Transcript for Episode 35
Grant:
My guest today is Ben Miller. Ben is the chief strategy officer for Well Being Trust, a national foundation committed to advancing the mental, social, and spiritual health of the nation. At the Well Being Trust, Ben helps oversee the foundation's portfolio, ensuring alignment across grantees, overall strategy and direction, and connection of the work to advance policy.
Prior to joining the Well Being Trust, Dr. Miller spent eight years as an associate professor in the Department of Family Medicine at the University of Colorado School of Medicine, where he was the founding director of Eugene S. Farley, Jr. Health Policy Center. Dr. Miller’s research interests include models of integrating mental health and substance use, primary care practice design using practice-based research networks to advance whole person health care, financing health care, and health policy. He received his doctorate in clinical psychology from Spalding University in Louisville, Kentucky. So, Ben, you and I have known each other for, I think, the last seven or eight years. I don't know if you remember when we first met.
Ben:
How could I forget? I mean, this is something they make movies about, right? In the back of a shared Uber. I remember this.
Grant:
That's right. A shared Uber from the Rosalynn Carter Center in Atlanta, where we were both participating, I believe, in a caregiver conference. And I knew from that car ride that we had a lot in common. I think we had a lot to talk about. So, I'm really looking forward to this conversation. And we've regularly run into each other or sat on panels together at conferences, and finally we got to work on a project together for Medicare about four years ago. So, I'm really looking forward to this conversation with you.
So, I was hoping that you could fill out your biography a bit. How did you get to where you are now?
Ben:
Well as a musician, it wasn't paying the bills, so I figured I should become an academician. Truly, I was passionately into music. And when I got done with college, I started looking around and I'm like, you know, you can't make a living playing music. As much as I would like to try, you can't really do that. So, I taught special education. And not many people know this, but when you're looking for a job straight out of college and your, your degrees are in religion and psychology, double major, there's not like five thousand jobs waiting for you. And so, I was recruited to work as—recruited [is the] optimal word here—to work at a school for kids with severe emotional disturbance in Chattanooga, Tennessee.
And at that school, there was this amazing, visionary principal who happened to be a psychologist. I spent about two years there, and this guy, he showed me the ropes. He taught me everything he could and really helped me understand that if I wanted to make a difference in people's lives, if I wanted to do something with that undergraduate degree in psychology, I probably should go get more education, so I could work on changing the system that these kids that I saw every day were suffering under.
So I, I went to got my doctorate, worked mainly in primary care settings throughout graduate school, which I have to tell you, Grant (and I know we'll talk about this), changed my entire way of thinking about mental health. You know, in graduate school, you're often trained to be a specialist. And what primary care taught me was that actually, we need to be more generalist, that we need mental health clinicians in all the places that people show up. And so, did that training, fell in love with the idea of integration, fell in love with the concepts of policy. And then, you know, fifteen years later, I get to talk to smart people like you on podcasts.
Grant:
Well, great. So, as I've been reading your work, this is a real fun opportunity to go through what you've been working on recently. There's a couple of terms that you use extensively, and I suspect we'll be talking about them. For the listeners, I was hoping you could tease some of these out. So, you often use “mental health,” “whole health,” “wellness,” and “well-being,” sometimes interchangeably, and sometimes you distinguish between those. But I was hoping that you could tease those out a bit for our listeners.
Ben:
Yeah. So, language changes culture, right? And the language that you and I have inherited, that the listeners probably have inherited too, is not necessarily the best language to describe the concepts that we're going to discuss today. But it's the only language we have because it's the culture that we've been given.
So, when I talk about mental health, I want to very quickly decouple that from mental illness. Because when we talk about mental health, we view it as foundational for your health. When you talk about health, our definition of health is that it's the foundation for achievement, and you can't have a successful life and achieve the goals you have for yourself if you don't have good mental health, which could include your thoughts, your feelings, the way your thoughts and feelings, you know, interact with your behavior. All of the stuff that you're typically taught in Psychology 101. But where mental illness comes in is what happens when you don't, you know, aren't necessarily able to manage or cope with some of the stressors or things that come at you in life. Now, sometimes this is genetic. We've inherited this. Sometimes it's a stressor, then we just have to manage it. Sometimes it might be a variety of different things that lead us down a path where our mental health becomes a bigger problem and ultimately does become a diagnosis and therefore classified as an illness.
So, we think about mental health a little bit more broadly than some people do, and we do decouple it from mental illness. Now, “whole health” and “well-being” and “wellness” and all these other terms that we use, I'll let me see if I can unpack these really quickly ’cause I don't want to bore people to death.
Wellness is a term that I feel started off on the right road. People were understanding that wellness is more than just like, you know, it was more than just like your, your health and just things about you. It had to include other things than just your health, like your physical diagnoses or whatever they might be. But it got co-opted pretty quickly by an industry that said, “We want wellness to be about these five things. And if you don't do these five things, then, you know, you're not well.” And that got a lot of people confused on what wellness is. So, we actually don't use wellness a lot because of that, the problem that, of it being somewhat co-opted. And we talk about well-being more often.
Grant:
Are you thinking particularly of being co-opted sort of by the workout industry?
Ben:
Well, yeah, I mean, if you look back into like the ’90s and even the early 2000s, there was a lot of workplaces, employers that were doing these wellness programs, you know: come do this; come do that; join the Jazzercise class at noon; or come to the quit smoking class at two. All of those things are great, right? But they very much focused on kind of the physical aspects of health and didn't go so much into more of the emotional or the mental side of health. And honestly, I mean, if your reader or your listeners want to get a little bit deeper in here, go and read some of the literature. Most of the wellness programs failed miserably. They didn't actually improve health.
And so, part of the reason why they didn't improve health is they didn't go to the well-being side. And on the well-being side is when you can incorporate things like emotional health, your mental health, where you live, much more of the community conditions and factors that give rise to your overall well-being. And so, we actually hang out more in that space.
Now, when you're in that space, because it's, it's inclusive of like where you live, transportation, your job, how engaged you are civically, as well as health-care access, insurance, your own mental and physical health. It does feel like a pretty big umbrella. And so, other words get thrown in there too. And you've mentioned these: “whole health,” “comprehensiveness.” These things get kind of thrown in there because it's an attempt for us to simplify with another word this really broad and complex, but yet extremely important, construct of well-being. Hopefully that helps a little bit.
Grant:
It does. And, you know, as we expand this understanding of health, one term I've been using quite a bit is human flourishing to try to encapsulate both the physical, the mental, the spiritual, and even the moral life. And so that adds another word into this, and I don't know if that is a word that you've incorporated all into your thinking.
Ben:
Oh, absolutely. I mean, who wouldn't want to flourish? Not only is it a, just a beautiful word to use, but it's, it actually is something that's more aspirational. Like we don't just want to exist. We don't just want to get by. We actually want to flourish. We want to be our best selves. And that's why I go back to the beginning of what I was saying here. If health is a foundation for achievement, then to be your best self, that foundation needs to be firmly rooted in the things that actually matter to you, that allow you to thrive and succeed. And so, I know we'll talk more about that, but yeah, I love the word.
Grant:
Yeah. So, when, when you and I first met, you were largely a health services researcher. And for our listeners that aren't familiar with this term, that's sort of a multidisciplinary field that is interested in finance and organization of health care and how it impacts cost, quality, access, and health. And one of your big interests was improving mental health services, especially within the primary-care context, as you mentioned, so this notion of integrated primary care. But you've argued in quite a bit of your writing that mental health and addiction services is fragmented, overburdened, and underfunded. So, what do you think are the major challenges, in your estimation, in the mental health delivery system?
Ben:
Whew. Wow. Where to start? Well, I think for the listeners that aren't as well-versed and haven't read all the history books as, maybe, as I have, it's a good place to start at the beginning of how we began to ultimately think about where mental health fit in health care. And I can take you all the way back to, you know, philosophical times and René Descartes, and we can describe the mind-body dualism. We won't go there.
Let's just kind of start with John F. Kennedy because it was in the early ’60s that we saw some of the most radical reforms for mental health. Now, it's important to note that what JFK did was actually act on a series of recommendations that, that had been given to him from a task force that was looking at mental illness. And he recognized, and I think the, the committee itself, the task force, recognized that simply institutionalizing individuals for mental illness was not necessarily getting the outcomes that anyone wanted. As a matter of fact, people were languishing. People were dying prematurely. They were being, in some cases, and this is the nasty history of mental health, being used as test subjects to understand the brain a little bit better.
And so, in the ’60s, when JFK de-institutionalized mental health, meaning he took the hospitals and said, “Your role should not be primary; it should be secondary.” (And we get our public health terms right, it should be tertiary.) It should be a place that people go when they have no other place to go, because things are so bad. It shouldn't be the one place you go just because you've received a diagnosis, which is what a lot of things happened back, you know, early ’50s and ’60s—actually way before then, too. So, that was the first decision that began to separate out mental health into the community.
Now, the problem here, Grant, is that the resources, the dollars that were supposed to fulfill this vision of truly comprehensive, community mental health never came to fruition. They never followed the visionary statements that were put out in 1963. And there's a long history here of decisions that would have been made in terms of presidents, executive orders, commissions that have really never rectified this problem back then. So, fragmentation, if you're just looking in the last fifty years, sixty years, began when we actually put mental health into the communities and said, “Create a new system; create a separate system for mental health.” There was really no such thing as mental health benefits, you know, until we started to having to pay for mental health on the, in, in the communities and that allowed for folks to then create their new business models that supported mental health or a new delivery system that supported mental health. So that's the origin story for fragmentation.
It's not as exciting as like, you know, Superman, but it's pretty important that we get that most of what we've inherited has been because of decades of piling on top of workarounds and workarounds and workarounds to get us to a place that we're trying to integrate, which is what we should have done back in the ’60s.
Grant:
And I know that even historically, there is even this question about whether or not mental health care was even health care and whether or not psychiatrists were even physicians. So, that augmentation goes back very far. So, what do you think Congress can do to improve mental health delivery? What's the biggest bang for the buck?
Ben:
Well, the biggest bang for the buck is not just putting more money into what we've got. The biggest bang for the buck could be actually pursuing policies that restructure how we think about mental health and restructure how we finance and how we deliver mental health services. So, as you and I have talked about already and a theme that I think will permeate our discussions today, is that we've got to make sure that mental health and addiction services or wherever people are. In too many states, especially within our Medicaid programs, there might be one door that you could go into as a Medicaid beneficiary. And that one door, we know from, you know, decades of literature, is not usually the one door that people go into.
So, that one door for most is community mental health centers or some specialty mental health setting. And we know from lots of experience here, that if you look at schools or if you look at places like primary care, or even now in current times jails and prisons, this is where a lot of people have their first interface around mental health. It is not in a mental health center. People don't just wake up one day and say, “You know what? I think that these symptoms I've been experiencing are consistent with that of depression. I should probably find somebody that can diagnose me and then allow for a prior authorization for me to show up and talk to a psychologist, psychiatrist, social worker.” That doesn't work that way. People are able to be identified wherever they are. And, usually, the places that identify them don't have the resources to treat them.
So, Congress—going back to that—you know, Congress could actually really rethink some of those structural impediments as to how people can get access to care wherever they might be.
And, I mean, I love this topic. I could spend six hours talking about it. It’s at least twenty podcasts, but I will pause on that.
Grant:
So, this notion of integration is trying to figure out ways to place those mental health providers within the settings in which people are saying to somebody, “I'm struggling, and I need help.” And there's potentially an easy handoff then to someone who can actually help them.
Ben:
Yeah. And I think most people in their lives have been in a situation where they're going through a hard time. And it's hard enough to tell your family or your friends that you might be struggling with something. And for some people, it's a lot easier to tell a stranger, someone who they might have a relationship with, but it's your primary care doc that you see once or twice a year, whatever, however often you see them.
And so, the goal here is to wherever you show up with those needs, that instead of the referral being kind of the immediate knee-jerk response, that there's another person there, a mental health clinician there or a mental health expert who can help. And that way it defragments, right? It solves some of those problems that we've already had for a long time on, you know, you having to bounce around from place to place. And it gives you more immediate accessibility to people that can provide some immediate solution.
I mean, average wait times in the United States in 2020. I mean, if you look at the, you know, there's, there's all kinds of studies that have looked at this, but you know, some studies have shown, it could take anywhere from two weeks to twenty-nine days. Other studies, if you're looking for a specialist like a child and adolescent psychiatrist and you're in a rural part of town, it could take upwards of six months. And so, like, nobody wants to wait. And going back to our flourish and languish continuum, you're going to languish if you have an unmet need that is something that is, like, literally pushing on all the buttons in your life and you can't get help with it. We don't treat anything else in health care this way. Nothing. Nothing. But yet, for some reason, and I think the reasons we've already touched a little bit on, mental health is continually looked at as this thing that's distinct and different. When, as we've already said, it is foundational, and we still don't treat it as such.
Grant:
Yeah. So, it seems to me that your career took a bit of a turn when you went to the Well Being Trust. So, first you moved out of academia into philanthropy. And then also it seems as though you're moving a little bit away from this field of health services research into more community-based issues that are related to the social and cultural conditions that promote or impede health. So, is that a fair characterization of the way that your career has gone? Are you moving sort of out of health services research and a little bit more into these community-based questions?
Ben:
Well, while I, myself, may not be a principal investigator on federal grants to, you know, analyze or examine the importance of this integration stuff, I'm still very much at my heart a health services researcher. I'm always thinking about the question. You know, what is the question that we need to have answered?
And leaving academia and coming over to, to this side of the world, where I do a lot more on the philanthropic giving side, we, we are much more of an impact philanthropy. You know, we want to make a difference, and we want to push on the things that we think are going to add the most value for advancing mental health. So, that means that my background as an academician—as a health services researcher—actually is extremely important because not only am I able to synthesize the literature, not only am I able to have kind of a fundamental grasp of where we are in terms of the science, but I'm actually able to apply a higher level of scrutiny to some of the investments, just because I know what the evidence base is.
So, while I don't think of myself, you know, going out there and doing the research anymore, I'm still thinking about every dollar that goes out the door from our foundation as being a dollar that I want to make sure has a measurable impact. And that's part of my joy in this job is that, you know, we get to actually give resources to people who are making a big difference, whose work is impacting countless lives, and who is in ways measuring that in a way that actually will allow us to scale and sustain it and share it, frankly, with folks all over the country.
Grant:
So, in a recent paper that you put into Health Affairs, which is the primary health services and policy journal, you talked extensively about the possibilities of major good that can be done through philanthropic grantmaking, particularly in terms of improving the nation's mental health. So, what do you think private philanthropies can do in their grantmaking that federal mechanisms such as NIH are not able to do? What's your unique contribution to improving mental health?
Ben:
Well, foundations have been the lifeblood of mental health innovation for, you know, for as long as I think we've had foundations. A couple of things that foundations are really good at. Number one, it's supporting the stuff that nobody else supports. It's putting resources into the pockets of frontline clinicians, staff, organizations that might be doing some of the most innovative work, but there isn't currently a payment mechanism or a funding mechanism to, to support it. So, foundations have done a really good job with that. The second thing they've done is that they've really been kind of out in front pushing for change. And this is where the leadership ideas come around with foundations. Like how can foundations be leaders in their communities? And for us, we've tried to embrace both of these things. Not only do we want to invest in solutions that are likely going to have the ability to make a huge impact, but we also want to be out in front talking about these issues.
So, while I think some aspects of my life and my thinking has changed, Grant, I think for the most part it's actually allowed me—and I, with tremendous respect to my academic life, which I still have, I just don't do it primarily—is that it's given me a little bit bigger field to play in and that I don't have to worry so much about tightly framing the question just to get that review committee, review section, to give me the thumbs up green light that they're going to score my grant. That I actually get to be a little bit more flexible in that question and take more risk. As a soft-funded researcher when I was at CU, you know, you can take a few risks. And my mentor, the chair of our department, always said, you know, “Fail fast. Fail smart.” Because you need to fail in order to ultimately learn, but you need to fail and ultimately to achieve something that's probably going to be a difference maker.
And being in philanthropy, it’s one of the things that I feel like we almost use as a mantra every day. Like we could go big and take huge risk and fail miserably, or we can learn and we will still actually be okay. I mean, I'm not going to lose my job. I'm not going to lose my laboratory or my team. I'm not going to have the Dean sending me a letter saying, “Where's your funding, Dr. Miller?” You know, I don't have to worry about that stuff anymore. So, I guess what I'm saying to you is that it's still core to who I think I am. I just get a little bit more flexibility around how I do what I was doing, you know, five, ten years ago.
Grant:
So, we know that the United States spends an inordinate amount of money on health care, approximately 17% of the economy. But we also know, at the same time, health care, health services, explain a relatively small amount of the variation in health-care outcomes. And that's things like death, probably explains even less in terms of well-being or human flourishing. Why do we invest so much money in our health-care system at the expense of the social, cultural, spiritual, economic aspects of our lives that contribute so much more to overall well-being?
Ben:
We did a really wonderful paper on this with the Lown Institute, and we analyzed a state budget, specifically in California. And we wanted to see, with health-care prices, as you said, rising exponentially, and just continuing to skyrocket, how does that impact on where a state puts its money for other aspects of health, like social service programs? Does it begin to mitigate or slow the investment potential in these social programs because we have to pay more for health care?
And what we found out is that absolutely it does. If you have a limited budget, and your health care, which most people will say is the most important thing, continues to rise and you’ve got to figure out a way to pay for that, but at what cost, what else do you cut? And so, what we've found is that a lot of times some of the social programs in communities, those that actually could more positively impact on health and well-being, were being cut over time. And that just was the, we called it a paradox because it was a counter to what needed to be done.
And so, a lot of states are in this situation. For us, I think that, you know, we always talk about how can you reign in cost? Control costs? How can you think a little bit more strategically about ways to be more efficient with your dollar, decrease waste, etc.? But the thing that I think is most prominent in any discussions that we have now on this, Grant, is that there has been this co-opting—I'm gonna use that term again. I used it earlier. I'm gonna use it again—co-opting of health. And it's been done by this, the, what my mentor would always say the “wealth care” system, right? It's the business side of health care. Those that have figured out a way to make a dollar on sickness and not about health.
And we haven't really shifted that paradigm, which is part of the reason why GDP continues to go this way. You know, prices continue to rise because they can; there's no control on that. There's no limitations on, well, how much should we actually pay for a service? And in the middle of all of this are people, people like you and I, our friends, our family, who suffer, who, as we've seen from COVID, will delay even seeking out the most basic services, not just out of fear that they might contract the virus, but because they might've lost their job and no longer have health insurance.
These things are very real. And I think that if we take a step back and just begin to analyze where do, what do we get from the dollars that we put into health care? And we look at where our country is going in terms of life expectancy, in terms of some of the other metrics that we might look at for well-being, it’s the wrong direction. Which for me, as a kind of an old-school clinician, if it's not working, stop doing it. We haven't figured out yet how to do that in health care.
Grant:
So, one thing, as a health services researcher, I'm becoming, I don't know if cynical is the right word, but I'll use cynical, that any of our approaches and our strategies are really gonna make much of a difference. We've been trying to do value-based purchasing, patient cost sharing, and it doesn't seem to be leading to major cost reductions. But we do know that the largest driver of health-care costs are prices. That's, our prices in United States are much higher, and particularly provider salaries, particularly physician salaries. We know that physicians are one of the largest, most powerful lobbying agencies in Washington, DC. Is there any hope that we can actually do anything meaningful to reduce costs and relocate some of these funds to other areas that would support strong families, ensuring meaningful work? Or do we have to exist in the context that we're in given the power structure at play?
Ben:
I remember reading an article years ago, and it was talking about at what point will middle-class, middle-income families stop being able to afford their health insurance premiums. And it was really getting to the heart of your question, Grant, which is, you know, if health-care costs continue to skyrocket and health insurance gets more expensive because we're trying to figure out how to pay more for the same thing, you know, who ultimately is going to benefit and who's going to lose? And the paper that I'm referencing, I think they said by 2038, that families won't be able to—so seventeen years from now—families wouldn't be able, the, the amount of health-care premium would surpass the annual median family income. And that was just like, hit me right here, just right between the eyes. Like, how could we do this to people? In one of the richest nations in the world, we have families that go hungry because they're paying for their premiums because they need to keep their health insurance because they're terrified what would happen if they got sick.
And so, I will be cynical with you and say that we talked about, you know, ten years ago: well, we're at a point in health care where it's a crisis. I remember reading another article that talked about how every president since Nixon has declared health care as a crisis. And it's predicated in part on the logic that you laid out, which is how can we keep paying more for health care? But yet we do.
So here we are, you know, our nose is touching the ceiling of 18% GDP, and I don't really see a lot of radical reforms that are taking us down any other direction. And I think that that's because—and I know this can take us far off track here—but I think that's because people are fearful of really being able to, or starting to, reign in some of these costs, because it does mean that some of the folks that have made seven figure salaries a year are not going to be able to make that. And it does mean that we're going to actually have to put a ceiling on what some services actually might cost. And that is not a popular sentiment here because you know, in a capitalistic society where the market drives everything, the market continues to allow for prices to go upwards. And I just don't know how you change that, how you, how you change that without somebody coming in and being the most unpopular person in the room for a few years. And when they do that, maybe you will see change. But I don't think it's going to be just on the back of creating more of an efficient program or showing another study that demonstrates cost effectiveness. I think it's a much deeply rooted problem than just that.
Grant:
Yeah. And this is very much out of my character, but I'm becoming more and more convinced that a single payer is what we need, with stronger negotiating power. And I think maybe at some point, we get to the point at which families are spending 40% of their take-home pay on health insurance premiums, there might be a re-openness to this sort of scheme. I don't know.
Ben:
Well, I mean, something's got to happen, my friend. And when you see President Biden, now, you know, talking about what he's going to do for the ACA, when you see Senators Bennet and Kaine come out and talk about Medicare acts and a public option for Medicare, the reasons that people continue to look for solutions is because they know what you just said. That it's really hard to kind of wipe the slate clean and to control some of these costs in a consistent way if you have multiple competing business interests. So, the single payer does solve some of the problems. Now it introduces other problems, but you know, those are probably far fewer in comparison to what we experience right now. In terms of, you know, what is it? One third of bankruptcies are because of health care—health insurance or health-care costs. I think that's what it is. Something like that. So, I don't know. I mean, we'll see, but I think it's either our kids or grandkids or somebody is going to be having, they're going to be doing a podcast or whatever they do in twenty, thirty years, and they're going to say, “You know, how much worse can it get? You know, we're at 25% GDP now. Like, what are we going to do about it?”
Grant:
Yeah. And also, we have to have the hard realization too, that despite the historic nature of the ACA, it didn't really work. In terms of, we cover more people, but it certainly didn't put the cap on costs. So, I think there's a, probably a fundamental change—if we want to take costs seriously and we do think it's a problem—a fundamental change that may be getting more people access to even more expensive insurance might not solve.
Ben:
Yeah. This will be the topic du jour for the foreseeable future. And just a small side note here for the listeners, like, it is a small frustration of mine as a health services guy, like you, where 90% of the policy discussions that we have around health have to do with health insurance. And it's all about coverage when there's so much cool stuff that happens in the deep end of the delivery and payment pool. We just don't give that enough time and attention because the health insurance is sucking all the air out of the room. All the time. And, I mean, I guess for good reason, right? We’ve got to do something about it. But there's so much innovation that has just gone under the radar that no one's ever paid attention to and delivery that could get policies that support it a little bit more rigorously that haven't even been given the light of day, which I think is a major frustration of those folks that are out there on the ground doing the good work.
Grant:
I also tell my students that once the health insurance problem gets taken care of, there's still all sorts of things that are keeping people from being happy. And so, this is a relatively small input and we've got a lot of work.
So how about I move a little bit to another topic? Your website states that the Well Being Trust focuses on mental, social, and spiritual health of the nation. I'm interested in this question of spiritual health. So, what does it mean to the Well Being Trust to improve spiritual health? What are some of the ways that we can improve spiritual health given this great multiplicity of spiritual expressions in the United States?
Ben:
Well, Well Being Trust was started by the Providence Health System, which is part of the Catholic health system. And the, the sisters that believed that the health system could do more for mental health were the ones that basically described Well Being Trust as, as a prayer, you know, we don't know what kind of prayer you're going to be, but you're a prayer because we think that you're going to go out and do something in the world that impacts, you know, lives around mental health.
And so, we inherited that from our beginnings as a part of our ethos, like who we were. How we've been able to capitalize on that and what we've been able to do in terms of investment and leadership, is something, honestly Grant, that we're still working through. It's very easy for a foundation to immediately get pulled into programs. And it's very easy for those programs to look at things like social or mental health. When you begin to talk about spiritual health, that takes on a very different meaning. And it's not just about having relationships with, you know, the faith community and figuring out what they could do for mental health. It's a much deeper, meaning-driven type of discussion that unfolds. And unfortunately or fortunately—I actually think it's more fortunate—those are not easily amenable to just writing a check and saying, “Go do these three things.”
Because the way that I think about spirituality is it's very much about a meaning. It's about meaning and purpose and a connection. And when you consider that and consider maybe it's, for some, it might be a connection to God or a higher power, it is very personal. And just creating a kind of standalone program or some type of new brochure that talks about this great app that you can use to enhance your spiritual health. Things like that just don't exist. And if they do, it's only going to reach a small subset. So, we've been doing a lot of exploration, and I would encourage listeners to let us know what you think we should be doing in that space. But we feel like you can't fundamentally get at the whole of health without including things like spiritual health, because it does drive so much of that, that meaning in our lives that goes beyond just kind of the typical social determinant stuff. It's really about meaning, purpose, a deeper sense of self, and in some cases, belonging and what that ultimately does for you when you're able to come face-to-face with it. So, I wish I had a better answer for you, my friend, but we are on that journey with you and many others.
Grant:
Yeah. And this is a particularly hard time when recent studies showed that about 25% of Americans consider themselves Nones—N-O-N-E-S. And it's interesting to reimagine what spiritual health might look like outside of such institutional contexts.
Ben:
I love that. I mean, I honestly, you know, I grew up in the South and I think this has been one of the hardest things for the institutionalized more religion side of spirituality to come face-to-face with is: what do we do when the congregational aspects of how we define our faith community are stricken from us? How do we really approach and engage around spirituality when how most people define that spirituality was through the religious or the congregational context. And this feels really deep and, and I'll make it a little more simple, but I actually have talked to a lot of Millennials—I've talked to a lot of the next generation—about their own spirituality, and we've seen things that they are saying. Well, we actually have, there's been some studies that have shown that when you look at some of the indicators that we use—not anymore, thank God—on you know, well, how much are you abiding by the—let's use the Protestant religion for a second—how much are you keeping yourself in line with that tradition? Are you not having premarital sex? Or not engaging in theft? Or whatever it might be. And come to find out that these youth, they're not involved as much in churches, but they have lower rates of teen pregnancy or lower rates of incarceration or lower rates of smoking or whatever it might be. And so, we've, we've kind of got this weird little opportunity here to actually go deeper on spiritual health.
And I think the next generation is going to lead us down that path. But, I believe fundamentally that it will not be on the back of just another brick-and-mortar building. Kind of like health care, you know, I don't think that just building another church or a mosque or temple is the solution for, you know, getting people more involved in their spiritual health. I think that it's gotta be much deeper than that. Some of the most powerful things that come out of the faith traditions are the gathering, you know, gathering together for a common purpose. And worship is a part of that. But connecting on similar things that we all care about, there's something very healing and very powerful about that.
And, and I feel like I just rambled all over your question, but for me, this is something that I do think that our nation and our communities are going to continue to have to, to redefine and reassess.
Grant:
Yeah. And we're going to come back to this at some point, but there is this, there's obviously multiple benefits of religion. One is to the extent that you believe that it's connecting you with God. But then, the other is more instrumental benefits that you get to be together with other people, and you have some sense of meaning and purpose. And it's a moral system that, hopefully, allows you to participate pro-socially in life. There's an interesting book by Tara Isabella Burton, who I believe is a journalist, I think at the New York Times, but she wrote a book called Strange Rites: New Religions for a Godless World, where she really explores sort of the new spiritual expressions by young Americans and refers to them as remix religions. And I would commend that to our listeners if for a better understanding of, of what the spiritual life of young Americans it looks like.
So, you do mention that it is an interesting paradox of young Millennials, where, to your point, there's fewer pregnancies—I think some of that might have to do with people sitting in their basement, playing video games and watching pornography—but it is true that there's a much more pro-social behavior. But at the same time, they're exceptionally lonely and they're killing themselves at a rate that's much higher than historically. So, there is this sense in which it seems like there's been some gains but also some, some losses.
So, I want to return to that question of suicide, unfortunately, a little bit later, but I do want to talk a little bit about COVID. You know, I've been trying really hard to avoid this conversation in the podcast, but I know that this is top of mind for you. So I want to talk about it a little bit. So, you've been sounding the alarm bells about the major impact that COVID-19 might have a mental health and well-being of Americans. So, at the very beginning of the pandemic, you released a report that suggests that up to 75,000 people might die from deaths of despair, such as alcoholism, drug overdoses, suicides, due to unemployment, depression from isolation, fear of the indefinite future, the uncertain future, associated with the pandemic. So, there seemed to almost be a suggestion in that report that these despair deaths might even be more than deaths from COVID itself. But here we are twelve months later, some 500,000 COVID deaths and more. So, how do you think that article has aged? Are you seeing major impacts of COVID on mental health? Deaths of despair?
Ben:
Well, deaths of despair, for the listeners that aren't as familiar, are deaths to drug, alcohol, and suicide. And it's actually a term that was coined by two economists that were examining what happened after the great recession of 2008. Now, what they found was that a lot of communities that lost jobs were where they saw an uptick in drug-overdose deaths and suicide. And they tracked those trends, and they were able to isolate some of the variables, and they determined that it was these communities—they call it despair because the communities had basically lost everything.
And so, we, you know, we've been looking a lot at that literature, talking to a lot of really smart folks about this, and have been studying deaths of despair. The CDC started collecting data on deaths of despair. They didn't call it that in ’99, but they did start collecting deaths on drug, alcohol, and suicide in 1999. And so, we've been analyzing those data since then and showed that there's been an upward increase every year from those deaths. And just to give your listeners a data point, because it is actually a lot of folks, because considering these are all preventable deaths, it was a little over 150,000 in 2018, with a 5% increase in 2019. And drug overdose because of opioids has also been, you know, substantially on the rise, which has been one of the primary contributors to lower life expectancy and the decline of that.
So, we wanted to say, “Okay, if the factors that contribute to a death of despair is economic, what happens when our economy goes in the tank again like it did in ’08?” Could we show some projections? You know, these are just predictions. We have no idea if these things are ever going to happen, just our attempt to kind of predict what might occur. How bad could it be? And so, we looked at recovery models, like how quickly would we get the jobs back? how quickly would the economy increase? etc. And we made the projections. You gave the median. It was, you could actually have twice the amount you told or much less. And we said, “Okay, well the one difference-maker here for deaths of despair in 2020–2021 that they did not have in 2008 was the social disconnection, the social isolation.”
And that's the one, honestly Grant, like, if you get me on a raw day where I've been talking about this stuff all day, it's the one that still scares me the most, because just because folks are getting shots in arms now doesn't mean they feel comfortable to go out and re-engage with the world. Just because you got a shot in your arm, doesn't mean you're willing to open up about the struggles that you've been experiencing the last six to twelve to eighteen months. And so, I do worry still that the deaths of despair are going to be worse than we might know. But the key—and as an academic, I feel obligated to say this to you—is that we don't know how bad it's been during the pandemic because suicide data specifically—we can look at ideation and attempts based on E.D. data, emergency department data—but we actually don't get the suicide, actually, completion of suicide data for sometimes eighteen months after the fact.
So, we don't know how bad it's been. Now, we've had some snazzy reporters that have gone out and contacted a certain state to look at drug overdose deaths. And we have seen a spike in drug overdose deaths during the pandemic, but no one knows how bad suicide may or may not be. And, hopefully, it will not be, because these are not certainties, but we hope that it is not as bad as what could be.
But our goal in doing that report was to draw attention that those lives were being lost at exponential rates prior to the pandemic. And the pandemic went and exacerbated— magnifying glass on top of this—which could only make them worse, if we did nothing about it. And we're slowly starting to see something done about it, right? In the recovery act that just passed a few days ago. You know, we've now got billions of dollars going into mental health. That might help a little bit. We've got economic recovery because we're putting money back in the pockets of people, which will help a lot, believe it or not. And we're starting to open up pieces of our communities again, because we're getting the shots in arms. So, our hope was that something will change.
So, how has the paper aged and how well has it—yeah, you know, do we still stand by those things? Well, the economy has slowly begun to recover. The job unemployment rate is at 6% now, so it's still higher than I think it should be, but it's gotten a little bit better. And so, because of that and because of the hope that now people might have and more of the certitude because we're being given facts now, instead of a lot of rhetoric, I think people are more convinced that, you know, things are going to be okay. So, if you ask me that question again in a year, based on the data, I can actually tell you with the evidence. But for now, in what we've seen, you've got a lot of surveys out there showing three-fold increases in depression, half the country experiencing depression, anxiety, increase in youth suicide attempts in the emergency departments, all that, but I actually don't know, ultimately, how many more lives we've lost because of the pandemic, yet.
Grant:
So, in many ways, the pandemic forced on us something that was there already, sort of a hyper focus on digital communication, isolation, loneliness. We know that rates of loneliness have been increasing over time. I've been having conversations with people, wondering if this, if COVID, will create a backlash. We realize that we had been so alone before COVID; it made us even more lonely. And now we put the phones down, and we see our neighbors. Or, the alternative is we get used to it, right? A number of my students—they're welcome to join me in class or they can come via Zoom—and I have about four or five out of fifteen show up. And I asked the ones that don't come, “Well, why?” There's a number of reasons. Some of them are concerned about being infected, but a number of them said, “I’ve just gotten used to it.” And I've said to them, “Don't get used to it. If you can, please come.” And I wonder, what's your take? Do we rebound and over-correct and realize that we just want to be together, or do we get used to our isolation and lean into it?
Ben:
That's a good question. Isolation is sometimes a choice, right? You know, unless you live…well, it's still a choice if you live in a remote part of the country…but, you know, you deciding to not go outside or to not go to class is on you. Loneliness can still be experienced even when you're not isolated. And they're two different concepts. And I think we should tease them apart for the listener. There are people that you probably sit in meetings with or Zoom with all day that are extremely lonely. And, and so, you know, just because you're isolated doesn't mean you're lonely. And just because, you know, you're connected doesn't mean you're not. So, those things, I think, are important to say.
I fear, as you, that we are in the middle of redefining the type of social contracts that we have with one another: Is Grant safe? Is it okay to go to his house? What type of relationships do I really want to have? Do I need to travel every week like I used to? We're redefining those things in real time. And, for some people, that's actually going to work in the positive. It's going to mean that they are spending more time with their family because they're not traveling as much. It's going to mean that they might actually force themselves to go back and re-engage with communities because they feel something that they couldn't feel when they were on their own.
But because COVID has put this uncertainty into all our lives, even when you've got vaccinated or even when you're wearing your mask and you’re six-feet distance, it's forced us to re-examine a lot of the social relationships. But here's the key: we are inherently social creatures. We need each other to live. And when we remove ourselves from one another, it's to our detriment; it's to, you know, the negative for our health. And that's where loneliness gets so much attention because it's true that loneliness can be as bad for you as the often quoted, you know, smoking a pack of cigarettes a day. It can have a tremendously negative impact on your overall health.
So, I would encourage anybody who is listening that might find themselves to be a little bit more isolated and feeling lonely, to take the first step and to get out—when it's safe, of course, and do it in a responsible way, caveat myself there. But we need one another. And it could start with a simple phone call. It could start by having meeting at the park, and you just go for a walk with your friend. It could start by writing a letter to somebody. There are ways to socially connect that don't require you to necessarily have to get out and do things. But I do think that fundamentally because we are humans, there's something powerful about the proximity and the touch and the things that we've missed during this pandemic.
Grant:
So, as you know, many schools in the United States have been shut down for almost a year now. There are significant concerns that children's academic performance will be severely impacted by these shutdowns, but moreover this question of loneliness and isolation. But at the same time, you published a paper in JAMA Pediatrics recently, and you mentioned that something like 35% of children receive mental health treatment at school. So, on top of being isolated and stuck on screens all day, they're probably not getting the services that they had access to a year ago. Some teachers’ unions are refusing to return to school until 100% of teachers and staff get fully immunized. What's your message for teachers? I know I don't want to downplay their fear, but at the same time, there's a real concern about these children. How, if you were the mediator, what would be your response?
Ben:
Well, as a former teacher, an educator myself, I can tell you that the United States has not valued teachers for a long time. We underpay them. We ask that they work extremely difficult hours. We don't equip their classrooms for them to be successful. There's a lot of reasons why our teachers are constantly being put in positions that they shouldn't have to be put in that is on us.
So, here's another one: Our inability to get the virus under control and our inability to really listen to common-sense public health practice meant that our teachers, our frontline teachers, those that are most influential in our kids' lives, are just as much at risk as our kids are. And I think that goes, I think we don't pay a lot of attention to that sometimes. We look the kids—for good reason—and we say, “You know what? They're not able to socialize. They're missing out on these opportunities to learn. And we know that social emotional development occurs when they're young.” All this stuff. Yes. I agree with that. It’s why we write articles like the one you referenced. But I don't feel like we've paid enough attention to the teachers. And are we taking care of their mental health? Are we talking to them about how they're doing during this pandemic? They're the ones that probably have kids, too. And their kids, if they're Zooming all day, you know, how are they going to manage a classroom, when they're worried about their kids who were also at home doing a Zoom class? How are you going to manage that?
So, I feel like fundamentally, Grant, the first major misstep that we made as a society was to not get this under control ourselves. And we put it on the back of people like teachers to now have to manage that. Same thing with college students. I can go around the room and blame a whole bunch of folks and say, “You know what? It's our fault that people are now pointing at you.” But I believe that teachers should feel safe in their classrooms. And there are, the CDC has made, recommendations on safe ways to do that. Vaccination should be prioritized for teachers. Absolutely. They should be in whatever category that state might have because they are, in my opinion, high risk because they're high touch. They're around kids all day. Now, we can look at the evidence and look at transmission rates between kids and adults and all that stuff. But simply put, you as an educator are not going to be a good role model or teacher for that student if you are not feeling like you're your best self. And you can't feel like you're your best self if you don't feel safe and secure in the classroom that is yours. And if that comes through a shot in the arm, so be it. Make it happen. But we've got to go back there and we've got to figure out a way to prioritize our teachers more often and in more things than just vaccines. So that is important.
Grant:
Yeah, no, I agree with that. I want to return to this question of suicide. Unfortunately, I don't want to end on this, but this is the nature of the way that our conversation is going. You wrote another paper in Health Affairs that proposed a number of policy solutions around the issue of suicide. So, one thing I noticed is that, although you focus on prevention, a lot of those policy solutions that you recommended were sort of far down the causal chain, right? Sort of at the end. How do we move upstream to strengthen individual and community factors that prevent this sort of despair in the first place? I think particularly, again, of connectedness with people, a sense of meaning. And I'll just add a little bit onto that. We know that, you know, the United Kingdom has established a Minister of Loneliness to tackle this one potential cause of depression and despair. What are the limits of government in addressing these factors? And can they move upstream? And if they can't, what do we do?
Ben:
Well, there's a huge opportunity for government to get involved in things that actually help keep people alive, which is jobs and money. We know this, I mean, the literature is very clear on what happens when you lose your job. What happens when you don't have money to provide for your family. So, this is an argument for government's involvement, whether it be increasing the minimum wage to $15 an hour or a universal basic income, which cities like Stockton have really embraced, to show, you know, major, profound, positive impacts on overall community well-being. Like, we've got to go there. That is as upstream as it gets, Grant. I mean, we could talk about housing and we could talk about, you know, safe neighborhoods and sidewalks and all that stuff. But fundamentally, you know, people need to have a sense of purpose and meaning. And for many of us, for better or for worse in this society, it comes from a job. It comes from being able to do something in service to your family, to someone else, to your community. So that is first and foremost what you can do, and that's as upstream as you can get.
Now, one of the points that we made in the paper, which I think is really important is that suicide prevention is everyone's responsibility. And as you described, yeah, we do go a little downstream, and we talk about education settings, criminal justice and health-care settings, and all that. But my problem is when I look at the literature and I look at what most people are doing in the suicide prevention space, they put it on the back of the mental health community to be the solver, the solution. And that is like catching, you know, the home run on the other side of the fence. You know, it's still a home run. Okay. You're just out of bounds now. I mean, it's just way too late. And you gotta be thinking about how to make suicide prevention everyone's responsibility.
And we don't infuse this type of thinking into our economic or tax policies and to things like universal basic income. We don't necessarily think that a by-product of UBI is that now people might not die by suicide, but yet these things are connected. And, with our youth, which we've seen a disturbing increase in suicide ideation and attempts, and even, you know, completion, it is something where we actually have to begin to go back and ask ourselves the question: What have we missed in providing opportunities for our youth to feel like they are engaged actively with one another, that they are intimately connected to others and are working in tandem towards something else? There's a powerful intervention that occurs when you do something with someone else, that service mentality that I've talked about for loneliness. It works actually to help mitigate some of those pieces around suicide, too.
And so, you know, our biggest takeaway from the article was that—you know what?—this needs to be everyone's responsibility. There's active strategies that we can use today to help, and please don't go a day without asking somebody, you know, how they're doing, because that might be the most simple, most powerful intervention to assist.
Grant:
So, it's interesting that you talk about employment, and employment both has the positive benefit of income and it allows you to fund your life, but at the same time, it creates this context of which we have meaning and purpose. You talked about volunteerism and connection. So, one thing that really made me think of is that we're in this particular moment in which there's these tremendous fraying of social institutions in the United States. We think over the last twenty years or so massive retreat in the significance of voluntary associations, like churches, Kiwanis club, Boy Scouts, and particularly the family, right? That's an institution that in many ways is under threat. So, historically these have been institutions that helped people grow in character, develop a sense of purpose and meaning, create social connections. And these are now being replaced by social media and other ways that people are trying to connect with each other but may not be quite as effective—or maybe they are. So, how important is this, the recession of these institutions? How important are they in this spike that we see in loneliness and mental health concerns?
Ben:
Well, I mean, I think to be short and simple, I think they're very important because we have put a disproportionate amount of attention on the back of technology to solve some of what ails us. And while technology can augment and in some cases supplement, it can't ever replace the fundamental need that we will have to connect with one another through institutional means. And whatever that might be that it brings us together, we must work towards a society that embraces that as a part of who we are. And I agree. I mean, I think it's been a very disturbing trend to see us move away from more of that pluralistic community-driven type of society to make it about me. How many likes can I get on Instagram or Facebook? You know, how many clicks on Twitter? It's very much about me and, you know, this external validation of folks saying that what I'm doing is great when, in reality, that should have no value in how you determine how important you are as a person. And so, we've moved away from that. I mean, it just used to be, “Well, I got a hug from, you know, Aunt Susie on Sundays at church, and that gave me, you know, strength or energy.” And now it's just like, “Well, nobody liked my Facebook post.” So, I think we’ve created ourselves a little bit of a problem here. And I'm not trying to say that social media and technology is bad. I'm just saying that in many cases, because of the breakdown of the institutions that you described, we have moved more into this almost like a smaller microcosm of an institution, but it's really one that's just us looking in the mirror and not one where we're actually surrounded by people that can help. So, that's another podcast for another day, my friend, that's a huge question and a tough topic.
Grant:
Yeah. Well, we can revisit it someday cause this was a lot of fun. And I knew that when I invited you that this would be a really stimulating conversation. You certainly more than lived up to my expectations. So, Ben, I want to thank you for joining me today, and hopefully our paths will cross again someday, if we ever go to conferences again. That's, like, our one instance to really see each other in person.
Ben:
Well, I'm okay to not go to conferences again, but you and I do need to hang out, Grant. You're good, man. Thanks for letting me come on your show and talk about the things that I think are pretty important.
Grant:
All right. Well thanks, Ben. I really appreciate it. And I agree. Hopefully we'll see each other again someday.
Ben:
All right.
Grant:
All right. Take care.
Ben:
[several words inaudible]