728 18 FEBRUARY 2022 • VOL 375 ISSUE 6582 science.org SCIENCEPHOTO: LEXEY SWALL/THE NEW YORK TIMES/REDUXBy Benjamin F. MillerT
he United States’ failings concerning
mental illness are well documented.
Despite decades of grim data, mean-
ingful change to this aspect of hu-
man health has, as yet, failed to
materialize. Somewhat paradoxi-
cally, this lack of progress has occurred
during a period in which the science that
has helped shape our understanding of
mental illness has increased drastically. As
Thomas Insel writes in his book, Healing:
Our Path from Mental Illness to Mental
Health, we are stuck.
Insel is well positioned to describe the
pervasive mental health problems plagu-
ing our nation. He has held several rel-evant leadership positions, serving, for
example, for 13 years as the director of the
National Institute of Mental Health, and
his commitment to advancing scientific re-
search drives much of his thinking. In this
book, Insel looks back at the evolution of
our understanding of mental illness and
forward to the next chapter in this story.
The book’s first section, “A Crisis of Care,”
documents how the United States has tra-
ditionally approached mental health care.Here, Insel outlines both the structures
and foundations on which we continue to
build and reform mental health.
From care delivery systems that separate
mental and physical health to siloed pay-
ment models, the fractured treatment of
mental illness—and frequently comorbid
conditions such as substance abuse and
addiction—has been all but codified in US
policy. Adding to this complexity is a lack of
attention to community factors and to pre-
vention, both of which seem to have been
an afterthought in the creation of the sys-
tem. Insel returns frequently to this theme
throughout the book—and for good reason:
You cannot improve mental health outcomes
if you do not address the underlying factors
that cause and exacerbate mental illness.At times, the reader can feel Insel’s frus-
tration in the anecdotes and stories he relays
and in the phrasing he uses. The movement
to “deinstitutionalize” the mentally ill, he
notes, for example, might be more accurately
described as “transinstitutionalization,” be-
cause “policies that limited hospital access
for people with mental illness created an on-
ramp to the criminal justice system.” These
recollections give depth and provide a hu-
man face to the problems he articulates and
offer hints at possible solutions.
“Overcoming the Barriers to Change,”
the book’s second section, elaborates on thethemes explored in the first but views them
through more contemporary lenses. Major
topics here include reimagining crisis care,
addressing gaps in quality, and moving be-
yond stigma.
Like a good doctor, Insel identifies symp-
toms and prescribes solutions to the prob-
lems that plague the country’s mental health
infrastructure, but he maintains that holistic
strategies are needed. “I argue that we need a
medical approach to define the problem, but
social and relational approaches to solve it,”
he writes.
For mental health, Insel posits, our tradi-
tional approaches usually come too late in
the process; they are applied infrequently
enough that improvement is not guaran-
teed; and in some cases, our solutions are
focused on the wrong problems. Greater at-
tention must be paid to “people, place, and
purpose” as the keys to recovery, he writes.
Insel makes his most forceful arguments
in the book’s third section, which sketches
potential paths forward. Here, the reader
perceives most acutely a tension that under-
lies the rest of the book: Medical treatments
and traditional care delivery are important,
but they are wholly insufficient for address-
ing the size and scale of the mental health
crisis. Without a more thoughtful approach
that better integrates mental health into
health care structures and communities, we
perpetuate the same flawed silos that have
kept us stymied for decades.
“At the beginning of my journey, I already
recognized that none of these massive social
challenges would be solved without fixing
the mental health crisis,” Insel notes. “By the
end of my journey, I was convinced that the
mental health crisis could be solved, but not
without taking on these social challenges.”
In the book’s final section, titled “The
Way Forward,” Insel maintains that “mental
health has become a measure of the soul of
our nation.” If this is true, then our coun-
try’s soul is in a decidedly bad place. Heal-
ing suggests a path toward a better one. j10.1126/science.abn8143HEALTH POLICYMaking progress on mental illness
A former NIH leader advocates more holistic approaches to mental health care
Healing: Our Path
from Mental Illness
to Mental Health
Thomas Insel
Penguin, 2022. 336 pp.Mental health care must be better integrated into health care structures, argues Thomas Insel.INSIGHTS | BOOKSThe reviewer is president of Well Being Trust, Oakland, CA
94612, USA. Email: [email protected]