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Speaker 2: Join health is something quite different. Has a lot more
Speaker 2: to do with where you live, who you live with,
Speaker 2: how you live, what you live for.
Speaker 1: Welcome to the one you feed Throughout time. Great thinkers
Speaker 1: have recognized the importance of the thoughts we have. Quotes
Speaker 1: like garbage in, garbage out, or you are what you
Speaker 1: think ring true, and yet for many of us, our
Speaker 1: thoughts don't strengthen.
Speaker 3: Or empower us.
Speaker 1: We tend toward negativetivity, self pity, jealousy, or fear. We
Speaker 1: see what we don't have instead of what we do.
Speaker 1: We think things that hold us back and dampen our spirit.
Speaker 1: But it's not just about thinking. Our actions matter. It
Speaker 1: takes conscious, consistent and creative effort to make a life
Speaker 1: worth living. This podcast is about how other people keep
Speaker 1: themselves moving in the right direction, how they feed their
Speaker 1: good wolf. Thanks for joining us. Our guest on this
Speaker 1: episode is doctor Thomas Insel, an American neuroscientist, psychiatrist, entrepreneur,
Speaker 1: and author who led the National Institute of Mental Health
Speaker 1: from two thousand and two until twenty fifteen. Prior to
Speaker 1: becoming the director of NIMH, he was the founding director
Speaker 1: of the Center for Behavioral Neuroscience at Emory University in Atlanta, Georgia.
Speaker 1: Tom also co founded Humanist Care, Neuroweal Therapeutics, and Mindsight News,
Speaker 1: and as a member of the scientific Advisory Board for
Speaker 1: Compass Pathways. Today, Tom and Eric discuss his book Healing
Speaker 1: Our Path from Mental Illness to Mental Health.
Speaker 3: Hi, Tom, Welcome to the show.
Speaker 2: Eric, good to be here. Delighted to have a chance
Speaker 2: to chat with you.
Speaker 4: Yeah, I'm excited to talk with you about your book,
Speaker 4: which is called Healing Our Path from Mental Illness to
Speaker 4: Mental Health. But before we get into that, we'll start,
Speaker 4: like we always do, with the parable of the two wolves.
Speaker 4: In the parable, there's a grandparent who's talking with their
Speaker 4: grandchild and they say, in life, there's two wolves inside
Speaker 4: of us.
Speaker 3: That are always a battle.
Speaker 4: One is a good wolf, which represents things like kindness
Speaker 4: and bravery and love, and the other's a bad wolf,
Speaker 4: which represents things like greed and hatred and fear. And
Speaker 4: the grandchild stops. They think about it for a second.
Speaker 4: They look up at their grandparents. They say, well, which
Speaker 4: one wins? And the grandparent says, the one you feed.
Speaker 4: So I'd like to start off by asking you what
Speaker 4: does that parable mean to you in your life and
Speaker 4: in the work that you do.
Speaker 2: In listening to that parable, the thought I have is
Speaker 2: it actually less about the personal and more about the policy.
Speaker 2: I'm very frustrated with mental health policy today, with the
Speaker 2: way that we are spending quite a bit of money
Speaker 2: and getting really poor results. And for me, it's because
Speaker 2: of the wolf that's being fed. It's because the incentives
Speaker 2: are all out of line, so we are essentially feeding
Speaker 2: the wolf that is about we'll call it greed, but
Speaker 2: it's really about commerce. It's about a medical industry that
Speaker 2: I think does make sense in the care of cancer
Speaker 2: and heart disease and maybe diabetes, but it really doesn't
Speaker 2: work or doesn't deliver for people who have a range
Speaker 2: of emotional problem from the anxiety depression onto more serious
Speaker 2: mental illnesses like bipolar disorder or schizophrenia. And so my
Speaker 2: concern is that we have built a system. Some people
Speaker 2: would say it's not a system, but we built a
Speaker 2: set of policies all to feed that particular wolf, and
Speaker 2: probably good for some payers, and it seems to be
Speaker 2: pretty good for the pharma industry, but it's really not
Speaker 2: that great for families, it's not that great for patients.
Speaker 2: It just hasn't worked out for us. So anyway, that
Speaker 2: was my first association with the two wolves.
Speaker 4: Yeah, you know, and I think to say that the
Speaker 4: rest of the healthcare system is working well in comparison
Speaker 4: gives you a sense of perhaps just how bad the
Speaker 4: mental health system might be.
Speaker 2: Fair point, that's right, that's right.
Speaker 4: Let's start off with talking a little bit about your
Speaker 4: role at the National Institute of Mental Health. You were
Speaker 4: the director of it. Often we're referred to as the
Speaker 4: nation's psychiatrist. So that's kind of where a lot of
Speaker 4: your seminal experiences began, or maybe not began, but that
Speaker 4: inform a lot of this book. And I want to
Speaker 4: ask a question about that because you reference early on
Speaker 4: a pretty important moment where you realized that you had
Speaker 4: been helping guide policy towards a lot of money into
Speaker 4: research and development, and felt very optimistic about that and
Speaker 4: that that was the path forward. And then some things
Speaker 4: started to happen where you started to say, well, maybe
Speaker 4: that's not the whole picture. Can you share a little
Speaker 4: bit more about that?
Speaker 2: Sure? Yeah, And I was in that role for thirteen years.
Speaker 2: Just for context. The National Institudent Mental Health is part
Speaker 2: of the National Institutes of Health the NIH. It has
Speaker 2: twenty seven institutes and centers, and I MH Mental Health
Speaker 2: Institute is one of the larger ones. The budget currently
Speaker 2: is about two billion dollars a year, magnificant amount of money,
Speaker 2: all devoted to research. It's a scientific agency within the
Speaker 2: federal government. It has its own laboratories and clinics, but
Speaker 2: it also about ninety percent of the money goes out
Speaker 2: the door to support academic scientists around the country, even
Speaker 2: around the world. And the basic mission is to try
Speaker 2: to figure out more about, in the case of this institute,
Speaker 2: mental illness, with the idea that we can do better
Speaker 2: on diagnosis and treatment going forward. So it's a bit
Speaker 2: of a public health mission. As I say in the book,
Speaker 2: I was giving a presentation on much of the work
Speaker 2: that the Institute was doing, as well as the Obama
Speaker 2: Brain Initiative, which I helped to direct along with others.
Speaker 2: And it was a group of people I was talking
Speaker 2: to were mostly family members and advocates in the mental
Speaker 2: health space. And at the end, somebody got up and said, man,
Speaker 2: you just don't get it. You know, I have a
Speaker 2: son who's twenty four years old. He's been hospitalized four
Speaker 2: or five times, been a couple of times, he's made
Speaker 2: it a couple suicide attempts, and he's currently homeless and
Speaker 2: we don't even know where he is. Our house is
Speaker 2: on fire, and you're telling us about the chemistry and
Speaker 2: the paint. And that was kind of a seminal moment
Speaker 2: that was a bit of an epiphany for me where
Speaker 2: I had to say WHOA. On the one hand, I
Speaker 2: was defensive, but I had to recognize that he had
Speaker 2: a point, that the needs for mental health care had
Speaker 2: become urgent, and actually we had good things to offer
Speaker 2: based on all the science that had been done, based
Speaker 2: on the work of places like NIMH. So we had
Speaker 2: a lot to offer, and it wasn't getting out there.
Speaker 2: And I began to ask myself, how much more of
Speaker 2: my time do I want to spend on the research
Speaker 2: and discovery side. I think saying it's the chemistry the
Speaker 2: paint is pejorative. I actually think we need to understand
Speaker 2: the chemistry of the paint. And I think there's a
Speaker 2: lot of hope and a lot of promise coming from science.
Speaker 2: But at some point you have to be accountable. At
Speaker 2: some point you have to say, you know, we've spent
Speaker 2: a lot of money, We've done a lot of science,
Speaker 2: We've written a lot of great papers, we have some
Speaker 2: interesting insights and even products to offer. Why aren't they
Speaker 2: getting out there? Why aren't we actually having a public
Speaker 2: health impact? And what does it take to make that happen?
Speaker 2: And that was the moment where I started to say, well,
Speaker 2: maybe the academic scientific community is not the community to
Speaker 2: do that. I mean, they have teed up some great
Speaker 2: things to offer, but we've got to find a way
Speaker 2: to get it out there. That's when I left for Google,
Speaker 2: thinking that working at that point in twenty fifteen, working
Speaker 2: with the largest marketing company in the world really, which
Speaker 2: was Google and through Google Search in Google Ads, that
Speaker 2: maybe there would be an opportunity to actually have a
Speaker 2: bigger impact than what we were able to do through
Speaker 2: the academic research.
Speaker 3: Yeah, I think it's interesting.
Speaker 4: It makes me think as you were talking, and it
Speaker 4: made me think a little bit about having the right
Speaker 4: vaccines that can at least help with a problem, and
Speaker 4: the problem being that people aren't getting them in the
Speaker 4: way that they need to get them. They're not getting
Speaker 4: access to them, they don't know what to take. There's
Speaker 4: no continuity to make sure that you actually take all
Speaker 4: three doses of it right. That that framework is totally missing.
Speaker 4: And so while we could continue to improve vaccines and should,
Speaker 4: if they're not getting to people in a way that's
Speaker 4: actually helpful, that seems to be a pretty important place
Speaker 4: to focus.
Speaker 2: Yeah. Some people have taken this as an indictment of
Speaker 2: the NIH or the NIMH. It actually isn't. I think
Speaker 2: we need those folks to do what they do, but
Speaker 2: we need something else. Yeah, we need to keep creating vaccines,
Speaker 2: but we need to be mindful of how to deliver
Speaker 2: vaccinations as well, and who's going to do that and
Speaker 2: how does that happen. And that is in some ways
Speaker 2: part of what you want the private sector to do,
Speaker 2: or maybe a public private partnership that begins to evolve.
Speaker 2: I think it's super relevant to the question about psych
Speaker 2: piatric or psychological treatments we have. Like, for instance, while
Speaker 2: I was an IMH, we did a lot to focus
Speaker 2: on anorexia because it's one of the most fatal psychiatric disorders,
Speaker 2: and I'm proud to say I think we funded the
Speaker 2: development of some really significant advances. But even now a
Speaker 2: decade later, there's just a handful of people who are
Speaker 2: trained to do those psychological interventions on teenagers with anorexia. Fortunately,
Speaker 2: that's a theme that's been picked up by a startup
Speaker 2: that's actually grown very quickly. It's probably delivered more of
Speaker 2: the bespoke therapy that we know works to more people
Speaker 2: with better results than we could have ever done in
Speaker 2: a brick and mortar, one by one clinic. So there
Speaker 2: is hope, and I do think that there are ways
Speaker 2: to scale what we want to deliver through technology, but
Speaker 2: it's been a slow burn. It hasn't happen as quickly
Speaker 2: as I'd hoped.
Speaker 4: Yeah, before we get into some more of what can
Speaker 4: we do to improve, like to start by just getting
Speaker 4: clear on when you talk about mental illness or you
Speaker 4: talk about mental health, What do those.
Speaker 3: Two things mean to you?
Speaker 4: And then from there I'd like to then get even
Speaker 4: more specific and talk about what serious mental illness is,
Speaker 4: what that means, and the distinction.
Speaker 2: Yeah, it's a good framing discussion to have. There's no
Speaker 2: great definition of mental health for it. Used to define
Speaker 2: it as the ability to love and to work, which
Speaker 2: isn't such a bad place to start. It's probably a
Speaker 2: little easier to talk about mental illness in terms of
Speaker 2: now it being defined by a manual that has a
Speaker 2: set of signs and symptoms and if you meet criteria,
Speaker 2: then you get a diagnosis. So mental illness is medical,
Speaker 2: tends to be constrained by these diagnostic categories, and serious
Speaker 2: mental illness is nothing more than the deep end of
Speaker 2: the pool. It's those people who have that group of
Speaker 2: illnesses like schizophrenia, bipolar disorder, schizoaffective disorder which is kind
Speaker 2: of a mix, sometimes severe depression or severe PTSD, those
Speaker 2: disorders that cause enough disability to put you in that
Speaker 2: deep end of the pool. That is, people who are
Speaker 2: not able to function because of their mental illness. We
Speaker 2: think they're about fourteen maybe fifteen million people who meet
Speaker 2: the definition of serious mental illness. The number of people
Speaker 2: who meet some criteria for some mental illness is in
Speaker 2: a forty to fifty million range in the United States,
Speaker 2: and of course many of those have something that's fairly minorus.
Speaker 2: You know, having a spiderphobia would be a mental illness,
Speaker 2: but it doesn't really lead to you being very disabled
Speaker 2: in most cases. One other I think really important distinction
Speaker 2: to make while we're talking about language is that when
Speaker 2: we talk about health or mental health, pretty quickly we
Speaker 2: start talking about health care and mental health care. And
Speaker 2: I think it's an important moment to say, hold on
Speaker 2: health is not just healthcare, right that if you look
Speaker 2: at what predicts health, what are the determinants of health,
Speaker 2: healthcare is one of them, but it's maybe ten, maybe
Speaker 2: twenty percent of ultimate determinants of what gives you longevity,
Speaker 2: what gives you well being. So health is something quite different.
Speaker 2: Has a lot more to do with where you live,
Speaker 2: who you live, with, how what you live for. All
Speaker 2: of those things are much stronger predictors of health outcomes
Speaker 2: than your health care. I think that's the distinction we
Speaker 2: often overlook in the United States when we quickly start
Speaker 2: talking about healthcare. When we want to really be talking
Speaker 2: about health.
Speaker 4: Right exactly, and I think it applies one hundred percent
Speaker 4: in the same way to mental health and often the
Speaker 4: very same things that predict good overall health. Maybe predict
Speaker 4: is the wrong word, that could be determinants of good
Speaker 4: overall health or also tend to be good for our
Speaker 4: mental health at the same time, Like there's a lot
Speaker 4: of overlap there.
Speaker 2: Yeah, exactly, I think that's really true. This sort of
Speaker 2: gets us into having to come up with some better language. So, like, Eric,
Speaker 2: love your thoughts about this as well. I've become really
Speaker 2: intrigued by recovery as a better term to be talking
Speaker 2: about when we start to talk about health and healthcare.
Speaker 2: I think it's really significant for us that this gets
Speaker 2: back to your two wolves question that recovery is a goal,
Speaker 2: is something that we can point to. It's something that
Speaker 2: we can define, something we can work towards. Not actually
Speaker 2: clear that much of what leads to recovery is within
Speaker 2: the healthcare system or it gets reimbursed with healthcare dollars.
Speaker 2: We can unpackt this a little further, but you know,
Speaker 2: I'm pretty invested in this issue right now because it
Speaker 2: feels to me that in a country that's spending four
Speaker 2: point three trillion dollars on healthcare. Those agencies that are
Speaker 2: focused on recovery shouldn't just be existing on bake sales
Speaker 2: and galas right. What they do, which is so significant
Speaker 2: for health you know, delivering recovery services ought to be
Speaker 2: considered like a really significant part of healthcare because they
Speaker 2: are really delivering health outcomes, and yet they're largely nonprofits.
Speaker 2: They may be staffed by volunteers. It's kind of weird
Speaker 2: to me. In the mental health space, when we're talking
Speaker 2: about recovery, we're talking about sort of nonprofit, community based
Speaker 2: organizations often that are struggling just to keep operations going.
Speaker 2: Whereas you know, in this kind of adjacent or peril
Speaker 2: universe of medical care, if someone's on dialysis where they're
Speaker 2: having to recover from chronic renal disease, the another actually
Speaker 2: get to recovery until they get a transplant. But nobody
Speaker 2: expects dialysis to be paid for through bake sales. And
Speaker 2: nobody expects that if you're even getting physical therapy after
Speaker 2: a car accident, that that's something that doesn't get supported.
Speaker 2: As you recover your physical capability, that that's of course
Speaker 2: going to get paid for through health insurance, and yet
Speaker 2: recovery on the psychological side, on the behavioral side, it's
Speaker 2: somehow considered qualitatively different that you leave that to volunteers,
Speaker 2: you leave that to the world of community based nonprofits.
Speaker 2: I don't get that, and I don't think we should
Speaker 2: accept that necessarily. So I've been thinking a lot about
Speaker 2: that double standard.
Speaker 3: Right, lack of parody.
Speaker 4: There's a lack of you point this out in the book,
Speaker 4: often sort of continuing care. Right, there's no continuity of
Speaker 4: care for somebody with mental health. Right. It tends to
Speaker 4: be you're on one end of a spectrum. Your primary
Speaker 4: care doctor has given you a pill and that's it,
Speaker 4: or you're being hospitalized in a psychiatric unit. But there's
Speaker 4: a whole world in between that is not being well
Speaker 4: tended to. I think your point about recovery, I think
Speaker 4: it's an interesting model.
Speaker 3: The term recovery is very helpful in some ways.
Speaker 4: I think it's a little bit of a misleading term,
Speaker 4: because for most people who are going through an addiction
Speaker 4: or a serious mental disorder, you're actually.
Speaker 3: Not going to recover who you were.
Speaker 4: You actually emerge into somebody new and different, And so
Speaker 4: to think of going backwards sometimes feels like not the
Speaker 4: right analogy, but your point about what happens in recovery
Speaker 4: is true. And as we've looked deeper into substance use, right,
Speaker 4: we can talk about the social determinants of recovery. Right,
Speaker 4: we know that somebody who has a job, a place
Speaker 4: to live where there's not other drug use being done,
Speaker 4: someone who can take care of their kids so that
Speaker 4: they can go to recovery meetings. That all these things
Speaker 4: make it more likely that somebody's going to get sober
Speaker 4: and stay sober. Doesn't mean everybody who gets those things will,
Speaker 4: and it doesn't mean that people who don't get those
Speaker 4: things won't, but it just makes it a whole lot
Speaker 4: more likely and a whole lot easier. And I think
Speaker 4: the same things you're saying sort of apply to our
Speaker 4: mental health. Right to embark on a healing journey is
Speaker 4: to need a certain degree of support, at least early
Speaker 4: on for a little while. And that support is not
Speaker 4: just a therapist, right, It is how do I get
Speaker 4: back into the workplace so that I can make a
Speaker 4: living and feel good about myself? How do I have
Speaker 4: friends who understand me? And I mean that all these
Speaker 4: elements go into it so I do think that we
Speaker 4: need a lot more focus there. I do think it
Speaker 4: gets a little trick when these small scale organizations that
Speaker 4: seem to work so well on bake sales become bigger
Speaker 4: and well funded. Things get a little weird. You know.
Speaker 4: One of the things that Alcoholics Anonymous did well, now
Speaker 4: lots of things I think could be different, but was
Speaker 4: that they remained forever non professional. They kept a certain
Speaker 4: element of people putting a dollar in a basket is
Speaker 4: the way the organization function, and that gave it a
Speaker 4: certain independence and a certain community.
Speaker 3: Spirit that I do think is valuable.
Speaker 4: But I don't think everything should be that way, and
Speaker 4: I think there is somewhere in between those two extremes
Speaker 4: where we could be spending money much more wisely than
Speaker 4: we do.
Speaker 2: It's a great point something I should think a little
Speaker 2: bit about it as well, that part of the effectiveness
Speaker 2: of a group like AA is simply the fact that
Speaker 2: it isn't professionalized. You know, it isn't commercialized in any way,
Speaker 2: shape or form, and so everybody who's there is there
Speaker 2: for the right reason, essentially on this concept of what
Speaker 2: you need for recovery. I write about that a little
Speaker 2: bit in the book, and I kind of come around
Speaker 2: to this idea that was not my own. It came
Speaker 2: to me through John Sharon, a psychiatrist in Los Angeles,
Speaker 2: who was saying that recovery is really the three piece
Speaker 2: that you need, all three p's to go on this journey.
Speaker 2: And he wasn't talking about necessarily recovery from addiction, but
Speaker 2: any kind of recovery. And Eric your point about remembering
Speaker 2: that recovery isn't really going back to where you were,
Speaker 2: it's more becoming something that you haven't been. His idea
Speaker 2: was that it was people, place, and purpose that you
Speaker 2: need social support. You do need a group of people
Speaker 2: around you who have your back, and by the way,
Speaker 2: you have theirs as well. So this sense of community
Speaker 2: incredibly important and very very powerful. It's one of the
Speaker 2: ways that AA is so effective. You need a place
Speaker 2: and that means an environment that free of all the triggers,
Speaker 2: but also an environment that is nurturing and allows you
Speaker 2: to grow and to change. And then I think the
Speaker 2: third P, which is the one that we never talk
Speaker 2: about but is probably in some ways the most critical,
Speaker 2: is you need a purpose. You need a mission, You
Speaker 2: need something to wake up for every day. You need
Speaker 2: something to sacrifice for and to give yourself to something
Speaker 2: bigger than you. That third pe is almost never in
Speaker 2: the conversation around healthcare, and yet it is fundamental. I mean,
Speaker 2: in the book, I go back to this idea from
Speaker 2: years and years and years ago of logo therapy, the
Speaker 2: idea that the person who has a why can live
Speaker 2: with anyhow that's right. That's a really useful mantra, useful concept,
Speaker 2: but one that you don't hear much about in the
Speaker 2: traditional healthcare journey. Is just not something that people get
Speaker 2: to right.
Speaker 4: And there are elements that I think could be better,
Speaker 4: and I often think there's things that are needed in
Speaker 4: addition to AA.
Speaker 3: But one of the things it.
Speaker 4: Does well is that it gives you that community, but
Speaker 4: it also gives you purpose because right away, in the
Speaker 4: right place, you're encouraged that when you have five days sober,
Speaker 4: someone who has one day sober is walking in the door,
Speaker 4: and so you already have something, however small, to offer
Speaker 4: to that person. You know that right away you have
Speaker 4: a purpose, you have value you can contribute.
Speaker 3: And for me it was fundamental.
Speaker 4: It was really an important part of me that had
Speaker 4: to get unlocked. And I've just noticed over my life,
Speaker 4: and I can look back over my whole life when
Speaker 4: I've been engaged in doing something that's decent for the world,
Speaker 4: that's good for the world, it's contributive. I've been well,
Speaker 4: and when I am not, I have been sick, whether
Speaker 4: it be depressively, whether it be addictively, whether it be
Speaker 4: any other sort of variety of behavior problems. But I
Speaker 4: can look back and I can see it from even
Speaker 4: being a small child, you know, like when I was
Speaker 4: in trouble and when I wasn't and it was all
Speaker 4: about that purpose.
Speaker 2: It's super interesting. I co founded a company called Humanest,
Speaker 2: like Humanists, but with Nest at the end. Humanest care
Speaker 2: around just this principle was basically taking the AA approach,
Speaker 2: putting it online and allowing people the opportunity to help
Speaker 2: each other. And it's just been so fascinating to see
Speaker 2: how that took off, particularly amongst university students. So we
Speaker 2: have a fair amount of activity at you see Berkeley
Speaker 2: here in the Bay Area and asking students where the
Speaker 2: value of this is because it's really connected to the
Speaker 2: counseling center at Berkeley. And the idea was to give
Speaker 2: students something quickly so they weren't on a long waiting list.
Speaker 2: And what we found was that the real value wasn't
Speaker 2: just what students got, it was what they were able
Speaker 2: to give. That was the most therapeutic part of this.
Speaker 2: And you know it's the piece that again, healthcare as
Speaker 2: we know it never goes there. It's just not a
Speaker 2: part of what you get when you go to see
Speaker 2: your primary care doctor. They don't ask you, so, who
Speaker 2: are you helping today? I'm helping you, but I who
Speaker 2: are you helping as part of this? And how do
Speaker 2: you pass it on? So it's really, I think, a
Speaker 2: different approach, a different formulation, but a tremendous opportunity to
Speaker 2: change what we do. And it's all in this kind
Speaker 2: of spirit of helping people to recover or at least
Speaker 2: to be able to function in a way that's to
Speaker 2: them closer to this mental health idea of being able
Speaker 2: to love and to work.
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Speaker 4: There's been a big emergence in the mental health field
Speaker 4: around peer support other people who've been through what you've
Speaker 4: been through, and as you read about it, one thing
Speaker 4: that you always hear is the benefit for someone else,
Speaker 4: But obviously it's the peer who's providing the service who's
Speaker 4: also getting a lot of the benefit out of it.
Speaker 4: But you were initially skeptical of this model because you're
Speaker 4: a believer that there are evidence based things that work,
Speaker 4: and then there are other things, and that getting the
Speaker 4: right type of care to people is really important, and
Speaker 4: that's one of the things AA has the peer piece
Speaker 4: figured out very well, But there is almost no innovation
Speaker 4: in what we know, more of the modern ideas, more
Speaker 4: of the evidence based theories about what works.
Speaker 3: So I see this sort of I guess.
Speaker 4: It's a dilemma. Maybe it's a matter of balance of
Speaker 4: On one hand, there's the peer support model, which provides
Speaker 4: benefit to both sides of that equation, right, and that
Speaker 4: there's also very clear interventions that can be done at
Speaker 4: a professional level that are often very important to me.
Speaker 4: It seems you need a blend of both. Kind of
Speaker 4: curious what your thought is about that and how you're
Speaker 4: thinking about the peer movement has changed.
Speaker 2: Well, it has changed in a variety of ways. I
Speaker 2: think my concern many many years ago, when there was
Speaker 2: a lot of talk about this, maybe ten fifteen years ago,
Speaker 2: as the peer movement really began to get traction, was
Speaker 2: I worried that we were going to lose quality in
Speaker 2: a field that has so few people providing the care
Speaker 2: that works. We were going to end up with an
Speaker 2: army of people even further away from the kind of
Speaker 2: training that was required. I have to say I've kind
Speaker 2: of gone in a couple of different directions. With this
Speaker 2: one I think is that to realize that the real
Speaker 2: problem we face on the mental health population wise is
Speaker 2: not so much on the world of caregivers. It's in
Speaker 2: the world of what people experience who should and could
Speaker 2: be in care. And this is true for serious mental illness.
Speaker 2: It's probably true for people who have less serious forms.
Speaker 2: But the reality is that we have good stuff to offer,
Speaker 2: but only a tiny fraction of people who could and
Speaker 2: should benefit or getting care. And the reasons for that
Speaker 2: are not so much that they don't get access. Yeah,
Speaker 2: there's a bit of that. I mean, there's a supply
Speaker 2: demand problem. I get it. I think that's always been true.
Speaker 2: It's much worse now. But there's another side to it,
Speaker 2: which is that for a range of reasons, people do
Speaker 2: not seek care who should. And the problem for me
Speaker 2: isn't so much access, it's engagement. How do you engage
Speaker 2: those people it would really benefit, so that you get
Speaker 2: to them before they're in a crisis, before they're suicidal,
Speaker 2: before they're in the emergency room, and before you're actually
Speaker 2: ending up in this kind of medical system which isn't
Speaker 2: really incentivized towards helping you in the way that does
Speaker 2: have the continuity and the recovery focus and all the
Speaker 2: things we've been talking about. That engagement piece is done
Speaker 2: by peers better than anybody else. That is where you
Speaker 2: can begin to solve for the population health problem the
Speaker 2: seventy percent of people or sixty percent of people who
Speaker 2: are outside of care. And I think peers have a
Speaker 2: lot to offer there. I don't think they're the full answer,
Speaker 2: because you still need to be able to get the
Speaker 2: highest quality interventions, which may require someone who's had twenty
Speaker 2: years of experience. And often what happens with peers as
Speaker 2: committed as they are and as passionate as they are,
Speaker 2: you know, their education is largely in the end of
Speaker 2: one They have their experience and sometimes is right, sometimes
Speaker 2: it's not right, and so there's real value there. The
Speaker 2: other thing we have to be honest about is that
Speaker 2: asking peers to do some of the heaviest lifting years
Speaker 2: also exposing them to a range of triggers that probably
Speaker 2: not necessarily in their best interest, and so you have
Speaker 2: to be mindful of what works what doesn't. I do
Speaker 2: think engagement say it's something that peers do well. I
Speaker 2: think they're part of a larger army of people that
Speaker 2: would include community health workers, people who have lived experience
Speaker 2: in their families, people who may have just been really
Speaker 2: interested in being in the community and being able to
Speaker 2: meet people where they are rather than waiting for someone
Speaker 2: to show up at a clinic. So I think we
Speaker 2: need all of that. And if we are going to
Speaker 2: involve peers in the workforce, and I certainly hope that
Speaker 2: we do, I think we need to. If we're going
Speaker 2: to be successful, we have to pay them well. We
Speaker 2: have to professionalize this, and we have to make sure
Speaker 2: that yes, they're not simply token in some way, or
Speaker 2: they're not there simply to fill some kind of quota,
Speaker 2: but that they're given real jobs with real responsibilities and
Speaker 2: paid accordingly. And I don't see that happening everywhere.
Speaker 4: All your points there on the peer challenges I think
Speaker 4: are really spot on, and I've seen them over the
Speaker 4: years in recovery from addiction. One being the quality of
Speaker 4: recovery is wildly disparate. Right, go to five different AA
Speaker 4: meetings and you may find five very different experiences, which
Speaker 4: is good in some way. If you have access to five, right,
Speaker 4: and you can go pick the one that fits for you,
Speaker 4: but sometimes people don't have the energy to do that.
Speaker 3: And I do think that.
Speaker 4: End of one thing is also true because this worked
Speaker 4: for me, and I become very fervent about it when
Speaker 4: I think the challenges of twelve step recovery is dogmatism, Right,
Speaker 4: is that I got sober? So now that old saying,
Speaker 4: nobody's zealous as the newly converted.
Speaker 3: Right, So that's good and bad.
Speaker 4: Right.
Speaker 3: It's good because they've got the.
Speaker 4: Energy to devote and really be there, and it's bad
Speaker 4: because we're only looking at a very small amount of
Speaker 4: options and there may be other evidence based treatments that
Speaker 4: are really good. So I think a blend is really good.
Speaker 4: You know. An example would be if you were coming
Speaker 4: into recovery and you also, let's say, have a serious
Speaker 4: trauma past.
Speaker 3: Right to not get quality trauma care is.
Speaker 4: To miss half the game, right, Whereas if you're in recovery,
Speaker 4: some people might say, you don't need that, just come
Speaker 4: to AA, and it's like, well, for some people, yes,
Speaker 4: but other people know. So I think it's a blend,
Speaker 4: But I think your point is right. Ultimately, my recovery
Speaker 4: from addiction and depression has taken a combination of peers
Speaker 4: support and professional support, good professional support.
Speaker 2: Yeah, let me just add that. You know, at Humanists
Speaker 2: we had both peers and credential therapists. And yeah, it's
Speaker 2: so hard to generalize. I have to say the peers
Speaker 2: that we had. I'm no longer actively doing operations in
Speaker 2: the company, but when I was a couple of years
Speaker 2: ago during the pandemic, the peers are spectacular. I mean
Speaker 2: they were. They were really every bit is good and
Speaker 2: maybe better in many cases than credential therapists. And I
Speaker 2: was giving a talk about the need for us to
Speaker 2: have evidence based treatments in every part of what we
Speaker 2: do in the mental health care space, and somebody got
Speaker 2: up afterwards and said, you know, you've got to remember
Speaker 2: that the therapist this is important as a therapy. It
Speaker 2: really ultimately comes down to having the right person, not
Speaker 2: necessarily the right brand of therapy. And you know, he
Speaker 2: went on to say, you know that he was a
Speaker 2: scientist and even looking at this for a long time,
Speaker 2: and I started to dig into this literature a little bit.
Speaker 2: It goes all the way back to Healing and Persuasion
Speaker 2: by Jerome Frank back in the nineteen sixties. Because it's
Speaker 2: so relevant now, But that was Jerome Frank's important insight
Speaker 2: at a point when people were very focused on the
Speaker 2: psychoanalysis and doing it in a very precisely technical way,
Speaker 2: showing that hey, you know, what really mattered was the
Speaker 2: person and their relatedlationship that they built, and not so
Speaker 2: much whether they followed precise rules of how this therapy
Speaker 2: was supposed to be delivered. There's an important lesson in that,
Speaker 2: something that we need to remember even today, that it's
Speaker 2: what you bring to this experience, into this relationship that's
Speaker 2: probably as valuable as whatever particular credentialing of whatever particular
Speaker 2: brand of treatment you've been trained to do. You can
Speaker 2: go too far in that direction, but I need to
Speaker 2: keep an open mind that people bring lots of things
Speaker 2: to the table, and not all of it is exactly their.
Speaker 4: Training right to be able to say exactly what the
Speaker 4: exact conditions are that will bring about recovery from a
Speaker 4: mental illness or an addiction for an individual person, we
Speaker 4: don't know that. We can see population level data, we
Speaker 4: can see scientific level data, we can see how many
Speaker 4: people in this particular thing went this way, but ultimately
Speaker 4: it's a deeply individual thing and what will lead me
Speaker 4: to get into recovery might be very different than the
Speaker 4: person sitting next to me.
Speaker 3: You know, I might need.
Speaker 4: Very by the book CBT that really helps me to
Speaker 4: work on my thoughts and that's the thing that unlocks.
Speaker 4: And the person next to me might really need a
Speaker 4: trusted person that they can check in with every week
Speaker 4: and that be the most important thing for them.
Speaker 3: And it's a lot of trial and error.
Speaker 4: And I think that's partially what's frustrating about mental health
Speaker 4: recovery and even substance abuse recovery, is that ultimately there
Speaker 4: is a certain amount of trial and error that most
Speaker 4: people go through before they quite find the right secret
Speaker 4: sauce that works for them. And that can be frustrating
Speaker 4: and hard to do often if you're in the midst
Speaker 4: of a crisis. But that's been my experience, is that
Speaker 4: I've had to try a variety of different things and
Speaker 4: sort of piece some different things together and ultimately find like, Okay,
Speaker 4: this is the combination of things that really works best
Speaker 4: for me.
Speaker 2: Yeah, so that's a challenge. I hear the point, and
Speaker 2: I think you could have said the same thing about
Speaker 2: treating an infectious disease fifty years ago. But we've gotten
Speaker 2: a lot better and not knowing how to do that.
Speaker 2: There's this whole movement called precision psychiatry or precision mental health,
Speaker 2: which is still maybe a little bit in its infancy,
Speaker 2: but I think has enormous promise to help get beyond
Speaker 2: trial and error and to put together different kinds of
Speaker 2: information in a way that allows us to get somewhat better.
Speaker 2: At the end of the day. I still think relationship matters,
Speaker 2: but at least to get to a point where you're
Speaker 2: able to say if medication is indicated, which medication, psychotherapy
Speaker 2: is indicated, which psycho therapy, and then to understand who
Speaker 2: can deliver that in a way that works best for you.
Speaker 2: I don't think that's that far into the future. There
Speaker 2: are groups doing this now and bringing together multiple predictors.
Speaker 2: I think the lesson that we have over the last
Speaker 2: four or five years is that there's no magic bullet.
Speaker 2: It's not like genetics or imaging are going to sort
Speaker 2: of answer those questions like where the science is right now.
Speaker 2: It says that if you bring together cognitive testing eeg.
Speaker 2: Some work on actually accounting for symptoms, and then some
Speaker 2: sensor data on sleep and on activity and your patterns,
Speaker 2: we can begin to triangulate all of that to get
Speaker 2: an understanding of what might be most helpful on the
Speaker 2: medical site, to say, oh, you've got a version of
Speaker 2: depression or PTSD that's going to respond best to X,
Speaker 2: Y or Z, and also in some cases insight that says, actually,
Speaker 2: you know what, the kind of depression you have responds
Speaker 2: far better to this version of psychotherapy that it will
Speaker 2: to any medication. I mean, I think we can do
Speaker 2: that today, for many many people, it's not being done.
Speaker 2: We don't again back to your original question, Eric about
Speaker 2: the wolves, we're not incentivized to do that. That day
Speaker 2: is coming. I think there'll be a moment when the
Speaker 2: way in which our field will be reimbursed and supported
Speaker 2: will require that kind of rigor and that kind of
Speaker 2: outcome driven approach that says, you know, if you're a provider,
Speaker 2: you'll get paid based on how much good you're doing,
Speaker 2: not on how many hours you're spending, and't wait.
Speaker 4: For that day to come or even whatever advances continue
Speaker 4: to come in that way, because like the medication thing, right,
Speaker 4: that is the frustration of so many people, and most
Speaker 4: of my experience, I'll say is with people who have
Speaker 4: what I would call a lower grade depression slash anxiety OCD.
Speaker 4: You know, it's not what we would call fully disabling,
Speaker 4: but it's deeply problematic. The medicine thing does feel today
Speaker 4: very much like trial and error, like try this one.
Speaker 4: Maybe that sort of helped, But what if I increase
Speaker 4: the dose? Well maybe, But so I think that if
Speaker 4: we can get closer to that, I think that's a
Speaker 4: really big deal to be able to get a little
Speaker 4: bit more targeted in those Now I want to pivot
Speaker 4: off of that question because I think it goes a
Speaker 4: different direction than I wanted to try and go with
Speaker 4: you for a second, which is that there seems to
Speaker 4: be more of a movement that I've been hearing about
Speaker 4: and detecting that is starting to say that the DSM
Speaker 4: is not a really useful tool in certain ways, and
Speaker 4: that trying to segment these different things apart from each
Speaker 4: other might be missing an underlying common factor. Right. I
Speaker 4: think there were studies that showed maybe there's a P
Speaker 4: factor that underlies mental illness, and the people who talk
Speaker 4: about that say the reason that they come to that
Speaker 4: conclusion is two things. And I would really love your
Speaker 4: thoughts on this one. Is comorbidity, right, Like, if you
Speaker 4: have depression, you're likely to have anxiety, and you're also
Speaker 4: more likely to have this and that, and you end
Speaker 4: up with five diagnoses and you kind of go, well,
Speaker 4: am I really that unfortunate that I got all five
Speaker 4: of these?
Speaker 3: That seems unfair?
Speaker 4: Right? And then heterogeneity right, meaning that the way my
Speaker 4: depression manifest could be different than your depression. You know,
Speaker 4: mine might cause me not to be able to sleep,
Speaker 4: yours might cause you to sleep all the time. And
Speaker 4: that we're tweezing things apart that maybe aren't as separate
Speaker 4: as we think. And I would just love to hear
Speaker 4: your thoughts on that, because I've been hearing a lot
Speaker 4: more of that lately.
Speaker 3: Yeah.
Speaker 2: Actually, I should just say I haven't thought a lot
Speaker 2: about this recently. This was a big topic when I
Speaker 2: was a NIMH SO a decade ago, when DSM five
Speaker 2: was coming out.
Speaker 3: Very current apparently, but at that.
Speaker 2: Point we were, as NIMH scientists, we were having to
Speaker 2: ask the question, is this really progress? Is this helpful
Speaker 2: to have yet another diagnostic and statistical manual that essentially
Speaker 2: reifies these clusters of symptoms when, as you say, they're
Speaker 2: so heterogeneous and so NONSPENSEI. So just as an example,
Speaker 2: in that DSM four version you had diagnosis. To get
Speaker 2: a diagnosis of major depressive disorder, there were nine factors.
Speaker 2: You had to have five of them for two weeks.
Speaker 2: So you could imagine two people walking in who had
Speaker 2: five of the nine but only overlapped on one, so
Speaker 2: had one out of nine they shared, and yet they
Speaker 2: had the same label. If this didn't make a lot
Speaker 2: of sense. Furthermore, you'd see the same person over time
Speaker 2: and it would be, as you say, every time you'd
Speaker 2: see them, that'd be a slightly different pattern. And so
Speaker 2: you just had the sense that, as somebody said to me,
Speaker 2: we weren't cutting nature at the joints. It wasn't really
Speaker 2: capturing the fundamentals. We started a project that was then
Speaker 2: called the Research Domain Criteria Project. Our doc very controversial
Speaker 2: at the time, but we basically said, look for research.
Speaker 2: DSM isn't working, and the reason it's not working is
Speaker 2: because we're funding people to do ile markers of depression
Speaker 2: and they go out and they measure something in spinal
Speaker 2: fluid or blood or they do a brain scan, and
Speaker 2: everybody with major depressant disorder as defined by DSM, and
Speaker 2: they only see the finding in fifty percent, so they
Speaker 2: decide it's not useful. And our response was to say, nonsense.
Speaker 2: Maybe you start there on everybody who has the same
Speaker 2: brain scan and you work from there. Instead of throwing
Speaker 2: that way and saying, oh, it has to obey exactly
Speaker 2: what the APA suggests is ground truth. We just didn't
Speaker 2: think we had really anybody had really established ground truth.
Speaker 3: So to do that.
Speaker 2: What we were asking this research community to do was
Speaker 2: to not use DSM except in a kind of distal way,
Speaker 2: but really to begin to collect the data about large
Speaker 2: numbers of individuals to see where the different factors would aggregate.
Speaker 2: So if you took everybody you know with some frontal
Speaker 2: temp disconnection syndrome on their fMRI, does that give you
Speaker 2: something you can work with a lot of this was
Speaker 2: really borrowing from what we were learning on precision medicine
Speaker 2: and cancer. You know, previously cancer diagnosis had been based
Speaker 2: on gross pathology, and you grouped everybody together based on that,
Speaker 2: and then you discovered when we got into genetics that wow,
Speaker 2: that didn't work at all, that what really mattered was
Speaker 2: identifying the molecular lesion because that would determine who would
Speaker 2: respond to which treatment, and you'd find the same molecular
Speaker 2: lesion in tumors that look grossly, very very different. So
Speaker 2: we began to realize in cancer diagnosis that wow, we
Speaker 2: can't really use just the observations we have to have
Speaker 2: genetics and mental health genetics itself doesn't really seem to
Speaker 2: work that well. It might work for autism, but it
Speaker 2: doesn't seem to work so much in current areas that
Speaker 2: we look at. They just aren't kind of specific lesions
Speaker 2: the way you have them in cancer. But there are
Speaker 2: other things we can begin to use, and I mentioned
Speaker 2: them before, approaches like EEG and cognitive testing, and I
Speaker 2: think there's a lot we can do just to understand
Speaker 2: behavior better. Beginning to look not only at sleep where
Speaker 2: you actually measure sleep, but looking at activity and looking
Speaker 2: at voice and speech and how all those things are changing,
Speaker 2: we can begin to provide much more objective data about
Speaker 2: mood and anxiety and cognition and psychosis. I mean, all
Speaker 2: of that. We can do far more precisely than what
Speaker 2: we've been doing. And with that, I think we can
Speaker 2: start to rebuild how we think about the labels that
Speaker 2: we need in this field. Really interesting set of studies
Speaker 2: by guy at Harvard, John Weiss, who I think is
Speaker 2: worth reading. I talk about him in my book, and
Speaker 2: John is just focusing on children in particular, and he
Speaker 2: sort of just does away with all these type nut things.
Speaker 2: It says, look, there are just really five things in
Speaker 2: kids that you want to be able to understand in
Speaker 2: terms of dimensions of behavior, and each of them has
Speaker 2: its own intervention that you need. And I read that
Speaker 2: it all became just much simpler, and I actually think
Speaker 2: that probably where we need to go is not we're
Speaker 2: now what at three hundred and fifty or something like that,
Speaker 2: three hundred and sixty labels in DSM. Maybe we need ten,
Speaker 2: maybe we need five. I don't know, but I think,
Speaker 2: you know, what John Weiss has done for kids is
Speaker 2: actually a very interesting project that something like that might
Speaker 2: help to inform what we do more broadly in adults.
Speaker 2: I think our doc itself was an interesting way of
Speaker 2: sort of trying to turn the herd, trying to move
Speaker 2: the research community in a different direction. It was never
Speaker 2: meant to be a clinical tool, but the hope was
Speaker 2: that it would begin to inform whatever DSM six becomes,
Speaker 2: and we'll have to see whether that happens. I do
Speaker 2: think to go back to your original question, Eric, is
Speaker 2: we had to do a better job of thinking about
Speaker 2: what to diagnose us for and how do we use it,
Speaker 2: because at this point, you know what really accounts I
Speaker 2: think is treatment, it's interventions, and it's not helping us
Speaker 2: and choosing interventions for the most part. And I think
Speaker 2: that was really the problem with our doc. It was
Speaker 2: never really tied to treatment response. It wasn't intended for that.
Speaker 2: But ultimately, you want to be in a world where
Speaker 2: you are collecting information about how people think, how they feel,
Speaker 2: how they behave, and using that to provide interventions that
Speaker 2: help them to get from where they are to where
Speaker 2: they want to be. They haven't done that. I don't
Speaker 2: think DSM does that. I don't think our doctor has
Speaker 2: yet done that, And I think we have to get
Speaker 2: maybe much simpler if we want to be able to
Speaker 2: accomplish that. But I'm not sure I know how to
Speaker 2: do that yet.
Speaker 4: Thank you for that, because I've heard our doc often
Speaker 4: quoted when they come to this conclusion, they talk about, well,
Speaker 4: even Nimh came to that conclusion. So your background on that,
Speaker 4: how it was really intended for research is really helpful
Speaker 4: because it sounds like, on one hand, we're sort of
Speaker 4: saying almost two things, and I want to get a
Speaker 4: little clarification. On one hand, we're talking about getting far
Speaker 4: more precise and specific in precision medicine. We're actually going
Speaker 4: even deeper than these different clusters of syndromes, and we're
Speaker 4: really narrowing into Eric right, what's going on with Eric right?
Speaker 4: And at the same time, we're also talking about maybe
Speaker 4: simplifying some of the overall models so that they make
Speaker 4: more sense with what's happening. So it sort of sounds like,
Speaker 4: in your mind, it's sort of both, right, let's get
Speaker 4: simpler in certain ways, but in other ways, we're actually saying,
Speaker 4: let's get even more specific. Let's go beyond going from
Speaker 4: let's say there's five hundred diagnoses in DSM, and instead
Speaker 4: of going to seven hundred and fifty diagnoses, right, we
Speaker 4: actually go to Eric. Yeah, And we're precise enough to
Speaker 4: say we don't even necessarily have to give it a name,
Speaker 4: but we know, based on what's going on with Eric here,
Speaker 4: the interventions that we think are going to be most
Speaker 4: likely to be helpful.
Speaker 3: Is that an accurate way of saying it.
Speaker 2: Yeah, well, I think that's where we have gone with cancer.
Speaker 2: We haven't done that for every tumor, but at least
Speaker 2: in lung and breast and many solid tumors, we've gotten very,
Speaker 2: very good at being able to say, what we thought
Speaker 2: was one disease is twenty different diseases, and each of
Speaker 2: those twenty require a different treatment. And you're finally, based
Speaker 2: on that beginning to bend the curve for mortality and
Speaker 2: morbidity from cancer. Pretty dark cool. We don't know how
Speaker 2: to do that yet for depression or anxiety disorders or
Speaker 2: psychotic disorders, but my goodness, as you said before, Eric,
Speaker 2: I mean, they're incredibly heterogeneous. At the end of the day.
Speaker 2: What you really care about is what can we do
Speaker 2: for one person at a time, what really makes sense,
Speaker 2: And so I would agree with you. We want to
Speaker 2: both make it simpler, but we also want to make
Speaker 2: it very individual, and understanding how to do that will
Speaker 2: be important. We also want to kind of empower people
Speaker 2: to help themselves in ways that we haven't had, and
Speaker 2: I think that in some ways is very different than
Speaker 2: the cancer model. So the cancer model really comes out
Speaker 2: of the medical approach that if we can just get
Speaker 2: smart enough, our experts will figure this out. What I
Speaker 2: want to suggest here is this is not the same.
Speaker 2: It's a different set of problems and that people place
Speaker 2: in purpose, creating community, creating environments, creating purpose, which is
Speaker 2: really the essence of what we're going to need for recovery.
Speaker 2: There is no single magic bullet. There's not going to
Speaker 2: be a genetic finding that gets you there. It really
Speaker 2: requires a different way of thinking about the problem and
Speaker 2: a different orientation to solutions. The solutions that are much
Speaker 2: more social than medical. And I'm not sure we've quite
Speaker 2: grasped that as a field. And that's not to say
Speaker 2: I mean I often try to get away from these
Speaker 2: dichotomies and the way I've tried to resolve this one,
Speaker 2: and I struggle with this in the book, and I
Speaker 2: kind of finally end up this way is to say,
Speaker 2: I think that we can define the problem as medical,
Speaker 2: but the solutions are going to be social, environmental, even political.
Speaker 2: I wouldn't say that about breast cancer or hypertension. I think,
Speaker 2: you know, the problem is medical, and the solutions are
Speaker 2: mostly coming up with the right medical intervention. Here, I
Speaker 2: think the problem can be defined as medical. I think
Speaker 2: there's fundamentally, particularly for people with serious mental illness, you're
Speaker 2: talking about something in the brainers or people with addiction,
Speaker 2: it's now a brain disorder. But those solutions are going
Speaker 2: to require something very different than what we do in
Speaker 2: the rest of medicine. I think it's a particular challenge
Speaker 2: for us to figure out how do we do that,
Speaker 2: who does that, how do we pay for that, how
Speaker 2: do we make it happen? And that's where I think
Speaker 2: the book kind of goes into asking for a radical
Speaker 2: rethinking and actually a new social movement, kind of like
Speaker 2: a civil rights movement, to say, we're in the Jim
Speaker 2: Crow era here that people with serious mental illness end
Speaker 2: up incarcerated or homeless instead of in treatment, and the
Speaker 2: treatments that they get when they do get treatment is
Speaker 2: so coercive and so ineffective. We have good stuff to offer,
Speaker 2: they don't get it. How do we turn that around,
Speaker 2: and how do we make sure that those fourteen or
Speaker 2: so million people who currently are mostly found in the
Speaker 2: criminal justice system are to use. President Kennedy's original comment
Speaker 2: about this in nineteen sixty three said they must no
Speaker 2: longer be alien to our affections. That's Our challenge is
Speaker 2: figuring out how to make sure that this group of
Speaker 2: people who have become so disaffected and so disenfranchised by us,
Speaker 2: to be really clear, they're really marginalized. How do we
Speaker 2: take them into our hearts and start to provide people
Speaker 2: place and purpose to allow them to recover. That's to
Speaker 2: me a massive social movement that needs to be undertaken
Speaker 2: and needs to happen yesterday.
Speaker 4: Yeah, I think that that's one of the things that's
Speaker 4: often been confusing for people around thinking of alcoholism is
Speaker 4: called a disease for a while, right, and that got
Speaker 4: confusing because the primary treatment for people was for a
Speaker 4: long time and still to a large extent today. When
Speaker 4: I said AA hadn't become professionalized, that's not entirely true.
Speaker 4: AA has remained unprofessionalized, but an entire infrastructure that uses
Speaker 4: twelve step as its method of recovery has been professionalized
Speaker 4: all around it. But when you look at it, one
Speaker 4: of the things that becomes difficult to say, well, I've.
Speaker 3: Got a disease.
Speaker 4: We're saying there's a medical component, but the thing you're
Speaker 4: giving me to do looks somewhere between moral spiritual community.
Speaker 4: Like those two things feel like they don't quite line up,
Speaker 4: and I think that makes it a more confusing thing.
Speaker 4: And I think we're talking about the same thing here now.
Speaker 4: I also think with SMI, it's important that we should
Speaker 4: mention we've been talking about the three p's, but in
Speaker 4: no way, shape or form are you saying that medicine
Speaker 4: and the psychiatric drugs that we have they have a place,
Speaker 4: and they have a purpose, and they can really be beneficial.
Speaker 4: So we're not saying the three piece at the exclusion
Speaker 4: of those. I just want to clarify that what you're
Speaker 4: saying is we may be delivering some of the medicines
Speaker 4: well enough, but probably not. But on top of it,
Speaker 4: we also need to be looking at this other element.
Speaker 4: When those things are delivered, they're delivered very fragmented from
Speaker 4: each other.
Speaker 3: You might get one or not the other. You might
Speaker 3: not get either.
Speaker 4: You might you know, but they're not coming together into
Speaker 4: a coherent treatment plan.
Speaker 2: You've got it. You said it better than I would have.
Speaker 2: I mean, that is the issue is that this is
Speaker 2: not instead of it's in addition to and I don't
Speaker 2: really fully understand this, that this field, this mental health field,
Speaker 2: has become so polarized. It's either medical or its recovery.
Speaker 2: It's either getting medication or you're getting psychotherapy. Who benefits
Speaker 2: from that polarization? Why do we tolerate this? We wouldn't
Speaker 2: tolerate it for most other human problems. You want people
Speaker 2: to get access to as many things as possible, and
Speaker 2: I think some of it comes about because it's more
Speaker 2: about us as providers than it is about the people
Speaker 2: who we should be trying to serve. And if you
Speaker 2: see it from the consumer point of view, it's like
Speaker 2: what's best for me, and it's often not one thing,
Speaker 2: it's a combination of things, and very often that's just
Speaker 2: not possible to do. They end up with a primary
Speaker 2: care doctor who's going to write them a prescription for
Speaker 2: an SSRI, or they end up in psychotherapy with a
Speaker 2: social worker who's going to spend a lot of time
Speaker 2: exploring their past trauma. It just feels to me like
Speaker 2: someone needs to knock down that divide so that you
Speaker 2: get access to both when you need it.
Speaker 4: I couldn't agree more. And you know, we get lots
Speaker 4: of requests for guests on the show, and there are
Speaker 4: all sorts of people who will fall on either of
Speaker 4: those extremes, and what they want to promote, and I'm
Speaker 4: just not interested in promoting that.
Speaker 3: You know, Like, are.
Speaker 4: There problems with big Pharma and our use of psychiatric drugs?
Speaker 4: Of course there are, but that doesn't mean that they're
Speaker 4: not enormously helpful to so many people. You know, For me,
Speaker 4: my recovery has been I often say my recovery from
Speaker 4: depression has been by throwing the kitchen sink at it.
Speaker 4: Medicine has been a part of that. Exercise is a
Speaker 4: part of that, sleep is a part of that, My
Speaker 4: community is a part of that. For me, it's been like,
Speaker 4: let me bring it all to the table, and which
Speaker 4: is more valuable than the other? I couldn't begin to
Speaker 4: tell you at this point because they've become so intermixed
Speaker 4: over the years. But I wouldn't want to try without
Speaker 4: one of them. I wouldn't like to just jettison one
Speaker 4: of them, be like, well, let's see what happens. You know,
Speaker 4: I found something that works for me. And I do
Speaker 4: think that this polarization is not helpful because it leads
Speaker 4: people to either only depend on medicine or not take
Speaker 4: medicine at all. And the answer is far more nuanced.
Speaker 4: We just don't happen to be a culture that's very
Speaker 4: into nuanced conversation.
Speaker 2: Yeah, I think that's right. I guess the message I
Speaker 2: want listeners to take on this though, is that believe
Speaker 2: it or not, most people ultimately find something helpful because
Speaker 2: there's a lot out there to choose from, and whether
Speaker 2: that's medication or therapy, or the social support networks like
Speaker 2: AA you know in a church basement, or humanest online.
Speaker 2: I mean, they're just a range of things that people
Speaker 2: can engage with. And you know, one of the things
Speaker 2: that's happened during the pandemic is we now have literally
Speaker 2: hundreds of different online services, some of which are very
Speaker 2: good and are trying to do kind of what AA does,
Speaker 2: but doing it in a way that's far more convenient.
Speaker 2: I think there are plenty of opportunities to get help
Speaker 2: in a way that works for you. And that's the
Speaker 2: great thing now is you don't necessarily have to wait
Speaker 2: three and a half months on a waiting list to
Speaker 2: see a therapist. You can probably find someone, or you
Speaker 2: can choose amongst thousands of people who would be available
Speaker 2: online through one of the current therapy or medication companies.
Speaker 4: I think that's a really important message of hope and
Speaker 4: a message of to continue to seek help. You know,
Speaker 4: one of AA's key lines is keep coming back right,
Speaker 4: And to me that actually should be broader than AA right,
Speaker 4: but it just means there is hope, there is help,
Speaker 4: keep investigating, keep trying, which can get discouraging but is
Speaker 4: really important. I want to hit one last idea with
Speaker 4: you then wrap up. You talk about something you call
Speaker 4: the pro doome, meaning that before somebody develops severe psychosis, right,
Speaker 4: there's often a multi year period where behavior is beginning
Speaker 4: to change. There are things we know to look for,
Speaker 4: and that early intervention makes a lot of sense. Now
Speaker 4: I think this is common sense. Maybe it's not common sense,
Speaker 4: maybe it is just to me, I think that's a
Speaker 4: really important point. My question is more around similar to
Speaker 4: alcoholism or addiction, and this is starting to change a
Speaker 4: little bit. But things have to get to a certain
Speaker 4: level of bad before people are willing to do a
Speaker 4: whole lot about it. So do you have any insight
Speaker 4: into how to get people to help sooner before it
Speaker 4: becomes a crisis, Any thoughts on that?
Speaker 5: A lot of thoughts on the mental health side, So
Speaker 5: we know a lot about it, and nimh was deep
Speaker 5: into this area of science trying to understand for those
Speaker 5: maybe they're one hundred thousand young adults who will have
Speaker 5: a first psychotic break, first episode of psychosis this year
Speaker 5: in the United States, usually between about ages fifteen and
Speaker 5: twenty five.
Speaker 2: That's kind of the vulnerable years. And as people have
Speaker 2: looked at that, they began to realize that, in fact,
Speaker 2: there were a lot of warning science sometimes going back
Speaker 2: two or three years. That's this prodrome idea as opposed
Speaker 2: to the syndrome. Is before there's a syndrome as the prodrome,
Speaker 2: and the concept was if we get to detect that,
Speaker 2: like pre diabetes, could we treat it and actually prevent
Speaker 2: the psychotic episode. And so a lot of energy's gone
Speaker 2: into this. It turns out to be harder than you think.
Speaker 2: So many people between the ages of fifteen and twenty five,
Speaker 2: or if you go three years earlier, between the ages
Speaker 2: of twelve and twenty two, you know they're experiencing a
Speaker 2: lot of emotional chaos. That is what adolescence is all about.
Speaker 2: So knowing which one of those people is will go
Speaker 2: on to hearing voices and becoming delusional is hard to
Speaker 2: really to predict. We're learning more, and the thought had
Speaker 2: been that, well, maybe there'll be some biological factor that
Speaker 2: will help us predict and there are some pretty good signs.
Speaker 2: I think the science there is interesting, but none of
Speaker 2: its scales to allow you to do this for a
Speaker 2: whole population. So we're still, i'd say, trying to figure
Speaker 2: this out whether you could do the same thing for
Speaker 2: you know, when does social drinking become alcoholism, When does
Speaker 2: the use of any addictive compound begin to become a problem?
Speaker 2: I'm not sure sure we've thought is well about that,
Speaker 2: and it may have to do more with not what
Speaker 2: you use, but how you use it and whether, as
Speaker 2: my colleague ATNIDA used to say, when it goes from
Speaker 2: being something that you'd like to something that you need.
Speaker 2: That's really the transition, and that happens in various ways.
Speaker 2: It's so interesting to me that it's not a function
Speaker 2: of how much somebody uses the substance, but how that
Speaker 2: substance uses them and how it changes what they do,
Speaker 2: and that dependence is really often dictated by lots of
Speaker 2: things that are not just about the pharmacology of the
Speaker 2: compound or the biology of the person, but other factors.
Speaker 4: Yeah, yeah, I think there is a difference between those
Speaker 4: two in that you know, addicts are using their substance
Speaker 4: because they're getting a lot out of it, right, I mean,
Speaker 4: make no mistake, there's a period of time where it
Speaker 4: feels like a positive experience, right, and so it's harder
Speaker 4: to give up because you're still getting something. Whereas you
Speaker 4: know a lot of these sort of emotional or mental disorders,
Speaker 4: you may be able to have more success intervening earlier
Speaker 4: because it doesn't tend to be pleasant.
Speaker 2: Yeah, I think that's certainly true for this prodrome thing,
Speaker 2: but almost no one gets help for that. And the
Speaker 2: fact is we're not even sure what is the right intervention.
Speaker 2: There have been lots of attempts to find that it's
Speaker 2: probably going to be a cognitive intervention, but helping people
Speaker 2: with working memory, helping them with focus, helping them if
Speaker 2: they have ADHD at the same time to get that
Speaker 2: under control, I don't know. I do think that one
Speaker 2: of the lessons generally is that the earlier you can
Speaker 2: detect and the earlier you can intervene, the better the outcomes.
Speaker 2: And that just seems to be a fundamental truth across
Speaker 2: all disorders in medicine. No less true here, but we're
Speaker 2: not very good at that. We tend to get involved
Speaker 2: in the late innings when we're already a few runs behind.
Speaker 2: It's really hard to win the game under those circumstances.
Speaker 4: Well, I think that we can end with the hope
Speaker 4: that there are treatments and the idea that early intervention
Speaker 4: is better. Tom, thank you so much for coming on.
Speaker 4: I feel like I could ask you a hundred more questions,
Speaker 4: but you probably have a few other things to do today,
Speaker 4: So thank you so much. I really enjoyed the book,
Speaker 4: I really enjoyed talking with you, and thank you for
Speaker 4: all the great work you're doing in this field.
Speaker 2: Eric, it's a pleasure. Thanks for having me.
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