Chapter 1. Introduction

Our country is of two minds about mental illness. On the one hand, people of the United States overwhelmingly endorse the idea that mental illness is real medical illness. A near-unanimous public majority maintains that mental illness is both real (97%) and treatable (86%–95%) (American Psychological Association 2019; Universal Health Services 2019). One recent poll showed that 87% assert that mental health disorders are “nothing to be ashamed of” (American Psychological Association 2019). And a surprising 71%–89% classify mental and physical health as equally important (Research American 2006; Universal Health Services 2019).

People agree that mental illness is real. On the other hand, people act as if mental illness is not real. If public opinion has steadily shifted toward a recognition of psychiatric illness, public behavior has not. Less than half of people with diagnosable mental illness get treatment in any given year (Substance Abuse and Mental Health Services Administration 2018), and this number has changed little in nearly two decades (Wang et al. 2005). Of those who do get treatment, only about half adhere to it (Sajatovic et al. 2010). Thus, the vast majority of people with mental illness do not accept treatment for it, and do not fully accept the medical necessity of such treatment.

This radical inconsistency of thought and action should not surprise any mental health professional. The contradiction between belief and behavior lay at the root of Freud’s insights about the unconscious, and continued in the “split brain” experiments of Gazzaniga and Sperry that heralded the beginning of modern neuropsychology. It is part of the daily fare of mental health practitioners. Put simply, it is possible to know one thing and do another. Our brain systems for conscious understanding seem to operate along different pathways from those for feeling and motivation. When these contradictions become unbearable, we seek mental health treatment or other forms of growth and healing. Even so, self-contradictory behaviors are a fixture of human nature and can become embarrassingly obvious in both individual and community life. To say one thing and do another is simply a part of the human condition.

Although I cannot prove it, I see the opposite contradiction in the current culture of mental health professionals. On the one hand, we seem to act every bit as if mental illness is real medical illness. Everywhere I look, I see colleagues going about their business in a straightforward, rational, scientifically grounded manner. I see all sorts of health professionals, from primary care physicians to social workers, treating mental health conditions as medical illnesses with medical treatments. Every day, I see psychotherapists recommending medications and pharmacotherapists recommending talk therapy. Although our field is fraught with challenges, I do not generally see massive overdiagnosis, overmedication, or overreliance on just one form of treatment. Nor do I see any crisis of confidence that prevents us from diagnosing and treating mental illnesses in a vigorous manner. Instead, I see a steadily maturing field of mostly well-trained, thoughtful clinicians who go about their business according to appropriate professional and scientific standards.

On the other hand, while mental health professionals act as if mental illness is treatable and real, we regularly speak as if it is not. Of course, in an implicit sense, almost all clinicians “know” that mental illness is real and treatable. It is in our bones and in our guts, a reality that is usually too obvious for words. Most of us do not spend time debating the nature of mental illness any more than surgeons spend time debating the reality or definition of medical illness. We sense clearly enough that it is real and that we need to get on with treating it.

Even so, when we begin to talk explicitly about mental illness, our professional culture begins to sound radically uncertain. We rarely articulate the confidence we enact in clinical practice. For instance, it is commonplace to assert that we cannot generally define mental illness. Some academic experts have even asserted that we should give up trying (Phillips et al. 2012). It is just as common to assert that we do not know the neurobiology of our most important mental illnesses. We do not know the central pathophysiology of major depression, or the neurobiological cause of schizophrenia, or why some people get PTSD and others do not. So (it is said) we cannot even define what we are treating, philosophically or medically. In similar fashion, debates about the reality of various mental illnesses regularly resurface, even among medical professionals (Pies 2015). The New England Journal of Medicine, for instance, occasionally features articles debating whether addiction is a mental illness or simply a learned behavior (Lewis 2018; Volkow et al. 2016). Meanwhile, the British Psychological Society’s report on schizophrenia allowed that psychotic symptoms could amount to social deviance or simple eccentricities (Cooke 2014; Frances 2013). And, of course, there is the long-running debate over the nature and legitimacy of DSM, along with regular criticisms that psychiatry is vastly overdiagnosing and overmedicating our population (see Chapter 4).

Such literary conversations stimulate those within our field but confuse those outside it. We should not be surprised, therefore, that skepticism about psychiatry is considered sophisticated among educated Americans. Publications such as The Atlantic, The New York Times, and The New Yorker contain periodic features with titles like “Mental Illness Is All in Your Brain—or Is It?” (Szalai 2019) and “Psychiatry’s Incurable Hubris” (Greenberg 2019). Historians continue to document the failures of psychiatry, characterizing it as frequently misguided, overconfident, and reductionistic (Harrington 2019). And there are a host of popular books that question the entire mental health enterprise, from DSM to clinical diagnosis to treatment (see Chapter 4).

Full-scale attacks on psychiatry are commonplace from both within and without, yet strangely enough, few mental health professionals think of defending it so vigorously. We rarely see anyone explaining the entire edifice of mental health diagnosis and treatment, much less defending it. I suspect this is because mental health clinicians and researchers sense that the scientific debate ended years ago. Scientific research has obviated the traditional critiques of our field, which are mostly irrelevant to both practice and research. Most of the questions that do remain relevant (such as areas of overdiagnosis or overmedication) are peripheral and not central to our craft. That is, they are questions of degree (how much to diagnose and treat) and not kind (whether to diagnose and treat at all). Most clinicians do not think of defending the legitimacy of mental illness and its treatment any more than surgeons think of defending the existence of surgery. For surgeons, the relevant question is when to utilize surgery, not whether surgery should be used at all. In the same way, clinicians think actively about when to diagnose and apply treatments for mental illness and are usually quite skillful in helping patients understand their plight. But few of us think about mental health practice in a general way or feel compelled to explain the generalities to patients and their families.

What results is a strange dichotomy in our culture: Clinicians treat mental illness as real but do not sound as if they know it is real. The public, on the other hand, says that mental illness is real but acts as if it is not. To be a bit more precise: The public acts confused about the nature of mental health, as well it should be, judging from public discussions of the subject. On the one hand, people rightfully accept the pronouncements of medical authorities, government agencies (such as the National Institute for Mental Health [NIMH]), and nonprofit groups (such as the National Alliance on Mental Illness [NAMI]) that mental illness is both real and treatable. On the other hand, people live with the uneasy sense that something is deeply wrong with mental health treatment, a sense fed by uncontradicted critiques of psychiatry. It is as if people viscerally know something is rotten in mental health and cannot stop searching for it. People suspect that there must be some source of corruption and mismanagement, even if they are not really sure whether there is widespread corruption and mismanagement. And people feel that psychiatry must have a shaky or nonexistent scientific basis, even as the public “oohs and aahs” over the latest neuroscience research. The public rarely hears a full explanation of our mental health practices and rarely hears about the overwhelming scientific evidence that supports such practices. And so, most people affirm the goodness of psychiatric treatment while strenuously avoiding it.

The signs of public ambivalence are not especially hard to notice: Acceptance of mental health diagnosis and treatment is growing, while at the same time rates of treatment do not increase. Understanding of mental illness is growing, yet stigma continues (Livingston and Boyd 2010; Parcesepe and Cabassa 2013). Governments and insurers now accept that mental health should be addressed as other medical problems, yet mental health treatment is handled in a drastically different fashion by both. We discriminate against mental disorders at the same time we declare such discrimination illegal. Our own patients go to great lengths to get treatment yet still feel “weak” for seeking it and ashamed of receiving it. They doubt the reality of their illnesses and the legitimacy of their treatments, regularly going on and off medications, cycling in and out of treatment. Patients, like the rest of the public, know that mental illness is real but feel as if it is not. They see the necessity of psychiatric treatment but feel that it is self-indulgent.

The national tension about mental health is not dramatic, but the results are disastrous. The ambivalence that we Americans have toward medical treatment of mental illness costs thousands of lives every year and incalculable levels of human suffering. While we accept mental illness in general, we reject those who carry it and socially distance ourselves from them (De Pinto and Backus 2019; Parcesepe and Cabassa 2013). While greater numbers of people access mental health care, deaths from substance use and suicide rise dramatically (Woolf and Schoomaker 2019). By law, insurance companies must cover mental illnesses as they do other medical problems, yet in practice this does not occur (Appelbaum and Parks 2020). Psychiatric treatment is grossly underfunded and overcontrolled by insurers and governments. For years, everyone has agreed that people with severe mental illness should receive the highest levels of treatment and social support. Yet treatment of severe mental illness in this country constitutes a scandal and a human rights disaster. Everyone knows that individuals with severe mental illness are more likely to be jailed than treated (Torrey et al. 2010). Everyone knows that treatment funding is preposterously low for those with serious illness, and yet the situation remains unaltered.

If we fully believed in the medical realities of mental illness, such events would not be tolerated. Imagine, for instance, that severe forms of cancer received no more treatment and research funding than mild forms. Imagine patients with metastatic cancer languishing in the streets because of utterly inadequate social and medical support. Imagine that all forms of treatment for diabetes were underfunded except for outpatient appointments and medications, leaving those with ketoacidosis, hyperglycemic crisis, and osteomyelitis to fend for themselves as outpatients. What if people with medical illness and delirium were regularly jailed with minimal medical care due to being combative or socially disruptive? It is difficult to imagine, because such actions violate common sense and simple humanity.

This ambivalence is costing patients dearly, and we who are mental health professionals cannot simply wait for the situation to improve. Due to the COVID-19 pandemic, the long-term situation is far more likely to worsen than improve (Vindegaard and Benros 2020). The plight of our patients is already urgent. Therefore, the plight of our profession is urgent. It is time for the second-class status of psychiatry and other mental health care to come to an end. It is time for our national ambivalence to end. It is time for half measures in the treatment of mental illness to come to an end. And it is time for us to end it. We as medical and mental health providers have the authority, the experience, and the understanding to do so. We have the instrument (science) and the means (access to our patients and communities), and the goal is well within our reach—if we have the will to take hold of it.

Honestly, I am writing a book about advocacy, yet prior to becoming involved, I would never have sought out a book or lecture on the topic. I am a psychiatrist in long-term private practice. I spend my time in individual dialogue with patients, offering psychotherapy and biological treatments to one patient at a time. Though I have spent time in academic and research settings (and continue to teach), I find my clinical work to be overwhelmingly satisfying. I do not feel a great need to be out among large groups, and I only began regular public advocacy by chance. I have since then spoken about mental illness to large and small groups of almost every description—business leaders, NAMI members, faith groups, young adults, and of course thousands of patients. Yet I never thought of myself as an advocate, or even thought that I needed to learn about advocacy.

So who advocates? Most of us have the same reflexive response: someone else. To various degrees, we all support our professional organizations, advocacy groups such as NAMI, and government agencies such as NIMH. All of these are prominent public advocates, and all of these do an excellent job. But all of them would tell us that together they are not enough. The evidence itself tells us that they are not enough. We, the community of clinicians who treat mental health disorders, are enough. We are numerous enough and influential enough to push our larger culture to a complete acceptance of the realities of mental illness and the necessities of its treatment.

Over 38,000 psychiatrists are practicing in the United States (Bishop et al. 2016). This number pales in comparison to the more than 200,000 primary care physicians (Agency for Healthcare Research and Quality 2018b) and 50,000 nurse practitioners in primary care, along with over 30,000 physician assistants (Agency for Healthcare Research and Quality 2018a). In mental health, there are more than 350,000 licensed social workers (Salsberg et al. 2017), 100,000 licensed psychologists (American Psychological Association 2014), and 250,000 mental health therapists and addiction therapists (U.S. Bureau of Labor Statistics 2019). Given these numbers, it seems safe to say that there are about a million professionals who regularly treat mental illness in this country, not including nurses, nursing assistants, crisis line workers, and mental health aides and technicians. There are too many to count, and more than enough to form a critical mass for the cultural change we need.

All of these million or so people advocate. Everyone reading this book is an advocate. Everyone who explains mental illness to a client or patient or friend advocates. Everyone who recommends a treatment for mental illness advocates. Everyone who supports family members with mental illness advocates. When we offer information to trainees, support personnel, and fellow clinicians, we advocate. When we talk to a friend about depression or a family member about alcoholism, we advocate. Most of us do not think of ourselves as advocates because we engage only in grassroots, person-to-person advocacy. We advocate unofficially and unconsciously, but this is the most important kind of advocacy. When someone we know and trust tells us about mental illness, we are inclined to listen.

And all of us together have been powerful advocates. In truth, the last couple of generations have seen astounding improvements in our cultural understanding and response to mental illness. Put another way, there has been more progress in understanding and helping those with mental illness in the last 70 years than in all eras of previous human history combined. Every advocate and every mental health professional should take justifiable pride in this fact, and every one of us should feel grateful for the generations of advocates and educators who came before us. Psychiatrists, psychologists, social workers, physicians of other medical specialties, researchers, members of NAMI, families, and people with mental illness have all contributed mightily to this cause. The medical and social treatment of those with mental illness is unrecognizable compared with treatment of the mid-twentieth century: We now have scientifically validated treatments of all major forms of mental illness. We have widely shared standards for diagnosing mental illness. Mental health care is accepted and practiced as an integral part of medical care. At least in principle, we have agreement by the government and insurers that mental illness is true medical illness. Parity between mental and medical illness is now a matter of law. The public, researchers, and medical professionals agree that mental illness is biologically and medically real. Mental illness is no longer a taboo topic in the popular culture, and sympathetic treatments appear regularly in film and television. Patients and families are empowered participants rather than helpless victims.

All of us should feel immensely proud of our collective efforts. From a wider historical view, the results have been spectacular. We should all feel proud, but at the same time we can all do better. All of us can do more in ways that are congenial to our individual personalities and habits. All of us can be better prepared to educate, more up-to-date and confident in our knowledge base. All of us can be more attentive for opportunities to advocate outside of the clinic, and braver in responding to them. All of us can be more clear, powerful, and on point in the way we present the information. All of us have community connections among extended family, groups of friends, faith communities, book clubs, volunteer organizations, sports organizations, and internet chat boards. And all of us can wield greater influence on behalf of those countless millions who face mental illness. I hope that this book will be one of many tools to help us do all of these things.

All mental health clinicians know the following from experience: If we want to help others heal, we need to pursue healing in ourselves. We cannot offer others what we do not have. So we need to embody the change we seek to bring about in our culture. If we intend to “heal” our national ambivalence about mental health, we need to resolve our own ambivalence first.

In one way, the information in this book—and the information that the public needs—is already part of the professional DNA of every competent mental health practitioner. We all implicitly know that mental illness is real medical illness, that it is deadly serious, that treatment is anything but hopeless. But in another way, we all have our own residual doubts and biases, hindrances that keep us from true clarity on this issue and from advocating for our field in a straightforward, unhesitating way. When we and colleagues in our field still feel ashamed about our own mental illness, when so many of us still avoid full treatment of it, when so many of us have to avoid fully disclosing our mental illness to medical employers and professional organizations, it is clear that our professional culture still embodies some of the residual ambivalence that most of us carry. So I hope that this book will provide more than a review of the information we all need for advocacy and education. I hope that the reading experience will foster a full emotional conviction to accompany our intimate knowledge of the realities of mental illness. Without such emotional clarity, we will never have the motivation or the will to do the community work we need to do.

Although personal and emotional empowerment is most important, we also need conceptual clarity to advocate more effectively. We need the right information at our fingertips, and it is often different from the information that we need to practice as mental health professionals. I have tried to summarize this information as concisely as possible. All of us “know” the basic information of mental health science contained in this book, but we all need to master this information, not through a one-time review, but through a regular process of relearning and reintegration, each time at a deeper and more thorough level. I have personally been over this material hundreds of times, and each time I review it, I experience it as new, exciting, and powerful. Each time, I learn and understand it more deeply. Each time, I experience a shock of recognition, a sense that I knew this before but did not truly know and grasp the overwhelming significance of mental health for myself and everyone else in our culture.

In brief, our task is to thoroughly integrate this information into the emotional, social, and cognitive levels of our nervous systems. I do not think this task should be daunting. On a deep and intuitive level, we understand the realities of mental illness and its treatment. We could not practice effectively if we did not. We are most of the way there. But all of us have pockets of ambivalence, based on gaps in our education, personal issues with mental illness, and, most of all, old attitudes and feelings that color our current views. And we must address these old attitudes.

More than any other group, mental health practitioners understand that the past colors our view of the present. Yet, like every other discipline, psychiatry suffers from an unconscious hangover of old attitudes and old ways of thinking. Most of us seem to fall back into these when publicly speaking of mental health, even if they influence little of what we do as practitioners. Still, they confuse us and our listeners when we attempt to engage with widespread skepticism about our craft. And so we need to name and correct them.

These old ways of thinking reflect unreal dichotomies, “either/or” approaches that do not honor current holistic ways of understanding our field. These black-and-white characterizations usually distort the many-shaded nature of reality and use one truth to cancel out another. The history of mental health is littered with such long-running debates as genes vs. environment, conscious vs. unconscious mental life, and the importance of behavior vs. affect vs. cognition. We have to take particular care to avoid these dichotomies when speaking publicly.

The approach of this book is simple: We need to advocate by communicating the fundamental scientific basis of mental health care, a basis that most clinicians assume but do not articulate. Although we all know the following statements are true, few of us bother to regularly articulate them:

These assertions would not raise an eyebrow in any mental health or even medical clinic. And members of the public recognize that these constitute the party line on mental illness (as the polls show). But members of the public seem to take these statements more as ideological beliefs than as descriptions of reality. They know they “should” believe this catechism, and they try their best to believe it. But they are not wholly convinced, and their deeper beliefs about mental illness repeatedly resurface in their behaviors. They do not realize that there is a bedrock of science supporting these assertions. They do not know that these assertions are now beyond serious scientific debate. They do not yet feel the emotional conviction that comes with deeper knowledge about the realities of mental illness and mental health. Neither do most of our intelligentsia—our journalists, historians, and cultural critics who comment on mental illness. They all need to learn, and we need to help them do so.

Rather than hearing broad generalities, members of the public need to experience a deeper, more detailed level of understanding for themselves. They need to see the science for themselves. They need to look at the numbers, the graphs, the headscan photos, and even some of the studies for themselves. Because mental health science is immensely complicated, these only amount to examples. But specific examples will carry a power far beyond that of generalities. Though most will not remember the details of such examples, they will carry away a deeper conviction that mental illness is indeed real medical illness. And perhaps for the first time, they will experience mental illness and its treatment to be grounded in reality rather than cultural consensus alone. Treatment of mental illness will then become as intuitively obvious as treatment of a broken bone or appendicitis.

“See one, do one, teach one.” All of us with medical training have heard this saying, and most of us have practiced it. I often think how appalled patients would be to know that this has been a longtime refrain in our medical education system. Nevertheless, there is a great deal of wisdom in this proverbial saying. Medicine (including mental health treatment) is a practical art. It is a practical art based on science, but it is primarily about doing, not just knowing. Therefore, the best way to learn medicine is to observe it and then do it, once we know enough to understand what we are doing. I believe that advocacy is also a practical art and can best be learned in a similar fashion.

Most medical and mental health training requires spending some time in the classroom, but more time observing and practicing our art. We begin as observing students, move up to being carefully supervised interns and residents, and finally attempt to become independent practitioners and teachers of our craft. This book follows a similar principle, though in a much more modest way: The rest of this book is presented as a “see one” experience, an example of advocacy in action. Therefore I have written the bulk of each chapter as if I were addressing members of the public for the purposes of advocacy. It is meant to teach (sharpen what we know about mental illness), but even more to lay out a way of articulating and presenting the nature of mental illness and mental health treatment.

In spite of my introductory remarks, I do not believe that my colleagues need much formal training in how to speak to people, how to make an emotional connection, or how to deal with contentious issues. We as mental health professionals do these every day in clinical practice. Although admonitions such as “be concise” or “use everyday language” are correct, they do little to help us refine our ability to advocate. Personal stories and case examples are powerful tools in advocacy, but I will assume you have plenty of your own to offer. So I will offer only a smattering of these, and predominantly provide an example of advocacy for you to adapt to your own style and needs. For those seeking more specific direction, I have included a section with some practical reminders at the end of each chapter called “Advice for Advocacy.” But, more importantly, I sincerely hope that you will improve upon this model as you consciously observe yourself in various forms of advocacy, and find what works for you and the specific people whom you address. All of us naturally take bits and pieces from our teachers and colleagues: sayings, attitudes, and important facts. And all of us combine and integrate them in a way that best suits our own personalities and practices.

As a “see one,” the chapters that follow are “addressed” to members of the public. The illustrations and captions have been presented in the same way. That is, the language and visual aids will be suited to the general public rather than reflecting the way that mental health and medical professionals communicate with each other. As advocates, our job is not to teach mental health science, but to translate science into the vernacular and the thought world of people outside our field. Therefore, I have written the bulk of each chapter as if I were addressing members of the public for the purposes of advocacy. The introduction to each chapter is addressed directly to mental health professionals, but the remainder is “spoken” as if to the public, the objects of our advocacy. This unusual approach is meant to provide an exemplar for advocacy, a template that you can adapt to your own needs and preferences. The result, I hope, is informal and open, but not disorganized or rambling. The sequence of ideas, the vocabulary used to express them, and the emphasis on particular topics have not developed randomly. All are based on my long experience with advocacy among nonprofessionals. All of them reflect an intentional way of approaching nonprofessionals for the purposes of mental health education.

For instance, I have avoided arguing with critics of psychiatry, regardless of whether they are internal or external. A debating attitude implies that the content of the information is controversial, when in fact it is established science. Criticisms of psychiatry are lumped together in Chapter 4. At that point in the book, they serve to heighten the “dramatic tension” and increase motivation for a deeper level of knowledge about mental illness. Why do I not begin the book with criticisms of psychiatry? Because the most important way to introduce mental illness (after providing a few definitions) is to show that it relates to everyone. Why should you care about mental illness? Because you or someone you love has experienced mental illness. It matters to you personally, whether or not you knew it in the past. Only people who view mental health as personally relevant will bother to listen attentively to the rest of what we as advocates have to say about mental health. Therefore, the emphasis of the first part of the book is on epidemiology and the universal significance of mental health.

It would be tedious to detail my reasons for the myriad of other choices behind these pages. You will find it easy enough to evaluate whether they are helpful to your work. I hope that you will not be put off by reading chapters pitched at the level of laypersons rather than professionals. I have attempted to communicate in a way that is straightforward and fast-moving, rather than patronizing or simplistic. I hope that you will read the book from a personal and not merely critical perspective, and that you will experience the fascination, hope, and enthusiasm that I feel when contemplating the extraordinary edifice of science and medicine that stands behind our work. Those of us privileged enough to practice mental health care are among the luckiest people on earth, in my opinion. Our field gives us intellectual fascination, emotional connection, and ethical/existential purpose. And thanks to many decades of research, we can now appreciate that our work addresses the physical, emotional, and social well-being of our patients in real and effective ways. This information—the powerful science supporting our work—should energize and stimulate us, and likewise should energize the public on behalf of those with mental illness. Laid out before us, it should provide more than enough conviction that the time is ripe for cultural transformation and a new era in the treatment of mental health disorders. If it did not, I would be as surprised as I was disappointed. But it will do so, because such information ultimately rests on reality even more than on idealism, hope, and passion.

With these preliminaries out of the way, let’s begin the “see one” part of the book. I would like to start with a summary of the whole book, so you know exactly where this discussion is going. The following chapters are filled with facts and details, so these paragraphs will give you a sense of the whole. I hope they clearly convey the central thrust of this book: Mental illness is common, real, serious, and treatable.

Chapter 2: What Is Mental Illness? This book is about mental illness. What do I mean by mental illness? I mean a kind of medical illness that is like every other kind of medical illness, with one addition: mental illness is also mental. While we recognize mental illness from mental symptoms, mental illness also has all the characteristic of medical illnesses. Mental illness is medical illness that primarily affects mental functions. So when the part of the body that we need for normal moods gets sick, we can have a mood disorder like major depression or bipolar disorder. Or if the part of the body we need for normal memory gets sick, we can have a memory disorder like Alzheimer’s dementia, and so on.

Chapter 3: Mental Illness Is Common. Why should you care about mental illness? Mental illness is relevant to you, because it is relevant to all of us. Mental illness affects you personally, either directly and/or indirectly. How do we know? Several large and detailed studies of the U.S. population find stunningly high rates of mental illness. About one in four persons experiences mental illness every year, and more than half the population will do so during a lifetime. Half of all Americans will experience mental illness at some point in life. And statistically, that means either you will be affected yourself or someone you love will be affected. So mental illness concerns you indirectly through people you love, or directly by experiencing it yourself.

Chapter 4: The Myth of Mental Illness? How can so many people have mental illness? Some people do not believe mental illness could be so common. They include doctors, university professors, and even psychiatrists and psychologists. They say that the huge numbers in these studies cannot be real because mental illness is not truly real. Some of them do not believe that mental illness is a physical illness. Others think that we simply do not know whether mental illness is medically real, and accuse doctors of creating definitions of mental illness that suit their own ideas. Finally, some think that while some mental illnesses are probably real, doctors have over-diagnosed and overmedicated people without much justification. But all of them believe that mental health care lacks a medical and scientific foundation.

Chapter 5: Mental Illness Is Real. How do we know that mental illness is medically real? Because the scientific research is clear and definitive. We have countless scientific studies that document the biological reality of mental disorders: Genetic studies show that the risk of mental illness is physically passed down over generations. Head scan studies show dysfunction and deterioration of living brains during episodes of mental illness. We can show that hormones and brain transmitters change during mental illness. Other studies show increased inflammation in the body and brain at the same time. We have all this evidence, and much more.

Chapter 6: Mental Illness Is Serious. There is another way to show that mental illness is real. We can show that mental illness has all the real consequences of any medical illness. As supported by facts in Chapter 6, mental illness is serious. Why do we dread medical illness? We fear death, disability, and deterioration of our health. These three consequences—death, disability, and deterioration—are just as common in mental illness as in other types of medical illness. For instance, suicide (sudden death from mental illness) is the fourth leading cause of death for adults ages 18–65. And mental illness causes people to spend more time in disability than any other kind of illness. Finally, mental illness causes wear and tear on our bodies, increasing our risk of heart disease and other chronic illnesses.

Chapter 7: Mental Illness Is Nobody’s Fault. Mental illness is bad news. But there is also some good news. No one is to blame for mental illness. It is not the fault of parents, of mental health professionals, or of the people who have it. Why does this matter? People with mental illness and their families have been blamed, shamed, and abused for centuries. Most people dealing with mental illness have experienced stigma and misunderstanding. So not blaming anyone is a big deal. Understanding the real causes of mental illness would be even better, especially because the basic causes of mental illness are simple: genes plus stresses.

Chapter 8: Mental Illness Is Treatable. Everyone knows there are treatments for mental illness, but few people know just how effective these treatments are. Most people know that we cannot (usually) cure mental illness, but most people forget that we cannot usually cure high blood pressure, diabetes, heart disease, or most other chronic illnesses. Yet we can treat them all. And it turns out that treatment for mental illness is generally as good as treatment for other chronic medical conditions. Medicines for mental health are just as likely to work as medicines for other conditions. And on top of medicines, we have powerful and proven treatments such as talk therapy and social supports.

Chapter 9: Mental Illness Is Our Teacher: How can mental illness become our teacher? Mental illness usually begins early in life, when people are teenagers or young adults. Facing chronic illness and limitations as a young person is excruciatingly painful. At the same time, those who do face the realities of illness and limitations in life develop a deep wisdom that we will all need at some point. They have learned how to accept life on its own terms and to find meaning and satisfaction in life despite the presence of pain and adversity. This is a profound understanding of the human condition, and we would all do well to listen and learn from it, because mental illness is just another part of the human condition, every bit as much as illness, aging, and death are.

Chapter 10: A Vision of Unity. Mental illness affects everyone. Sigmund Freud had mental illness, and so have many famous psychiatrists and psychologists of history. Why should we remember this? We should remember that there is really no difference between people with mental illness and everybody else. “They” are not a separate category of persons. “They” are the doctors, the family members, the people with mental illness, the people who love people with mental illness. We are all in the same boat, and the sooner we all realize this, the sooner that boat will go in the right direction.

What is the point of this book? The point is that you or someone you love has had or currently has mental illness. And if you or someone you love has mental illness, it is possible to know and fully experience the following truths with confidence and clarity: