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Mental Health at Startups

What is the root of mental health issues with entrepreneurs, and what can we do to support founders and their early stage employees?
The statistics are frightening. If you are an entrepreneur, you are 50% more likely to report having a mental health condition (. The same study revealed that founders are:
2X more likely to suffer from depression
6X more likely to suffer from ADHD
3X more likely to suffer from substance abuse
10X more likely to suffer from bi-polar disorder
2X more likely to have psychiatric hospitalization
2X more likely to have suicidal thoughts

What is the root of these statistics and what can we do to support founders and their early stage employees? The Homebrew guide to Mental Health will explore these issues and solutions.

Entrepreneurship can be stressful

The life of a founder can be lonely and isolating. As a first time or even repeat founder, you might have no idea what you’re signing up for. You start a company, raise venture money, and the pressures grow exponentially. Let’s take a look at some of these common stress inducing factors:
Delegating/letting go. Letting other people take over jobs you’ve been doing is a scary thing. Your startup is your baby and you want to tell your story. You are essentially “firing” yourself from a part of your job when you hire someone and that is frightening. Hiring the wrong person is even scarier. However, once you realize someone may be able to do something better than you and free up some of your time, the result can be freeing.
Balance. Founders tend to throw themselves into their work 150% and things outside of work may fall to the wayside (relationships, health/exercise, and hobbies that bring joy). When relationships suffer, stress can manifest. When one stops exercising, health is impacted. Lack of interests outside of work can lead to creativity blocks for some.
Fundraising. You will experience a lot of rejection and many “keep in touch” messages. Your startup is your baby and your baby will get rejected on a regular basis. Being “on” all the time is exhausting. Managing your team and investor’s expectations is exhausting. Getting investors to move forward as a “herd” is exhausting. Investors give you unclear signals that are hard to calibrate. All of these factors contribute to a highly stressful process.
Hiring. Startup founders spend around 50% of their time hiring. Hiring in a competitive market is exhausting, time consuming and filled with rejection. When companies start closing business faster than they can hire, the stress of a founder or an employee taking on several roles at one time can lead to burnout.
Putting others’ needs before your own. There’s a reason you put your own oxygen mask on before your child’s. If you run out of oxygen, you can’t help anyone else. When a founder takes care of her employees first and ignores her own needs (mental and physical), this can lead to mental stress. A healthy founder is in a much better position to be a great leader, friend, partner, and influencer.
How do mental health issues manifest and what are the signs to look for? The three main types of mental health issues are: anxiety, depression, and substance abuse. Sometimes the signs are obvious, especially if they are physical (significant weight loss, gain, or exhaustion). Then there are the changes in behavior such as someone showing up differently than before. Examples include:
Inability to make decisions.
Missing deadlines.
Lack of motivation.
Acting short with a colleague, or family member.
Feelings of existential dread “Why am I here?” “What are we even doing?”
Withdrawing from others and wanting to work independently.
OR the opposite end of the spectrum -- micromanaging or absolute chaos.
Consuming oneself with the question “Am I doing this right?”
Constantly rescheduling things and showing up late.

Mental Health and Stigma

There are two types of stigma associated with mental health -- social and self perceived. Some are worried about what others may think of them and some feel self shame. People don’t want to ask for help with regards to a mental health issue for fear they will be perceived as weak. There may be shame associated with showing emotion or vulnerability.
What can we do about this? First, we need to get rid of the idea that you are weak or unfit if you ask for help. We need to make resources readily available and get founders and investors talking and sharing stories. This must be top down -- investors to founders and founders to employees. Many well known founders have battled with mental health issues and have shared their stories, such as and

I think I may be suffering from depression but I’m not sure. I may just be in a funk. Is there a way I can assess myself?

Here are 2 useful self assessment tools:

I don’t think I’m depressed, I think I’m just burned out. What can I do to prevent burnout?

Make sure you are getting enough of your basic needs (sleep, exercise, healthy food, time with your family). If you aren’t working with a therapist, leverage a friend who can be an “accountability partner.” This person is someone to help you take responsibility for your actions and not make excuses for taking care of yourself. Think of this person as a coach who makes sure you keep your commitments. It can be a friend, coworker, or a partner.

How do you encourage someone to ask for help?

Regardless of whether this person is a founder or an early stage employee, there needs to be a sense of normalcy/normalization. If you are feeling stressed or anxious, you are not an exception to the rule. Everyone needs help from time to time. Many founders, successful executives and high performing employees have coaches and or therapists they speak with on a regular basis. You should not be ashamed if you need help. Seek it out. You are not in the minority. As investors, we see the value in getting help and seeking out experts when it comes to mental health. We hope you will be open to this, too. It has helped many founders get through mental “blocks” and dark times.
A culture of support must come from the top. If employees don’t hear founders addressing the topic of mental health or see founders practicing what they preach, then it is very difficult to build an emotionally fit company. The message should be loud and clear -- getting resources and help is a sign of growth as opposed to a sign of weakness. There is no shame in getting help.

So how do I get help?

Start with your health insurance. You may have an EAP (Employee Assistance Program) which is part of your benefits program that helps with personal and work related problems that impact job performance, health and emotional well being. If you don’t have an EAP program, you will need to find a therapist outside of work. It is important to get a referral from a reputable source (a trusted friend, colleague, or family member who has worked with a therapist) vs. just finding someone online. There are tons of therapists out there but the best way to go about it is to find someone who is a referral and who has worked with entrepreneurs. Your primary care doctor may be a good resource as well.
Amy Buechler, a licensed therapist who’s also a batch director at Y Combinator, the well-known Silicon Valley seed accelerator, offers her thoughts on finding and affording a therapist
In order for companies to scale, retain employees and build a healthy culture, the overall well being of each employee needs to be prioritized. If a founder isn’t taking care of herself, we can’t expect a company to be emotionally fit. If we get investors and founders to be more aware of mental health issues, sharing their personal stories and getting rid of the shame associated with mental health issues, we are moving towards a much healthier culture.

I’m not sure I understand the difference between a therapist and a coach.

A therapist (often called a psychologist or counselor) is a licensed (by state) medical professional who has completed graduate degree work. Therapists tend to focus on the past vs. the future.
Coaches (executive coach, life coach) may have a certification but are not required to by law. This is not a regulated profession. Anyone can call themselves a “coach” and set up shop.
Therapy is more focused on emotional resolutions whereas coaching is about new life paths.

How do I find a therapist?

Let’s first figure out what you might need. There are a lot of labels. You need to understand the difference between the types of therapists:
Psychiatrist: A psychiatrist is a MD/Medical Doctor/attended medical school who can diagnose mental illness and prescribe medication.
Psychologist: A psychologist has a graduate/doctorate degree (PhD or PsyD) in psychology but has not attended medical school. They are trained in testing counseling, and psychotherapy. They are not licensed to give out medication.
Marriage and Family Therapist (MFT): MFT is a license that requires a minimum of a master’s degree, two years’ supervised clinical experience and are licensed to independently diagnose and treat mental health and substance abuse problems.

I understand the different labels but I still don’t know where to start.

Ask close family members or friends for trusted referrals. Know that you may have to talk to a few people until you find someone you connect with.
Talk to your primary care doctor. If you don’t have one, set up an appointment at One Medical. They have experience making these types of referrals.
If your company has an EAP (Employee Assistance Program), make the call. The counselors will help get you to the right referral.

Resources for Founders

*Thank you to Jackie Vouthouris/Corigan Ventures and Amy Buechler/formerly @YC for their input on this document.

Updated 12.1.23

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