Before I explain what I see as twenty keys to a mental health revolution, I want to describe a wide-ranging research project that would support such a revolution. This research project need not predate the revolution; it wouldn’t be wise to wait on the revolution until research results came in. After all, research about being human, as opposed to research in the hard sciences, is highly overrated and probably shouldn’t be called research at all. Greek and Roman philosophers knew a lot about being human without the benefit of any research. Indeed, it is not at all clear that we functionally know more now than we did then, when Aristotle, Plato, Socrates, Democritus, Heraclitus, Epicurus, Cicero, Aristophanes, Euclid, Euripides, and friends engaged in that wide-ranging thinking called “natural philosophy.”
If learning about the research I have in mind doesn’t interest you, please skip this chapter. But I think it is interesting in its own right, since its description sheds additional light on the issues we’ve been discussing. As I grew up in Brooklyn, and as the name I’ve picked is suggestive of another rather large, important project, the Manhattan Project, I’ve decided to call this research project the Brooklyn Project. The Brooklyn Project could be carried out worldwide at many collaborating institutions, at one particular academic institution, or at a governmental institute parallel to the National Institute of Mental Health. Its physical location and auspices would matter considerably less than the quality, heart, and courage of the researchers involved.
Its overarching goal would not be to arrive at perfect answers or even decent answers to the questions researchers posed but for the first time to look critically at what we claim to know about being human. This is an impossible, messy goal that reverses the academic trend of narrowly looking at “psychology,” “anthropology,” “sociology,” and so on, and takes as its evidence and its interests everything, absolutely everything, just as the Greek and Roman natural philosophers did. It might well not even call itself a research project, as research is a word that suggests science and knowing. Maybe it would describe itself as a worldwide super-brainstorming session about being human.
Brilliant people would be needed for this. Right now many of those brilliant people go into the hard sciences. We understand why. But perhaps some disaffected hard scientists who have seen the limits of science and would like to do some fascinating blue-sky thinking will come aboard and join top-notch youngsters who intuit that the Brooklyn Project might be much more interesting—and valuable—than software engineering or particle physics. Lawyers, doctors, business-people, poets, and other disaffected souls who, never previously having found a place to deeply think, might join them too.
Let us remember that there is an agenda here, in addition to better understanding what it means to be human. That is to interrogate and ultimately to overthrow the current mental health establishment model of “diagnosing” and “treating.” The primary activity of the Brooklyn Project would be to step right into the forefront of the battle being waged against current constructs. It is first of all asking the question, “What is it exactly that psychiatry does?” and second of all demanding, “Let us put the whole field of psychology under a microscope.” It would look closely at all of the issues we’ve discussed so far: what we mean by normal and abnormal, what we mean by cause and effect in human affairs, what actually helps reduce emotional distress and who should be tasked with helping the distressed, what makes for better mental health institutions and therapeutic communities, and so on.
That is, the Brooklyn Project is a mental health project. It is looking at everything human not so as to create some sort of new encyclopedia of humanness but so as to come up with recommendations about what needs to change in current mental health practices and what better mental health practices might look like. While the National Institute of Mental Health is looking at “the biological bases of mental illness,” the wild bunch at the Brooklyn Project would be throwing everything about “mental health” into question for the sake of arriving at more understanding and best practices. Its agenda is not the accumulation of knowledge but the creation of a whole new way of looking at “mental health.”
Here are some of the sorts of issues that might occupy folks at the Brooklyn Project:
1. If we want to start fresh and do a better job of conceptualizing “mental health” and “mental disorders” so as to provide more help to sufferers, what sort of research agenda might we set? First, what do we mean by “research” in this context? Do we mean experiments involving human beings? Do we mean white coat science? Do we mean observation and empiricism? Do we mean statistical analysis? Do we mean thought experiments, as in theoretical physics? Do we mean rounding up anecdotal evidence, say from “mental health patients”? Do we mean “Just thinking”? As a corollary question, might graduate students who are currently obliged to do research be allowed to tackle large “meta questions,” even if those efforts look more like natural philosophy than science? What is the “right way” or “right ways” to “research” what it means to be human?
2. How might we conceptualize the task of rethinking mental health if research turns out to be out of the question? How, for example, could we research the nature of the original endowment with which each individual arrives in the world (what I have elsewhere called “original personality”)? Can this be researched or is research here out of the question? How could we research the amount of sadness generated by a stray cloud passing in front of the sun twenty years ago in the life of a given individual? Isn’t research about such things completely impossible? How could we research what we mean by “normal” and “abnormal”? What if much of what we need to know can’t be researched? What, if any, are the alternatives to scientific research, and by what criteria would we want to judge the soundness, reliability, or usefulness of each of these alternative approaches?
3. What various definitions of “mental health” might be proposed? How might we characterize the underlying idea of each definition? If a given definition of mental health rested on some other construct like “good coping skills,” “resilience,” “high functioning in society,” “absence of undue emotional distress,” or “self-report of contentment,” what is our rationale for choosing that underlying construct rather than a competing one? Who would decide which definition of “mental health” ought to be used and by what authority would that entity get to make such a decision? As a corollary question, what category of person should be considered “expert” in the matter of defining “mental health,” given the poor record of current and past putative experts? Given that the very idea of “mental health” is up for grabs, who should be authorized to grab it?
4. What are the various possible relationships between “mental health” and “emotional distress”? For example, is it reasonable to suppose that a person could be mentally healthy but also emotionally distressed? Surely it is. Is it reasonable to suppose that a person could be mentally unhealthy, whatever that phrase might mean, and also not mentally distressed at all? For example, might not a mentally healthy person be considerably distressed by the famine affecting his society and a mentally unhealthy person experience no distress as he commits a murder? If the relationship between “mental health” and “emotional distress” isn’t straightforward and if we aren’t entitled to say that the presence of emotional distress means the absence of mental health, what are various ways that we might conceptualize the relationship between the two? To put the question differently, is there any “amount” of emotional distress the presence of which “generates” the label of “mentally unhealthy” or “mentally disordered”? If the answer is no, are we saying that “emotional distress” and “mental health” are unconnected, or are we saying that they are connected but in complicated and even seemingly paradoxical ways?
5. What are the current “psychological models of distress” (like, for example, the Freudian model), “mental disorder models of distress” (like, for example, the DSM model), and “social and political models of distress” (say, for example, the Marxist model)? How do we judge their strengths and weaknesses? And how do we tease out what we want a knowledgeable service provider to know from these models? What do we want to “do” with all these existing models? At least get them listed, described, and organized? As a corollary idea, what constructs or concepts within a given psychological model are strong, true, or sensible? Even if a given theory, vision, or set of opinions is not strong in its aggregate, how might we judge if a given idea within it is useful? For example, might the idea of a “midlife crisis” be a useful concept irrespective of whether or not any other Jungian ideas are useful or true? How can we judge the strength, truth, or importance of the countless concepts that have already been generated?
6. To what extent do we currently rely on self-reports to “diagnose mental disorders,” and if that reliance is very high (or even total), on what else might we rely? What do we rely on in medicine to make diagnoses and to what extent is any of that apparatus currently available or logically applicable when it comes to “mental distress” or “mental disorder”? If what we are talking about has little or nothing to do with “the brain” and everything to do with “the mind,” on what should we rely in addition to or separate from self-reports from the individual? As a corollary idea, if we designate someone as entitled to “diagnose mental disorders,” what ought we demand that he or she rely on separate from or in addition to the self-report of the individual? If he or she says, “I observed the individual,” by what criteria shall we judge that what was observed amounted to a “mental disorder” and not something else? If he or she says, “I tested the individual,” by what criteria shall we judge the appropriateness or soundness of the test itself given the way that psychological tests are constructed and given that they are self-reports. To put this another way, how do we “test” for what ails a person—especially if what ails a person is life?
7. How might we conceptualize an individual’s contribution to the maintenance of his or her emotional distress? If, for example, an individual agrees that she would feel less sad if she did x but is reluctant to do x, how might we conceptualize that reluctance? Might we say, for example, that it is hard to make a change, even a desired one, that there are “unconscious reasons for her reluctance,” that “not rocking the boat is more important to her than reducing her sadness,” and so on? What (presumably very many) hypotheses might we generate as to why people do not do what they know to do to reduce their mental distress or improve their lives? Second, how can we come to know which hypotheses are true so that we could arm helpers with tactics for dealing with this disinterest in or lack of cooperation? As a corollary idea, how might we gauge or measure an individual’s contribution to the maintenance of his or her emotional distress? How can we know when and to what extent an individual is participating in the maintenance of his or her distress? To say this differently, if our goal is to help, how do we factor in the extent to which the people we intend to help are often not very helpful?
8. What do we take “behavior” to stand for or count for? What sort of marker is bed-wetting, “excessive” hand washing, “alcoholic” drinking, or a suicide gesture? What are the arguments for linking any given behavior to a construct called a “mental disorder” or a “mental disease”? If we claim that it is some single necessary linkage, like “lack of control,” how do we know if the individual lacks that control or prefers not to exert that control? If an individual can go from “drinking alcoholically” one day to “entering recovery” the next, what did we mean by “lack of control” when and if we used it as a criterion for labeling? What, if any, are the ways that we can get at a true or accurate picture of the relationship between observed behavior and the generating cause or causes of that behavior? If we can’t really know the linkage between “the mind” and “behavior,” what should we take observable behavior to mean?
9. To continue on this theme, how should we conceptualize the differences between or the relationships between a behavior and an inner state? Tossing aside the book you’re reading is a behavior. Tossing it aside because it bores you or because it angers you reflects an inner state of mind, tossing it aside because it has become electrified is a biological reflex, tossing it aside because a policeman orders you to toss it aside reflects a social interaction, and so on. Tossing the book aside is an “observable behavior,” but what it means is not known simply by observing such an action out of its human context. How can we conceptualize the task of relating observable behavior to the “causes” or “sources” of that behavior?
10. How do we retain the sense that a human being is involved here? Humanistic psychology, person-centered psychology, and existential psychology, to name a few “psychological orientations,” explicitly state that the individual is a member of a certain species with certain human desires and challenges, that he or she must be consulted, respected, and understood, and that a “real person” is different from a “patient.” Other orientations take different stances, and in the current “medical model,” we have lost the person almost entirely. How might a human being’s “individuality and instrumentality” be conceptualized, do we know enough to do that conceptualizing, and if we don’t know enough, where should we err? On the side of “acting as if” the individual is a person, a collection of dynamic forces, a symptom generator, or something else? How might we tease apart “the place of the person” in relation to the provision of mental health services, with an eye to generating respect and compassion for the individual in question?
11. In line with the above, what shall we call a person who walks into the office of a “mental health service provider”? Since there are many compelling reasons not to call that person a “patient,” shall we call that person a “client,” as that is the other term most often used in this context? Is there a better word to use than “patient” or “client,” and what are the arguments for that better word or those better words? In some contexts we call a person a customer (when she enters a store), in some a client (when she hires a lawyer), in some a patient (when she sees her dentist), in some a parishioner (when she sits with her priest), in some a student (when she takes a class), and so on. What is the relationship with a mental health provider most like, and if it is different from all of the above, do we need a new word to communicate that difference? (A full discussion of this issue can be found in chapter 5.)
12. What will a “new mental health service provider” provide? If it is wise to repudiate the DSM “medical catalogue” approach, as I believe it is, and if we come to see that it is not appropriate to act as if the interaction between client and provider is the “diagnosing and treating of mental disorders,” what will a person currently called a “psychotherapist” or some new provider be doing or providing? Will his or her “talk” not need to change at all in some cases? Has he or she perhaps been simply providing “wise counsel” all along and never really “diagnosing and treating mental disorders” and therefore not need to change his or her tactics? On the other hand, will some providers need to completely overhaul what they do, insofar as they were operating from and invested in the “medical catalogue” model? As a corollary idea, what should the state claim to be sanctioning and what position should it take with respect to “standards of care”? If it acts as if there are “mental disorders to be diagnosed and treated” and demands that its licensed or certified professionals play along with this idea even if in their office they simply offer wise counsel, should this shadow game end? If so, what would the fallout be, for example, in the courts? What do we want providers to provide, and how can we get society aligned with what may prove to be completely new standards of care?
13. If it turns out that something like a “wise counsel” model is the most appropriate model for service provision, how do we train “wise counselors” (providers I have dubbed human experience specialists), how do we change curricula to reflect our new understanding about the logic and content of courses like “introduction to abnormal psychology” or “understanding the DSM,” and how do we distinguish between “coaching” and “psychotherapy”? In short, how do we conceptualize the change in the naming and training of “mental health service providers” to reflect the changes that might be wanted? What do we do “with” or “about” existing psychiatrists, psychologists, marriage and family therapists, clinical social workers, and other “mental health service providers”? Do we allow them to continue on “as is” even if the game has changed? Do we demand that they make certain changes in their outlook and their practices, changes that they must somehow “prove” have occurred (for example, through continuing education classes)? If, for example, it becomes common wisdom and general understanding that there is no “mental disorder of depression,” can we allow mental health service providers to keep “diagnosing and treating depression”? What are our options in this regard?
14. Whether or not we ever understand what is really going on in the minds of people, we nevertheless want to be of aid to people seeking help with their emotional distress. Given that, what helps? How shall we research the “best helping methods” given that we may well not be talking about organic problems but reactions to life challenges? How can we tease out the relationships between a given problem (say, despair or intense anxiety) and the best, most logical, or most appropriate “treatment methods” or “helping methods”? What do we take “this really works” to mean in this context: that a “symptom is removed,” that a person’s life is radically changed for the better, that the presenting problem (like despair) still remains but the individual can tolerate it better, and so on? We need a wide-ranging exploration of what “help” means in a human context, which “help” helps the most, and which “help” we ought to offer according to which problem is presented. (For example, is the same “help” best for despair, anxiety, addictive behaviors, etc.?)
15. What might be the rationale for a given helping strategy or tactic? What is the legitimacy of that rationale? Can we perhaps employ strategies without knowing their rationale or without granting the legitimacy of that rationale if individuals report that the strategy has helped them? For example, should we grant dream interpretation a place at the helping table even if there is no proof that “dreams are the royal road to the unconscious” and even if the practitioner has no rationale at all for using it except to say, “I know it helps”? Is a self-report of reduced emotional distress or some other self-report of ratification on a client’s part “enough” to validate helping methods, given what we know about the placebo effect? Is a self-report of success the only validation necessary, or might there be other methods or measures? How might the matter of “How do we know what helps?” be conceptualized?
16. What is cause and what is effect? When, for example, we see a certain pattern in a brain scan, how should we go about deciding whether the individual’s despair caused that brain look or whether that brain look is actually telling us anything about the cause of his or her despair? Is our sleeplessness a cause of our anxiety or is our anxiety a cause of our sleeplessness? What is cause and what is effect, what is chicken and what is egg? How can complicated causal chains in human affairs be examined or understood, and how can this problem be best articulated and addressed? If perhaps we can’t ever know what is cause and what is effect, what helping strategies might we nevertheless employ in the absence of that knowledge? Is there “best help” to provide if you do know the cause or causes of the distress and different “best help” to provide if you can’t know the cause or causes of the distress?
17. What do we mean by “reducing emotional distress” or “improving our mental health”? As an important corollary idea, is “feeling better” always the highest good? For example, if a lobotomy would reduce or eliminate your emotional distress but also make you a zombie, surely that is too high a price to pay for “feeling better.” What if a chemical can help you feel better in some senses and worse in other senses? How can we measure the “net benefits” of a chemical or a strategy when it produces both positives and negatives? What are the “right” or appropriate prices to pay for feeling better? Is “feeling better” even the goal? How can these matters be conceptualized?
18. Given the variety of stakeholders, the history and customs of the trade, and the fact that the welfare and emotional health of hundreds of millions of human beings worldwide will be affected by any changes to the model and the system (including all the people taking “medication” for what may no longer be seen as “medical disorders or diseases”), how should we handle this moment and determine who takes responsibility? If a certain shift turns out to be clearly desirable, should it be a bottom-up shift (for example, with new human experience specialists hanging out their shingles, with ad campaigns plastered on the sides of buses, and so on), a top-down shift (for example, with the empaneling of a governmental “blue ribbon panel” made up of system insiders but also of system outsiders), or both? If conclusions are reached and action steps proposed, how can those action steps be implemented in the real world?
It is easier to understand the workings of the universe than the workings of a person. With human beings, there is much that is strictly unknowable. We can’t know if a person is born with a particular original personality and with a particular blueprint for development. We can’t know enough about the virtually infinite number of links in the causal chain that produces a feeling or a behavior. We can’t know whether a person is visited by emotional distress or invites that visitation. The list of what we can never know about human beings is very long and includes what is most important to know.
But we also don’t know if we can’t perhaps do a much better job—a really improved job—of knowing. The folks at The Brooklyn Project would give that a try. They would shake their heads at the absurdity of the task and the impossibility of success and then roll up their sleeves and see what new understanding is possible. The Manhattan Project arose because of the astounding threat that Hitler posed. Our current threat is also unprecedented: the threat to our children, that virtually all of them will find themselves with a mental disorder diagnosis and on a regimen of powerful chemicals, and the threat to everyone that our unchallenged “epidemic of emotional distress” is causing. A Brooklyn Project might help.