Reforming Mental Health Support for Students and Health Care Workers

JOEL BERVELL: My guest on this episode of The Dose is Dr. Jessi Gold, a psychiatrist and author now serving as a first-ever chief wellness officer at the University of Tennessee, a very diverse five-campus system. There, student mental health is her focus. Right now, nearly everywhere we look we are bombarded with data that young people are struggling with mental health. This is a fact of life before and since COVID. And yet, infrastructure and attitudes are still catching up. We'll talk about mental health on campus and what it means for students to seek and find the right kinds of help.

The pandemic also sparked another project for my guest, as she was surrounded by colleagues in the caring professions who she noticed were rarely acknowledged or addressed as people and professionals with their own mental health challenges. The result is a brand-new book out this month, How Do You Feel? We'll talk about the research and what it means for caregivers to preserve and support their own mental health as we dedicate our professional lives to caring for others.

Dr. Gold, thank you so much for being here with me.

JESSI GOLD: Thanks for having me.

JOEL BERVELL: So as I mentioned in the show open, you are the inaugural chief wellness officer at the University of Tennessee campus. Let's level set. Why now? And why is this important?

JESSI GOLD: I would love to tell you it was always important to everyone. It was always important to me. But I think inherently the pandemic really opened people's eyes to just how bad our mental health was. I think it kind of widened the existing cracks, which we saw in the system, in all systems, honestly. Where there were challenges, we saw more challenges. And I think on a college campus, putting me in charge of this system as a person who will center wellness and can do that across the state and all five campuses, and they're really diverse in different campuses, also suggests it's a systems problem, right?

It's not just a problem you can fix by getting more counselors, which I think is what people would love to do. And I think that that is not the right answer all the time. When they created this, it wasn't out of crisis, it was out of concern. And I've been able to go all across the state and get to see really, really different campuses, like one that's really sports and fraternities and sororities, one that's a thousand students. Those are very, very different populations. And my job isn't to come tell them what to do, it's to kind of add and find the ways that I can be helpful.

JOEL BERVELL: Absolutely. You kind of sit at this interesting perch of being able to give us a snapshot and insights more broadly on student mental health today. As a student myself, it does feel like there's been more conversations about mental health than there were when I was an undergraduate, but does that track with what you're seeing actually on the ground and through your work?

JESSI GOLD: I think there's more conversations, but I don't know if there's more help-seeking. I know that sounds strange because it would make sense if people talk about things more that then they would come get help because they identify it more. But I kind of feel like talking about it and having the words for it doesn't always translate into people going, "Oh, now I should get help for it," and certainly not early. I think we still really define the need for help around crises and around my grades are bad. So you could say to a student, "What else is going on in your life?" And they're like, "I haven't left my room. I drink sometimes. I don't sleep." And then you're like, "But my grades are good, so I'm great."

And they have a bigger vocabulary around mental health, but I don't think that they always know what it means. Like when I had a conversation with a bunch of grad students recently, and the number one thing they said that they needed on campus for them was awareness. And it's that they feel like they don't have it in that they don't know where to go for help and they don't know how to access help and they don't know when to ask for help. They just know that mental health is more normalized.

JOEL BERVELL: I think that's such a really interesting point. It makes a lot of sense. And we'll get to social media in a second.

JESSI GOLD: For sure.

JOEL BERVELL: But curious, has there been an uptick in diagnoses on campuses too when you think about, like you said, people seeking less mental health access and accommodations, maybe feeling like they know what it is, seeing it on social media. Has there been an actual uptick in diagnosis on campuses for students?

JESSI GOLD: Yeah. I mean, I think it's been, it was a crisis before the pandemic, so I just want to say that this time period is particularly stressful for people. It's a time of identity development and experimentation. It's a time of just neurobiology causing mental health conditions in that age group. And so I think it's really important for people to know it's not like the pandemic magically made them feel bad, but it did really change what college looked like for them. And it did really change their social interactions and their isolation. And people talk a lot about trouble making friends now. And I don't know that they would have felt like that before, but maybe they did and we just didn't ask them.

But what I see is still like we've definitely had more crises. We definitely have more people asking for time off from school. I think depression, anxiety, ADHD are still the most common diagnoses you see on a campus, but I think students use the word trauma a lot more than they used to and I think identify it and are aware of it. And that makes it hard for therapists on campus that are really supposed to be short-term therapists to help manage all of that. And so I think what they're seeing has become a little more challenging for them just because sometimes sort of the way the system is set up to take care of folks, it's really set up to deal with adjustment issues, like you're having a breakup, you don't like your class, you are struggling for an exam. It's not as much set up to deal with all these people coming in with psychiatric illnesses who need medication and all these people who develop them and get crises.

And so not every campus can get a psychiatrist to work there, and I think that that's a big thing. And also, it also suggests that we're better at managing mental health in younger folks. So the people who are going to college might come in with a more complex history, but if they're treated and they made it to college, maybe we just supported people who would've never made it to college before because our meds are better and our treatment in younger folks is better and the way that we're finding it and assessing it is better. And so we're getting some sicker folks coming in, but is that because we are better at dealing with them when they're younger? Or is that because they're sicker because of the pandemic? I don't know that we could a hundred percent say the answer to that.

JOEL BERVELL: Yeah. And I want to shift to social media for a moment, particularly platforms like Instagram and TikTok, which we both use . . .

JESSI GOLD: Yes.

JOEL BERVELL: . . . very frequently. But as we both know . . .

JESSI GOLD: . . . you more than me.

JOEL BERVELL: Not true. You're doing an incredible job. I love your content. But as we both know, last year the surgeon general issued a new advisory about the effects that social media has on youth mental health. I'm curious, given your role as a mental health advocate, how do you navigate those complexities and, at times, the irony that's there with promoting mental health well-being in these digital spaces and balancing doing good and giving education with the harms of it?

JESSI GOLD: Yeah. I'm really glad that you mentioned the balance because I think sometimes when this issue is presented, it's like social media is so bad, get off social media, everyone should be off social media. And I don't feel like that. I think it has some benefits. It definitely has benefits in what we do in educating in misinformation, and we really would be harming our patients if we were off of it entirely. That's what I think. And so for me, I've noticed there are times where it really affects my mental health. The pandemic was a really big time for me. There was a bit of conversation for a while where the health care workers would talk about their experience, and I somehow got in my head that my job on X was to basically be like, "I'm here. I validate you. Thanks for sharing." And I felt somehow responsible for finding all of the people who were sharing and validating their experiences. And I would stay up super late thinking that my job was to fix that for them because if they disclosed and no one said anything, they've never disclosed before. This is new, we need to support them. And I really had to evaluate where that was coming from and why.

I think some of it was a need to be really helpful and try to be a beneficial person on social for them. But also, I needed to actually say, "This is affecting sleep and that's not good. This is making me mad and that's not good. This is becoming sort of a weird obsession and that's not good." And I think it was serving some purpose for me that I didn't realize at the time. And I needed to step back and say, "Someone else will handle it," or, "Mute is okay." I think it's a balance and it's about understanding what it's like for you and knowing that you're allowed to take breaks and you're allowed to not respond right away and you don't owe anybody anything.

JOEL BERVELL: No, that's really powerful. And it's not easy to do it all to step away, especially when you went into a career dedicated to try and help people, right? But when helping, maybe hurting yourself. You can't do everything all at once, no matter how much we want to. For many college students, especially in their first year, of course, it's the first time that they're away from home, having to navigate self-care on every level. I remember my own experience having to be in a new environment where you don't have your parents that are taking care of you anymore. And data tells us that one in five Gen Zers are in therapy. Sixty percent take some medication to help manage mental health. College students right now are mostly Gen Zers. And you touched on this before, but are students adept at navigating the on-campus mental health systems, finding the right help? And kind of bring it back to social media as well, how are they using social media, and how's that influencing how they come to you when they do seek help?

JESSI GOLD: Oh, these are such good questions. Thank you for asking them. I think when you land on campus, you often can get lost in the system. And that is because you don't realize how much your parents were doing for you. So sometimes your parents pick up your refills. Sometimes your parents make your appointments or whoever your guardian is. And so a lot of people just in the transition will be like, "I feel fine," and have that sort of adrenaline from the beginning and just think that they don't need meds anymore because they feel fine. And then a bit later they have finals or midterms or whatever. And all of a sudden it's like, "Oh no, I need an appointment now." But that's a lot harder to get in, right? And so I think that the transition period can be really hard because they don't realize how much they actually needed it or they want to try without it, and that can be a big challenge.

I think some schools have too many resources and some schools have too few, and both are hard for people. So if there's a lot, sometimes people don't even know where to start and they're like, "Do I go see a dean? Do I go see student success? Do I go to housing? Do I go to counseling? When do I use these things?" And so I think that can be really confusing in places that have tried to have a lot of resources for students. And then, obviously, not every campus is able to do that either. And in more rural areas, there might be one counselor, and recruiting that counselor could be a lot of work to even have that person. And then if students don't like that person, what are you supposed to do about that? Because you couldn't find one in the first place. So that I see a lot.

And then the social media question as a psychiatrist is kind of interesting. I think in therapy people have mentioned that people use words more, like therapy-speak, like come in with a diagnosis already or use words like triggered or narcissist or trauma because they saw it on TikTok or Instagram and they think they know what it means from that and they use it a lot in everyday conversation. But just because they kind of have heard it doesn't mean they're using it right, but also doesn't necessarily mean that they have a diagnosis, first of all. Sometimes they're labeling things that are just feelings as a diagnosis. And then sometimes they come in with a laundry list of things that they saw on TikTok, for example, that told them they had a diagnosis. And it's really because of the algorithm, because the algorithm was like, "Ooh, you watched a video on ADHD. Want another one? Want another one?"

And so they come in and they say, "I have ADHD." And then you say, "Well, why?" And they just describe the videos. And I'm not an invalidating person, and so I say, "Okay, tell me more. What about that resonated?", and all of that. And then I say something like, "Have you ever thought that concentration could be something more than ADHD or different than ADHD?" And they haven't because they saw 75 ADHD videos. And so sometimes they'll listen and they'll hear about how you can have poor concentration because of sleep, you can have poor concentration because of anxiety, you can have poor concentration because of depression. But sometimes they're like, "You are invalidating my experience."

I think that that can be particularly challenging if the groups that are coming in are groups that are traditionally underdiagnosed for things like that. So if it's a female or a person of color, the internet is saying, and they're not wrong, that you've long been underdiagnosed. And so you come in and you say, "I've long been underdiagnosed. I should be diagnosed." And it can feel really bad to those people and I think, for me, has been hard to navigate good patient-doctor relationships in those settings. As much as I am fully aware of what they see on social and probably more open to those conversations than some of my older peers, I think that they still just don't want to hear that. And that can be pretty hard for me because I'm not going to give a medication that can worsen your anxiety if you have anxiety. I'm just not going to do it. And I get why you think I should, but I can't because it's not good practice.

JOEL BERVELL: I'm nodding my head so much right now because I find myself at this intersection sometimes of wanting to put information out there, but then actually worrying that I may be contributing to people only getting one piece of it, right? In medical school we learn about the differential diagnosis, how there could be so many things going on, but when you can only talk about one of what the possible 20 could be. But it can be difficult to have those conversations in a way that makes sure that the patient feels heard, but at the same time is getting to the heart of their diagnosis. And I'm glad you mentioned people of color and how that can be underdiagnosed as well for specific groups. You oversee a really diverse collection of the five campuses in Tennessee. Some of them are more urban, some are more rural. Is there enough culturally competent or fluent care available? And also looking at kind of mediums that it's delivered through, whether it's telehealth options or in-person options.

JESSI GOLD: Yeah. I mean, there are a lot of telehealth companies that have tried to fill this gap and taken to really target college populations because licensing alone is really complicated if you see a college student because you have to be licensed in the state that they are in physically. It doesn't matter if they saw you in Tennessee. If you're not licensed in California when they go home for the summer, you really aren't supposed to see them. And so for college students, because there's a lot of transitions, there's internships and jobs and school and you're going all over the place. And that can make something like a telehealth company make sense because they have people who are licensed a lot of places or you could switch pretty easily in a place where you're trying to recruit to a college campus where they're paid less than working in private practice, where it's a rural setting and maybe you only want to live there because your family's close, right?

It's a very specific person that you're recruiting for that. And if you try to expand, first, your school doesn't have the money, but you're also not competitively recruiting. And that makes it really hard. I know a lot of therapists that work on college campuses and they do it because they care about the students and the populations. Because if they took another job, if they did anything else, they'd make so much more money and have a better lifestyle. The telehealth companies really can bridge that gap and do try with access and just if you have one therapist on a campus, the chance that that therapist matches any identity you're looking for. A lot of students really want people who look like them to take care of them, particularly in mental health because they don't want to educate around the issues.

And so there's access through those sites to have a bit more ability to match, even have people who can speak different languages. And I think if college can't afford it and integrate it into their system, it kind of balances it. But the need and the ability to actually solve the perfect matching is a huge problem in mental health around the country, in all health care around the country. I think that I feel comfortable treating people who don't look like me because there's like 2 to 3 percent Black psychiatrists and I'm very used to that conversation. But I often say, "If you want me to help you find someone who looks like you, I will do my best to help you. But I must also tell you that it's rare and you might not be able to." And I think that that is a hard conversation because I get why you might think, especially in mental health, that you're better off with somebody who has a similar life experience.

JOEL BERVELL: Absolutely. I think that's a perfect transition point to start talking about caregiver mental health. So as I mentioned briefly earlier, as a psychiatrist, you experienced and you saw your colleagues across the health care landscape pushing in historic ways to care for patients during COVID. Your book is a blend of memoir, reflections on your own experiences, but it's also more than that because you conducted research and really dive into some questions that hadn't previously been well-illuminated. So very basically, how are our carers doing?

JESSI GOLD: I mean, very similarly to college students - honestly not well. We were another group that was struggling long before COVID that COVID added these additional stressors and made things worse. Our burnout in health care was like 50 percent pre-COVID, right? And that's more than any other profession, any age-matched peers. And then you know all of the challenges that came with COVID. I mean, the uncertainty of it, the way medicine was first appreciated, then not, the way that we were taking care of really sick patients who were dying at rates we weren't expecting. Those were all new stressors added on top of the clear problems in the system of medicine.

And burnout is relevant to everyone because not just is it related to depression? It is. It related to substance use? It is. But in patients it's related to errors or people staying in the hospital longer or people not being as satisfied with care. And then on a bigger system level, people leave. When you're burnt out, you leave. And we just talked about access. If you're the one person who does this particular thing and you leave, people don't have access anymore. If you're the one person that looks like the population and you leave, people don't have access anymore. And that makes a huge difference in outcomes and care.

JOEL BERVELL: Absolutely. And I'd like to also focus in on nurses, pharmacists, that entire ecosystem of professional caregivers that surround and support us and our patients. How are they kind of faring with everything as well?

JESSI GOLD: Thank you for asking that. I think sometimes we get the microphone and don't pass it in these situations. And I used to see people who were cleaning the hospital or greeters in the hospital. We don't have any data on what their mental health is like. Or the people answering the phones, we don't have information about that. We have some on doctors, we have a little less on nurses, and then it really starts to get pretty small when you get to pharmacy or dentistry.

But what you see is people who care for other people traditionally are not good at caring for themselves. And as a result of culture and stigma and sort of belief that we're not supposed to get help and our jobs are not supposed to affect us, a lot of us don't get help when we need it. In nursing, a lot of it affects things like staffing ratios and doing extra shifts to cover for people who couldn't stay. And you hear from nurses the shortage really can impact their mental health because they're taking on more or there's travel nurses and they have to train them. And so there's all these systems at play, but it makes it harder for the people who are in it.

JOEL BERVELL: Absolutely. In your clinical practice, you treat many health care professionals. There are mental health strategies that are broadly useful, but what specifically is there for caregiving professionals?

JESSI GOLD: Yeah. So I wish we were treated like a separate population and we had cultural competency for health care. We do for police and people who are EMTs and we don't for us. And I think we do have a specific set of needs that are not covered. And every time someone comes to me and they go, "You're an expert in this. Who is an expert in this? That's awesome." I think it's really important that we realize that we have differences, because we don't want to be told to go to sleep when we can't.

If our shift is like, it's just impossible to do that. Or as a resident, "Get more control over your schedule." Okay, that's not a helpful thing to tell me, right? And so inherently I think things that work for us, we're perfectionists, we're very bad at self-compassion. So when I say that, I mean how nice are we to our brains? And so sometimes if we make a mistake, we're much more likely than other professions to say "That's on me and I'm a horrible person" than "I should learn from that."

I think another thing that tends to work for health care workers is not prescribing a coping skill but letting them figure out what that looks like for them. So I think, traditionally, things have been offered in hospitals and it has always kind of come off silly to folks. They're like, "Oh, good, a yoga class. Oh, good mindfulness." They're just not going to fix anything and they're just going to do this instead. And there's truth to that and how that feels for folks. So I could tell you there's evidence that mindfulness works, but I could also tell you I hate mindfulness, and I've tried it a bunch of times. And that doesn't make me somehow bad at coping, which I've heard from patients. It just means that you could try something else, and that's okay.

And maybe third, which is maybe surprising to some people because they haven't thought about it, we're really bad at identifying any sort of mental health word or feeling. Some of that comes from the fact that all in training they tell you not to pee, not to eat, all this stuff. And so you basically ignore all your physical sensations, and so why would a feeling be allowed? You don't see people talking about their feelings either, and so you push those down just like you do all your physical sensations.

And then when you say, "How are you?," I mean, they don't have feelings. They can't name words like "It's okay, I'm fine," which aren't feelings. Or they feel numb a lot of times, but they don't realize it. And so getting to the ability to sort of identify how things affect you and that they can affect you and that those words can be named can be a pretty simple thing but can make a big difference.

JOEL BERVELL: And the title of your book is How Do You Feel? How did you land on that?

JESSI GOLD: I mean, so psychiatrists maybe traditionally do a lot of, "Well, how does that make you feel?" But inherently for me, I felt like seeing health care workers we spend so much time asking that of other people, but we don't actually use the you to mean ourselves. It's a deeper thing than just saying, "How are you?" "How do you feel?" has a bit of a deeper word than that. But the you is, to me, what's the most important there.

JOEL BERVELL: The you is what's the most important, I love that. Now, as we wrap this conversation, I'm curious, in researching your book, what was something that shocked you, surprised you, or that you hope that people when they read it are left with?

JESSI GOLD: So something that surprised me is how many people told me codes are how they learned about emotions in medicine. So codes, if you're not in health care listening, doing CPR and somebody who may or may not survive. Across the board if I was actually tallying them, I would say 90 percent of people said they learned emotions in codes, because as a med student you maybe see your first one and nobody reacts. Nobody does anything. So if you react, you stand out. We don't want to stand out at all. We already don't like standing out for the size or length of our white coat, right? We're hoping that we don't stand out. And so we learn not to. And we learn that it's not acceptable or you're not supposed to react to it.

And almost every single person I talked to had a conversation like that with me where they said codes were the reason. And I hadn't really thought about that because it just, it didn't cross my mind that that was such a pivotal thing for people to see. But of course, seeing someone die especially would be impactful on people. But I think it's the death with no acknowledgement. And so there's some places that do things like a pause and they don't talk and they just give you a moment. And I think that it can be a tiny but good intervention where you're actually acknowledging that you're human in that setting, and that that might have affected you. Obviously, talking about it is nice too, but that doesn't always happen in our setting or we don't always have time.

JOEL BERVELL: What did you want to surface in the book when you heard so many people mention that they first learned about emotions through codes?

JESSI GOLD: I mean, I think that we don't talk enough about the culture of medicine. The same way when I said that we don't really consider ourselves or we're not viewed as a different population that needs cultural competency, we don't like to admit that, when you are in medicine, you learn a lot of things that you're learning from what's around you, not in a book. And part of that sort of, we call it hidden curriculum, is emotions. We learn that good doctors are stoic, that if you share your feelings or have feelings, you are making it about you. That if bad things happen, they are supposed to because that's life and you're a doctor and people die. And that's just what you see and what you're told. You're not going to have feelings until you have really bad, big, big, big feelings. And those will be the ones that end up in my office.

I also think it teaches you a lot about how to interact with trainees. Because to me, if that is where everybody's learning about emotions, we need to intervene there. We shouldn't just go to lunch. We should have pauses or we should have conversations. Or we should at least say to the trainee, "Is that the first time you've ever seen that? Is that something you want to talk about?", and at least give them the space to do it. I've heard plenty of people where the trainee still sort of buttons up and gets angry about being asked and feels like somehow they did something wrong, and I totally get that. But I think noticing those places where we learn these things and doing better is why I ask those questions, because we can do better. And a lot of that is culture change and that's on us.

JOEL BERVELL: Dr. Jessi Gold, thank you so much for asking the question, how do you feel? Not just to patients, but also to caregivers because it's truly making a difference. And thank you for being on the podcast and sharing your thoughts. I learned so much from you.

JESSI GOLD: Thanks for having me.

JOEL BERVELL: This episode of The Dose was produced by Jody Becker, Mickey Kapper, and Naomi Leibowitz. Special thanks to Barry Scholl for editing, Jen Wilson and Rose Wong for art and design, and Paul Frame for web support. Our theme music is "Arizona Moon" by Blue Dot Sessions. If you want to check us out online, visit thedose.show. There, you'll be able to learn more about today's episode and explore other resources. That's it for The Dose. I'm Joel Bervell, and thank you for listening.

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