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Healing: Our Path from Mental Illness to Mental Health
A bold, expert, and actionable map for the re-invention of America’s broken mental health care system.“Healing is truly one of the best books ever written about mental illness, and I think I’ve read them all." —Pete Earley, author of CrazyAs director of the National Institute of Mental Health, Dr. Thomas Insel was giving a presentation when the father of a boy with schizophrenia yelled from the back of the room, “Our house is on fire and you’re telling me about the chemistry of the paint! What are you doing to put out the fire?” Dr. Insel knew in his heart that the answer was not nearly enough. The gargantuan American mental health industry was not healing millions who were desperately in need. He left his position atop the mental health research world to investigate all that was broken—and what a better path to mental health might look like. In the United States, we have treatments that work, but our system fails at every stage to deliver care well. Even before COVID, mental illness was claiming a life every eleven minutes by suicide. Quality of care varies widely, and much of the field lacks accountability. We focus on drug therapies for symptom reduction rather than on plans for long-term recovery. Care is often unaffordable and unavailable, particularly for those who need it most and are homeless or incarcerated. Where was the justice for the millions of Americans suffering from mental illness? Who was helping their families? But Dr. Insel also found that we do have approaches that work, both in the U.S. and globally. Mental illnesses are medical problems, but he discovers that the cures for the crisis are not just medical, but social. This path to healing, built upon what he calls the three Ps (people, place, and purpose), is more straightforward than we might imagine. Dr. Insel offers a comprehensive plan for our failing system and for families trying to discern the way forward. The fruit of a lifetime of expertise and a global quest for answers, Healing is a hopeful, actionable account and achievable vision for us all in this time of mental health crisis.
336 pages, Hardcover
Published February 22, 2022
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January 18, 2022
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.
I received a reviewer copy from the publisher through Netgalley.
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.
I received a reviewer copy from the publisher through Netgalley.
November 22, 2022
Nobody feels good about the state of American mental health care. Happily there’s a lot of agreement about what’s wrong and even what could fix things, though the anti-psychiatry movement - which, once again, please leave me the fuck alone - would certainly disagree. And yet the problems seem intractable, thanks to the general structural problems of health care funding in the United States and the specific issues with psychiatric medicine, including resistance to care and treatments that are only modestly effective, carry debilitating side effects, or both.
Dr. Thomas Insel is in a good position to take a bird’s eye view on the entire system, as he served as the director of the National Institute of Mental Health from 2002 to 2015. (He presumably did not take part in any experiments to increase the intelligence of rats.) Insel is not just a psychiatrist but a neuroscientist, and he was part of a revolution in seeing psychiatric medicine as essentially a branch of neuroscience, a movement to seek the physiological origins of mental illness and treat with that knowledge. Given the degree to which psychiatry was and often still is associated with seeking origins for mental health problems in vague childhood traumas and assigning treatment with embarrassingly little scientific evidence, this was all very sensible, and for the record I think there’s no real long-term progress in this field that does not entail better understanding of the brain. But at the very beginning of the book, with admirable bluntness Insel admits that the revolution he was a part of was a failed one. Massive investments of money, time, and energy into brain research have not led to more effective treatments of mental illness, and in fact have borne little fruit even in terms of basic understanding of the brain.
So Insel’s new book Healing: Our Path from Mental Illness to Mental Health is in some ways a mea culpa. And it’s a (consistently interesting, somewhat cliched, overlong) embrace of a different paradigm, that of true community medicine, of a whole-patient philosophy, of the “three Ps”: people, place, and purpose. It’s an argument, if you’ll forgive me, that it takes a village. That argument is not wrong, and on specific issue after specific issue I would love to be able to make Insel’s vision come true. But for me, Healing is just not particularly compelling as a description of reforms that can actually happen in any likely near future.
First, I want to highlight a point he makes early on: the deinstitutionalization movement, still lionized by many left-leaning people and frequently represented as a triumph of humane public health policy, was a disaster.
If you’re unaware, deinstitutionalization was a movement of the 1960s, 70s, and 80s to shutter state mental institutions (asylums), under the theory that such facilities functioned as warehouses for some of society’s most vulnerable. With the specter of lobotomies and patients in straightjackets locked in padded rooms hanging over psychiatric medicine, John F. Kennedy pushed for deinstitutionalization with his 1963 Community Mental Health Act, the last major act of legislation he ever signed. Many of the existing mental health facilities were in fact not healthy or nurturing spaces for their patients. The trouble is that, aside from a few federally-funded institutions that had widely differing levels of care thanks to inadequate standardization, there was nowhere for patients who left the state facilities to go. Nowhere, that is, except for prison and the streets, which is exactly where they went. I still interact with many people who defend deinstitutionalization; they are generally the same people who think injectable antipsychotics are abuse and that no one should ever be involuntarily held in a psychiatric facility, despite both saving countless lives.
Even absent the deinstitutionalization fiasco, American mental health care would no doubt be a tattered patchwork quilt. What are some of the big-picture problems with our system?
Though none of this was novel for me, Insel draws it all well, and the book is if nothing else a good overview of the current state of American mental health care for those who want one. I would perhaps like a little more insider knowledge on behalf of the former director of NIMH (there are no juicy institutional tidbits here), but it’s yeoman’s work. Insel illustrates his discussion with stories of patients, composites of typical people with typical mental health problems like schizophrenia, anorexia, or depression. These too are mostly well done, if sometimes a little on the nose.
When it comes to his description of where we are, the only place I have to complain is Insel’s somewhat rosy description of the efficacy of currently-available treatments. There’s in fact an entire early chapter that takes as its major message that, contrary to what’s sometimes believed, our mental health care problem is an access problem and not a problem with the effectiveness of the treatments we have today. He puts it starkly: “the care crisis requires nothing more than a wider application of the best care we can offer.” To which I say… eh.
I am frequently pushing people who approach me with psychiatric crises to get into care. I have told people to “go in” more times than I can count. I truly believe that currently-existing psychiatric medicines save a lot of lives, and for the fortunate, they can relieve several kinds of pain. Contrary to what many skeptics believe, the majority of people who pursue treatment for mental illnesses eventually achieve stability and remission. In August I will reach five years of continuous medication for my bipolar disorder, and there is little doubt that being medicated has saved at least the quality of my life, and perhaps my life itself. But.
You have the continued, widely-lamented lack of efficacy of antidepressants. I am convinced by those who argue that SSRIs offer real improvements, but they are small even in the rosiest analysis of the data. You have frequent arguments that most psychiatric drugs are really just sedating, that they do not address underlying conditions and instead merely incapacitate to the point that those conditions can’t surface. (I strongly disagree that this is the case with antipsychotics, but that doesn’t mean that they are fixing any core problems, either.) You have the dependency and addiction issues that are common to these drugs. You have the weeks it takes many psychiatric drugs to build up in your system before they take effect, which is a major problem during a crisis. And you have the truly ruinous side effects that these drugs come packaged with, which help explain why adherence to treatment is so poor. Beyond medication, you have ever-percolating controversies over whether therapy works, or which kinds, or whether the kinds that do can ever be adequately scaled. We all know people who have been in talk therapy for years without any clear indication that they are improving, or any specific sense of what improvement would look like.
So I’m not sure that the situation is as simple as an access problem for effective treatments. Neither is Insel, apparently, as he eventually layers on enough qualifications and exceptions that I more or less agree with him. It definitely dulls the fire that he brings when he first insists that we have the tools we need, but then again I get the desire to present things that way, given the national scandal that is our terrible failure to provide access to treatment to the mentally ill.
I will now inevitably give the book’s second half short shrift. That’s the solution half, the prescription to go along with the description. That’s the important part, to many people. I’ve already previewed it for you a bit: Insel thinks that we need to truly implement community-based care of the kind that was imagined but not achieved with the Community Mental Health Act. Insel correctly diagnoses a system that only intervenes in emergencies, only in pieces, and without anything like adequate follow-up care or infrastructure to return people to functioning life. (With mental illness this is somewhat in contrast with drug addiction, where there’s at least some degree of functioning intermediary system between detox and civilian life, although of course not equitably or inexpensively distributed.)
Those three Ps - people, or a connection to those who can provide support and accountability; place, which yes means communal spaces that provide structure but also literal places where people can undertake the healing process; and purpose, or something for the mentally ill patient in treatment to work for, a sense of working for a greater good than simply “getting better.” If this sounds a little loosey-goosey, Insel peppers it all with references to real programs that have had good outcomes in various places, and does keep an eye towards the horizon of “precision medicine,” the failed dream of treating the mind by learning about the brain, as well as about genetics. All of this will take money, taxpayer money, as well as easing of various regulatory burdens, a more evidence-based approach to therapeutic techniques, and evidence-gathering that contributes to greater accountability about what works and for whom. Insel’s portrait of a more effective and more humane system of psychiatric medicine is a remarkable document overall, something worth working towards.
And this is where the cynic in me says… and a poney.
I’m not trying to be a jerk, or fatalistic. I think we are capable of vastly better than we’re currently providing. We have to do better than we’re doing. And as Insel repeatedly says, the current system is inefficient as well as frequently ineffective, and in the long run many of these reforms could pay for themselves by saving money on incarceration and residential care. But simply in terms of getting the dollars we need, federal and state and private, the lift will be enormous. Nor is it easy to unwind the tangled thicket of state and local laws and practices, which often vary tremendously from place to place. Insel stresses the need for education and awareness, which sounds great, but by whom, and where? And since it’s 2022, he says that the movement to reform mental health must get on board the social justice bus. There’s just a lot of demand here, and when Insel analogizes the problem to environmental issues, I think the comparison is apt in ways that don’t help him and which he may not intend. The kind of whole-planet, we’ve-got-to-change-everything philosophy of environmentalism referred to here seems no more likely to actually be achieved than Insel’s dreams.
In the final chapter, in the midst of calling for profound changes to policy, funding, and philosophy, Insel says gravely that “America as a nation of ‘I’ needs again to become a nation of ‘we.’” Sounds simple! I like the ambition. I admire the plan. I could not be more on board with the necessity. But Insel’s book, while a lovingly prepared and deeply humane text, often feels like it could just as well be talking about how badly we need to bring community mental health to the Moon.
Dr. Thomas Insel is in a good position to take a bird’s eye view on the entire system, as he served as the director of the National Institute of Mental Health from 2002 to 2015. (He presumably did not take part in any experiments to increase the intelligence of rats.) Insel is not just a psychiatrist but a neuroscientist, and he was part of a revolution in seeing psychiatric medicine as essentially a branch of neuroscience, a movement to seek the physiological origins of mental illness and treat with that knowledge. Given the degree to which psychiatry was and often still is associated with seeking origins for mental health problems in vague childhood traumas and assigning treatment with embarrassingly little scientific evidence, this was all very sensible, and for the record I think there’s no real long-term progress in this field that does not entail better understanding of the brain. But at the very beginning of the book, with admirable bluntness Insel admits that the revolution he was a part of was a failed one. Massive investments of money, time, and energy into brain research have not led to more effective treatments of mental illness, and in fact have borne little fruit even in terms of basic understanding of the brain.
So Insel’s new book Healing: Our Path from Mental Illness to Mental Health is in some ways a mea culpa. And it’s a (consistently interesting, somewhat cliched, overlong) embrace of a different paradigm, that of true community medicine, of a whole-patient philosophy, of the “three Ps”: people, place, and purpose. It’s an argument, if you’ll forgive me, that it takes a village. That argument is not wrong, and on specific issue after specific issue I would love to be able to make Insel’s vision come true. But for me, Healing is just not particularly compelling as a description of reforms that can actually happen in any likely near future.
First, I want to highlight a point he makes early on: the deinstitutionalization movement, still lionized by many left-leaning people and frequently represented as a triumph of humane public health policy, was a disaster.
If you’re unaware, deinstitutionalization was a movement of the 1960s, 70s, and 80s to shutter state mental institutions (asylums), under the theory that such facilities functioned as warehouses for some of society’s most vulnerable. With the specter of lobotomies and patients in straightjackets locked in padded rooms hanging over psychiatric medicine, John F. Kennedy pushed for deinstitutionalization with his 1963 Community Mental Health Act, the last major act of legislation he ever signed. Many of the existing mental health facilities were in fact not healthy or nurturing spaces for their patients. The trouble is that, aside from a few federally-funded institutions that had widely differing levels of care thanks to inadequate standardization, there was nowhere for patients who left the state facilities to go. Nowhere, that is, except for prison and the streets, which is exactly where they went. I still interact with many people who defend deinstitutionalization; they are generally the same people who think injectable antipsychotics are abuse and that no one should ever be involuntarily held in a psychiatric facility, despite both saving countless lives.
Even absent the deinstitutionalization fiasco, American mental health care would no doubt be a tattered patchwork quilt. What are some of the big-picture problems with our system?
The same immense access and affordability problems as the rest of American healthcare. We lack a national system that ensures universal access to medicine, and our care is among the most expensive in the world.
Even within the context of the American system, psychiatry is rich people’s medicine. Insel quotes incredible numbers, such as the fact that 57% of American psychiatrists do not accept Medicaid while 45% do not accept conventional health insurance. A vast number of doctors and institutions in this country accept only cash payments, in practice if not by admission, effectively shutting out not just the poor but the vast majority of the working and middle classes.
Though there are a huge number of people working in the broad field of psychiatric or psychological medicine - there are more psychiatrists than any other physician specialty, save internists or pediatricians - they are profoundly unevenly distributed by geography, leaving many parts of the country starved for care, especially from specialists. Likewise, some professions and roles within the profession appear to be overrepresented, while others are woefully short-staffed, especially nurses.
As suggested above, we lack basic scientific knowledge about core elements of the brain, how it functions, and its relationship to the mind, a degree of ignorance about elementary functioning that is rare in other avenues of conventional medicine.
The field is far less scientifically based and evidence-driven than other fields of medicine, and some forms of effective medicines are simply underutilized, often because personnel haven’t been trained in them. In therapy in particular there is an attachment to outdated and empirically unjustifiable psychoanalytic techniques, typically fixated on childhood memories, while far more scientifically sound approaches (such as behavioral activation for depression) are barely attempted.
Too many of those who need mental health care the most only receive it in light of an immediate psychiatric emergency, such as a psychotic break; as Insel says, this is like “managing heart disease one heart attack at a time.”
To a degree that is unusual relative to other diseases and disorders, those who suffer from serious mental health issues are frequently treatment-resistant, typically thanks to the nature of those illnesses themselves, that is, how they commandeer the mind.
Though none of this was novel for me, Insel draws it all well, and the book is if nothing else a good overview of the current state of American mental health care for those who want one. I would perhaps like a little more insider knowledge on behalf of the former director of NIMH (there are no juicy institutional tidbits here), but it’s yeoman’s work. Insel illustrates his discussion with stories of patients, composites of typical people with typical mental health problems like schizophrenia, anorexia, or depression. These too are mostly well done, if sometimes a little on the nose.
When it comes to his description of where we are, the only place I have to complain is Insel’s somewhat rosy description of the efficacy of currently-available treatments. There’s in fact an entire early chapter that takes as its major message that, contrary to what’s sometimes believed, our mental health care problem is an access problem and not a problem with the effectiveness of the treatments we have today. He puts it starkly: “the care crisis requires nothing more than a wider application of the best care we can offer.” To which I say… eh.
I am frequently pushing people who approach me with psychiatric crises to get into care. I have told people to “go in” more times than I can count. I truly believe that currently-existing psychiatric medicines save a lot of lives, and for the fortunate, they can relieve several kinds of pain. Contrary to what many skeptics believe, the majority of people who pursue treatment for mental illnesses eventually achieve stability and remission. In August I will reach five years of continuous medication for my bipolar disorder, and there is little doubt that being medicated has saved at least the quality of my life, and perhaps my life itself. But.
You have the continued, widely-lamented lack of efficacy of antidepressants. I am convinced by those who argue that SSRIs offer real improvements, but they are small even in the rosiest analysis of the data. You have frequent arguments that most psychiatric drugs are really just sedating, that they do not address underlying conditions and instead merely incapacitate to the point that those conditions can’t surface. (I strongly disagree that this is the case with antipsychotics, but that doesn’t mean that they are fixing any core problems, either.) You have the dependency and addiction issues that are common to these drugs. You have the weeks it takes many psychiatric drugs to build up in your system before they take effect, which is a major problem during a crisis. And you have the truly ruinous side effects that these drugs come packaged with, which help explain why adherence to treatment is so poor. Beyond medication, you have ever-percolating controversies over whether therapy works, or which kinds, or whether the kinds that do can ever be adequately scaled. We all know people who have been in talk therapy for years without any clear indication that they are improving, or any specific sense of what improvement would look like.
So I’m not sure that the situation is as simple as an access problem for effective treatments. Neither is Insel, apparently, as he eventually layers on enough qualifications and exceptions that I more or less agree with him. It definitely dulls the fire that he brings when he first insists that we have the tools we need, but then again I get the desire to present things that way, given the national scandal that is our terrible failure to provide access to treatment to the mentally ill.
I will now inevitably give the book’s second half short shrift. That’s the solution half, the prescription to go along with the description. That’s the important part, to many people. I’ve already previewed it for you a bit: Insel thinks that we need to truly implement community-based care of the kind that was imagined but not achieved with the Community Mental Health Act. Insel correctly diagnoses a system that only intervenes in emergencies, only in pieces, and without anything like adequate follow-up care or infrastructure to return people to functioning life. (With mental illness this is somewhat in contrast with drug addiction, where there’s at least some degree of functioning intermediary system between detox and civilian life, although of course not equitably or inexpensively distributed.)
Those three Ps - people, or a connection to those who can provide support and accountability; place, which yes means communal spaces that provide structure but also literal places where people can undertake the healing process; and purpose, or something for the mentally ill patient in treatment to work for, a sense of working for a greater good than simply “getting better.” If this sounds a little loosey-goosey, Insel peppers it all with references to real programs that have had good outcomes in various places, and does keep an eye towards the horizon of “precision medicine,” the failed dream of treating the mind by learning about the brain, as well as about genetics. All of this will take money, taxpayer money, as well as easing of various regulatory burdens, a more evidence-based approach to therapeutic techniques, and evidence-gathering that contributes to greater accountability about what works and for whom. Insel’s portrait of a more effective and more humane system of psychiatric medicine is a remarkable document overall, something worth working towards.
And this is where the cynic in me says… and a poney.
I’m not trying to be a jerk, or fatalistic. I think we are capable of vastly better than we’re currently providing. We have to do better than we’re doing. And as Insel repeatedly says, the current system is inefficient as well as frequently ineffective, and in the long run many of these reforms could pay for themselves by saving money on incarceration and residential care. But simply in terms of getting the dollars we need, federal and state and private, the lift will be enormous. Nor is it easy to unwind the tangled thicket of state and local laws and practices, which often vary tremendously from place to place. Insel stresses the need for education and awareness, which sounds great, but by whom, and where? And since it’s 2022, he says that the movement to reform mental health must get on board the social justice bus. There’s just a lot of demand here, and when Insel analogizes the problem to environmental issues, I think the comparison is apt in ways that don’t help him and which he may not intend. The kind of whole-planet, we’ve-got-to-change-everything philosophy of environmentalism referred to here seems no more likely to actually be achieved than Insel’s dreams.
In the final chapter, in the midst of calling for profound changes to policy, funding, and philosophy, Insel says gravely that “America as a nation of ‘I’ needs again to become a nation of ‘we.’” Sounds simple! I like the ambition. I admire the plan. I could not be more on board with the necessity. But Insel’s book, while a lovingly prepared and deeply humane text, often feels like it could just as well be talking about how badly we need to bring community mental health to the Moon.
July 22, 2022
An important book adding urgency to addressing our mental health crisis. I love when Dr. Insel says SMI is "the largest health disparity we don't talk about." Also that he critiques his own life work, along with our "sysyem."
Some of my favorite take aways: You can't improve quality without measuring functional outcomes, like education and employment.
National health care makes measurement and going to scale easier. Our mental health system spends money in all the wrong places, such as crisis care, jails and prisons. Simple things, such as using health home nurses to coordinate care, peer involvement and Clubhouses, would be better and cheaper. Loneliness exacerbates mental illness. Equipping police on calls to communicate with mental health professionals on the spot improves outcomes.
Two things I would edit: Insel calls often for benefits of family involvement but doesn't mention the destructive role of HIPPA zealots. He starts out emphasizing SMI and pointing out that the sickest get the worst care, but this focus seems to blur as the book progresses.
I loved the personal stories woven throughout the book, including those of his own children.
I hope this excellent book is a vehicle for Dr. Insel to help institute many of the needed changes he calls for.
Some of my favorite take aways: You can't improve quality without measuring functional outcomes, like education and employment.
National health care makes measurement and going to scale easier. Our mental health system spends money in all the wrong places, such as crisis care, jails and prisons. Simple things, such as using health home nurses to coordinate care, peer involvement and Clubhouses, would be better and cheaper. Loneliness exacerbates mental illness. Equipping police on calls to communicate with mental health professionals on the spot improves outcomes.
Two things I would edit: Insel calls often for benefits of family involvement but doesn't mention the destructive role of HIPPA zealots. He starts out emphasizing SMI and pointing out that the sickest get the worst care, but this focus seems to blur as the book progresses.
I loved the personal stories woven throughout the book, including those of his own children.
I hope this excellent book is a vehicle for Dr. Insel to help institute many of the needed changes he calls for.
This entire review has been hidden because of spoilers.
April 19, 2023
Thomas Insel makes the point multiple times in here that healing from mental illness is 10% medical and 90% about "people, place, and purpose." Putting aside the weirdness of trying to quantify these sorts of things, it's an interesting admission from the former head of the world's largest research group on mental illness (the federal National Institute of Mental Health or NIMH) for 13 years. He was the head at the moment (early 2000s) when the psychiatric exuberance of the "decade of the brain" was just reaching its peak and about to collapse into fragmentation again. Nancy Andreason had just published Brave New Brain: Conquering Mental Illness in the Era of the Genome two years earlier.
So he sets about here trying to impart the lessons he's learned from that failure. Fine. It's an interesting set up! But, he just cant see the big picture here and this is just the biggest and most popular example of a classic case of idealistic optimism. He is able to see that outcomes are good for the rich: they get follow-up care, prevention, and even if not, they have access to a well-rounded team of social supports, trained nurses, and whatever else they need. Outcomes for the poor? Horrible, of course. Late interventions, repeated hospitalizations, a lifetime of increasing medication dependence, isolation, and suicide. He fails to see how these two outcomes are actually connected. Like most idealists in mental health, he thinks the issue is our "mindset" and ideas. So this book sets out to change our ideas. He never considers that our ideas might be shaped by the economic and political system under which psychiatry exists. In fact, he never mentions either. Just "poverty," and "racial injustice," which seem to happen by magic or mistake instead of by necessity.
On top of that, his optimism around technology (he moved to Silicon Valley after serving as head of NIMH to work at mental health tech firms) is incredibly naive and he comes out supporting initiatives like Facebook monitoring for suicide and using the enormous amount of Google data to understand bipolar disorder as if these same firms aren't just another part of the problem. Maybe it's unfair to hold a pop-psychiatry book up to the standards of philosophy or political economy, but I don't see what the mountain of books trying to "change our minds" have to offer when they can't even adequately describe the world they live in. Again, it's the inability to make connections, see structure that plagues books like this. Everything just stands on its own and is taken on its own merits, distinct from the social whole that created it.
So he sets about here trying to impart the lessons he's learned from that failure. Fine. It's an interesting set up! But, he just cant see the big picture here and this is just the biggest and most popular example of a classic case of idealistic optimism. He is able to see that outcomes are good for the rich: they get follow-up care, prevention, and even if not, they have access to a well-rounded team of social supports, trained nurses, and whatever else they need. Outcomes for the poor? Horrible, of course. Late interventions, repeated hospitalizations, a lifetime of increasing medication dependence, isolation, and suicide. He fails to see how these two outcomes are actually connected. Like most idealists in mental health, he thinks the issue is our "mindset" and ideas. So this book sets out to change our ideas. He never considers that our ideas might be shaped by the economic and political system under which psychiatry exists. In fact, he never mentions either. Just "poverty," and "racial injustice," which seem to happen by magic or mistake instead of by necessity.
On top of that, his optimism around technology (he moved to Silicon Valley after serving as head of NIMH to work at mental health tech firms) is incredibly naive and he comes out supporting initiatives like Facebook monitoring for suicide and using the enormous amount of Google data to understand bipolar disorder as if these same firms aren't just another part of the problem. Maybe it's unfair to hold a pop-psychiatry book up to the standards of philosophy or political economy, but I don't see what the mountain of books trying to "change our minds" have to offer when they can't even adequately describe the world they live in. Again, it's the inability to make connections, see structure that plagues books like this. Everything just stands on its own and is taken on its own merits, distinct from the social whole that created it.
March 31, 2022
When this book came out, he took a ton of flak on a couple psychologist/psychotherapist listservs I'm on for being late to the party, bordering on hypocritical. Having gone scorched earth on research funding for psychosocial research when he was director of NIMH, he's born again per this book as an advocate for evidence-based psychotherapy (very positive comments on IAPT program in the UK) and community mental health (clubhouses, integrated collaborative care, prison reform.....) and skeptic of the public health impact (thus far) of the neuroscience revolution.
And to be sure, the book largely ignores his own role in tilting research support to the brain -- he's open about having changed his mind about whether magic bullet drugs or neuromodulatory interventions are just about ready to scale up and solve our worldwide mental health crisis, but it reads as though he just sort of rethought the matter after switching jobs, interviewing people in the field, thinking about his own family situation, etc.
Hard to describe, but it's sort of like a retired CEO of Exxon writing a book along the lines of "you know I used to enjoy driving my big gas guzzler down the highway with the a/c on blast, but in the past couple years i've talked to some green folks, and you know what? we actually need to get off of fossil fuels -- i mean they still have a role, but they need to be supplemented with solar panels and all that"
So i get the outrage, but.................if you ignore the personal history of who's writing it and just take in what he's saying, it's quite good. Very broad-brush overview -- any one of these topics (prediction of suicidal behavior from implicit attitude tests, just to pluck one out arbitrarily, or effectiveness of depression treatment apps, or peer support interventions for loneliness.......) would support its own much more detailed review and analysis. But you could do a lot worse in looking for a good overview of how we got into this mess and some hopeful signs for how we might get out.
And to be sure, the book largely ignores his own role in tilting research support to the brain -- he's open about having changed his mind about whether magic bullet drugs or neuromodulatory interventions are just about ready to scale up and solve our worldwide mental health crisis, but it reads as though he just sort of rethought the matter after switching jobs, interviewing people in the field, thinking about his own family situation, etc.
Hard to describe, but it's sort of like a retired CEO of Exxon writing a book along the lines of "you know I used to enjoy driving my big gas guzzler down the highway with the a/c on blast, but in the past couple years i've talked to some green folks, and you know what? we actually need to get off of fossil fuels -- i mean they still have a role, but they need to be supplemented with solar panels and all that"
So i get the outrage, but.................if you ignore the personal history of who's writing it and just take in what he's saying, it's quite good. Very broad-brush overview -- any one of these topics (prediction of suicidal behavior from implicit attitude tests, just to pluck one out arbitrarily, or effectiveness of depression treatment apps, or peer support interventions for loneliness.......) would support its own much more detailed review and analysis. But you could do a lot worse in looking for a good overview of how we got into this mess and some hopeful signs for how we might get out.
August 30, 2022
This book gives “what would a white guy at the top of the mental health power structures say about how to fix the system” vibes throughout. If you’re looking for someone who doesn’t recognize the need to talk to care providers at all levels about how to fix the system, who refuses to see and acknowledge what a massive role the lack of universal health insurance availability plays in this area, and who demonstrates nothing more than a cursory understanding (or willingness to talk about) how much race mediates mental health outcomes and service access, Thomas Insel is your guy and Healing is your book.
April 14, 2022
ALL THE STARS. I am a huge fan of Dr. Insel and his cunning but humble ability to navigate a career on the cutting edge of mental health. While this book may be a bit of RDoC propaganda (I’m here for it) his nuanced, cautious perspective on mental health and tech is fascinating and respectable due to his ties to leaders in the field (inc. Google, psychedelic therapy etc.) The best comprehensive view on mental health, the mental health crisis, mental health care, treatment options, systemic components, person centered care, and a high touch>high tech approach ever. Also easy to read and understand. A book not a treatment, but I still have faith that it may make accessibility of care one step closer to reality. This book is an atlas for anyone remotely interested in any facet of mental health care.
Dr. Insel if you read this pls hire me.
Dr. Insel if you read this pls hire me.
September 26, 2023
everyone should read this.
November 8, 2022
As a therapist, I found this book fundamentally uninspiring, bland, and disappointing. For a book of its scope and written by a person of incredible experience and responsibility in the field of mental health, there is just little to no new ideas or perspective. Its the same old we need more of x and y, like housing, 'quality' treatments, and 'precision medicine'. Oh and crisis care sucks, we need to focus on prevention instead of treatment. This is just an overly long B+ undergraduate essay that will get an A just because it mentioned hip millennial concepts like big data and natural language processing technologies.
Its the same old fucking uncontroversial story. Something this bland and lacking narrative should have never been a book and stayed an opinion piece on an old school internet news outlet. My mistake for assuming a NiMH leader would have anything thought provoking to say.
Its the same old fucking uncontroversial story. Something this bland and lacking narrative should have never been a book and stayed an opinion piece on an old school internet news outlet. My mistake for assuming a NiMH leader would have anything thought provoking to say.
May 6, 2022
Admirable in its call for destigmatization, really informative, both in explaining how we got here and in medical developments, but despite its optimistic tone and pointed criticism of certain systemic failures within the healthcare community/industry this too often either turns a blind eye to or just breezes past the profiteering institutions/lawmakers that consistently and without remorse fail the nation’s citizens, even by the end barely paying lip service to the taxing psycho/socioeconomic effects of living in late stage capitalism. It admits that systemic change is needed but rarely touches on the BIG system, and it culminates in little more than limp we-can-do-better posturing. Just refuses to get aggressive.
March 14, 2022
It’s well written and overall the author is spot on regarding the woes of mental health treatment. But the author’s comments about psychotherapists not using evidenced based interventions and relying more on psychodynamic therapy are flat out wrong. Would have rated higher but for this.
This entire review has been hidden because of spoilers.
December 6, 2025
This reads like a long self-interrogation from someone who spent decades at the center of American psychiatric research and finally admitted that the system he helped steward is failing in the most basic ways. The book lays out Insel’s critique: despite real scientific progress, people with mental illness still struggle to access care, continuity is rare, and the outcomes—whether measured by hospitalization, disability, or incarceration—tell a bleak story. Insel reframes the problem not as a lack of knowledge but as a lack of infrastructure, and that distinction shapes the entire book.
Insel’s framework of people, place, and purpose anchors the argument. Insel insists that recovery is built as much through stable relationships, supportive environments, and meaningful daily structure as through medication or therapy. He surveys models that embody this: coordinated specialty care, community-based programs, clubhouses, and integrated teams that follow a patient rather than lose them between handoffs. In these sections, he writes with the clarity of someone trying to translate systems-level issues into something the public can see, not just something policymakers can debate.
The book’s strengths lie in this broad, systemic lens. Insel is particularly good at tracing how insurance design, fragmented service providers, underfunded community programs, and the carceral system have together created what he calls a “mental sick-care system.” His use of data is steady but not overbearing, and the personal vignettes—families navigating impossible gaps, clinicians burning out, individuals trying to stay afloat without stable support—keep the narrative grounded.
At the same time, there are some limitations. Insel’s enthusiasm for evidence-based care can edge toward idealization; he sometimes sidesteps the distrust that grows from lived experiences of coercion, misdiagnosis, or dismissive treatment. His discussion of stigma also flattens a multidimensional social phenomenon into something that feels too narrowly defined. And several of his proposed solutions, while appealing, function more as policy aspirations than operational strategies.
Still, the book succeeds on its own terms. Insel doesn’t offer a grand unifying fix, but he does articulate why our current approach fails and what a more humane system might require with candor. For readers interested in the intersection of mental health, public policy, and social infrastructure, Healing is a thoughtful and necessary contribution: not revolutionary, but deeply clarifying.
Insel’s framework of people, place, and purpose anchors the argument. Insel insists that recovery is built as much through stable relationships, supportive environments, and meaningful daily structure as through medication or therapy. He surveys models that embody this: coordinated specialty care, community-based programs, clubhouses, and integrated teams that follow a patient rather than lose them between handoffs. In these sections, he writes with the clarity of someone trying to translate systems-level issues into something the public can see, not just something policymakers can debate.
The book’s strengths lie in this broad, systemic lens. Insel is particularly good at tracing how insurance design, fragmented service providers, underfunded community programs, and the carceral system have together created what he calls a “mental sick-care system.” His use of data is steady but not overbearing, and the personal vignettes—families navigating impossible gaps, clinicians burning out, individuals trying to stay afloat without stable support—keep the narrative grounded.
At the same time, there are some limitations. Insel’s enthusiasm for evidence-based care can edge toward idealization; he sometimes sidesteps the distrust that grows from lived experiences of coercion, misdiagnosis, or dismissive treatment. His discussion of stigma also flattens a multidimensional social phenomenon into something that feels too narrowly defined. And several of his proposed solutions, while appealing, function more as policy aspirations than operational strategies.
Still, the book succeeds on its own terms. Insel doesn’t offer a grand unifying fix, but he does articulate why our current approach fails and what a more humane system might require with candor. For readers interested in the intersection of mental health, public policy, and social infrastructure, Healing is a thoughtful and necessary contribution: not revolutionary, but deeply clarifying.
February 4, 2024
reading books in my field to try and be in my smart girl nonfiction era ✨
reading books by literal doctors or whateverrr 😌
this was SO america-centric and a lot of the historical and legal stuff got reallyyy tedious, but it was also very well written and gave an insightful perspective on the current state of mental health care and how it can be improved. i especially appreciated the case study parts and insel’s detailed experiences working with mentally ill people in various environments. it showcased the vast amount of knowledge and experience he’s accumulated, which affirmed the credibility of his opinions to me. while the primarily medical approach was a bit out of my realm of knowledge, i liked learning more about it, specifically the ways it converges with the psychosocial aspects of mental illness
most importantly, i felt smart while reading this 👩🏻🎓 (okay, more like at the fact that i was reading it at all. i reallyyy didn’t understand a lot of the intensely legal and medical stuff 😭)
reading books by literal doctors or whateverrr 😌
this was SO america-centric and a lot of the historical and legal stuff got reallyyy tedious, but it was also very well written and gave an insightful perspective on the current state of mental health care and how it can be improved. i especially appreciated the case study parts and insel’s detailed experiences working with mentally ill people in various environments. it showcased the vast amount of knowledge and experience he’s accumulated, which affirmed the credibility of his opinions to me. while the primarily medical approach was a bit out of my realm of knowledge, i liked learning more about it, specifically the ways it converges with the psychosocial aspects of mental illness
most importantly, i felt smart while reading this 👩🏻🎓 (okay, more like at the fact that i was reading it at all. i reallyyy didn’t understand a lot of the intensely legal and medical stuff 😭)
October 23, 2025
I read this book for my works book club (I am a hospital social worker) and the topic is very relevant to my job. But after finishing this book, I think everyone should read it. It is known that the “mental health system” in America is messed up, but the statistics in this book are truly eye opening. It sheds a light on the current “mental health system” in America, where things went wrong and some possible solutions. It talks about other countries and how they address mental health. The book was very easy to listen to and did not read like a textbook for school at all. I hope everyone reads this book someday; and I hope there can be change in the “mental health system” in America.
January 29, 2023
I've worked in suicide prevention now for about twenty years, on the training and implementation side, and it will take the kind of commitment that Dr. Insel has to get suicide to zero. At the end of his book Dr. Insel calls for leadership, and he has cited prominent leaders, like David Covington, throughout the book. These leaders, too, have tenacity in working on problems. Although I disagree some of the generalities he shares, like therapists not using CBT and that 95% of suicides are by people with mental illness, his history, story sharing, and best practices are for the most part sound. Although there is a lot of work to do, I found the book inspiring and think that some of the newer funding developments hold much promise for scalable solutions that work toward health, mental health, and zero suicide.
May 23, 2022
Healing is an engaging look at a daunting problem: the state of mental health care in the United States. Thomas Insel brings some expertise to the subject as a psychiatrist and as the former director of the National Institute of Mental Health*, but he opens the book with a startling confession: NIMH's emphasis on basic science research to cure mental illness at the expense (literally) of exploring and promoting other avenues of treatment and recovery left millions of Americans without relief for far too long.
Here, as the subtitle indicates, he embraces the recovery model that is used so effectively by community groups and national advocacy groups such as the National Alliance on Mental Illness.
Insel doesn't abandon his roots, however, arguing persuasively for identifying evidence-based treatments and then finding ways to scale them for the entire population. Insel leaves the reader feeling hopeful that there is momentum for change and treatments available to take advantage of it. I hope he's correct.
* And, no, I could never did stop wondering if he knew any of the famous rats from NIMH.
Here, as the subtitle indicates, he embraces the recovery model that is used so effectively by community groups and national advocacy groups such as the National Alliance on Mental Illness.
Insel doesn't abandon his roots, however, arguing persuasively for identifying evidence-based treatments and then finding ways to scale them for the entire population. Insel leaves the reader feeling hopeful that there is momentum for change and treatments available to take advantage of it. I hope he's correct.
* And, no, I could never did stop wondering if he knew any of the famous rats from NIMH.
February 5, 2024
3 stars! i once again read this book for my internship so i didn’t expect it to be anything more than a 3 star read for me. it was interesting and holds some good information so in that case it’s good!
January 29, 2023
A must-read for all, especially those working in the mental health field, policy makers, advocates for social change, and really anyone in our communities interested in clarifying the gap between "what we know about mental health and "what we do about mental health."
December 12, 2022
“The moral test of government is how that government treats those who are in the dawn of life, the children; those who are in the twilight of life, the elderly; and those who are in the shadows of life-the sick, the needy, and the handicapped.”
This book should be required reading. As the author correctly states, the above quote “is the moral test of our nation. People with mental illness are in the shadow of life. They want nothing more than people, place, and purpose, which after all are precisely what all of us want.”
As I’ve seen firsthand, there is a crisis of quality of care and access in the mental health field. The author, who was the former director of the National Institute of Mental Health, tries in the book to explain why we in the United States have more mental healthcare workers per capita than any other country, yet our outcomes are so poor. Quality is only one of the problems. In addition, there is little coordination, and most don’t take any insurance which leads to one of the biggest problems, inequality. How can we fix a mental health crisis without trying to fix some of the underlying problems which can lead to or worsen mental health? As the author repeatedly mentions, if tens of thousands of cancer patients were being treated by inadequately trained oncologists and surgeons, were dying and there was no data or the oncologists refused to accept insurance, would we accept that? The answer is a resounding “no.”
The author was criticized for being late to the party in that he strongly supported research funding. He has now come to realize that the three P’s are of the utmost importance and discusses some very interesting programs in other countries that have worked. I thought it was an excellent overview of how we got where we are today. Unfortunately, there is no easy answer on how to rectify the situation. Without funding and support, it will never happen.
This book should be required reading. As the author correctly states, the above quote “is the moral test of our nation. People with mental illness are in the shadow of life. They want nothing more than people, place, and purpose, which after all are precisely what all of us want.”
As I’ve seen firsthand, there is a crisis of quality of care and access in the mental health field. The author, who was the former director of the National Institute of Mental Health, tries in the book to explain why we in the United States have more mental healthcare workers per capita than any other country, yet our outcomes are so poor. Quality is only one of the problems. In addition, there is little coordination, and most don’t take any insurance which leads to one of the biggest problems, inequality. How can we fix a mental health crisis without trying to fix some of the underlying problems which can lead to or worsen mental health? As the author repeatedly mentions, if tens of thousands of cancer patients were being treated by inadequately trained oncologists and surgeons, were dying and there was no data or the oncologists refused to accept insurance, would we accept that? The answer is a resounding “no.”
The author was criticized for being late to the party in that he strongly supported research funding. He has now come to realize that the three P’s are of the utmost importance and discusses some very interesting programs in other countries that have worked. I thought it was an excellent overview of how we got where we are today. Unfortunately, there is no easy answer on how to rectify the situation. Without funding and support, it will never happen.
July 8, 2022
A comprehensive history on mental health from the former director of the National Institute of Mental Health. There’s an excellent personal and national narrative presented, but it’s a little weird. Dr. Insel was responsible for contributing to some problems within mental health, mainly focusing on only identifying causes of mental illness instead of creating immediate solutions. But after leaving the director position at the NIMH, he essentially talked to some other people and realized that there were better solutions. It’s hard to describe why it’s so weird to read, but basically imagine the head of the EPA realized later in life that meat was bad for the environment only after they left the EPA. Something about that just feels… weird. 3.5/5 stars rounded up to 4.
Want to read
June 6, 2025I don‘t like Insel because of his bullshit research domain criteria - i am a mental health nurse working in inpatient camhs and this bullshit lies will do harm to us & service users & psy* survivors!
July 30, 2023
Attaining mental health from pervasive mental illness presents a contemporary challenge to the American healthcare system. Decades of progress in the basic science have not resulted in progress among outcomes, sadly. This reflects a broader observation that scientific advances have not been accompanied by necessary social advances. After a lifetime spent bettering patients’ lives as a psychiatrist and researcher, Thomas Insel here points the way to what an America with true mental health would look like and to how we can get there.
As a former director of the National Institute of Mental Health (NIMH), Insel sat in a privileged position to see and direct federal expenditures for research into mental illness and mental health. In this book, he concludes that most of the therapies that we have indeed work; the problem is that the “social determinants of health” (in other words, your zip code) have a far greater impact than the treatments themselves. Today, limits to access and community/familial support matter more to good psychiatric outcomes than anything else. This points us how to focus our help better.
After a decade at the NIMH under Republican and Democratic administrations, Insel went west to California to help with innovative software projects in Silicon Valley that promise to disrupt how individuals receive diagnosis and treatment. Despite this technological effort and despite exploring biologic markers of psychiatric disease in the lab, he concludes that the social domain is where we need to concentrate future efforts and dollars. Our system simply does not reward practitioners for outcomes, only for giving treatment, and this needs to change.
“Mental health” is a buzzword in today’s news every time bad things happen. However, the popularity of these words is not matched by corresponding depths of exploration. Reading Insel’s book can change this. He’s balanced and realistic about the challenges that we face. Many books on mental health turn into opinion-based, semi-political diatribes that stray from scientific findings. This book does not. It informs and reasons first. Filled with patient stories, it is also approachable for those with mental illness or those affected by mental illness. Psychiatric patients – and who doesn’t know one these days? – can learn how to have better mental health themselves and to help their friends, neighbors, and family to achieve this, too. Coming from a psych patient myself, it’s high time we do something big about mental health, and Insel’s roadmap is one I can support fully.
As a former director of the National Institute of Mental Health (NIMH), Insel sat in a privileged position to see and direct federal expenditures for research into mental illness and mental health. In this book, he concludes that most of the therapies that we have indeed work; the problem is that the “social determinants of health” (in other words, your zip code) have a far greater impact than the treatments themselves. Today, limits to access and community/familial support matter more to good psychiatric outcomes than anything else. This points us how to focus our help better.
After a decade at the NIMH under Republican and Democratic administrations, Insel went west to California to help with innovative software projects in Silicon Valley that promise to disrupt how individuals receive diagnosis and treatment. Despite this technological effort and despite exploring biologic markers of psychiatric disease in the lab, he concludes that the social domain is where we need to concentrate future efforts and dollars. Our system simply does not reward practitioners for outcomes, only for giving treatment, and this needs to change.
“Mental health” is a buzzword in today’s news every time bad things happen. However, the popularity of these words is not matched by corresponding depths of exploration. Reading Insel’s book can change this. He’s balanced and realistic about the challenges that we face. Many books on mental health turn into opinion-based, semi-political diatribes that stray from scientific findings. This book does not. It informs and reasons first. Filled with patient stories, it is also approachable for those with mental illness or those affected by mental illness. Psychiatric patients – and who doesn’t know one these days? – can learn how to have better mental health themselves and to help their friends, neighbors, and family to achieve this, too. Coming from a psych patient myself, it’s high time we do something big about mental health, and Insel’s roadmap is one I can support fully.
September 26, 2024
We read this for a neuroscience book club I co-run, message me if you'd like our book report :)
In this book, Dr. Insel reflects on his decades-long career as a psychiatrist and former director of the National Institute of Mental Health (NIMH). The book is a candid exploration of the failures and successes of the mental health care system in America, emphasizing that while scientific progress in understanding mental illnesses has been significant, the system itself remains deeply flawed in its approach to treatment and care. Importantly, Insel argues that we already have the medical technology we need to treat people with severe mental illness effectively enough that the vast majority would have normal lifespans and lead productive lives. But that’s far from our reality today.
Insel argues that the mental health crisis is not just a medical issue but a broader human rights issue. He explains that the current system is more of a "mental sick-care" system, focused on crisis management rather than prevention and recovery. Despite advancements in neuroscience and pharmacology, people with mental illnesses, especially those with serious mental illness (SMI), continue to face high rates of homelessness, incarceration, and early mortality.
He offers many solutions, which include reducing the fragmentation of care (integrating behavioral health with health care more broadly, including insurance coverage), community support that involves social support from trained peers as a supplement to mental health professionals, stable housing, the use of digital tools for early detection and care, and many other simple solutions for which we already have the necessary technology.
Overall, Insel makes the very surprising case that if we increased commitment to solving the crisis of serious mental illness in America, we could do it very quickly with technology that already exists such that about 80% of severely mentally ill people would have normal life spans and a good quality of life. I found that tragic, as well as startling.
In this book, Dr. Insel reflects on his decades-long career as a psychiatrist and former director of the National Institute of Mental Health (NIMH). The book is a candid exploration of the failures and successes of the mental health care system in America, emphasizing that while scientific progress in understanding mental illnesses has been significant, the system itself remains deeply flawed in its approach to treatment and care. Importantly, Insel argues that we already have the medical technology we need to treat people with severe mental illness effectively enough that the vast majority would have normal lifespans and lead productive lives. But that’s far from our reality today.
Insel argues that the mental health crisis is not just a medical issue but a broader human rights issue. He explains that the current system is more of a "mental sick-care" system, focused on crisis management rather than prevention and recovery. Despite advancements in neuroscience and pharmacology, people with mental illnesses, especially those with serious mental illness (SMI), continue to face high rates of homelessness, incarceration, and early mortality.
He offers many solutions, which include reducing the fragmentation of care (integrating behavioral health with health care more broadly, including insurance coverage), community support that involves social support from trained peers as a supplement to mental health professionals, stable housing, the use of digital tools for early detection and care, and many other simple solutions for which we already have the necessary technology.
Overall, Insel makes the very surprising case that if we increased commitment to solving the crisis of serious mental illness in America, we could do it very quickly with technology that already exists such that about 80% of severely mentally ill people would have normal life spans and a good quality of life. I found that tragic, as well as startling.
December 29, 2024
In “Healing: Our Path from Mental Illness to Mental Health”, Dr. Insel draws on his experience as the former director of the National Institute of Mental Health to discuss the state of the mental health care system in the United States. Insel makes a startling and energizing assertion: that the vast majority of mental illness in the United States (about 80%) would be treatable – leading to normal lifespans and good quality of life – if the U.S. healthcare system chose to invest in and utilize the existing evidence-based practices for the treatment of mental illness.
Unfortunately, our system of “mental sick care,” which focuses on crisis management, is not an effective solution. Insel tells us what the solutions are: more integration of care, community support involving trained peers, stable housing, tools for early detection, and using evidence-based practices rather than using practices that have less support. Pervasive stigma of mental illness seems to get in the way of progressive change, and it’s a tragedy.
Unfortunately, our system of “mental sick care,” which focuses on crisis management, is not an effective solution. Insel tells us what the solutions are: more integration of care, community support involving trained peers, stable housing, tools for early detection, and using evidence-based practices rather than using practices that have less support. Pervasive stigma of mental illness seems to get in the way of progressive change, and it’s a tragedy.
October 3, 2022
I keep trying to write a review and I don’t have the right words for this one. It meant a lot to me to read my own family’s experience so vividly. And to feel less alone. But also it brought up most of my continual grief over what mental illness has taken from my family. Overall I loved it so much and think it should be required reading for every American. Especially those have haven’t experienced severe mental illness first hand. Thomas Insel has so much experience around mental health care and the policy side of things and has worked in the thick of it for over 4 decades so I really appreciated hearing his insight. And I wholeheartedly agree with his advice. Please read!!!
March 19, 2023
Good book with some good quotes, but nothing groundbreaking in it. All of Insel's thoughts and ideas have been reported before (or maybe I just pay attention to this topic). I also think he misses the mark on a lot of what mentally ails us as a country (though touches on it in a DEI way) trauma. Those with mental illness are traumatized by a myriad of life events. He also barely mentions substance use - a huge driver of trauma and mental illness. A good book if you don't work in the mental health field already (i.e. lay people).
April 2, 2025
Luettu englanniksi: kansankielinen, mutta pitkälti mielenterveysalaan tai politiikkaan perehtyneiden kirja mielenterveyshoidon haasteista ja mahdollisuuksista erityisesti Yhdysvalloissa. Kirjan tarinaa ja asioiden tärkeyttä on tuotu hyvin esiin "keksityin", oikeisiin henkilöihin ja kirjoittajan perheseen liittyvin esimerkein. Inselin kokemus, tieteellisyys, ymmärrys, humaanius sekä toiveikkuus tulivat erinomaisesti esiin. Vahva suositus mielenterveystyötä tekeville tai mielenterveyspolitiikasta kiinnostuneille, mutta lisäksi mielenterveyden haasteiden kanssa kamppaileville ja heidän läheisilleen.
October 23, 2023
enlightening! a really helpful guide for a system whose goal should be to provide effective, person-centered, recovery-oriented, wrap-around care to folks who are impacted by mental health. our path forward moves beyond the the healthcare system and into society where one's overall health and wellness is defined by social determinants of health.
March 19, 2025
Interesting approach on what is wrong with today's mental health crisis. This book talks about what's wrong with our sick care system and how it's not built for people with SMI. Although, I hoped this book would give me more hope and tools to heal SMI, it was more about tired treatments that don't really work for most. (He includes how the majority of treatments just aren't sustainable for true healing)
January 20, 2026
This book touches on the evolution of mental health and mental illness over the years from a doctors standpoint, as well as an in depth personal analysis of his education and all of his years as a practicing doctor. Worth the read and very informative!
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