Stephanie Nelson, PhD, ABPP, ABPdN, is a board-certified pediatric neuropsychologist and founder of The Peer Consult, where she provides consultation and mentorship to assessment psychologists. Her interests include clinical reasoning, psychological assessment, and understanding human behavior through developmental, contextual, and systems-oriented perspectives.
This guest post is the first of a pair of articles by Stephanie Nelson in response to recent posts on Psychiatry at the Margins. It is a comment on:
In a recent essay, I Believe in a Radical Abundance of Relational Care, Dr. Aftab makes a compelling case for expanding access to thoughtful and individualized psychiatric care. He argues that many of the problems associated with contemporary mental health treatment arise from scarcity: limited time, limited attention, and limited alternatives to the relatively narrow range of interventions that are readily available. He’s understandably wary of reform efforts organized around reducing diagnoses, prescriptions, or other care when so many are struggling to get the help they need. Instead, he envisions a radical abundance of good care, in which people have access to a wide range of meaningful options. I share his aspirations, and much of his reasoning, but his essay brought into focus a question I’ve been wrestling with about the kinds of care we’ve already made abundant.
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. Indeed, someone might receive a great deal of psychological attention and still be missing precisely the understanding, support, or changes to their circumstances that would actually help them.
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 psychological care are not merely inferior substitutes that people choose because richer relational care is unavailable. Perhaps what we’ve made abundant changes in 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.
These are the questions I’m still trying to think through.
I share Dr. Aftab’s 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 pruning as well as planting. The pruning may involve questioning some of our defaults: reflexive labeling, familiar interventions offered without sufficient consideration of alternatives, a tendency to interpret all problem-in-living as psychological concerns, and institutional incentives that favor what is easy to provide over what might actually be helpful. It may mean being willing to consider whether each form of care we offer truly relieves suffering, deepens understanding, increases people’s capacities or resources, or helps create circumstances in which they can live more effectively. Thoughtful gardening requires watering and weeding, especially when 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 what nourishes.
See also:
Thank you for this spot-on analysis. I think when psychiatrists were classically trained in psychotherapy there was at least a chance of getting the proper nutrients. But by succumbing to the financial pressures wrought by the insurance industry, psychiatrists paved the way for this malnourishment