All right. So I'm David Francis. I'm a rare psychologist in this organization of physicians. And so the program today that I'm going to talk about really concerns the term mental health and how it's largely inappropriate in the year 2024. So the agenda is really in two parts. Part one is the term mental health is just not consistent with evidence-based medicine. So I want to talk about that. And then the second part is the term itself, mental health, is likely stigma-inducing, although it needs to be validated experimentally. Feel free to interrupt at any time. With a question or a sneeze, it's okay. So for starters, what's the first thing that you think of when you see this term? Psychological. All right. Not bad. How many of you were thinking of something positive, like confidence, self-esteem, happiness? No. A lot of no's there. I'm not going to ask how many of you were thinking crazy, but, you know, that's pretty typical. All right. What about this term? What's the first thing you think about when you see this term? Thinking. Thinking or, okay, what is it? Or neutral, okay? So what's my point? My point is the term mental has baggage. I mean, there it is. People think about stuff like that. It's real. It counts. So mental health is a term that's really outdated. It's obsolete. It doesn't really belong in the medical vocabulary here in 2024. Because why? Because it's linked to the mind. And so what? Well, the mind is not definable. And in science, we have to be able to measure stuff. So you can't measure mind per se. So what kind of, what can you measure when it comes to mental health? What are the things that you can measure? Well, let's take a look at the definition. So the DSM-5 definition is a very wordy definition. A mental disorder is a syndrome characterized by clinically significant disturbance in an individual's cognition, emotion, regulation, or behavior that reflects a dysfunction in the psychological, biological, or developmental processes underlying mental function. That's a lot of words. And a lot of redundancy. So we're saying a disorder is actually a syndrome and a disturbance and a dysfunction. It's all that stuff. So what happens if you reduce the definition to its core, to what it's really saying? So that's what I've done. So I've lopped off the extraneous verbiage. So the definition reduces to something manageable. The actual definition is a mental disorder is characterized by clinically significant disturbance in an individual's cognition, emotion, regulation, or behavior. So it's really those three variables by which to measure mental health. The only thing that's missing is a social determinants. It's really where does the person come from? Where does the person live? What are the relationships like? What's their circumstance in life? Obviously that contributes to mental health. And so the social determinants lead to thinking. Thinking leads to feelings. The feelings to behavior. And behavior influences your circumstances. But it turns out all of these variables equilibrate. They all feed back on one another. So how you feel influences what you think. What you think influences what you feel. How you behave influences your environment. Your environment influences your behavior, and so forth. And how you behave influences what you think. What you think influences your behavior. So these are really the variables associated with mental health. And they're measurable, unlike the mind, which is not measurable. So there are lots of evidence-based treatments. Well, not lots. There are some evidence-based treatments that are more popular than others. The most popular one is cognitive behavioral therapy. And this is the most researched evidence-based psychotherapy. And it's actually the default mental health treatment in the National Health Service of the United Kingdom, and also Australia. There are other evidence-based treatments, including EMDR, which is strange, if you know anything about it. But effective for people recovering from trauma. And cognitive behavioral therapy, acceptance and commitment therapy. So these are all evidence-based treatments. So the pioneers in the field of evidence-based psychotherapy, there are three main ones. The first was Albert Ellis, who, in 1962, came up with rational emotive therapy. So he was the first one that really focused in on how your thoughts determine how you feel. But Aaron Beck, in 1977, came up with an important study that demonstrated that cognitive behavioral therapy was as effective, and even more effective, than medical treatment for certain psychological conditions. In fact, over time, it proved to be more effective. So Aaron Beck, who is a professor at University of Pennsylvania Medical School, is considered to be the father of cognitive therapy. Initially, it was called cognitive therapy. Now it's called CBT, cognitive behavioral therapy. Anyhow, his legacy is the Center for Cognitive Therapy, which is run by his daughter, Judith Beck. And now, that's the Beck Center. The Center for Cognitive Therapy is a unit of UPenn Medical School. And the third most important pioneer is David Burns, who wrote a best-selling book in 1980 called Feeling Good. He updated it to Feeling Great. So now he's feeling great instead of feeling good. And this has sold millions of copies. So he's feeling very great. I like David Burns. So later on in this presentation, I'm going to show you the 10 most common cognitive distortions as defined by David Burns. It really takes the mystery out of therapy. Okay, so there's lots of research regarding cognitive behavioral therapy. I have two pages of compendia about research in cognitive behavioral therapy. All of these slides I turned into a PDF for handouts. So all of these citations, you don't have to take notes, all of these references have citations attached. So you can just use the links if you're interested. Anyhow, so this first one is from Hopkins. So this is a nice, relatively compact summary of research in cognitive behavioral therapy. Some groups have labeled CBT the gold standard of psychotherapy, which actually it is. And this other book here is published by Guilford Press, which publishes most of the academic serious books about evidence-based psychotherapy. So this is a very nice volume. I like this third study because what's interesting here is, okay, they did a meta-analysis of 409 trials to determine what Aaron Beck already determined in 1977, which is CBT works great and it works better than medication over time. And of course, the reason is, when you think about it, is because CBT actually changes stuff. You know, the meds just influence the symptoms. Sometimes they're necessary and important, but, you know, CBT actually gets inside there and changes what's messing people up. Okay, so let's take a look at evidence. So in medicine, evidence is important. In the olden days, we had all of these terms to designate diseases. But in modern times, those terms changed. Why did they change? They changed because of knowledge, because of discoveries. So the old names didn't make much sense. Language matters. So it has a potential to shape therapeutic relationships and the specific word choices really influence people. People embrace them, especially in medical narratives. Now, over the last couple of weeks, there were three articles that I found in popular literature that make this point. So I integrated them into the program, just because it's, you know, this is out there. So one of them was an article in the Journal of Affective Disorders, and this was with a bunch of college students who were self-labeling with medical terms. You know, I'm diagnosed with depression. I'm diagnosed with, you know. So there are diagnoses that they embraced. So students who embraced those medical terms regarding their psychological issues demonstrated lower levels of control in their life. I'm a depressed person. I'm a bipolar person. Excuse me. They tended to catastrophize more. That was a term invented by Albert Ellis, by the way. You know, catastrophizing and awfulizing. I like those terms. That really does say what anxiety-prone people do. So these students had less ability to really take an objective look at their lives, but interestingly, they were more positive about drugs, you know, give me those drugs to fix the problem, than they were about therapy. They didn't have a lot of confidence in therapy. The second article was in the New Yorker, like, last week. And so this was interesting, and it approached the whole business from a different angle. A review of more than 500 targeted MRI studies of people engaged in specific tests found that although brain imaging was able to locate specific loci in the brain, they were not able to match them with specific conditions. So yeah, there's activity going on here, but okay. It failed to distinguish between these different medical labels. So the author's conclusion, the DSM's approach to categorization increasingly looks arbitrary and anachronistic. Well, yeah. So the same author also said that people who are caught up in that whole world of psychiatric diagnoses embrace it and have personal stakes in it, making it more difficult to change. You know, they bought into it. This is not unusual, of course, in the history of medicine. There's always objections when change is volunteered, even when it makes sense. I'm reading a really terrific book right now that I recommend to all of you. It's called The Song of the Cell. It's by Siddhartha Mukherjee. He's the one that wrote The History of Cancer. And it's a beautiful book. You know, the guy is a great writer. Anyway, I mention this because at every stage in the development of cell biology, which is what this was about, there was opposition. And the people, of course, that proposed these evidence-based ideas were scorned and rejected and ostracized. That's how it is, folks. The third article was in Scientific American and by a couple of Harvard researchers. And their conclusions are that people develop implicit beliefs that affect their health. So, for instance, a person may think they can spot the signs that they are getting sick or older. Their expectations, which structure how they feel, what they think, what they do, shape what happens next. So the point is the language influences your condition and how you might deal with it or not. So one way that would make more sense for the public to understand psychological health would be to pose it as a function of thinking, because literally that's what it is. You can say good mental health really means the tendency to do rational thinking. And just about every mental health disorder is a function of irrational thinking, often self-defeating thinking. So another way to make sense of psychological health would be to acknowledge that we all have self-defeating thinking habits. Everybody does. We all do. So I'm always amazed. You know, I've done certain training sessions at major companies on unlearning self-defeating thinking habits, and they are always well attended, you know, because there's no stigma there. Yeah, it's true. I forget my keys. Yeah. Sometimes I go to another room and I wonder, what am I doing here? You all know what I'm talking about. Anyway, the point is that the frequency and intensity of such habits determine if they're problematic or not. How much do you fuss? So the thing is, you can track that stuff. You can count those things. There's not a whole lot of mystery there. You just have to know what to focus on. So everyone is capable, a lot of people will say, I don't really hear my thoughts, especially when I'm most agitated. So there's a nice little exercise here posed by Bernard Bars in his book on consciousness, which I think is very interesting. Try to read the following words without hearing them in your head. It ain't possible. So, because it makes no sense. So yeah, you're trying to make sense out of it and you're repeating those words in your head, okay. So through inner speech and imagery, we can reflect upon, monitor, problem solve, try to modify our own functioning. I mean, that's the point. So what I'm really looking for in people, now, I owned an EAP company for 32 years. And what I have always been looking for with people is to develop what I call cognitive awareness. Which is really the ability to hear your inner dialogue. And the ability to associate thoughts with emotions, the ability to enable you to identify your self-defeating thoughts, to label them, because if you can label them, you gain more control, and to dispute and counter them, and then to feel better about yourself. Hmm. So our constituency here in AECOM are working well, are people who hold jobs. And as you know, psychologically, the predominant conditions that you see among this group are anxiety and depression, big time. You know, this is it. And when I was an EAP guy, this is what I saw all the time. So many common psychological problems can be reduced to specific thinking habits that you can track. For example, if you worry and fuss a lot, you're gonna be anxious. This should come as no surprise, because what is a worry? A worry is a prediction about future disaster. And so your poor old bod is, you know, kicking into the fight or flight response. Why? Because you're saying, oh my God, it's gonna be awful. Okay, and you buy it, you believe it in the moment. But that's a cognitive habit. Relentless self-deprecation. Again, this is characteristic of all depressed people. Also, many high-performing people, like doctors, for example. Because you are relentless self-critics. So depressed people are relentless self-critics. But often they're very high achievers, you know, for the same reason, because they're pushing and pushing. So if you have cognitive awareness and you think of your psychological issues in this way, it eliminates the mystery. You know, it's not a question of identifying a key event that occurred 37 years ago. That ain't it. Because whatever happened 37 years ago is history. It only exists today in your head, in your thoughts. You know, so what you're thinking really matters, and you can track that. Okay, so just knowing about them sharply reduces speculation, for sure. For example, so this is a nice graphic. A person with all kinds of self-deprecating adjectives in their head. So now I'm gonna just show you briefly what David Burns' 10 categories are. I like them because there's no jargon. They're very understandable. And I think it's important to know they're very understandable. Cognitive distortion, number one, all or nothing. This is typical of depressed people. Either I'm great or I'm a loser. Overgeneralizing, so something bad happened and then you generalize that into a never-ending trend. Mental filter, you weed out the good things and you only emphasize the negatives. My achievements don't count, that's discounting the positives. Jumping to conclusions, there's two kinds of jumping to conclusions. Fortune telling, which is really what worrying is, and mind reading. I just know they're gonna hate me. How do you know that? Well, I just feel that way. What do you mean? Well, I didn't like the look on his face. Well, what does that mean? It means he hates me. Does that make any sense? Maybe, but usually not. And here's where the Albert Ellis terms are very good. Catastrophizing and awfulizing. Magnifying or minimizing. Emotional reasoning. I feel like a terrible person, therefore I must be a terrible person. So these are all categories that you can identify in characteristic thinking habits. Should statements. This is always characteristic of guilt. That's why I love the graphic. The graphic is really great. I mean, she's got guilt. And should statements are kind of moral imperatives. I should have done this. I ought to have done this. I didn't do it. Therefore, I'm a bad person. Come on. Anyway. Labeling, calling yourself names instead of really focusing in on the actual behavior. Taking ownership for things. You know, personalizing things that you really are not responsible for. So these are the most, so this is Burns's list of cognitive distortions, which I think just hits the mark. All right, so evidence-based psychotherapy minimizes historical insight. I'm sorry about your past. You have had a rough time growing up. It's true, but we're not gonna focus on that. It lives today now in your thinking. It uses ordinary language, as you see. Focuses on problem solving. In the present. It's not seeking insight. You probably already have insight. You probably already know why. I mean, you can ask more questions to learn, find details of why. It's really what. What are you doing now? And how can we change that so that you don't feel miserable all the time? So, but the caveats are that what I'm talking about here, cognitive awareness is not therapy. It's not CBT. CBT is different. CBT really requires work. Usually with the help of a coach or, you know, some kind of a psychologist or a psychiatrist, some kind of counselor. It requires daily homework assignments. You get people to write stuff down. What are you actually thinking when you feel terrible? So, and what we're really looking for are automatic thoughts. These can be whole sentences, partial sentences, or pictures. They, a lot of times you don't hear them because they're background noise. It's automatic. It's you being you. But you are doing stuff. So let's identify it. Like, they're habitual. So like other habits, they were learned. They can be unlearned. And they can certainly be irrational and self-defeating. So in the moment, you tend to believe these things. So what many cognitive therapists do is they use a thought log. So a thought log looks something like this. Or this is one version of it, anyhow. And, you know, if you look at the, let's see. Where's the, well, I don't know how to do the laser on this one. Well, doesn't matter. All right. So anyhow, so you see the first line. The person is frustrated. And the person is thinking, and you ask the person to rate the degree of emotionality. And what were you thinking at the time? I was thinking, line one, I'll never be able to organize this mess. Well, how much did you believe it? Well, how much did you believe it? Well, around 70%. Well, take the last line. Depressed person. How depressed were you? 90. Well, that's pretty depressed. And what are you thinking? I'm such a loser. Did you believe it in the moment? Yeah, sure did. 90%. Okay, so now we discuss this. Are there alternative thoughts? If you could get inside your head and change those thoughts, which you agree are negative, not the least bit helpful. And it's coming from a credible source. It's you. And you're believing you. And you're saying all these awful things about yourself. Is there another interpretation if you could get in there and change it? Yes. So, all right. So first of all, you label, I like labeling those thoughts. Because again, the labeling says, okay, I have some control over it. It's not just endless. So what are some alternative thoughts? Wait a second. Well, all right. So for the top line, it would be, if I do a little bit at a time, I will be able to organize it. Okay, does that make sense? Is that rational? Well, yeah, it is actually. I don't tend to think about that at the time, but yeah, okay, it makes sense. How much do you buy it? 75%. Okay, that's cool. So now, how frustrated are you? Well, now it's reduced to 40%. Okay, so you pick it apart. You're actually getting inside their head, hearing the inner voice, and pouncing on it. Not letting it do its evil deeds. Influencing you. All right, and for the bottom line, depressed. Initially, you said, I'm such a loser. Well, that's labeling. You're calling yourself a name. And I'm really not a loser. I mean, after all, I was valedictorian, and I did go to medical school, and I did this fancy residency. So I have a lot of achievements, actually. So I've accomplished a lot, and it's never too late if I really want to accomplish more. Anyhow, all right, so it's a more positive statement. So now, how depressed are you? Well, I'm still depressed. Okay, boy, you're really tough. Yes, I am. But I'm less depressed, because now I'm thinking more rationally. Okay, thought log. So what if you don't hear your thoughts? This is what a lot of people say. Take an educated guess. Picture a thought bubble over your head. And what were you probably thinking at the time? And that's good enough. That's okay, that's good enough. What were you probably thinking? And again, it can be whole sentences, partial sentences, or pictures. The idea is to take these thoughts out of your head. As long as these thoughts are inside your head, they bounce around like an echo in a cave. So you want to get these thoughts out of your head, because your head is really powerful. And if you can, put it on paper, or put it on your computer. You could do it at night. It's hard for most people to do it in real time. So I always say, think about your day. When were the low points of your day? What were you probably thinking? Take control. Do you see a recurring pattern? Okay. Are any of them clearly not rational? Then you categorize them, like we did before, using Burns's categories, which I still think are the best categories. So what I'm really saying here is that mental health and cognitive health are equivalent. One is rooted in the mind, which is an unscientific term, and the other in cognitions, which is observable, and countable, and even modifiable. So psychological states are largely determined by these thinking habits. And these habits certainly can be identified and categorized, and if desired, modified. So what happens to the self-defeating thoughts over time? Well, over time, you'll learn to hear them, categorize and dispute them. You may still have them, but they don't have the same power. So their power diminishes over time. And is that the result? Yeah, sure. Okay. So cognitive health, what I'm saying, obviously, is an evidence-based alternative to mental health. It's pertinent, it's measurable. Its use may reduce or eliminate mental health stigma. And you can talk about stuff, that's the other thing. You can talk about these problems without using the term mental. And people are willing to do that. Because again, we all have self-defeating thinking habits that are a pain in the neck, but we've all got them. Okay. Question? Yes. Could you just elaborate a little bit more on the measurable part? I know you discussed that a little bit. The measurable, when you say cognitive... Oh, yeah. Well, they're measurable insofar as you ask people, what were you thinking? You can even count them. For example, anxiety people usually do a lot of what-if statements. They worry a lot. And open-ended questions, rhetorical questions like what-if are really predictions, but they're more damaging than statements because you can't challenge a question. What if it happens? What it really means is, oh my God, it's gonna happen. So that's what I mean. You can identify the specific thoughts. Usually anxiety people have two or three ones that they do over and over again. Sometimes I would get people just to count them. You know, before we all had fancy telephones with fancy apps on them, I used to have a risk counter, a mechanical risk counter. So I'd say, you know, every time you worry, just do a click. And we would count them. And that too was quite interesting. So that's what I mean by trackable because typically I would say to people, how many times, I know you're a big worrier. How many times a day do you worry, do you think? Oh, I worry all day. Yeah, that's what people always say. Oh, I worry all day. But give me a guess, what do you think? Oh, a hundred times a day. Okay, so here's a risk counter. I want you to count the number of worries that you do because I think you understand now, every time you do worry, you're predicting disaster. Of course, you're feeling anxious. Okay, and the most amazing thing in all those years of doing EAP, I never encountered somebody who did more than 40 a day. That was the ceiling, 40 a day. 40 worries a day, how interesting. And the thing is, if you know that you're doing 40 a day on average, now you try to beat that total. So as long as you got this, so that's what I mean by countable, trackable. So now they're trying to do 35. You know, we would set goals. You know, I'm gonna shoot for 20 a day, yeah. Okay. Okay? Yeah, because when I think of measurable, I think of something, you know, a validated tool like a PHQ-2 or PH. Well, yes, there are scales, yeah. Yeah. Yeah, it's been a while since I've done that. You're right. I used to use the Beck Depression Inventory for depression, which is a great scale. And it's readily available, public access. There are also ones for anxiety, but I just don't remember the best ones. You know, excellent point. It's more quantitative. Okay. What else? Yeah, so if you use the term cognitive health, that's more likely to steer people towards evidence-based treatment. You know? Meanwhile, what about the effects of stigma? Well, in case you have any doubts that stigma inhibits people from seeking treatment, there are more than 100 peer-reviewed empirical articles which state this, which prove that stigma inhibits people from seeking treatment. So what might happen to mental health stigma if you didn't use the term mental health? What if you start using cognitive health instead of mental health? Eliminating mental in favor of cognitive would educate employees about evidence-based treatment, might reduce stigma. I think it's likely to. But what it wouldn't do, it wouldn't minimize the seriousness of psychological problems. I'm not poo-pooing that. When you're seriously depressed, it hurts, man. It slows you down. It's bad. It wouldn't minimize the value of talking about things. That's important. No matter what the philosophy is of the talk, to get people to talk about things is a first step. So that's really important. It wouldn't eliminate the effective use of medication. I'm not saying this is a substitute. Sometimes you have to use medication. Sometimes it just really does fit. But I would say for the bulk of people, in my opinion, based upon my own experience, the bulk of workers, of employees, the people that we see are amenable to cognitive awareness, to thinking about their own thoughts, and to initial education about the whole idea of how your thoughts influence how you feel. They can gain control without seeing a therapist, by attending a couple of training sessions. It's doable. So interestingly, so here's an article that was in our own journal, Journal of OEM. Discrimination against those suffering from mental illness is still rampant. So an article in our journal said that 47% of the general public express an unwillingness to work with people diagnosed with depression. Wow. Moreover, 30% were unwilling to socialize with them. How come you don't wanna hang out with them? He's depressed. So, well, I don't like that. Okay, all right. Would such avoidance behavior exist toward people who have cognitive problems? Hmm. I have cognitive problems too. I still don't like that guy. Okay, all right. To our credit, this organization, ACOM, has an award. It's called the Mattingly Award. And the Mattingly Award is for companies or organizations that demonstrate exemplary efforts to promote workplace mental health. And here are the criteria, positive organizational culture, robust mental health benefits, all good. This is all good stuff. Healthy work environment, positive outcomes, innovation. That's all good. There's something missing here, however. See, I think this list could be greatly enhanced if companies would promote evidence-based concepts regarding treatment. That's not on the list. So all those things are very good, but if you wanna improve mental health, why not promote evidence-based treatment? So I think that should be on the list. That's my opinion. So, because most psychological problems impacting work can be conceptualized as cognitive behavioral problems, as we've said. I know I'm repeating myself, but it bears repeating. Cognitive awareness would alleviate the mystery, definitely. So I took this next slide from a book that came out in February, and I'm actually gonna read the slide, which I don't like to do, but I like the way she put it, because it's true. The name of the book is Bad Therapy. And here's what it says. More mental health treatment has occurred for Generation Z, those are the younger people, has not resulted in less depression. Unlike breast cancer deaths, which have plummeted with early detection, or tooth decay, adolescent anxiety and depression have ballooned. Almost 40% of the rising generation has received treatment from a mental health professional compared with 26% of their predecessors. Since 1986, every decade has seen a near doubling of U.S. expenditures on mental health. So that's a biggie in companies, in organizations. You know this, you're concerned if you're a corporate medical director, you see this happening. So, and again, so the citation's down here. Name of the book is Bad Therapy by Abigail Schreier. So why has the term mental health persisted? You gotta ask yourself. I mean, I think I'm making a compelling case here. Well, one reason is momentum, just because it's been the default label for so long. No doubt about that. The other reason is that treatments not based upon the medical model are often disregarded or minimized. Because you're, as a doc, you're trained to see things as medical problems. So there is a, often there's an inaccurate belief that anything that's really not medical is superficial. But you know, controversies within medicine are not new. They've been going on for a long time, like forever. New treatments often elicit skepticism. For example, there's always, there's been a long running debate about whether mental health problems are diseases. Obviously, there's no pathogenic agent, per se. And the biggest critics have been psychiatrists, Thomas Szasz, R.D. Lange, E. Fuller Torrey. And Szasz is the most famous of these. And his book, The Myth of Mental Illness, stated that there are neither biological or chemical tests, nor biopsy, nor necroscopy findings for verifying the diagnoses in DSM. And he's right. So he believes that mental illness is really a metaphor for human problems in living. Okay. So, I wanna volunteer a reasonable hypothesis that has never been tested. This is a famous scientist. Not. Okay. So, and here's the hypothesis, that determined mental health creates stigma. You know that there's no research on this? There's none. If mental were placed by cognitive, I think stigma would diminish. This idea needs to be tested scientifically. It never has been. So here's some ideas to test this hypothesis. So whenever possible, corporate medical directors, if possible, change the name of the mental health benefit to the cognitive health benefit. In many companies, that's doable. You can retain the same reimbursement, the same everything, you just call it something else. But if you do something like that, you have to accompany it with lunch and learns and some kind of education so that people understand what you're doing. Why have you changed the name mental health to this other thing? Anyhow, if you did that, if you did that, if you changed the name, then you could do a lot of pre-post comparisons. This would not be difficult. EAP usage, for example, pre-post. Psychological referrals, mental health claims, pre and post. You could do surveys asking people about stigma, pre and post name change. It's all doable. What can you do as an OEM doc? Well, whenever possible, when you see people who tell you that they're depressed, again, I'm not asking you to be a shrink. I'm not asking you to really do cognitive therapy. But you might just suggest to the person, what do you tend to think? You prompt them. I hear that you're depressed, I see that you're depressed and it's really hurting you, it's bringing you down. I think it might be helpful if you're tuned in to the self put downs. What do you mean? I think that you're probably doing a lot of them. Again, you don't have to, you can just plant the idea. And you can actually, I used to have a lot of David Burns' book in paperback. You can get them at discounted rates, you know? And it's just so easy to understand. That's another way to help people, especially smart people, to gain control. Encourage cognitive awareness whenever appropriate. When you're discussing workforce well-being and all of those mental health claims, when you're talking with top management about that, they're concerned. You can maybe try to maneuver into changing the term. Try to influence your EAP to recommend and evidence-based referral resources. Encourage them to provide links to the many apps that exist now. Cognitive behavioral apps and online training courses. You know, the leader is the Australian National University. They have a website called Mood Gym, which is really great. It's not free though. But it's good, you know, it's very good. And you can also encourage your EAP to provide these kinds of trainings and professional literature regarding evidence-based concepts. All right, so that's really it. I just want to review what I've discussed and leave it open for questions if you have questions. So the first part of the program was that the term mental health is just not consistent with evidence-based medicine because it's predicated upon the mind, which is not definable. And the second part is that the term mental health itself may cause stigma, likely does. And that a reasonable anti-stigma hypothesis recommended by George Carlin needs to be tested. Okay, so that's it. So I'm done, are there any questions? Yes. Yes, so you run an EAP program or? I am no longer, no. I was just going to ask if you know of EAP providers who actually use the term cognitive health and how that has gone from a marketing perspective and so on. It's a great question. And then my second question, sorry, but just to add on. Yeah. What is your take on the rise of mental illness? In reference to SARS, do we have a crisis or is it more about, I wanted to hear your perspective on that, so. Well, okay, first part of the question, no, I'm not, I don't do EAP anymore. I write proposals, I do articles. So no, I actually don't know. The company that bought my company is called ESI. They seem very competent. I don't, I have not, they have very good promotional literature, but I haven't seen references to cognitive health per se. Is there a mental health crisis? Well, if you, you know, if you picture my model, social determinants, cognitions, emotions, behavior, I think you would all agree that the social determinant part has changed for all of us. We're talking about global pandemic. We're talking about authoritarian types of politicians throughout the world. We're talking about wars every place. So it's kind of a rotten situation for most of us. Just for starters. So is there an epidemic? You know, the world is an unfriendlier place than when I was a kid, that's for sure. So I think it's that fueled by the medical diagnoses. So I think that that one study was very revealing about college age students. As long as you think of yourself as a diagnostic label, yeah, you feel worse about it. And that's been widely promoted. And the fact that we have our magic phones, you know, keep us in touch with the latest and greatest awful things. So we know about everything that's terrible. And especially if you're young and you're on TikTok, and cause that's what sells. So is there, yeah, so I would say yes. You know, like the happiness scale, for example. What does that say? You know, are the Scandinavian countries still up high or is it lower than it has been? What's your take on that? So this is Eunice, and you know, in his country, in Abu Dhabi, they're tuned into the global happiness scale. I'm not sure about the result. I'm not up to date to that. Okay. But they keep changing. to scale it down to kind of educational and work space as well, so they have their own indicators. All right, well, all right. Well, there's, I mean, that's sensible and smart. So- There is a score for the nation and there is a score for education and different institutions. Yeah, I guess all I'm wondering is, has the baseline changed? I don't know, but yeah, all right. Is there an epidemic? Yeah. Yes. I guess this is more of a educational question, but from a medical diagnosis- Wait, wait, hold up. From a medical diagnosis perspective, we treat someone who has a broken arm. We say, hey, it's gonna be six weeks. You're gonna be fine. You're gonna go on with your life. For mental health, cognitive health, it's like you get sucked into a black hole. It's not six weeks. It's gonna be forever. And because we don't give a definite timeframe of when you should be healed, that it's even more fear-inducing. Like, I'm gonna be like this forever. And is that our fault? Yeah. I agree. So what you're saying is- Thank you. Sure. It's exactly what I wanna hear. You're talking about the open-endedness. You're aware, of course, of certain traditional therapists who'll string you along for 20 years. That's what they taught. They're sincere. They wanna help. They just believe that if you get excruciatingly detailed insight, you will be cured. Except that it doesn't work. It's not proven. It's not scientific. So it's open-ended, kinda creepy. There was another question. Yes. I've heard several companies using terms like emotional health, behavioral health, even healthcare providers. Do you think these names could reduce stigma? Yeah. So some people have suggested behavioral health. Actually, the United States Army changed from mental health to behavioral health because they correctly identified that mental health creates stigma. The problem, of course, is when you think of behavioral health, you're thinking of behavior problems. To me, it doesn't really capture what's going on. Yes, you do behavior, but honestly, this is the master control right here. Some people have suggested brain health. And there, too, the study that I acknowledged here was that they've done some very interesting things with targeted MRIs, and it's still mysterious. Okay, there's activity going on here when you're depressed, but how do we translate that out into anything practical? So there have been alternatives. To me, the only sensible, of course, obviously, I'm very biased. The only sensible alternative, I believe, is to reference thinking, cognitive health. Or initially, Aaron Beck called it cognitive therapy, but nowadays, it's called cognitive behavioral therapy because it includes behavior. Question? I apologize if it's a little inchoate to bother to borrow a word from your slide, but a lot of us take care of groups of people. Yeah. And I'd like to think for a minute about stigma as a group activity. I had occasion to look into suicide among law enforcement officers a couple years ago, and one of the things that came up was this concept of pluralistic ignorance. So you talk to an individual police officer about their attitudes toward working with people who have mental health issues or cognitive health issues, whatever term you want to use, and they generally are pretty accepting. They understand this happens to everybody. And then you ask them, well, what do you think your colleagues think? Okay, what's the mood in the locker room, basically, right? And their answer's very different. Oh, no, they wouldn't go for it. They perceive themselves as a group to be buying into the stigma far more than they actually do themselves as individuals. And I'm wondering how we as healthcare providers to groups can move that needle a little bit. Well, yeah, I like that question. I believe it's education, honestly. I personally have done, like I said, a one-hour presentation on unlearning self-defeating thinking habits, which people go, oh, yeah, okay. So, and it's not threatening at all. It's a lunch and learn. I would recommend some kind of training like that that's not really medicalized, that's not highly technical, that just talks about that and labels it cognitive. Oh, and by the way, yes, we're all subject to this, but you know, people that have extreme habits like this, like putting themselves down or like worrying a lot have mental health problems. I mean, that's what it is. It's all part of a continuum. Well, now, you know that, we know that, us docs, but the public doesn't actually know that. Mental health people, they're different. Crazy people, they're different. Well, not really. They're just like us, but they're at the extreme. So, I would recommend that kind of educational effort and printed educational matter as well. So, Yunus does a lot of work with police in his country. You link it to the physical health. If you are in compact and your colleague is shut down, would you be his buddy? Would you take him back? So, if we're military, you link the military, this is the same, it's a cognitive injury, okay? Would you help him if your buddy, worker, coworker, would you take him home? Would you take him back, you know, to the safe zone or no? So, there is kind of approach where you have to get his back, whatever. Is it physical injury or cognitive injury or mental injury? So, in the military, they have that concept. I will not let my buddy down. I'm taking him home, yes? So, once you implant the seed that injury here is like injury in the feet, injury in, he will take time to heal and rehab, that concept have to be promoted. Once you get that link, I think it will work. I believe, I don't have the evidence, but there is few references where they actually, this is the way should we deal with it in military and police forces. Okay, okay, thank you. So, I applaud, I agree with your efforts to move away from mental health. You know, it does carry a lot of stigma. I just think we have to be careful about unintended consequences in terms of the label, the new label you choose. So, I wonder if we shouldn't go with more of a term like resilience or coping health. To me, cognitive, I associate that with IQ. I think of cognitive disabilities, you know, intellectual disabilities. So, you know, that's what popped into my mind when I heard cognitive health. So, maybe moving more towards functional, you know, coping abilities. Oh, yeah, okay, that's a good idea. Thing is, if you look at the CDC website, for example, the only references to cognitive are aging, you know, people who, dementia people. Yeah, so, you know, that's one reason why you associate cognitive with that, I guess. People with intellectual disabilities. Yeah, yeah. Yeah, I mean, that's, yes. That term is really. I, that's, yes, and I think that that association is common, I'm guessing, with medically educated people. I'm guessing that with the public, they don't even know what it is. That's my guess. Again, it needs to be researched. I'm guessing that, you know, for the average audience, you say cognitive, you know, I mean, you've read all this stuff about aging and dementia. Well, except, you know, family members with individuals with dementia or with children with autism and intellectual disabilities. I'm sure they think of cognitive. Yes. Related to. I agree. IQ, cognitive ability. Right. The problem I have with resilience is, I mean, it's a good thing to have, but if you're a depressed person, you're thinking, ah, my life sucks. You know, I'm miserable. It's never gonna be better. Well, you need to be more resilient. I, yeah, well, but I, you know, I'm in the pits. Yeah, but well, it's semantics, it's public relations, but it's a good idea. I mean, I hear what you're saying, you know, and you're right that there are those associations. Definitely. So you have to change the mental part, I guess. All right, Craig, you got a question? No, I think there was one just before me. Wait, wait, I can't hear you. There's a question, I think it was, I can't just. Oh. Question, no question? Yeah, yeah, comment, good. So most of us are evidence-based and measurable, and this is the world that we're in, but there's an entire population of people that believe in spiritual and things that are not measurable. And I know that we're always called to always measure, but when we see these patients, and when we, even in our personal life, come across things, there's other ways to approach it than just measurable. So I know you're struggling to get sort of like a, well, if we all have a consensus, it will be more adopted, but there should be a consensus about how do we get that side, a big sort of underserved population, served with this as well, so. It's an excellent point. Of course, there's so many people that are not the least bit spiritual, and so I'm just thinking in terms of broader generalizability, but it's an excellent point. Greg. So David, thanks again for your thought and your efforts to teach members of the college. And I think it's a great call to leadership and OEM for us to, I hope, be energized to go back to our organizations and really work on this. It's increasingly important, I think. I guess my main question, given your wisdom, how can we go back and test these concepts before we introduce them? Well, yeah, it's a good question. I'm just thinking, do you have the power at the Cleveland Clinic to change the name of the benefit? Maybe. Well, I mean, that would be very influential. You know, Cleveland. I don't know how to test what, or to use that. There's such a diverse population, all the way from the top surgeons to wage-earning cost-caller, and so on. I agree with you. I don't think it's easy. I mean, you know. So I'm writing a book. You know, maybe that, you know. Because I've thought about this a lot. And as you know, I've been ranting about this for several years. You know, I come to this meeting and people agree. And, you know, I don't have a lot of opposition. People say, oh yeah, that makes a lot of sense. But what do I do? You know, how do I implement that? So it ain't easy. So my answer is to write a best-selling book. You know, I mean, you know, I've started. It ain't bad. We'll see. But that's the only thing I could think. An influential organization like Cleveland Clinic, if you did something, some kind of pilot program that we could discuss if you want, you know, that would have impact. And, you know, you would publish it. And, you know, people would listen to you, I think. That's my call to action. I would listen to you. I wonder if anybody else has any thoughts about how you get to the goal, the concept, and then over to the population. Somebody mentioned, you know, unintended negative consequences. I think the uptake of the benefit when people come and there is more and more people. For example, if you change it to cognitive, so. I know people avoiding coming forward to occupational health because of the stigma of mental. So if you change from mental to cognitive or happiness programs or cognitive program, I think you can measure the people getting forward and applying for that as an indicator. The percentage of your employees want to be happy or want to be cognitively well or smart. Whatever name is there, you label it. But we agree that it shouldn't be mental. Especially with like, if you go, oh, he's walking to the mental health booth. Is it easier to say, oh, he's walking to the happiness booth? You understand me? So I think people are more happy to walk toward something with less stigma. Cognitive happiness rather than mental. And I think change it to, just changing the label. More people will come forward and join the program. And you can measure it. Maybe someone will correct me as a percentage of people taking the programs, coming forward and admitting they are not cognitively well or not happy. Okay, we have another comment here. So I think what we're talking about is rebranding a health phenomenon. And I think brands need to be changed now and again. And when my parents went to elementary school, special needs class was called the classes rendered for the mentally deficient. Which sounds pretty horrible to us at the moment. And then was probably cutting edge. And there have been many iterations since then. It seems to me that when we're talking about a rebranding exercise, we maybe need to use the methodology of advertising agencies with focus groups and things like that to try and get an understanding of what our current workforce, how they would perceive it. What does term that works for them to get across the ideas that we wanna get across and not fall into the pitfalls that we've been in with the current terminology. So I would probably look at it doing it that way. Well, I like that. Focus groups. Okay. Okay, anyone else? All right. Well, thanks everybody. Appreciate it. Thank you.

mental health

cognitive health

evidence-based medicine

stigma

cognition

emotion

behavior

mind

self-defeating thinking habits

cognitive behavioral therapy