E189 | Psychiatry Treats Mental Disorders: But What Is Mental Health? (w/ John T. Maier)

0:00 Today we're going to be discussing the all-important question and perhaps one we don't discuss enough on the podcast. What is mental health? And to help us discuss that deceptively simple question, I'm joined by John T. Meyer. John teaches philosophy at Simmons University and he's a psychotherapist in private practice and he's the author of the upcoming book, The Minds We Want: a Theory of Mental Health.

0:26 John, thanks so much for joining me.

0:28 Thanks for having me, Alex.

0:30 I'm not trained in philosophy, so I'm definitely out of my depth for this conversation. The kind of question you're going to be asking in your book is the kind of question I really love, you know, a question aiming at fundamentals. And it strikes me that we do discuss mental health a ton nowadays in our culture, but we very rarely try and define it.

0:50 There's a lot of implicit definitions, you know, psychiatry and psychotherapy, I think, have a lot of their implicit uh definitions of what mental health is, and yet we never discuss it out loud out loud. Perhaps we don't dare to. What motivated you to try and answer this question?

1:08 And to begin, that's a great place to start. I mean, as you say, it's something we talk about all the time. It comes into usage around the late 1940s, 1950s, and has just kind of skyrocketed since then. And so we constantly talk about it. And various people have, as you say, sort of implicit and some institutions have explicit definitions of mental health.

1:28 None of them quite, I think, quite fit. So we don't fully know what we're talking about. And so any time like that is like a ripe area for philosophical investigation.

1:40 Why is it important, do you think, to start to define it?

1:43 Yeah, I mean, there are a bunch of reasons, um, but uh maybe I'll start off with my clinical experience. Like, I think we don't, I so my earliest clinical experience was working in a clinic with adults with schizophrenia, um, who had a wide range of psychological states. I think some of them were doing quite poorly, some of them were quite doing quite well, had rich spiritual and social lives.

2:08 And if you look at kind of textbook, understand it's a mental health, you'll see it'll say, oh, if you have schizophrenia, you don't have mental health because you have a mental disorder, and schizophrenia is a mental disorder. That seems to me wrong. It seems like there's a spectrum of mental health.

2:22 It can coexist with mental disorder. So I think as far as thinking about working with clients or working, you know, non-professionally with people who are friends, it's quite important to be clear. Well, what are we talking about when we say that someone does or doesn't have mental health? That seems to me of a paramount importance in kind of treating people um in the right way.

2:41 And that's a that's a really compelling place to start. So you're working with people with schizophrenia and you're saying, hey, even though ostensibly these patients have a quote unquote mental illness, some of them are really living rich lives and some of them aren't. So perhaps the definitions of mental health are a little bit more complex than we imagine.

3:03 Quite, and rich, not just rich, but kind of mentally, you know, comfortable in their own skin, you know, at ease with their minds, you know, the sort of intuitive markers of mental health, despite, you know, or while having a diagnosis of schizophrenia. Conversely, I had people in my own life, maybe you have people in your own life who don't have any diagnosable mental disorder, but don't seem extremely mentally healthy, seem stressed out, what have you.

3:28 So it seems like mental health kind of cross-cuts these sort of psychiatric categories. And so it's quite important to be clear about well, what exactly is it? And is there such a thing as mental health? That's something we should ask too. You know, is this a real thing or is this just something that's been made up somewhere along the way?

3:44 That's a question, too.

3:45 Yeah, in a way, mental health is the great unifier because no matter your circumstances, uh, anyone can be, you know, not in a very mentally healthy place. Obviously, we know there are factors that make it, you know, more likely that he might have some kind of mental disturbance, poor socioeconomic background, abuse, trauma, but you know, you could be wealthy, you could be sitting in a private plane, and you could be in a lot of sort of long-term mental distress.

4:14 I think that question you raised just earlier is really useful. Uh, is there such a thing as mental health? Can we say that decisively, do you think?

4:22 I mean, so I don't think we can say decisively. I mean, I think we should, I mean, I guess my methodology is when, you know, when people talk about a thing, you know, you'll talk to psychiatrists, you'll talk to therapists, you'll talk to ordinary people, they seem to think there's something called mental health.

4:39 They might not have a definition ready at hand, but they kind of know what they're talking about when when a when a when a client comes in and says, I just don't, I don't feel like I don't feel like I'm really mentally healthy lately. You feel like they're saying something and you take them at face value in what they say.

4:54 So I think our default should be, well, there probably is such a thing here. You know, this probably isn't something that's totally made up, you know, at least take people at face value. Um, but then what people what people say is influenced by what's said by, you know, various medical institutions and stuff like that.

5:10 So we should also be skeptical. So I'd say like uh like take take people at face value and and assume there's such a thing, but be skeptical, you know, is there really? And if if there is, what exactly is it? So that's kind of what motivates this line of inquiry in the book.

5:24 How do you go so now we're gonna assume there is such a thing as mental health, and that's an assumption. I'm gonna be open to saying I make that assumption for kind of the reasons you outlined and some of my own reasons. How do you go about trying to answer this question of how do we define mental health or mental ill health?

5:41 What like sources do you use? Do you use client work? Do you use your own personal reflections? How do you go about it?

5:48 Yeah, I think it's a it's a mix. I mean, I think as with anything, so I I think you there aren't we aren't going to get something like, well, here's the official definition of mental health, and here are all the clauses, and we fit we figured it out exactly. We look at the general practice of mental health, look at the look at look at psychiatry, look at therapy, look at how these practices work with mental health.

6:13 Sometimes that involves drawing on my own personal experience as a as a therapist, and so that's fair game, but also looking at the literature, you know, looking at looking at what's considered a successful course of therapy, what are the metrics people are using. So kind of broadly empirical investigation into how these things are typically used, and then you try to systematize them.

6:33 Then this is the philosophical step. Well, what is it? You know, let's think through, given this thing that has all these kind of complicated properties, what in the neighborhood um plays the mental health role? This is a kind of turn of phrase philosophers sometimes use. You know, what's the real thing there that's playing this role?

6:51 And then you ask it. So it's a mix, I think, like most philosophy, um, and it's a and like most psychology, I think it's a mix of empirical investigation plus a more sort of philosophical analysis.

7:06 Did you draw on spiritual traditions at all? Uh, older philosophical traditions like Buddhism or any individual, do any in of the big individual philosophers have views? Does Nietzsche have a view on what it means to be mentally healthy, anything like that?

7:21 Nietzsche, I can't, I can't speak to as much. Uh the spiritual traditions, I know the spiritual traditions, I think, really, I mean, I often I often use the case of a of a monk, of monks. You know, I'm thinking, I think I don't really specify that this would either apply to Christian or to Buddhist monks.

7:36 So I often discuss monks as someone, you know, not not all monks are mentally healthy. A lot of monks have have serious mental health concerns, but some are. Um, but being a monk is a pretty, from the point of view of of psychiatry, is a pretty unusual. You know, you don't have that much, you know, you have a lot of social connection in a way, but but but it's quite circumscribed.

7:59 You're sleep deprived a lot of the time. You're not engaged in productive, you know, depending on your monastery, you're not engaged in productive or at least very economically productive work. So it doesn't check a lot of the boxes of like of what a of what a flourishing human look life looks like. Um, but a lot of monks have have profound mental health.

8:19 Um and so, and so spiritual traditions for me, the way they come in for me is they they awaken us to the variety of mental health, to the many different things a good ment a mentally healthy life can look like. And we shouldn't assume that it involves, you know, being married and having a certain kind of job and things like this.

8:40 And so spiritual traditions are quite useful for me in in kind of reminding me of how diverse mental health can be.

8:46 Yeah, and I guess something I got, at least from learning just a little bit about Buddhism, for example, is the value of really advanced levels of introspection that if you spend a lot of time sitting with your mind, you actually can learn some really useful stuff. That's not to say, you know, dwelling on your thoughts is necessarily always a good idea.

9:06 I don't know if you're I brought this up on the podcast like a couple of months ago, but there's this billionaire named Mark Andreessen who recently had like a viral clip going around the internet because he talked about how introspection has no value and introspection is everything that's wrong with today's society, and you just need to move forward in life.

9:25 How did you come across this?

9:27 I didn't know, but uh no, I hadn't.

9:30 It's pretty hilarious, and it's probably like one of the litany of like absurd things a tech billionaire has said recently. But obviously, it's something I disagree with. If you spend a lot of time with your mind, you can learn like really, really useful lessons. That doesn't mean, again, you need to be stuck in your negative thoughts, but you get to learn how your mind works if you sit with it for long enough, you know.

9:51 And and I think and introspection is a great one. Not that I I mean, introspection is a great example. I think for me, there are many things that are that are kind of uh uh you know good for some people but not for others, and it really depends. Like I take as I said, there's the Socratic view that it's always introspection is always the highest value, and you're not really living a proper human life unless you're friendly introspective.

10:12 And like you, I tend to side more with that view than with the Andreessen view, but I think there's a spectrum here. For some people, introspection is a mark of a flourishing mental life for them, and it's a and it's a big component of mental health. For other people, not so much, and that's okay too, on my view.

10:28 Like it can get it really depends on the person. Yeah.

10:31 And I totally agree that there's a matter of degrees, but I guess I would argue that a life of like zero introspection is probably unlikely to be a good idea.

10:42 Yeah, I it would be yeah, it's hard to imagine what a life like that would look like for a creature with a mind like ours. So it is it's I I find it hard to imagine, I guess. Yeah.

10:52 So again, if you talk to a psychiatrist, you know, I I so I've trained as a psychiatrist and a therapist, and I function in both roles. And if you talk to a psychiatrist or a therapist, particularly a psychiatrist, they'll rarely outline a definition of mental health, they'll never say, you know, this is what we're shooting for, necessarily.

11:14 Um, and this bothered me in medical school. In medical school, I remember before we learned about uh kidney disease, we had to read a whole book about how the kidney works just under normal conditions. Yeah, and it bothered me that in psychiatry, when I did like my psychiatry module in undergrad, we never did a module on this is how emotions and mental life work under normal conditions.

11:37 This is how there's like a good relationship with your thoughts or good relationship with other people that just go straight into schizophrenia, depression, personality disorder. Yes. So so I feel like psychiatry is carrying a mental health definition, but it never really talks about it. And to a lesser extent, I think this is also true of the psychotherapy world.

11:56 What do you think are the implicit ways these fields define mental health typically?

12:03 Yeah, and I just want to dwell on that analogy because it's a great one. It would be if you asked a cardiologist, well, what is a good heart? And they said, I have no idea what that was.

12:10 Yeah. What do you think about it? Cardiologists would talk to you for hours about that. Yeah, exactly. Yeah, they're gonna be doing it.

12:17 Here's what the heart is supposed to do. Yeah, and so so you here's what the brain is supposed to do. Um, and I think ultimately there are disanalogies between the mental case and the physical case that are that are important. But uh to answer your question, and and it's it's I mean, it'd be interesting to hear from more psychiatrists because I think you're right.

12:32 There's there's not like uh there's not like an official, official definition to my knowledge, what the working definition, and sometimes it's made explicit, goes by there are these diagnostic manuals, the DSM in in in North America, um, that outline the category of mental disorders. Mental disorders are defined more or less functionally in terms of, you know, in terms of their impact on one's life.

12:55 And at first approximation, you might say someone has mental health just in case she does not have one of these mental disorders. If you don't have schizophrenia, if you don't have a personality disorder, that's don't have a substance use disorder, go on down the line, then you're mentally healthy. So that's a view.

13:12 It's hard to, that's a kind of crude view. And I don't I doubt there are many working psychiatrists who would like sign their names to that definition, but that seems to be the definition that's that's implicit in a lot of clinical practice, which is, as you say, guided by looking at psychopathology and then trying to like get rid of psychopathology and what's left over is close enough to mental health.

13:34 That seems to often be the working view.

13:36 Yeah, and I think that is the working view. I agree that psychiatrists will rarely kind of actually agree with that view, and yet it's so important to actually bring it up and think about it and talk about it, because even though psychiatrists may not agree with it explicitly, it influences their practice all the time.

13:54 I think psychiatrists are often disarmed when it comes to actually helping, maybe giving some positive kind of advice. Hey, these are some things maybe should try in your life, other than these are ways to reduce symptoms, reduce low mood, uh reduce maybe hallucinations, maybe reduce like symptoms of ADHD.

14:16 That's where we're focused. I think that can often be a bit narrow. I think often it can leave our patients feeling something, wanting something more. In the psychotherapy world, I think this is particularly true of psychodynamic psychoanalytic methods. I mean, Freud famously said, you know, we're kind of what we're shooting for is garden variety unhappiness, you know, let's remove the major conflicts internally from someone.

14:44 Um, and I think it's also true of the cognitive behavioral perspective that again we're aiming for let's take away a harmful relationship with our thoughts and emotions, but what should we shoot for exactly? Not so clear. I guess where it does shine through differently is humanistic psychotherapy and um positive psychology.

15:05 Are these are these things you looked at when you were writing this book?

15:09 Somewhat. And I look at a range of things in the book. Humanistic psychology, I think humanistic psychology a bit more than than positive psychology, but I they come under the headings of things that are potentially useful interventions. And the book, by the way, is and we can get more into this, but the book is not unsympathetic to cognitive behavioral therapy or to psychoanalysis.

15:29 I think these properly done. If anything, it's trying to give an account of what these things, when they're done well, what they're doing. So it's so so all of these things might be legitimate interventions. The one that I focus on the most is acceptance and commitment therapy or ACT, which is kind of a you know third-wave behavioral therapy that has a lot of focus on mindfulness connected to your remarks about um uh about Buddhism earlier, um, as well as on kind of living a life that's that's concordant with one's values, which is moving more towards that positive side of things.

16:04 So I uh so the the case study I really focus on is acceptance condemnotherapy, where I think that's properly understood, that's as something that's that's promoting mental health. And so that's uh that's a kind of standard therapy that I think that I think does do a good job of not describing the doing the sort of thing that I'm describing.

16:21 Yes. Uh and obviously I also agree these approaches can all be legitimate, you know, when they're done well. But what do you think is the problem? So if we take the psychiatric view, you know, we've got lists of possible disorders, which we as a psychiatrist, I may or may not diagnose someone with. Uh, I guess if I do diagnose someone, I'm gonna aim to reduce those symptoms or even make them go away entirely as much as possible through a variety of means, sometimes medication, not always.

16:48 What's the problem with that view? Isn't that isn't that reasonable?

16:52 I mean, the first I mean the first problem is the definitional issue that came up when I was talking about schizophrenia. Schizophrenia is the kind of is often taken to be the paradigm mental disorder, but a lot of people can have schizophrenia. You know, if you're in treatment for schizophrenia, taking antipsychotics, you still meet criteria for diagnosis of schizophrenia.

17:09 So you have the mental disorder. Nonetheless, I think you can have you can have pretty good mental health. So I think as a definition of mental health, the psychiatrist that's kind of working psychiatric definition just can't be right. Um, and conversely, again, people who don't have diagnosable mental disorders um uh but don't have mental health either, they kind of fall outside of the province of psychiatry, and psychiatrists never see them because they don't have, or typically don't see them because they don't have mental disorders.

17:38 Nonetheless, a lot of poor mental health falls into that bucket as well. So I think the place to start is that working definition just doesn't get the extension that is the the the scope of mental health correct.

17:51 Right. So we're missing something. The definition is missing something, something important.

17:56 Yeah, we're we're missing something, which is not to say, I mean, psychiatry, there's this book finds a big role. I mean, psychiatry, you know, a lot of these medications have, you know, the clients I was working with, you know, had their lives profoundly changed by psychiatric medications. So this book is not anti-psychiatry or anti-psychiatric medication.

18:16 So there's a huge role for psychiatry. Um, and it might be that psychiatry, one thought is, you know, a standard view, at least in certain circles, is that psychiatry is kind of the the foremost of the mental health specialties, and then and then it's sort of clinical psychology, and then you do your own hierarchy from there.

18:33 One view of this is that's not quite the right way of thinking about them. That psychiatry is a very useful specialty that focuses on one aspect of mental health, but it's not really the it's not really the it's it's one piece of a much more complicated puzzle, and it's really good at finding medications that are helpful for people.

18:51 Yeah, I think psychiatry functions best and has always functioned. Actually, I'm not even sure I agree with that. I think psychiatry functions best at the extremes. So when people are in extreme mental states, you know, psychosis, mania, extreme suicidality, you know, ADHD when the symptoms are really severe, depression when the symptoms are severe.

19:13 I think psychiatry, I think those are the states when like a disease model or a medical model makes the most sense. Where you can make the strongest arguments for it and where it can be of the most help. I've made many suggestions on the podcast on how I think that could even still be improved. Um, but that's where I think psychiatry works the most effectively.

19:34 And I think one reason why psychiatry is often seen as less effective and can be less effective is because it's almost trying to do too much and trying to um treat the problems of such a wide variety of people, people whom whose problems might be better addressed by different modalities, perhaps a primarily psychological modality, or maybe a sociocultural way of looking at things, or maybe a combination.

20:00 So, so before we move on to okay, what you think, what your theory of mental health is, perhaps we can say like it's useful to define what mental disorders are, and mental disorders like are an important piece that may very well impact your mental health, uh, but they're not the whole picture. So you may have or not have a mental disorder, and irrespective of that, you may or may not have be overall mentally healthy, so to speak, or have a lot of mental distress.

20:26 Is that a fair way of putting it?

20:29 Um, yes, I think uh yes, the mental disorder is a is a certain thing which we've yet to kind of define that has a sort of cross-cutting relationship with mental health. Might impact mental health, might not. Um, it depends a bit on the case.

20:42 And I'd like to kind of go through. So I in in the paper you sent me, there are these like three levels you go through when you're thinking about defining mental health, which is firstly, should we think about mental health as having certain positive aspects, as in having certain things, or is mental health the absence of things?

21:03 So, for example, in psychiatry, mental health is the absence of symptoms. Yes. But what you're saying is mental health is having a whole bunch of positive traits. And then the second level is is mental health a state of being or is it a functional state? And then the third level is is it subjectively defined, defined by the individual, or is it defined more objectively?

21:27 Which I assume you you mean defined by others? Is that what that means?

21:33 That's a that's a yeah, that's a hard question. Maybe I'll yeah, what people mean exactly by objective. Um uh maybe I can because those are that's a useful because I kind of ran those through those three together a bit. So that's so just to to echo what you just said. That's that's really helpful. So is mental health positive or negative?

21:51 Psychiatrists think it's negative, their working definition. As long as you don't have X, Y, Z, you're good to go. Yeah, our intuitive notion of mental health. Health is kind of positive. If you ask why does you know you talk about your mentally healthy friends? Well, she's so she has such good mental health.

22:06 You typically say positive things. You know, she's calm, she's easygoing, whatever it might be. Mental health seems like a positive thing.

22:12 Not traits that someone possesses that makes them mentally healthy. Yeah. Yeah.

22:16 They tend to be positive traits rather than absence of functional disorders, which is what are central to psychiatry. So positive, and then it's it's not functional, it's kind of non-functional. That being, you know, you know, it's being in a certain state that might manifest itself, you know, when you ask your mentally healthy friend to go out to the movies with you, she is kind of engaging and fun and so forth, and those are functional things.

22:40 But beyond that, there's a state, a state of mental health that's kind of non-functionally designed, a kind of a state of well-being. So it's mental health is a positive state as opposed to an absence of function. So that's the that's the kind of core disagreement with the psychological model.

22:58 So are you saying being mentally healthy is not about having the capacity to do certain things and carry out certain functions. It's more a state of being, is that what you mean?

23:09 That's my view. Not it's not primarily that. It might enable that. If you're mentally healthy, that you know, mentally healthy people, you know, have good employment outcomes, have good relationship outcomes, and there's all sorts of knock-on effects functionally. But it what it is fundamentally is a non-functional state, which again is contrasts with how psychiatrists think about it.

23:29 It also contrasts there's a very the World Health Organization has a has a very prominent definition of mental health that's prominent, partly because it influences WHO funding and is uh and and is a very influential this this uh definition, and that definition is explicitly functional. Um, so I think in public health, mental health is often thought of in functional terms, um and and yeah, and I think that's yeah, that's incorrect.

23:55 And then level three, yes, is mental health subjective or objective meaning, and my understanding is so do I as I do I, Alex, and as the individual, get to decide from my point of view if I'm mentally healthy, or does my psychiatrist or do the people or community around me decide that would be the objective view?

24:18 Is that right? Is that right, that way of defining it?

24:21 It does, although even I I would think objective, and maybe maybe this is used as maybe philosophers think of this somewhat differently, is even broader than that. Because the community might on the objective view, the community might get things wrong. It's what is what is mental health, actually.

24:36 And I think of a lot of I mean uh I mean experts, maybe experts have a definition.

24:41 But even the experts could be wrong. Like I think in if you think of like cardiology again, like in cardiology, you know, the act there's an expert consensus on how the heart works, but that could be wrong. It's been it's been wrong in the past. And so there's an object, there's an objective, you know, what good functioning for the heart is a relatively objective thing.

24:58 Oh, right. So it's like an objective reality that perhaps might not be known, but it exists.

25:03 Right. That would be a that would be, I guess it's again, these are all spectra. So that's another spectrum. So there's an so the extreme objective view is it's like cardiology or something like that. There's a real there's something that really is mental health, and we're trying to figure it out. Um, and so and then and then we there are variety of views kind of in between.

25:24 Yes, okay. So I'm just gonna recap just for to make it easier for me to edit and for for our listeners. So we're we're having a little bit of a we're gonna have a bit of a debate. So is mental health about having certain traits, or is it the absence of traits that defines it? Is it about is mental health about having certain functions and allowing a person to do stuff primarily, or is it primarily a state of being?

25:51 And then lastly, is mental health this subjective thing that we largely experience and and define for ourselves and we decide if we're kind of mentally healthy or perhaps our community, or is there some objective sense of uh uh a mentally healthy person that we might try and move towards? Now, my first question about this, and do you uh bear with me because I'm not a trained philosopher, so maybe these questions are stupid, but my first question is do we even have to have these dichotomies?

26:21 So do we have to commit in, for example, for does mental health have to be primarily either function or a state of being? Can't it be both?

26:34 Yeah, I mean, I think I I think there's something to that. Like, I think these are all, as I said earlier, these are all spectra. So there's there's it's not quite black and white, they're all sorts of intermediate positions. Um, I think functional, I I I guess I took care in setting up those oppositions to to treat things that are genuinely opposition.

26:56 So I think positive, negative, that's that's oppositional. I think functional, non-functional, as I as I as I think maybe I I go back and forth with well-being, but functional, non-functional is the other one, and then subjective, objective. And so those are those are pretty um oppositional. Um, they're they're all there are always intermediate positions, but I think those mark real points.

27:19 And by the way, these aren't, I guess, these aren't entirely, these are attempts to describe positions on the mental health debate that already exist. So this is in a way a taxonomy that's meant to outline the various positions that people already have. So it's not saying here are the three possible degrees of of disagreement.

27:38 It's kind of a map of current views on mental health. So that's the primary role for these kind of oppositions.

27:44 So it's a beaten path and they're they're sufficiently oppositional that it makes sense to try and choose one of the one over the other primarily.

27:53 That's how that's how I would put it, yeah.

27:56 Okay. And then can you continue to elaborate on on your theory of mental health and and how uh it's about creating the mind you want? So could you give us an example of what mental health might look like in an individual by that definition?

28:11 Yeah, so it's so I think I think again, these points that have already come up in the conversation about the diversity of mental health are useful. So I already mentioned monks. Uh, an opposition that I use in the book is the difference between a monk and the parent of a of a young child. So I I'm not a monk and I don't have young children, but I've spent time with monks and with and with parents of young children, and they're very different.

28:31 Like the what it is to be a monk, it's a very different life. And more importantly, it's a very different psychological life. A monk, there's a lot of quiet, um, and um, and a lot of sort of you know, a lot of different things going on. Uh parent of a young child, it's a lot of stress, it's limited sleep, a lot of interspersed with with moments of joy.

28:52 Um, it's a there's there are a lot of ups and downs um in that person's psychological life. Typically, people vary, of course. Um, but I think those can both be paradigms of mental health, that a monk and a parent of a young child can can really both have excellent mental health, even though their mental lives look totally different.

29:12 Um and so I think that's the starting place for thinking, well, whatever it is, like whatever thing you wanted to name as the hallmark of mental health, that's probably not going to show up in both the monk and the parent of a young child. You know, maybe you can engineer things that would, but they look so different that we need to look for a different kind of standard, not some feature that's a hallmark of mental health, but rather something, something more general.

29:37 Um, so that's what leads you to think, well, maybe it's having having the mind you want. That's a much that's much different kind of standard that can accommodate the diversity of mental health. So mental health, whatever it is, is compatible with having this sort of stressful, interspersed with joy experience of parenting young children.

29:55 It's also compatible, whatever it is, with the prolonged stretches of quiet and isolation that distinguish the life of a Buddhist or of a Christian monk. So whatever it is, it's it's quite different. Like it it looks quite quite different in the two cases. So it has to be something quite sort of abstract if it can if it can be so different at the first order level.

30:19 That's the thought.

30:20 So would you say fundamentally you're kind of more agnostic about what makes someone mentally healthy in the end?

30:30 Yes and no. Yes and no. I in some sense, I think what makes you mentally healthy. So the view is um what makes you mentally healthy is having the mind you want or the mind you value. And so, and you know, and and and and that's the part of the view I'm relatively confident about. What do people actually want?

30:49 What does a given client actually want? What does someone in some scenario that I don't know that well? You know, I don't I I know, you know, monks would know better, parents of young children know better, the details of these scenarios, you know, um people are endlessly inscrutable and complicated. So I often don't know what people want for their minds and whether they're getting what they want.

31:10 So there's a deep agnosticism there about whether any individual has mental health. Um, so the the part the piece that I'm more confident about is the view of what's involved in having mental health, if that if that makes sense.

31:22 So it's uh by by this definition of incredibly individual thing and does rely on a lot of, I guess it would rely on someone doing a lot of introspection to really find out what what kind of mind they do want.

31:36 You can have the mind you want without knowing without knowing the what you want from your mind. So you can just guess. Like I think a lot of people are lucky or or you could be in some society. I mean, I think a lot of people have good, I mean, maybe this is contentious, but I think a lot of people have good lives, even though they've never thought deeply about what they want from life.

31:57 They're just in some in some community where there are certain norms, and it just so happens that following those norms you you have are relatively, you kind of get the kind of life that you life that you want. So I think you can do this with you don't need to introspect deeply in order to do this.

32:16 And I do you think that all the cultures were just better at creating environments which people could be in a more harmonious band with mentally just by virtue of having a lot of time to figure out certain traditions, certain rituals, certain ways of setting up a society and relationships between people that is just more likely to be equanimous as opposed to Western cultures where things are a bit newer, the technological landscape is changing really fast, and so we're finding ourselves in these very alien environments, often without ritual, without certain cultural landmarks to keep us sane.

32:54 Uh and therefore all the cultures have a bit of an edge in actually helping people have like a good life or a mentally healthy life just more naturally.

33:04 Maybe, yeah. I'd love to know, I'd love to know more about, and we certainly have a good sense of the things that are undermining our own mental health in the year 2026, you know, whether it's phones and all these other things that are that seem to be really causing negative mental health effects. What it was like in 1900 or, you know, among the Romans, what their mental health, I would love to read more.

33:24 And may there may there are books I haven't read, but you know, more history on this. I mean, though the and I I'm quite I'm quite sympathetic to the thought that other cultures had better practices um around these. On the other hand, and one thing that tends to be inimical to mental health is poverty, and and people are are you know gradually getting wealthier, and that's probably on balance, you know.

33:50 Obviously, these these effects can can be more complicated, but that's on balance, probably good for mental health. Um uh so but but but beyond that, beyond that, I I just I just don't know what it was like in other places or other times.

34:04 I'd love to share some of my thoughts, and again, these aren't thoughts I've spent an enormous amount of time thinking about, but I was like jotting things down as I was reading the paper you sent me, and I'd love to guess your reaction to them. So, in terms of like the first level we talked about, is mental health about having certain traits or is it about the absence of traits?

34:24 I think I just agree. I think mental health is definitely about having traits. I think mental disorder is more about the absence of certain kind of negative traits, but mental mental health, I think, is about having a bunch of traits. I think when it comes to is mentally mental health about a state, a non-functional state that you're in, versus is it about how having functional capacities?

34:48 I think I land on I think it is about having functional capacities. And the reason I think that is because our minds were designed by evolution, so I do tend to take an evolutionary point of view often in these things, and so I don't think evolution designed our minds to exist in a certain non-functional state, but rather evolution is quite cutthroat, wants our minds to be able to do certain things, to adapt, to survive, to reproduce.

35:21 I think that's why you know we really weren't designed by evolution to be happy, not that someone shouldn't seek happiness or that there aren't ways of seeking happiness, because I definitely think there are, but it's good to know I don't think our minds were designed by evolution for happiness. And so I think uh evolution definitely wanted us to be able to do a bunch of things with our minds, and it and it has worked in some sense, in the sense that we've become the dominant species of the planet, for better or for worse, that's quite an accomplishment.

35:51 Um, and in terms of like what those sort of functions are, having a think about those, I was thinking about clearly problem solving. I think the ability to solve problems is a feature of mental health. Um, I think flexibility and adaptability, so the ability to be put in a novel or relatively novel situation, and again, perhaps solve problems or in some way decipher what that situation is about and get a better outcome, uh, is a feature of mental health.

36:21 One thing that came up for me is orientation to time. So, by which I mean being able to focus on the present when you need to focus on the present, to be able to have a healthy relationship with the past, by which, like, I mean, I want to think about the past and maybe what lessons could I learn from the past that could help me now, um, as opposed to getting stuck in the past and dwelling on the past, and also a healthy orientation towards the future.

36:52 Okay, I have I know a future is coming, and how could I prepare for it, as opposed to being really you know paralyzed about the future and just being really anxious, but not being able to actually do anything if to prepare. So I was thinking about that. I thought a ton about relationships, uh, and I do I use the cognitive triad for this, so relationship to self, uh, to to others and to the world, and being able to form a relationship with yourself, with others, and to the world at large that is of mutual benefit, uh, kind of a win-win, if you like.

37:27 I think that's a feature of mental health. And um, I think I thought about what you said, being able to have the mind that you want, and I think I disagree a little bit there. I kind of seeing it as making peace with your mind and making peace with your predispositions. And for this, I'm thinking about personality science, where we know like around 50% on average of your personality is genetically influenced, around 50% is environment, uh environmentally influenced, but not basically none of those you choose, at least, especially not originally, especially not early in life.

38:09 And so you're gonna have a bunch of these personality traits, and I think a lot of like mental health is figuring out how to make peace with them, how to create and continue to create an environment that is equanimous with those personality traits, and maybe working a little bit on your personality weaknesses and vulnerabilities a little bit.

38:28 I thought about Maslow's hierarchy of needs, obviously, and that's a whole other discussion. And I also thought, you know, I don't think mental health is a is a have or a have not. I think there's various degrees, it's a spectrum, no one's like mentally healthy, and they're all on a spectrum, and different situations might kind of reveal different strengths or vulnerabilities that we have.

38:50 So I don't know if there's any of those you want to pick up in particular, or any of those you particularly agree or disagree with, but we can go to the really yeah, I can tell, yeah, it's a it's a fascinating, it's a fascinating account, and it's well worth it's well worth considering.

39:02 I think I want to speak to that. I too think our minds are the products of evolution. Um, I don't I don't know if mental health is necessarily going to match onto something that's I don't know if mental health, as I understand, is something that's selected for. It might kind of fall out in a way. It's more of a spandrel or something that kind of falls out of other things that are selected for.

39:21 Um uh so I don't, so just so that just being a selectionist doesn't mean it doesn't quite push me to a functional account. But I agree that it's a really nice functional account. I wanted to actually, and maybe the time one, because that that seems like a very intuitive one to me. Um, that yes, when I think about mental, when I'm, you know, when I'm mentally healthy, I'm kind of at peace with the past and I'm future oriented.

39:43 I I think like there's been this discussion around prolonged grief disorder where people are, you know, people grieve their loved ones for, you know, for for a long, long time. And there's been a question of does that rise to the level of a psychiatric disorder at some point if it goes on for a long, long time and it's and it's um uh and it's causing significant functional interference with that person's life.

40:06 And I tend to think, I mean, this is maybe here I'm more sort of subjectivist maybe than you are, but I tend to think, oh, it depends. I mean, that's kind of how some people choose to live their lives. Some people lose a loved one and the rest of their life is spent in grief for that loved one, and they're mentally healthier.

40:21 I don't want to say by definition that they're not mentally healthy, even though they're fully preoccupied with the past, and that's where their emotional life lives. So the things to that sort of thing sounds like the things you were describing sound to me pretty good, and things that I'd like you know more of in my own life, but I wouldn't quite want to make them definitional of mental health for that, for that kind of reason, if that makes sense.

40:41 In terms of the last levels, kind of like the subjective versus the objective. I think I'm I'm inclined for for this level not to commit to one. I think a balance of of both, like a harmony of to some degree of both, where uh I think clearly there's an enormous subjective component to mental health, and I think that's where the the ability to think carefully about what is the mind that you want and clearly what is the life that you want is hugely valuable.

41:11 But again, even from very different life situations, I think you can pull kind of objective principles that work well across many, many different situations. And again, that's probably where I would refer back to some of the other things I was mentioning before, like again, the ability to uh solve problems.

41:33 It would be hard to say, you know, someone's mentally healthy if they couldn't solve a problem at all, if they couldn't solve any problems for themselves, even if they, for example, said, I can't solve any problems, but I'm perfectly happy with that, and I'm really mentally healthy. So are there likely to be some traits, higher order principles by which someone can like say, okay, I think this is a level of mental health that someone's achieved.

41:57 I think probably likely. So I think probably I land on there being some harmony in between those two.

42:05 Yeah, the the the ones that you were suggesting, that it sounds like more of an some of those sound like relatively objective standards that either you can do these things or or or can't. And so um uh so it it would it does sound like it's kind of pushing towards a more kind of objective conception of mental health.

42:24 And I guess another one kind of in this category would be like mutually beneficial relationships with others, leaving aside maybe a mutually beneficial relationship with yourself, which might be harder to define, but an ability to form relationships with other people, or perhaps the world at large where both people are getting some benefit from I think again, I think evolution is a like a huge driver of this because you can almost say, you know, humans aren't individuals, they're like we're communities, you know, we're incredibly incredibly relational creatures.

42:55 When we're evolving in our hunter-gatherer past, we are functionally dead if we were isolated from the tribe, you know, for any serious length of time. And so that ability to form part of like a community to help your community and to have your community help you in some way, shape, or form, I think is a big feature of mental health.

43:14 And it's hard, it would be hard to imagine um someone being mentally healthy when they have no relationships with other people, or if they have relationships with other people, but they're like either win-lose or like kind of destructive.

43:29 Yeah. Although I think of the the monks or maybe the hermits, they have a relationship, they have a relationship with God. I don't know if God counts, uh, but they God can't be benefited. It's not like a selective for relationship. Yeah. And so that there I want to say they they can have and and even more clinically, I mean, I think a lot of people with I don't the literature on this is sort of mixed, but I found that a lot of people with with um schizophrenia and psychosis spectrum disorders have have more, have less kind of interpersonal relationships, even.

44:00 relative to their well being. Like it might be that certain mental disorders are just are are sort of hindrances to certain kinds of interpersonal relationships, but aren't aren't necessarily hindrances to to mental health.

44:10 But they're not less, but they wouldn't have zero to the other. Well no, that's yeah zero zero is to find a person with zero. It's kind of like the introspection hermits.

44:19 Yeah hermits there are really really hermits yeah so that's a real thing.

44:22 Yeah but but but but yeah you're right you're right in the in the general population it's harder to find people with zero yeah is there anything you you want to add about your theory of mental health before we talk about kind of the practical implications of this is there anything you want listeners to know about how you think about or define mental health?

44:40 No I think I I want to kind of methodologically the spirit this feels like exactly the kind of conversation I want to be having where it's like I think the the the message of the book is not so much here is the definitive view of mental health. The message of the book is like you know what is mental health here's a here's a working theory you know what are the what's the what's the logical space look like what are the possible theories and so this is uh the kind of takeaway I'm hoping people will have from the book of like how do I work out you know what's what's my preferred view of mental health and how would it stand up the counterexample and things like this.

45:08 So this is the converse kind of conversation I want the book to right uh inspire. So I'm really enjoying this.

45:14 Okay great. Um maybe one more point we can discuss again before we go on to practical implications. So the the difference I raise so you you between you saying mental health is about having the mind that you want versus I guess my position would be more like mental health is more like reconciling your life with your mind you're given a mind of sorts you're given a a whole set of predispositions and and I think part of one's life task might be to cultivate some of those predispositions fruitfully part of it might be to make peace with some of them various ways you could approach that but how do you respond to that?

45:55 Yeah I there's I think this is an important phenomenon I'm not I'm not quite sure there's quite speaking in the book I speak about the difference between downward and upward psychological change which is so downward psychological change is I've got these desires for my mind and then well how do I bring these you know I want more peace in my life okay I meditate more and I've got more peace in my life so I I take my higher desires and influence my first order mental life but certain sometimes sometimes first order aspects of our lives are as you say kind of more intractable than that.

46:25 Certain, you know they might be genetically determined you know if you're if you're introverted you know there are things you can do to become more extroverted but it's somewhat it's somewhat it's somewhat robust against interventions. And so sometimes there's room for in my view for what you call reconciliation I call it upward psychological change.

46:43 Part of the process might be coming to have you know desire you know or value the sort of particular things that you have which I think is exactly what you were talking about. So one way of bringing your mind into agreement with your desires for your mind might be to change your mind. A different way might be to change your desires for your mind.

47:02 I mean of course there are worries there worries about like adaptive preference and worries about you know you know kind of bad faith like falling into you know being like okay with your aspects of your mind that you don't like but I think holding those fixed I think there's definitely room in my view for what I call upward psychological change which is changing your desires or values to accept for lack of a better word certain certain robust features of your of your mental life.

47:29 So you so you okay so you're leaving the door open to the fact that sometimes you can change your mind and sometimes you can change what you want but it's that reconciliation between what is the texture of your mind and what what do you want that to look like there there's room for both I mean I think both personally and clinically there's there's definitely I prioritize the downward kind because we kind of I think in general we you know in general um that's the the that's the most that's often the most effective thing is to change you know the first order aspects of our mind and there are all sorts of there are all sorts of possibilities for self-deception when you try to go the other way around.

48:09 But I think the other way around that is being like look this is an aspect of my mind that's just fixed I have to change my desires or values that's also a route that's available. And so I so that's definitely a possibility on my deal.

48:20 A lot of people again in in the humanistic tradition but even psychoanalysts like Karen Horneye talk about notions of self-actualization.

48:31 Yeah.

48:31 What do you think about self-actualization?

48:34 Yeah I like Karen Horneye a lot. Let's see what do I think about self-actualization yeah I mean I guess I'm I'm I'm not I'm not against it um uh it depends a bit what's what's meant but I think I think the idea of I mean I think the idea of realizing as I would put it one's one's values for one's mind that's you know that's I think a big goal of of clinical work and and of of life more generally so it depend I guess a short answer is it depends a bit what's meant by by self-actualization here.

49:11 Maybe I can give you an example. So I think maybe I think often in people you can draw a correlation between someone's personality their values uh their beliefs their behavior and the degree to which they actualize all of those things. So for example someone might be by personality uh born an extrovert and you see you know you hear about this someone would say you know my my kid was an extrovert pretty much from day one always hanging out with other kids.

49:44 So they're at a personality level they're uh extroverted and maybe as a result of that personality trait and other forces maybe they value what they really care about is being with other people making other people happy and socializing. They love socializing and and and social spaces where people can get along and be happy and maybe in terms of like behaviors what that translates to is they become an events planner and they love planning events and it's a job and a way of making a living which is again mutually beneficial relationship with other people and that that helps them to uh act on the personality trait and act on the values and what they think and what they care about.

50:26 And to the degree that they do that that is an actualizing process. So they are they are not just they don't have an uncultivated extroversion for example you might imagine another extrovert who for whatever reason they're they're stuck in their parents' basement and they can't actually get outside and actualize it or make cultivate the extroversion to something meaningful useful and something other people can enjoy but that person is really cultivating it and actualizing it.

50:52 So to the extent that they're doing that that is the self-actualizing process and that is a cool thing because it makes it means people get to unfold and not like reach their objective true potential but they make something of the potential that they have inside them and something that's good for them and good for other people.

51:15 So what do you think about that kind of definition?

51:17 Yeah yeah I I guess that's how I was I was thinking of it and it's I guess that seem that does seem an important good I mean it often it feels like it's gonna depend a lot on external factors. Like it's much easier to self-actualize when you have a lot of money um I would I would imagine like at least that doesn't hurt.

51:37 Well I think I think it's uh it's a double edged sword but in print yeah I think I agree with you in large part.

51:42 Yeah yeah yeah it is a double edged yeah but but but yeah other things being equal it's probably better to have more money to go to a better college things like this. And so I think actualization does seem like an important thing although it's often it's sort of a a sort of broadly functional good that's going to be influenced as much by kind of socioeconomic factors as it is by psychological ones.

52:03 I guess that's that's how I that's how I hear that notion of actualization.

52:07 But even actualization can be something much more humble than that and doesn't even have to involve money or it doesn't even have to involve you know working for a living. So like actualization might be uh I love guitar I love music I pick up a guitar and I learn how to play songs on guitar. It might be as simple as that but that is still an actualizing process.

52:29 Sure sure and and that in general is going to be I mean I think it's gonna be and and I would make the point that actualizing to the extent that you can do that it's conducive to good mental health.

52:40 That yeah I guess conducive is a good word I mean it to me it's it's not because for me mental health is ultimately a state of you know state of mind and this is more kind of a state of of life um actualization. So it can conducive to I think it's conducive to mental health I think mental health is probably conducive to it.

52:58 When you have the mind you want you're probably more likely to actualize your special abilities and talents so it's definitely promoted by and maybe promotes also mental health although I'd want to say it's something a bit different from mental health it's one of these and I think I think mental health when I said earlier you know insane mental health is non-functional I don't mean to say it mental health is great for you in all sorts of ways you know people you know improves relationships, improves employments, maybe improves actualization too.

53:25 I think I put actualization as one of those very important sort of fundamental functional goods that's sort of that's sort of enabled by mental health maybe that's how I think of it. But I I guess what you are saying and correct me if I'm wrong is that mental health starts as a kind of state of being and then goes outwards into functionality whereas I might say maybe sometimes it could be the opposite maybe it starts with functionality which translates to a state of being downstream Yeah I think if we're thinking about causal connections I think it could potential go either way like having a you know being being around being around lots of stimulating people early in one's life who are supportive

54:12 of one's goals and and are listened to what one has to say um that sort of that sort of free and supportive you know early upbringing environment that's a functional good but I think it I I don't know the research on this I don't know if there is research on this but I would guess that that's more likely to result in mental health on my definition than otherwise so there are definitely causal connections I want to say in in both directions.

54:37 Given what you've learned in writing this book what are we getting wrong on the ground in mental health services do you think?

54:45 Yeah I mean so I think the the first thing to say is not necessarily I don't think you know not necessarily the things that we're doing are not necessarily wrong. So I think one way of reading this book is as a way of understanding things that we're already doing. So what are we doing when we're doing CBT?

55:04 What are we doing when we're prescribing psychiatric medications? Well on my view we're promoting mental health at least in the CBT case um and mental health is having the mind that you want. So in one way this book is just giving us an account of what we're already doing pretty well if we're experienced clinicians we're already doing it um pretty well that said um there are at least a couple areas um where would be um uh where it would be useful to change things or at least modify things I think one is one one's kind of obvious like this is something and this is from a therapy point of view this is something one can talk about with one's clients and it's not necessarily a standard question that

55:44 comes up in intakes or even even in extended work what kind of mind do you want? Or if you woke up tomorrow, this is like the miracle question, you know, if you woke up tomorrow and you and you had the mind that you want how would you notice like what would be different inside your mind um questions like this I think are interesting.

56:02 I think I find them in my experience this is a bit anecdotal but I find them to be rich rich lines of questioning and so and getting to know what clients want from their minds which is these questions don't always don't always have as you would expect that you get very different answers from very different people because people want different things from their minds.

56:19 And so asking rather than presupposing what a given client wants from their mind I think is the is the main clinical implication. The broader I mean the broader more sort of um policy based implication I mean this points to a very patient or client-centered view of a lot of mental health policy the idea that the idea that mental health policy is primarily devoted to reducing you know something called mental disorder um and you know through kind of broad scale interventions um that kind of public health model of mental health policy I think is is misguided.

57:01 I think mental health policy is is much more like politics generally there are a lot of people who have lots of desires a lot of different desires and we have to find some way of satisfying the the very different desires that people have in an equitable way that gives due justice to people's rights. So mental health policy looks a lot more like politics than it does like than it does like so-called public health policy.

57:24 That that second one is a bit is a bit broader but I'd be happy to say more about that.

57:28 Yeah that's interesting I I the my issue my issue with mental health policy is it's just seems very disconnected from people's real quality of lives. So we're at least in the UK when we talk about mental health policy we're saying okay we're talking about reducing rates of depression we're talking about reducing hospitalizations reducing addictions reducing self-harm again there's very kind of trying to create the absence of negative things um and in keeping in the kind of with the spirit of this discussion today I feel like mental health policy needs to be much more geared towards what is what constitutes a good quality of life and how can we help people get there.

58:11 And that's my main concern is we're not helping people even figure out what the life they might want is which I I think is very important and we're not giving them tools to help them get there.

58:25 Yeah I I agree with that um and I think that and and I think often the tools would be quite um again since people want different things there's this notion in in um in John Rawls the political philosopher has this notion of primary goods so primary goods are kind of goods that's whatever else you want you want them um so like capital is an example of a primary good you know whether you want to start a start an art gallery or whether you want to start a you know a copper factory you you probably want some capital.

58:55 And so these things that are good for people say I think we need to focus more on what I call psychological primary goods. Everyone has different different things they want from their life we want to give them give you things that whatever you want it's useful to have this thing which may often be literally money um but often it can be resources things like better access to care things that people are already advocating for.

59:16 But we're advocating these as as you say ways of ways of helping people promote their own wellbeing rather than ways of eradicating you know some some mental disorder or what have you yeah I I definitely think something like this could definitely call for a menu of options just because you know as we've discussed people are so different and they want different things although many people want kind of a common array of things and and do you have like any notion of what like might be really useful sort of psychological goods we can throw out as an example as an example I mean access and I know and this is salient in the in the US I know this is salient in the UK and it's a very simple thing but

59:57 you know more more ready access to to mental health providers you know at at the at the ground level and this is this is kind of an obvious thing but it's despite being obvious it's still it's still very hard to actually to actually get this done. And so so I think thinking this in in terms of in terms of a of of a of a basic good for people's wellbeing might be a useful way of framing this sort of this sort of policy intervention.

1:00:24 So better access to to kind of mental mental primary care um and resources I think I mean in a lot of the things resources often in terms of financial resources a lot of the things we've talked about today are things that are much easier to do if you have you know something like a something like a a decent a decent income relative to your relative to the country that you're living in.

1:00:46 So I think so so those sorts of things. So again as with the clinical thing the policy it's not like the policy recommendations here are 180 degrees from things that are people are already recommending basic access to mental health care and and and basic um and basic um uh income are in my mind are quite are quite useful interventions but the reason for them is not again the public health one but rather rather promoting people's psychological well-being and giving them psychological primary goods.

1:01:16 Yeah and I can't help but think of community as well helping people especially in the West when we are more isolated just easy simple ways to meet people and have access to a group of people that might be a group of people maybe with the same kind of difficulties you might be experiencing like a hearing voices group for example but even just people in general um because I just think that that's that for me community is definitely going to be like a huge psychological primary good.

1:01:45 Yeah I think so and pure peer support groups which I'm a big I mean I'm independently a a big fan of of of kind of peer support groups of various of various kinds and I think they they're very consonant with the sort of view of mental health that I'm that I'm advocating in the book.

1:02:01 We're out of time I feel we've kind of almost only just started the discussion but I look forward to reading your book when it comes out and no doubt when I do that I'll probably have some more thoughts and perhaps we could have another discussion again in the future.

1:02:15 That would be great.

1:02:16 Wonderful John thanks so much for joining me today.

1:02:19 Okay thank you a lot