Thomas Insel MD - Healing: Our Path from Mental Illness to Mental Health

Any conversation about mental health has to navigate a linguistic landscape fraught with political, historical, and professional conflicts. Are we dealing with mental illness, mental health, mental health disorders, brain disorders, or behavioral disorders? Are these illnesses, disorders, or conditions? Is the field mental health or behavioral health? And are the people affected patients, clients, consumers, or survivors? Words matter. In this book, I use the term mental illness to refer to disorders of the mind, manifested as changes in how we think, feel, and behave.

I appreciate these disorders originate in the brain, but the term brain disorder connotes an irreversible lesion. Mood, anxiety, and psychotic disorders involve a dysregulation of brain activity, perhaps a disorder of connectivity or a brain arrhythmia, but not (yet) an identifiable lesion. And relative to some neurodegenerative disorders, people can recover from mental disorders. On the other hand, brain disorder accurately conveys the serious nature of the problem. There is a risk that the term mental disorder means a mild or moderate condition that is neither deadly nor disabling.

Behavioral disorders include addictions, from nicotine to opiates. Substance use and abuse is frequently associated with mental illness, but for this book will be treated as a consequence and not a core form of mental illness. I avoid the terms behavioral health and behavioral disorder when talking about serious mental illness because these disorders involve much more than behavior, but I recognize that for health systems and payers, behavioral health describes the broad area of mental illness, addiction, and sometimes wellness.

The term mental health disorder is one I particularly dislike. We speak of heart diseases, not heart health disorders, or metabolic diseases, not metabolic health disorders. I see no reason to treat mental illnesses differently.

Are these disorders, illnesses, or conditions? I will use the terms disorder and illness interchangeably. In either case, we do well to remember that the labels we use are simply conventions with limitations. Labels like illness or disorder describe a set of symptoms. They do not define a person.

And I refer to people with these illnesses as patients. Psychotherapists use the term client and health systems refer to consumers. People with lived experience sometimes call themselves survivors. My approach is unapologetically medical, not because I believe in a paternalistic medical model for treatment (I dont) and not because I think that medication is the only treatment for mental illness (I dont), but for two practical reasons: first, I want public and private health insurance to pay for the treatments that work, and second, I want the standards we expect for medical and surgical care to apply to the treatment of mental illness. You cant demand parity for clients who are not patients. If we want the benefits and rigor of medical science, our language needs to adhere to medical and scientific conventions. But as you will see, a medical approach introduces a mountain range of constraints that we will need to cross if we want a different future for people with mental illness.

Finally, a note about names. Individuals identified with only a first name in the text are aggregates of many individuals and a complete description of no one. These are fictional, in the sense that none of these people exist, but specific characteristics are derived from real people with details changed to protect anonymity. These case histories were constructed to be representative. They may therefore seem familiar to people I have known and to millions I have not known. But these case histories are not portrayals of any individual, and any resemblance to a person living or dead is both unintended and unavoidable. By contrast, individuals identified with first and last names are real, and those interviewed and quoted have reviewed the contents for accuracy.