In the field of mental health we confront so many unmet needs. We experience them personally or we observe them with compassion and wonder what to do. Changemakers are individuals for whom the problem becomes a calling. Unstoppable, they find what they need and they build some missing piece of the solution. Mental Health Changemakers is a series of interviews with individuals and grassroots organisations who work at the intersection of vision, practical skills and determination. These are the people whose innovations give us those eureka moments: yes, of course!
"Insight is the beginning of change, and some degree of change is inevitable. So let’s make it positive change!" So says Dr Tracey Marks, an outspoken voice for mental health education. Marks has practised general psychiatry and forensic psychiatry for 20 years, drafting more than one thousand expert opinions on mental health issues for federal and state court cases. From the legal consequences of mental health, Marks wants to draw our attention toward cause and prevention. As an author, blogger and YouTuber; Marks is on a mission to dismantle mental health stigma by educating people and normalising everyday conversation about conditions including depression, rage, psychopathy, sleep and mood disorders, anxiety, burnout—and some of the more troubling conduct of politicians.
It’s a pleasure to meet you. Your work is really very broad! Looking back, was psychiatry a field that always spoke to you?
In African American families in particular, the culture [says that] the way you get ahead is through education. So my parents were very encouraging, and pushing me toward doing something more than they did. They wanted me to be something more than a teacher.
I was going to do internal medicine and if you know much about the ‘becoming a doctor’ process, your training is like a draft process. You interview where you want to go, you put in your preference, the hospitals put in their preferences, you get assigned a place and they call it the match.
I matched in internal medicine and then changed afterwards. I wasn’t interested in psychiatry because I didn’t have much exposure to it and didn’t see why people even needed to see psychiatrists. But one of the things that my mother said to me a long time ago that has stuck with me, was that I was [the] kind of child who wants to take in the bird with the broken wing—befriend people. My mother said to me, ‘You’re attracted to people with problems. You better watch that.'
And I realised at some point that I do have a lot of empathy for people with emotional problems. Instead of having them all be part of my personal life, I can make that part of my profession. In medical school, when I did my psychiatry rotation, it clicked with me and I realised I got more satisfaction [from] helping people with their emotional pain than I did [with] physical issues.
So it is a part of you. And within psychiatry, your work has ranged widely including the field of forensic psychiatry. Can you explain what that is? How does psychiatry intersect with law?
It can include criminal issues and civil issues as well. So, the criminal issues would be things like, was someone insane at the time of committing the offence. That’s the most popular thing we do criminally. The insanity defence, evaluating people for that—is someone competent to stand trial? And civil issues would be things like if someone has a lawsuit against some entity and they are also claiming mental damages as a result of it. A psychiatrist or psychologist or mental health person would do an evaluation to see if there were real damages caused by this thing.
Personally, you have also covered a lot of ground. You grew up in Florida, did your residency in New York, and you practise in Atlanta: three very different parts of the US. As a Black psychiatrist, do you observe that the issues or obstacles vary for Black Americans in those communities when they need mental health care?
First of all, I think a big obstacle has just been cultural bias: ‘Why would you see a psychiatrist?’ ‘The system isn’t going to understand me.' Growing up in my own household, that’s not something you would do, is to go see a psychiatrist. My parents were not proud of me changing my focus to psychiatry, actually. When I told them after graduation that 'Oh, by the way, I’m not doing internal medicine, I’m doing psychiatry,' I know they were disappointed. I could tell by their reaction: silence.
Sadly or not, I have not stood up on a platform of focus on Black people. It might be because I’m in a very high[ly] ethnic community. Atlanta is maybe 40 percent African American. I’m surrounded by people of colour, whether Black, Asian or Indian; so in some way I may take it for granted that there’s this [service] gap in this issue. It’s all around me. I’m not seeing the void as much as I would have back in Florida. All that to say, it is not top of mind for me as far as addressing issues of African American people being without in some way.
There’s a lot of wealth here in the [Atlanta] Black community. When I first moved here, it took me about six months [to get used to] seeing Black people everywhere I went. Even in New York, it wasn’t like that. It is still very diverse, but just differently diverse.
Across all races and identities, one obstacle to obtaining good mental health care will be the cost. It’s different in every country, but how does cost factor into psychiatric care in the US?
One challenge has to with how people regard mental health treatment when it comes to paying for it. [Insurers] and other entities, third-party payers, will want to regularly downgrade the value of the care and not pay psychiatrists as much as they would pay another doctor for the same amount of time. So as a result, there’s a lot of psychiatrists who don’t take insurance—because if you do, you’ll be struggling, sadly, because they don’t want to pay much for the appointments. That’s one challenge.
[I would like] to see parity actually be realised between mental health care and physical care, so that it’s much easier for people to be able to get their treatment paid for. Often the cost is prohibitive for many who may lack the financial assets to pay for ongoing therapy.
There’s a whole big issue of fairness in assessing what essential medicine is. Mental issues should be on par with physical issues when it comes to treatment and that’s been a big push. We’ve made some progress with mental health stuff not being carved out of insurance plans, but we’re still not there yet.
Not there yet in any country, it seems. Let’s look ahead to the changes that you are working to bring about. What is the change you would like to see?
I would love for the topic of mental disorders and symptoms to be just ordinary conversation, and not be something someone has to whisper about, or look around to see who’s in the room [in order] to be more comfortable talking about it. As easily as you can say, 'I sprained my ankle yesterday,' I’d like to see people able to say, 'I felt depressed' or 'I feel like I might be getting depressed,' and not have to feel like there’s any retaliation or grief and judgement, and not . . . feel ashamed.
I want to get into schools, to talk about anxiety in youth because that’s a big deal and that’s when it starts. Every time I hear about a suicide in [a] high school, my heart just sinks. I haven’t gotten started with it yet, because I’ve been doing other stuff, but that’s where I’m wanting to go next.
We all see the terrible consequences of avoiding mental health issues. We always read about signs that should have been picked up before the violence. Do you advocate for particular solutions?
There’s no one solution. We do all this backtracking after the fact, such as in a mass shooting. 'Well, this guy was a loner.' What are we going to do? Take all [the] loners now and keep an eye on them? ‘This guy was talking about how he hated the people, his teachers, wished they were dead.’ Well, anyone who verbalises that now, are we going to contain them? ‘What are we going to do about this?’ You know, people still have rights to privacy and there’s a conflict between privacy and knowing everything so we can predict things.
Criticism of the system, that does kind of go in the direction of blaming after the fact: 'Who didn’t pick up on this?' There isn’t a good way to pick up on this, because even if we come up with a list or a profile of people who do shootings, what are we going to do—gather all those people up and put them somewhere to make sure they don’t do something in five years?
We can get very occupied [by] foreseeability or what we call ‘hindsight bias’. 'Well, now that we know what happened, all these people should have known it was going to happen and now we’re going after them.'
Your work has moved in a circle, from forensic insight after the fact, to your current work to de-stigmatise and discuss issues openly before things go wrong. The material on your website and videos is again very broad. Can you mention a couple of your publications that stand out for you?
One of my most recent videos focuses on ADHD (Attention Deficit Hyperactivity Disorder) . . . I have a soft spot for that because of having personal experience with it. I was diagnosed with it as a child, but my problems haven’t been as impactful in my adult life. And I hurt for some people who suffer when it comes to their self-esteem and how they live their lives because of their gross disorganisation from their ADHD—a disorder that some people don’t even believe is real. So, that said, a long caveat to the more recent video that I really liked: Why Some People with ADHD Procrastinate. It was very popular.
And then there’s another one that is a few years older but on a similar theme and talks about executive dysfunction. We know about poor attention, poor focus, forgetfulness; but there are other aspects of it that are really impairing and those can really get in the way of relationships and get in the way of how you feel about yourself.