The original post for this episode can be found here.
John August: Hey this is John. Today’s episode comes from a panel recorded last week in cooperation with Hollywood Health and Society. If you want to see video from the panel there’s a link in the show notes. But realistically if you’re already listening to this audio you are fine. You don’t need to see the video. There’s no slides or anything you’re going to miss.
Now, Craig was planning to cohost this panel with me, but he has had a family medical situation, so I did this one solo. But I think Craig is really going to enjoy this episode, if he listens, which I hope he listens to it because he really will like this episode. We have a remarkable showrunner, Gemma Baker, we also have a medical doctor who can talk about the science of addiction. We have a therapist who can talk about young people and mental health. And we have a journalist who writes extensively on drug policy. It’s a really great group.
We talk about writing protagonists dealing with mental health and addiction issues, their impact on other characters, the responsibility of writers addressing those topics, and what writers need to keep in mind about their own mental health.
This episode pairs really well with Episode 99 if you want to go back and listen to that one.
Today’s episode was produced by Megana Rao, with music and editing by Matthew Chilelli. Special thanks to Marty Kaplan, Kate Folb, and everyone at Hollywood Health and Society for putting together the event. Enjoy.
Hello and welcome. My name is John August. I host a weekly podcast with Craig Mazin called Scriptnotes and we talk a lot about writing and things that are interesting to screenwriters. And as we talk about screenwriting we’re always trying to focus on specifics, like what is the specificity of this moment, what is the reality behind this thing? Why are characters doing what they’re doing? We will talk about the words on the page, but we’ll also talk about the experience of watching the stories that we’re trying to tell. And we’ll bring on guests sometimes to talk about very specific things that they wish we as writers could do a better job at.
We had Rachel Bloom on recently to talk about how we portray sex on screen and how we can portray sex more realistically on screen.
So when I found out this panel was happening I virtually threw myself in front of Kate to say like, hey, do you need a host, because I really wanted to talk with these very smart people about addiction and mental health.
Another thing we talk about on Scriptnotes a lot is structure, so let me talk a little bit about the structure of tonight’s evening. I want to start by talking about the experience of a character facing addiction or mental health challenges. Then talk about the characters around them, sort of how that character is impacting the world around them. We’ll then step outside a little bit and talk about how the stories we tell are perceived by the world out there and what is our responsibility, what are our opportunities as we’re telling these stories. And finally as we’re talking about addiction and mental health, how do we as creators have to be mindful of our own mental health? And things we can be looking out for for ourselves.
So that’s sort of the structure for the evening. There will be questions and Q&A at the end, so if a question comes up along the way remember it because we’ll get to that at the end. But I want to start by talking about how our characters come into our stories and I want to start with you, Gemma. So, Gemma Baker is a writer and producer and the co-creator of the hit CBS comedy series, Mom, a show lauded for its portrayal of addiction. She previously wrote on Two and a Half Men. She graduated from Tisch with a degree in theater.
Gemma Baker: Hello.
John: My question for you, so the two lead characters on Mom both have addiction issues. How early in the process of coming up with Mom did you know that this was a thing that you were going to want to explore?
Gemma: In the very, very beginning. So when it was first being talked about the idea was for the character to be a mom who has addiction, active addiction and drug problem. They knew they wanted – it was Chuck Lorre and Eddie Gorodetsky – and they wanted to do a show about a mom and they thought we’re going to bring in a mom. And they asked me if I thought that could be funny. And I just thought, well, if people don’t think that the kids are safe they’re not going to feel OK laughing. And so what if the character was in recovery? And you could root for her, because you knew she was trying to change. And so that was our starting point.
John: What was the starting point for your research into this? How did you find out about what recovery would look like and sort of where the opportunities were and where the challenges were for these characters? What was that research process like for you?
Gemma: I think one of the things that was really important for us was that a lot of times when recovery is portrayed, not necessarily now, but then it felt like it was dreary and that there was no joy and light and there wasn’t a lot of hope in the portrayal of it. And I think that that is what we felt was missing, you know. And that anyone who knows and loves someone in recovery knows that that’s such a huge part of it. And also so often recovery is the end of the story. You know, you watch a whole movie about addiction and it’s so awful and painful and heart-wrenching and then at the very end it’s like and then they got sober, the end, roll credits.
John: Sometimes they’ll give you nice little title cards.
Gemma: And then they got sober and it worked out.
Gemma: And I think that recovery is not the end of the story. It is the beginning of the story. It is having a chance. It is where it’s the beginning. And so we wanted to tell a story that started there. That was really important to us.
John: That’s great. Well let’s talk more about recovery. So our next guest, Dr. Corey Waller, is a nationally-recognized addiction expert and currently practicing specialist in addiction, pain, and emergency medicine. Through his work with the Health Management Associates and the National Center for Complex Health and Social Needs he has developed addiction treatment methods, provider training, and educational outreach delivered by that center. Dr. Corey Waller, thank you for being here.
Dr. Corey Waller: Thanks.
John: We’re going to be talking about addiction and mental health. And because you’re the actual doctor here can you help us get our terms straight. When we say someone is dealing with addiction what does addiction mean in a medical sense? Or what’s helpful for us to be thinking about when you use the term addiction?
Corey: That’s a great question and I think a lot of people misinterpret what addiction is. Addiction is not the presence or absence of a drug in somebody’s system. It’s the way in which they behave in obtaining and using the drug. And we actually define addiction based on nine very specific behaviors. That means they’re predictable. I mean, in the Diagnostic and Statistic Manual we’ve identified nine specific behaviors associated with both drugs and/or a behavior like gambling that ultimately tell us whether or not someone has addiction. And we can use those behaviors and the presence or absence of those to determine how severe it is.
And so with that, that’s how we create our interventions and have done all of our testing to identify how to appropriately treat people at the beginning because they have predictable behaviors that we identify as addiction. And unfortunately those behaviors many times are misinterpreted as frustration or anger when in actuality they’re just symptoms of a disease. And so I think that’s the big piece around addiction is that it’s definable, it’s identifiable, and it’s not because somebody is mean or it’s not because somebody got drunk at a party. And it’s not because somebody used cocaine on a Friday. It’s what does that look like in their life in general and do they have control over that drug. Do they have control over their behavior when obtaining that drug? Do they try to obtain that drug over their safety or over the safety of their kids? Or do they lose their job because of the drug? These are the ways we define it.
And so many times that term is slung around in a pretty messy way. But medically we have very specific criteria for what addiction is. And we actually know more about the neurobiology of addiction than any other chronic brain disease.
John: So as we’re talking about terms, addictions can have a pejorative context. Like someone has – and we need to get past that. That’s the stigma thing we’re trying to get past tonight. But a word like addict – is addict a useful word or not a useful word? What’s helpful for us to be saying when we’re talking with somebody who is dealing with these issues?
Corey: Well person. If we just start with that. But in general people aren’t defined by their disease. We’ve gone really far to make sure that people with diabetes and cancer and other medical illnesses aren’t defined as their disease, because they’re a person with that disease. And the disease is a part of who they are, but it’s not how we define them.
So we don’t in a perfect world call them addicts. We call them a person with addiction. And then we can get very specific in healthcare terms. They have an opioid use disorder, or a substance use disorder. Terms like clean and dirty, those are terms that are utilized that have no medical connection whatsoever. Even like a urine drug test. They dropped “dirty.” I have doctors say that. There is no clinical terminology. What does that mean? It get mud in it? I don’t really know.
What we have to start doing is not taking on how the patient’s very self-stigmatizing language is utilized. And it’s used a little bit to combat the shame and the fear of this disease and not take that language and somehow weaponize it toward them. Because as people in healthcare and even just society in general, using a term like a person with addiction is just – it is what it is. And that’s where I think we should start.
John: And thinking about this as writers, as we’re coming up with character descriptions, we’re trying to describe what a character is like, if we use a word like addict that just stops us dead it’s very hard to see anything else around that character. We’re not seeing what they’re doing and we’re not seeing the choices they’re making. It’s taken all the agency away from that character. And so finding the right words to use feels really important.
The other part of our panel tonight, our discussion, is about mental health. Where are the overlaps between people with problems with addiction and mental health things? Is there a big crossover between the two?
Corey: Yeah. And so the crossover seems to really be identified in those with what we call adverse childhood events. So early life trauma. I ran a clinic dedicated to pregnant and parenting females. So we saw hundreds of females who had addiction while they were pregnant and all but two of those hundreds had a significant early life trauma, most of that sexual trauma. And so the early life experiences that occur to someone increase the chances of them having not only addiction but a co-occurring mental health disorder.
And that mental health disorder if not treated while you’re treating addiction will make the addiction unstable. And if you’re treating the mental health disorder on one side but not addressing the addiction you’re never going to get the addiction stable. So it’s a matter of most people who have addiction also have a co-occurring identifiable mental health disorder.
It’s unclear early in treatment if that’s going to be there after we stabilize them in treatment. And so you have to go through a pretty significant process. But quite honestly as you’ll hear, one side doesn’t necessarily talk to the other. You hear, “I treat addiction,” or “I treat only psychiatric ailments.” But rarely do those ships meet in the night. I mean, honestly, it’s crazy because that one book has all of the descriptions and a third of it is about addiction but then there are psychiatrists who are like, “Eh, I just kind of ignored that part,” and moved on. And then addiction medicine providers who don’t read the other stuff. So it’s very disconnected where it really shouldn’t be.
John: All right. Let’s keep looking for that crossover. Our next guest is Dr. Holly Daniels. She is the managing director of the California Association of Marriage and Family Therapists, supporting 32,000 clinicians. She has worked as a clinician, teacher, therapeutic consultant for over 15 years, specializing in addictions, eating disorders, and other mental health issues using her extensive knowledge with treatment programs on university and college campuses to help young adults thrive. She received her Ph.D. in psychology from Sophia University. So you’re working with younger populations, what are some things that we as sort of non – older than college students – might not be aware of that are happening on campuses, college campuses and high school campuses? What do you see that we may not be aware of? What are the things that young people are facing?
Dr. Holly Daniels: Well there’s a really interesting dynamic right now in that our society as a whole has embraced talking more about mental illness in general and substance use disorder. And that’s really prevalent in the younger generation. So kids are actually talking more on campus about – even about their mental health issues, about having anxiety, about being depressed, and there’s more of a discourse. And I would say thank you to television and film, actually, for opening up a lot of that discourse. Kids feel more free to talk about it. But, you know, there is kind of that backlash of the more they’re talking about it and there isn’t really the science-based support to help them through it, right, there’s still a lot of issues with drug and alcohol abuse, you know, from age 10 up. And there really isn’t unfortunately enough support in our school systems or in our education system. And the education that they’re getting about mental health issues and substance use issues is coming from the media, right.
I mean, that is their discourse. The film and television and what they’re watching. And so sometimes it’s a really helpful education. And I don’t know if anybody has seen Eighth Grade, but I loved Eighth Grade by Bo Burnham which talked a lot about anxiety. We have shows like Euphoria which I’ll let us – maybe I’ll talk about that later. I have different ideas, I have thoughts, too.
But overall I would say the big positive is that, just like Corey was talking about, we really need to chance as a society and stop penalizing mental health issues and criminalizing substance use. And the great thing is when we can see those stories in television and film and we can see people having compassion and leaning in to support the people who are struggling that gives our young kids, our adolescents and our young adults, that model to be like, oh, if somebody is struggling I reach in and help. I don’t call them a bad person or say that they have a moral failing. I want to help.
And that’s actually really a hopeful thing that’s happening on campuses is that kids want to help each other. They want to be there for each other and that’s a beautiful thing.
John: Yeah. I definitely noticed that kids, teenagers, want to help each other but sometimes don’t have the actual skills to be helping each other.
John: And to what degree do we need to be aware of contagion or the sense of like a person with a challenge spreads to other – like how as a person who is dealing with young populations what are some things that we have to be aware of with teenagers? Are there are different things that happen with them?
Holly: Such a good question. And this is why the work that Hollywood Health and Society does is so important and being able to as film and TV writers reach out to experts to understand where that fine line is when you’re portraying heroin use, or when you’re talking about kids committing suicide. What are the things that you can do so that the visuals, right, are not more triggering than they need to be? It’s a fine line of we want to be able to talk about this, and we want to be able to portray it because that’s important. But we also don’t want to cause children out there to hurt themselves, right, or create an atmosphere in which they feel like it’s glamorized or it’s cool to self-harm.
John: So finding that balance between realism and glamorization is a challenging thing. We’ll keep talking about more of that tonight. But I want to introduce Zachary Siegel. He is a journalist who covers public health, mental health, and criminal justice. His work has appeared in The New York Times Magazine, The Atlantic, New Republic, Slate, Wired, and Politico Magazine. He’s currently a journalism fellow at Northeastern University, the university’s Health and Justice Action Lab where he has spearheaded the “Change the Narrative” project. He cohosts Narcotica, a podcast about drugs that’s informed by science, policy, and the lives of real drug users.
I have a rival podcaster on the panel. I’m not sure I—
Zachary Siegel: That’s OK.
Kate Folb: That’s why we put them as far away as possible.
Zachary: We’re hoping to steal this audio, too, for our own podcast so we’ll talk later.
John: All right. It all crosses over. Zach, could we talk about sort of your experiences with addiction and sort of the degree to which Hollywood and the things you saw in movies and television influenced the start of that, the progress of that, the recovery from that. What did you see as you were encountering it for the first time?
Zachary: Yeah, so I’ll try to keep this brief because it’s a long story. So, full disclosure, when I was about 17 had opioid use disorder as we call it now. And it really started with friends and I exchanging pharmaceuticals and really what happened was as a young, anxious, sort of nervous Jewish teenager trying to figure out what the world was like I took an opioid and finally felt normal. Like I finally felt OK. And it’s a cliché at this point, but it is really true. When most people take opioids they get kind itchy and constipated and they don’t really like them. When I take an opioid it was like, OK, the clouds have parted and I feel very, very comfortable, which can be a very dangerous feeling for a teenager.
And so that progressed and progressed and progressed, like all the way up to heroin use, but to not like [unintelligible] with that story because really I was just like watching movies like pretty zonked out five hours a day. It was not a productive time of my life. But I did watch a lot of media. So I can talk about, for example, like how maybe the first time I ever saw injection heroin use on screen was Basketball Diaries with Leonardo DiCaprio. And I think that had a huge impact on me and I wanted to be a writer and be in like sort of the beat scene in New York and that whole thing was very attractive. But, you know, the sort of delusion that has to be confronted is like people on drugs typically, you know, life is really hard and you can’t necessarily be productive.
Like I was not a successful writer when I was using heroin because I had to think basically in six-hour timetables where, OK, here’s one fix and where’s money for the next one. And to live in this sort of collapsed time where you’re very much encased by the next one and the next one. It was incredibly difficult. And so I can talk more about media, but yeah I do think the way that I consumed media and the things that I saw were very impactful.
It may sound random, but there’s a documentary called Methadonia produced on HBO. I don’t know if anyone saw this, but it was a horrific portrayal of a drug called Methadone. And just the quick facts, Methadone saves lives. It reduces someone’s risk of fatally overdosing by 50% or more. And this documentary however portrayed it so negatively and I think I was a teenager watching that before I’d ever really like thought that one day I might need this drug. But as the recovery process sort of unfolded for me and I didn’t wind up in a Methadone program I had to confront my own stigma about people who take Methadone because of that documentary.
So these things have – it’s just a huge responsibility to portray this.
John: So I thought we would start by talking about the experience of a central character in our story, so either a movie or a television show, who is dealing with an issue and sort of talk about the timeframe, the things, the challenges, what are the realities there so we can then think about how we are going to portray them and sort of what are the opportunities. And so my hypothetical character I want to introduce is a character named Jane. She’s 28. Boyfriend, not married. An alcoholic. And we can talk about where her alcoholism is. I use the term alcoholic. I probably should use a person dealing with alcoholism. But this is where the character is that we’re meeting. But we could meet her at many places along the spectrum.
So Gemma, you decided for your show to show somebody who is already in recovery. Corey, can you talk me through someone who is dealing with alcoholism where are some points along the way we might meet that character? What are the stages where we might meet a character who is grappling with it?
Corey: Well, I mean, a bar. Common location. So a couple of things—
John: The timespan. The stages of—
Corey: I know. So as we look at this, alcohol use disorder is the most prevalent addiction period. You add all the other ones together, it’s still not as many people that have alcohol use disorder in the country. So it is still the most prevalent, but it’s also the one that is more normalized. And so people can go to a bar and get barely able to stand or walk and we’ll call them an Uber and send them home, but we don’t think about that in the context of alcohol use disorder a lot. So somebody tied one on, or you’re hungover this morning, or that kind of piece.
But generally speaking the first time that we interact with them in a healthcare setting is going to be when they accidentally fall and break an ankle. Or they get picked up by police and are incoherent and show up – you know, I’m an emergency medicine doctor, I still practice – and so I’ll see people in the emergency department and that’s how I first encounter them many times is intoxicated. And just being intoxicated doesn’t mean you have an alcohol use disorder, but it starts to really add up a lot of those points that we talked about when you are intoxicated, and you fell, and you hurt yourself, and you ended up in the emergency department because of the intoxication.
So it’s not always just the homeless intoxicated person who shows up to the emergency department. The early part of the disease means that there are times in which things are stable. They’re still able to generally go to work. They’re still able to have an interaction. They’re still able to have friends and connections. And over time those things start to wane. So that first time that we get them is the best time to intervene because we generally have milder disease than if we wait this out.
And so this concept of they’ll come and get help when they’re ready, or this concept of rock bottom, basically means we’re going to see if they wash out through dying before we treat them. And so the times that we’re going to interact are going to be the times that they drunk dial mom at three o’clock in the morning. The times that their boyfriend confronts them because they’re frustrated about how they embarrassed them at these places. Or the boyfriend or significant other also has an alcohol use disorder and maybe they’re perpetuating this.
Those are the times that we’re more likely to make the biggest difference in someone are those early signs of addiction which is they’re missing work. And so I have a staff of 30 people and I was the chief of pain medicine for a health system, so if a doctor started having odd behavior I would pull them aside and have to be like, “What’s going on?” We are scared to do that in society. We’re scared to call people out because we don’t know how to do it many times. But an empathetic ear and somebody just saying I care about you, if you want to chat about this, really opens up the door for that early interaction to occur.
By the time I get them, I mean, the train has crashed at that point. This is a point where they’re either mandated by court or intervened by family or their life is in complete shambles and they have nowhere else to go. And that’s just too late. And so I think recognizing that 60% of people who at some point meet for an alcohol use disorder self-resolve.
So, I always use the anecdote of when I was in college I tried really hard to be an alcoholic. It just didn’t work. And that’s good for me, but that’s a lot of people. If you think about back in school and that the number of people who drank to the point of failing a class or missing class or failing out of college but then kind of bounced back, early in life – in adolescence and in early adulthood we have kind of resolution of an acute version of addiction. Now that is an increased risk for later that something may recur, but if you can catch them at that phase and really kind of work with them we don’t necessarily have to even label them long term.
I mean, I have a roommate who drank just as much as I did. He has a label of an alcohol use disorder. But I don’t. And we have the same trajectory in the end. So it’s just a matter of when you catch them. So I think early and it’s those little pieces where we find them the most. And that’s where they start to struggle with isolation which we find is the early form of kind of the fear and stigma they put on themselves. And from a character perspective, being able to portray that shame and isolation that occurs very early in this disease that is the path to the more severe version of the disease that leads to bad outcomes that I would see.
And so that guilt and shame keeps them – they hide. They start to drink alone. They start to separate from people. Go to different bars where they’re not going to be noticed. And it’s not a control issue. It’s a part of the brain. You know, we know exactly what part of the brain it is. It’s the default behavior for an input called cue associated relapse. And it’s not a decision like we think about. It’s not a pros and cons sheet. It’s a reflex once they’ve started using.
John: Gemma, he’s talking about self-stopping and sort of control. And we always as we write our characters we want our characters to – we’re sort of cruel gods aren’t we as writers? We’re always creating these challenges and obstacles for our characters to face. As you look at the characters you’re dealing with in your show how are you as a writer and as a writers’ room talking about characters’ awareness of the behaviors that they’re doing? Awareness of the problems that they are encountering for themselves? Because it sounds like any one of the characters we set off in our stories could end up in a very dark place. And yet you are mostly responsible for getting them back to a good place by the end of 30 minutes. So how are you talking about that in a writers’ room? How are you figuring out sort of how to get a character through these situations?
Gemma: Well, I think, you know, one of the things that sitcom characters are not known for is growth and change. So, but we have this amazing opportunity, and I think responsibility, to say that these characters, now we’re going into season seven, they have grown. They have changed because they’re sober and because they’re facing life in a new way and because they’re doing it together and because they’re using certain principles to change and grow.
And so I think that’s been really fun. When we feel like they’re starting to get stuck we’re like, oh, you know, that season two Bonnie, that’s not season seven Bonnie. Season seven Bonnie is going to handle that better. So we keep ourselves sort of accountable to that. We sometimes have the actual meeting portrayed. We have this device of people sharing. Also on a sitcom you don’t necessarily see someone just tell you where they’re at for two minutes, but we have that ability to do that because our characters literally are sharing where they’re at. And so that helps us to – they might begin their share thinking one thing and then hear something and get to another place quickly.
John: So the idea of a group meeting, a 12-step meeting, or some other place where people come in and describe what they’re going through, Holly could you speak to sort of what the role of group meetings is in Jane’s life. Let’s say that Jane is making progress. What would that meeting really be like and what are the things you don’t see that we might be showing better?
Holly: Well, there’s really huge power in group share. And that’s why the Alcoholics Anonymous movement has been so successful actually in helping a lot of people get sober and get better. And it’s a place where you can feel like somebody sees you and somebody gives you space to be who you are and be going through what you’re going through. And that is huge and that actually is what television and film does for us, too, right. When there’s a representation in a television show or a film of what we’re going through and how we can identify that’s just so very powerful and empowering.
And so when we’re working with people who are dealing with mental health issues or substance use issues definitely we want to employ groups and as an individual therapist I would definitely and do definitely encourage my clients to find a group and to utilize the group and the support of the group. But that is kind of on the recovery side.
And I did want to mention, and maybe you’re going to get to this John, but what I would like to see more in film and television is the group that the person is with while they are in their addiction, while they’re really struggling, because we are systems people. Right? We’re in a system. And there are always people who are enabling or ignoring what we’re going through, or you might meet Jane at a bar but then fairly soon you’re going to meet Jane in her room drinking by herself and she’s waking up and shaking and her boyfriend is going and buying her some alcohol because he wants to help stop the shaking. But he doesn’t realize that he’s actually perpetuating her illness.
And there are some really complex dynamics that go into the system that is supporting the person who is struggling to continue to struggle unfortunately. And that’s something that I haven’t seen really deeply portrayed in all of its complexity which would be really neat to see.
John: Zach, as you watch film and television and you watch individual therapists or you watch group settings what are we getting right and what do you think we’re missing? And what is the ideal role of the expert, the therapist, the person who is there to help the person. Again, I think we idealize them so much in Hollywood, but what is the real function of that person that you see?
Zach: Well, I think to, yeah, be scientifically and medically accurate and grounded as any expert in this field treating addiction should be. And that means oftentimes not sending people to Malibu for 30 days and pet horses on a ranch. Like that is not how we treat any other addiction or any other medical condition.
Holly: I used to work at one of those places so I take offense.
Zach: Sorry. And especially in terms of opioids which it’s on my mind a lot, there’s an overdose crisis, and I think that there’s a lot of opportunity to communicate health messaging with media by having a therapist say, “You know what? Actually you’re a perfect candidate for Buprenorphine. And let’s get you to the right doctor who can prescribe this drug and, you know what, maybe when you go to a recovery meeting or group share on Buprenorphine you might be stigmatized because within this community frankly they don’t often have most science-based approach to things like medication.”
So I think to see that play out in a narrative would be very powerful.
John: Well, I should say writers, we love conflict. So if there is a conflict that can be introduced that could be a useful thing. And do you–
Zach: This one has been going on forever.
John: Yeah. But I would say that most people don’t realize it exists.
Corey: Well, I think two pieces that I would pull out is, one, for our 28-year-old female character she’s prey in these settings sometimes. If you get into the wrong meeting and you’re very unstable in your disease people that are also unstable in their disease can be a predator in that setting. And so it can be very unsettling for that person to show up to that meeting to someone to seems to get them unlike their boyfriend or maybe unlike their parents. And they use that angle to actually connect themselves in a pretty pathological way. And I’ve seen that happen a number of times for females in recovery going to some meeting. So they need to find the right one, right? It can’t just be any random place.
And I think the other portion is to understand that everybody has their path to recovery. But at this point for opioid use disorder 12-step abstinence-based treatment is only 8 to 12% effective. Now, for alcohol use disorder it has a higher rate of effectiveness. But the research was done on generally speaking doctors, pilots, and lawyers of white origin, so when we start to think about what modalities we’re looking at and what the data looks like that data looks very clearly good for doctors, pilots, and lawyers, especially those that are Caucasian. It’s about 85 to 90% effective for alcohol use disorder.
But for the population that I see when I was in Camden or when I was in Detroit or Philly, wherever that is, that’s not effective treatment for them. But it’s also about timing and dosing. So thinking about somebody who is really unstable, that’s probably not the best time for that. We do find, however, when they need to reconnect that may be the perfect time to add something like that. So just recognizing that it’s not the default treatment for everybody. Most people get treatment outpatient. Most people don’t go to residential treatment. Most people get their treatment in an outpatient setting just like they would for congestive heart failure.
So sometimes creating less conflict with it, because there’s plenty of conflict in their life otherwise, so the treatment of their addiction doesn’t have to be the conflict point. There are so many other pathways because this disease is such a socially connected disease. It creates conflict in families. Conflict at work. Conflict in just going to the store and walking past beer. I mean, those are conflicts that are there.
So creating the conflict in the treatment sometimes stigmatizes the treatment. So I think that it’s a little lazy, to be honest, because it’s not the place where drama has to be. We know how to treat it. We have effective treatments. It’s pretty matter of fact. And we know how to know where they go. I mean, so that part of it and understanding where meetings are and what role they do play, it’s not the treatment. It’s just a part of a larger normal approach to treatment that we would take.
Holly: And if I may add to that, Corey, I agree. Not only is it a place where people could be preyed upon or, you know, but it also is a place that you actually don’t want to go into a group setting – to piggyback off what Corey said – until you really are stabilized internally. Because it might be very difficult and re-traumatizing for somebody to hear everybody else’s stories about their trauma. And when we’re talking about trauma I’m not talking about getting shot with a gun or run over by a car, I’m talking about complex emotional relational trauma we call that which goes back to the adverse childhood experiences which so many of the people struggling with substance use have.
And so you have to maybe work one-on-one with medication, get yourself stabilized, before you go into a group where you’re going to hear a bunch of stories about a bunch of other people’s really difficult times because that can be very triggering and re-traumatizing.
Corey: By the way, you guys portray – it’s the only show I can actually watch with addiction, to be honest.
Holly: Love your show, Gemma.
Corey: The rest of them are triggering to me, honestly, as a practitioner, frustrates me and gets me angry so I can’t watch it. But so this one is one that does it in a way that people in recovery they do well in those situations.
Gemma: Thank you.
John: And I think it’s because you’re offering hope. There’s characters who are dealing with a thing and it’s never going to be completely resolved. It’s not like the monster is ever fully killed. But they are able to have productive lives. And that’s obviously an early decision you’ve made that you’ve been able to keep up for eight seasons.
Gemma: Yeah. To be able to watch someone’s life get bigger. To have our main character. If I could go back in time in the pilot we said that she wanted to be a psychologist and then we quickly changed her into a lawyer. If I had a time machine and I would go back and just correct that one line in the pilot to say she wanted to be a lawyer. But I can’t, so we just ignore it. And pretend that her dream was always to be a lawyer.
And it was important for us to do that. It takes a while to become a lawyer and it’s hard to write becoming a lawyer stuff. But we’re doing it – and make it funny – but we’re doing it in real time because we hope that we are going to be on long enough to see that happen and to watch that whole process. And for her the ups and downs and the doubts and just showing up for all of it sober.
John: Cool. Let’s try and experiment with a different character. Carlos, 35, depression. And so this is a character who is dealing with depression. What things will we see outwardly as we’re looking at the character of Carlos that might tell us that he’s dealing with depression and help me figure out both his inner state, so what he’s going through, but what externally we would see for Carlos. What would be the things that we would be noticing? Holly, do you have a sense of what we’d see first?
Holly: Yeah. I think that, you know, it’s not totally unlike symptoms of substance use disorder in that you’ll see changes in behavior that suddenly Carlos isn’t around very much, or he made plans and he didn’t keep them, right, that his circle will notice. That he’s just not feeling up to doing the regular activities that he might want to do. And when it really progresses he might lose his job because he can’t get into work and he can’t get out of bed and doesn’t want to return phone calls. And maybe then when is confronted is able to like buck up enough to be like, “I’m fine, I’m fine, everybody don’t worry. I just need some time alone. Don’t worry.” And it really takes a supportive person in Carlos’s circle to say, “You’re not fine. Can we help you get some support?”
Because depression is one of those things. It can be a little bit under wraps. You know, people can be really struggling with depression for a really long time and still show up to life just enough that they’re not going to get into a car accident or break their ankle or do something that’s so big because of being high or drunk that it can really go under the wire for a long time.
And that’s what is so scary about it, too. And especially if Carlos starts to become suicidal. And most people who die from suicide don’t leave a note or give any signs beforehand. And so it really takes a community, right, to be around Carlos to say, “Hey, you know, this is the fourth time you haven’t come out and you usually came out with us and ate dinner every Friday night and now you’re not doing that anymore. What’s going on? And can we help?” Because Carlos can hide it for a good deal of time.
John: Quite a few people I follow on Twitter self-identify as dealing with depression and they’ll talk about medications they’re on. They’ll talk about the struggles that they’re going through. I admire them for doing it. Is that useful for them? Is it useful for everybody else? I always wonder the degree to which self-identifying as this can become an identity of being a depressed person. What is the current science and best thinking in terms of when a person who has depression is in treatment and is improving talking about it? What is the best way to interact with that character?
Let’s say Carlos has started getting some help. What do we do with Carlos? And what changes do we see with Carlos?
Holly: That’s a really good question. It’s a personal question, right? So sometimes the diagnosis can be really empowering and it’s something that you can share and you can say, “Omg this is what’s going on with me. I have this chemical imbalance and it is a disease and it’s an illness.” And so it’s a little bit freeing. For some people having a diagnosis is very shaming and it’s very difficult for them to carry that with them. So that’s part of our job as mental health workers to kind of be there with each individual and decide is this somebody who is going to feel empowered with the diagnosis? Is this somebody who is going to feel shame with the diagnosis and to be able to talk through all of that with them?
But for the most part I think it is, for the people I’ve worked with, it’s empowering. And it’s a way to build community because mental health illness and substance use disorder they are isolating. That is one of the things that happens is people become more and more isolated. So if you can say, “Hey, I’m struggling with this thing” and find other people in the community that say, “Hey, me too.” And you can have that back and forth and connection. It can be really a powerful help. Yeah.
John: Let’s point our discussion and talk about the community around Jane and Carlos and sort of how they’re interacting with family, with friends, with the medical establishment, with the police. What do those interactions look like? So we talked about earlier that Jane would come into a medical situation because she’d broken her ankle or law enforcement if she was drunk driving. There’s natural ways to do that. How would Carlos come into a medical community? How would he come into a law enforcement community? What are the interactions that we see with these characters as they’re doing their thing and the impacts they’re having around other people. Zach, what do you see as Jane’s – the circle that she was drinking with? The social circle that was helping her stay there. How do we portray them responsibly and accurately?
I mean, the people who are in some ways helping her stay the way she is.
Zach: I mean, I think it’s super contextual. And I think there’s one very recent example of a portrayal of depression is Euphoria. And in a recent episode of Euphoria, so Rue is the main character and she is so depressed that she has watched 22 hours of Love Island straight. And there’s this sort of ongoing, very painful experience of being too depressed to walk up to go to the restroom. And so her bladder begins to hurt and so I think one thing that was really interesting and somewhat playful there was that depression hurts. It’s not just an emotional/psychological pain. It is physical. Like if you really miss someone, like it hurts when they’re not around. And I think that having different ways of portraying psychological pain manifesting as physical pain could be an interesting thing to show onscreen.
Corey: I would say that the science backs that up 100% because the two chemicals responsible for depression are norepinephrine and serotonin, these two chemicals. Dopamine can play a place in one type. But those are also really important chemicals in pain. So, in theory if you have a low serotonin level and a low norepinephrine level you’re going to have depression. We find this really commonly. Interestingly, if I decrease those in the spinal cord that also makes your pain sensor higher. Everything hurts worse, literally.
So, when somebody has depression almost always they have physical pain. And it may manifest—
Holly: Which is why they want to use drugs.
Corey: Right. No, exactly. And here’s an opioid and I’ve just wrecked your life. So the pieces, there’s really hard science to back up physical ailments that go with anxiety or depression. The place in the body with the most serotonin is not your brain, it’s your gut. So this why we see nausea and stuff in people with low serotonin states because it’s not working properly. They don’t digest food properly. It’s one of the most common complaints I would get for patients with depression. They wouldn’t complain about being sad or crying. They would complain about their belly. And then when you dig into it a little more it’s major depressive disorder.
Holly: Especially for young kids, right?
Holly: When a young child is dealing with a mental health issue they’re almost always going to tell you their stomach hurts. It’s a big thing to know.
John: Great. So let’s talk about a young child. Let’s talk about a young child dealing with depression or anxiety or these issues. What are the idealized perfect Hollywood parents and what are realistic parents that we’re maybe not seeing as much onscreen? Holly, what’s your take on those parents?
Holly: The perfect parent would say to their young child, “How are you feeling? Can you talk to me about what you’re feeling? If you can’t use words can you give it a color? Can you describe it in some way? All feelings are welcome here. We want to talk about all feelings. They’re important. Your feelings are important. And if you’re having some painful feelings, or if your stomach keeps hurting well guess what? We know where we can go and find some help and find somebody who can support you and help you feel better because as your parents we’re here for you, but we don’t have all the answers either. And sometimes we hurt, too. And so let’s go to the experts and find somebody who can help us out.”
John: That’s the perfect. That’s the dream. But let’s talk about more realistic things, because in real life parents don’t know what they’re doing. They’re busy doing lots of other things. They have jobs. They have other stresses. They are going through their other issues. On your show Allison Janney’s character is dealing with addiction herself and has a daughter dealing with it. So, and yet you’re trying to be a comedy. So, how do you find the balance of talking about these things and still finding the funny in there? And dealing with the fact that she’s not a perfect mother?
Gemma: We don’t have perfect parents on our show. No. I think that’s why people like it. I think it’s a relief. I think I don’t want to after I’ve made a mistake as a parent tune in and watch a perfect parent. Like that just makes me feel worse. Really just, oh, I could have done that and I didn’t.
I like characters that are flawed. That are trying but who fall down and make mistakes. And I think that that is where we find humor is in the trying. And, you know, we deal with a lot of difficult subjects. And those are the scripts that I want to write. Those are the ones that are so much fun, because there’s something to hold onto. And those are the ones where you can go into some really deep, painful places. I’ve always loved like a lot of sadness in my comedy, which did not make me a successful standup. But I found a place where it’s working.
But I think that’s – I don’t know, I think that’s the fun stuff to write. The pain.
John: And there’s also a lot of fear. I know as a parent there’s also a tremendous amount of fear. So it’s not that you’re just ignorant to what’s going on, but you’re also afraid of what’s going on. You’re afraid is this a small thing or is this a giant thing? Where does this all lead?
And one of the other fears is the cost of things. And so if we have a character with a child who might be having these issues what is the reality of going to get help? And so would they first go to their pediatrician? Would they then go to a specialist? How much of that could be covered by whatever insurance? What are the realities of someone seeking treatment for addiction or for mental health? Where does that money come from?
And Zach you may have some sense of this, too. You’ve done reporting on the realities of this. What does it look like right now in 2019 at least in the US for someone dealing with these things?
Zach: Well so there are too many uninsured people in this country. Too many people who are underinsured in this country. And I think getting into healthcare policy and portraying that rightly in an entertainment narrative would be quite difficult. But I do think that having conversations about insurance do work and is done. In 6 Balloons, did anyone see 6 Balloons? It’s like a day in the life of a heroin user played by Dave Franco and Abbi Jacobson from Broad City is his sister and they take him to detox which is kind of the wrong thing to do. Detox for opioids is not really a thing. But they take him to detox and there’s this whole rigmarole because insurance isn’t paying for it and they don’t have the right coverage. And then someone says, “Well, go down to this clinic. They might have the right coverage.”
And so I think that’s actually a very realistic run-in with the bureaucracy of American healthcare. And I think that’s actually very realistic because I think people do have a lot of trouble what’s in their provider, what’s out of their provider. I think health insurance adds a very complex layer to this. We can also get into parity insurance. It’s forced to, but sometimes doesn’t cover mental health as it should like they do with physical health. These things are separate and I think it’s very critical that we don’t separate these things. That they’re all part of hospital treatment and primary care and that these are all treated by doctors like this guy.
Holly: And when they aren’t treated by doctors, I mean I think there’s a very common experience that I’ve even had working with young adults, even in Los Angeles which is not the poor rural area where I grew up in that people, like adolescents and young adults, want therapy but their parents can’t afford therapy. And it’s like this lament, the young adult lament of like I want therapy or you’re 26 and you’re no longer on your parents’ insurance and you want therapy and you can’t find it. And it’s really sad. But this is actually – and I don’t want to get too tangential, but this is where the social media platforms actually can be a positive.
Because I’m not saying anybody should go get therapy on a Facebook group. The kids don’t use Facebook anymore. I don’t know what I’m what I’m talking about. But there are Reddit, I don’t know, listservs somewhere. Kids are able to find support groups. And I, through some of my clients, and I also have two teenagers, have been able to look into some of these online support groups and they’re not terrible. You know, the kids are like offering each other some support and some good advice. And it’s really interesting how the support that our community is offering is changing in this way because of social media. Social media is not all bad. There’s actually some really positive things that can come from it.
Zach: So I don’t go to AA or NA meetings, but Twitter is my support group.
Holly: There you go.
Zach: No joke. A bunch of my good friends on Twitter are in this room and we are always on it. And we’re working together. We’re part of something bigger. It’s really important to me.
Corey: For young kids, I had three in my clinic that were pretty recalcitrant and very difficult to treat. And I started playing video games with them on Xbox and we would play Halo and have a closed chat. And actually they told me everything there, but when I was in front of them as an old guy in front of them they didn’t want to say a word. They were clammed up. But when I game them my gamer tag and they came on and we literally sat down and played Halo, you know, in the evening sometimes I got everything from them. And then they would come in and tell me more there.
So it’s about building a connection, which means you have to break down these preconceived barriers with kids. And I think we don’t really build – we haven’t built a system for that. We’ve built a security for adults that we somehow adapted to kids and it doesn’t really work. I mean, I use this now even with my kids. When I’m on the road we play Apex and just can chat. And they’ll tell me more things.
So I think there are some things with gaming and social media and a new path that have real potential to make big change. And just kind of throwing those out there as nuggets for what connects to kids and allowing kids to inform that because the minute that they break down those walls they’re ready to talk about stuff. They don’t like where they are. They’re frustrated. They’re scared. They’re sad. They want to be successful. They want their peers to see them in a certain way and they hate that they’re being seen as this person. But the minute they’re that person they will fully embody it because they have this need to own it. Which many times can rapidly create severe illness. And so just figuring out these other ways that we can come at it would be really important.
John: Classically we talk about our protagonist, generally our hero who is – the character is going on a journey. The character who is changing over the course of the story. And there’s an antagonist. And sometimes we think of that antagonist as being a villain, like the bad guy of the story. But it sounds like what you’re describing really is a therapist as antagonist. The person who is helping the protagonist change, is causing the change. And so there can be friction there at the start, but ultimately you’re trying to get to a relationship there so that you can help this person get to the next place. That sounds like the nature of that relationship there. Great.
We are mostly talking about characters, but we are also writers who have minds ourselves. And sometimes deal with these issues ourselves. So before we get to questions I want to ask you guys – if someone is watching this from the Facebook stream or they’re here in the audience and they’re saying like, oh, you know what, I think this has made me realize that I may have a substance use problem, that I may actually have some mental health thing that I should be doing something about. What is the thing they should do tonight? Like what is the first step that somebody who is watching this or listening to this should be doing if they have that moment of awareness?
Corey: Don’t go to Google. I mean, honestly, this is the problem because at this point in time mainstream medicine is still really crappy at this. I mean, the vast majority of people aren’t really trained. It’s not mandated in medical schools for a doctor to be trained. I mean, I’m board certified and I’ve done it for over a decade. I feel comfortable in the neuroscience of it. That’s kind of not the average person who sees a patient when they walk into a hospital and there’s still this stigma that we have to break down.
And so what I would say for a person in here, first is get my LinkedIn and call me. I’ll hook you up. I mean, I know everybody who does this work. I mean, honestly it comes down to a provider being available to help a person in need, but more importantly a friend being willing to walk with them through this. And I think that’s one of the biggest pieces, and you talked about not only the character but the people around them. The thing I’ve never seen portrayed truly effectively is a non-family member friend having a truly empathetic connection with a person with addiction to help them take that next step. What we call the trans-theoretical model of change.
And moving them from this pre-contemplative state to actually going and get help. And it’s very simple. You look at them and you say I care about you and I have your back. Because they feel so isolated that they don’t do it. And as a physician when I say that in the emergency department it’s amazing the switch that flips in people when I’m treating them in a time of crisis to actually want to get help and kind of empty themselves a little bit at that point.
And so I think the biggest thing that I would say is I could give you the one-liner of go to the SAMHSA website, Substance Abuse Mental Health Services Administration, and type in your zip code and it will give you providers. Or I could say go to the – if you feel unsafe. But find the person you trust the most and connect with them. And ask for them to walk with you through this. And they really will. That’s the first step. And then together you can start to find the pathway for treatment because it’s not predictable yet. We’re just now building these systems appropriately and that’s why these billions of dollars from federal government are coming in because the systems don’t exist.
It’s been kind of an on-your-own pathway. And so don’t let it be on your own. The first thing is to make that strong connection with the person you trust the most. And then start the journey together. And that can be a family member. It can be a friend. Whoever doesn’t trigger you and enable you, identify them. Not the person who just says yes to whatever you want to do. But somebody who cares about you. And I think that’s the first step that I would say for anybody in here who is struggling with this.
And you know what? 10% of you are. And so this is just a reality. And so that would be it. And honestly find me, call me, I’m happy to answer those questions with you. I still have my homeless population in Camden that I see that still calls my cell phone sometimes randomly.
Holly: And as the therapist I’m going to say if somebody feels like they might be struggling and they don’t know, if they are and they’re wondering if they should take that step to reach out to take a really deep breath, to love yourself, to understand that we are all experiencing pain and we’re all going through something and that it’s OK to be struggling. And that you deserve a good life and happiness and allow yourself to reach out for help. Because sometimes that’s the very first step that has to happen because the self-loathing is so great that people feel like they don’t even deserve to be able to ask for help. And that’s sometimes the biggest hurdle. Love yourself. Allow it to be – we’re all human. We’re all in this together. None of us really knows why we’re here, right? And we’re doing the best we can and it’s OK to be struggling and it’s OK to need help.
John: Zach as a writer you’re often dealing with the struggle of getting stuff down on the page. Is there any special thing you want to say about sort of the writing process and how it ties into these two things and the desire to recognize when you need help? Is there anything that’s different about that?
Zach: So I work from home and I joke that I’m a stay at home dad with no kids. And so it’s really nice that I have a partner, Logan. She gets home at around five. So I try to simulate as best I can a 9 to 5 job. Because if you’re writing it’s not 9 to 5 and it’s whenever you get an email or it’s whenever someone shares the doc and you’re in it.
So, I think because things are unstable and not exactly steady I would try my best – and this is just what helps me is get structure. I think – any writer I think is very obsessive. Reading the same sentence a hundred times and it doesn’t look any different and I keep reading the same sentence. I think there’s just part of the process that for someone like me who has had addiction that I have found a way to channel some of the obsessiveness that is part of addiction into something that I think is helpful and something that I think is useful.
Like I don’t really have a big writing process because journalistically things are just moving too fast sometimes to have a cup of tea and put on the right music. It’s like, no, it’s just like–
John: The deadline.
Zach: I’ve just got to go.
John: Gemma, now you get to work – you don’t have to work all by yourself because you get to work with a staff.
Gemma: Oh thank god.
John: But there must be some aspect of the caretaking that you guys are doing of each other and sort of watching out for each other. And there’s the whole production of the crew that makes your show. As a person who is managing these people how do you look out for these folks? And how does a writer on your staff, how could she feel comfortable speaking up if she’s struggling, if she’s having an issue? What guidance could you give to somebody who is on a writing staff, not yours necessarily? But in general what should they do if they’re struggling?
Gemma: Well first of all I mean in our room we get taken care of so well. Like we are fed and watered and coffee’d. Like over our hiatus I almost starved to death because I didn’t know how to get lunch. Sort of a joke but not totally.
John: I know it.
Gemma: So I think self-care in general is so important. And I think – I don’t know necessarily about other people, but I know for myself there’s a lot of gymnastics that I have to go through to get to the point that I can, I don’t know, find the funny, you know. And I’ve had to face a lot of stuff and deal with a lot of stuff on my time and get through that. Because if I don’t get through that I’m going to bring that – I’m just going to come into work and weep. And I need to find another way.
You know, so I do things every day. I try to meditate before work. I try to get some exercise in. I try to do that book, The Artist’s Way.
John: Five minutes–
Gemma: The three pages. I’m on week one, year eight. I’ve never gotten past week one. But week one is great because she talks about the morning pages. And I do that which is like the three – and if take a moment, and a lot of moments, 30 moments in the morning to do that. To just write down the voices in my head that are like you don’t deserve anything. You know, if I can just write that down so that I don’t bring that into the room I do so much better.
And my husband and I have a deal if I meet an untimely death that he will never read my morning pages notebook because he will so worry about what I was going through. But it’s just that yammering to get that out.
And then certainly if anyone in our room is going through something I think that we give them the feeling that they can come to us and that, you know, there’s a lot of trust that has to happen in a writers’ room. And you’re sharing your personal stories and experiences and some of them are funny and a lot of them are not. And you need to be able to trust that that is sort of a sacred space where that stuff isn’t going to get shared elsewhere. And the people in my room know me really well. You know, they know a lot. And there’s something wonderful about that. It’s also difficult sometimes because they know me really well. But I don’t know, it’s a very cool relationship.
John: Now usually on the podcast we would do a One Cool Thing, but for tonight I wanted to do a new segment called Please Stop. And so I asked everyone to prepare a Please Stop for something that they see in films and television that they wish they would not see ever again, or that people would cut way back on.
So, here’s my Please Stop. Can we please stop with the actual quantity of alcohol we see characters drinking in movies and TV shows? Because it’s physically impossible. You see these characters, I mean, this is really an appeal to writers and directors, but also like the prop people. Because people will drink these massive quantities. And we all know that it’s like tea or something in there, so they’re not actually drinking bourbon. But characters drink so much that they would be dead in some of these things.
So if we could keep an extra eye out for the actual volume of alcohol we’re having our characters drink that would be my appeal and ask to Please Stop overdoing the alcohol.
Gemma, do you have a Please Stop?
Gemma: Yes. Can we Please Stop when people are, you know, identifying in a 12-step meeting and they say, “Hi. My name is Bob.” And then everyone says, “Hi Bob.” That, I just, I don’t like it. I don’t like it. It’s so depressing and it’s so – I don’t know.
John: It’s cliché. Corey, what do you have?
Corey: I’d say the biggest one is Please Stop portraying someone who is in recovery from addiction as having a weakness inherently. And on the opposite side of that just to add to it, don’t portray people who decide not to use drugs or drink as lame. Because what it does is it portrays, one, that those who did drink and it happened to be the thing that made them feel normal for the first time and they develop addiction, but then they went through all the work and frustration and pain in that to get well. Treat them like they’ve overcome cancer because this disease has the same mortality rate.
So, as we start to look at it they have fought to get there. And they should actually be as someone who has really been through a battle and won. And it should be portrayed positively as like this is a person I want on my team because I’ve seen them fight a fight and win. But on the other side don’t make the dude who’s like, “Yeah, I’m cool, I don’t want a drink,” as like the lame-o that night. Or “I don’t smoke weed” is like boo, he can’t go to White Castle. Like I still go to White Castle, I don’t smoke weed. So it’s OK.
And so I just think those two pieces go together.
John: Both in our media but also in real life. I mean, a thing I often say is if someone says they don’t drink you don’t have to ask a follow up question. They’ve said, great, so they can have something else and let’s move on and have a great night. Holly?
Holly: Please Stop portraying mental illness and substance use disorder as anomalies. Almost 25% of people have a diagnosable mental health issue. I would say millions more have maybe a sub-clinical anxiety or depression issue. So, it’s a lot of us and it shouldn’t be like that character has a mental health issue, or that character has an addiction. It’s much more ubiquitous than that and would love to see a more realistic portrayal of that.
John: Zach, what’s your Please Stop?
Zach: OK. I would say to stop glorifying DEA agents and criminalizing the US/Mexico border.
Holly: Here here!
Zach: So just one thing, obviously DEA agents, like we make them look tough. And their job is futile and they’re abysmal at doing it. So, let’s just not make them cool people.
John: Thank you, Zach. All right. Sicario [as a comedy]. Now we have time for some questions. So if you have a question – a reminder that a question is a question. It’s not a story with a question mark at the end – raise your hand and I’m happy to call on you. Right here?
Male Audience Member: Well I guess this is for all of you. I’m just curious, I read Michael Pollan’s new book How to Change Your Mind, which I don’t know if you guys are familiar with that, but they start talking about drug addiction and the use of psychedelics and other drugs. I haven’t gotten all the way through the book yet. But I’m just curious if you’ve researched any of that or could talk about that for a second.
Corey: So the psychedelic research is kind of resurgent. There was a time in the ‘60s in which it was actually done quite a bit and looked pretty promising even then. I think that the research that’s now coming out looks equally as promising. So I think it’s about dosing and timing and you have to do science. And science is you have to identify whether or not if I give somebody this versus somebody who got a placebo, like a sugar pill, does it work in that scenario? Because we develop an idea of should I use this based on if nobody knows what’s happening do they do better. And if that’s the case then game on. I mean, there’s nobody really against this in medicine. Medicine is pretty straightforward. I mean, we just like to see a randomized control trial in a population we can believe by a scientist we can trust. And we’re like, OK, cool, this is great.
So, yeah, I think it definitely has a future. And in the mental health there’s a lot of research there where I think for depression and stuff looks great.
Holly: Absolutely. Depression, trauma, PTSD. It’s very effective, ketamine treatment and LSD micro-dosing. Very effective. And it’s hopefully going to just be allowed to be used more. Unfortunately it’s over-regulated right now.
Zach: One more DEA thing. It’s because of the DEA that we cannot research these drugs.
Holly: Yes. That’s true.
Zach: So let’s de-schedule these so we can actually research and see what kind of potentials they have.
John: Another question, right here.
Female Audience Member: I’ve been researching neuro feedback that people do. I did it as a kid and I didn’t realize I was doing it. I was just brought by my mom. But I just listened to a podcast about it and they claim that there’s no such thing as a chemical imbalance. And I’m confused by that because I currently take medication and it works great. And the neuro feedback I do not remember working at all for ADHD.
Corey: I’m a neuro molecular biologist at grad school, so this stuff is really interesting to me. So sometimes we oversimplify things to the point of being wrong. And it’s not necessarily an imbalance, because neuro feedback has very little to do with the actual neuro transmitter, the chemical, and more to do with actually building certain signal pathways. Because if you do neuro feedback you’re creating a default reaction to a cue. I mean, we know the lateral habenula. We know exactly what part of the brain we’re working on because it’s the default reaction to a cue that we’re trying to change. And so neuro feedback is I’m feeling anxious but let’s focus on your heart and see if we can decrease your heart rate during that moment.
And so that cue would be to switch from being anxious to thinking about this, which would then lay down new tracks. It would then lower your heart rate and decrease your anxiety. It’s not a chemical imbalance to be depressed because I may – it’s a chemical imbalance in the sense that for your brain the chemicals are a little bit out of whack. And whether that’s structure, or chemicals, we never know. Because some people have – like schizophrenia is a structural problem, not a chemical problem. It’s what we call arborization which is where over time your brain connects a bunch of nerves. And then it trims a bunch of nerves, too, so that you don’t have too many, so that your brain can communicate. So you can have internal thoughts while you’re having external thoughts.
If you don’t trim those branches then you can have internal thoughts way too loudly while you’re having external thoughts and you get a different voice. So it’s these changes in structure. So mental illness is not a chemical imbalance, unless it is, which in that case it’s a lower or higher serotonin. It could be structural or this. So it’s an oversimplification.
The heterogeneity of mental illness has a lot to do with trauma. Has to do with is it group trauma, meaning a whole group of people experience this versus an individual. It changes the whole dynamic of the brain is wired. So, oversimplification, but they’re also wrong because they became black and white. So if anybody is black and white in this space they’re wrong. It’s all grey. Because the science we know a lot, but we don’t know everything.
So if they’re not speaking in – if they’re speaking in absolutes turn it off, because it’s just wrong.
Zach: And pharmaceutical companies wrote the copy for chemical imbalance. Like it’s not a thing.
John: All right. A hand right there. Yes?
Female Audience Member: Thank you. The thing I’ve personally experienced a lot is somebody whose friends and family think they have an addiction or mental health issue but that person either doesn’t think they do or doesn’t want treatment. What does the ideal friend or family member do in that situation and how does that fit in the timeline of issues that we’ve been talking about?
Holly: Should bug them every day. Tell them they have to go to treatment. The people around them should spend all their time worrying about whether the person is in treatment yet.
John: Just badger, badger, badger.
Holly: Yes, badger, badger, badger. That’s what works. I’m good.
No, yeah, you know, grownups make their own decisions. And if somebody is not ready to get treatment they’re not ready to get treatment. And we have to respect that and live our own lives and take care of our own selves. But you can still be there in a way to say, “Look, I’m here when you are ready to get help. I’m here if ever you want to get help.” And you might want to say that every couple of weeks, but probably not every day, right? So that they know when they are ready to get help that you’re there. You can’t force anybody to be ready to go to treatment, right? Or to get any kind of help.
What you’re talking to, and I don’t want to get too complicated, is actually though one of the systemic problems of something that might keep somebody sick. Because there might be what we call enablers, and I hate that word, but it’s a good word, who are spending their entire lives worrying about that other person. Wanting to make sure that they’re OK. Resentful that they’re spending all their time worrying about the other person being OK. And in that system the sick person almost might want to stay sick unconsciously because they’re getting all that attention around them and there are these weird payoffs. So actually the healthiest thing to do is to step back, be your own person, you know, say when my loved one is ready to get treatment he or she will. And until then I’ll live my own life. I’ll be a model of setting good boundaries and living my best life. And as long as they know I’m here that’s all I can do.
Corey: And from a provider’s standpoint we use a technique called motivational interviewing which is basically a science-based interaction technique. It’s like The Force. It’s awesome. I mean, literally these are not the droids you’re looking for. I mean, you can get someone through just appropriate empathetic questioning, but it has rigid structure in the way in which you approach it. So, if you want to know the right way to say things that might help someone move through those stages of change and get ready faster rarely can a family member do this because there’s too much emotional connection and discourse.
Holly: Can be shaming, sorry Corey. It can be a little shaming.
Corey: Yeah. It can be, if overdone. But at the same time motivational interviewing is the basis for getting someone to start to slowly move through these stages of change. And it’s the language that should be mimicked if you’re going to try to portray someone who is kind of doing the right thing. Not overdoing it. But the basics of it.
Zach: A last thing I’ll add is if someone is actively using and they are not ready to stop it’s a good time for them to learn about harm reduction. It’s a good time for them to find out where the local syringe exchange program is, where they distribute in a naloxone, where someone around them can naloxone which reverses the effects overdoses which someone who knows how to do the proper breathing in case this person isn’t breathing. So there’s ways to keep this person safe and know that they’re cared for even though treatment isn’t on the table right now.
Holly: That’s a huge important point. If you have somebody in your life who has an opioid addiction or might have an opioid addiction get some Narcan. And will you explain more what that is? And you can get it at your pharmacy. You can ask your pharmacy for Narcan to be there. If there is an overdose you can help them stay alive.
Corey: Yeah. So an overdose is when the opioid or other substance, or a combination of substances, in fact most overdoses are not just opioids. They’re an opioid plus like a benzodiazepine like Xanax or Valium or alcohol on top of it. And it suppresses the breathing in the brain stem. And so when that occurs if that’s not reversed then the patient will die because you’re not breathing.
Narcan, or naloxone, which is a nose stray or an injection. In fact, what’s out in the public right now is just a nasal spray.
Holly: It’s easy.
Corey: It gets to the brain. It blocks the receptor that the opioid goes to and reverses that. So, what it does is it wakes them up and puts them into [floored] withdrawal, but it keeps them from dying. And that’s the important part. Because I can never get somebody who is dead well. So, we need to make sure that any chance that we have this. My seven-year-old knows how to deliver this. My nine-year-old knows how to deliver. They carry it in their backpacks. And I live in Ann Arbor, which is not really a place where you’re most likely going to find as much of this in density. But it should just be that ubiquitously.
So if I asked the question how many of you have Narcan on you, it honestly should be kind of everybody, because it is the one thing that literally is a life-saving drug that anybody can give that nobody is going to steal. It has no street value other than keeping somebody alive. And if I’m walking back to my hotel tonight, you know, you need to be able to give that.
Holly: Go to your pharmacy and say I’d like some Narcan or some naloxone and your pharmacist will help you figure that out.
John: There are going to be so many scenes with Narcan in these people’s scripts and it’s going to be great.
Zach: That’s good. That’s very good. More naloxone.
John: Question right here.
Female Audience Member: So, as you know what happens to people of color who have mental health or addiction is very different from what happens to white people in this country. And I’m wondering what you would like to see be different in the program that we have around race and mental health and addiction.
John: Let’s talk about both sort of portrayals right now and also reality, so we make sure that we are addressing both things.
Corey: The data is very clear that medicine is racist. I mean, very racist. Not a little bit. This is not unconscious bias. It’s racism. And so racism is shown to be systemic in even doctors of color. And so it’s not just everybody. It’s the field of medicine that is racist. And this has been well studied and it basically shows that if you are an African American female you are going to receive the least effective care that we can deliver as compared to anybody else. And the spectrum changes. So poverty and the appearance of poverty and color also put you even below that.
So the minute you come in and you code as impoverished or you code as African American from that culture, or you code as American Indian or Latino, you’re going to get worse care. And so that’s a reality and I think quite honestly is worth beating up in TV shows. Meaning this needs to be called out.
I have this conversation with my patients, because obviously they’re going to look at me and be like well what do you know about this. I’m a white male doctor. I can walk into a room and have immediate power without having done anything, right? That’s just a reality of America.
And so I think what I would love to see is how to actually have that conversation from someone like me and someone like that to cross that bridge because it’s crossable. It really is. But you have to call out the fact that the entire system is actually built against that population. And that’s a systemic historical problematic issue that we’re going to have to deal with. And until we really beat it up in anecdote and emotion and story it’s not going to change in the bigger picture. That’s a great question.
Holly: It is a great question. And something that I wish – we all wish – was more addressed in television and film, too. Because it’s just so empowering to make sure that there is representation in our media. Mental health wise, too. It’s really unfortunate that there is a bias within the system and there are also cultural biases, some groups are more prevalent to ask for help or reach out for help. And I wish that story was told more, too, because it’s really, really important.
John: Yeah. This panel is set up to talk about stigma and I think it’s also important as we do our research on these things make sure we’re looking at cultural groups and what are the stigmas about these specific things within that group that would cause different outcomes or cause people to make different choices, be it for getting help or other things. It doesn’t stop at sort of doing the research on what is the issue, but like what is that issue within that culture is crucial. And that’s why you have to have representation in your room to figure out what’s going on there.
I think we can take one more question. I didn’t anyone in the back, so I see one hand in the back. I can’t even really see your face, but I see your hand up very, very high.
Male Audience Member: Back to screenwriting, within the 12-step programs there’s actually a tradition in not talking about the 12 steps in radio, television, and film. So as screenwriters how do you approach that because you would want to be responsible to that. And like Zach said with the doc he watched that gave him an unconscious bias on wanting to take methadone, so if as screenwriters we do the best that we can, or don’t, like what is our level of responsibility? And is there a higher level to the networks and studios to oversee how we’re portraying these 12-step programs or recovery in general?
John: I can start answering the question, but I think we have very smart people up here who can also answer it. I think as screenwriters we’re always looking for that balance of what is realism versus what is the point that we’re trying to make. And what you’re describing is that sometimes the absolutely realistic version of what that 12-step program might be like might be divulging stuff that is not helpful for the community as a whole. So you may want to make some choices that are different.
You’re always going to approach the scene from what are you trying to do for that character. What is the essence of that scene for that character? And there may be ways to use the nature of that scene or sort of what’s the arc of that scene to get at that thing without revealing things that you don’t need to be revealing. Or getting into esoterica that’s not meant to be discussed. But what do you guys think? To what degree is talking about the specifics of recovery, or sometimes the specific of a certain kind of treatment where you can’t walk somebody through the whole thing and you’re going to be doing some short-handing.
Crazy Ex-Girlfriend is a show I loved and in this final season Rachel Bloom’s character is going through a program and you can sort of squint and probably figure out what she’s going through, but they weren’t specific about the nature of the program. Is that an appropriate choice to not give it the name? Where do you guys land on this?
Gemma: Well I can speak to that. My understanding of that tradition is that it is not to break personal anonymity but not that you can’t discuss the program. So, that is a difference and we’re dealing with fictional characters. And to do it in a responsible way I think is definitely important. But I don’t think it breaks that tradition. And that’s sort of the stigma of recovery that I was sort of talking about earlier is something that is real and it gives people a sense that there isn’t hope and that if you seek recovery that your life is over and that you won’t find joy or happiness again. And I think that that is false.
Corey: It’s national security. I mean, it’s not like you’re going to divulge something that’s going to make every person with addiction suddenly worse. I think transparency is really important for all aspects of treatment. Both for addiction and mental health. And in that because the more we normalize these things the more likely it’s less stigmatizing. And I think hiding it and separating it and keeping it under the covers just continues to perpetuate that stigma about people who are in recovery and what these things mean.
And if somebody goes to a cancer support group then we talk all about that. In fact, that’s entire storylines of pathways for people in shows. So I think that with this it’s a step. It’s a pathway in their recovery. And sometimes and for some people it’s not a part at all. Some people it’s a big part. Some people it’s transient. And it just is what it is. So normalizing it as much as you can through the stories that you tell becomes really important for destigmatizing the treatment of addiction and not keeping things under wraps and scary in a sense.
Zach: Yeah. I just think anonymity, it’s important for people who want to protect their identity, obviously. But I do think we are in, like that book, The Traditions, I think it was written in the 1930s or the 1940s, and I don’t think these traditions are mapping super neatly onto where we are now as a culture in society, namely that when there was an HIV epidemic a saying was literally Science = Death. That was the slogan. And right now there’s an overdose crisis where 70,000 people are dying every single year. And I think that there’s a responsibility to not be quiet about that. And to speak up. And the more that people like me are in places like this and the more that there’s people who use drugs, people who are using drugs, we need to hear from them. And, yeah, so I don’t think they should be anonymous. But that’s just my take.
John: I want to thank our fantastic panelists for a very great night.
- Hollywood Health and Society
- 6 Balloons with Dave Franco
- Motivational Interviewing
- Follow Corey Waller on Twitter here.
- Follow Holly Daniels on Twitter here.
- Follow Zachary Siegel on Twitter here. Follow his project Changing the Narrative on Twitter here or using #ChangingtheNarrative.
- John August on Twitter
- Craig Mazin on Twitter
- John on Instagram
- Outro by Matthew Chilelli (send us yours!)
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