Opinion | A Top Mental Health Expert on Where America Went Wrong


ezra klein

I’m Ezra Klein. This is “The Ezra Klein Show.”

Before we begin, the researcher position is closed. We’re going to go through the applications, and if you applied — and thank you so much if you did — you’ll hear from us within the next few weeks.

OK. But today, let me just begin with a question. How are you? How are you right now? It’s so rote, right? I know the answer to that. I’m fine. I’m OK. Pretty good. That’s typically my answer if it’s true or not. Someone asked me a version of that question recently, and before I answered they said, stop to sit for a moment. Really how are you? I was almost mad at them for that. I don’t want to have to actually feel how I was in that moment or think about what it meant.

A lot of people aren’t great right now. In America there’s a death by suicide about every 11 minutes. About half of those people receive no mental health care whatsoever before taking their own life. Almost a fifth of American adults now have a prescription for a drug that is treating a mental health issue. It seems almost stranger right now to feel well than to not. Mental health in this society, in this economy? And so there’s this weird tension here. More people are being treated for mental health issues than ever, but outcomes are not getting better. We have a crisis of mental illness, but we also have a crisis in mental health care.

And Tom Insel should know. He was a director of the National Institute of Mental Health for 13 years. He was a Special Advisor on Mental Health Care to Governor Gavin Newsom in California to the point where he got called California’s Mental Health Czar. But his new book, “Healing,” is about how badly we’re failing at mental health care and how much more we could do with what we already have, what we already know. He writes, quote, “The mental health problem is medical, but the solutions are not just medical. They’re social, environmental, and political.” So what are they? As always, my email if you have guest suggestions, feedback, recommendations for things we should read, or hear, or see, ezrakleinshow@nytimes.com.

Tom Insel, welcome to the show.

thomas insel

Great to be here. Thanks for having me.

ezra klein

So let’s start here. What do you think the prevalence of mental health issues in the country is right now?

thomas insel

If you use the government statistics that we have, the epidemiology says that one in five people has a form of mental illness. I don’t think that’s a helpful number because a lot of that is spider phobias and more minor issues that probably don’t really impair the way people function. But if you ask how many people have serious mental illness — that is mental illness defined by some kind of disability, schizophrenia, bipolar illness, severe depression, PTSD — it’s about 1 in 20.

That’s a fairly large number, and that’s for adults. When you look at kids, the numbers are a little bit higher. So these are more common than we might think, and it’s probably fair to say, as I say in the book, that every family is dealing with mental illness now or soon will, that there are really only two kinds of families, those dealing with this and those who aren’t dealing with it yet.

ezra klein

And is that number stable? Is it changing over time?

thomas insel

Well, that’s an interesting question, Ezra. It turns out that, when you look at the adult numbers, it’s really — in spite of the sense that we have a crisis going on, the prevalence hasn’t changed that much. The prevalence of schizophrenia and bipolar illness is about what it’s been for decades.

There is an increase in depression and anxiety in adolescents and in people under the age of 24. Those numbers are going up. They start going up about 2005, 2007, and they’ve continued to climb. And of course, the pandemic has pushed them up considerably more.

But this is a useful question because we need to think about the crisis not so much as a crisis of prevalence or what epidemiologists would call incidence, which is the change in prevalence over time. It’s really a crisis of care. So serious mental illness — about 14.2 million people in the United States affected. That number has gone up a little bit, not much, over time, and yet our ability to help them recover has gone down, not up.

ezra klein

Before we go to the crisis of care question, I do want to hone in on that issue of at least apparently rising mental illness and just suffering among adolescents. So we do seem to see a rise in depression and anxiety.

And when I began seeing that data, my first instinct was to say that we have made it more socially acceptable to report. I think we’re much more open with anxiety and depression than we once were. But we’re also seeing more suicide attempts. We’re seeing more self-harm. We’re seeing data from emergency rooms, functionally. That makes me pretty convinced something real is happening there. So how do you understand that rise?

thomas insel

It may not be one thing. I think you can have multiple factors feeding into this. And part of it is that there is, if you will, less stigma amongst young people to talk about these issues. Increasingly this has become part of the culture, and it’s part of what they do want to talk about.

I was doing an event in Los Angeles earlier this year, and I asked a group of young people, is this something you can talk about with your friends? And they said, oh, absolutely. It’s all we talk about. We just can’t talk about it with our parents.

So there is a generational change there, which I think is part of this effect.

But let’s be clear. There is really something else going on, that more kids are actually not only just coming for help but needing help in a serious way. It shows up mostly in the data that we have from emergency room visits for eating disorders, clearly up during the pandemic, strikingly up. These are disorders that affect adolescents across the board.

The other place where I think we’re seeing continued increases are more in the sort of social anxiety syndromes for boys, which is up. And I must say, I was just looking at some data from Crisis Text Line, which is this terrific online service nonprofit, and 50 percent of their crisis calls or crisis text requests out of 1.2 million last year — 50 percent were from young people who identified as L.G.B.T.Q. So that population in particular is struggling in a way that we need to start to really understand more deeply.

ezra klein

And there’s an actual rise in suicide more broadly across the United States. Something that you write in the book which I found very striking is that suicide numbers in the United States have been going up when in many of our peer nations they’ve been going down.

thomas insel

Overall the numbers are — from about 2000 to now, suicide’s gone up. Suicide mortality has gone up about 30 percent in the United States. Globally it’s down about 18 percent at least in Western nations, so the U.S., as we’ll talk about, is exceptional in a number of ways. And that’s one of them.

We really have not seen the suicide rate going down until the last couple of years, oddly enough. During the pandemic the numbers have going down slightly. It’s not clear yet whether that is a real decrease that will be sustained, and it’s not in all populations. The numbers actually have gone up for young people of color during the pandemic.

ezra klein

Is mental illness contagious?

thomas insel

It is not contagious, and we should probably take a moment to talk about what is mental illness and what is mental health. And third bucket is one his mental health care because those are three very different things. So mental illness, as we’ll talk about it here, is a set of disorders recognized by kind of a consensus definition of symptoms.

And all of those disorders share a few things. They’re all about subjective experience of suffering in some deep way. Broadly, they’re anxiety disorders, mood disorders, psychotic disorders, eating disorders and then there’s sort of attentional disorders like A.D.H.D. There are a few others, but that captures a large part of what we’re talking about in the mental illness category. And I do like the term “mental illness.” I think that’s a useful construct, although not everybody agrees.

Mental health — what is that? Well, Freud defined mental health as the ability to love and to work. I don’t know if that’s the right definition. We argue about where the continuum is, how you measure that.

But what’s interesting to me is that Freud’s original definition doesn’t talk about happiness, doesn’t talk about success. It just fundamentally keeps it simple. And he talks about it as an ability or a capacity, which is kind of an interesting way to go after it. I think there’s some validity to that.

And I think that one of the ways in which our conversations about mental health, and health in general have been, I’ll just say, biased or kind of off target is that if you and I start talking about health of any sort, pretty quickly we’ll be talking about health care. And yet if you look at the data that increasingly is beginning to come out of many sources, it’s clear that health care predicts a very limited part of health outcomes.

Health itself, the outcomes in health — and this is true for mental health as well — are much more about where you live, who you live with, how you live and much less about how many clinic visits you have, how many medications you’re on, how many surgical procedures you’ve had. All of that may be part of it, and I think many people would say it’s 10 percent to 15 percent. But it’s a really interesting discussion, I think, that we need to have as a nation to understand health as something different than health care.

ezra klein

So this is very much a favored topic of mine, but I want to put a pin in it because you went off of something I’m interested in a little too quickly. I’d asked you about whether or not mental illness is contagious, and the reason I did is that, on the one hand, depression isn’t contagious in the way Covid is. You don’t sneeze on somebody and they get depression.

But we do seem to know that at least certain terrible things that I think of as related to mental illness are contagious. We know that suicide can be contagious if people see more presentations of it, if it becomes more normalized in society. We know that certain kinds of violence are contagious.

And something I’ve wondered about, particularly seeing the rise in anxiety and depression among adolescents and eating disorders, is whether or not we should understand that as a kind of contagion. There’s one way of saying, we’re either looking at a policy failure or a set of social conditions that have become, I guess, anxietyogenic, for lack of a better term.

And I suspect that’s true. I tend to be a believer that, among other things, social media is creating a lot of anxiety but that these things can also create their own momentum. And so you said pretty quickly that it’s not, so do you think that way of looking at it is wrong?

thomas insel

Let’s take a case example because it was curious to me about why eating disorders would have gone up as much as they have during the pandemic. You could imagine a lot of things going up, but why that? And I’ve gone to a number of experts to ask them that question, and I don’t know that anybody has a definitive answer, I think. When we’re looking at pandemic effects, we’re still collecting data and still trying to understand what’s driving what.

But there are two answers that I was really intrigued by. One was an academic who said, kids with eating disorders are very stress-sensitive. They’re like the canaries in the coal mine. And so when you have stress increasing in the population, you’re going to see it more there than anywhere else. They’re going to carry the social stress, and they’ll play that out in the way that they lose weight and the way that they handle themselves.

The second explanation which I thought wasn’t competitive but was kind of interesting was that somebody who said that during the pandemic kids were spending much, much more time on social media. And social media, while it may not cause eating disorders, is absolutely an accelerant. There’s lots of sites that girls can go to and not just girls, but where they can find out how to lose more weight more quickly.

And so one of the concerns is that what we’ve seen during this time is simply people getting much sicker much faster than what had been happening before the pandemic, which is why so much of this shows up in the E.R. data rather than in other kinds of prevalence data.

ezra klein

One thing this, I think, brings us back to is something you were beginning to touch on a few minutes ago, which is the fairly low proportion of health outcomes and mental health outcomes that can be attributed directly to health care and to mental health care. You say in the book that “health care itself explains only about 10 percent of health outcomes. The same is true for mental health.” I’ve looked at this data lot over the years. I wrote a piece years ago when I was at “The American Prospect” called “Health Care, not Wealth Care,” and the point is that a tremendous amount of our political conversation about health care and health is actually just about health insurance. It’s just about how we’ll pay for the health treatments people get, not about the things that drive their health.

One thing that I have found when I try to dig into that data is it’s pretty quick for people to tell you what happens in a hospital, mental or otherwise, is a small proportion of what drives health outcomes. But when you say, OK, well, how do you break down the rest of it, the disagreement gets really sharp really fast.

So we know that it’s not primarily what happens in doctor’s office, but how you understand what is happening in the broader society does become important. So on the mental health side, when you say we have a crisis of care, when you say we have begun failing to create the conditions for people to thrive mentally, how do you begin to layer in the causes?

thomas insel

Yeah, well, that’s kind of why I wrote the book. On the one hand, we’ve made so much progress. We actually have come to understand an awful lot more about these disorders, and we have really good treatments, medications, psychological treatments, rehabilitative care. We know what to do, and those things work, right?

So when you talk to providers, as I did, most of them say, yeah, we’re doing better than ever, and yet when one looks at the population data, it’s going all the wrong ways. You’ve got more suicides, as we mentioned. We’ve got more morbidity, more disability. You have more people with mental illness incarcerated, more of them homeless.

So how did those two things add up? And that’s really what drove me to try to work on this. What it comes down to is kind of just what you were saying, Ezra, that, in a sense, the problem is medical, but the solutions are social. They’re relational. They’re environmental. They’re political. There’s a bunch of other things in play here that don’t get captured by the way we measure health care as just a medical problem.

ezra klein

Compare society today and 50 years ago. Socially, is this a better or worse society for people’s mental health or, if you think this is a separate question, for people with mental illness?

thomas insel

It’s a separate question. I’ll take the second one first. I’m old enough to remember what it was like for people with mental illness in 1972. That’s when I was in training, so I have a pretty good sense of what that was like. That’s when I decided to go into this field.

And I decided that because it was pretty exciting. It really was a moment in which you could see a transformation in care. There were two things happening. One was the innovation in medications. We suddenly had medicines that worked pretty well. They weren’t great. They had terrible side effects.

But they did acutely help people to reduce psychotic symptoms, to reduce depression. And lithium, which we had then, was a pretty good medication, probably still the best medication we have for bipolar disorder. That was one piece of it.

The other piece was more to your question. We had a national commitment, as President Kennedy said in 1963, to ensure, in his words, that people with mental illness would no longer be alien to our affections or apart from the caring of our communities. That was his commitment.

October 31, 1963, one of the last bills that he signed before he was assassinated three weeks later was the Community Mental Health Act. And what that did was to put the federal government in the driver’s seat in a way that said, for people with mental illness there will be a federally-funded clinic within what they called a catchment area, within reachable area for where you live that will provide not just medication but therapy and social support, will work with families and where you will find people who will help you to recover.

And that was really the commitment of the Community Mental Health Act starting in ‘63, and then when you add in Medicaid, Medicare, S.S.I., all these other things that happened in the 1960s through the Johnson administration, yeah, it was a somewhat better world for people with mental illness.

There was what we then called a safety net. There was housing. There was the opportunity to get the kind of care that helped people to recover — actually, it’s interesting because we had fewer assets then. We had fewer of the therapies we use today, fewer of the medications. But I felt in the beginning of my career — and I was not alone — that we were doing pretty well by the people we saw, and we saw them get better.

And by the way, it was not just that the care was more comprehensive. It was more continuous. We were accountable to make sure that people got better. Today for people with mental illness what they find is generally a very fragmented system. There is no one accountable. There’s no one who’s there for the whole journey.

And many of the things that made up that safety net, the housing support, the institutional support, a lot of the things that people could rely on in the 1970s — they’re gone. They may come back, but they’re not there now. The federal government, which had made that commitment by Kennedy, really checked out in 1980 and didn’t come back into this game until 2018, 2019.

And the amazing thing is just in the last two or three years, partly through the pandemic, we’ve seen a new, massive federal commitment to people with mental illness, something we haven’t seen since the 1960s. It’s funny that people don’t talk about this. They don’t know much about it. Probably the most consequential bill for people with mental illness, particularly those with serious mental illness, was the bipartisan Safer Communities Act that was passed three weeks ago as the gun bill, oddly enough. I’m not sure what that’s going to do for gun safety, but it will do a lot for people with serious mental illness. It’s a massive new —

ezra klein

What will it do for them?

thomas insel

Well, there’s a massive new commitment to something called the Certified Community Behavioral Health Centers, and when you put this together with the money that’s already been committed to that program, it’s over $10 billion that will be establishing clinics around the country very much like what Kennedy envisioned in 1960, again, whole-person care, comprehensive care with the idea that many of the things that we are critical for recovery, whether that’s from substance abuse or from mental illnesses like schizophrenia, will be paid for and will be provided in a way that will be more continuous and more comprehensive.

So it’s a new day and a really interesting question is whether this time around the federal government’s commitment — because it is a little bit like deja vu all over again. But will we learn from the mistakes made in the ‘60s and ‘70s? Can we do this better? Can we do it in a way that will be sustained this time? And can we actually begin to change population health? Can we actually begin to see suicide and disability come down?

ezra klein

I’d like to — there are a lot of places I want to go on that, but I do want to spend a little bit more time in that story that you went over a little quickly there. So Kennedy makes his commitment, and then you say a lot of mistakes get made in the ‘60s and ‘70s, and then you say something changes in the ‘80s.

Tell a little bit more of that because I think it is under-explained how a lot of our mental health care infrastructure has not traveled along the same path of a lot of our other safety net infrastructure — most things have gotten bigger that the government does, not always been true here exactly. So what happens in the ‘60s, ‘70s and ‘80s?

thomas insel

Yeah, it’s an old story and one that’s — it does bear deep study, I think, at this point because we’re about to go into another period like we were in then. So the history of mental health care was largely — before 1963 was the story of the state asylums what was called the moral treatment. In the early 19th century, in this country as well as in Europe, people with mental illness were incarcerated. They were put into jails and usually kept in chains.

And Dorothea Dix in this country and others in France and in England decided that was immoral, that these are people that had a health problem, and they called for creating hospitals which became the state institutions in the United States, the state hospital system.

And from 1850 until, really, the almost 1950 period state hospitals were built and expanded, often in rural areas away from the cities where people would go for — when they were in crisis they might go for a few weeks but often would go for months and often stay for years.

When Kennedy decided that something needed to be done about this — and in his words he said, this has been tolerated for way too long. He pointed out that we had 600,000 people with mental illness in these institutions, and the average length of stay was 10 years. Kind of hard to believe that today, but that’s where we were in 1963.

He was able to say because of the advent of Thorazine that we could now get people out of the hospital and help them in the community. That was the vision. And that was what that community mental health system was set up to do, but it didn’t.

And it didn’t for a bunch of reasons, but if you look now at the data that we’ve got from those years, what’s really clear is that only about 10 percent of the people seen in the community health centers were people who had been in state hospitals. Many of those people — I think Kennedy’s original idea was that they would leave the hospitals and go back to their families.

They didn’t have families, many of them, and many of them ended up in single-room-occupancy hotels, some of them in nursing homes, some of them in other facilities. The federal government said, we’re not going to pay for any kind of institutional care except in nursing facilities, but we will pay for community care. And that’s where the money was going.

But the community facilities themselves, federally-funded, were actually more interested in treating people who were looking for psychoanalytic psychotherapy and not necessarily people who had been for 10 years kept in a state institution. And that’s what they did. It was great for the clinicians, for the providers but not really great for the people who needed the most significant care. By the way, that wasn’t true everywhere. I worked in one of those places in the 1970s where we actually took very good care of people with serious mental illness and we worked really closely with the remaining state hospital. All of that ended in 1980 when Reagan said, why are we doing this? We’ve got an economic challenge here. The government shouldn’t be spending $10 billion a year on what is really the responsibility of the states.

So it was like your classic hot-potato game. It went from the states to the federal government, federal government back to the states. States in the 1980s said, we don’t have this money anymore. We’ve closed our state hospitals. We’re not going to rebuild them. We’re not going to reopen them. We don’t have the money for these clinics. Maybe the counties can take this?

So they tried to pass it off to counties. And that tension continued for, really, the last 40 years with the federal government basically saying, well, whatever the states do we’ll match it with Medicaid, so we’ll help there. The original community mental health centers were converted to block grants, and there’s an agency called the Substance Abuse Mental Health Services Administration or SAMHSA, which actually administers those block grants.

But the numbers never went up very much. The entire SAMHSA budget up until three years ago was about $3 billion with about a third of that going to people with serious mental illness. So it’s been a very limited federal commitment.

ezra klein

I was stunned by a number you have in the book. Since the 1950s, there’s been about a 95 percent decrease per person in the number of psychiatric beds that are considered public beds, so hospital beds for people without private insurance or their own wealth to pay for them. Now, other kinds of beds opened up elsewhere, but that’s a really tremendous drop in a very important kind of public health infrastructure.

thomas insel

Yeah, we went from 600,000 to about 34,000 beds in the state hospital system. And as I say in the book, what happened was that the jails and prisons became our default mental health institutions, so essentially those old state hospitals became like jails and prisons. So we just did a strange flip-flop on this.


ezra klein

My bias going into the book was that we have quite poor treatment for most mental illnesses, much worse than what we have for other kinds of illness. And you argue throughout that that’s not true. Why?

thomas insel

Because it’s not true. We actually have good treatments. I’m not here saying that a medication is a cure for any of these mental illnesses or that psychotherapy works in all cases, but the combination of medication, psychotherapy, but most of all, recovery services, the kinds of the things that — we often call them enhanced care management, but teams that go out and actually proactively engage people, build trust, ensure that people get to a clubhouse where they can spend the day and get job training, get help getting back to school —

These things like these sorts of teams, these sorts of clubhouses, job training, which is called supported employment or supportive housing — these are massively successful and massively helpful. The people who run clubhouses and —

ezra klein

What is a clubhouse?

thomas insel

A clubhouse is a place where someone with a serious mental illness can spend the day. And they get meals. They get help on how to find a job. Now they can get training for a job in some clubhouses. Some clubhouses provide health care as well.

It’s a sort of sanctuary for people. I like to say they provide people, place and purpose — social support. They provide a healthy environment, and they help people to kind of get back on their feet.

But my point, Ezra — and this is really one of the pieces that I keep wanting to come back to — is that in a country that’s spending $3.8 trillion for health care, clubhouses stay open with bake sales and philanthropic dollars that they can get from willing donors.

We don’t pay for any of that. All those recovery services, which I would argue are the most effective for helping people with mental illness, especially serious mental illness — they’re not paid for through health care dollars. And even much psychotherapy ends up being out of pocket. I don’t see how that’s fair.

ezra klein

I certainly agree that it’s not fair, but I do want to pick at this because the book has a very complicated relationship with treatment where sometimes the orientation of it is, there’s much more capacity here than you realize, much more effectiveness than you realize. And sometimes you read things like this in the book, quote, “When it comes to mental illness, there are more people getting more treatment than ever, yet death and disability continue to rise. How can more treatment be associated with worse outcomes?”

And I think that gets to what a lot of people see when they look at this. It seems like many more people are on mental — on drugs to treat mental illness. Many more people are in therapy than ever before. There’s much less stigma around it. There is still stigma but less than there was at other times.

And yet, you know, you were one of the leading mental health policymakers in the country, and you’re sitting here writing a book about how the system is broken. Talk to me about that, more treatment, worse outcomes. And at the same time you’re saying treatment is actually pretty good.

thomas insel

Yeah, so on the face of it it doesn’t make sense right. This is really what the meat of the book is about. It’s trying to explain that paradox. And you have to hold a couple of things in your head at the same time. One is that while the treatments are effective, they’re effective and given in the right way, the right dose, the right time to the right person. And we’re not very good at that.

So there’s what I’ll call a general quality problem. And that’s not only true for medication. It’s true for psychotherapy. We do have therapies that work, that are effective, but very few people are trained to do the ones that we have the best scientific evidence for.

That’s not true, by the way, in cancer therapy. It’s not true in cardiovascular medicine. But in mental health, the vast majority of people who are in practice are people who have minimal training in the very things that are most effective.

ezra klein

Be very specific here. You had a daughter — you write about that you have a daughter — you write about this in the book — who struggled seriously with an eating disorder. If you’re a random family, this begins to affect your family, you try to get help. You go to a therapist. You ask your local pediatrician.

What are you likely to get, and what is the treatment you’re saying we actually know works and is hard to get?

thomas insel

So most medications are provided by primary care, so if you’re going to go to a pediatrician, you may get medication without therapy. If you do go for therapy, you’re likely to get therapy that is more generic. A lot of it today would — there are going to be lots of different names for this, but fundamentally what people are going to do is sit with your daughter and ask questions about trauma, ask questions about history, maybe about self-esteem.

There may be attempts to engage on how someone feels about where they are in their life, which is fine. We know there is a treatment, particularly for adolescents with anorexia nervosa, called family-based therapy, which was developed at Stanford but also in the U.K.

That’s not what you get with talk therapy that’s not focused. It doesn’t have an evidence base. So I’m a huge proponent of psychotherapy, but it has to be psychotherapy that actually involves those kind of skills learning that has a kind of scientific basis to it with people trained to do it in the way that works. Just like you would for any surgical procedure, it’s got to be done well.

ezra klein

There are two things that strike me about this, and I’ll try to do my part in stigma reduction and say that I’ve been looking for a therapist lately. It’s been a rough year for a bunch of different reasons. And I’m somebody who’s covered health care professionally for a lot of my career primarily, not mental health care but somewhat. I’m somebody who talks to mental health experts on my show. I have you on. I’ve had Bessel van der Kolk, and Jud Brewer, and others on.

And I’m always struck when I go looking for my own care that, on the one hand, it is hard to know what the modalities that have the evidence base for the things I might need.

thomas insel

How do you look? Tell me how you look.

ezra klein

I literally just — my friend has a good therapist, and I ask for some referrals. And then I get some referrals, and I begin looking at them. And then this gets to the second point where it’s very hard to the quality of mental health professionals.

So if you have a serious illness, I think the way people can, on the margin, try to figure out the quality of care providers — and it’s not perfect, but it’s the reputation of institutions. If you’re in the Bay Area and you have something pretty complicated, U.C.S.F. is known to be a very good institution, and you’re going to be able to find really good people there, not to say there aren’t people there who aren’t as good, but it’s a good bet.

There’s nothing really like that in mental health care, at least not at the individual therapeutic level, and so you’re really just flying blind at an unbelievable degree. So you don’t really what people are doing, what they’re really trained in. Most people don’t know what has an evidence base behind it, and you don’t know how to tell the people you’re looking at are any good at what they’re saying they know how to do.

It’s a completely crazy — I don’t exactly want to call it a market. But given the importance of this, I think it is worth dwelling for a minute on actually how hard it is to make a choice, and then these choices are being made under duress and sometimes by people whose faculties are limited by a mental crisis. It’s just a kind of crazy way to operate.

thomas insel

There are some options. So some people use Psychology Today, which has a pretty good website. For people with serious mental illness, families can check in with the local NAMI chapter because NAMI is a really good resource.

ezra klein

What is NAMI?

thomas insel

National Alliance for Mental Illness, very much a family-run organization, advocacy organization, but it’s a really helpful one for family-to-family support. So if you’re just getting into this, you’ll find somebody who’s been through it. I call them involuntary experts, and they can be very helpful.

But that’s really if you have a 19-year-old who’s suddenly manic or psychotic. That’s where that tends to be most useful, I think. When you’re looking for your own care, like the way we’re talking about, Ezra, it really is a bit of trial and error, and the reality is sometimes it is a matter of calling up somebody else who’s willing to tell you who they’ve seen and getting their best recommendations, not perfect.

ezra klein

But I want to zoom out on this to get back to the point you were making, which is that it is a unnerving fact about our mental health care system that if the account you give here is right — and I have no reason to believe it isn’t — that we actually do have quite effective treatments for quite a lot of things or at least treatments that compare in effectiveness to treatments we have for other kinds of physical ailments, it is very hard to know and you cannot simply trust that when you go in to see a mental health professional they are trained in the right treatments.

thomas insel

Bingo, right. A lot of people will say that the problem is access, that we don’t have the number of providers, the wait times are too long, there’s no one within network, all of which could be true. I think the bigger problem is quality.

I gave a talk at U.C.S.F. recently, and I talked about this very point, that it’s really important to get somebody who knows how to do the right kind of therapy. And somebody wrote to me later, and he said, look at the data. Look at the studies that have been done. Most of them show that the therapist is more important than the therapy when you look at overall outcomes.

A good point, and I think you want to make sure you cover both bases. You want to make sure you’ve got somebody who’s trained to do the things that work that are often skill-based and you’ve got somebody who you can have a rapport and a sense of trust with, really important part of this.

ezra klein

Let me ask you about the other side of it. So for most of my life I think the dominant metaphor for mental illness — and it was meant literally, not just as metaphor — has been this idea of chemical imbalance. So I grew up with the kind of vague understanding that people with severe depression have an imbalance of, say, serotonin in their brains.

And you write about how that’s changing and that newer research is starting to understand particularly severe mental illnesses to the extent they have a physical signature. It’s more like an arrhythmia of the brain, a problem of communication. Can you talk through that a bit?

thomas insel

Well, look, these are all metaphors, and they are constructs that we develop — that are largely based on what we understand at the time. So when I got into the field, it wasn’t chemical imbalance. It was a hydraulic model. It was all about psychic energy, and maybe that’s because we were still in that world of thinking about motors, and the automotive age, and building stuff like that.

I think it really was the advent of tools for the whole explosion of biochemistry and biology and chemistry and beginning to be able to measure chemicals that led to huge advances in the ‘60s, ‘70s and ‘80s in medicine. And in the area of mental health, partly because of the apparent effectiveness of medications, people began saying, well, whatever it is the medications do, that must have been fixing whatever the fundamental problem was.

And so medications increased serotonin, so this must have been a serotonin deficiency, which is — it’s such an incredibly impoverished view of how the brain works. And thinking of it as a large chemical soup does, I think, a tremendous injustice. But it did fit in with the zeitgeist of how we were thinking in the ‘70s, ‘80s and ‘90s.

And of course, in the computer age we’re much more thinking about circuits and trying to understand how do things connect and where’s the microprocessor leading to. So this is an era where we talk about connectivity, and we talk about what’s in the brain, what areas talk to what areas and how does that happen. Is that a better metaphor? I don’t know.

ezra klein

Well, my understanding, though, from your book — tell me if this is wrong — is that we’re not just talking about metaphors. I’m always a little skeptical of imaging research —

thomas insel

Good. You should be.

ezra klein

— because over time, imaging research — I don’t think we understand what it says. But your argument there is that a lot of the research is showing in imaging that you can begin to see connectivity problems.

thomas insel

You can see really good connectivity problems in C. elegans and in drosophila, and maybe even in mice where we have the tools. But make no mistake about this — human imaging is of value when you have hundreds or thousands of patients.

For the individual patient, there’s a very limited value in what we’re doing. Unless there’s a structural lesion in the brain, very limited value to fM.R.I., or M.R.I., or even the CT scans. None of that really is telling us something that’s clinically actionable today, nor does it explain the difference between the brain of somebody who has major depressive disorder and somebody who doesn’t.

ezra klein

So your view here — it’s actually helpful for me to hear you say this — is that one shouldn’t take this research too seriously.

thomas insel

It’s evolving. I think it’s at an early stage. I don’t think —

ezra klein

That’s a long way of saying yes.

thomas insel

Yes, that’s a long way. Touche. Look, I think it’s fascinating, and there are some wonderful kinds of studies. But as somebody who works in my own career much more at a cellular level, it’s really hard for me to read these papers about area A talking to area B, are the two of them being in synchrony, and thinking that is actually how the brain works.

Because when you actually study the brain in experimental animals and you look at how activity relates to behavior, it’s incredibly complicated. And every time you’re looking at communication of area A to area B, you discover that there are recursive fibers that are causing just as much communication from B to A. So getting directionality and understanding how the brain works, very hard to do with the kind of fM.R.I. we do today.

ezra klein

But in a way, this answer, I think, gets at both a core story you’re trying to tell in the book or argument you’re making in it and, as far as I understand it, the core metanarrative of your own career, that you ran the main funder of mental health scientific research in this country.

And as I read you now, I think you’re telling people, we’re not going to solve this through a pill. There isn’t some breakthrough study we’re finally going to conduct and then we’re going to know how to cure schizophrenia, that we are going to need to put together services, treatments we already have in a quite different way than we have in order to make progress and build more social infrastructure.

It feels to me like you have moved a little bit away from believing that this is a scientific problem and I guess towards believing it’s a social and a social coordination problem. Is that a reasonable way to put it?

thomas insel

I think it is. The origin narrative for the book was — I think I say this at the very beginning — giving a talk about all the advances we had made at the N.I.M.H. through our funding with everything from stem cells, to cellular imaging, to spectacular work on autism and somebody getting up at the back of the room and saying, man, you just don’t get it. I have a son with schizophrenia. He’s been hospitalized about four times. He’s made two suicide attempts. Listen, our house is on fire, and you’re talking about the chemistry of the paint.

And I did see that as a wake up call. Now, let me be really clear. I think the chemistry of the paint is super important, and I wouldn’t for a moment want to slow down the science that’s trying to give us better treatments. What I’m arguing for is the urgency of this problem in this moment means we’ve got to use the things that have come out of previous research and make sure we’re doing them.

So to your point, yeah, thinking about how we connect the dots and how we create through what some people would call implementation and how do we deliver on what we already know — that, to me, seems to be a much more urgent question. By the way, I think it’s a really hopeful one because it says, we can do so much better with what we know right now.

ezra klein

OK, but then why don’t we? And let me pick up here on a story that lurks in your book and that, to me, did not have a satisfying resolution. So you run the big scientific funding agency, and then Gavin Newsom, the governor of California appears occasionally in the book as a kind of heroic figure.

When he becomes governor, he reaches out to you, makes you mental health czar, says, look, when I was mayor of S.F., we needed to do so much more on mental health than we did and mental illness than we did, and I don’t plan to make that mistake again.

And you talk about traveling up and down California, trying to understand our system. A lot of the stories are from there. So you had a willing governor. You had you, literally, the guy in front of me, writing this book in the driver’s seat as a policymaker. California is a big, rich state, big budget surplus. Certainly my understanding is that our mental health system isn’t fixed. So why not?

thomas insel

Yeah, it’s a fair and painful question. I’ll say the fair question and painful answer. This is much harder to do than I had even realized, and when he asked me to be czar I said, I won’t be czar, but I will be your sherpa. I’ll carry the water for a while and try to understand what’s working and what isn’t.

And what I learned pretty quickly was it’s a very fragmented system. Even in a state as wealthy as California — and maybe it’s partly because of the wealth. In our state, mental health care is distributed across 58 counties. None of them really work together, and there’s no coherence.

There’s no one at the top who says, hey, gang, this is what we’re all working towards. Look, we are going to pull out all the stops and spend whatever it takes to reduce suicide or to make sure, as the governor said, that any young person that has a first episode of psychosis will never have a second episode. We’re going to commit to that.

Or another place we’ve been talking about is that any young person with mental illness will graduate from high school. We’ve got to make sure that they get that far. Those are all things we could do and should do, but there is no coherence. There’s no way to bring everybody in line yet.

What I think — and I’m no longer involved in this project —

ezra klein

But wait. Hold on a second.

thomas insel


ezra klein

Because what do you mean by that? Gavin Newsom is a dictator. But these counties — they don’t want suicides. They don’t want a lot of kids having psychotic breaks. We’re sitting here in San Francisco. San Francisco is rich. It’s a very, very rich place, unbelievably, unfathomably, disgustingly rich.

It has a mayor who would really, really benefit politically from the streets not being so filled with mental illness and drug use. It has quite a bit of internal medical expertise, U.C.S.F. system. You live not far from here. You’re in the East Bay. You’re not in the county here. But they could call you. I’m sure you’d come over the bridge and help out.

If they wanted to — and presumably they do — can they do it? What is the thing?

thomas insel

Yeah, actually, that is a really good question that I was asking two or three years ago. And you’re not going to this, Ezra, but there’s a really good answer, which is, it’s happening. It’s happening in a really interesting way.

Now, I may be proven wrong in three or four years, but California has done three things right. But the three things that they have done which are remarkable is, one, they have changed what they do with their Medicaid money. Medicaid is the largest payer for mental health services in the United States.

But it largely pays for medication, clinic visits, and crisis care. California set up something that said, that’s not really working for us. We want to pay for a lot of things that have not been within health care before. We want our mental health professionals to be able to write a prescription for food or for housing.

And amazingly, C.M.S. — that’s the federal agency that oversees Medicaid — provided an approval for that waiver, which allows us, through a project called CalAIM — that is actually just beginning now — to transform the kind of care that is supported and the kind of people who will be giving that care. So all of a sudden, it’s not just a matter of how much money there is, but how that money gets used begins to change.

Number two was that the governor felt strongly that when we had a bit of a surplus during last year that we needed to go upstream from the crisis care system we have today, which is really the way it has been built out. And he wanted to focus on youth mental health, and he put together a package called the Youth and Child Behavioral Health Initiative, $4.4 billion.

And it’s to not only build out school mental health in a new way but to rethink what we mean by mental healthy care for kids so that you don’t need a diagnosis to get services so that you can begin with what’s called dyadic care. You begin working with new families long before there’s a problem because these are families at risk.

You create a way that any pediatrician can get an immediate consult from a mental health professional, a child psychiatrist. There’s a whole range of issues. The one that’s right now very current is putting out a portal so that families will know what all the services are, and they can start to solve for that fragmentation themselves because they’ll have the information at their fingertips.

There’s one-third, I think, piece to the secret sauce here, and that actually starts tomorrow. So this is — when we’re recording this it’s July 15. July 16, 2022 is a very important day in California or not in California but in the nation. It’s the beginning of what’s called the 988 Program.

So a huge problem that we’ve had for people with mental illness broadly is that when there’s a crisis it’s usually addressed by police with guns, and if there isn’t a terrible interaction there, they may either take you to jail or to a medical surgical emergency room.

Almost no part of that is optimal, so what a 988 does is it’s a new number that one calls — and there will also be a way to text to the same source — as opposed to 911. So this becomes kind of the catalyst for really transforming how we do mental health crisis response —

988 — it’s not like 911 where you have a dispatcher who’s going to send out fire or police. It’s really a telehealth support line where the person may stay on with you for 40, 50, 60 minutes, and they may call you back the next day.

We know that when this is done well about 90 percent of calls are handled right there, but in those that can’t be handled, instead of cops with guns you’ll have a van with a nurse, a peer, a social worker who can show up and help to try to solve the problem on site.

If that can’t be done, you don’t go to jail. You don’t go to a medical surgical E.R. You’ll go to a psych drop-off for what’s called a Crisis Stabilization Unit. So there’s more to this, but it’s a whole continuum of someone to call, someone to come, someplace to go.

ezra klein

And that’s rolling out across California?

thomas insel

It’s rolling out across the nation tomorrow. Now, the good news is that the federal government has laid this down as a mandate. We were saying before how it’s been a hot potato between federal, state, and county. This is like the first sign that the federal government is coming back in, saying, enough, enough already. We’re tired of seeing the fact that people with serious mental illness are 16 times more likely to be shot by police than anybody else. That’s just not right. We can do better.

So the federal government has said that July 16, 2022, every jurisdiction has to have a 988 number for mental health crisis. Are we ready? Absolutely not.

ezra klein

Yeah, I was going to say, I don’t —

thomas insel

No one even knows about this, right.

ezra klein

Not only does nobody know about it, but as somebody who knows the budgets of a bunch of these places reasonably well, I don’t believe that we’ve created a gigantic new mental health response infrastructure.

thomas insel

In San Francisco we are doing it. We have pieces of it. So the vans are there. The stabilization units are being stood up. There’s a whole bunch of this that’s happening. But to be clear —

ezra klein

Nationwide, I mean.

thomas insel

Nationwide, this is the beginning. So tomorrow marks the beginning of a new era. It took us two or three decades to get 911 to work, and that’s just a dispatch number. This is going to require — it’s going to require some time.

But having the federal mandate and having people now beginning to fixate on, OK, we’re going to have to transform the system, that what we’ve been doing is not good for anybody — I think it’s a really hopeful moment.


ezra klein

One thing I worry about our conversation here is whether or not it reflects a problem you’ve pointed out elsewhere, which is the tendency to immediately focus on policy and response for crisis, right? If 10 percent of mental health outcomes are what happens in the mental health hospital or care providing point, you want to be, as Newsom, I guess, has said, quite a bit upstream from that.

And you talked about this a lot in the book as being around people, place and purpose, and so I want to make sure before we end that we do talk a bit about that. And I’d like to start with people.

Before we turned on the mics, you and I were talking a little bit about social isolation, whether or not our society has evolved in a way that has eroded community, that has led to unusually small families and less support than we’ve seen for people at most times in human history. What is the context in which the people layer, the social layer, of mental health plays out now? And how do we need to understand that as a contributor or a possible solution to the problems people have?

thomas insel

I’m going to play psychiatrist and throw that question back at you because I know you’ve been thinking about that personally and been thinking about it a lot. I’d love to sort of draw you out on this, Ezra. I know you’ve been interested in the power of social connection and where we’ve failed as a society to do that.

So let me ask you to unpack this a little bit more. What are you thinking when you’re asking that question?

ezra klein

We are running an experiment on our society in which we have made people much more mobile, in which family size has gotten a lot smaller, in which — this is not true for everybody, obviously, but it is true for a lot of people — in which, when people are young, they move often away from their social support networks at a time when they need a minimum of support. We often seem to me to be optimized for people’s 20s. You move somewhere. You’re pursuing a job. Again, that’s not what everybody does.

But then, as your life changes and you need support, you have children, you have health problems, you age, you have mental health problems, all the things that make us interdependent on others, our lives are in places where we don’t have a lot of support for that. And our families are much smaller, and what we can ask of each other is somewhat less.

So you talk a lot throughout the book about isolation as a cause here, but you say that social isolation is the most under-discussed dimension of serious mental illness that there is. And I was thinking about that for this because when you think about whether or not we’ve created a society that is poorly set up for mental illness, we have all these policy solutions we’re talking about.

But one way in which the past might have been better is that there was simply more kin. There was simply more community. There was simply more people who knew you. And so I’m trying to draw you out a little bit on this question because there are things policy can do, but it can’t do all this.

And we’ve used the word family a bunch of times, but around the edges. We’ve used the word families, people who are out seeking care and help from policymakers. But families are the people who deal with this for the most part. Families are the places where people with illness go back when they’re out of the mental hospital or wherever.

So the actual question of how this gets dealt with in a real way seems to me to be much more located in the family and the community than a lot of policy making makes it sound.

thomas insel

Yes and no. I’m going to push back a little bit with this idea that policy doesn’t help us to create family and community because I think it absolutely could and should. And this is another area of American exceptionalism, where we have not committed to that in this country. It’s not a value for this country, never has been. And that shows up particularly now.

Vivek Murthy, who’s the surgeon general, is a good friend — he’s done, I think, a terrific job in pointing this issue out around this sort of disconnection we all have. In an era where everybody is online and connected more than ever supposedly, there’s a greater sense of loneliness, which is different than being alone but a sense of loneliness. And you’re right. In the book I talk about how that is a feature of mental illness, which is one of the most disabling and difficult. And when you talk to people who recover they almost always start by telling you about a person who had their back, someone who they trusted who gave them hope.

And so in putting my vision about how to fix this problem together, I came up with those three Ps. It wasn’t my idea. It was the idea of a very wise street psychiatrist in L.A. who also was running the L.A. County Department of Mental Health, Jonathan Sherin who said, it’s really people, place and purpose. If you provide those, people will, in fact, recover.

So the first part of that, that social support, is, I think, entirely critical, and it’s a great place to start. And it could come from family. It could come from a peer who’s been down this road. It could come from a neighbor. There are all sorts of ways to make that happen.

And to build it into policy, it starts with things like having parental leave. It’s not in our value system, and I do think there’s a policy issue here that we ought to bring front and center. It’s one of the reasons why I said, the problem here is medical, but the solutions are social, they’re environmental. But they’re also political.

We need to actually get on top of this and say, hey, we care about community. We care about family. We care about making sure that people are not lonely, and we will build pieces into place to make sure that happens. That’s where I mentioned the clubhouse, which is just one example of what we can do to make sure that happens.

ezra klein

But, listen, I’m a policy person. I want to believe everything can be solved through policy.

thomas insel

And I thought you were. I was sure you —

ezra klein

And I am 100 percent on board with paid parental leave, paid mental health leave. Everything you could think of here I would functionally support. But I don’t totally —

thomas insel

And there’s a but. Here’s the but.

ezra klein

Yes. but I don’t totally want to let this off the hook. I want to ask you, as somebody who’s begun thinking about mental illness from a social perspective. We have built a lonelier society. We just have. We’ve built this — we have a society that’s evolving towards smaller families.

Does this create a harder context in which mental health crises play out? Is there something different about having a member of a family where there are 35 people in that family within a 25 mile radius with a serious mental health issue and having a member of a family where there are five people in that family within a 25-mile radius? That was true for my family growing up. Thank God we didn’t have a serious mental health issue, but I mean isn’t that different?

thomas insel

Well, you bet. Families matter. They’re important. And it’s not the number of people but having a person who has your back, who’s there in the middle of the night, who’s there to tell you sometimes what you don’t want to hear but is there in a way that you can trust and you can listen to.

It’s really been interesting to me — I’ve been collecting recovery stories, and not in all cases but in most cases people will start talking pretty quickly about their family and who helped them. The unfortunate piece, as you’re pointing out, is not everybody has that privilege, and that is really — to go back to your point, Ezra, I think that’s the issue is that we’ve become atomized, right? We just don’t have that kind of inborn connectivity that you might find in the developing world much more often.

ezra klein

And this seems to me always to be a place where there’s a particular viciousness to mental illness. Vivek and I have actually had this conversation about loneliness. One of the parts of his book and his work that is really affected me in the way I think about it is the way that loneliness changes people’s social nature. It makes them more wary. It makes them more snappish. It makes them — because it activates a sense of threat at an almost biological level.

It also makes people a little harder to help, and that is so much truer for mental illness. I mean, people who are very depressed, who are schizophrenic, who are psychotic, who struggle a lot with anxiety — you write about this. It often ends up isolating them. And so that then creates the conditions for those conditions to worsen.

I’m curious, not here on the policy-level but on the human-level, how you tell people who do have somebody with severe mental illness around them to maintain that connection without feeling sometimes like they’re drowning themselves.

thomas insel

Yeah, so obviously this has been a contentious piece of the history of mental health care because for many, many years families were considered part of the problem, not part of the solution, and they’ve been kept out. And sometimes they still are.

And one of the ways in which NAMI, that advocacy organization, can be so helpful and has been helpful is to engage them and to make sure that they do advocate for being part of the solution because they are critical. And they will be. When I was writing the book, it was one of the kind of inconvenient truths that just kept coming up over and over again, that what became really clear to me was that families are really critical.

So let me turn this around a little bit because I think your focus on the loneliness, and the despair that comes with that, and that sense of futility is really, for me, an invitation to say, it doesn’t have to be that way, that we can provide a lot of support here.

So this isn’t like having to come up with an mRNA vaccine. This is coming up with an individual — maybe somebody who’s had a similar experience — who wants to be helpful, wants to pass it forward and can actually make a huge difference.

This isn’t incredibly expensive. It’s not incredibly high-tech. It’s not really a mystery. You don’t need stem cell biology to do this. You simply need to be willing to engage people who care and help them to reach out to someone who has been really struggling.

We have this whole new peer movement, which I think is going to transform the way care is provided. I’m actually in the middle of standing up a company that’s actually trying to scale this so that we’ll have a chance to see how all of those recovery services not only work at scale but they actually save money for the health care system.

They reduce the amount of incarceration. They reduce a lot of the other problems that we’re seeing downstream simply because a lot of what we do is simply provide social support to people who’ve become very isolated and are kind of locked in to their own paranoid, grandiose, psychotic world that is not where they need to be.

ezra klein

Let me end by asking you to tell a story that I found very stirring on this. Can you talk about Geel?

thomas insel

Yeah, the actual pronunciation, I think, if I get it right — I’m not good at this. This is a town in Belgium called Geel. It’s like in the back of your throat where you have to say this. But it’s this small town that’s been around since I think the 12th century, and there was a myth about a murder that took place there that was really horrendous and a shrine that was developed for the saint who died defending her purity.

In the — I think it was the 13th, 14th, 15th centuries families began bringing their ill children to this shrine, and there were enough of them that as the town grew the families would sometimes leave the kids there. And the young people would stay behind, often people with serious mental illness, with schizophrenia or something like that.

And they ended up being taken in by the community as what ultimately became a kind of adult foster system. So they would work on the farm. They would essentially be part of the family. And this has gone on now for hundreds of years, and it’s this beautiful story about a different approach to — approach that really is about inclusion and acceptance.

By the way, it’s different than where I’m coming from and where a lot of advocates are now, which is saying we need recovery. They don’t really say people need to recover. They just say people need to be accepted, and they can contribute. That really is a story that we do need to hear, that there’s a different way because what we do here is we incarcerate people. We let them become homeless, and we do as little as possible to help them recover.

ezra klein

I think that’s a good place to end. Always our final question — what are the three books you would recommend to the audience?

thomas insel

All right, well, let’s do three books that are relevant to this conversation. One that came out I think this past year — Roy Richards Grinker’s book called “Nobody’s Normal.” Grinker is an iconic name in mental health, and he’s written this incredibly interesting book about stigma and what do we mean when we talk about mental illness, what are the borders, what are the boundaries, and how do we think about that. A lot of it is an anthropologist eye on the world of mental health.

I think for the story about the history of what’s happened in mental health care, the role of the federal government, you can’t do better than E. Fuller Torrey’s book called “American Psychosis,” which is really the story of what went wrong with the Community Mental Health Act and the 1960s, ‘70s, ‘80s and ‘90s.

Then, I think, for families who want to read about just the challenge here, Pete Earley’s book — Pete’s a Washington Post journalist who wrote a book called “Crazy” to describe what he went through with his own son and trying to get care and how he had to tell people that his son was violent in order to get him into the care system. He had to lie about that.

So I think it was just an extraordinary indictment of where the system is. Pete’s been a fantastic advocate in this whole area, and I think that book, for any family that’s been through that, reminds you that you’re not alone.

ezra klein

Tom Insel, your new book is called “Healing.” Thank you very much.

thomas insel

Thanks for having me.

ezra klein

“The Ezra Klein Show” is produced by Annie Galvin and Roge Karma, fact-checking by Michelle Harris, Mary Marge Locker and Kate Sinclair. Mixing by Sonia Herrero and Carole Sabouraud and Isaac Jones. Original music by Isaac Jones. Audience strategy by Shannon Busta, and special thanks to Kristin Lin and Kristina Samulewski.


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