In 1927, the Harvard professor Francis Peabody famously noted that, "The secret to the care of the patient is caring for the patient." In mental health, caring means much more than a prescription or a therapy hour. Radical abundance -- in line with Ezra Klein and Derek Thompson's approach to socio-political issues -- reminds us that we have a lot to offer to people struggling with a serious mental illness. There are clubhouses and ACT teams and supported employment and a world of other psychosocial supports that are keys to recovery but lack a CPT code and therefore belong to the kingdom of scarcity. Coordinated Specialty Care is still tough to cover with Medicaid reimbursement in most states. Physical rehab for 6 months following a femur break - no problem. Psychosocial rehab after a psychotic break - not so much. Imagine what we could do for people with serious mental illness if we focus less on restrictions and more on "caring" even when that moves outside the bounds of what today a prior auth review deems as "medical necessity."
This mess is complex, as are every one of us humans. One key element in the complexity is the use of the mask of science to legitimize practices derived from guesses, hunches, and theoretical projections. This inauthentic presentation comes from multiple motivations including those of wanting to serve, to help, to relieve suffering in addition to those that are more self-serving.
One thing that would make a significant difference moving forward, I believe, is to develop a true science of subjective experience. I've been working on this for three decades and have made significant progress. But because it falls outside the norms (science is assumed not to be do-able in this realm), I have gotten nowhere in trying to contribute this to the monolith. Which is kind of a bummer.
When you actually have decent tools for observing what is within us, it becomes very clear, very quickly, that the complexity we carry within us is so far beyond what we have ever had any basis for imagining. So far beyond. And it also becomes very clear that our civilization's choice to prioritize (and essentially worship) objectivity and rationality above all else has caused a massive distortion of our nature. We are no longer living as our natural selves, and the barriers to that inherent wisdom, adaptability and responsiveness are extensive and locked in, bound to the systems we've created both in shaping and being shaped by those systems.
It will take us generations, I believe, to make the shift you are calling for. No less. And I wish I had answers for exactly how to move forward in facilitating that shift. It's gonna be a long road.
In the meantime, I will continue to develop my work, you will continue to strengthen your voice for change, and together, many of us will set things in motion. All the people fighting in all the directions are expressions of people actually waking up, and waking up is a movement that happens in small steps. We wake up to this. And then we wake up to that. One bit at a time we become slowly more aware and more capable of responding to this epic challenge we face. Thank you for your voice in this, for the way you nudge more and more people to open their awareness, first here, then there, gradually on the way.
Well, the best place to start is here on Substack, https://frontiers.psychotopology.com/ which includes all the chapters of Volume 1 and draft chapters unfolding for Volume 2. And I'm happy to share pdf/ebook versions of Volume 1 to anyone who'd like one. Thanks for asking!
I love the idea of radical abundance, in part because abundance is why I came into this field in the first place.
I work with children, and early in my career I felt as though I was surrounded by kids experiencing the psychological equivalent of hunger. Empty bellies, aching bodies, nutrient deficiencies. They needed more understanding, more generous attention, more options, and more support. I wanted us to build a world in which there was so much good psychological care available that people could choose among many nourishing possibilities and figure out what actually worked for them. And many of us worked very hard to make more food.
But lately I find myself wondering whether something changed along the way.
We unquestionably have more “psychological food” than we used to. More people are in therapy, taking psychiatric medication, receiving diagnoses, asking for accommodations, consuming mental-health information, and understanding themselves through psychological language. Yet, I’m increasingly uneasy that much of what has become abundant resembles ultra-processed food: highly accessible, easy to consume and provide, often satisfying in the short term, but perhaps not terribly nourishing.
In my corner of the world, its ingredients often include a rapid move toward diagnosis, locating the problem inside the individual, accommodations without enough attention to development or environment, and explanations that gradually strip away context and individuality.
Meanwhile, the people arriving at the clinic have changed too. I still see children who are psychologically starving. But I also increasingly see people in genuine distress who seem less like people suffering from caloric deprivation, and more like people eating plenty while nevertheless feeling unwell: micronutrient deficiencies, perhaps, or problems arising partly from the composition of the diet itself.
I want to be extremely careful here, because their suffering is real. I don’t want to resurrect a distinction between people who “deserve” care and people who don’t. Nor do I want fewer possibilities available to people simply for the sake of having less treatment.
But I do wonder whether this complicates the abundance argument.
Ultra-processed food doesn’t merely coexist with better food. Once it becomes cheap, ubiquitous, convenient, heavily reinforced, and culturally familiar, it changes the entire food environment. It shapes preferences and expectations. It changes what producers make. And simply making fresh vegetables abundant alongside it doesn’t necessarily undo those effects.
Could psychological care operate similarly?
Perhaps some forms of care are not merely inferior substitutes people choose because richer relational care is unavailable. Perhaps the abundance itself changes how we conceptualize distress, what people learn to ask for, what clinicians learn to provide, what institutions incentivize, and where our precious, scarce attention ultimately goes. And perhaps that helps explain the strange coexistence we now have, of ever-expanding mental-health treatment alongside people with serious mental illness and high support needs who remain profoundly underserved.
That’s the part I would love your help thinking through.
I share your desire for a radical abundance of care. I’m just increasingly unsure that the answer can be “keep everything we have and add much more excellent care beside it.” I wonder whether abundance sometimes requires gardening as well as planting, cultivating much more of what nourishes, while also recognizing that some extremely successful species may be crowding out the ecosystem we were trying to create.
Maybe, in other words, there is a humane subtractive agenda? Not subtraction as austerity, suspicion, or denial of suffering, but subtraction in service of making room for something better.
You’ve put the counter-point very well! I’d say I’m in general agreement and I really like the ultraprocessed food and gardening metaphors. I will think more about this. In the meantime, did you see this post from a few weeks back? I’d love to hear your thoughts on it: https://www.psychiatrymargins.com/p/adiposity-by-self-report
I look forward to your further thoughts! Thanks for pointing me to your adiposity by self report post — I left a comment on that post rather than here. Thought provoking as always.
Your thoughts here lay out a really interesting perspective on not just the struggles in psychiatry and psychotherapy, but across the board in all of society. This is a cultural vibe you're describing.
One question that arises for me in reading this: is it possible that even if there was an abundance of purely grown, perfectly healthy food, perhaps the cultural practices of how food is cooked and served would corrupt it entirely? Or maybe it wouldn't be able to be recognized and would be thrown out in favor of something unhealthy. I mean, is there something inherent in our culture that makes it impossible to even ingest something good for us without mixing it with toxins first?
What are your thoughts about that? If something like that were true, would we be able to trust ourselves to come up with either the humane subtraction or the something better to replace what is subtracted? Or maybe a better question is, *how* would we be able to do this, what would it take, how would such an effort begin?
I absolutely agree. The lack apparent concern for suffering, except for that which is iatrogenic, greatly troubles me too. You've clarified that for me! Thanks
Attention is the rarest and purest form of placebo. When I sit with my patients in suffering I am unable to ameliorate, I believe my presence is a balm. Thank you so much for so clearly articulating this.
I agree that the critical issue is trust. But patients distrust our entire medical system not just psychiatry. Unfortunately as the only clearly visible element of that system, doctors have become lightening rods. What’s really to blame is the practices of the pharmaceutical, insurance and graduate education industries. However, nowhere is their influence more apparent than In psychiatry.
I am immensely sympathetic to Awais’s framing of this discussion. Greater access to psychiatry’s many modalities would doubtless benefit people who are underserved—or simply ill-served—by the scarcity endemic to American health care. But abundance alone is not an unequivocal good. More of what is currently inadequate for many and harmful for some is not necessarily better care.
No one here is proposing anything remotely like this, of course, but consider a metaphor that no one in their right mind would ever suggest, let alone advocate: the fantastical idea of putting everything “psychiatry currently has in its toolkit” into the water supply, like fluoride. That’s terrifying. Whereas the analogous fantasy applied to cardiology’s toolkit is not nearly so disturbing, given cardiology’s significantly more secure evidentiary understanding of the heart and circulatory system compared with psychiatry’s understanding of the brain and its neurocircuitry—to say nothing of how that circuitry contributes to thought, mood, and behavior.
That seems to me the important qualification to an abundance agenda: what we need is not simply more care, but more good care—and considerably better evidence for distinguishing it from care that merely bears the name.
In the 1990s we were supposed to finally give up paternalism in psychiatry but today doctors are still as paternalistic as ever, but it is the paternalism of an absent father (“provider”) who lovingly sends money or care packages.
It leaves patients neglected and overly enthusiastic about medications, since medications are all they get— a substitute for real parenting.
Thanks for articulating this so well. I see this part happening now with psychedelics: “I find it odd that so many smart colleagues in prior decades have focused on expanding access to psychiatric medications as the primary issue, as if the mental health crises we face can be addressed by something akin to putting SSRIs in the water supply.”
For those unaware of the reference, I’m riffing on a famous quote by Simone Weil: “Attention is the rarest and purest form of generosity.”
In 1927, the Harvard professor Francis Peabody famously noted that, "The secret to the care of the patient is caring for the patient." In mental health, caring means much more than a prescription or a therapy hour. Radical abundance -- in line with Ezra Klein and Derek Thompson's approach to socio-political issues -- reminds us that we have a lot to offer to people struggling with a serious mental illness. There are clubhouses and ACT teams and supported employment and a world of other psychosocial supports that are keys to recovery but lack a CPT code and therefore belong to the kingdom of scarcity. Coordinated Specialty Care is still tough to cover with Medicaid reimbursement in most states. Physical rehab for 6 months following a femur break - no problem. Psychosocial rehab after a psychotic break - not so much. Imagine what we could do for people with serious mental illness if we focus less on restrictions and more on "caring" even when that moves outside the bounds of what today a prior auth review deems as "medical necessity."
Wow, this post and your last one (https://www.psychiatrymargins.com/p/maybe-dont-ask-your-doctor-if-zoloft) come through loud and clear, and I'm really appreciating this voice of yours. I want to offer a very simple expansion of your message, if I may.
This mess is complex, as are every one of us humans. One key element in the complexity is the use of the mask of science to legitimize practices derived from guesses, hunches, and theoretical projections. This inauthentic presentation comes from multiple motivations including those of wanting to serve, to help, to relieve suffering in addition to those that are more self-serving.
One thing that would make a significant difference moving forward, I believe, is to develop a true science of subjective experience. I've been working on this for three decades and have made significant progress. But because it falls outside the norms (science is assumed not to be do-able in this realm), I have gotten nowhere in trying to contribute this to the monolith. Which is kind of a bummer.
When you actually have decent tools for observing what is within us, it becomes very clear, very quickly, that the complexity we carry within us is so far beyond what we have ever had any basis for imagining. So far beyond. And it also becomes very clear that our civilization's choice to prioritize (and essentially worship) objectivity and rationality above all else has caused a massive distortion of our nature. We are no longer living as our natural selves, and the barriers to that inherent wisdom, adaptability and responsiveness are extensive and locked in, bound to the systems we've created both in shaping and being shaped by those systems.
It will take us generations, I believe, to make the shift you are calling for. No less. And I wish I had answers for exactly how to move forward in facilitating that shift. It's gonna be a long road.
In the meantime, I will continue to develop my work, you will continue to strengthen your voice for change, and together, many of us will set things in motion. All the people fighting in all the directions are expressions of people actually waking up, and waking up is a movement that happens in small steps. We wake up to this. And then we wake up to that. One bit at a time we become slowly more aware and more capable of responding to this epic challenge we face. Thank you for your voice in this, for the way you nudge more and more people to open their awareness, first here, then there, gradually on the way.
Joe, for folks unfamiliar with your work, what’s the best place for them to start to learn about it? As in, specific posts or specific articles.
Well, the best place to start is here on Substack, https://frontiers.psychotopology.com/ which includes all the chapters of Volume 1 and draft chapters unfolding for Volume 2. And I'm happy to share pdf/ebook versions of Volume 1 to anyone who'd like one. Thanks for asking!
I love the idea of radical abundance, in part because abundance is why I came into this field in the first place.
I work with children, and early in my career I felt as though I was surrounded by kids experiencing the psychological equivalent of hunger. Empty bellies, aching bodies, nutrient deficiencies. They needed more understanding, more generous attention, more options, and more support. I wanted us to build a world in which there was so much good psychological care available that people could choose among many nourishing possibilities and figure out what actually worked for them. And many of us worked very hard to make more food.
But lately I find myself wondering whether something changed along the way.
We unquestionably have more “psychological food” than we used to. More people are in therapy, taking psychiatric medication, receiving diagnoses, asking for accommodations, consuming mental-health information, and understanding themselves through psychological language. Yet, I’m increasingly uneasy that much of what has become abundant resembles ultra-processed food: highly accessible, easy to consume and provide, often satisfying in the short term, but perhaps not terribly nourishing.
In my corner of the world, its ingredients often include a rapid move toward diagnosis, locating the problem inside the individual, accommodations without enough attention to development or environment, and explanations that gradually strip away context and individuality.
Meanwhile, the people arriving at the clinic have changed too. I still see children who are psychologically starving. But I also increasingly see people in genuine distress who seem less like people suffering from caloric deprivation, and more like people eating plenty while nevertheless feeling unwell: micronutrient deficiencies, perhaps, or problems arising partly from the composition of the diet itself.
I want to be extremely careful here, because their suffering is real. I don’t want to resurrect a distinction between people who “deserve” care and people who don’t. Nor do I want fewer possibilities available to people simply for the sake of having less treatment.
But I do wonder whether this complicates the abundance argument.
Ultra-processed food doesn’t merely coexist with better food. Once it becomes cheap, ubiquitous, convenient, heavily reinforced, and culturally familiar, it changes the entire food environment. It shapes preferences and expectations. It changes what producers make. And simply making fresh vegetables abundant alongside it doesn’t necessarily undo those effects.
Could psychological care operate similarly?
Perhaps some forms of care are not merely inferior substitutes people choose because richer relational care is unavailable. Perhaps the abundance itself changes how we conceptualize distress, what people learn to ask for, what clinicians learn to provide, what institutions incentivize, and where our precious, scarce attention ultimately goes. And perhaps that helps explain the strange coexistence we now have, of ever-expanding mental-health treatment alongside people with serious mental illness and high support needs who remain profoundly underserved.
That’s the part I would love your help thinking through.
I share your desire for a radical abundance of care. I’m just increasingly unsure that the answer can be “keep everything we have and add much more excellent care beside it.” I wonder whether abundance sometimes requires gardening as well as planting, cultivating much more of what nourishes, while also recognizing that some extremely successful species may be crowding out the ecosystem we were trying to create.
Maybe, in other words, there is a humane subtractive agenda? Not subtraction as austerity, suspicion, or denial of suffering, but subtraction in service of making room for something better.
You’ve put the counter-point very well! I’d say I’m in general agreement and I really like the ultraprocessed food and gardening metaphors. I will think more about this. In the meantime, did you see this post from a few weeks back? I’d love to hear your thoughts on it: https://www.psychiatrymargins.com/p/adiposity-by-self-report
I look forward to your further thoughts! Thanks for pointing me to your adiposity by self report post — I left a comment on that post rather than here. Thought provoking as always.
Your thoughts here lay out a really interesting perspective on not just the struggles in psychiatry and psychotherapy, but across the board in all of society. This is a cultural vibe you're describing.
One question that arises for me in reading this: is it possible that even if there was an abundance of purely grown, perfectly healthy food, perhaps the cultural practices of how food is cooked and served would corrupt it entirely? Or maybe it wouldn't be able to be recognized and would be thrown out in favor of something unhealthy. I mean, is there something inherent in our culture that makes it impossible to even ingest something good for us without mixing it with toxins first?
What are your thoughts about that? If something like that were true, would we be able to trust ourselves to come up with either the humane subtraction or the something better to replace what is subtracted? Or maybe a better question is, *how* would we be able to do this, what would it take, how would such an effort begin?
I absolutely agree. The lack apparent concern for suffering, except for that which is iatrogenic, greatly troubles me too. You've clarified that for me! Thanks
Attention is the rarest and purest form of placebo. When I sit with my patients in suffering I am unable to ameliorate, I believe my presence is a balm. Thank you so much for so clearly articulating this.
I agree that the critical issue is trust. But patients distrust our entire medical system not just psychiatry. Unfortunately as the only clearly visible element of that system, doctors have become lightening rods. What’s really to blame is the practices of the pharmaceutical, insurance and graduate education industries. However, nowhere is their influence more apparent than In psychiatry.
Thank you so much for this.
Love it. Keep writing Awais. Your voice is essential.
I am immensely sympathetic to Awais’s framing of this discussion. Greater access to psychiatry’s many modalities would doubtless benefit people who are underserved—or simply ill-served—by the scarcity endemic to American health care. But abundance alone is not an unequivocal good. More of what is currently inadequate for many and harmful for some is not necessarily better care.
No one here is proposing anything remotely like this, of course, but consider a metaphor that no one in their right mind would ever suggest, let alone advocate: the fantastical idea of putting everything “psychiatry currently has in its toolkit” into the water supply, like fluoride. That’s terrifying. Whereas the analogous fantasy applied to cardiology’s toolkit is not nearly so disturbing, given cardiology’s significantly more secure evidentiary understanding of the heart and circulatory system compared with psychiatry’s understanding of the brain and its neurocircuitry—to say nothing of how that circuitry contributes to thought, mood, and behavior.
That seems to me the important qualification to an abundance agenda: what we need is not simply more care, but more good care—and considerably better evidence for distinguishing it from care that merely bears the name.
In the 1990s we were supposed to finally give up paternalism in psychiatry but today doctors are still as paternalistic as ever, but it is the paternalism of an absent father (“provider”) who lovingly sends money or care packages.
It leaves patients neglected and overly enthusiastic about medications, since medications are all they get— a substitute for real parenting.
Thanks for articulating this so well. I see this part happening now with psychedelics: “I find it odd that so many smart colleagues in prior decades have focused on expanding access to psychiatric medications as the primary issue, as if the mental health crises we face can be addressed by something akin to putting SSRIs in the water supply.”