony Bourdain because almost everything we say is either a telling warning or an effective prevention does not apply to those two high profile cases . . . which only means that all of our conversations about depression, suicide, and addiction must also contain some humility and a willingness to not be entirely correct.
Again, in matters of psychology, we say that when we hear hoof beats we think about horses rather than zebras. When we ask ourselves, “Why did this person commit suicide?” there are always a host of possible causes or reasons, many of which will never be mentioned in a suicide note.
But if I may offer a large umbrella of causation, and I’ll be interested to know Paul’s take on this, but most suicide victims felt that they were a burden, an embarrassment, that they were somehow in the way and unneeded by the people closest to them.
And to say that you have to set aside all of the suicidal gestures made for attention or control by people with borderline personality disorders and things of that ilk. People commit suicide because they have been publicly humiliated, or because they have become a financial burden or a liability to their family.
event. I brought up this fact . . . suicide is the number 2 reason for death among teenagers but gay teens, of all racial and ethnic groups, are four to five times as likely to commit suicide as heterosexuals.
Who teaches gay kids that it is not ok to be gay? Who makes them feel fear? Who teaches them to fear that their families would reject them if they find out?
And this, ladies and gentlemen, was when I was told that I would not be allowed to speak at the conference. A survivor whose husband had committed suicide looked at me several times during our lunch meeting and declared, “My husband was not gay.” And I never said that he was. I never said that most teen suicides are gay, I’m just saying that gay kids are fives times as likely to commit suicide as their straight peers. But gay kids only make up between five and ten percent of the population.
But, as they say, that’s none of my business.
But here is what is my business because I am a minister. . . here is what I might have said if I had been allowed on the stage with Paul at that event:
Being homosexual is no more a sin than is having red hair or brown eyes. Your gender orientation, while it may be somewhat influenced by environment, it is indisputably overwhelmingly a condition of birth and judging anyone for their sexual orientation, whether that is family judgement or religious judgement is flat out wrong. This is not opinion, this is medical, psychological, and I will argue, theologically true.
I will leave it to Paul to talk about suicide prevention in the broader context, but we are in a church and I am a 40-year veteran of the clergy and I need to speak to this specific piece of real estate:
The Catholic Church’s 16 century long oppression of women, treating them as second-class citizens who can never become a member of the clergy, and their continued insistence that being homosexual is a sin for which one will burn eternally in their imaginary and non-existent hell, is not acceptable. I don’t care that there are progressive priests who are trying to change this, I don’t care that most Catholics ignore these antiquated and abusive beliefs: that fact is that there is a casualty count here. Children and adults kill themselves because of the condemnation of the church. It is 2019. If you changed today, you would still be two generations late. You don’t get more time. Your time is up.
And the evangelical churches, of which the Assemblies of God, the Baptists, the Pentecostals and such may be the worst offenders but the Methodist Church just voted in favor of maintaining this bigotry and a lot of other denominations that have enjoyed being called “main stream” have sat on the fence for way too long.
If you knew someone who was taking their kids to some cult that taught them to loath themselves, to despise who they are and cannot help being, you would report them for child abuse. . . wouldn’t you? How is the fact that the Catholic Church has been doing it for 1600 years make it different? How is it that most Protestant churches can get a pass on this child abuse just because they have been doing it for 500 years? It is unacceptable. It has to stop.
Parents, you cannot look at your kids and just know which ones are or will be gay. If you take them to a church that teaches them that hell awaits gay people, you are setting your own children up to become a victim of suicide. I have a modest proposal: parents, love your children. All of your children. No matter what.
America’s Diseases: Depression, Addiction, and Suicide
Drs. Roger Ray & Paul Thomlinson
I want to talk about root causes today. We are always looking for root causes in health care, and in behavioral health, where bad outcomes are a fact of life. We are always trying to get upstream so we can figure out why people are sick, why they die from alcoholism or opioid overdose, why they are depressed, why they die by suicide. In fact, there is a technique we use in root cause analysis called The Five Whys, wherein we ask why up to five times in order to get upstream far enough to understand the cause and effect chain.
For example: I got a speeding ticket.
Why? Because I was late for work and driving fast to get there.
Why was I late for work? Because I overslept.
Why did I oversleep? Because my alarm clock didn’t go off.
Why didn’t my alarm clock go off? Because the batteries were dead.
Why were the batteries dead? Because I forgot to replace them.
Ahh, there’s the root cause, and it’s what we need to do something about to prevent a recurrence of getting speeding tickets and getting to work late.
Of course, this is a very simple example to illustrate The Five Whys, but I can tell you I’ve done a lot of root cause analyses over the years, and when you ask why the depression, why the addiction, why the suicide enough times, you will almost always eventually get to the root cause of disconnection from othersand the terrible downstream consequences that come from being in that state of loneliness, isolation, and even alienation.
What Do We Mean by Loneliness?
It should be clear that loneliness is not at all related to the actual number of friends or social contacts one has. Most of us have probably had the feeling of being alone in a crowd. Roger mentioned Anthony Bourdain and Robin Williams, two fabulously wealthy and famous men “with friends possessed,” who died by suicide. Yet, in retrospect, a psychological autopsy would almost certainly conclude that they were excruciatingly lonely. Loneliness is that emotional state created when people have fewer meaningful relationshipsthan they want, fewer than they need. That is, they have inadequate relationships to make them feel known and understood. How do we define it? Basically, irrespective of the number of folks in your contacts list, your Facebook friends list, or your social network, if you feel lonely, then you are lonely.
Loneliness is characterized by emotional suffering created by feeling separate, isolated, alone and disconnected. You can listen to the Hank Williams masterpiece “I’m So Lonesome I Could Cry,” for a musical deep dive into the emotional experience of loneliness. Loneliness is literally painful, and it is also fearful:at the heart of it is often a deep-seated fear that our life-giving and nourishing attachments to others are either missing or are at risk of being pulled apart or shattered. These are fears that most of us experience at some point, carrying with them a disturbing sense of impending incompleteness, insecurity, and lack of grounding.
I want to point out the crucial distinction between distressing loneliness as I’ve been describing, and a healthy sense of solitude. Aloneness differs from loneliness. Of course, we known that Eastern and many meditative and mindfulness approaches regard solitude as an essential and healthy state. It is a state characterized by feelings of trust, security, and wholeness that leads to equanimity and calmness, rather than distress. That is a sharp contrast to the aching chasm of loneliness in which so many find themselves these days.
The Epidemic of Loneliness
Although living alone does not always equate to being lonely, we know that a quarter of the US population, and 28% of older adults, live alone. Nearly half of adults characterize themselves as lonely right now…about twice as many as a couple of decades ago. Thirteen percent of people report that there are zero people who know them well! We are living through what may rightly be called an epidemic of loneliness. I had the privilege of hearing former Surgeon General Dr. Vivek Murthy recently, and it stuck with me when he said, “During my years caring for patients, the most common pathology I saw was not heart disease or diabetes…it was loneliness."
Why The Epidemic?
There is no single answer to the question of why twice as many people now feel lonely as did a few decades ago, and why the average American's number of close confidants has shrunk by more than one-third since 1985. But here are some possible causes:
· One reason could be the aging of the Boomers, who had fewer children and more divorces than their parents, leaving many without companions in their, ahem, our old age. About 10% of Americans over 50 do not have a spouse, romantic partner, or living child—so about one in six Boomers live alone.
· It is possible that the new gig economy and the increasingly transient nature of our work is also making people lonely, as Americans are often forced to leave their families and hometowns for their careers or paychecks.
· Maybe we have somehow gotten dramatically worse at meeting basic human needs, which every Psych 101 student who ever took a gander at Maslow’s hierarchy could tell you is really crucial. As Johann Hari puts it in his simple but radical book, Lost Connections: “We all know that every human being has basic physical needs: for food, for water, for shelter, for clean air. It turns out that, in the same way, all humans have certain basic psychological needs. We need to feel we belong. We need to feel valued. We need to feel we’re good at something. We need to feel we have a secure future. And there is growing evidence that our culture isn’t meeting those psychological needs for many — perhaps most — people.”
What Is The Impact of Loneliness On Our Health and Well-Being?
Some time ago, we heard from a Mayo Clinic physician named Dr. James Levine, that sitting is the new smoking, warning us of the harmful health effects of a sedentary lifestyle.
I am here today to assert that it is no stretch to say that loneliness is the new, new smoking. The health impact of loneliness and social isolation can roughly be equated to the effects of smoking 15 cigarettes a day. And the same study that established this, also shows that loneliness causes a 26% increase in mortality.
Why or how is physical health affected by loneliness? What is the virus, the bacterium, the teratogen embedded in this equation? Not surprisingly, it is stress.We are animals, right? But we are exquisitely entrained social animals, almost above all. Feelings of loneliness are an evolutionary phenomenon, for certain. In the same fashion that hunger drives animals to seek and find food, loneliness drives humans to fervently desire and seek out the protection of connectionto the group, thus increasing our chances of survival. There is safety in numbers, right? By the way, on this point, I love how University of Chicago neuroscientist and loneliness researcher John Cacioppo has put it: Denying you feel lonely makes no more sense than denying you feel hunger.
How does this relate to stress and negative health effects? Well, we know from psychoneuroimmunology research that our loneliness (that is, feeling separate, isolated, vulnerable on our own) triggers the release of stress hormones, cortisol in particular. This stress hormone is remarkable and necessary, and in small doses, helps make us more alert to the dangers in our environment. But when our bloodstream is flooded with cortisol and other stress hormones over prolonged periods, they inflict great harm by causing high blood pressure (of course, one of the most potent risk factors for all cardiovascular diseases), increased inflammation (which we are learning is related to all manner of horrible health outcomes from gingivitis to heart attack to stroke), and a weakened immune system (which makes us susceptible to opportunistic infections, of which there are seemingly endless new and terrifying strains afoot in the world).
Without a warm, nourishing emotional support network (or even just one single source of such support), lonely people are undoubtedly more likely to fall prey to unhealthy habits, including substance abuse, overeating, and not exercising. Ahh, so perhaps loneliness is the root cause for sitting too much after all…another point in favor of my previous assertion: Loneliness is the new smoking.
I also want to summarize and put a finer point on loneliness and America’s diseases of depression, addiction, and suicide. There is no question after reading the credible research that lonely individuals are more prone to depression. It is also very clear that addiction is very often rooted in disconnection and alienation from others—like those solitary rats in an empty and desolate cage who consumed the heroin-laced water. Why? Because their lives sucked and were devoid of connection to anything other than that heroin nipple and the resulting high. And we know that loneliness and low levels of social interaction predict suicide, in all age groups, but especially in older age. The very best research-based model of suicide, developed and tested by Dr. Tom Joiner at Florida State University, shows that those who hold the twin psychological states of lack of belonging and a sense of burdensomeness will eventually consider taking their own lives. And of course, they often succeed.
Is Loneliness A Root Cause for Political Polarization?
The rise in loneliness may also be one of the root causes for America's seemingly hopelessly polarized politics, and the accompanying viciousness on social media. How? Psychiatrists Schwartz & Olds describe loneliness as theelephant in the room of American politics.The reasoning goes like this: Social isolation makes people less empathetic and more likely to view the world in the bipolar terms of us and them. Olds puts it this way: "I think comparing notes in a civil way is the antidote to a polarized society in which we don't understand a point of view other than our own. If we are so lonely that we have no one to compare notes with, we tend to become more polarized." Also, it may be, as Republican Senator Ben Sasse of Nebraska asserts, that we are turning to political tribalism for the essential sense of communitywe used to get from simple connection to those around us. I think Senator Sasse nails it in his book Them: Why We Hate Each Other — and How to Heal, when he writes, "Alienated from each other, and uprooted from places we can call home, we're reduced to shrieking."
The Connection Solution
Loneliness is an epidemic, but it is preventable, treatable, and manageable! Psychologists and social scientists have known for a long time that both intellectual and social engagement prevent loneliness and its damaging physical and psychological effects. The active ingredientis relationships that are high in quality, not merely extensive in number—ones having authenticity and meaningfulness, richness and reciprocity. As an antidote to loneliness, there is no real substitute for having someone to talk to regularly, someone with which to share the contents of our hearts and minds.
There is also good evidence that mindfulness exercises can help reduce feelings of isolation by creating a sense of connection to the world, to others, even to the universe. In fact, I think we need to be careful about expecting the benefits of connection to others while ignoring the most crucial connection of all—the connection to ourselves. There is a reason that Dr. Dan Goleman and others have called self-awareness the cornerstone of emotional intelligence. There is a reason the Oracle at Delphi dispensed the exhortation to know thyself!
God bless good-hearted warriors in the fight against loneliness, like Robin Caruso, whose "Togetherness" initiative aims to combat the epidemic among seniors through weekly phone calls, home visits and community programs. By the way, if you are thinking about how to reach out and connect with someone you think is suffering loneliness, it is not enough to just talk to and engage with them in efforts to ease their suffering. It is important how we talk to them, and how we interact with them. Lonely people very often have the perception that others are not listening to them, not taking them seriously, not making eye contact, and basically dismissing them. So, we need to be careful to do the opposite of all those things…be not false in your affections, use active listening skills, lean into it, reflect back that you heard what they said, and you may help add years to someone’s life as well as life to someone’s years.
