The Universe in a Box: Models of Mental Health

(Note: I'm an accountant. I have lived experience with mental health conditions, curiosity, and a desire to do my part to spread love and healing in the world, but I'm not a mental health professional in any form. I share experiences, information, and ideas - mostly borrowed ones - in hope that they may be of help to others stepping onto, or already on, their own healing path, based on their own body of learning and support from the professionals that they connect with. Nothing below is advice, just my musings. I always welcome any counterpoints or corrections.)

How can we talk about mental health in a way that resonates broadly?

The basic premise of mental health seems fairly simple: humans seek to be in a state of mind where we're able to communicate, work, play, learn, grow, and contribute as our unique selves, with a reasonable degree of happiness, and free from excessive or chronic distress.

The details, however, are a little trickier. What does it feel like to be in an ideal state of mind - moment to moment, and over longer periods? What about when we're not? What should we do to maintain mental health? Is mental health just about not having a diagnosed mental health condition? What is distress, and how much is too much? What is dysfunction, and how much does our definition of dysfunction depend on social norms? And what is the "self", anyway?

We're dealing with the human body and brain, an incredibly complex system which we're far from fully understanding, and consciousness, a phenomenon we experience but often struggle to describe, much less explain. Professionals devote entire careers to studying niche areas of psychology, trauma, or neuroscience. It seems impossible to wrap our heads around mental health in a complete way.

And yet understanding our minds lies at the core of the human experience as we strive to "become who we are", achieve our individual versions of equilibrium, and live authentic lives where we show up for ourselves and our communities .

So how can we talk about mental health in a way that promotes self-understanding, interpersonal common ground, and improved outcomes? What might we change about the discourse around mental health that could stem the rising tide of mental distress in our society?

Primary goals of mental health programming

Breaking down that initial premise a bit further, we could attempt to categorize, at a very high level, what we're trying to achieve and who it applies to.

The primary goals of mental health programming - whether thinking at the level of the individual, family, organization, or society - could be set out as:

1. Promote good mental health.
2. Prevent mental health conditions (disorders, illnesses, challenges, episodes, etc.) from occurring.
3. Treat mental health conditions when they do occur.

There are many more sub-objectives in service of these goals (increasing awareness, reducing stigma, ensuring accessibility and equity, developing a workforce of mental health professionals, etc.), but these seem to be at the core of what we're after. Now, who are we aiming to support with each of these goals?

1. The first goal encompasses everyone.
2. Some might consider the second goal to do the same; others might think about preventing mental health conditions only in a subset of the population considered to be predisposed to them.
3. The third goal appears, on the surface, to apply only to those who are diagnosed with mental health conditions.

This stratification can lead to a division in many people's minds between people who could or do experience mental health conditions, and everyone else. Individuals who aren't in the group that could or do experience mental health conditions may consider mental health only very generally applicable to them.

While an understandable position to adopt, especially given how Western society has talked about mental health in the past, this binary view has negative impacts.

Disordered, or not?

I'm not alone in that I first experienced the realm of mental health through the lens of psychiatric disorders. In my late teens, a major depressive episode led me to finally seek treatment, and it dawned on me that what I'd been experiencing throughout childhood wasn't "good mental health".

I'll refer to the model of care that I received as the "medical model", recognizing that it leaned toward a more traditional application of psychiatry where disorders are treated as illnesses akin to physical ailments. Psychiatry is evolving and there are diverse applications of it, so I won't use the term "psychiatric model", which, today, doesn't refer to a single methodology - different psychiatrists may have widely different approaches, with some still using a traditional "diagnose-and-prescribe" model mainly focused on medication, and others incorporating more novel modalities such as trauma-informed care and humanistic and existential care practices.

My initial experience of the medical model was that, after getting over the fear and self-stigma of a diagnosis, it was helpful to place structure around my condition. I was able to relate to others with my diagnoses, let go of a little bit of the shame around my past behaviour, practice therapeutic exercises and coping tools, and study what was going on more deeply. I worked with a psychologist, was prescribed medication, and read technical literature. There was some relief, and I began laying a foundation of self-understanding.

But as the months and years progressed, the medical model felt less and less effective for me. The version of care I experienced seemed to focus heavily on managing symptoms, not fundamental change - and my symptoms, while sometimes reduced, remained highly variable, continuing to include periods where my ability to function effectively was compromised and my physical health was threatened. I really didn't want to be on medication for my whole life; it made me feel like someone other than myself. I still felt incomplete and at risk, was searching for something, and had a nagging sense that there was deeper work I could do to achieve lasting change.

One of the pitfalls of the medical model is that it supports that binary thinking around mental health: either you have a disorder or you don't. While many professionals deal with mental health with more nuance these days, for a lot of the general public this remains the basis of their perspective of mental health. It was my frame of reference for many years, and limited me from understanding myself and seeking care in broader ways.

This is not to say we should do away with the Diagnostic and Statistical Manual of Mental Disorders (current version DSM-5-TR, but I'll just call it DSM-5 in this article), although some think it needs a major overhaul . It can be useful, sometimes critical, to define mental health conditions so they can be appropriately treated.

But it's also helpful to take the medical model in context and think about how it interacts and contrasts with other frameworks, understanding that it is only one of many ways to understand mental health, and that it has limitations and drawbacks .

Opening the door to a human lens

Given our limited understanding of the complex thing we call the mind, even if we somehow developed technology to fully map an individual person's consciousness, we might yet struggle to synthesize and act on the vast amount of information that would yield. Yet it's essential to have an image of what we're working with in order to improve mental health.

We're therefore required to create reductive abstractions of the mind in order to understand and improve its function. We do this in many different ways: grouping sets of behaviours, isolating biological factors, categorizing thought patterns, creating symbols and metaphors.

The medical model is one such human-constructed abstraction of the mind. While useful, it is, to a large degree, arbitrary: different reorganizations or thresholds of diagnostic criteria could be empirically supported in the same ways the current ones are, and the underlying premise that variations in human cognition and behaviour are pathological can be challenged .

Its binary diagnosed-or-not nature also raises the question of at what point the severity of symptoms reach the level of a disorder (the fuzzy borders problem), and what to do when someone is almost but not quite at the point of diagnosis, or trending toward being there, or stably at some lesser fraction of meeting the criteria for a diagnosis but nonetheless dissatisfied with their mental wellness and seeking improvement.

And then there is the question of treatment: a medical model typically considers the condition to be an illness, with drugs and mechanical therapies applied accordingly; the goal is to modify the brain's structure and neurochemistry, in fairly linear fashion. While our biology obviously underpins our mental state, this approach leaves a gaping hole in care, because our minds are not simply machines to be tinkered with. They give rise to our consciousness, emotions, drives and desires; they seek meaning and connection. They interact with our environment, culture, and other minds in complex ways. They can even be understood to exist beyond our physical body.

Many, if not most, people seeking mental health treatment have experiential factors they seek to work through - trauma, life circumstances, relationships, connection to community, purpose, environmental factors, memories, stories - with a recognition of their uniqueness, an attempt to find their place in the world, and with a supportive care that will allow the mind and body to go to difficult places where healing can occur.

I came to realize I felt something troublingly nihilistic and incomplete about any practice that reduced existence to the particular arrangement of particles in my physical self. There was something deeply embedded in me that medications and behaviour-change exercises, while useful supports at times, simply could not access or modify. Ultimately, I found the medical approach to care to be lacking a recognition of my humanity that, for me, was critical to finding a path of wellness.

It was only when I stumbled upon practitioners and practices that really saw me, in all my messy humanness, that my protective parts could finally let their guard down and allow me to go deeper within. I don't think it was coincidence that these were the first practitioners who were deep into their own self-work, holding the capacity to offer unconditional love to others. This is where I discovered healing, understanding, and lasting change.

I find it hard to see how we could separate a comprehensive view of mental health from fundamental questions about who we are and how we interact with each other and our world. The specific questions may vary from person to person, but they recognize that we're conscious creatures seeking meaning, each with valid experiences and perceptions that shape who we are.

Supporting commonality: the continuum approach

We experience many thoughts and emotions associated with worse mental health - such as worry, disordered thoughts, and apathy - on a spectrum of intensity. They are not on-or-off experiences, and their intensity changes over time in response to factors both internal and external. Our overall experience of mental health thus also occurs on a continuum, and many policy and treatment frameworks have shifted toward this approach.

This approach is not to diminish the experience of severe mental health challenges, or to equate everyday emotions such as sadness or worry with persistent, debilitating depression or anxiety. I've been hospitalized as a result of my past mental health, and I've stared death in the face as then-unembraced parts of me demanded that I end the pain for good - I don't take severe mental health conditions lightly. A continuum does not mean everyone is the same, or should receive the same care - but it does help open the door to normalizing the receiving of care, reducing stigma, and finding common ground.

The continuum illustrates that individuals with persistent characteristics of mental health challenges (such as intrusive thoughts, periodic episodes of intense negative emotions, episodic or lower-level anxiety, and even delusions) can still experience high levels of overall mental wellbeing, and individuals who normally don't experience such challenges can go through periods of low mental wellbeing. The continuum is sometimes represented as a one-dimensional spectrum between fitness and illness, or functioning and disordered, but this still contributes to binary thinking because it is often assumed that everyone within a range of the "severe symptoms" end of the spectrum has a mental illness.

Including the second dimension better reflects the all-encompassing, temporal nature of mental health and reduces the dichotomy between those with a psychiatric diagnosis and everyone else, while still recognizing that people have varying susceptibility to experience lower levels of mental wellbeing, and may require more or less support to achieve optimal wellbeing. (A two-dimensional model remains a vast simplification of the human condition, of course. How we actually experience the world and aim to thrive is multidimensional and complex, with no two humans identical - further supporting that we don't neatly fall into buckets of mentally unwell or not.)

I also remove the necessity of a psychiatric diagnosis toward the left side of the graph, recognizing that not everyone who experiences serious persistent mental health challenges considers themselves to have a mental disorder or has been diagnosed with one, and some may reject the diagnostic model outright.

Included on this graph are a rough estimation of how I've moved on the continuum from my lowest point of mental dysfunction/distress to where I am today, plus two hypothetical other people. These are to illustrate two things:

1. Attending to mental health can contribute to sustainable reductions in persistent challenges (and increase persistent positive characteristics, such as focus and emotional regulation). It can, but does not always, move us toward the right of the continuum, not just upward. (A little-mentioned component of the DSM-5 framework is that an individual patient can have a diagnosis removed if care leads to lasting change.)
2. Attending to mental health can be of significant benefit to people regardless of where they begin on the continuum. Someone who has never experienced depression, anxiety, or disordered thoughts, and is feeling relatively good and performing well, may yet have much to gain. Improved sense of purpose, deep experiences of joy, abatement of anger, reduction of nicotine and caffeine intake, and enhanced connection with family, friends, and colleagues are but a few examples.

With these points in mind, our view of mental health programming could look like this instead:

This is not to say that all people require work on their mental health - some people are well satisfied with key aspects of themselves, their relationships, and their lives. It is to point out that there are many available benefits to mental health care, beyond treating disorders or other categorizations of poor mental health, that can better our lives and communities.

The pathway to peace lays beyond my pain and fear

Like many folks I know, I grew up in an environment that prioritized toughness, emotional suppression, academic achievement, and intense competition. There was little inquiry within or exploration of existential questions in my childhood. The drive to be "the best", to accumulate prestige, and to conform to arbitrary structure were maxims of the day, and focusing time on feelings was considered childish and the concept of "finding yourself" openly mocked.

An attempt is sometimes made to subjugate emotion and rationalize a materialist view of the world. Vulnerability is weakness, happiness is derived primarily from utilitarian resource accumulation, spirituality is nonsense, everything can be reduced to logic and scientific observation; so the materialist view often goes.

The problem: at least in the realm of human thriving and suffering, these axioms don't seem to be true. We're ultimately driven by deeper motivations than unfettered instincts for survival; instincts which can lead to hoarding and dominion. Those of us who steel ourselves and set out on quests to complete ourselves through accumulation may come to realize, once we've hoarded and dominated awhile, that the hole in our soul remains unfilled, and only when we turn to the subtle yet profound do we find that meaning was there all along.

Suddenly, I saw the love in the process of learning and innovating, in the little moments with close ones, in the beauty always around me, in the messy dance through which humans advance the world. I now know there is no end game where I will achieve completeness, no point at which I'll have achieved and acquired and experienced enough to say, "I'm done now". I'm never done, yet I have always been enough. I have always been complete - tough emotions and all.

I think this is true for everyone. Quoting Aldous Huxley, "Our goal is to discover that we have always been where we ought to be. Unhappily we make the task exceedingly difficult for ourselves." (I acknowledge that there are people in the world facing war, hunger, poverty, and subjugation for whom such a goal may seem a privileged luxury. My hope is that by realizing it for myself, I will be better equipped to play a part in relieving others' suffering.)

As I peer back on the attempts of behaviourist movements of the 20th century to deny the importance of emotion, they seem more than a bit absurd. We receive huge amounts of sensory data in each living moment, and even if we had a meaningful internal computational framework of rationality, it is impossible to process and be cognitively aware of all of the data in order to always make rational, conscious decisions about everything we do.

While rationality has contributed to many positive human advancements, we rely on emotions to drive much of our behaviour. Pretending that I didn't experience sadness or fear, and that they didn't drive my behaviour, didn't make it so - it only meant that I was unaware of myself, and prone to unexpected and often suboptimal actions that I was all-too-capable of rationalizing away (often by blaming others).

The human societies which have followed a path of industrialization and domination of the natural world for the past few centuries, which have accumulated the most material wealth, which live with luxuries that would have been unimaginable to people alive not long ago, are the societies now looking around asking, "Why are we in such distress? Why are we so divided? Why are we so angry?"

I was angry, I was divided, and I was in distress because I was afraid, and sad, and hurt, and denying all of those facts. And I was afraid, and sad, and hurt not because I'm weak or pitiful, but because I am a human being and these are fundamental components of our existence. Distress persisted because I didn't have the tools to deeply feel, and process, pain that I'd endured, or express things I was afraid of - so I buried pain and fear deep inside, where they stewed and amplified and expressed through anger, addiction, and unbalanced pursuit of achievement.

I'm not alone in this experience. Denying our our emotional - and spiritual - nature appears to have left many of us with wounds, which are also manifesting at the level of society.

Recognizing and attending to our emotional sides does not render us weak, docile, or ineffective - precisely the opposite. The ability to deeply feel emotion provides agency to respond to difficult circumstances with equanimity, to connect with intuition and align our pursuits with our core values, to work with focus and intrinsic motivation. While we may deeply fear it, this process doesn't explode our being and replace us with some unpredictable new entity; it removes masks and barriers and allows us to move closer to who we already truly are within.

For me, the practice of reconnecting with emotion and allowing myself to finally, deeply feel some of the most difficult things I had suppressed has been long, winding, and both excruciating and beautiful. It's involved work, some hard looks in the mirror, and good fortune in being introduced to caregivers who I connected with and who offered high quality care. It has strengthened my love for the things I'm passionate about - my family, my work as a CPA, athletics, creative pursuits - and helped me set aside things I was doing for the wrong reasons. It hasn't been easy, but it's been worth it, and my wish is that others who seek it can have their version of the same experience.

A perpetual, omnipresent model of mental health

I don't think there can be any magic, get-fixed-quick solutions to mental health. Healing and discovery of our authentic selves is a lifelong journey, and something, for me, that is worth committing to for the long haul. My hope is that one day our education system will place more focus on setting our kids on this path, and that emotional awareness, spirituality, and humanist and existential inquiry will be part of our normal discourse.

The many, varied mental health care modalities (diving into which is a post for a future day) take different approaches to abstracting core components of who we are. None can be said to be an all-encompassing version of "truth" that describes the universe of the human mind - but each can help lead us to our inner truth. We can find the care practices and practitioners that resonate with us, and they can help us work toward living in alignment with our authentic selves, and offer a practice that can be used throughout our lives to heal, and maintain balance, focus, presence, and peace. I think it's worth expanding care in its various forms so that it's accessible to everyone. I think everyone is worthy of it.

The basic components of human wellness are rightfully touted as foundational to mental health. We ought to all have shelter, healthy food, adequate sleep, sustainable levels of stress, exercise, financial security, and access to spiritual supports (much more work remains, obviously, to make this a possibility for all people).

An important nuance, though, is that when we are hurting, it is more difficult for us to provide these things to ourselves. We're more likely to stress eat, throw off our sleep with weekday wine, skip the gym for overwork, and seek material comforts, not due to failures of willpower or moral adherence, but because we're hurting. It's through tending to ourselves that we achieve the healing and inner alignment that leads to simply enjoying doing things that are good for us. They are no longer chores or constant inner battles, they just become the natural order.

So, returning to our theoretical primary objectives:

1. Promote good mental health.
2. Prevent mental health conditions (disorders, illnesses, challenges, episodes, etc.) from occurring.
3. Treat mental health conditions when they do occur.

Perhaps we can think about these objectives in a more integrated way, where we are always in a practice of caring for ourselves and supporting the care of others. Where care may intensify when someone is in particular distress or is ready to take on difficult self-work, but where care exists in an ebb and flow that never ceases. Where the process of living authentically is one and the same with bettering our mental wellness.

We may have beautiful, interesting, exciting domains of our minds waiting to be discovered. We may have tender parts that are worthy of being held. We may carry guilt that, with guidance, can be gently put down. We may have deep emotional wounds that can be healed. We all have the capacity to grow the connection within us, and radiate that outward.

Such care may not only significantly improve our individual lives, but also give us tools and capacity to lift others in deeper and lasting ways, to build understanding of people who are different from us, and to enhance clarity in addressing the complicated problems the world faces today.

For me, the pathway to peace lay beyond my pain and fear. I'll remain on that pathway for the rest of my life, learning and discovering myself and the world, doing my small part to leave things better than I found them. I'll never have all the answers, but I'll know for certain that I am, and always have been, everything I'm meant to be. That I am whole, even though I have wounds.