It’s about mental health, not mental illness


In my 30 years as a practicing psychologist, I’ve seen a lot of patients with many diagnoses. In that time, I’ve seen treatment approaches evolve.  Periodically, when news of a mass shooting makes the headlines, the dialogue about mental health will rise to the top of the national agenda, but — in general — we still have a long way to go in our attitudes toward mental illness.

I think it’s time to make the discussion about mental health and mental illness an open and ongoing one. Here’s the good news: If we stop the ruminating, we can, instead, focus on what we can do to turn the tide — by thinking differently about mental illness and how to get people healthy.  Here are a few of my initial thoughts:

1. Statistics are great, but they can’t predict individual behavior. When someone with mental illness commits an act of violence and makes the front page, the media and pundits all want answers. How could we have predicted this? How could we have prevented it?

The fact is: We need to be okay with not being able to predict, or know with certainty, who will commit these types of atrocities. Why? Because all psychiatric diagnosis is really about history. The best predictor of future behavior is past behavior.  Even the Diagnostic and Statistical Manual of Mental Disorders (DSM) uses time-based criteria (such as symptoms that have been ongoing “for at least two weeks”) for diagnosis.

In addition, we can talk about what a dangerous person might look like, but we can only say a specific person is dangerous based on his or her past behavior and knowing his or her current condition. We can draw generalizations, but we can’t predict individual behavior from statistics; people who tell you they can are lying. It’s one of the basics of statistics. Would you want to stigmatize or incarcerate somebody for the rest of his life based on a probability?

But when you add the knowledge of who people are, how they think, how they feel, and how they behave in the world, then you start to make a more educated prediction.  And if you actually talk to them, you might even find out.

This is the state of the art right now, and it’s far more productive to be realistic as we think about preventing the kind of tragic incidents we all hear about.  I think what causes us to reach for broad, sweeping solutions is our attitude toward mental illness, and our horror as we watch events unfold — events we’re powerless to do anything about. We just don’t want to see it again. We want it under control.

These attitudes come with us as we negotiate our everyday lives, and for those of us who see patients, those attitudes come right into the room with them.

2. We need to stop over-pathologizing attitudes about mental illness and focus helping patients get healthy. What do I mean? We have no trouble distinguishing people from their physical illnesses; just because you have diabetes doesn’t mean you are diabetes. The focus is helping people live a life in which they can stay as healthy as they can despite being diabetic. But in our efforts to be helpful when people get depressed or stressed, we deprive them of their individuality, their personal identity. We talk about symptoms and behaviors. We make a diagnosis and say “that person is depressed,” but often what we mean is that person is depression. We only focus on their symptoms, which are, of course, important — but hardly tell the whole story.

People with depression (and other mental illnesses) have normal, everyday thoughts and feelings too — and they have feelings about those thoughts, and thoughts about those feelings. Then they interact with their environment, which generates new thoughts and feelings. This is just a natural part of who people are.  While affective disorders can color those feelings, they are still their feelings and their experience.

People with mental illness deserve the dignity of their own human feelings — those feelings don’t go away just because they’re mentally ill. Symptoms exist in three-dimensional people who live in the real world. We have to give mental illness back its humanity.

3. We must admit what we don’t know. When it comes to mental illness, we know people can get better, but don’t always know why. Experts have done countless studies trying to figure it out. We try all kinds of psychotropic medication, but there are more off-label uses for medications than the uses for which they were originally intended.

On the other hand, there’s a lot we do know. When I have a patient in front of me, I think, “How am I going to help this person?” So I reach into what I know, or go find out what I need to know, or make a referral if I think someone else can better help that person. I try to give people a reason to tolerate their anxiety as we work through the therapeutic process together. This is what we all do for our patients to be good people. Because we care about them, we keep trying.

Can we really say exactly what’s so therapeutic about therapy? I don’t think we can just yet — but from my experience, I would make one exception. I’ve learned from my work that the one thing I believe to be therapeutic about therapy is what psychiatrist Irvin Yalom called “the instillation of hope in the patient.”  Not a novel idea, but it’s that hope that can help both the patient and the therapist. I tend to believe that nothing succeeds like success. If you think you’re going to get better — and your therapist thinks you’re going to get better — you’re more likely to get better. That hope doesn’t come from working with a collection of symptoms; instead, it springs from the human being across from you who thinks and feels.  It’s more than possible to improve someone’s mental health and sense of well-being, even if he or she is not symptom-free.

In short: We have to learn how to be both realistic and hopeful — scientifically driven and empathically aware of just who that person in front of you is.  We need to focus more on helping that human being and bring the “health” back to mental health.

Wouldn’t it be great to hear the media talk about that — rather than looking for a way to control people with a mental illness?

Jeff Rubin is a psychologist and vice president, behavioral operations, Accolade.


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