Healing by Thomas Insel, the former director of the National Institute of Mental Health (NIMH), explores what’s wrong with the mental health care system and why there are so often poor outcomes for people with mental illness. While he characterized the current system as broken, he expressed hope that there are ways to fix it, and the pieces of that fix already exist.
The author described a “crisis of care” in relation to what he called the 40-40-33 law; only about 40% of people with mental illness are in care, only 40% of those are receiving evidence-based treatment, and among people getting treatment, 1/3 are doing well, 1/3 are getting some benefit, and 1/3 aren’t responding. That means a lot of people aren’t getting access to the help they deserve. He pointed out that the illness itself often makes people less likely to seek care, particularly with respect to serious mental illness involving a lack of insight. This point was repeated a few times throughout the book, and I would have liked to see a little bit more of an acknowledgement that negative experiences within the health care system and with individual health professionals can also serve as deterrents.
In terms of systems issues, the book described the way mental health care is delivered in the United States, although much of it is still relevant for non-US readers. It was interesting to see how different pieces of government legislation have led to the current state of affairs and blocked funding for psychiatric hospitalization.
Insel argued that currently available treatments for mental illness work, but that’s not reflected in outcomes because treatments aren’t being delivered based on what’s known about what works. He identified a number of issues that get in the way, including a focus on crisis-based care, limited use of evidence-based interventions, issues with insurance coverage, and broader issues like homelessness and transinstitutionalization (deinstitutionalization shifting large numbers of people with serious mental illness into the criminal justice system).
The middle section of the book looked at ways to overcome barriers to change. Some of the solutions that were proposed included greater implementation of (and training in) evidence-based care and addressing the fragmentation of care. The author gave examples of practices that have demonstrated benefits, including the use of care coordinators to promote collaborative care. The clubhouse model was presented as a way to address the elements of recovery, identified as people, place, and purpose.
There was a chapter on precision medicine in which the author discussed the importance of coming up with a diagnostic system that makes use of objective measures and is better able to direct people towards treatments that are likely to work for them. He suggested that while science’s understanding of the biology of the brain is a factor, negative attitudes about diagnosis and treatment may be an even bigger challenge to address.
In a chapter on stigma, Insel linked the word “stigma” to victimization and inaction, writing that he prefers the term “discrimination.” To me it seems bizarre to call stigma “victim language,” but I think the author and I are looking at the word stigma very differently. I’m looking at the bigger sociological package of the characteristic (mental illness) that society has deemed to be deviant, the stereotypes that are applied based on the presence of that characteristic, and the prejudiced attitudes and discriminatory behaviours that result. It seems like Insel was using “stigma” to refer only to the characteristic and arguing that we need to focus on the discrimination piece instead. I would argue that we need to consider how the entire process happens as a whole rather than only addressing the consequences. There were several other points in this chapter on which I disagreed with the author, but I think it all came down to a difference in perspective on what stigma is.
The final section of the book focused on how to move forward. The author emphasized the importance of addressing prevention and recovery, along with more integrated care, more rehabilitative care oriented toward recovery rather than just symptoms, and more attention paid to social determinants of health. He discussed the benefits of using peer support, different payment models, and the potential role of technology. He also addressed the importance of suicide prevention, making the interesting point that it’s not a great approach to rely on people that are unpaid and not mental health professionals to address people’s most acute needs on crisis hotlines.
This was quite an interesting book. The author explained that after having dealt with mental illness for years as a clinician, scientist, and parent, this book comes from him taking a journalistic approach, visiting different places and talking to different innovators about what was working. He didn’t hold back in his criticism of things that don’t seem to be working, like many therapists’ lack of training in evidence-based therapies and the reliance on therapeutic approaches like psychodynamic psychotherapy that aren’t optimal for serious mental illness.
If you’re reading this book as a person with a mental illness, you’ll probably find a mix of some bits that prompt an eyebrow raise and other bits that have you nodding your head vigorously in agreement. Probably not all of the potential solutions suggested in this book are going to be palatable to you, but I don’t think the author was trying to suggest that every idea is going to be right for everyone.
The book is definitely effective at capturing some of the things that really aren’t working in the current American mental health care system (that isn’t really a system at all). There are some glaring issues specific to the US that need to be fixed, and fixed yesterday, and I think this book has some valuable messages for people running the show.
Overall, there’s a lot of interesting food for thought here, and I like that there’s not just talk about problems, but also plenty of talk about solutions.
Healing is available on Amazon (affiliate link).
I received a reviewer copy from the publisher through Netgalley.